June 23, 2022

Body horror dwells in the fear of damage that cannot be undone. It involves stories of skin, and limbs, and teeth, and eyes — precious and irreplaceable, now scarred or severed or irrevocably changed. In some versions, the Icarus stories, the damage is self-inflicted: fevered experimentation becomes joyful discovery becomes tragic hubris, the enterprising scientist watching with fascination as his body falls to pieces, a disintegrating structure with his consciousness trapped inside.

But in others, it’s the result of medical madness, a doctor so drunk on the possibility of a breakthrough — or so convinced he’s already made one — that he presses forward in violation of scientific principle, of basic decency, of his own humanity. These latter stories are more frightening. It’s the betrayal of it: the violation of that sacred oath to do no harm, and of the trust we place in the physicians who care for us at our most vulnerable.

That fear — of medical mutilation, of waking up from surgical sleep to find your body altered in ways you never wanted — has roots not just in horror but in history, where doctors who fancied themselves as cutting-edge would infect their patients with deadly diseases, or lobotomise them, or surgically extract their teeth and organs (this last item was part of an early 20th century vogue for “surgical bacteriology”; the doctor who disfigured his patients was hailed at the time as a pioneer). Today, we can find the same fear lurking just beneath the surface of the debate over transgender medicine.

Eight years after Time magazine declared that we are living through a transgender tipping point, there’s a growing sense of unease in the US, that we might have tipped too far, too fast. The momentum of the movement has given way to unanswered questions and nagging doubts: about the long-term side effects of using puberty blockers off-label, about the revelation that patients who begin to transition as children are likely to experience infertility or sexual dysfunction, about the testimony of regretful transitioners who say they were rushed by a gung-ho medical establishment into lives, and bodies, that they didn’t really want.

Some of the detransition stories are heartbreaking, or haunting. Some are… more than that. “No one told me that the base area of your penis is left, it can’t be removed — meaning you’re left with a literal stump inside that twitches. When you take Testosterone and your libido returns, you wake up with morning wood, without the tree,” reads one representative account. “I dream often, that I have both sets of genitals, in the dream I’m distressed I have both. Why both I think? I tell myself to wake up because I know it’s just a dream. And I awaken into a living nightmare.”

Unlike in Britain, stories like this, horrifying to the average person, do not appear to have breached the consciousness of the American government. The Biden White House has enthusiastically taken up the cause of not just ensuring access to medical transition for children who identify as trans, but taking other treatment options off the table. Last week, the White House announced that Biden will sign an executive order which takes specific aim at “so-called ‘conversion therapy’ — a discredited and dangerous practice that seeks to suppress or change the sexual orientation or gender identity of LGBTQI+ people”.

Critics have already noted the error in lumping in conversion therapy practices in relation to sexual orientation — which were ineffective at best and barbaric at worst — with the type of therapy that aims to help patients find a measure of peace with the bodies they have; such concerns have already led to the exclusion of transgender people from a government ban on conversion therapy in England and Wales. In the US, it is not yet clear whether a doctor with a patient who presented with gender dysphoria and an eating disorder, for instance, would be guilty of practising “conversion therapy” if he tried to address the patient’s mental health issues before opening the door to puberty blockers, hormones, and gender reassignment surgery.

But what this debate also illuminates is a growing tension over what it means, in one’s capacity as a medical doctor, to do no harm — when a growing contingent insists, passionately, that the worst harm one can do to a trans person is to fail to affirm their identity.

Two different ideas have emerged; two answers to the question about what medicine is for. Once, we agreed that the point was to be healed and made whole. The endpoint of the patient’s journey is that he stops being one; the doctor’s triumph is in seeing him walk out the door with high hopes that they’ll never meet again. Also in most cases, the process of healing was governed by a certain conservatism: a desire that the cure not be worse than the disease, a reluctance to adopt extreme measures when more moderate ones might suffice. And so your doctor would likely prescribe physical therapy before surgery, or try to restore healthy function to the organs you have before removing them from your body and replacing them with transplants. The most invasive, disruptive, and destructive treatments — amputation, chemotherapy — were understood as last resorts, to be held back until and unless they would make the difference between life and death.

The progressive wisdom surrounding trans medical care is a near-complete inversion of these norms, save that last one: here, gender dysphoria is seen as no less serious than cancer or gangrene in its necessity for urgent treatment. In place of the ominous shadow on an X-ray, we have the spectre of suicide among trans teens: without immediate and aggressive medical intervention, we are told, the patient will die.

The urgency makes sense, especially as a rhetorical strategy aimed at the parents of gender dysphoric teens. The question “Would you rather have a living daughter or a dead son?” is thrown around a lot these days (obviously, nobody ever wants the latter). And if you accept the premise, if you imagine a dozen bodies piling up for every second spent on debating best practices, then of course the conservative approach of a do-no-harm doctor would seem like the most harmful thing imaginable. But it’s worth noting how this understanding reverses the nature of the patient’s trajectory: now, one enters the system and does not leave. Now, there’s no end point, no cure, only treatment. The patient will spend the rest of his life undergoing procedures, taking hormones, being monitored by doctors. The journey never ends.

This, of course, is the best-case scenario. The worst-case scenario, the one beginning to make itself known in Substack posts and Twitter threads, is either downplayed or ignored by activists who imagine — not incorrectly — that to acknowledge it would be a giant wrench in the works of what they hope to achieve. The narratives of regretted transition are too ghastly: how can your guts not twist at the image of that phantom appendage, long since severed, still twitching with desire at the root? How can you not share the outrage when he writes: “I cannot believe they were allowed to do this to me.”

Would psychological treatment aimed at persuading this patient not to undergo a penectomy fall under the auspices of conversion therapy? Maybe: but if so, you will have trouble convincing most people that conversion therapy is a bad thing. Most people would prefer that he had the chance, every chance, to avoid such terrible regret. To make peace with the body he had — a body that is now altered, forever — before a surgeon began removing pieces of it.

There is a powerful push at the moment to make the above sentiment unspeakable, and I understand why. As rare as stories of detransition are, they are viscerally horrifying in their evocation of the undoable. They fester and wriggle in the same dark part of the imagination as Jeff Goldblum in Cronenberg’s The Fly, saving his body parts in his medicine cabinet as they fall off one by one — or Ronald Reagan in King’s Row, waking up to find his legs amputated, screaming “Where’s the rest of me?” — or that recurring nightmare, ubiquitous around the world, that all your teeth have fallen out. You can’t fight horror like that with pleas for sympathy. Your best hope is to make it taboo.

Whether it should be remains to be seen. Certainly, none of this is to say that no young person can benefit from medical transition. Perhaps many of them would, and perhaps the urge to tap the brakes in this moment will prove to have been a mistake. Some predict that we’ll soon be hit by a tidal wave of lawsuits from former patients who were rushed into medical transition too quickly; others are no less certain that countless trans youth will suffer terribly, if not die, due to state laws that challenge their access to cross-sex hormones and surgery.

But the quest to redefine “harm” in a medical context, to enshrine identity rather than health as the North Star which physicians should follow, and to make it taboo even to consider therapeutic alternatives to medical transition, will be a particularly uphill battle for reasons that go beyond politics. For all our sympathy, all our care, all of the passionate and persuasive arguments that it is the job of medicine not just to heal a patient’s ailments but affirm his sense of self, most people will never overcome the conviction — a visceral sense as much as an intellectual one — that doctors should not cut into us first and ask questions later.