Human Reproduction vol.15 no.4 pp.

737738, 2000

DEBATE
Gender reassignment and assisted reproduction
An ethical analysis
Di Brothers1,3, W.C.L.Ford2 and the University
of Bristol Centre for Reproductive Medicine
Ethics Advisory Committee
1University

of Bristol Postgraduate School of Education,

810 Berkeley Square, Clifton, Bristol BS8, and 2Division
of Obstetrics & Gynaecology, University of Bristol, Bristol
BS8, UK
3To

whom correspondence should be addressed

This debate was previously published on Webtrack,

January 7, 2000

An approach for donor insemination (DI) treatment from a

couple in which the male partner was a woman who had
undergone gender reassignment led us to explore the ethical
implications of offering assisted reproduction in such a situation. In doing this, our paramount consideration was that an
unborn child should receive good and effective parenting, but
we also considered risks to individuals and to society.
Firstly, it is important to define the condition exactly. Gender
dysphoria and gender identity disorder are terms used to
describe a persistent desire to be of the opposite sex combined
with persistent discomfort about ones assigned sex or gender
role. The diagnosis requires the absence of physical intersex
conditions and the presence of clinically significant distress or
impairment of psychological function (American Psychological
Association, 1994). The condition varies in intensity from mild
anxiety which may be managed by occasional cross-dressing,
to a deeper confusion where counselling is necessary, or to
the profound anxiety of being in the wrong body. Only in
the more extreme cases is gender reassignment the appropriate
treatment (Brown, 1990, Schlatterer et al., 1996; CohenKettenis and Gooren, 1999).
Confusion about sexual identity can be viewed as comprising
two distinguishable sub-divisions: (i) where individuals question their core morphological identity (i.e. the gender they
were born with) and where the emerging self concept of being
male or female is contradicted by their physical characteristics,
e.g. My body is male but I believe myself to be female; and
(ii) where there is confusion around gender identity based on
gender role behaviour. My experience of women and their
roles has repulsed me so much that I do not wish to be a
woman: I want to be male.
It is members of the former group (primary) who go on to
seek gender reassignment and who, as part of a couple, apply
for assisted reproduction. Guidelines for proper management
of the condition have been developed (Walker et al., 1995)
but the diagnosis of the condition and the assessment of
patients for surgical treatment are long and complex (Brown,
European Society of Human Reproduction and Embryology

1990; Schlaterer et al., 1996; Webster, 1998; Cohen-Kettenis

and Gooren, 1999). The following analysis assumes that
the prospective patient has been successfully treated by an
appropriate specialist.

Why does the issue arouse ethical considerations?

One concern for the well-being of the unborn child would be
the mental stability of a parent who is undergoing, or has
undergone, such a fundamental change, and whether the root
cause lies in psychological disturbance.
There is a complex debate as to the cause of this condition.
Can gender dysphoria be labelled a psychiatric disorder, and
therefore imply potential mental instability and the need for
psychiatric treatment? The discussion surrounding this issue
in recent literature seems to offer a parallel with the earlier
debate about the roots of homosexuality (Reiche, 1984). In
both cases we are left with a confusion of psychoanalytic
labelling and evidence of the impact of both nature and nurture
(Lothstein 1979; Cohen-Kettenis and Gooren, 1999). There is
evidence of associated changes in brain morphology. Postmortem studies have shown that the bed nucleus of the stria
terminalis is of smaller, typically female, size in male to female
transsexuals (Zhou et al., 1995). Individuals in the primary
gender dysphoria category also exhibit a well-documented
lifelong deep disorder of core sexual identity not linked to
stress (Levine and Lothstein 1981). It would seem from this
that transexual feelings represent not only a psychological
disorder, but also a social phenomenon with roots in possible
physiological differences.
This debate illustrates the difficulties involved in labelling
the condition of gender identity disorder and how to assess
concomitant mental stability. Where gender dysphoria is
untreated, then by adulthood there is a strong risk of depression
and suicide linked to the struggle to overcome deep-seated
desires and to cover up these feelings (Anonymous, 1998).
But with appropriate treatment there seems to be no special
risk of mental disorder or of suicide. Pierre Banzet (Banzet
and Revol, 1996), a plastic surgeon involved with gender
reassignment, considers that with rigorous selection gender
reassignment offers the prospect of long-term psychological
health. He has described operations on 98 males and 68
females over the past 15 years all of whom were subjected to
a thorough diagnosis with a rigid selection system to ensure
that the individual had intact reality awareness and stable ego
strength. In every case the outcome after surgery was positive.
Webster (1998) in her review of relevant literature arrives at
a similar conclusion. However, in general female to male
transsexuals achieve greater mental stability than male to
female transsexuals (De Cuypere et al., 1995; Cohen-Kettenis
737

D.Brothers, W.C.L.Ford and the University of Bristol Ethics Advisory Committee

and Gooren, 1999). This would need to be taken into account

into assessing their suitability for assisted reproduction.
The last and possibly most important question concerns the
impact on the child of having a gender reassigned parent.
Green (1978) produces evidence to show that the development
of sexual identity in children with ages ranging from 3 to 20
years was unaffected by living with parents, one of whom had
gender reassignment. Within this group it is interesting to note
that some children were aware of the gender change, and,
indeed, had been part of the process, whereas others were
completely unaware of the difference. In all cases the children
showed normal and heterosexual development as measured
by best toy, peer group, clothing preferences, vocational
aspirations, roles played in fantasy games, and (in older
children) romantic crushes, erotic fantasies and inter-personal
sexual behaviour. The critical point of interest is not
the sexuality of the young, but the absence of confusion over
sexual identity and sexuality.
Given the difficulties in attributing psychological or behavioural characteristics to individuals with reassigned genders,
the Ethics Committee agreed that reassigned gender in itself
should not automatically debar an individual from consideration for assisted reproduction. Individuals with gender identity
disorder exhibit the full range of social class, intellectual
competence, sexual orientations, and mental stability or illness
seen in the general population (Hoenig and Henna, 1978). The
issue of gender reassignment must not be allowed to mask
any other factor relevant to ethical decision making and
the couples should be assessed using the same criteria as
heterosexual couples within the overall constraint that the
welfare of future children must be the paramount consideration.

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