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