Medical Report on the Affidavits of William Jenkins

As submitted to the judicial review of the cases of ’P’ and ’G’ vs H.M.Govt., March 1996

1 Introduction

1.1 This report provides a response to the affidavits of William Jenkins dated 1 April 1995 and 30 August 1995 in the case of P and 14 December 1995 in the case of G. It deals with the issues of:

1.1.3 the classification of Transsexualism and its treatment;

1.1.3 the medical evidence submitted with Mr Jenkins’s affidavit of 30 August 1995;

1.1.3 criteria for deciding the sex of an individual;

1.1.3 other relevant medical issues.

1.2 This report should be read in conjunction with the two documents attached which represent the most recent medical research into transsexualism and the current medical viewpoint:

1.2.3 J N Zhou, M A Hofman, L Gooren & D F Swaab, ’A sex difference in the human brain and its relation to transsexuality’, Nature, 2 November 1995, vol 378: 6552, pp. 68-70. Nature is an international journal of the scientific community which is highly respected both in academic and professional circles;

1.2.3 de Cegli D, Dalrymple J, Gooren L, Green R, Money, J & Reid, R Transsexualism: The Current Medical Viewpoint, produced for the Parliamentary Forum on Transsexualism, 2nd edition, January 1996.

2 The Classification Of Transsexualism And Its Treatment

2.1 Paragraph 5 Of Mr Jenkins’s Affidavit of 1 April 1995 concerns the corrections made to the birth certificates of Roberta Cowell, Georgina Turtle and Michael Dillon and says that none of these cases concerned a person whose birth certificate was altered because they underwent gender reassignment surgery after birth. In other words, it asserts that those individuals were not treated for transsexualism.

2.2 The medical issues here are the ones of the classification of medical conditions (nosology) and the diagnosis given which, of course, depends on the terminology of classification. At the point at which the Birth Certificates were corrected, the condition of transsexualism did not have an agreed medical definition and other terms, which have now fallen out of usage, were often preferred.

2.3 By way of background it is important to note that the term "transsexualism" was brought into mainstream medical literature by Harry Benjamin in 1954, who regarded it as a biologically-based condition.1 Before then and in the years following, the term had a variety of applications. It was commonly used as interchangeable with "transvestite", with "sexual intermediacy", "constitutional invert", "male with a female outlook", "sex transmutationist"2 "eonism" and "psychic hermaphroditism".3 Although the term was being integrated into medical thought during the 1960s, it did not appear as a separate heading in the Index Medicus in 1968.4 Up to that point, cases of transsexualism were listed under transvestism and sometimes were defined as transvestism even though their treatment by sex reassignment surgery makes it clear that they would now be diagnosed as transsexualism, not transvestism.5 Transsexualism appeared in the American Psychiatric Association’s Diagnostic and Statistical Manual in 19806 and it was not until it was defined formally in this way that the controversy over the use of sex reassignment surgery in its treatment dissipated.7

2.4 Effective medical treatment and surgical reconstruction became possible in the 1930s when synthetic oestrogens were produced successfully and an effective method of creating an artificial vagina was devised. Reports of twenty eight cases of transsexualism were published before 1953, although the actual condition of such patients is often unclear. 8 However, all the measures now in use were used then, including hormone therapy, penectomy, orchidectomy, vaginoplasty, bilateral mastectomy, hysterectomy, oopherectomy and phalloplasty.

2.5 Concern over the possible legal consequences of orchidectomy meant that some surgeons insisted that patients went abroad for orchidectomy, although in some cases the phrase "castrated abroad" was merely a euphemism to hide the identity of the surgeon concerned. 9 Hospital records also disguised the nature of the operation as, for example, "congenital absence of vagina."10 By 1959, the syndrome was prevalent enough for a study of fifty cases to be published in the BMJ.11

3 The Medical Evidence Submitted With Mr Jenkins’s Affidavit of 30 August 1995

3.1 The affidavit draws attention to a book edited by Rutter, Taylor and Hersov entitled Child and Adolescent Psychiatry: Modern Approaches (3rd ed., 1994) and in particular a chapter in it by Professor Richard Green on ’Atypical Psychosexual Development’. On page 756 of the chapter Professor Green states ’Because transsexualism and transvestism are mental disorders and homosexuality and bisexuality are not, it would be helpful to clinicians who see children with atypical psychosexual development if specific childhood behaviours predictive of these outcomes could be established’. There are two issues here, the status of transsexualism as a ’mental disorder’ and the relationship between transvestism and transsexualism.

3.2 The first point to note here is that recent medical evidence has demonstrated that transsexualism is a physiologically based condition rather than a mental disorder. J N Zhou, M A Hofman, L Gooren & D F Swaab, ’A sex difference in the human brain and its relation to transsexuality’, Nature, 2 November 1995, vol 378: 6552, pp. 68-70 shows ’a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones’. Further, D de Cegli, J Dalrymple, L Gooren, R Green, J Money & R Reid, Transsexualism: the Current Medical Viewpoint, produced on 18 January 1996 for the UK Parliamentary Forum on Transsexualism chaired by Dr Lynne Jones MP, states ’the weight of current scientific evidence suggests a biologically-based, multifactorial etiology for transsexualism’. A copy of each article is attached to this report.

3.3 The second point to note is that recent research has made a clear distinction between the psychopathology of transsexuals and people diagnosed with other gender identity disorders, such as transvestism. For example, O Bodlund & K Armelius, ’Self-image and personality traits in gender identity disorders: an empirical study’, Journal of Sex and Marital Therapy, Winter 1994, 20 (4), pp. 303-17 ’found more differences than similarities in the studied aspects’ and were able to ’clearly differentiate’ transsexuals from non-transsexuals, with non-transsexuals exhibiting a ’negative self-image’ and transsexuals exhibiting ’a normal self-image’.

3.4 The apparent contradiction between the views expressed by Professor Green in the book cited by Mr Jenkins and those which he expresses in Transsexualism: the Current Medical Viewpoint and which are substantiated by other research can be accounted for quite simply. Child and Adolescent Psychiatry: Modern Approaches is a generalist work, aimed at describing ’Modern Approaches’ for postgraduate medical students. Debate about etiology is outside its scope, therefore, and in common with other works of this sort, it focuses instead on diagnosis. In this context, the bracketting of transsexualism with transvestism as a mental illness is appropriate since both appear in the Diagnostic and Statistical Manual of Registered Mental Illnesses12 which is the standard work used in diagnosing transsexualism. The purpose of including transsexualism in this work is to enable a differential diagnosis to be made between transsexualism and transvestism: hence, as Professor Green points out, ’it would be helpful to clinicians who see children (with disorders of this kind) if behaviours predictive of these outcomes could be established’.

4 Criteria for Deciding the Sex of an Individual

4.1 In William Jenkins’s affidavit of 1st April 1995 he repeats the criteria which I understand first appeared in the case of Corbett v Corbett of chromosomal, gonadal and genital sex. These criteria are not in currency today in the treatment of transsexualism: gonads are considered to be part of the genitalia rather than separate from them.

4.2 It is incumbent on medical practitioners to determine what constitutes the sex of an individual. The document entitled Transsexualism: the Current Medical Viewpoint attached to this report indicates that the criteria used by the Registrar General are obsolete and no longer reliable in the light of new scientific information. In a paper given to the Council of Europe’s XXIIIrd Colloquy on European Law, in 1993, Gooren suggested that ’there is now evidence to believe that in transsexuals the sexual differentiation process of the brain taking place in the first years after birth has not followed the course anticipated of the preceding criteria of sex (chromosomal, gonadal and genital)’.13 Thus, although sex assignment at birth by the criterion of the external genitalia is statistically reliable, in people experiencing transsexualism it is not: they are exceptions to the statistical rule. Further, the attached extract from Nature entitled ’A sex difference in the human brain and its relation to transsexuality’ concerns a study which has been carried out of a region in the hypothalamus of the brain which is smaller in women than in men. Strikingly, the region was of female size or smaller in six male-to-female transsexuals, regardless of hormone treatment. This research indicates quite clearly that, medically, the sex of an individual must be regarded as being decided by the construction of the brain: it is not an issue of ’psychological sex’ but of physiological differentiation.

5 Other Relevant Medical Issues

5.1 The World Health Organisation defines health as ’a state of complete physical, mental and social well-being and not merely the absence of any disease or infirmity’.14 As the attached document Transsexualism: the Current Medical Viewpoint points out, it is a matter of concern to the UK medical community that the current legal status of people who have been treated for Transsexualism works against their achievement of this. Their legal status marginalises individuals who have no visible difference from others and prevents them from being able to integrate, make relationships or live fulfilling lives and thus impairs quality of life.

5.2 Medically, this inappropriate legal status means that patients are obliged to live with an unnecessarily stigmatising condition. The success rate for treatment of transsexualism is very high and the medical treatment which they receive enables the majority of individuals to live an otherwise quite normal, unremarkable life. An important part of the doctor’s role is to support the individual through the series of rigorous procedures and process of extreme change which constitute the typical effective model of treatment. The aim is to ensure that the individual will be able to live a balanced and fulfilled life in their reassigned gender role, that they will have a positive sense of themselves and be able to realise their full potential, after a lifetime of discomfort and limitation. The typical patient works through this difficult and lengthy medical agenda with courage, patience and dignity. From the above it is obvious that the inability of individuals to document in its entirety their true sex undermines to a great extent the treatment which we give them.

5.3 Quite simply, the lack of an appropriate legal status means that the patient is in the constant situation of having to believe two quite opposite things about themselves at the same time, that on the one hand they are female and that on the other hand they are male. This is a massive assault on their sense of self, their well-being and, potentially, on their mental stability.

5.4 The impossibility of having a complete identity because of the failure of society to allow transsexuals to alter all documentation is likely to affect the individual adversely in a variety of ways. To be constantly reminded of one’s past history and diagnoses is therapeutically counterproductive and militates against the acceptance of body image and the resolution of their new gender role. Possible consequences are distress and despair, leading to clinical depression, with social withdrawal, diminished self-worth and self-esteeem.

5.5 It is clear from this that the current legal status of people treated for transsexualism works directly against their health, as defined by the WHO, and against the best efforts of medicine to maintain their healthy status. It is impossible not to conclude that, for the individual, their legal circumstances constitute a fundamental violation of their right to human dignity.

Dr Russell Reid
Consultant Psychiatrist
Hillingdon Hospital
Pield Heath Road
Uxbridge
Middlesex UB8 3NN

References

1	Benjamin, H. (1953) ’Transvestism and Transsexualism’, International Journal of Sexology, 7:1, 12-14.
2	King, D. (1993) The Transvestite and the Transsexual, Avebury: Aldershot, pp. 41-53.
3	Hamburger, C., Sturrup, G. K. & Dahl-Iversen, E. (1953) ’Transvestism: Hormonal, Psychiatric and Surgical Treatment’, Journal of the American Medical Association, AMA: Chicago, pp. 391-6, p. 391.
4	American Medical Association (1968) Index Medicus, AMA: Chicago.
5	See, for example, Hamburger, C., Sturrup, G. K. & Dahl-Iversen, E. (1953) ’Transvestism: Hormonal, Psychiatric and Surgical Treatment’, Journal of the American Medical Association, AMA: Chicago, pp. 391-6; Glaus, A. (1952) ’Life History of a Transvestite: Third Person to Obtain Official Change of Sex Status in Switzerland’, Montsschrifte fur Psychiatrie und Neurologie, 124, Oct-Dec, Karger, pp. 245-258.
6	American Psychiatric Association (1980) Diagnostic and Statistical Manual of Registered Mental Disorders, Washington: APA, pp. 261-4.
7	Green, R. (1985) ’Foreword’, Gender Dysphoria: Development, Research, Management, ed. B. W. Steiner, New York: Plenum, p. ix.
8	King (1993), p. 41.
9	King (1993), p. 54.
10	Op.cit.
11	Randell, J.B. (1959) "Transvestism and Transsexualism: A Study of 50 Cases", British Medical Journal 26 December, 1448-1452.
12	American Psychiatric Association, (1994) Diagnostic and Statistical Manual of Registered Mental Illnesses, 4th edition Washington:APA
13	Gooren, L J G (1993) ’Biological Aspects of Transsexualism and their relevance to its legal aspects’, Proceedings of the XXIIIrd Colloquy on European Law: Transsexualism, Medicine and the Law, Strasbourg: Council of Europe.
14	World Health Organisation, Constitution (Geneva: WHO, 1946); quoted in Aggleton, P, Health (London: Routledge, 1990), p. 8.