Why ‘When Harry Became Sally’ Matters
[Editor’s note: A physician of stellar credentials sent me this review of Ryan T. Anderson’s book to be published anonymously on this blog. I know who the physician is and can vouch for said credentials, but if I published this under his or her name, his or her career would be over. Having seen what Amazon did recently in delisting ‘When Harry Became Sally,’ the physician concluded that the public should understand what an important book it is, and why it’s a very big deal that Amazon spiked a book as carefully and as compassionately written as Anderson’s, apparently (because the retailing giant did not offer an explanation) because the book presents evidence that contradicts the progressive narrative on transgenderism. I am pleased to present the physician’s review here; I read Anderson’s book when it was first published, and agree with every word below. — RD]
By Anonymous, M.D.
In the late 20th century, American psychiatry suffered a schism over the idea of recovered memory. At the time, a number of patients, encouraged by their psychiatrists and psychotherapists, falsely accused their parents and teachers of sexually abusing them. According to their therapists, the patients had waited so long before making accusations because they had repressed their memories of sexual abuse; only with prolonged counseling were these memories “recovered.” After a number of scandals, a small group of skeptical psychiatrists challenged these claims, courts decided cases in favor of the accused, and the influence of recovered memory advocates waned. As critics pointed out, memory of traumatic events is not usually repressed–it remains, rather, percolating beneath the surface, haunting its victims. But much damage was done before the idea of “recovered memory” lost its authority, despite the absence of supporting evidence. It was a terrifying and consequential example of the false security of consensus.
The passionate adherence to a perspective, and the accompanying resistance to any challenges, resembles the insistent sure-footedness of the modern transgender movement. Once victims to a seemingly untreatable diagnosis, gender dysphoric patients who feel their gender identity differs from their biological gender, now have therapeutic options: reconstructive surgery and hormonal therapy for transitioning to the correct gender. Despite the potential side effects of these therapies—which may include but are not limited to increased red blood cell counts, increased plaque buildup in the arteries, reproductive sterility, infections, blood clots, failure of the surgery itself to create the properly functioning new genitalia, or abnormal connections between different organs in the abdomen due to the invasive nature of the surgical procedures–many transgender advocates, psychiatrists, pediatricians and surgeons believe that the benefits of these interventions outweigh the risks; that the well-being of transgender patients depends on supporting their sexual identity through such interventions. As Dr. Deanna Adkins, a professor at the Duke University School of Medicine and the director of the Duke Center for Child and Adolescent Gender Care argues, the “appropriate treatment for individuals who are transgender must focus on alleviating distress through supporting outward expressions of the person’s gender identity and bringing the body into alignment with that identity.”
And the number of patients bringing their bodies into alignment with that identity has dramatically increased: the number of patients referred to gender identity clinics to receive treatment for gender dysphoria, according to one Dutch study, increased 20-fold from 1980 to 2015. From 2000 to 2014, the number of gender-affirming surgeries to change one’s sex increased fourfold. In May 2014, Medicare ended its 33-year ban on transgender surgeries. Supporting this trend, in popular culture, transgenderism is more visible than ever before. Most notably Bruce Jenner, the former olympic athlete, transitioned to a woman, Caitlyn Jenner. Featured on the cover of Vanity Fair, Jenner won the Arthur Ashe Courage Award from ESPN and Woman of the Year award from Glamour magazine. We have reached a consensus, it seems, that the transition to one’s perceived gender is necessary for one’s health and thus worthy of celebration and encouragement.
This consensus, however, argues Ryan T. Anderson, President of the Ethics and Public Policy Center, in his book, When Harry Became Sally, is misguided and deleterious to those it is most meant to help. Anderson provides the reader with a clear-eyed picture of what gender identity activists believe and subsequently makes both philosophical and scientific arguments for why they are wrong and the potential dangers of their certainty. However, he does not insult or dismiss transgender patients. He explains, “We must be careful not to stigmatize those who are suffering….We must avoid adding to the pain experienced by people with gender dysphoria, while we present them with alternatives to transitioning.” Nevertheless, according to Anderson, the scientific evidence for hormonal and surgical therapy as an effective treatment for gender dysphoria is wanting.
Initially, this assertion might be a bit shocking given the widespread and passionate convictions in favor of gender transition—shouldn’t treatment for transgender patients encourage the transition to the gender one is most comfortable with? And wouldn’t our modern ability to administer hormones and operate be the best solution for these patients? But the answers, Mr. Anderson suggests, are not straightforward. “Judging from the evidence available so far,” writes Anderson, “the psychological benefit” of sex reassignment procedures “is not very great.” In a chapter on this topic, Anderson quotes most heavily from a literature review in The New Atlantis in the Fall of 2016 by Dr. Paul McHugh, the University Distinguished Service Professor of Psychiatry at Johns Hopkins, and Dr. Lawrence Mayer, a physician and epidemiologist. According to their review of the literature, McHugh and Mayer write: “the scientific evidence summarized suggests we take a skeptical view toward the claim that sex-reassignment procedures provide the hoped-for benefits or resolve the underlying issues that contribute to elevated mental health risks among the transgender population.”
A close look at the primary literature from one of the most prominent researchers in the field does support Anderson’s skepticism about gender reassignment procedures. In a population-based matched cohort study in 2011, Dr. Cecilia Dhejne of the Karolinska Institute and her coauthors identified patients with gender identity disorder who underwent sex-reassignment surgery and matched them to two age-matched controls: people of the same biologic sex as the transsexual patient at birth and people of the same gender identity with which the transsexual patient identified. The “overall mortality” for sex-reassigned persons was higher during follow up, “particularly death from suicide.” Moreover, “sex-reassigned persons also had an increased risk for suicide attempts” and psychiatric inpatient care. To be sure, outcome variables were not evaluated before surgery and these patients may have done worse without the surgery. Because of the limitations, “the results should not be interpreted such as sex reassignment per se increases morbidity and mortality.” Nevertheless, this imperfect study questions the efficacy of gender reassignment surgeries.
On the other hand, in 2016, Dr. Dhejne and colleagues analyzed 38 studies describing outcomes in pre-and post-gender-confirming medical interventions for patients with gender dysphoria in the International Review of Psychiatry. Among their conclusions, the authors wrote: “Longitudinal studies investigating the same cohort of trans people pre- and post-interventions [gender confirming medical interventions] showed an overall improvement in psychopathology and psychiatric disorders post-treatment.” And yet, many of the studies they analyzed were methodologically weak; they demonstrated “selection bias” or were limited by patients who were lost-to-follow-up; or there was “lack of matching according to known risk factors for psychiatric disorders and psychopathology within the general population”; or trans people were included at different stages of treatment. In short, the studies Dhejne and her colleagues reviewed were not robust. Such flaws cast serious doubts, as Dhejne admits, on far-reaching conclusions from these studies: “Since most included only individuals attending transgender health-care services, the results are not generalizable to the overall trans population” and “it cannot be ruled out that it [the improvement in psychopathology and psychiatric disorders post-treatment] relates instead or as well to the benefits that accrue from being validated and accepted for treatment.” Another, more recent study from 2019 with results favoring gender-affirming surgery had significant weaknesses and its overreaching conclusions required correction.
In short, a dearth of definitive data exists to support using surgery and hormones for all gender dysphoric patients. If this alone were the case, it would be enough to approach such aggressive interventions with hesitancy. But there are other elements to the clinical situation which should give one even more pause.
If gender depends on the subjective feeling of the patient, it is not static but fluid. Thus, even after hormones and surgery, patients change their minds only to confront the irreversibility of some of the treatments. In the most powerful chapter of his book, Ryan Anderson gives voice to those who “detransitioned” back to their biological gender. Anderson quotes Cari Stella, a detransitioned 22-year-old woman: “When I was transitioning, no one in the medical or psychological field ever tried to dissuade me, to offer other options, to do really anything to stop me besides tell me I should wait till I was 18.” In an extensive and thorough essay for The Atlantic, Jesse Singal documented some of the same thoughtless pressure from medical professionals: “Many of these so-called detransitioners argue that their dysphoria was caused…by mental health problems, trauma…They say they were nudged toward physical interventions of hormones or surgery by peer pressure or by clinicians who overlooked other potential explanations for their distress.”
This societal pressure primarily harms patients; but it also harms and all too often attempts to silence the frank and productive debate necessary to evaluate any medical intervention. As Anderson documents, in October 2017, “the governor of California signed a new law that could send health-care workers to jail for failing to use a person’s chosen pronouns.” In February, 2018, the New York Timespublished a column by Jennifer Finney Boylan, claiming Ryan Anderson’s book “suggests that transgender people are crazy, and that what we deserve at every turn is scorn, contempt and belittlement.” No passage in the book even remotely implies this. Only a few years ago, Dr. Kenneth Zucker, a world-renowned psychological expert on gender dysphoria and gender identity development, was fired from the Child Youth and Family Gender Identity Clinic in Toronto, likely for taking a somewhat conservative approach to pre-pubescent children expressing gender dysphoria. His concern, that young patients might change their minds, led him to recommend a watchful and cautious approach rather than an aggressive medical approach to transition patients immediately. He was unceremoniously dismissed.
The coup de grâce came only last month when Amazon, a site responsible for 83% of books sold in the US, removed Ryan Anderson’s book from its site without any explanation and without any forewarning, a clear and disturbing instance of censoriousness. And yet, on Amazon, one can still purchase Adolf Hitler’s Mein Kampf, Josef Stalin’s Selected Works, and In Defense of Looting.
How can any academic participate in an honest discussion when a controversial idea or research finding results in potentially career-ending or damaging consequences? In this milieu, a simple book review like this one must be written under anonymously for fear of, to put it lightly, professional costs. But it is also for this reason that Ryan Anderson’s book, one of the few dissenting voices, is so important.
Oliver Wendell Holmes, a 19th century professor of anatomy at Harvard Medical School, once wrote, “The truth is, that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density.” As with the memory wars of the past century, we now confront a precarious situation in medicine where outside influences push us beyond the realm of our scientific knowledge. Indeed, we presume to know much about transgenderism but in fact know little. Acknowledging this, Anderson barely mentions concrete, alternative treatment options for transgender patients in his conclusion. This is because of our paucity of knowledge about what leads to gender dysphoria and how to treat it. Our practices lack rigorous scientific evidence. Consequently, it is entirely possible Ryan Anderson is wrong about all this. It is possible more definitive research may quash the doubts he eloquently expresses about hormones and surgical treatment for transgender patients. But until that time, if it comes, we in the medical field ought to resist consensus based on external political and popular influences and search for what is best for our patients.
[Editor’s note: Walmart has joined Amazon in delisting Anderson’s book, but you can still purchase it from its publisher, Encounter Books — and you should. There’s a reason these corporate behemoths don’t want you to read “When Harry Became Sally” — and that’s why you should read it! It is a disgrace that the US has become a country in which a distinguished physician can only write approvingly about this book without using his or her name, but that’s what we have become. This is what the activist left, woke capitalists, and transgender activists, have done to our liberties. — RD]