The ethics of gender reassignment surgery

Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.

Gender reassignment

This chapter deals with the definitions, history, incidence, and background to both gender dysphoria as a whole and male-to-female gender reassignment surgery specifically. Other chapters deal with surgical procedures for female to male reassignment that are within the scope of this textbook.

The complex case of Ellie Anderson

Ellie Anderson had always known that she wanted to have children. Her mother, Louise, was aware of this wish. Ellie was designated male at birth, but according to news sources, identified as a girl from the age of three. She was hoping to undergo gender reassignment surgery at 18, but died unexpectedly at only 16, leaving Louise grappling not only with the grief of losing her daughter, but with a complex legal problem. Ellie had had her sperm frozen before starting hormone treatment, specifically so that she would retain the chance of becoming a parent after her gender reassignment. Ellie had considered what might happen to the sperm if she died and was adamant that her children should be brought into the world. She made her mother promise to ensure that this would happen. But according to UK law, Ellie’s mother has no legal right to retain her sperm, or to use it to fulfil Ellie’s wishes. In this paper, we raise several key ethical questions on this case, namely: does a refusal to bring Ellie’s children into the world wrong her posthumously? Is Ellie’s mother morally entitled to use her daughter’s sperm as Ellie wished? Should the fact that Ellie was a minor at the time of her death or the fact that she was transgendered undermine her wish to have children? Can Ellie become a parent posthumously? We consider how these complex ethical questions could be approached.

Quality of life after gender reassignment surgery in transwomen

Background: Gender dysphoria is a condition in which there is discrepancy between a person's gender identity and that person's sex assigned at birth. Gender reassignment surgery (GRS) has an important role in alleviating the distress caused by gender dysphoria and it is medically necessary. The literature on quality of life (QoL) of transgenders post-GRS is limited in India.Methods: This is a prospective study on transgender women who volunteered to undergo male to female (MtF) GRS from March 2015 to August 2017. The demographic details and the surgical complications were registered. The Quality of life using the WHOQOL-BREF questionnaire was measured both before and a year after the surgery. The data were compared and presented.Results: A total of 62 GRS were performed during the study period. In that, 43 patients are literate (69.35%) and only 31.93% are employed in a socially respectable position. Our study shows significant improvement in physical, psychological and social health domains after the Surgery. Highest improvement was observed in the psychological health domain. There were no major complications observed in our study group.Conclusions: The surgical management improved the QOL in the first three domains of WHOQOL-BREF instrument namely physical health, psychological health and social relationship. Among these three domains, there is a significant improvement in psychological health. Hence, GRS has an important role in relieving the psychological distress caused by gender dysphoria and significantly improves the quality of life postoperatively.

Assessment of the medical radiation and non-radiation risks for the patients undergoing the surgical gender reassignment from female to male

The aim of the current study was to perform a comparative assessment of the radiation and non-radiation health risks for the sample of transgenders as well as the assessment of their perception of these risks. The study was performed on the sample of patients, undergoing the gender reassignment surgery from female to male. The structure of surgical procedures and the corresponding X-ray examinations was analyzed with the subsequent assessment of the radiation and non-radiation health risks. The level of patient knowledge on the risks and benefits of the medical procedures and perception of the ratio of radiation and non-radiation risks were evaluated based on the results of the sociological study. The study included the patients that underwent gender reassignment surgery in August 2012 – February 2018 on the base of I.M. Sechenov First Moscow State Medical University. Data collection and questioning were performed in August 2019 – March 2020. Data on the structure of the surgical procedures and X-ray examinations was collected for 99 patients; 86 patients agreed to participate in the questioning. The results indicate that the selected sample of patients, undergoing the gender reassignment surgery from female to male, is a high risk group both for radiation and non-radiation factors. For the whole multi-stage gender reassignment surgery, a patient could receive a total effective dose up to 250 mSv due to repeated computed tomography scans of chest, abdomen and head with contrast, corresponding to the lifetime attributive radiation risk of up to 1×10-2. Comparison of radiation and non-radiation risks for that patient sample indicates the dominance of the risk of successful suicide attempts (5×10-2). Radiation risks are equal to or even exceed (for the final stages of the gender reassignment surgery) the other risks of mortality from the non-radiation factors (anesthesia – 5,4×10-5, thrombosis – 2×10-5, post-surgical complications – 6×10-2). The reduction of suicide risks, as a result of the treatment, outweighs all other risk factors and justifies the gender reassignment surgery. The results of a sociological study show a decrease from 77% to 23% of suicidal thoughts among the patients. The study indicates that risk-communication was performed on the unsatisfactory level: less than 40% of the patients were informed about the possible health risks during the treatment; less than 50% of respondents knew about the benefits of X-ray examinations. About 70% of the patients rate their current problems with health higher compared to the risks from diagnostics and surgery. It explains the lack of interest to the radiation risk.