In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?
Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.
These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.
Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.
The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.
The Money Perspective
Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.
Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.
Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).
Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.
Adult Reassignment Surgery Motivation
Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.
In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.
McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.
If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.
To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.
Adult Reassignment Results
Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman (Tootsie). Diligent as the actor was in his preparation, his character looked masculine.
For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”
According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:
“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.
Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.
What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.
McHugh's views are associated with the religious right-wing that has lost ground in this area.
Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.
Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).
Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.
The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).
All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”
1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.
2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.
3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden. Plos One.