Page 4 - My Project1

gonad. Klebs’s classification gained the power of a medical doctrine: the nature of the gonad, ovary or testis, was the ultimate criterion of masculinity or femininity and consequently the nature of the gonad was also the divining rod for sex assignment of intersexed subjects. It was assumed that other characteristics of sex, such as self-awareness of being man or woman and sexual attraction to the opposite sex, would submit to the authentication of the criterion of the gonadal sex. This reasoning has subsequently been abandoned. Now most experts would agree that biological character-istics (such as chromosomal pattern, nature of the gonad, and so on) are not sufficient to provide reliable indicators for determining a person’s ‘true’ sex status as a man or woman. 3–7 Though relevant, they presently do not fully govern the decision to assign a particular sex to a newborn with ambiguous genitalia. A widely adopted policy is to arrive at a prognosis on the ‘optimal sex’ for the newborn, the elements of which are an over-all sex-appropriate appearance with stable gender identity, good sexual function (prefer-ably combined with reproductive function if attainable), minimal medical/surgical proce-dures, and a reasonably fulfilling life ham-pered as little as possible by the condition. 4–8

The extensive experience with this policy has vindicated the view that self-awareness of being man or woman is not exclusively dependant on biological determinants of sex alone (chromosomes, gonads, genitalia and hormones). While these are not irrelevant, other factors, still largely unidentified, also play a significant role. And of course sex assignment and the consequent rearing of the child as a member of that sex is certainly very significant.

TRANSSEXUALISM/THE SUBJECTIVE EXPERIENCE

In order to understand the phenomenon of transsexualism, it is useful to introduce some technical terms. For example, gender identity is a person’s inner sense of being male or female. This develops in early childhood and is strengthened by the hormonal changes of puberty. For most people, such a term has little relevance as the male or female bodies they possess never leave them in any doubt about whether they are men or women. Transsexuals are another matter. While they are lucidly aware of the physical reality of their bodies, this conflicts with their inner sense of being male or female, and is a source of great distress in their lives. Transsexualism can be best defined as an extreme form of gender dysphoria, which

is a discrepancy between gender identity/ role on the one hand and the actual physical characteristics of the body on the other. In transsexualism, the gender identity/role of the one sex coexists with the primary and secondary characteristics of the other sex in one and the same person. To the non-trans-sexual, this problem is so alien and unima-ginable that it is difficult to sympathize with the transsexual’s predicament.

With most types of suffering, such as the loss by death of a loved one, we can identify with the feelings of those we are close to, and share in their grief. To understand and sym-pathize with transsexuals is, in the first instance, more of a cerebral act, though one cannot escape the awareness that their plight is genuine and heart-felt. Male readers may be able to get some sense of the transsexual’s dilemma by imagining how they would feel if they suddenly developed prominent breasts. This is not entirely theoretical; it is the medi-cal condition known as gynaecomastia. The female equivalent would be experiencing a marked deepening of the voice and the development of male pattern beard and body hair growth. This is also a real condition that is not all that rare. Though these conditions are usually medically insignificant, the subjective experience of them can be a painfully humi-liating diminution of one’s manhood or wo-manhood. Transsexuals live permanently in this state of feeling betrayed by their physical selves. They feel trapped in their bodies: ‘I felt my body was a prison cell. There were no windows. I could not breathe; I could not get out, I did not have the key’.

Medical evaluation of transsexuals reveals no objective signs of intersexuality that can be detected with existing techniques of assessing biological parameters of sex. Therefore, in traditional medical practice, a transsexual will be advised to undergo psychotherapy in an attempt to adjust the body concept (which is perceived as a mental function) to concur with the actual physical reality of the body. On the face of it, this might seem a reasonable approach, but the transsexual will view such advice as improper and even insulting since it is totally at odds with his or her own percep-tion. To the transsexual, the problem is not in the mind, but in the body.

pleasure comes from the physical functioning of his or her sexual organs. The only differ-ence is that sexual gratification can only be obtained in encounters with a person with the same apparent sex. By contrast, transsex-uals experience the physical functioning of their sex organs as estranged from their selves. They seek physical reassignment, to the fullest extent possible, to the sex they feel themselves to be.

In recent times, an increasing number of people have been presenting themselves who only want to rid themselves of the character-istics of the natal sex without seeking further sex reassignment, or who want only partial adaptation to the opposite sex (‘the lady with the penis’). They seek to have an in-between sex status. There may be a social transition to the opposite sex, but sometimes only on a part-time basis. For this category, the term ‘transgenderism’ has been proposed. There are difficulties with transgenderism from a medical ethical viewpoint. Should a subject’s self-assessment of gender status prevail and does medicine have an ethical obligation to provide care for those who seem to genuinely find themselves in an in-between gender sta-tus through no choice of their own, and to assist them to live in peace with that gender status?

Prevalence

Calculations of prevalence data are likely to be influenced by the prevailing social cli-mate and provisions for medical treatment. Another factor is definition of the condi-tion; prevalence/incidence studies sometimes make no clear distinction between transsex-uals and other subjects with transgenderism. The prevalence of transsexualism as assessed in The Netherlands and based on numbers of people seeking sex reassignment, is 1 : 11 900 men and 1 : 30 400 women. 9 These figures are very stable. They are somewhat lower than those of Singapore but higher than those in Sweden. Incidence data in Sweden and The Netherlands show a very constant pattern over time. Recent data from Japan indicate a prevalence of 1 : 25 000 men and 1 : 11 000 women. 10 Larger countries like the United States are harder to gauge. Figures are usually determined from the numbers attending clin-ical programs, but some may turn elsewhere and the bigger the country is, the less precise the calculation. Nevertheless, increasing num-bers of people with ‘gender identity disorder’ are seeking help in North America. The 3 : 1 ratio of males/females encoun-tered in the Western world is not universal. 9