All treatment decisions involve the tacit decision to treat or to withhold treatment. Although often not expressed, the “not to treat” side of the analysis of risks versus benefits is quite important and should be explored in patients with GID and its variants (Brown et al. 1988a). The availability of somatic treatments as accepted interventions for the overall management of GID raises a number of bioethical issues for some psychiatrists. The medical literature rarely is as rife with affect as when this issue is discussed by those who oppose the application of surgical treatments as part of the treatment plan for gender transmutation:
This passing fad for what is miscalled “transsexualism” has led to the most tragic betrayal of human expectation in which medicine and modern endocrinology and surgery have been engaged. (Kubie 1974, p. 350)
As recently as 1998, one psychiatrist discussed her countertransference difficulties in using the proper pronouns to refer to a patient with GID who had already undergone “vaginoplasty as a young man and had since been living as a woman” (Quinodoz 1998, p. 95). Clearly, empathic contact with a patient is highly unlikely if the therapist refers to a person legally and anatomically female as “he.” The importance of using appropriate pronouns has been emphasized elsewhere (Brown 1990a).
Psychiatrists’ responses to requests for treatment from those with GID range from the nearly cavalier referral for hormones and sex reassignment surgery to an inflexible reticence to entertain any such referrals, erecting the defensive facades of “do no harm” and “never deliberately remove a healthy organ.” The latter tack is exemplified by Kavanaugh and Volkan’s (1978-1979) pejorative description of SRS as “a new type of psychosurgery.” Psychoanalytic theory often refers to one’s “highly prized sexual organs” (Brenner 1974) and the cathexis of libidinal energy. A man who pleads for castration and amputation of his penis may arouse, on an unconscious level, significant anxiety in male psychiatrists. The capacity to fully empathize with severely gender-dysphoric patients may be rarely, if ever, found in non-gender-dysphoric individuals, setting the stage for empathic failures in treatment and in referral decisions. A surgeon known to be sympathetic to the plight of those with GID was quoted as saying: “Our big problem is to differentiate the dissatisfied old homosexuals who just want a new thrill from the true transsexuals” (Glenn 1979, p. 130).
In spite of the fact that somatic treatments have been used for over 30 years in the United States, clinical decisions must be made in the absence of well-controlled trials that compare multimodal treatment (which includes hormones and SRS) to purely psychiatric interventions (Eldh et al. 1997; Green and Fleming 1990; Mate-Kole et al. 1990; Strapko et al. 1999). Although there is far more evidence in favor of utilizing somatic treatments as part of the treatment plan for carefully evaluated persons with GID (e.g., Huang 1995; van Kesteren et al. 1996a), decisions must be made with the awareness that the psychiatrist shares the “moral responsibility for that decision (i.e., whether or not to refer for SRS) with the surgeon who accepts that recommendation” (P. Walker et al. 1985, p. 84). The decision to withhold somatic treatments carries with it a significant risk that must also be taken into consideration (Abramowitz 1986; G. R. Brown 1988a). For example, the incidence of suicidal behavior and genital self-mutilatory behavior appears to be greater in those denied SRS than in those referred for this procedure (Gallarda et al. 1997; Lundstrom 1979; Pauly 1981). Along with psychotic decompensation (Van Putten and Fawzy 1976), postoperative suicide due to regrets over having had SRS is often cited as the most compelling reason to withhold this intervention (Abramowitz 1986; Sorensen 1981a, 1981b). Both of these negative outcomes are actually quite unusual, however, as noted by follow-up studies in countries that have the ability to monitor outcomes in fairly homogeneous societies with centralized health care registries (Landen et al. 1998b; Lundstrom et al. 1984). Given the very low rate of requests for reversal in many recent studies from around the world, it appears that some of the earlier concerns about somatic treatments have not been borne out. The author has not had any cases of requests for reversal, suicidality after SRS, or postoperative psychosis in any patients referred over a 20-year span. Levine (1984; Levine and Shumaker 1983) reported one case of a negative outcome attributed to transition and SRS, although the lack of a temporal linkage (suicide many years after SRS) makes it difficult to establish a causal relationship. In spite of a preponderance of clinical reports supportive of providing somatic treatments in carefully selected patients, clinicians faced with the evaluation and treatment of gender-dysphoric persons must address both countertransference issues and bioethical concerns in the absence of well-controlled, prospective studies of large numbers of patients over lengthy follow-up periods (
Table 70-14). The author has been able to follow most of his patients referred for SRS, and there is no question that multimodal treatment, including SRS, is a lifesaving, medically necessary treatment for some patients with GID.
While the medical community seems to have few qualms about genital surgery on minors (with substituted consent) for inborn biological errors such as ambiguous genitalia conditions and pseudohermaphroditism (Money et al. 1986), the same detached approach has not been applied to altering the anatomy of adults and adolescents with bona fide GID. Patients with severe GID often have pervasive disturbances in their sense of self and are willing to seek out mental health care professionals who are able to confront their own ethical, moral, and spiritual standards in an attempt to provide compassionate care or competent referrals.
An additional bioethical issue that is still actively debated is whether to provide SRS for applicants who are HIV infected. Some persons with GID engage in commercial sex work or are otherwise at increased risk for acquiring bloodborne infections (Bockting et al. 1998; Reback and Lombardi 1999). Indeed, an HIV test is usually part of the required preoperative testing. Speaking to this issue, the HBIGDA adopted a resolution in September 1997 that states: “The availability of sex reassignment surgery should not be denied solely on the basis of blood seropositivity for blood borne infections (such as HIV, hepatitis B or C, etc.)” (HBIGDA 1997). This resolution has not been embraced by all health care providers, however, and it is often difficult for otherwise qualified, appropriate candidates for SRS to receive this treatment due to reticence on the part of some surgeons who perform this procedure (W. J. Meyer 1999). Many state medical licensing boards also make it illegal to discriminate on the basis of HIV seropositivity in the delivery of health care services. However, there remains controversy in surgical circles over the ethical issue of balancing risks to surgeons and the rights of patients referred for this procedure (Pang et al. 1994).
Psychiatrists need to be knowledgeable about the existence of transvestism and GID and the potential treatments available. Although the majority of mental health care practitioners will be asked to evaluate patients with these conditions, few will gain expertise in this limited field of study. However, many of the principles of psychotherapy with these patients are fairly standard therapeutic approaches that can be supplemented by the didactic information in this chapter and elsewhere to assist patients who are suffering a great deal from the tribulations of gender transposition in a largely intolerant society. Competent referrals, especially in the face of unaddressed countertransference about persons with these problems, should be considered if the therapist is unwilling or unable to embark upon a therapeutic journey into poorly charted waters.
Revision date: July 5, 2011
Last revised: by Dave R. Roger, M.D.