Course:FMST/4

Wiki Problem Statement

You are the ten owners of Sexual Consultants Ltd. The government has contracted with your company to provide them with background research and a proposed policy statement on a very contentious issue (refer to below). The government wants a position paper with background information and a clear policy statement so they can formulate appropriate legislation. In the paper, you are to provide the government with a clear and concise recommendation of how they should proceed.Some physicians and psychologists treating adolescent transsexuals argue that the best treatment would be gender-reassignment surgery before puberty. Concise 1000 words. This should include (i) a statement of the problem, (ii) a brief review of the medical and psychological literature pertaining to the issue, (iii) a statement of the political “risks” as you see them, (iv) your recommendation, and (v) any limitations to the application of the policy, including MSP coverage, age considerations, parental consultation requirements, etc.Remember, this is a cooperative project. The group mark for an individual will be adjusted by a peer recommendation to Dr. Hannah reflecting the effort and contribution made by each member of your group.

FINAL WORK

A statement of the problem

At Sexual Consultants Ltd., we believe that adolescent transsexuals should be given the opportunity to be treated with gender-reassignment surgery before puberty. Due to the absence of secondary sex characteristics, less reconstructive surgery would be required and the psychological conflict many individuals experience after puberty and surgery could be avoided. The decision to undergo this procedure would require extensive screening to ensure candidates meet specific criteria. Special precautions and additional qualifications by health professionals are vital. Education on the risks and consequences would be mandatory, with assessment and counselling by a trained professional before and after treatment. Gender-reassignment surgery before puberty may not be suited for all adolescents, but it is an option that should be available.

A brief review of the medical and psychological literature

SUPPORT FOR SRS PRE-PUBERTY

Smith, van Goozen, and Cohen-Kettenis (2001) conducted a study on Adolescents (aged 13.7-20.2 pretest, and 15.7-26.2 posttest) with Gender Identity Disorder (GID) who were accepted or rejected for Sex Reassignment Surgery. They found the following results: GID disappeared for transsexual adolescents after treatment; postoperatively they were more satisfied with their primary and secondary sexual characteristics than at pretest. Treatment subjects demonstrated superior functioning both socially and psychologically. Subjects rejected for surgery functioned worse at follow-up than those who had undergone surgery. Treatment subjects received hormone treatment before reaching their last pubertal phase, which accounts for easy transition into their new role. These results were compared with results from an adult Dutch transsexual study (Kuiper and Cohen-Kettenis, 1988): adolescents in this study demonstrated better overall functioning than adults in the Dutch study, this is most often attributed to adults receiving late treatment, and less support from their environment.

Cohen-Kettenis & van Goozen (1997) conducted a follow-up study on Adolescent Transsexuals who had undergone SRS 1-5 years ago. Results of posttests indicated the following: SRS was therapeutic and beneficial; no subjects expressed feelings of regret about their decision to undergo SRS; there was a majority satisfaction with general appearance; interviewer's noted difficulty discerning signs of the biological sex; satisfaction with primary and secondary sexual characteristics post treatment; 89% felt accepted and supported in new gender role, 11% felt accepted by several people; no treatment subjects had been approached by strangers as if members of the opposite sex; post treatment increase in extroversion, indicating subjects were more active toward social contacts.

SUPPORT FOR PROHIBITING SRS PRE-PUBERTY

Although a number of research studies indicate that transsexuals who undergo SRS before puberty tend to experience more successful outcomes in terms of subjective well-being than those who undergo SRS in adulthood, many researchers argue that SRS should not be undertaken prior to adulthood for the following reasons: Delemarre-van de Waal and Cohen-Kettenis (2006) conclude that “clinicians are usually reluctant to start the SR procedure before adulthood. They assume that adolescents are not able to make a sensible decision about something as drastic as SR. They fear that the risk of postoperative regrets will be high and the treatment will have unfavorable physical, psychological or social consequences.” Cohen-Kettenis and Van Goosen (1997) conclude that “in most countries it is common practice not to start the actual SRS procedure earlier than 18 or even 21 years of age.” This is because “adolescence is a phase in which many identities are developed. Professionals fear that experimenting with certain aspects of gender, such as gender role behavior, will lead adolescents to conclude that they have a gender identity problem and that they will, as a result, wrongly seek a medical means of resolving their confusion. The chance of making the wrong diagnosis and the consequent risk of postoperative regret is therefore felt to be higher in adolescents than in adults, as a consequence of the developmental phase itself.”

A statement of the political “risks” as you see them

In the debate of enacting legislation to perform gender reassignment surgeries for adolescents, several political risks arise which effectively limit the likelihood of such legislation. The political risks of enacting legislation to support gender reassignment in adolescents is first categorized by whether or not such an issue can be considered a civil rights issue. Arguments from both sides of this issue are often seen as nonsensical by their opponents, or the only palpable viewpoint to those who support the argument. Other than moral or religious reasons for protesting such an issue, the lack of universal support over proposed legislation can cause negative political effects if lobbyists or taxpayers begin measures to oppose legislation. Though there are measures to limit lobbyist contributions to officials and legislation, by the sheer controversial nature of the topic, it is reasonable to conclude that many different lobbyist groups, churches, and even concerned citizens will rally in protest. Also, any controversial legislation may incite lobbyist groups to drop their support of a given party, thus affecting their ability to enact social change in other avenues. Any such legislation is therefore a political risk for the official’s political career if they propose or enact legislation. Combined with the moral issues, the cost of such procedures and for the rehabilitation after would either force an increase in taxes, or shift resources away from a different issue to this one.

MPP France Gélinas argues that the rehabilitation process is integral to the success of the program (Gibson, J., 2007), but with such additional costs on top of the surgery, it may be hard to convince conservatives that this socialist approach to paying for this surgery, and the rehabilitation afterwards, is in the interest of the general public. This specifically is where the “cosmetic vs medical” procedure argument becomes especially relevant. In the European case of P. v. S. and Cornwall Count Council, it was ruled that any discrimination towards people seeking treatment is sexual discrimination, and that surgery is necessary to stabilize the person, which essentially ruled that such a surgery is not cosmetic (Stychin, 1997). Though, even with such a ruling, there is still not universal support over the necessity of gender reassignment surgery, which means it will be the politician’s responsibility to declare that such a surgery is necessary, which may be difficult in this political climate and social climate where different LGBT rights are still controversial.

In discussing transsexual surgery in Canada, it is very important to take a look at the potential political risk that would result from conflicts between the values. Canada is widely known as a multicultural society and the phenomenon witnessed in the last century has been a dramatic increase in a number of Asian cultures and their associated values. Chinese comprise a large proportion (4.31% in 2006, www.wikipedia.org), which has been influential in many provinces, including BC. Certainly, it is difficult to generalize the nation; however, it is still important to point out the historic background and value of the population if it could create conflict with the early transsexual surgery in Canada.

For example, Ruan, who was 20-years-old in 1988, was the first Chinese to have transsexual surgery to become a woman. It was adjustment surgery to correct “her” gender the what she had supposed it to be for a long time. However, as soon as she recovered, she had to move to the US where attitudes towards transsexuals were more accepting.(Fang-Fu, Ruan, and Vern L. Bullough, 1988) Although it cannot be said that the prior historical evidence of Chinese attitude can determine modern trend of the particular Asian criticism, we still need to acknowledge the potential clash of values that could result from the surgery. Truly, discrimination to sexual minorities is not unusual in Asian culture. For example, in Taiwan, in 2003, religious and conservative NGOs filed against Josephine Ho, researcher in the Center for the Study of Sexualities in National Central University, who supported marginalized sexual minorities in the country, for "propagating obscenities that corrupt traditional values".(Ping, Wang, 2004) Here, it is interesting to point out that even the freedom of expression was not truly supported in regards to sexual minorities, especially in Asian culture. Although it does not necessarily mean that every ethnic minority, including those have undergone sexual re-assignment surgery, would face discrimination in Canada, we should be aware of potential criticizing voices that can rise from any particular culture inevitable in our multicultural society. This does not mean that only Chinese would have critical eyes on our operation; indeed, many Asian nations such as Korean and Japanese, who share the Confucian belief that man and woman has historically fixed social roles, would join to raise voices over the issue. It is important to be aware of this, and expect certain oppression, demonstration or even boycott towards the consulting products from the customers. The government should also prepare to inform the demonstrators of the right of the patient to have surgery for gender-reassignment. Overall, the concerns which arise from morality issues, and issues dealing with tax payer dollars both pose significant political risks in enacting this legislation.

Your recommendation

Based on the articles and discussions our recommendation is to allow for case by case decisions regarding gender reassignment before puberty and in adolescence. We recommended that children and adolescents are required to undergo psychiatric evaluation and live for a minimum of one year as the destination gender without any medical intervention. After this one year period and based on professional medical and psychiatric analysis of their ability to adjust, a recommendation will be provided outlining whether they are ready or not to undergo hormone therapy and surgery. This will provide the ability to reclaim the patients' original gender identity or continue with gender reassignment as appropriate. In order for children to cope with gender transition and reassignment it is recommended that they take part in support groups with other transitioning children and transitioned adults to share coping skills and provide support.

There are currently provisions for gender sensitivity workshops in schools, as documented in "Canadian Guidelines for Sexual Health Education": "Sexuality is a central aspect of being human throughout life and encompasses biological sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.

"Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors''"

"Effective sexual health education maintains an open dialogue that respects individual beliefs. It is sensitive to diverse needs of Canadians irrespective of their gender, sexual orientation, ethnicity, culture and religious backgrounds"Canadian Guidelines for Sexual Health Education

However, as no sexual education program is compulsory, and parents reserve the right to remove their children from class for these lessons, it is likely that those likely to remove their children from such programs are the ones most likely to offend (or at least a part of a demographic who tend to be exclusive and not accepting of differences). For this reason, there is a need to be some compulsory system to be put in place that a) gender sensitivity is actually including in sex education and b) all students are exposed to this in some format - it need not be specific to sexual orientation or gender identity, as we must protect rights to religious freedom, but it must convey that same message of tolerance and inclusion.

Any limitations to the application of the policy

Adult gender-reassignment surgery has been a controversial topic, which is favoured by certain community groups, but opposed by others. Moreover, to introduce adolescent gender-reassignment surgery before puberty into government policies is more likely to be subjected to heated debates. Thus, limitations that hinder the approval of such policy must be addressed early on and be promptly solved.

The first proposed limitation is the age required for an individual to make an autonomous and competent decision. Autonomy simply means “freedom” and thus an individual is said to be autonomous when one makes a decision about the course of his/her own life. From this point of view, it can be argued that everyone has the right to make an autonomous decision. The Infant’s Act is the current law in British Columbia which physicians follow when assessing the age of autonomy and competency. The law states that every individual from birth on is presumed to be competent, where competence is defined as the ability to understand the nature and consequences of the intervention. Furthermore, based on a section of the common law, a mature minor is a person under the age of majority (18 or 19 depending on the province or territory) who is considered to be capable of understanding the scope of their medical risk and the consequences of accepting such intervention. To conclude, an individual who feels strongly about having gender-reassignment surgery, and understands the risks and complications associated before, during and after surgery should not be refused from such intervention. In essence, there are no justifiable reasons to setting a minimum age for adolescents who want to undergo gender-reassignment surgery.

Another major limitation is the issue of parental consent. According to the Canadian common law, parents must act in the best interests of their children. If the health-care provider believes that a parent’s or guardian’s decision to withhold or withdraw gender-reassignment surgery would be in the best interests of the child, then the health-care provider must proceed as the parents’ wish. However, if the health-care provider does not agree with the parent or guardian and finds that the decision made does not act in the best interests of the child, then the provider must contact the appropriate authorities and seek authorization from the state (whether that be child and family services or a court). Much of the parental refusal is subjected to court. In Canada, it is unlikely that minors who understand the nature and consequences of the decision to undergo gender-reassignment surgery will have their wishes refused by the courts. However, if the courts believe that the decision was made under an external influences or the patient is not fully aware of the emotional and physical consequences involved after the surgery, than the court will refuse gender-reassignment surgery and act against the minors' best interests.

For people seeking SRS one of the main concerns is the high cost of the surgery. B.C. provides coverage for male-to-female reassignment surgery. For trans women, BC covers vaginoplasty and, in some cases, breast augmentation. Trans men are funded only for mastectomy and the removal of their reproductive organs, not for the creation of male genitals. BC considers phalloplasty (the creation of a penis by plastic surgery), to be experimental surgery and does not provide coverage for female-to-male surgery not performed in B.C

At the moment no surgeons are doing phalloplasty in B.C. Patients that are looking for phalloplasty should seek surgery in other provinces but then getting the cost of surgery which could be up to $90000 from MSP would be difficult. B.C. health ministry would only pay the physicians' fees at the rate as if the surgery had been performed in B.C., which is substantially less than the amount patients pay. BC medical services plan covers some of the medical care related to SRS but doest not extend to travel or postoperative clinic stays.

Beside the SRS some of the transgenders will need a facial feminization surgery and facial hairemoval, which they desire to be included in the BC health program. Right now, surgeries such as the reshaping of nose and jawbones- which may diminish the look of having experienced puberty in a male body – are not covered at all by BC’s medical services plan.

Most provinces across Canada do not provide coverage for phalloplasty, although Quebec provides coverage in exceptional circumstances approved by the minister of health, and Newfoundland provides coverage on an individual approval basis if a candidate is assessed and recommended by the Clarke Institute. Currently, no province in Canada covers facial feminization surgeries or depilatory methods for trans women.

Another issue would be changing the person's sex in their birth certificate. Sex on a birth certificate issued in BC can be altered if 1) the sex was recorded in error at the time of birth, or 2) the person has undergone SRS. The applicant must provide a certificate from the physician who performed the SRS; evidence that the physician is licensed in the jurisdiction where the surgery was performed; and a certificate from a physician licensed to practise in the jurisdiction where the applicant resides, stating that the person has completed SRS. (The government does not require a specific type of surgery to be performed, but that the physicians certify that the sex has been reassigned according to accepted medical standards.)

REFERENCES

Cohen-Kettenis, PT., & Van Goozen, SHM. (1997) Sex Reassignment of Adolescent Transsexuals: A Follow-up Study. American Academy of Child and Adolescent Psychiatry. 36(2).

Delemarre-van de Waal, HA. and Peggy T Cohen-Kettenis (2006) Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, Vol 155, suppl_1, S131-S137

"Demographics of Canada". www.wikipedia.org

Fang-Fu, Ruan, and Vern L. Bullough, (1988). The First Case of Transsexual Surgery in Mainland China. The Journal of Sex Research, Vol. 25, No. 4, pp. 546-547

Gibson, J., (2007). Ministry of Health to pay for gender reassignment surgery. http://www.northernlife.ca/News/LocalNews.

Ping, Wang, (2004) . The Prosecution of Taiwan Sexuality Researcher and Activist Josephine Ho, Reproductive Health Matters. Vol. 12, No. 23, Sexuality, Right and Social Justice, pp.111-115.

Smith, L. S. Y., VanGoozen, M. H. S., & Cohen-Kettenis, T. P. (2001) Adolescents With Gender Identity Disorder Who Were Accepted or Rejected for Sex Reassignment Surgery: A Prospective Follow-up Study. Journal of American Academy of Child and Adolescent Psychiatry, 40(4).

Stychin, C. F., (1997) Troubling Genders. International Journal of Discrimination and the Law, 2(3), 217-222.

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