性別重置手術的醫學實證及帶來的社會 和倫理問題
袁維昌醫生 , 太平紳士 二零一八年五月二十四日
Content 內容
The difference between sex and gender, gender identity ( 性別認同 )and sex orientation ( 性取向 )
What is the normal development of gender identity （正常的性別認同發展）
What is the abnormal development of gender identity （不正常的性別認同發展）
What are the problems arising from gender identity dysphoria ( 性別認同障礙產生怎麼問題？
）
How to solve the problems - different approaches overseas and local 外國與本地的解決方 法）
History of transsexual surgery （變性手術的歷史）
Steps to transsexual surgery （造變性手術前到評估和準備）
Aftermath of transsexual surgery （手術後的結果）
Ethical and moral issues arisen （變性手術所產生社會和道德倫理問題）
Gender and Sex （性別 )
Sex tends to refer to biological differences （生理上的性別） : Male and Female, Intersex
Gender more often refers to cultural and social differences （文化和社會上的性 別） and sometimes encompasses a broader range of identities than the
binary of male and female （可以多過二元分別） ….Oxford living dictionary
Gender identity （性別認同） is defined as a personal conception of oneself as male or female (or rarely, both or neither). （男 , 女 , 男轉女 , 女轉男 , 不男不 女 ,時男時女 . ）…
Gender Identity Disorder (性別認同障礙 ), Gender Dysphoria( 性別認同焦慮 症 ) ． Medical terms 醫學名詞
Transgender 跨性別 . 社會名詞
Gender Dysphoria ( 性別認同焦慮 症）
Old term : Gender Identity Disorder ( 性別認同障礙 )
According to DSM-V diagnostic and Statistical Manual of Mental Disorder version V
Distress which accompanies the incongruence between one’s experienced or expressed gender and one’s assigned gender at birth ( 心靈與身體不吻合導改持續嚴重精神困擾 )
Keywords are distress and incongruence
Sex Orientation ( 性取向 ) ≠ Gender identity ( 性別認 同 ) Gender Dysphoria( 性別認同焦慮症 ) ≠
Homosexualism(
同性戀 )
Homosexualism( 同性戀 ) is not a disease ( 不是疾病 , 不需要治療）
Much more common than Gender Identity Disorder
They never ask to change their bodies. （他們對自身無疑問）
LGBT is misleading （將病人與非病人混為一起）
Conditions which may mimic Gender Identity Disorder （需要區分的精神疾病）
Schizophrenia ( 精神分裂 )
Transvestism( 易服癖 )
Normal Development of Gender Identity
兩歲開始能分辨二種性別 : 男和女 在六歲前，絕大部份能確認自己性別
在小學期間 , 行為上 ( 同性一起做不同的活動和運動 ), 衣著上有不同 在中學期間 , 青春期 , 有更多明顯的生理改變
Behaviour problems in Gender Identity Disorder in childhood and adolescence （兒童成長時期的行為麻 煩）
Born as a boy
Asserted as a girl or going to be a woman
Prefers playing with girls
Prefers to wear woman clothing, role playing as girl, like fantasy toy, avoid contact sports,
Some insist to void on sitting
At puberty, shave their legs at the first sign of hair growth
Bind their penis to conceal erection
Born as a girl
Asserted as a boy, prefers to be called a boy’s name, reluctant to wear girl’s clothing,
Prefers contact sports, boyhood sports and prefers playing with boymates
At puberty, bind their breasts , wearing loose sweaters
Risk and consequences
Fail to establish age-typical same-sex peer relationship resulting in isolation
Some refuse to attend school to avoid teasing and harassment of not wearing attire of the assigned sex
Difficult relationship at school and at work
Negative self esteem, school dropout, unemployment
Anxiety and depression
Many develop gender identity consistent with their anatomic sex.
Some become homosexual or bisexual, while others may not.
Mental and social problems in Adults
Rejection of one’s body
Wish for opposite sex body
Education and employment
Difficult relation with parents, friend, colleagues
Toilet and changing room
Marriage
Guilt feeling, Depression, suicide
Solution to Gender Dysphoria 解決方法
Change the public to fit the oneself( 改變大眾的看法 )
Change oneself to fit the world: change the mind or change the body ( 改變自己 : 心靈或身體 )
解決辦法一 : 改變大眾
Change the world to fit the person
Change public opinion to minimize discrimination
Change the toilet facilities, changing room
Change unnecessary documentation of gender
Change of legislation
In Germany, Denmark and UK
解決辦法二 : 改變自己的心態
Behavioral treatment for cross-gendered children may be harmful to the child's self-esteem and serves only to convince the child that his/her feelings are wrong, mistaken, or even evil.
The World Professional Association for Transgender Health Standards of Care identify as unethical
Very difficult when the person reaches adulthood
解決辦法二 : 改變身體 , 外貌以適合心 態
Change of external appearance by clothing , dress , hair style, tattoos
Change the body by Hormone and surgery ( 用激素和手術改變身 體 )
History of transsexual treatment
In 1910, MAGNUS HIRSCHFELD, a German physician, wrote a two volume
monograph describing several gender variant individuals, who would likely be classified as transsexuals today.
1931, First Male to Female operation in Berlin
the early years of WWII ,the first estrogens became available in 1938
In 1944-5, a British surgeon, Harold Gillies used the wartime technique of flap surgery, which proved to be a crucial advancement for FTM surgery.
in 1965 America's first Gender Identity Clinic at John Hopkins Hospital
In 1977, John Hopkins University reported that SRS confered no objective advantage in terms of social rehabilitation for transsexuals. Although the paper was widely criticized as flawed, it led to the October 1979 closing of the Johns Hopkins Gender Identity Clinic.
Setting up The Standards of Care in January 1980 and revised in March 1981, January 1990, June 1998, and February 2001.
Around 1983, setting up HK Gender Identity Team in Queen Mary Hospital
91 persons with Transsexual surgery in HK from 1987 to 2014
87-91 92-96 97-01 02-06 07-11 12-14
0 5 10 15 20 25 30
Age of transsexuals at time of
surgery ( from 1987-2014)
Change the body by Hormone and surgery ( 用激素 和手術改變身體 )
Psychiatrist + clinical psychologist assessment for at least two years 兩年心理評估
Opposite sex hormone for at least six months 異性激素治療
Real life experience ( to live comfortably as opposite sex)for at least one year 生活體驗
Surgeon assessment
Effects of Female hormone on a male
Effects Expected onset Exp Max effect
Body fat redistribution 3-6 months 2-5 years
Decreased muscle mass 3-6 months 1-2 years
Softening of skin/ decreased oilness 3-6 months unknown
Decreased libido 1-3 months 1-2 years
Decrease spontaneous erection 1-3 months 3-6 months
Breast growth 3-6 months 2-3 years
Decrease testicular volume 3-6 months 2-3 years Thinning and slowed growth of body
and facial hair 6-12 months >3 years
Male pattern baldness Loss stops 1-3
months 1-2 years
Effects and expected time course of male hormone on Female
Effect Expected Onset Expected Maximum
Effect Skin oilness/acne 1-6 months 1-2 Years Facial/body hair
growth 3-6 months 3-5 years
Scalp hair loss > 12 months variable Increased muscle
mass/ strength 6-12 months 2-5 years Body fat redistribution 3-6 months 2-5 years Cessation of menses 2-6 months n/a
Clitoral enlargement 3-6 months 1-2 years Vaginal atrophy 3-6 months 1-2 years Deepened voice 3-12 months 1-2 years
Operation 手術目的
Male to Female
切除男性的陰莖和睾丸
建造陰道
割除喉核
Female to Male
切除乳房 , 卵巢 , 子宮
建造陰莖
手術後 , 大部份滿意 , 極小病人後悔 ,
Male to female
Sitting on voiding
Vaginal intercourse possible
Change of sex in ID card
Right of marriage to a male
infertility
Female to male
Flat chest
No menstruation
May still void on sitting
Vaginal intercourse may not be possible
Change of sex in ID card
Right of marriage to a female
Infertility
Ethical questions
產生的社會和倫理問題
1. What is the best solution for the gender dysphoric person: to treat the person or the public?
(改變社會或改變病人自己 )
2. Is transsexual surgery a torture/ violation of human right?(變性手術是否違反人權 ?)
3. After surgery, should their sex /name in ID card/ birth certificate be changed?( 性別是否可 以改變 ? 手術後 , 性別可否改變 ?)
4. Without surgery or hormone, can those be changed?( 不做手術 , 性別是否可以改變 ?
5. Who should pay the surgery?(誰付鈔 ?)
6. After surgery, can one marry? Would it be homosexual marriage or heterosexual marriage?
(術後人士結婚可否承認 ? 同性或是異性婚姻 ?)
7. Should transsexual surgery be performed if one is married or one has one’s offspring?(婚後 人士可否做手術 ? 做完後 , 以前的婚姻是否無效 ? 他們所生的孩子是否有兩個爸爸 / 媽媽 ?)
