Sex reassignment therapy

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Sex reassignment therapy can consist of hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance. including permanent hair removal for trans women.

In addition to undergoing medical procedures, transsexual people who go through sex reassignment therapy usually change their social gender roles, legal names and legal sex designation. The entire process of change from one gender presentation to another is known as transition.

In appropriately evaluated cases of severe gender identity disorder, sex reassignment therapy is often the best when standards of care are followed.[1]:1570[2]:2108 There is academic concern over the low quality of the evidence supporting the efficacy of sex reassignment therapy as treatment for gender identity disorder, but more robust studies are impractical to carry out;[3]:22 as well, there exists a broad clinical consensus, supplementing the academic research, that supports the effectiveness in terms of subjective improvement of sex reassignment therapy in appropriately selected patients.[3]:2–3 Treatment of gender identity disorder does not involve attempting to correct the patient's gender identity, but to help the patient adapt.[1]:1568

Major health organizations in the U.S.A. and U.K. have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases.[4][5][6][7]

Eligibility[edit]

In current medical practice, a diagnosis is required for sex reassignment therapy. In the International Classification of Diseases the diagnosis is known as transsexualism ([8]). The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender identity disorder (in version 4) or gender dysphoria (in version 5[9]). While the diagnosis is a requirement for determining medical necessity of sex reassignment therapy, some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

Transsexualism[edit]

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7.[10] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)... Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

Local standards of care exist in many countries.

In cases of comorbid psychopathology, the standards are to first manage the psychopathology and then evaluate the patient's gender identity disorder. Treatment may still be appropriate and necessary in cases of significant comorbid psychopathology, as "cases have been reported in which the individual was both suffering from severe co-occurring psychopathology, and was a 'late-onset, gynephilic' MTF transgender adult, and yet experienced a long-term, positive outcome with hormonal and surgical gender transition."[3]:22

However, some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. The DSM-IV itself states that in rare instances, gender identity disorder may co-exist with schizophrenia, and that psychiatric disorders are generally not considered contraindications to sex reassignment therapy unless they are the primary cause of the patient's gender dysphoria. [11]:108

Eligibility for different stages of treatment[edit]

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended.[10]

Hormone replacement therapy is to be initiated on referral from a qualified health professional. The general requirements, according to the WPATH standards, include:

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to consent for treatment; 3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents); 4. If significant medical or mental health con cerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone.[10]

As surgery is a radical and irreversible intervention, more stringent standards are usually applied. Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the members of their target gender in all possible ways for at least a year ("cross-live"), prior to the start of surgery, in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.

The time period of "cross-living" is usually known as the Real-Life-Test (RLT) or Real-Life-Experience (RLE). It is sometimes required even before hormone therapy, but this is not always possible; transsexual men frequently cannot "pass" this period without hormones. Transsexual women may also require hormones to pass as women in society. Most trans women also require facial hair removal, voice training or voice surgery, and sometimes, facial feminization surgery, to be passable as females; these treatments are usually provided upon request with no requirements for psychotherapy or "cross-living".

Some surgeons who perform sex reassignment surgeries may require their patients to live as members of their target gender in as many ways as possible for a specified period of time, prior to any surgery. However, some surgeons recognize that this so-called real-life test for trans men, without breast removal and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of sex reassignment surgery without a real-life test. This is especially common amongst surgeons who practice in Asia. However, almost all surgeons practicing in North America and Europe who perform genital reassignment surgery require letters of approval from two psychotherapists; most Standards of Care recommend, and most therapists require, a one-year real-life test prior to genital reassignment surgery, though some therapists are willing to waive this requirement for certain patients.

The requirements for chest reconstruction surgery are different for transmen and transwomen. The Standards of Care require trans men to undergo either 3 months of Real-life-test or psychological evaluation before surgery whereas transwomen are required to undergo 18 months of hormone therapy. The requirement for trans men is due to the difficulty in presenting as male with female breasts, especially those of a C cup or larger. For very large breasts it can be impossible for the trans man to present as male before surgery. For trans women, the extra time is required to allow for complete breast development from hormone therapy. Having breast augmentation before that point can result in uneven breasts due to hormonal development, or removal of the implant if hormonal breast development is significant and results in larger breasts than desired.

Eligibility of minors[edit]

While the WPATH standards of care generally require the patient to have reached age of majority, they include a separate section devoted to children and adolescents.

While there is anecdotal evidence of cases where a child firmly identified as the other sex from a very early age, studies cited in the standards of care show that in the majority of cases such identification in childhood does not persist into adulthood. Therefore no intervention can be justified at that stage. However, with adolescents, persistence is much more likely, and so non-reversible treatment by puberty blockers can be prescribed.

The treatment is controversial as the use of puberty blockers involves risk of adverse physical effects. However, a risk is also associated with denying such treatment, as it might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization.[10]

Psychological treatment[edit]

According to the WPATH SOC v7, "Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience" is a treatment option.[10]

Hormone replacement therapy[edit]

For transsexual men and women, hormone replacement therapy (HRT) causes the development of many of the secondary sexual characteristics of their desired sex. However, many of the existing primary and secondary sexual characteristics cannot be reversed by HRT. For example, HRT can induce breast growth for transsexual women but cannot reduce breasts for transsexual men. HRT can prompt facial hair growth for transsexual men, but cannot regress facial hair for transsexual women. HRT may, however, reverse some characteristics, such as distribution of body fat and muscle, as well as menstruation in transsexual men.

Generally, those traits that are easily reversible will revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many transsexual people, surgery is required to obtain satisfactory physical characteristics. But in trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when high hormone doses are taken as is common for pre-operative transsexual patients. It is always advised that all changes in therapeutic hormonal treatment should be supervised by a physician because starting, stopping or even changing dosage rates and levels can have physical and psychological health risks.

Although some transsexual women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been performed with regards to the safety or effectiveness of such products. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if at all noticeable, when compared to conventional hormone therapy.

Some transsexual men and women are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Chest reconstruction surgery[edit]

For most trans men chest reconstruction is required to present as male. Binding of the chest tissue can cause a variety of health issues including reduced lung capacity and even broken ribs if improper techniques or materials are used. A Mastectomy is performed, often including a nipple graft for those with a B or larger cup size.

For trans women, breast augmentation is done in a similar manner to those done for cisgendered women. As with cisgender women, there is a limit on the size of implant that may be used, depending on the amount of pre-existing breast tissue.

Sex reassignment surgery[edit]

Sex reassignment surgery (SRS) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.

Sex reassignment surgery is the most common term for what may be more accurately described as "genital reassignment surgery" or "genital reconstruction surgery." Other proposed terms for SRS include "gender confirmation surgery," "gender realignment surgery," and "transsexual surgery." The aforementioned terms may also specifically refer to genital surgeries like vaginoplasty and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is genital reassignment surgery (GRS). There are significant medical risks associated with SRS that should be considered before undergoing the surgery.

Effectiveness[edit]

The Merck Manual states, in regards to male-to-female transsexuals, "In follow-up studies, genital surgery has helped some transsexuals live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexuals, who have completed a 1- to 2-year real-life experience in the opposite gender role. Before surgery, transsexuals often need assistance with passing in public, including help with gestures and voice modulation. Participation in support groups, available in most large cities, is usually helpful."[1]:1570 With regards to female-to-male transsexuals, it states, "Surgery may help certain [female-to-male] patients achieve greater adaptation and life satisfaction. Similar to male-to-female transsexuals, female-to-male transsexuals should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for male-to-female transsexuals. Complications are common, especially in procedures that involve extending the urethra into the neophallus."[1]:1570

Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, with regards to adults, "When patient gender dysphoria is severe and intractable, sex reassignment is often the best solution."[2]:2108 Regret tends to occur in cases of misdiagnosis, no Real Life Experience, and poor surgical results. Risk factors for return to original gender role include history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good post-operative outcomes. Many prepubescent children with cross-gender identities do not persist with gender identity disorder.[2]:2109–2110

A 2009 systematic review looking at individual surgical procedures found that "[t]he evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence."[12]

A 2010 meta-analysis of follow-up studies reported that "[v]ery low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life. MF transsexuals may have worse outcomes than FM individuals." Specifically, the study found that "Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%)."[13]

With regards to follow-up, Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, "Clinicians are less likely to report poor outcomes in their patients, thus shifting the reporting bias to positive results. However, some successful patients who wish to blend into the community as men or women do not make themselves available for follow-up. Also, some patients who are not happy with their reassignment may be more known to clinicians as they continue clinical contact."[2]:2109

A recent Swedish study (2010) found that “almost all patients were satisfied with sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in global functioning”[14] A prospective study in the Netherlands that looked at the psychological and sexual functioning of 162 adult applicants of adult sex reassignment applicants before and after hormonal and surgical treatment found, "The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets." (The term "non-homosexual" in this context refers to persons who were attracted to persons of the sex that was opposite to their birth sex prior to surgery - that is, male-to-female transsexuals who were attracted to women and female-to-male transsexuals who were attracted to men.)[15]

A long-term follow-up study performed in Sweden over a long period of time (1973–2003) found that morbidity, suicidality, and mortality in post-operative transsexual persons were still significantly higher than in the general population, suggesting that sex reassignment therapy is not enough to treat gender identity disorder, highlighting the need for improved health care following sex reassignment surgery. The study, however, states that "no inferences can be drawn [from this study] as to the effectiveness of sex reassignment as a treatment for transsexualism," citing studies showing the effectiveness of sex reassignment therapy, though noting their poor quality. The authors noted that the results suggested that those who received sex reassignment surgery before 1989 had worse mortality, suicidality, and crime rates than those who received surgery on or after 1989: mortality, suicidality, and crime rates for the 1989-2003 cohort were not statistically significant compared to healthy controls (though psychiatric morbidity was); it is not clear if this is because these negative factors tended to increase a decade after surgery or because in the 1990s and later improved treatment and social attitudes may have led to better outcomes.[16]

The abstract of the American Psychiatric Association Task Force on GID's report from 2012 states, "The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups."[3] The APA Task Force states, with regard to the quality of studies, "For some important aspects of transgender care, it would be impossible or unwise to engage in more robust study designs due to ethical concerns and lack of volunteer enrollment. For example, it would be extremely problematic to include a 'long-term placebo treated control group' in an RCT of hormone therapy efficacy among gender variant adults desiring to use hormonal treatments." [3]:22 The Royal College of Psychiatrists concurs with regards to SRS in trans women, stating, "There is no level 1 or 2 evidence (Oxford levels) supporting the use of feminising vaginoplasty in women but this is to be expected since a randomised controlled study for this scenario would be impossible to carry out."[7]

Following up on the APA Task Force's report, the APA issued a statement stating that the APA recognizes that in "appropriately evaluated" cases, hormonal and surgical interventions may be medically necessary and opposes "categorical exclusions" of such treatment by third-party payers.[4] The American Medical Association's Resolution 122 states, "An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID".[5]

The need for treatment is emphasized by the higher rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics.[17][18]

Ethical, cultural, and political considerations[edit]

Sex reassignment therapy is a controversial ethical subject. Notably, the Roman Catholic church, according to an unpublished Vatican document, holds that changing sex is not possible and, while in some cases treatment might be necessary, it does not change the person's sex in the eyes of the church.[19] Some Catholic ethicists go further, proclaiming that a "sex change operation" is "mutilation" and therefore immoral.[20]

Paul R. McHugh, a psychiatrist affiliated with the Roman Catholic Church,[21] is a well-known opponent of sex reassignment therapy. According to his own article,[22] when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Science, it was part of his intention to end sex reassignment surgery there. McHugh succeeded in ending it at the university.[23]

Ethical opposition was also expressed by several writers identifying as feminist, most famously Janice Raymond. Her paper was allegedly instrumental in removing Medicaid and Medicare support for sex reassignment therapy in the US.[24]

Sex reassignment therapy, especially surgery, tends to be expensive and is not always covered by public or private health insurance. In many areas with comprehensive nationalized health care, such as some Canadian provinces and most European countries, SRT is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. The government of Iran, however, pays for such surgery because it is believed to be valid under Shi'ite Belief.[25]

A significant and growing political movement exists, pushing to redefine the standards of care, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.[26]

The United States[edit]

From 1981 until 2014, the Centers for Medicare and Medicaid Services (CMS) categorically excluded coverage of sex reassignment surgery by Medicare in its National Coverage Determination (NCD) "140.3 Transsexual Surgery." but that categorical exclusion came under challenge by an "aggrieved party" in an Acceptable NCD Complaint in 2013 and was subsequently struck down the following year by the Departmental Appeals Board (DAB), the administrative court of the U.S. Department of Health and Human Services (HHS).[27][28] In late 2013, the DAB issued a ruling finding the evidence on record was "not complete and adequate to support the validity of the NCD" and then moved on to discovery to determine if the exclusion was valid.[29] CMS did not defend its exclusion throughout the entire process. On May 30, 2014, HHS announced that the categorical exclusion was found by the DAB to not be valid "under the 'reasonableness standard,'" allowing for Medicare coverage of sex reassignment surgery to be decided on a case-by-case basis. HHS says it will move to implement the ruling. As Medicaid and private insurers often take their cues from Medicare on what to cover, this may lead to coverage of sex reassignment therapy by Medicaid and private insurers.[27][28] The evidence in the case "outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental," according to the DAB in its 2014 ruling.[30]

A 2014 article published in American Journal of Public Health called on third-party payers to cover sex reassignment therapy in appropriately selected cases.[31]

See also[edit]

References[edit]

  1. ^ a b c d George R. Brown, MD (20 July 2011). "Chapter 165 Sexuality and Sexual Disorders". In Robert S. Porter, MD; et al. The Merck Manual of Diagnosis and Therapy (19th ed.). Whitehouse Station, NJ, USA: Merck & Co., Inc. pp. 1567–1573. ISBN 978-0-911910-19-3. 
  2. ^ a b c d Richard M. Green, M.D., J.D. (June 8, 2009). "18.3 Gender Identity Disorders". In Benjamin Sadock; Viginia Alcott Sadock; Pedro Ruiz. Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed.). Lippincott Williams & Wilkins. pp. 2099–2111. ISBN 0781768993. 
  3. ^ a b c d e William Byne, Susan J. Bradley, Eli Coleman, A. Evan Eyler, Richard Green, Edgardo J. Menvielle, Heino F. L. Meyer-Bahlburg, Richard R. Pleak & D. Andrew Tompkins (August 2012). "Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder". Archives of sexual behavior 41 (4): 759–796 (pages cited as pages at link). doi:10.1007/s10508-012-9975-x. PMID 22736225. 
  4. ^ a b Drescher, Jack; Haller, Ellen (July 2012). "Position Statement on Access to Care for Transgender and Gender Variant Individuals". American Psychiatric Association. American Psychiatric Association. Retrieved 17 January 2014. 
  5. ^ a b "AMA Resolution 122". AMA House of Delegates May 2008 Report (showing that Resolution 122 was affirmed). American Medical Association. May 2008. Retrieved 17 January 2014. 
  6. ^ "APA Policy Statement: Transgender, Gender Identity, & Gender Expression Non-Discrimination". American Psychological Association. American Psychological Association. August 2008. Retrieved 17 January 2014. 
  7. ^ a b "Good practice guidelines for the assessment and treatment of adults with gender dysphoria". Royal College of Psychiatrists. Royal College of Psychiatrists. October 2013. Retrieved 17 January 2014. 
  8. ^ F64.0"Excerpt from ICD 10". 
  9. ^ "DSM 5 gender dysphoria fact sheet". 
  10. ^ a b c d e "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7". 
  11. ^ Brown, Mildred (2003). True selves : understanding transsexualism-- for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. ISBN 978-0-7879-6702-4. 
  12. ^ P. A. Sutcliffe, S. Dixon, R. L. Akehurst, A. Wilkinson, A. Shippam, S. White, R. Richards & C. M. Caddy (March 2009). "Evaluation of surgical procedures for sex reassignment: a systematic review". Journal of plastic, reconstructive & aesthetic surgery : JPRAS 62 (3): 294–306. doi:10.1016/j.bjps.2007.12.009. PMID 18222742. 
  13. ^ Murad, Mohammad Hassan; Elamin, Mohamed B.; Garcia, Magaly Zumaeta; Mullan, Rebecca J.; Murad, Ayman; Erwin, Patricia J.; Montori, Victor M. (2010). "Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes". Clinical Endocrinology 72 (2): 214–31. doi:10.1111/j.1365-2265.2009.03625.x. PMID 19473181. 
  14. ^ Johansson, Annika; Sundbom, Elisabet; Höjerback, Torvald; Bodlund, Owe (2009). "A Five-Year Follow-Up Study of Swedish Adults with Gender Identity Disorder". Archives of Sexual Behavior 39 (6): 1429–37. doi:10.1007/s10508-009-9551-1. PMID 19816764. 
  15. ^ Bancroft, J. (2009). Human sexuality and its problems. Elsevier. p. 291. ISBN 978-0-443-05161-6. 
  16. ^ Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L. V.; Långström, Niklas; Landén, Mikael (2011). "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden". In Scott, James. PLoS ONE 6 (2): e16885. doi:10.1371/journal.pone.0016885. PMC 3043071. PMID 21364939. 
  17. ^ Heylens, Gunter; Verroken, Charlotte; De Cock, Sanne; T'Sjoen, Guy; De Cuypere, Griet (2013). "Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder". The Journal of Sexual Medicine: n/a–n/a. doi:10.1111/jsm.12363. ISSN 1743-6095. 
  18. ^ Yolanda L. S. Smith, Stephanie H. M. Van Goozen, Abraham J. Kuiper & Peggy T. Cohen-Kettenis (January 2005). "Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals". Psychological medicine 35 (1): 89–99. PMID 15842032. 
  19. ^ "Vatican says 'sex-change' operation does not change person's gender". National Catholic Reporter. 
  20. ^ "FAQ on Gender Identity Disorder and "Sex Change" Operations". National Catholic Bioethics Center. 
  21. ^ Goode, Erica (August 5, 2002). "Psychiatrist Says He Was Surprised by Furor Over His Role on Abuse Panel". The New York Times. 
  22. ^ Paul McHugh. "Psychiatric misadventures". 
  23. ^ Richard P. Fitzgibbons, M.D., Philip M. Sutton, and Dale O’Leary, The Psychopathology of “Sex Reassignment” Surgery, Assessing Its Medical, Psychological, and Ethical Appropriateness, The National Catholic Bioethics Quarterly, Spring 2009, p. 100.
  24. ^ "Why The Trans Community Hates Dr. Janice G. Raymond". TransGRiot. 
  25. ^ Iran's gay plan, Matthew Hays, Canadian Broadcasting Corporation, August 26, 2008; accessed August 13, 2009.
  26. ^ Kuiper, A.J; P.T. Cohen-Kettenis (September 1998). "Gender Role Reversal among Postoperative Transsexuals". International Journal of Transgenderism 2 (3). Archived from the original on 2007-02-04. Retrieved 2007-02-25. 
  27. ^ a b Wayne, Alex (30 May 2014). "Medicare Ordered to Consider Covering Sex-Change Surgery". Bloomberg. Retrieved 30 May 2014. 
  28. ^ a b McMorris-Santoro, Evan (30 May 2014). "Obama Administration Opens The Door To Medicare-Funded Sex Reassignment Surgery". BuzzFeed Politics. Retrieved 30 May 2014. 
  29. ^ Leslie A. Sussan; Constance B. Tobias; Sheila Ann Hegy (presiding) (2 Dec 2013). "NCD 140.3 Transsexual Surgery: NCD Ruling No. 2" (PDF). Acceptable National Coverage Determination Complaints (DAB). HHS.gov. Docket No. A-13-47. Retrieved 7 Feb 2014. 
  30. ^ Leslie A. Sussan; Constance B. Tobias; Sheila Ann Hegy (presiding) (30 May 2014). "NCD 140.3 Transsexual Surgery: Decision No. 2576" (PDF). Acceptable National Coverage Determination Complaints (DAB). HHS.gov. Docket No. A-13-87. Retrieved 4 Jul 2014. 
  31. ^ Daphna Stroumsa (January 2014). "The State of Transgender Health Care: Policy, Law, and Medical Frameworks". American Journal of Public Health (electronic version) 104 (3): e31–8. doi:10.2105/AJPH.2013.301789. PMID 24432926. 

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