To Be or Not To Be: How Gender Norms and Roles Affect Patients Desiring Sex Reassignment Surgery

February 13, 2013


“Normality, then, is the backdrop against which our individuality, that individuality for which we desire to be loved, becomes foregrounded. We fear that without normality we move outside of the recognizable and so the cognizable.” —Eva Feder Kittay

In August 2012, Susan and Rob allowed their son, Alex, to go to preschool in a dress. In an e-mail to parents of his classmates the night before, they wrote, “[Alex] has been gender-fluid for as long as we can remember, and at the moment he is equally passionate about and identified with soccer players and princesses, superheroes and ballerinas.” (Padawer 1). It was explained that he had become inconsolable about the fact that he could not wear dresses beyond dress-up time. After consulting a pediatrician, psychologist and “parents of other non-conforming children,” they came to the conclusion that it was more important to “teach him not to be ashamed of who he feels he is,” and not make him feel as if reacting in that way to his gender, not identifying with one or other, is something forbidden. (Padawer 1). At the age of four he had identified as “a boy and a girl,” but has since then been clear that he is a boy who simply “likes to dress and play in conventionally feminine ways.” (Padawer 1). There have always been people that defy gender norms. It was not until the mid-20th century when doctors were trying “corrective therapy” to “extinguish atypical gender behaviors,” that the idea of gender questioning, as a whole, went from stigmatized to forbidden; it became an act that was portrayed as being punishable, something that would eventually if not immediately ostracize and isolate you, not only from society, but from other individuals within society as well. (Padawer 1).

The term “gender” has come to represent the binary by which we live our own lives, constantly within one category or another, never allowing a middle ground to become known. Our human identities, which are the ideas of who we are and the different societal influences that impact that identity, are shaped, for the most part, initially, by our gender or sex. An individual’s sex can be defined as their biological sex; their gender is defined as the one they identify with the most, which can be different from their biological sex. As we mature and grow older, our human identities become interconnected with the image that society has of a person’s identity and the traits that are most favorable; in the end, the acceptance and rejection of those specific traits become intertwined with the identities that we want individuals within society to have. In terms of normalization, which can be defined as the process of becoming normal (in this case meant to represent the standards deemed acceptable by society), the justification or validation of processes that pursue normality in a way that defies the accepted norms, completely eclipse these ideas of individual human identity. An individual’s identity then becomes the one society would like to have.

This is most commonly seen within the context of Gender Reassignment Surgery, in which society’s own ideas and beliefs about gender-variant individuals, specifically transgender individuals, greatly influence the acceptance of them into society. The surgery itself is meant to normalize, to change the gender of someone who in their defiance of gender norms (Ex. You should not identify with a gender different than your biological sex. Your sex is your gender) still abides by the binary gender division; they change their own gender because even in their ambivalence of their gender “born in one and belonging to another,” it is important to fit into the two categories that society has deemed acceptable. (Padawer 2). Yet, even with the clear divide—the all or nothing—thoughts still remain about the origin of these “norms,” and the different ways that we, as humans, have allowed them to influence our own perceptions of what the words normal and acceptable represent, or should represent, to each individual.

Our ideas of normal, then, and our reactions to gender-variant individuals especially concerning Gender Reassignment are heavily influenced by them; to understand the surgery and the motivation behind it, whether or not the perspective given agrees, disagrees, or finds a middle ground with it, is to comprehend the affects that these ideas have on socially constructed gender norms and how they affect the patients that desire the surgery. What is normal? Does being “normal” provide the happiness that the patients seek when desiring the surgery? How do we move forward, away from these ideas of conformity and abiding to gender norms, and accept those individuals that defy the norm?

What is normality, normalization, and what are normalizing surgeries?

Based on Eva Feder Kittay’s theory of normalization which states, “To be normal is to be desirable, and as an extension of that, to be loved, not in spite of but because of our abnormalities,” ideas of normal come from the traits that have been deemed as desirable; from our own perceptions of those traits, individuals form their identities. Normality, in many cases, represents a standard set of conditions that are generally accepted and used within society; the word “normal” similarly signifies a standard or regular pattern that people abide by each day. Of course, within these definitions, different aspects apply in various ways through different contexts; however, as a whole, “normality” and “normal”, for the sole purpose of this discussion, will be used to represent the definitions listed above.

In its origin, norms and normalization were created to stabilize. Within societies at the precipice of their success, any deviation from the norm, any lack of stability, could completely destroy any foundation already established. Even in fully developed countries and areas of the world, norms and standards of human behavior and interaction were necessary to keep the peace, and after times of crisis, unify society and its’ individuals. For example, the United States post-World War II, as well as other areas of the world, understandably, began to cling to concepts of normal, hoping to stabilize society and reestablish the foundation that it was developed on. From a single, isolated incident such as that, where people purposefully came together in order to restore what they thought society should be and to protect it from what it could, in its’ darkest moments, be capable of: normality became as immutable and rigid as it is today. It is in situations such as those that take the initial idea of normal—stability and safety—and transform it into something unrecognizable and intolerant of differences; the desire for normality, rather, what it once represented, became, instead of a portrayal of reality and human experiences, a judgment of value. What is not normal is deemed as being without value.

“If we ask about the desire for normalcy when we understand normal as a judgment of value (of what is desirable), not of reality, the statement that we desire normality becomes a near tautology—for to be normal is to be something desirable. Conversely, the stigma that attaches to the normal is again analytically entailed by this notion of normalcy, for that which is not normal is precisely that which is not valued and so not desirable. Those who inhabit the space of the non-normal do not merely occupy value-neutral positions that deviate from a norm. They occupy positions marked as not valued, not desirable, [and] stigmatized.” (Kittay 96)

Difference has become so devalued that what is normal has come precisely to represent what is desired because the statistical norm—which has been deemed acceptable—has become the basis of social norms and institutions, “exclusion to which we feel valued—or endangered—by the community of which we are apart.” (Kittay 98). Conformity to a standard carries with it a revulsion to and exclusion of any variation. It gives a dull lifestyle for those who remain within the norm and results in “isolation—even immiseration—for those excluded.” (Kittay 98). It is assumed, in the construction of these norms and abidance to them, that the way we exist socially should be the basis of our own viewpoints of normal and the ways in which we carry out those conformities to the norm. Our ideas of normal, then, and our reactions to gender-variant individuals especially concerning Gender Reassignment are heavily influenced by them; to understand the surgery and the motivation behind it, whether or not the perspective given agrees, disagrees, or finds a middle ground with it, is to comprehend the affects that these ideas have on socially constructed gender norms and how they affect the patients that desire the surgery.

Agreeing with Gender Reassignment Surgery

The term “transsexual” is essentially the same identification as the term “transgender”; both individuals agree that their biological sex is not the one for them and often feel as if they have been born in the “wrong body.” Harry Benjamin, a sexologist (someone who studies human sexuality, including human sexual interests, behavior and functions), describes true transsexualism in this way: “True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such. For them, their sex organs…are disgusting deformities that must be changed by the surgeon’s knife.” In terms of Gender Reassignment Surgery, this idea coincides directly because of its’ acceptance of the main objective that most patients desiring the surgery employ; in their minds, to get the surgery signifies the transition from a life that represented ostracism and to a life that will gain them acceptance and in turn makes them normal and desirable to society. And because, “The desire for normal is intimately tied to our desire for love,” patients go into the surgery process with these types of long term goals in mind. (Kittay 106). Getting the surgery is fairly short-term for what the patients actually hope to accomplish down the road: to get the surgery is to accept the long journey ahead that includes adjusting to life with a different gender and becoming comfortable with the new social dynamic that exists after the transition has been made.

There is a huge disconnect between what gender one identifies with and the actual sex which is why I decided to base my research around the norm: your gender matches your sex. The norm, as most social norms, implies that all people think and feel in the same ways. Sex or Gender Reassignment Surgery is the process of changing an individuals’ sex to fit their own identification; if a man were to receive the surgery, he would want to make the transformation from a man to a woman. To obtain sex reassignment therapy, transsexual people are generally required to undergo a psychological evaluation and receive a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as published by the World Professional Association for Transgender Health. This assessment is usually accompanied by counseling on issues of adjustment to the desired gender role, effects and risks of medical treatments, and sometimes also by psychological therapy. The SOC are intended as guidelines, not inflexible rules, and are intended to ensure that clients are properly informed and in sound psychological health, and to discourage people from transitioning based on unrealistic expectations.

Psychological techniques that attempt to alter gender identity to one considered appropriate for the person’s assigned sex are typically ineffective; for example, therapy to treat the patient for Gender Identity Disorder which denies the patient’s own opinion of their identification. The diagnosis of Gender Identity Disorder insults transgender individuals because they do not view their own identification as a disorder or something to be fixed; this often leads to questioning about gender identity and gender roles within society. The widely-recognized Standards of Carenote that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy. Many transgender and transsexual activists, and many caregivers, note that these problems are not usually related to the gender identity issues themselves, but the social and cultural responses to gender-variant individuals. Some transsexual people reject the counseling that is recommended by the Standards of Care because they don’t consider their gender identity to be a psychological problem.

A surgeon that performs what he names, Gender Confirmation Surgery (which is the same as Gender Reassignment), states, “If the primary goal of plastic surgery and cosmetic surgery is to help people feel better about themselves, we could think of transgender surgery as the ultimate cosmetic surgery. I believe there is no type of surgery or any other field in or out of the medical world which creates such a profound and positive change in both the physical, emotional, and mental status of a person as with transgender surgery.” From his perspective, the surgery is confirmation of a lifestyle, an affirmation of identity that patients had previously been searching for. From this, it is suggested that the idea of surgery in and of itself, because it is classified as cosmetic since it’s not medically necessary, is the most honorable of surgeries. All cosmetic surgeries seek to change the appearance to make the patient feel better; however, because of the multi-faceted complications of Gender Reassignment Surgery and the problems it can solve (mental, emotional, and physical), the surgeon suggests that these factors alone set it apart from other surgeries. “Each transition is an intimate, distinct experience.” To truly agree with the surgery, is to believe these things to be true, that the surgery won’t only change the physical appearance but the complete outlook on life.

Disagreeing with Gender Reassignment Surgery

Some people consider research into the alleged causes of transsexualism to be based on the assumption that it is a pathology–an assumption that is rejected by many transsexual people. Others think of the condition as a form of intersexuality and support research into possible causes, believing that it will verify the theory of a biological origin and thereby reduce social stigma by demonstrating that it is not a delusion or a political statement. The disagreeing perspective most often argues that the surgery, which is supposed to help you gain acceptance, contradicts its main objective. Instead of gaining acceptance, you cheat yourself out of it by submitting to the more dominant gender.

A life with what is believed to be “the right gender,” is not, from this perspective, thought to be fully helpful for patients; instead, some would argue that it only worsens the situation. For some who disagree with this surgical procedure as a means to gain acceptance, to get the surgery is to succumb to the dominant gender which is the source of their difficulty, so to get it would be a contradiction. For those who disagree, the surgery is a form of enhancement—it does nothing therapeutic, therefore it would be done just to change the way a person look for the benefit of self-acceptance.

Middle Ground Perspective

Any form of behavior that seeks to “correct” the “abnormality” (which in this case is specifically an abnormal attraction or identification with another gender) can be severely damaging to people who are already questioning their identities, especially in terms of their sexual preferences. “Transgender people preserve the traditional binary gender division: born in one and belonging in the other…But [some]…argue that gender is a spectrum rather than two opposing categories, neither of which any real man or woman precisely fits.” (Padawer 2). Gender identification is so central to identity that as a small child, if raised with the perception that questioning your gender is something that should be hidden or something that is unacceptable in society, you are more likely to have issues with it in the future. By not allowing patients to occupy a “middle space” as they are developing, you eliminate their chances; is it not wrong to then punish them when they try to answer those lingering questions they have about themselves that were never answered or looked into, because of the fact that it was socially rejected?

The Accepted and Rejected: How Acceptance Plays a Role within Gender Reassignment Surgery

In the Agreement Perspective to get the surgery is to start the journey to not only being accepted by others, but accepting yourself. For individuals whose internal struggles with gender identity interfere with their own self-esteem and mental well-being, getting to a point where the idea of being gender-variant is comprehensible still presents concerns to those involved. Susan, the mother of the aforementioned four-year old Alex questions similarly, “I worried that if I was having a hard time wrapping my mind around my kid, and I love him more than life itself, then how would the rest of the world react to him?” (Padawer 3). Given how central gender is to identity, she fears the wrong parenting decision could devastate her child’s social or emotional well-being. What else would a society founded on upholding norms hold for transgender individuals if not rejection and judgment?  With this evaluation of the situation, Gender Reassignment Surgery offers an opportunity for these individuals to gain acceptance without receiving the already immense, backlash of simply remaining one sex but identifying with another.

In contrast the Disagreement Perspective argues: to get the surgery is to have a false sense of acceptance; no one is really accepting you, they are accepting the newer version of you. It contradicts the purpose behind the action. This false sense of acceptance comes from not truly being accepted as the individual that you are; instead, it comes from the individual that you have engineered yourself to become, the one that society will accept. If the whole point of receiving the surgery is to move away from societies’ standards and create your own, why would receiving the surgery aid that objective? How does it even allow the patient to hold onto their own values without sacrificing them for others more socially acceptable? The logic does not seem to make sense if it rejects the principles it seeks to uphold; however, even more compelling, is the thought that the motivation to receive surgery does not present itself wholly as a means to achieve a sense of acceptance based on conformity to gender norms preset by society. What if the motive behind it merely hopes to change social constructs in order to benefit the lives of many transgender and questioning individuals?

The main idea within the Middle Ground Perspective argues that whether patients receive the surgery or go without it, society and each individual should be able to work towards higher levels of tolerance and acceptance of these individuals; this idea is considered especially important in situations that go far beyond socially accepted norms. Susan, the mother of the aforementioned four-year old Alex, agrees, “It’s hard to put a finger on why gender identity makes such a difference to our sense of who a person is, but it does.” (Padawer 2).The issue of Gender Reassignment Surgery goes far beyond issues with accepting those who receive it; to understand its’ impact it is necessary to become aware of the harsh stigma placed on these individuals when they dare to balance their lives in the middle. How can those individuals even be expected to confine their own gender identity to the ones that society places on them when they cannot even comfortably address their internal concerns without fearing rejection or judgment? In light of the Disagreement Perspective, thoughts such as these, that seek to go far beyond the experience of the patient, finding a middle ground eliminates the complications put forward. Elimination of those boundaries is the first step, perhaps the hardest but when in comparison with the last: acceptance, it may seem even more daunting; yet in the face of these issues, society must work toward changing their perceptions. Without understanding the connections between the ways in which social expectations affect transgender individuals who struggle internally for long periods of time before confronting a defiance of those norms, society will not be able to transcend and remove those boundaries that constantly bar them from a life of happiness. If, however, society can move forward, it can also work on creating a more functional and happy world that both learns to accept and acknowledge the situations presented.

Fulfilling Goals: How Fulfillment Plays a Role within Gender Reassignment Surgery

Within the agreement perspective, to get the surgery is to fulfill a lifelong goal: to belong to society, to function as an accepted individual on your own terms. As previously mentioned, the main objective within Gender Reassignment Surgery, as a whole, is to begin leading a life of happiness which coincides both with acceptance and fulfillment. Yet, fulfillment, though closely related to acceptance represents a different point of view that perhaps in the context of such abstract concepts as normalization and gender norms affecting livelihoods of gender-variant individuals signifies a situation much more relatable to individuals that have no issues facing gender norms because they identify with them. Fulfillment, in all senses of the word, means a completion or achievement of a goal or a satisfaction of it. To comprehend why fulfillment could mean as much, if not more, than acceptance, perhaps think of something the average person would dream of fulfilling or carrying out; for example, when pursuing a career an individual always has a position in mind that they would like to achieve. If that person was never able to reach that position for a long period of time, not due to a lack of experience or preparation for the job’s duties, how happy would the person be if they were chosen for the position? Surely, plenty of celebration would be done, as well as congratulations on this achievement. With this situation in mind, it is simpler to imagine what the surgery must signify to patients in terms of fulfillment. It is more than a technical process; it represents a transformation, a confirmation of their identity; in essence, it is a new life to be celebrated. Why not accept it in the same way?

Within the Disagreement Perspective, receiving the surgery doesn’t fulfill the goal of acceptance because it is not gained in an authentic way; instead you gain fulfillment because you have submitted to the more dominant norm. The patient identifies with in reaction to society’s intolerance of their “middle space.” Similar to acceptance, the logic of fulfillment as a value that should support Gender Reassignment Surgery only takes two steps back; it contradicts itself instead of building an argument. But the point still remains: the goal of the surgery extends beyond its’ immediate results and surely, far beyond the impact it has on one individual.

The Middle Ground Perspective establishes the idea that: to get the surgery or to go without it does not matter as long as the issue is confronted both by the individual and society; no one is purely masculine or feminine. To judge someone because they acknowledge and implement this ambiguity into their own lifestyle is to condemn and try to correct the behavior when it may not have been entirely incorrect in the beginning. To see the larger issue with assigning categories and expecting people to fit into one another without allowing them to make their own choices, directly influences their responses to intolerance negatively. It also urges them to conform for fear of being judged too quickly. In accepting this middle ground and the fact that nothing can be categorized so that it falls neatly into one box as is seen to be appropriate by society, you must also accept the prevalence of these issues in society and their increasing impact on the lives and relationships of individuals everywhere. Acceptance, in and of itself, may begin to eliminate the absurd expectations we have on individuals to fulfill them when they completely ignore concerns for human well-being. Perhaps, with these thoughts in mind, tolerance can be achieved.

Conclusion: Tolerance and the Road to Acceptance for Society

By no means is normality “bad.” In fact, in many cases social norms have helped society (i.e. the U.S. post-World War II) and have created boundaries that do not hinder society. “Normality becomes a tyrant when it becomes immutable, rigid, impervious to the fact of its own construction, and blind to the subjectivity with which it is infused.”  (Kittay 108). Founded with the intention of stabilizing society and creating a world that would ensure a peaceful coexistence for all parties, it seems as if society has taken a dire turn left—away from the aspects that made ideas of normality so inviting to the average individual. At present, concerning the issue of Gender Reassignment Surgery, each individual who has been excluded as a result of our preoccupation over maintaining all preset constructions of society, has suffered. With the rigid acceptance of two all-or-nothing categories, individuals who do not fit in are not only placed in “value-neutral positions” that deviate from a norm; instead, they actually begin to occupy positions that in their defiance deems them as “not valued, not desirable, [and] stigmatized.” (Kittay 96).

Normality and social norms have come to harm because they have become misrepresentations of the judgment of value (of what is desirable) that we use to judge one another. What is normal is desirable and conversely what is not normal is not desirable. It is assumed that the way we exist socially should be the basis of our viewpoints of normal. To understand the actual concept of normality is to acknowledge and act on the subjectivity with which it was established and allow situations to blur between those categories as a result of that comprehension. We should not devalue difference so that what is normal has the same significance as what is desirable.

At its core, normality and the connection it has with gender norms and in a broader sense, Gender Reassignment Surgery desperately needs to adopt a middle ground perspective. It gives the patient a choice, which is at the end of it all, the thing needed the most—an opportunity for a choice or even an acknowledgment that a choice can and should be made willingly makes a crucial difference. Patients, being acknowledged, appreciated as individuals and valued as members of society would of course greatly find this attempt at picking up the pieces, sharing their experiences and making others aware of the reality of their own lives, a fulfillment in and of itself. More must be done but just the thought of coming together in this way is a step in the right direction.

There is potential, in fact, for this goal to be met but it must be a collaboration, an agreement, and a commitment to humanity and more specifically to the individuals that have been most affected. They must know that society is taking large steps to move forward. Perhaps, if the benefits of adopting a Middle Ground Perspective could be seen by individuals not only affected, the road to tolerance could be established; if each individual built up the courage to speak out against these painful experiences and support individuals who need it the most, society would begin to see the harm it has, at times indirectly, caused and attempt to repair it.

Works Cited

­­­Dreger, Alice. “Essay; When Medicine Goes Too Far in the Pursuit of Normality.” NY Times [New York] 28 July 1998, Science: n. page. Print.

Hume, Maggi Colene (2011) “Sex, Lies, and Surgery: The Ethics of Gender Reassignment Surgery,” Res Cogitans: Vol. 2: Iss. 1, Article 5.

“Inviting Dr. Phil to join us in the in-between.” Pink is for Boys. WordPress, Jan. 2010. Web. 25 Jan. 2013.<>.

Kittay, Eva Feder. Surgically Shaping Children: Technology, Ethics and the Pursuit of Normality. Baltimore: The Johns Hopkins University Press, 2006. Print.

Leis, Sherman. “Why I am a Gender Confirmation Surgeon.” The Philadelphia Center for Transgender Surgery. Phoenix Consultants Group, Inc., n.d. Web. 12 Jan. 2013. <>.

Nelson, James Lindemann. “Still Quiet After All These Years (Bioethical Inquiry).” 6 July 2012. Digital file.

Padawer, Ruth. “What’s So Bad About a Boy Who Wants to Wear a Dress?” The New York Times. The New York Times Company, n.d. Web. 27 Sept. 2012.

Brianna Velez is a senior at Kent Place School. She initially joined The Bioethics Project 2012 out of a desire to learn more about ethics and the ways in which those conflicts appeared in everyday life. She took a particular interest in the effects that society has on our own perceptions of right and wrong and how those ideas also shape society's perception of normality and gender; from this, she chose to conduct research on Gender Reassignment Surgery and the affects these concepts have on transgender patients. Her favorite subjects are English and History and in the future, she hopes to teach high school students in one of those areas.

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