Treating people as means to an end devalues them individually and people in general. I don't get that same feeling from organ donation. — T Clark

Aye! I think that's what makes the argument particularly uncomfortable. It invites asking why is one so bad when the other isn't. Give it a go! Eg; why is WBGD devaluing people by treating them as a means to an end, but organ donation isn't?

But the idea of my body sitting there for nine months with pumps and feeding tubes gives me an upset stomach. — T Clark

Aye. It's a sickening and horrifying idea. Though neither of those things mean it's wrong.

That started me thinking. Keeping a body alive for nine months would very expensive. If it weren't covered by insurance, only rich people could do it. Probably very rich people. In my state, Massachusetts, it is a requirement that insurance plans cover fertility treatments, including in vitro fertilization, but surrogacy is not covered. I certainly wouldn't want insurance plans to be required to pay for this type of "treatment." — T Clark

I generally agree. And also in the abstract. The proposal has so many implementation problems it's quite impossible to implement, or unethical for what you would need to do to get it doing. Though, interestingly to me, those aren't the reasons I expected to reject the argument on. I was expecting to reject it on the basis of autonomy violation, going in, but that way has so many assumptions and branching paths of argument it's like getting lost in an alien world.

This amounts to denying this premise:

( 11 ) Harms to the living derive from the denial of bodily autonomy.

And its downstream influences - not all the harms to the living derive from the denial of bodily autonomy, implementation details would disrupt funerals, have significant costs, be difficult to maintain, the repugnancy of the idea could very well impede regular organ harvesting and so on.

It also fails to consider aspects of the procedure which would decrease the expected utility: eg, the body decaying after brain death, even when maintained, also makes it very unlikely the body could fully gestate.

Ultimately perhaps the referenced argument by Ber is stronger, but likely to be even more repugnant - the donor body isn't dead, it's in a persistent vegetative state.

So I find the opt-out program is morally wrong and unjust. The utilitarian argument for “presumed consent”, in this case using human beings as incubators without their consent, whether for organs or children, requires too much faith in human infallibility and authority for me to be comfortable with. It illegitimately considers human beings as state property. The acquisition of the human being as property was unjust. For these reasons I wouldn’t make it past the first premise. — NOS4A2

Is there any way, for you, that the amount of good done by the opt out organ donation program is worth the fallible way consent is established in it?

Should they be kept alive so that we may harvest their organs should the need arise? — NOS4A2

People who have been declared dead are already circulated with oxygen so their organs are recoverable in a good state. In that respect, the distinction between organ donation (not just opt out) and WGBD is the duration of the circulatory period. It could be true that it's morally wrong to circulate oxygen around the donor's body for the period of a pregnancy, but not for organ donation, but it would need arguing.

The article puts it like this:

Prolonging ventilation and somatic survival in brain-dead patients is undoubtedly a disturbing prospect. WBGD involves treating the patient’s dead body as a means to an end, rather than as an end in itself. The patient moves from being the focus of medical concern, to being a repository of tissues that can be used to benefit others. The prolongation of the ventilation period exacerbates our awareness of this. Yet this is already a part of our organ donation process. Organ donors are almost invariably patients who are already being ventilated, as part of their medical treatment. If the patient is deemed to be a suitable organ donor, ventilation will be continued along with other interventions to ensure that the organs will be maintained for transplant in optimal condition. Thus, we already prolong ventilation in order to facilitate organ donation.

WBGD would involve extending this prolongation considerably further. But ventilating someone for two days, two weeks, or two years makes little difference except insofar as it forces us to acknowledge and recognise what we are doing before we hasten on to the next stage. The justification for prolonging somatic survival in conventional organ donation is primarily the benefits that are expected to derive for others, but also the idea that if someone wants to donate their organs, it may be reasonable to take the steps to preserve the organs even when this is no longer directly in the patient’s medical best interests. The same criteria apply to WBGD; the period of prolongation is further extended, but the means and justification are the same.

Edit: a possibility I'd not considered here is that braindead bodies in cannot be prevented from decomposing before gestation completes, given current medical knowledge. This is another point in favour of the scenario just being a sci fi hypothetical.

I’m trying to think of an example of something that exists only within philosophy’s practice (or doesn’t exist only within its practice). Put differently, isnt the aim of philosophy to address within its practice such inclusive concepts as world, existence , reality and truth? — Joshs

Entities in thought experiments? Swamp man, twin earth, brains in vats, grue and bleen, the utility monster, Gigantor...

But the law is not enacted to solve ethical issues but to reach equity. That's why I see it is fine if a judge needs to make a decision because we consider judges and courts as third parts who resolve problems of the societies and they interpret what should be someone's wishes if the interests of a person is at risk. — javi2541997

I think I see where you're coming from. Am I right in thinking you're suggesting that because these decisions are made by judges and laws, a dead person's articulated informed consent is not required?

In a similar vein, would you feel differently about this if the organs were used for cosmetic surgery rather than surgery that is medically necessary. — T Clark

Edit: I misread that you were talking about opt out organ harvesting rather than WBGD, but my position's the same. Cosmetic use of organs vs clinical need. Clinical need seems very much a part of what's granted to make organ harvesting ethical.

Undecided. If you bracket the autonomy consideration; I think some element of medical necessity is required to stave off feminist concerns and curtail possible horrific cases of abuse. I'm honestly not sure what to think due to how much branching occurs in the argument in the paper. In general I think the weakest section is its rather trite response to possible feminist responses, and this speaks exactly to the harms engendered if it can be used for convenience. How that fits into my summary would be undermining this premise:

( 11 ) Harms to the living derive from the denial of bodily autonomy.

Because the harms done may also include institutionalising the objectification of women's bodies, which induces discrimination more generally rather than the specific denial of reproductive rights.

I'll quote it:

One might argue that WBGD involving brain-dead women has no implications for living women, any more than harvesting the heart from a brain-dead man has an impact on living men. However, perhaps this is disingenuous. WBGD necessarily involves the separation of women’s reproductive functions from their very consciousness. Even if no-one would suggest that this should alter the way we regard ordinary women and their pregnancies, it might send an implicit message, or reinforcement to deeply entrenched assumptions and prejudices. The prospect of the unconscious woman’s body, filled and used by others as a vessel, is a vivid illustration of just what feminists have fought against for many years.

These feminist concerns, however, might be mitigated if men could also participate in WBGD. The prospect of male pregnancy is not, as many would imagine, fanciful, or a piece of science fiction. In 1999, Robert Winston told reporters that there were no intrinsic medical problems with initiating a male pregnancy: the danger would be in the delivery. We already know that pregnancies can come to term outside the uterus [31]. The liver is a promising implantation site, because of its excellent blood supply. However, as Winston noted, this could be risky – even fatal - for the person carrying the pregnancy. But for brain-dead donors, the concept ‘fatal’ is meaningless: the gestator is already dead. Thus, even if the liver is damaged beyond repair after the gestation, this would not pose a problem except insofar as it might mean that male gestators could carry only one pregnancy, rather than many consecutive ones.

The prospect of the male gestator could thus appease some feminists who might otherwise feel that brain-dead gestation is a step too far in the objectification of women’s reproductive functions.

The paragraph seems to say the WBGD could not be discriminatory because it would be possible to implant babies in men in the same way. That response isn't just trite, it's unrealistic as AFAIK it could not be practically implemented. If it's not possible, the sub argument's premises don't hold.

Regardless, if it were granted as a "sci fi" thought experiment scenario, it may still follow. However, it would mean imagining a much different society than we're in now. One where WBGD didn't provide a unique vector for control of women's bodies. The question remains though - does it reinforce control and discrimination and how does it do so? In what sense does it objectify women's bodies? Then in terms of risk - is this mitigated in any way by making it only administered when it allows an otherwise unable parent to have a child - some kind of necessity of intervention? Can having a womb be rendered incidental to process?

My initial problem is with the word 'harvesting'. The citizenry as a crop; the government as reaper. There is something very skewed about that concept, even before the ethics of the situation - properly called dismemberment of dead bodies.
The ethical consideration rests on one question:
Is leaving one's body to the nation an articulated condition of citizenship? — Vera Mont

I think I can give the same response to this as I did to @Tzeentch, if you grant that opt out organ harvesting is unethical, you already choose one horn of the constructive dilemma. Opt out organ harvesting and WBGD would both be unethical on this basis.

1. Whenever a person dies, he/she loses her/his civil personality and then he/she lacks his/her own right to claim.[ * (Yet, an authority represented by their interests can take decision on order to complement someone's interests)

2. Public order must prevail over private. A judge must decide and authorize an organ donation if the health and life of others is at risk, even if the donor had not expressed his agreement or disagreement while alive. — javi2541997

Thanks for this detail Javi! I think the argument in the paper uses something like ( 1 ) as an assumption - losing civil personality occurs with death. You have also highlighted a flashpoint in the article - an ambiguity about what "articulated consent means", and also what informed consent entails.

Specifically this considers whether: "an authority representing (the dead's) interests" may, and needs to, be consulted on whether the procedure respects the potential donor's wishes. If it were established that that is the only ethical form of opt out organ donation, it would undermine any point in the argument which said "articulated consent" - which is perhaps equivocated with every form of consent. IE, someone articulating consent on your behalf may be an exclusion to this.

The article tries to parry this attack through biting the bullet then a tu quoque. The relevant section is this:

However, the consent requirements for organ donation are extremely loose, in comparison with consents required for other forms of medical intervention. Recent legislative changes in the UK, for example, mean that a person’s organs may be harvested without any clear indication that they wished for this to happen. Should we expect something more demanding than this, if we include WBGD among the uses of a person’s body after their (brain) death? If so, why, given that we accept such minimal requirements for ‘normal’ organ donation? Perhaps one answer here is that WBGD is not something that people understand or have knowledge of. Therefore ‘deemed consent’ such as the organ donation framework relies on, is not properly informed. People who fail to opt out of the organ donation system can be regarded as having passively consented to something they have sufficient knowledge about. Everyone has heard of organ donation. No-one has heard of WBGD. Moreover, WBGD is qualitatively different in that it entails ventilation over an extended period. And, of course, its aim is not ‘life-saving’ per se as organ donation is usually understood to be.

It attacks the legitimacy of deemed consent for current organ donation practices - specifically because people do not typically understand what they've signed up for with organ donation. One relevant point is that bodies are kept on respirators to pump the body full of oxygen. If people were aware that their body would be kept in such a state as their organs were removed, would that impede consent? More precisely, if people do not need to know such details to count as giving consent in organ donation, what distinguishes this from WBGD?

This paints a picture of consent in ethical opt out organ donation: the potential donor has not provided a written statement of intent. Furthermore, deemed consent is seen as acceptable when your wishes are not known and who is arguing on your behalf could not give informed consent due to not knowing your mind on the details of the procedures.

So, the article argues, while it may be true in principle consent is required, in practice organ donation's deemed consent requirements cannot be guaranteed to respect the potential donor's wishes. If you grant this renders opt out organ donation unethical, then one side of the constructive dilemma has been chosen.

If you insist that, nevertheless, WBGD is unethical and opt-out organ harvesting is ethical, it may need to be on a different basis than "deemed consent" through a third party.

if the health and life of others is at risk — javi2541997

This is another counterpoint discussed in the article; though in this case they break the direct comparison with organ harvesting and transfer and into a broader harm prevention framework:

Unlike any other form of organ donation, WBGD imposes no risks on the ‘recipient’. It has the additional advantage of conveying significant clinical benefits on women who make use of it. If WBGD were offered as an alternative to pregnancy generally, the clinical benefits would be striking. It is here that I diverge most significantly from Ber. Ber argues that only the neediest of claimants should have access to WBGD – those who have clear medical contra-indications to pregnancy or lack a uterus altogether. The problem with this is that pregnancy itself should properly speaking be medically contra-indicated for women generally.

It is well known that pregnancy and childbirth carry significant health risks, even in affluent settings with sophisticated healthcare systems [26, 27]. To expose oneself to risks comparable to pregnancy and childbirth would be deemed foolish and pathological in any other context. I have previously shown that in a comparison between pregnancy and measles, pregnancy comes out considerably the worse in terms of morbidity and mortality [28]. Yet concerted medical efforts are focussed on ridding ourselves of measles, while women are expected to submit themselves to the greater risks of pregnancy and childbirth almost without thinking about it.

The author argues that the harm prevented by WBGD would actually classify it as an excellent medical procedure. The risks of pregnancy to a living person could be totally mitigated by the use of a dead one. And those risks are quite considerable.

In that respect, the intervention is construed not as life saving in the sense that someone will immediately die without the its use, it's construed as life saving in the same manner as a vaccine; prevention, rather than cure.

Nevertheless, that is a distinguishing feature of opt out organ harvesting from WBGD - it raises the question, what is the ethical distinction when both are harm reducers and life enablers? How would this distinction block the concluded entailment?

Nah, my presentation was unclear. I appreciate you engaging with it.

I've added notes to describe the logic of the argument @Tzeentch. They're in the *s. Whether the inferences really hold are still up for debate.

In other words, I would consider any use of the body without articulated permission a violation of bodily autonomy. — Tzeentch

Fair! Then you'd see opt out organ harvesting as unethical. Which is also consistent with the argument.

The person's body and the organs therein are no one's property to "harvest" after death. As much would imply the person's body is the property of the state, and it is simply for the duration that the person's soul occupies the body that it is lended to the person. — Tzeentch

I think there's two ways to take this, the first is going down the path that you can harvest people's organs without seeing the bodies as property, the second is that ( 2 ) is an assumption in the argument for establishing a conditional, rather than an argument for the claim. Perhaps that misinterpretation is my fault. I think the second path is more relevant; the truth or falsity of ( 2 ) doesn't figure in the validity of the argument, only "IF ( 2 ) is true THEN (the argument's conclusion)" matters. The argument is indifferent to whether ( 2 ) is true.

"who was phone?" is the one true muse.

More seriously though, in what sense could philosophy even be said to have a starting point? Philosophical concepts come from different starting points - it might be substance, process, bodies, love, assemblages. It might be indifferent to starting points; "groundless grounds", anything which treats foundationalisms with suspicion. Philosophy's origins as contested base assumptions.

Philosophical ideas are also historically situated and embedding in social conduct. Revolutions and revolutionary philosophy, suffrage and critical theory, spiritual metaphysics and meditation, materialism and science. They arise whenever their context needs thought. Philosophy's origins as political and historical.

There's also philosophy in the institutional sense. Where do philosophical ideas come from? Well, how are they produced? Academies, books. Philosophy's origins as an actor network.

IMO, ideas have more than one type of origin, they are created when they are needed. And sometimes they are stories about what's already done. If it's possible to construe philosophy as "seeing how things (in the broadest possible sense) hang together (in the broadest possible sense)" it'll be ordered thought in response to how something works or is done. More or less formal, more or less discursive, more or less practically inclined.

Also committed to join. Thanks for the heads up.

Agnosticism is not having a belief concerning god. — Banno

Therefore rocks are agnostic!

We needed to hit all of the contentious topics - we started with sexism, we moved to transphobia, then to racism, and now it's abortion!

I don't want to defend anti-abortion sentiment. I simply got the impression that @unenlightened agrees on the political points and looks at them with pained goggles on. Happy to be corrected though.

So the division between state of nature and social artifice is indeed part of the same division in psyche, and of course the individual cannot actually be divided, so some aspect must dominate and some aspect must be suppressed. Or some aspect acted out, and some aspect hidden away. and because we feel this division, we look for and cherish the imagined unity of 'authenticity', the great prize of therapy. — unenlightened

I'm still struggling to understand your view and how it relates to the topic. I think I'm getting there though. Are there norms in the "state of nature"? What's the state of nature made of? If humans are essentially undivided why do we see the proliferation of identities in contravention of that fact?

B2. This is a huge question, that I could make a whole thread on. From shame one hides oneself and tries to be what one is not, leading to anxiety of being exposed as a fraud, and from being hidden comes the sense of isolation and loneliness. Think of anorexia for an example of how social pressure creates lethal misery through body-shaming. — unenlightened

I can see the case for anorexia and shame. I think applying the same to trans people is... problematic... though. When you say "From shame one hides oneself and tries to be what one is not" - in the context of a trans person, are you saying that an M2F trans person "really is" a man but feels the need to become a woman?

To be honest, I don't have the expertise to answer — unenlightened

I also don't have the expertise to answer. Regardless, I have an opinion and feelings on the matter, and I want it all battle tested.

This all feels to me rather like the question of abortion. Given social pressures, economic and normative, on women who become pregnant, that we are not going to treat or try to change, should, abortion be legal? A reluctant yes, but removing the stigma and properly funding childcare and motherhood would be a better solution in almost every case.

To be honest, I don't have the expertise to answer, but it is clear to me that there is a need or desire to transition only to the extent that what one is, is, or is felt to be, "wrong". And that means it is a social artefact. And what is permissible is an artefact of the same society. So I suppose that what society says is wrong with an individual, it needs to facilitate them changing. But I don't have to like it. — unenlightened

That makes sense to me. I can sympathise with reluctant support somewhat. Do you think it's in no one's "character" to transition? Further, is gender part of someone's character (vs sex)? Like... is it in my character to have male gender identity?

B1. Shame is ubiquitous, but what stops it from being essential is that it can only arise from comparison. — unenlightened

I see! This is what I'm getting at. You seem to be construing character as a collection of unary properties of a person ("I am good at mathematics"), and identity as a collection of comparison relations which obtain of he people ("I need to be stronger" or "I need to present (more like X)"). Usually there's a good distinction to be had between those unary properties - like "is red"- vs relational properties - like "is redder than" - but I think that's quite hard to draw a firm line on here.

The reason being is that personal characteristics also seem socially constructed to a large degree, like you being good at mathematics. Does that mean you were demonstrated to be better than your peers through exams/implicit assessments of competence/demonstrations through completing exercises? I'm sure you see in each of those cases, there is a social relation underlying the ascription of the property "is good at mathematics" to yourself, even if the property itself is unary. The stated examples are also comparisons - "good at mathematics (relative to this exam performance record)", "good at mathematics (relative to aggregate peer approval)", "good at mathematics (as ensured by passing these exercises)". Why do you get to be "good at mathematics" in your character? I'm not doubting that you *are* good at it btw, I'm asking how you make sense of it given the above.

@unenlightened

Yes. I'm saying that Any combination of male/female/no-sex brain and body, along with any combination of hormone regime that naturally occurs is bound, short of physical pain resulting, to be accepted as 'just the way I am' unless there is an induced conflict between that and 'the way I ought to be'.

In short the only possible source of conflicted identity is social. I mean who d'you even think you are, fdrake? That's just a duck! :razz: — unenlightened

Shitposting:

One of my high school friends used to troll internet forums and voice hang outs as "The French Pirate". They invited me, it sounded fun. It was fun. I wanted to be "The French Privateer", so Francis Drake. There was also a character called "X-Drake" in a manga I was reading at the time. Hence the name.

And it just kinda stuck. I'm quite grateful I didn't choose the name "schlongpusher69". I imagine that would've stuck too.

Substantive:

Angle 1

You've raised some good points about social conflicts being internalised as identities, especially about shame. I'll raise you the same challenge I did with Isaac, how does that cash out in this context?

A1 ) Surgical transition is permissible in some contexts, y/n?
A2 ) Hormone treatment is permissible in some contexts, y/n?
A3 ) Gender affirmation schooling (voice therapy) is permissible in some contexts, y/n?
A4 ) Therapy for gender dysphoria is permissible in some contexts, y/n?
A5 ) Counselling for trauma which has caused all this shame is permissible in some contexts, y/n?

In addition to the answers, I would like a description of why that seems right to you.

Angle 2

If I've read you correctly, I believe the what marked (whatever identities are in play) here as artificial for you was that they seemed to come bundled with shame, rooted in social conflict. This was contrasted to someone's "character", which describes who they are without the social baptisms of shame, trauma and other "holes". I have some questions about that:

B1 ) If identities are socially constructed, what stops shame from being an essential part of one?
B2 ) What general consequences does this "artificiality" of shame have for people who have it?
B3 ) Why can't people's characters be inherently shameful? We can be quiet or good at mathematics, but not shameful, why?
B4 ) Why is it appropriate to treat "character" as a state of nature, prior to social identity, whenever we observe someone their character's expression becomes identified? As much as socialisation builds character, it builds identity - that these two develop in tandem undermines treating one as a state of nature and the other as social artifice.

@Isaac

But it may be a clash of incompatible world-views. Happy to drop it if so, I've been there before to no gain. — Isaac

Yeah there's no point us pursuing the pharmaceutical industry's corruption in this context. It's a reason to be suspicious of all drugs which are prescribed without assessment. Among other reasons. Smoking gun absent, I don't see much point. This is just a context thing, would be happy to pursue it in other contexts - like you invoking it for the Pfizer/AstraZeneca vaccine trials seemed very justified to me. The difference here is just the degree to which the specifics are left to speculation.

That's true, to a point. But as I said. The Mermaids campaign slogan is not "things are fine just as they are, but let's not let them get worse". If there are currently sufficient barriers to treatment (and if treatment is something which oughtn't be 'handed out like candy') then things are fine as they are, the campaign objective of Mermaids are wrong. — Isaac

What do you take as the campaign objectives of Mermaids? I don't have a good sense of a unified ideology for them, over and above making things easier for trans people.

The argument (for me) is the one I gave above. If we have a material solution vs a mental solution, the material solution will be favoured (regardless of long term outcomes). It's easier and we have a psychological bias in favour of believing external causes more than we believe internal ones. Also, the end points are insufficiently robust at measuring personal gains, they still ask about 'satisfaction' or 'regret' which are both socially mediated. Clinical interventions ought not be measured on the basis of the degree to which society finds the end goals attractive. — Isaac

Solution is a bit of an overstatement, one of the premises of this discussion was that long term therapy is ineffective in preventing relapses - so we're not contrasting long term solutions to an issue, we're contrasting based on limited evidence in order to minimise present and ongoing suffering. This will be heuristic, ideologically motivated, institutionally suspect, involve various lobbying groups. Such as the decision made this week from the English government blocking Scotland's passed reforms on gender recognition - this wasn't done using longitudinal studies either.

I get the impression that, because your position applies to lots of medical interventions, the best consistent response for you is to bite the bullet that recognises the inconsistent and flawed treatment in society, mandate "it ought to be the case that more medical interventions should be strongly based on data from controlled studies", and claim in absence of such data, no intervention should be taken. Whenever benefits+uncertainty = costs + uncertainty, do nothing.

That crisis was brought about by northing else but the over-prescription of anti-biotics. Medical interventions are not isolated. Our biochemistry is not like the custom car whose parts can be swapped out. We ourselves are a very finely tuned ecosystem of chemicals and biota, and socially we form an even greater such system. — Isaac

I think this would have more bite if it wasn't already granted that gender affirmation treatment is both a social and a bodily intervention.

If we can't make a society in which a few incompatible narratives can be allowed to exist alongside one another without resorting to court or institutional bullying then we've lost hope. — Isaac

I agree. What is especially frustrating is that Mermaids and trans rights groups are not problematising the discussion by themselves, the arguments you're giving really are used by people "out in the wild" as means of stymying the improvements of trans rights. In our context, we can discuss them with more leeway. Out in the wild, they're often treated as weapons, so it's no surprise that such moves are seen as attacks.

That makes it important for there to be a community with enough freely available narratives for people to be able to find ones which make sense of their particular experiences. — Isaac

This would be nice. As supporting argument for an argument I think it's not a good one, though. Firstly it's an "ought" statement, "it's important", secondly it's currently false for transgender issues. I believe you are suggesting that nonmedical interventions are more appropriate, because the reason medical interventions are being pursued for trans people is ultimately because society's fucking awful for minorities. This is also similar to @unenlightened's point I think, though from a different angle.

Like I asked @unenlightened, how do you think trans people ought to be treated?

But also the giving of medical advice to children contrary to NHS guidelines. It's not a good look. — Isaac

I can agree it's not a good look, I'm left with a similar feeling that the significance of it not being a good look hasn't been articulated. I'm left with a sense that you believe these misadministration are a direct result of how trans rights organisations comport themselves? If so, why do you think that's the case? I'm imagining the premise that there's something sinister about the comportment of trans rights orgs is required to get your objection going, enough to treat that conduct as direct cause for inappropriate medical guidance being given to trans people.

I don't necessarily agree with the suppositions required to get this line of inquiry going, nevertheless I am interested in how you're tying it all together.

The rest of that paragraph I think requires a different tack.

Examples of court cases? No, I think that's the one all this has pretty much coalesced into. but I'm talking about the wider debate, the attempt to demonise people like Kathleen Stock, the harassment of feminist journalists like Julie Bindell, Suzanne Moore, Hadley Freeman... But also the giving of medical advice to children contrary to NHS guidelines. It's not a good look. — Isaac

I believe you are construing that how these people were treated was at best unreasonable and at worst wrong. I think there's a convincing case that the conduct is reasonable, despite the harms. But I would also need to know why you believe this state of affairs isn't a good look to engage properly with your
opinions.

To tackle (1). I've not yet heard any update to Dr Cass's meta study for the NHS. It may be that I'm out of the loop, but at this stage, the best data I have on evidence is that it is "weak". That goes for 'puberty blockers', gender re-assignment surgery, and gonadotropin therapies. So I consider (1) to be a given, but I may be persuaded otherwise in the light of new evidence. — Isaac

Is this being evaluated in terms of long term alleviation of mental health symptoms associated with gender incongruence? Would appreciate the paper link. Regardless, there is always going to be an issue painting with too broad a brush - many therapies don't have well demonstrated long term health outcomes, especially for mental health issues, nevertheless they are administered and justified in terms of their risk/reward ratio. I believe a consistent case could be made for cancelling/deprioritising resource allocation to these treatments, but to me it seems suspicious why a broad point like insufficient evidence of improving long term health outcomes is being leveraged in the context of trans healthcare rather than for the broad swathe of treatment it would apply to. Why appeal in this context and not others?

In that regard there's also a concreteness problem, documented evidence or a strong argument that such a broad thing ought apply more in this case than others, and why. I think we'd need an argument that also takes into account the very low regret rate of transition surgery - which is much less than other highly promoted, even deemed necessary, surgeries which manifestly alleviate some source of harm (lined earlier, can relink if required).

I think you're presenting evidence very strongly here, which I appreciate. What I'm not following well is the philosophical side of your position. How you're linking your points, how the concepts you're employing relate to evidence, justifying how you infer one thing from another.

So to (2), a much harder case to make. Is leaving things alone the best policy if you've only weak evidence an intervention will help? I have to admit that this comes from a gut feeling. I'm going to justify it, but I'm going to be open about the fact that the justification is post hoc. I wouldn't have to give it a moment's thought to feel it's wrong to give medication to someone because it might help them. I suppose an obvious life-or-death situation would change my mind, but it would have to be clear, not just more guesswork on weak evidence. — Isaac

I agree there, it's hard to argue for that, nevertheless it's a commonplace occurrence for healthcare providers to make that gamble. Medication for mental illness is a particularly strong example, but the same also goes for other health conditions. EG: I've had a rash on my body since just after covid, it's spread to lots of places. I've never been sent to a dermatologist, nevertheless I've been prescribed treatment courses for allergies, eczema, and fungal infections with no tests to see what is what. I am not trying to claim this is right (I would prefer the test), I'm trying to say it's commonplace. In that regard, it seems this is another place where the means of your criticism applies generically to healthcare services, rather than to gender affirmation specifically.

Of course, I wouldn't advocate a position that no medication can now be trusted, that would be absurd, but I do think it has to constantly weigh in the balance now. We're just unfortunately in an economic system where that's a constant factor. If one is weighing risks, one has to include in that calculation the risk of fraud. — Isaac

Like here, you seem aware that the points you're making apply in lots of cases, to the extent where you noted that the point is general enough to apply to all treatments, nevertheless there isn't much of an argument taking this intuition and contextualising why it is sufficiently prescient to gender affirmation treatments to "flip" some issue one way vs the other. Also about what "the issue" is.

IMO, this isn't necessarily a problem, it's just that concrete instances and arguments are required to render these perspectives relevant to the case (evidentially), on precisely what the case is (conceptually), and what we ought to do about it (normatively).

I also thank you for the post-hoc admission, I've noticed the same in myself. I have a lot of beliefs I've
picked up from the media I read/watch in this area, and I appreciate the opportunity to examine them.

So, to actually attempt a post hoc justification. I think the first argument is one of a sensible baseline for therapy (of any sort). If we don't accept a 'state of nature' as a baseline, then we have no grounds to distinguish pathology from merely bad design. Is my appendix a pathology? Should women's cervical openings be a little wider for easier childbirth? Do I have the optimum number of fingers? It's essential in medicine to be able to identify a pathology. That's done by assuming that whatever flaws it may have, there exists an archetype which acts as a default model of physiological function, and that archetype is based, not on a sci-fi 'blue-sky-thinking' ideal. It's based on a 'state of nature'.[/quote

I think this is a decent start. Though I don't think it plays well with the simultaneous intuition that gender is socially constructed. A "state of nature" in context, seems to me, would consist of the current state of play of gender norms and an individual's place within them. The archetypes there would be the gender roles of men and women, which are the default mode. The default mode of functioning would be expected conduct and appearance of men and women.

I don't find what I just wrote particularly persuasive, what I want it to do is draw out how badly those two concepts play with each other.
— Isaac

The second argument is one of responsibility (not going to invoke the bloody trolley scenario but...). We are generally held to be more responsible for that which we actively do than for that which we reasonably fail to prevent. I'm responsible if I detonate the bomb, but I'm not responsible for not interfering with its detonation (unless doing so would be really easy - hence 'reasonable'). As such, doctors and other clinicians ought pay closer attention to the potential side effects of the drugs they administer than to the potential outcomes of a failure to administer. Side effects are weighted more heavily. In the case of weak evidence for both, weak evidence of side effects trumps weak evidence for negative outcomes from a failure to intervene. — Isaac

I think that's one system of norms which applies to the issue, which could be persuasive. The other regards informed consent, the ongoing horribleness of inhabiting what you feel is the wrong gendered body for you, and how intervention does indeed remove a constant source of social trauma for those who'd opt for it.

I believe this should be evaluated in the context of prescription without testing in general. What do you think distinguishes the seemingly benign example of administering anti-fungals for a non-fungal rash with no test from the less benign example of administering gender affirmative interventions after other mental health screening has been done?

Trying to render your perspective in an argument:

( 1 ) We are judged more harshly for that which we do than that which we don't.
( 2 ) Mitigating circumstances for doing something change the harshness of judgement about it.
( 3 ) Mitigating circumstances for not doing something change the harshness of judgement about it.
( 4 ) There are mitigating circumstances for not medically intervening in trans people's lives (in unspecified circumstances X for unspecified reasons Y) when it would really do more harm than good.
( 5 ) There are no mitigating circumstances for medically intervening in trans people's lives (with the same qualifier) when it would really do more harm than good.
( 6 ) Therefore we would be judged more harshly for medically intervening in trans peoples' lives (in unspecified circumstances X for unspecified reasons Y).

Mine is something like:

( 1 ) If a person desires treatment X, and we would not be judged harshly for administering it, then X can be administered without harsh judgment.
( 2 ) If administering X to a person is desired by the person and seen as sufficiently justified by a qualified set of clinicians, then administering X to the person would not be judged harshly.
( 3 ) X is judged by the person and some qualified clinician to be sufficiently justified in that case.
( 4 ) The person desires X.
( 5 ) We would not be judged harshly for administering X to the person.

I think both arguments are valid, we're largely talking about the concept "and we would not be judged harshly for administering it". I treat ( 2 ) as sufficient to establish the treatment wouldn't come with harsh judgement, I think you're arguing that there isn't a way for (some class of treatments) to be sufficiently justified by a qualified set of clinicians in this instance?

Also, this is just a literature request: I am interested in "potential side effects of failing to administer" too, do you have any literature on this? As for potential side effects of administering - my intuition is that judging negative effects of therapy would be similar to judging negative effects of voice coaching, counselling etc as part of gender affirmation. Surgery and hormone therapy maybe come with different risk assessments (I think this is reflected in the NHS's current treatment pathways).

I've taken a similar approach with the highlighting of qualifiers. What measures the strength of such a relationship and in saying it needs to be 'more' concrete, you're implying some target level of concreteness that's not yet been reached? What is this target level? The pharmaceutical companies have been legally (in some cases criminally) convicted of fraud. I'm struggling to see what greater level of evidence would be required that they engage in fraud. I can see a point about not assuming every drug is promoted fraudulently, simply because some are, but I can't see how one would support a proposition that multiple convictions for fraudulent activity do not weigh at all into an argument about whether some current activity might not be entirely on the level. — Isaac

I can be quite specific about what I'd need to be convinced that concerns about pharmaceutical companies' influence were relevant.

hat measures the strength of such a relationship and in saying it needs to be 'more' concrete, you're implying some target level of concreteness that's not yet been reached?

Yes. It's clearly true that there are vested interests in prescribing drugs to make profit, even when they're not needed. It's not clear how this interfaces with trans treatment. As far as I know, even non-surgical interventions are relatively difficult to obtain - if they were handed out like candy there would be much fewer complaints about the process being obstructive. I believe that's also evinced by the NHS report. Though there's no guarantee that every healthcare system has similarly strict/harsh/draconian/badly administered barriers. I think that's a mark against the factual claim that there's been an effective pressure by drug companies to popularise transition treatment and hormone therapies - they're still seen as insufficiently available or badly administered by trans rights groups.

I suppose there is an angle there where pharmaceutical companies are making policy decisions for trans rights groups, or some entryist angle, but I wouldn't believe that without hard evidence in context.

Hard evidence in context is what I meant by concreteness. Give me documentation about exactly how one pharmaceutical company has influenced one major service provider and I'll be more convinced this line is relevant.

but I can't see how one would support a proposition that multiple convictions for fraudulent activity do not weigh at all into an argument about whether some current activity might not be entirely on the level. — Isaac

I do think they weigh in, just weakly. They weigh on one issue in our discussion specifically - healthcare provision. If you focus on that, there's no evidence been provided about how these fraudulent patterns have effected gender affirmative treatment. Then there's also no evidence, so far, that whatever effect is postulated has sufficient impact on the issue as a whole to support any particular point in it. So it's relevant, and if pharmaceutical companies lobbying (or other corruption) were demonstrated to be a major driver on the adoption of trans healthcare measures, that those adoptions were nevertheless wrong also hasn't been demonstrated.

Those two sources of uncertainty make me not want to discuss it further, as I believe it would derail our discussion. Though if you wrote an essaypost with evidence and extremely detailed links to at least one issue in gender affirmative treatment, I'd be more inclined to go down that route. Ball's in your court.

Though do take note if you decide to write it of how many connections you need to document to the issues we're discussing. Closing that gap would take us far afield.

Will respond to your other points later.

Agreed. It's good to talk without the usual knee-jerk tribalism these topics so often descend into. As I've said, I've had colleagues affected by this. There are establishments, academic and otherwise, where this very conversation would at least be flagged, if not muffled entirely. — Isaac

Yes. I believe there aren't many spaces in which this discussion could be had. I am grateful for it.

based on their other activities (for example their attempt to de-legitimize LGB charities) — Isaac

Is this the LGB Alliance you're talking about? Any other examples?

I believe I've read it. This one? — Isaac

Yes.

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simply don't know enough to do that. — Isaac

I need to ask why though. I can see the premise:

( 1 ) We don't know enough about the risks involved.

And the conclusion:

( 2 ) We ought not modify bodies.

But it's not a very strong argument by itself. Too many qualifying phrases, and the overall pattern of inference isn't justified either. So you'd need to demonstrate why ( 1 ) implies ( 2 ) and flesh out these qualifying words:

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simplydon't know enough to do that. — Isaac

Underlined and bold are underlined modifiers to currently unarticulated premises, which are bolded. There's also the issue of going from a factual statement:
"..seem wrong.."
implied by "..because we shouldn't.."+(analogy)+(causal statement)+(qualifier to causal statement) ).

If you can't see what bits are which in the above quote to my paraphrase of the argument, I can throw more words at it. We may need to have a similar discussion about how you were using natural and constructed in relation to when we ought to apply treatment earlier.

I do find what you're saying plausible though, I figured it was time I started asking you hard questions as well.

2) I don't think the social peer effects can be ruled out. The placebo effect of having a cure for which everyone congratulates you ("how brave!") rather than berates you (the stigma of mental health treatment remains undented) is enormous when considering that the end points are all expressed in mental terms (how 'satisfied' you are, how many 'regrets'...as if such end points were not themselves social!) — Isaac

I agree peer effects can't be ruled out, but I don't think it's been demonstrated that the intervention is a placebo, or whether that matters for administering treatment. Answering the above exercise would help with that, I think.

3) I know I've mentioned it before and you've diligently (and probably, sensibly) avoided it but I can't ignore the fact that the sex change option is supported by one of the largest industries in the world with the largest lobbying power by far. We can't pretend that isn't going to have an impact anywhere in this. Therapy is cheap and creates only employment. Drugs are expensive and generate huge profits for very powerful industries with a proven history of pushing profitable solutions over efficacious ones. — Isaac

Yes. It is a reason to be suspicious, but it's of weak relationship to any norms of administrative treatment in this context. It would need to be more concrete and evinced. Without those things and exhaustive contextual efforts, I doubt this train of argument would be a decisive factor either way given the uncertainties we've agreed surround other issues and this issue's relationship to the broader picture. I believe we can't practically tell if such weak evidence (in that Bayesian sense) would be decisive in this state of evidence, therefore it would not be decisive in our discussion. That is why I've ignored the point.

He'd received two warnings and not improved. He stuck around for three years after his first warning, 6 months after his second. If anything we should have acted quicker.

Redact this, it's about Bart. I am derp.

1) It kinda makes it sound like society is OK to push harsh bio-chemical interventions on it's minorities (rather than simply tolerate them) on the grounds that they "don't mind". I can't get to feeling good about that, even though I've no strict moral objection. I can get to a reluctant "Oh well, I suppose if they don't mind then I've no reason to stop them", but it's not something I'm going to waive flags over, I'm not going out on the street to cheer on the fact that society's found a way to get out of it's obligation to tolerate differences by using drugs. — Isaac

I can understand the concern with that. There's two things I want to highlight. The first is that it's worthwhile recalling the distinction between how the treatment is administered and whether it's worthwhile to do. That is relevant because perhaps Mermaids aims of depathologizing trans identity and making treatment more accessible perhaps could be attained by making the current system better administered, the people who administer treatment more informed, and educating GP gatekeepers to treatments (this includes voice coaching and other non-invasive interventions etc). There was an NHS report to this effect (can cite if required) - a lot can be gained by making the current treatment work better without a fundamental reimagining of how trans identity is seen by doctors. Though the latter, I strongly believe, would aid the former. And of course the former would aid the latter.

The second thing I'd want to raise is a kind of case study. If we assume that the only reason for gender affirmation interventions is, essentially, peer pressure to shame their recipients, that would collapse the distinction between gender affirmation and "conversion therapy". The latter is universally traumatogenic, the former has a less than 1% rate of regret. It may be difficult to establish long term improvements in condition caused by the assignment, but exactly the same would hold for the kind of non-invasive treatments which are stipulated to be worthwhile in this context. Like therapy, you'll know how the short term effects swamp the long term ones - the further out in time you go from the intervention the less the observed impact on health outcomes. On that basis, should we scrap all mental health interventions because there's insufficient evidence it works long term?

And if we're working on a basis of "do no harm and this might work" - like therapy - why wouldn't greater access to medical aid for trans people (including reassignment surgery) be entailed by the same humanitarian premises which suggest that increased access to mental health services is necessary?

I'd guess you do see a distinction between conversion therapy and gender reassignment? If you don't we probably need to examine that area of the dialogue before we can proceed.

I think we have made some progress though, it seems we agree that there is a way to thread the needle between gender as a social construct with biological enablers vs male/female brains, I think we also agree that this hasn't been definitively established. Do we also agree the theory "social constructions alone determine gender incongruity" isn't established, and is likely to be too reductive

Unlike your definition of gender dysphoria, this definition still seems too vague to work with. It's seems no more than saying people who are trans, are trans. What is it to be trans? Is it wanting to act like another gender to the one assigned to you at birth, or is it wanting a different sexual phenotype to the one you have? Or is it both? — Isaac

Apologies, I'd previously construed trans identity as gender incongruence. Rather than trans identity as gender dysphoria. There's an argument there that Diné gender norms couldn't produce gender incongruity in Nádleehi because Nádleehi are an "axis" on the space of gender. But I've made the assumption that such identities aren't orthogonal/independent from the other gender constructs, they're desires to express otherwise, to claim a different place on the same axis, or a mixed state of its values.

What is it to be trans? Is it wanting to act like another gender to the one assigned to you at birth, or is it wanting a different sexual phenotype to the one you have? Or is it both? — Isaac

I imagine it's both? I think gender incongruence is worldwide, right (cultural universal + biological predisposition ?) But how gender incongruence manifests is localised to a system of gender norms.

If the latter, then why sexual characteristics? Why not arm length, or head size, or hair colour? — Isaac

Why not for what purpose?

I think that works as far as avoiding the 'female brain' problem, but it lands us straight back into the idea that medication is only needed to better meet societal expectations. Again, would skin-whitening for black kids in racists communities be a good solution, something to promote? If not, then why sex changes for trans kids in gender-strict communities? — Isaac

The best distinction I can come up with is that one - skin whitening - shames the body that it's applied to, and one is either an expression of that body's nature or is caused by a shamed incongruity between body and norm. I think the first is prejudicial violence "these people need to be white!" whereas the second is expressive change "We need to be otherwise!".

You could maybe rejoinder that someone could want to change their skin colour for precisely the same reasons. In that case, I think it's either a bullet bite scenario (which I don't like) or I should parry with a distinction. If we use @unenlightened's social pressure/identity+shame dynamic as a proxy, the skin bleaching is explainable entirely by shaming social norms, my response to him was that trans identity is isn't explainable by shame, only trauma is.

The question about gender reassignment I think comes after the question about whether someone is trans, and the ethical norms are different. Oppression vs expression, shame being imposed from without vs undoing shame from within. I'd prefer not to think about it in terms of shame, because as you've highlighted people from more supportive social backgrounds (I imagine) have less chance of being traumatised about their gender incongruence.

I would be interested in finding out whether trans people without trauma express the desire to transition with a different frequency than those with it!

If both of those make you feel a little icky, then what's the difference between them and gender re-assignment for people suffering the sort of trauma Fred Martinez experienced? — Isaac

There's a volitional aspect to it. I think we can grant that societal pressures are in play without throwing informed consent and expression of will out the window. If this syllogism was valid:

( 1 ) Decision X is influenced by norm Y.
( 2 ) Norm Y is coercive.
( 3 ) Decision X was done with highly restricted agency.

We'd either be biting the bullet that most decisions were done with restricted (so the force of your distinctions is undermined, all agency is restricted what's the big deal), or alternatively we could quibble about what a sufficient degree of restriction and coercion is for the decision to count as being done from a position of highly restricted agency.

We'd be going back to a previous discussion about informed consent there though. Resolving it would require us to map out how volition, expression and autonomy work in the presence of norms, and a theory of how norms coerce. I don't think we're resolving that here, and I don't know where I'd start.

Yes, I think we agree there, that's where I'd end up too. I can see a situation where there could be sufficient biological tendencies (through behaviours like imprinting) to explain universal gender preferences without resorting to notions like a 'female brain'. — Isaac

I'm glad that we see eye to eye on that.

Yes, that's the direction I was going in. There's all sorts of clashes between one's body and society's acceptance of it, between one's body and one's own desires for it. Why privilege sexual characteristics? — Isaac

Maybe an inverse argument works here. Perhaps we privilege sexual characteristics precisely because of the desires and social status of people with gender incongruity and gender dysphoria, so we're making that decision "after the fact", rather than through an a-priori comparison.

Societally, I don't know why sexual characteristics are privileged. I could imagine a horrific world where skin bleaching is NHS prescribed rather than something you buy at Boots (though both are horrid). I suppose the distinction for me is that I intuit that someone can choose to undergo transition for expressive reasons, and it meaningfully effects change.

Inversely, do you think there's something about white-skin identity which would be expressed by skin bleaching? That wrings as wrong in my head as your examples did. I'm not even sure there is a specific white-skin identity, just a "not-dark skinned" one. Putting it pretentiously, I'm under the impression that there's something affirmative in gender transition, but only something negating in the skin bleaching one. "Make me not this!" (skin bleaching) vs "Make me not this AND make me this" (transition).

Do you get the same impression?

. It's not that all of our feels will be different, it's that it's possible, in a functional, physicalist sense, for them to be so. — Moliere

Am I right in thinking that there's also a modal angle to Chalmer's argument? I vaguely recall there being a link from the inverted spectrum to conceivability of the difference, to the metaphysical possibility of the difference, which negates the metaphysical necessity of their identity. So the motive force in the argument is largely establishing entailments between modality concepts (conceivability=metaphysical possibility), then using the inverted spectrum as a conceivability premise? Is my limited recollection anyway.

The challenge to anyone who wants to reject my thesis is to come up with an answer to this question that is not based on relations with society. — unenlightened

I think I largely stated my position on this to @Isaac here. The tl;dr in our context that "based in the social" and "based in the body" are sufficiently mingled up that construing gender identity as "based in the social" does a disservice to gender identity being a social relation between bodies, afforded by those bodies' developmental mechanisms.

When that character interacts with the education system, quiet passivity becomes laziness, unsteady hands become carelessness, forgetting names and faces is inattention and rude, and so on. I become moralised, and these things become 'wrong' with me rather than mere facts about me.

Otherwise than through they eyes of convention, how could there be anything wrong, uncomfortable, conflictual with being a man with a vagina, or a woman with a penis? One's physicality can only possibly be in conflict with an image of an ideal, which necessarily must come from others. — unenlightened

But we might even agree in general. Am I right in thinking you see the genesis of identity as some kind social trauma, whereas character is something innate?

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). — Isaac

I think there's three different concepts bleeding together here.

The first is trans identity. I think broadly construed that applies to people who've transitioned surgically, people who live as the opposite gender otherwise, and I'd guess people like the Nádleehi. To me this is a binary concept - someone has trans identity or they don't. People are cis or trans. People are two-spirit or not. There could be a discussion regarding a-gender, genderfluid people there, but let's not go there for now unless you think it's necessary. I don't think they fit on the binary, but I don't think they're necessarily trans either.

The second is gender dysphoria. This is clinically significant distress caused by having a gender identity different from the assigned gender of a body. As far as I'm aware the current metagame for defining trans identity (operationally) treats gender dysphoria as determinative of being trans. You are trans if you've got gender dysphoria.

The third is gender as a social construct. This is as it says on the tin (up to an account of social construction lol). What gender means for the two-spirit, I imagine, is different from what gender means for a trans person in the UK.

So, onto a critical account using these distinctions.

If you specify gender as a concept within a mechanism of social construction, you evaluate trans identity within that mechanism of social construction. If you have the UK gender construct in mind, you end up with (some) trans people wanting to go from one side of the construct to the other in the account of trans identity. Then it appears perplexing that something which seems natural (bodily variation) seems to coincide with something granted as socially constructed (gender identity).

On the flip side, the presence of people of trans identity seems close to a cultural universal. There are people who are gender incongruous regardless of the gender concept, and there will be people who identify with what is rendered incongruous (like identifying as a woman while having male natal sex). Then there is how that gender incongruity is expressed through social constructions.

So with respect to:

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?

The precedent being that gender roles are known to vary across societies. If system of gender norms contains a positive and supportive role for a Nádleehi, I imagine they would have less "clinically significant distress" for them in that context. In a traumatic context, more clinically significant distress. I tried looking for an experiment of someone who's family environment/upbringing was Nádleehi for some time, and then they were immersed in a scenario with westernised/(Christian etc etc) gender norms.

It is an anecdote supported with a newspaper article, but it is better than nothing:

I have read of instances in the past where, when a Nadleehi was born into a family, a celebration involving other families would be held, as having a Nadleehi child was considered to be a great event. Then, in modern times, I see LGBTQ2S Diné and Nadleehi people today who were kicked out of their families, bullied viciously, or in the case of Fred C. Martinez, murdered.

I would not learn any of this until I went to college and started researching Nadleehi and other tribes that had Two Spirit people. When I first read about Fred C. Martinez and what happened to her, I wept. She was accepted by the matriarchs and women in her family as Nadleehi, yet would be bullied at school and sent home by officials for “wearing feminine clothing.”

Her life would come to a tragic end when she went to a party and left with Shaun Murphy. Her body would be found a week later and it was never charged as a hate crime. — The Struggle to be Nádleehi

with supplementary information about the murder of Fred Martinez here.

"Cortez is a good community, but it has been my experience after living here 20 years that there are definite conflicts between Indians and whites," says Mark Larson, who represents Cortez in the state house of representatives. "We had [an incident in which] high school youth beat a Ute Indian to death in the park several years ago. And we had another incident where a couple of youths beat another Indian to near death."

But none of that history kept Martinez--a proud Navajo--in the closet. Friends always assumed that he might be gay, and his mother says she knew for three or four years that he was nadleehi. But it wasn't until summer 2000, right before his freshman year at Montezuma-Cortez High School, that the 6-foot-tall, 200-pound Martinez started to let his dark hair down and live in a manner that felt natural to him.

"He just started wearing makeup. He liked girl stuff," Mitchell says. "He felt good and he felt happy for being that way. And he said to his brothers and me, 'If you don't like the way I am, go ahead and tell me right now.' But nobody said anything."

Not at home, anyway. Friends, however, say Martinez was a frequent target of verbal harassment at school, and Mitchell says her son was sent home by school officials for painting his nails, plucking his eyebrows, and wearing makeup. "He would say to me, 'People don't like me for the way I am,'" she says. "And I would just tell him, 'Sonny, you just have to be yourself.'"

Dee Goodrich knows how difficult it must have been for Martinez to be himself. Goodrich, who is 26, is both Navajo and nadleehi. He grew up in Cortez and, until a couple of years ago, dressed almost exclusively as a woman.

"My sister was real traditional in her ways and was real active in the powwow circuit. I wanted to be just like her," says Goodrich, who performed as a female in powwow "jingle dances" and still designs stunning powwow costumes for his niece and others.

"Nadleehi is an old word for people who are blessed with the gift of being both a man and a woman at the same time. It's a sacred word," he says. "I always wanted to be like that. I always felt more feminine than I did masculine."

However, not all of Goodrich's classmates were privy to the same Native American teachings. And when Goodrich started to call himself Deanna, pluck his eyebrows, and powder his face, he was treated as anything but sacred. "No matter how many times I thought I was going to go to school and have a good day, I got harassed," he says; "faggot" was the slur most often tossed his way. "I felt secure the way that I was, so I didn't understand why people had to say what they said. For some reason some people just really wanted to knock me down." — Getting along in Cortez...

I think this establishes that Martinez was gender incongruous, had a supportive environment at home (was good there), was recognised as Nadheeli there, but when exposed more strongly to violent gender norms, they were bullied and then murdered. The lack of clinically significant distress, plus the desire to express in a gender incongruous manner I think demonstrates that trans identity isn't reducible to gender dysphoria.

It might be worthwhile thinking about how "clinically significant distress" could be caused in this context. If we've got someone who grew up without clinically significant distress associated with their gender identity for some time, then (plausibly) you're bullied and attacked for that identity, it will traumatise you, and has a high chance of causing clinically significant distress. The proximal cause of the trauma seems to be having a tendency towards gender incongruous expression and people treating you like shit for not abiding to norms which forbid that expression. Compound event of what looks like an innate tendency with a social construction.

Where are the distraught Nádleehi? Wherever their identity and norms grate on each other. A construal of gender incongruence that reaches before gendered expression in social norms needs support from a bodily capacity which engenders (pun intended) bodies to gender incongruous behaviour.

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?

My intuition for how to thread it is to look for more interaction effects, I suspect (with some support) that these interactions render it impossible to reduce causation to a single bodily mechanism, or even bodies as a whole. In its simplest form, the manifestation of gender incongruence seems bodily and social, and is effected by gene expression - which itself is environmentally mediated.

So, I suspect it can be threaded. With the construal that having a trans identity is biologically predisposed, but that gender expression is socially constructed, administering hormones would change the biology but also the interaction effect. To put it another way. body properties are gendered, gendering works through societal expectation, if you change the body to better fit the societal expectation of the body, you'd be making a social and bodily intervention at the same time.

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?

If this is a question about NHS resource allocation, I'll address it later. I don't think it's a coincidence, but I don't think that the desire for something socially constructed (to gender express in a certain way) renders the desire not naturally occurring. Like if you've got a sweet tooth, cookies or cake may suffice. If you've never seen a cake, you'd only crave a cookie.

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.

Maybe we've not removed the clinical need - that would be true if trans people didn't have clinically significant distress. What I've tried to show is that gender dysphoria isn't determinative of trans identity. Someone who is not distressed by their body wouldn't necessarily get the surgery, or have resources allocated to it based on clinical need.

In terms of the others, I believe you can change your body's impact on your gender expression only with surgery+hormone+gender expression treatment. You need help and drugs for that. And it's something that needs medical intervention to change in some cases.

There's a sub issue here about distinguishing NHS time for treatment (a resource question) and whether it's permissible to treat some body issues with surgical/drug interventions in a moral sense.

I'd be interested to hear your thinking on what problems the account I've given runs into (different from merely the plausibility of alternative models), such that it might fail to account for some aspect of the phenomena. That might also serve to focus the discussion - what aspects of the phenomena do we see which stand out as requiring certain types of explanation? — Isaac

I'm gonna bracket away any of the legal recognition stuff for this post. Despite it being important. I'll focus on what I understand to be the medical takes. A lot of these are references taken from Philosophy Tube's recent video on the topic, which is localised to NHS England. I'm not authoritative, and I can neither say whether the sources are authoritative or representative of ideologies etc.

If I understand the current medical metagame on what counts as a trans person in the UK, it's typified by the following (classes of) live events:
( 1 ) Person has gender atypical behaviour+identification for their associated natal sex young age. This can include the assigned gender role just "feeling wrong", the body feeling off and so on (gender incongruence)
( 2 ) ??? - this is experimentation with gender expression, learning how to perform your gender, internalising social norms, and trauma.
( 3 ) ??? - somehow ( 2 ) leads to mental illness.
( 4 ) Clinically significant distress associated with the experiences in ( 1 ) and ( 2 ) make the person diagnosable with gender dysphoria.
( 5 ) They count as trans because of the diagnosis.

That seem about right? The socially defining trait for being trans is the conjunction of gender incongruence and clinically significant distress yielding a diagnosis of gender dysphoria.

I think the more progressive account keeps the gender incongruence, but drops the clinically significant distress. That transforms it from necessarily a pathology to often associated with a pathology.

One way this manifests in treatment access is that allocation of gender therapy/gender reassignment is done to alleviate distress (as you'd expect any medical treatment), so that aligns the administration of treatment (in the public mind) with alleviating gender dysphoria - the clinically significant distress. Rather than aligning treatment to remove gender incongruence for aesthetic/personal/life affirming reasons (like cosmetics or restorative surgery). There's a difference in how treatment behaves in those as well I think?

The bar for obtaining hormone therapy and surgical interventions for adults at the minute is still fairly high, the treatment pathway goes through nonsurgical and non-medicational therapies and assessments first (see flowcharts here). In that regard a diagnosis of gender dysphoria is almost a necessary condition for receipt of gender affirmation therapy. It is nowhere near a sufficient one. The process of obtaining gender affirmation therapy/interventions is very long even after gender dysphoria is diagnosed AFAIK.

In contrast, changing it so that gender incongruence plays the role of that necessary condition, you can depathologise trans identities more while maintaining similar screening processes and what treatments are (in principle) available). The bar may be lowered for gender affirmation by removing the emphasis on clinically significant distress being tied to the gender incongruence. I think this is the thrust of the following passage in the Trans Health Manifesto of the Edinburgh branch of Action for Trans Healthcare.

TRANS HEALTH MANIFESTO

Trans health is bodily autonomy. We will express our needs, and they will be met. We will change our bodies however we want. We will have universally accessible and freely available hormones & blockers, surgical procedures, and any other relevant treatments and therapies. We will end the medical gatekeeping of our bodies. We will have full, historical accountability for the abuses perpetuated against us in the name of 'healthcare'. We will see reparations for these crimes, and the crimes committed against others in our names.

We are not too ill, too disabled, too anxious, too depressed, too psychotic, too Mad, too foreign, too young, too old, too fat, too thin, too poor, or too queer to make decisions about our bodies and our futures. We are all self-medicating. Our agency will be recognised. We each labour far harder for the health of ourselves and those around us than any doctor ever has, and we will continue build supportive communities on principles of mutual aid.

We deny the separation of bodies, minds, and selves - a violence against any part of us is a violence against all of us. We believe that the epidemic of chronic conditions in our communities is a consequence of the war of attrition waged against us over centuries. We do not exist in isolation, and it is essential to our healthcare that we are all healing together, healing each other, and healing our world.

(They are strongly left wing).

And here's a supporting quote to contrast the role gender dysphoria plays in current treatment availability:

Appendix B: Referral for surgical intervention
Referrals for a surgical intervention must be made by a Lead Clinician from a
specialist Gender Dysphoria Clinic that is commissioned by NHS England, with
necessary accompanying clinical opinions as described in this service specification.
A decision about an individual’s suitability for surgical interventions to alleviate
gender dysphoria requires careful assessment and support from a specialist multidisciplinary team, taking into account medical, psychological, emotional and social
issues in combination. As such, and given the potential range of complexities that
may be experienced by individuals on the NHS pathway of care and the potential
treatments, referrals to the specialist surgical team will not be accepted from other
providers or health professionals.
Before a referral for surgery is made, the Lead Clinician in the Gender Dysphoria
Clinic will have met with the individual to review current treatment interventions, and
to assess the individual’s needs and readiness for the surgical intervention, both as
described in the criteria below and as an assessment of the individual’s physical
health generally. The processes of shared decision making and of obtaining consent
(as described earlier in this document) will provide the patient with necessary
information, and will allow the individual sufficient time to ask questions, and to
reflect on the advice of the Lead Clinician to enable an informed decision on the
treatment options, risks and benefits. — Service specification: Gender Identity Services for Adults (Surgical Interventions)

So the thing which I think is inaccurate, and even dangerous for health outcomes of trans people, is the insistence on clinically significant distress as part of the determination of (the diagnosis which) gives access (start of access...) to gender affirmation therapy. It simultaneously pathologises and confounds the identity with its comorbidities, saying "too much", but also too little constitutively of the origin of gender incongruence, saying "too little".

Though, how the gender affirmation healthcare system functions is... more orthogonal... to this more fundamental shift I've portrayed. The whole thing could be made a lot better for trans people with the current definition and treatment pathways (can grab you more citations if needed).

So - to your question. Is it judgement neutral? I doubt it. I don't know anyone's capable of that, but here I'm small-c conservative. If we're to accept that clinicians are pressured into conformity (and assuming they can be persuaded out of it eventually) then I'd far rather they conform to existing societal pressures (which at the least are well known, if not all that healthy) than conform to what essentially can be indistinguishable from the latest fad. We have an obligation to do no harm, and I don't think that's met by rushing into treatments with low quality evidence when the evidence of the harm being mitigated is only of similarly low quality. — Isaac

Maybe this intersects with the obliqueness of the issues - while the determinative aspects of trans identity influence the healthcare pathways, the current administration of the system can be discussed more independently of it. There's much more discussion of these operational aspects in the video I linked.

There are certainly issues here. On the one side I've got Davidson's argument in On the Very Idea... and on the other Midgley's not so well articulated distinction between intentional conversations and extensional conversations... not between intensional and extensional; I borrow willy-nilly from both, throwing in a bit of Searle's social intentionality an Davidson's animalism of the mental, and while it all takes on a sort of sense, It's certainly not tight. — Banno

Can you give me more references for these please?

Because the rule of contribution in the shoutbox permits any conversation or contribution, any posts in it are on topic. The hidden purpose of the shoutbox is to produce a satori about the nature of discourse; the philosophical underpinnings of conversation are the conversational underpinnings of philosophy.

Naturally the equation of the two in principle does not establish the equation of the two as practices. But since both are practices there's no identity established in principle either.

QED through the absence of proof. The Shoutbox stays.

If I can explain the phenomena using existing models, I'm not sure I need to go looking for a new one. — Isaac

Eh, assumes that the phenomenon can be explained with existing models. Think that's be problematised enough nowadays where it can no longer safely be assumed as the reference position. And even then, the question of how that default position ought be managed societally is different still.

Society as a whole imposes the notion that some of it's smorgasbord of identities are available only to those with breasts, or only to those with penises (as well as other such restrictions). Thus anyone whose internal biological constraints might limit their choice of socially constructed identity to only those society makes available to the female form will be stuffed if they happen to have a male body. The solution is for more people to choose those options anyway. It is not for people to change their body to comply with society's arbitrary criteria as to who can have what identity. — Isaac

The meaningful therapeutic distinction between gender therapies (like puberty blockers and reassignment) and one of "those options" is something that would need to be established. Just like with cosmetic surgeries - do you think someone who's had a single breast mastectomy is similarly obliged not to get a suitable breast implant because to do so would reinforce stereotypes on women's appearances? Those two things could be consistently asserted (both ought not for the same reason, permissible to do it for both) but I don't find moral preferences in this situation consistent at all.

No child is traumatised by their inability to get a tattoo despite feeling strongly that they want to present that way. Individual ideas about presentation may drive some gender expressions (and include bodily re-forming), but it's society which renders the inability to achieve that traumatic, as opposed to merely frustrating. — Isaac

Yes! I think that's true. My perspective on that is largely harm minimisation, I think there's a compelling case that gender therapy ought to include transition as part of it on that basis. But we probably don't need to get into that here.

There's already explanations with existing models which don't in any way fail to capture the nature of the phenomena. — Isaac

I don't believe that's conclusively demonstrated. Like DSM-5 distinguishes gender dysphoria (which AFAIK is the explanation you're gesturing toward?) from transgender identity:

Gender dysphoria: A concept designated in the DSM-5-TR as clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience gender dysphoria...

Family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender.14 Family and couples’ therapy can be important for creating a supportive environment that will allow a person’s mental health to thrive. Parents of children and adolescents who are transgender may benefit from support groups. Peer support groups for transgender people themselves are often helpful for validating and sharing experiences.

You have gender dysphoria coupling with other mental illness among the trans population, but nevertheless they aren't determinative of trans identity. The probability of being trans given self reports of gender dysphoria is definitely much higher than the probability of reporting not trans, regardless that probability increase isn't determinative of having trans identity. That's also baked in the DSM right, you need clinically significant distress for gender dysphoria (so someone who's trans but doesn't have clinically significant distress), and if you didn't satisfy enough of the diagnostic criteria you wouldn't have it anyway:

The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

(it's 6 for kids)

The overall thrust there is that transgenderism isn't reducible to societally induced trauma, just strongly correlated with it. Analogously to what you said later, it would be like defining heterosexual partnership only using womens' forced consent into marriages of servitude. Since at the time marriages of servitude were the gold standard of romantic relationships.

It's certainly a point for the social determination of all of these surrounding categories, but by my reckoning a point against any reductive explanation. Broadly speaking because, in both cases, the underlying constructs which are being used are at least historically variable - and currently in visible flux for the gender identity ones, and also there's good reason to suspect there are relevant biology-society interaction effects here (again AFAIK, provided a citation to @unenlightened for it).

As we've seen at Tavistock, that trust can be interfered with by social pressure and campaigns. That's not a good thing. — Isaac

Are you meaning this in a judgement neutral sense? Like "the trust was interfered with which resulted in a good change)" vs "the trust was interfered with which resulted in a bad change" - all you care about is the societal pressure on treatment one way or the other, not that one could be better than the other. I'm sure we could have a long political/ethical discussion about Tavistock elsewhere too.

Furthermore, the whole issue is about societal pressures, which, if real, precede consent. One consents to that which one feels one ought to consent to. If society is creating unhealthy pressures then it will act on consent as much as any other choice made. Women were not, centauries ago, dragged kicking and screaming into loveless marriages of servitude. They consented to them. They consented because society imposed, from birth, the idea that they ought to consent.

Definitely, though it isn't a specific issue for transgender surgeries. A whole swathe of surgeries and interventions can be argued against using this as a premise.

So that we don't go down infinitely many rabbit holes at once, I suggest we focus on one or two subdiscussions. I don't know how to do that though, any guidance?

The need for acceptance is so fundamental that more than one psychologist, can think it insane for even a slave to resist their identification as such. And more than one slave can accept the identity in order to be accepted. We go back again and again to our abusers, because to be abused is to be confirmed and accepted as part of the society. To be alone is death.

But again, all this must be denied, and the identity of the self-interested rational responsible man who is the captain of his fate etc must be affirmed, because to be so dependent and fragile in one's identity is also death. — unenlightened

I think we generally agree about identity, personality and those like concepts being (to a large degree) socially constructed. I appreciated your point about the need for acceptance being more fundamental than whatever plane of social relations identities are constructed within. It's good to highlight that there are some conditions of possibility/generative presuppositions for the formation of a psyche; those capacities which render us social, feeling beings.

I've got two points+questions about it. I'll reiterate that I'm not authoritative and I'm not in a position to judge the veracity of a study, I'm just trying to use them to make sure what I'm saying isn't beyond the pale.

( 1 ) While I'm not sold on this one. I think it's worth considering that while a given identity is socially constructed, we do have these psyche generative mechanisms/capacities which apply at the individual level. They're shared capacities to be sure, they apply to everyone. I intuit that those capacities are manifested by bodies in different ways, though. How I am rendered social is different from how you are rendered social - our tendencies for psyche-genesis will have been different. Examples there might be synesthesia, neurological conditions and disabilities. Bodies have some say in the psyches which may dwell within them.

I don't mean to suggest that there are male or female brains (like @Isaac highlighted, this is bogus), I mean to suggest that we've not ruled out that an individual's body constraints the genesis of their psyche differently than others. As far as I'm aware there is some evidence that this is the case here, some of which consists of review content.

To my understanding, those differences can arise from genetics, the developmental environment, and possibly epigenetic effects. The epigenetic aspect there renders biological factors socially mediated, and social factors biologically mediated.

I'm not trying to suggest that gender stereotypes should be naturalised, I'm more approaching this from the angle that the genesis of social identity implodes a hard distinction between nature and culture - since they both mediated the others' mechanisms.

The question I have in that respect is - what gives you the intuition (if it does) that the most part of trans identity comes from social factors rather than the body those social forces can inhabit/en-mind? Further, do you see these individual level bodily differences as showing that it's plausible that trans identity isn't entirely socially determined?

( 2 ) More broadly, I think your comments apply (and perhaps are even designed to apply?) to other identity categories. One of your example was race and your daughter going to nursery, if I understood it - race was being sustained/generated in their mind by the differences in expectation they've picked up. What's the practical import of your criticism for trans people vs racialised people? What ought people do and not do?

Interesting point about conflict/mismatch as a commensuration relation. Would love to see it worked out in more detail. Think it's a similar discussion to the one @Joshs highlighted here:

Davidson thinks he is dismissing the very notion of a conceptual scheme, when in fact he is only dismissing the Quinean model and its underlying Kantian scheme-content dualism( Davidson’s third dogma of empiricism) , which involves the identification of conceptual schemes with sentential languages and the thesis of redistribution of truth-values across different conceptual schemes. Two schemes/languages differ when some substantial sentences of one language are not held to be true in the other in a systematic manner.

Conceptual relativism does not involve “confrontations between two conceptual schemes with different distributions of truth-values over their assertions, but rather confrontations between two languages with different distributions of truth-value status over their sentences due to incompat­ible metaphysical presuppositions. They do not lie in the sphere of disagreement or conflict of the sort arising when one theory holds something to be true that the other holds to be false. The difference lies in the fact that one side has nothing to say about what is claimed by the other side. It is not that they say the same thing differently, but rather that they say totally different things. The key contrast here is between saying something (asserting or denying) and saying nothing.”(On Davidson’s Refutation of Conceptual Schemes and Conceptual Relativism) — Joshs

I'm too much of a libra to pick a side though. Have thoughts but I couldn't back them up well.

Thanks!

'Establish'? That would imply the default position is that it isn't (or that it's not being so has already been established such that I need present evidence to the contrary). — Isaac

Ideally default positions have arguments for them IMO. But I doubt we need to get into it here.

1. there exists such a thing as a male/female brain and as such it is possible to be born with the wrong brain for your body. — Isaac

I think this is factually nonsense too, but rhetorically useful. Like the neurodivergent banner and neurodivergent brains. I think position ( 2 ) is a possible explanation for it, but I don't think it's easy to establish as true.

While it's probably true that some of the pain and behaviour of trans folks is motivated by fitting into a societal norm, like "passing" there's a question about whether this is even an atypical response to particularly salient and fundamental norms about society. You can find similarly strong norms about race, disability and sexuality. There is a third possibility, which I think @unenlightened is close to (though please correct me if I'm wrong), in which all identity works like passing, and passing is nevertheless expressive.

This is from the paper I linked earlier, I found it quickly for a citation, I don't know and am not in a position to judge if it is authoritative.

]An interesting example, relevant to this discussion and regarding the social recognition of gender is the experience of some cisgender women that are high-performance athletes. Some of them become so muscular that, in the eyes of society, they lose their femininity, and begin to be mistaken for men, despite their identifying as cis women. Some of them speak of difficulties when trying to use the women's bathroom, being frequently kicked out by other users or cleaning staff, claiming that they are men. One athlete tells of a time when she had to raise her blouse and show her breasts to prove she was a woman and be allowed to use the women's bathroom (Jardim, 2018). They do not have intelligible bodies.

For that reason, Amara Moira Rodovalho (2017) suggested that the idea of cis and trans identities also includes the element of social recognition, which goes beyond the simple subjective identification with these identities (as though one thing could occur independently from the other). She defined cisgender women as “those women that, having been raised as women due to the genitals they were born with, exist for themselves and society under the identity of woman” (Rodovalho, 2017, p. 373). This implies that the intrasubjective aspect is not enough to define cis/trans identities, as also the intersubjective one is necessary. Social recognition is part of the process.

To achieve social recognition, it is fundamental that the individual adjusts to the normative model of their gender. This brings them legitimacy, intelligibility and saves them much trouble in social dynamics. Obviously, being trans will never entirely stop being an issue. That is why “passing” as a cis person is so fundamental.2 Let us now go back to the points defined by Duque (2013) that are crucial for recognition and gender passing. The outfit also plays an essential role in passing, as, at an intrapersonal level, it materializes the image that the persons construct of themselves. In contrast, at an interpersonal level, it fulfils the expectations of how one socially expects to see a masculine or feminine person — Dias et al 2021

There is a trope that the pressure to transition comes from trans activists, I want to make an argument against that here.

If we think of passing as a moral imperative, that "if you are X then you ought to behave as expected of X", it raises the question of where those expectations are coming from. I don't think it's reasonable to explain the imperative to conform to cisgender+heteronormative gender norms as arising from trans activist pressure to pass, transition etc - that expectation arises from a social consensus. It's societal standards which give rise to the imperative to conform to standard categories of gender expression "in public", rather than the criticisms of trans activists. So the pressure derives from societal norms rather than transgender rights activist groups and their allies. The trans activist origin of this pressure is also undermined by the same norms forcing conformity on cis men, women and people who don't fit on the binary.

When speaking about that pressure, there is a question about whether it is sufficient to explain why some transgender people want to present as more traditionally female - is it all fear, or is it also a self affirmation? Some testimony favours the latter, despite acknowledging the mix:

Assimilation is powerful and affirming, but it is also a bind that traps me, tempting me into closing the door behind me to all of the trans people who cannot assimilate or do not want to. It’s a false choice between the allure of belonging and the power of speaking out against injustice. Early in my transition, a trans guy friend told me that sometimes trans people are so aware of their individual privileges that they become all they can see. I didn’t understand what he was saying at the time. I do now.

But my friend said something else, too, which is that one’s own happiness is not a sin. Assimilating, blending in, is not a choice I made for safety reasons or even aesthetic ones. It’s an expression of who I really am. The challenge is to keep holding that door open, to not close it behind me, to take a sledgehammer to its edges until it’s wide enough for everyone. Womanhood is too expansive a category to be defined by limited parameters, no matter how it’s marketed.

Capitalism feeds off this ideal woman, but it didn’t strictly create her. She’s an outgrowth of all of us, a golem created over millennia by an ever-shifting set of thoughts on what it means to be a woman. To be a trans woman is perhaps to be more aware of this odd set of expectations, of the way you probably don’t need that pink razor but want it anyway. But it’s not to be uniquely aware of those expectations. I am an assimilationist not because I have failed to examine my choices or the options afforded me under capitalism, but because when I find myself affirmed by family, by friends, by random strangers, I realize how deeply intoxicating it can be to love your life.

What a novelty this is! To fight and fight and fight and discover the simple beauty of actually living the life you merely occupied before. — Emily St. James, Vox

It is majorly affirming to have something which you identify as a core aspect of your being affirmed socially. Not just for "fleeing shame", but by skilfully controlling an aspect of your presentation to better perform your identity.

The role that medical interventions might play in this is self affirmation in that regard. Restorative rather than pandering to societally inflicted wounds. Would we see the desire to get surgery in a society that had less confining gender norms? Who knows, I guess it comes down to how much transgenderism is rooted in less socially constructed aspects of embodiment (like is it somehow an interaction between developmental tendencies of proprioception and social norms?) - would the desire for a different body matter less if it was less gender-normy?

Anyway, if we're talking about whether it's permissible to surgically transition or delay puberty, we've got informed consent for that right? The bar seems quite high to establish that either of those are impermissible given that it improves stated wellbeing for those who want it.

These are obviously just snippets within the wider debate. as I said, I'm less interested in the technical details here than in the manner in which the discussion is conducted. — Isaac

Yeah that's fair enough. It'll come down to a risk assessment on an individual level basis, and the individual's desires ought to play a big role in that. Should they be determinative? I'd side with yes if we're comparing it to unestablished future risks vs established reports that individuals tend to be satisfied and have low levels of regret for surgery , but I don't think I've got a fortress of an argument for that claim.