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Baroness Finlay of Llandaff: My Lords, I apologise to the House that I have been unable actively to participate until this stage. I want simply to reinforce most strongly the points made by the noble Lord, Lord Chan, particularly that of protecting the patients and the medical member of the panel. The wording of the Bill strikes me as containing a small wording conflict in that it includes clinical psychologists as medical rather than clinical members of the panel. That might have been a more accurate description. But the importance of being trained in this very small and highly specialised area, dealing with people who are undertaking complex decisions—the rigors of which were eloquently outlined by the noble Lord, Lord Carlile—indicates that Amendment No. 13 in particular is crucial to protect all involved in the process.

2.45 p.m.

Lord Turnberg: I want specifically to address the amendment moved by the noble Lord, Lord Chan, which introduces the need for surgical intervention. I can well understand the noble Lord's desire to be absolutely convinced that the people who wish to be given a gender recognition certificate should have demonstrated beyond doubt that they are sufficiently determined by having surgery to change their gender. But I am afraid I cannot accept that as being a mandatory procedure.

Of course many will have had surgery, but it is worth remembering just what this type of surgery entails. In a woman who wishes to be regarded as a man, it would involve the removal of the uterus and the ovaries, probably a bilateral mastectomy, and possibly plastic surgery to construct a phallus. In a man, it would involve removal of the penis and testes, with the possible construction of a vagina.

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I am sorry to be so graphic, but I want to emphasise that these sorts of operations are not undertaken lightly. And as with all operations, they are not without risk. Most individuals are likely to be fearful and others may simply not be fit. The fact that most do go through with all this is a testament to their determination, but to insist that they all do so seems quite unnecessarily cruel. To demand surgery to confirm a diagnosis of dysphoria also seems perverse: we do not insist in law on surgery to make any other sort of diagnosis—cancer and the like. I am afraid I cannot support that particular amendment.

Perhaps I may be forgiven for returning to the dilemma of the noble Lord, Lord Tebbit, over sex and gender. The sex of an individual may be defined entirely in biological terms as possession of" or Y, or both, genes. It cannot be defined in terms of other sexual characteristics such as external genitalia because they do not always coincide at birth with the chromosomal determinates. Some babies at birth are difficult or impossible to sex. So if we are to be entirely clear, it is the chromosomal features only.

When we come to gender, this is the state that can be defined only in terms of possession of multiple factors which take into account the physical and psychological make-up of an individual, which can be defined and which make up the totality of that individual.

Baroness O'Cathain: One does not have to support the Bill to support these amendments, which impose a much more rigorous standard of testing on those who wish to go forward for gender recognition. There is evidence that there are people who have been rail-roaded through sex-change operations without any consideration of the alternative. The noble Lord, Lord Turnberg, has just given us a graphic description of what is involved in all this. I touched on the subject when I spoke to the amendment tabled by my noble friend Lord Tebbit and I shall return to the point when I move my Amendment No. 19.

It is an obvious failing that the Bill as drafted contains no requirements of psychiatric evidence. It could be that there are severe psychiatric reasons why such a change should not be made. Yet such evidence could be excluded. The panel may never see it and I do not believe that that is right. Furthermore, these amendments would create a system of assessment which was left open to abuse. By selecting the right medical expert and learning to say the right thing at the right time, transsexuals could quite easily pass the test laid down by the Bill at present.

I read recently that there are websites which teach transsexuals the right things to say when being interviewed by medical professionals. They advise them, basically, on how to cheat; on how to present the classic symptoms of gender dysphoria in order to get the operation they feel they want. I have no doubt that with the growth of cyberspace there will soon be websites advising on the best way to get a gender recognition certificate. We must take steps to limit the scope of that kind of abuse.

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A more rigorous regime is all the more necessary because the medical profession itself seems to be in turmoil over the appropriate standards to be applied in these cases. Some medical professionals working in this area feel that some of their colleagues are less than rigorous in assessing people. Indeed, the noble Lord, Lord Chan, has given us a description of one such case. Perhaps some professionals feel that their duty is simply to give the patient what he or she wants. I suggest that that is a dangerous approach to take. Not only is it a dangerous approach, but it is an enormous step to take.

Sadly there is plenty of evidence that people regret having a sex change. Only today my attention was drawn to a television programme broadcast in September of last year on ABC, the Australian broadcasting network. It was called "Boy Interrupted" and was about Alan Finch who, with the support of health professionals, had sex-change surgery at the age of 19. He now says,

    "Anatomically, I was never a woman . . . Everything was fake about it from top to toe".

At age 31 he decided to change back to his biological sex.

There are many unresolved issues and many uncertainties about the whole process. That goes back to the points that I made at Second Reading and in Grand Committee. Today, just as an aside, we have another uncertainty: the noble Lord, Lord Chan, and the noble Baroness, Lady Finlay, suddenly made me realise that as a lay person I did not have the definitions clear in my mind. I would like confirmation that a medical doctor is a member of the medical profession, but that a consultant clinical psychologist is not a member of the medical profession. Is a consultant clinical psychologist a member of the health profession? There are health professionals as well as medical professionals. It is just so complicated.

In the Bill the least we can do to try to make matters less complicated is to ensure that the medical assessment through which applicants go is thorough and genuine and not just a rubber-stamping of their current wishes.

Lord Tebbit: I thank the noble Lord, Lord Turnberg, for his post-mortem comments on amendments that have already been debated. Turning to the present matter—Amendment No. 12 in the name of the noble Lord, Lord Chan—it seems to me that the extra precautions that he would insert as regards additional members of panels and matters of that kind, are thoroughly sensible and reasonable. But, like the noble Lord, Lord Turnberg, I hesitate to follow him on the subject of Amendment No. 16. He said that it would indicate whether a person had been willing to undergo the sex reassignment surgery, which I prefer to call sexual mutilation. In parenthesis, we Westerners criticise primitive tribes for their sexual mutilation practices, but perhaps those people should read the Bill and consider this kind of matter.

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The noble Lord, Lord Chan, said that a person would have to be convinced that he or she really was a transsexual. Yes, but that conviction could come about through a serious psychological disorder. I do not believe that it would be appropriate to persuade people who were suffering from a severe psychological disorder, which may perhaps be temporary or which certainly may not be completely permanent that, to achieve the objective which their disorder told them to follow, they should be subjected to irreversible surgery. That would be going too far. I go along with the noble Lord, Lord Chan, on all the amendments in this group, barring Amendment No. 16. I believe that that amendment goes too far and that it would be unduly cruel to people for whom we all have very great sympathy in their dilemma.

Lord Filkin: Before the moment passes, I celebrate the fact that the noble Lord, Lord Tebbit, and I agree on one point. That is a comfort to me, if not to him.

The problem with these amendments is that while I respect the objectives behind them in terms of trying to ensure that there is a credible process, they tend to add to the complexity and they tend to focus on the process rather than on the outcome. By doing that, they attempt to fetter the discretion of the panel. I shall return to why I believe that the panel needs to carry the burden that we, as legislators, will impose on it, rather than us over-specifying the mechanisms by which it is to fulfil those duties.

The panel must be satisfied that the criteria set out in the Bill have been met. That is its job. First, it has to be convinced that the person has or has had gender dysphoria. I shall not speak at length about the process of diagnosing and treating gender dysphoria. The noble Lord, Lord Carlile, spoke about that earlier and we may have spoken about it also in Committee. In essence, it is not a sudden process; it takes many years. It requires an initial diagnosis which is likely to involve psychotherapy, psychological tests and other medical tests. That is followed by a process of real life experience, so that before further medical treatments are given, the reality of the person's conviction is tested in the fierce crucible of living out in the real world in the gender that they believe to be true for them.

After that process has been under way for a good period of time and if it is appropriate after a further assessment process, hormone treatment can be undertaken. Subsequently— again if it is appropriate and advisable—there can be surgery. I shall not go into detail; the process is available from a number of sources, and I stress how necessarily cautious and lengthy it should be and needs to be.

Clearly, the test of gender dysphoria has to be carried out by a specialist. A person working in the area of gender dysphoria will have to make the critical judgment of whether a person has gender dysphoria as a precondition of an application to succeed. Amendments Nos. 20 and 22 provide that there must be two diagnoses of gender dysphoria, one from a registered medical practitioner and one from a consultant psychiatrist. We do not see the need for that. The panel will not simply take the diagnosis of

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gender dysphoria from anyone at large. It will have a list of people who work in the area of gender dysphoria, which will be drawn up in conjunction with the professional bodies to ensure that evidence comes from reliable sources. If there is any doubt in the minds of the members of the panel they will make further inquiries. Therefore, the burden is on the panel to be satisfied that the diagnosis of gender dysphoria is one on which they can lean and if in doubt they should not do so.

Next, the person must prove that he or she has lived in the acquired gender for at least two years and provide medical evidence of treatment that has been received. That evidence will be considered by the panel. So a person will have a diagnosis of gender dysphoria from a specialist and evidence of living in the acquired gender for at least two years. A person must provide evidence of medical treatment and will have to convince the panel that he or she intends to live permanently in the acquired gender. That is a proper and substantial process of testing.

Amendment No. 15 would add that a person must have lived successfully in the acquired gender. I do not know what weight to put on that, but it also adds that two witnesses must attest to the fact that the person has lived for at least two years in the acquired gender.

Quite rightly, the approach taken by the Bill is that the panel has to satisfy itself that an applicant has lived in the acquired gender for the past two years. It leaves open the evidential requirements, which is how one should treat judicial panels. They should be at liberty to decide what evidence they believe will satisfy them; if they are not satisfied they should ask for further evidence; and if they are still not satisfied they should refuse the application. We do not need to specify exactly how they go about their business. The panel will be chaired by a circuit judge. Such people are not unaware of proper process.

The panel must satisfy itself that an applicant has lived in the acquired gender for the past two years, not two witnesses. The applicant can submit further evidence if he or she wishes; or the applicant can be required to do so if the panel is not satisfied.

Finally, the amendment also requires that the two witnesses attest to the applicant's assertion that he or she intends to live permanently in the acquired gender. Again, we think that it is the job of the panel to take what tests, measures, evidence or inquiries it thinks appropriate to meet that test. It is not a good use of our time to seek to fetter the discretion or specify the processes by which a judicial panel should meet the burden the legislation imposes on it.

If, on the sum of the evidence, the panel is convinced that an applicant has taken decisive steps to live permanently in the acquired gender, has or has had gender dysphoria, and has demonstrated a commitment to live in the acquired gender, only then will it give a certificate. If it is not satisfied, it will not do so, nor should it.

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Amendment No. 16 seeks to add an additional criterion: that a person must have first undergone reassignment surgery. I do not wish to add much. A number of noble Lords have said why they believe that that is wrong. I start with an explanation. Most people who have gender dysphoria undoubtedly wish to have surgery. The individual wishes to bring his or her bodily state into alignment with that person's profound belief. Most will have done so. To require those persons to do so is wrong for all the reasons given by the noble Lord, Lord Tebbit, and others. One should not force that process on people as a necessary test.

Some people may be too old to be able to cope with the rigours of surgery. It would be wrong to deny them legal recognition if the three tests in the Bill were met. Let me not labour that point.

I turn the argument round the other way. It does not mean that the process is any the less severe. Clearly a person who has gone through the horrors of surgical realignment in this way does in a sense demonstrate how severe his or her conviction is that there is a problem which needs to be remedied. I signalled in Committee that where a person has not had surgery I would expect the panel to be more alert in inquiring whether there were sufficient evidence of commitment to a permanent change. That is not the same as saying that a person who has not had surgery should not be recognised. It is to say that the panel would want to inquire why the person had not had surgery. If it was because at heart there was doubt in the person's mind about whether he or she was going to make a committed and permanent change the panel would not grant a gender certificate. I do not think that we are at risk in this respect. The panel is likely to want to inquire more in such circumstances.

3 p.m.

Baroness O'Cathain: My Lords, I thank the Minister for giving way. That is my point. If a person goes to a gender recognition panel, the individual can have in mind the fact that he or she wants to change gender but does not want to undertake surgery for all the reasons that have been explained. That person can convince the panel yet be in a situation where he or she was going to cheat. I am sorry, but that is the reality. When I made the point earlier, the noble Lord, Lord Carlile, chided me.

One of my great concerns about the Bill is that an individual can have a gender recognition certificate without having surgery. It depends on how determined that person is in his or her own mind about the belief that he or she is of the opposite sex. I find that very distressing.

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