变性手术伦理争议思考

变性手术伦理争议思考 医学伦理学 变性手术争议的回顾和再思考 梁壮 20120141056 12岐黄2班 2014年6月28号 on duty day and night, and led by the site shift, full-time staff, found problems resolved in a timely manner. 3) material preparation: raincoat, rubber boots, shovels, plastic sheeting, 130 cars, submersible pumps, water pipes, sewage pump, sheet. 8.6.1.2 in rainy season construction measure 1 ... 1) safety precautions a. after rain, organize relevant personnel in a timely manner on the shelves, electrical and mechanical equipment, such as program check, found hidden immediately for resolution. B. electrical and non-electrical personnel not to move equipment. Regular maintenance of overhead lines, found that the problem resolved in a timely manner. C. distribution boxes, switch boxes, surface electrical equipment should with rainproof measures. Iron gate box skin electric equipment ground fault protection, leakage protection device is in accordance with the regulations. 2) fire-fighting measures a. fire-fighting equipment must be protected against rain, moisture, Sun protection, underground fire hydrants of the well is not lower than the General floor. B. acetylene and oxygen cylinders to have a sun protection and strict control of inventories. C. After Sun or rain, burning, explosion-prone items should be kept properly kept, and good ventilation, Sun-proof, moisture-proof. 8.6.2 summer construction measures 8.6.2.1 summer and common characteristic is the high temperature, the water evaporates in the dry season, and prone to shrinkage cracks on concrete surface, and should seek to prevent sun exposure, reduce moisture evaporation, timely pouring time covered and moist curing. 8.6.2.2 avoid pouring. To make full use of 6 o'clock in the afternoon to finish construction before the next day at 10 o'clock. 8.6.2.3 prepare enough coverage tools, awnings, if necessary, to prevent direct sunlight, and awning can also be used in the rain. 8.6.2.4 due to high temperatures in the summer, should pay attention to the safety of construction workers, should be prepared to heatstroke prevention medicine. 变性手术争议的回顾和再思考 摘要 易性癖是一种要求改变自己性别的心理疾病。变性手术则是最有效的治疗。该方法历来争议颇多。本文在简要介绍易性癖和变性手术这对供求关系之后，接着对变性手术的争议点从正反两方面在医学、伦理、心理、法律等各方面进行了回顾和总结，最后笔者针对争论本身进行了简短评论，指出争论本身的现实和其中的无奈，对未来的发展示应有的期许。 关键词 易性癖 变性手术 争议 思考 一(现实:供求关系 所谓易性癖，通常被认为是在个体性角色中表现出的性别自我认知障碍性疾患。屡被引用的著名精神病学、性学和内分泌专家Harry Benjamin对“性”和“性别”论述说:“性(Sex)是你所看到的，性别(gender)是你所感觉到的。这两者之间的协调对人类的幸福至关重要。”易性癖患者是这样一个特殊的人群，他们清楚地知道自己的生物学性别，但却在心理上感觉并深信自己为另一性别的人，并强烈要求改变自己的生物学性别，渴望完全按异性的角色去生活。其主要表现在患者坚信自己显露出来的躯体性别器官是错误的，因此其行为指向是通过手术改变性器官，或以异性着装和行为来掩饰其躯体性别。患者为自己的灵肉不一而承受着巨大的心理煎熬和痛苦，其大都有不同程度心理障碍，心理封闭且多不稳定。由于社会认同度低，性格常自卑、孤僻、脆弱。情况严重者，往往有自残和自杀倾向。1949年考德威尔首先把这种现象称为“易性癖”，相关个体称为“易性癖者”。其发病率各家报道不一。在美国,男易性癖的发病率为1/10万,女性为1/40万;在新加坡，男性的发病率为3512/10万,女性为12/10万。我国的资料不详，或说男女比例约为3比1。 原因和措施易性癖的病因不十分清楚，目前学术界普遍认为该病与患者幼年时期的生活经历有关。在早期的性别教育中，错误的性别角色教育与异性癖有明显相关性。至于该病是否有先天影响因素， 根据目前医学上的研究表明可能胚胎在发育的时候，头脑中诱导性别的物质发生了紊乱， 导致婴儿出生就有易性癖的倾向，并且在五六岁的时候诱发。同时! 国外学者研究还发现异性癖患者体内的激素量与正常人存在一定差别， 但相关的研究成果尚不成熟。 异性癖的治疗比较困难，目前主要采用药物、心理治疗和变性手术。解决冲突的最佳途径, 应当是以心理治疗或行为治疗去纠正患者的病态心理, 使之心理性别与生理性别、社会性别达到一致, 从而解除病人及其家庭的痛苦，只有在心理治疗和行为治疗宣告失败之后, 才能考虑变性手术。但事实上对于易性癖者而言, 尽管心理治疗、药物治疗安全性更高，但往往没有持久的疗效, 因此, 最终都不得不求助于变性手术。 变性手术是针对易性癖患者进行的性别重塑整形外科手术。。变性手术以形态学和解剖学研究为基础，有男—女易性整形手术和女—男易性整形手术。以男—女易性整形手术为例，手术包括:阴茎和睾丸的切除、尿道移位、人工阴道形成及诸如乳房增大成型和鼻整形、颧颊部等面部骨骼女性化的手术、甲状软骨缩小成性、声调调整、电解或手术除毛等附加手术和疗法。全部手术不仅包括切除原有生殖器官、重建新的生殖器官,还包括第二性征的整复,使患者从头到脚各部位与改造后的性别身份相适应,使其身体符合心理状况。变性手术是一种复杂的外科手术。可以说，变性手术是一门很复杂、很精细、要求很高的医学科学，这种手术代表一个国家的整形外科的整体水平。 1931年世界首例变性手术后，全球己超过1万多人变性，全世界每10万中有4个易性症患者，目前我国已有1千余人做变性手术，但同时大约有40万人要求进行变性手术，供需矛盾非常突出。 二(争议:破立之间 on duty day and night, and led by the site shift, full-time staff, found problems resolved in a timely manner. 3) material preparation: raincoat, rubber boots, shovels, plastic sheeting, 130 cars, submersible pumps, water pipes, sewage pump, sheet. 8.6.1.2 in rainy season construction measure 1 ... 1) safety precautions a. after rain, organize relevant personnel in a timely manner on the shelves, electrical and mechanical equipment, such as program check, found hidden immediately for resolution. B. electrical and non-electrical personnel not to move equipment. Regular maintenance of overhead lines, found that the problem resolved in a timely manner. C. distribution boxes, switch boxes, surface electrical equipment should with rainproof measures. Iron gate box skin electric equipment ground fault protection, leakage protection device is in accordance with the regulations. 2) fire-fighting measures a. fire-fighting equipment must be protected against rain, moisture, Sun protection, underground fire hydrants of the well is not lower than the General floor. B. acetylene and oxygen cylinders to have a sun protection and strict control of inventories. C. After Sun or rain, burning, explosion-prone items should be kept properly kept, and good ventilation, Sun-proof, moisture-proof. 8.6.2 summer construction measures 8.6.2.1 summer and common characteristic is the high temperature, the water evaporates in the dry season, and prone to shrinkage cracks on concrete surface, and should seek to prevent sun exposure, reduce moisture evaporation, timely pouring time covered and moist curing. 8.6.2.2 avoid pouring. To make full use of 6 o'clock in the afternoon to finish construction before the next day at 10 o'clock. 8.6.2.3 prepare enough coverage tools, awnings, if necessary, to prevent direct sunlight, and awning can also be used in the rain. 8.6.2.4 due to high temperatures in the summer, should pay attention to the safety of construction workers, should be prepared to heatstroke prevention medicine. 对于易性癖，当代学界已普遍将其视为一种严重的心理疾病，伦理上争议并不突出，主要集中在患者的法律地位。世界各国互有不同在中国易性症者是被作为限制行为能力人来对待的, 变性手术作为易性症者改变性别的一种特殊治疗手段, 则自诞生之日起就常引发医学和伦理学上的争议。学者从医学、伦理、心理、法律等各方面展开争论。关于变性者本身及之后的变性人，则主要是从变性者的主体资格问题如“变性手术是否需患者本人同意”、“患者是否具有完全民事行为能力的人”、“已婚者是否能够变性”、“ 特殊身份者是否能够变性”等以及变性人身份与性别的法律问题。本文仅就变性手术本身的争议进行回顾和总结。 反对意见上，从医学的角度而言, 变性手术具有不可逆性, 会给病人带来永久性创伤。手术之后，正常生理现象如遗精或月经等消失; 性感受微弱; 不能生育;外源性激素的长期使用，将对内分泌产生影响并带来身体的其他不良症等等是事实也是论者的重要论点。重庆医科大学冯泽永教授的观点颇具代表性，他认为: 变性手术不是纠正其病态之心以适应正常之身, 而是变完善之身为残缺之身以适应变态之心, 这不是治本之术, 决非上乘之选，认为变性手术是治疗易性癖的下策。从伦理学的角度来看, 变性触及了性别这一敏感的人伦之理。性别是人的自然属性之一, 是性关系以及婚姻家庭的基础。以手术的方式来改变人的性别, 这是社会传统道德所不能想象的。有论者即以此认为变性是破坏天赋之属性，是对自然规律的破坏和亵渎。“它改变了人类正常的健康准则, 从根本上违反了人的自然本性, 并据此怀疑当代科学发展的某些趋势是否弊大于利, 是否把整个人类社会引向一个比核战争更恐怖的深渊。”妥当与否姑且不论，确实真切地反映了相关人士的忧虑。心理学的角度看, 变性改变了个人的性别身份, 他们新的性别身份往往被社会普通大众所歧视、 误解, 因而导致他们的心理产生极大的痛苦和反差，不少研究的结论是“事实上是, 接受变性手术的人并不意味着从此就真的找到了幸福”。从法律层面上看，变性手术是是一种破坏正常功能的人体器官的手术，一些国家的刑事法律中明确规定残害正常器官要负刑事责任，因此手术与相关法律原则相抵触，是某种程度上的“违法行为”。 赞成方则认为:从医学的角度上看，易性癖既然是一种心理疾病, 就有通过医疗行为加以治疗的权利。变性手术能满足易性症者的心理需求, 符合“对病人有利”原则的医学伦理。它对易性癖是一项非常有效和适当、甚至是唯一的治疗方法。它是一种破坏正常身体器官的技术，但它首先是一项针对心理疾患的治疗。从伦理的角度而言, 自主和宽容是一个社会最大的伦理。首先一个人选择变性与否，涉及的是他个人的自我选择问题, 我们应当尊重他人的自我选择。从法律上“性别权实际上是一种隐性的人格权。”在性别上给予他们自我选择权, 无疑是对他们实在的关怀。其次, 应当用一种多元的、渐进的眼光来对待易性症者们的特殊人格，保留他们充分的权利空间。从心理上看，尽管变性者并不能完全地以正常的人的角色进入社会，但与施术前相比，患者心理状态明显改善，社会接受度得到提高。从法律上看，“性别权实际上是一种隐性的人格权。”从民法生命健康权保护的角度看, 一个人实现自己心理性别的权利也是人的“生命健康权 利”的一种具体的权利形式变性手术就是一个人治疗自己疾病时使用的一种方法而已，身有病痛，通过医疗手段使之消失，是生命健康权利的应有之义。另外，变性手术通过改变器官和身体构造从而达到改变性别的目的, 实际上是对身体权支配的一种表现。只要这种支配与处分不侵害他人利益和社会公共利益，就应该受到我们充分的尊重和理解。 从各国相关立法上，我们也可以看出争议的存在。不少国家的法律规定禁止变性。如西班牙、土耳其等国家法律规定,对易性症者施行变性手术是一种违法犯罪行为。同时有更多的国家对变性手术给予了充分的理解以及必要的限制。我国则在相关法律上一直停滞不前，一定程度上是社会对其激烈而无休止的争论的结果2009年11 月13 日, 我国卫生部发布《变性手术技术管理规范(试行)》，这表明我国开始对变性手术进行规范，也表明社会意见开始on duty day and night, and led by the site shift, full-time staff, found problems resolved in a timely manner. 3) material preparation: raincoat, rubber boots, shovels, plastic sheeting, 130 cars, submersible pumps, water pipes, sewage pump, sheet. 8.6.1.2 in rainy season construction measure 1 ... 1) safety precautions a. after rain, organize relevant personnel in a timely manner on the shelves, electrical and mechanical equipment, such as program check, found hidden immediately for resolution. B. electrical and non-electrical personnel not to move equipment. Regular maintenance of overhead lines, found that the problem resolved in a timely manner. C. distribution boxes, switch boxes, surface electrical equipment should with rainproof measures. Iron gate box skin electric equipment ground fault protection, leakage protection device is in accordance with the regulations. 2) fire-fighting measures a. fire-fighting equipment must be protected against rain, moisture, Sun protection, underground fire hydrants of the well is not lower than the General floor. B. acetylene and oxygen cylinders to have a sun protection and strict control of inventories. C. After Sun or rain, burning, explosion-prone items should be kept properly kept, and good ventilation, Sun-proof, moisture-proof. 8.6.2 summer construction measures 8.6.2.1 summer and common characteristic is the high temperature, the water evaporates in the dry season, and prone to shrinkage cracks on concrete surface, and should seek to prevent sun exposure, reduce moisture evaporation, timely pouring time covered and moist curing. 8.6.2.2 avoid pouring. To make full use of 6 o'clock in the afternoon to finish construction before the next day at 10 o'clock. 8.6.2.3 prepare enough coverage tools, awnings, if necessary, to prevent direct sunlight, and awning can also be used in the rain. 8.6.2.4 due to high temperatures in the summer, should pay attention to the safety of construction workers, should be prepared to heatstroke prevention medicine. 融合。 三(思考:墨守和悲悯 从争论双方的论点和论据可以看出，反对方的各个论点几乎被赞成方一一击破，天平的倾斜已经无可避免，近年来变性手术的发展也从事实上说明了这一点。我们应该思考的问题是胜利女神是如何一点点地作出判断的。笔者认为，双方的观点契合了近年来有关医学技术争议的保守与激进两派，前者多为学者，是传统道德和理论纯洁的代表，尊重道德和自然规律的同时未免将其夸大，“墨守成规”;后者多为施术的临床医生，更接近患者和技术本身，所以展现了对现有道德的突破态势，以此来适应最近的医学发展。 但争议双方从来都不是天生的矛与盾。变形手术的是和非的背后，我们兴尽其致的同时，不应忽略的一个背景是，对与易性癖，且不考虑经济的因素，变形手术是比之心理治疗和药物治疗几乎唯一的有效的方式，以往后两者的成功多是假性病例。这是一个无奈的事实，现代医学的局限，是我们对于这些“上帝的失误”的受害者，既不知其所以然，又只能以最为极端的方式，让灵肉归于一致。争议的双方不管观点如何，出发点都是对于患者，道德，社会和法律的关切，反对方想尽量减少患者受到的痛苦，维持道德层面对于现行世界的最大程度的包容，弥合法律出现的一切缺口;赞成方则将患者置于考虑的中心，不惜以现实的道德争议和法律更迭为代价，已达到技术进步对人类利益的提高。都是出于一种悲悯的心态看待这一富有争议的技术。我们的任务不是禁止变性手术, 而是构建规范变性手术的具体规则，发展变性手术的技术，以最大程度上维护易性癖者的合法权益。 我们也应看到变性手术的并不能完全解决患者的价值冲突, 也不能彻底解除他和他家庭的痛苦，只能使一种冲突变为另一种冲突。问题的解决需要进一步的进步，坚持人道主义，包容与和谐的价值观，代表了我们对新技术无限的希冀。 参考文献 [1]周丹,贺苗,. 变性手术面临的困境与对策研究[J]. 医学与哲学,2013,(12). 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[15]梁晓琴,唐胜建,苗春雷,牟少春,. 易性癖诊治前后的几点思考[J]. 医学与哲学(人文on duty day and night, and led by the site shift, full-time staff, found problems resolved in a timely manner. 3) material preparation: raincoat, rubber boots, shovels, plastic sheeting, 130 cars, submersible pumps, water pipes, sewage pump, sheet. 8.6.1.2 in rainy season construction measure 1 ... 1) safety precautions a. after rain, organize relevant personnel in a timely manner on the shelves, electrical and mechanical equipment, such as program check, found hidden immediately for resolution. B. electrical and non-electrical personnel not to move equipment. Regular maintenance of overhead lines, found that the problem resolved in a timely manner. C. distribution boxes, switch boxes, surface electrical equipment should with rainproof measures. Iron gate box skin electric equipment ground fault protection, leakage protection device is in accordance with the regulations. 2) fire-fighting measures a. fire-fighting equipment must be protected against rain, moisture, Sun protection, underground fire hydrants of the well is not lower than the General floor. B. acetylene and oxygen cylinders to have a sun protection and strict control of inventories. C. After Sun or rain, burning, explosion-prone items should be kept properly kept, and good ventilation, Sun-proof, moisture-proof. 8.6.2 summer construction measures 8.6.2.1 summer and common characteristic is the high temperature, the water evaporates in the dry season, and prone to shrinkage cracks on concrete surface, and should seek to prevent sun exposure, reduce moisture evaporation, timely pouring time covered and moist curing. 8.6.2.2 avoid pouring. To make full use of 6 o'clock in the afternoon to finish construction before the next day at 10 o'clock. 8.6.2.3 prepare enough coverage tools, awnings, if necessary, to prevent direct sunlight, and awning can also be used in the rain. 8.6.2.4 due to high temperatures in the summer, should pay attention to the safety of construction workers, should be prepared to heatstroke prevention medicine. 社会医学版),2007,(8). [16]邢新，郭恩覃. 易性癖的病因研究[J]. 中国神经精神疾病杂志,1995,(2). [17]朱晓华，陈小平. 易性癖的临床观察[J]. 临床精神医学杂志,1995,(2). [18]刘文阁,杨佩瑛,王默,马桂娥,袁志伟,曹艳,田迎节,宋新梅,. 易性癖患者的心理护理探索[J]. 中国美容医学,1996,(4). [19]柯巧云,林明珠. 易性癖患者的心理分析及对策[J]. 护士进修杂志,1997,(8). [20]程志让,张志俊. 女性易性癖七年追踪报告[J]. 临床精神医学杂志,1998,(5). [21]陈远岭,. 一例易性癖的分析性心理治疗[J]. 性学,1994,(2). [22]朱顺生,李杨兴,寿正哲. 男性易性癖[J]. 第一军医大学学报,1992,(3). [23]邢新,郭恩覃,. 易性癖现象[J]. 中华整形烧伤外科杂志,1993,(3). [24]尘土. 令人忧虑的易性癖[J]. 医药与保健,1994,(2). [25]大伟,. 易性癖成因及治疗[J]. 人人健康,2000,(10). [26]陈元根. 套在男人躯壳里的女人——一个易性癖男子的痛苦人生[J]. 医药与保健,2002,(9). [27]师建国. 实话实说 易性癖[J]. 医药与保健,2002,(9). [28]李梦霞. 国内当代大学生对易性癖的认识和态度调查[C]. Proceedings of Conference on Psychology and Social Harmony(CPSH2012).2012 on duty day and night, and led by the site shift, full-time staff, found problems resolved in a timely manner. 3) material preparation: raincoat, rubber boots, shovels, plastic sheeting, 130 cars, submersible pumps, water pipes, sewage pump, sheet. 8.6.1.2 in rainy season construction measure 1 ... 1) safety precautions a. after rain, organize relevant personnel in a timely manner on the shelves, electrical and mechanical equipment, such as program check, found hidden immediately for resolution. B. electrical and non-electrical personnel not to move equipment. Regular maintenance of overhead lines, found that the problem resolved in a timely manner. C. distribution boxes, switch boxes, surface electrical equipment should with rainproof measures. Iron gate box skin electric equipment ground fault protection, leakage protection device is in accordance with the regulations. 2) fire-fighting measures a. fire-fighting equipment must be protected against rain, moisture, Sun protection, underground fire hydrants of the well is not lower than the General floor. B. acetylene and oxygen cylinders to have a sun protection and strict control of inventories. C. After Sun or rain, burning, explosion-prone items should be kept properly kept, and good ventilation, Sun-proof, moisture-proof. 8.6.2 summer construction measures 8.6.2.1 summer and common characteristic is the high temperature, the water evaporates in the dry season, and prone to shrinkage cracks on concrete surface, and should seek to prevent sun exposure, reduce moisture evaporation, timely pouring time covered and moist curing. 8.6.2.2 avoid pouring. To make full use of 6 o'clock in the afternoon to finish construction before the next day at 10 o'clock. 8.6.2.3 prepare enough coverage tools, awnings, if necessary, to prevent direct sunlight, and awning can also be used in the rain. 8.6.2.4 due to high temperatures in the summer, should pay attention to the safety of construction workers, should be prepared to heatstroke prevention medicine.