MILTON DIAMOND, PH.D.
& HAZEL GLENN BEH, PH.D., J.D.
THE RIGHT TO BE
Sex and Gender Decisions
A series of events occurred within a very short period and prompted consideration
of the ethical dimensions of how, when, and why individuals, institutions or
governments decide to get involved in people’s lives. In particular we began to
question if they should get involved with allowing, or not allowing, people to
make major decisions regarding their own bodies. This is an essay reflecting
such thoughts. It involves consideration of two tenets of medical practice: Relieve pain and suffering; and First, do
In order of occurrence, the events
started when we were considering a legal case involving a 13-year-old female.1
Alex, as the judge sitting on the case called her, had successfully argued in
an Australian court that, in accordance with her wishes, she could live as a
male and obtain the necessary medical help to achieve this. This means Alex,
from that time on, will be getting hormones to prevent typical female puberty
and at the age of sixteen years will receive androgenic hormones to virilize
bodily and facial features. At the age of eighteen Alex will be eligible to
obtain a hysterectomy and ovariectomy to stop any menses and feminization, and
eventually to have a phallus constructed if he so wishes. The appropriate legal
and professional psychological and medical experts, consulted prior to the
decision, have made these recommendations Religious and other factions,
however, immediately challenged the decision. They complained Alex was too
young to make such a choice, that the procedures would lead to later regret,
and most crucially, would end Alex’s ability to have children. 2
The second instance involved a legal
suit brought against a gender clinic by someone who had surgically and socially
transitioned from living as a male to living as a female. Alan Finch, at the
age of twenty-one had applied to the clinic for help with a desire for sex
reassignment surgery (SRS). Therapists at the clinic vetted Mr. Jones’s
situation and approved of the transition. Surgeons subsequently removed his
penis and testicles and in their stead fashioned a vulva and vagina. After
living as a woman for eight years Mr. Finch decided it had been a mistake and
now feels he should never have been allowed to transition and he ought to live
as a man.3 Mr. Finch blames the psychiatrists who counselled him and is suing
the clinic at which they worked. Although he admits to having lied to the
therapists during his meetings with them, he
claims they should have realized he was conflicted over his gender. The clinic
is protesting the suit saying, on the one hand, that the therapists involved
had followed established procedures, and in any case, this had all occurred
prior to the expiration of the statute of limitations. According to records,
indeed, the clinic professionals did adhere to professionally approved
procedures.4 The local government is presently conducting a clinical review of
the complaint and relevant occurrences.5 In the meanwhile, factions both
supporting and ridiculing the original transition, the secondary one, and the
claim against the clinic have come forward. 6
The third case involved a tragedy.
David Reimer, while still an infant had his gender changed. A botched
circumcision to repair phimosis of his penis resulted in its destruction. His
parents were advised that life as a male without a penis would be intolerable
and that he should be raised as a girl. They were told that he would then
develop satisfactorily as a female (Diamond and Sigmundson, 1997; Colapinto
2000). This did not happen. David consistently objected to his life as a girl
and repeatedly asked to live as the boy he felt to be. His life became so
miserable that, at the age of 14, without knowing of his history, he threatened
suicide unless he could live as a male. While he subsequently grew to live and
marry as a man at the age of 25, he continued to have flashbacks to his early
troubled life so that he eventually committed suicide at the age of
The practice of sex reassignment in similar cases when a penis has been lost
due to infant trauma or accident, or when it is considered unusually small, is
still current. It also occurs in many cases of intersexuality without the
child’s consent.8 The correctness of this practice is a subject of current
professional and lay debate. Some physicians still hold to its justification;
while others, particularly those individuals who feel they were ill-served by
such treatment, object (Diamond, 2004). We say more of this below. David’s
story is better known as the case of John/Joan and received wide coverage from
The fourth case is more mundane and also more common. A married father of two
wrote to one of us (MD) seeking advice. For this discussion we call him Phil
Johnson. At his age of 42 Phil said that he was finally seriously thinking of
transitioning to live as a woman. Although having thought for years about
transitioning, he felt he had come to a junction in his life where he had to
make a decision. However, he was conflicted. On the one hand, Mr. Johnson
feared that by transitioning he would lose his wife and children, and on the
other, he felt driven to follow a life long compulsion. Whether he stays with
his family and sacrifices his gender desires or denies his family aspirations
involves a decision with both positive and negative consequences. But Phil felt
at a choice-point and a decision had to be made. Under certain jurisdictions
those who transition, if married, are obligated to divorce. In other cases,
those who transition cannot later marry someone of the sex from which they
changed. Not only does Phil’s conundrum involve legal repercussions, but also
similar cases have become part of the “same-sex marriage” argument with
positions strongly held by those for and against the legality of transsexual
change and subsequent marriage.10
In the first two cases the gender shift was at the request of the individual
involved and in the third it was imposed from without. The fourth case is yet
to be resolved. The types of transitions involved are not unique. Over the last
such cases have become the fodder of tabloids, television chat shows,
documentaries and more.
The Internet has become home to scores of communities
that offer space for questioning, ventilation, counseling, and discussion on
all sides of the relevant issues. In all of the cases, and others like them,
outside individuals and groups have felt called upon to voice their opinions as
to the right or wrong of these actions and choices. Some even want governmental
agencies to regulate such conduct.
Three of the foregoing four cases involved individuals usually called transsexuals. They were said to be suffering from a
condition medically called Gender Identity Dysphoria (OlD) or Gender Identity
Disorder. In brief, gender identity disorder is defined as the strong and
persistent disturbing belief for at least two years that one is actually a
member of the opposite sex (Frances et al., 1995). In David Reimer’s case, he
too wanted to change his gender, but it was to regain something taken away from
him. While not usually identified as such, it might be said that he had an
imposed disturbance of gender identity.
A basic question arises for all of these cases. Who should or should not have
a right to dictate, or even have a say, in how one lives and what a person may
do with his or her own body?11 Should the voices of individuals, religious
groups, political factions, or even families have determining weight in other
people’s decisions of such personal bodily alteration?
Those who protest against the requests often feel they are acting in the best
interests not only of the individuals concerned, but also of society in
general. Considering cases such as Alex’s, it is plausible that a minor might
change his or her mindset with increasing age and maturity. There is also logic
in believing that adults, like Alan Finch or Phil Johnson, who have lived a life
in one gender might regret leaving it to live in another. And experience has
shown that physicians and other trained professionals usually have knowledge
that should be taken into account when making life-altering decisions. There is
certainly reason to accept that one might grieve over loss of genitals,
facility, or opportunity. Further, it is probable that the full repercussions
of any particular action might not be known or ever be known. But is it really
likely that the individual involved has not considered most of the relevant
matters brought up by others? Is it truly logical to believe these criticisms
and objections, as well as others that might be more salient to the person
involved, have not been thought of and examined?
From the point of view of the individuals concerned, there surely are
important factors to consider. In Alex’s case, aside from the public clamor,
there is scientific evidence to complicate matters. Minors who desire
sex/gender change frequently change their minds as they get to adulthood. It is
also true that a majority of those considering a gender reassignment as minors,
when adult manifest as persons demonstrating homosexuality without the gender
dysphoria (Green, 1987; Zucker, 2004). Thus, for the adolescent, even allowing reversible
treatment and permitting the adolescent to present in the opposite sex has
future consequences if it solidifies a gender presentation that might have
otherwise been later abandoned.
Alan Finch’s situation is unusual since most transsexuals following surgery
express satisfaction and delight at the outcome (Smith, et al., 2005). Only a
minority experience regret. This case is further clouded by not knowing what
induced Mr. Finch to originally
desire a sex change so deeply that he would lie to the therapists regarding his
life situation and motivation.
In Phil Johnson’s case there are obvious family aspects of any decision that
will affect others as well. Phil presents with pro and con issues of his own
that must be resolved. His situation is not rare.
The original treatment for David Reimer was predicated on several points of
faulty logic. The first was a belief that individuals are psychosexually
neutral at birth and will adapt to any gender in which they are reared. The
second was that any individual without a penis should be raised as a girl. From
the start of his imposed transition, David objected to his treatment. The
continued imposition of his management against his desires might even be
considered child abuse. Nevertheless, the thinking that led to David’s
management is still used in dealing with many cases of intersexuality where
ambiguous genitalia or a micropenis is present, or when genitalia are missing,
as in cloacal exstrophy (Reiner, 2004).
In addition to any personal reason that might be involved, a justification
offered by those that refer to the need for society’s involvement in these
personal decisions arises from the fear that certain actions provide a negative
role model for others, or might serve as a precedent and challenge to a basic
tenet held dear. They think this is reason enough to impose legal regulations
on what individuals can and cannot do. Many social, governmental, and religious
institutions, for example, are threatened if people make unique and atypical
gender choices even if as minor as dressing in the clothes of the opposite sex.
Other factions are disturbed if they or those they represent are not involved
in decision making. For instance, psychotherapists or physicians might object
if those among their number are not consulted regarding any gender transition.
However, the role modelling has effect only on those persons who are themselves
considering options regarding a possible transition. In that regard, we see it
as any other educational source. We also do not believe that such actions are
attractive enough to the average “onlooker” that they will be taken as
behaviors to be emulated.
Some among the criticizing public base their objections on religious grounds.
They quote biblical verse claiming the body is a holy temple12 or they contend
that man is made in God’s image.13 Some also think that procreation is a
religious obligation and that a voluntary surrendering of reproductive ability
is sinful. For many reasons individuals of different religious persuasions
think the body should not be altered.
Regardless of the source of criticism, the heart of the issue is, should
final decisions on instances such as the ones presented be left to government, agencies,
factions, physicians, psychologists, priests, counsellors, or any other than
the person particularly involved? We think not.
Certainly we think that parents or family can have a say and openly express
their opinions. Yes, we think any and all groups might be consulted if that is
the wish of the individual. Yes, we think interested groups should be free to
offer advice and suggestions for alternate solutions to the situations faced by
those like Alex, Alan, David or Phil. And we think it is prudent to postpone
the enactment of any of the actions associated with similar cases until a
suitable interval of time has passed between the decision and desired action.
We also think it proper that organizations such as the Harry Benjamin
International Gender Dysphoria Association (HBIGDA) establish guidelines for
the transition process for transsexuals, and respective medical associations
have standards for specific medical procedures.14
To the extent that physicians or other professionals can predict that an
individual or a population is at risk for later regret, they have an ethical
obligation to identify that risk and counsel the patient appropriately. For
example, studies of women undergoing tubal sterilization reveal that approximately
14% will have some degree of regret in later years. The age at which
sterilization occurs strongly correlates with the likelihood and degree of
later regret: young women are significantly more likely to regret the decision
(Schmidt et al., 2000). Yet no one would suggest that medical or other
professionals should deny all younger women the choice to be sterilized because
they are more vulnerable to later regret. Instead, this finding warrants extra
emphasis on pre-surgery counseling for younger individuals.
We believe the ultimate decision to proceed or not should be left to the
competent and mentally mature individual involved regardless of whether doing
so is in keeping with the desires or advice of the public, any specified
institution, or involved professionals. In terms of making decisions regarding
one’s own body, we believe every individual has a right to be self-determining;
every one has a right to even be wrong.
Our thinking in all these cases is that rational individuals ought have
authority to make even life-altering choices when it involves their bodies,
regardless of public acceptance or rejection. This holds as long as these
persons are then ready to live by any consequences and not hold others liable
for that determination. As enunciated by philosophers such as John Stuart Mill
we consider these actions as a basic tenet of individual freedom.
Mill, in his essay entitled On Liberty expressed it thus:
“The sole end for which mankind is
warranted, individually or collectively in interfering with the liberty of
action of any of their number, is self-protection. That the only purpose for
which power can be rightfully exercised over any member of a civilized
community, against his will is to prevent harm to others. His own good,
either physical or moral, is not a sufficient warrant. He cannot rightfully be
compelled to do or forbear because it will be better for him to do so, because
it will make him happier, because, in the opinions of others, to do so would be
wise, or even right.” (Emphasis ours.) 15
now turns to an opposite extreme regarding bodily integrity—a discussion of
intersexed persons and how they are often treated. Intersexed individuals are
persons with apparent anatomical admixtures of male and female biological
characteristics. Such persons are not rare. Estimates of their frequency in the
population vary. A conservative approximation is that an intersexed child
occurs in about one per two thousand people and is recognized at birth by
genitals considered ambiguously male or female (Blackless et al., 2000).16
Since the 1950’s and 1960s early surgical intervention for such individuals
often was imposed. Predicated on the misguided belief that such genitals
provoked a medical emergency, intersexed infants were subjected to surgery to
“normalize” their genital appearance.
These surgeries were frequently done without the parents being notified of the
reasoning for the operations.
In most cases the surgery involved sex-reassigning the infant from male to
female since fabrication of female appearing genitals was easier than
structuring male genitals. Such surgeries were also imposed when a male
infant’s penis had been severely mutilated by trauma (as in David Reimer’s
situation) or was considered significantly small (Beh and Diamond, 2000). These
procedures were often instigated without informed consent of the parents in the
belief that withholding information about the ambiguities and sex reassignment
would foster a more satisfactory upbringing for the child. It was thought that
if the parents didn’t know, they would not prejudice the infant’s upbringing.
These practices, while less frequent, still occur.
When parents were informed of the prospect of surgery and sex reassignment they
were often told that the “normal” looking genitalia would dictate the child’s
gender development, and that any innate gender propensity would be changed by
upbringing. Despite a lack of confirming evidence, medical literature from the
1970s to the late 1990s had promoted this treatment. Supporting evidence is
still scant and there is a great deal of evidence against the belief (Diamond,
1999). Much depends upon the particular intersex condition being considered.
A significant number of intersexed persons were raised in their
sex-reassigned gender and then, on their own, either switched to their opposite
or instead elected to see themselves, not as male or female, but as
intersexed.17 Many of the intersexed infants that had surgery, even if staying
within their assigned gender, have come to criticize such treatment. Many of
the original surgeries had to be redone and many surgeries reduced the erotic
sensitivity of the genitals.18 Why, these intersexed individuals ask, couldn’t
they be allowed to live as they were born? Many question what right the
surgeons had, with or without permission of their parents, to decide to subject
them to surgery? Groups of intersexed individuals, such as those of the
Intersex Society of North America (ISNA), A Kindred Spirit, and Bodies Like
Ours have formed and voiced objection to such treatments.
Arguments supporting reconstruction of the genitals are based on the beliefs
that humans are psychosexually neutral at birth and that they fare better in
life if their gender and genitals match. Reconstruction of the genitals and sex
reassignment is, therefore, justified. Little evidence has been offered to
substantiate that claim, however. In contrast, neurological and biological
studies support the premise that humans are, in keeping with their mammalian
heritage, primarily predisposed and biased to interact with environmental,
familial, and social forces in either a male or female mode.19 Further, there
is no evidence from medical or other records that intersexed individuals with
ambiguous genitalia faired poorly if no surgery was imposed.
Physicians further justify their surgeries on the premises that growing up
with ambiguous genitalia would lead to uncertainty on the part of the child as
to its gender, and that the ambiguous genitalia would elicit unflattering and
derogatorily shaming comments from others. There is only untested theory
bolstering the belief about gender development, and only anecdote about the
occurrence and effect of unflattering and shaming comments.
major ethical problems with “normalizing” ambiguous genitalia without informed
consent of the individual involved. The most significant is that doing so
ignores the possibility that the child, when an adult, might have a different
concept of what is “normal” and what is desirable. And collusion in the surgery
by well-meaning parents does not rectify the situation. Indeed, it might make
it worse if the mature child comes to wonder why he or she could not be loved
as they were born. There are many cases where those who had such surgery as
infants later rue the procedures and the thinking that went with it. In cases
of infant intersexuality, we think the most ethical stance is to hold open the
infant’s surgical future when any proposed change is not medically, but only
cosmetically, at issue. At a later date, the child can then elect or decline
any appropriate surgery (Beh and Diamond, 2000).
We thus present two sides of an issue: where those who wish to change their
bodies meet with social criticism and where those who involuntarily had their
bodies modified criticize the social forces that led to their unwelcome
surgery. In both types of situations, the critics claim they are looking out
for the best interests of the individuals involved, the public good, or both.
When a decision is in keeping with social norms, the populace and most
professional groups generally approve and consent is tacit. When an
individual’s choice is unpopular, however, it causes consternation and unease.
Evidence for this is not difficult to come by. Cosmetic or psychiatric surgery
obtained by minors is not uncommon in the United States in instances other than
transsexual considerations. According to the American Society of Plastic
Surgeons the number of cosmetic surgeries performed on people under the age of
18 exceeded 74,000 in 2003, a 14 percent increase from 2000. In 2003 some 3,700
breast-augmentation surgeries were performed on teenage girls and almost as many
teenage boys had their breasts reduced.20 All that was generally needed to
obtain these operations was the financial ability to pay and the consent of
parents or guardians. For those that wanted to go contrary to the usual in
terms of gender, however, roadblocks of all sorts existed. Males and females,
thus, are denied surgery if it is associated with a desire to change their sex,
but not if it is to enhance gender stereotypes. And surgery toward
“normalization” is promulgated when genitalia are believed to be unusual and
differ from the norm.
We accept that those who chose might be making a mistake they will later
regret. Yes, there might be repercussions difficult to remedy. But mistakes
happen even when actions are made following the best of intentions. Regrets are
not only for taking the road less travelled, but for taking the highway as
well. And there are honest differences of opinion as to those persons who make
the right decision and those who make wrong. Who is to say?
In discussion of this matter we can even call upon a concept of freedom in
its broadest sense and immortalized in our country’s central documents. The
constitution starts off with our ancestor’s desire to “secure the Blessings of
Liberty to ourselves and our Posterity” and the Declaration of Independence
declares: “We hold these truths to be self-evident: that all men are created
equal; that they are endowed by their Creator with certain unalienable rights;
that among these are life, liberty, and the pursuit of happiness.”
If liberty is to mean anything it must offer freedom from external restraint
or compulsion. A person’s liberty must be seen as a condition of legal
non-restraint of natural
powers.21 And as liberty is an inalienable right it cannot be surrendered or
We thus think it is unethical to make bodily modification of adult or mature
minors difficult or illegal when it is desired, and we think it equally
unethical to impose, encourage, and promote it in infants when it has not been
proven justified and when many on whom it has been imposed criticize the
practice even to the point of claiming that it is harmful. People have a right
to modify their bodies when they so choose and not have it modified without
their expressed informed consent.
A parallel issue needs be considered in this discussion since the individual
is not a completely independent agent. The transsexual who wants surgery, or
the intersexed individual who doesn’t, must interact with different
professionals, usually psychotherapists and physicians.
While we presume informed patients with decisional capacity have the right to
make medical treatment choices that may bother or offend the larger society, we
must also acknowledge the professional’s right and obligation to act within his
or her conscience in cooperating with those choices. Professional obligations
can serve as a legitimate limitation on patient autonomy. Nevertheless, we feel
that patient autonomy should be paramount even, or perhaps especially, when
exercising choice, which may result in later regret. Yet, patients do not and
cannot make medical treatment decisions alone, because medical treatment, by
its nature requires the participation of others who are obliged to follow their
own conscience and are bound by rules of professional conduct. Thus, informed
consent from competent patients may not alone suffice. Professional medical
ethics, and the ethical codes of other helping professionals, preclude
providing treatments for which there is no indication and those that offer no
possible benefit.23 Patients are not entitled to treatments “simply because
they demand them” and physicians or others “are not ethically obligated to
deliver care that, in their best professional judgment, will not have a
reasonable chance of benefiting their patients.”24
Admittedly, in some cases it might be difficult for transsexuals who desire
counseling, hormones, or surgery, to everywhere find professionals willing and
able to provide these services. However, there is no shortage of qualified
specialists who are willing to serve. How to keep the intersexed individual
from imposed surgery, however, is more problematic. Having a knowledgeable and
understanding pediatrician is a place to start.
In summary, we think it is appropriate to call upon long held professional
guidelines for those in the helping professions. In the first set of instances
we offer “Relieve pain and suffering.” The psychic pain and suffering of
those diagnosed as transsexuals is well documented. The advice for the second
set of instances, where individuals have not themselves requested surgery, is
to refrain: “First, do no harm.” The obligation for these decisions
ultimately remains with the individual, and yes, every person has a right to be
1 In any discussion of transsexuality and intersex there is a sensitive issue
of how nouns and pronouns are used. Most persons with a transsexual condition
identif’ themselves unequivocally as members of the sex in which they aspire to
live. Thus, Alex identifies as a male. And to Alex, sex and gender are
equivalent so that male means boy or man. To most medical personnel and
scientists, however, sex and gender are separate (Diamond 2002) so that a
female can live and identify as a boy or man and a male can live and identify
as a girl or woman. Part of the issue is how an individual’s sex is determined.
Over the years various indicators of sex have been emphasized (Dreger 1998);
the most commonly emphasized have been chromosomes, gonads, hormonal titers,
intemal genitalia, external genital appearance, and social lifestyle. As
knowledge and sophistication increase, however, more factors can influence the
determination; a final determination of a person’s “sex” might involve
different gene constellations as well as brain sex. Traditionally the primaly
sex characteristic has been the gonads. It is now understood that an
individual’s gonads or related characteristics frequently do not correspond with
other features of self and that variations are common. Such discrepancies and
variations arise in conditions of transsexuality and intersex (and
transsexuality can be considered a form of intersexuality) (Diamond, 2002).
These discrepancies and variations have implications over and above any
grammatical matter. A resolution of the conflicting methods for assaying sex
would have legal and practical relevance. It would address the problem that
arises when a person is considered a male in one state, a female in another,
and an intersexed person in a third. Persons with an intersexed or transsexual
condition consider, not their gonads, but their brains, their core sense of
self, as the primary determinant of sex. Presently this is best evaluated by
the individual’s own admission rather than by any scientifically objective
measure. In this paper we use the terms as they are most generally understood.
In general, however, persons of any category should be addressed and regarded
as they see themselves. See also Wallbank (2004).
2 “Re Alex: Hormonal Treatment for Gender Identity Dysphoria.” FLR 180.89
(2004). Available at
<http://www.austlii.edu.au/au/cases/cth/family_ct/2004/297.html> See also
Beh & Diamond, “Ethical Concerns.”
3 Patrick Goodenough. “Sex-Change’ Clinic Faces Inquiry, Lawsuit.” Cnsnews.com:
May 05, 2004. Available at
“Double Sex-Change Patient to Sue.” Fairfax Digital: 2004. Available at
<http://www.smh.com.au/articles/2004/09/l51l094927634658.html?from=storylhs&oneclick=true#>; “Alan Finch-Man to
Sue Over Sex Change.” ABC NewsOnLine. Available at
4 Standardized procedures for the treatment of GID have been established by the
Hariy Benjamin International Gender Dysphoria Association. Available at
5 Op. Cit. Goodenough ‘Sex-Change.” Last Update: Friday, November 12, 2004.
6 Greg Ansley. “Alan Finch-Caught in the Wrong Body.” New Zealand Herald. (2004).
Available at <http://www.gendertrust.org.uk/newsl57.php>
7 Black, Debra. “Sex, Lies and a Quest for Identity.” Toronto Star. (May
11, 2004, A3).
8 Beh, H. G. and M. Diamond (2000); Kipnis, K. and M. Diamond (1998).
9 Colapinto, J. “The Boy Who Was Turned into a Girl.” BBC Horizon
Productions: Dec. 6. 2000; “Sex Unknown.” PBS NOVA: 30 October 2001 (WGBH
10 Littleton v Prange (Texas case) at
<http://www.pfc.org.uk/legal/littletn.htm>; Wilgoren, Jodi. “Suit Over
Estate Claims a Widow Is Not a Woman.” New York Times. (January 13, 2002).
11 We are not extending this discussion to include issues such as prostitution,
drug use or other practices that involve one’s voluntary exposure of the body
to risk. Those topics involve public policies that already have histories of
extensive debate. This current discussion is limited to issues of body
12 1 Corinthians 6:19-20.
13 Genesis 1:26-27.
14 HBIGDA is a professional organization devoted to research and overview of
the clinical management of transsexualism.
15 Mill, J. S. (1909).
16 A more liberal consideration of the frequency of individuals in the
population with intersex conditions gives a figure exceeding one percent
17 Diamond, Milton (2004); Diamond, M. and L. A. Watson (2004); Beh, H. G. and
M. Diamond (2000); Schober, J. M. (2001).
18 Creighton, Sarah M., C. L. Minto, Ct
al. (2001); Kuhnle, U., M. Bullinger,
et al. (1995).
19 Diamond, Milton (1995); Diamond, M. and L. A. Watson (2004); Hamer, D. and
P. Copeland (1998). Wilson, B. E. and W. G. Reiner(1998).
20 Mary Duenwald. “The Consumer; How Young Is Too Young to have a Nose Job and
Breast Implants?” N.Y. Times. (Sept. 28, 2004 at F5). Available at
21 Gove, P. B. Webster’s Third New International Dictionary of the English
Language, Unabridged. Springfield, Mass: G. & C. Merriam Company, 1971.
22 “At the heart of liberty is the right to define one’s own concept of
existence, of meaning, of the universe, and of the mystery of human life.” Lawrence v. Texas 213 S. Ct., 2472, 2481 (2003).
23 AMA Code of Medical Ethics, Opinions on Practice Matters E-8.20.
24 MvIA Code of Medical Ethics, Opinions on Social Policy Issues E-2.035.
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Blackless, Melanie, A. Charuvastra, et al. “How Sexually Dimorphic Are We?” American
Journal of Human Biology 12(2000): 151-166.
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