I think essentially the conversation here cannot really progress without addressing the issue of negative pressure and positive ideology in the medical service provision. As I cited earlier, the evidence for both efficacy and safety of all medical interventions is sketchy at best, as is evidence of the harms suffered without those interventions.
Obviously, in such an environment, campaign groups are not going to just throw their hands up and say "oh well, we can't resolve this yet, more research need", they're going to cherry-pick the best sounding results from the weak collection and stick them front-and-centre. This goes for both side, clearly. So I don't see much room for progress on medical grounds alone. the most comprehensive meta-analysis I've managed to find (NICE and the review of GIDS in the UK) concluded the evidence was weak. As far as I'm concerned, that shifts the discussion to that about sensible default positions,
not correct medical approach, which, in my view, simply cannot be established using the quality of evidence we currently have.
I think there are still issues of philosophical interest, but if any argument hinges on the medical question of efficacy, it needs to do so from a position that the question is, as yet, unresolved. It cannot do so from a position that the medical treatments are safe and efficacious, and the processes best practice. Not only is this questionable on epistemological grounds, but the premise of any 'campaign' is that current practice is flawed. Such a premise must have, as a fundamental axiom, the notion that existing knowledge and practices can be flawed. It cannot then use, as a basis for it's argument, the unquestioned accuracy of any current knowledge and practice.
I agree that the pathologising of the issue is the problem, but where I think I struggle is with what happens once that's been removed. If we no loner require the 'clinical distress', then the harm being resolved by the medical intervention is not clinical any more, it becomes, if not societal, then...
ecological? We'd be claiming that there exists, naturally, a cohort of humans who identify as some other sexual phenotype than the one they were born as, but without this being a medical issue (not a defect), nor a societal one (we haven't fucked up and made a whole cohort of people unable to fit in). Just a naturally occurring feature of a population that some of them desperately (but not clinically desperate) need a different body (but not just any different body, they don't need a tail or broader shoulders, or a third arm, they need the body of the other sex).
On its face I find this implausible, but to dig a little deeper for some more flesh on those bones...
1. Why sex? Why not skin colour, hair type, height? If this phenomenon naturally occurs and isn't socially constructed, then is it just coincidence that it hinges on the most socially relevant phenotypical traits and not the socially irrelevant ones?
2. Where's the precedent? Tribes famously have long-accepted cross-gender roles. Some consider there to be a third gender, some simply accept that some women do men's things and vice versa. Suicide rates in tribes are famously low (with some not even having a word for the act). So where are the distraught
Nádleehi, for example?
3. Why would this particular form of dissatisfaction deserve attention? We have famously limited resources (NHS on it's knees etc), if we remove the clinical need, then what differentiates this form of bodily dissatisfaction from any other? On what grounds do we deny steroids to the unhappily puny? On what grounds would we deny hair straighteners to those dissatisfied with their afros? I don't want this to be taken as a slippery slope argument, more a question of where (if) we'd draw a line.
4. How do we frame such a state of affairs without invoking a 'female/male brain'? At best there's what appears to me to be a very thin line to tread here. We want to say that it's the sex of the body that matters (not just any bodily dissatisfaction will do). We want to fix that using endocrinological interventions (about as close to the brain as you can get without actual lobotomy). But we want to stop short of saying that the brain is sexualised in any way. Do you think that needle can be threaded? How are we to explain how GnRH therapy works to bring about the chosen identity, but at the same time
not say that such an identity is created by natural gonadotrophin? I struggle to see how we can leave open to those who have naturally occurring gonadotrophins of one functional sort, any identity they choose, but at the same time say with confidence that artificial GnRH therapy brings about a certain identity with efficacy?
There's many other questions, but I'll leave it there for now. The issue is a large and varied one.