Sex Change Surgery: Therapy or Enhancement?

Introduction

In the discussion on human enhancement, it does not seem likely that sex change surgery would count as an instance of “enhancement”. After all, what is being enhanced? When one looks at sex change or sex realignment surgery, it is unclear at first what exactly is being enhanced instead of “changed” or “realigned”. Yet there seems to be a sense in which to classify sex change surgery as a kind of enhancement would be ethically plausible. At the very least, what seems to be enhanced here are the physical and physiological aspects of the subject’s own body that undergo transformation through the surgery, so that he or she now possesses the kind of body that he or she wants. In this sense, it is the aspect of the body that is in alignment with the subject’s own view of what his or her body should look like that appears to be enhanced. If it is the case of a man changing into a woman, then obviously the breasts would be “enhanced”.

In this article, I would like to argue that there is a certain confusion regarding whether sex change surgery is a kind of therapy or enhancement. My thesis is that this confusion stems from the deeper confusion surrounding the issue of therapy and enhancement in general. Those who argue against human enhancement usually say that the distinction between therapy and enhancement is a hard and fast one. While there is nothing ethically problematic with therapy, those who object to human enhancement typically argue that enhancement in general is ethically problematic precisely because enhancement is a use of technologies to transform either the physical and mental capabilities of the human body in such a way that is not intended by nature, so to speak. Hence, the argument is based on a strong separation between therapy and enhancement (see, for example, “Distinguishing Therapy and Enhancement”, 2002). What is precisely problematic is that human beings, in this view, should remain within the confine delimited by what is considered to be “natural.” To use medical technologies in such a way that extends the capabilities of normal healthy persons would then be ethically objectionable because it goes against this notion of what constitutes the normal in humans. (Actually there are other issues such as the enhancement might benefit only certain groups and not others, but that is another issue. What is being considered here is the act of enhancement in itself.) However, as I shall try to make clear in the article, there is a set of conceptual confusions surrounding the whole idea of what actually is a normal human individual. The discussion of sex change operation offered in the article then serves as a case study on the larger issue of what I believe to be the untenability of the distinction between therapy and enhancement in general.

Thailand in recent years has become quite well-known around the world as a haven for those who want to have sex change operations, and the practice has been actively promoted in the country’s attempt to become a medical tourism hub (Saniotis 2007). The quality and skills of the Thai doctors and surgeons are such that the country could well become a global hub in this field. The liberal attitude of the Thai people in general with regards to gender identity also contributes to the reputation.

The popularity of sex change surgery in Thailand led the Thai Medical Council to issue a set of rules that regulate the practice in the country. The purpose of the rules is to safeguard patients who might want to have the operation but might not be ready in one way or another. Doctors can perform sex change operations on patients only on these conditions:

• • Patients must be at least 18 years of age. If they are between 18 and 20 years old, parental consent is needed.

• • Surgeons can only operate on those who have been judged by two psychiatrists to suffer from “gender identity disorder” and to have met certain conditions for surgery.

And these conditions are:

• • The patient must have lived “successfully” in...