Medicine, Health Care and Philosophy

, Volume 15, Issue 1, pp 31–40

Sliding doors: should treatment of gender identity disorder and other body modifications be privately funded?

Scientific Contribution

DOI: 10.1007/s11019-010-9303-y

Cite this article as:
Giordano, S. Med Health Care and Philos (2012) 15: 31. doi:10.1007/s11019-010-9303-y


Gender Identity Disorder (GID) is regarded as a mental illness and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It will also appear in the DSM-V, due to be published in 2013. The classification of GID as a mental illness is contentious. But what would happen to sufferers if it were removed from the diagnostic manuals? Would people lose their entitlement to funded medical care, or to reimbursement under insurance schemes? On what basis should medical treatment for GID be provided? What are the moral arguments for and against funded or reimbursed medical care for GID? This paper starts out with a fiction: GID is removed from the diagnostic manuals. Then the paper splits in two, as in happened in the Howitt’s 1998 film Sliding Doors. The two scenarios run parallel. In one, it is argued that GID is on a par with other body modifications, such as cosmetic and racial surgery, and that, for ethical reasons, treatment for GID should be privately negotiated by applicants and professionals and privately paid for. In the other scenario, it is argued that the comparison between GID and other body modifications is misleading. Whether or not medical treatment should be funded or reimbursed is independent of whether GID is on a par with other forms of body dissatisfaction.


Gender identity disorder Body modification DSM Access to treatment Cosmetic surgery Racial surgery 


Gender Identity Disorder1 (GID) is described as a mental disorder characterised by a ‘mismatch’ between the assigned gender and biological sex, and one’s perceived gender. GID is included both in the DSM-IV (APA 2000) and in the ICD-10 (WHO 1992). It will also appear in the DSM-V, due to be published in May 2013 (APAa 2010) (Kornstein 2010). The inclusion of GID among mental illnesses is contentious (Arlene 2006). The Council of Europe, in January 2010, has also stressed the need for recasting transsexualism in terms of individual and private difference, rather than as a mental disorder (CoE 2010). But if GID were to be removed from diagnostic manuals, where would this leave people with gender dysphoria, in terms of access to medical care?2 Should the state (or insurance companies) pay for medical treatment for gender issues?


The methods used here are somewhat a departure from the typical methods of bioethics. First, I ground the paper on a fiction: the fiction is that GID is no longer officially regarded as pathology. Second, on this assumption, I construe two cases: one gestures towards the conclusion that, if it is accepted that gender issues are not pathology, then they should be treated in the same way as other types of body dissatisfaction: medical treatment should be negotiated by applicants and healthcare professionals, as in cases of ‘cosmetic’3 surgery; the transaction is a private matter and medical treatment should be paid for privately by the applicant. In the other line of argument it is claimed that gender issues are not necessarily comparable, in normatively relevant ways, to other types of body dissatisfaction, and that it would be unethical to refuse funded medical treatment if that treatment is likely to prevent serious harm. Within each scenario, the arguments are explored with the classic methods of analytic philosophy: the morally relevant facts are identified, and the reasons for and against publicly funded or reimbursed care for gender issues are explored.

Aims and conclusions

The main aim of this paper is to illustrate the complexities relating to medical treatment for gender dysphoria, and to show how seemingly plausible arguments may prompt seemingly irreconcilable conclusions. I will not criticise each argument in turn, but, in running parallel railways, the arguments themselves will oppose to one another and the relative pitfalls of each contention will become apparent in the course of the paper. I will in the end offer my resolution to the dilemma. I will argue that, in cases of gender identity issues, we have prima facie stringent moral reasons to offer funded medical treatment.

Instructions for use

After reading the summary, please do proceed reading one column first, all the way to the bottom, and then the other. It is indifferent which column you read first, whether the one on the left or on the right. Try not to swap from scenario 1 to 2 on your first reading.

Sliding doors

This paper is inspired by the film Sliding Doors, (directed by Peter Howitt). In the film Helen, the protagonist, is fired and leaves her office to get a train back home. In the underground, her life (and the film) splits. In one scenario, she manages to catch the train, but she arrives home earlier than expected, to find her partner in bed with his ex-girlfriend. In the other scenario, she misses the train, and thus she remains ignorant of her partner’s affair. From the time at which the train’s doors slide, either in front or behind her, the film narrates two parallel lives, which unfold in a completely different way, and which run in a paradoxical time overlap.

In the fiction proposed in this paper we also have two scenarios. In both scenarios GID is removed from diagnostic manuals: the human right to be different is upheld; it is claimed that people should not be discriminated against, subjected to any form of abuse and violence for reasons relating to their sex and gender orientation; each individual should be free to explore and construct their identity, without for that reason having to pay the price of being called mentally ill, or the price of any other type of discrimination and abuse.

The difference between the two scenarios concerns what this personal freedom entails, and here the paper splits… (see Table 1)
Table 1

Sliding doors

Scenario 1

Scenario 2

Felines, Star Treks and other varieties: should doctors do this?

Felines, Star Treks and other varieties: should doctors do this?

People may be unhappy with some body parts: the fact, itself, is of no surprise. But sometimes, dissatisfaction may be extreme. Some people would rather not be human. Picture 1 portrays the “Cat-Woman”, who underwent several interventions of facial surgery to look like a cata

The fiction Star Trek prompted another trend: the application of silicon to look like the characters of the film (see Picture 2).

People of course also seek what may appear to be more moderate interventions. For example, a growing number of Asian women seek blefaroplasty (Kaw 2003), and an increasing number of black women seek surgery to look more Caucasian (Haiken 1997, p. 203) (Baumann 2008) (Charles 2003)

Whereas these types of medical interventions might seem less extreme than the ones reported before, they give raise to perhaps more acute ethical dilemmas, as they are based on ‘suspect’ (Little 1996) (Little 1998) norms of social acceptability. In some cases, these norms are inherently racist, and are more worrying to the extent that they are internalised by the person belonging to the discriminated group. It could be argued that the medical profession, by accepting to provide medical treatment to people seeking ‘racial’b surgery, somehow contributes to crystallise the idea that, in order to be acceptable, a person must conform to a stated normative aesthetic standard, which is arguably racist

Let’s see what this all has to do with transsexualism and access to medical treatment

The case of gender identity

Ethically, those interventions that seek to amend ethnic features, as well as many so-called ‘cosmetic’ types of surgery, such as breast implants, liposuction and similar may be even more problematic than a (more unconventional and perhaps more autonomous) preference to look like Mr Spock. They in fact appear to induce people to conform to (or reveal the way in which people internalise) stated standards of social, or even moral (Giordano 2010a) (Giordano 2005, chapters 5 and 6) acceptability, which are suspect or even openly racist.

Not dissimilarly to many of those seeking ‘cosmetic’ and ‘racial’ surgery, people with gender dysphoria also appear to suffer because of ‘suspect’ norms of social acceptability. In many Western societies it is assumed that people should be either men or women. The binary model of gender does not represent the many ways in which gender may develop (Kitzinger 2001). In societies where the gender divide is not as marked trans-people suffer less (Lorber 1995, p. 40). Transsexuals often report that a significant portion of their suffering relates to the disillusion of expectations that the significant others, primarily their parents, construct around their gender. One sufferer narrates:

[The problem with gender is] “not just about you, it is about those you love and the social environment you have to live in. It takes tremendous courage to wear your soul on your shoulders and go and show the ‘real’ you to the world. Even more so to your parents, who have dreams and aspirations that are in line with physical gender […]” (anonymous, personal communication).

Gender dysphoria is in an important way a function of societal inability to contemplate alternative representations of one’s identity (Scott 1986): it is thus on a par with other types of body dissatisfaction, whose causes are unknown (like in Body Dysmorphic Disorder) (Lawrence 2006) or caused by suspect norms of social acceptability. These norms, in the some cases, are clearly morally discriminatory and racist. In the case of gender, they are not only morally dubious (they in fact condemn those with atypical gender identification to the corner of ‘deviance’): they are also conceptually mistaken, as we are now going to see.

Gender as a social construct

The idea that there are only two genders, fixed and stable across one’s life, is a mistake: the binomial distinction of gender does not capture the diversity in which gender may develop; it also assumes that normality requires sex and gender to be congruent, and thus conjectures that biological sex is a clear datum, observable by means of empirical inspection. Under this perspective, an XX individual with primary and secondary sex characteristics congruent with genetic and chromosomal heritage (a biological female), who does not identify with the biological sex, may suffer from gender dysphoria.

However the biological facts are not straightforward. In 1030 Avicenna, the Arabian physician and philosopher, author of the Canon of Medicine, provided one of the very first observations of hermaphrodites. In his De Hermaphrodito, Avicenna says that the hermaphrodito is “the person who has neither the female nor the male member” (Avicenna 1030). Probably for the first time, he gave a medical classification of the phenomenon as well as medical recommendations. We today know of various forms of intersex, technically called Disorders of Sexual Differentiation (DSDs). If biological sex was truly the standard test to assess normality, then those with DSDs should always be confused about their gender. However, this is not the case. Many intersex individuals have unequivocal gender identification. Many of those with atypical gender, reversibly, often have no identifiable DSD (De Vries et al. 2007).

It is not always true, and according to some it is never true, that biology determines gender identity (Scott 1986). Gender is thus, to a large extent at least, a social construct. Various experiments in developmental psychology have shown how gender is construed around the cues (positive and negative reinforcements) provided by the significant others at a developmental stage (Lorber 1994) (Ruspini 2009, p.73) (Archer and Lloyd 2002, pp. 60–71) (Will et al. 1976).

This has important ethical implications for medical practice.

Ethical implications for medicine

If the primary cause of people’s suffering is the set of unrealistic stereotypes around sex and gender, it follows that medicine should be wary of reinforcing models of ‘normality’ or ‘acceptability’ that are responsible for tribulation. Agencies with an important social influence (such as the National Health Service or its equivalent) have a responsibility not to reinforce potentially dangerous prototypes. The case of the media and anorexia nervosa is a glaring illustration of this liability: the British Medical Association (BMA) has suggested that the use of very thin models may trigger anorexia in young women, and has warned the media and the fashion industry to exhibit more realistic images of the female body (BMA 2000, p.43); in some jurisdictions, emaciated models have even been banned from the cat-walks (CCN 2006) (Giordano 2010a, Chapter 5). The argument is that if models of unrealistic beauty are dangerous, there is a reason not to use them. Why shouldn’t the medical profession be subjected to the same norms of moral responsibility?

The effort in the direction of dignity for all, in spite of personal arbitrary differences (such as body shape, age, and gender) should be a concerted effort by all those with public influence over people’s welfare. Therefore certainly the state should not give its support to practices that are ethically dubious, and that risk reinforcing discrimination against those who are different. If suffering is caused primarily by suspect norms, then the state should not provide support for medical practices that, implicitly, contribute to crystallise those norms. Instead, the state and civil society should attempt to change suspect norms, rather people’s bodies.

A matter of private transaction?

It could be objected that even if some conditions are primarily social in nature, this does not mean that medical treatment should be denied: first, it is not always clear to what extent suffering is caused by social factors; personal variables, intrapsychic factors, even unknown biological influences may also be implicated in any dis-ease. It cannot be up to doctors to make judgments over the authenticityc of one’s requests. Second, all our preferences or needs are somehow influenced by society and environment, and it is customary for medicine to intervene despite this. Infertility treatments, surgery for bat ears, breast reconstruction after cancer treatment, are only a few examples of medical interventions provided largely because of social stereotypes of ‘normality’: they are administered purely on psychological grounds (Drop et al. 1998), and are often publicly funded or reimbursed under insurance schemes (Giordano 2010c). Denying treatments for socially determined suffering would lead to a whole recasting of medicine.d Third, it could be objected that whereas influential agencies have a responsibility not to spread dangerous models of social acceptability, individuals should not be turned into martyr of ideals:e if I request skin bleaching because I experience being black as disadvantageous, it is of a little help to me to be denied the treatment that would improve the quality of my life, in the name of ideals of equality or non-discrimination in which I do not recognise myself.

For these reasons, provision of these treatments is not unethical, but it must remain between the arena of private transactions between applicants and professionals (Brazier and Glover 2000). Competent adults have significant freedom to decide what they want to do with their body and with their private life: over these matters they have a prima facie right to absolute non-interference. Decisions relating to one’s body, within the limits of duty of care and professional responsibility, should be matters relating to personal freedom, and should be treated as private transactions between applicants and professionals.

All people are free in dignity and rights”…

…recites The Universal Declaration of Human Rights (United Nations 1948). Thus, people with similar problems should be treated similarly. To fund treatment for gender issues at the expense of equally valid claims is an infringement of this important principle of ethics: not only this would imply that those other claims are less worthy of attention; it would also insinuate that people with gender dysphoria are a case apart. Rather than protecting and defending transgender people from discrimination and stigma, a default policy that provides publicly funded treatment for transsexualism but not for other similar claims reinforces the label of transsexualism as an illness, a deviance.

All desires to look more ‘like oneself’, to feel better in one’s skin are on a par: they are either all paid for, or none is paid for. If only some can be paid for, then they should be chosen at random, or based on income, or on some other morally neutral criteria. Distribution in these cases should not be based on a fictional ‘clinical’ need, as becoming feline may be as important to the Cat Woman as a breast implant to a transsexual.

Moreover, one should ask: what are ‘gender’ issues? The answer to this question is not straightforward and this illustrates further how it would be unethical to publicly fund sex-realignment treatment but not other body modifications.

Suppose I suffer because I have an androgynous structure: my perceived gender, my sense of who I am collides with the way I look. Mine is of course an issue of mismatch between my external phenotypical appearance and who I feel I am. Why should I pay for hair removal and breast implant, which relieves my mismatch, whereas females who want a penis should not pay to correct their own mismatch?


The classification of gender dysphoria amongst mental illnesses in the DSM was a violation of the human right to be different, as upheld by the Universal Declaration of Human Rights, amongst others. But also demanding that treatment should be publicly funded is a violation of the human right to be different and to be treated equally regardless of one’s arbitrary differences. In fact, offering special treatment to one category of potential applicants (transgenders) over other similar applicants, equally unhappy with the way they look, violates the human right of the latter category to be treated with equal concern and respect, and continues to condemn the group of transgenders to the stigma of being a category apart.

From all this, a number of consequences follow: society has a responsibility to reduce the stigma associated with one’s arbitrary features (such as ethnic origins, age, sex and gender). Nonetheless, the principle of autonomy over one’s body cannot and should not be abridged: people should retain the freedom to modify their body, to the extent that this causes no direct harm to others or limits an equal freedom of others. Offering publicly funded treatment to the category of transgenders at the expense of other categories of people seeking body modifications limits the equal freedom of these others; it also continues to stigmatise the category of transgenders as ‘special’ and ‘different’ from all others. Therefore treatment for gender issues should be a matter of private transaction. Within the limits imposed by the duty of care and professional obligations, doctors and patients should negotiate desired outcomes, and patients should pay for their treatment.

A woman has undertaken several surgical interventions to look like a cat. Some people apparently ask for medical help to replicate the characters of Star Trek.f Some want to have their tongue split into two, like snakes. Should doctors do this?

In principle, in the UK at least, doctors have no (legal) duty to satisfy people’s requests for medical treatment. They do not have a duty to file my nose or jaws, should I wish to look like Julia Roberts, and certainly they do not have an obligation to help me look more feline. At the most, within the limits imposed by their duty of care, doctors have a legal and moral right to provide these treatments, provided that the applicants give valid consent and that the treatment is in their best interests

Whereas what is in someone’s best interests may be debatable, and whereas it may be asked what my best interests may ethically impose on others, certainly omissions are not morally neutral options (Giordano 2007). Doctors’ right not to treat is not absolute: they generally must provide cogent moral or clinical reasons to withdraw their services (Hope et al. 2008, Chapter 9). Doctors (like other professionals) have a duty of care towards those who apply for their services (patients/clients), which imposes them not to harm those under their care (Giordano 2010a, Chapter 8), even if they are consenting adults, unless the harm is inflicted to prevent even greater harm or to produce a significant benefit. Surgery, for example, causes harm to the patient, but it is justified if it minimises greater harm or leads to acquisition of significant benefits to the patient. The notions of ‘harm’ and ‘benefits’ should not be understood narrowly as risks/benefits of the treatment only, but should include an assessment of the overall consequences of treatment versus non-treatment upon an applicant’s welfare (Giordano 2008). For example, people with so-called Body Dysmorphic Disorder have received amputations, even if clinically unnecessary, to prevent greater harm (BBC News, 2000) (Brazier and Glover 2000, p. 373).g There is a forceful argument to make, that if the patient will hack off his own legs, as it has happened, by sitting his legs in iced water for 8 h or by laying on the railways to have a train to do the jobh (Furth and Smith 2000), thus betting his life, then the amputation is no less of a life-saving intervention than an amputation for gangrene. Arguably, in these cases it would be unethical to deny such treatment, as the likely foreseeable consequences of omission are pernicious or fatal. This obligation can in these cases be subsumed under the rule of rescue (McKie and Richardson 2003).

Let’s see what this all has to do with transsexualism and access to medical treatment.

The case of gender identity

Gender dysphoria is characterised by severe and persistent discomfort with the assigned gender. Where the condition is persistent, the psycho-social adjustment of the sufferer is typically very difficult. There is high suicidal ideation amongst people (including youth) with atypical gender, especially when timely medical treatment has not been provided (Imbimbo et al. 2009) (Giordano 2008). Whereas doctors have no legal obligation, at least in the UK, to intervene at request, it can be argued that they should provide treatment for gender dysphoria when three important conditions are met: first, the person must be in distress, and his/her suffering cannot be ameliorated with psychological/social intervention (for example, with psychotherapy, family or school involvement); second, the applicant has been assessed by specialists according to the best international clinical guidelines (WPATH 2001) (Endocrine Society 2009), and it must be sufficiently clear that the person’s gender identification is atypical and that the person will benefit from medical intervention; finally, it should be expected that non-treatment is the most risky option: for example it should be probable that the overall psycho-social sequel associated with non-treatment is pernicious and worse for the applicant than that associated with treatment. When these conditions are met, medical intervention is ethical, and it would indeed be unethical to deny it (Giordano 2008). This should stand not only for transgenderism, but also for other types of body dissatisfaction, whether ‘cosmetic’, ‘racial’ or otherwise.

It should in fact be noted that the comparison between ‘racial’, ‘cosmetic’ surgery, and medical treatment for gender dysphoria is misleading. It suggests that, if treatment for gender dysphoria is on a par with ‘racial’ or ‘cosmetic’ surgery, then doctors have no moral obligation to provide it, and even a contentious moral right to satisfy the applicant’s requests. Instead, here it is not a matter of first determining whether the intervention for gender dysphoria is (or is on a par with) ‘cosmetic’ or ‘racial’ interventions and then deciding on that basis whether medical treatment is ethically justified or not. Doing so begs the question as to why some requests are regarded as ‘clinical needs’ and others are not. Also, this is not a matter of drawing lists of demands that should or should not be fulfilled, based on the way in which these demands are qualified (as ‘cosmetic’ or ‘racial’ as opposed to ‘medical’). It is instead a matter of assessing, together with the applicant, the overall expected consequences of treatment versus non-treatment. Where the risk–benefit ratio appears to be in favour of medical intervention, then, prima facie, intervention should be provided, and society and the state have a responsibility to provide public support for requested interventions. This obligation can also be subsumed under the rule of rescue.

Gender as a social construct

The suffering associated with gender dysphoria is caused to a significant extent by a suspect bi-polar model of gender (Giordano 2010c). Gender dysphoria is somehow construed around norms of social acceptability (Giordano 2010b): these are scientifically ungrounded and also unethical, to the extent that they promote the idea that gender difference is a deviance. It could thus be argued that treatment for gender dysphoria is on a par with ‘cosmetic’ or ‘racial’ surgery, and that we shouldn’t change people’s body, we should change the social norms.

This argument reminds us of the responsibility society has to ensure equal dignity for all, regardless of gender orientation. However it misses out on some important points: first, many transsexuals do not wish to conform to social stereotypes of masculinity or femininity: in fact, they often depart radically from those. Many explore different gender identities in different contexts (use their female identity in some settings and their male identity in others); many take hormones to become more masculine or feminine, but want to keep their genitals. Many embrace various elements of both genders, well beyond the classic gender divide. Thus there is a difference between those who seek medical intervention to conform to social norms of acceptability, and those who seek medical intervention against social stereotypes in order to express more fully who they are. Second, society should ensure that everybody’s dignity and rights are protected regardless of arbitrary features such as race, age, and gender. But from it does not follow that transsexuals should receive no medical care (or no funded medical care). Of course if society is wrong we should change society. However this does not imply that we should deny medical treatment that may also be necessary in order to ensure that everybody’s differences are respected and protected. If it is possible to alleviate people’s suffering, then there is a prima facie stringent moral reason to do so.

This has important ethical implications for medical practice.

Ethical implications for medicine

Doctors perhaps have a responsibility not to reinforce mistaken norms of social acceptability (as the fashion industry and the media, for example, also have). However, they have a responsibility to alleviate people’s suffering and ameliorate their quality of life. A principle of minimisation of harm and a principle of beneficence are found in virtually all moral and professional codes (Giordano 2010a Chapter 9). The fact that a condition is partly determined by social factors should not cloud our judgment in observing and assessing that condition. Infertility is in many cases socially induced. Many women, due to social variables, seek children late in life, when their fertility decreases. In those cases, infertility is clearly a function of social factors, but this does not imply that, for that reason, medical treatment should not be provided and funded publicly. The state also funds medical treatment for conditions on social and psychological grounds (Drop et al. 1998): breast reconstructions after accidents or breast cancer, surgery for bat ears and hormonal treatment for excessive or retarded growthi are all examples of interventions meant to align the person to social standards of normality. These are typically funded publicly or reimbursed under many insurance schemes (Giordano 2010c).

Even if suffering is to a significant extent socially determined, it does not follow that people should not receive treatment that is proven to alleviate their affliction. Only by tempering that distress and allowing people to flourish, the medical profession may promote acceptance for people’s differences.

A matter of private transaction?

Even if gender dysphoria is not an illness, treatment should not be regarded as a matter of private transaction. First, not being an illness is normatively irrelevant in this sense (Brazier and Glover 2000): it is well-known that some disability-right activists contested that their conditions are not disabilities but different abilities (Giordano 2010d). Some have tried to have deaf children, contending that deafness is indeed a privileged state (McKie and Hinsliff 2008). This shows that the notions of disability/disorder are not just a matter of empirical or scientific observation, but of value, and that their nature is elusive. As Brazier and Glover write, “unless the law can settle upon some coherent and defensible definition of illness, the elasticity of concepts of illness may snap” (Brazier and Glover 2000, p. 375).

Therefore these notions cannot be and should not be the standard test to decide whether people are entitled to funded care. Moreover, the argument that being ill is a necessary condition for obtaining funded treatment begs the question as to why some conditions (which appear deserving treatment) are regarded as illnesses and others are not. Second, there many conditions are treated medically in spite of not being ‘illnesses’ (see previous section). If treatment for these conditions is offered, then prima facie treatment for gender dysphoria should also be on the same grounds: if it is likely to reduce suffering or prevent greater harm, is potentially life-saving, and is likely to ameliorate the sufferer’s quality of life.

All people are free in dignity and rights”…

…recites The Universal Declaration of Human Rights (United Nations 1948). Thus, people with similar problems should be treated similarly. To fund treatment for gender issues at the expense of equally valid claims is, it could be argued, an infringement of this important principle of ethics. However, gender dysphoria is not on a par with the wish to become feline or with the unease with some of our body parts. First, for many of those affected, gender dysphoria is a terrible state to be in. If not treated, the psychological and social sequel is for them grim and hideous (Delemarre-van de Waal and Cohen-Kettenis 2006). One may object that the psycho-social adjustment of the Cat Woman was very poor before becoming feline. However, there is much less evidence about the psychological dynamics and outcomes for those seeking ‘racial’, ‘cosmetic’ (or feline) surgery. An empirical assessment of various applicants to treatment for gender dysphoria and other body modifications would be necessary before one can argue that these various conditions are on a par and should be treated in the same way. Second, receiving medical treatment is a life/death matter for many transgenders. In these cases, treatment should be regarded as life-saving (Giordano 2008). Of course if rhinoplasty were to save someone’s life, it should equally be regarded as life-saving. Third, whereas the predilection for a smaller nose or bigger breasts can be a preference, it is not clear that gender dysphoria is a preference in the same way. The onset of transgenderism is in many cases very early (at the age of 2 to 4) (Manners 2009) and is often persistent. It is thus likely that gender dysphoria has to do with early development of gender identity, rather than with the susceptibility to and acquisition of social stereotypes. Thus, gender variance is not comparable in all morally relevant senses to other types of body discomfort. The causes of this phenomenon are unknown and are probably multiple (Moller et al. 2009) (Nawata et al. 2010), but its severity and early onset may indicate that there is something non-negotiable about atypical gender identification.


The argument that:

Because atypical gender development is not to be regarded as an illness therefore it should be considered on a par with other forms of body discomfort is incomplete. The fact that several types of body discomfort are not illnesses does not mean they are all on a par.

The argument that:

Because many types of body modifications are matters of private transaction therefore medical treatment for gender dysphoria must also be is also flawed. It might well be that some other types of body modifications should also be funded publicly or reimbursed under insurance schemes.

From all this, a number of consequences follow: society has a responsibility to reduce the stigma associated with one’s arbitrary features (such as ethnic origins, age, sex and gender). This does not mean that all claims to body modifications deserve social support. It means that treatment (whether ‘cosmetic’ or otherwise) should be offered and publicly funded when the conditions discussed above are met. Whether or not medical treatment should be offered and paid for depends not on they type of condition one has, but on whether the condition (whether associated with gender, ethnic belonging or others) is severe enough to impinge significantly upon the quality of life of the sufferer, to markedly jeopardise his/her psycho-social functioning, and whether available medical treatment is likely to ameliorate his/her condition.

aThe source of these pictures is

bI put racial in inverted commas because the qualification of a medical intervention as ‘racial’ implies a morally negative connotation, and thus somewhat the adjective begs the question as to why these interventions are regarded as ‘racial’ and therefore morally controversial. In this paper by ‘racial’ I refer to those interventions that seek to temper features associated with one’s ethnic origins. In this paper the case of ‘racial’ surgery is only used to illustrate an instance of ethically controversial medical procedure

cBy authenticity here I mean the extent to which these wishes are formed autonomously and are not purely the result of social conditioning

dOf course, in this case, one should also accept that doctors be in charge of resolving the epistemic problem of determining the degree in which the request is ‘socially’ determined, and the moral problem of deciding when the request is ‘too’ socially constructed to deserve medical attention

eI owe this observation to Charles Erin

fReferences available in scenario 1

gBrazier and Glover point out that in the cases occurred in the early 2000 in Scotland treatment was paid for privately. The NHS Trust immediately prohibited any such operation nonetheless. Brazier and Glover argue that the ‘illness’ requisite is ‘too elastic’ to grant access to funded treatment, and that these types of treatments should be privately paid for. They argue that the ‘illness’ requirement should be retained for publicly funded care. In one scenario of this paper I contend that treatment for this or any other condition should be paid for by the community or reimbursed by insurance schemes, when the conditions explained in this paper, are met, regardless of the classification of the dis-ease as ‘illness’. See Brazier and Glover 2000, pp. 371–388

hRobert Smith, Consultant surgeon at Forth Valley Acute Hospitals Robert offered a presentation of these cases in his “Less is More: Body Integrity Identity Disorder” at the University of Manchester. Unpublished. See also Furth and Smith 2000

iI owe this observation to Peter Clayton

What we have reason to prefer

The Polish film director and writer Krzysztof Kieslowsky produced a film in 1982, called Blind Chance, from which perhaps Sliding Doors took inspiration. The film splits in three, rather than two stories. At the beginning of the film, Witek, the protagonist, runs to the station to get a train to Warsaw. He crashes into an old man who is drinking a beer. In one scenario, he ignores the fact and, by a moment, he is able to jump on the last carriage of the already moving train. In the second scenario, he just apologises quickly, but nonetheless misses the train. In the third, he stops to help the old man, and misses the train. His life, from now onwards, depends on whether he apologises for spilling the beer of an old man. The paths his life takes, depending on these seemingly inconsequential facts and choices (an old man is on his way, and how he decides to respond to his disappointment), are drastically different.

The moral of the film is as obvious as is somehow disquieting: accidental facts beyond our control, combined with the moral choices we and others may make, can radically change our life. This incontrovertible truth goes often unnoticed, and the film brings it to light and compels us to think about the moral responsibility we bear, when the actors are us.

In this paper, I have wanted to highlight some of the complexities relating to the treatment of gender identity issues. Both scenarios offer seemingly plausible arguments for and against providing publicly funded treatment for gender dysphoria. But what is more important is what these parallel railways may tell us: the moral choices that the actors may make over the random facts of our life (I happen to be born black or short, or I happen to develop my gender in an atypical way in Thailand, rather than Belgium rather than in Bristol, where both society and the medical profession may make a number of diverse moral choices relating to my condition) can have a number of splayed consequences in our own life. In this light, it becomes imperative that we, as actors, take the course of action that, with the insight of available evidence, is likely to promote the best outcome and to minimise the risk of highly negative consequences.

The following extract explains some of the consequences of not providing treatment for people with gender dysphoria (including publicly funded treatment, when needed).

First, it […] alienates [sufferers] from medical providers […]. Because of this increased distrust, many may not return for primary care, HIV testing, STD treatment and other essential care […] [T]hese denials also create a necessity […] to seek this care out elsewhere. For many, this care is the only way to express their gender fully so that they can seek employment, attend school, and deal with every day interactions in their new gender. Without hormones, many have a difficult time being perceived by others correctly, opening them up to consistent harassment and violence. For many young people [medical treatment] feels like a life or death need, and they will do whatever is necessary to get this treatment. Many, when rejected at a clinic […], buy their hormones from friends or on the street, injecting without medical supervision at dosages that may not be appropriate and without monitoring by medical professionals. This opens them up to high risk for HIV, hepatitis, and other serious health concerns. Additionally, many youth have difficulty raising money to buy these hormones illegally because they do not have parental support for their transition and face severe job discrimination as young transgender applicants. For many, criminalized behaviour such as prostitution is the only way to raise the money. Doing this work makes them vulnerable to violence, trauma, HIV, and STD infection, and entanglement in the […] justice system […] (Fenner and Mananzala 2005)

These are anecdotal pieces of evidence, but they are the pieces of evidence provided by those who are best equipped to tell us what it is to have a complicated gender development and what it means to be denied access to funded medical care. For many transsexuals, receiving proper medical treatment as well as psychological support is a life or death matter. Whatever other considerations may need to be addressed, there is thus a prima facie moral reason to provide treatment. Whereas there may be a case for reconstructing healthcare funding maybe according to personal finances (as is the case in some Mediterranean countries, where people may have to pay for a share of the healthcare costs according to income4), and whereas certainly there is a case for improving social acceptance of gender variance, the compelling reason to offer medical intervention is that the condition, whatever its aetiology may be, is severe, and medical treatment can make the whole difference between one life that is acceptable and relatively flourishing, and another life which is condemned to overarching grief.

GID is also called ‘transsexualism’, ‘transgenderism’, gender dysphoria, gender variance, atypical gender identity organisation. In this paper I will use the terms as synonymous.


I use ‘medical care’, ‘intervention’ and ‘treatment’ as synonymous, even if there is no ‘illness’ to ‘cure’ in gender dysphoria.


I use ‘cosmetic’ in inverted commas for the following reasons: first, it is unclear what it is that makes some interventions ‘cosmetic’ rather than, ‘reparative’, or ‘regenerative’, for example. Thus the term appears too imprecise to qualify what it proposes to qualify. Second, the adjective has important normative connotations. It qualifies the intervention as ‘non-medical’, as somehow superfluous. This begs the question as to why some types of requests are thought of as based on a ‘clinical’ necessity whereas others are regarded as based on a somehow more ‘arbitrary’ preference. Finally, it implies that a claim for ‘cosmetic’ intervention does not have the same compelling force than a claim based on a ‘clinical’ need: this assumes somehow what needs demonstrating. One of the arguments of this paper is that the way requests are qualified (as cosmetic rather than otherwise) bears no normative relevance.


This is an example of how this works: in 2010, in Italy, in a family with a cumulative income of over 40,000 Euros per year, a dermatological visit at a specialist clinic costs 24 Euros (against anything between 60 and 150 Euros in the private sector, and in addition to normal yearly tax based on income). Families with a cumulative salary of less than 40,000 Euros will be exempt.




I wish to thank Simon Barnes, Dino Topi, John Harris, Soren Holm, Margaret Brazier and Charles Erin for reading and commenting on this manuscript, and for providing useful reference and insight for the realisation of this project. I would like to acknowledge the stimulus and support of the iSEI Wellcome Strategic Programme in The Human Body, its Scope Limits and Future in the preparation of this paper.

Copyright information

© Springer Science+Business Media B.V. 2010

Authors and Affiliations

  1. 1.Reader of Bioethics, CSEP/iSEIThe University of Manchester, The School of LawManchesterUK

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