(This essay is a response to “Transgenderism" by Norman Spack, MD, in Lahey Clinic Medical Ethics Journal, Fall 2006.)
The psychiatric diagnosis of gender dysphoria and its more recent medical treatment, as admirably summarized by Dr. Spack, (Lahey Clinic Medical Ethics, Fall 2005) is contested and eroding. Although "medicalization" has helped transgendered people to acquire therapy and social acceptance, transgenderism is part of a larger social struggle between defenders of the "natural" and "God-given" and the right of individuals to control their own bodies and define their own lives.
In 2003, psychologist Michael Bailey stepped into this volatile debate with his book The Man Who Would Be Queen: The Science of Gender Bending and Trans-sexualism. 1 Based on observations of transsexuals and transvestites, the book purported to confirm an out-of-favor psychosexual etiology of transsexualism rather than the dominant medicalized diagnosis of gender dysphoria. For Bailey, male transsexuals can be parsed into two broad groups, neither appropriately understood as a "woman trapped in a man’s body": (1) effeminate homosexual men who want to have sex with men and believe that as women they can better attract straight men, and (2) straight men fixated on having sex involving female genitals, but who get confused and turned on by the idea of having their own female genitalia, i.e., "autogynephiles."
Not surprisingly, the book created a fifirestorm of protest among trans-gender activists, who condemned Bailey’s unscientific methodology. Transgender activists also saw that Bailey’s psychosexual etiology would be ammunition for the opponents of trans-gender therapies. The Christian Right embraced Bailey’s book as evidence that transsexuals should be denied surgery and hormones, and directed to psychotherapy instead.
For instance, writing in the conservative Christian journal First Things in 2004, Dr. Paul McHugh, psychiatrist-in-chief of Johns Hopkins Hospital, said:
"I have witnessed a great deal of damage from sex-reassignment… We psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them for surgery and for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it." 2
In 2002 Dr. McHugh was appointed to the President’s Council on Bioethics (PCB) and participated in the deliberations that led to the PCB’s critique of human enhancement therapies, Beyond Therapy. 3 In his 2004 critique of sex re-assignment, Dr. McHugh pointed to the larger philosophical issue swirling around the contested diagnosis of gender dysphoria. "There is a deep prejudice in favor of the idea that nature is totally malleable," he said. "Without any fifixed position on what is given in human nature, any manipulation of it can be defended as legitimate."
The emerging attack on the diagnosis of gender dysphoria and the malleability of "human nature" does not come only from cultural conservatives however, but also from some on the Left. For bioethicist Carl Elliot, author of Better Than Well, gender dysphoria is one of many forms of self-mutilation sold to Americans by a profit-driven medical-industrial complex. 4 To underline his point, Elliot compares sex reassignment surgery to the psychiatric condition "apotemnophilia," the obsession that one should be an amputee. Like gender dysphorics, apotemnophilics are chronically depressed, because they see their "true selves" without the offending appendages. Unlike gender dysphorics, apotemnophilics are almost universally seen as needing psychiatric treatment, rather than medical help to transition to their desired body. For Elliot, like the conservative critics, sex re-assignment is a sign that we are using technology inappropriately to cure spiritual and psychiatric ailments.
Advances in global access to sex reassignment surgery, our understanding of the diversity of biological sex and our technologies of body modification, all promise to make the battles over sex re-assignment even more intense in the near future, and to further polarize bioconservatives from advocates of morphological self-determination.
As transgender attorney Dean Spade points out, we don’t make women suffering from "rhino-identity disorder" live as small-nosed people for a year before their surgery. But the protocols of the Harry Benjamin International Gender Dysphoria Association (HBIGDA) call for the "patient" to spend a year attempting to live as the opposite sex before they receive surgery. While an understandable attempt to prevent postsurgical regret (which is extremely rare among transsexuals), many transgender people find the HBIGDA protocols patronizing and, in a world in which cross-dressers can be the victims of violence, potentially dangerous. Thai surgeons, who perform some of the highest volume sex re-assignments in the world, for an order of magnitude lower cost than North American surgeons, do not follow the HBIGDA protocols, but instead make a case-by-case assessment of psychological appropriateness. As medical tourism to Latin America and Asia becomes more common and attractive, the rigid HBIGDA protocols will become irrelevant.
The idea of passing as the "opposite" gender is also based on pass binary assumptions about gender. Just as transgendered people are no longer expected to manifest "appropriate" sexual preferences, there is a growing acceptance of transgendered people who decide to only partially transition, or consciously adopt a neither-male-nor-female gender identity. 5 Female-to-male patients may decide to take testosterone, but forego phalloplasty and traditional male dress. Male-to-female patients may get breast implants, take hormones, and cross-dress, but see no need for genital reconstruction. "Gender-queer" theorists such as Kate Bornstein and Martine Rothblatt argue that such ambiguous gender positions are a political statement against binary "gender apartheid." 6,7
The evolution of gender dysphoria from a male/female gender correction, to an experimental, analog form of self-expression is also in line with recent thought on the non-binary nature of biological sex. 8 Anne Fausto-Sterling has popularized the fact that about 1% of all births are "intersexed," from classical hermaphrodites and people with a mismatch of body genitalia and DNA to genital malformations such as hypospadias, a congenital deformation of the penis. 9,10 If easily observable morphological differences are as prevalent as 1%, brains that are neither completely male nor female must presumably be at least as common, to the extent that there is a "gendered brain." 11 The Intersex Society of North America 12 has emerged to campaign for the right of intersex children to define their own gender identity and not be surgically "fixed" at birth.
Emerging medical technologies promise to make the modification of physiological gender even easier, cheaper and safer. Tissue engineering is rapidly advancing, growing breast tissue for breast implants and penile erectile tissue that could be used for phalloplasties. Within decades we will likely have gene therapy to modify the endocrine system, making exogenous hormones unnecessary. Surgeons are perfecting the shaving down of Adam’s apples and reshaping of the chin, buttocks and knees. Whatever neurochemistry and neurophysiology may characterize the gendered brain, if any, they will also become malleable, allowing more complete gender transitions.
Insofar as we discover genetic, hormonal and neurophysiological determinants of gender identity and sexual preference, future neurotechnology (gene therapy, pharmaceuticals or neurocybernetics) will permit the trans-gendered to not only adjust their desires and gender identity into alignment with their identity, but also with their born sex. Some gender dysphorics may follow the path of least resistance. But as the medical risks and social sanctions of gender transgression decline, and our lifespans and the efficacy of body modification technologies increase, a growing proportion of us will want to try on features of the other gender from metro-sexual cross-gender dress, to hormone supplementation to modify personality, to topical gene therapy to change skin and hair, to designer genitalia.
As the medical model of gender dysphoria is challenged by morphological liberationism on the one hand, and bioconservativism on the other, it will be difficult to make the case for covering the therapies with public or private insurance. But instead of reifying the medical model, transgender therapy should be used to challenge the illusory therapy/enhancement distinction, and establish that facilitating full self-expression is as legitimate a use of biotechnology as the fixing of diseases and disorders. There is little difference in the utility produced in someone’s life from plastic surgery after an accident or burn, and plastic surgery to adjust a feature that has caused life-long dissatisfaction. There is no reason for insurance to discriminate against the latter in favor of the former. Why is breast reconstruction for the woman recovering from breast cancer surgery politically privileged over breast construction for the trans-woman? Neither are "medically necessary" and both done to give psychological relief.
The bioconservatives are correct that we might all be happier if we were enlightened enough to be content with whatever we were dealt by fate. But that is also a formula for personal and social stasis. Transgendered individuals are entitled to access to medical technology not because, as the advocates of the medical model such as Dr. Spack assert, they have a medical condition that demands correction, but because we should respect the right to morphological self-determination. I pin my hopes with John Stuart Mill that we all will be enriched when society helps each of us find our own personal self-expression.
Footnotes
1 Bailey JM. The Man Who Would Be Queen: The Science of Gender Bending and Transsexualism. Washington, DC: Joseph Henry Press; 2003.
2 McHugh P. Surgical sex. First Things. November 2004;147:34-38.
3 The President’s Council On Bioethics. Beyond Therapy: Biotechnology and the Pursuit of Happiness. Washington, DC: October 2003.
4 Elliot C. Better Than Well. New York, NY: W.W. Norton & Co.; 2003.
5 Israel GE.Transgenderists: when self-identification challenges transgender stereotypes. 1996. http://www.firelily.com/ gender/gianna/transgenderists.html.
6 Bornstein K. Gender Outlaw: On Men, Women and the Rest of Us. New York, NY: Vintage; 1995.
7 Rothblatt, M. The Apartheid of Sex: A Manifesto of the Freedom of Gender. New York, NY: Crown; 1995.
8 Dreger, AD.Hermaphrodites and the Medical Invention of Sex. Cambridge, Mass: Harvard University Press; 2000.
9 Fausto-Sterling A. Myths of Gender: Biological Theories About Women and Men. New York, NY: Basic Books; 1992.
10 Fausto-Sterling A. Sexing the Body: Gender Politics and the Construction of Sexuality. New York, NY: Basic Books; 2000.
11 Moir A, Jessel D. Brain Sex: The Real Difference Between Men and Women. New York, NY: Delta; 1989.
12 http://isna.org
James Hughes Ph.D., the IEET Executive Director, is a bioethicist and sociologist at Trinity College in Hartford Connecticut USA. He is author of Citizen Cyborg and is working on a second book tentatively titled Cyborg Buddha. He produces a syndicated weekly radio program, Changesurfer Radio.