Brother David: An Ethical Tale, Part 3
By Polly Davis and Frank Steiner
Part 2 in this series discusses medical ethics in the context of surgery for treating mental disorders, and presents an overview of the four broadly accepted ethical principles in medicine: beneficence, nonmaleficence, justice, and patient autonomy. In cases of patients with Body Integrity Dysphoria (BID), some doctors have resorted to amputation, but this treatment is controversial and fraught with ethical problems. Similarly, the practice of lobotomy, although once considered an accepted treatment for serious mental illness, has been rejected and is recognized as a failure of medical ethics.
Questioning the Sanity of Gender Medicine Ethics
Brother David’s case study, research on Body Integrity Dysphoria, and the history of lobotomy shine a spotlight on the ethical issues faced by doctors who consider treating patients by severing their healthy body parts. Contrast these patients with those who seek care for gender dysphoria or incongruence. The World Professional Association for Transgender Health (WPATH) has written standards of care for healthcare providers who treat transgender and gender diverse individuals. The most recent version, Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC8), was published in 2022. These standards include the use of puberty blockers, hormone blockers, cross-sex hormones, and gender-affirming surgery as treatments. Although WPATH claims its standards are evidence-based, systematic reviews of the evidence for pediatric gender medicine have found it to be insufficient and inconclusive. These reviews have also judged the quality of the evidence supporting medicalized interventions to be very low. Nevertheless, organizations such as the American Medical Association, American Academy of Pediatrics, and the Endocrine Society have embraced WPATH’s standards of care.
Because gender medicine involves administering pharmaceuticals to healthy individuals as well as removing healthy body parts and surgically constructing imitation, cross-sex body parts, it would be logical to assume that WPATH would provide a detailed analysis of the ethical considerations for its treatment standards. Nothing could be further from the truth.
SOC8 mentions ethics in a scattered and disjointed manner throughout the document. For example, SOC8 emphasizes the importance of informed consent, a component of the ethical principle of patient autonomy, but does not connect this process to the actual risks and benefits of gender medicine. (Informed consent requires an understanding of the risks and benefits of a proposed medical treatment, as well as any alternative treatments or no treatment.) The standards state that the risks and benefits of gender-affirming medical and/or surgical treatments are not fully known because “it is not possible to know all the potential consequences of a health care treatment” (p. S38). WPATH gets around this inconvenience by asserting that a patient’s understanding of what would be “‘reasonable’ to expect” from gender medicine can be “used as a minimum criterion for [informed] consent” (ibid.). By making these statements, SOC8 implies that a basis for informed consent can be the reasonable expectation that the outcome of medical gender treatment will be positive and beneficial. A patient would not reasonably expect a medical treatment intended to improve a person’s psychological well-being to result in loss of fertility and sexual function, and turn the individual into a life-long medical patient. WPATH appears to trivialize the necessity of understanding these negative outcomes.
While puberty blockers and cross-sex hormones have their own set of negative outcomes, gender-affirming surgery is disfiguring, irreversible, and sometimes results in death. In 1931, one of the earliest patients to undergo transgender surgery, Einar Wegener, alias Lili Elbe, “The Danish Girl,” died as a consequence of a surgical procedure he believed would enable him to function completely as a woman. In the Introduction to his biography, Man Into Woman, An Authentic Record of a Change of Sex, Norman Haire (1892-1952), a physician and sexologist, wrote:
…I cannot help thinking that until we know more about sexual physiology it is unwise to carry out, even at the patient’s own request, such operations as were performed in this case. It would, I think, have been better to try the effect of psychological treatment. [Einar Wegener] might either have been cured, or at least enabled to adapt himself to life. By proper psychological treatment, the duplication of personality [whereby Einar felt he was a dual being, part male and part female] might have been resolved and he might have been enabled to lead a reasonably happy life instead of embarking on a series of painful and dangerous operations which ended only with his death. (“Man into Woman”(American Edition, accessed 9 Dec. 2025.)
By recommending psychological treatment for Einar Wegener to enable him to adapt and lead a happy life, Dr. Haire was effectively promoting what trans activists denounce as “conversion therapy.” SOC8 strongly states that attempts at conversion therapy are unethical. WPATH reveals its dogmatism in the citations included in SOC8 to support the unethical nature of this form of therapy. Most of these references point to a tautological circle-jerk: they assert that conversion therapy is unethical because it is considered unethical. Dr. Haire begs to differ. If Einar Wegener had been treated with psychotherapy instead of surgery, it might have saved his life!
SOC8 cautions against Dr. Haire’s recommendation for therapy when it is not affirming and might attempt to “thwart an adolescent’s expression of gender diversity or [prevent the] assertion of a gender identity other than the expression and behavior that conforms to the sex assigned at birth” (p.S53). WPATH’s standards recommend that in order to be ethical and therapeutic, exploration of gender should affirm and support the patient’s ideas about identity and expression. The document asserts that there are “larger ethical reasons” (ibid.) for therapists to uphold an individual’s subjective gender identity, but fails to specify what they might be. Considering the frequent statements in SOC8 describing transgender and gender diverse people as a marginalized group that is subject to discrimination, it is likely WPATH was invoking the ethical principle of justice.
Throughout the document, SOC8 overvalues and misapplies the ethical principles of justice and patient autonomy. For example, in a brief, three-sentence subsection entitled, “Ethical and human rights perspectives,” SOC8 emphasizes the importance of allowing adolescents to participate in their own health care decisions, another component of the ethical principle of patient autonomy. WPATH ignores the ethical controversy over whether adolescents have the capacity to give informed consent at all. This is especially worrisome considering the permanent effects of gender medical treatment, adolescents’ underdeveloped decision-making skills, limited life experience, and their inability to know or sometimes even imagine their future desires.
Ironically, this tiny subsection on ethics states that puberty is irreversible and that allowing it to progress may have “lifelong harmful effects” (S48). From WPATH’s perspective, it is a human right, an aspect of the ethical principle of justice, to not experience puberty. SOC8 indicates that adolescents have the right to participate in the decision to receive puberty blockers, presumably to avoid the alleged harms of puberty. Nowhere does WPATH hint that puberty itself, the natural biological process of changing from a child to an adult, is a human right. Generally, SOC8 is more concerned with whether transgender and gender diverse individuals might be denied care, a perceived denial of justice in a marginalized and vulnerable group, than whether they have the opportunity to refuse it, the foundation for the requirement of informed consent. The right to withhold consent to treatment is not the same as the right to demand it.
Although justice and patient autonomy are important principles, for any patient to be given the opportunity to consent to a treatment option, the treatment must be ethically and medically justified. In other words, the benefits must outweigh the harms. Gender-affirming medical and surgical treatments can result in blood clots, metabolic changes, decreased bone density, infection, loss of fertility, sexual dysfunction, and permanent disfigurement. We have no good evidence that medical treatments for gender dysphoria are effective or provide more benefits than burdens.
The Cass Review, published in 2024, independently evaluated the evidence behind the provision of gender identity services for children and young people. It found a lack of high-quality evidence to support the routine use of medical interventions for treating gender dysphoria in this age group and advised the use of extreme caution with regard to providing cross-sex hormones to those under age 18. Additionally, in 2025, the U.S. Department of Health and Human Services released a review of the evidence and best practices for the treatment for gender dysphoria in children. This report devoted an entire chapter to ethical considerations and found that the benefits of hormonal and surgical intervention in children do not justify the risks of serious harm. It concluded that pediatric medical transition, even for the purposes of research, is not ethical.
Instead of providing an analysis of the ethics of gender medicine, WPATH included the following statement in SOC8:
The Education Chapter was originally intended to cover both education and ethics. A decision was made to create a separate committee to write a chapter on ethics. In the course of writing the chapter, it was later determined [that the] topic of ethics was best placed external to the SOC8 and required further in-depth examination of ethical considerations relevant to transgender health (p. S248).
To date, WPATH has not published this in-depth ethical examination.
Surgically removing a healthy body part when patients experience dysphoria or a sense that they would be happier or more complete without it is ethically suspect. The ethics committee in Brother David’s case made this clear. Ethical analyses of surgery for patients with BID demonstrate that amputating healthy body parts has enormous risks and consequences that outweigh the patient’s desire to be disabled. Even if patients gave informed consent prior to a lobotomy, the procedure would still be unethical. A similar analysis applies to gender medicine. The risks inherent in gender-affirming medical treatment outweigh the perceived benefits. The principles of justice and patient autonomy cannot compensate for the life-long harms that transgender medical patients will have to endure.
Ethics stopped doctors from surgically castrating Brother David. Ethics guide the decisions of physicians when treating individuals who feel the urge to rid themselves of a healthy arm or leg. Ethics ended the use of lobotomy for the treatment of serious mental illness. Ethics contributed to the Catholic Church’s influence in halting the practice of mutilating boy singers to preserve their youthful voices. If ethics prevented the severing of healthy body parts in these cases, why would a sane healthcare industry promote the surgical removal of healthy gonads and genitalia from individuals who believe their body is the wrong sex?
Epilogue
Brother David’s case study was published in the March 1998 issue of the American Journal of Psychiatry. Brother David had previously given voluntary, informed consent to Dr. Michael Hollifield to share his patient history so that other clinicians might benefit from it. We do not know whether David was able to find a surgeon to perform the orchiectomy he had been seeking. We do know that David was one of the 39 members of the Heaven’s Gate cult who committed mass suicide in March 1997 in an attempt to transform into Next Level beings and be taken away by the spaceship they believed was traveling in the tail of the Hale-Bopp comet. When the chief medical examiner performed autopsies on the bodies, he found that 18 of the victims were men, and eight, nearly half, had been castrated.
To learn more about the authors, Frank Steiner and Polly Davis, please visit their Substack Prank and Folly
Genspect publishes a variety of authors with different perspectives. Any opinions expressed in this article are the author’s and do not necessarily reflect Genspect’s official position. For more on Genspect, visit our FAQs.