1. Gender Reassignment Surgery Carol Bayley, PhD October 3, 2007 National Ethics Education Collaborative

2. Overview Background Distinctions Two ways to view gender dysphoria Ethical issues Further thinking

3. Background Assumptions Sex has three meanings Genetic (XY, XX, XXY, etc.) Phenotypic (what you look like physically) Social (how you are raised, how you present) Gender has one (main) meaning: the social or behavior aspects of sexual identity. There is no 1:1 relationship between sex and gender

4. Background Assumptions Sexual dimorphism is part of the mental landscape in our culture. First question when baby is born “treatment” of intersex babies As species go, we are not too dimorphic; variations within the sexes are greater than the variations between them.

5. Background Assumptions There is a lot we don’t know about sexual and gender development How genotype is translated into phenotype What hormone surges (in utero and at puberty) do; what can go wrong How people “feel” like women or men apart from social conditioning

6. Distinctions Heterosexual Homosexual Bisexual Transvestite Transsexual Transgender

7. Distinctions Heterosexual, homosexual, and bisexual describe sexual attraction, grounded in biology but affected by culture. Medically speaking, these are not disorders. Attraction is fluid and changing; most people think attraction is established before birth. DSM-III (1974) Transvestite describes people who wear clothes of the other gender. Motives differ.

8. (Catholic Teaching: Sexual function has two purposes Fun (aka “union”) Babies (aka “procreation”) Double effect Good or morally neutral act One effect intended, one foreseen Bad effect is not a means to the good )

9. Transsexual/Transgender terms refer to the same thing gender dysphoria (DSM-IV) Transgendered persons can self-identify as gay or straight. Some transgendered persons get married; some engage in homosexual relationships with members of their new sex.

10. Gender Dysphoria: one view Objectively disordered Psychiatric in nature You don’t do surgery for psychiatric symptoms (unless you do; see Elliot) Gender reassignment surgery mutilates and results in sterilization, therefore it is wrong.

11. Gender Dysphoria: other view Biological in nature; hormone surge in utero contributes to sexualization of fetus. Disruption can “cause” GD. Male and female brains differ; in some respects, m->f brains look like female brains and f->m brains look like male brains.

12. GD: other view If GD is biological, then surgical correction is appropriate. Other surgical corrections: Strabismus Cochlear implant Aortic repair Lasix surgery; septoplasty Mutilation and sterilization are side effects. (see Double Effect)

13. Surgery is last step in transition Transition includes Psychological counseling Living as “the other” Hormone treatments to affect secondary sex characteristics (hair growth, breast size, voice) Plastic surgery to fashion new genital and urethral equipment; mastectomy for f->m

14. Some transitions are finished without surgery Expense Mutilation Irreversibility

15. Ethical Issues Should surgeons be allowed to perform gender reassignment surgery? How do we take care of patients after surgery? How do we take care of transgendered persons in the hospital for other reasons?

16. Allowing surgery for GRS Patient must be part of program Program must be rigorous Surgeon must have experience; double boarded in some cases (e.g., urology and plastic surgery) Treat these patients fairly

17. Ethical Issues Respect for transgendered persons means: Using the form of address and pronoun he or she chooses. How the person presents is the person’s social identity and should be honored. Protecting privacy, especially with regard to roommate if there is one. Private rooms are nice but not always possible. No one taking care of the patient should be surprised; confidence must be held carefully.

18. Stoke your imagination Stories of Native Americans Middlesex by Jeffrey Eugenides Oscar-nominated film Transamerica Carl Elliot, “A New Way to Be Mad.” Atlantic Monthly, Dec 2000. Call Me Malcolm (UCC: Office of LGBT Concerns in Cleveland has copies)