[sihaya]

Let's have some fun with ethical reasoning...
[Warning... contains description of a medical condition that some may find disturbing.]

When I was doing a rotation in my bioethics program, we were told a TRUE story of a kid from a middle eastern country who had come to the US to have plastic surgery to remove small breasts he had developed. This isn't so uncommon. A lot of men/boys have this kind of unfortunate fat distribution. It's a simple thing to "fix." But this boy was also experiencing some bleeding with urination.

Turns out... the boy is not a boy at all. He's a girl with an XX cromesome. All "his" female parts are fully functioning (medically, "he's" a healthy girl by every measure). The reason he was always thought to be a boy was because "he" was born with an enlarged clitoris (which in a child, looks an awful lot like a penis). The blood in his urine that came once a month was actually "his" menstral cycle.

Now here comes the tricky part... his parents want to keep him a boy. They want the menstral cycles to stop, his breasts removed, etc. But in order to make all that happen, the kid's uterus would have to be removed and he'd have to be put on hormones to maintain a "male appearance." Essentually, they'd have to do a full scale sex change on a 13 year old girl.

Before you get all angry at the parents, think about the culture they are from. They're from a middle eastern country where boys are in a class altogether above and beyond that of girls. For this kid to find out that he's not a boy but a girl, would be devastating beyond comprehension. The parents honestly and truly love this kid no matter what he/she is... it's clear that they only want what's really best for him/her.

Just to complicate things further... the child has always loved children and looks forward to having children of his/her own. But, if they do this sex change operation, he/she will never be able to have kids (though she/he could have them as a woman... since he/she has a fully functioning uterus).

So, if you were the doctor, what would you do?

[disclaimer: I know that not all Islamic cultures devalue women... it just so happens that the one where these people are from does to an extreme. I'm well aware that there are many Islamic people and cultures that do not have the same views. The dilemma here isn't meant to be about the faith or culture... just about this particular situation.]

[Ninong]

The doctor should not operate on this young girl. This isn't even a close call.

[almostdiva]

I agree w Ninong. And I've read writings by several hermaphrodites who were raised as the opposite gender they were genetically b/c of appearance until puberty kicked in and radically 'upset the applecart", who basically almost all say they should be their genetic gender, not their "appearance" gender, no matter how awkward or socially touchy that decision may be. Granted, none of the work I have read has been by a Moselem from the Middle East, but I dont' think that changes the game.

Rebecca

[Ninong]

Rebecca,

That would be gender assignment surgery performed in infancy. In many of those cases, they got it wrong. Which is why I believe they should hold off, especially now that they can check to see if the infant has the xx or the xy chromosome.

In the example given above, we're talking about gender reassignment surgery on a perfectly normal 13-yr-old girl. I hope none of the law students in that class got that question wrong.

[sihaya]

Originally Posted by Ninong

The doctor should not operate on this young girl. This isn't even a close call.

Are you sure? And if this kid commits suicide when he finds out he's a girl... or after his social status plummets as a result of it... you would still think that's the right decision?

Try to imagine what this kid would have to go through going back home as a girl. "He" would no longer be lookiing at an education or a career. Any hopes and dreams of a free life would be gone. He wouldn't be allowed to drive or vote. And he'd have to stop playing all the sports he's currently in.

I don't think it's as clear cut as it appears at first glance. When I first heard the story I reacted just the way you did. But then I tried to think about what it would be like to have to give up doing most the things I enjoy... being stripped of things I considered my rights... being viewed as suddenly much less than I was.... having to completely overhaul my view of myself. I don't know if I could survive something like that (especially not at 13).

[sihaya]

Originally Posted by Ninong

In the example given above, we're talking about gender reassignment surgery on a perfectly normal 13-yr-old girl. I hope none of the law students in that class got that question wrong.

Believe it or not, this isn't much of a legal issue. This is between the doctors and the family. The only way it would become a legal issue is if years later the kid tried to sue the doctors for their decision (but the kid could sue in either case.. and in eiher case it's still a very grey area... I doubt the courts would have an easy time with it).

[sihaya]

Another set of problems comes up when the child starts having sexual desires. If "he" starts feeling attracted to men (as a straight girl would), he may be thought to be gay and stoned for it. Or, if he married and is later found out to be a woman (as is not terribly unlikely) he/she could be stoned for being a lesbian... or for pretending to be a man.

It's just a mess of a problem.

[sihaya]

I honestly don't know for sure what I'd do if I were the doctor... but if I were the parents, I'd hold off on the surgery and apply for asylum within the US were my kid could come to accept being a girl in a more woman-friendly environment. But that would not be an easy thing to do!

[Ninong]

Originally Posted by sihaya

Are you sure?

Yes.

And if this kid commits suicide when he finds out he's a girl...

If she's 13 years old, she already knows she's a girl. It is much more likely that she might commit suicide years later if this outrageous gender reassignment surgery is performed. This would be the reverse of the more common blunder that doctors made years ago in assigning female gender to infants born with both male and female characteristics. Then when the girl reached puberty, she realized she was attracted to other girls because she was genetically male with an xy chromosome.

or after his social status plummets as a result of it... you would still think that's the right decision?

This should have absolutely no bearing on the ethics of the matter. None whatsoever.

Try to imagine what this kid would have to go through going back home as a girl. "He" would no longer be lookiing at an education or a career. Any hopes and dreams of a free life would be gone. He wouldn't be allowed to drive or vote. And he'd have to stop playing all the sports he's currently in.

All of this is inconsequential considering that you are talking about the most fundamental identification in a person's life -- their gender. If there is any doubt whatsoever, the doctors and the parents should allow the child to make this decision after the child is a legal adult.

You do realize, of course, that this child is not a boy. This child is a girl. I doubt seriously that she will be competitive with boys in most sports unless she starts getting steroid injections.

I don't think it's as clear cut as it appears at first glance. When I first heard the story I reacted just the way you did. But then I tried to think about what it would be like to have to give up doing most the things I enjoy... being stripped of things I considered my rights... being viewed as suddenly much less than I was.... having to completely overhaul my view of myself. I don't know if I could survive something like that (especially not at 13).

This has all the earmarks of a sneaky question put forth by a female law professor to stir up the women in the class. Seriously, I can't imagine where the confusion would come in and I can't imagine any difficulty figuring out the ethics of this particular case.

[Ninong]

Originally Posted by sihaya

Believe it or not, this isn't much of a legal issue. This is between the doctors and the family. The only way it would become a legal issue is if years later the kid tried to sue the doctors for their decision (but the kid could sue in either case.. and in eiher case it's still a very grey area... I doubt the courts would have an easy time with it).

Are you talking about legal issues under U.S. law or under Sharia law?

[Ninong]

Originally Posted by sihaya

Another set of problems comes up when the child starts having sexual desires. If "he" starts feeling attracted to men (as a straight girl would), he may be thought to be gay and stoned for it. Or, if he married and is later found out to be a woman (as is not terribly unlikely) he/she could be stoned for being a lesbian... or for pretending to be a man.

It's just a mess of a problem.

Yes, this is exactly the problem that arises when doctors mistakenly assign female gender surgically to an infant that should be a boy. This is the screwup that was most common in the past.

[sihaya]

Originally Posted by Ninong

This should have absolutely no bearing on the ethics of the matter. None whatsoever.

Really?! Why? How could it not?

All of this is inconsequential considering that you are talking about the most fundamental identification in a person's life -- their gender.

I beg to differ....

If there is any doubt whatsoever, the doctors and the parents should allow the child to make this decision after the child is a legal adult.

Normally I'd agree... but it's too late in this case. The kid has already been labeled as a boy.

You do realize, of course, that this child is not a boy. This child is a girl. I doubt seriously that she will be competitive with boys in most sports unless she starts getting steroid injections.

She was holding her own at the time... she made it onto a several teams. I doubt she was the star player, but she was still involved.

This has all the earmarks of a sneaky question put forth by a female law professor to stir up the women in the class.

Could be, but it was a true story told by a nurse in my bioethics class... before I went to law school.

Seriously, I can't imagine where the confusion would come in and I can't imagine any difficulty figuring out the ethics of this particular case.

I think that's because you're giving no weight to how miserable this kid will be once he/she finds out he's a girl. The kid would likely commit suicide.

You're placing genetic gender identity above all quality of life issues... which is one way to look at it. But there are many others. That's why it's an interesting problem.

[Ninong]

Originally Posted by sihaya

I honestly don't know for sure what I'd do if I were the doctor... but if I were the parents, I'd hold off on the surgery and apply for asylum within the US were my kid could come to accept being a girl in a more woman-friendly environment. But that would not be an easy thing to do!

I don't know if they take a Hippocratic oath in Saudi Arabia but doctors here take an oath to "do no harm."

All of the other issues, the gender equality issues, are irrelevant to the fundamental question at hand. For the life of me, I cannot understand the logic of posing this as an ethics question in a law school.

There are so many flaws in the way it has been presented, assuming those objections were actually raised. The child is 13 years old. She has known her sexual identity for years. That comes way before sexual attraction to the opposite sex. Speaking of participation in sports makes no sense whatsoever. There is no way that a teenage girl can compete with teenage boys on an equal footing in most sports. If they want to be the kicker, fine, let 'em. If they want to be the quarterback, fine, but they could get hurt. All of these issues are only important to women. Only a female law professor would think that any of these equality issues should be taken into consideration in deciding whether to perform gender reassignment surgery on a healthy 13-year-old girl.

None of the cultural issues, none of the issues of gender equality have anything to do with the decision at hand. If anything, this situation might be used in a class discussion of the rights of the child.

[sihaya]

I honestly didn't raise this as a gender-bias issue... it's more of a Principles vs. Cost-benefit issue. In other words... do you hold to a principle even when it's outrageously impractical? Some say yes, some say no... it's not always that obvious.

[sihaya]

The hippocratic oath is actually essentually meaningless. It carries no legal weight... and little moral weight in reality. It's far more a tradition than anything else.

And actually, the original hippocratic oath is NOTHING like the one we know and love today. For example... the orginal hippocratic oath promised never to cut someone (which would make all surgery against the oath). Seriously, the oath has changed so much it's hardly even recognizable to anyone who might be familiar with the original. And many medical schools even have thier own version.

[Ninong]

Originally Posted by sihaya

Could be, but it was a true story told by a nurse in my bioethics class... before I went to law school.

A female nurse?

I think that's because you're giving no weight to how miserable this kid will be once he/she finds out he's a girl. The kid would likely commit suicide.

It is MUCH more likely that the kid would commit suicide from the frustrations and complications of trying to live as a teenage boy when she is truly a teenage girl. The question of "once she finds out" she's a girl makes absolutely no sense whatsoever. She knows she's a girl already.

You're placing genetic gender identity above all quality of life issues... which is one way to look at it. But there are many others. That's why it's an interesting problem.

The gender identity issue has ABSOLUTELY nothing to do with the quality of life issues. You can't possibly be saying that it would be better to try to fake it as a boy because boys have more rights in that country?

Again, this isn't even remotely a close call. No way! The only way it could even be considered as a choice would be if what you are suggesting is actually possible, but it's not. It is not possible for this child to live anything close to a normal life as a boy if she is a girl. This is one of those situations that women dream up to discuss gender equality.

[Ninong]

I didn't raise the Hippocratic oath as a legal constraint, only to point out that most doctors feel a moral obligation to do no harm. According to Dr. Frist, this restriction does not apply to cats.

[Ninong]

Originally Posted by sihaya

I honestly didn't raise this as a gender-bias issue... it's more of a Principles vs. Cost-benefit issue. In other words... do you hold to a principle even when it's outrageously impractical? Some say yes, some say no... it's not always that obvious.

All legal issues aside, there is no question about the morality of the question. None!

The child is a girl. Nothing they do surgically is going to change that and doing anything is morally wrong.

[sihaya]

In general though, even the "above all else, do no harm" is not always strictly adhered to. For example, there a often times very risky, very dangerous treatment for some medical problems that are highly experimental. They are actually sometimes more likely to cause harm than to help. But... when a person is dying and out of options, and they want to try anything and everything... it's not considered unethical for the doctor to try these kinds of treatments (provided the patient is well aware of the risk they're taking).

[Ninong]

Can we please get off of the Hippocratic oath?

I just threw it out there to point out that most doctors claim to hold themselves to high moral standards. They pretend to be morally superior to, say, lawyers.