Sexual Consultants Ltd.
Position Paper
Gender-Reassignment Surgery before Puberty in Adolescents
Introduction
Gender Identity Disorder, formerly defined as gender dysphoria and
transsexualism, is the phenomenon experienced by individuals who “experience an
irreconcilable discrepancy between the biological sex they were born with and the
opposite biological sex they feel they belong to.” (Smith, van Goozen, & Cohen-Kettenis,
2001). The sexual identity of an individual both predetermines and directs masculine or
feminine socialization roles that include societal/life expectations. These are primarily
determined at birth with the current trend towards orienting an individual to coincide with
the physical expression of genitalia. The experienced discrepancy of an individual’s
‘assigned gender role’ and the internal sense and desire to assume the role of other gender
despite ambiguous or opposite expression of genitalia is not well understood.
Advances
in modern medicine can provide the opportunity for gender reassignment through
surgical and hormonal treatments. This position paper discusses the merits and
disadvantages of gender reassignment surgery during adolescence and presents a
recommended position based on analyzing current empirical research compiled by
renowned professional experts in this specialized field.
Problem Statement
Should sex reassignment surgery be completed in adolescence?
Background, Literature Review and Definitions
Gender Identity Disorder (GID) has existed throughout history as documented in
many different countries and cultures. (Wren, 2000). This phenomenon has been met
with varying degrees of acceptance depending on cultural context. In cultures that
ascribe to a binary model that represents two sexes or gender expressions, (male
and/or female), acceptance of GID is greatly lower resulting in a negative overtone,
which often leads to an ostracizing social reaction resulting in social marginalization
through discrimination and stigmatization practices. (Wren, 2000; Newman, 2002).
Understanding into the occurrence of GID is still within its infancy with current and
ongoing research. The reclassification of ‘transsexualism’ as a psychiatric
disturbance as described in the Diagnostic and Statistical Manual of Mental
Disorders, IV, (DSM IV) in 1994 to its current diagnostic classification of GID,
embraces a holistic view of the experience of “…desiring to be, or feel themselves to
be, the other sex…” and a wish to live as the other sex, apart from their physical
anatomic expression. (Wren, 2000). The manifest of GID begins early in life and
there is no clear consensus for biologic, genetic or social etiology. (Cohen, Ruiter,
Ringelberg & Cohen-Kettenis; Chu, 2003). Due to the permanency and irreversibility
of sex reassignment surgery, it is crucial that careful diagnosis and strict criteria is
met to sufficiently justify the treatment for positive outcomes. To this end, it is
imperative that any decision in developing policies regarding SAS is based on
empirical knowledge that has been gleaned in consultation with trained experts in this
specialized field. This position paper examines empirical studies published on GID
and SAS conducted through a literature search performed through the University of
British Columbia on-line Library services, using databases known for aggregating
medical and nursing research: Cumulated Index to Nursing and Allied Health
Literature, (CINAHL), PsycINFO, and PubMed (1949 to present). Information was
also accessed through accredited websites. Keywords were kept systematically the
same in all database searches: “dysphoria,” “AND transsexualism,” and “AND
gender identity disorder.” The search was limited to documents with full free linked
text, abstract available, English, and no date restriction. Additional limiting
parameters included: research papers, case studies, doctoral dissertations, clinical
trials, qualitative studies, quantitative studies, meta-analysis, empirical studies,
follow-up studies, longitudinal studies, retroactive studies, randomized controlled
trials, and clinical case studies.
I. Thesis Assertion
What is Gender Reassignment Surgery?
Key Issues
Application of the Human Rights Principle
Pre-emptive Assumptions
Consideration of the Procedures and their Consequences
Compliance with International Human Rights Treaties
II.
Rebuttal Argument – Political Risks
Rebuttal Summary
Supporting Research
Evidence in Argument
III.
Recommendation
Opinion and Conclusion
IV.
Policy Limitations
V.
Policy Implementation Considerations
VI.
References
a Campo, J. Nijman, H., Merckelbach, H. & Evers, C. (2003). Psychiatric comorbidity of gender
identity disorders: a survey among dutch psychiatrists. The American Journal of
Psychiatry. 160, 1332-1336. Retrieved on October 17, 2008 from
http://ajp.psychiatryonline.org/cgi/content/full/160/7/1332
di Ceglie, D. (2002). Castaway's corner. Clinical Child Psychology and Psychiatry. 7, 487.
Retrieved on October 17, 2008 from http://ccp.sagepub.com
Bodlund, O. & Armelius, K. (1994). Self-image and personality traits in gender identity
disorders: an empirical study. Journal of Sex and Marital Therapy, 20(4), 303-317.
Retrieved on October 19, 2008 from http://www.atyponlink.com/SJP/doi/abs/10.2224/sbp.2006.34.8.927?cookieSet=1&journalCode=sbp
Bowman, C. & Goldberg, J. (2006). Care of the patient undergoing sex reassignment surgery
(SRS). Vancouver Coastal Health, Transcend Transgender Support & Education Society,
and the Canadian Rainbow Health Coalition. Retrieved on October 18, 2008 from
http://www.vch.ca/transhealth
Chu, D. (2003). Sex reassignment surgery (SRS).
Cohen-Kettenis P.& van Goozen, S. (1998). Pubertal delay as an aid in diagnosis and treatment
of a transsexual adolescent. European Child & Adolescent Psychiatry, 7 (4), 246-8,
Retrieved on October 22, 2008 from
http://web.ebscohost.com/ehost/pdf?vid=5&hid=22&sid=8b39be7e-aaf2-4690-be1a36a9b5daa8d4%40sessionmgr9
Cohen, L., de Ruiter, C., Ringelberg, H. & Cohen-Kettenis, P. (1997). Psychological functioning
of adolescent transsexuals: Personality and psychopathology. Journal of Clinical
Psychology, 53(2), 187-196. Retrieved on October 22, 2008 from
http://web.ebscohost.com/ehost/detail?vid=9&hid=12&sid=369c43b0-f11c-4de0-a05cff69916000f0%40sessionmgr3&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh
&AN=1997-08160-012
Giltay, E., Gooren, L., Cohen-Kettenis, P., Boenink, A., Eeckhout, A., & Heller, H. (2004).
Comorbidity of gender identity disorders. The American Journal of Psychiatry, 161(4),
934. Retrieved on October 24, 2008 from
http://ajp.psychiatryonline.org/cgi/content/full/160/7/1332
Griffiths, M. (2002). Invisibilty: the major obstacle in understanding and diagnosing
transsexualism. Clinical Child Psychology and Psychiatry. 7, 493-496. Retrieved on
October 17, 2008 from http://ccp.sagepub.com
Israel, G. (2004). Supporting transgender and sex reassignment issues: couple and family
dynamics. Journal of Couple and Relationship Therapy, 3(2/3), 53-63. Retrieved on
October 22, 2008 from
http://web.ebscohost.com/ehost/detail?vid=5&hid=22&sid=8b39be7e-aaf2-4690-be1a36a9b5daa8d4%40sessionmgr9&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=c8h
&AN=2005101985
Lombardi, E. (2001). Enhancing transgender health care. American Journal of Public Health. 91,
869-872. Retrieved on November 1, 2008 from
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1446458&blobtype=pdf
Midence, K, & Hargreaves, I. (1997). Psychosocial adjustment in male-to-female transsexuals:
An overview of the research evidence. Journal of Psychology: Interdisciplinary and
Applied, 131(6), 602-614. Retrieved on October 22, 2008 from
http://www.garfield.library.upenn.edu/histcomp/intersex_keypapers/index-aus-2.html
Newman, L. (2002). Sex, gender and culture: Issues in the definition, assessment and treatment
of gender identity disorder. Clinical Child Psychology and Psychiatry. 7, 352. Retrieved
on October 19, 2008 from http://ccp.sagepub.com/cgi/content/abstract/7/3/352
Phornphutkul, C, Fausto-Sterling, A., & Gruppsuso, P. (2000). Gender self-reassignment in an
XY adolescent female born with ambiguous genitalia. Journal of the American Academy
of Pediatrics. 106, 135-137. Retrieved on October 19, 2008 from
http://pediatrics.aappublications.org/cgi/content/full/106/1/135
Smith, Y., van Goozen, S., Kuiper, A., & Cohen-Kettenis, P. (2005). Sex reassignment:
outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological
Medicine. 35, 89-99. Retrieved on October 17, 2008 from
http://pt.wkhealth.com/pt/re/pgme/abstract.00006826-20050100000011.htm;jsessionid=JHmThywTv7nn1lTWLzl2VPHN1JvpwN6mfQgTrGBK7bQbG0
KjDdx9!-975242908!181195629!8091!-1
Sobralske, M. (2005). Primary care needs of patients who have undergone gender reassignment.
Journal of the American Academy of Nurse Practitioners. 17, 4. Retrieved on October 19,
2008 from
http://direct.bl.uk/bld/PlaceOrder.do?UIN=167217021&ETOC=RN&from=searchengine
Tasker, F. & Wren, B. (2002). Editorial: sexual identity and gender identity: understanding
difference. Clinical Child Psychology and Psychiatry. 7, 315-319. Retrieved on October
17, 2008 from http://ccp.sagepub.com
Wren, B. (2000). Early physical intervention for young people with atypical gender identity
development. Clinical Child Psychology and Psychiatry. 5, 220. Retrieved on October 19,
2008 from http://ccp.sagepub.comcgi/content/abstract/5/2/220
Wilson, I., Griffin, C. & Wren, B. (2002). The validity of the diagnosis of gender identity
disorder (child and adolescent criteria). Clinical Child Psychology and Psychiatry. 7, 335496. Retrieved on October 17, 2008 from http://ccp.sagepub.com
Zucker, K, Owen, A., Bradley, S and Ameeriar, L. (2002). Gender-Dysphoric Children and
Adolescents: a comparative analysis of demographic characteristics and behavioral
problems. Clinical Child Psychology and Psychiatry, 7, 398, Retrieved on October 19,
2008 from http://ccp.sagepub.com/cgi/content/abstract/7/3/398