MILTON DIAMOND,
PH.D. & HAZEL GLENN BEH, PH.D., J.D.
THE RIGHT TO BE
WRONG
Sex and Gender Decisions
1. INTRODUCTION
A series of
events occurred within a very short period and prompted consideration of the
ethical dimensions of how, when, and why individuals, institutions or
governments decide to get involved in people’s lives. In particular we began to
question if they should get involved with allowing, or not allowing, people to
make major decisions regarding their own bodies. This is an essay reflecting
such thoughts. It involves consideration of two tenets of medical practice:
Relieve pain and suffering;
and First, do no harm.
In order of occurrence, the events started when we were
considering a legal case involving a 13-year-old female.1
Alex, as the judge sitting on the case called her, had successfully argued in an
Australian court that, in accordance with her wishes, she could live as a male
and obtain the necessary medical help to achieve this. This means Alex, from
that time on, will be getting hormones to prevent typical female puberty and at
the age of sixteen years will receive androgenic hormones to virilize bodily and
facial features. At the age of eighteen Alex will be eligible to obtain a
hysterectomy and ovariectomy to stop any menses and feminization, and eventually
to have a phallus constructed if he so wishes. The appropriate legal and
professional psychological and medical experts, consulted prior to the decision,
have made these recommendations Religious and other factions, however,
immediately challenged the decision. They complained Alex was too young to make
such a choice, that the procedures would lead to later regret, and most
crucially, would end Alex’s ability to have children. 2
The second instance involved a
legal suit brought against a gender clinic by someone who had surgically and
socially transitioned from living as a male to living as a female. Alan Finch,
at the age of twenty-one had applied to the clinic for help with a desire for
sex reassignment surgery (SRS). Therapists at the clinic vetted Mr. Jones’s
situation and approved of the transition. Surgeons subsequently removed his
penis and testicles and in their stead fashioned a vulva and vagina. After
living as a woman for eight years Mr. Finch decided it had been a mistake and
now feels he should never have been allowed to transition and he ought to live
as a man.3
Mr. Finch blames the psychiatrists who counselled him and is suing the clinic at
which they worked. Although he admits to having lied to the therapists during
his meetings
[EditorS.
Systma] (ed.), [Intersex &
Ethics], I—li. In Press
©
2005 Kiuwer Academic Publishers.
Printed in the Netherlands.
2
MILTON DIAMOND, PH.D. & HAZEL GLENN BEH, PH.D., J.D.
with them, he claims
they should have realized he was conflicted over his gender. The clinic is
protesting the suit saying, on the one hand, that the therapists involved had
followed established procedures, and in any case, this had all occurred prior to
the expiration of the statute of limitations. According to records, indeed, the
clinic professionals did adhere to professionally approved procedures.4
The local government is presently conducting a clinical review of the complaint
and relevant occurrences.5
In the meanwhile, factions both supporting and ridiculing the original
transition, the secondary one, and the claim against the clinic have come
forward. 6
The third case involved a
tragedy. David Reimer, while still an infant had his gender changed. A botched
circumcision to repair phimosis of his penis resulted in its destruction. His
parents were advised that life as a male without a penis would be intolerable
and that he should be raised as a girl. They were told that he would then
develop satisfactorily as a female (Diamond and Sigmundson, 1997; Colapinto
2000). This did not happen. David consistently objected to his life as a girl
and repeatedly asked to live as the boy he felt to be. His life became so
miserable that, at the age of 14, without knowing of his history, he threatened
suicide unless he could live as a male. While he subsequently grew to live and
marry as a man at the age of 25, he continued to have flashbacks to his early
troubled life so that he eventually committed suicide at the age of
thirty-eight.7
The practice of sex reassignment in similar cases when a penis has
been lost due to infant trauma or accident, or when it is considered unusually
small, is still current. It also occurs in many cases of intersexuality without
the child’s consent.8
The correctness of this practice is a subject of current professional and lay
debate. Some physicians still hold to its justification; while others,
particularly those individuals who feel they were ill-served by such treatment,
object (Diamond, 2004). We say more of this below. David’s story is better known
as the case of John/Joan and received wide coverage from many media.9
The fourth case is more mundane and also more common. A married
father of two wrote to one of us (MD) seeking advice. For this discussion we
call him Phil Johnson. At his age of 42 Phil said that he was finally seriously
thinking of transitioning to live as a woman. Although having thought for years
about transitioning, he felt he had come to a junction in his life where he had
to make a decision. However, he was conflicted. On the one hand, Mr. Johnson
feared that by transitioning he would lose his wife and children, and on the
other, he felt driven to follow a life long compulsion. Whether he stays with
his family and sacrifices his gender desires or denies his family aspirations
involves a decision with both positive and negative consequences. But Phil felt
at a choice-point and a decision had to be made. Under certain jurisdictions
those who transition, if married, are obligated to divorce. In other cases,
those who transition cannot later marry someone of the sex from which they
changed. Not only does Phil’s conundrum involve legal repercussions, but also
similar cases have become part of the “same-sex marriage” argument with
positions strongly held by those for and against the legality of transsexual
change and subsequent marriage.10
In the first two cases the gender shift was at the request of the
individual involved and in the third it was imposed from without. The fourth
case is yet to be resolved. The types of transitions involved are not unique.
Over the last several
3 THE RIGHT TO BE WRONG
decades such cases
have become the fodder of tabloids, television chat shows, documentaries and
more. The Internet has become home to scores of communities that offer space for
questioning, ventilation, counseling, and discussion on all sides of the
relevant issues. In all of the cases, and others like them, outside individuals
and groups have felt called upon to voice their opinions as to the right or
wrong of these actions and choices. Some even want governmental agencies to
regulate such conduct.
Three of the foregoing four cases involved
individuals usually called transsexuals.
They were said to be
suffering from a condition medically called Gender Identity Dysphoria (OlD) or
Gender Identity Disorder. In brief, gender identity disorder is defined as the
strong and persistent disturbing belief for at least two years that one is
actually a member of the opposite sex (Frances et al., 1995). In David Reimer’s
case, he too wanted to change his gender, but it was to regain something taken
away from him. While not usually identified as such, it might be said that he
had an imposed disturbance of gender identity.
A basic question
arises for all of these cases. Who should or should not have a right to dictate,
or even have a say, in how one lives and what a person may do with his or her
own body?11
Should the voices of individuals, religious groups, political factions, or even
families have determining weight in other people’s decisions of such personal
bodily alteration?
Those who protest against the requests often feel
they are acting in the best interests not only of the individuals concerned, but
also of society in general. Considering cases such as Alex’s, it is plausible
that a minor might change his or her mindset with increasing age and maturity.
There is also logic in believing that adults, like Alan Finch or Phil Johnson,
who have lived a life in one gender might regret leaving it to live in another.
And experience has shown that physicians and other trained professionals usually
have knowledge that should be taken into account when making life-altering
decisions. There is certainly reason to accept that one might grieve over loss
of genitals, facility, or opportunity. Further, it is probable that the full
repercussions of any particular action might not be known or ever be known. But
is it really likely that the individual involved has not considered most of the
relevant matters brought up by others? Is it truly logical to believe these
criticisms and objections, as well as others that might be more salient to the
person involved, have not been thought of and examined?
From the
point of view of the individuals concerned, there surely are important factors
to consider. In Alex’s case, aside from the public clamor, there is scientific
evidence to complicate matters. Minors who desire sex/gender change frequently
change their minds as they get to adulthood. It is also true that a majority of
those considering a gender reassignment as minors, when adult manifest as
persons demonstrating homosexuality without the gender dysphoria (Green, 1987;
Zucker, 2004). Thus, for the adolescent, even allowing reversible treatment and
permitting the adolescent to present in the opposite sex has future consequences
if it solidifies a gender presentation that might have otherwise been later
abandoned.
Alan Finch’s situation is unusual since most transsexuals
following surgery express satisfaction and delight at the outcome (Smith, et
al., 2005). Only a minority experience regret. This case is further clouded by
not knowing what induced Mr.
4
MILTON DIAMOND, PH.D. & HAZEL GLENN BEH, PH.D., J.D.
Finch to originally
desire a sex change so deeply that he would lie to the therapists regarding his
life situation and motivation.
In Phil Johnson’s case there are obvious
family aspects of any decision that will affect others as well. Phil presents
with pro and con issues of his own that must be resolved. His situation is not
rare.
The original treatment for David Reimer was predicated on
several points of faulty logic. The first was a belief that individuals are
psychosexually neutral at birth and will adapt to any gender in which they are
reared. The second was that any individual without a penis should be raised as a
girl. From the start of his imposed transition, David objected to his treatment.
The continued imposition of his management against his desires might even be
considered child abuse. Nevertheless, the thinking that led to David’s
management is still used in dealing with many cases of intersexuality where
ambiguous genitalia or a micropenis is present, or when genitalia are missing,
as in cloacal exstrophy (Reiner, 2004).
In addition to any personal
reason that might be involved, a justification offered by those that refer to
the need for society’s involvement in these personal decisions arises from the
fear that certain actions provide a negative role model for others, or might
serve as a precedent and challenge to a basic tenet held dear. They think this
is reason enough to impose legal regulations on what individuals can and cannot
do. Many social, governmental, and religious institutions, for example, are
threatened if people make unique and atypical gender choices even if as minor as
dressing in the clothes of the opposite sex. Other factions are disturbed if
they or those they represent are not involved in decision making. For instance,
psychotherapists or physicians might object if those among their number are not
consulted regarding any gender transition. However, the role modelling has
effect only on those persons who are themselves considering options regarding a
possible transition. In that regard, we see it as any other educational source.
We also do not believe that such actions are attractive enough to the average
“onlooker” that they will be taken as behaviors to be emulated.
Some
among the criticizing public base their objections on religious grounds. They
quote biblical verse claiming the body is a holy temple12
or they contend that man is made in God’s image.13
Some also think that procreation is a religious obligation and that a voluntary
surrendering of reproductive ability is sinful. For many reasons individuals of
different religious persuasions think the body should not be altered.
Regardless of the source of criticism, the heart of the issue is, should final
decisions on instances such as the ones presented be left to government,
agencies, factions, physicians, psychologists, priests, counsellors, or any
other than the person particularly involved? We think not.
Certainly
we think that parents or family can have a say and openly express their
opinions. Yes, we think any and all groups might be consulted if that is the
wish of the individual. Yes, we think interested groups should be free to offer
advice and suggestions for alternate solutions to the situations faced by those
like Alex, Alan, David or Phil. And we think it is prudent to postpone the
enactment of any of the actions associated with similar cases until a suitable
interval of time has passed between the decision and desired action. We also
think it proper that organizations
5 THE RIGHT TO BE WRONG
such as the
Harry Benjamin International Gender Dysphoria Association (HBIGDA) establish
guidelines for the transition process for transsexuals, and respective medical
associations have standards for specific medical procedures.14
To the extent that physicians or other professionals can predict that
an individual or a population is at risk for later regret, they have an ethical
obligation to identify that risk and counsel the patient appropriately. For
example, studies of women undergoing tubal sterilization reveal that
approximately 14% will have some degree of regret in later years. The age at
which sterilization occurs strongly correlates with the likelihood and degree of
later regret: young women are significantly more likely to regret the decision
(Schmidt et al., 2000). Yet no one would suggest that medical or other
professionals should deny all younger women the choice to be sterilized because
they are more vulnerable to later regret. Instead, this finding warrants extra
emphasis on pre-surgery counseling for younger individuals.
We
believe the ultimate decision to proceed or not should be left to the competent
and mentally mature individual involved regardless of whether doing so is in
keeping with the desires or advice of the public, any specified institution, or
involved professionals. In terms of making decisions regarding one’s own body,
we believe every individual has a right to be self-determining; every one has a
right to even be wrong.
Our thinking in all these cases is that
rational individuals ought have authority to make even life-altering choices
when it involves their bodies, regardless of public acceptance or rejection.
This holds as long as these persons are then ready to live by any consequences
and not hold others liable for that determination. As enunciated by philosophers
such as John Stuart Mill we consider these actions as a basic tenet of
individual freedom.
Mill, in his essay entitled On Liberty
expressed it thus:
“The sole
end for which mankind is warranted, individually or collectively in interfering
with the liberty of action of any of their number, is self-protection. That the
only purpose for which power can be rightfully exercised over any member of a
civilized community, against his will is to prevent harm to others. His own
good, either physical or moral, is not a sufficient warrant. He cannot
rightfully be compelled to do or forbear because it will be better for him to do
so, because it will make him happier, because, in the opinions of others, to do
so would be wise, or even right.” (Emphasis ours.) 15
Our discussion now turns to an opposite extreme regarding bodily integrity—a discussion of intersexed persons and how they are often treated. Intersexed individuals are persons with apparent anatomical admixtures of male and female biological characteristics. Such persons are not rare. Estimates of their frequency in the population vary. A conservative approximation is that an intersexed child occurs in about one per two thousand people and is recognized at birth by genitals considered ambiguously male or female (Blackless et al., 2000).16 Since the 1950’s and 1960s early surgical intervention for such individuals often was imposed. Predicated on the misguided belief that such genitals provoked a medical emergency, intersexed infants were subjected to surgery to “normalize” their genital
6
MILTON DIAMOND, PH.D. & HAZEL GLENN BEH, PH.D., J.D.
appearance. These
surgeries were frequently done without the parents being notified of the
reasoning for the operations.
In most cases the surgery involved
sex-reassigning the infant from male to female since fabrication of female
appearing genitals was easier than structuring male genitals. Such surgeries
were also imposed when a male infant’s penis had been severely mutilated by
trauma (as in David Reimer’s situation) or was considered significantly small
(Beh and Diamond, 2000). These procedures were often instigated without informed
consent of the parents in the belief that withholding information about the
ambiguities and sex reassignment would foster a more satisfactory upbringing for
the child. It was thought that if the parents didn’t know, they would not
prejudice the infant’s upbringing. These practices, while less frequent, still
occur.
When parents were informed of the prospect of surgery and sex
reassignment they were often told that the “normal” looking genitalia would
dictate the child’s gender development, and that any innate gender propensity
would be changed by upbringing. Despite a lack of confirming evidence, medical
literature from the 1970s to the late 1990s had promoted this treatment.
Supporting evidence is still scant and there is a great deal of evidence against
the belief (Diamond, 1999). Much depends upon the particular intersex condition
being considered.
A significant number of intersexed persons were
raised in their sex-reassigned gender and then, on their own, either switched to
their opposite or instead elected to see themselves, not as male or female, but
as intersexed.17
Many of the intersexed infants that had surgery, even if staying within their
assigned gender, have come to criticize such treatment. Many of the original
surgeries had to be redone and many surgeries reduced the erotic sensitivity of
the genitals.18
Why, these intersexed individuals ask, couldn’t they be allowed to live as they
were born? Many question what right the surgeons had, with or without permission
of their parents, to decide to subject them to surgery? Groups of intersexed
individuals, such as those of the Intersex Society of North America (ISNA), A
Kindred Spirit, and Bodies Like Ours have formed and voiced objection to such
treatments.
Arguments supporting reconstruction of the genitals are
based on the beliefs that humans are psychosexually neutral at birth and that
they fare better in life if their gender and genitals match. Reconstruction of
the genitals and sex reassignment is, therefore, justified. Little evidence has
been offered to substantiate that claim, however. In contrast, neurological and
biological studies support the premise that humans are, in keeping with their
mammalian heritage, primarily predisposed and biased to interact with
environmental, familial, and social forces in either a male or female mode.19
Further, there is no evidence from medical or other records that intersexed
individuals with ambiguous genitalia faired poorly if no surgery was imposed.
Physicians further justify their surgeries on the premises that
growing up with ambiguous genitalia would lead to uncertainty on the part of the
child as to its gender, and that the ambiguous genitalia would elicit
unflattering and derogatorily shaming comments from others. There is only
untested theory bolstering the belief about gender development, and only
anecdote about the occurrence and effect of unflattering and shaming comments.
7
THE RIGHT TO BE WRONG
There are
major ethical problems with “normalizing” ambiguous genitalia without informed
consent of the individual involved. The most significant is that doing so
ignores the possibility that the child, when an adult, might have a different
concept of what is “normal” and what is desirable. And collusion in the surgery
by well-meaning parents does not rectify the situation. Indeed, it might make it
worse if the mature child comes to wonder why he or she could not be loved as
they were born. There are many cases where those who had such surgery as infants
later rue the procedures and the thinking that went with it. In cases of infant
intersexuality, we think the most ethical stance is to hold open the infant’s
surgical future when any proposed change is not medically, but only
cosmetically, at issue. At a later date, the child can then elect or decline any
appropriate surgery (Beh and Diamond, 2000).
We thus present two
sides of an issue: where those who wish to change their bodies meet with social
criticism and where those who involuntarily had their bodies modified criticize
the social forces that led to their unwelcome surgery. In both types of
situations, the critics claim they are looking out for the best interests of the
individuals involved, the public good, or both. When a decision is in keeping
with social norms, the populace and most professional groups generally approve
and consent is tacit. When an individual’s choice is unpopular, however, it
causes consternation and unease. Evidence for this is not difficult to come by.
Cosmetic or psychiatric surgery obtained by minors is not uncommon in the United
States in instances other than transsexual considerations. According to the
American Society of Plastic Surgeons the number of cosmetic surgeries performed
on people under the age of 18 exceeded 74,000 in 2003, a 14 percent increase
from 2000. In 2003 some 3,700 breast-augmentation surgeries were performed on
teenage girls and almost as many teenage boys had their breasts reduced.20
All that was generally needed to obtain these operations was the financial
ability to pay and the consent of parents or guardians. For those that wanted to
go contrary to the usual in terms of gender, however, roadblocks of all sorts
existed. Males and females, thus, are denied surgery if it is associated with a
desire to change their sex, but not if it is to enhance gender stereotypes. And
surgery toward “normalization” is promulgated when genitalia are believed to be
unusual and differ from the norm.
We accept that those who chose
might be making a mistake they will later regret. Yes, there might be
repercussions difficult to remedy. But mistakes happen even when actions are
made following the best of intentions. Regrets are not only for taking the road
less travelled, but for taking the highway as well. And there are honest
differences of opinion as to those persons who make the right decision and those
who make wrong. Who is to say?
In discussion of this matter we can
even call upon a concept of freedom in its broadest sense and immortalized in
our country’s central documents. The constitution starts off with our ancestor’s
desire to “secure the Blessings of Liberty to ourselves and our Posterity” and
the Declaration of Independence declares: “We hold these truths to be
self-evident: that all men are created equal; that they are endowed by their
Creator with certain unalienable rights; that among these are life, liberty, and
the pursuit of happiness.”
If liberty is to mean anything it must
offer freedom from external restraint or compulsion. A person’s liberty must be
seen as a condition of legal non-restraint of
8
MILTON DIAMOND, PH.D. & HAZEL GLENN BEH, PH.D., J.D.
natural powers.21
And as liberty is an inalienable right it cannot be surrendered or
transferred.22
We thus think it is unethical to make bodily modification of adult or
mature minors difficult or illegal when it is desired, and we think it equally
unethical to impose, encourage, and promote it in infants when it has not been
proven justified and when many on whom it has been imposed criticize the
practice even to the point of claiming that it is harmful. People have a right
to modify their bodies when they so choose and not have it modified without
their expressed informed consent.
A parallel issue needs be
considered in this discussion since the individual is not a completely
independent agent. The transsexual who wants surgery, or the intersexed
individual who doesn’t, must interact with different professionals, usually
psychotherapists and physicians.
While we presume informed patients
with decisional capacity have the right to make medical treatment choices that
may bother or offend the larger society, we must also acknowledge the
professional’s right and obligation to act within his or her conscience in
cooperating with those choices. Professional obligations can serve as a
legitimate limitation on patient autonomy. Nevertheless, we feel that patient
autonomy should be paramount even, or perhaps especially, when exercising
choice, which may result in later regret. Yet, patients do not and cannot make
medical treatment decisions alone, because medical treatment, by its nature
requires the participation of others who are obliged to follow their own
conscience and are bound by rules of professional conduct. Thus, informed
consent from competent patients may not alone suffice. Professional medical
ethics, and the ethical codes of other helping professionals, preclude providing
treatments for which there is no indication and those that offer no possible
benefit.23
Patients are not entitled to treatments “simply because they demand them” and
physicians or others “are not ethically obligated to deliver care that, in their
best professional judgment, will not have a reasonable chance of benefiting
their patients.”24
Admittedly, in some cases it might be difficult for transsexuals who
desire counseling, hormones, or surgery, to everywhere find professionals
willing and able to provide these services. However, there is no shortage of
qualified specialists who are willing to serve. How to keep the intersexed
individual from imposed surgery, however, is more problematic. Having a
knowledgeable and understanding pediatrician is a place to start.
In
summary, we think it is appropriate to call upon long held professional
guidelines for those in the helping professions. In the first set of instances
we offer “Relieve pain and suffering.” The psychic pain and suffering of
those diagnosed as transsexuals is well documented. The advice for the second
set of instances, where individuals have not themselves requested surgery, is to
refrain: “First, do no harm.” The obligation for these decisions
ultimately remains with the individual, and yes, every person has a right to be
wrong.
9 THE RIGHT TO BE WRONG
NOTES
1
In any discussion of transsexuality and intersex there is a sensitive issue of
how nouns and pronouns are used. Most persons with a transsexual condition
identif’ themselves unequivocally as members of the sex in which they aspire to
live. Thus, Alex identifies as a male. And to Alex, sex and gender are
equivalent so that male means boy or man. To most medical personnel and
scientists, however, sex and gender are separate (Diamond 2002) so that a female
can live and identify as a boy or man and a male can live and identify as a girl
or woman. Part of the issue is how an individual’s sex is determined. Over the
years various indicators of sex have been emphasized (Dreger 1998); the most
commonly emphasized have been chromosomes, gonads, hormonal titers, intemal
genitalia, external genital appearance, and social lifestyle. As knowledge and
sophistication increase, however, more factors can influence the determination;
a final determination of a person’s “sex” might involve different gene
constellations as well as brain sex. Traditionally the primaly sex
characteristic has been the gonads. It is now understood that an individual’s
gonads or related characteristics frequently do not correspond with other
features of self and that variations are common. Such discrepancies and
variations arise in conditions of transsexuality and intersex (and
transsexuality can be considered a form of intersexuality) (Diamond, 2002).
These discrepancies and variations have implications over and above any
grammatical matter. A resolution of the conflicting methods for assaying sex
would have legal and practical relevance. It would address the problem that
arises when a person is considered a male in one state, a female in another, and
an intersexed person in a third. Persons with an intersexed or transsexual
condition consider, not their gonads, but their brains, their core sense of
self, as the primary determinant of sex. Presently this is best evaluated by the
individual’s own admission rather than by any scientifically objective measure.
In this paper we use the terms as they are most generally understood. In
general, however, persons of any category should be addressed and regarded as
they see themselves. See also Wallbank (2004).
2 “Re Alex:
Hormonal Treatment for Gender Identity Dysphoria.” FLR 180.89 (2004). Available
at <http://www.austlii.edu.au/au/cases/cth/family_ct/2004/297.html> See
also Beh & Diamond, “Ethical Concerns.”
3 Patrick
Goodenough. “Sex-Change’ Clinic Faces Inquiry, Lawsuit.” Cnsnews.com: May 05,
2004. Available at
<http://www.cnsnews.com/ForeignBureaus/Archive/200405/FOR20040505a.html>;
“Double Sex-Change Patient to Sue.” Fairfax Digital: 2004. Available at
<http://www.smh.com.au/articles/2004/09/l51l094927634658.html?from=storylhs&oneclick=true#>;
“Alan Finch-Man to Sue Over Sex Change.” ABC NewsOnLine. Available at
<http://www.gendertrust.org.uk/news162.php>
4
Standardized procedures for the treatment of GID have been established by the
Hariy Benjamin International Gender Dysphoria Association. Available at
<http://www.hbigda.org/soc.cftn>
5 Op. Cit. Goodenough
‘Sex-Change.” Last Update: Friday, November 12, 2004. 5:49pm (AEDT)
6 Greg Ansley. “Alan Finch-Caught in the Wrong Body.” New
Zealand Herald. (2004).
Available at <http://www.gendertrust.org.uk/newsl57.php>
7 Black, Debra. “Sex, Lies and a Quest for Identity.”
Toronto Star. (May 11, 2004, A3).
8 Beh, H. G.
and M. Diamond (2000); Kipnis, K. and M. Diamond (1998).
9
Colapinto, J. “The Boy Who Was Turned into a Girl.” BBC Horizon Productions:
Dec. 6. 2000; “Sex Unknown.” PBS NOVA: 30 October 2001 (WGBH
Productions).
10 Littleton v Prange (Texas case)
at <http://www.pfc.org.uk/legal/littletn.htm>; Wilgoren, Jodi. “Suit Over
Estate Claims a Widow Is Not a Woman.” New
York Times. (January 13, 2002).
11 We are not
extending this discussion to include issues such as prostitution, drug use or
other practices that involve one’s voluntary exposure of the body to risk. Those
topics involve public policies that already have histories of extensive debate.
This current discussion is limited to issues of body modification.
12 1 Corinthians 6:19-20.
13 Genesis 1:26-27.
14 HBIGDA is a professional organization devoted to research
and overview of the clinical management of transsexualism.
15
Mill, J. S. (1909).
10 MILTON DIAMOND,
PH.D. & HAZEL GLENN BEH, PH.D., J.D.
16 A more
liberal consideration of the frequency of individuals in the population with
intersex conditions gives a figure exceeding one percent (Fausto-Sterling,
2000).
17 Diamond, Milton (2004); Diamond, M. and L. A.
Watson (2004); Beh, H. G. and M. Diamond (2000); Schober, J. M. (2001).
18 Creighton, Sarah M., C. L. Minto, Ct al. (2001);
Kuhnle, U., M. Bullinger, et al. (1995).
19 Diamond, Milton
(1995); Diamond, M. and L. A. Watson (2004); Hamer, D. and P. Copeland (1998).
Wilson, B. E. and W. G. Reiner(1998).
20 Mary Duenwald. “The
Consumer; How Young Is Too Young to have a Nose Job and Breast Implants?”
N.Y. Times. (Sept. 28, 2004 at F5). Available at
<http://www.nytimes.com/2004/09/28/health/28cons>
21
Gove, P. B. Webster’s Third New International Dictionary of the English
Language, Unabridged. Springfield, Mass: G. & C. Merriam Company, 1971.
22 “At the heart of liberty is the right to define one’s own
concept of existence, of meaning, of the universe, and of the mystery of human
life.” Lawrence v. Texas 213 S. Ct., 2472, 2481 (2003).
23 AMA Code of Medical Ethics, Opinions on Practice Matters E-8.20.
24 MvIA Code of Medical Ethics, Opinions on Social Policy
Issues E-2.035.
REFERENCES
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