gender reassignment surgery medical ethics

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13.1 The ethics of gender reassignment surgery

• Published: August 2021
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Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.

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• Open access
• Published: 29 October 2020

A principled ethical approach to intersex paediatric surgeries

• Kevin G. Behrens   ORCID: orcid.org/0000-0002-7595-7486 1  

BMC Medical Ethics volume  21 , Article number:  108 ( 2020 ) Cite this article

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Surgery for intersex infants should be delayed until individuals are able to decide for themselves, except where it is a medical necessity. In an ideal world, this single principle would suffice and such surgeries could be totally prohibited. Unfortunately, the world is not perfect, and, in some places, intersex neonates are at risk of being abandoned, mutilated or even killed. As long as intersex persons are at such high risk in some places, any ethical guidelines for intersex surgeries will need to take these extreme risks of harm into account.

I therefore argue for five basic principles that ought to inform ethics guidelines for surgical interventions in intersex children, specifically in contexts in which such children are at risk of significant harm. What I set out to come up with is a set of principles that do not completely prohibit surgery, but only allow it where a strong case can be made for its necessity, in the best interests of the child, and where there is some kind of oversight to prevent misuse. The first principle is that interventions as drastic as these surgeries should only be performed when there is strong evidence that they are beneficial and not harmful. The second principle is that in surgeries should normally only be performed in cases of true medical necessity. Principle three is that surgeries should normally be delayed until such time as the intersex person is mature enough to assent to treatment or decide against it. Principle four is that the conventional ethical requirements regarding truth telling apply equally to intersex children as to anyone else. The final principle is that where physicians or parents think that surgery is in the best interests of the child, the burden of proof lies with them.

It is hoped that these principles might help medical teams and parents make better decisions about intersex surgeries on children, and they would make such surgeries very rare indeed, if they happen at all.

Peer Review reports

On 24 January 2018, a South African newspaper, the Mail and Guardian , posted an article online. It was entitled ‘Intersex babies killed at birth because they are bad omens’. In it the author describes an incident in a rural South African village in which a traditional healer, assisting with the delivery of a baby, witnessed how the baby was killed by family members when it was discovered that it had been born with ambiguous genitalia. They decided to lie to the mother and tell her that the child was stillborn. The author points out that this is an example of many cases of intersex infanticide that occur because of a belief that ‘intersex babies are bad omens. They are seen as a sign of witchcraft and a curse on the family and the community as a whole’ [ 1 ].

While we do not have reliable statistical data for how often intersex infanticide takes place in South Africa, there is sufficient evidence to know that it does occur. In an informal study conducted by Tunchio Teriso in a rural area of South Africa, 88 out of the 90 traditional midwives and birth attendees interviewed owned up to having killed babies born with ambiguous genitalia [ 1 , 2 ]. Furthermore, we know that, in a context in which an intersex person is sometimes believed to be a bad omen, a curse, or a sign of punishment, witchcraft, or the displeasure of ancestors, intersex children are exceptionally vulnerable to social stigma, rejection and even physical violence [ 1 , 2 ]. It is against this contextual backdrop that I seek, in this paper, to develop a set of principles to guide medical teams and parents to make ethically justified decisions about intersex paediatric surgeries.

While this article has arisen out of the situation in rural South Africa described above, it is of relevance in other contexts, too. It is likely that if intersex babies are killed in South Africa, they are also killed in other countries on the continent, and indeed in other parts of the world, where similar beliefs about intersex children prevail. Intersex infanticide or attempted infanticide has been reported from Uganda [ 3 ], Kenya [ 4 ] and China [ 5 ]. It is likely that the most vulnerable intersex infants are those born in rural communities, where births take place in private homes and out of sight of authorities. Furthermore, globally, intersex infants are at risk of being discarded, abandoned, neglected or mutilated [ 6 ]. Intersex individuals are also vulnerable to violence and even murder after infancy and right through into adulthood. What all of this suggests is that there is a need for an approach to early infant intersex surgeries that is cognisant of the very real threat to life and limb of intersex individuals.

The first talk I gave on this subject was to staff and students of the Philosophy department at a neighbouring university in Johannesburg. I took a hard line, arguing for law reform to completely prohibit medically unnecessary intersex surgeries before an age where intersex persons can give consent or at least express their wishes. During question time, I was challenged on this by one of the academics in the audience. He asked me whether I had considered the possibility that in the South African context, prohibiting surgeries completely might have the unintended consequence of leading to even more intersex infanticide or abandonment. Perhaps, he said, the option of surgery could potentially save lives, and removing the option could have disastrous consequences.

Another person asked whether—in communities in which intersex persons are so feared—surgery might not sometimes be necessary to prevent a child from experiencing terrible ostracization, rejection, violent assault, and even murder. Of course, I defended my position by saying that we should not give in to prejudice and ignorance, and we should work on the root of problem: changing beliefs and attitudes in the community, so that intersex people are welcomed and not rejected. But, I left the talk feeling rather perplexed and uncertain of my position. How would I feel if the total prohibition of child surgeries did have the effect of a significant rise in infanticide or abandonment, or if worried parents resorted to back street surgeries, with the predictable, harmful consequences? Changing beliefs and entrenched cultural practices takes time. We would be foolish to think that that it would not take decades for even well-conceived and funded education programmes to be successful in effecting such change. So, my interlocuters had a point. I would need to carefully consider the potentially very harmful unintended consequences of simple prohibition. It is for this reason that I here adopt a slightly less rigid approach that would make surgical procedures a rare exception only to be used in cases where they might be necessary to protect an intersex person from serious harm.

In this paper, my aim is not to argue for legal reform, but rather to address the problem of early intersex surgeries Footnote 1 by seeking to influence the decisions and actions mainly of health care professionals. Partly this is because I am employed as a teacher of bioethics to such professionals. However, I am also mindful of the very significant role health professionals play in the decisions made by parents regarding the treatment of their intersex children. Parents frequently rely on their counsel as medical experts, and their opinions are very influential. While it is parents who must give consent for treatment and surgery, it is often the physicians’ views that swing the outcome [ 7 , 8 ], even if (in some cases) it is only in conceding to parental choices where these are not in the best interests of the child. Thus, I have chosen to essentially target health professionals and, through them, the parents of intersex children.

I have also chosen to focus on health professionals because it is the case that resorting to early surgeries remains a common response to intersex births in my home country, South Africa, as well as in many other countries. With what is already a comparatively high incidence of intersex births [ 1 ], South Africa has no official professional ethical guidelines for medical specialists on such surgeries and is not party to the Chicago Consensus [ 9 ], the one multinational set of professional guidelines that does exist. This results in a situation in which surgery is the default option, seriously affecting large numbers of intersex children born in the country [ 10 ]. While it is difficult to find data on the prevalence of infant genital ‘normalisation’ surgeries in other parts of the world, where intersex individuals are at significant risk of harm, it is clear that there are still many countries in which early surgery remains the preferred approach to intersex births. What is required, in places where such surgeries are available, are some ethical guidelines aimed at ensuring that surgery does not remain the default option, and that it is only chosen in cases where it can be robustly defended, ethically. This paper is intended to provide some basic principles to guide health professional bodies to develop appropriate guidelines on infant intersex surgeries. I am very aware that this can, at best, be one component of a much broader and multi-faceted strategy that is necessary to address all of the issues around the human rights and well-being of the intersex community, including education, advocacy, legal reform, social change and even moves toward a global ban on surgeries. However, I hope that by getting through to those who are most involved in the decisions about surgery, the health professionals and parents, surgeries will become at best very rare and certainly no longer the default choice.

I propose five basic principles that ought to be used as the scaffolding for a set of ethics guidelines for surgical interventions in intersex children, specifically in contexts in which intersex children are at risk of significant harm. What I set out to come up with is a set of principles that does not completely prohibit surgery, but only allows it where a strong case can be made for its necessity, in the best interests of the child, and where there is some kind of oversight to prevent misuse. I believe these principles are congruent with the Malta Declaration developed by the International Intersex Forum [ 11 ]. Footnote 2

Principle 1: interventions as drastic as these surgeries should only be performed when there is strong evidence that they are, all things considered, beneficial and not harmful

One might think that this goes without saying. However, whilst it has often been claimed that genital ‘normalising’ surgeries Footnote 3 that are not a strict medical necessity are beneficial, there is a paucity of evidence to justify such claims. These surgeries first began to be done at the Johns Hopkins Hospital in Baltimore in the 1950s, and spread around the world, soon becoming the global standard of care. Primarily grounded in the work of the psychologist, John Money, they were justified on two main assumptions, the first being that gender identity is more a matter of nurture than nature. So long as the child had surgery to ‘normalise’ the appearance of the genitals, the child would grow up to identify with the gender it was raised as [ 7 , 12 ]. The second was the belief that it was in the best interests of the intersex child to be raised as ‘normally’ as possible. Surgery would help the child to appear more ‘normal’ and ‘fit in’ better socially [ 13 , 14 ]. We now know that both of these assumptions turned out to be false.

The first claim—that it was possible to socialise a child into a chosen gender identity—was shown to be false very soon. Money frequently defended his claim by making reference to a case that was to become famous. He had been approached for advice on how to manage a situation in which a botched circumcision on an 8 month old identical twin boy had caused the child to lose his penis. Money advised the parents to obtain surgery to remove the boy’s testicles and reconstruct the external genitalia to resemble the typical genitalia of a girl. Furthermore, he recommended that the child be raised as girl, and that his medical history should be hidden from him. Convinced that gender identity could be altered by such socialisation, Money believed that it would be better for the child to undergo the surgery and be raised as a girl. He believed this would be better than the alternative ‘to raise him as a boy with an inadequate penis’ which would purportedly cause ‘the child [to] suffer severe psychological trauma’ [ 7 ]. Despite the fact that the child in this case was not born intersex, at the time, the case was lauded as evidence that Money was right about how best to treat intersex infants. Julie Greenberg describes how this case was received in the context of the time as follows:

This ‘male turned into a female’ case made headlines. Because the doctors involved in the treatment reported that the child and the parents had successfully adapted to the sex/gender alteration, sociology, psychology, and women’s studies texts were rewritten to argue,’[t]his dramatic case... provides strong support... that conventional patterns of masculine and feminine behaviour can be altered. It also casts doubt on the theory that major sex differences, psychological as well as anatomical, are immutably set by the genes at conception.’ [ 13 ]

The purported success of this case became the subject of much debate some years later, in 1997, when Milton Diamond and Keith Sigmundson published an article that told the story of what had become of the twin boy who had been raised as a girl. Contrary to Money’s claims that the child had self-identified as a girl, he had, in fact, always preferred typically male toys and behaviours, even preferring to urinate standing up. At the age of 14, he confided in a doctor that he identified as a boy and wished to live as boy. He then began the process of re-transitioning back to male [ 13 ]. He was to live the rest of his life as a male, even marrying a woman and adopting her children, before his death by suicide in 2004 at the age of 38 [ 14 ].

The failure to socialise a child into a chosen gender identity after reassignment surgery in this one case is insufficient evidence, on its own, to refute Money’s original claims. More evidence was soon to follow, however. Greenberg cites a presentation given by William Reiner, a urologist and psychiatrist at Johns Hopkins Hospital, at a Paediatric Endocrine Society meeting in 2000. Reiner reported on preliminary findings of a study of 27 infant boys born without penises. Of these, 25 had undergone sex re-assignment surgery and had been raised as girls. Of these, only 14 ended up identifying as boys. Furthermore, the two infants who had not undergone surgery and were raised as boys were ‘better adjusted’ than the others [ 13 ]. Dolgin writes:

research has failed to demonstrate that early surgery to re-shape an intersex child’s genitals, accompanied by socialization within the assigned gender, results in a better or ‘more typical’ childhood. To the contrary, surgery to conform the appearance of genitalia to a gender selected by doctors and/or parents early in a child’s life is likely to result in psychological difficulties that affect the child and the adult that child will become [ 14 ].

Far too many intersex adults who were raised as one gender or the other, after genital ‘normalisation’ surgery, turned out not to identify with the gender that had been assigned to them [ 15 , 16 , 17 ]. Of course, the knowledge we now have about gender identity shows that it is much more complex than we used to think it was, as the very existence of transgender people demonstrates. Furthermore, the whole idea was originally grounded in the work of Money, the underlying assumptions of which have been discredited. By now, the idea that we can simply socialise a child into a chosen gender has been thoroughly debunked and any health professional still making that claim opens themselves to the accusation of being ignorant or wilfully ignoring the evidence. Yet, these surgeries continue. Most often, this is because the health professionals still hold to the truth of the second assumption, that surgery is in the best interests of the child. This is a claim about the psycho-social well-being of the intersex person. Returning to my principle, I have stated that because these interventions are so drastic, they should only be performed where there is evidence that they are, all things considered, beneficial and not harmful. There is plenty of evidence that these surgeries cause many kinds of harm. Greenberg writes that some intersex activists and experts

believe that the traditional model results in stigma and trauma. Because of the emphasis on ‘normalizing’ the infant’s genitalia, parents will experience guilt and shame over giving birth to an ‘abnormal’ baby and the intersex patient will experience a sense of rejection. They question the traditional assumption that concealing or downplaying the existence of the intersex condition will help the family lead a ‘normal’ life [ 13 ].

Cresti describes some of the consequences of early surgeries as ‘pain, lifelong depression, incontinence, and scarring’ and points out that

another objection is that early surgery is ‘worthless mutilation’ that causes damage to individuals who have not chosen to be subjected to those interventions. Indeed, those interventions reduce sexual pleasure in many cases…, impose a sex that might not coincide with future gender identity, and in most cases are irreversible. Furthermore, outcome studies are scarce and surgical outcomes are uncertain [ 15 ].

Greenberg provides a comprehensive account of the harms that intersex persons who have had early surgery experience:

During the 1990s, a number of intersex activist groups also began to question the standard protocol for treating intersexuality. Because genital surgery may result in a loss of reproductive capacity, a loss of erotic response, genital pain or discomfort, infections, scarring, urinary incontinence, and genitalia that are not cosmetically acceptable, these groups believe that such surgery should not be performed without the informed consent of the intersex patient. In addition, they maintain that the current treatment protocol exacerbates an intersexual’s sense of shame by reinforcing cultural norms of sexual abnormality [ 13 ].

I am not aware of any studies or other actual evidence the supports the idea that it is, in fact, beneficial to the psycho-social well-being of intersex people when they are subjected to early surgery. In the absence of evidence, we should always make decisions based on what we actually do know [ 13 ]. So, until research is done showing that there are such benefits, we are morally obliged not to perform such drastic surgeries.

Principle 2: surgeries should normally only be performed on intersex infants in cases of true medical necessity

If my claims in the previous section are right, if a child’s gender identity cannot be fixed just by rearing, and if it is not at all clear that the psycho-social consequences of infant genital ‘normalisation’ are more beneficial than harmful, then there is, ordinarily, no justification for proceeding with these surgeries, except where there is a medical necessity. Footnote 4

There are some cases in which intersex conditions may require immediate surgical intervention, such as when there is malignant tissue that needs to be removed or when an opening for urination needs to be created [ 8 ]. Of course, there is likely to be disagreement among experts over what conditions do require early surgical intervention. While total consensus might elude us, medical profession bodies should be able to come up with satisfactory guidelines for best practice in this regard. The point of my principle is to allow for paediatric intersex surgery in the rare cases where it is arguably a medical necessity, while preventing surgeries for any other reasons.

It should be noted that this principle deals with surgical interventions only. There may be other serious or even life-threatening conditions affecting intersex infants that require immediate medical attention (for example, congenital adrenal hyperplasia can be fatal in the early stages of infancy if not treated with steroids) [ 12 ]. Since the focus of this article is only on paediatric intersex surgeries, these will not be discussed further here.

Setting aside definitional difficulties, I will simply rely on solid ethical precedent and the generally accepted moral intuition that we ought not to perform unnecessary surgeries, certainly not when the patient has not expressly requested such of their own accord. I will rest my case with this for now.

Principle 3: surgeries should normally be delayed until such time as the intersex person is mature enough to assent to treatment or decide against it

The exceptionalism that routinely applies in these cases is quite baffling: where else would we routinely override the conventional ethical requirements for age-appropriate assent or informed consent for elective surgeries with no medical necessity and where the consequences could be very harmful to the patient? It is trite to say that is established ethical practice not to perform such surgeries without the agreement of the person having the surgery. In the case of children, it is generally regarded as both legally and ethically permissible for parents or legal guardians to consent to treatment on behalf of minors who are not capable of giving informed consent. However, this concession is intended to allow for medically necessary or urgent interventions, and in many jurisdictions is subject to the principle that it is only permissible if done in the ‘best interest of the child’ Footnote 5 [ 12 , 13 , 15 ].

Cresti, Nave and Lala provide a cogent account of the ethical limitations that apply to parental consent. They write:

In the case of intersex newborns, there is no doubt about their inability to make their own decisions. Some solid moral reasons justify the attribution of decision-making ownership to the parents of minors… Such parental decision-making ownership finds a limit in the obligation not to harm, and this harm can also include any impact on the ability of the individual to exercise their autonomy in future. Their interpretation of beneficence prevails on the other interpretations, but it cannot lead to the presumption of making personal and permanent decisions better than could the intersex person herself. Surgical sex assignment leads to irreversible body modifications, body perception, and functionality, and clinical and pathological reasons do not justify this. Only individuals whose body undergoes such treatments should give informed consent to these practices [ 15 ].

Cresti et al. are quite right in asserting that parental consent to treatment cannot be justifiable if it causes harm to the child. Footnote 6 I have already given an account of the many different kinds of serious harms such surgeries can cause. Yet, critics might argue that not performing genital ‘normalising’ surgery at an early age may cause even more weighty harms—primarily of a psycho-social nature. When discussing my first proposed principle, I referenced much evidence that calls this claim into question. To a large extent, this is a question of fact, and empirical evidence should be able to provide us with a clear answer. Unfortunately, there have not been enough focussed and comprehensive longitudinal studies on intersex persons who underwent surgery at a young age for us to have a clear picture of their well-being over time. But, we have enough evidence to suggest that many of them experience severely harmful effects [ 12 , 13 , 14 , 15 , 16 , 17 ]. Thus it is both prudent and ethically necessary to not subject infants to such risk of harm without their assent or consent, in all cases where a delay in making the decision on whether to proceed with surgery is possible.

Studies are even more rare regarding the long-term well-being of intersex infants who were not subjected to early surgeries. This is likely the case for a number of reasons. Firstly, from the 1950s until fairly recently, surgery was the standard treatment approach in most parts of the world, leaving few untreated persons to include in studies. Secondly, possibly because of embarrassment or fear of social exclusion, intersex individuals who have managed to get through life without being identified as intersex may not be inclined to participate in research. Be that as it may, the one very comprehensive study on the well-being of intersex individuals who had not undergone surgery was done, paradoxically, by John Money some years before he began to promote his assertion that gender identity was mutable and more a matter of nurture than nature. For his Ph.D. thesis at Harvard University in 1951, Money reviewed the cases of some 250 intersex individuals who had not received surgical intervention as infants. In particular, Money focussed on the experiences of children who naturally developed to have genitals of the sex opposite to the sex of their rearing. It was his initial expectation that such individuals would struggle to adjust to normal life because of their obvious psycho-sexual issues. He reported that he was amazed to discover that even the most ambisexual of these intersex individuals showed no increased incidence of functional psychoses, and managed to cope with the tasks of ordinary living: holding down a job, earning a salary and getting an education [ 7 ]. The study included in-depth interviews with 10 individuals who did not receive surgical or hormonal treatment until they were old enough to decide for themselves. They came across as remarkably well-adjusted, resilient, confident and sometimes even optimistic. Colapinto writes: ‘Their lives only strengthened the investigator’s impression that the condition of the genitalia plays a strikingly insignificant part in the way a person develops a stable and healthy gender identity, not to mention a secure and confident self-image’ [ 7 ].

It is unclear what caused Money to abandon the evidence of his own PhD research. However, some 4 year later, he began publishing papers on intersex infants in which he promoted early ‘normalisation’ surgeries to align with a chosen gender of rearing as being in the best interest of these children. What his exhaustive PhD study does suggest, in the end, is that delaying surgeries does not necessarily result in any real harm for most individuals. Since it has already been shown that performing these surgeries does result in harms for at least a significant proportion of children, it is clear that the more ethically justified action would be to delay surgeries.

Cresti et al. also make the provocative, but plausible, claim that one of the harms caused by early surgeries arises out of the fact that they rob the individual of their autonomy in the future [ 15 ]. Many of these surgical interventions are partially and even fully irreversible [ 8 , 12 ], and early surgeries often impose severe limitations on the medical and operative options that would still be available to the patient later in life. As Cresti et al. suggest, what is stake in these cases are matters that are extremely personal and ‘life-altering’, and that only the individuals themselves can decide how best to integrate their ‘body and personal and social identity’ [ 15 ]. They go on: ‘The incompetence of these minors is constitutive, provisional, and destined to be replaced by full decision-making and self-determination capacities. Identity and bodily integrity of intersex infants must, therefore, be defended from surgical or other assaults until they can decide for themselves’ [ 15 ].

Establishing an optimal age for when intersex children will be ready to make decisions about their gender expression and whether to undergo surgery or not is not an easy task. It is beyond the scope of this paper to discuss this here. But, it is important that this issue be given careful consideration. While infant surgeries should not be allowed, it might be too late to wait for adulthood before allowing those children who feel ready to do so to decide what they want. Hormonal treatment before the onset of puberty could go a long way to easing any transition and surgery later. As Crestio et al. write: ‘The ability of individuals to make decisions according to their values and beliefs should be able to be exercised before their bodies and their developing sexual and gender identity is irreversibly compromised’ [ 15 ]. What is clear is that the principle of delaying surgeries until children are able to make their own choices holds.

Principle 4: conventional ethical requirements regarding veracity/truth-telling apply equally to intersex children as to anyone else

This principle is important because deception and hiding the truth have long been commonplace in how intersex children have been treated [ 7 , 8 ]. In her account of what she calls the ‘current dominant medical practice’ (of performing early ‘normalisation’ surgeries), Greenberg identifies some deception or withholding of information as being almost a necessary condition for the practice to be successful: ‘This model emphasizes the need for a clear and unambiguous gender identification. To achieve this goal, the child should receive surgery and the parents and the intersex child may benefit by being told less than the whole truth about the nature of the condition’ [ 13 ]. Dickens writes: ‘Predetermining children’s futures by such interventions is also liable to require continuing deception regarding their biological and/or genetic inheritance, contrary to ethical expectations of truth telling and legal requirements of informed consent to treatment’ [ 12 ].

In other medical contexts, deception or withholding of the truth from patients would be taken to be obviously unethical. Yet, the personal experience of many intersex individuals who have been subjected to early surgeries was that they were often lied to or not fully informed about their medical histories [ 8 ]. Partially, this may have been because parents were following the advice of people like Money, who insisted that successful identification with the gender of rearing required that the child be raised to believe in the gender assignment, absolutely. Some parents may have been fearful of divulging any part of the truth, lest it lead to the child failing to identify with the assigned gender.

At a more profound level, it is also likely that parents and physicians fail to divulge the truth of their medical history to intersex children who have been subjected to surgery because of a deep internal discomfort about intersexuality and its implications. Indeed, many of the decisions to go ahead with early surgeries may have more to do with parents’ and physicians’ discomfort with ‘difference’ than with what is truly in the best interests of the child [ 8 ]. Cresti et al. write

It seems as though these treatments really ‘have been contrived solely to conform people to our narrow ideas of “normal”…. A reason for this is that human adults are afraid of “atypicality.” They possess specific ideas, culturally situated and socially built, about the kind of body human beings must have, and it is this normativity, imagined by adults, which is incised upon the body of intersexual children’ [ 15 ].

Dickens writes:

It was observed 20 years ago in medical practice that parents of intersex children and the children as they mature ‘are lied to; risky procedures are performed without follow-up; consent is not fully informed; autonomy and health are risked because of unproven (and even disproven) fears that atypical anatomy will lead to psychological disaster’ [ 12 ].

It is not only intersex persons who have routinely been lied to or have not been fully informed. I have already quoted Greenberg’s assertion that medical experts often believe that it is better for parents to be told ‘less than the whole truth’ [ 13 ]. She maintains that physicians do not always inform parents that their child might not end up identifying with the assigned gender after surgery, and that they deliberately downplay revealing anything that might cause confusion, in order that parents will feel comfortable with consenting to surgery [ 13 ]. She writes: ‘Although parents believe they are considering the best interests of their children when they make their treatment decision, it is difficult for parents to rationally assess whether they are focusing on their need to have a “normal” infant over the long-term interests of their child’ [ 13 ].

None of these reasons for withholding the truth about their conditions and medical history from intersex individuals or their parents can be ethically justified. Again, what is most baffling is the exceptionalism that so often seems to apply in these cases. It is by now an established ethical principle that health professionals ought to tell their patients the whole truth about their health, unless there are very good reasons not to. Clinical medicine rejected paternalism and the so-called physician’s therapeutic privilege to decide what to tell patients decades ago. This generally applies to children, too [ 12 ]. Only in cases where telling the truth to a child is likely to be beyond their comprehension can any kind of deception or withholding of the truth be morally justified. And even then, such decisions need to be regularly reviewed in the light of the child’s increasing maturity and understanding. The truth should always be told in an age appropriate manner [ 12 ]. These days this is standard practice, even in cases where children have serious illnesses or terminal conditions. We have discovered that children are far more capable of understanding and far more resilient than we used to think. Intersex children should be told the truth just like anyone else. Furthermore, this will contribute to an ending of the conspiracy of silence around intersex and variations of sexual characteristics. Ignorance lies at the root of so much societal prejudice, and silence feeds it.

Infant genital ‘normalisation’ surgeries have been part of the standard approach to intersex births for some decades now, but since the purported grounds for these interventions have been shown to be unfounded, it is becoming more likely that intersex activists, victims of unjustified surgeries, medical experts and society at large will challenge these practices, and the deception that routinely accompanies them. It is likely only a matter of time before someone turns to the courts to challenge these practices. Dickens warns:

However well-intentioned, parents, doctors, psychologists and others risk ethical and legal violations if they seek to escape the challenges of educating parents and providing age-appropriate education to growing children by discarding the ordinary principles of offering and providing medical services, such as honesty, adequate disclosure, and indicated follow- up care [ 12 ].

A commitment to truth-telling will also have the consequence of moderating drastic choices by parents and medical teams, as they know they will have to account to the intersex child when she or he is older.

Principle 5: where physicians and/or parents think that surgery truly is in the best interests of the child, in terms of safety or psycho-social well-being, the burden of proof lies with them

This principle seeks to ensure that the typical or default decision will be to not perform surgery, and that those who want to perform surgery on children will need to provide very good reasons why this is necessary. Given that there are contexts in which intersex infants can be killed or be in constant danger of physical harm, this at least keeps the door open to surgeries performed in the interests of the safety of the child, but only in exceptional cases. What needs to change urgently is resorting to surgery as the default choice. Professional guidelines should clearly recommend delaying surgeries and require physicians and parents who believe that surgery is necessary for the safety of the child to provide a strong motivation for why this is so. It needs to be understood that it is almost always unethical to perform genital ‘normalising’ surgeries on intersex children, where there is no medical necessity. Where such surgeries are given the go-ahead, this should be a reluctantly granted concession that is made only because of a serious risk of harm to the child. Furthermore, this should be seen as a last resort, only to be effected when alternatives have been exhausted or where it is thought that they would be ineffectual or impracticable.

To ensure that this concession is not abused, I would also propose that some kind oversight body, comprised of suitably qualified persons, should be required to review applications for early surgeries and approve or reject them on their merits.

Surgery for intersex infants should be delayed until the intersex individual is able to make their own decisions in this regard, except in cases where surgery is a medical necessity. In an ideal world, this single principle would suffice and surgeries that are not medically necessary could be totally prohibited. Unfortunately, the world is less than perfect, and, in some parts of the world, intersex neonates are at risk of being killed, abandoned or mutilated. These risks of harm accompany some intersex persons throughout their childhood and even into adulthood. As long as intersex persons are at such high risk in some places, any ethical guidelines for intersex surgeries will need to take these extreme risks of harm into account. In this paper, I have therefore argued for a set of five basic principles that can form the foundation for professional ethical guidelines for best practice regarding intersex infants. It is hoped that these principles might help medical teams and parents make better decisions about intersex surgeries on children, and they would make such surgeries very rare indeed, if they happen at all. As Carpenter and Cabral write:

’Normalizing’ procedures violate the right to physical and mental integrity, the right to freedom from torture and medical abuses, the right to not being subjected to experimentation, the right to take informed choices and give informed consent, the right to privacy and, in general, sexual and reproductive rights [ 18 ] .

I give the last word to South African intersex activist, Nthabiseng Moekwena, who has said:

I am so pleased I never had surgery. The people I met, most of them, black and white, who have had surgery as babies, usually ha[d] confused parents who[m] the doctors incorrect[ly] informed, and the children were subjected to surgery which has ended up being far more traumatic and confusing… We have been raised in a world that makes us feel like monsters. My advice to other intersex people is to love and accept. Only then will you make the right decision about surgery… Surgery is not a magic pill that has no consequences [ 19 ].

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

I deliberately use the term ‘intersex’ throughout this article, as this is appears to be the term preferred by intersex activist groups. There are many Variations in Sex Characteristics (VSC) or Differences in Sex Development, ranging from a minor displacement of the urethral orifice to truly ambiguous genitalia and total discordance of anatomical and chromosomal sex. Many VSCs do not fall into the category of intersex. Since the focus of this paper is on surgeries in infants born with VSCs, the scope of the discussion is limited to those kinds of VSCs that would likely give rise to surgery being considered as a possibility. Because this entails cases where the outward appearance of the genitalia is obviously atypical or ambiguous, the use of the term ‘intersex surgeries’ is appropriate.

By contrast, my principles take a stronger position against normalizing surgeries that are not medically necessary than the positions taken in the Chicago Consensus document [ 8 ] or the principles proposed by Gillam et al. [ 20 ].

Many of the kinds of surgeries typically performed on intersex infants are far more than merely cosmetic. They might include castration, hysterectomy, or the creation of an artificial vagina, among others.

I use the phrase ‘true medical necessity’ to denote conditions where surgery is required to preserve the life or ensure the physical health of the patient. This would ordinarily exclude surgeries performed solely for the purpose of ‘normalising’ the appearance of the genitalia.

Although I argue strongly that ‘normalising’ surgeries should be delayed until children are mature enough to assent to treatment or decide against it, I acknowledge that many parents might consider surgery because they are truly concerned for their children’s well-being. Without access to empirical evidence of the harms that such surgeries can cause, it is understandable that some parents might think that ‘normalisation’ is the best way to protect their child from stigmatisation and growing up ‘different’.

The extent to which parents have rights to decide the fate of their children is contentious [ 21 ]. However, article 3 of the United Nations Convention on the Rights of the Child states that ‘in all actions concerning children…the best interests of the child shall be a primary consideration’ [ 22 ]. In line with this statement, many jurisdictions now recognise, in their law relating to children, that the principle of the best interests of the child should be a paramount consideration. In my own country, South Africa, this principle has been applied to establish the legal precedent that parents’ decisions to deny blood transfusions to children on religious grounds may be overridden and that cultural practices like female circumcision are forbidden. There is a growing consensus position that parents do not have unlimited rights to make decisions on behalf of their children, and that they do not have the right to make decisions that are likely to cause non-trivial, avoidable harm to their children.

Abbreviations

Variations in sexual characteristics

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The Ethical Intricacies of Transgender Surgery

Illustration by Taimi Xu

Article by Leyla Giordano

Over the past decade, the transgender population has increased in visibility dramatically in the United States. The medical field has made progress when it comes to access to gender-affirming surgery; however, the progress has not rid society of discrimination and bias towards the transgender population, and access to care is still limited. Thus, it is essential to train medical professionals to care for this vulnerable population with compassion and knowledge. During the summer of 2018, I interned at the Gender Reassignment Department of Mount Sinai Hospital, where Dr. Jess Ting pioneered New York City’s first surgical program dedicated to transgender surgery. I learned that he transforms bodies every day in his operating room and cares for his patients with empathy, but he also struggles with feelings of helplessness when his patients share their devastating stories and disappointment when his surgeries are unable to live up to their expectations.

The American Psychiatric Association defines transgender as “a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align with their gender identity (i.e., one’s psychological sense of their gender).” 1 Further, a subset of transgender individuals will experience gender dysphoria, defined by the American Psychiatric Association as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” 1 Thus, the dysphoria refers to the psychological distress that can often result from being transgender. In response to gender dysphoria, one may seek affirmations in several areas, including but not limited to social, legal, medical, or surgical. Medical and surgical affirmations are two ways in which one’s true identity can be revealed externally to society. Gender affirming surgery includes vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, and others. 3 Surgeries like these can help reduce an individual’s gender dysphoria so that their physical body matches their gender identity.

Overall, transgender surgery improves lives because it gives trans individuals a body in which they feel more like themselves. However, the transgender population faces significant disparities in social determinants of health. These detrimental determinants limit Dr. Ting’s ability to heal this vulnerable population, frustrating him as he is ultimately unable to fix the discriminatory social context they encounter outside of the hospital. This paper will first discuss what it means to be transgender and how Dr. Ting’s work improves their life experiences. It will then move into the broader traumas that transgender individuals face. Finally, this paper will discuss the limitations and frustrations of Dr. Ting’s practice and how they have affected his approach.

Being transgender in our society and life-changing surgery

Since the 1900s, historians, activists, anthropologists, and many others have engaged in the debate between sex and gender. The social presentation and embodiment of one’s gender can differ from the anatomy or chromosomes with which one is born. Until recently, people have assumed that females act feminine because they have a uterus, not because they identify as a “female.” Society has assigned certain characteristics to what it means to be a girl, such as wanting to wear lipstick and play with Barbies. In the 1960s, a white and Western feminist theory emerged that posits that sex refers to the natural anatomical features, whereas gender refers to the culturally constructed norms that have been built based on one’s sex. 2 This theory persisted into the 1990s, when Judith Butler argued that, in addition to gender, sex is also a social construct. She posited that if gender and sex are both social constructs, then these two terms are essentially the same. 2

For decades, long-standing ideologies have informed beliefs that the trans identity is unacceptable since it runs contrary to the societally constructed connection between sex and gender. However, individuals like Dr. Jess Ting are contributing to the current shift in that dialogue surrounding the acceptance of trans identities. The Gender Reassignment Department that Dr. Jess Ting helped create at Mount Sinai Hospital gives transgender individuals the medical care that they need, changing the discourse around the transgender identity from taboo to celebrated. For example, in an interview I conducted with Dr. Ting, he recounted a memory about his oldest patient, who has stayed with him for five years. She was 77 years old and had been married to a man for many years. She told Dr. Ting that “this [surgery] is something I want to do for myself. I’ve wanted it since I was five years old, and I have never been able to get it.” As soon as Dr. Ting began to sign her up for surgery, she began to cry. She said, “I thought you were going to tell me that I was too old for surgery.” This story has stuck with Dr. Ting ever since because, as he says, “it’s powerful to give someone something that they have wanted for their whole life.” This patient had previously not gone to a doctor for the surgery out of fear that she herself and her identity would never be accepted. She also never had access to surgery because until 2016, no surgical programs existed in the state of New York. However, at the age of 77, the discussion around the transgender population has become significantly more welcoming and access to these operations increased such that Dr. Ting’s patient was able to finally get the gender-affirming surgery for herself.

A significant number of Dr. Ting’s operations are facial feminization surgeries. Facial feminization surgery, which includes shaving the male protruding forehead and brow ridge and softening the nose and jaw, are sought out by transgender individuals who identify as women and hope to have society externally view them as women. It is difficult to masculinize a face, but facial feminization surgery is extremely effective in giving a patient the stereotypical female features, such as a less-protruding forehead. Society consistently puts pressure on each gender to embody certain characteristics, as Eric Plemons points out in The Look of a Woman : “Yes, [the operating room] was the precise location in which patients’ longed-for physical transformations took place. But it was also a place whose material dynamics pushed and pulled at conceptual frameworks of embodiment and selfhood that lay at the heart of trans-body projects.” 3 Dr. Ting revealed to me that the most common reaction he gets from his patients post-surgery is, “I just feel like me now,” as the material change in their appearance is an important part of what finally allows them to externally embody their ideal selves. Thus, the operating room becomes a place where the physical transformation makes it possible for a transgender individual to finally fit their own vision of themselves.

In a visual society such as ours, one’s facial features become the most salient factor in society’s recognition of one’s sex. As Plemons mentions, “Facial feminization surgery is guided by hope for future phenomenological integration and social recognition the creation of a body that (re)presents the self.” 3 Transgender individuals are unable to embody their ideal selves when they remain in the body they were given at birth. However, through facial feminization surgery, a transgender female can be outwardly recognized as a woman, making gendered embodiment a social phenomenon. As Rosalind expresses in Plemons’ article, “‘I’ve spent twenty-five years of my life thinking about not looking like I do now. I want that to go away. Constant thinking about that ruins the mind. After this I’ll be able to think of other things, everyday things.’” 3 Rosalind’s inability to embody her ideal self consumes her, as she is told every day by society that her gender identity is based off her recognizable characteristics like her Adam’s apple and her “Neanderthal brow.” 3 Facial feminization surgery is, thus, a popular way to experience the world in a body that is outwardly recognizable and accepted as female.

The stereotypical facial features of a woman are what have been defined as “normal” to society. These features include a softer brow ridge and forehead, eyebrows with a slight arch, fuller lips, no facial hair, and a smaller nose. Society defines these characteristics as female, and it also defines a binary of female and male as the only acceptable genders. According to Abramowitz’s three definitions of “normal,”—socially accepted or morally condoned, statistically most common, and frequently occurring in everyday life—each society determines that a specific anomaly is not “normal.” 4 Using these definitions, society sees transgender individuals as not “normal.” However, this is not how society should see the transgender population. This isolation is the exact disposition that leads to transphobia and a lack of transgender-specialized healthcare in the United States. Transgender individuals have reported that the most significant barrier to health care is the lack of physicians who are culturally competent and knowledgeable on the population. 5 Dr. Ting echoed this shortage when he discussed his introduction into the field: “When we started our program in 2016, there was no place in New York City to access transgender surgery.” Despite the discrimination they face, transgender individuals are normal and should be considered normal by society; they are simply human beings who do not feel comfortable in their own bodies. Through his work at Mount Sinai Hospital, Dr. Ting became a pioneer in this field of medicine, making the transition to an embodiment of transgender individuals’ ideal selves possible.

The broader traumas

Trans individuals’ health outcomes are negatively impacted through several factors, such as intense stigma, increased harassment, and restricted access to employment, healthcare, and insurance. The detrimental effect that these factors cause can extend as far as suicide. Dr. Ting revealed, “The thing that was most impactful for me was when we first started seeing patients. One of the patients that I had interviewed and was going to schedule for surgery killed themselves. And up until that moment, I did not understand what the trans experience meant. That’s how I came to understand why these surgeries can be lifesaving.” Despite the beneficial impact of transgender surgery, it cannot rid the United States of its unequal structural and social determinants of health. Transgender individuals often have restricted access to employment, healthcare, and housing compared to cisgender individuals. 6 Dr. Ting mentioned in our interview, “So many of my patients are sex workers, are undomiciled, and are living in shelters. This made me realize that I was judgmental. There’s not much that separates us from people who live on the streets or who are sex workers. When you have no other options, that is your only way of surviving.” The lack of these fundamental resources can lead to increased stress and poor physical and mental health, such as depression, suicidality, and chronic illnesses. 6

The othering of the transgender population leads to an intense and detrimental stigma surrounding the trans identity. Transgender individuals experience structural stigma (societal norms), interpersonal stigma (verbal harassment, physical violence, sexual assault), and individual stigma (the feelings these individuals hold about themselves that may shape future behavior such as the anticipation of discrimination). Structural stigma originates from the socially constructed gender binary, and therefore marginalizes those that are considered “abnormal.” This stigma may “therefore operate as a form of symbolic violence in which structures, such as communities, institutions, or governments, […] restrict and forcibly reshape transgender individuals in ways that ultimately serve to maintain the power and privilege of the cisgender majority.” 6 For example, a lack of insurance within the transgender population may lead trans individuals to pay out of pocket for procedures, which therefore makes it more likely that they feel they have no option other than to use cheaper street hormones acquired through friends or online. 6 Secondly, interpersonal stigma refers to the increased levels of physical and sexual harassment:“It is theorized that gender nonconformity causes perpetrators of violence to become anxious and angry, ultimately enacting violence against transgender people as a means of rejecting and diminishing that which they fear.” 6 Further, a national survey showed that, out of 402 transgender individuals, 47% had been assaulted and 14% of the 47% had been raped or survived attempted rape. 7 Thus, transgender individuals experience disproportionate abuse in their lifetimes, whether that be in the form of hate crimes, sexual assault, or verbal abuse. Finally, individual stigma refers to transgender individuals’ negative image of themselves. This stigma makes them anxious to seek out healthcare and destroys their ability to deal with external stressors, leading to an increase in preventable deaths such as suicide.

Another crucial example of  negative health outcomes among the transgender population is the increased rate of HIV. According to the Journal of Virus Eradication , “transgender women have a pooled HIV prevalence of 19.1%, […] For transgender women sex workers, HIV prevalence is even greater, estimated at 27.3%.” 8 Researchers believe that the increased risk is multifactorial and may be “due to differing psychosocial risk factors, poorer access to transgender-specific healthcare, a higher likelihood of using exogenous hormones or fillers without direct medical supervision, interactions between hormonal therapy and antiretroviral therapy, and direct effects of hormonal therapy on HIV acquisition and immune control.” 8 The fear of the medical setting that is present in the transgender population could lead to decrease testing for sexually transmitted infections, and therefore higher rates of HIV. Additionally, the stigma that surrounds the trans population leads to an alarming amount of trans individuals going into sex work due to the absence of other employment opportunities, which could also lead to increased levels of HIV.

The aforementioned factors contribute to a symbolic violence in which transgender individuals internalize the social asymmetries they experience. 9 This internalization can lead to a reactive personality and may even culminate in a personality disorder such as borderline personality disorder, since transgender individuals become used to the abuse and thus have learned to fight for themselves. As Dr. Ting reflected, “When anything goes wrong, [my patients’] reactions can be overwhelming and out of proportion to what you would expect. They blow up at me all the time. […] Trans people have a lived experience where […] they are subjected to abuse, and they are ignored. When you live like that, you build up your fences and you learn that you have to fight and scream for just regular occurrences.” Every day, Dr. Ting sees first-hand the internalization of the stigma that the transgender population faces. Trans individuals begin to view themselves and their self-worth through how they are negatively treated, prompting the development of a personality that is programmed to protect oneself against the world.

Limitations of Dr. Ting’s practice and their effects

The discrimination and abuse that Dr. Ting’s patients experience often exceed the medical realm, so an approach that focuses on narrative medicine and listening to his patients’ personal stories is important. 10 In “Narrative Medicine: Attention, Representation, Affiliation,” Rita Charon moves past the narrow focus on her patients’ physical bodies and approaches her patients with a dedication to their stories. 11 As Charon writes about a patient, “It was not just a matter of my having to know which section of his brain infarcted in his stroke but also what his stroke made of him, what it did to him, how he fought back from it, […] whether he will be the person he once was. It mattered to him and to our future clinical relationship that I know these things, that I have heard his fears and rage and grieving.” 11 Similarly, Dr. Ting is committed to listening to his patients’ personal stories about their experiences as transgender individuals. In our interview, he emphasized how important it was to him to listen to his patients and their concerns, as his patients often lack a support system. In this way, similarly to Dr. Charon, Dr. Ting acts as an empathic witness for his suffering patients. 10

However, physicians can only open themselves up to others’ suffering to a certain extent, and this balance has been difficult for Dr. Ting. When his patients come to his office, they have looked forward to their gender-affirming surgery for years, putting immense pressure on the outcome. This pressure can also lead to a dependency on the physician after a successful surgery for further help; however, Dr. Ting can only accept so much responsibility. During our interview, Dr. Ting reflected on a close relationship he built with one of his patients that caused him a large amount of grief: “One of my patients killed himself. He didn’t have a very smooth postoperative course. During Thanksgiving, he was texting me and meeting with a urologist. The urologist didn’t like the way that this patient was speaking to him. He can be a little rough, and the urologist [denied him care]. He then texted me saying, ‘What am I going to do now?’ I remember that I was out of town, and I responded ‘Don’t worry, we’ll find you someone else. It’s going to be okay.’ And he texted a few more times on Thursday or Friday, and then over the weekend, I noticed that I hadn’t heard from him in a while. I texted him on Monday to ask how he was doing, and I never heard back. A few days later, I found out that he had killed himself on the Monday after Thanksgiving.” With this news, Dr. Ting blamed himself, thinking that it was the complications from his surgery that made his patient commit suicide.

Physicians around the country experience burnout from job demands such as an overwhelming workload and emotional demands. Research on the mental health of psychologists and other physicians shows that these occupations aim to help people in need, leading to a high level of responsibility and increased emotional and interpersonal stressors for the physicians themselves. 12 Dr. Ting could not help but assign blame to himself for his patient’s suicide. In the process of doing so, the high level of compassion and empathy required of him negatively affected Dr. Ting. For psychologists, emotional exhaustion is the most commonly reported cause of burnout. 12 Although Dr. Ting is not a psychologist, his patients often depend on him for matters that extend past his office due to their lack of a support system. Dr. Ting provides life-changing surgeries to a very vulnerable population and deeply cares about his patients, and that type of work requires high levels of involvement, which can lead to burnout. As a consequence of burnout, research has shown that physicians then “seek an escape or distance themselves from their work both emotionally and cognitively, and [the burnout] is thought to lead on to feelings of cynicism.” 12 Dr. Ting felt himself burning out from the emotional burden he experienced while forming close relationships with his patients, and it forced him to place distance between him and his patients.

Thus, especially after his patient’s suicide, Dr. Ting decided to set a boundary between him and his patients by strictly keeping his relationships to his office. It was necessary for Dr. Ting to adopt a medical gaze to take care of himself. 13 In the process, he lamented the loss of the personal relationships he had built:

In the beginning, I would find myself getting very close to patients, sharing lots of details of their lives. In a way, that was really gratifying and rewarding for them to share emotionally fraught things. That’s why you become a healer. You want to heal people, and part of that is the positive feedback you get back from patients. Over time, I found that 99% of patients would be great, but the one complication would take so much out of me mentally. I could feel myself burning out a lot, so now, I am much more careful with patients in terms of creating boundaries. I don’t get as close to patients, which is sad, but it is necessary to protect myself. When I go see patients after surgery, and they tell me that I changed their lives, [saying] “How can I ever thank you?”, I feel like I have become a little numb to that, and I put up the boundaries where I’m afraid to let myself get close with patients.

Dr. Ting struggles between his commitment to his patients on a personal level and protecting himself from extreme responsibility for his patients’ distress. This complicated experience unfortunately limits the extent of his care. Despite the loss of many relationships that he values and his commitment to his patients past their physical bodies, Dr. Ting finds himself having to take a step back to separate himself from the burden of his patients’ trauma.

Overall, Dr. Ting changes his patients’ lives by giving them a body they can finally love and claim as their own. However, this responsibility brings a lot of pressure, as Dr. Ting expressed in our interview: “There is this tendency to idealize what’s going to happen or to feel like this surgery will cure everything – it will cure ‘all my ails.’ It doesn’t do that, it doesn’t cure all the ails of society – it makes your body align better with your internal identity, but you still have to go out into the world, and the world is not a better place.” Dr. Ting’s contributions to the transgender community supersede all expectations and grant so many the bodies and comfort they so desperately need, but he himself cannot change the society that transgender individuals enter back into when they leave the hospital. Despite the intense grief that Dr. Ting conveyed when he talked about the suicide of a patient and close friend, he ended our interview by relaying an encouraging conversation he had with his late patient’s partner: “She told me that the patient loved the body that I made for him, even with the complications. She told me that if he hadn’t had that surgery earlier, he would’ve died even sooner. He would not have even lived this long. For me, that lifted a heavy burden. I realized that maybe it wasn’t my fault, and that I did help him.” It’s clear that to Dr. Ting, the complicated moral experience that he faces within and beyond his office is worth it when he can aid individuals  that are so desperately in need of his care.

• “What is Gender Dysphoria?” American Psychiatric Association . https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
• Mason, Katherine. “Embodiment.” (Brown University, February 14, 2022).
• Plemons, Eric. “The Operating Room | The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine | Books Gateway | Duke University Press,” Chapter 5.
• Mason, Katherine. “The Normal and the Abnormal.” (Brown University, February 7, 2022).
• Safer, Joshua D., Eli Coleman, Jamie Feldman, Robert Garofalo, Wylie Hembree, Asa Radix, and Jae Sevelius. “Barriers to health care for transgender individuals.” Current opinion in endocrinology, diabetes, and obesity 23, no. 2 (2016): 168-171. 10.1097/MED.0000000000000227
• White Hughto, Jaclyn M., Sari L. Reisner, and John E. Pachankis. “Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanisms, and Interventions.” Social Science & Medicine 147 (December 1, 2015): 222–31. https://doi.org/10.1016/j.socscimed.2015.11.010 .
• Mizock, Lauren, and Thomas K. Lewis. “Trauma in Transgender Populations: Risk, Resilience, and Clinical Care.” Journal of Emotional Abuse 8, no. 3 (August 26, 2008): 335–54. https://doi.org/10.1080/10926790802262523 .
• Wansom, Tanyaporn, Thomas E. Guadamuz, and Sandhya Vasan. “Transgender Populations         and HIV: Unique Risks, Challenges and Opportunities.” Journal of Virus Eradication 2, no. 2 (April 1, 2016): 87–93. https://doi.org/10.1016/S2055-6640(20)30475-1 .
• Mason, Katherine. “Narrative, Stories, and Healing.” (Brown University, February 23, 2022).
• Charon, Rita. “Narrative Medicine: Attention, Representation, Affiliation.” Narrative 13, no. 3 (2005): 261-270. https://library.brown.edu/reserves/pdffiles/55716_rita_charon.pdf .
• McCormack, Hannah M., Tadhg E. MacIntyre, Deirdre O’Shea, Matthew P. Herring, and Mark J. Campbell. “The prevalence and cause (s) of burnout among applied psychologists: A systematic review.” Frontiers in psychology (2018): 1897. https://doi.org/10.3389/fpsyg.2018.01897
• Mason, Katherine. “(Bio)medical Training and Professions.” (Brown University, March 7, 2022).

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Starting Point: the World Professional Association of Transgender Health Standards of Care

Initial ethics discussions, is there a sound medical rationale for the treatment or surgery to be provided through the center is such treatment or surgery consistent with the practice of evidence-based medicine, is establishment of the center consistent with the hospital’s mission, does the establishment of the center, and the delivery of its services, demonstrate respect for human dignity and worth, does the establishment of the center, and delivery of its services, demonstrate respect for patient autonomy, if the procedures performed by the center elicit some public criticism on the basis of religious or moral views, how should the hospital respond, how will the center show respect for, and accommodate, religious or moral objections by staff to participating in the procedures offered by the center, how should the center allocate resources in the event that the need for services exceeds capacity, the dilemma of patient age, conclusions, acknowledgments, ethical issues considered when establishing a pediatrics gender surgery center.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Elizabeth R. Boskey , Judith A. Johnson , Charlotte Harrison , Jonathan M. Marron , Leah Abecassis , Allison Scobie-Carroll , Julian Willard , David A. Diamond , Amir H. Taghinia , Oren Ganor; Ethical Issues Considered When Establishing a Pediatrics Gender Surgery Center. Pediatrics June 2019; 143 (6): e20183053. 10.1542/peds.2018-3053

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As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital’s ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital’s mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center’s services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution.

As part of the development of the Center for Gender Surgery at Boston Children’s Hospital (BCH), the surgical team decided to initiate a process of ethical and legal consultation. As the first gender surgical center to be housed in a pediatric facility in the United States, it was expected that there would be ethical and legal concerns that were unique to the setting, in addition to the broader concerns around gender surgery raised by other authors. 1 , 2 In the fall of 2017, these concerns were raised over a series of discussions with the hospital’s administration, ethics committee, legal team, community members, and other stakeholders, and several concerns were identified that might be relevant to both this center and other centers working with younger transgender patients.

The World Professional Association of Transgender Health (WPATH) has laid out standards of care (SOC) 3 for the treatment of gender-nonconforming people. Although these SOC are in the process of being reviewed and revised, 4 and are not without controversy, 2 , 5 , – 8 the center team decided to use them as a starting point for policy development. As a starting point, the center decided to follow recommendations in the SOC that state that patients are not eligible for genital surgery until they have reached the age of majority and have lived for at least a year in their affirmed gender. Twelve months of hormone therapy is also required, unless hormone therapy is not clinically indicated. 3 With respect to chest surgeries, the SOC state that “Chest surgery in [female-to-male] patients could be conducted earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. 3 ” Other requirements for chest surgery in both men and women are persistent, well-documented gender dysphoria; capacity to make an informed decision; and evidence that any significant medical and mental health conditions are well controlled. (Note, the requirements for living in the affirmed gender do not require living in a binary gender.) Another important aspect of the SOC guidelines is the requirement for screening by a behavioral health professional, which is designed to provide the surgeon with relevant information about the patient’s gender identity and overall mental health. That screening is provided to the surgeon in the form of a letter, required for most insurance authorizations, that establishes the patient's suitability for gender affirming surgery. This requirement is somewhat controversial and has occasionally been referred to as “gatekeeping.”

Despite their awareness of this controversy, the center staff believed it was appropriate for the care paradigm to include a surgery-specific behavioral health assessment. The implemented protocol covers general readiness for surgery, case management issues that may occur around the time of surgery, assessment of whether the patient’s expectations for surgery are realistic, awareness of postsurgical care requirements and likelihood of compliance, gender history, and fertility assessment.

The center staff consists of a multidisciplinary team of surgeons (2 plastic surgeons, 1 urologist), midlevel providers, nurses, a social worker and researcher, an administrator, and a designated research specialist. The idea for the center originated with the 3 surgeons, who serve as codirectors. After a year of planning and seeking out professional development options in transgender care, the codirectors brought the social worker and researcher onto the team because of her extensive experience working with the gender-diverse patient population. Together, those 4 team members drafted an evidence-based proposal for how the center would be structured and how care would be delivered. They also prepared a presentation in which they highlighted the needs of young people for gender-affirming surgery, key criteria and conceptual underpinnings for offering the surgery (including the SOC), and specific surgical solutions. This material was then presented to the hospital ethics committee for discussion. The ethics committee includes members from a range of medical and surgical services, nursing, patient care services, social services, pastoral care, and other clinical services as well as community representatives and ex-officio participants from administration and legal counsel. 9  

The ethics committee meeting lasted ∼2 hours, and there was a vigorous discussion of concerns across a broad range of domains. A smaller team of ethics committee members and ethics staff then distilled the discussion points into an outline of ethical issues and general recommendations for approaches the center might follow in determining how to address them. This document was brought back to center staff and used to inform policy development and help formulate the center’s mission and values statements ( Fig 1 ). As additional issues, particularly those around the intersection of hospital policy, state law, and fertility preservation, arose for center staff, less-formal discussions were held with ethics and/or legal teams to explore relevant factors to be considered by the center in developing its policies.

Mission statement and values.

Key questions that arose from the ethics discussions are addressed below.

Gender dysphoria is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the distress that occurs when there is a marked incongruence between the gender a person was assigned at birth and the gender that they experience or express. 10 The experience of gender dysphoria, and/or identifying as transgender, has been associated with a number of serious physical and mental health disparities, including elevated risks of depression, anxiety, suicidality, substance abuse, and HIV. 11 , – 15 Some of these disparities can be reduced with access to transgender-affirming health care and gender affirmation procedures. 11 , 16  

The center planned to offer gender affirmation chest reconstruction, phalloplasty, and metoidioplasty for transmasculine individuals (those assigned female at birth with a more male gender identity) and breast augmentation and vaginoplasty for transfeminine individuals (those assigned male at birth with a more female gender identity). Although the quality of the evidence base is low and relies mostly on short-term follow-up, the limited existing reports suggest that these treatments can be an effective way to improve gender congruence and body satisfaction for transgender individuals who are interested in such surgeries, and they have also been shown to improve depression, anxiety, and overall quality of life. 17 , – 24 Reports of regret do occur, but they are rare, affecting <1% of patients in 1 large study. 25 This rate is substantially lower than for breast reconstruction after mastectomy, a contextually similar surgical procedure (reconstructive but optional, often involving body image and sexuality) for which decision regret has been studied. 26 , 27 On the basis of research in the field, the clinicians were able to present solid evidence that the treatments to be provided at the center were medically sound and necessary to improve the health and well-being of the patients to whom they would be provided, including reduction or alleviation of symptoms of gender dysphoria.

Genital affirmation surgeries, such as vaginoplasty and phalloplasty, are generally offered to adult patients rather than pediatric patients. Therefore, one of the questions that received substantial discussion at the ethics meeting was whether and how these surgeries fit into the mission of a pediatric hospital, including its primary commitment to the health and well-being of pediatric patients. The hospital’s patient care policy defines pediatric patients as those who are under the age of 21.

The conclusion that the program was consistent with the hospital’s mission was based on several factors. First, the hospital’s mission statement addresses the importance of serving unmet need. Because of this mission, the hospital had previously established that it is appropriate to follow pediatric conditions into adulthood when other specialty care for these conditions is not available. In fact, a number of hospital departments, including surgical specialties, already provided care for patients into or through adulthood, and the hospital also had standard criteria for patients being treated through age 35. Because gender dysphoria is often a condition that originates in childhood, it meets the basis of that criteria to the extent that equivalent care is not available. 28 , 29 Evidence was presented that there was currently a significant unmet need for gender affirmation procedures in New England. Although several surgeons offered chest surgeries in the Boston area, there was limited access to care for adolescents. There was one other surgical team in the area offering genital affirmation surgeries for transgender women, but genital affirmation surgeries for transgender men were completely unavailable in the area before the opening of the center. As such, one of the motivations for forming the center was the community reaching out to local hospitals looking for providers to address this gap in care. While it might, on the surface, make more sense to offer genital surgeries for transgender men at an adult hospital, at the time the center was formed, there were no surgeons in local adult facilities interested in providing that care. In contrast, the center surgeons had both appropriate expertise and interest in addressing the unmet need.

In addition to the unmet need in the area as a whole, clinical leaders at BCH also recognized an unmet need affecting current patients and appealed to the hospital for support. The hospital houses the Gender Management Service 30 , 31 (GeMS), a leader in medical gender affirmation for transgender youth that was founded in 2007 and currently works with hundreds of patients a year. However, when GeMS patients were ready to surgically transition, their care had to be referred outside of the hospital system. There was agreement by center staff and hospital leaders that a dedicated gender surgery center would best serve the hospital’s mission by providing comprehensive care options and continuity of care for those transgender adolescents and young adults who had been treated in GeMS and were interested in surgical affirmation. Although the 2 programs run entirely separately, the location of the center in a pediatric hospital, with access to the expertise of GeMS providers, meant that it was also well placed to address the particular psychological and medical challenges experienced by transgender youth, including an elevated risk of bullying, violence, and other forms of school-based harrassment. 32 , – 34  

The hospital’s mission also includes research and education. Given its academic nature, and the presence of the GeMS program, the center is well situated to contribute to research in the field of transgender care (especially continuity of care from prepuberty to adult transitioning). The center can also support the hospital’s commitment to education, as is more fully described below.

Respect for human dignity and worth, including support for individual self-determination, are fundamental elements of medical ethics. 35 The hospital has a stated commitment to serving a diverse population, representing many nationalities, cultures, faiths, and value systems as well as those with diverse gender identities and sexual preferences. The ethics discussion process addressed this question by examining research in which it was shown that identifying with a gender that is inconsistent with one’s physical characteristics can lead to psychosocial difficulties and a decreased sense of self-worth. 36 , – 41 Although not all transgender individuals want surgery, treatment to help reduce the dissonance between physical body and gender identity has the potential to restore individuals’ sense of dignity and worth. In support of this goal, the ethics team recommended that the center provide services designed to meet patients’ psychosocial, emotional, and spiritual needs. This recommendation was addressed by the integration of a social worker with transgender health experience and training in the core team, who would explore patients’ motivations for surgery as part of the assessment ( Fig 2 ), and by the availability of transgender-affirming chaplaincy staff within the hospital. Center staff also determined that discussions of any surgical procedure should be instituted by the patient rather than offered by the team, to avoid giving the impression that providers felt any particular surgery was a necessary component of transition. The ethics team also recommended that center staff identify avenues for increasing understanding of the population served by the center, both within and outside the walls of BCH; fostering sensitivity and support throughout the center and the hospital for this population; and including input of this community into the development and operations of the center. In agreement with this goal, center staff have sought out opportunities to train providers and community members both inside and outside of the hospital 42 and continue to seek out opportunities to provide professional and community education whenever possible. This includes participation in the Care for Patients with Diverse Sexual Orientations and Gender Identities elective at Harvard Medical School and offering medical students opportunities to engage in additional research and practice with this population. The center has also sought input from community members and actively recruited transgender staff.

Patient care flow sheet. MD, medical doctor; NP, nurse practitioner; PA, physician’s assistant; SW, social worker.

Respect for patient autonomy is the ethical principle that generated the most controversy when developing the center’s policies and practices for patient care. Questions of respect for patient autonomy are at the core of much of the debate around the current WPATH SOC and screening guidelines, specifically care structures that require behavioral health professionals to provide approval to access care rather than prioritizing access through a process of informed consent, a model that is being adopted more and more often for hormone treatment. 6 This is true not just in the adult setting, but in the pediatric setting, as well. Although the GeMS model requires extensive psychological screening, 30 other models are also in place for pediatric hormone access, 43 , 44 and the center sees patients who have taken various routes to medical transition.

Debate on this topic is not restricted to medical transition care. There is also substantial disagreement among providers and others as to whether the current guidelines requiring one or more mental health assessments for patients to move forward with gender affirmation surgeries are critical to providing quality care, are problematic gatekeeping, or are something in between. 45 , – 51 Because a clear answer to the appropriateness of these guidelines is not supported in the current evidence base, the center decided that the most-appropriate way to address the controversy would be to follow the SOC while researching the burdens and benefits of the behavioral health requirements, particularly with respect to providing services to adolescents. To date, the center has enrolled over 70 patients into a longitudinal study in which researchers are assessing quality of life, mental health, and issues and costs of health care access in the context of gender-affirming surgery.

A related issue was whether minors were able to provide informed assent to the kinds of procedures being offered. Addressing this issue is a required component of the outside letters of support needed to access surgery. In addition, it has been previously established that minors legally and ethically can provide informed consent, without parent permission, for many medical therapies related to sexual and mental health. 52  

Another issue raised around informed consent was specific to the pediatric population, namely the role of parents and guardians in providing informed consent (sometimes referred to as informed permission), because minors generally can provide assent but not consent for care. 52 There was substantial discussion among the ethics team, hospital counsel, and center providers as to whether the consent of both parents must be required for minor patients to undergo gender-affirming surgery. Although consent from both parents, alongside assent from the minor, is the standard for care in the hospital’s GeMS program, many transgender youth have complicated family situations. 32 , 53 , – 57 This may make acquiring 2-parent consent to perform surgery on an adolescent unfeasible or impossible, particularly when 1 parent is no longer involved in the minor’s life. Eventually, the center decided on a policy incorporating the standard of 2-parent consent but with the intention to develop formal procedures allowing for appeal in cases in which such a requirement appears to interfere unduly with the informed choices of minors and raises the possibility of significant harm.

Although for some people the requirements for parental consent and behavioral health assessment raised questions about the autonomy of adolescent patients, for others it was reassuring. There is substantial debate around adolescents’ capacity for decision-making and ability to conceptualize long-term outcomes. 58 , – 60 The involvement of both parents and multiple behavioral health providers in the process of determining eligibility for surgery, as well as the patients’ discussion with the interdisciplinary team of the benefits and risks (including possible regrets), serves as a check on the possibility of impulsivity and reduces the likelihood that age-related cognitive factors would lead to decision regret.

As such, the role of parents is not simply to provide informed consent. They are also important sources of insight and support throughout the gender affirmation process. Parental concerns can give important insights into adolescent maturity, gender stability, mental health, and well-being and provide a window into additional areas that the behavioral health provider might need to explore before surgical approval. Because of this, parent and guardian education is an important part of the consult process for minors seeking surgery, as is assessment of those adults’ interest in and willingness to support the patient through surgery. Situations in which parents disagree with each other are particularly challenging and addressed on a case-by-case basis.

Members of the ethics committee brought up a concern that some members of the public may have moral or religious objections to transgender surgery. Objections had been raised when the GeMS program was first started, including some death threats to staff, and it was thought that it would be important to prepare for any similar backlash in response to the start of the center. The possibility of moral or religious objections to surgery was not seen as a barrier to providing these services, and the ethics team recommended that appropriate hospital staff, including public relations staff, familiarize themselves with the nature of possible objections to the establishment of the center and with the underlying medical and ethical reasons for establishing the center to be able to engage in informed communication with the public. To accomplish this goal, center staff worked with marketing and communications staff at the hospital to develop evidenced-based messaging and responses to expected objections and to increase staff confidence with transgender issues. Center staff have also offered, and continue to provide in an ongoing manner, training to health care and support professionals throughout the hospital on both how to support patients and the importance of gender-affirming care for individual well-being.

The hospital has some existing policies related to religious and moral objections by staff. The personnel policy on “Requests to be excused from Patient Care Responsibilities,” for example, states that the hospital “will consider a request by a staff member not to participate in aspects of a patient’s care or treatment when such care or treatment conflicts with a staff member’s bona fide ethical or religious beliefs.” However, the policy is also clear that such a request cannot be accommodated if it will negatively affect care for the patient.

All participants involved in the discussions recognized the importance of education in addressing staff moral and religious concerns. To help accomplish this goal, center staff involved in education attempt to provide a safe space for questioning and discussion of care practices. 42 In addition, center staff are currently in the process of deploying a validated survey 61 to examine provider attitudes about and self-assessed competence in lesbian, gay, bisexual, and transgender health care across the hospital. It is suggested in the preliminary results that provider attitudes are primarily positive, although there were some responses expressing moral concerns about working with lesbian, gay, bisexual, and transgender patients and families. Results also suggest that providers were consistently less comfortable, and felt less competent, about working with transgender patients and families than lesbian, gay, and bisexual patients and families. 62 This is being addressed through offering increased opportunities for professional education on gender surgery and gender-affirming care throughout the hospital. Center staff offered more than 20 trainings to BCH staff between December 2017 and December 2018, and trainings continue to be requested across a variety of units and departments.

There is a documented unmet need for gender-affirming services, including surgical procedures. 32 , 63 , – 66 This was clearly visible in the fact that, within a few months of Boston Medical Center starting to offer insurance-covered vaginoplasty, their waitlist quickly grew to over 200 patients. 67 Because of the possibility of waitlists for the center’s services, the ethics team recommended that the center have a clear and consistent method of prioritizing patients for care. The center decided to take a first-come, first-served approach to initial consultation with patients. However, the center recognized there would be a need to undertake further exploration of methods for allocating resources in the event that limits were reached. From the beginning, center staff anticipated that hair removal would likely provide the primary scheduling barrier for patients seeking genital affirmation, and that has proven to be the case. (Hair removal is a requirement for genital surgery because of concerns about the presence of hair in the neourethra or neovagina.) Chest surgery scheduling is more straightforward and primarily limited by the availability of operating room time. While continuing to use the first come, first served principle, the center is working on ways to shorten waiting times whenever feasible.

After the initial ethical discussions were conducted, there remained several questions that the center wished to explore further. One such question was determining an appropriate age range for patients to be able to access each type of gender-affirming surgical procedure. Because the hospital is a pediatric institution, with policies about the age ranges for which it is appropriate to provide care, this discussion needed to address both the lower and upper bounds of care.

The WPATH SOC state that genital surgery should not be done until the age of majority in any given country (18 in the United States), but that it may be reasonable for chest surgeries to be done earlier. 3 Unfortunately, there is extremely limited published research on the impact of chest surgeries on the pediatric and young adult population. In what research there is, it is suggested that chest surgery can make it easier for young transmasculine individuals to participate more fully in society, including making it easier to exercise and maintain their health. 68 This research is supported by the clinical experience of center staff. Breast augmentation also has the potential to allow young transfeminine individuals to present more effectively as feminine, although fewer transfeminine than transmasculine individuals are interested in chest surgery. 32  

After weighing the guidelines and feedback from stakeholders, the center decided to deviate from the SOC and set 15 as a minimum age for undergoing a chest reconstruction or breast augmentation, with surgery at age 15 only being appropriate for those individuals who have had a strong and consistent gender identity and, in rare cases, those who are significantly limited in life activities by the presence of their breasts. Because the risk of desistence of a transgender identity declines sharply after puberty, 22 , 69 the center thought that this allowed for a reasonable balance of recognizing the possible risk of a premature decision with respecting patients’ current needs and preferences.

Determining the minimum age for genital surgeries was somewhat more complicated. Although all center staff felt comfortable with requiring phalloplasty candidates to wait until the age of majority for surgery, the same was not true for vaginoplasty candidates. Transgender women who have not undergone vaginoplasty may face a number of challenges related to the existential threat that is sometimes perceived to accrue through the presence of male genitalia in a women’s-only space. 42 This concern may be particularly salient for young transgender women who are going off to college and who want to live, and be treated, like any other young women on campus. As a result, a number of American surgeons perform vaginoplasty procedures in patients under the age of 18 to allow young women to begin their adult lives feeling safe and affirmed in their gender. 5 Although mental health outcomes associated with vaginoplasty have generally been shown to be quite positive, to date there have been few published studies specifically exploring the psychosocial outcomes of vaginoplasty in minors. 70 , 71 Two studies following the same small population of girls who underwent vaginoplasty during adolescence did report improved psychological functioning and decreased gender dysphoria at 1 and 5 years follow-up. 72 , 73  

However, performing vaginoplasty in patients under the age of 18 raises several particular concerns. 1 These include the ability of the patient to adequately provide assent 52 and a detailed assessment of whether the young woman will be capable of the extensive postsurgical care required by the procedure. 72 , 74 It is also critical to explicitly address the fact that the procedure will render the patient permanently sterile and attempt to determine whether the patient is capable of making an informed decision to permanently impact their fertility. Although fertility assessment is, in theory, a standard part of assessment earlier in the transition process, the center team felt it was critical to include such an assessment as part of the initial social work consult with every potential patient, regardless of age. This fertility assessment includes questions about whether the patient wants to have biological children, any history of gamete preservation, and appropriate referrals as necessary. The center team has found that doing such an assessment is critical because a sizeable minority of patients do not have a clear understanding of the fertility impacts of gender transition at the time of the initial consult.

The center staff eventually came to the conclusion that it is appropriate to offer vaginoplasties to certain individuals before the age of majority so that they can safely embark on their adult lives. However, to address legal concerns related to performing vaginoplasties in Massachusetts minors, it was necessary to institute a policy requiring such patients to either have undergone fertility preservation or to seek out a court order granting permission for surgery. To date, the only family to which this option has been offered has decided to pursue the court order.

Building a gender surgery center in a pediatric setting requires institutions to address unique ethical and legal challenges. It is important for providers and administrators to have a clear understanding of the local legal environment and relevant ethical principles. Plans for navigation of ethical challenges should be discussed early in the process, and institutions should plan to respond to ethical and moral considerations brought up by staff, patients, and the public at large. Ongoing ethical and legal consultation, as well as a broad range of staff, patient, and public educational opportunities, are likely to be needed. Such processes are necessary to provide optimal care for members of the transgender community in an ethically responsible fashion.

Dr Boskey copresented to the ethics committee, provided topic-specific documentation to the committee for review, drafted the manuscript, and oversaw all revisions; Ms Johnson led the drafting of the ethics committee response to the initial committee consultation, which was used in the drafting of the manuscript, and contributed significantly to revisions; Dr Harrison, Dr Marron, Ms Abecassis, Ms Scobie-Carroll, and Dr Willard contributed to the ethics committee consultation and contributed significantly to revisions; and Drs Diamond, Taghinia, and Ganor initiated the ethics consultation process, copresented to the ethics committee, worked on all consultations, and contributed significantly to revisions; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

The authors thank the members of Boston Children’s Hospital Ethics Advisory Committee for thoughtful comments and insights during their meeting to discuss this topic.

Boston Children’s Hospital

Gender Management Service

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World Professional Association of Transgender Health

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Ethical issues raised by the treatment of gender-variant prepubescent children

• PMID: 25231780
• DOI: 10.1002/hast.365

Transgender issues and transgender rights have become increasingly a matter of media attention and public policy debates. Reflecting changes in psychiatric perspectives, the diagnosis of "trans-sexualism" first appeared in the International Statistical Classification of Diseases and Related Health Problems in 1975 and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders. Since that time, international standards of care have been developed, and today those standards are followed by clinicians across diverse cultures. In many instances, treatment of older adolescents and adults is covered by national health care systems and, in some cases, by private health insurance. Most recently, the Medicare ban on coverage for gender reassignment surgery was lifted in 2014. In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred to in both DSM-IV-TR and ICD-10 as gender identity disorder in children and now in DSM-5 as gender dysphoria. One reason for the differing attitudes has to do with the pervasive nature of gender dysphoria in older adolescents and adults: it rarely desists, and so the treatment of choice is gender or sex reassignment. On the subject of treating children, however, as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood. Further, most of the boys' gender dysphoria desisted, and in adulthood, they identified as gay rather than as transgender. In an effort to clarify best treatment practices for transgender individuals, a recent American Psychiatric Association Task Force on the Treatment of Gender Identity outlined three differing approaches to treating prepubescent gender dysphoric children.

© 2014 by The Hastings Center.

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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The Psychopathology of "Sex Reassignment" Surgery: Assessing Its Medical Psychological, and Ethical Appropriateness

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A Contribution to the Debate About the Ordination of Homosexuals 

Court says state health-care plans can’t exclude gender-affirming surgery

A federal appellate court in Richmond became the first in the country to rule that state health-care plans must pay for gender-affirming surgeries, a major win for transgender rights amid a nationwide wave of anti-trans activism and legislation.

The decision came from a set of cases out of North Carolina and West Virginia, where state officials argued that their policies were based on cost concerns rather than bias. The U.S. Court of Appeals for the 4th Circuit rejected that argument, saying the plans were discriminating against trans people in need of treatment.

Judge Roger L. Gregory, an appointee of President Bill Clinton, wrote for the majority that the restrictions were “obviously discriminatory” based on both sex and gender.

“In this case, discriminating on the basis of diagnosis is discriminating on the basis of gender identity and sex,” Gregory wrote, because “gender dysphoria is so intimately related to transgender status as to be virtually indistinguishable from it.”

The majority ruled that West Virginia’s policy also violated the Affordable Care Act’s anti-discrimination provision, a finding that has broad implications for other states’ Medicaid programs.

It’s the second ruling in favor of trans rights this month from the 4th Circuit, a once-conservative court that has become a trailblazer in the realm of transgender rights. The court was the first to say trans students had a right to use the bathrooms that align with their gender identity and the first to recognize gender dysphoria as a protected disability. Earlier this month, the court said a federally funded middle school could not ban a trans 13-year-old from playing on the girls’ track and field team.

The decision will be appealed to the Supreme Court, which recently allowed Idaho to enforce a ban on gender-affirming care for minors. West Virginia Attorney General Patrick Morrisey, who is running for governor, said in a statement Monday that he would “take this up to the Supreme Court and win.”

But the conservative-led Supreme Court has been reluctant to engage on these issues, letting multiple 4th Circuit rulings in favor of transgender rights stand. The court also generally waits until there is disagreement between circuit courts before getting involved.

All of these rulings split the 4th Circuit court down ideological lines, with judges appointed by Democrats joining the majority opinion and those appointed by Republicans dissenting. In the lead dissent from the ruling Monday, Judge Jay Richardson, a Trump appointee, wrote that there was no role for the federal court in policing what treatments health-care plans decide to cover.

The majority opinion, Richardson wrote, “treats these cases as new fronts upon which this conflict must be waged. But not every battle is part of a larger war. In the majority’s haste to champion plaintiffs’ cause, today’s result oversteps the bounds of the law.”

Richardson said what mattered is that trans patients have the same coverage of the same conditions as others. For example, he said, a trans patient with uterine cancer could get a hysterectomy under these plans.

“The different coverage accorded to treatments for different diagnoses is … based on medical judgment of biological reality,” he wrote. “States can reasonably decide that certain gender-dysphoria services are not cost-justified, in part because they question the services’ medical efficacy and necessity.”

Other states have banned hormonal treatment and surgery for trans minors; some have restricted care for transgender adults as well. Multiple other states have similar laws against insurance coverage for transition-related treatment. The Biden administration has moved to protect trans Americans through federal regulations, including guidelines released Monday that treat misuse of pronouns or refusal to let transgender employees use their preferred bathroom as workplace harassment.

In West Virginia, transgender Medicaid users challenged the state’s program, which since 2004 has by law banned “transsexual surgeries.” In North Carolina, state employees challenged their coverage, which in 2018 excluded surgical treatment of gender dysphoria — the clinical diagnosis of a disconnect between a person’s gender and birth sex.

Both states insisted that there was no bias in their coverage limitations, only cost concerns. Trans patients, they argued, were entitled to the same health treatments as everyone else but not specialized care.

“There is no service that is covered for a cisgendered person that is not covered for a transgender person meeting the same criteria,” Caleb David, an attorney for West Virginia, told judges on the appellate court during the oral argument. David added that the state had decided to provide psychiatric and hormonal treatment for gender dysphoria — just not surgery.

Advocates for trans patients said there was no medical justification for drawing the line there, when the state would cover such procedures for other conditions. They also said the financial explanation was suspect because so few people get gender-affirming surgery. It’s “a drop in the bucket,” Lambda Legal attorney Tara Borelli said during oral arguments. But even if the cost was significant, she argued, the cost of public health insurance “has to be a shared burden. It can’t be shunted onto the backs of a vulnerable minority group.”

The court agreed, saying cost-cutting could not justify covering the same treatments for health concerns other than gender dysphoria. For example, Gregory noted that under these plans, “cisgender people do receive coverage for certain gender-affirming surgeries,” including breast reconstruction for cancer patients after a mastectomy.

North Carolina began covering gender-affirming care in 2017 and stopped the following year, when Republican Dale Folwell became state treasurer. Julia McKeown, a professor at North Carolina State University, accepted her job in 2016, a few years into fully transitioning after a lifetime of “being adamant about what my gender was” but being limited in expressing it. She spent months preparing for surgery, only to be forced to cover the full cost along with all other treatment.

“It’s like having the rug pulled out from under you,” she said. “In some ways it’s worse than going in and knowing it was going to be denied.” She cut into her retirement savings rather than delay the surgery, calling herself “fortunate” to be able to do so.

McKeown grew up in a rural town in Florida and spent years pretending to be a man for fear of social and professional exclusion. Joining the lawsuit meant exposing herself to hate mail from strangers.

“In an ideal world, I would have loved to just move on with my life” after the surgery, she said. “At the same time, I feel a moral obligation to help those who can’t speak up for themselves, and for those who risk being fired or who have dependents on the state health-care plan who need access to treatment.”

Twenty-one Republican-led states asked the court to rule against the plaintiffs, focusing on disagreement over what physical interventions should be available to trans youth. But most major medical plans and the federal government cover gender transition treatment, which has been endorsed by mainstream medical associations. Studies indicate very few people who transition regret doing so or seek to reverse the changes, including those who start treatment in their teens.

Seventeen Democratic-led states and the District of Columbia urged the court to rule for the coverage, saying their “experience demonstrates that protecting access to gender-affirming care improves health outcomes for our transgender residents at little cost.”

An earlier version of this story reported that the contested insurance plans covered mastectomies for cancer patients but not for trans women. The plans covered mastectomies for all cancer patients, but did not cover the procedure for trans men who wanted their breasts removed to treat gender dysphoria.

State health plans must cover gender-affirming surgery, US appeals court rules

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Brendan Pierson reports on product liability litigation and on all areas of health care law. He can be reached at [email protected].

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Medindia » Articles » Procedure » Gender-Reassignment Surgery: Everything You Need to Know

Gender-Reassignment Surgery: Everything You Need to Know

• Indications

Non-Surgical Procedures

• Surgical Procedures

Risks in Non-Surgical and Surgical Procedures

• Whom to consult?
• Pre-Op Considerations
• Post-Op Considerations

Impact on Mental Health

• Cost of the Surgery

Gender reassignment surgery, also known as gender-affirming surgery, is a medical procedure or series of procedures aimed at altering an individual's physical appearance and sexual characteristics to align with their gender identity.

In Simple words, it can be defined as the alteration of a person's physical sex characteristics by surgery in order to match the person’s gender identity

This transformative process is often pursued by transgender individuals, as well as some cisgender and non-binary individuals. It involves various surgical interventions to modify primary and secondary sexual characteristics, thereby affirming an individual's gender identity( 1 ✔ ✔ Trusted Source Sex Reassignment Surgery in the Female-to-Male Transsexual Go to source ).

Alternative Names for Gender-Affirming Surgery

• Gender reassignment surgery (GRS)
• Gender-affirmation surgery
• Gender confirmation surgery
• Sex reassignment surgery

Who Can Get Gender Reassignment Surgery?

Transgender individuals.

Transgender individuals are those whose gender identity differs from the sex they were assigned at birth. Many transgender individuals experience gender dysphoria, a condition characterized by distress or discomfort caused by a misalignment between their gender identity and physical body. Gender reassignment surgery is often sought by transgender individuals as part of their transition journey to alleviate gender dysphoria and align their physical appearance with their gender identity.

Trans Women: Assigned male at birth but identify and live as women. Trans women may pursue feminizing surgeries such as vaginoplasty (creation of a vagina), breast augmentation, facial feminization surgery, and voice feminization surgery to affirm their gender identity.

Trans Men: Assigned female at birth but identify and live as men. Trans men may undergo masculinizing surgeries such as chest reconstruction (removal of breast tissue), hysterectomy (removal of the uterus), and phalloplasty or metoidioplasty (creation of a penis) to align their bodies with their gender identity.

Intersex Individuals

Intersex is a term used to describe individuals who are born with variations in their biological sex characteristics (chromosomes, gonads (testes/ovaries), reproductive organs (prostate/uterus) or external genitalia (penis/clitoris)) that do not fit typical definitions of male or female..

Intersex Individuals with Gender Dysphoria: While intersex individuals can be transgender if their gender identity does not match the sex they were raised or assigned as, some intersex individuals may experience distress or discomfort, known as gender dysphoria , due to a misalignment between their gender identity and assigned sex characteristics, and seek gender-affirming surgery to align their physical appearance with their gender identity( 2 ✔ ✔ Trusted Source Gender Affirmation Surgeries Go to source ).

Drag Performers

Drag performers are individuals who utilize clothing, makeup, and performance art to explore and celebrate gender expression. They are typically associated with a gender different from their own. These performers engage in drag for various reasons, including self-expression, artistic exploration, and entertainment purposes.

While some drag performers may identify as transgender or non-binary and use drag as a form of self-expression or exploration of their gender identity, others may identify as cisgender and engage in drag purely for entertainment or artistic expression.

Drag Queens and Drag Kings : Drag queens are typically male individuals who dress in feminine attire and adopt exaggerated female personas for performance. Drag kings, on the other hand, present as male or masculine while performing. While some drag performers may identify as transgender and may ultimately pursue gender-affirming surgeries, the act of performing drag does not inherently imply a desire for surgical intervention.

Individuals with Klinefelter Syndrome

Klinefelter syndrome is a chromosomal condition in which individuals are born with an extra X chromosome (XXY), resulting in differences in sexual development and often leading to infertility and other physical characteristics such as tall stature, reduced muscle mass, and gynecomastia (enlarged breast tissue in males)( 4 ✔ ✔ Trusted Source Klinefelter syndrome Go to source ).

While not directly related to transgender identity, some individuals with Klinefelter syndrome may experience gender dysphoria and seek gender-affirming treatments, including surgery. These individuals may undergo procedures to modify their physical characteristics to better align with their gender identity and alleviate distress associated with gender dysphoria.

Non-Binary Individuals

"Non-binary" is a term used to describe individuals whose gender identity does not exclusively align with the categories of male or female. This is a deeply personal and internal sense of one's own gender. Non-binary individuals may identify as both, neither, a combination of both, or as a gender entirely different from male or female.

Bigenital Operation: Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Some non-binary individuals may opt for these surgeries to achieve a physical presentation that aligns with their gender identity while maintaining aspects of their original anatomy. These surgeries cater to the diverse spectrum of gender identities and expressions and provide options for individuals who do not fit within the traditional binary understanding of gender.

"Cisgender" is a term used to describe individuals whose gender identity aligns with the sex they were assigned at birth. In other words, someone who is cisgender identifies as the gender typically associated with the biological sex they were born with. For example, a person who was assigned female at birth and identifies as a woman is considered cisgender. The term "cisgender" is often used in contrast to "transgender," which describes individuals whose gender identity differs from the sex they were assigned at birth

While gender dysphoria is often associated with transgender individuals, cisgender people can also experience it. In some cases, cisgender individuals with severe gender dysphoria may seek gender-affirming surgeries to alleviate their distress and bring their physical appearance into alignment with their gender identity. These surgeries are typically pursued after extensive evaluation and therapy, and they can significantly improve the mental health and well-being of individuals experiencing gender dysphoria.

Is Gender Dysphoria the only Reason for Gender Reassignment Surgery?

No, not only gender dysphoric individuals seek gender reassignment surgery. While gender dysphoria is a common reason why individuals pursue gender-affirming surgeries, it's not the only factor. Some people may choose to undergo these surgeries for reasons beyond alleviating distress associated with gender dysphoria.

For example, individuals with intersex variations may seek gender-affirming surgeries to align their physical appearance with their gender identity, even if they do not experience gender dysphoria. Similarly, some non-binary individuals may opt for surgeries to achieve a physical presentation that better aligns with their gender identity, regardless of whether they experience gender dysphoria.

Furthermore, some cisgender individuals may also undergo gender-affirming surgeries for reasons related to body dysmorphia or dissatisfaction with their physical appearance, rather than gender dysphoria.

Ultimately, the decision to pursue gender reassignment surgery is deeply personal and can be influenced by a variety of factors beyond gender dysphoria alone.

Hormonal injections is the only available non-surgical procedure.It isa form of hormone replacement therapy (HRT) commonly used in transgender healthcare to induce and maintain desired physical changes consistent with an individual's gender identity.

These injections typically involve the administration of testosterone for transmasculine individuals (female-to-male, or FtM) and estrogen for transfeminine individuals (male-to-female, or MtF).

Testosterone Injections (for Transmasculine Individuals)

Purpose : Testosterone injections are administered to induce masculine changes, such as increased facial and body hair growth, deepening of the voice, muscle development, and redistribution of body fat.

Types of Testosterone : There are different formulations of testosterone available for injection, including testosterone cypionate, testosterone enanthate, and testosterone undecanoate.

Administration : Testosterone injections are typically administered intramuscularly (into the muscle) in either the gluteal (buttocks) or deltoid (upper arm) muscle.

Dosage and Frequency : The dosage and frequency of testosterone injections can vary depending on individual factors such as age, weight, hormone levels, and desired changes. Typically, injections are administered every one to two weeks to maintain stable testosterone levels in the body.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant markers is essential to ensure the safety and effectiveness of testosterone therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Estrogen Injections (for Transfeminine Individuals)

Purpose : Estrogen injections are administered to induce feminine changes, such as breastdevelopment, redistribution of body fat, softening of the skin, and reduction of muscle mass.

Types of Estrogen : The most common form of estrogen used in injections is estradiol valerate.

Administration : Estrogen injections are typically administered intramuscularly, similar to testosterone injections, in the gluteal or deltoid muscle.

Dosage and Frequency : The dosage and frequency of estrogen injections vary depending on individual factors and treatment goals. Typically, injections are administered every one to two weeks.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant parameters is crucial for ensuring the safety and effectiveness of estrogen therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Time Frame of Use of Hormonal Injections

Initiation : Hormonal injections are often initiated after a thorough evaluation by healthcare providers, including discussions about treatment goals, potential risks and benefits, and informed consent. The timing of initiation may vary depending on individual factors such as age, readiness for treatment, and presence of any underlying health conditions.

Duration : Hormonal injections are typically used as part of long-term hormone replacement therapy to maintain desired physical changes and support overall well-being. The duration of hormone therapy may vary from individual to individual and often continues indefinitely, especially for those who desire ongoing maintenance of gender-affirming changes.

Discontinuation : In some cases, individuals may choose to discontinue hormonal injections for various reasons, such as personal preference, changes in health status, or the achievement of desired physical changes. It's essential for individuals to discuss any plans to discontinue hormone therapy with their healthcare provider to ensure proper management of any potential effects or complications.

Surgical Procedures: Gender Affirming Surgery

These surgical procedures play vital roles in gender affirmation for transgender individuals, aligning their physical appearance with their gender identity( 3 ✔ ✔ Trusted Source Gender Confirmation Surgery Go to source ).

Male-to-Female (MtF) Transitions:

• Tracheal Shave: This procedure reduces the prominence of the Adam's apple, a typically male characteristic, to create a smoother, more feminine neck contour.
• Breast Augmentation: Transfeminine individuals undergo breast augmentation to develop fuller, more feminine breast contours. Breast implants are placed behind breast tissue or chest muscle to achieve the desired size and shape.
• Facial Feminization Surgery (FFS): FFS encompasses various surgical procedures aimed at feminizing facial features. Techniques may include forehead contouring, rhinoplasty , cheek augmentation, chin and jaw reshaping, tracheal shave, lip augmentation, and hairline lowering to achieve a more traditionally feminine appearance.
• Male-to-Female Genital Sex Reassignment (Vaginoplasty): This surgical procedure constructs female genitalia for transfeminine individuals seeking alignment with their gender identity. Techniques involve using penile and scrotal tissue to create the vaginal canal, labia, and clitoral hood. The procedure may also include the creation of a neurovascular neoclitoris, providing both aesthetic and functional female genitalia in one operation.

Female-to-Male (FtM) Transitions:

• Hysterectomy and Oophorectomy: This procedure involves the removal of the uterus and ovaries, reducing the production of female hormones (estrogen and progesterone).
• Vaginectomy: Vaginectomy is the surgical removal of the vaginal canal, aligning the physical anatomy with a masculine appearance.
• Chest Reconstruction (Top Surgery): FtM individuals undergo chest reconstruction surgery to remove breast tissue and reshape the chest to achieve a more masculine contour. Techniques include subcutaneous mastectomy or double mastectomy with or without nipple reconstruction.
• Female-to-Male Genital Sex Reassignment (Phalloplasty): Phalloplasty is a surgical procedure to construct a phallus for FtM individuals seeking male genitalia. The radial forearm flap method is commonly used, involving tissue grafting from the forearm to create the phallus and urethra for standing urination. This procedure can be performed concurrently with a hysterectomy/vaginectomy to complete the transition process. A scrotum with testicular implants may be constructed in a second stage.

These surgical interventions are integral to gender affirmation for transgender individuals, helping align their physical appearance with their gender identity and alleviating gender dysphoria. Each procedure is tailored to the individual's unique needs and goals, reflecting the diversity of experiences within the transgender community.

Risks in Hormone Therapies

• Cardiovascular Risks : Hormone replacement therapy (HRT) may increase the risk of cardiovascular events such as heart attacks and strokes, especially in older individuals or those with pre-existing cardiovascular conditions.
• Thromboembolic Events : Estrogen therapy, particularly in forms like oral contraceptives, may elevate the risk of blood clots, leading to thromboembolic events such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Endocrine Disruption : Hormone therapies can disrupt the body's natural hormone balance, leading to potential complications such as metabolic disturbances, including insulin resistance and dyslipidemia.
• Breast Cancer Risk : Some studies suggest that long-term use of hormone replacement therapy, especially estrogen-only formulations, may increase the risk of breast cancer in transgender women.
• Liver Dysfunction : Hormone therapies, particularly oral estrogen formulations, may affect liver function and increase the risk of liver disease or dysfunction.

Risks in Gender Reassignment Surgeries

• Surgical Complications : As with any surgical procedure, gender reassignment surgeries carry risks such as infection, bleeding , anesthesia complications, and adverse reactions to medications.
• Scarring : Gender-affirming surgeries, especially those involving breast augmentation, chest reconstruction, or genital reconstruction, may result in visible scarring that could impact body image and self-esteem.
• Loss of Sensation : Surgeries involving genital reconstruction, such as vaginoplasty or phalloplasty, may result in loss of sensation or altered sensation in the genital region, affecting sexual function and satisfaction.
• Functional Complications : Some individuals may experience functional complications post-surgery, such as urinary incontinence , erectile dysfunction, or difficulties with sexual arousal or orgasm.
• Psychological Impact : Gender reassignment surgeries can have profound psychological effects, including adjustment difficulties, post-operative depression, and challenges related to body image and identity.

Guidance on Surgical Procedures: Whom to Consult?

When contemplating gender reassignment surgery, it's essential for individuals to consult with a team of experienced healthcare providers specializing in transgender care. Here's whom to consider consulting:

1. Gender-Affirming Surgeons

Gender-affirming surgeons specialize in performing gender reassignment surgeries and have expertise in various surgical techniques, including chest surgery (for both masculinization and feminization procedures), genital reconstruction, and facial feminization surgery. These surgeons can provide comprehensive information about the surgical options available, discuss the potential risks and benefits, and guide individuals through the decision-making process.

2. Endocrinologists

Endocrinologists play a crucial role in managing hormone therapy for transgender individuals. They can provide guidance on hormone replacement therapy (HRT), including the use of testosterone for transmasculine individuals and estrogen for transfeminine individuals. Endocrinologists can assess hormone levels, monitor any potential side effects, and adjust hormone regimens as needed to support the transition process.

3. Mental Health Professionals

Mental health professionals, such as psychologists, psychiatrists, or licensed therapists, offer invaluable support throughout the gender transition journey. They can assist individuals in exploring their gender identity, coping with gender dysphoria, and addressing any psychological concerns or challenges that may arise before, during, or after surgery. Mental health professionals also play a role in assessing readiness for surgery and providing pre- and post-operative counseling and support.

4. Primary Care Physicians

Primary care physicians are essential members of the healthcare team and can provide general medical care, coordinate referrals to specialists, and monitor overall health and well-being. They can also assist with managing any pre-existing medical conditions and ensuring that individuals are physically fit for surgery.

5. Support Groups and Advocacy Organizations

Support groups and advocacy organizations within the transgender community can offer valuable peer support, resources, and information about gender-affirming surgeries. These groups provide opportunities for individuals to connect with others who have undergone similar experiences, share insights, and seek guidance from those who have navigated the transition process.

Consulting with a multidisciplinary team of healthcare providers ensures that individuals receive comprehensive care tailored to their unique needs and goals. This collaborative approach helps individuals make informed decisions about gender reassignment surgery and supports their overall health and well-being throughout the transition process.

Pre-operative Considerations

1. Medical Considerations

Transgender individuals may have preexisting health conditions like diabetes , asthma , or HIV, which can impact their eligibility for surgery and postoperative care. Surgeons often consult with endocrinologists to assess the patient's physical fitness for surgery, especially considering the complex medication regimens involved in hormone therapy before and after surgery.

2. Fertility Concerns

Patients considering sex reassignment surgery (SRS) are informed about potential infertility, particularly if procedures like orchiectomy or oophorectomy are performed as part of the transition process. Preservation of fertility options may be discussed before surgery.

3. Age and Consent

SRS is generally not performed on children under 18, with rare exceptions made for adolescents based on healthcare provider assessments and potential benefits or risks. Consent from parents or legal guardians is required, along with long-term mental health counseling to confirm persistent gender dysphoria.

4. Intersex and Trauma Cases

Infants born with intersex traits may undergo surgical interventions at or near birth, raising ethical concerns about human rights implications. Trauma cases also require careful consideration, as surgically assigned gender may not align with the individual's gender identity, leading to negative outcomes later in life.

5. Standards of Care

Many regions follow Standards of Care for the Health of Transgender and Gender Diverse People (SOC), such as those published by the World Professional Association for Transgender Health (WPATH). These guidelines outline minimum requirements for treatment, including psychological evaluation and living as the desired gender before surgery.

6. Insurance Coverage

Obtaining insurance coverage for SRS may require documented assessments by mental health professionals, evidence of persistent gender dysphoria, and completion of physician-supervised hormone therapy for a specified duration.

Post-operative Considerations

1. Quality of Life and Physical Health

Studies assessing postoperative quality of life vary, with some reporting similar quality to control groups while others note lower quality in domains of health and limitations. Overall, many individuals report improvements in mental health, satisfaction with physical appearance, and overall well-being after surgery.

2. Psychological and Social Consequences

SRS has been shown to be effective in relieving gender dysphoria, though some studies highlight methodological limitations. Patients often report reduced anxiety, depression , and hostility levels post-surgery, with improvements in self-perceived physical and mental health.

3. Sexuality and Sexual Satisfaction

SRS can significantly impact individuals' sexual experiences and satisfaction. Most transsexual individuals report enjoying better sex lives and improved sexual satisfaction after surgery, with changes in orgasm frequency, intensity, and masturbation habits observed. However, satisfaction levels may vary between trans men and trans women, and expectations for sexual aspects of life may differ from cisgender individuals.

4. Continued Support

Comprehensive postoperative care involves ongoing psychological support, management of any complications, and assistance with adjustment to physical changes. Social support networks play a crucial role in helping individuals navigate their post-surgical experiences and integrate their gender identities into their daily lives.

The denial or limited access to gender-affirming surgeries can have severe consequences for the mental health and well-being of transgender individuals.

1. Persistent Gender Dysphoria

Without access to surgery, transgender individuals may continue to experience intense distress and discomfort due to the misalignment between their gender identity and physical characteristics. This persistent gender dysphoria can lead to heightened anxiety, depression, and a sense of hopelessness.

2. Heightened Anxiety

Living in a body that does not align with one's gender identity can contribute to persistent anxiety. The frustration of being unable to access necessary medical care and the ongoing struggle to navigate societal expectations can exacerbate feelings of stress and worry.

3. Increased Depression

Untreated gender dysphoria and the inability to undergo gender-affirming surgeries can lead to deepening feelings of depression and despair. Transgender individuals may struggle with low self-esteem, feelings of worthlessness, and a sense of isolation from not being able to live authentically.

4. Social Withdrawal

The distress caused by the incongruence between one's gender identity and physical appearance can result in social withdrawal and avoidance of social interactions. Transgender individuals may feel ashamed or uncomfortable in social settings, leading to further isolation and loneliness.

5. Suicidal Ideation

The lack of access to gender-affirming surgeries and the ongoing struggle with gender dysphoria can significantly increase the risk of suicidal thoughts and behaviors. Without the hope of being able to live authentically and alleviate their distress, transgender individuals may experience profound feelings of hopelessness and desperation.

Click here to know more about Mental health in transgender community

Affordable Surgery Options

Gender-affirming surgeries, including gender reassignment surgery (GRS), vary widely in cost globally. Affordable options exist in countries like Turkey, Brazil, Argentina, and Belgium. Turkey offers the most budget-friendly option, followed by Brazil, Argentina, and Belgium. While these countries provide competitive prices, individuals should consider factors beyond cost, such as healthcare quality and legal protections.

Click here for detailed information on the global cost of these surgeries and to find out which options are more affordable

In summary, gender reassignment surgery serves as a vital tool in validating the gender identities of transgender and intersex individuals, enabling them to harmonize their external appearance with their innate sense of self. Despite its transformative potential, many face obstacles in accessing this essential care, including financial constraints, inadequate insurance coverage, and legal hurdles.

As society progresses towards greater awareness and acceptance of transgender rights, it's imperative to prioritize equitable access to gender-affirming treatments and offer unwavering support to individuals throughout their transition journey. By dismantling these barriers and fostering inclusivity within healthcare systems, we can empower transgender individuals to live authentically and flourish in their gender identity.

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• Sex Reassignment Surgery in the Female-to-Male Transsexual - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/)
• Gender Affirmation Surgeries - (https://www.hopkinsmedicine.org/health/wellness-and-prevention/gender-affirmation-surgeries)
• Gender Confirmation Surgery - (https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery)
• Klinefelter syndrome - (https://www.nhs.uk/conditions/klinefelters-syndrome/)

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StarTribune

Ethics panel takes up complaint against republican senator who sent graphic video link.

An ethics panel Tuesday delayed action for yet another day on the question of whether Sen. Glenn Gruenhagen violated the norms of the state Senate by sending to his 66 colleagues a link to a video about gender-affirming surgery.

Sen. Erin Maye Quade, DFL-Apple Valley, filed the complaint against the Glencoe Republican in April 2023, but the Senate's ethics subcommittee didn't take it up until now. The four-person panel agreed to think about it and come back at 3 p.m. Wednesday to decide what, if anything, should be done.

The timing of the meeting was a concern for the two Republicans on the committee, who noted that the hearing occurred only after a complaint was recently filed against Sen. Nicole Mitchell, DFL-Woodbury, over her alleged attempted first-degree burglary of the Detroit Lakes home of her father's widow.

"The perception is the only reason we have this complaint in front of us now is because the other complaint was filed," Sen. Jeremy Miller, R-Winona, said. Sen. Andrew Mathews, R-Princeton, expressed similar concerns.

For more than two hours, the committee heard from and questioned Maye Quade and Gruenhagen before agreeing on a motion by Sen. Mary Kunesh, DFL-New Brighton, to think about it overnight.

Mathews initially moved for a finding of no probable cause for wrongdoing. But the motion failed on a tie with the two Republicans voting for it and Kunesh and Chair Bobby Joe Champion, DFL-Minneapolis, against it.

Maye Quade argued that by sending a link of gender-affirming surgery to all senators last year, Gruenhagen violated the Senate norms and should be sent to sensitivity training on LGBTQIA+ matters. She said Gruenhagen labeled the contents "extremely graphic and disturbing" and "sent it anyway."

She said the email was gratuitous and not related to pending legislation. "We can and should express our opinions and educate each other about topics," she said, but added that Gruenhagen's email "demonstrated a deep lack of understanding about LGBTQIA+ people."

Gruenhagen countered that he was providing information about a bill passed late last April. "We have an obligation and a responsibility to do the research," Gruenhagen said. He said the email linked to an academic, medical video created to train physicians on male to female gender reassignment surgery.

"You had to click twice to get to the videos. You could have hit erase," he said. "What's at stake is whether a member can share information, even if it's explicit, on a bill that's coming before the Senate to vote on."

The bill, which is now law , provided protections from legal repercussions and extradition orders for transgender people and their families traveling to Minnesota for treatment.

Rochelle Olson is a reporter on the politics and government team.

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