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Thursday, September 06, 2012

Transgender Trouble

Draft. Do not quote without permission. Submitted to the journal: VERIFICHE. Under review.

This paper has been written with Sandra Vial, Professor of Sociology of Health at the University UNISINOS - Porto Alegre. Thanks to the FERIE Program in Paris and the CAPES Program in Porto Alegre which made our collaboration possible through their generous grants.

Gloria Origgi - CNRS - Institut Nicod, Paris
Sandra Vial - UNISINOS - Porto Alegre

This paper stems from a collaboration between a philosopher and a sociologist of health and human rights both interested in transdisciplinary approaches to social sciences. While working together in Porto Alegre and in Paris, we realized that sex,  more than gender, is one of the most interesting transdisciplinary notions in contemporary social sciences and that the failure of treating it in transdisciplinary terms still has heavy consequences in political and legal decisions about the recognition of transexual identity. We focus our analysis on the normative consequences of ambiguous conceptions of sex by comparing some in legal sentences on sex change in Brazil and Europe and will comment on the recent adoption in Argentine of a jurisdiction that recognizes transgender rights by clearly prying apart gender identity from the anatomical/biological sexual identity determined at birth. We conclude that a full-fledged consideration of transexuality as a human and health right should normatively account for the distinction between sex and gender. This will in general improve the rights not only of transexuals but also of all the transgender attitudes towards sexuality that struggle to be recognized because of the conceptual confusions among different interpretations of what sexual identity is.

A Transdisciplinary Approach to Transexuals’ Rights

Since the publication of Judith Butler’s book, Gender Trouble, in 1990, gender studies have progressed in an impressive way, by overcoming the binary polarization between male and female as the two unique possible expressions of gender identity. If the classical feminist debate aimed at debunking a fixed correlation between gender and sex, that is, between a set of stereotypical practices and norms of behavior and a biological bodily expression, thus showing to what extent sexual roles were socially constructed (cf. De Beauvoir, 1949), Butler’s essay paved the way of a new interpretation of gender by challenging a restrictive notion of gender associated with received notions of masculinity and femininity.[1] According to her view, gender is the “cultural meaning that the sexed body assumes”.[2] Clusters of properties, traits and behaviors that are traditionally associated to one gender or the other may be distributed in a variety of ways when not constrained by restrictive social norms and coercive institutions that force individuals to mold their behaviors and attitudes in order to fit social stereotypes. As she says: “The presumption of a binary gender system implicitly retains the belief in a mimetic relation of gender to sex whereby gender mirrors sex or is otherwise restricted by it”.[3] Transgender social types, that is, patterns of behavior that mix in a creative and original way traits coming from the two main genders (masculine and feminine) are today an acknowledged subject of cultural studies[4] and, at least in some parts of the world, an actual option of expression of the self.
Yet, while the study of gender has evolved in a direction that frees people from a too rigid determination of their sexual identity, in most countries legal and social norms about gender determination have not always taken into account these interesting developments.
If we look at the way in which legal norms deal around the world with transexual identities, we realize to what extent the binary gender distinction as well as the mimetic relation between gender and sex evoked by Butler still shape litigations and court decisions about the expression of gender identity and the rights associated to it.
This opens two orders of debate about the role of the state and the legal system over the determination of gender identity: (1) on the one hand, one may simply ask why should the state have the power to define sex? Which rights and duties clearly follow from the sex distinction? And do these rights and duties justify the power of states to define once for life the sex of their citizens?[5] (2) On the other hand, even if we give (1) for granted and acknowledge the right of states of determining the sex of, their citizens on what conception on male/female distinction should a nation ground its power of defining sex/gender identity?
In what follows, we will argue that the notion of “sex” on which states base their power to establish a sexual identity of their citizens fails to take into account the transdisciplinary dimension of this notion. We will also argue that the way in which legal systems define sex is normatively charged and biased toward a binary conception of sexuality and a mimetic interpretation of the relation between sex and gender according to which gender distinctions should mirror the binary sexual distinction.

1. Sex as a transdisciplinary notion
If one takes a closer look at the medical definitions of sex, it is easy to realize to what extent we are dealing with a plurality of notions that come from very different fields of research.The definition that we may find in a standard medical dictionary distinguishes among:
Sex (chromosomal):  A distinctive character of most animals and plants determined by the presence of the XX (female) or the XY (male) genotype in somatic cells, without regard to phenotypic manifestations.
Sex (endocrinological): Based on the type of gametes produced by the gonads, ova (macrogametes) being typical of the female, and spermatozoa (microgametes) of the male, or the category in which the individual is placed on such basis.
Sex (anatomical): That part of the phenotypic sex that is determined by the morphology or genital tissues.
Sex (behavioral1): The sum of functional and behavioral characteristics of living things that are involved in reproduction and that distinguish males and females.
Sex (behavioral2): The sum of social orientations and intimate behaviors that characterize the sexual identity of an individual.

As we can see, these definitions appeal to a variety of scientific expertise, from genetics to endocrinology, from anatomy to psychology and sociology. The biological received view about sexual determination is that each human has two sex chromosomes coding for maleness and femaleness that produce gonadal differences in utero and initiate a cascade of sexual differences in pre and post-natal development. But the relation between genetic and phenotypic expression is far from being understood in modern biology, and a certain determinism that characterized genetic biology in the XX century, according to which genes determine the phenotype is today obsolete.[6]
The anatomical view associates phenotypical expressions to morphological traits. But, as classical research on hermaphroditism has shown,[7] the morphological expression of the gonadal anatomy is not enough to determine the sex of the individual. In a famous survey over more than one hundred cases of children hermaphodytes, the psychologist and sexologist John Money[8] suggested that gender should not be assigned to hermaphrodite children according to their anatomy, but according to observation of their behavior after the age of two-and-a-half-year. By the way, it is interesting to remind that Money was one of the first psychologists who claimed that distinguishing between sex and gender was necessary in cases of sex reassignment, although he is notoriously famous for the sad case of the sex reassignment of David Reimer (born Bruce Peter Reimer in 1965), whose penis was accidentally destroyed during a circumcision when he was a child and was reassigned and raised by his parents as a female  - following the suggestion of Dr. Money. The reassignment, based on Money’s insights about the opportunity of a gender/sex distinction, ended up in a disaster. He decided to go back to his male identity during his adolescence, and, after a series of ups and downs and a broken marriage, he committed suicide at age 38. This sad story shows how delicate is to stick to the anatomical expression of sexual tissues to a permanent identity.
As the behavioral characteristics associated with sex, there exist a vast empirical literature that shows how weak and contextually dependent these associations are.[9] As we have said, deconstructing the binary boundaries of gender has been a major intellectual achievement of gender studies in the 1990.[10] But, as the definitions of sex discussed above show, it is clear that the notion of sex also is problematic, heavily socially constructed and normatively used in many contexts.[11]
Instead of restating what the literature on gender studies has already said, that is, that both gender and sex are socially constructed notions, we would like to take a transdisciplinary stance and insisting on the vectorial, multidimensional transdisciplinary dimension of the notion of sex. Sexual differences are a societal norm, a biological reality, a strong social intuition that allows us to make sense of the social world is around us. Revealing their socially constructed dimension doesn’t mean that we can get rid of them: reading the social world as a sexed reality is something that is there to stay, even if we can avoid many prejudices and injustices by acknowledging the transdisciplinary aspect of the notion.
2. Health as a transdisciplinary notion
Health is also a transdisciplinary notion that is unstable between a normative and a descriptive reading. The World Health Organization defines health in the following way: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.[12] “To be in good health thus describes a much more complex state than just the absence of any infirmity: the definition points to a state of well-being whose realization goes far beyond the medical competences and involves the whole organization of society.
In order to assure health as a fundamental right, a legislation must exist that is able to realize the infrastructures, the institutions and the social conditions for the realization of this right.
Sexual health is defined by the OMS in the following way:
“Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”[13]
Thus, as we may see, health is not a medical notion, rather, a complex, transdisciplinary notion that involves all the layers of society: legal, social, economical and moral. The definition of sexual rights is also complex and far from being uncontroversial: On the website of WHO, although the definition is not considered as “official” (yet, it is odd that an “unofficial” definition is displayed on the website…) we find the following defintion:
 Sexual rights
Sexual rights embrace human rights that are already recognized in national laws, international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination and violence, to:
    .             the highest attainable standard of sexual health, including access to sexual and reproductive health care services;
    .             seek, receive and impart information related to sexuality;
    .             sexuality education;
    .             respect for bodily integrity;
    .             choose their partner;
    .             decide to be sexually active or not;
    .             consensual sexual relations;
    .             consensual marriage;
    .             decide whether or not, and when, to have children; and
    .             pursue a satisfying, safe and pleasurable sexual life.

The responsible exercise of human rights requires that all persons respect the rights of others.
As we may see, here also, we deal with a cluster of notions, norms, descriptions, desiderata, that involve educational issues, norms on marriage, reproductive needs, and information disclosure. There is no single discipline that can deal with the different cultures of marriage, the access of sexual education and the prevention of infective diseased sexually transmitted. There is no discipline that may set the standards of what is a “satisfying, safe and pleasurable sexual life”.
In the following we will take this transdisciplinary perspective to discuss the right of the determination of one’s own gender as a fundamental human and health right. As we hope to show, the failure to take into account the transdisciplinary dimensions of all these notions (sex, gender and health) has created ambiguous interpretations of the law and a normative vacuum on the right of deciding of one’s own gender determination and the practices associated to the public acknowledgement of this right.

3. A brief history of transexualism
Historically, transexualism was identified in psychoanalysis as an undifferentiated perversion, close to a cluster of pathologies  such as transvestic fetishism (DSM IV, 302.3) that involves cross-dressing. The first operation of sex reassignment was performed in Germany by Magnus Hirschfeld in 1931.[14] But the first case in which transexualism was recognized as a distinctive gender dysphoria from transvestitism and other pathologies was in 1952, when Christine (George) Jorgensen was operated in Denmark under the claim that he was a woman “trapped” in a man’s body. This allowed for the definition of a new syndrome, distinct from the pathology of transvestitism, called “transexualism”. The endocrinologist Harry Benjamin defined in 1954 transexualism as unique illness, a non-psychopatic sexual disorder, distinct from homosexuality and transvestitism and perhaps related to endocrinological problems. In United States, between 1950 and 1970, there was a lively discussion around Benjamin’s idea of a special transexual illness, especially among psychoanalists who went on for longtime considering transexualism as a mental pathology to be healed through psychotherapy and not through clinical surgery.[15]
The current diagnosis of transexualism in the DSM and in the International Classification of Diseases (ICD-10) is a medical condition although not a mental illness. For reasons that are left unspecified (genetical/endocrinological) transexual subjects feel and declare that they belong to the opposite sex. As the DSMIV specifies: “The cross-gender identification must not merely be a desire for any perceived cultural advantaged of being the other sex. There must be also evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex […] To make the diagnosis, there must be evidence of clinical significant distress or impairment in social, occupational and other important areas of functioning” (p.533). The ICD-10 classification reads as follows: “"F64.0 Transsexualism A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex."

Transexualism as a “social kind” to use the expression of the philosopher Ian Hacking, has thus an unstable history: one the one hand, its conceptualization as a mental illness was challenged by scientists and by transexual people, claiming that it was not just a variant of “gender identity disorder”, but a real physical state of being “trapped” in the wrong sex. On the other hand, this claim promoted the surgery of sex reassignment, thus the strong association between sexual identity and the anatomical expression of sex, an association that, as we will see, has been challenged in the recent years. In the Seventies, the John Hopkins hospital became in United States the center of the competences for sex reassignment surgery, under the influence of psychiatrists such as John Money and Eugene Meyer surgeons such as Milton Edgerton. The reaction of the psychiatric/psychoanalitic community to this practice was strong: there were many who affirmed that those who practiced sex reassignment plastic surgery were complying with psychopats: They attacked surgery as non-therapeutic. If patients' requests represented "a  surgical acting out of psychosis" (Volkan and Bhatti, 1973), then surgeons were guilty of  "collaboration with psychosis" (Meerloo, 1967:263). In an arm race of surveys and publications, evidence was found for the two positions: it was shown that most of the patients applying to the surgery were affected by various psychotic diseases, such as schizophrenia, neurosis, thus confirming the idea that sexual reassignment surgery was a “way of collaborating with psychosis”. Yet, Pauley (1968) reviewed 121 cases of transexual surgeries and concluded that patients had improved their psychical condition after surgery. These data are today challenged by other surveys (see Billing and Urban 1982 for a review)
Thus, the making of “transexualism” as a special condition has a complex history that alternates two interpretations of this psycho/physical state as well as different “fights for rights”. The recognition of transexualism as a distinct condition thanks to the research at the John Hopkins hospital in the Sixties was certainly an improvement towards the rights of transgender people and the public awareness of a further option of sexual identity beyond the male/female distinction. Yet, the price for this recognition was to stick together the surgical intervention with the transexual identity, thus paving the way for a legal recognition of transexuality in terms of physical/surgical change of the sexual apparatus.
As we will see in the next section, the “sociomedical construction” of transexualism as a disease whose only cure was represented by the sex reassignment surgery had heavy implications on the legislation and the rights associated to the possibility of changing sex.

4. Transgender Rights, Legal Decisions and the Evolution of Norms of Identity
In 1989 in Europe, a recommendation of the Assemblée Parlamentaire of the European Council (recommendation n. 1117)[16] invited the member states to develop a legal framework to treat these cases. The recommendation recognizes transexuals as people who have a “double personality” (without any mention of a mental illness) in which their physical sex doesn’t correspond to their psychical one, thus endorsing a classical theory of gender-identity in which sex determines gender. It is then stated that “Thanks to the advancement of medical research and to the possibility of surgical intervention for sex reassignment” the condition of transexual people can be improved. Finally, it encourages the member states to allow for the change of sex at the physical level and at the legal level. Even if a clear-cut causal or normative link between the medical sex-reassignement and the legal sex-reassignement is not stated, the recommendation clearly reads as the two were closely related. It is the existence of a medical technique of sex reassignment that makes the legal sex reassignment possible.
The legal endorsement of the member states of the recommendation has been different in each state.  Sweden, Italy, Germany, Belgium and Turkey have promulgated laws about the conditions of sex-reassignment. Two states, Andorra and Hungary, do not allow sex reassignment surgery. Other states, like Great-Britain, have adopted a pragmatic stance, that is, a case by case strategy, although specific legal measures have been taken to avoid discriminations of transexual people at work, through a 1999 regulation on gender reassignment.[17] As for the extension of legal rights to people who have undergone sex-reassignment, the British governmental policy recognizes the following rights:
“Once they are living permanently in their acquired gender, most transsexual people want their official documentation to reflect their new gender identity. They may obtain some official documents (including passports, National Insurance cards and driving licences) in their new name and gender, and the Department for Work and Pensions will make special arrangements for handling their records sensitively. Many private companies too have special arrangements for transsexual people. They are not currently entitled, however, to have their birth certificates revised, nor to enjoy any rights legally confined to persons of the gender to which they feel they belong. They cannot marry in their acquired gender, nor draw the State pension at the age appropriate to that gender”.
However, after the judgments of the European Court of Human Rights in Goodwin -vs UK, delivered on 11 July 2002, Great-Britain has simplified the procedures for the legal sex-reassignment. A Gender Recognition Panel, composed by a medical as well as a legal staff, is now enough to deliver a certificate of recognition of the new sex.
Spain has promulgated a law in 2007 that doesn’t require anymore the sex-reassignment surgery in order to ask for legal gender reassignment. In general, the most advanced policies in this matter have simplified the administrative procedures to obtain the legal gender reassignment and relaxed the medical criteria to recognize to the person the need of reassignment.
It is interesting to notice that in many legal literature, having gone through an operation of sex reassignment was seen not only as a pre-condition for asking legal reassignment, but also as a “sign” of commitment of the person, given the sufferings and the efforts of the operation: “The United Kingdom national health service, in common with the vast majority of Contracting States, acknowledges the existence of the condition and provides or permits treatment, including irreversible surgery. The medical and surgical acts which in this case rendered the gender re-assignment possible were indeed carried out under the supervision of the national health authorities. Nor, given the numerous and painful interventions involved in such surgery and the level of commitment and conviction required to achieve a change in social gender role, can it be suggested that there is anything arbitrary or capricious in the decision taken by a person to undergo gender re-assignment. In those circumstances, the ongoing scientific and medical debate as to the exact causes of the condition is of diminished relevance”.[18]

 In France also, there is no substantial legislation on gender reassignment, and a case by case policy is encouraged by the government. In 1992, the European Court of Human Rights condemned France in the case B. Vs. France for violation of the article 8 of the European Convention of Human Rights (concerning the rights to the respect of private life). Miss B appealed to the court after having being denied gender reassignment, even if she had undergone an operation,  on the basis of the conclusion of the judges that a person having acquired the physical “appearances” of the other sex cannot be considered of that sex if he or she lacks some fundamental characteristics of that sex: in this case, the “fundamental characteristic” was reproduction: being recognized as a woman would imply, for that judge, to be able to  make children!

Although the first surgery of sex reassignment in Brazil was performed in 1971, that is, during the hardest years of the dictatorship, it was only after the first Federal Constitution promulgated in 1988 that discriminations on the basis of sexual behavior started to be sanctioned. The first article of the new Brazilian constitution affirms the dignity of the human person as the foundation of a democratic state based on rights and the third article states that the objective of the democratic state is “to promote the well being of everybody without prejudices of origin, race, sex or color”. The Brazilian Federal Medical Council allowed the sex reassignment surgery in 1997 (resolução n°1.482/97) and extended the conditions and criteria in 2002. In 2008, the Ministry of Health institutionalized a processo transexualisador and acknowledged the right of performing sex-reassignment surgeries in public health structures. By doing this, the Ministry of Health, was acknowledging a conception of health as a transdisciplinary notion, well beyond the narrow sense of “absence of infermity” and involving a societal dimension of recognition of one’s own personal identity. Sexual orientation and gender identity were thus considered as fundamental elements of health, as a general well-being that involves conditions of respect and expression of one’s identity and personality.
It is important to notice that it was in the name of the respect of identity as a condition of well-being that rights to sex reassignment were expanded, and not in the name of the medical condition of “transexuality” as a precise disease. Newcomers in terms of rights and health rights, such as Brazil, which has a fairly recent constitution and healthcare system, have avoided the ambiguities of older legislations in which the medical condition of the transexual as a pathology was a crucial element in the determination of the rights to perform the operation. Since 1997, the surgery has been considered “ethical” in order to provide healthcare to transexual patients that cannot live a life within a sexual determination that doesn’t correspond to their actual sexual identity.
As in most countries, Brazil has established a series of procedures to accord the right of sex reassignment surgery. Candidates must be under observation for two years by a multidisciplinary team of psychiatrists, legal experts, surgeons, social workers, etc. They must be 21 years old and not showing other conditions that may conflict with a surgical intervention. As we have seen, these criteria, with some variations, are present in all countries that accept the sex reassignment surgery.
Yet, some recent decision have acknowledged legal sex reassignment  and change of name in absence of any surgery:
Ementa: APELAÇÃO. RETIFICAÇÃO DE REGISTRO CIVIL. TRANSEXUALISMO. TRAVESTISMO. ALTERAÇÃO DE PRENOME INDEPENDENTEMENTE DA REALIZAÇÃO DE CIRURGIA DE TRANSGENITALIZAÇÃO. DIREITO À IDENTIDADE PESSOAL E À DIGNIDADE. A demonstração de que as características físicas e psíquicas do indivíduo, que se apresenta como mulher, não estão em conformidade com as características que o seu nome masculino representa coletiva e individualmente são suficientes para determinar a sua alteração. A distinção entre transexualidade e travestismo não é requisito para a efetivação do direito à dignidade. Tais fatos autorizam, mesmo sem a realização da cirurgia de transgenitalização, a retificação do nome da requerente para conformá-lo com a sua identidade social. DERAM PROVIMENTO. (Apelação Cível Nº 70030504070, Oitava Câmara Cível, Tribunal de Justiça do RS, Relator: Rui Portanova, Julgado em 29/10/2009)

This goes with the tendency of many countries around the world (as we have seen Spain, for example, in Europe) to overcome the rigid OMS interpretation of transexualism as an infirmity that must be surgically treated and that integrate a broader notion of gender identity that comes from the debates we mentioned at the beginning of this paper. Here is another decision in this direction:

Ementa: APELAÇÃO CÍVEL. TRANSEXUALISMO.RETIFICAÇÃO DE REGISTRO CIVIL. NOME E SEXO. É possível a alteração do registro de nascimento relativamente ao sexo e ao nome em virtude da realização da cirurgia de redesignação sexual. Vedação de extração de certidões referentes à situação anterior do requerente, sob pena de discriminação. RECURSO IMPROVIDO. (Apelação Cível Nº 70028694479, Oitava Câmara Cível, Tribunal de Justiça do RS, Relator: Claudir Fidelis Faccenda, Julgado em 28/05/2009)

That is, a country such as Brazil, with a past of hard sexual discriminations, that has adopted a democratic constitution only in 1988 is more easily integrating a view of the rights of expression of gender identity as “rights of persons” than as “rights of patients”.
The same can be said of the recent approval (2012) in Argentine of a legislation proposed in 2011 of “rights for gender identity” that allows citizen to freely change their gender identity without any need of surgical intervention or any diagnosis by teams of specialists:
Gender Identity Law
Article 1 – Right to gender identity. All persons have the right,
a) To the recognition of their gender identity;
b) To the free development of their person according to their gender
c) To be treated according to their gender identity and, particularly, to
be identified in that way in the documents proving their identity in
terms of the first name/s, image and sex recorded there.
Article 2  – Definition.  Gender identity is understood as the internal and
individual way in which gender is perceived by persons, that can correspond
or not to the gender assigned at birth, including the personal experience of the
body. This can involve modifying bodily appearance or functions through
pharmacological, surgical or other means, provided it is freely chosen. It also
includes other expressions of gender such as dress, ways of speaking and
Article 3  – Exercise.  All persons can request that the recorded sex be
amended, along with the changes in first name and image, whenever they do
not agree with the self-perceived gender identity.
Article 4 – Requirements. All persons requesting that their recorded sex be
amended and their first name and images changed invoking the current law,
must comply with the following requirements:
1. Prove that they have reached the minimum age of eighteen (18) years,
with the exception established in Article 5 of the current law.
2. To submit to the National Bureau of Vital Statistics or their
corresponding district offices, a request stating that they fall under the
protection of the current law and requesting the amendment of their
birth certificate in the records and a new national identity card, with
the same number as the original one.
3. To provide the new first name with which they want to be registered.
In no case will it be needed to prove that a surgical procedure for total or
partial genital reassignment, hormonal therapies or any other psychological or medical treatment has taken place.

5. Conclusions


[1] Butler’s essay was a major contribution to the field of Queer Studies and LGBT studies, that have become an established academic field since the 1980. See E. Sedwick (1985) Epsitemology of the Closet, University of California Press.
[2] Cf. Butler, p. 9.
[3] Cf. Butler, p. 9.
[4] Cf. L. Feinberg (1996) Transgender Warriors: Making History from Joan of Arc to RuPaul, Beacon Press, Boston.
[5] Paisley, Currah, “Defending Genders: Sex and Gender Non-Conformity in the Civil. Rights Strategies of Sexual Minorities”, 48 Hastings L. J. 1363, 1363-68
[6] Cf. R. Lewontin (2000)
[7] Cf. Money, John, Joan Hampson and John Hampson
1955 "Hermaphroditism: Recommendations concerning assignment of sex, change of sex, and psychologic management." Bulletin of the Johns Hopkins Hospital 96-97:284-300.
[8] Money, John 1972 "Sex reassignment therapy in gender identity disorders." International Psychiatry Clinics
[9] Cf. Kessler, S., McKenna, W. (1978) Gender: An Ethnomethodological Approach, Chicago University Press.
[11] See Laqueur (1990) Making Sex, Harvard University Press. For a review of the literature on the social construction of sex, see:
[12] Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
[14] Cf. Pauly IB (1965)” Male psychosexual inversion: Transsexualism: A review of 100 cases” Arch Gen Psychiatry.
[15] For a historical review of the debate, see: D. Billings, T. Urban: “The socio-medical construction of transexualism: an interpretation and critique”, SOCIAL PROBLEMS,  Vol. 29, No. 3, February 1982

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