In March this year, professor of psychiatry, Stephen B. Levine, published an article in the Journal of Sex and Marital Therapy (see HERE), in which he addressed several aspects of this sexual condition which, in our opinion, is worth discussing.
According to his curriculum on Wikipedia, Dr. Levine studied at Case Western Reserve University School of Medicine before starting his clinical practice at the Cleveland Sexual Dysfunction Clinic; in 1993, he began working in The Center for Marital and Sexual Health in Beachwood, Ohio. He has published numerous articles and several books on sexuality and is unquestionably an expert in this area.
When Wikipedia focuses more on his field of knowledge, it says that he has worked on premature ejaculation and erectile dysfunction, proposing several treatments for these conditions, among them the use of Viagra, but stressing that the most potent aphrodisiacs for stimulating sexual activity are psychological intimacy and voyeurism, understanding as such “looking at pictures or movies of people engaged in genital or romantic interplay” to stimulate them sexually.
Strictly scientific criteria although ideologically distant from us
As is easily understandable, this focus on the treatment of certain human sexual anomalies is very distant from the proposals that the UCV Bioethics Observatory would suggest treating these cases. It, therefore, seems particularly interesting to bring up what a qualified psychiatrist, distant from our ideological stance, thinks about human sexuality — and more specifically transsexuality — because it is possible, I’m sure, that although ideologically distant, we can agree on many aspects of this condition, transsexualism. For if objective scientific data are used, we can remain aloof from the often unsubstantiated opinions on transsexuality, and the possible measures to be applied to transsexuals and their families that are featured in some mass media, and above all are promoted by certain political groups, with aims closer to partisan ideological manipulation than to strictly scientific criteria.
Transexxauls persons. “At the moment, nobody really knows what to do with these individuals”.
Levine begins by stating that the first difficulty (which we share) when helping transsexuals is that, “at the moment, nobody really knows what to do with these individuals”. That is, their care continues to be a problem, but a problem that we must try to resolve.
Seven questions for which there is no definite answer
In this respect, and especially as regards the ethical aspect, Levine makes reference to a report (see HERE) by 17 international groups who work with potentially transsexual teenagers, in which he lists seven questions with a broad ethical component for which there is presently no definite answer:
1) What is gender dysphoria (see HERE)
2) Is gender dysphoria a normal variation, a social construct or a mental illness? (see the video HERE)
3) What role does physiological puberty play in developing gender identity?
4) What is the significance of the psychiatric comorbidities that can often occur?
5) What are the possible physical or psychological effects of early medical interventions?
6) To what extent are children competent to make decisions about their future bodies?
7) How do different social contexts affect gender dysphoria?
After asking these questions, he concludes that, for now, there are no answers that can be widely assumed on these issues (quoting an article in the Lancet see HERE ). We do not have answers either, encouraging us, if possible, to reflect more on them and to try to delve into them, in the quest for objectively acceptable solutions. This is an incentive for the study of transsexuality, and above all, to try to find positive solutions to the problems of these children and their families.
However, since it is not easy to make an individual assessment of each of the points, we shall dwell on some specific aspects.
Transsexual quality of life should prevail
One of these, often debated in proposed bills on this topic, is whether it is fair to dedicate so many material and human resources for a condition with such low prevalence. Levine refers to this by noting that among young Americans, transsexuality has a prevalence of between 0.17% and 1.3 %; the psychiatrist, therefore, asks if it is fair “to promote special services for transsexuals and so many specialized clinics, as are flourishing in many institutions and cities”. The Williams Institute 2016 shows that the prevalence in the general population is 0,58 % and in young Americans (18 a 24 years old) 0,66 %, (see study HERE).
Fundamental objective of various trans-related activist groups is to depathologize this condition
Similarly, another aspect highly debated in the specialized literature is whether a pathological component can be attributed to transsexuality since a fundamental objective of various trans-related groups is to depathologize this condition. In relation to this, Levine states that “these are patients who are waiting for the transition to living as a member of the opposite sex with the help of various specialists”. Emphasized in this statement is the need to attend specialists, and the adjectivization of transsexuals as patients, which may undoubtedly refer in some way to the nature of this condition.
Gender dysphoria should be seen as something closer to mental illness than to mental health
On analyzing the matter, and after saying that it can be considered a mental disorder, Levine says that “a number of organizations try not to consider these problems as a mental illness or disease or at least classify it in a different section of the ICD,” adding that “this classification would be easier if there was a broad medical consensus that it is a mental illness or if a well-defined line could be established between mental illness and behavioral health”, but he concludes that “gender dysphoria should be seen as something closer to mental illness than to mental health”.
As regards determining what transsexuality is due to, Levine defends the existence of an underlying biological factor, which does not preclude that certain psychosocial factors also play a certain role, since, in his opinion, few sexual phenomena have an exclusively biological cause, as the environment may play an objective role.
It is not well determined is to what extent these treatments – hormones and mayor surgical reassignment – are effective over time. The transsexual quality of life hasn’t been studied.
Certainly one of the most widely debated aspects is which treatments should be given to these children (read HERE), and if they have to be done, when should they be started? What there does seems to be a consensus on (see HERE ), though, is that hormones should be given after the age of 16, and surgical reassignment after the age of 18. Nevertheless, what is not well determined is to what extent these treatments are effective over time, “because it seems well documented that most transsexual children desist in their interest in continuing to live as the other gender during adolescence and that some tend to develop a homosexual orientation” (See HERE). Again, though, it is stated that it is still not clear how to distinguish those who desist from remaining in their new gender from those who persist in their decision, so Levine says that this leads professionals to an ethical dilemma to know which path to choose, although in the end they will have to decide “above all do no harm”.
Another question discussed, which often arises, is whether hormone treatments and surgical reassignment offer improvements that are maintained over time. In relation to this, Levine says that “in the United States, it is extremely difficult to perform the longitudinal long-term follow-up of these patients, to determine to what extent the individual benefits are maintained in them”. Again, he calls attention to the fact that this group are called “patients”, but above all that, among the remaining unanswered questions, is to determine what percentage of these remain satisfied throughout their lives after the transition process; what percentage return to the gender they were assigned at birth; how many have work problems, and what percentage stabilize their intimate personal relationships”. Many questions, which we also ask, and which, without doubt, should be taken into account in the guidelines promoted from different social and political institutions in Spain and which, in our opinion, still remain unanswered.
The suicide rate was 19.1 times higher than the control group and many of these deaths occurred within 12 months of the surgery. Transsexual quality of life should be considered.
On what there does seem to be greater consensus is on the side effects that the trans collective may suffer after the application of medical solutions, especially hormone therapy, and sex reassignment surgery. To address this issue, Levine basically uses the findings of two studies, one Swedish and the other Danish, which evaluated almost all patients who had undergone sex reassignment surgery over 30 years in Sweden and in a Danish group. The more recent study, the Danish one, which includes data from 98 patients, confirmed the results of the larger Swedish study, which included 324 patients. Both showed high mortality; the suicide rate was 19.1 times higher than the control group and many of these deaths occurred within 12 months of the surgery. Both studies also found that admission to a psychiatric hospital after sex reassignment surgery was much more common in the patient group than in the control group, so Levine concluded that “both studies confirm that there are considerable psychiatric problems after gender reassignment surgery”. A Swedish similar study concluded that 53% of 796 transsexuals had some type of disability, while another in Swiss transsexuals (see HERE ) concluded that, 15 years after sex reassignment, patients had significantly poorer quality of life than the healthy population. A recent study should also be highlighted, in which a group of male-to-female transsexuals had requested reconstruction of their genitals to their original male condition (see HERE). Despite this, Levine says that “some trans individuals are happy and live a full life after sex reassignment surgery, but the question is to determine the proportion of these happy individuals“.
In view of the above, we need to ask whether these findings are taken into consideration when many political institutions are advocating hormone therapy and sex reassignment surgery in children and young adolescents, or if they are acting more for ideological reasons than for medical evidence.
Justo Aznar MD PhD
Bioethics Observatory – Institute of Life Sciences