Dissecting denialism: How transphobia’s bad science turned a Washington hospital into a battleground

This summer, Pullman Regional Hospital near the Washington-Idaho border became the site of a wholly unnecessary conflict over vaginoplasty for trans women. The Washington Post reported that after surgeon Geoff Stiller sought permission to begin performing the procedure, an evangelical Christian physician at the hospital, Dr. Rod Story, began to agitate against the surgery and led opposition from hospital staff as well as the surrounding community. While the hospital’s board members ultimately agreed unanimously to go ahead with providing vaginoplasty, the public controversy surrounding the proceedings serves as an illustrative example of how the pseudoscience of transphobia can directly interfere with a useful grasp of medical evidence on an individual level, as well as the provisioning of necessary care on an institutional level.

A medical provider’s evaluation of whether a given procedure should be made available would seem to be a matter of some very straightforward, narrow, and well-defined considerations: Are patient health outcomes significantly improved by the procedure? How strong is the evidence base supporting the procedure as medically effective – is there sufficient evidence to recommend it as a matter of routine practice? Do its benefits broadly outweigh its risks? On all of these questions, the scientific evidence is consistent and unambiguous. For trans women, vaginoplasty is associated with a reduction in gender dysphoria (de Vries et al., 2014; Kuiper & Cohen-Kettenis, 1988), better general functioning, improved social functioning (Smith et al., 2001), a reduction in suicide attempts (De Cuypere et al., 2006), greater body satisfaction, greater sexual satisfaction (Weyers et al., 2009), improved mental health overall, and greater quality of life (Ainsworth & Spiegel, 2010). For these reasons, numerous professional medical organizations, including the American Psychological Association (2008) and American Psychiatric Association (Drescher et al., 2012), have taken a stance in favor of the availability and coverage of vaginoplasty and other transition treatments.

However, Dr. Story was initially able to persuade the hospital administrators to delay making a decision on the surgery and open a period of public comment:

Story sent the email and waited a day as his note spread around the hospital. Then, his phone rang. He was called into a meeting with the hospital chief executive, Scott Adams, and the chief medical officer, Gerald Early. They talked for more than an hour, according to notes Story kept, and by the end, Adams wondered if the hospital had been moving too fast. He called Story’s objections “the tipping point.”

What happened after that was an announcement: Even as Stiller performed two training vaginoplasties — supervised by a more experienced surgeon from Los Angeles — Pullman Regional said it would ask for public input, accepting comments from residents for three weeks. The initial hospital announcement was just a short news release with an email address, but soon the announcement was posted all over Facebook, and that was all it took to open a split in the community.

The hospital’s solicitation of public input provided a valuable opportunity to observe how the general public and non-experts were able to turn the dispassionate evaluation of consistent science into an apparent controversy. This was chiefly accomplished by the propagation of well-worn anti-trans tropes, the introduction of irrelevant theological opinions, the intentional omission of relevant information, and the invocation of a deliberately cultivated science denialism given a patina of authority by bad actors such as Paul McHugh.

Dr. Story’s initial opposition to vaginoplasty appears to be based on an incorrect understanding of even the basics of what gender dysphoria is:

First, he did some research. He Googled terms like “transgender surgery risk,” collecting 40 transgender-related links on his computer, and what he concluded was that Stiller was right to be concerned about the patients and wrong to offer them surgery. These were patients with mental conditions, Story felt. “It’s a body dysmorphic disorder,” he said of the conclusion he had reached. “You have an incorrect perception of your body. Probably the most common example is anorexia.” It was a hospital’s job to protect those patients, not enable their wishes.

Here, Story has conflated two distinct conditions. Body dysmorphic disorder involves an obsessive and impairing fixation on an appearance defect that is either minor or entirely imagined, and medical efforts to correct this “defect” through plastic surgery or other means are typically unsatisfying. Individuals with gender dysphoria, however, do not have an inaccurate perception of their bodily features – we are intensely aware of the reality of our bodies, as well as how those features are perceived by others. Given that transition procedures are effective in treating gender dysphoria and improving our body image, withholding these procedures does not serve to protect us from ourselves – this is only “protecting” us from receiving provably beneficial care. Paul McHugh, who shuttered the gender clinic at Johns Hopkins in the 1970s based on inadequate data and personal motivations, has repeated the false comparison to body dysmorphic disorder in a number of right-wing outlets (1, 2, 3), and this is likely the source of Dr. Story’s information.

In his statement to the hospital board, Story further promotes misunderstandings of suicidality among trans people:

As a medical doctor, I am opposed. GID is a complex, neuro-psychiatric condition for which surgery has not been shown to have long-term benefits. Studies over decades in Canada and Sweden have shown that transgendered patients continue to suffer from extensive mental health issues, including extremely high rates of suicidality.

The reference to studies from Sweden on suicidality is characteristic of Paul McHugh and has since become a mainstay of anti-trans discourse. This misconception largely stems from McHugh’s misreading of Dhejne et al. (2011), a misreading which falsely claims that trans people who transition experience elevated suicide and suicide attempt rates, and was explicitly refuted in a later research review coauthored by Cecilia Dhejne (Dhejne et al., 2016):

Only one study looking at Axis I disorders compares a trans group with a cis control group matched for age, natal sex and new assigned sex (Dhejne et al., 2011). This study, which uses data from the national register in Sweden, focuses on trans people following gender-confirming medical interventions and found higher rates of psychiatric disorders and suicide in this group. It found, however, that there was an improvement over time, i.e. rates of psychiatric disorders and suicide became more similar to controls over time; for the period 1989–2003, there was no difference in the number of suicide attempts compared to controls.

Story further appeals to the principle of “first, do no harm”, and describes vaginoplasty as “removing healthy organs”. These criticisms were repeated by an ER doctor, Heidi Abraham:

On the other side of the issue is Dr. Heidi Abraham, an emergency room physician, who wrote she is “deeply disturbed” about gender reassignment surgeries occurring at her hospital.

Doctors take an oath to abstain from intentional wrong-doing and harm, Abraham said. “In any other context, this would be considered genital mutilation and removal of healthy organs: gross malpractice, and utterly unacceptable behavior for a physician.”

Such arguments elect to disregard the well-being of patients in favor of an unhelpfully narrow focus on the anatomical conformance of isolated organs. If it were claimed that gender dysphoria is a structural defect localized within the penis, the assertion that this organ is healthy might be relevant – but no one is making such a claim, because that’s not what gender dysphoria is. When the presence of certain anatomy is understood to contribute to an individual’s symptoms of gender dysphoria, and surgery on that anatomy is known to reduce gender dysphoria and its associated comorbidities, withholding access to that surgery is not “doing no harm”. It is a conscious choice to allow individuals to continue to suffer the harm of untreated gender dysphoria. This tunnel-like focus on “do no harm”, to the detriment of all other relevant principles and the broader purpose of medical ethics, advances the largely unsupportable contention that an unhealthy patient with a healthy penis is preferable to a healthy patient with a healthy neovagina.

Further input from the community continued this descent into the depths of irrelevance. Numerous public comments focused on the role of sex chromosomes:

“Cutting off/out sexual organs doesn’t change our chromosomes,” said another.

Ben Zornes of the Moscow-Pullman area disagrees. Gender reassignment surgery alters people’s anatomy without changing their DNA, Zornes wrote. “If you proceed down this path, you are leaving the tradition of medical practice behind and have made yourselves servants to public opinion rather than the truth of science derived from the laws of nature and nature’s God.”

Vaginoplasty indeed does not alter an individual’s genome – but the editing of chromosomes is not the purpose of vaginoplasty. Hypothetical alterations to sex chromosomes are not necessary in order to achieve the known medical benefits of this surgery. One could truthfully say that vaginoplasty does not change your brake fluid either, but no one would pretend that this is pertinent to the evidence surrounding the procedure and its intended outcomes.

Certain religious groups in the community chose to extend their arguments beyond nature and the systematic observation of phenomena within the natural world:

Story, meantime, posted his views on social media, then one Sunday walked into his church and found out that the sermon was about him. “Think of Rod and Jenny Story right now,” the pastor, Ty Knight, told the congregation, and Story could feel some eyes turn toward him and his wife.

Story had sometimes felt alone since writing the letter. His initial email had been read by almost everybody at Pullman Regional, posted at nurse’s stations, and only two people had responded to him. But that was the medical community, and this was the church, and there were 120 people in the pews, and a thousand other members of affiliated congregations in the area, and it was here at least where Story sensed support.

“There is a great sin that is looking to come into the [region] of having transgender surgery,” the pastor said. “Rod is faithfully holding to God’s word.”

While such positions may have a place within the theology of certain evangelical Christian sects, it is unclear why they would have a place in the evaluation of medical evidence. The contention that this surgery constitutes a “great sin” cannot be meaningfully operationalized into a statement that can be verified or disconfirmed by the rigorous studies and clinical evidence on which medical practice depends. Indeed, there is no way that the statement “transgender surgery is a great sin” can be shown to be more or less true than the statements “withholding transgender surgery is a great sin” or “transgender surgery rotates your soul 180 degrees”. Such theological concepts are nebulous, widely disputed both within religion and without, and have no workable, broadly agreeable definition that can be usefully applied in the context of clinical recommendations.

The evidence for the efficacy of vaginoplasty in the treatment of gender dysphoria is not controversial – it consistently shows a beneficial effect. We can easily imagine possible worlds where this is not the case, worlds where these studies have instead shown that vaginoplasty produces no improvement or worse outcomes along these many measures. If we lived in such a world, the opponents of vaginoplasty in this small community would have simply been able to present that evidence. But such evidence does not exist in this world, and in its absence, they chose to justify their opposition using deliberate distortions of one study, false claims that erase the distinctions between separate conditions, vague and unconvincing appeals to very limited conceptions of medical ethics, and metaphysical religious claims that cannot possibly be proven or disproven. Controversy could only be created here by this deliberate and bad-faith contamination of discourse. In his statement to the hospital board, Dr. Story asserts that studies supporting the efficacy of vaginoplasty provide only “very low quality evidence”, before quoting the Bible and claiming that “to attempt to change someone’s gender hormonally and surgically is to violate their body, created in God’s image”. It is worth asking why Story and his supporters did not see fit to apply a similarly stringent standard of evidence to their own positions. ■

References

• Ainsworth, T. A., & Spiegel, J. H. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research, 19(7), 1019–1024. [Abstract]
• American Psychological Association. (2008). Transgender, gender identity, & gender expression non-discrimination. Retrieved from http://www.apa.org/about/policy/transgender.aspx
• De Cuypere, G., Elaut, E., Heylens, G., Van Maele, G., Selvaggi, G., T’Sjoen, G., . . . Monstrey, S. (2006). Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies, 15(2), 126–133. [Abstract]
• de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. [Full text]
• Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One, 6(2), e16885. [Full text]
• Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: a review of the literature. International Review of Psychiatry, 28(1), 44–57. [Abstract]
• Drescher, J., Haller, E., & American Psychiatric Caucus of Lesbian, Gay and Bisexual Psychiatrists. (2012). Position statement on access to care for transgender and gender variant individuals. Washington, DC: American Psychiatric Association (APA Official Actions). [Full text]
• Kuiper, B., & Cohen-Kettenis, P. (1988). Sex reassignment surgery: a study of 141 Dutch transsexuals. Archives of Sexual Behavior, 17(5), 439–457. [Abstract]
• Smith, Y. L., van Goozen, S. H., & Cohen-Kettenis, P. T. (2001). Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 40(4), 472–481. [Abstract]
• Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G., Heylens, G., . . . Verstraelen, H. (2009). Long-term assessment of the physical, mental, and sexual health among transsexual women. Journal of Sexual Medicine, 6(3), 752–760. [Abstract]