The Surgeries Are Immoral

Cole S. Aronson
April 5, 2023
Reproduced with Permission
Public Discourse

Florida has made it illegal for doctors to surgically alter the genitals of minors to treat gender dysphoria. In November 2022, after the Florida Board of Medicine took an initial step toward banning "gender-affirming" procedures, Florida Surgeon General Joseph Lapado praised the board's members for "ruling in the best interest of children in Florida despite facing tremendous pressure to permit these unproven and risky treatments." The pressure was indeed quite strong. But describing the procedures as "unproven and risky" misleadingly suggests a technical difficulty that could be fixed with better data or tools.

The real problem is more basic: the surgeries remove healthy organs without good reason. That's not risky - it's harmful and morally wrong. The people who seek such surgeries are trying to alleviate very real suffering, but whether surgery addresses such suffering humanely is not a question patients are automatically best positioned to answer. That's true of any patient seeking any medical procedure.

The question is both a moral and a political one. If the surgeries grievously injure the vulnerable people they're supposed to help, then patients shouldn't seek them, doctors shouldn't administer them - and voters and legislators should seriously think about banning them.

In many surgeries, acts that would normally be harmful and wrong are made beneficial and right by special circumstances. Sticking pieces of metal into a human hand is normally wrong to do, but certain hand surgeries require it. What makes that morally acceptable? Besides having particular shapes, hands have certain functions, like grasping and pushing and pulling. These functions aren't accidental. Being able to perform them is what makes a hand good at being a hand. When a hand is limp or broken, then what would normally be harmful to the hand - adjusting bones, pricking its skin - is helpful if it's what a surgeon needs to do to get the hand working normally.

For removing an organ to be morally permissible, you need a very powerful reason - something like countering a mortal threat from the organ.

The basic principle goes back at least to Aristotle. The parts of an organism ought to serve the whole organism. Helping someone's organs function as parts of their body is how doctors care for a patient's physical well-being.

Some of the surgeries administered to treat gender dysphoria involve acts much more extreme than small incisions. Hysterectomies, mastectomies, and penectomies don't just alter but remove organs. Sometimes, taking out an organ is morally quite right - if an organ is cancerous, for instance, or at serious risk of becoming cancerous. Again, organs ought to serve the good of the whole organism - which, minimally, means that organs shouldn't host agents of harm to the organism. That's why bilateral mastectomies can often be the right treatment for breast cancer (or for the genetic risk of breast cancer), why hysterectomies can be the right treatment for cervical cancer, and so on.

For removing an organ to be morally permissible, you need a very powerful reason - something like countering a mortal threat from the organ. It's true that there are cases in which removing a perfectly healthy organ from a patient is morally acceptable - live organ donation, for instance. But in all cases of licit organ donation, the functions performed by the donated organ are performed by organs that remain in the body. That isn't true for the surgeries covered by the Florida ban.

The big question is whether something about gender dysphoric patients can justify the surgeries we're talking about. I think the answer is no. Even assuming the psychological facts most favorable to proponents of the surgeries, and even assuming ideal conditions of autonomous consent, the surgeries are unjustified and therefore harmful. Compassion demands acknowledging the pain of transgender people; it equally demands not performing surgeries that make their lives worse.

Some patients seeking the treatments we're discussing claim to be assigned to the wrong sex, to have a gender (a psycho-social sense of self) that doesn't match their body. Surgery, this argument goes, could settle the conflict between, say, a female gender and a male body by surgically reforming the latter to mesh harmoniously with the former.

I think it is always an error to say you're a woman trapped in a man's body. Whether one is male or female is determined not by psychology, but by organs that serve distinct reproductive roles. Interestingly enough, this point actually seems to be accepted by those who say the bodies of gender dysphoric patients should be altered from one sex to the other. If whether someone is male or female isn't determined by reproductive organs, why should gender dysphoria be treated by altering just those organs? The problem is not misassigned sex, because sex cannot be assigned or misassigned or reassigned. It can only be embodied.

But for the sake of argument, let's assume that you could be a woman trapped in a man's body. Surgery wouldn't change that. Altering a man's genitalia may disable him from engaging in reproductive acts, but it does not - indeed, it cannot - produce the organs that enable a woman to engage in reproductive acts. A man cannot become a woman, no matter what a surgeon does to his genitalia. If that weren't true, then the many people who in the history of human cruelty have had their genitals forcibly removed would have thereby been moved closer to membership in the opposite sex. But that is simply not so.

If whether someone is male or female isn't determined by reproductive organs, why should gender dysphoria be treated by altering just those organs?

Altering a woman's genitals doesn't make her into a man, and altering a man's genitals doesn't make him into a woman. Even assuming that the proponents of the surgeries are right about the psychological states of patients before the surgeries, the surgeries don't achieve their intended result.

Perhaps what's morally relevant isn't whether a surgery switches the patient's sex, but whether it gives the patient psychic relief. If the patient is psychologically improved by the surgery, does that make the surgery morally permissible? Whether something gender-related caused a patient distress before the surgery isn't relevant to our question; all that matters is whether the patient feels better afterward.

As before, let's grant the proponents of surgery their best-case psychological scenario. Assume these surgeries do, in fact, induce relief, contentment, a sense of wholeness, or some such positive mental state. Here's the problem: any positive mental state will be an unfitting response to the physical harm caused by the surgery. The patient might feel better, but they will feel better about a situation about which they ought to feel worse, so the surgery will have replaced one mismatch between mind and body with another.

Consider, for example, the mental state of fear. Fear is that distinctively unwelcome, repellent, dominating frisson. Fear is appropriate for dangerous situations and a bad fit for harmless ones. Fear has norms. There could be such norms only if fear, in addition to being a feeling, also depicted the world outside the mind in a certain way. To be afraid of something is for one's mind to claim that the something is threatening, dangerous, to be avoided. If a situation is in fact dangerous - if fear is making a true claim about the situation - then fear is the right response. Otherwise, it is not.

As it is with fear, so it is with contentment, pleasure, relief, and other mental states. They can be judged appropriate or inappropriate only with reference to the situations to which they respond. Take contentment, for instance - that calm state of desire for things to continue as they are. That's the correct response to a loving marriage or a good job. But it's an incorrect response to injustice, because injustice ought to be rectified, and contentment is a state of satisfaction. Or take relief, that lessening of felt urgency or pressure. Relief is a good response to, say, the successful end of an important and difficult project, but not to the accidental, unexpected death of a beloved child. The same goes for pleasure, that warm feeling of attraction and inner harmony. Taking pleasure in another's suffering is wrong, because suffering calls for sympathy, a desire to aid the victim, and perhaps anger.

For one's mental states to respond improperly to the world is a sad thing, and it calls for compassion, not blame. People who have been depressed know how frustrating it is to feel numb at what ought to elicit joy or sadness. I know people for whom everyday stuff is terrifying. This is an awful experience, not because terror is always bad - it's often fitting and valuable - but because everyday stuff just doesn't call for terror.

The mental states we are discussing can be valuable only if they fit the situations to which they respond. So, even if removing a healthy sexual organ makes a patient content, the contentment itself is valuable and worth aiming at only if the removal of the healthy organ is something with which one ought to be pleased. But considered on its own, the removal of healthy organs is physically harmful.

Surgeons who try to relieve their patients' pain by stunting or removing healthy organs are doubly in the wrong: they are harming their patients' bodies, and they are doing it in order to induce an inappropriate mental response. It would be similar for a doctor to help a teenager cut herself to alleviate her anxiety.

But maybe we should take a longer-term view of benefits to patients. Let's say that some surgery relieved a patient of psychic distress that had blocked the patient from having the friendships they wanted, the job they hoped for, or some other aspect of human flourishing. Would the gain to the patient's life outweigh the direct harm of the surgery?

No, because well-being shouldn't be instrumentalized that way. Imagine that some people said you could be friends with them, but only if you did some degrading thing in public, or if you slept with every member of the group, or if you stole from your grandmother, all these acts would be as immoral as physical self-harm. Moreover, they're not the sorts of things good friends would ask of someone, since good friends try to promote one another's well-being, not to harm it.

Let's imagine a friendship between two people, one of whom has gender dysphoria (but who has not had any surgeries). Besides the standard duties of friendship, the friend without dysphoria has duties owing to the other's dysphoria: sympathetically acknowledging their distress, helping them to accept identity in their body, encouraging them to seek psychiatric treatment, and so on. If anything, surgery would make these duties harder to discharge, even if the surgery delivered psychic relief. The patient would be physically worse off (because they would have lost healthy organs) and would not be mentally well either (because they are now psychically relieved at having sustained a physical injury). Advancing the health of the dysphoric friend would mean undoing the psychological effects and alleviating the physical harm done by the surgery. Not advancing the health of the dysphoric friend would mean neglecting a basic purpose of friendship - to help unwell friends to get well, which at a minimum requires not acquiescing in their belief that they are well when the belief is false.

Up until now, I've been exploring whether the surgeries can be justified by their benefits to a patient's mental health, or to some part of their life that might be affected by mental health. I've assumed the psychological facts that are most favorable to proponents of the surgeries, and still, a good justification for the surgeries hasn't been found.

It could be that we have been looking for the justification in the wrong place. Maybe it's not the patient's improved mental health (as well as related goods, like friendship) that makes a surgery moral, but rather autonomous consent to the surgery. In the preface to his book When Harry Became Sally, Ryan Anderson discusses a 2018 New York Times op-ed by Andrea Long Chu, who identifies as a transgender woman. Chu intended to undergo vaginoplasty surgery in the coming days, but he didn't expect the six-hour procedure to make him happier or relieve his dysphoric thoughts. To Chu, that was beside the point: "no amount of pain, anticipated or continuing, justifies ... withholding [the surgery]. ... [S]urgery's only prerequisite should be a simple demonstration of want."

When a human being acts wrongfully and autonomously, she isn't an accidental part of chain of events that produces something undesirable. She's consciously willing the wrong thing.

If a surgery considered in itself is wrong, it's difficult to see how consent could make it right. Consent just doesn't seem to have that power. Consider some other wrongful acts: tearing the wings off of butterflies, cheating on an exam, lying to a friend. Does the fact that one freely chooses to do these things somehow make them morally right? On the contrary, to quote the great liberal political theorist Joseph Raz: "Demeaning, or narrow-minded, or ungenerous, or insensitive behavior is worse when autonomously chosen or indulged in." When a human being acts wrongfully and autonomously, she isn't an accidental part of chain of events that produces something undesirable. She's consciously willing the wrong thing.

At this point, a proponent of the surgeries might dig in their heels and say we have unlimited moral sovereignty over our bodies. I find it hard to argue against this opinion, though I find it equally hard to imagine how one might argue for it. But consider the consequences. Torture, live vivisection or burial, slavery, drowning, and so on would all be considered morally acceptable, as long as someone freely signed a consent form. Our basic dignity would be exchangeable if only we agreed to the exchange. The idea is obscene.

None of the potential justifications for the surgeries has passed muster. If the surgeries aren't justified, then the extreme acts they involve - such as amputation - are not helpful but severely harmful. That means patients shouldn't request the surgeries, and doctors shouldn't agree to perform them.

Generally, the medical profession can be counted on not to perform harmful procedures. Patients who have Body Integrity Identity Disorder (BIID), for example, believe that they would be better off if an arm or a leg were amputated. Both BIID and gender dysphoria involve a deep alienation from one's body. But while many doctors in America do remove organs to treat gender dysphoria, they do not amputate limbs to treat BIID (according to Dr. Peter Brugger, a Swiss research physician who's published extensively on the disorder, whom I interviewed over email). This is not - so far as I can tell - because the law prohibits it.

Sometimes there are good reasons for the law to step in and just say no to a procedure. Many American states have made it illegal to perform gay conversion therapy. The risk of serious harm was judged too high to leave to the medical field to regulate. Sex-reassignment surgeries, which are increasingly popular to perform and risky to oppose publicly, should be banned on similar grounds. Such surgeries aren't a run-of-the-mill vice like excessive smoking that the state should, given limited resources, leave to individuals. The surgeries do direct, grievous, physical, irreparable harm to the vulnerable, under the auspices of medical care.

There is a very brave and growing movement to persuade states to ban these surgeries, along with puberty-blockers and cross-sex hormones, for minors. Proponents of such bans often argue that we lack empirical data about the treatments, that there may be bad long-term psychological effects to such treatments, and that minors are at a delicate stage in life and should wait until they have grown up (by which time their gender dysphoria may have abated).

I worry that appeals to data outsource the final word to the researchers in the fields of psychology and psychiatry. Given the present state of these professions, does anyone have serious doubts about the results the experts will deliver?

Addiction, loneliness, our inhumane sexual culture, and the ever more popular desire to reconfigure one's body with surgery aren't isolated problems - they result from a national refusal to put political and cultural heft behind the conditions of genuine flourishing.

Untethered to a principled view that the surgeries are wrong, the anti-surgery camp may find itself making concession after concession - to the poignancy of severe cases of gender dysphoria, to the independence of the medical profession, to ignorance about the long-term effects of the surgeries (which ignorance could be remedied only by letting the surgeries be performed and observing the results), and, of course, to patient autonomy.

Instead, we should oppose the surgeries with an account of human freedom ordered toward the goods that make freedom a blessing rather than a curse. The goal of self-government, at the political level, is to help citizens govern themselves fruitfully in their personal lives. Addiction, loneliness, our inhumane sexual culture, and the ever more popular desire to reconfigure one's body with surgery aren't isolated problems - they result from a national refusal to put political and cultural heft behind the conditions of genuine flourishing.

Unfortunately, American conservatives are wary of political appeals to flourishing. They prefer to talk about freedom and leave matters there. That was fine when America's enemy was the Soviet Union and when American culture generally promoted the fruitful use of freedom. What about when America allows 100,000 people to die from alcohol and opioids in one year, sees over half of all marriages dissolve, can't find enough military recruits, empties out church pews, and fills heads with TikTok, porn, and Adderall? Americans are used to thinking of their free society as a humane society, and the more humane for being free. But a society can be both free and inhumane if that society's culture and laws are neutral about the virtues enabling the proper uses of freedom.

Conservatives need to choose between their impulse to let people live as they damn well please and their opposition to the grisly stuff being done by scientists and surgeons. One of these days, artificial intelligence and medical technology are going to get together and transform flesh-and-blood men and women into bespoke apparatuses of circuitry and steel. What will conservatives say then?

Certain limits cannot be transgressed without abolishing our humanity. The time to build a political coalition around the significance of our embodied personhood is now, when the practice to be opposed is the not-terribly-alluring one of cutting off the genitalia of vulnerable people. Next time, conservatives may not be so lucky.