I feel totally unequipped to talk intelligently about transgender issues. Frankly, I don’t think I’ve developed a very mature philosophy or even attitude about the issue, but at least I’m self-aware. I understand Kevin Williamson’s basic argument, although I am really only sympathetic to one narrow part of it. And, by sympathetic, I don’t mean that I agree with it. I mean that I think his challenge needs to be answered.

I think the American Psychiatric Association (APA) was correct to remove gender identity disorder from its list of mental illnesses. Mr. Williamson obviously disagrees. But Mr. Williamson makes the following point:

We have created a rhetoric of “gender identity” that is disconnected from biological sexual fact, and we have done so largely in the service of enabling the sexual mutilation of physically healthy men and women (significantly more men) by medical authorities who should be barred by professional convention if not by conscience from the removal of healthy organs (and limbs, more on that later), an act that by any reasonable standard ought to be considered mutilation rather than therapy. This is not to discount the feelings of people who suffer from gender-identity disorders — to the contrary, those feelings must be taken into account in determining courses of treatment for people who have severe personality disorders. But those subjective experiences do not render inconsequential the biological facts: A man who believes he is a woman trapped in a man’s body, no matter the intensity of his feeling, is no such thing. The duty of the medical profession is not to encourage and enable delusions, but to help those who suffer from them to cope with them. It is worth noting here that as a matter of law and a matter of social expectation, the fiction of sex change is treated as the paramount good: We are not expected to treat those who have undergone the procedure as men who have taken surgical and hormonal steps to impersonate women (or vice versa) but as people who have literally changed sex, which they have not — no more than Dennis Avner, the famous “Stalking Cat” who attempted to physically transform himself into a tiger, changed species.

The only piece of that argument that I have trouble dismissing is the idea that medical professionals have an ethical dilemma when faced with a patient who wants them to physically alter their body in a way that would ordinarily be considered mutilation. To put it in the most juvenile terms, if some man comes to you and says, “I feel like a woman, please remove my penis,” I think you have to consider the possibility that psychiatric help is preferred to doing the operation. Admittedly, this an extreme case, but faced with it, how do you best follow the Hippocratic Oath to “first do no harm”?

Is it sufficient to satisfy yourself that the patient isn’t suffering from some transitory desire? That they haven’t had some traumatic experience? That they appear to be healthy and of sound mind?

Do you need to be convinced that only a sex change will alleviate their mental distress?

This is in a different category from recognizing and respecting gender dysphoria, and making accommodations for it in the law so that people are not mistreated or discriminated against. We’re talking about operating on people. We’re talking about sound medical and psychiatric practice.

I can respect Bradley Manning’s wishes and refer to him as Chelsea Manning. I can go along with his desire to use the women’s bathroom. But I don’t know that I am qualified to approve his sex change, nor do I have much of a clue of how one might develop ethical practices that would serve as a guide for those who would do the surgery.

Like I said, I haven’t thought much about these issues. I’m not even pretending to have any kind of expert opinion.

I’m willing to listen.