Page 5 - My Project1

This may be related to the fact that their cultures do not view transsexualism as an expression of moral depravity but rather as an expression of the diverseness of nature, including human nature. It has been hy-pothesized that in cultures with a rigorous definition of manhood and womanhood, men who fail to fulfill the exigencies of manhood would resort to a transsexual state, but in the author’s experience, this is not the case.

Transsexualism in the medical discourse Transsexualism has always met with a great deal of scepticism and equivocation in medi-cine. Its diagnosis and particularly hormonal and surgical treatment are unorthodoxies in medical conduct. The transsexual’s com-plaint that the sexual differentiation of his or her body is a source of unease strikes both layman and physician with disbelief; it is not something one can immediately sympathize with. The wish to ‘tamper’ with the sexual integrity of a correctly functioning body must seem abhorrent to the outsider. Further, if the transsexual succeeds in conveying the mess-age that life is miserable and not worth living unless ‘the body is adapted to the mind’, how certain can it be that this conviction will never change? In other words: will irreversible med-ical interventions be regretted later in life in the course of the ongoing process of evalu-ating things differently as one grows older and wiser?

For the medical profession, the treatment of transsexualism represents a major departure from its traditional mode of operation. Nor-mally, a subjective complaint of a patient is verified by physical examination complemen-ted nowadays by the objectivity of diagnostic technology. If the outcome of the investigations is in concordance with the subjective complaint of the patient, a medical intervention is under-taken. But if that is not the case, the patient is reassured or may be advised to seek psycho-logical help. With the present state of the art up to 2004, transsexualism presently has no (patho)biological substrate which would per-mit its verification in clinical practice according to the above diagnostic strategy. Adagia such as ‘in dubio abstine’ and ‘primum non nocere’ still enjoy respect in medicine and the medical pro-fession is still reserved as to hormonal and sur-gical treatment.

Those in the medical field who have set out to undertake sex reassignment of transsexuals have met strong reservations from the peer group. Can it be ethically and medically defended that tissue, healthy by standards of medical pathology, is tampered with solely on the grounds of the purely subjective assertion of the transsexual that life in the natal sex is intolerable? Can hormones and the surgical scalpel actually correct whatever has gone wrong in the apparently ‘psychological’ pro-cess of gender identity and role formation? Is not one of the tenets of psychotherapy (in particular psychoanalysis) that errors in our psychological development can be undone provided that the will and the commitment to invest in psychotherapy are present? Arguments that transsexuals can be ‘cured’ by psychotherapy have never been corrobo-rated by clinical studies providing evidence. Naturally, they may benefit from psychother-apy to help them cope with their predica-ment, but there seems to be no hope that it will fundamentally solve their gender identity disorder.

The counter-argument to those who pro-vide sex reassignment is that they have no cure to offer either. Can a transsexual who has undergone hormonal and surgical sex reassignment truly be said to have become a member of the new sex? The answer emerges if one reflects on what medicine in general has to offer to the sufferings of mankind, appro-priately phrased by John Money in 1971: 15

‘Some illnesses are acute, time-limited, and subject to therapeutic arrest or reversal, fol-lowed by return to health. These, in the Hippocratic tradition, the physician aims to cure. Other illnesses are chronic, progressive and deteriorative. For these the physician is less ambitious. He aims to ameliorate or pal-liate, with whatever treatment is available, the suffering they engender. Still other illnesses or conditions are chronically, though not pro-gressively disabling. For these the physician’s goal is ameliorative plus rehabilitative. Transsexualism is not a reversible con-dition, judging by today’s therapeutic tech-niques. Nor is it a progressively deteriorative condition, but it does represent a chronic dis-ability, requiring a patient’s life to be rehabili-tated. Sex reassignment—social, hormonal, surgical, and legal—is an ameliorative and rehabilitative treatment for transsexualism. There cannot be a cure for this condition in the absence of a clearly formulated etiology so far not discovered’.

As Money et al. observes, a true cure is relatively rare in medicine; rehabilitation is the most common sort of help that can be

offered. By way of comparison, a young person paralysed and crippled in a traffic accident may be enormously helped by an orthopedically inspired but ‘unnatural’ sur-gical transposition of tendons aimed at improved mobility and a corresponding reduction of dependence on others. Such an intervention, in no way defensible in a healthy person, can be in the best interests of a person in this unhappy circumstance. It is not a cure, but an attempt to rehabilitate a person stuck in this situation. It demon-strates that improvement of the health of the whole person can legitimately take pre-cedence over the health of individual body parts. In fact, the situation of the trans-sexual is not essentially different.

Sexual differentiation of the brain In the daily practice of medicine, we deal with verifiable biological criteria of sex (chromo-somal patterns, nature of the gonad and gen-italia, and sex hormone levels), but there is little attention for another dimension of sex-ual differentiation: the sex of the brain. It can be argued that this does not usually pose an issue since the sex of the brain almost always conforms to other specifications of sexual differentiation.

From the beginning of the 20th century, studies in rats, mice and other lower mam-mals have made it apparent that sexual differ-entiation does not stop with the development of the external genitalia into male or female sex organs (the usual criterion for labelling creatures as male or female). Rather, this development is succeeded by a corresponding differentiation of the brain to match that of the gonad and genitalia. This sexual differ-entiation of the brain can be demonstrated neuroanatomically. It expresses itself not only in sex-dimorphic sexual behaviour (such as copulatory positions) but also in sex-dimorphic non-sexual behaviour such as aggression, defence of territory and caring for the young. The paradigm of this step in the sexual differentiation process of lower mammals is similar to preceding ones: in the presence of androgens (normally pro-duced by the testis of the fetus), a male brain differentiation occurs; if no androgens are present (the normal situation in females), a female brain differentiation follows. This pro-cess has been termed the organisation, or ‘wiring’ of the brain to prepare it for future sexual and reproductive behaviour in accord-ance with the gonadal/genital status. 16 This programming laid down during the fetal per-iod or shortly thereafter becomes activated by the hormones of puberty. 16