Consider the violent benevolence of penile skin inversion vaginoplasty. It involves the complete disassembly of the penis — a carving out and amputation of all erectile tissue and the employment of the remaining penile components in the construction of the new vulva, clitoris and vagina. Tactile and erogenous sensitivity (i.e. the Piano in Rachmaninoff’s third i.e. the whole point of it) is laboriously preserved by dissecting the sexually sensate glans, on a pedicled leash of its own sovereign blood and nerve supply, to sculpt and create the neo-clitoris. To make the new vagina, the skin of the penile shaft and prepuce is fashioned into a tube flap, which is then inverted into a cavity created in the perineum somewhere between the urethra-bladder complex and the rectum. The remaining part of the base of the penile skin is used, by means of a minor origami manoeuvre, to form the labia minora and hood for the neo-clitoris. The labia majora come into being from the hollowed scrotal skin after excision of both testes.

This is the current standard of care, the optimal treatment for male to female transgenderism, in conjunction with facial feminisation surgery (forehead reconstruction, burring of the lateral brow, Adam’s apple reduction, feminisation of the larynx) and breast augmentation. Gender affirmation surgery (GAS) is the currently accepted genteelism for this cluster of procedures.

In the Diagnostic and Statistical Manual of Mental Disorders , fifth edition ( DSM-5 , 2013, by common consensus the updated, supreme oracle on psychiatric diagnoses), there has been a softening of nomenclature. DSM-5 replaces the earlier diagnosis of gender identity disorder with gender dysphoria. Dysphoria is the presence of clinically significant distress or impairment in social, occupational or other areas of functioning. In plain terms it’s because the biological (chromosomal, gonadal) sex doesn’t match a person’s gender identity.

Does the inclusion of gender identity disorder in a psychiatric diagnostic nosology mean the labelling of transgenders with a mental illness? The answer lies in the distinction between the labels disorder and dysphoria. The disorder might owe its existence to the doctrine of gender identity.

Gender identity can only be defined entirely subjectively. Sex is what you are biologically; gender is your awareness of what you are, what you believe yourself to be. Gender identity is a deeply felt internal and individual experience of your gendered self. The word gender, it should be noted, appears on both sides of this definition — the property that is being defined and the definition of that property. To break it down further, gender identity is the psychological definition of oneself as a boy/man or girl/woman — a sense of one’s masculinity or femininity. Which leads to the inescapable question: Where does this sense come from, if not from our sexed bodies?

I have it on good authority (from the social sciences) that gender identity is believed to be a pre-social property, formed and fixed perhaps in utero. It is instructive to note that your natal, physical, biological sex is what is ‘assigned’ at birth. Your gender is innate and can be independent of natal sex. Which bears the question: What kind of deeply felt internal and individual experience of boyhood or girlhood could form and consolidate in a foetus? What are the signs of and criteria for girlhood (or womanhood) that are not duteous to the sexed body? What is the feminine essence? Mannerisms? Dispositions? Feminine patterns of behaviour? Affinities? Other traits that can be classified under the heading ‘stereotypical gender norms’? Those can’t be pre-social? If they can’t then this is a formal fallacy riding on an informal one.

Let us frame the proposition differently. Empirically, the male facial skeleton has greater bone volume. The male nose is generally larger, the cheekbones are more pronounced, the lower jaw is squarer, the hairline is M-shaped with recessions at the temples. If a woman were to have one or more of these features, even all of them, it wouldn’t make her a man. It would make her a woman with masculine craniofacial structure. Forgive my tautology, but patterns of behaviour also fall on both ends of the bell curve. Having feminine traits, affinities, and dispositions doesn’t make a man a woman. It makes him a man with feminine traits, which is normal.

Most children at the age of three start the process of classifying everything. Aided and abetted by their training as regards their required affinities and social and cultural roles, they make models and stereotypes inside their heads. Pink vs blue, dolls vs trucks, long hair + hair clips vs short cropped hair. At the age of five, they also make their first, tentative attempts at self-categorisation. I like dolls and wearing frocks; that must mean I’m a girl. Now, if a little boy likes frocks and dolls, he’s not the other gender. He’s just on the far end of the bell curve. Well, not if you subscribe to the doctrine of gender identity. In that case, he’s transgender and it’s bad form to affirm his biological sex. According to the DSM-5 , 90 per cent of gender-confused boys and girls eventually accept their biological sex after naturally passing through puberty. They are overwhelmingly likely to be homosexual adults but not transgender. This is important because gender clinics across the world are being referred transgender kids aged three. They’re seeing soaring numbers of under-10s. Increasingly, these clinics are treating them with puberty-blocking hormones to impersonate the opposite sex and following it up with cross-sex hormones in late adolescence.

The American College of Paediatricians recently issued a position statement on the subject. It’s called Gender Ideology Harms Children (updated in January 2017) and has the following salient features:

No one is born with a gender. Gender is a sociological and psychological concept. A person’s belief that he or she is something they are not is, at best, a sign of confused thinking. Conditioning children into believing that a lifetime of chemical and surgical impersonation of the opposite sex is normal and healthful is child abuse.

The gender theory gives children a simple answer to all their confused feelings: They have the wrong body for their gender. It allows gender specialists to fix something non-pathological in the head by medically and surgically treating the healthy body, by mutilating healthy organs to match a psychological identity. Gender dysphoria has become a social justice diagnosis. Hormonal therapy and GAS is covered in 75 colleges and universities in America under student health insurance. They’re also the only procedures to be authorised by a fatwa in Iran (in 1979, by the Ayatollah), for a different reason. Homosexuality is a crime in Iran; transgenderism is considered an illness that can be cured. GAS, in Iran, is surgically creating heterosexuality. The suicide rates in transgenders post GAS don’t change. They’re as high as 40 per cent with or without treatment, even in Sweden. Rank dysphoria, if indulged, could end up as a disorder.

It’s time to consider that there might be a problem with the total acceptance of the gender theory in the media. It could be the cause of the disordering of feminine boys and masculine girls.

I’ll close with the story of Jewel Shuping from North Carolina, who suffers from body integrity identity disorder. Despite having normal vision, she self-identified as blind since childhood. As a child she’d spend hours watching the sun to blind herself. As she grew up, she began imitating the practices of the sightless. At age 20, she could read Braille. In 2007, at the age of 21, she found a sympathetic psychologist in the Midwest who blinded her by pouring drain cleaner into her eyes.

Now let’s celebrate Shuping and put her on a magazine cover.

Ambarish Satwikis a Delhi-based vascular surgeon and writer; asatwik@gmail.com

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