🇬🇧 The Medical Ethics of ‘Gender Confirmation’ Surgery

By Heather Brunskell Evans

Most plastic surgeons who carry out ‘sex re-assignment’ procedures such as mastectomies, oophorectomies, and phalloplasty rest easy in their beds. They can do so because their medical ethics – ‘first do no harm’ – are based on the following foundational pre-suppositions which are rarely, if ever, questioned:

  • Firstly, the patient is an adult who actively wants surgery

  • Secondly, the patient has undergone a thorough mental health or psychiatric assessment which has concluded she or he will benefit psychologically from surgery.

  • Thirdly, the incidents of regret are minimal. For example, a research study by plastic and reconstructive surgeons Bustos et al published in 2021 has carried what it describes a systematic review of several databases and estimates that only 1% of adults regret ‘gender-affirming surgery.

In this presentation, I advise those of you who carry out ‘sex-reassignment surgery’ to reflect on these pre-suppositions. I will take each one in turn and demonstrate that below the surface of each there is a complex and troubling set of issues that urgently need addressing.

Firstly, the patient’s will for surgery needs to be put into the context of the sociological and political context in which that will is incited and realised. In the past 10 years, ‘sex re-assignment’ surgery has been increasingly normalized in North America, Western Europe, Australia, New Zealand, and the United Kingdom. The rationale is broadly similar in each country. A minority rights paradigm underpinned by postmodern theory, in particular queer theory, has influenced public policy, the education of paediatricians, endocrinologists, and mental health professionals. In this view, gender identity is inherent but biological sex (the binary categories of male and female) is socially constructed.

Although this postmodern, queer view of sex and gender has no scientific basis it is a discourse in which ‘sex re-assignment’ surgeons unwittingly (or in some cases wittingly) participate. But as you know, biological sex is a fixed aspect of human nature; by contrast, gender is the social and psychological roles expected of the sexes. When plastic surgeons carry out what is now fashionably called ‘gender confirmation’ surgery what you are confirming is a social construct – a sex-role stereotype of what it means to be a woman or a man. The moral question for plastic surgeons thus becomes whether in facilitating the individual to conform to what it means to be a woman or a man, and by helping them attempt to change their sexed bodies to appear as the opposite sex, you are behaving ethically.

Scott Newgent, a female to male 48-year-old ‘trans man’ who began a medical journey six years ago when she was a 42-year-old lesbian describes the devastating lasting consequences of phalloplasty for which her surgeon did not prepare her or convey the true reality. Newgent willed to be male and thus consented to this treatment. Reflecting on the permanent, painful debilitation of the arm from which the flesh was harvested for a faux penis Newgent describes phalloplasty as “like the wild, wild west of surgery”.

Secondly, the issue of psychiatric assessment needs to be addressed. Plastic surgeons have a lack of thoughtfulness and curiosity about patients who identify as ‘trans’, outsourcing questions about the psychological state of the patient to the psychiatrist. But the psychiatrist is merely ruling out evidence of any major psychoses as the root of the person’s decision to undergo surgery, and ‘allowing’ the surgeons to proceed. The will to change sex is the one area where psychiatrists do not think in any in-depth way and turn a blind eye to the possible psychological causes for fear of being accused of conversion therapy. Psychiatrists adopt a non-analytic affirmative approach, yet affirmation has arisen out of identity politics and trans activism, not medicine. As such, there is a mutual evasion of responsibility shared by psychiatrists and plastic surgeons, as well as the unacknowledged participation in the ideological project in which the patient herself is steeped.

Thirdly, if plastic surgeons think about it at all, they are informed that regret is extremely low. But this is a complete fiction. No one knows what the regret rate actually is, and the low-rate results of the study to which I previously referred arise from the lack of any information being collected on the latest cohort of people undergoing surgery. The technological advances in surgery have created the demand for sex reassignment, not the other way around. Historically, it was men who since the mid 20th century have wanted sex-reassignment surgeries and the numbers were small. Currently men are largely spurning genital surgery because their ‘felt’ experience of being female is, according to postmodern queer politics and increasingly the law, sufficient to claim that they are women. It is adolescent girls in their droves who have been seeking medical intervention but who are now regretting surgical ‘sex re-assignment’.

The consciousness has arisen between young women who belong to expanding detransitioner networks that they have been collectively facilitated to divorce themselves from their female bodies. As adolescents, they experienced a sense of discomfort or rejection of their female sex. They fantasised this would be sorted out by changing sex, egged on by social media sites that glamorise female to male ‘sex change’ and which describe them as heroes at the vanguard of progressive politics. In some cases, there is an initial period of euphoria after surgery, but sometimes young women’s immediate experience is of grief for lost organs. They realise the original sense of body dysmorphia persists, only now in a body that is irreversibly changed.

The personal stories of individual detransitioners can be mapped onto the ideological narratives of our culture about what it means to be female or male. The voices of detransitioned women matter not only therefore as an indictment of the medical industry, plastic surgeons, and psychiatry but as a warning that in our sexualised culture ‘femininity’ bears symbolic and political meaning. One detransitioner asks, “What do the voices of detransitioned women say”? “We say the blame rests on lesbophobia and a queer theory which glamorizes disembodiment … on mental illness … [and] a crime that was done to us”.

An examination of ‘transgender’ health care reveals it is rarely expert, evidenced-based, or objective but on the contrary, is highly politicized and controversial and driven by trans activist lobby groups. If you are not persuaded that in carrying out sex-reassignment surgery you perpetrate harm, then I suggest you desist by turning to the issue of the lawsuits that may be coming your way in the not-too-distant future. In Britain, the successful case against the Tavistock and Portman NHS Hospital Trust brought by the detransitioner Keira Bell might be the forerunner of lawsuits against private medicine and individual surgeons. Young women are waking up to the fact that that they have beards, deep voices, various mutilations of their bodies, and that they are infertile. They are building up an evidence base of the harms that were perpetrated on them. They are asking the grown-ups: “How did you let this happen?”

In conclusion, I leave you with the voice of Olivia, a detransitioned German woman in her early twenties. She started breast-binding at 18, saw a psychiatrist at 19, took testosterone a month after her 20th birthday, and had a mastectomy, hysterectomy, and oophorectomy by the time she was 23. Mourning the loss of her breasts and her fertility Olivia asks: “What are the surgeons doing calling this … gender-affirming health care”? “These surgeons … should be in prison for doing this.” Medical intervention “does not make you less female ... It’s not a sex change, its castration”.

The paper “The Medical Ethics of ‘Gender Confirmation’” was given at the Plastic Surgery and Aesthetic Practices 4th International Conference (September 06,202)

Heather Brunskell- Evans is a Philosopher/Foucault scholar. Founder of the WHRC @whrcuk and co-author of Declaration on Women's Sex-Based Rights. Book: Transgender Body Politics (2020) United Kingdomheather-brunskell-evans.co.uk

Twitter: @brunskellevans