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January 2017 Pulse

In 2006, in an article published in Methodist Message, I argued that gender dysphoria is a form of mental disorder – a view I still hold today. If this judgement is sound, then far from being a helpful correction to the condition, sexual reassignment surgery (SRS) is in fact collaborating with the illness.

In this article, we focus on a different but not unrelated question. SRS is legal in many countries, including Singapore and Iran (because homosexual acts are punishable by death, homosexuals in Iran are forced to undergo SRS – but that’s another story). Countries like Thailand and South Korea have become international hubs for SRS, attracting medical tourists from across the globe.

SRS may be legal, but is it ethical from the standpoint of medical ethics? To answer this question, we must examine what SRS entails and what benefits (if any) it brings to persons suffering from gender dysphoria.

SRS is a major procedure with significant risks.

SRS for the male involves hormone treatment, the removal of the penis and testes, preparation of genital tissue for the creation of pseudo-vagina, the creation of the pseudo-vagina, opening the urethra, breast implants, silicone implants in the hips and buttocks, and cosmetic surgery.

For the female, SRS involves hormone treatments, mastectomy, hysterectomy, the creation of a pseudo-penis and testes, and treatment to increase testosterone levels to stimulate hair and muscle growth.

The pressing question here is whether it is ethical to perform a procedure that not only mutilates but also destroys healthy sexual and reproductive organs.

SRS must be distinguished from surgical procedures to correct or restore deformities in the sexual organs caused by congenital defect, genetic abnormalities, injury or disease. While the latter procedures are performed to correct deformities, it is debatable if SRS could even be described as treatment – although this remains a contentious issue.

One of the most important principles in medical ethics is nonmaleficence. This principle obligates physicians not to cause harm to their patients, encapsulated in the oft-quoted maxim Primum non nocere (“Above all [or first] do no harm”).

Some ethicists have combined this principle with that of beneficence into a broader principle. But Tom Beauchamp and James Childress are surely right to argue that “conflating nonmaleficence and beneficence into a single principle obscures critical moral distinctions as well as different types of moral theory”.

In destroying healthy sexual and reproductive organs, SRS has arguably transgressed this important principle in medical ethics – to “do no harm”.

But does SRS benefit the person suffering from gender dysphoria? Two important points must be made in answer to this question.

Firstly, SRS does not change the sex of the person with gender dysphoria, but only creates an illusion of change. As Richard P. Fitzgibbons, Philip M. Sutton and Dale O’Leary have pointed out in their excellent study: “It is physiologically impossible to change a person’s sex, since the sex of each individual is encoded in the genes – XX if female, XY if male. Surgery can only create the appearance of the other sex.”

Secondly, persons who have undergone SRS continue to struggle with problems of sexual identity. A recent Swedish study showed that persons “after sexual reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population”.

SRS therefore is not a treatment for sexual dysphoria. As Dr Paul McHugh has put it quite bluntly in his article ‘Surgical Sex’: “We psychiatrists … would do better to concentrate on trying to fix their minds and not their genitalia.”

The language that we routinely and very often uncritically use has clouded our thinking on this issue, creating more confusion than clarity.

“Sexual reassignment surgery” is itself a problematic term because it implies that the sex of a person assigned at birth can be reassigned by surgery. This, as we have seen, is not the case at all. The term “transsexual” is equally problematic because it suggests that a person of a certain genetic sex can simply move to the other sex.

With the technical possibility of surgically creating pseudo-genitals, these disturbingly misleading misnomers have given rise to yet another misleading idea: that SRS is a form of treatment for people suffering from gender dysphoria.

Perhaps it is time to re-examine the ethics (and legality) of SRS.

Dr Roland Chia is Chew Hock Hin Professor of Christian Doctrine at Trinity Theological College and Theological and Research Advisor for the Ethos Institute for Public Christianity. This article is first published in Methodist Message.