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Ethical Issues in Considering Transsexual Surgeries As Aesthetic Plastic Surgery

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Ethical Issues in Considering Transsexual Surgeries As Aesthetic Plastic Surgery Aesth Plast Surg (2013) 37:648–649 DOI 10.1007/s00266-013-0100-x LETTER TO THE EDITOR EXPERIMENTAL/SPECIAL TOPICS Ethical Issues in Considering Transsexual Surgeries as Aesthetic Plastic Surgery J. Latham Received: 17 August 2012 / Accepted: 23 February 2013 / Published online: 15 March 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013 Level of Evidence V This journal requires that authors proceed with such surgeries, psychiatric assessment and a assign a level of evidence to each article. For a full diagnosis of ‘‘gender identity disorder’’ are required. description of these Evidence-Based Medicine ratings, However, many transsexual surgeries may be analogous please refer to the Table of Contents or the online to nontranssexual cosmetic surgeries. For example, breast Instructions to Authors www.springer.com/00266. reduction in the female patient is considered cosmetic Transsexual surgeries are almost always aesthetic sur- unless the entire breast is removed. Requests for complete geries, although they are rarely if ever interpreted this way. breast removal are pathologized as ‘‘radical,’’ and patients Following the standards laid out in Sterodimas, Radwanski, are routinely referred for psychiatric assessment solely on and Pitanguy’s ‘‘Ethical Issues in Plastic and Reconstruc- the basis that their aesthetic desires do not enforce a cul- tive Surgery’’ [1], plastic surgeons may need to reconsider tural norm (e.g., that females have breasts). referring transsexual patients for psychological evaluation as a matter of course. Expert psychological assessment may be necessary, as with all patients requesting cosmetic sur- Patient Autonomy, Beneficence, Nonmalfeasance, geries. However, to respect patient autonomy, perhaps and Justice psychiatric referral should be made on an individual case- by-case basis, as it is with other aesthetic surgeries. Psychiatric assessment is an important tool for plastic surgeons that must be used when necessary. Plastic sur- geons must preoperatively evaluate and counsel all patients Transsexual Surgeries to fulfill the principles of beneficence and nonmalfeasance: to determine the patient’s ‘‘best interests’’ and to ‘‘do no Surgeries may include radical double mastectomy and harm.’’ chest reconstruction, phalloplasty in female-to-male pro- In relation to requests for surgery by transsexual cedures, penectomy and orchiectomy, vaginoplasty and patients, surgeons must consider that transsexual patients labiaplasty, voice and face feminization, tracheal shaving, understand the social risks of gender transitioning surgeries and breast and buttock augmentation in male-to-female [4]. All patients must be informed concerning the likely procedures. Not all surgeries are genital, and indeed many benefits and risks of surgery and anesthesia, as well as the transsexuals do not desire genital surgery [2]. Surgeries alternative nonsurgical options in order to give informed that actively seek to change an individual’s gender and consent. As with all other patients, surgeons must ask of those interpreted as such are considered ‘‘radical’’ [3]. To the transsexual patient: ‘‘Is the proposed surgery realistic? Does the patient seem competent to make the decision to have surgery?’’ [1]. Compulsory referral of all patients seeking transsexual & J. Latham ( ) surgeries may violate the patient’s ethical right to self- ARCSHS, La Trobe University, 215 Franklin Street, Melbourne, VIC 3000, Australia determination [4], to direct what happens to his or her body, e-mail: [email protected] and may therefore constitute a form of discrimination. 123 Aesth Plast Surg (2013) 37:648–649 649 Psychiatric assessment can be intrusive and costly and is not on the patient. Many transsexual surgeries differ from standard in clinical plastic surgery practice [5] unless the cosmetic surgeries only due to the sex of the patient patient is transsexual. Desiring a surgery considered to be making the request, such as breast removal. Psychiatric gender inappropriate (e.g., breast removal in the female) is assessment can be intrusive and costly and should not be not sufficient grounds for requiring psychological obligatory for transsexual patients merely because their evaluation. surgical requests do not enforce a cultural norm. Aesthetic surgery clinics need to rethink their ethical treatment of transsexual patients. The ability for the Psychological Well-Being transsexual patient to be deemed competent and to give informed consent without psychiatric assessment warrants Sterodimas et al. [1] state that ‘‘undertaking surgery to consideration. improve a patient’s self-image and self-esteem is accept- able.’’ Transsexual patients desire aesthetic surgeries to Conflict of interest The author declares that they have no conflict ‘‘look normal’’ and ‘‘enhance beauty’’ [1] just as other of interest. patients do, only their requests are ‘‘cross-gendered.’’ When considered in terms of ‘‘degree of deformity,’’ gynecomastia for the male patient is treated routinely with References breast removal [6]. This is analogous to the transsexual female-to-male patient’s request for breast removal [7]. 1. Sterodimas A, Radwanski HN, Pitanguy I (2011) Ethical issues in In order to uphold the principle of justice, ‘‘giving to plastic and reconstructive surgery (review). Aesthetic Plast Surg each that which is his due,’’ transsexual patients should not 35:262–267 2. Rubin H (2003) Self-made men: identity and embodiment among automatically be considered ‘‘dysmorphic’’ (one who transsexual men. Vanderbilt University Press, Nashville blames unhappiness on a minimal or nonexistent defect). 3. Brownstein ML (2009) Ethical questions concerning sex reas- Findings have proved dysmorphic patients to be dissatisfied signment surgery: revisions for version 7 of the World Profes- with surgery results [8], whereas very few transsexual sional Association for Transgender Health’s Standards of Care. Int J Trans 11:220–221 patients have this outcome. Transsexual recipients of var- 4. Hume MC (2011) Sex, lies, and surgery: the ethics of gender ious aesthetic surgeries overwhelmingly report increased reassignment surgery. Dialogue 53:140–148 psychological well-being after surgery [9]. 5. Hodgkinson DJ (2005) Identifying the body-dysmorphic patient Due to the way that transsexual surgeries are currently in aesthetic surgery. Aesthetic Plast Surg 29:503–509 6. de Barros ACSD, Sampaio MDM (2012) Gynecomastia: phys- pathologized, it is difficult to discern the rates of compe- iopathology, evaluation and treatment (review). Sao Paulo Med J tency in transsexual versus nontranssexual patients because 130:187–197 transsexual patients must pass the test of competency to be 7. Colic´ MM, Colic´ MM (2000) Circumareolar mastectomy in treated as transsexual patients. Within the population of female-to-male transsexuals and large gynecomastias: a personal approach. Aesthetic Plast Surg 24:450–454 cosmetic surgery patients, 50 % are receiving psychotropic 8. Honigman RJ, Phillips KA, Castle DJ (2004) A review of psy- medications when they present to a clinic, and 27 % are chological outcomes for patients seeking cosmetic surgery taking antidepressants [10]. These patients routinely (review). Plast Reconstr Surg 113:1229–1237 receive surgery without a psychological evaluation, and it 9. Lev AI (2004) Transgender emergence: guidelines for working with gender-variant people and their families. Haworth Press, is estimated that 6–15 % of cosmetic surgery patients may Binghamton be experiencing body dysmorphophobia and thus will not 10. Meningaud JP, Benadiba L, Servant JM, Herve C, Bertrand JC, benefit from surgery [11]. Although highly publicized, Pelicie Y (2001) Depression, anxiety, and quality of life amongst rates of regret among transsexual surgery recipients are scheduled cosmetic surgery patients: multicentre prospective study. J Craniomaxillofac Surg 29:177–180 very low [12]. 11. Sarwer DR, Wadden TA, Pertschuk MJ, Whitaker LA (1998) Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 101:1644–1649 Conclusions 12. Smith YLS, Van Goozen SHM, Kuiper AJ, Cohen-Kettenis PT (2005) Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med 35:89–99 Requiring the diagnosis of ‘‘gender identity disorder’’ for any and all transsexual aesthetic surgeries puts undue strain 123.
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