ON CULTURAL COMPETENCE AND SCIENTIFIC RIGOR IN TRANSGENDER TREATMENT

Fee et al. argue that “[L]egal requirements for [sex reassignment surgery] as a condition of changing one’s gender need to be carefully reexamined.”1 Readers have a right to assume that authors have some authoritative knowledge about the subject about which they are writing.2 However, Fee et al. (2 historians and a contractor) appear to lack the clinical credentials to make policy recommendations about transgender care. Further, their factual data are scientifically invalid and inadequate.

No one ever suggested that surgical sex reassignment is, in the words of Fee et al., a “one size fits all” solution or the “gold standard” for treating transgender people. Transgender individuals who seek surgery (transsexuals) constitute a conceptual category at the extreme end of the gender identity disorder (GID) continuum.3 Only a small segment of the transgender community meets the criteria for GID.3–9 Transgender individuals live full- or part-time as members of a gender discordant with their anatomic sex, often with hormonal support.8 GID is a psychopathology7; transgender identity is not.4–8 “To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning” as well as cross-gender identity and gender dysphoria.7(p576) There is no difference in the prevalence of psychopathology between nonclinical samples of lesbians and transgender individuals.4,6

The authors’ assertion was based on scientifically invalid and inadequate scholarship. Despite their affiliation with the renowned National Library of Medicine, Fee et al. resorted to anecdotes and unrepresentative data, making reference to one postoperative transsexual’s wish that “there could have been an alternative” to surgical sex reassignment and referring to a single Web site warning of suboptimal surgical outcomes. The National Library of Medicine provides unparalleled resources for authors wishing to present a systematic review of the extant literature or to compare a representative sample of transgender care Web sites with the relevant standards of care.9 The use of selective, anecdotal data despite the availability of these resources indicates an insidious lack of scientific rigor and a dearth of transgender cultural competence.4

The transgender community has enough clinical experts and allies to preclude the need to rely on or tolerate the kind of scientifically inadequate and culturally insensitive input disseminated by Fee et al. Biased anecdotes and misleading, unrepresentative electronic data are an insufficient and inappropriate basis on which to make a policy recommendation for reconsideration of the legal standards for surgical sex reassignment.