If someone identifies as an amputee they are given psychological help

[quote Broomfondle]@suggestionsplease1

I don't think what you have linked is as applicable to this as it seems.
But lets work on the understanding that there are femaley and maley kind of brains.
And let's look into the difference between gender and seeing little green men.
Seeing things that aren't there is a hallucination (assuming the little green men aren't there). Ascribing false ideas to something that is there can be a delusion (there is in fact a red car at the end of your road - but you believe this is a signal to the CIA that the chip in your brain is about to receive alien messages).
Say a male person had a femaley type brain - that could be correct, but the belief that this then means your sex/your body is wrong could be considered a delusion. Delusions are in a sense, beliefs. They're meanings
From what I've seen they aren't too different to a sense of identity. You can have delusions of guilt, delusions of grandeur etc. It's an entirely debatable point why some of these beliefs are considered acceptable and some considered pathological. We usually say delusions are false beliefs and so you come back to the question of what is true? Who knew trans rights debates could become so existential![/quote]
I'm with you on your definitions of what a hallucination is and what a delusion is, and agree that your examples for both are fine... but I don't agree with your logic that being a male person (and I think we need to specify here a person with male genitalia as we're talking brain / body differences) and having a 'femaley' type brain should mean that you are delusional for feeling you are female rather than male.

Does it depend on the value that you place on visible genitalia? Because this person can visibly see their male genitalia does that inherently mean they are delusional for thinking they are female? Because I am sure we are all aware of the babies with botched circumscisions who were brought up as female but changed gender identity to male during adolescence or later. Are they delusional for feeling male?

I think gender identity is a little more nuanced and complex than the single linear dimension of height which can be determined by a number alone!

A more detailed reply to this.

Suppose that there is some attribute of brains which is only ever found in female brains. By definition, this attribute, being exclusively female, will never be observed in male brains.

Now suppose that a man's brain is analysed, and he is found to have this attribute which it was thought was only ever present in women's brains. What this means is that the original assumption (that this attribute is exclusively found in female brains and never in male brains) was incorrect, and the attribute is actually found in both male and female brains, but is more commonly found in female brains. It doesn't mean that this man has a 'female' brain in his male body.

If there was a scietific test to determine whether a brain was male or female, it would actually prove that transgenderism doesn't exist in the sense of having a brain of the opposite sex to the body.

Psychiatrists recognise different kinds of false beliefs

An outright delusional idea is demonstrably false and often bizarre as encountered in psychotic mental illness and the solution is usually antipsychotic medication. I don't think a belief that you are transgender is that kind of idea

Overvalued ideas however are those that occur in eg anorexia and OCD where when heavily challenged the person will admit that their belief is odd, wouldn't be shared by others and is not evidence based, but it very strongly feels like that to them (a psychotic person makes no concessions they know they are right) eg anorexics don't deny their actual low weight they just think it has a different meaning.
Body dysmorphic disorder is this kind of disorder. It's not a psychosis as such. Psychotherapy is the mainstay of treating these kinds of conditions.

It may very well be the case that for psychotic ideas and for overvalued ideas there are some things about peoples brains that cause them to have those thoughts but still it doesn't make the thoughts true.

In all of these conditions kindness and compassion are needed for recovery but not collusion. In none of these conditions would anyone suggest going along with or facilitating the ideas and in fact if this does happen the person will not get better.

I honestly do find it hard not to see gender identity disorder/ gender dysphoria as subsets of body dysmorphic disorder with an overvalued belief that you have the wrong sex body. Plainly you do not because that is scientifically impossible but the feeling is very real and I expect distressing (although some say it's not distressing) and there will be reasons why a person has that belief. I would think the vast majority of them could be helped to feel differently if they wanted to.

Some late FtM transitions seem to be less about a sexual fetish and not dysphoria and many TRAs these days say that gender dysphoria is not a part of being trans and trans people don't need therapy. That is fine if they are happy then they are free to carry on living as they wish as long as it is harming no-one and believing what they wish but no therapy then no surgery I would say.

In fact you can live your life believing all kinds of very bizarre psychotic things and no one will force treatment on you if you don't want it and if you are causing no harm to yourself or anyone else. That is where the law draws the line.

I think gender identity is a little more nuanced and complex than the single linear dimension of height which can be determined by a number alone!

You already said that there is overlap between the attributes of male and female brains. So at what point does a 'male' brain become a 'female' brain, and not simply one which appears more similar to a typical female brain than a typical male brain?

And can you define exactly what you mean by 'gender identity'?

And when you look at the studies on brain structure and function which show that trans peoples' brains tend to be more similar to brains of the sex they identify with rather than the sex that their body parts would say they have, that is meaningful isn't it?

So far as I'm aware, this isn't true, as a) there's no such thing as a typical female-pattern or male-pattern brain for trans-identified people's brains to be compared with and b) these studies don't tend to distinguish adequately between reported sexual orientation and actual sexual orientation.

HSTS males have brains in line with other homosexual males (in terms of comparison with heterosexual male brains); heterosexual trans males have brains resembling those of other heterosexual males. Quite difficult to tease this information out when the latter category are permitted to self-identify as lesbians, however.

Sex dysmorphia may be detectable in the same regions of the brain as other disorders of body-perception; this is not evidence of a "female brain" unless, of course, "disordered body perception" is part of your definition of "female".

And when you look at the studies on brain structure and function which show that trans peoples' brains tend to be more similar to brains of the sex they identify with rather than the sex that their body parts would say they have, that is meaningful isn't it? (And I am in no way being absolutist about this, there is no such binary as a 'male' brain and a 'female' brain, these are not separate circles on a Venn diagram to my mind, and any individual identifying in any particular way might have any variant on brain structure and function.....but yet there are trends in structure and functioning at a male/female population level)

So if there is overlap, then there is no such thing as a 'male' or 'female' brain (other than the fact that a male brain is found in a male body and a female brain is found in a female body). So trans people's brains can't be 'more similar to brains of the sex they identify with', because they are part of the category of the brains of the sex they are.

What you're saying is the equivalent of saying a tall woman has a 'male' height and a short man has a 'female' height.

Can someone explain this to me please (genuinely)? If a Transperson believes they were born into the wrong body, how can they deny that there is a physical difference between male and female bodies?

@suggestionsplease1

I don't think what you have linked is as applicable to this as it seems.
But lets work on the understanding that there are femaley and maley kind of brains.
And let's look into the difference between gender and seeing little green men.
Seeing things that aren't there is a hallucination (assuming the little green men aren't there). Ascribing false ideas to something that is there can be a delusion (there is in fact a red car at the end of your road - but you believe this is a signal to the CIA that the chip in your brain is about to receive alien messages).
Say a male person had a femaley type brain - that could be correct, but the belief that this then means your sex/your body is wrong could be considered a delusion. Delusions are in a sense, beliefs. They're meanings
From what I've seen they aren't too different to a sense of identity. You can have delusions of guilt, delusions of grandeur etc. It's an entirely debatable point why some of these beliefs are considered acceptable and some considered pathological. We usually say delusions are false beliefs and so you come back to the question of what is true? Who knew trans rights debates could become so existential!

@suggestionsplease1 I think that is an interesting point but I think it is of limited use here as the "trans umbrella " is so wide that it now encompasses people who are trans for a wide variety of reasons.

Refusing to believe gender identity exists is a strange way to phrase it. Do you think trans people are making it all up?

No but I don't think it is caused by being born in the wrong body and I don't think if you transition you actually change sex or that this means you were actually always the sex that you transitioned to. However, this seems to be what we are now expected to believe. If I believe this is possible for someone else then logically I have to either believe it is true for everyone or that it is, similar to anorexia, a mental health condition. Or am I missing something?

So it seems in this post you're examining whether there are similarities to people who experience delusions and over-valued ideas, and you tend to feel that there are.

But there is a difference between the process of thinking, which might, in disordered patients, become delusional, and sense of identity isn't there? I think most people who state that they are trans are expressing at heart a gut feeling about who they are as a person, and that's different from a series of disordered thoughts isn't it?

And when you look at the studies on brain structure and function which show that trans peoples' brains tend to be more similar to brains of the sex they identify with rather than the sex that their body parts would say they have, that is meaningful isn't it? (And I am in no way being absolutist about this, there is no such binary as a 'male' brain and a 'female' brain, these are not separate circles on a Venn diagram to my mind, and any individual identifying in any particular way might have any variant on brain structure and function.....but yet there are trends in structure and functioning at a male/female population level)

health.clevelandclinic.org/research-on-the-transgender-brain-what-you-should-know/

www.sciencedaily.com/releases/2018/05/180524112351.htm

Given that it appears that there may be this biological underpinning to an individual's sense of gender, can they really be considered 'delusional' in the same way that that the patient who insists they see little green men sitting on the sofa next to you? (of course, when you know objectively there are none ;)

Agree with Jellyslice that its separate. I've never been clinically depressed or even experienced prolonged depression. Dysmorphia and identity issues are rife though.

Having suffered both dysphoria and depression I can only say that they are different and separate. One may influence the other, but they are independent of each other. At least they were in my case. I think the dysphoria did not make the depression worse (the depression predated the dysphoria), but recovery from depression helped me accept the cause of the dysphoria and helped me change the way I dealt with it, thus easing the dysphoria.

You're better comparing depression to the body dysmorphia btw rather than the dysphoria.

Also with depression theres not necessarily a trigger. More a build up. Dysphoria and euphoria can be triggered out of no where.

Depression does not need an opposite. You have depression.

If you suffer with dysphoria you will also have euphoria. Both require balancing because both are equally as destructive and damaging in the long run.

I also have BDD. For me the key difference seems to be that people with gender dysphoria feel better after transitioning and surgery. However with BDD, surgery or other treatments or anything that increases the focus at all on the appearance makes it worse.

Interestingly one if the symptoms of BDD is researching obsessively "treatments" for perceived flaws. Again something that feeds the condition and increases anxiety.

Most anxiety disorders work like this. Increasing the focus on the anxiety or responding to obsessions related to the anxiety makes the anxiety worse and feeds the disorder.

I dint understand why gender dysphoria doesn't work in the same way. It perhaps it is less like other anxiety disorders including BDD than the name suggests.

@oldcrone depression is a similar set of chemicals in your brain. The difference to me seems to be in the trigger for it and the intensity of it.

Sort of like depression being a slow burner. Dysphoria being a quicker more intense rush.

Dysmorphia is a mental illness - the feeling that there is something wrong with a healthy body (the 'morph' bit is to do with the shape of the body).

If someone thinks that there is something very wrong with their body, it is a normal reaction to feel distress, or dysphoria. So it would be wrong to classify this distress or dysphoria as a mental illness, since someone who genuinely has something wrong with their body would suffer similar distress. But presumably if someone became severely depressed, then it would be classified as an illness.

But I still don't understand this, because now I don't know what the difference is between dysphoria and depression.

@Broomfondle great post definitely food for thought.

Do you think trans people are making it all up?

Some of them. The vast majority of male transitioners appear to be AGP males or opportunistic MRAs. Interestingly, they are also often the loudest and most demanding trans people.

I have no doubt that there are some people who genuinely believe that they are not or should not be the sex of their body, people who have gender dysmorphia/dysphoria. I would consider most ROGD teens as temporary members of this group.

@broomfondle Definitely food for thought. It's a real shame this isn't debated more widely.

@theid Very well put.

My approach has always been that people can believe and do whatever they like, provided it doesn't impact on my life or put anyone in danger. It doesn't matter whether it's religion, politics, transgenderism, alien abduction, or anything else I don't agree with. I'm happy to debate it even, but I would never accept that I HAD to change my beliefs to match theirs.

Let’s look at this from a medic ethics perspective. Here are four of the basic principles that help inform medical decision making:
Beneficence - acting in the patient’s best interest
Non-maleficence - do no harm
Autonomy - the patient’s right to refuse/choose their treatment
Justice - the fair sharing of resources

Its helpful to look at this through an NHS lens as 4 actually helps how we judge the first 3.
There are always conflicts of beneficence vs autonomy - a patient wants something that is not in their best interest. As long as you have capacity patients are within their rights to choose what is not good for them. However this normally always applies to refusal of treatment, not receiving of treatment. You can refuse an appendectomy you may need (for example) but you can’t demand one you don’t need. This is why I think its helpful to use an NHS way of looking at things as in countries where private healthcare is more abundant the autonomy/justice conflict is more blurred.

Non-malificence - that plays into the not performing an appendectomy that is not needed decision, as does justice. However it is not absolute, patients undergo harm all the time. Chemotherapy for example. Or say there is only one doctor on a ward, one patient has a headache and wants paracetamol prescribing, one is having severe chest pains and might be having a heart attack. We can (probably!) agree it is ethical to leave the patient with a mild headache in pain while the heart attack is treated, even though it is doing that first patient ‘harm’. Or stable, elective patients that have their surgery delayed due to emergencies. This also comes back to a share fairing of resources.

Why don’t we do cosmetic surgery on the NHS? People may want it (autonomy) and it may make them feel better (beneficence). However it has inherent risks that outweigh the benefit (non-malificence) and has been decided not to be a fair use of resources when there are waiting lists/restrictions to treatment for physical illnesses. There is obviously an argument about risk vs harm of cosmetic surgery if someone is unhappy with a body part but this is the current position of the NHS. Or is it? Breast reconstruction is offered after a mastectomy for cancer for example. No one needs implants under their skin for their organs to function correctly. What is so different about this situation to an 18 year old girl who would feel happier with bigger boobs?

For all the principles you will likely find an ‘anomaly’ you could reasonably argue against.

Ethics aside, surgical treatment for gender dysphoria is a psychiatric anomaly. There are physical treatments for psychiatric disorders - vagus nerve stimulators, ECT for depression for example and all psychiatric drugs try to change physiology in some way. However this would be the only current surgical treatment of a psychiatric disease (I think!), even those that involve physical delusions/symptoms etc. Patients with functional neurological disorders have symptoms that are real, but their belief in the cause of those symptoms is not always correct (understandably). Some believe they have a tumour causing their symptoms despite no evidence of one, they should not be treated as if they have a tumour and offered surgery, it wouldn't be in their best interests or avoid harm. It’s why psychiatrists aren’t surgeons. Well maybe what is happening with gender dysphoria is just an advancement in medicine? Except it is a healthy body. It would be the first non-cosmetic surgery carried out on a healthy body with an aim to cure a disease (even prophylactic mastectomies etc are done on the basis of a gene test showing increased risk of cancer). There is nothing wrong with the physical organs of a person experiencing gender dysphoria. But if it makes them happier what’s the harm? Well exactly. Does it fall under treating them in their best interests? Does it fall under doing no harm? Does it fall under justice? Does it even fall under autonomy if you doubt their ability to make an informed decision? Are they currently experiencing a mental disorder that informs their decision making? How do we answer these questions? Evidence. I don’t believe we have the evidence to answer those questions.

I would argue ‘happiness’ is not good evidence. People struggling with anorexia can report being much ‘happier’ at extremely low weights and would fight every suggestion otherwise. People with addictions can find life much harder without their substance. Manic episodes can feel extremely thrilling. However if you value autonomy then in these situations you could argue - well crack on then. It’s your body. If self-harm helps you cope then carry on. If starving yourself gives you a sense of control that you feel you need then off you go. We have to ask ourselves why we don’t take this approach in these situations but should or shouldn’t in gender dysphoria.

We also have to be careful about ascribing ‘happiness’ post-surgery to the surgery itself. Maybe having gender reassignment surgery is an ‘end of the road’ type situation. There is nowhere further to go. It forces a state of acceptance. Is it the acceptance itself that can lead to a lowering of overt distress? And importantly, is there a less harmful alternative? Is there another road to acceptance? There is evidence that allowing people with gender dysphoria to go through puberty, with support and to live their lives can ease dysphoria. Is the cause of gender dysphoria in middle aged males the same as in pre-pubescent girls? Or children? Should the treatment be the same?

Is it a mental disorder at all? If not, why not? If not, are we mischaracterising other mental disorders? Should all the treatment be cosmetic? And done privately in the UK? Then only people with the funds could afford gender reassignment. But is that ok if its just an aesthetic choice like buttock implants? Or is it unethical as people with less resources could experience more distress. But that would take us back into the realms of a mental disorder...

Is it like sexuality? If not, why not? If it is surely the NHS should have no involvement whatsoever.

Why is paedophilia not treated as a valid sexual preference the world just needs to accept? Where do we need to challenge the ‘accepted norm’ and where is there validity in widely held societal beliefs?

My personal take on it is gender dysphoria has a lot more in common with other mental conditions than with a sexuality and I have yet to see the evidence for why it should be treated so differently. And not just in terms of medical/surgical treatment, but in terms of medical ethics, safeguarding, Gillick competence, consent, affirmation, legal recognition etc. I believe if the evidence is missing then the medical profession should not proceed on ‘assumptions’ in the mean time.

Autonomy can’t trump all here. The medical and surgical treatments are not benign or reversible. The surgery itself does not make a vagina, or a penis. These people do not become the other sex. They live with a facsimile which has inherent risks to their physical and mental wellbeing which you can’t address through psychotherapy etc. I really feel this fact seems to be forgotten.

I do not have the answers. I think we need much more evidence before we can unpick this more intelligently, but I believe while we don’t have the answers it is not ethical to carry on as we are.

A personal note - I have experience on both sides of the coin, from the professional side and I have experienced a delusion regarding my body. I begged the NHS for a transplant. I begged for a surgical solution to a mental problem and would have argued up down and sideways why that was valid. I really do have sympathy for both sides.