As a pediatric neurosurgeon, I have followed the proliferation of surgical procedures for so-called “gender affirmation” with increasing dismay. That public schools now advocate such treatments to young children is particularly alarming. I say this based not on personal opinion but on 35 years of experience as a surgeon and instructor of surgeons.
I teach at a medical school and I am a residency director for neurosurgery in my institution. This means I am in charge of training young neurosurgeons. I emphasize to medical students and resident neurosurgeons that the first and most fundamental responsibility a surgeon has to his patients is to make an appropriate initial decision as to whether to operate and if surgery is in the patient’s best interest.
A well-performed operation is still malpractice (or even assault) if it is not done for valid medical reasons. Operating for marginal (or less) reasons is more common than most of the public realizes — after all, surgeons are paid (quite well) to operate, and they rightly take pride in operating with skill. To be paid handsomely for what you love to do is a privilege, a joy, and a very dangerous temptation. Not every patient who consults a surgeon really needs surgery — often, non-surgical treatment is more effective and less risky.
Thus, when I quiz my students and residents about treatment options for various conditions, I always insist that they begin with a discussion of non-surgical treatments. Honest and conscientious surgeons only do surgery when less invasive options are inadequate and there are clear, justified reasons for surgery. The patient’s health, not the surgeon’s ego, is paramount. This is basic surgical ethics.
So-Called ‘Gender Affirmation’ Surgery Violates Ethics
Surgery for so-called “gender affirmation” or ill-named “sex reassignment” grossly violates the ethical canons I have taught, that were taught to me, and that were taught to all surgeons until very recently. Such surgery entails radical and irreversible operations on normal healthy organs — mastectomy performed on normal breasts, amputation of the normal penis and scrotum (with construction of an opening to imitate a vagina), excision of the normal uterus and ovaries (with construction of a skin-tube to imitate a penis), among other procedures. These procedures are permanently disfiguring and render patients sterile.
What is the ethical basis for such mutilating surgery performed on perfectly healthy organs? It is a basic principle of medical ethics that surgeons are under no obligation to perform surgery on healthy body parts simply because a patient requests it. In fact, a surgeon is generally obligated to refuse to damage a patient’s normal organs or body parts just because the patient wants it done — e.g., it is unethical for a general surgeon to amputate a patient’s normal healthy arm or leg just because the patient requests it (this is a real issue), or remove a patient’s healthy eyes or a healthy part of a patient’s brain, simply because of a patient’s request. There are patients who suffer greatly from Body Integrity Image Disorder, but it is a psychiatric condition, not a surgical condition. Surgical mutilation is not a treatment for psychiatric illness.
Patients with gender dysphoria obviously share much in common with patients with Body Integrity Image Disorder — it may reasonably be understood as a variant of it. Under what circumstances are radical and permanent surgical procedures justified for these patients?
Mental Not Physical Illness
To consider the ethics of surgical treatment for gender dysphoria, I note that these patients are mentally ill. I don’t mean this term in a derogatory sense. I mean it in a medical sense. Patients presenting to a physician for gender dysphoria are certainly ill, in that they are seeking medical help. If they were not ill, they wouldn’t be going to a doctor. And gender dysphoria is a mental, rather than physical illness, because the sexual organs of people with gender dysphoria are functioning normally. There is nothing physically wrong with the penis and testicles of a man who claims to be a woman, or with the uterus and ovaries of a woman who purports to be a man. The illness is mental — the patient does not feel like his or her sex and does not want to be his or her sex. This of course can cause great suffering — it is a real illness — but the suffering is mental, not physical.
The primary justification for radical medical and surgical “treatment” of gender dysphoria is that it reduces the risk of suicide, but this is not supported by the evidence. Furthermore, the assertion, “I’m going to kill myself if doctors don’t mutilate my body,” emphasizes the psychiatric, rather than physical, nature of gender dysphoria illness. There are well-established treatments for suicidal ideation, none of which entail the destruction of normal body parts by hormonal castration or surgical mutilation.
Gender dysphoria is a psychiatric illness, and should be treated by psychiatric therapy, not by hormones or by scalpels. It is to the great discredit of the medical profession that we perform and sanction these radical operations. Surgery for gender dysphoria is profoundly unethical according to generally accepted standards of surgical practice. Surgeons should not deliberately destroy normal organs or body parts.
Patients with gender dysphoria have a psychiatric illness, and our efforts at treatment of this condition should be directed to the psychiatric issues involved, for which there are good and established principles of care. It is to the psychiatric care and social support of people with gender dysphoria that our resources should be devoted.
Dr. Michael Egnor is a professor of neurosurgery and pediatrics at the Renaissance School of Medicine in Stony Brook University, New York.
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