We could easily be caught off-guard by this request due to its infrequency. Transsexuals have replaced homosexuals in the minority marketplace, seeking to claim normality and acceptance in the eyes of modern society. The estimated incidence of transsexuality in the UK population is less than 0.003%.

Historically, transsexuality has been considered a psychiatric condition, whereby one rejects one's biologically and genetically determined sex, preferring to dress and live as a member of the opposite sex. However, the availability of gender reassignment surgery (GRS), by implication, re-labels the condition as a medical one.

Gender reassignment

It used to be accepted medical wisdom that GRS should be the absolute last resort for transsexuals, if at the end of extensive psychological counselling, it was deemed to be appropriate and necessary, on a case-by-case basis. It is believed that some 50% of transsexuals undergo this almost irreversible procedure, in which extensive plastic surgery is carried out, with extensive preparation and follow up required.

Experts in their field at the Portman Clinic in London believe that offering GRS to transsexuals is preying on their delusional fantasies and is, in itself, absurd. The expectation of GRS is that it will afford the transsexual acceptance; there is no evidence to show this is true. An Australian transsexual is suing the state of Victoria for giving him poor advice, which led to him agreeing to GRS; he claims that it has not helped him and has actually harmed him further psychologically. There are other post-operative transsexuals preparing to follow suit or seeking to reverse surgical procedures.

Compassion

Responding to such a request would be difficult; we need compassion and an ability to empathise with the emotional and psychological struggle going on in front of us. Most doctors know very little about transsexuals and this will make things harder. I recommend the Evangelical Alliance's short book on the subject. It addresses the historical, medical, political and scriptural perspectives. After reading it you will have a reasonable understanding of transsexuality and be more confident in defending a biblical position.

A biblical view

The creation account in Genesis 1 gives us clear guidance in the area of sexuality: 'Male and female he created them' (v27). My sexual identity is part of the given nature of who I am. It is not something that I have choice over, nor is it something that can be decided by how I feel. As Christians we are called to be faithful to God's creation ideal and demonstrate this in our fallen world. Many of our patients have been brainwashed into thinking that the emancipation of sex has delivered freedom without consequences. Rising rates of sexually transmitted infections are a stark reminder that this is simply false!

Genesis 2:18-25 sets out God's ideal for sexual relationships. They should be monogamous, heterosexual and willing for the possibility of procreation. The latter two are particularly difficult to fulfil in a relationship between a couple where one or both are gender reassigned. The Bible is clear that the answer to sin is not to cover it up by legitimising it. Instead we should be honest, confront it and seek to put right where we have failed. We know from the Fall that we will have to deal with its consequences, especially in our lives and the lives of our patients. We must seek to show a better way, in love and gentleness. A reminder of God's redemption and final restoration completes the gospel of hope.

Practical steps

I would ask this gentleman about his past. Emphasis on his birth history and childhood may help to understand his current thinking. I would try to establish why it is he feels 'trapped in a man's body', and learn more about his previous relationships. Try to help him to explore his feelings; these may include deep hurts. There may be an opportunity to discuss what makes us human and what identifies a person as one sex or another. I would emphasise that I am no expert in this type of problem and would be happy to refer him to a psychologist to explore his request further. I might even get his permission to explain to him the Bible's perspective as outlined above. Pray hard for him in your head and if the Holy Spirit leads you, offer to pray for him out loud.

You may have guessed, but I think that it would be wrong to refer this patient directly to a surgeon for GRS. I would want to encourage him to think carefully about where he gets his sense of identity. Referring him directly for surgery after 15 minutes discussion would, I believe, be doing him harm in the long term. His autonomy is important, but as the General Medical Council reminds us in Duties of a Doctor, 'First do no harm'.

The hospice movement has shown that requests for euthanasia usually fade away when a patient knows they are heard, understood and cared for. This may also be the key in responding to requests for GRS.