If sex reassignment surgery is the answer, what is the question?

Michael Cook*

Sex reassignment surgery requires the intervention of doctors. But what kind of treatment is it? Is it a therapy for a disease which should be offered only after psychiatric authorization? Or is it a biomedical enhancement which anyone can freely choose?

The answer to this theoretical question has practical consequences. If it is a therapy, then transgenderism is a disease. If it is an enhancement, then it hardly deserves to be funded by the government.

In a very interesting article in the Journal of Medicine and Philosophy, Tomislav Bracanović, of the University of Zagreb, in Croatia, analyses the competing conceptions.

Transgender scholars contend that sex reassignment surgery is not a therapy for gender identity disorder, because the feeling of being a man in a woman's body or a woman in a man's body is not a disorder. It is a "normal, albeit rare, human condition that is medicalized as a consequence of general discrimination of transsexual population. It should be removed, therefore, from all classifications of mental disorders, and sex reassignment surgery should be made available without medical "gatekeepers" deciding who qualifies for it and who does not."

Their conclusion is that a sex change is no more a therapy than a "nose job". They would prefer to describe sex reassignment surgery as an enhancement, like cosmetic surgery.

But is it plausible to describe it as non-therapeutic enhancement? Bracanović believes that it is not. "It does not improve, augment, or increase—above average—any trait or function typically mentioned in philosophical debates about enhancement. Intelligence, vision, hearing, physical strength, and immunity, for example, after sex reassignment surgery remain more or less the same as they were before."

There is another way of framing enhancement, though: the welfarist model – does it enhance quality of life? At first blush this seems plausible because people who have had the operation report more satisfaction and a decrease in dissatisfaction. However, Bracanović  points out that the evidence for this is weak. There have been very few long-term studies of postoperative transsexuals's quality of life.

... imagine the "sex change drug" that has the same risk–benefit ratio as sex reassignment surgery. Even if it improved the condition of many clinical trial subjects, it would probably not be approved by any regulatory agency (as either "therapy" or "enhancement"), if a large number of subjects mysteriously disappeared from the trial after taking the drug.

So Bracanović concludes that it would be wise to keep the gatekeepers for this type of surgery and to restrict access to it. Given the current state of knowledge, there is too great a risk of harm to the patients. Furthermore, if it is an enhancement which increases a person's well-being, as transgender scholars contend, it is obviously more like enhancement for artistic ability rather than curing paraplegia. With limited resources, society would normally focus on paraplegia rather than gender dysphoria. The only way to prioritise it above paraplegia would be to medicalise it and describe it as a serious disorder – which theorists vehemently reject.

This article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.