A Bioethics Perspective on Sex Reassignment TherapyLaura Purdy

Professor Emerita Wells CollegeApril 2015

Why might one want to look at the bioethics of Gender Identity Disorder (GID) or transsexualism? The need for humility is great,1 the terrain slippery and hazardous.2 The difficulties start from the outset with the question what to call the condition,3 given that the DSM-IV description of the transsexualism (“Gender Identity Disorder,” or GID4) implies thatit is a disease, which some activists vehemently deny.5 The

1 See C. Jacob Hale, Suggested Rules for Non-Transsexuals Writing about Transsexuals, Transsexuality, Transsexualism, or Trans________. Accessed August 16, 2011, at http://sandystone.com/hale.rules.html.2 Alice D. Dreger, The Controversy Surrounding The Man Who Would Be Queen: A CaseHistory of the Politics of Science, Identity, and Sex in the Internet Age. Arch Sex Behav 2008; 37: 366-421; for related problems, see Tia Ghose, Chronic Fatigue Scientists Get Death Threats, The Scientist, August 23, 2011.3 I use the terms interchangeably, deliberately to underline my view that it is possible to reach useful conclusions without taking a stand on whether the condition is a pathology.4 American Psychiatric Association, 1994. Diagnostic and Statistical Manul of Mental Disorders. (SM-IV), p. 823.5 Dreger writes: “. . . as long as they talk of any kind of transsexuality as a paraphilia, I think it is unlikelyBlanchard’s theory will find anything like general acceptance among politically conscious trans people who, understandably, are sick and tired of being treated as if they suffer from a pathology” (p. 416). More generally, activists are concerned about viewing gender nonconformity, rather than distress caused by it, as pathological. (See GID Reform Weblog, by Kelley Winters, 2013, http://gidreform.wordpress.com/category/dsm-5-2/, accessed 9/3/2013.) See C. Jacob Hale, Suggested Rules for Non-Transsexuals Writing about Transsexuals, Transsexuality, Transsexualism, or Trans________. Accessed August 16, 2011, at http://sandystone.com/hale.rules.html. Alice D. Dreger, The Controversy Surrounding The Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age.

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worries connected with this issue appear to be at least somewhat reduced now that “Gender Dysphoria” has been substituted for GID in the recently published DSM-5, and has been removed from “Sexual Dysfunctions and Paraphilic Disorders.” It is now in a category of its own.6 However, as the title of the DSM-5 is “Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (emphasis mine), this move could be construed as window-dressing.7 More generally, as James L. Nelson suggests, not

Arch Sex Behav 2008; 37: 366-421; for related problems, see Tia Ghose, Chronic Fatigue Scientists Get Death Threats, The Scientist, August 23, 2011. I use the terms interchangeably, deliberately to underline my view that it ispossible to reach useful conclusions without taking a stand on whether the condition is a pathology. American Psychiatric Association, 1994. Diagnostic and Statistical Manul of Mental Disorders. (SM-IV), p. 823.

Dreger writes: “. . . as long as they talk of any kind of transsexuality as a paraphilia, I think it is unlikelyBlanchard’s theory will find anything like general acceptance among politically conscious trans people who, understandably, are sick and tired of being treated as if they suffer from a pathology” (p. 416). More generally, activists are concerned about viewing gender nonconformity, rather than distress caused by it

6 See the Gender Dysphoria Fact Sheet, www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdfAccessed 9/2/2013.7 The lack of clarity here is somewhat understandable, given the DSM’s track record on homosexuality. The DSM-5 defines “mental disorder” as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning (p. 18). Gender dysphoria is defined as “clinically significant distress or impairment in social, occupational or other important areas of functioning caused by “a marked incongruence between one’s experienced/expressed gender and assigned gender “ (pp. 452-3). There is thus no dysphoria in the absence of distress/impairment. However, it seems more than a bit strange to declare that distress or impairment due to a particular cause constitutes a mental disease (when the cause itself is not a disease), since it would seem that the DSM would now have to be littered with diseases constituted by suffering/impairment arising from a huge range of possible causes that are not obviously diseases in themselves. This interpretation is in part blocked, though, by the following caveat in the definition of a mental

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everyone may be up for braving the anxieties generated by questions about the sex/gender system that lie at the heart of transsexual issues.8

Despite these obstacles, there are clearly moral and conceptual questions here calling out for scrutiny. A good starting point is the website for GID Reform Advocates (GidReform.org, which lays out this Vision for reform policy:9

It is time for the medical professions to affirm that difference is not disease, nonconformity is not pathology, and uniqueness is not illness

It is time for culturally competent psychiatric policies that recognize the legitimacy of cross-gender identity and yet distinguish gender dysphoria as a serious condition, treatable with medical procedures.

It is time for diagnostic criteria that serve a clear therapeutic purpose, are appropriately inclusive, and definedisorder on the basis of distress or impairment and not uponsocial nonconformity.

It is time for medical policies which, above all, do no harmto those they are intended to help.

disorder: “an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.” Even more confusing, “socially deviant behavior . . .and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual . . . . “ (p. 18) So, is the relevant incongruence such a dysfunction? Is it a commonstressor or loss? Are the suffering/impairment merely a result of conflicts between the individual and society—not underlying dysfunction? Considerable further inquiry seems to me to be needed to answer these questions in a coherent and plausible way. 8 James L. Nelson, The Silence of the Bioethicists: Ethical and Political Aspects of Managing Gender Dysphoria, GLQ 1998;4(2): 213-230. See also, SusanStryker, 2008. Transgender History. (Berkeley, CA: Seal Press), especially chapter 4.9 Kelley Winters, GID Reform Advocates, accessed August 12, 2011.

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These points about the need for respectful care, and the conceptual and moral tangles lurking in them, demand attention, despite the relatively “boutique” nature of the topic, compared, say, to universal access to quality health care or the health implications of climate change. Nonetheless, the issue also connects upwith broader questions, such whether the military may legitimately withhold treatment desired by those it has power over, such as Chelsea Manning, and, more broadly, the appropriategoals of health care in general.

I start my examination by focusing on sex reassignment treatments (SRT)10 intended to help transsexuals alter their sex characteristics, arguing that they raise moral red flags and create genuine conflicts in values that can be difficult to sort out in a satisfying way.11

I conclude that it would be morally inappropriate to preventtreatment for those experiencing incongruence between their senseof who they are and their physical sex characteristics. But this conclusion is far more guarded than one might expect on the basisof the explosion of normalizing attention to this topic in the last few years, together with the predominance of autonomy in bioethics. To counteract these factors, I believe that it is necessary to dig into the sometimes gory details more deeply thanmight otherwise appear to be necessary, and to consider modified approaches that could most safely lead to the desired life for those experiencing such incongruity. Only this path can take truly seriously the suspected and unknown risks in current invasive treatment, and incorporate the worthwhile insights from the burgeoning literature on medicalization, and, in particular, feminist caution about expanding reliance on medical technology.

10 I use SRT broadly to cover both surgery and hormones; SRS covers just surgery.11 Of course these procedures raise a variety of interesting issues that must be left for another day. Among them is the question whether they collude in transsexuals’ deception of sexual partners. Michael Lavin considers this question in his intriguing 1987 paper Mutilation, Deception, and Sex Changes, concluding that there is no such deception, although he fails to consider the possibility that such sex partners might also want children. (J Med Ethics, 13: 86-91.)

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These concerns also motivate my comments about the basis for suchexperiences of incongruity.12

SEX REASSIGNMENT THERAPIES

The two main types of sex reassignment therapies are hormones and surgery, although of course the details differ for males who desire female characteristics and females who desire male ones (“MtF” and “FtM”).

Primary and secondary sex characteristics are evident throughout the body, and so, for those who want, are medically eligible for, and can afford, the full monty, there is a breathtaking array of possible treatments. Males who want more feminine bodies can have their penis and testicles removed, with some of that (or other) tissue used to create a “neovagina,” and clitoris. They can also have their face and throat surgically sculpted for a more feminine look, which may involve reducing thelarynx, jaw, and nose, and smoothing the forehead. They can also take estrogen to reduce face and body hair, and change the distribution of their body fat. Surgery and hormones can also create breasts. Women who want more masculine bodies can have their uterus, ovaries and breasts removed, and a penis and scrotum created surgically. They can also take testosterone to grow more facial and body hair, and to become more muscular. To judge by photos available in articles and on the web, these treatments can be astoundingly successful at making individuals look like members of their desired sex.13

At the same time, it is clear that these may be vast bodily changes, and many of the treatments are deeply invasive. Thus, like all medical treatments, they involve some degree of risk. A closer look highlights both the known risks and the unknown ones.

Hormones

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13 See for example photos of Loren Cameron, and Andrea James, at (respectively), http://hrexach.wordpress.com/2014/02/02/loren-rex-cameron-transgendered/ and http://en.wikipedia.org/wiki/Andrea_James.

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Estrogen is a powerful drug. In women, even at “normal” low doses, it is known to increase risks for very serious health problems. The Women’s Health Initiative found that Hormone Replacement Therapy previously recommended for most menopausal women (without adequate previous study)14 increased rates of heart attack, blood clots, stroke, and breast cancer.15 And, contrary to previous assertions that HRT protects the brain, the study showed that it could double the rate of dementia.16 Other widely prescribed forms of estrogen, such as DES and (especially,early high-estrogen formulations of ) The Pill also caused significant harm.17

Can these results be extrapolated to men? We don’t know.18 Studies needed to provide the answer are apparently not being done, and there are serious obstacles to such studies in any case. These therapies have a relatively short history, the numberof patients is small, the specific treatments are evolving, and as we will see later, follow-up could be much better. Most studies so far are relatively short-term, which underlines the

14 For a short account of the problem, see Amy Allina and Cindy Pearson, Now the Truth is Known, Women’s Health Activist Newsletter. September/October 2001, http://nwhn.org/now-truth-known (accessed 2/13/2014)..15 For a summary of the WHI findings, see Menopause Hormone Therapy Overview Fact Sheets at http://nwhn.org/menopause-hormone-therapy-overview (accessed 3/8/2014). Among its other findings, the WHI estrogen+progestin arm of the study found that it might increase ovarian cancer, a finding supported by subsequent studies. (See the National Women’s Health Network Fact Sheet Menopause Hormone Therapy and Ovarian Cancer, updated May 2012, and accessed 3/8/2014).16 See Jonathan Raymond, Hormone Therapy and Cognitive Preservation—Now a Distant Memory, Women’s Health Activist Newsletter, September/October 2009, available at http://nwhn.org/hormone-therapy-and-cognitive-preservation-%E2%80%93-now-distant-memory (accessed 3/8/2014.).17 See Barbara Seaman, 1983. Women and the Crisis in Sex Hormones New York: Bantam. .18 See Susan’s Place Transgender Resources, Estrogen Therapy for MTF Transexuals, at http://www.susans.org/reference/hormones/estherap.html, (accessed 3/8/2014).Another page on this site (Hormones: Dream Goal or Time Bomb? http://www.susans.org/reference/hormones/hormoneb.html) has an anonymous essay warning of eventual sterility, and mood disturbances, as well as social problems, especially difficulties in social acceptance. Naturally, we need solid data about these issues to make good policy.

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difficulty of discerning long-term consequences in these relatively young and healthy populations. There is no possibilityof doing double-blind, randomly controlled studies. Hence, there are no good data to relieve worry about the potential effects of such large amounts of estrogen on male bodies, especially over the long-term.19 All informed consent procedures can do is emphasize that much is unknown, including whether patients might be at considerably greater risk of developing lethal diseases prematurely.

Because of the ratio of MtF and FtM (3/1), women seeking treatment face an even more worrisome dearth of information aboutthe effects of the hormones they are taking. How safe is testosterone taken for many years, in the large quantities neededfor the bodily changes they seek? We don’t know.20

A few years ago, the FDA refused to approve a testosterone patch for women (Intrinsa) because studies showed a small but statistically valid increase in breast cancer, and researchers also concluded that there is some reason for believing that there

19 MtFs may be prescribed doses 10 times higher than those prescribed for women. (Eva Moore, Amy Wisniewski, and Adrien Dobs, Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects, J. Clin. Endocrinol. Metab. 2003;88 (8):3467-3474.) Moore et al. also write that “results from our survey of MTF transsexual people demonstrated markedly elevated hormone doses and even greater complexity in their treatment regimens. Estrogen doses were often at alarming levels, and multiple formulations were used” (p. 3471). It is known that they may be obtaining unregulated drugs on the street, either because they cannot obtain them from medical sources or, to supplement their regular prescriptions, on the theory that if some is good, more is better. 20See Susan R. Davis, Should Women Receive Androgen Replacement Therapy, and If So, How? Clin Endocrinol (2010); 72(2): 149-150. Four references in this paper address the issue of safety. Two comment on the need for additional study of possible long-term effects. One finds no evidence of increased risk of breast cancer, but the median treatment duration was 1.3 years, and mean follow-up was 6.7 plus or minus 4.6 years. The most intriguing one studied women on standard HRT with and without the addition of testosterone; it found that those on testosterone had noticeably lower rates of breast cancer. However, average duration of testosterone therapy was 5-6 years, and mean duration of follow-up was 5.8 years; in addition, the study groups were small.Thus none of these findings give us much guidance, either about long-term risks for breast cancer, or for other diseases.

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might also be elevated risk of cardiovascular diseases.21 Intrinsa was designed to deliver 300 micrograms of testosterone aday; FtMs may be taking far higher doses. Moore et al. report that “retrospective data from 293 patients report no change in mortality, but the population [studied] may not be large enough to assess more subtle differences in morbidity and mortality” (p.3470).22 And, again, cancer or heart disease may take many years to develop.23

In addition, a few FTMs are now becoming pregnant after some transitional treatments. Do past or current hormonal treatments put these babies at risk?

Surgery

As we have seen, surgeries for MTFs may include excision thepenis and testicles, construction of a vagina and clitoris, breast creation, and facial feminization. As with any surgery, the results may fall short of what is desired, such as when the neovagina turns out to be too short for full penetration or the breasts viewed as too small.24 Or, the near-term aftermath may be21 Steven Nissan, consultant to the FDA committee.22 The Tom Waddell Center warns of additional possible adverse effects, such as increased weight, erythrocitosis, liver enzyme elevations, coarsening of skin, headache, emotional changes (such as increased aggressiveness), male pattern baldness, and hyptertension. Moore et al. add stroke, polycystic ovarian disease, endometrial hyperplasia, and perhaps ovarian cancer.23 Levy et al. conclude somewhat reassuringly that “complications, principallyvenous thromboembolism in male-to-female and potentially osteoporosis in female-to-make, are highly amenable to treatment” p. 16 (A. Levy, A. Crown andRussell Reid, Endocrine intervention for transsexuals, Clin Endocrinol 2003; 59, 409-418. However, earlier in the paper, they emphasize the significant risk ofthe former (412). And, the difficulty of disambiguating the risks of gender dysphoria itself and its treatment (411). But again, this is a relatively short-term perspective, underlain in part by concern that risk of suicide fromfailure to treat dwarfs the risks of treatment. However, this population has significantly higher risk of suicide—as well as psychiatric problems and overall mortality—even after SRS. See Cecilia Dhejne et al., Long-Term Follow-Upof Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden, PL0S One 2011;6(2): e 16885.24 Levy et al. state that “unfortunately, only one-third of transsexuals achieve more than a B cup and with 45% not advancing beyond an A cup, at least

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painful or dangerous developments, such as necrosis of the vaginaand labia, fistulas between vagina and bladder or bowel, or stenosis of the urethra. Breast surgery can cause infection or capsular fibrosis. Facial feminization can lead to nerve injuriesand bone infections, or injury to the vocal cords. Not too surprisingly, given the technical challenges, genital surgeries for FTMs tend to be less satisfactory overall than those for MTFs, and mastectomy may cause nipple necrosis or serious scarring.

Of course, conscientious surgeons and physicians monitor treatment outcomes, insofar as they are able, and it is reasonable to believe that this is leading to continual improvements in immediate and short-term outcomes. However, because of the obstacles to solid research in this area, these are really innovative therapies, not well-grounded medicine, and thus patients are to some extent guinea pigs in a poorly regulated experiment.25

This point is reinforced by a pair of recent follow-up studies. One found that fifteen years out, overall satisfaction with health, personal, physical and role limitations in those whohad had sex reassignment surgery were significantly lower than that of control subjects.26 The other looked in more detail at the consequences of surgery for pelvic floor functioning.27 It found a relatively high incidence of problems, including

60% require breast augmentation to achieve the appearance they desire or at least find acceptable” (413). This issue raises additional questions about noxious social norms regarding desirable breast size, of course.25 See, for example, a comment by Deirdre N. McCloskey, in her 1999 memoir, Crossing: A Memoir (The University of Chicago Press (Chicago and London).. She writes: “Her medical glitches such as her nonfunctioning vocal surgery or her nonfunctioning urethra or her nonfunctioning facelift often made her cry. . . “ (p. 208). Of course, given the obstacles to truly solid medical research, this appears to be true of therapies for many other problems as well. See David H. Freedman, “Lies, Damned Lies, and Medical Science,” http://www.theatlantic.com/magazine/print/2010/11/lies-damned-lies-and-medical-science/308269/, accessed 7/29/ 2013.26 Annette Kuhn, Christine Bodmer, Werner Stadimayr,Peter Kuhn, Michael D. Mueller, and Martin Birkhauser, Quality of Life 15 Years After Sex Reassignment Surgery for Transsexualism, Ferti and Steril, November 2009; 92(5): 1685-1689.

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prolapse, and bladder, bowel, and sexual problems. Obviously, there need to be more such follow-up studies to see whether thesefindings are replicated.

All of these issues are moral red flags.

ACCESS TO TREATMENT

Some transsexual activists call for unfettered access to SRT. Is the foregoing information sufficient grounds for resisting that call?

In the bad old days of paternalistic medicine, physicians were in charge of treatment decisions and could deny access or even, in some cases, impose care on patients without their consent. In the 1960s, this presumption was overturned in favor of a client-based professional model that left much decision-making in the hands of patients.28

This revolution aimed to put the power to choose among the therapies on offer firmly in patients’ hands. Informed Consent (IC) was intended to be the vehicle for doing so. It required that patients be informed about the pros and cons of proposed care, and its alternatives, and that they be encouraged to consult their deepest wishes and values and resources, reconciling them with an informed understanding of their own bestinterests. Untouched was the extent to which patients had a rightto treatments providers might be reluctant (or refuse) to offer, a key issue here.

27 A. Kuhn, A Santi, and M Birkhauser, Vaginal Prolapse, Pelvic Floor Function, and Related Symptoms 16 Years after Sex Reassignment Surgery in Transsexuals, Fertil and Steril 2011; 95(7): 2379-82. They write: “Of the 55 transsexuals who participated in this study. . . .7.5% showed a prolapse greater than or similar to ICS-POP stage 2, and 3.8% required surgical intervention. For bladder symptoms, 47% reported voiding difficulties, 24.6% urgency, 17% urge incontinence, and 23% stress incontinence. Fecal urgency andincomplete emptying of the bowel occurred in 9.4% and 7.6% of patients, respectively. In addition, 23% reported that they were never satisfied with their sexual function” (2379).28 Of course, in some cases, health care personnel sometimes still treat without consent. Some such cases involve the violation of informed consent laws; in others, society—for better or for worse—grants providers the power tooverride patients’ preferences.

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The partial nature of this revolution is reflected in two quite different proposals for an SRT standard of care.29 On the one hand, the Harry Benjamin Standard lays out a series of demanding conditions for SRT candidates before they are offered full services.30 On the other, the Health Law Standard proposes only minimal conditions for such services.31

In short, the Benjamin Standard makes physicians gate-keepers, whereas the Health Law Standard empowers those who seek treatment. This allocation of authority reflects an underlying disagreement about medicine’s role in society. The traditional view is that it should treat disease and disability. The alternative is that if a condition can be ameliorated by medical expertise, such measures may be appropriate even if it is not considered a disease or disability.

This is a much debated issue. Among the drawbacks of the traditional view are the problems of defining “disease” and “disability” and the exclusion or noxious medicalization of contested procedures such as abortion that some find immoral or distasteful as the skills needed for them are monopolized by those with medical licenses.32

Excluding contested procedures from health care leaves thosewho want such treatment to the black market and the dangerous ministrations of the untrained. Thus, for example, many transsexuals apparently already supplement their prescribed drugswith possibly unsafe, unregulated street drugs, or rely on them altogether, leaving them unmonitored for dangerous side-effects. Untrained “pumpers” are also apparently injecting thousands of

29 See Nelson.

30 Now the WPATH (World Professional Association for Transgender Health) Standards of Care; see http://www.wpath.org/publications_standards.cfm, accessed 7/23/2012.31The first is that the patient has no health problems that will be worsened by the care; the second is that patients agree to minimal follow-up testing. (Nelson, p. 219ff.)32 Just for example, see my “Medicalization, Medical Necessity, and Feminist

Medicine,” Bioethics, vol. 15(3), June 2001, 248-61..

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transwomen with liquid silicone to mimic the female curves they crave, with sometimes disastrous results.

Medicalization can have similarly undesirable consequences, as the GD debate shows: those who want treatment (or want it paidfor by insurance or national health care systems) are labeled “diseased,” even where it’s unclear whether that they fit the criteria for this label.

The alternative—viewing health care as a means for preventing suffering and enhancing human welfare—rather than fighting disease—most clearly advances the transfer of power overcare from medicine to patients. It also safeguards rights to helpwith conditions—like unwanted fertility or pregnancy—that are notdiseases but need medical skills. Adopting this alternative view of medicine’s social role also enables us to finesse the vexed question whether GD (or some forms of it) is a disease. As is evident from the GID Reform Advocates Vision, even the activist community is unsure about exactly where to come down on this issue and how to reconcile the need for care with the assertion that the condition is not a disease. Given the current lack of clarity about the underlying nature and causes of GD, such agnosticism is, it seems to me, the most appropriate stance.

These considerations argue for the relatively laissez-faire approach to SRT implied by the Health Law Standard as a starting point for discussion. Thus the burden of proof should rest with those who would limit or ban SRT.

Alas, agnosticism about the nature of GD, and a preference for client-centered medicine rather than a more paternalistic model does not resolve all these questions, given that there might still be good reasons for limiting access to certain types of care.

One, as Nelson points out, is that opening up medicine to any desired treatment “marginalize(s) the agency of service providers” (p. 224). Quite apart from GD, this is currently a hugely contested area in medicine.

Reluctance to provide desired services can be fueled by professionals’ personal (and sometimes questionable) moral stands, such as a belief that contraception, sterilization, abortion or euthanasia is morally unacceptable. But doubts could

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also arise from practitioners’ principled concerns about the the balance of risks and benefits of a given procedure.

Given the worries raised here about some elements of SRT, itwould not be surprising were health care providers reluctant or unwilling to offer them. But there appear to be enough willing providers so that is not an issue. Are these providers merely business people cynically providing well-compensated services, regardless of whether they believe them appropriate or beneficial? Motivations can be notoriously difficult to determine, but the tenor of the literature on SRT suggests that many truly are deeply concerned about the welfare of their patients and that they believe SRT to be currently the best hope for relieving their suffering, despite its risks.

More generally, the laissez-faire approach raises huge problems about the allocation of scarce medical resources in the face of almost unlimited demand and the difficulty of drawing anylines at all between permissible and impermissible procedures, especially where such health care is socially provided.33 Until these broader issues are resolved, procedures need to be examinedon a category by category basis.

Do concerns about the allocation of scarce medical resourcesjustify limiting or prohibiting access to SRT? This position should be a hard sell, at least in the U.S., as many other “lifestyle” treatments, such as cosmetic surgery, are available, at least to those who can pay for them. Blanchard also makes a strong case for public funding in the Canadian medical system.34 It follows that except perhaps for impoverished countries still focused on the very most basic medical services, SRT should be both available and funded socially or by at least some insurance companies.

But what, then, about the risks of the more invasive treatments described here, risks that further research might reveal to be still greater than we now imagine? Can IC protect patients from very risky treatments or is there a case for

33Most of the literature focuses on health care providers, but I see no logical limit to the assertion that one has a right to withhold services to anyone in any realm if one can link that refusal to some “religious” claim.34 Ray Blanchard. The Case for Publicly Funded Transsexual Surgery, Psychiatry Rounds 2000; 4(2), 4-6.

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paternalistically limiting of access to them, even within the context of the relatively laissez-faire conception of medicine? This question is even more pressing in cases like this one where there is considerable lack of clarity about how well they satisfytheir needs and desires, as we have seen.

The next section of this paper will explore this issue in more detail.

IC, Risk, and Satisfaction

As we have seen, informed decision-making requires both solid information to guide choices, and a supportive environment that encourages rigorous and thorough self-examination. The difficulties of providing the latter, especially in fee-for-service medicine, are well-known. Clearly, they are very general,and not limited to this case; however, they are particularly troubling here given the emotional intensity that accompanies GD together with the invasive or irreversible nature of some treatments.

Thus I will focus here on the information component of decision-making. Although we appear to know quite a bit about thepossible short-term health risks of some of the treatments,35 this is clearly not true for longer range ones.36 These potentiallong-term effects are the most worrisome from the perspective of IC. We do know that humans tend to discount potential harm when arealistic assessment of their nature and/or probability would strongly urge one to pull back from a desired course; this tendency is especially powerful when that harm is somewhat speculative. Of course, should such harms materialize, one might later regret one’s earlier choices. This is a serious concern, and patients who are trying to decide whether to go forward with

35 However, I have been unable to find much information about the incidence ofthese nearer term problems, and it is a bit unclear about the extent to which the information we do have is biased by small samples, etc.36 I have already raised worries about lethal diseases like cancer and heart disease. But we need to know much more about other potentially serious problems. For example, what percentage of surgical patients later have major problems connected with those surgeries? Consider the detailed findings of theaforementioned long-term study by Kuhn et al. (n. 25).

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treatment need to be aware—at the gut level—of its implications for their own best interests.

Equally important—and elusive—is solid information about theoverall benefit of SRT. Much of the literature I have examined, especially the more popular pieces, maintains that satisfaction with SRT is very high. Moreover, leading scholars, such as Dreger, are convinced that (at least MTFs) generally are benefitted.37 However, it seems to me that although some researchers have worked tireless to find answers, the studies shecites are somewhat limited, so that further research and analysisis needed here.

Several different issues are at stake. Most fundamentally, can the methodological requirements for valid and useful researchbe met here?

Psychoanalytic psychiatrist Ethel Spector Person, contemplating some difficult cases she dealt with, raises a key question when she points to “the hazards of thinking we could ever be certain of the ultimate resolution—or lack of resolution—at which patients with cross-gender disorders arrive” (p. 265).” She also argues that it is “the very nature of the disorder” thatengenders key difficulties with follow-up. In particular, she points to the fact that significant numbers of patients disappear. Would their inclusion change the outcome of the studies? No one knows. Snaith et al. who lay out standards for evaluating outcomes, follow-up study is meaningful only once patients have had enough time to adjust to their new situation.38

They also require that follow-up be undertaken by an independent research team, not the SRT team. As well, the criteria chosen forevaluating the value of the outcome should be “realistic to the condition.” In other words, it is unreasonable to expect major personality changes, “social success,” or a better job with higher pay.

37She asserts, defending the work of Ray Blanchard and Anne Lawrence, that they “have done the work to show that [MTFs} generally are better off” after it (Dreger, p. 416).38 This raises the question of how long after treatment is long enough, both in terms of adjusting to the changes, and allowing enough time for potential problems (such as those mentioned above) to emerge.

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This last point on Snaith et al.’s part may have been intended as a criticism of one of the earliest, and most influential attempts to measure the value of sex reassignment surgery (SRS).

The famous (notorious!) John Money was instrumental in founding the first Gender Identity Clinic, at Johns Hopkins University, in 1966. In 1969, psychiatrist Jon Meyer took over the clinic, bringing uncertainty about the value of SRT to a head. After doing a study to determine the benefits of surgery, he concluded that

To say that this type of surgery cures psychiatric disturbances is incorrect. We now have objective evidence that there is no real difference in the transsexuals’ adjustment to life in terms of jobs, educational attainment,marital adjustment and social stability.39

By 1979, Meyer’s position had hardened still further, and he and DJ Reter published an influential study reaffirming the view thatsince GID is a psychiatric disorder, physical treatments were inappropriate. They buttressed this position with the results of a study for which they had developed a series of allegedly objective criteria of the kind mentioned above to measure the results of surgery. Their study of JH “graduates” using those criteria led them to conclude that there was no difference in quality of life for those who had had SRS and those who had not.40

The debate that followed suggests that their criteria were questionable.41 Nonetheless, their paper ended the heyday of such

39 Laura Wexler. Identity Crisis, Style Magazine January-February 2007.40 Meyer, J K, Reter, DJ. Sex Reassignment, Arch Gen Psychiatry, 1979; 36:1010-1015.41 See, for instance, R. Blanchard, and P. M. Sheridan in R. Blanchard and B. W. Steiner (Eds.). 1990. Clinical Management of Gender Identity Disorders in Children and Adults, pp. 159-189. Washington, D.C., American Psychiatric Press, and Michael Fleming, Carol Steinman, and Gene Bocknek, Methodological Problems in Assessing Sex-Reassignment Surgery: A Reply to Meyer and Reter, The International Journal of Transgenderism, April-June 1998; 2(2), op 1980 in Arch Sex. Behav., 9:451-456.

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university-based GID clinics. Most SRT moved to the private sector, which, among other consequences, much reduced the impetusfor serious research on the issue.42

The critiques of Meyer and Reter’s paper spurred new interest in subjective measures of success. This opened up worthwhile new paths of inquiry, despite what seems to me to be premature loss of emphasis on developing better objective measures.

Blanchard & Sheridan (1990) survey many significant studies emphasizing subjective measures of satisfaction and regret, and summarize their conclusions as follows:

Currently available evidence indicates that operated transsexuals improve both before and after surgery. Preoperative improvement in mood and social adjustment is related to the nonsurgical aspects of gender reorientation: adopting the cross-gender role among friends, family, and strangers; choosing an opposite-sex name and obtaining new documents that bear it; getting a job or enrolling in schoolin the cross-gender role; commencing hormone treatment; and so on. Further, postoperative improvement relates to surgical simulation of the opposite-sex phenotype. In some jurisdictions, postoperative improvement in social or economic functioning may also relate to the legal consequences of sex-reassignment surgery, namely, the ability to change the stated sex on passports, driver’s licenses, and birth certificates (Blanchard & Sheridan, p. 186).

Such studies have also provided more helpful details. For example, one study suggests that not all the prerequisites required by the Harry Benjamin Standard satisfaction with SRT. A second potentially important piece of the picture is support for the view that homosexual transpeople are much less likely to regret SRS than heterosexual transwomen (B & S, p. 184). Moreover, it appears that overall satisfaction is—not too

42 See Stryker for an account that finds this move beneficial, in that it wrenched power to define and treat transsexualism from mainstream medicine; see Stryker.

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surprisingly—in large part a function of the aesthetic and functional results of their surgeries. See, for example, the caseof Nathan Verhelst, who was so horrified by the results of his treatment that he requested, and got, euthanasia, in Belgium.43 This suggests, as for any complicated procedure surely, that it should be done only in very large centers with a high volume of patients (B & S, pp. 182-183). It’s also useful to have support for the commonsense suspicion that wariness about treatment is positively correlated with later regret (B & S, p. 188).44

Oddly, there appears to be a relative dearth of detailed studies of the extent to which those who have undertaken SRS are happy with their sexual function (as opposed to whether they are in a relationship), and the findings are in any case somewhat inconsistent. The best conclusion that it seems possible to draw from the sparse information is that something like half have outcomes they regard as satisfactory.45 Another study, again oddly, shows considerable satisfaction in transwomen with neovaginas, despite the empirical finding that many are too shortfor full penetration. Given the importance of sexual satisfactionto most people, inattention to this subject, together with the

43 Tracy Miller, Belgian Transsexual Dies by Euthanasia after Unsatisfactory Sex Change Operation, Daily News, available at Accessed February 7, 2014, http://www.nydailynews.com/life-style/health/belgian-transsexual-dies-euthanasia-botched-sex-change-article-1.1473875, accessed 3/8/2014.44 For a more recent but limited overview ( of MtF), see Anne A. Lawrence. Factors Associated with Satisfaction or Regret Following Male-to Female Sex Reassignment Surgery, Arch of Sex Behav 2003: 32(4): 299-315.45 The two relatively recent articles on this topic provide only limited information as well. See Griet De Cuypere et al., Sexual and Physical Health After Sex Reassignment Surgery, Archives of Sexual Behavior 2005 (34(6):679-690, and Anne A. Lawrence, Sexuality Before and After Male-to-Female Sex Reassignment Surgery, Archives of Sexual Behavior. 2005; 34(2):147-166. The latter provides an overview of previous research, with results that are all over the map, 145-151. The specific study she is reporting on suggests greater sexual satisfaction. Overall though, studies are limited, and firm information is scarce. In addition, missing are good comparisons with sexual functioning in the general population. Laumann et al. found in their national survey that 24%of US women said that within the last 12 months, there had been a period of several months or more during which they had been unable to achieve orgasm (1994). However, perhaps the appropriate comparison group should be untreated men, who are presumably are much more reliably orgasmic. Also, see Kuhn et al.

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apparent lack of (reported?) distress about impaired or absent orgasm is truly puzzling.

Perhaps shyness or puritanism about addressing sexual pleasure can explain some of this. Or perhaps the methodological problems inherent in reliance on subjective reporting could shed some light here. For instance, it might be very difficult to facethe fact that the results are not all one had hoped for after such radical therapy. There may be other reasons as well why people don’t report their feelings accurately. Or, perhaps relieving the suffering wrought by the feeling of being in the wrong skin makes sexual satisfaction less important?46

It is thus clear, all things considered, that there is an urgent need for much more broad-ranging and comprehensive research about the risks, benefits, and outcomes of SRT in order to provide candidates with the very best information.

WHAT NOW?

Given the legitimate concern that significant elements of SRT may not be safe and effective for all who want it, what can we conclude about whether medicine should be offering it?

In favor of doing so is the promise to relieve significant suffering on the part of those who experience a strong and steadfast desire to live as a different sex, suffering that, unrelieved, raises suicide rates in this population. Studies—albeit less solid than one would like—do suggest that somewhere between a half and a majority of those who undertake some form ofSRT feel benefited by it. Moreover, as Blanchard pointed out in a2000 article, at present there is little else on offer:

If a non-surgical cure for transsexual feelings was within sight—say 3-4 years away—attending clinicians should and would advise their transsexual patients to wait for the

46 This seems to be a plausible interpretation of McCloskey comment that “Dee didn’t care when he lost the use of his penis for sexual purposes afew months after starting on hormones; Deirdre didn’t care when at last in Australia she said good-bye to it, and she didn’t care any time afterward” (p. 188).

And, Nelson, personal communication.19

cure, rather than undergo irreversible and merely palliativetreatment. The reality is that we are perhaps decades away from the most basic scientific understanding of normal gender identity, let alone any prospect of treatments that would reverse cross-gender identity in transsexual adults. To recommend to patients presenting today that they accept no treatment short of a “cure’ is to recommend that they relinquish their hopes for salvaging a blighted and tragic life—something few of us would be willing to accept for ourselves or for our friends.47

Thus SRT has much in common with other medical treatments now available, such as in vitro fertilization or kidney transplants. Much as we may worry about their use, overall, there is a strong case for access to those for which there is the best evidence of benefit, especially in the age of medical tourism.48 In fact, many such procedures are, in Lewis Thomas’ words, “half-way technologies” that provide some relief for a problem by addressing its symptoms rather than the underlying cause. It follows that denying access to SRT would require either showing that there is a morally relevant difference between it and these others or that some or all of these other technologies should also be prohibited

This way of conceptualizing SRT points the way to a better near-term future via practical, relatively narrowly focused research. What psychosocial measures would most help those with GID? Who is most likely to find that SRT worsens rather than improves their situation, and how could they be most helped in other ways? What are the longer-term risks of various elements ofSRT? To what extent—given the monumental changes that those with GD seek—would it be possible to develop safer invasive procedures?49 Can we get a better take on those for whom SRT willreduce the risk of suicide, and on those for whom it may not?

47 Ray Blanchard. The Case for Publicly Funded Transsexual Surgery.

48 For an analogous argument, see “In Vitro Fertilization Should Be an Option for Women,” in Contemporary Debates in Bioethics, eds ArthurL. Caplan and Robert Arp (John Wiley & Sons, 2013).

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It is possible that we may ultimately get good evidence thatat least some elements of current approaches are not satisfactoryand/or are so dangerous to patients’ health and well-being that they should not be available. If so, the demand for them will surely diminish and/or practitioners may refuse to offer them. Those eventualities would not, by themselves, constitute paternalism. If the failure to advance patient interests were sufficiently strong, I expect that the relevant professional societies would issue guidelines limiting some forms of SRT, rooted at least in some form of futility, as well, perhaps, as the injunction to do no harm. Perhaps this might be viewed as a weak form of paternalism, although perhaps not if it could be shown that patients’ emotional investment in them impaired their ability to make good judgments about such treatments. But we are nowhere near there yet, and given the moral superiority of the non-medicalized conception of medicine, the burden of proof remains on the shoulders of those who would limit access now.

One complication here is the still widespread hostility toward those who don’t fit mainstream sex or gender stereotypes, hostility that can lead to violence—even lethal violence—toward those at risk. As McCloskey comments,

On all counts it is better for a gender crosser to pass rapidly to the other side, and making the crossing rapid ought to be the purpose of medical intervention, such as facial surgery, and social interventions, such as counselingon gender clues. . . a nose job or a facelift or electrolysis that will make the gender crosser passable willalso make her less likely to be scorned or raped or killed—at any rate at no more than the shocking rates for genetic women (p.163). But those treatments won’t necessarily be theleast invasive or irreversible, so a delicate balancing act will be required to reconcile these two aims.

This state of affairs also underlines the need for basic research aimed at definitive treatments. Given the lack of clarity about the underlying nature and causes of GD, the current49 See for example De Cuypere et al.. This group attempts to minimize exposureto hormones (687).

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paucity of alternatives to SRT is not surprising.50 In the meantime, further research into additional measures that could help transsexuals adjust after treatment is clearly urgent as well, given the documented and potential physical problems, risk of suicide, unexplained deaths, and mental health problems in treated populations. As I argued earlier, although we can reasonably expect refinements in treatments that render them moreeffective and less risky, it seems unlikely that those with GD will ever be able to change their bodies as easily and safely as we now change hairdos. 51

One last concern remains: to what extent does SRT support and reinforce the morally noxious sex/gender system?52 The answerto this question might constitute the morally relevant differencebetween SRT and other half-way technologies I alluded to earlier.

Determining this requires consideration of three issues. Firstly, is the binary sex/gender system truly noxious? Secondly,does providing SRT reinforce and/or promote that system? And thirdly, is that damage sufficient to warrant limiting or even denying SRT?

Given the enormous literature demonstrating the unnecessary miseries arising from the sex/gender system, the answer to the first is clearly affirmative. Even if it did not involve the discriminatory valuing masculinity over femininity, it still putsgreat pressure on both females and males to conform to its norms,regardless of their own individual characters, with little or no benefit to them or to society as a whole.

50 Dreger’s paper suggests three models. One is preferred by the transsexual activist community, what she calls the “feminine essence narrative,” of simplybeing in the wrong body, perhaps because of some neurological intersex condition. Alternatives, according to Bailey, are that it is a form of effeminate homosexuality or of autogynephilia (Dreger, p. 375). It is worth noting that the dearth of such fundamental knowledge doesn’t necessarily prevent us from developing worthwhile treatments, but in this case this knowledge would clearly be helpful. For a discussion of this matter, see JamesH. Maxwell.The Iron Lung: Halfway Technology or Necessary Step? The Millbank Quarterly. 1986;64(1): 3-29.51 See Dhejne, et al. 52 Stryker, chap. 4.

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Does providing SRT promote and reinforce that system? To theextent that it caters to the conviction of those with GD that they cannot be happy in their own skins because their bodies and minds feel irreconcilably at odds, and that the only solution is to change their bodies, it does do so. It does so most clearly for those with homosexual desires who also have psychological traits more closely aligned with the other sex. It’s less clear how to analyze the situation of heterosexuals who feel distaste for their primary and/or secondary sex characteristics but not for the psychological traits expected of those with their own birth bodies.

Does providing SRT seriously undermine the movement toward more open and flexible conceptions of appropriate gender and sexual roles? No. Permitting or refusing SRT is unlikely to change the convictions of those with GD. Allocating resources forSRT does provide some—limited—social acceptability for it. However, this effect would be small if the context for that choice were widely understood.

As I argued earlier, the context of current SRT needs to be understood as a vehicle for the imperfect, half-way technology that it is, treatment that attempts to alleviate suffering and prevent harm, for want of a true cure. It is like in vitro fertilization in that it constitutes a painful, risky, and expensive approach to a problem that in many cases might have been prevented—in the case of IVF by social and public health prioritizing fertility conservation. It is like many kidney or heart transplants as well, transplants that could have been prevented by measures to reduce the incidence of diabetes. In neither of these types of cases does medicine or society deny treatment on the grounds that they are treatments not cures, or that they are far less desirable on every count than the measuresthat would have prevented them.

Moreover, it is reasonable to judge that SRT’s support for the gender system is trivial compared with other forces. Female and male babies are treated differently from birth, and their development in different directions is massively reinforced by gender-specific toys, clothes, books, media, and expectations of most parents and teachers. The consequences of such differing treatment and expectations are apparent everywhere, and the

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backlash against attempts to eradicate distinctions based on sex or gender is intense and vitriolic. Given the societal failure toseriouslyaddress those massive influences, withholding SRT on this ground is indefensible.

Consequently, none of the objections to offering SRT justifylimits on it at this time, even if it is less than satisfactory. At best, the kind of research I argue for may render it somewhat more satisfactory, even if it offers little hope of the equivalent of policies that promote healthy fertility or diabetesprevention.

Where might we look for the equivalents here of pro-fertility and anti-diabetes policies? Is there a world where GD might never develop?

Imagine a world with no gender socialization, no notice of bodily sex (except where necessary for reproduction), and no moral stigma for any sexual activity between competent, consenting adults.53

This change would be independently desirable, quite apart from the possibility that it might reduce GD. Many of the demandson people that limit their lives in ways that lead to misery would disappear, and it would take the flourishing of individuality envisioned by J.S. Mill in to a much deeper level than he would have envisioned. But might it not also be a place where many more of us feel at home in our own skins, no matter what form they take? Transsexual activists often emphasize that the condition is about the conviction that one is in the wrong body, but McCloskey’s work strongly implies that gender norms maynonetheless be deeply entangled in that conviction.

Just as a more intelligent and broadly supportive environment would cause a good deal of disability to evaporate, might not much sex and gender related discomfort evaporate in theworld just described? If so, wouldn’t that be part—or perhaps even all—of a definitive (non) treatment for transsexualism? Thismight be true regardless of whether that system is responsible for causing GD, or perhaps even whether GD is regarded as pathology. Just as universal design can reduce or eliminate handicaps caused by differences in bodily ability, regardless of 53 One thought here is that if safer anal intercourse were not stigmatized, perhaps some who yearn for a neovagina would be content without one.

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how they came about, more open sex and gender norms could reduce or eliminate suffering caused by GD.

This answer is purely speculative at this point, but it is worth exploring, given the problems those with GD now face.

Is this scenario plausible? It certainly is worth exploring further. But such exploration should build on the issues I raise here, and the effects for GD of eradicating the sex/gender systemwould trump any such theorizing.

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