I believe that people should be free to express their tastes, preferences, and personalities without legal limits if little or no harm is done to others by doing so. Not including mere hurt feelings, however: if it did, no one would be free to do much of anything.

Likewise, I believe we have positive moral obligations to respect each other and ourselves, and to do so, we should work to free ourselves from harmful biases and distastes based on cultural, racial, religious, and gender stereotypes and narrow standards of beauty.

But when a popular social practice seems to promote one of these principles while betraying the other, it can be difficult to decide whether it’s right or wrong, good or bad.

Take plastic surgery, Botox injections, and other body-altering elective procedures done for non-reconstructive, ‘vanity’ purposes. I’ve dubbed them cosmetic medical interventions. Last year, I examined the benefits and impacts of these, both personal and social. Many, even most, would consider opting for one of these cosmetic treatments  anything from harmless vanity to helpful in boosting self-esteem, and most would consider it a purely personal matter and no-one else’s business. Yet I found that the social acceptance and increasing prevalence of cosmetic medical interventions can have significant impacts that affect a whole culture. While I didn’t find sufficient justification for banning most of them or even for claiming they’re immoral across the board, I believe I presented evidence and arguments sufficient to show they can cause harm, especially in the aggregate. While cosmetic medical interventions can and do make some individuals happy in particular circumstances, they can present health risks, be disfiguring, become psychologically addictive, and perpetuate gender stereotypes, ageism, racism, classism, and other mindsets that erode respect and tolerance.

And as my examination progressed, an uneasy realization kept nagging at me. Many of my questions and concerns about cosmetic medical interventions could apply, for the same or similar reasons, to sex reassignment surgery. I decided not to include it in that discussion because it’s embraced by so many as an important way to achieve fulfillment, acceptance, and equality for traditionally marginalized transgender people, making it a politically ‘hot’ and delicate issue warranting its own careful examination.

Then not too long ago, I heard this story on NPR about one of two twin boys, self-identified as a girl since the age of three, who became the young woman she identifies as today through sex reassignment surgery. Nicole’s story, while fascinating in its own right, struck me at the moment because of the terminology used: gender reassignment surgery.

That got me to thinking a lot about the issue again. Hmm, I thought, ‘gender reassignment surgery’, that’s a new way of putting it… but wait a minute: isn’t there a glaring assumption, even some contradictions, contained in that phrase?

For one thing, haven’t critics of traditional, binary gender roles been arguing that gender is neither dichotomic nor fixed? That gender is a set of attributes culturally or personally assigned according to sex, transmitted through social practice and the enforcement of norms? If so, how can gender, not just sex, be surgically altered? Sex can be reassigned to a certain extent: physical appearance can be surgically altered to match the general appearance of persons of the opposite biological sex, though we can’t transplant or build functioning reproductive organs (as of yet, anyway). And gender can be reassigned through self-identification, mental state, legal status, social acceptance, and many other means.

But how can gender be surgically reassigned, unless we accept the assumption that gender is tied to sex and an accompanying set of particular physical attributes?

I recognize that calling it ‘gender reassignment surgery’ is motivated by progressive values. Besides the regressive assumption I perceive in the term, it’s also forward-thinking in its attempt to reflect the best science available about transgender people, and a sympathetic recognition of the difficulties they experience in binary-gendered societies. The term hints at part of what science shows us: the experience of gender is at least partly biological in origin. However, gender is not, as the term also indicates, inextricably linked to how closely one’s physical appearance correlates with the general appearance of males and females. Science reveals that the feeling of belonging to a particular gender is generally correlated with sex, as biologist and neuroscientist Robert Sapolsky explains; however, it’s more complicated than that. We now have the capability of studying the brains of people who seek sex reassignment surgery because they feel their gender doesn’t match the body they’re born with. When transgender people like Nicole from the NPR story, who just know from a very young age that they really belong to a different gender than others perceive, we can actually see that their brains are physically different from the average person whose gender and sex fit the more common binary system. For example, the brain of a young male-sexed person who has felt female for years can look, in some regions, more like the average brain of a female than of a male. And the tenuous link between sex and gender for many people doesn’t end there: physical expression of sex can be ambiguous, with some bodies having genitalia with both male and female characteristics, or not identifiably either, whatever the gender.

Therefore, the phrase ‘gender reassignment surgery’ misses the boat in reflecting the science of transgender experience and its biological origins. But it’s also regressive insofar as it contradicts that valuable, hard-won insight that gender is also cultural. The larger question of who we want to be, as it relates to gender, isn’t determined by the appearance of our bodies and whether that appearance matches one sex or another: it’s also determined by how other people treat us based on the appearance of our bodies and how we present ourselves. And the way other people treat us has as more to do more to do with culturally instilled values and expectations than with strictly biological instincts.

So the NPR story led me to expand my initial questions and concerns arising from my examination of cosmetic medical interventions: is sex reassignment surgery also such a good thing on the whole, for society and for individuals? And to add: might it do more to reinforce gender stereotypes and the notion that our physical appearance determines our fate, than it enhances our freedom and long term sense of self-worth and happiness?

The evidence regarding the latter is very limited, since sex reassignment surgery hasn’t been done on a large scale for very long. There’s a(n) (in)famous study from Sweden from a few years ago that found that rates of suicide and psychiatric disorders were higher in those that received sex reassignment surgery and hormone therapy. People of every political persuasion drew wildly different conclusions from this, generally to fit their already held convictions: either that the higher rates of suicide and psychiatric disorder only reveal the stigma that transgender people face, not that transgender people are mentally ill or sex reassignment surgery is bad, or, that the higher rates of undesirable outcomes reveal that sex reassignment surgery is an invasive, painful, and harmful mistreatment of what’s really a cultural and psychological problem.

I don’t believe it’s hard for most of us to accept that many opt for cosmetic medical interventions because they feel driven to it by pervasive ageism, sexism, and gender stereotypes. If you’re convinced that you’re too ‘old’, ‘wrinkled’, ‘fat’ ‘flat-chested’, or otherwise don’t match cultural standards of what a beautiful and successful person looks like, than you feel you need surgery in order to be accepted, to succeed, and to be admired. Sometimes, opting for cosmetic medical interventions helps to achieve these goals in come circumstances. In similar ways, some may feel the need for sex reassignment surgery because they’ve been told throughout their life, regardless of how they feel about themselves and what their preferences are, that they can’t wear a dress or makeup, be tough, be cute, play rough, take a leadership role, be forthright and assertive, pursue their real interests, or otherwise express their true personalities because they look like a boy or a girl. And sometimes for these transgender people, sex reassignment surgery helps them to express who they feel they really are, because their new appearance changes the way others perceive them and expect them to act.

Does this mean that we need to accept that sex reassignment surgery, or cosmetic medical intervention for that matter, is the best way to help us achieve the freedom to be who we want to be? Does it help instill in us the values of respect and tolerance for others and for ourselves, regardless of physical appearance? Is it really the key to breaking down gender stereotypes and increasing the freedom to be who we really are?

I have some questions and some doubts.

Don’t get me wrong: I believe that our newfound willingness to accept that people have the right to present or alter themselves as they see fit, and to recognize that their reasons for doing so may be good or at least understandable, is a good thing: it shows we’ve become more generous, our imaginations have broadened, and we’ve become more solicitous of other people’s interest in seeking their own happiness than we are concerned with whether their actions conform to our own moral or religious standards. I’m not exploring this issue because I doubt that society is moving towards increased tolerance, respect for diversity, and commitment to increasing human freedom; in fact, I believe that we’ve generally progressed a lot on all of these fronts, and will continue to do so. I’m exploring it because I’m doubtful that sex reassignment surgery is the best solution overall or in the long term to furthering these excellent ends, for the individual and for society.

For one thing, sex reassignment surgery seems to reinforce the idea that we need to look a certain way in order to be a certain way. In fact, it’s very name, like NPR’s term gender reassignment surgery, concedes this. Do we ‘feel like a man’, but ‘look like a woman’? Then to match our own and other’s ideas of what ‘feeling like a man’ should look like, we alter our body: remove the breasts, add a penis, and take hormones to deepen the voice, broaden the shoulders, and increase body hair. Or vice versa.

But why must we concede that changing the way our bodies look is the best way to resolve the disparity between how we look and what we and others expect of ourselves because of it? Sex reassignment surgery and the term gender reassignment surgery seem to concede too much to this assumption, to the point of people feeling that the radical step of extensive cosmetic surgery, with all its associated risks of infection, scarring, and other side effects, is necessary for them to be happy in their own skin. It’s also very expensive, and available mostly to the relatively wealthy and to those willing or able to get into debt, which, like cosmetic medical interventions, adds a classist element, making gender-as-sex expression the privilege of the few. It seems to me that sex reassignment surgery can serve to reinforce the notion that gender is strictly binary because of the way it conforms our bodies to it. So while the overall goal of sex reassignment surgery might be to break down rigid, narrow cultural perceptions of the link between sex and gender, it seems to act more as a concession to them.

I’m also not so sure about the real freedom of choice that many feel they have when they opt for sex reassignment surgery. Since most of us treat others quite differently according to their perceived gender, for those who feel like they belong to another gender than people perceive them as, the disparity can grow intolerable over time. Thus, sex reassignment surgery can appear to be their only viable alternative. Imagine being treated all the time like a different person than you know you are, and you can imagine the frustration. Perhaps you are an intellectual by inclination, but your family doesn’t fully educate you as a child or encourage an academic career for you as an adult because of their religious conviction that only men are the God-appointed thinkers and leaders of church and home. Perhaps your curvy figure and heart-shaped face lead people to treat you as if you are little more than a ‘bimbo’, a ‘sex kitten’, or on the make (I’m thinking of the brilliant and lovely Hedy Lamarr, actress and inventor). Perhaps you are a biological woman who likes to wear short hair and comfortable, practical, and sturdy ‘masculine’ clothing, who find makeup and ‘feminine’ clothing binding and unsuited to your personality and lifestyle, and you find yourself unable to go about your daily business without people treating you as if you’re not a ‘real woman’ (whatever THAT means!) or as if you are ‘asexual’ or ‘hate men’.

I can imagine these situations, and I’ve experienced some version of all of these myself in my own life. For transgender people, the disparity is more pronounced, and the need for a lasting solution more urgent. In this sense, I not only appreciate the perceived necessity for a solution like sex reassignment surgery, but am deeply sympathetic as well.

Yet the problem here, again, is similar to that I’ve addressed when considering cosmetic medical interventions: while we might be happier as individuals or in the short term by surgically or chemically altering our appearance, is it really a good long-term solution to the underlying problem? Mightn’t we actually be prolonging it by perpetuating and strengthening sex and gender stereotypes through sex reassignment surgery, as we’ve considered? Is it really a good thing to allow ourselves too much leeway by accepting, out of hand, that surgically altering our bodies to fit society’s standards is better than the option of training ourselves and each other to learn to be comfortable with, and even love and appreciate, the bodies nature has given us? It seems that the latter is actually more conducive to creating a world where racism, ageism, and rigid binary sex and gender codes lose their hold on our imagination and moral sense, and a sustainable solution at that, available to rich and poor alike.

Acceptance of the practice of sex reassignment surgery may be a necessary step, even if a flawed one, on the way to creating a society that not only tolerates, but values, increasing diversity in cultural- and self-expression. I don’t believe for a moment that any individual person who opts to have sex reassignment wants to impose their ideas about gender on anyone else; they’re seeking to be true to themselves the best way they know how. And sometimes, for some people, it does the trick. That’s why, like with cosmetic medical intervention, I’m loathe to make the claim that we should ban sex reassignment surgery for consenting adults. But the social outcome of the practice in the aggregate, as it becomes an institution, may undermine the very good it’s trying to do. Whatever the intention, sex reassignment surgery leaves physical scars just as it can social and psychological ones, as our unreadiness, our inability, our unwillingness, or our refusal to accept ourselves and each other as we really are is carved into the very bodies of transgender people.

Perhaps the liberty to choose sex reassignment surgery is what we need right now to break old habits and attain the freedom to be who we know ourselves to be. I hope that this, in turn, will become the freedom from having to change our bodies to coincide with our own and other people’s preconceptions on sex and gender.

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Sources and inspiration:

‘Becoming Nicole’ Recounts One Family’s Acceptance Of A Transgender Child’. NPR: National Public Radio. Oct 20, 2015 http://www.npr.org/sections/health-shots/2015/10/19/449937765/becoming-nicole-recounts-one-familys-acceptance-of-their-transgender-child

Dhejne, Cecilia et al. ‘Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden’. Feb 22, 2011
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043071/

Glicksman, Eve. ‘Transgender Today: Throughout History, Transgender People Have Been Misunderstood and Seldom Studied. That’s Beginning to Change.’ American Psychological Association. April 2013. http://www.apa.org/monitor/2013/04/transgender.aspx

Sapolsky, Robert. ‘Caitlyn Jenner and Our Cognitive Dissonance’
http://nautil.us/issue/28/2050/caitlyn-jenner-and-our-cognitive-dissonance