Fatwa ID: 22813
Title: Gender identity disorder and sex reassignment surgery
Category: Varieties
Scholar: Dr. Hatem al-Haj
Date: 08/20/2007

Question

In the Name of Allah, the Beneficent, the Merciful,

 

May the peace, mercy and blessing of Allah be upon you,

 

We thank you for your bounteous efforts to serve Islam and the Muslims. I hope you will help me as a physician in arriving at a definitive ruling with evidence in relation to the issue concerning a not entirely small group of the Muslims over which fiqh scholars have differed, namely, Gender Identity Disorder. I ask you by Allah to advise us. Know that there are patients whose worldly lives rest on this response. All of their hope in life is to live like the rest of human beings, and as such, I ask you to be swift in responding.

 

I will start with another clarification of the understanding the medical community has reached concerning this disease. Gender Identity Disorder, mentioned in all psychiatric sources, both Arab and international, is a congenital condition, the cause of which they trace to environment and upbringing; however, with advancements in medicine, it has become clear that there is something called the "gender or sex lines in the brain," which are responsible for the brain defining and feeling to which gender one belongs, and this is known as gender identity. Scientists have concluded that these lines are different in these patients such that the person feels since birth that he belongs to the opposite anatomical gender.

 

It has become clear that this difference stems from a hormonal imbalance to which the fetus is exposed before birth which affects its genes and therefore the gender lines in the brain which starts the tragedy of gender identity disorder.

 

The obvious symptoms begin after birth (since the behavior of a male baby differs from that of the female baby), and the affected child follows the behavior of the opposite gender. Then it gets worse and symptoms appear during early childhood, and the male child (for instance), who is not even three years old, feels that he is female and he displays the behavior of a girl in different aspects of his life, from the way he plays, to even the way he relieves himself!

 

Multiple instances of this disorder in one of two identical twins, and not the other, is clear, unarguable proof that a person is born with this disorder and that it has absolutely no relation to environment, upbringing, personal desires or the whisperings of Satan, as the ignorant claim. From this simplified presentation of the disorder, it is clear that, even if the symptoms appear psychological, the cause is physiological - a congenital anomaly in the brain which makes the person's gender identity differ from his anatomical and chromosomal sex, which leads to profound conflict between the mind and the body, making the patient hate his genitals and the manifestations of puberty intensely. He wants to get rid of them in any way to be freed from his imprisonment in this body which his brain considers not his body.

 

This differs completely from sexual deviance or homosexuality, in which a person does not want to change his gender at all, but he believes that it is possible to have sexual relations between two people of the same gender. A person suffering from Gender Identity Disorder, on the other hand, does not believe this at all. He considers it deviance from the pure, natural state, even though he might do things like this in despair and grief under the influence of his feeling that he is of the other gender and his insistent desire to change his body.

 

Over the years, with all of the amazing medical advancements, psychiatric therapy has not been able to treat any of these patients and it has not succeeded in changing their gender identity (which resides in the brain) to correspond to their bodies. Nothing remains for medicine, but surgical treatment to save these patients from their profound despair of life and preference for death rather than to live in bodies they reject, or rather by which their minds are repulsed.

 

The fatwas that prohibit sex reassignment surgery for these patients do not offer them any alternative solution to their lack of ability to continue living under the shadow of being torn between the mind and the body, which leads them to fall into vice from which they always hope to purify themselves by having surgery and entering into a legitimate Islamic marriage.

 

If someone was born with any obvious or hidden congenital abnormality (such as blindness, for example), and he had the chance to be treated and get back his sight, would that be considered "changing the creation of Allah"? Wasn't Allah capable of creating him with sight from the start if He so willed? So, why are those operations not prohibited and similar ones, too?

 

Someone born blind is exactly like someone born with gender dysphoria, yet there are those who say that the meaning intended in the Noble Verse (in meaning), {…and indeed I will order them to change the nature created by Allah…}[Al-Nisa' 4:119] is sex reassignment surgery! Why not consider in vitro fertilization "changing the creation and will of Allah"? {…and He renders barren whom He wills…}[Al-Shura 42:50] Also, birth control methods, organ transplants, medicines that contain hormones and many others…

 

Is it possible that Allah created human beings and created in them sexual instincts only to prohibit them from using them in a lawful way, while permitting this for the rest of humanity (and even animals)? He is the Beneficent, the Merciful, Who said (in meaning),

 

{It is made lawful for you to have sexual relations with your wives on the night of the fasts. They are a screen (or pleasure) for you and you are the same for them. Allah knows that you used to deceive yourselves, so He turned to you (accepted your repentance) and forgave you.}

[Al-Baqarah 2: 187]

 

Here we see the vastness of Allah's Mercy and He knows better about His creatures than themselves! He knows that these instincts are very strong and that the human being is a weak creature. How merciful is Allah (Azza wa Jall) and how cruel are human beings!

 

Do we tell these patients that they must fast until Allah has mercy on them and they die? You must fast as much as you are able and endure the hardship and deprivation of fasting in addition to your own suffering, torment and deprivation? You have no share in this world, but you will have the gardens of Paradise, insha'Allah (God willing)? Don't try to search for medicine because the hadith of Allah's Messenger (saws), "O slaves of Allah, seek treatment, for Allah has not made a malady, except that He has made for it a remedy," isn't directed to you? Because the fiqh scholars said that Allah wants to torture you in this world, so don't work for this world of yours as though you will live forever; rather, work for your Hereafter as though you will die tomorrow? Wish for death because you have no other solution? Is that the meaning of the fatwa that prohibits sex reassignment surgery for patients with Gender Identity Disorder? It is impossible for normal people to imagine the amount of suffering, pain and torment this patient has experienced from the time he was born, through his sad childhood, and then, the struggles of adolescence, until reaching the point of losing all hope in life as a young man and his persistent desire to die because it is the only solution.

 

We ask you to study this issue carefully and to issue a ruling on this case of ours based on what has been previously mentioned. Your Excellency should know that there are many Muslims whose lives rest on your wise opinion. We ask Allah to grant us and you success and guidance.

 

You have our utmost gratitude,

A Muslim doctor

Answer

All praise is due to Allah, and may peace and blessing be upon the Messenger of Allah. To proceed:

 

Linguistically: the khunthâ, someone who is not purely male or female; also, the khunthâ, someone who has what men have and what women have together. The plural is khanâthâ, according to the same pattern as al-habâlâ [another Arabic word]; al-inkhinâth, to walk with a swinging gait and to speak with a soft tone. The man khanitha [verb, past tense: he was effeminate] khanthan [verbal noun, adverb: effeminately], so he is khanith [adjective: effeminate], and takhannatha and inkhanatha [other verb forms]: all meaning to walk with a swinging gait and to speak softly.

 

Perhaps the technical definition in Shari`ah does not differ from the linguistic meaning, for it says in the Fiqh Encyclopedia, "The khunthâ is the one who was created with the genitalia of the man and the genitalia of the woman." Likewise, he may have neither of the two. In the encyclopedia, they differ between the khunthâ and the mukhannath, defining the mukhannath as someone who speaks softly, walks with a swinging gait and his movements resemble those of women in appearance and mannerisms. Therefore, the word, "mukhannath," is more general than "khunthâ."

 

Perhaps it appears from the doctor's question that she does not mean the physiological defect, but rather the behavioral defect. However, before explaining the ruling of Shari`ah and its wisdom, we must clarify the levels and defining characteristics of gender, which are:

 

A. The Chromosomal Determining Level

This is determined - by the Command of Allah (swt) - when a sperm carrying the Y chromosome or a sperm carrying the X chromosome fertilizes an ovum which always carries the X chromosome, thus making the fertilized egg either XY (male) or XX (female).

 

B. The Gonadal Sex Determining Level

This is determined - by the Permission of Allah Most High - during the sixth or seventh week after fertilization. These gonads are the organs that secrete the hormones that regulate the final level.

 

C. The Reproductive Organ Determining Level

Reproductive organs are both external and internal. The internal organs in the female are the ovaries, the uterus, the cervix and the vagina. As for the internal organs in the male, they are the vas deferens, the testicles and the prostate gland. These organs are not distinct until the ninth week. Then they begin the slow, hidden process of differentiation in the ninth week. They then become clear and apparent in the twelfth week.

 

The internal and external reproductive organs then proceed to follow the growth trajectory to the default gender – female - unless they find a certain amount of the male hormone, testosterone, which is secreted by the testes, until they are formed (in other words, until the end of the sixth week), and this is what determines the trajectory of the reproductive organs, both internal and external. Therefore, the removal of the testes from the male fetus or the lack of development leads to the presence of a female reproductive system, even though the sex of the fetus on the chromosomal level is male (XY). As for the removal of the ovaries or the lack of development, this does not affect the track of the reproductive organs which progress in a female direction. In fact, when there is only one X chromosome as in Turner's Syndrome, the reproductive system that develops will be female. Therefore, the default reproductive system, both internally and externally (with the exception of the gonads) is female, but if you find testes or the hormone, testosterone, the reproductive system transforms into male organs.

 

Note: Some divide this level into two subcategories; one of them being the determination of internal organs and the second being the determination of external organs, due to the difference between them sometimes.

 

D. The Behavioral-Training Determining Level

This refers particularly to upbringing and inclinations.

 

Before answering, it is also necessary to draw attention to certain problematic aspects of the question:

 

The inquirer (may Allah guide her to success) stated:

 

Gender Identity Disorder, mentioned in all psychiatric sources, both Arab and international, is a congenital condition, the cause of which they trace to environment and upbringing; however, with advancements in medicine, it has become clear that there is something called the "gender or sex lines in the brain," which are responsible for the brain defining and feeling to which gender one belongs, and this is known as gender identity. Scientists have concluded that these lines are different in these patients such that the person feels since birth that he belongs to the opposite anatomical gender.

 

In all honesty, the statement made has not been established by rigorous scientific testing. The defining characteristics of gender are of five levels, as we mentioned, and the issue is not simply brain patterns determining a person's feelings toward his gender. Rather, specialists are aware of the significant role of upbringing.

 

As for these patterns, there is no way to prove the claim that their role determines an individual's feelings towards his gender. Even if this plays a role (and it is difficult to deny this altogether), it is still a disease which can either be treated or endured with patience, just like any other disease.

 

Most of that which researchers use as evidence in this respect (of those who support the rights of homosexuals) is magnetic resonance imaging of the brain, which does not establish reasonable grounds for anyone to believe the claims made, and specialists differ over how these should be interpreted.

 

The inquirer (may Allah guide her to success) also stated:

 

Multiple instances of this disorder in one of two identical twins, and not the other, is clear, unarguable proof that a person is born with this disorder and that it has absolutely no relation to environment, upbringing, personal desires or the whisperings of Satan, as the ignorant claim.

 

Contrary to what the inquirer states, the difference between twins is that which can be used to prove that the condition is not physiological, but rather behavioral, for the norm is that as the similarity between twins increases, preference is shown to physiological, hereditary (genetic) factors. As for this difference being proof that the matter has no relation to the whisperings of Satan, well, that is strange, for whoever said that Satan whispers to both twins at once? Behavioral differences between twins are extensive and significant. This is something witnessed by and known to specialists.

 

The inquirer (may Allah guide her to success) stated:

 

Is it possible that Allah created human beings and created in them sexual instincts only to prohibit them from using them in a lawful way, while permitting this for the rest of humanity (and even animals)? He is the Beneficent, the Merciful…

 

Allah created human beings thousands of years ago and sex reassignment surgery has only been known for decades. So, we put the question back to the inquirer, asking her about the millions of human beings who have lived and died before the appearance of these operations. Did Allah want for them to be unchaste? We will explain that reassignment does not put an end to these people's suffering.

 

The inquirer (may Allah guide her to success) stated:

 

yet there are those who say that the meaning intended in the Noble Verse (in meaning), {…and indeed I will order them to change the nature created by Allah…}[Al-Nisa' 4:119] is sex reassignment surgery! Why not consider in vitro fertilization "changing the creation and will of Allah"? {…and He renders barren whom He wills…}[Al-Shura 42:50] Also, birth control methods, organ transplants, medicines that contain hormones and many others…

 

The answer is that what is forbidden is to change the pure, undefective nature that suffers no illness, without permission from Allah, and that which the sister mentioned is a type of medical treatment which bears no resemblance to "changing" [the nature created by Allah]. Using hormones for medical treatment is permissible, but it is forbidden if it is for changing the nature by making a man who is completely male into a female, and vice versa.

 

As for the ruling on sex reassignment surgery, perhaps in the answer of the Islamic Fiqh Council of the Muslim World League there is a sufficiently clear explanation of the ruling of the Legislator (Allah) on sex reassignment surgery and the difference in this respect between the khuntha and the mukhannath. To quote:

 

The Islamic Fiqh Council – Decision No. 5, Session 11

 

The text of the decision: In respect to changing a male into a female and vice versa

 

All praise is due to Allah, and may peace and blessing be upon him after whom there will be no other prophet, our master and prophet, Muhammad, and upon his household and his companions.

 

To proceed:

 

The Islamic Fiqh Council of the Muslim World League, has looked into the matter of changing a male into a female and vice versa, and, after research and discussion amongst its members, the following has been decided:

 

Firstly: It is not permissible for either a man whose male organs are fully formed or a woman whose female organs are fully formed to change into the other gender. The attempt to do so is a crime, the perpetrator of which deserves to be punished for changing the creation of Allah. Allah (Subhanuhu) has forbidden this changing, in His Saying (may He be exalted), when He informs us of what Satan said (in meaning),

 

{…and indeed I will order them to change the nature created by Allah…}

[Al-Nisa' 4:119]

 

Furthermore, it states in Sahih Muslim, on the authority of Ibn Mas`oud, who said, "Allah has cursed the tattooists and those who get tattoos, the eyebrow pluckers and those who have their eyebrows plucked, and those who file a space between the front teeth and the incisors for beautification purposes – those who change the creation of Allah (Mighty & Majestic)." Then he said, "Should I not curse those whom Allah's Messenger cursed, when it is in the Book of Allah (Mighty & Majestic), meaning His Saying (in meaning), {And whatsoever the Messenger (Muhammad, saws) gives you, take it, and whatsoever he forbids you, abstain (from it)…}[Al-Hashr 59:7]?"

 

Secondly: As for those whose organs combine characteristics of women and men, the predominant nature of his situation should be considered. Whoever is predominantly male, it would be permissible to treat him medically with that which would remove the disparity in his masculinity, and whoever exhibits predominantly female characteristics, it would be permissible to treat her medically with that which would remove the disparity in her femininity, whether that be treatment with surgery or hormones, because that is an illness and the intention of treatment is to be cured, not to change the creation of Allah (Mighty & Majestic).

 

May Allah send blessing and great peace upon our master, Muhammad, upon his household and his companions, and all praise is due to Allah, Lord of the Worlds.

 

In addition to the prohibition mentioned on changing the creation of Allah is the prohibition of imitating the opposite gender, for Allah's Messenger (may Allah bless him and grant him peace) cursed: "Those imitators of men among the women and those imitators of women among the men," "The man who wears women's clothing and the woman who wears men's clothing," and "Masculine women."

 

Also, Allah has commanded us to be content with what He has given us, saying (in meaning):

 

{And wish not for the things in which Allah has made some of you to excel over others. For men there is reward for what they have earned, (and likewise) for women there is reward for what they have earned, and ask Allah of His Bounty. Surely, Allah is Ever the All-Knower of everything.}

[Al-Nisa' 4:32]

 

We know, therefore, that these operations are prohibited and that no one from among the scholars whose opinion is considered permits them, save with the exception mentioned in the council's response.

 

The unavoidable truth is that the wisdom of prohibiting these operations is clear to rational members of a variety of religions and societies, due to the danger these types of behaviors present to the social and moral fabric of nations. As is well-known, justifying these thoughts and behaviors leads to their spread amongst those who only yesterday were unaffected.

 

Even if some people believe there to be some benefit from these operations, the end result is negative, and their evil is far greater than their good, if there is any to begin with. Furthermore, reassignment does not end these people's suffering as has been witnessed in both East and West. They do not have stable relationships with partners of the opposite gender (their pre-operative gender). Likewise, transition does not make a man a woman in the true sense of the word, for a woman can get pregnant, give birth and breastfeed. As for the man (or the female-to-male transsexual), it is impossible for her to be fully male, as is known to specialists. And all of them are infertile after transition.

 

The BBC published an article on August 1, 2007 in which they mentioned that doctors admit that sex reassignment surgery has not been researched satisfactorily and that the outcomes are unknown. Some specialists said that its motivations and justifications are not based on scientific fact. In addition to that, many of those who have undergone sex reassignment surgery have expressed regret over what has been done to them. One of them, named Charles Kane before they changed him into Sam Hashimi, cried, "Make me a man again!" And how impossible is that!

 

Using the justification of a physiological factor that affects the feeling of gender identity does not change that fact at all. The existence of certain physiological or psychological factors which make these people more affected by the whisperings of Satan than others in this respect does not permit them to do anything prohibited, nor does it absolve them of responsibility, for this is a type of trial about which they must either seek treatment or bear it with full patience, just like those who have been tried with nymphomania or a strong libido.

 

Imam Ahmad has narrated that:

 

A young man came to Allah's Messenger (may Allah bless him and grant him peace), asking permission to commit zina (unlawful fornication), due to the intensity of his desire. He said, "Oh Messenger of Allah, permit zina for me." So, the people gathered around him and scolded him, telling him, "Hush! Hush!" So he [the Prophet (saws)] said, "Bring him near." He came close to him and sat down. He asked, "Would you like that for your mother?" He replied, "No, by Allah, may Allah sacrifice me for you." He said, "Nor would the people like that for their mothers." He asked, "Would you like that for your daughter?" So, he placed his hand on him and said, "Oh Allah, forgive his sins, purify his heart and guard his private parts." And thereafter, the young man no longer looked at anything [desirable women].

 

This young man was tried with desire greater than others. Some people are tried with intense greed, but that does not make stealing permissible for them. And so on.

 

On the contrary, the same magnetic resonance imaging of the brain which some use to prove the existence of physiological factors that affect gender tendencies have demonstrated that murderers differ from others in brain scans. So, would any rational person absolve them of the consequences of their actions?

 

As for alternatives and advice for people with these conditions (may Allah make them well), the people of knowledge have not neglected them; however, perhaps a convincing answer has not yet reached the questioner, so we will restate in brief points that which is apparent to us:

 

These people will not be accounted for the thoughts and obsessions to which they are subjected as long as these do not drive them to any prohibited speech or action. Allah's Messenger (may Allah bless him and grant him peace) said (in meaning), "Verily, Allah (Mighty & Majestic) has overlooked for my nation their internal dialogue as long as they do not act upon it or speak of it." [Agreed upon] This is from Allah's Justice and Perfect Mercy upon His slaves.

 

What these people should do is to keep these thoughts away so that they do not become ingrained in their personalities and then push them, in the end, to prohibited activities or to ruining their own lives. Imam Ibn ul-Qayyim has said something invaluable in this regard, so I thought to quote it in full. He (may Allah have mercy on him) said:

 

Keep ill thoughts at bay, for if you do not, they will become an idea. Then, keep bad ideas at bay, for if you do not, they will become desires. And fight them, for if you do not, they will become determination and resolve. Then, if you do not keep them at bay, they will become action, and if you do not fight this with its opposite, it will become habit, and it will be difficult for you to get away from it. Therefore, see what is the first step to addiction: it is this ill thought which roams around, but does not settle in the mind. Then a person lets himself keep coming back to it, and he makes an idea out of it, coming and going with it. Then, it goes from a thought to an idea, embedding itself in the mind and establishing itself therein. Then, his mind begins to flirt with the reasons that would lead to it and in imagining the pleasure he would get from it. Then, it blends into his heart, becoming a desire, pleasant and familiar to his soul, to which his heart inclines. Thereafter, it becomes determination and resolve to which his feelings have been stirred up, and his self is motivated to do it. In fact, perhaps his idea has occupied him completely, so that he no longer hears anything but that which will lead to it. He does not see anything but that which will bind him to it. He has no taste for anything but that which will aid him in it. Whereupon, in these moments, he needs decisive strength and a powerful deterrent; otherwise, he will succumb to action. In other words, he falls into sin. He said: "fight it with its opposite": with good works, seeking forgiveness and repentance, for if you do not, it will become habit, difficult to get away from. So, let everyone look at the sins into which he falls, and he will find that they follow a chain of events such as this. A person with astute understanding and avid true belief is the one nips it in the bud, not allowing ill thoughts or base ideas to mix with his mind, nor does he occupy his thoughts with them.

 

Whoever keeps these thoughts away and bears patiently this trial will be rewarded by Allah. Patience is a virtue known to every Muslim. These people are to be advised to busy themselves with Truth, from worship to work to their studies and permissible recreation, such as permissible sports and the like. They must have good companionship, for "a person is on the religion of his most beloved friend," and "friends pull" [you towards either good or evil]. Likewise, they must frequent the mosques, for they are the Houses of Allah, purified and raised for His remembrance.

 

They are advised to be treated medically – if recommended by a trustworthy doctor – by taking hormones which would establish their real gender.

 

The most important advice is to throw themselves in humility between the Hands of their Master (Allah), asking Him for patience and guidance, for He is the One Capable of everything, Worthy of responding. He is the Best of Protectors and the Best of Helpers.

 

And Allah Almighty is the Most High, and He knows best.