Sexual Reasignement 2023 Updated Version PDF

CHANGING OF SEX DISORDERS OF SEX DEVELOPMENT Disorders of sex development A 2004 consensus guidelines workshop held in Chicago resolved that the use of the term ‘intersex’ should be abandoned and replaced with a new term, ‘disorders of sex development’ or DSD. Garry L.Warne....

CHANGING OF SEX DISORDERS OF SEX DEVELOPMENT Disorders of sex development A 2004 consensus guidelines workshop held in Chicago resolved that the use of the term ‘intersex’ should be abandoned and replaced with a new term, ‘disorders of sex development’ or DSD. Garry L.Warne. Pediatric Urology Book. http://www.pediatricurologybook.com/endocrinology.html Disorders of sex development The workshop defined DSDs as congenital conditions in which gonadal, anatomical or chromosomal sex is atypical. Terminology was revised, removing a number of terms that were considered pejorative (e.g male and female pseudohermaphroditism, testicular feminization, adrenogenital syndrome, true hermaphroditism, XX male syndrome, sex reversal) and introducing a new classification based on karyotype, the type of gonad, and the underlying functional defect, when known. Disorders of sex development The benefits of the new diagnostic terms are that they are neutral, descriptive and objective, making them more useful to clinicians when explaining a DSD to the parents of a child or at a later stage, to the patient. Some conditions, such as Turner syndrome and Klinefelter syndrome, which were not previously thought of as intersex conditions, are now redefined as DSD because of the sex chromosome abnormality. Human Chromosomal Aneuploids Sex Chromosome Aneuploids Turner Syndrome 45, XO Sterile female Triplo-X 47, XXX Fertile female Klinefelter Syndrome 47, XXY Sterile male XYY Syndrome 47, XYY Fertile male Human Sex Chromosome Abnormality Turner Syndrome XO One copy of X No second sex chromosome How can Turner Syndrome occur? Eg. Egg with 0 copies of X (22 chromosomes) +Sperm with 1 copy of X (23 chromosomes) = Embryo with 1 copy of X (45 chromosomes) Turner syndrome Most common abnormality in early abortion Female, short stature, primary amenorrhea, sterility, spares hair and underdeveloped breast Neonatal: wide spaced nipple, lymphedema , shield chest, Coarctation of the aorta Continue Turner syndrome Normal IQ scale with difficulty in spatial orientation such as map Present with short stature or delay sex maturation Hormonal therapy Karyotype for Turner’s Syndrome  Klinefelter syndrome ▪99% infertility(blocked spermatogenesis) ▪Feminisation ▪ 47 XXY in 80% and mosaic in 20% ▪IQ is 98 (normal) with mild decrease in verbal IQ ▪gynecomastia ▪decrease libido may improve with testesterone, XXY Frequency: 1 in 1000 boys Ethical framework for decision making Decisions about performing surgery to alter the appearance of the genitalia or to remove gonadal tissue have profound implications for the person concerned and they often need to be made long before it is possible to discern the person’s gender identity. Ethical framework for decision making The validity of parental consent for such procedures is being challenged and some advocates argue that a decision to operate on an infant with DSD should require authorization from a court of law. Even if this were to become the accepted practice, the ethical issues would remain. Gillam LH, Hewitt JK, Warne GL. Ethical principles for the management of infants with disorders of sex development. Horm. Res. Paediatr. 2010; 74: 412-8. Ethical framework for decision making The treatment that would be in the best interests of the child would need to fulfil six ethical principles: 1. Minimization of physical harm to the child 2. Minimization of psycho-social harm to the child 3. Maximizing the chance of fertility 4. Maximizing opportunities for satisfying sexual relations, if desired 5. Keeping options open for the future 6. Respecting the wishes and beliefs of the parents Ethical framework for decision making In all these cases, there is a biological cause, which is why both surgical interventions and hormone therapy are used, not to change the sex but to correct the sex. Therefore, there is no ethical problem with this. Changing terminology Until the middle of the 20th century, the difference between man and woman was clear to the simple observer of reality and to the scientist: the former knows and sees the different forms of man and woman and that children are born by a woman; the latter also knows that the secondary (sexual) characteristics of a woman's body are due to the action of oestrogen and that of a man's to the effect of testosterone; and the scientist understands this effect, which begins in the intrauterine period of the baby's development, with particular precision at the level of the cellular biochemical process. Changing terminology At the Beijing Women's Conference in 1995, the common English word for "sex" was replaced by "gender", under the influence of organizations representing women's and sexual minority movements. When delegates from pro-life countries questioned the use of this term, the final conference document reflected a compromise solution to the debate: the term was retained without being defined. The term "gender" was not defined in the text. Changing terminology In some countries, such as Africa, the English version of the word "gender" was even more favourable than the word "sex": the latter was linked to the breakdown of moral norms in the Western world after the sexual revolution of the 1960s. The participants were left with the impression that the word "gender" is only synonymous with "sex". Changing terminology However, subsequent documents from influential international institutions did not avoid to define the term 'gender' and 'gender identity'. The definition used in the Yogyakarta Principles, developed by the ideologues of gender theory, which states that: „Gender identity is understood to refer to each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms“. Glossary Sex at Birth Infants are assigned a sex at birth, “male” or “female,” based on the appearance of their external anatomy, and an M or an F is written on the birth certificate (boy or girl is born). Transgender An adjective to describe people whose gender identity differs from the sex they were assigned at birth. Transgender Man A man who was assigned female at birth may use this term to describe himself Transgender Woman A woman who was assigned male at birth may use this term to describe herself. Glossary Transsexual An older term that originated in the medical and psychological communities. As the gay and lesbian community rejected homosexual and replaced it with gay and lesbian, the transgender community rejected transsexual and replaced it with transgender. Some people within the trans community may still call themselves transsexual. Do not use transsexual to describe a person unless it is a word they use to describe themself. Glossary Cisgender An adjective used to describe people who are not transgender. “Cis-” is a Latin prefix meaning “on the same side as,” and is therefore an antonym of “trans-.” A cisgender person is a person whose gender identity is aligned with the sex they were assigned at birth. Currently, cisgender is a word not widely understood by most people, however, it is commonly used by younger people and transgender people.  The phenomenon of transsexualism Although transsexualism has deep historical, cultural and anthropological roots, it was not until 1980 that it was formally recognized by the American Psychiatric Association as a serious emotional disorder. ICD - 10 The ICD - 10 code F64 is used to code Classification of transsexual people The classification of transsexual people and people with other gender atypicalities has been done since the mid- 1960s.  ICD - 11 The United States is expected to adopt the ICD-11 in 2025. 17 - Conditions related to sexual health International Classification of Diseases for Mortality and Morbidity Statistics, 11th Revision, v2023-01 sections/codes in this chapter Sexual dysfunctions (HA00-HA0Z) Sexual pain disorders (HA20-HA2Z) Aetiological considerations in sexual dysfunctions and sexual pain disorders (HA40) Gender incongruence (HA60-HA6Z) Other specified conditions related to sexual health (HA8Y) Conditions related to sexual health, unspecified (HA8Z) ICD - 11 Gender incongruence 17 Conditions related to sexual health Description Gender incongruence is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group. ICD - 11 sections/codes in this section (HA60-HA6Z) Gender incongruence of adolescence or adulthood (HA60) Gender incongruence of childhood (HA61) Gender incongruence, unspecified (HA6Z) Historical remarks The term “transsexual” appears in the literature in 1949 and it was not until 1966 that it was accorded clinical status by Benjamin whose pioneering work The Transsexual Phenomenon provided the first textbook on transsexualism. In this sense the clinical disorder of transsexualism is a recent phenomenon. Only then scientifical disscusions on transsexualism started. A kind of confusion regarding genital identity is the situation where individuals anatomically are clearly male or female, but feel, and indeed are convinced, that in essence they belong to the opposite gender from that which their anatomy would signify. DSM - V According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V, the following criteria must be observed for a diagnosis of transsexualism: DSM - V A sense of discomfort and inappropriateness about one’s anatomic sex. A wish to be rid of one’s own genitals and to live as a member of the other sex. The disturbance has been continuous ( not limited to periods of stress ) for at least two years. The absence of physical intersex or genetic abnormality. Not due to another mental disorder such as schizophrenia. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition DSM-5) Washington CD: American Psychiatric Publishing; 2013. Gender dysphoria syndrome These criteria reflect the so called gender dysphoria syndrome, that is, an anxiety, sometimes reaching suicidal depression, as the result of the obsessive feeling that one’s “real” sex is the opposite of one’s phenotypic sex. DSM - V Some transgender advocates believe the inclusion of Gender Dysphoria in the DSM is necessary in order to obtain health insurance that covers the medically necessary treatment recommended for transgender people. Do not characterize being transgender as a mental disorder. Neither the American Psychiatric Association nor the American Psychological Association consider being transgender a “mental disorder.” Incidence in the general population According to the most commonly cited epidemiological indicators, the prevalence of gender dysphoria syndrome in adults ranges from 1:10 000 to 1:30 000 in males and from 1:40 000 to 1:100 000 in females. There could be 6-18 adolescent boys with gender dysphoria and 2-4 adolescent girls in Finland (Finland has twice the population of Lithuania). Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder. Int J Transgenderism. 2009;11:8–18. doi: 10.1080/15532730902799946. The literature distinguishes the person with gender dysphoria syndrome from both: The transvestite (a person who dresses in clothes primarily associated with the opposite sex typically used of a man) The homosexual ( since they are not homosexually attracted to the members of the sex to which they feel that they really belong ). The hermaphrodite (ambivalent sexual development). The history of sexual reassignement surgery Enjar-Lili, 1930 m. Rudolf-Dorchen, 1932 m Germany before the Nazi regime In 1910, Dr Magnus Hirschfeld describes the phenomenon of transsexuality in his book Die Transvestiten. He makes a distinction between transsexuality and transvestitism. In 1919, Dr. Magnus Hirschfeld establishes the world's first sexological research institute in Berlin. In 1920, Dr. Hirschfeld refers his first patient to the surgeon Dr. Felix Abraham for consultation. Germany before the Nazi regime In 1921, private surgeon Gohrbandt performs the first surgical interventions. In 1930, a paper on transsexualism is read at the World Congress of Psychotherapists. The scientific debate begins. Today Transgender people can be treated with gender-affirming hormones to induce desired physical changes. Transgender women (male sex assigned at birth, female gender identity) are usually treated with antiandrogens and oestrogens to induce feminisation. To induce masculinisation, transgender men (female sex assigned at birth, male gender identity) are usually treated with testosterone. Christel JM de Blok, Chantal M Wiepjes, at al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology, 2021; 9(10): 663 – 670. Today After 1 year of hormone treatment, transgender people can choose gender-affirming surgery as part of their transition. In transgender women, this can include orchiectomy with or without vaginoplasty, breast augmentation, and facial feminisation surgery. In transgender men, this can include mastectomy, removal of uterus with or without ovaries, and phalloplasty. After orchiectomy in transgender women, antiandrogen treatment is ceased. Christel JM de Blok, Chantal M Wiepjes, at al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology, 2021; 9(10): 663 – 670.  Surgery and it’s results The argument of surgeons who undertake sexual reassignment as a remedy for gender dysphoria syndrome is that the victims find no relief in other therapies, and insist on surgery even to the point of threatening suicide. But it has not been proved yet that the cause of gender dysphoria syndrome is biological, although this theory has been suggested by some experts. No such cause is evident at the genotypic or phenotypic level, and as the evidence shows the reason transsexuals believe that they have “a soul different from body” is caused by some development accidents. So the gender ambiguity in question is primarily psychological and should be treated psychotherapeutically. If we take transsexual surgery in direct meaning, the philosophical question of “Can it be done?” precedes the moral question of “Should it be done?” The first question regards what a human sex is and whether anatomical substitutions and plastic redesign plus the synthetic hormonal reinforcement of congruent sex characteristics actually do change the sex of an individual. External genital morphology, internal genital morphology, chromosomal sex, and gender role have commonly been referred to as the determinants of sex. The most significant question here is whether all or some of these elements are determinants of sex or signs of sex. If all of them are signs rather than determinants, changing the signs would not be the same as changing the sex. It is clear that one cannot change one's or another's human karyotype. Genetic scientists acknowledge and insist that one's sex is biologically determined and genetically imprinted by karyotype in each and every nucleated cell of the individual. Science rejects the dogma that male and female embryos develop in identical fashion: there are gender-related differences at the very early stages of human embryos development. Transsexualism cannot and does not bring about any change in this bio-genetic attribute of the particular individual It is impossible to change the sex of an individual by simply removing the external sex organs of one sex and seeking to construct a reasonable facsimile of some of the sex organs of the opposite sex as well as trying to complement the surgery by substituting hormonal adjustment. Hence it is morally unacceptable to make this artificial substitution attempting to help an individual to adjust to a psychological aberration for which psychiatry sometimes has no adequate cure. Surgery cannot be called treatment in the case of transsexualism. The principle of totality teaches that a functional part of the body must not be removed, destroyed or otherwise incapacitated unless necessary to preserve the health or wellbeing of the person as a whole. Hence, changing radically one’s sexual anatomy and destroying the fertility by removing healthy organs is an unjustified mutilation and violation of the principle of totality. So many experts believe that the sacrifice of bodily integrity in an effort to achieve a degree of mental stability is not justified. Surgery in this case is not even at best palliative because normal genital tissue is mutilated and destroyed which not only renders the patient irreversibly infertile, but leaves the problem unresolved and makes any alternative approach impossible. The destroying of natural fertility leads to medico – legal consequences. Castration not only renders infertility and incapacity conferring invalidity status but increases the danger of atherosclerosis, myocardial infarction and stroke. It is important to emphasize that the sexual reassignment has an irrevocable character which shows once more the inadmissibility of such operations. There is a quite large number of individuals undergoing the sexual reassignment operations later want to return to their former state. In Sweden having analysed sexual reassignment experience from 1965 to 1995 it became clear that as much as 136 individuals have undergone the surgery. Out of this number only 55 % of males turned into females and 34 % of females turned into males declared to be completely satisfied after the sexual reassignment. Plg. Eldh J., Berg A., Gustafsson M. Long – term Follow up After Sex – reassignment Surgery // Scandinavian Journal of Plastic and Reconstructive Surgery, 1997, Nr. 31 ( 1 ), 39 – 45. When this type of surgery was first introduced there were enthusiastic reports of its success, however the latest studies evaluating the outcome of transsexual surgery showed that surgery offers no advantage over psychotherapy. It was the reason why John Hopkins University announced the suspension of its program in this field. Plg. Meyer J. K. Sex Reassignment: Follow Up // Archives of General Psychiatry, August 1979, Nr. 36 ( 9 ), 1010 – 1015. Plg. Jacobs S. Determination of Medical Necessity: Medical Funding for Sex Reassignement Surgery // Case Western Reserve Law Review, 1980, vol. 31, 179. Cost of Surgery Surgery can be prohibitively expensive for many transsexual individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. It is somewhat more expensive to transition from male to female than from female to male. Health insurance sometimes covers a portion of the expenses. Consequences of sex reassignment A 2011 study at the Karolinska Institute in Sweden followed 324 people after sex reassignment surgery for 30 years. ▪The study showed that around 10 years after the operations, psychological problems started to increase. ▪The most shocking finding was that the suicide rate was 20 times higher among these individuals than in the general population.  Consequences of sex reassignment This disturbing fact has no one clear explanation, but researchers link it to an increasing sense of isolation with ageing after surgical intervention. High suicide rates are an important signal to reconsider sex reassignment surgery. http://online.wsj.com/articles/paul-mchugh-transgender- surgery-isnt-the-solution-1402615120,  Gender reassignment for minors In Finland, adolescents seeking gender reassignment have various psychopathologies. ▪More than two thirds have been bullied before the onset of gender dysphoria. ▪More than 75% (35 out of 47) have been treated by psychotherapists for other reasons: 64% for depression 53% for suicidal thoughts and self-harm. Riittakerttu K., at all. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development/ Child Adolesc Psychiatry Ment Health, 2015; 9:9.  Problems associated with hormone therapy Many medical, ethical and even legal problems arise from the hormone therapy applied to transsexual patients. It is known that the transsexual individuals have a normal hormone balance as well as the normal function of sex glands. Pharmacovigilance Most of the laws legalising sex reassignment came at a time when pharmacovigilance was still emerging as a science, and pharmacovigilance centres were only a few countries in the world. A medicine is an active substance intended to treat a disease or to improve impaired bodily functions. Rational use of medicines according to WHO: Medicines are used rationally when: "patients receive medicines according to their clinical needs, in doses individually tailored to their needs, used for a sufficient period of time, and available at the lowest cost to them and to society as a whole". Promoting rational use of medicines: core components. WHO policy perspectives on medicines. September 2002, WHO, Geneva, P.1. Therefore, the use of opposite-sex hormones is not only misleading but also fails to meet the basic criterion of rational use of medicines: ▪The desire for gender reassignment in a genetically determined and physiologically perfectly healthy man or woman cannot be pathophysiologically recognised as a clinical need; ▪The use of medicines, including hormonal products, without ascertaining their safety and for indications that have not been clinically tested and validated (off-label use) is in itself an inappropriate, medically unjustifiable and irresponsible use of medicinal substances.  Pharmacovigilance The use of hormones of the opposite sex, where the law permits the alteration of a person's gender identity code, is not only biologically artificial, but also cannot be equated with the use of hormone therapy on persons of the same sex from birth, since what is desirable for the latter is biologically alien, inappropriate and dangerous for the former. Use of hormones for hormone replacement therapy (HRT) HRT using either oestrogen alone or a combination of oestrogen and progesterone is no longer recommended for women. EMEA Public statement on recent publications regarding hormone replacement therapy. London, 3 December 2003 EMEA/330065/03; www.emea.eu.int This provision takes into account: ◦Women’s Health Initiative (WHI) Trial; Chlebowski RT, Hendrix SL, Langer RD et al. JAMA, 2003; 289(24):3243- 3253. ◦Million Women Study; Million Women Study Collaborators. The Lancet, 2003;362:419-27. Million Women Study stated: HRT increases the risk of breast cancer; There is no evidence that HRT reduces cardiovascular disease. There are studies showing an increased risk of myocardial infarction and venous thrombosis, especially in the first year of use. Million Women Study Collaborators. The Lancet 2003;362:419-27. Hormonal therapy There is not enough data on how hormone therapy affects men's bodies, nor has the effect of therapy on the development of prostate cancer and thrombus formation been evaluated.  ▪ Consequences of long-term use In retrospective cohort study done in the gender identity clinic of the Amsterdam University Medical Centres people were included if they had started hormone treatment between 1972 and 2018. 4568 transgender people were included in the study, 2927 transgender women and 1641 transgender men. The median age at the start of hormone treatment was 30 years. Christel JM de Blok, Chantal M Wiepjes, at al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology, 2021; 9(10): 663 – 670. Consequences of long-term use This study showed an approximate two-fold increase in mortality risk in transgender people compared with people from the general population. This risk did not decrease over the five decades studied. Increased mortality in transgender women showed high risks of death because of cardiovascular disease, HIV-related disease, lung cancer, and suicide. In transgender men, the observed increased mortality compared with general population women was mainly attributed to non-natural causes of death. Christel JM de Blok, Chantal M Wiepjes, at al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology, 2021; 9(10): 663 – 670. Conclusions All the above mentioned investigations show that the sexual reassignment surgery and large dozes of the opposite gender hormones cannot be neither justified nor considered an ade - quate medical treatment. Conclusions The gender dysphoria syndrome in fact rests on the psychological level. Since the gender ambiguity in question is primarily a psychological problem it should be treated psychotherapeutically. Conclusions Sexual reassignment is biologically impossible. People who have undergone sexual reassignment have not changed from male to female and vice versa. They have only become more feminine men and more masculine women (transgender women are often diagnosed with prostate cancer, transgender men sometimes giving birth to children). Dr. McHugh, former psychiatrist in chief at Johns Hopkins Hospital, is the author of "Try to Remember: Psychiatry's Clash Over Meaning, Memory, and Mind" (Dana Press, 2008).