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Transsexualism: The Current Medical
Viewpoint
Dr. R Reid, Hillingdon Hospital
(Medical Sub-Group Convenor); Dr. Domenico di Ceglie, Tavistock Clinic; Mr.
James Dalrymple, London Bridge Hospital; Professor Louis Gooren, University
of Amsterdam; Professor Richard Green, Charing Cross Hospital; and Professor
John Money, Johns Hopkins Hospital, USA produced for the UK Parliamentary
Forum on Transsexualism. Chair : Lynne Jones, MP.
[Abstract] Full Text [PDF]
Purpose
This document provides an overview of current
best practice in providing effective health care for persons with the
transsexual syndrome. It describes the nature of the syndrome, its
diagnosis, treatment and outcomes; recognises its biological aetiology; and
makes recommendations for the legal status of people experiencing
transsexualism. It updates a similar document produced for the Forum on 14
February 1995.
The syndrome
Transsexualism is a Gender Identity Disorder
in which there is a strong and on-going cross-gender identification, i.e. a
desire to live and be accepted as a member of the opposite sex. There is a
persistent discomfort with his or her anatomical sex and a sense of
inappropriateness in the gender role of that sex. There is a wish to have
hormonal treatment and surgery to make one's body as congruent as possible
with one's psychological sex.
Treatment
The currently accepted and effective model of
treatment utilises hormone therapy and surgical reconstruction and may
include counselling and other psychotherapeutic approaches; electrolysis;
and speech therapy. In all cases, the length and kind of treatment provided
will depend on the individual needs of the patient and will be subject to
negotiation between the Consultants involved, the patient's General
Practitioner and the patient.
Outcomes
Studies which have been carried out into
long-term outcomes indicate that a treatment model using the principles
described above is highly successful, with some suggesting up to a 97%
success rate. This compares extremely favourably with the outcomes of
treatment for other chronic conditions.
Aetiology
Dr. Harry Benjamin, who introduced the
syndrome to the general medical community in the early 1950s, favoured a
biological explanation of the syndrome, believing that the genetic and
endocrine systems must provide a "fertile soil" for environmental
influences. The weight of current scientific evidence suggests a
biologically-based, multifactoral aetiology for transsexualism. Most
recently, for example, a study identified a region in the hypothalamus of
the brain which is markedly smaller in women than in men. The brains of
transsexual women examined in this study show a similar brain development to
that of other women.
Legal Position
The present legal position is that people who
have been diagnosed as experiencing transsexualism immediately lose a
substantial part of their civil liberties. It appears that this situation
was decided by the decision in the case of Corbett v Corbett (1970)
which defined the legal sex of the plaintiff as male, using genital and
chromosomal criteria which have now been superseded. Medically, there is no
reason why people receiving treatment for transsexualism and who have
permanently changed gender role should be given any lesser legal status than
that of any other person.
1. Aims and Objectives of this Document
1.1 The aim of this document is to
provide an overview of current best practice in providing effective health
care for persons with the transsexual syndrome.
1.2 Its objectives are to:
- describe the nature of the medical
evidence
- identify appropriate diagnostic criteria
for transsexualism
- indicate the main features of
appropriate models of treatment
- identify outcomes and measures in terms
of improved quality of life
- describe the case for a biological
aetiology
- make recommendations for the legal
status of people experiencing transsexualism
2. The Nature of the Medical Evidence
2.1 Following the general move away
from a mechanistic base of thought by the scientific community at large, new
views of medicine, health and disease have arisen1. In the UK,
these have been accompanied by a government policy which identifies patient
care as the main expected outcome of medical research and development2.
An important response of the medical profession to these changes has been
its growing recognition that the application of quantitative,
empirically-based methodologies to the social phenomenon of health does not
necessarily produce results which can usefully inform the practice of
medicine in its lived social and cultural contexts3. Instead,
there has been an increasing emphasis on the quality of life for patients as
the measure of the effectiveness of healthcare4.
2.2 One result of this has been that
in the process model of aetiology - diagnosis - treatment - outcome,
expectations of proving causality are now less significant. Instead,
interest in aetiology has focused increasingly on its usefulness in
informing treatment and contributing to successful outcomes. This trend
reflects the fact that the aetiology of many of the chronic conditions for
which medicine provides treatment is unknown. It also recognises that the
growing complexity of scientific and social theories and their
interrelationship makes causality increasingly difficult to define.
2.3 Thus, in the case of
transsexualism, current medical practice considers it from the viewpoints
of:
- its sociobiological context, that is,
its relationship to the overall functioning of individuals in their
social contexts
- measuring the effectiveness of diagnosis
and treatment through outcomes expressed as improvements in the
patient's quality of life
- relating UK practices to comparative
practices elsewhere in Europe and the developed western world
- treating each patient according to their
individual need rather than by a standard, prescriptive regimen of
healthcare
- having an aetiology which is unproven
and which does not, therefore, provide appropriate evidence for an
adversarial court-room setting
- increasing concern that an inappropriate
focus on aetiology rather than an appropriate focus on the outcomes of
treatment could operate to the disadvantage of patients
3. Diagnostic Criteria
3.1 Two main diagnostic systems for
transsexualism are in operation, ICD 105. and DSM IV6. Diagnostic criteria
which combine features of both systems are as follows:
- Transsexualism is a Gender Identity
Disorder in which there is a strong and on-going cross-gender
identification, and a desire to live and be accepted as a member of the
opposite sex. There is a persistent discomfort with his or her
anatomical sex and a sense of inappropriateness in the gender role of
that sex. There is a wish to have hormonal treatment and surgery to make
one's body as congruent as possible with one's psychological sex.
- The diagnosis of transsexualism is
confirmed when gender dysphoria has been present for at least two years
and has been alleviated by cross-gender identification.
- Transsexualism is linked with, but
distinct from
- Intersex conditions (e.g. androgen
insensitivity syndrome or congenital adrenal hyperplasia) and
accompanying gender dysphoria.
- Transient, stress related
cross-dressing behaviour.
- Persistent pre-occupation with
castration or penectomy without a desire to acquire the sex
characteristics of the other sex.
4. Treatment
4.1 There is no single model of
treatment: rather, variety in approach is both supported and sought as part
of the continuing professional discussion of the syndrome. Typically,
however, an effective model of treatment will utilise hormone therapy and
surgical reconstruction, and also include:7
- counselling
- psychotherapeutic approaches
- electrolysis
- speech therapy
4.2 Assessment of the patient's
progress is likely to take place at approximately three monthly intervals
and at the appropriate point surgery will be used. Depending on the
physicality and the overall health of the patient, surgery may include, for
male to female transsexuals:
- vaginoplasty (construction of a
vagina);
- penectomy (removal of penis);
- orchidectomy (removal of testes);
- clitoroplasty (construction of a
clitoris);
- and possibly breast augmentation
(enlargement of the breasts);
- rhinoplasty (reshaping the nose);
- cosmetic surgery such as hair
transplants or facial remodeling;
- thyroid chondroplasty (shaving of the
Adam's apple);
- crico-thyroid approximation and
anterior commisure advancement (for raising the pitch of the voice);
and for female to male transsexuals:
- hysterectomy & oophorectomy
(removal of uterus and ovaries);
- bilateral mastectomy (breast removal)
- and possibly phalloplasty
(construction of a penis).
4.3 As medical and surgical
techniques and knowledge increases, other or additional treatments may be
used. In all cases, the length and kind of treatment provided will depend
upon the individual needs of the patient and will be subject to negotiation
between the Consultants involved, the patient's General Practitioner, and
the patient. Involving the patient (and, in the case of minors, the parents
or guardians of patients) in the management of their own programme of care
is considered to be extremely important.
5. Outcomes and measures
5.1 There is a paucity of research into
the long-term outcomes of treatment for transsexualism. However, the studies
which have been carried out indicate that a treatment model using the
principles described above is highly successful, with some suggesting up to
a 97% success rate8. This compares extremely favourably with the
outcomes of treatment for other chronic conditions.
5.2 Using a "Quality of
Life" model for measuring the effectiveness of patient care, outcomes
of this kind may be measured in terms of expressed patient satisfaction with
their ability to:
- find employment
- make relationships
- integrate with the larger community
- live fulfilling lives
5.3 It is a matter of concern to the
UK medical community that the current legal status of people who have been
treated for Transsexualism works against the achievement of these
performance indicators. That status marginalises individuals who have no
visible difference from others and prevents them from being able to
integrate, make relationships or live fulfilling lives and thus impairs
quality of life9. In particular, the lack of substantive
employment rights works directly against the important economic performance
indicator of finding and maintaining employment.
5.4 The heterosexual or homosexual
partnership of the patient bears no predictable relation to outcomes of
treatment for Transsexualism and should not be considered to be a measure
for the effectiveness of treatment.
6. Aetiology
6.1 Dr. Harry Benjamin introduced the
syndrome to the general medical community in the early 1950s and advocated
the compassionate treatment of it10. Benjamin favoured a
biological explanation to the syndrome, believing that the genetic and
endocrine systems must provide a "fertile soil" for environmental
influences11.
6.2 In their work on plastic surgery
techniques four years later, Gillies and Millard echoed Benjamin's point of
view and suggested that transsexualism should be classified as an intersex
condition12.
6.3 In an authoritative review of
research in this field in 1985, Hoenig follows Benjamin in ultimately
depending on a biological force or forces to account for transsexualism13.
Summarising and commenting on this and other medical viewpoints three years
later, in 1988, Docter indicates that the overall weight of evidence is that
there is "the formation of some kind of gender system within the brain
that is fundamental to ultimate gender identity and gender-role
development"14.
6.4 It is a viewpoint of this kind
that Money suggests in an authoritative paper The Concept of Gender
Identity Disorder in Childhood and Adolescence after 37 years where he
states 'causality with respect to gender identity disorder is subdivisible
into genetic, prenatal hormonal, postnatal social, and postpubertal hormonal
determinants' and suggests "there is no one cause of a gender
role.....Nature alone is not responsible, nor is nurture, alone. They work
together, hand in glove."15.
6.5 More recently, in a paper given
to the Council
of Europe's XXIIIrd Colloquy on European Law, Gooren has suggested that
"there is now evidence to believe that in transsexuals the
differentiation process of the brain taking place in the first years after
birth has not followed the course anticipated of the preceding criteria of
sex (chromosomal, gonadal, and genital)"16. Thus, although
sex assignment at birth by the criterion of the external genitalia is
statistically reliable, in people experiencing transsexualism it is not:
they are exceptions to the statistical rule.
6.6 Most recently, a study has been
carried out of a region in the hypothalamus of the brain which is smaller in
women than in men. Strikingly, the region was of female size or smaller in
six male-to-female transsexuals, regardless of hormone treatment. This
result supports the hypothesis that gender identity stems from an
interaction between the developing brain and sex hormones17.
6.7 This view that the weight of
current scientific evidence suggests a biologically-based, multifactorial
aetiology for transsexualism is supported by articles in journals, the press
and popular scientific works18.
7. Recommendations for Legal Status
7.1 The present legal position is that
people who have been diagnosed as experiencing transsexualism immediately
lose a substantial part of their civil liberties19. It appears
that this situation was decided by the decision in Corbett v Corbett
(1970) which invoked 'chromosomal, gonadal, and genital' tests to define
the legal sex of the plaintiff in the case20. This definition has
since been applied to employment to the disadvantage of persons with the
transsexual syndrome, for example, by placing them apparently outside the
remit of the Sex Discrimination Act21. These tests must be
considered obsolete now in the light of new scientific information and the
legal view has recently been challenged in the European Court of Justice by
the case of P v S and Cornwall County Council where the Advocate
General has declared that the Equal Treatment Directive 'must be interpreted
as precluding the dismissal of a transsexual on account of a change of sex'22.
7.2 Current medical knowledge
recognises that an absolute aetiology for transsexualism is not available
although the present weight of evidence is in favour of a
biologically-based, multifactorial causality. It is considered, therefore,
that scientific knowledge of transsexualism has progressed considerably
since Corbett v Corbett and that the evidence presented there is no
longer reliable. From the point of view of medical ethics, the imperatives
of respect for autonomy, beneficence, non-maleficence and justice23
mean that medicine would not support any legal interpretation of its
research into transsexualism that would operate against the health,
well-being or advantage of patients. Medically, there is no reason why
people receiving treatment for transsexualism and who have permanently
changed gender role24 should be given any lesser legal status
than that of any other person.
References
1. More general works such as Lupton, D
(1992) Medicine and Culture, London: Sage and Seedhouse, D (1991) Liberating
Medicine, Chichester: Wiley, provide a useful overview and synthesis of
the major work in this field, including that of, for example, Illich;
Foucault; and Ian Kennedy.
2. See, for example, NHS (1994) Supporting
Research and Development in the NHS, London: HMSO, Working for Patients,
Managing the New NHS, the Calman Report.
3. See, for example, Colquhoun, D
and Kellehar, A, eds. (1993) Health Research in Practice: Political,
Ethical and Methodological Issues, (London, Chapman and Hall).
4. See, for example, Fallowfield, L
(1990) The Quality of Life: The Missing Measurement in Health Care,
London, Souvenir Press.
5. World Health Organisation (1992) International
Classification of Disorders, Geneva, WHO.
6. American Psychiatric Association
(1994) Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition Washington: APA.
7. See, for example, Reid, R. (1992)
'Working with Gender Dysphoria', Counselling Gender Dysphoria, Ed.
Z-J Playdon, Devon: ATC.
8. Green, R and Fleming D T (1990)
'Transsexual Surgery Follow-Up: Status in the 1990s', Annual Review of
Sex Research, ed. J Bancroft, vol 1, 1990, pp. 163-174. Of the 130 F-Ms
reported in the study, 97% of the outcomes were considered to be
satisfactory; of the 220 M-Fs, 87% of the outcomes were considered to be
satisfactory. See also Pfafflin, F & Junge, A (1992) Geschlechtumwandlung
Schattauer, Stuttgart/New York for en extensive survey on outcome.
9. For a general discussion of the
medical effects of social stigmatisation see Scambler, G (1991) 'Deviance,
sick role and stigma', Sociology As Applied to Medicine, ed. G
Scambler, 3rd. edition, London: Balliere Tindall, pp 185-196.
10. King, D (1993) The
Transvestite and the Transsexual, Newcastle upon Tyne: Athenaeum Press,
p. 46
11. Benjamin stated that 'if the
soma is healthy and normal no severe case of transsexualism....is likely to
develop in spite of all provocations'. Benjamin, H (1953) 'Transvestism and
Transsexualism', Journal of Sex Research, 5:2, p. 13.
12. 'The physical sex picture does
not always bear a fixed relation to the behaviour pattern shown by an
individual. One or other hormone may determine an individual's male or
female proclivities quite independently of the absence of some of the
appropriate physical organs. It may be suggested, therefore, that the
definition of hermaphroditism should not be confined to those rare
individuals with proved testes and ovaries but extended to include all those
with indefinite sex attitudes.' Gillies, H and Millard D R (1957) The
Principles and Art of Plastic Surgery, Vol. 1, London, Butterworth, p.
370-1.
13. Hoenig, J (1985) 'The Origin of
Gender Identity' Gender Dysphoria, ed. Steiner, B W, New York: Plenum
Press.
14. Docter, R F (1988)
Transvestites and Transsexuals, Towards a Theory of Cross-Gender Behaviour,
New York: Plenum Press, p. 63.
15. Money, J (1994) 'The Concept of
Gender Identity Disorder in Childhood and Adolescence After 39 Years', Journal
of Sex and Marital Therapy, 20 (3:163-177).
16. Gooren L G J (1993) 'Biological
Aspects of Transsexualism and their relevance to its legal aspects', Proceedings
of the XXIIIrd Colloquy on European Law: Transsexualism, Medicine and the
Law, Strasbourg; Council of Europe.
17. J N Zhou, M A Hoffman, L Gooren
and D F Swaab, 'A sex difference in the human brain and its relation to
transsexuality', Nature, 2 November 1995, vol 378:6552, pp 68-70
18. For example, Moir, A and Jessel,
D (1989) Brainsex London: Michael Joseph; Gorman, C (1992)
"Sizing up the Sexes", Time, 20 January 1992, pp 38-45;
"Sex is all in the Brain", Times 12 September 1992.
19. McMullen, M & Whittle, S
(1994) Transvestism, Transsexualism and the Law, (London, Gender
Trust).
20. All England Law Reports (1970)
Vol 2 pp. 32-51 Corbett v Corbett otherwise Ashley.
21. Industrial Tribunal Case No.
16132/93 (1993) Interim Decision of the Industrial Tribunal P v S and
Cornwall County Council.
22. Court of Justice of the European
Communities, Opinion of the Advocate General in the case of P v S and
Cornwall County Council (1995) case C-13/94, para 25.
23. Gillon, R (1994) "Medical
Ethics; four principles plus attention to scope" British Medical
Journal, vol 309 (16 July 1994) pp. 184-188.
24. The point of permanent change of
gender role is decided by the consultant psychiatrist in negotiation with
the patient and is usually the commencement of the 'life test'.
Authors
This document was produced as part of the work
of the UK Parliamentary Forum on Transsexualism chaired by Dr. Lynne
Jones MP. Its authorship was led by Dr. Russell Reid, Hillingdon Hospital,
London, in collaboration with:
Dr. Domenico di Ceglie, Tavistock Clinic
Mr. James Dalrymple, London Bridge Hospital
Professor Louis Gooren, University of Amsterdam
Dr. Richard Green, Gender Identity Clinic, Charing Cross Hospital
Professor John Money, Johns Hopkins Hospital, USA
For enquiries contact:
Dr. R Reid
Consultant Psychiatrist
Hillingdon Hospital
Pield Heath Road
Uxbridge
Middlesex
UB8 3NN
18 January 1996
Citation:
January 18, 1996; Second Edition an article
published on the Internet by UK Press for Change <http://www.pfc.org.uk/medical/mediview.htm>
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