During the last thirty years medical professionals and concerned public have with even greater frequency begun to consider the medical interests of transgendered people (Eyler and Wright, 1997). The discussion has primarily focused on the significance of both the political and social issues transgenderism evokes rather than the technical process of sex reassignment surgery (SRS) performed by either private practitioners or specialized doctors working in prominent gender identity clinics. Since the late 1940s, when both the endocrinological and surgical means to ‘change sex’ began to be more widely employed, medical doctors and therapists regarded transgenderism as a disorder referred to as gender identity dysphoria. Discrepancies concerning the appropriate treatment of this dysphoria, however, emerged within the medical field. Several doctors and therapists advocated the psychological elimination of the transgender person’s ‘pathological’ desires while other doctors encouraged a surgical sex change (Ekins and King, 1997). This article is not written with the purpose of engaging as a proponent of either political or social debates in the medical arena, but to highlight the arguments surrounding transgender issues.
One of the major debates within the field of medicine is whether transgenderism is a ‘biological’ or ‘invented’ disorder. "The medical conception of transsexualism is," according to doctors and psychologists engaged in transgender research, "an illusion, a fabrication whose explanation must therefore be sought in terms other than the putative ‘thing’ itself" (Ekins and King, 1997). As a result, medical doctors and therapists are concerned with whether or not they should treat the transgendered client by helping them adjust to their current body, or whether they should adjust the current body to fit the individual’s self. Should doctors perform an operation to change a biological female who identifies as a male into a male with the appropriate sexual organs (FTM) or a male who identifies as a female into to sexually equipped female (MTF)? Or, alternatively, should doctors refer transgender people to psychologists? The debate within such fields, however, were not limited to only such questions. Other questions arose concerning whether or not the medical field was responsible for addressing the social conflicts surrounding the issues of transsexualism. Issues involving the ethical legitimacy of the sex reassignment surgery emerged. Sex reassignment surgery, according to certain professionals, caused problems within families and tension within the workplace because of the inability of family members and co-workers to adapt to the change. "The disunity of people in families and at places of work as to the gender of a member was transformed into heated medical debates or professional ethics concerning the legitimacy of genital surgery" (Hirschauer, 1997). The final debate within the medical field that is discussed in this article is whether or not operations involving female-to-male or male-to-female operations should be covered by socialized medicare.
Two of the most common complaints about gender dysphoria is that doctors refuse to treat dysphoric individuals seriously or they attempt to encourage their clients to accept the gender identity problem rather than help to solve it. Harry Benjamin was one of the first endocrinologists to to recognize the complexities of gender identity problems and transsexualism. In his book The Transsexual Problem (1966), Benjamin argued that therapy aimed at attempting to cure a person of transsexualism or gender identity disorder began from a faulty premise and was, therefore, not the best way to go about dealing with transgenderism. Attempting to posit a ‘cure’ resulted in harmful, and sometimes irreversible, ramifications to the psychological and physical well-being of the client. Benjamin argued that:
Since it is evident that the mind of the transsexual cannot be adjusted to the body, it is logical and justifiable to attempt the opposite, to adjust the body to the mind. If such a thought is rejected, we would be faced with a therapeutic nihilism to which I could never subscribe in view of the experiences with patients who have undoubtedly been salvaged or at least distinctly helped by their conversion (Vitale, 1997).
In 1977 the Harry Benjamin International Gender Dysphoria Association (HBIGDA) was established in which professional doctors and therapists participated to create the STANDARDS OF CARE: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons to ensure that transsexuals were provided with the best form of treatment available (Coombs, 1998).
Following the path set by Benjamin and his colleagues, most psychologists and gender identity specialists in the field today realize that gender identity dysphoria is not a delusional reaction to societal norms recognizing that it should be treated separately from other types of disorders. Although there is no one clear distinction concerning what exactly causes gender identity disorders, there reliable information concerning fetal and childhood development that suggests that the disorder is caused by a biological condition. Anne Vitae has explained that the scientific evidence needed to suggest that transsexualism is a biological phenomenon is available:
For a male embryo to develop, something must be added ... a Y chromosome inherited from the father ... [the] Y chromosome must contain a gene known as the Testes Determining Factor (TDF), telling the embryo to differentiate and develop male genitalia. Embryos without the factor continue to develop undifferentiated as female. Nature takes male differentiation further by having the newly formed male testes flood the brain with androgenizing hormones at around the third month of pregnancy. This sudden surge of brain masculinizing hormones -- the creation of the male gendermap -- occurs again in males somewhere between the second and twelfth week after birth. Importantly, there is no corresponding feminizing hormonal surge sequence observed in females (Vitale, 1997).
The above observation suggests the possibility that male hormones must be produced in both sufficient amounts and at a particular time to ensure that an individual born with male sex organs feels maleness. If there is insufficient androgen, or the hormones are produced either too early or too late, the result may be a child who does not adequately identify as a male. These disruptions of hormonal spurts may result from a number of factors – a disorder in the mother’s endocrine system such as a hormone secreting tumor, maternal stress, medications or other toxic substances (Vitale, 1997).
Furthermore, most doctors and psychologists believe that gender dysphoria is profound, deep-seated, and non-delusional. "Even more significantly," argues Ann Vitale, "outcome studies now clearly indicate that when three conditions are met: a proper differential diagnosis, a significantly long trial period of living in the gender of choice, and a satisfactory surgical result, there is only a small incidence of post-operative regret" (Vitale, 1997). In contrast, individuals with gender dysphoria who remain untreated may become suicidal or unable to function adequately. Additionally, the psychologist’s or doctor’s misunderstanding of the dysphoria may also potentially harm the client (Green, 1999).
In clinical settings, members of the medical community tend to regard gender identity disorders as a pathological disorder which diverts the effectiveness of any treatment offered. Pathologizing also gives an unequal advantage to the clinicians. "In the clinic setting, the doctor is well and the patient is ill. To further distance the individual ... from the process, committees sit periodically and review the current case load. Essentially, clinicians, some of who may not have ever met the client, decide if the individual is a candidate for hormone therapy, and eventually, if the patient is eligible for sex reassignment therapy" (Vitale, 1997). Vitale argues that though this approach ensures the professionalism guaranteed by clinicians, it also separates the patient from the doctor in a counterproductive way. Though clinicians believe that they are being responsible, Vitale argues that there are more satisfactory ways for exercising responsibility for both the doctor and the patient. Vitale suggests that the more responsible the client is made in the decision making process the more successful the outcome.
Although extreme measures such as requiring medical doctors to perform sex change operations is drastic, requiring that such doctors are educated about the issue is not. Because doctors and psychiatrists often know little about the issues surrounding transsexualism, transgender individuals frequently rely on hormones obtained on the black market for self-administration (Dean, Meyer, Robinson, Randall, Sember, Silenzo, Wolfe, Bowen, Bradford, Rothblum. Scout, White, Dunn, 2000). In addition, few hospitals or therapeutic resources are available for transgender people to exploit. More importantly, because the debates within the medical field have only been somewhat settled in recent years, the social problems surrounding the issue of transsexualism still continue. Instead of helping to legitimate the claims of transsexuals, the medical field has separated the transgendered experience from society by treating it as an individual problem. It is not treated by medical practitioners as a phenomenon that occurs due to pressures to adapt to prescribed social norms, but as a pathology that "is the property of individuals, incorporated in them as a transsexual substance – be it a gender identity or a hormonal defect. From the perspective of society this location of the phenomenon within gender migrants is a location outside of society" (Hirschauer, 1997).
Locating gender dysphoria outside of society benefits only those engaged in the medical field. It allows practitioners to individualize the concern without posing questions as to why certain people feel a need to undergo such a ‘radical’ treatment as a sex change. Yet, as Sue Watling argues, the male/female sex/gender binary is very much a social institution (Watling, 1998). Separating transgenderism from other social institutions only serves to individualize the problem and to eliminate the possible influences socially-accepted norms have on both the transsexual (feelings of inadequacy; guilt for transgressing gender ‘norms’) and the professional field of medicine (maintaining that transgenderism is a phenomenon that occurs in individuals and is not a result of societal pressure to conform) (Watling, 1998). The accepted roles accorded to both genders, however, permeates almost all aspects of most people’s lives. Sue Watling argues that gender-appropriated norms "reward behaviour and castigate that which it defines as deviant. It has its own statute book, its own portfolio of rules and regulation and its own standards of achievement. The only thing which is missing is an ombudsman to deal with complaints of dissatisfaction from individuals who feel uncomfortable with regard to their assigned sexual identities and associated gender roles" (Watling, 1998). Socially defined gender norms dichotomize the expectations placed on both sexes and prescribe what is and what is not accepted. As a result, anything that falls short of the ‘norm,’ such as transgenderism, results in an ostracization of the individual whether he/she is a trans male or trans female. The practice of the medical field to not recognize the effects such norms have on the behavior and mentality of transsexuals serves to maintain that the gender identity disorder is an individual problem within the transsexual alone and does not recognize the problems transsexuals have are equally caused by social pressure to comply with the norm (Frye, 1999).
The final debate within the medical field concerning transgenderism that is discussed in this article is whether or not the cost to perform sex reassignment surgery should be covered by socialized medicine in countries like Canada. Although the sentiments of those opposed to providing access to socialized health care for people awaiting sex reassignment surgery is keenly heard in numerous health care and public circles (including the media), the reality is that health care will have to make a financial commitment to allocating funds for reconstructive surgery as opposed to another form of health care. The financial cost is something that needs to be considered with heed given to proponents of both sides of the argument. Certainly, bigotry on the part of numerous right-wing groups need not be considered. A serious evaluation, however, is required if indeed it should be decided that the surgery improves the overall quality of a transgender person’s life. Unfortunately, some groups refuse to acknowledge that socialized medicare should be available to benefit the needs of all members of society. Journalist Derek DeCloet argued in the British Columbia Report that:
It seems likely that governments will be asked to fund projects that could never be described as essential medical services. Some of them will be far tougher for taxpayers to stomach ... for example, Health Canada is spending about $2.2 million over six years to set up the B.C. Centre of Excellence for Women's Health in Vancouver. The centre will not do biomedical research; instead, it researches the health status of "marginalized" women. One of its early projects is called "Lesbian health: Perceived barriers to care for lesbians in urban and isolated communities." The Vancouver Richmond Health Board, meanwhile, has set up a committee of gay, lesbian, bisexual and transgendered people to give advice on how their health needs can be meet. One of the committee's first ideas is a publicly funded "education" campaign to combat homophobia (DeCloet, 1997).
As is apparent from the above quote, economic disadvantages accompany the transgender community. Not only do transgender people suffer from isolation from family members and co-workers, but they are sometimes required to carry the burden of the high cost of surgery. For many, the basic cost of such surgery and the necessary hormonal treatment is unrealizable (Dean, Meyer, Robinson, Randall, Sember, Silenzo, Wolfe, Bowen, Bradford, Rothblum. Scout, White, Dunn, 2000).
This essay was not intended as a political statement advocating either of the issues concerning transgenderism. Instead, it was intended to provide an overall description of the arguments appertaining to the medical needs of transgender people. Many health care facilities as well as health care professionals in Canada and other parts of the world are making an attempt to provide better care for transgender individuals. Though social stigmatization still exists and is prevalent in much of the literature provided to both professional doctors, therapists, and the general public, further research is being conducted that will provide better insight into the topic of transgenderism.