Carlo Trombetta, Giovanni Liguori and Michele Bertolotto (eds.)Management of Gender Dysphoria10.1007/978-88-470-5696-1_38

38. Ethical Issues for the Practitioner Work in the Transgender Care

Cristoforo Pomara^{1, 2}, Andrea Brincat², Daniel Cassar², Massimo Martelloni³, Emanuela Turillazzi¹ and Stefano D’Errico³

(1)

Department of Forensic Medicine, University of Foggia, Foggia, Italy

(2)

Department of Anatomy, University of Malta, Msida, Malta

(3)

Department of Legal Medicine, USL2 Lucca, Lucca, Italy

Cristoforo Pomara

Email: cristoforopomara@hotmail.com

38.1 Introduction

All treatment decisions involve the tacit decision to treat or to withhold treatment. Although often not expressed, the “not to treat” side of the analysis of risks versus benefits is quite important and should be explored in patients with gender identity dysphoria (GID) and its variants [1]. The availability of somatic treatments as accepted interventions for the overall management of GID raises a number of bioethical issues. The medical literature rarely is as rife with affect as when this issue is discussed by those who oppose the application of surgical treatments as part of the treatment plan for gender transmutation.

This passing fad for what is miscalled “transsexualism” has led to the most tragic betrayal of human expectation in which medicine and modern endocrinology and surgery have been engaged [2].

Psychiatrists’ responses to requests for treatment from those with GID range from the nearly cavalier referral for hormones and sex reassignment surgery to an inflexible reticence to entertain any such referrals, erecting the defensive facades of “do no harm” and “never deliberately remove a healthy organ.”

In spite of the fact that somatic treatments have been used for over 30 years, clinical decisions must be made in the absence of well-controlled trials that compare multimodal treatment (which includes hormones and sex reassignment surgery – SRS) to purely psychiatric interventions [3–6]. Although there is far more evidence in favor of utilizing somatic treatments as part of the treatment plan for carefully evaluated persons with GID [7, 8], decisions must be made with the awareness that the psychiatrist shares the “moral responsibility for that decision (i.e., whether or not to refer for SRS) with the surgeon who accepts that recommendation” [9].

The decision to withhold somatic treatments carries with it a significant risk that must also be taken into consideration [10]. For example, the incidence of suicidal behavior and genital self-mutilatory behavior appears to be greater in those denied SRS than in those referred for this procedure [11–13]. Along with psychotic decompensation [14], postoperative suicide due to regrets over having had SRS is often cited as the most compelling reason to withhold this intervention [10, 15, 16].

Both of these negative outcomes are actually quite unusual, however, as noted by follow-up studies in countries that have the ability to monitor outcomes in fairly homogeneous societies with centralized health-care registries [12]. Given the very low rate of requests for reversal in many recent studies from around the world, it appears that some of the earlier concerns about somatic treatments have not been borne out.

In spite of a preponderance of clinical reports supportive of providing somatic treatments in carefully selected patients, clinicians faced with the evaluation and treatment of gender-dysphoric persons must address both countertransference issues and bioethical concerns in the absence of well-controlled, prospective studies of large numbers of patients over lengthy follow-up periods. While the medical community seems to have few qualms about genital surgery on minors (with substituted consent) for inborn biological errors such as ambiguous genitalia conditions and pseudohermaphroditism [17, 18], the same detached approach has not been applied to altering the anatomy of adults and adolescents with bona fide GID.

Patients with severe GID often have pervasive disturbances in their sense of self and are willing to seek out mental health-care professionals who are able to confront their own ethical, moral, and spiritual standards in an attempt to provide compassionate care or competent referrals.

An additional bioethical issue that is still actively debated is whether to provide SRS for applicants who are HIV infected. Some persons with GID engage in commercial sex work or are otherwise at increased risk for acquiring blood-borne infections [19, 20]. Indeed, an HIV test is usually part of the required preoperative testing. Speaking to this issue, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) adopted a resolution in September 1997 that states, “The availability of sex reassignment surgery should not be denied solely on the basis of blood seropositivity for blood borne infections (such as HIV, hepatitis B or C, etc.).” This resolution has not been embraced by all health-care providers, however, and it is often difficult for otherwise qualified, appropriate candidates for SRS to receive this treatment due to reticence on the part of some surgeons who perform this procedure [21]. Many state medical licensing boards also make it illegal to discriminate on the basis of HIV seropositivity in the delivery of health-care services. However, there remains controversy in surgical circles over the ethical issue of balancing risks to surgeons and the rights of patients referred for this procedure [22].

38.2 Ethical Issues for Practitioners

38.2.1 Background

Zandvliet defined gender “as the sum of a person’s non-physical and non-biological characteristics that determine their sense of being male, female or neither or any combination” [23]. More recently, Nagoshi and Burzuzy defined gender as “an identity that exists separate from the constraints of physical sex characteristics and the dictates of a binary that our society has imposed” [24].

Transsexual is a medical term. Transgender is frequently indicated as an “umbrella term” that is used to describe individuals whose gender self-identification or expression transgresses established gender norms [25, 26]. Specifically, it is the state of one’s gender identity (self-identification as male, female, both, or neither) not matching one’s assigned gender (identification by others as male or female based on natal sex) [27].

In 1980, the American Psychiatric Association included transsexualism and gender identity disorder of childhood in DSM-III-R [28, 29]. It was not until publication of the DSM-IV that the diagnosis GID as applied to adults was codified [30].

According to the DSM-IV, gender identity disorder, or transsexuality, involves “a strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex), persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex, clinically significant distress or impairment in social, occupational, or other important areas of functioning, all without having a physical intersex condition” [30–32].

In contrast to the American Psychological Association, it has been argued that transsexuality is not a mental disorder, but rather a physical problem which can be alleviated by means of a combination of physical therapies designed to change the body (“application of these diagnostic labels unnecessarily pathologizes transgender and gender-variant people”). Whether transsexuality is viewed as a mental disorder or whether it is viewed as simply another category of gender that should be accepted by society as legitimate, the moral tension on the issue of GRS remains strong since GRS is an invasive surgery or group of surgeries which requires lots of medical resources that may, at times, be scarce.

The availability of sex reassignment surgery as an intervention in the overall management of transsexualism raises a number of bioethical issues for physicians.

For those who accept the idea that transsexuality is a psychiatric disorder, there is moral tension regarding whether it is the duty of surgery to solve problems that could possibly be dealt with by means of a psychosocial approach or whether surgery is ever a morally acceptable, medically appropriate solution to the mind-body incongruity that exists in transsexual individuals.

People who maintain that all psychiatric disorders should be treated solely by psychologists and psychiatrists hold that GRS is not an acceptable solution to transsexualism. Additionally, it could be argued that surgeries which limit the function of healthy organs or produce significant health risk, as GRS does, should not be performed since surgery should only be done if it benefits a patient medically.

Those who believe that transsexualism is a physical problem, on the other hand, maintain that for some transsexuals, surgery is a medically appropriate treatment that has the potential to emotionally heal and provide a source of inner peace for those who feel their biological gender is incompatible with their inner gender identity [33, 34].

38.2.2 The Ethical Dilemma and Bioethical Principles

Considerations regarding the status of GID as a disorder and its relation to access to GRS are important since many people who identify as transsexual strongly desire body modification as the last step of their identity achievement. Serious incongruity between body and soul can, understandably, be very disquieting for an individual. Some transsexuals can achieve an adequate sense of body-soul congruency through hormonal therapies and cross-dressing, but for some, body modification is perceived as an integral part of achieving an identity as a member of the opposite gender. In order to achieve full body modification, surgery is often required for patient satisfaction. Hormone therapies can only do so much for patients; they can give male-to-female transsexuals breasts, but they can never give them a vagina. Cross-dressing and hormone therapies can give a female-to-male transsexual some sense of being male, but when he looks in the mirror, it is still a woman’s soft face which looks back at him [35].

Since the inner struggle that goes with transsexuality is something that can be fixed by changing the body through surgery, is surgery a viable treatment option? If someone wants to achieve a desired image that he or she feels “matches what’s on the inside” along with enough competence to fully understand the risks and benefits of undergoing surgery, then he or she has the right to do so? All gender-dysphoric patients should be approved for surgery?

It has been said for the moral permissibility of GRS that in cases in which “adult patients have been suffering from a severe gender-related mind-body imbalance which interferes with their everyday life functions, gender reassignment surgery is a morally permissible treatment option, provided that the patients requesting it are competent and are able to pay for the surgery out of pocket as an elective surgery without any serious financial detriment to their dependent family members” [36].

Patient autonomy. Competent adults who have identified themselves as transsexuals have the right to self-determination. Those who have the right to self-determination have the right to decide what to do with their bodies. Therefore, competent, adult individuals have the right to request and receive GRS [37].

Competence is the key when it comes to who should be able to obtain access to GRS. In this sense, the decision to undergo GRS has to represent the final step toward completion of a long, arduous journey of identity realization as a member of the opposite sex.

Most gender-variant people, in fact, go through stages in achieving their desired gender identity; some people stop at cross-dressing and hormone therapy, while others continue on to request GRS. Autonomy should be highly respected, but it should be especially respected for those making decisions which have such profound social risks.

Though it is true that the goals of medicine are diametrically opposed to the intentional, non-prophylactic removal of healthy organs, it is also true that in some cases, organs are not needed for certain goals of patients. Here, the role of patient autonomy is important. If a competent patient has determined that an organ is unnecessary to his or her goals for personal well-being and that, furthermore, said organ is causing him or her some type of discomfort, it can be considered morally permissible for a doctor to remove the said organ so long as removing the said organ will not profoundly and negatively affect other people.

Primum non nocere – do not harm. Physician response may be to ally with the patient in his all-encompassing quest for somatic treatment, leading to prescription of hormones and referral for SRS. Alternatively, physicians may be extremely reticent to entertain such treatment requests, erecting the defensive facades of “do no harm” and “never deliberately remove a healthy organ” [1]. The replacement of biological sex organs with nonfunctional sex organs can have a significant impact on the psychological well-being of the patient and should, therefore, be considered as having positive moral weight when one is evaluating the moral permissibility of removing healthy organs such as the mammary glands. It has been argued that men and women who are certain that they do not want to bear anymore children ask to undergo vasectomies and tubal ligations that will almost guarantee no more offspring will result from sexual intercourse. These procedures essentially incapacitate the sexual reproductive organs in males and females.

So, one cannot make the claim that there is a qualitative moral difference between such procedures and the procedures that remove sex organs in transsexuals during GRS.

The determination by some physicians to consider SRS an ethical therapeutic adjunct is largely a matter of personally witnessing individuals as they undergo the painful process of gender reorientation, which may include SRS and hormonal treatments. Numerous authors have reached the conclusion that SRS can contribute to the relief of suffering, enable better psychosocial adjustment, and impart a sense of well-being to these distressed individuals.

Physicians are faced with a complex dilemma that revolves around two central questions: What constitutes suffering in the gender-dysphoric patient? What are the ethically and morally viable interventions available to relieve suffering in these patients? The Oath of Hippocrates reminds us that the relief of suffering is the quintessential task of all of medicine.

The gender-dysphoric patient relates his or her subjective experience of suffering very clearly, but what the physician may do to relieve it is unclear; it is still unknown whether SRS is the most effective form of treatment for transsexualism. Clinical decisions must be made in the absence of definitive, prospective, long-term studies of the effectiveness of SRS compared to nonsurgical treatment modalities [1].

Others have disputed these claims, noting that positive outcome studies are seriously flawed by researcher bias and the lack of control groups.

Standards of care. Just as resourceful patients are able to obtain hormones illicitly, they can also obtain some forms of SRS from surgeons unaffiliated with established gender clinics. Many of these individuals have been subjected, in the past, to “inferior surgical techniques and preoperative selection procedures” with outcomes anecdotally reported as “horrifying” [37, 38].

Civil liability could be incurred by a surgeon in cases where the patient is dissatisfied with cosmetic and/or functional outcomes on the grounds that negligence occurred in preoperative evaluation. The case against the surgeon would be strengthened if the evaluation was brief and/or inconsistent with the standards of care, which clearly state that a minimum of two qualified mental health professionals must thoroughly evaluate the patient longitudinally, prior to recommendations for SRS [39]. Criminal charges could be filed as well, with prosecution based on the premeditated “act of intentionally mutilating a person’s body or injuring it so as to deprive him of a limb or any organ of the body. The probability of a poor outcome, including postoperative suicide, is believed to be increased in patients who receive SRS without proper evaluation and lengthy preoperative preparation” [1].

Surgery alone is not curative or rehabilitative. SRS is only one component of a multidisciplinary approach to the rehabilitation process and should be viewed as confirmation of what the patient has already achieved with medical assistance.

38.3 Transsexualism in Children and Adolescents

Estimating the prevalence of GID for adolescents and adults is very difficult due to the lack of population-based studies. Estimates of adults with GID have generally been based on the numbers of individuals who have had sexual reassignment operations or those seeking services at specialized clinics. The prevalence of childhood GID is not known with any certainty, and estimates come principally from small studies and clinical experience [40]. Researchers assume that it is more common in children than in adults, based on the observation that the childhood diagnosis does not usually persist until adulthood. In both adults and children, GID occurs more frequently in males than females; the effect of social and cultural factors to explain the differences is not clear. There is some support for the view that boys are identified more often because parents, teachers, and peers are less tolerant of cross-gender behavior in boys, and girls may need to display more cross-gender behavior than boys before a referral is initiated.

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