A second chance for Alex: sex affirmation in young people

Our sex is something we take for granted. Even when we prefer not to expose our genitals to others, our family and friends will know whether we are male or female from our appearance, mannerisms, preferences and speech. If an outsider, such as an employer or passport officer, requires confirmation of our legal sex, we can simply show our birth certificate. Identifying our legal sex is just so simple!

Despite common misperceptions, our sexiest organ by far is the brain. It contains a huge number of structures and their interconnections, some of which differentiate quite clearly between men and women. These differences can be observed in human behaviour, as well as in brain structures that can be viewed either by magnetic resonance interferometry, or in post-mortem brain slices. Brain-sex is really good for us, even though it is ever so complicated and little understood. Brain-sex allows us to envisage much more flexible gendered and sexual behaviours than could ever be possible by considering only the genitals. Most particularly, it means that occasionally people with female genitals have a brain-sex that is distinctly male. Either they can adjust somehow to this discrepancy, or like Alex, the 13-year-old genetic female whose wish to live as a male received legal recognition in a recent Family Court judgment, they can endure a life-threatening agony.

People like Alex experience a mismatch between their body-sex and their brain-sex. In other words, they are intersexed. Intersexed conditions also occur when children are born with ambiguous genitals or suffer from a physiological anomaly that prevents them from functioning as normal males or females. Adults with the same condition as Alex seek medical help to allow them to cope with their gender dysphoria. According to the internationally recognised Standards of Care, such people undergo at least three months of psychotherapy, followed inevitably by partially reversible hormone therapy. While undergoing hormone therapy, they are required to live full-time for about two years in their true gender-role, for example as men if they are genetically female. After successfully completing this real-life experience and having two independent psychiatric reports approving such an intervention, the candidate can undergo sex affirmation surgery to transform their female genitalia into their male equivalents, and affirm their true sexual identity. For adult male candidates, this procedure will often be preceded by the removal of breasts, ovaries and womb.

A detailed account of the treatment of child and adolescent transsexuals is contained in Cohen-Kettenis and Pfäfflin’s 2003 book entitled Transgenderism and intersexuality in childhood and adolescence: Making choices. This Dutch group, as well as a clinic directed by DiCeglie in London, has had the most experience in assisting young people like Alex. The standard treatment involves a careful psychological evaluation of the child’s gender dysphoria and associated distress, accompanied by interviews with parents, or guardian, and other family members. Although specialist counselling can assist some children to deal with their gender issues, there is no evidence that aversive behaviour modification procedures can effect a “cure” of gender dysphoria. Any unethical enforced change in gendered behaviour is usually transient. The underlying serious gender problem remains unaffected.

The procedures authorised by Judge Nicholson in the case of Alex are consistent with those adopted by the Dutch and English clinics. Since secondary sex changes during puberty are extremely distressful for such severely dysphoric young people, the recommended treatment includes puberty-delaying hormone therapy. This can be followed at a later age by testosterone therapy to initiate the development of male secondary sex characteristics, such as body and facial hair, a lower-pitched voice and an increase in muscle bulk. Life is made considerably easier for Alex at this stage since the pubertal-delay ensures that future removal of all breast tissue is not necessary. Upon maturity, ‘Alex” can be recommended for further surgery to permit some degree of male sexual function, including urinating whilst standing. A request for reversion to female sexual functioning following surgery is very rare, occurring in less than 3 per cent of cases. This relatively low level of post-operative regret is even less than that applying to some common surgical procedures, such as breast removal for cancer sufferers and physical castration for men with prostate cancer.

These procedures are accompanied by psychological counselling throughout medical treatment. Should Alex decide to change his mind at any stage prior to starting testosterone therapy, he can revert to female by simply removing the puberty-delaying medication. This strategy produces the minimum harm and the maximum potential benefit for someone like Alex. This enlightened approach conforms to the highest bioethical standards, but perhaps raises concerns among those who are ignorant of both Alex’s plight and the likely outcome of the authorised medical interventions.

Young people in a similar situation to Alex are frequently confused with lesbians simply because they both tend to exhibit a sexual preference for women. Whereas, lesbians are attracted to women in a same-sex liaison, young men like Alex tend to aspire for opposite-sex experiences with women, thus highlighting the fundamental differences between gender identity and sexual orientation in both brain-sex and expression. What is desperately needed is universal education on the immense complexities of human sex and gender issues. No person, such as Alex, must ever be allowed to suffer because of other people’s ignorance and intolerance.