Sex-change in Israel: Gender Trap

The Health Ministry panel charged with approving sex-reassignment surgery has been slammed as non-transparent.

In October 1985, a well-known plastic surgeon from the Italian Hospital in Haifa operated on a 21-year-old woman named Daniella. She had been born a boy, but lived life as a female in every sense and wanted to adjust her physiological gender to her internal gender identity. The operation went badly and Daniella was left without genitalia of either gender. A decade later, she won a malpractice suit against the physician.

In the wake of that case, the Health Ministry ordered an immediate moratorium on all sex-reassignment surgery - popularly known as sex-change operations - which until then had been done privately and without supervision. Henceforth, the ministry ruled, such operations could only be performed in public hospitals and with the authorization of a special panel under their control: the Committee for Sex Reassignment, based out of Sheba Medical Center, Tel Hashomer. In the 26 years that have gone by since them, the committee has been a nontransparent monopoly, basing its decisions on unknown criteria, and refusing to publish reports or information about its activity.

Two new studies, from researchers at Tel Aviv University and the Academic College of Tel Aviv-Yafo, respectively, reveal for the first time what goes on behind the scenes of the committee. The researchers found that it has been the subject of numerous complaints for displaying an insulting and discriminatory attitude, and a condescending, disrespectful approach. This body is also accused of pathologizing and being inattentive to the special needs of those who apply to it. Moreover, its guidelines have not been updated for three decades, despite the revolution undergone by medical and academic research on the transgender phenomenon, defined by the dictionary as referring to someone who expresses a "gender identity" different from the sex he or she was born with.

A circular issued by the director general of the Health Ministry in April 1986 stipulated that the committee would consist of a senior psychiatrist, a senior plastic surgeon, a urologist and an endocrinologist. A condition for undergoing surgery was that "the candidate shall live for a period of at least two years in the opposite sexual identity - [the one] to which he wishes to belong through the operation." Individuals wishing to undergo the operation were labeled "sick" in the circular, which also misspelled the word "transsexual" twice.

At the time the committee was established, the Health Ministry director general, Prof. Dan Michaeli, explained, "There are various aspects that must be examined before the surgery is performed, such as the psychological aspect. Is every crazy person [meshuga] who asks a doctor to perform the operation going to be operated on?"

Over the years, the panel cultivated a false image for itself, to the effect that it was established after a transgender woman tried to kill a surgeon by shooting him in a fit of insanity after a failed operation. Even the current chairman of the committee, Dr. Haim Kaplan, told TV Channel 10 in an interview half a year ago: "The Health Ministry changed the regulations in the wake of an unpleasant event in which a female patient tried to kill a doctor, because she was dissatisfied."

The first of the two new studies is by Yael Sinai, a graduate student in sociology at Tel Aviv University who is writing her master's thesis on the subject of the Sex Reassignment Committee. Sinai checked the press archives and discovered that there had been a case in which a former patient tried to kill the same surgeon who botched Daniella's operation, but that the woman involved was not a transgender patient.

"The 'chance' confusion between the stories is suggestive of the pathologizing conception of the medical establishment," Sinai says. "Instead of presenting the person under treatment as a [possible] victim of medical negligence, she is presented as being mentally disturbed and as trying in impulsive rage to harm her caregiver."

Sinai recently interviewed Dr. Dalia Gilboa, formerly the chief psychologist of the Health Ministry and currently the committee's psychologist. She asked Gilboa how she identifies those who are not fit for sex-change surgery. Gilboa told her that it is necessary to examine "whether the person is transsexual mentally; whether he really thinks so. First of all, [to determine] if he is psychotic and whether, within his psychosis, he also has this fantasy that he has to become a woman. That he was hearing voices ...." Gilboa added, "After you monitor someone for a year ... You already know him and [know] whether he is truly transsexual or it's a passing craze. Whether it was persistent, of whether the idea suddenly came to him and will go away just as easily."

The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association still recognizes what it calls "gender identity disorder" as a mental disturbance. However, the new edition of the DSM, due out next year, will replace the old term with "gender dysphoria" - the significance being that the essence of the problem is not transgender identity as such, but the distress it generates. Even physicians around the world who specialize in the field of transgender medicine maintain that transgenderism is not a mental disorder.

"The committee's current activity preserves the 'corrective' approach, which views a gender conflict as an illness originating in the mind, and holds that the medical establishment is responsible for diagnosing and curing the illness," Sinai says. In her study she quotes remarks made last year by Gilboa in a conference on the subject held in Tel Aviv: "I think I feel a very heavy responsibility ...[not] to send someone into surgery without being 100-percent certain that he is transsexual. And if I am not certain, maybe he too is not certain."

'Revolutionary' approach

Israel currently allows sex-reassignment surgery within the framework of public medicine and with state funding, as part of the so-called "health basket." The Health Ministry describes this approach as "revolutionary in its openness, even in comparison with Western countries." In response to a Haaretz query, the ministry said that "Israel is one of the most progressive countries" in this field.

In practice, as the new studies disclose, few people manage to have their cases discussed by the panel and undergo the coveted treatment.

"We do not know how many people are rejected by the committee and why they are rejected," says Nora Greenberg, a leading local transgender activist who has worked with hundreds of transgender people in treatment. "[The health authorities] have no answers, there is a communications breakdown. When I asked them for data I was astounded to see that they started to stammer. It turned out that they have no data, no records, no follow-up - nothing. I don't understand how they purport to make rulings on the subject without having facts to back up what they say. I used to have a conspiracy theory on this subject, but today I think it's because no one there is interested."

For its part, the Health Ministry refused to provide information about the number of people who apply to the committee and how many eventually undergo sex-change surgery. The ministry also refused to specify the reasons for rejection, or the criteria by which the committee operates. It provided only a general reply: "The committee examines each request on its merits and weighs medical and professional considerations in regard to the authorization [of surgery]."

The second research paper is by Shir Reichert, who recently completed a master's in psychology at the Tel Aviv-Yafo college, writing a thesis on transgenders and the health-care system. In the wake of a number of interviews she conducted with transgender people, Reichert asserts, "They are treated with extreme insensitivity by the Sex Reassignment Committee."

Gil (not his real name ), one of the interviewees, was born female and lives today as a male. Three years ago he underwent surgery in the United States. He explained to Reichert that he never even considered applying to the committee at Sheba Medical Center, Tel Hashomer because, "In Israel there is a kind of feeling that the doctors agree to treat you but don't really want to. They sometimes view you ... as mentally ill. It's like night and day compared with the situation overseas, where you have doctors who consider [conducting such surgery] a mission. It's a different experience, there is no way someone will address you in the wrong gender. In Israel ... it's appalling. You wake up after surgery and the last thing you want to do is to start correcting someone" - that is, to explain in which gender to address you in Hebrew.

Activist Greenberg is very familiar with this behavior. "I could fill quite a few books with the disturbing stories I have heard. The complaints are about unethical behavior and lack of professionalism, in some cases bordering on violation of the law," she says. However, for reasons of privacy and a desire to move on and forget the rough patch they experienced, few are willing to file an official complaint with the Health Ministry or tell their story to the media.

"The physicians' approach is very narrow and limited," Greenberg continues. "The emphasis is on recovering from the incisions, on lack of complications, and the like. Other aspects - mental and social - are not properly addressed. What's important for the doctors is for the treatment to go smoothly and for them not to be sued, and for the patient not to change his mind after the surgery is done. The truth is that the doctors view themselves as the 'gatekeepers,' who decide who enters and who does not. It's the antithesis to treatment, which is supposed to include support and follow-up. They do not see the whole picture; it doesn't interest them and they have no understanding of it."

Pricey private route

One of the possible roots of the problem is that there is only one surgeon who performs these operations in Israel: Dr. Haim Kaplan, a veteran plastic surgeon and the chairman of the Committee for Sex Reassignment. The website of his private clinic has a section of questions and answers dealing mainly with sex-reassignment surgery, which he performs on behalf of the state at Tel Hashomer. "Shimon," who gave his age as 23, used the "Q&A" section of Kaplan's wesbite to ask him about the possibility of funding for medical treatment or a sex-change operation. "I solve medical problems," replied Kaplan on the online forum, "not economic ones. Good luck" - an answer that is possibly suggestive of his approach to the subject.

Kaplan declined to be interviewed for this article. However, in October 2011 he was interviewed by Yael Sinai for her research paper. He told her frankly, "I have no desire at all to operate on more than one [transgender patient] a month. All told, I work two days a week [as a plastic surgeon] at Tel Hashomer ... If there are more [patients], I would be happier if there were more doctors who would do it. I think that would also help." Kaplan described the committee as "a kind of undesirable monopoly."

"Kaplan is not crazy about performing these operations. Apparently they do not bring him any great glory," says Dr. Ilana Berger, director of the Israeli Center for Sexuality and Sexual Identity, which specializes in counselling transgenders pre-and post surgery. To which Greenberg adds, "The other members of the committee are also physicians from Sheba Medical Center, who got stuck with the job."

Why is there only one surgeon in the country who is authorized to perform these operations? And why only at Sheba Medical Center? Again, the Health Ministry refuses to say. The direct result, in any case, is that many transgender people - a few dozen a year, according to data from the community - undergo the operation privately abroad at a cost ranging from thousands to tens of thousands of dollars, with prices varying widely according to the location of the surgery, and complexity of the procedures required by the patient.

Berger is also upset that a minimum age limit of 21 has been imposed for the operations. "Why this discrimination?" she asks. "If 18-year-olds are legally fit to die for the country in the army, why aren't they fit for this surgery?" (Abroad, by the way, such operations are routinely performed at the age of 18. ) Berger is also unhappy about the long waiting period until the operation is performed. "Everyone who comes before the committee," she says, "even if he has lived in his desired gender for 20 years and undergone a full process of change, is forced 'to live for two years in the new gender' until the operation."

The form that candidates for the operation are required to sign states that the procedure will not enable them to enjoy pleasure during sex or achieve orgasm. Greenberg finds this appalling: "It is accepted everywhere in the world that one of the required results of the operation is that it allows pleasure to be derived from sex, including orgasm. Otherwise it is a failure."

In 2008, the organization Physicians for Human Rights sent a letter to the Health Ministry stating that the existing method of dealing with persons seeking sex assignment surgery is seriously flawed, and demanding its annulment. Shortly afterward, there was a shift in the ministry's approach: It decided to set up another committee to reexamine the subject. However, the ministry refuses to entertain the possibility of abolishing the committee.

"Our position is that in every case the operation will be conditional on a committee's authorization, after it has examined the various aspects of this irreversible treatment," the ministry said in response to a query from Haaretz. "The treatment carries far-reaching consequences, such as loss of procreative ability."

Nora Greenberg was a member of the reexamination committee as the representative of the community, alongside representatives from the sex reassignment committee, the legal adviser to the Health Ministry, physicians from Sheba and from Rambam Medical Center in Haifa, and a representative of Physicians for Human Rights. After five meetings over long months, despite a few points of agreement, the discussions broke down and the committee was dissolved. "I understood that there was a clear intention to drag things out and kill the initiative with a kiss of death," Greenberg says.

A spokesperson for the Health Ministry stated that the reexamination committee "broke down because of fundamental professional disagreements. These included a demand by the [transgender] community's representative [Nora Greenberg] to allow every person "to undergo the operation without any restrictions whatsoever, and without the physician being able to consult anyone from the field of therapy."

Greenberg describes the ministry's statement as "a gross lie .... a recycling of a falsehood that is intended to cover up disgraceful behavior by the Ministry of Health."

Ayala Tal
Moti Kimche
Hadar Cohen