Gender reassignment and assisted reproduction

An ethical analysis

Di Brothers1,3, W.C.L. Ford2 and and the University of Bristol Centre for Reproductive Medicine Ethics Advisory Committee

1 University of Bristol Postgraduate School of Education, 8–10 Berkeley Square, Clifton, Bristol BS8, and 2 Division of Obstetrics & Gynaecology, University of Bristol, Bristol BS8, UK


    Introduction
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 Introduction
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An approach for donor insemination (DI) treatment from a couple in which the male partner was a woman who had undergone gender reassignment led us to explore the ethical implications of offering assisted reproduction in such a situation. In doing this, our paramount consideration was that an unborn child should receive good and effective parenting, but we also considered risks to individuals and to society.

Firstly, it is important to define the condition exactly. Gender dysphoria and gender identity disorder are terms used to describe a persistent desire to be of the opposite sex combined with persistent discomfort about one's assigned sex or gender role. The diagnosis requires the absence of physical intersex conditions and the presence of clinically significant distress or impairment of psychological function (American Psychological Association, 1994Go). The condition varies in intensity from mild anxiety which may be managed by occasional cross-dressing, to a deeper confusion where counselling is necessary, or to the profound anxiety of `being in the wrong body'. Only in the more extreme cases is gender reassignment the appropriate treatment (Brown, 1990Go, Schlatterer et al., 1996Go; Cohen-Kettenis and Gooren, 1999Go).

Confusion about sexual identity can be viewed as comprising two distinguishable sub-divisions: (i) where individuals question their core morphological identity (i.e. the gender they were born with) and where the emerging self concept of being male or female is contradicted by their physical characteristics, e.g. `My body is male but I believe myself to be female'; and (ii) where there is confusion around gender identity based on gender role behaviour. `My experience of women and their roles has repulsed me so much that I do not wish to be a woman: I want to be male.'

It is members of the former group (primary) who go on to seek gender reassignment and who, as part of a couple, apply for assisted reproduction. Guidelines for proper management of the condition have been developed (Walker et al., 1995) but the diagnosis of the condition and the assessment of patients for surgical treatment are long and complex (Brown, 1990Go; Schlaterer et al., 1996; Webster, 1998Go; Cohen-Kettenis and Gooren, 1999Go). The following analysis assumes that the prospective patient has been successfully treated by an appropriate specialist.


    Why does the issue arouse ethical considerations?
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 Introduction
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One concern for the well-being of the unborn child would be the mental stability of a parent who is undergoing, or has undergone, such a fundamental change, and whether the root cause lies in psychological disturbance.

There is a complex debate as to the cause of this condition. Can gender dysphoria be labelled a psychiatric disorder, and therefore imply potential mental instability and the need for psychiatric treatment? The discussion surrounding this issue in recent literature seems to offer a parallel with the earlier debate about the roots of homosexuality (Reiche, 1984Go). In both cases we are left with a confusion of psychoanalytic labelling and evidence of the impact of both nature and nurture (Lothstein 1979Go; Cohen-Kettenis and Gooren, 1999Go). There is evidence of associated changes in brain morphology. Post-mortem studies have shown that the bed nucleus of the stria terminalis is of smaller, typically female, size in male to female transsexuals (Zhou et al., 1995Go). Individuals in the primary gender dysphoria category also exhibit a well-documented lifelong deep disorder of core sexual identity not linked to stress (Levine and Lothstein 1981Go). It would seem from this that transexual feelings represent not only a psychological disorder, but also a social phenomenon with roots in possible physiological differences.

This debate illustrates the difficulties involved in labelling the condition of gender identity disorder and how to assess concomitant mental stability. Where gender dysphoria is untreated, then by adulthood there is a strong risk of depression and suicide linked to the struggle to overcome deep-seated desires and to cover up these feelings (Anonymous, 1998Go). But with appropriate treatment there seems to be no special risk of mental disorder or of suicide. Pierre Banzet (Banzet and Revol, 1996Go), a plastic surgeon involved with gender reassignment, considers that with rigorous selection gender reassignment offers the prospect of long-term psychological health. He has described operations on 98 males and 68 females over the past 15 years all of whom were subjected to a thorough diagnosis with a rigid selection system to ensure that the individual had intact reality awareness and stable ego strength. In every case the outcome after surgery was positive. Webster (1998) in her review of relevant literature arrives at a similar conclusion. However, in general female to male transsexuals achieve greater mental stability than male to female transsexuals (De Cuypere et al., 1995Go; Cohen-Kettenis and Gooren, 1999Go). This would need to be taken into account into assessing their suitability for assisted reproduction.

The last and possibly most important question concerns the impact on the child of having a gender reassigned parent. Green (1978) produces evidence to show that the development of sexual identity in children with ages ranging from 3 to 20 years was unaffected by living with parents, one of whom had gender reassignment. Within this group it is interesting to note that some children were aware of the gender change, and, indeed, had been part of the process, whereas others were completely unaware of the difference. In all cases the children showed normal and heterosexual development as measured by best toy, peer group, clothing preferences, vocational aspirations, roles played in fantasy games, and (in older children) romantic crushes, erotic fantasies and inter-personal sexual behaviour. The critical point of interest is not the sexuality of the young, but the absence of confusion over sexual identity and sexuality.

Given the difficulties in attributing psychological or behavioural characteristics to individuals with reassigned genders, the Ethics Committee agreed that reassigned gender in itself should not automatically debar an individual from consideration for assisted reproduction. Individuals with gender identity disorder exhibit the full range of social class, intellectual competence, sexual orientations, and mental stability or illness seen in the general population (Hoenig and Henna, 1978). The issue of gender reassignment must not be allowed to mask any other factor relevant to ethical decision making and the couples should be assessed using the same criteria as heterosexual couples within the overall constraint that the welfare of future children must be the paramount consideration.


    Notes
 
3 To whom correspondence should be addressed Back

This debate was previously published on Webtrack, January 7, 2000


    References
 Top
 Introduction
 Why does the issue...
 References
 
American Psychological Association (1994) Diagnostic and Statistical Manual of Mental Disorders. 4th edn. American Psychiatric Association, Washington DC, USA.

Anonymous (1998) Understanding Gender Dysphoria. MIND Publications, London, UK.

Banzet, P. and Revol, M. (1996) The Surgical Experience. Bull. Acad. Natl Méd., 180, 1395–1402.

Brown, G.R. (1990) A review of clinical approaches to gender dysphoria. J. Clin. Psychiatry, 51, 57–64.[ISI][Medline]

Cohen-Kettenis, P.T. and Gooren, L.J.G. (1999) Transsexualism: A review of etiology, diagnosis and treatment. J. Psychosomatic Res., 46, 315–333.[ISI][Medline]

De Cuypere, G., Jannes, C. and Rubens, R. (1995) Psychosexual functioning of transsexuals in Belgium. Acta Psychiatr. Scand., 91, 180–184.[ISI][Medline]

Green, R. (1978) Sexual Identity of 37 Children raised by Homosexual or Transexual Parents. Am. J. Psychiat., 135, 692–697.[Abstract]

Hoenig, J. and Henna, J.C. (1974) The Nosological Position of Transexualism. Arch. Sex. Behav., 3, 272–287.

Levine, S.B. and Lothstein, L.M. (1981) Transexualism or the Gender Dysphoric Syndrome. J. Sex. Marital Ther., 7, 85–113.[ISI][Medline]

Lothstein, L.M. (1979) Psychodynamics and sociodynamics of gender dysphoric states. Am. J. Psychother., 33, 214–238.[ISI][Medline]

Reiche, R. (1984) Sexuality, identity, transexuality. Beitrage zur Sexualforschung, 59, 51–64.[Medline]

Schlatterer, K., von Werder, K. and Stalla, G.K. (1996) Multistep treatment concept of transsexual patients. Endocrinol. Diabet., 104, 413–419.

Walker, P.A., Berger, C. and Green, R. (1985) Standards of care: the hormonal and surgical reassignment of gender dysphoric patients. Arch. Sex. Behav., 14, 79–90.[ISI][Medline]

Webster, L. (1998) Female to male gender re-assignment. Br. J. Sex. Med., 25, 8–10.

Zhou, J.N., Hofman, M.A., Gooren, L.J.G. and Swaab, D.F. (1995) A sex difference in the human brain and its relation to transsexuality. Nature, 378, 68–70.[ISI][Medline]