Transgender Surgery and Care from the View of Bioethics

Transgender surgery, also referred to as gender reassignment surgery, is associated with the psychiatric disorder called gender identity disorder. However, while there are psychological components attached to desiring this type of surgery because of the disorder, there are also bioethical considerations that present with the issue. Then there are also societal moralities that can be assessed when it comes to gender reassignment surgery. Some of the ethical theories that can serve as frameworks through which transgender surgery is examined include deontology or Kantian ethics, utilitarianism, and a religious view through the divine command theory.

Gender reassignment surgery involves an individual desiring to change their sex through medical-surgical interventions. The Diagnostics and Statistical Manual of Mental Disorders (DSM-IV) classifies gender identity disorder as being a “strong, long-standing identification with another gender, a long-standing disquiet about the sex assigned biologically, and a clinically significant discomfort or impairment at work, in social situations, or other important areas of life” (Hume, 2011 p. 138). The American Psychological Association, therefore, asserts that individuals seeking gender reassignment surgery do so because they suffer from gender identity disorder. However, there are many transgender reform advocates who argue that transsexuality is not a mental disorder but is a physiological problem that is resolvable through reassignment surgery, which they assert is a therapeutic measure. Regardless of whether gender reassignment surgery is thought to be constructed through a mental disorder or through a biological “mistake,” the fact remains that the procedure is invasive surgery that might require different medical interventions. Therefore, there are issues of bioethics and societal morality that come into play when this issue arises. If and when it comes to accepting that the state of transsexuality is a mental disorder, then there is a moral duty to the person to perform the surgery.

Deontological ethics, or Kantian ethics, states that there is a moral duty to resolve issues that can be mediated through a psychological approach or through a medically appropriate resolution that is morally acceptable. This is so there can be homeostasis between the mind and body that is absent in the transsexual person. As such, health is considered to be an inclusion of both physical and mental well-being; however, the social and moral aspects of such treatment need to be rejected as not being a legitimate argument against the measures required to help the individual to achieve a union of both mental and physical health (Hume, 2011). However, there is a duty to the individual to provide him or her with the means by which he or she can also achieve psychological and social well-being. This comes from treating the underlying presence of gender identity disorder itself because the disorder falls under the purview of the psychiatric rather than of the surgical. The individual also has a duty to the self. In accordance with Kantian ethics and predicated on the notion that many pre-operative transsexuals feel uncomfortable in their own skin and with their own identity, they have their own ethical duty to amend such a state of existence. In fact, “In cases in which adult patients have been suffering from a severe gender-related mind-body imbalance which interfered with their everyday life functions, gender reassignment surgery is a morally permissible treatment option, provided the patients requesting it are competent and are able to pay for the surgery out-of-pocket as an elective surgery” (Hume, 2011 p. 37). Since the discomfort can be addressed through surgical interventions, the patient has a deontologically predicated reason to have the surgery done. Then there is the utilitarian ethics theory promoted by Mill. Utilitarianism is the ethical theory that posits that actions should be based on the greatest amount of happiness for the greatest amount of people. This ethical theory was founded by Bentham and defended by Mill. As such, the utilitarian theorist would argue that, if an individual has a strong identification as being a transsexual, and he or she is desirous of having gender reassignment surgery, he or she should be able to do so. This is based on the theoretical framework of utilitarianism insofar that happiness can be attained by having the surgery, and that, in the majority of instances, that happiness is greater than any unhappiness that would beset that person’s familial or friend circles or society at large. Even if the surgery is not being accepted by the person’s family members, the utilitarian theory still holds.

This is because “the application of Utilitarian moral philosophy yields the conclusion that the amount of pleasure that stands to be gained from most prospective patients is far greater than the amount of pleasure that stands to be gained by family members in maintaining the status quo” (Hume, 2011 p. 142). As to societal happiness, it can be argued that having a citizen who is happy helps to foster happiness and productivity for others, therefore there is a greater utility in having the person undergo the surgery. Then there is the argument that arises out of the divine command theory.

The divine command theory comes through the religious realm and has been promoted by St. Augustine and Aquinas among others. What it states, in essence, is “that what makes something morally right is that God commands it, and what makes something morally wrong is that God forbids it” (Hare, 2016 para. 1). If it is accepted that God chooses only those things that are good, then there is a dilemma presented. One objection is referred to as Plato’s dilemma which he wrote about in the Euthyphro and asks: “Is the holy loved by the gods because it is holy, or is it holy because it is loved by the gods?” (Hare, 2016 para. 3). The premise that the holy is holy because the gods love it cannot be justified because, even today, with only a monotheistic perspective, it cannot be known what God loves or does not love. In addition, there can also be aesthetics to take into consideration such as what is just or beautiful, good or bad. There are societal morals and laws that dictate many of these constructs and this makes the divine command theory subject to evaluation. There is also a sense of the application of this theory being arbitrary, and God is not thought, at least to the philosophers, as being an arbitrary entity. Arbitrariness might be applicable to ancient thought, but not in any contemporary sense because it implies that relevant consideration has not been factored into the equation. It can be argued also that the technological advances and knowledge enhancements through the practice of medicine are the “good” that God has bestowed. If this were not true, then the surgery could not be performed. So, the ethics of gender reassignment surgery need to be considered ethical through all three theoretical perspectives.

As Nicholson-Flynn (2016) writes “Having access to the necessary transgender care is ethical mainly because it supports the rights of the individual to make decisions about their gender identity, and it is the duty of all other citizens, including medical practitioners, to honor this decision” (Nicholson-Flynn, 2016 para. 3). In this statement, the author is correct. As a society, people have a right to choose their best life that works for them, not for others as long as the decisions do not compromise others’ rights. The procedure is legal and affects mostly the person who undergoes it. It cannot be known without being a self-identified transsexual whether the condition presents as a mental disorder or if it is a physiological one. Many times, those who find themselves in this condition state that they have always known that they were in the “wrong” body and wanted to be the other sex. That assessment is entirely the feelings of another person, and feelings are one human characteristic that cannot be helped. Therefore, they should not be judged by others.

In addition, bioethics is a concern of the medical and nursing disciplines. As a nurse, I plan to develop my own sense of ethics through what has been set forth by the established bioethics authorities and to abide by such principles as best as possible without having to compromise ethics of my own. The realm of bioethics is not so much a blanket proposition; rather there are always going to be exceptions, and, in such instances, we, as healthcare providers, need to weigh the need against the consequences. This type of paradigm can present on an almost daily basis, and the astute provider needs to be prepared to meet such challenges.