A postmodern view of the world suggests that we can be anything we want to be and that no one should interfere with our decisions. Deciding which sex we would like to be, however, takes this concept to a new extreme. Changes in European and UK law now enable people with gender identity disorder (transsexualism) to change the sex recorded on their birth certificates, but do surgical, hormonal and legal fixes deal with the real problem? Do transsexual people have the wrong bodies, or the wrong beliefs?

On 11th July 2002, the European Court of Human Rights ruled that the UK had infringed Christine Goodwin's right to privacy under Article 8 of the European Convention on Human Rights. In refusing her the right to marry her partner, the UK government had additionally broken Article 12.(1) The court also handed down a similar ruling in the case of 'I' v the UK Government.(2)

The issue was that Christine Goodwin and 'I' claimed to be transsexual. Transsexual people are born with the anatomy and physiology of one sex but have an unshakeable belief that they belong to the opposite sex. Government estimates suggest that there are around 5,000 transsexual people in the UK, and NHS figures show that the health service performed 89 operations to reassign a person's gender in the year 2001-2002, all of which were on men. (3) There are claims that 10,000 such operations have been performed around the world. (4)

In response to the European ruling, the UK government set about altering UK law so that transsexual people can 'protect their privacy' by changing the sex registered on their birth certificates. This change in legal status would also open the way for them to marry a partner of their own sex.

Currently lawmakers around the world are looking to create policies that respect the human rights of people who feel marginalised, and to create a society in which no one is discriminated against. This is leading to a fundamental shift away from previously held basic principles in the way we view and value human life. In summing up the Goodwin case, Lord Nicholls of Birkenhead asked, 'Can a person change the sex with which he or she is born?' The answer that society decides to accept will reveal a lot about its underlying philosophy of human nature, and how best to treat people who are in some way different from the majority.

There is a need to assess the best available data on the causes and treatment of transsexualism before forming opinions about which policies will most benefit these people.

Medical description

In medical literature, transsexualism is poorly defined, but most psychiatrists studying people with the symptoms say that their beliefs can be described as 'over-valued ideas'.(5) People with over-valued ideas believe something to be true beyond any bounds of reason; they firmly believe they are one sex even though all physical evidence suggests that they are the other.

Similar psychiatric conditions include dysmorphophobia (grossly disturbed notions about body shape or bodily organs) and morbid jealousy (a delusional belief that his/her partner is being unfaithful). In these cases, no one would expect the State to modify the law to accommodate these people's beliefs, although medicine may well attempt to relieve the patient eg. with cosmetic surgery for the nose or breasts, or by means of counselling (psychotherapy).

Scientific objectivity

Since the middle of the seventeenth century Western societies have embraced a scientific understanding of the world, based on physical observations. This process applies to determining a child's sex at birth, which in most cases means simply looking for the presence of a penis or vulva.

If in doubt, doctors look for other gender specific characteristics. Males have XY chromosomes, while females have two X chromosomes; males have testes, while females have ovaries. Additional differences exist in other internal sex organs, so for instance, males have sperm ducts, while females have a uterus and fallopian tubes. Looking at biochemical markers there are measurable differences in levels of hormones such as testosterone and oestrogen. These trigger secondary sexual characteristics such as facial hair and body shape.

This fits with the biblical description of humanity that says humans are male or female. Genesis 1:27 states 'So God created man in his own image, in the image of God he created him; male and female he created them.'

In most people these sexual characteristics run together, although there are a few intersex people in whom there is genuine confusion (see box), and it may be very difficult to determine the person's sex. Unlike intersex people, there is no evidence that transsexual people are physiologically other than the sex they were registered as at birth.

Intersex

A person with an intersex condition is born with sex chromosomes, external genitalia, or an internal reproductive system that is not considered standard for either male or female.

The exact frequency of these conditions is difficult to determine because of the confidentiality that surrounds affected individuals. One survey that reviewed literature between 1955 and 1998 assessed the frequency of some of the more common intersex situations. (6)

• Not XX and not XY - one in 1,666 births
• Poorly developed or absent vagina - one in 6,000 births
• Androgen insensitivity syndrome - one in 13,000 births
• Classical congenital adrenal hyperplasia - one in 13,000 births
• Ovotestes - one in 83,000 births
• No discernable medical cause - one in 110,000 births
• Partial androgen insensitivity syndrome - one in 130,000 births
• Complete gonadal dysgenesis - one in 150,000 births

Sex and gender

Many commentators point to a need to distinguish sex and gender, where sex refers to the person's biological make-up, and gender applies to a person's roles and behaviour. And for gender roles, the situation is less fixed. For example, a man who enjoys looking after children could be said to have good 'mothering' skills.

Transsexual people, however, move the debate further, claiming that not only do they perform some of the gender roles of the opposite sex, but that they 'are' the opposite sex.

Causes

For some time there has been a debate as to whether this perception is purely psychological, or whether there is any physical influence such as some form of structural alteration within the individual's brain that might account for a man's conviction that he is a woman. There are some claims that variants in pre-natal exposure to hormones or pesticides like DDT can influence a person's sexual orientation and may play a role in establishing transsexuality. (7)

In another report, published in Nature, researchers measured the volume of an area in the red nucleus (part of the brainstem) in different people. This region is essential for sexual behaviour. They found that while this region was larger in men than in women, male-to-female transsexuals had female-sized regions. (8) This raises the question of whether the brain areas develop and then dictate behaviour, or whether their size changes in response to altered behaviour? Other research has cited excessive numbers of maternal aunts, birth order and left handedness as indicators of transsexuality.(9) (10) The research on this has been very limited, and at its strongest, the suggestions can only be seen as highly speculative.

Indeed the European Court's assessment of the medical and scientific data concluded that there is no scientific evidence to suggest any biological causal factors. (11)

Instead, the Court considered that it is 'more significant [that] transsexualism has wide international recognition as a medical condition'. After all, said the Court, doctors have recently relabelled transsexualism as 'Gender Identity Disorder' in a key psychiatric handbook, the Diagnostic and Statistical manual (4th edition) (DSM-IV). On top of this the Court pointed to the inclusion of Gender Identity Disorder in the International Classification of Diseases (10th Edition) of the World Health Organisation, although the Court did not mention that the term transsexualism is also retained in that book.

The problem here is that psychiatric diagnostic classifications say nothing about underlying causes. The terms are intended purely to describe symptoms, but the European Court treated them as if they identify definite physical disorders that can be solved by physical treatments.

In an attempt to prevent just this sort of misunderstanding, DSM-IV begins with a cautionary statement emphasising that its purpose 'is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that inclusion here… does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability.'

Treatment

The big question here is whether to treat the person's body so that it conforms to their self-image; to give psychological treatment that aims to alter the person's self-image to conform to their body, or to support them as they live in their contradictory state.

In the case of transsexualism, there is no consensus amongst clinicians about the effectiveness of psychological treatments, but there is evidence that, in a proportion at least, transsexual people's perceived quality of life may be improved by hormonal treatment and plastic surgery.

The hormonal treatments alter a person's appearance, but are not risk-free. For male-to-female transsexual people, one review found that these include a 20-fold increase in venous thrombosis, a significant increase in prolactin, which raises the possibility of stimulating some hormone sensitive tumours, and depression. (12) The same review also noted that 'serious adverse risks may be underestimated' in patients swapping from female to male. These include increased weight, decreased insulin sensitivity, poor lipid profile, and increased red cell mass.

The surgery needed to make the physical changes is also complex and involves numerous interventions. For male-to-female transsexual people this includes the removal of penis and testes and creation of an artificial vaginal pouch. Female-to-male patients need artificial penises that are usually built using skin and muscle from the person's arm. While attempts are made to maintain feeling in the newly created organs, they do not respond in a fully normal manner to sexual arousal.

Female-to-male transsexuals also have a double mastectomy and some people have surgery on their larynx aimed at altering the pitch of their voices. On top of this many have plastic surgery to feminise or masculinise their faces.[13] Supporters of the treatment argue that going through this degree of discomfort shows the level of commitment and conviction held by transsexual people, and reviews indicate that a majority of transsexual people are happy with their new identity.(14)

It is worth noting, though, that commitment and conviction are features of many psychiatric conditions in which individuals hold to beliefs that do not fit the facts. The degree of conviction with which a belief is held should not determine its validity.

Gender identity disorder is a mismatch between a person's perception of their body, and their actual body. The danger is that in giving so much attention to changing a person's body to bring the two in line, little effort is given to helping the person alter their perception to fit their body.

Furthermore, none of the treatments change a person's sex, even though they can help a person live more comfortably with their chosen gender. Claiming that a biologically normal person can change sex involves ignoring the compelling physical evidence that says their sex hasn't changed since birth. An operation may alter a person's appearance, and hormone therapy may build on this and modify behaviour, but the person's biological sex has remained unaltered.

Biblical sexuality

The Bible teaches that human beings are created in God's image and of two sexes - male and female. (15) Jesus drew on this when he commented, 'haven't you read, that at the beginning the Creator "made them male and female", and said, "For this reason a man will leave his father and mother and be united to his wife, and the two will become one flesh".' (16)

The Old Testament command 'you shall not commit adultery' also indicates that sexual intercourse should only occur within the framework of marriage.(17) Sex outside the marriage bond is wrong, whether with someone of the same or opposite sex.(18)

Christians acknowledge that the ideal pattern for existence was spoilt when mankind rebelled against God's rules. One consequence of this is that moral values and sexual patterns have been distorted so that people now ignore biblical patterns of sexual behaviour.

The good news at the centre of Christianity is that Jesus, through his death and resurrection, gives people new life and power to change. On top of this, there will be a time in the future when all rebellion against God's plans will come to an end and a perfect relationship with God can be fully restored. This brings the hope that transsexual people may find support as they seek to live in ways that are honest to the way God made them, and open to God's ideals.

It's worth noting that the Bible regards celibacy as a high calling. Jesus was fully human and male, but never married nor had sexual intercourse. He also taught that marriage is not for everyone: some 'are eunuchs because they were born that way; others were made that way by men; and others have renounced marriage because of the kingdom of heaven'. (19) The apostle Paul also taught that 'it is good for a man not to marry', (20) while at the same time affirming marriage as a legitimate choice.

Birth certificates

Many countries attempt to make life more comfortable for transsexual people by allowing them to alter their birth certificates and therefore live without the fear of discrimination. (21) At first sight this may appear to solve some concerns, but it also brings distinct problems by introducing an element of deceit into a legal document.

The change of legal identity cannot be absolute. For example in healthcare, doctors and nurses need to know a person's biological sex in order to provide best medical care. Sports organisations are also concerned that they will not be sure who is competing in women's events (22) and ministers of religion have protested that they would not want to be involved in marrying people of the same biological sex.

To avoid these situations, UK politicians plan to allow security and health services, sports organisations and insurance companies access to original certificates. Furthermore ministers of religion will not be liable for prosecution if they refuse to marry a person who they suspect may be a re-gendered transsexual.

Proponents of the move to enable people freedom to alter their birth certificates claim that this will keep the UK in line with other countries. A 1998 study by the pressure group Liberty pointed to a trend within states in Europe to introduce some recognition of gender reassignment. Of the 37 states the researchers considered, 33 permitted people to make changes to their birth certificate, though the nature of that change varied between countries.

The move to help transsexual people by allowing them to redefine their sex raises important issues. To start with, pretending to change a person's sex influences other people. Many people want to use female gym classes, or see a woman doctor. They may feel intimidated and believe that their privacy was invaded if they had to accept a transsexual gym instructor or doctor. How about facilities like sports club changing rooms? Which should a transsexual person use? The situation is even more complex if they have changed legal gender but had no surgical intervention.

Marriage

To satisfy other European Court concerns, there are also moves to enable transsexual people to marry partners of the opposite sex to their chosen gender. This cuts across the concept of marriage held by many faith and non-faith groups.

Part of the reason why marriage has a special status and privilege within society is that it provides a natural and safe haven for sexual expression and procreation, and is the surest foundation for raising children. By definition transsexual relationships involve a lifestyle that excludes authentic sexual relations and procreation.

Making transsexual identities legal not only changes the law on marriage, it also infringes a person's right to know that they are marrying someone of the opposite sex.

Conclusions

Christians should ensure that weak and marginalised people are protected. As such they should strongly endorse the safeguarding of the basic human rights of transsexual people, affirm their dignity and equality, and help protect them from discrimination. This support, however, needs to be based on an honest appraisal of the situation. Any solution that simply pretends that a person's sex is not biologically determined is both dishonest and uncaring.

Similarly, simply giving into people's medical and legal requests and demands will not always provide the support and care they need, particularly if fulfilling those demands could in itself harm them and their families and friends.

Transsexual people also complain of loneliness. Jesus spent much of his time with people who behaved in ways of which he didn't approve. (23) The challenge for Christians is to love all people genuinely and find ways of befriending them, while at the same time indicating that they don't agree with aspects of the person's lifestyle. At the heart of the Christian gospel is the idea that Jesus can help people change, so Christians should work to create environments where transsexual people can come to know the God who loves them and wishes to restore them to full psychological health.

People in the caring professions need to provide compassionate professional support for transsexual people that does not involve any form of deception.

References

• Goodwin v UK Government 2002
• 'I' v UK Government 2002
• House of Commons. Hansard 26 Feb 2003: Column 616W
• Israel G & Tarver DE. Transgender Care. Philadelphia: Temple University Press, 1997
• Gelder MG, López-Ibor JJ & Andreasen NC. New Oxford Textbook of Psychiatry. OUP. pp62 & 66. 2000
• Blackless M, et al. How sexually dimorphic are we? Review and synthesis. Am J Hum Biol 2000; 12: 151-166
• Dorner G et al. Genetic and Epigenetic Effects on Sexual Brains Organization Mediated by Sex Hormones. Neuroendocrin Let 2001; 22: 403-409
• Zhou JN et al. A sex difference in the human brain and its relation to transsexuality. Nature 1995; 378: 68-70
• Green R. Family occurence of "gender dysphoria": ten sibling or parent-child pairs. Arch Sex Behav 2000; 29: 499-507
• Green R and Keverne EB. The disparate maternal aunt-uncle ratio in male transsexuals: and explanation invoking genomic imprinting. J Theor Biol 2000; 202: 55-63
• Goodwin v UK Government, 2002
• Moore E, Wisniewski A & Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes and adverse effects. J Clin Endocrinol Metab 2003; 88: 3467-3473
• Monstrey S et al. Surgical therapy in transsexual patients: a multidisciplinary approach. Acta Chir Belg 2001; 101: 200-209
• Monstrey S. ibid.
• Genesis 1:27
• Matthew 19:4-5
• Exodus 20:14
• Leviticus 18:22, 20:10
• Matthew 19:12
• 1 Corinthians 7:1
• Integrating Transsexual and Transgendered People - A Comparative Study of European, Commonwealth and International Law. Liberty. 1998
• Barnes S. Welcome to sport's twilight world, where Tina Henman wins Wimbledon. The Times, 23 January, 2004
• Luke 5:30-32