Sex-Change Operations: Mistakes in God's Factory

Prognosis is tricky, though: It's impossible to determine whether a person is transsexual by using standard diagnostic tools like hormone level testing or computer tomography (cross-section images of the body). Psychiatrists base their diagnoses on how long a person has been living as a member of the opposite sex and how convincing he or she is in that role. In adults, medical standards require years of psychotherapy and a trial run as a member of the opposite sex before hormone treatment can start. Children in puberty have little time to satisfy these requirements.

Should doctors second-guess nature because of a teenager's wishes? Can't puberty change everything? And what if it all turns out to have been the wrong decision? Meyenburg has mixed feelings about the fact that more and more -- and younger -- patients are coming to him for advice these days.

"From a purely medical standpoint we are dealing with the mutilation of a biologically healthy body," says Meyenburg. "We face a real dilemma. If we do something about it, it's irreversible. And if we allow nature to take its course, that too is irreversible."

But in Kim's case, says Meyenburg, "it would have been a crime to let her grow up as a man. There are very few people in whom it's so obvious." It takes a great deal of experience to be able to differentiate between a temporary gender identity disorder and "true" transsexuality. Meyenburg recently met a 15-year-old girl who didn't want to be a woman. It took a while, but he discovered that the girl had been brutally abused by her father when she was seven. The trauma of the experience had triggered a deep identity disorder, but not transsexual development. In the end, the girl chose not to undergo a sex change.

Based in part on such experiences, Meyenburg says "psychotherapy is always worth a try -- not because being a transsexual is such a bad thing, but because it is probably easier to go through life as an effeminate dance instructor than as someone who has had a sex change operation." Even if the process goes on to indicate a sex change, most adolescents also benefit from psychotherapy. "After all," says Meyenburg, "there are also parents who attempt to beat it out of their children."

Meyenburg has been studying transsexuality since the 1970s. In those days, orthodox psychiatry believed that adverse social circumstances -- namely the parents -- were to blame when someone felt out of place in his or her biological gender. The perpetrators were domineering mothers, absent fathers, parents with emotional problems who were unfit as role models, repressed parental fear of homosexuality. New York psychoanalyst Susan Coates believed that a little boy's first steps in his mother's high heels occurred when the mother was depressed and emotionally unavailable. In these cases, Coates theorized, the child, instead of "having Mommy," would "be Mommy" to fend off his separation anxiety.

Even Meyenburg was long convinced that severe emotional trauma in childhood caused transsexualism. "On the other hand," he says today, "depression isn't exactly rare in mothers. Wouldn't that mean there should be far more transsexuals?" Meyenburg points out another inconsistency: "There are cases in which you could poke around in the parents' relationship as long as you wish and still find nothing. They are often very pleasant, normal and likable people."

Treating the unknown

Gender development in human beings is a complex of bio-psychological processes, and when something goes wrong, not everyone understands. The medical community in particular tends to impose order, asking itself questions like: "Which gender is the correct one?" Developmental psychologists, for example, long believed that children were born emotionally neutral, and that a person's perceived gender affiliation was the result of social influence.

This approach led to drastic measures. Some children -- hermaphrodites -- are born with both male and female sex organs, and in the past they were operated on as quickly as possible. Psychiatrists thought the children as well as their parents should be spared the pain of growing up without a clear gender identity. But many of these kids later became unhappy with their surgically-determined genders. Some even committed suicide. Social influence -- from early childhood on -- failed to adjust their inner identities. The preferred approach nowadays is to wait.

Experts still think a lot of gender-specific behavior is learned, but they also believe some of it is pre-wired in the womb. The extent to which androgen or estrogen shapes the brain to be male or female is debatable; the age at which gender identity is established is unknown. But certain tendencies manifest early: At only a few weeks of age, female babies spend more time looking at faces, while male babies are drawn to abstract shapes. Three-year-olds handed anatomically correct dolls can tell which ones represent their own genders. This distinction becomes noticeably more difficult for children with gender-identity disorder.

Treating the problem with therapy is controversial: After decades of attempts, and despite some therapists' claims to the contrary, there is still no evidence that psychotherapy can change a transsexual adolescent's gender identity. Whether the development of an identity can be interrupted during early childhood isn't clear, but some experts think therapy is simply the wrong approach for transsexuals.

"Nowadays we believe that it's both," says Meyenburg -- "environment and biology."

But that doesn't clear up the puzzle. Researchers in laboratories are still looking for a sound explanation for the mismatch between body and soul in transsexuals. There are many theories: One holds that a specific gene disables the Y chromosome; another says unusual hormone levels in the womb cause specific areas of the brain in male-to-female transsexuals to acquire the size typical for females. (Certain medications taken by the mother may be to blame under that hypothesis.) A third theory holds that atypical hormone excretions are to blame. Lately some endocrinologists also wonder if a still-unknown disorder in the way genes are expressed in fetuses could impair the function of a child's sex hormones.

None of the theories are proven, though, and the upshot is: If we don't know what causes transsexuality, how can it be treated?

Early hormone treatment may work

Experts in the Netherlands are the most experienced in the field. A so-called "gender team" of somaticists, child psychiatrists, psychotherapists, endocrinologists and surgeons have spent the last few years monitoring more than 350 children and adolescents with divergent gender identity. It isn't rare for these experts to see the metamorphosis of puberty -- and the forced role-shift that comes with it -- transform young people who were emotionally stable into heavily traumatized adults. Many of these individuals also face personality disorders as adults: drug addiction, depression and thoughts of suicide.

To address these problems, in the late 1990s the Dutch cautiously started hormone treatment in a small number of transsexual youths -- similar to the treatment Kim later received in Germany. Asked later about the experience, none of this group regretted choosing the treatment. They were leading more satisfied, normal lives than others in the study who went on living as members of what they perceived as a false or hated gender.

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• Part 1: Mistakes in God's Factory
• Part 2: "We face a real dilemma"
• Part 3: "God made you a boy"