Research: The lies of Gender Identity
Gender Identity
The
concept of biological sex is well defined, based on the binary roles that males
and females play in reproduction. By contrast, the concept of gender is not
well defined. It is generally taken to refer to behaviors and psychological
attributes that tend to be typical of a given sex. Some individuals identify as
a gender that does not correspond to their biological sex. The causes of such
cross-gender identification remain poorly understood. Research investigating
whether these transgender individuals have certain physiological features or
experiences in common with the opposite sex, such as brain structures or
atypical prenatal hormone exposures, has so far been inconclusive.
Gender
dysphoria — a sense of incongruence between one’s biological sex and one’s
gender, accompanied by clinically significant distress or impairment — is
sometimes treated in adults by hormones or surgery, but there is little
scientific evidence that these therapeutic interventions have psychological
benefits. Science has shown that gender identity issues in children usually do
not persist into adolescence or adulthood, and there is little scientific
evidence for the therapeutic value of puberty-delaying treatments. We are
concerned by the increasing tendency toward encouraging children with gender
identity issues to transition to their preferred gender through medical and
then surgical procedures. There is a clear need for more research in these
areas.
As described in Part One, there
is a widely held belief that sexual orientation is a well-defined concept, and that it is innate and fixed in each
person — as it is often put, gay people are “born that way.” Another emerging
and related view is that gender identity — the subjective, internal sense of being a man or a woman (or
some other gender category) — is also fixed at birth or at a very early age and
can diverge from a person’s biological sex. In the case of children, this is
sometimes articulated by saying that a little boy may be trapped in a little
girl’s body, or vice versa.
In Part One we argued that scientific research does not give much
support to the hypothesis that sexual orientation is innate and fixed. We will
argue here, similarly, that there is little scientific evidence that gender
identity is fixed at birth or at an early age. Though biological sex is innate,
and gender identity and biological sex are related in complex ways, they are
not identical; gender is sometimes defined or expressed in ways that have
little or no biological basis.
To clarify what is meant by “gender” and “sex,” we begin with a
widely used definition, here quoted from a pamphlet published by the American
Psychological Association (APA):
Sex is assigned at birth, refers to one’s biological status as either
male or female, and is associated primarily with physical attributes such as
chromosomes, hormone prevalence, and external and internal anatomy. Gender refers to the socially
constructed roles, behaviors, activities, and attributes that a given society
considers appropriate for boys and men or girls and women. These influence the
ways that people act, interact, and feel about themselves. While aspects of
biological sex are similar across different cultures, aspects of gender may
differ.[1]
This
definition points to the obvious fact that there are social norms for men and
women, norms that vary across different cultures and that are not simply
determined by biology. But it goes further in holding that gender is wholly
“socially constructed” — that it is detached from biological sex. This idea has
been an important part of a feminist movement to reform or eliminate
traditional gender roles. In the classic feminist book The Second Sex (1949), Simone de Beauvoir
wrote that “one is not born, but becomes a woman.”[2] This notion is an early version of the now familiar distinction
between sex as a biological designation and gender as a cultural construct:
though one is born, as the APA explains, with the “chromosomes, hormone
prevalence, and external and internal anatomy” of a female, one is socially
conditioned to take on the “roles, behaviors, activities, and attributes” of a
woman.
Developments in feminist theory in the second half of the twentieth century
further solidified the position that gender is socially constructed. One of the
first to use the term “gender” as distinct from sex in the social-science
literature was Ann Oakley in her 1972 book,Sex, Gender and Society.[3] In the 1978 book Gender: An
Ethnomethodological Approach, psychology professors
Suzanne Kessler and Wendy McKenna argued that “gender is a social construction,
that a world of two ‘sexes’ is a result of the socially shared, taken for
granted methods which members use to construct reality.”[4]
Anthropologist
Gayle Rubin expresses a similar view, writing in 1975 that “Gender is a
socially imposed division of the sexes. It is a product of the social relations
of sexuality.”[5] According to her argument, if it were not for this social
imposition, we would still have males and females but not “men” and “women.”
Furthermore, Rubin argues, if traditional gender roles are socially
constructed, then they can also be deconstructed, and we can eliminate “obligatory sexualities and sex
roles” and create “an androgynous and genderless (though not sexless) society,
in which one’s sexual anatomy is irrelevant to who one is, what one does, and
with whom one makes love.”[6]
The
relationship between gender theory and the deconstruction or overthrowing of
traditional gender roles is made even clearer in the works of the influential
feminist theorist Judith Butler. In works such as Gender Trouble: Feminism and the Subversion of Identity (1990)[7] and Undoing Gender (2004)[8]Butler advances what she describes as
“performativity theory,” according to which being a woman or man is not
something that one is but something that one does. “Gender is neither the causal result of sex nor as seemingly
fixed as sex,” as she put it.[9] Rather, gender is a constructed status radically independent from
biology or bodily traits, “a free floating artifice, with the consequence that man andmasculine might just as easily
signify a female body as a male one, and woman and feminine a male body as easily as a
female one.”[10]
This
view, that gender and thus gender identity are fluid and plastic, and not
necessarily binary, has recently become more prominent in popular culture. An
example is Facebook’s move in 2014 to include 56 new ways for users to describe
their gender, in addition to the options of male and female. As Facebook
explains, the new options allow the user to “feel comfortable being your true,
authentic self,” an important part of which is “the expression of gender.”[11] Options include agender, severalcis- and trans- variants, gender fluid, gender questioning, neither, other, pangender, and two-spirit.[12]
Whether
or not Judith Butler was correct in describing traditional gender roles of men
and women as “performative,” her theory of gender as a “free-floating artifice”
does seem to describe this new taxonomy of gender. As these terms multiply and
their meanings become more individualized, we lose any common set of criteria
for defining what gender distinctions mean. If gender is entirely detached from
the binary of biological sex, gender could come to refer to any distinctions in
behavior, biological attributes, or psychological traits, and each person could
have a gender defined by the unique combination of characteristics the person
possesses. This reductio ad absurdum is offered to present the
possibility that defining gender too broadly could lead to a definition that
has little meaning.
Alternatively, gender identity could be defined in terms of
sex-typical traits and behaviors, so that being a boy means behaving in the
ways boys typically behave — such as engaging in rough-and-tumble play and
expressing an interest in sports and liking toy guns more than dolls. But this
would imply that a boy who plays with dolls, hates guns, and refrains from
sports or rough-and-tumble play might be considered to be a girl, rather than
simply a boy who represents an exception to the typical patterns of male
behavior. The ability to recognize exceptions to sex-typical behavior relies on
an understanding of maleness and femaleness that is independent of these
stereotypical sex-appropriate behaviors. The underlying basis of maleness and
femaleness is the distinction between the reproductive roles of the sexes; in
mammals such as humans, the female gestates offspring and the male impregnates
the female. More universally, the male of the species fertilizes the egg cells
provided by the female of the species. This conceptual basis for sex roles is
binary and stable, and allows us to distinguish males from females on the
grounds of their reproductive systems, even when these individuals exhibit
behaviors that are not typical of males or females.
To
illustrate how reproductive roles define the differences between the sexes even
when behavior appears to be atypical for the particular sex, consider two
examples, one from the diversity of the animal kingdom, and one from the
diversity of human behavior. First, we look at the emperor penguin. Male
emperor penguins provide more care for eggs than do females, and in this sense,
the male emperor penguin could be described as more maternal than the female.[13] However, we recognize that the male emperor penguin is not in fact
female but rather that the species represents an exception to the general, but
not universal, tendency among animals for females to provide more care than
males for offspring. We recognize this because sex-typical behaviors like
parental care do not define the sexes; the individual’s role in sexual
reproduction does.
Even
other sex-typical biological traits, such as chromosomes, are not necessarily
helpful for defining sex in a universal way, as the penguin example further
illustrates. As with other birds, the genetics of sex determination in the
emperor penguin is different than the genetics of sex determination in mammals
and many other animals. In humans, males have XY chromosomes and females have
XX chromosomes; that is, males have a unique sex-determining chromosome that
they do not share with females, while females have two copies of a chromosome
that they share with males. But in birds, it is females, not males, that have
and pass on the sex-specific chromosome.[14] Just as the observation that male emperor penguins nurture their
offspring more than their partners did not lead zoologists to conclude that the
egg-laying member of the emperor penguin species was in fact the male, the
discovery of the ZW sex-determination system in birds did not lead geneticists
to challenge the age-old recognition that hens are females and roosters are
males. The only variable that serves as the fundamental and reliable basis for
biologists to distinguish the sexes of animals is their role in reproduction,
not some other behavioral or biological trait.
Another
example that, in this case, only appears to be non-sex-typical behavior is that
of Thomas Beatie, who made headlines as a man who gave birth to three children
between 2008 and 2010.[15]Thomas Beatie was born a woman,
Tracy Lehuanani LaGondino, and underwent a surgical and legal transition to
living as a man before deciding to have children. Because the medical procedures
he underwent did not involve the removal of his ovaries or uterus, Beatie was
capable of bearing children. The state of Arizona recognizes Thomas Beatie as
the father of his three children, even though, biologically, he is their
mother. Unlike the case of the male emperor penguin’s ostensibly maternal,
“feminine” parenting behavior, Beatie’s ability to have children does not
represent an exception to the normal inability of males to bear children. The
labeling of Beatie as a man despite his being biologically female is a
personal, social, and legal decision that was made without any basis in
biology; nothing whatsoever in biology suggests Thomas Beatie is a male.
In biology, an organism is male or female if it is structured to
perform one of the respective roles in reproduction. This definition does not
require any arbitrary measurable or quantifiable physical characteristics or
behaviors; it requires understanding the reproductive system and the
reproduction process. Different animals have different reproductive systems,
but sexual reproduction occurs when the sex cells from the male and female of
the species come together to form newly fertilized embryos. It is these
reproductive roles that provide the conceptual basis for the differentiation of
animals into the biological categories of male and female. There is no other
widely accepted biological classification for the sexes.
But
this definition of the biological category of sex is not universally accepted.
For example, philosopher and legal scholar Edward Stein maintains that
infertility poses a crucial problem for defining sex in terms of reproductive
roles, writing that defining sex in terms of these roles would define
“infertile males as females.”[16] Since an infertile male cannot play the reproductive role for
which males are structured, and an infertile female cannot play the
reproductive role for which females are structured, according to this line of
thinking, defining sex in terms of reproductive roles would not be appropriate,
as infertile males would be classified as females, and infertile females as
males. Nevertheless, while a reproductive system structured to serve a
particular reproductive role may be impaired in such a way that it cannot
perform its function, the system is still recognizably structured for that
role, so that biological sex can still be defined strictly in terms of the
structure of reproductive systems. A similar point can be made about
heterosexual couples who choose not to reproduce for any of a variety of
reasons. The male and female reproductive systems are generally clearly
recognizable, regardless of whether or not they are being used for purposes of
reproduction.
The following analogy illustrates how a system can be recognized
as having a particular purpose, even when that system is dysfunctional in a way
that renders it incapable of carrying out its purpose: Eyes are complex organs
that function as processors of vision. However, there are numerous conditions
affecting the eye that can impair vision, resulting in blindness. The eyes of
the blind are still recognizably organs structured for the function of sight.
Any impairments that result in blindness do not affect the purpose of the eye —
any more than wearing a blindfold — but only its function. The same is true for
the reproductive system. Infertility can be caused by many problems. However,
the reproductive system continues to exist for the purpose of begetting
children.
There are individuals, however, who are biologically “intersex,”
meaning that their sexual anatomy is ambiguous, usually for reasons of genetic
abnormalities. For example, the clitoris and penis are derived from the same
embryonic structures. A baby may display an abnormally large clitoris or an
abnormally small penis, causing its biological sex to be difficult to determine
long after birth.
The
first academic article to use the term “gender” appears to be the 1955 paper by
the psychiatry professor John Money of Johns Hopkins on the treatment of
“intersex” children (the term then used was “hermaphrodites”).[17] Money posited that gender identity, at least for these children,
was fluid and that it could be constructed. In his mind, making a child
identify with a gender only required constructing sex-typical genitalia and
creating a gender-appropriate environment for the child. The chosen gender for
these children was often female — a decision that was not based on genetics or
biology, nor on the belief that these children were “really” girls, but, in
part, on the fact that at the time it was easier surgically to construct a
vagina then it was to construct a penis.
The
most widely known patient of Dr. Money was David Reimer, a boy who was not born
with an intersex condition but whose penis was damaged during circumcision as
an infant.[18] David was raised by his parents as a girl named Brenda, and
provided with both surgical and hormonal interventions to ensure that he would
develop female-typical sex characteristics. However, the attempt to conceal
from the child what had happened to him was not successful — he self-identified
as a boy, and eventually, at the age of 14, his psychiatrist recommended to his
parents that they tell him the truth. David then began the difficult process of
reversing the hormonal and surgical interventions that had been performed to
feminize his body. But he continued to be tormented by his childhood ordeal,
and took his own life in 2004, at the age of 38.
David
Reimer is just one example of the harm wrought by theories that gender identity
can socially and medically be reassigned in children. In a 2004 paper, William
G. Reiner, a pediatric urologist and child and adolescent psychiatrist, and
John P. Gearhart, a professor of pediatric urology, followed up on the sexual
identities of 16 genetic males affected by cloacal exstrophy — a condition
involving a badly deformed bladder and genitals. Of the 16 subjects, 14 were
assigned female sex at birth, receiving surgical interventions to construct
female genitalia, and were raised as girls by their parents; 6 of these 14
later chose to identify as males, while 5 continued to identify as females and
2 declared themselves males at a young age but continued to be raised as
females because their parents rejected the children’s declarations. The
remaining subject, who had been told at age 12 that he was born male, refused
to discuss sexual identity.[19] So the assignment of female sex persisted in only 5 of the 13
cases with known results.
This lack of persistence is some evidence that the assignment of
sex through genital construction at birth with immersion into a
“gender-appropriate” environment is not likely to be a successful option for
managing the rare problem of genital ambiguity from birth defects. It is
important to note that the ages of these individuals at last follow-up ranged
from 9 to 19, so it is possible that some of them may have subsequently changed
their gender identities.
Reiner and Gearhart’s research indicates that gender is not
arbitrary; it suggests that a biological male (or female) will probably not
come to identify as the opposite gender after having been altered physically
and immersed into the corresponding gender-typical environment. The plasticity
of gender appears to have a limit.
What is clear is that biological sex is not a concept that can be
reduced to, or artificially assigned on the basis of, the type of external
genitalia alone. Surgeons are becoming more capable of constructing artificial
genitalia, but these “add-ons” do not change the biological sex of the
recipients, who are no more capable of playing the reproductive roles of the
opposite biological sex than they were without the surgery. Nor does biological
sex change as a function of the environment provided for the child. No degree
of supporting a little boy in converting to be considered, by himself and
others, to be a little girl makes him biologically a little girl. The
scientific definition of biological sex is, for almost all human beings, clear,
binary, and stable, reflecting an underlying biological reality that is not
contradicted by exceptions to sex-typical behavior, and cannot be altered by
surgery or social conditioning.
In a 2004 article summarizing the results of research related to
intersex conditions, Paul McHugh, the former chief of psychiatry at Johns
Hopkins Hospital (and the coauthor of this report), suggested:
We in the Johns Hopkins Psychiatry Department eventually concluded
that human sexual identity is mostly built into our constitution by the genes
we inherit and the embryogenesis we undergo. Male hormones sexualize the brain
and the mind. Sexual dysphoria — a sense of disquiet in one’s sexual role —
naturally occurs amongst those rare males who are raised as females in an
effort to correct an infantile genital structural problem.[20]
We
now turn our attention to transgender individuals — children and adults — who
choose to identify as a gender different from their biological sex, and explore
the meaning of gender identity in this context and what the scientific
literature tells us about its development.
While biological sex is, with very few exceptions, a well-defined,
binary trait (male versus female) corresponding to how the body is organized
for reproduction, gender identity is a more subjective
attribute. For most people, their own gender identity is probably not a
significant concern; most biological males identify as boys or men, and most
biological females identify as girls or women. But some individuals experience
an incongruence between their biological sex and their gender identity. If this
struggle causes them to seek professional help, then the problem is classified
as “gender dysphoria.”
Some male children raised as females, as described in Reiner and
colleagues’ 2004 study, came to experience problems with their gender identity
when their subjective sense of being boys conflicted with being identified and
treated as girls by their parents and doctors. The biological sex of the boys
was not in question (they had an XY genotype), and the cause of gender
dysphoria lay in the fact that they were genetically male, came to identify as
male, but had been assigned female gender identities. This suggests that gender
identity can be a complex and burdensome issue for those who choose (or have
others choose for them) a gender identity opposite their biological sex.
But
the cases of gender dysphoria that are the subject of much public debate are
those in which individuals come to identify as genders different from those
based on their biological sex. These people are usually identified, and
describe themselves, as “transgender.”[*]
According
to the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender dysphoria is marked by “incongruence
between one’s experienced/expressed gender and assigned gender,” as well as
“clinically significant distress or impairment in social, occupational, or
other important areas of functioning.”[21]
It
is important to clarify that gender dysphoria is not the same as gender
nonconformity or gender identity disorder. Gender nonconformity describes an
individual who behaves in a manner contrary to the gender-specific norms of his
or her biological sex. As the DSM-5 notes, most transvestites, for instance, are not transgender — men
who dress as women typically do not identify themselves as women.[22] (However, certain forms of transvestitism can be associated with
late-onset gender dysphoria.[23])
Gender
identity disorder, an obsolete term from an earlier version of the DSM that was removed in its fifth edition, was used as a psychiatric
diagnosis. If we compare the diagnostic criteria for gender dysphoria (the
current term) and gender identity disorder (the former term), we see that both
require the patient to display “a marked incongruence between one’s
experienced/expressed gender and assigned gender.”[24] The key difference is that a diagnosis of gender dysphoria
requires the patient additionally to experience a “clinically significant
distress or impairment in social, occupational, or other important areas of
functioning” associated with these incongruent feelings.[25] Thus the major set of diagnostic criteria used in contemporary
psychiatry does not designate all transgender individuals as having a
psychiatric disorder. For example, a biological male who identifies himself as
a female is not considered to have a psychiatric disorder unless the individual
is experiencing significant psychosocial distress at the incongruence. A
diagnosis of gender dysphoria may be part of the criteria used to justify
sex-reassignment surgery or other clinical interventions. Furthermore, a
patient who has had medical or surgical modifications to express his or her
gender identity may still suffer from gender dysphoria. It is the nature of the
struggle that defines the disorder, not the fact that the expressed gender
differs from the biological sex.
There is no scientific evidence that all transgender people have
gender dysphoria, or that they are all struggling with their gender identities.
Some individuals who are not transgender — that is, who do not identify as a
gender that does not correspond with their biological sex — might nonetheless
struggle with their gender identity; for example, girls who behave in some
male-typical ways might experience various forms of distress without ever
coming to identify as boys. Conversely, individuals who do identify as a gender
that does not correspond with their biological sex may not experience
clinically significant distress related to their gender identity. Even if only,
say, 40% of individuals who identify as a gender that does not correspond with
their biological sex experience significant distress related to their gender
identity, this would constitute a public health issue requiring clinicians and
others to act to support those with gender dysphoria, and hopefully, to reduce
the rate of gender dysphoria in the population. There is no evidence to suggest
that the other 60% in this hypothetical — that is, the individuals who identify
as a gender that does not correspond with their biological sex but who do not
experience significant distress — would require clinical treatment.
The DSM’s concept of subjectively
“experiencing” one’s gender as incongruent from one’s biological sex may
require more critical scrutiny and possibly modification. The exact definition
of gender dysphoria, however well-intentioned, is somewhat vague and confusing.
It does not account for individuals who self-identify as transgender but do not
experience dysphoria associated with their gender identity and who seek
psychiatric care for functional impairment for problems unrelated to their
gender identity, such as anxiety or depression. They may then be mislabeled as
having gender dysphoria simply because they have a desire to be identified as a
member of the opposite gender, when they have come to a satisfactory
resolution, subjectively, with this incongruence and may be depressed for
reasons having nothing to do with their gender identity.
The DSM-5 criteria for a diagnosis
of gender dysphoria in children are defined in a “more concrete, behavioral
manner than those for adolescents and adults.”[26] This is to say that some of the diagnostic criteria for gender
dysphoria in children refer to behaviors that are stereotypically associated
with the opposite gender. Clinically significant distress is still necessary
for a diagnosis of gender dysphoria in children, but some of the other
diagnostic criteria include, for instance, a “strong preference for the toys,
games, or activities stereotypically used or engaged in by the other gender.”[27] What of girls who are “tomboys” or boys who are not oriented
toward violence and guns, who prefer quieter play? Should parents worry that
their tomboy daughter is really a boy stuck in a girl’s body? There is no
scientific basis for believing that playing with toys typical of boys defines a
child as a boy, or that playing with toys typical of girls defines a child as a
girl. The DSM-5 criterion for diagnosing
gender dysphoria by reference to gender-typical toys is unsound; it appears to
ignore the fact that a child could display an expressed gender — manifested by
social or behavioral traits — incongruent with the child’s biological sex but
without identifying as the opposite gender.
Furthermore, even for children who do identify as a gender opposite their
biological sex, diagnoses of gender dysphoria are simply unreliable. The
reality is that they may have psychological difficulties in accepting their
biological sex as their gender. Children can have difficulty with the
expectations associated with those gender roles. Traumatic experiences can also
cause a child to express distress with the gender associated with his or her
biological sex.
Gender
identity problems can also arise with intersex conditions (the presence of
ambiguous genitalia due to genetic abnormalities), which we discussed earlier.
These disorders of sex development, while rare, can contribute to gender
dysphoria in some cases.[28] Some of these conditions include complete androgen insensitivity
syndrome, where individuals with XY (male) chromosomes lack receptors for male
sex hormones, leading them to develop the secondary sex characteristics of
females, rather than males (though they lack ovaries, do not menstruate, and
are consequently sterile).[29] Another hormonal disorder of sex development that can lead to individuals
developing in ways that are not typical of their genetic sex include congenital
adrenal hyperplasia, a condition that can masculinize XX (female) fetuses.[30] Other rare phenomena such as genetic mosaicism[31] or chimerism,[32] where some cells in the individual’s bodies contain XX chromosomes
and others contain XY chromosomes, can lead to considerable ambiguity in sex
characteristics, including individuals who possess both male and female gonads
and sex organs.
While
there are many cases of gender dysphoria that are not associated with these
identifiable intersex conditions, gender dysphoria may still represent a
different type of intersex condition in which the primary sex characteristics
such as genitalia develop normally while secondary sex characteristics
associated with the brain develop along the lines of the opposite sex.
Controversy exists over influences determining the nature of neurological,
psychological, and behavioral sex differences. The emerging consensus is that
there may be some differences in patterns of neurological development in- and
ex-utero for men and women.[33] Therefore, in theory, transgender individuals could be subject to
conditions allowing a more female-type brain to develop within a genetic male
(having the XY chromosomal patterns), and vice versa. However, as we will show
in the next section, the research supporting this idea is quite minimal.
As a way of surveying the biological and social science research
on gender dysphoria, we can list some of the important questions. Are there
biological factors that influence the development of a gender identity that
does not correspond with one’s biological sex? Are some individuals born with a
gender identity different from their biological sex? Is gender identity shaped
by environmental or nurturing conditions? How stable are choices of gender
identity? How common is gender dysphoria? Is it persistent across the lifespan?
Can a little boy who thinks he is a little girl change over the course of his
life to regard himself as male? If so, how often can such people change their
gender identities? How would someone’s gender identity be measured
scientifically? Does self-understanding suffice? Does a biological girl become
a gender boy by believing, or at least stating, she is a little boy? Do
people’s struggles with a sense of incongruity between their gender identity
and biological sex persist over the life course? Does gender dysphoria respond
to psychiatric interventions? Should those interventions focus on affirming the
gender identity of the patient or take a more neutral stance? Do efforts to
hormonally or surgically modify an individual’s primary or secondary sex
characteristics help resolve gender dysphoria? Does modification create further
psychiatric problems for some of those diagnosed with gender dysphoria, or does
it typically resolve existing psychiatric problems? We broach a few of these
critical questions in the following sections.
Robert Sapolsky, a Stanford professor of biology who has done
extensive neuroimaging research, suggested a possible neurobiological
explanation for cross-gender identification in a 2013 Wall Street Journal article, “Caught Between
Male and Female.” He asserted that recent neuroimaging studies of the brains of
transgender adults suggest that they may have brain structures more similar to
their gender identity than to their biological sex.[34] Sapolsky bases this assertion on the fact that there are
differences between male and female brains, and while the differences are
“small and variable,” they “probably contribute to the sex differences in
learning, emotion and socialization.”[35] He concludes: “The issue isn’t that sometimes people believe they
are of a different gender than they actually are. Remarkably, instead, it’s
that sometimes people are born with bodies whose gender is different from what
they actually are.”[36] In other words, he claims that some people can have a female-type
brain in a male body, or vice versa.
While
this kind of neurobiological theory of cross-gender identification remains
outside of the scientific mainstream, it has recently received scientific and
popular attention. It provides a potentially attractive explanation for
cross-gender identification, especially for individuals who are not affected by
any known genetic, hormonal, or psychosocial abnormalities.[37] However, while Sapolsky may be right, there is fairly little
support in the scientific literature for his contention. His neurological
explanation for differences between male and female brains and those
differences’ possible relevance to cross-gender identification warrant further
scientific consideration.
There are many small studies that attempt to define causal factors
of the experience of incongruence between one’s biological sex and felt gender.
These studies are described in the following pages, each pointing to an
influence that may contribute to the explanation for cross-gender
identification.
Nancy
Segal, a psychologist and geneticist, researched two case studies of identical
twins discordant for female-to-male (FtM) transsexualism.[38] Segal notes that, according to another, earlier study that
conducted nonclinical interviews with 45 FtM transsexuals, 60% suffered some
form of childhood abuse, with 31% experiencing sexual abuse, 29% experiencing
emotional abuse, and 38% physical abuse.[39]However, this earlier study did not
include a control group and was limited by its small sample size, making it
difficult to extract significant interactions, or generalizations, from the
data.
Segal’s
own first case study was of a 34-year-old FtM twin, whose identical twin sister
was married and the mother of seven children.[40] Several stressful events had occurred during the twins’ mother’s
pregnancy, and they were born five weeks prematurely. When they were eight
years old, their parents divorced. The FtM twin exhibited gender-nonconforming
behavior early and it persisted throughout childhood. She became attracted to
other girls in junior high school and as a teenager attempted suicide several
times. She reported physical abuse and emotional abuse at the hand of her mother.
The twins were raised in a Mormon household, in which transsexuality was not
tolerated.[41] The twin sister had never questioned her gender identity but did
experience some depression. For Segal, the FtM twin’s gender nonconformity and
abuse in childhood were factors that contributed to gender dysphoria; the other
twin was not subject to the same stressors in childhood, and did not develop
issues around her gender identity. Segal’s second case study also concerned
identical twins with one twin transitioning from female to male.[42] This FtM twin had early-onset nonconforming behaviors and
attempted suicide as a young adult. At age 29 she underwent reassignment
surgery, was well supported by family, met a woman, and married. As in the
first case, the other twin was reportedly always secure in her female gender
identity.
Segal
speculates that each set of twins may have had uneven prenatal androgen
exposures (though her study did not offer evidence to support this)[43] and concludes that “Transsexualism is unlikely to be associated
with a major gene, but is likely to be associated with multiple genetic,
epigenetic, developmental and experiential influences.”[44] Segal is critical of the notion that the maternal abuse
experienced by the FtM twin in her first case study may have played a causal
role in the twin’s “atypical gender identification” since the abuse “apparently followed” the twin’s
gender-atypical behaviors — though Segal acknowledges “it is possible that this
abuse reinforced his already atypical gender identification.”[45] These case studies, while informative, are not scientifically
strong, and do not provide direct evidence for any causal hypotheses about the
origins of atypical gender identification.
A
source of more information — but also inadequate to make direct causal
inferences — is a case analysis by Mayo Clinic psychiatrists J. Michael
Bostwick and Kari A. Martin of an intersex individual born with ambiguous
genitalia who was operated on and raised as a female.[46] By way of offering some background, the authors draw a distinction
between gender identity disorder (an “inconsistency between perceived gender
identity and phenotypic sex” that generally involves “no discernible
neuroendocrinological abnormality”[47]), and intersexuality (a condition
in which biological features of both sexes are present). They also provide a
summary and classification scheme of the various types of intersex disorders.
After a thorough discussion of the various intersex developmental issues that
can lead to a disjunction between the brain and body, the authors acknowledge
that “Some adult patients with severe dysphoria — transsexuals — have neither
history nor objective findings supporting a known biological cause of
brain-body disjunction.”[48] These patients require thorough medical and psychiatric attention
to avoid gender dysphoria.
After
this helpful summary, the authors state that “Absent psychosis or severe
character pathology, patients’ subjective assertions are presently the most
reliable standards for delineating core gender identity.”[49] But it is not clear how we could consider subjective assertions
more reliable in establishing gender identity, unless gender identity is
defined as a completely subjective phenomenon. The bulk of the article is
devoted to describing the various objectively discernible and identifiable ways
in which one’s identity as a male or female is imprinted on the nervous and
endocrine system. Even when something goes wrong with the development of external
genitalia, individuals are more likely to act in accordance with their
chromosomal and hormonal makeup.[50]
In
2011, Giuseppina Rametti and colleagues from various research centers in Spain
used MRI to study the brain structures of 18 FtM transsexuals who exhibited
gender nonconformity early in life and experienced sexual attraction to females
prior to hormone treatment.[51] The goal was to learn whether their brain features corresponded
more to their biological sex or to their sense of gender identity. The control
group consisted of 24 male and 19 female heterosexuals with gender identities
conforming to their biological sex. Differences were noted in the white matter
microstructure of specific brain areas. In untreated FtM transsexuals, that
structure was more similar to that of heterosexual males than to that of
heterosexual females in three of four brain areas.[52] In a complementary study, Rametti and colleagues compared 18 MtF
transsexuals to 19 female and 19 male heterosexual controls.[53] These MtF transsexuals had white matter tract averages in several
brain areas that fell between the averages of the control males and the control
females. The values, however, were typically closer to the males (that is, to
those that shared their biological sex) than to the females in most areas.[54] In controls the authors found that, as expected, the males had
greater amounts of gray and white matter and higher volumes of cerebrospinal
fluid than control females. The MtF transsexual brain volumes were all similar
to those of male controls and significantly different from those of females.[55]
Overall, the findings of these studies by Rametti and colleagues
do not sufficiently support the notion that transgender individuals have brains
more similar to their preferred gender than to the gender corresponding with
their biological sex. Both studies are limited by small sample sizes and lack
of a prospective hypothesis — both analyzed the MRI data to find the gender
differences and then looked to see where the data from transgender subjects
fit.
Whereas
both of these MRI studies looked at brain structure, a functional MRI study
by Emiliano Santarnecchi and colleagues from the University of Siena and the
University of Florence looked at brainfunction, examining gender-related
differences in spontaneous brain activity during the resting state.[56] The researchers compared a single FtM individual (declared
cross-gender since childhood), and control groups of 25 males and 25 females,
with regard to spontaneous brain activity. The FtM individual demonstrated a
“brain activity profile more close to his biological sex than to his desired
one,” and based in part on this result the authors concluded that “untreated
FtM transsexuals show a functional connectivity profile comparable to female
control subjects.”[57] With a sample size of one, this study’s statistical power is
virtually zero.
In
2013, Hsaio-Lun Ku and colleagues from various medical centers and research
institutes in Taiwan also conducted functional brain imaging studies. They
compared the brain activity of 41 transsexuals (21 FtMs, 20 MtFs) and 38
matched heterosexual controls (19 males and 19 females).[58] Arousal response of each cohort while viewing neutral as compared
to erotic films was compared between groups. All of the transsexuals in the
study reported sexual attractions to members of their natal, biological sex,
and exhibited more sexual arousal than heterosexual controls when viewing
erotic films that depicted sexual activity between subjects sharing their
biological sex. A “selfness” score was also incorporated into the study, in
which the researchers asked participants to “rate the degree to which you
identify yourself as the male or female in the film.”[59] The transsexuals in the study identified with those of their
preferred gender more than the controls identified with those of their
biological gender, in both erotic films and neutral films. The heterosexual
controls did not identify themselves with either males or females in either of
the film types. Ku and colleagues claim to have demonstrated characteristic
brain patterns for sexual attraction as related to biological sex but did not
make meaningful neurobiological gender-identity comparisons among the three
cohorts. In addition, they reported findings that transsexuals demonstrated
psychosocial maladaptive defensive styles.
A
2008 study by Hans Berglund and colleagues from Sweden’s Karolinska
Institute and Stockholm Brain Institute used PET and fMRI scans to compare
brain-area activation patterns in 12 MtF transgendered individuals who were
sexually attracted to women with those of 12 heterosexual women and 12
heterosexual men.[60] The first set of subjects took no hormones and had not undergone
sex-reassignment surgery. The experiment involved smelling odorous steroids
thought to be female pheromones, and other sexually neutral odors such as
lavender oil, cedar oil, eugenol, butanol, and odorless air. The results were
varied and mixed between the groups for the various odors, which should not be
surprising, since post hoc analyses usually lead to
contradictory findings.
In summary, the studies presented above show inconclusive evidence
and mixed findings regarding the brains of transgender adults. Brain-activation
patterns in these studies do not offer sufficient evidence for drawing sound
conclusions about possible associations between brain activation and sexual
identity or arousal. The results are conflicting and confusing. Since the data
by Ku and colleagues on brain-activation patterns are not universally
associated with a particular sex, it remains unclear whether and to what extent
neurobiological findings say anything meaningful about gender identity. It is
important to note that regardless of their findings, studies of this kind
cannot support any conclusion that individuals come to identify as a gender
that does not correspond to their biological sex because of an innate,
biological condition of the brain.
The question is not simply whether there are differences between
the brains of transgender individuals and people identifying with the gender
corresponding to their biological sex, but whether gender identity is a fixed,
innate, and biological trait, even when it does not correspond to biological
sex, or whether environmental or psychological causes contribute to the
development of a sense of gender identity in such cases. Neurological
differences in transgender adults might be the consequence of biological
factors such as genes or prenatal hormone exposure, or of psychological and
environmental factors such as childhood abuse, or they could result from some
combination of the two. There are no serial, longitudinal, or prospective
studies looking at the brains of cross-gender identifying children who develop
to later identify as transgender adults. Lack of this research severely limits
our ability to understand causal relationships between brain morphology, or
functional activity, and the later development of gender identity different
from biological sex.
More
generally, it is now widely recognized among psychiatrists and neuroscientists
who engage in brain imaging research that there are inherent and ineradicable
methodological limitations of anyneuroimaging study that simply associates a particular trait, such
as a certain behavior, with a particular brain morphology.[61] (And when the trait in question is not a concrete behavior but
something as elusive and vague as “gender identity,” these methodological
problems are even more serious.) These studies cannot provide statistical
evidence nor show a plausible biological mechanism strong enough to support causal connections between a brain feature
and the trait, behavior, or symptom in question. To support a conclusion of
causality, even epidemiological causality, we need to conduct prospective
longitudinal panel studies of a fixed set of individuals across the course of
sexual development if not their lifespan.
Studies
like these would use serial brain images at birth, in childhood, and at other
points along the developmental continuum, to see whether brain morphology
findings were there from the beginning. Otherwise, we cannot establish whether
certain brain features caused a trait, or whether the trait is innate and
perhaps fixed. Studies like those discussed above of individuals who already
exhibit the trait are incapable of distinguishing between causes and consequences of the trait. In most
cases transgender individuals have been acting and thinking for years in ways
that, through learned behavior and associated neuroplasticity, may have
produced brain changes that could differentiate them from other members of
their biological or natal sex. The only definitive way to establish
epidemiological causality between a brain feature and a trait (especially one
as complex as gender identity) is to conduct prospective, longitudinal,
preferably randomly sampled and population-based studies.
In
the absence of such prospective longitudinal studies, large representative
population-based samples with adequate statistical controls for confounding
factors may help narrow the possible causes of a
behavioral trait and thereby increase the probability of identifying a
neurological cause.[62]However, because the studies
conducted thus far use small convenience samples, none of them is especially
helpful for narrowing down the options for causality. To obtain a better study
sample, we would need to include neuroimaging in large-scale epidemiological
studies. In fact, given the small number of transgender individuals in the
general population,[63] the studies would need to be prohibitively large to attain
findings that would reach statistical significance.
Moreover,
if a study found significant differences between these groups — that is, a
number of differences higher than what would be expected by chance alone —
these differences would refer to the average in a population of each group.
Even if these two groups differed significantly for
all 100 measurements, it would not necessarily indicate a biological difference
among individuals at the extremes of the
distribution. Thus, a randomly selected transgender individual and a randomly
selected non-transgender individual might not differ on any of these 100
measurements. Additionally, since the probability that a randomly selected
person from the general population will be transgender is quite small,
statistically significant differences in the sample means are not sufficient
evidence to conclude that a particular measurement is predictive of whether the
person is transgender or not. If we measured the brain of an infant, toddler,
or adolescent and found this individual to be closer to one cohort than another
on these measures, it would not imply that this individual would grow up to
identify as a member of that cohort. It may be helpful to keep this caveat in
mind when interpreting research on transgender individuals.
In this context, it is important to note that there are no studies
that demonstrate that any of the biological differences being examined have
predictive power, and so all interpretations, usually in popular outlets, claiming
or suggesting that a statistically significant difference between the brains of
people who are transgender and those who are not is the cause of being
transgendered or not — that is to say, that the biological differences
determine the differences in gender identity — are unwarranted.
In short, the current studies on associations between brain
structure and transgender identity are small, methodologically limited,
inconclusive, and sometimes contradictory. Even if they were more
methodologically reliable, they would be insufficient to demonstrate that brain
structure is a cause, rather than an effect, of the gender-identity behavior.
They would likewise lack predictive power, the real challenge for any theory in
science.
For a simple example to illustrate this point, suppose we had a
room with 100 people in it. Two of them are transgender and all others are not.
I pick someone at random and ask you to guess the person’s gender identity. If
you know that 98 out of 100 of the individuals are not transgender, the safest
bet would be to guess that the individual is not transgender, since that answer
will be correct 98% of the time. Suppose, then, that you have the opportunity
to ask questions about the neurobiology and about the natal sex of the person.
Knowing the biology only helps in predicting whether the individual is
transgender if it can improve on the original guess that the person is not
transgender. So if knowing a characteristic of the individual’s brain does not
improve the ability to predict what group the patient belongs to, then the fact
that the two groups differ at the mean is almost irrelevant. Improving on the
original prediction is very difficult for a rare trait such as being
transgender, because the probability of that prediction being correct is
already very high. If there really were a clear difference between the brains
of transgender and non-transgender individuals, akin to the biological
differences between the sexes, then improving on the original guess would be
relatively easy. Unlike the differences between the sexes, however, there are
no biological features that can reliably identify transgender individuals as
different from others.
The consensus of scientific evidence overwhelmingly supports the
proposition that a physically and developmentally normal boy or girl is indeed
what he or she appears to be at birth. The available evidence from brain
imaging and genetics does not demonstrate that the development of gender
identity as different from biological sex is innate. Because scientists have
not established a solid framework for understanding the causes of cross-gender
identification, ongoing research should be open to psychological and social
causes, as well as biological ones.
In 2012, the Washington Post featured a story by Petula Dvorak, “Transgender at five,”[64] about a girl who at the age of 2 years began insisting that she
was a boy. The story recounts her mother’s interpretation of this behavior:
“Her little girl’s brain was different. Jean [her mother] could tell. She had
heard about transgender people, those who are one gender physically but the
other gender mentally.” The story recounts this mother’s distressed experiences
as she began researching gender identity problems in children and came to
understand other parents’ experiences:
Many talked about their painful decision to allow their children
to publicly transition to the opposite gender — a much tougher process for boys
who wanted to be girls. Some of what Jean heard was reassuring: Parents who
took the plunge said their children’s behavior problems largely disappeared,
schoolwork improved, happy kid smiles returned. But some of what she heard was
scary: children taking puberty blockers in elementary school and teens
embarking on hormone therapy before they’d even finished high school.[65]
The story goes on to describe how the sister, Moyin, of the
transgender child Tyler (formerly Kathryn) made sense of her sibling’s
identity:
Tyler’s sister, who’s 8, was much more casual about describing her
transgender sibling. “It’s just a boy mind in a girl body,” Moyin explained
matter-of-factly to her second-grade classmates at her private school, which
will allow Tyler to start kindergarten as a boy, with no mention of Kathryn.[66]
The remarks from the child’s sister encapsulate the popular notion
regarding gender identity: transgender individuals, or children who meet the
diagnostic criteria for gender dysphoria, are simply “a boy mind in a girl
body,” or vice versa. This view implies that gender identity is a persistent
and innate feature of human psychology, and it has inspired a gender-affirming
approach to children who experience gender identity issues at an early age.
As
we have seen above in the overview of the neurobiological and genetic research
on the origins of gender identity, there is little evidence that the phenomenon
of transgender identity has a biological basis. There is also little evidence
that gender identity issues have a high rate of persistence in children. According
to the DSM-5, “In natal [biological]
males, persistence [of gender dysphoria] has ranged from 2.2% to 30%. In natal
females, persistence has ranged from 12% to 50%.”[67] Scientific data on persistence of gender dysphoria remains sparse
due to the very low prevalence of the disorder in the general population, but
the wide range of findings in the literature suggests that there is still much
that we do not know about why gender dysphoria persists or desists in children.
As the DSM-5entry goes on to note, “It
is unclear if children ‘encouraged’ or supported to live socially in the
desired gender will show higher rates of persistence, since such children have
not yet been followed longitudinally in a systematic manner.”[68] There is a clear need for more research in these areas, and for
parents and therapists to acknowledge the great uncertainty regarding how to
interpret the behavior of these children.
With the uncertainty surrounding the diagnosis of and prognosis for
gender dysphoria in children, therapeutic decisions are particularly complex
and difficult. Therapeutic interventions for children must take into account
the probability that the children may outgrow cross-gender identification.
University of Toronto researcher and therapist Kenneth Zucker believes that
family and peer dynamics can play a significant role in the development and
persistence of gender-nonconforming behavior, writing that
it is important to consider both predisposing and perpetuating
factors that might inform a clinical formulation and the development of a
therapeutic plan: the role of temperament, parental reinforcement of
cross-gender behavior during the sensitive period of gender identity formation,
family dynamics, parental psychopathology, peer relationships and the multiple
meanings that might underlie the child’s fantasy of becoming a member of the
opposite sex.[69]
Zucker
worked for years with children experiencing feelings of gender incongruence,
offering psychosocial treatments to help them embrace the gender corresponding
with their biological sex — for instance, talk therapy, parent-arranged play
dates with same-sex peers, therapy for co-occurring psychopathological issues
such as autism spectrum disorder, and parent counseling.[70]
In
a follow-up study by Zucker and colleagues of children treated by them over the
course of thirty years at the Center for Mental Health and Addiction in
Toronto, they found that gender identity disorder persisted in only 3 of the 25
girls they had treated.[71] (Zucker’s clinic was closed by the Canadian government in 2015.[72])
An
alternative to Zucker’s approach that emphasizes affirming the child’s
preferred gender identity has become more common among therapists.[73] This approach involves helping the children to self-identify even
more with the gender label they prefer at the time. One component of the
gender-affirming approach has been the use of hormone treatments for
adolescents in order to delay the onset of sex-typical characteristics during
puberty and alleviate the feelings of dysphoria the adolescents will experience
as their bodies develop sex-typical characteristics that are at odds with the
gender with which they identify. There is relatively little evidence for the
therapeutic value of these kinds of puberty-delaying treatments, but they are
currently the subject of a large clinical study sponsored by the National
Institutes of Health.[74]
While
epidemiological data on the outcomes of medically delayed puberty is quite
limited, referrals for sex-reassignment hormones and surgical procedures appear
to be on the rise, and there is a push among many advocates to proceed with sex
reassignment at younger ages. According to a 2013 article in The Times of London, the United
Kingdom saw a 50% increase in the number of children referred to gender
dysphoria clinics from 2011 to 2012, and a nearly 50% increase in referrals
among adults from 2010 to 2012.[75] Whether this increase can be attributed to rising rates of gender
confusion, rising sensitivity to gender issues, growing acceptance of therapy
as an option, or other factors, the increase itself is concerning, and merits
further scientific inquiry into the family dynamics and other potential
problems, such as social rejection or developmental issues, that may be taken
as signs of childhood gender dysphoria.
A
study of psychological outcomes following puberty suppression and
sex-reassignment surgery, published in the journal Pediatrics in 2014 by child and
adolescent psychiatrist Annelou L.C. de Vries and colleagues, suggested
improved outcomes for individuals after receiving these interventions, with
well-being improving to a level similar to that of young adults from the
general population.[76] This study looked at 55 transgender adolescents and young adults
(22 MtF and 33 FtM) from a Dutch clinic who were assessed three times: before
the start of puberty suppression (mean age: 13.6 years), when cross-sex
hormones were introduced (mean age: 16.7 years), and at least one year after
sex-reassignment surgery (mean age: 20.7 years). The study did not provide a
matched group for comparison — that is, a group of transgender adolescents who
did not receive puberty-blocking hormones, cross-sex hormones, and/or
sex-reassignment surgery — which makes comparisons of outcomes more difficult.
In the study cohort, gender dysphoria improved over time, body
image improved on some measures, and overall functioning improved modestly. Due
to the lack of a matched control group it is unclear whether these changes are
attributable to the procedures or would have occurred in this cohort without
the medical and surgical interventions. Measures of anxiety, depression, and
anger showed some improvements over time, but these findings did not reach
statistical significance. While this study suggested some improvements over
time in this cohort, particularly the reported subjective satisfaction with the
procedures, detecting significant differences would require the study to be
replicated with a matched control group and a larger sample size. The
interventions also included care from a multidisciplinary team of medical
professionals, which could have had a beneficial effect. Future studies of this
kind would ideally include long-term follow-ups that assess outcomes and functioning
beyond the late teens or early twenties.
The potential that patients undergoing medical and surgical sex
reassignment may want to return to a gender identity consistent with their
biological sex suggests that reassignment carries considerable psychological
and physical risk, especially when performed in childhood, but also in
adulthood. It suggests that the patients’ pre-treatment beliefs about an ideal
post-treatment life may sometimes go unrealized.
In
2004, Birmingham University’s Aggressive Research Intelligence Facility (Arif)
assessed the findings of more than one hundred follow-up studies of
post-operative transsexuals.[77] An article in The Guardiansummarized the findings:
Arif ... concludes that none of the studies provides conclusive
evidence that gender reassignment is beneficial for patients. It found that
most research was poorly designed, which skewed the results in favour of
physically changing sex. There was no evaluation of whether other treatments,
such as long-term counselling, might help transsexuals, or whether their gender
confusion might lessen over time. Arif says the findings of the few studies
that have tracked significant numbers of patients over several years were
flawed because the researchers lost track of at least half of the participants.
The potential complications of hormones and genital surgery, which include deep
vein thrombosis and incontinence respectively, have not been thoroughly
investigated, either. “There is huge uncertainty over whether changing
someone’s sex is a good or a bad thing,” says Dr Chris Hyde, director of Arif.
“While no doubt great care is taken to ensure that appropriate patients undergo
gender reassignment, there’s still a large number of people who have the
surgery but remain traumatized — often to the point of committing suicide.”[78]
The high level of uncertainty regarding various outcomes after
sex-reassignment surgery makes it difficult to find clear answers about the
effects on patients of reassignment surgery. Since 2004, there have been other
studies on the efficacy of sex-reassignment surgery, using larger sample sizes
and better methodologies. We will now examine some of the more informative and
reliable studies on outcomes for individuals receiving sex-reassignment
surgery.
As
far back as 1979, Jon K. Meyer and Donna J. Reter published a longitudinal follow-up
study on the overall well-being of adults who underwent sex-reassignment
surgery.[79] The study compared the outcomes of 15 people who received surgery
with those of 35 people who requested but did not receive surgery (14 of these
individuals eventually received surgery later, resulting in three cohorts of
comparison: operated, not-operated, and operated later). Well-being was quantified
using a scoring system that assessed psychiatric, economic, legal, and
relationship outcome variables. Scores were determined by the researchers after
performing interviews with the subjects. Average follow-up time was
approximately five years for subjects who had sex change surgery, and about two
years for those subjects who did not.
Compared
to their condition before surgery, the individuals who had undergone surgery
appeared to show some improvement in well-being, though the results had a
fairly low level of statistical significance. Individuals who had no surgical
intervention did display a statistically significant improvement at follow-up.
However, there was no statistically significant difference between the two
groups’ scores of well-being at follow-up. The authors concluded that “sex
reassignment surgery confers no objective advantage in terms of social
rehabilitation, although it remains subjectively satisfying to those who have
rigorously pursued a trial period and who have undergone it.”[80] This study led the psychiatry department at Johns Hopkins Medical
Center (JHMC) to discontinue surgical interventions for sex changes for adults.[81]
However,
the study has important limitations. Selection bias was introduced in the study
population, because the subjects were drawn from those individuals who sought
sex-reassignment surgery at JHMC. In addition, the sample size was small. Also,
the individuals who did not undergo sex-reassignment surgery but presented to
JHMC for it did not represent a true control group. Random assignment of the
surgical procedure was not possible. Large differences in the average follow-up
time between those who underwent surgery and those who did not further reduces
any capacity to draw valid comparisons between the two groups. Additionally,
the study’s methodology was also criticized for the somewhat arbitrary and
idiosyncratic way it measured the well-being of its subjects. Cohabitation or
any form of contact with psychiatric services were scored as equally negative
factors as having been arrested.[82]
In
2011, Cecilia Dhejne and colleagues from the Karolinska Institute and
Gothenburg University in Sweden published one of the more robust and
well-designed studies to examine outcomes for persons who underwent
sex-reassignment surgery. Focusing on mortality, morbidity, and criminality
rates, the matched cohort study compared a total of 324 transsexual persons
(191 MtFs, 133 FtMs) who underwent sex reassignment between 1973 and 2003 to
two age-matched controls: people of the same sex as the transsexual person at
birth, and people of the sex to which the individual had been reassigned.[83]
Given
the relatively low number of transsexual persons in the general population, the
size of this study is impressive. Unlike Meyer and Reter, Dhejne and colleagues
did not seek to evaluate the patient satisfaction after sex-reassignment
surgery, which would have required a control group of transgender persons who
desired to have sex-reassignment surgery but did not receive it. Also, the
study did not compare outcome variables before and after sex-reassignment
surgery; only outcomes after surgery were evaluated. We need to keep these
caveats in mind as we look at what this study found.
Dhejne
and colleagues found statistically significant differences between the two
cohorts on several of the studied rates. For example, the postoperative
transsexual individuals had an approximately three times higher risk for
psychiatric hospitalization than the control groups, even after adjusting for
prior psychiatric treatment.[84] (However, the risk of being hospitalized for substance abuse was
not significantly higher after adjusting for prior psychiatric treatment, as
well as other covariates.) Sex-reassigned individuals had nearly a three times
higher risk of all-cause mortality after adjusting for covariates, although the
elevated risk was significant only for the time period of 1973–1988.[85] Those undergoing surgery during this period were also at increased
risk of being convicted of a crime.[86] Most alarmingly, sex-reassigned individuals were 4.9 times more
likely to attempt suicide and 19.1 times more likely to die by suicide compared
to controls.[87] “Mortality from suicide was strikingly high among sex-reassigned
persons, including after adjustment for prior psychiatric morbidity.”[88]
The
study design precludes drawing inferences “as to the effectiveness of sex
reassignment as a treatment for transsexualism,” although Dhejne and colleagues
state that it is possible that “things might have been even worse without sex
reassignment.”[89] Overall, post-surgical mental health was quite poor, as indicated
especially by the high rate of suicide attempts and all-cause mortality in the
1973–1988 group. (It is worth noting that for the transsexuals in the study who
underwent sex reassignment from 1989 to 2003, there were of course fewer years
of data available at the time the study was conducted than for those
transsexuals from the earlier period. The rates of mortality, morbidity, and
criminality in the later group may in time come to resemble the elevated risks
of the earlier group.) In summary, this study suggests that sex-reassignment
surgery may not rectify the comparatively poor health outcomes associated with
transgender populations in general. Still, because of the limitations of this
study mentioned above, the results also cannot establish that sex-reassignment
surgery causes poor health outcomes.
In
2009, Annette Kuhn and colleagues from the University Hospital and University
of Bern in Switzerland examined post-surgery quality of life in 52 MtF and 3
FtM transsexuals fifteen years after sex-reassignment surgery.[90] This study found considerably lower general life satisfaction in
post-surgical transsexuals as compared with females who had at least one pelvic
surgery in the past. The postoperative transsexuals reported lower satisfaction
with their general quality of health and with some of the personal, physical,
and social limitations they experienced with incontinence that resulted as a
side effect of the surgery. Again, inferences cannot be drawn from this study
regarding the efficacy of sex-reassignment surgery due to the lack of a control
group of transgender individuals who did not receive sex-reassignment surgery.
In
2010, Mohammad Hassan Murad and colleagues from the Mayo Clinic published a
systematic review of studies on the outcomes of hormonal therapies used in sex-reassignment
procedures, finding that there was “very low quality evidence” that sex
reassignment via hormonal interventions “likely improves gender dysphoria,
psychological functioning and comorbidities, sexual function and overall
quality of life.”[91] The authors identified 28 studies that together examined 1,833
patients who underwent sex-reassignment procedures that included hormonal
interventions (1,093 male-to-female, 801 female-to-male).[92] Pooling data across studies showed that, after receiving
sex-reassignment procedures, 80% of patients reported improvement in gender
dysphoria, 78% reported improvement in psychological symptoms, and 80% reported
improvement in quality of life.[93] None of the studies included the bias-limiting measure of
randomization (that is, in none of the studies were sex-reassignment procedures
assigned randomly to some patients but not to others), and only three of the
studies included control groups (that is, patients who were not provided the
treatment to serve as comparison cases for those who did).[94] Most of the studies examined in Murad and colleagues’ review
reported improvements in psychiatric comorbidities and quality of life, though
notably suicide rates remained higher for individuals who had received hormone
treatments than for the general population, despite reductions in suicide rates
following the treatments.[95] The authors also found that there were some exceptions to reports
of improvements in mental health and satisfaction with sex-reassignment
procedures; in one study, 3 of 17 individuals regretted the procedure with 2 of
these 3 seeking reversal procedures,[96] and four of the studies reviewed reported worsening quality of
life, including continuing social isolation, lack of improvement in social
relationships, and dependence on government welfare programs.[97]
The scientific evidence summarized suggests we take a skeptical
view toward the claim that sex-reassignment procedures provide the hoped-for
benefits or resolve the underlying issues that contribute to elevated mental
health risks among the transgender population. While we work to stop
maltreatment and misunderstanding, we should also work to study and understand
whatever factors may contribute to the high rates of suicide and other
psychological and behavioral health problems among the transgender population,
and to think more clearly about the treatment options that are available.
Notes
[*] A
note on terminology: In this report, we generally use the term transgender to refer to persons for whom there is
an incongruity between the gender identity they understand themselves to
possess and their biological sex. We use the term transsexual to refer to individuals who have
undergone medical interventions to transform their appearance to better
correspond with that of their preferred gender. The most familiar colloquial
term used to describe the medical interventions that transform the appearance of
transgender individuals may be “sex change” (or, in the case of surgery,
“sex-change operation”), but this is not commonly used in the scientific and
medical literature today. While no simple terms for these procedures are
completely satisfactory, in this report we employ the commonly used termssex
reassignment and sex-reassignment surgery,
except when quoting a source that uses “gender reassignment” or some other
term.
[1] American
Psychological Association, “Answers to Your Questions About Transgender People,
Gender Identity and Gender Expression” (pamphlet), http://www.apa.org/topics/lgbt/transgender.pdf.
[2] Simone
de Beauvoir, The Second Sex (New York: Vintage, 2011 [orig.
1949]), 283.
[3] Ann
Oakley, Sex, Gender and
Society (London: Maurice
Temple Smith, 1972).
[4] Suzanne
J. Kessler and Wendy McKenna, Gender:
An Ethnomethodological Approach (New
York: John Wiley & Sons, 1978), vii.
[5] Gayle
Rubin, “The Traffic in Women: Notes on the ‘Political Economy’ of Sex,” in Toward an Anthropology of Women,
ed. Rayna R. Reiter (New York and London: Monthly Review Press, 1975), 179.
[6] Ibid.,
204.
[7] Judith
Butler, Gender Trouble:
Feminism and the Subversion of Identity (London:
Routledge, 1990).
[8] Judith
Butler, Undoing Gender (New York: Routledge, 2004).
[9] Butler, Gender Trouble, 7.
[10] Ibid.,
6.
[11] “Facebook
Diversity” (web page),https://www.facebook.com/facebookdiversity/photos/a.196865713743272.42938.105225179573993/567587973337709/.
[12] Will
Oremus, “Here Are All the Different Genders You Can Be on Facebook,” Slate, February 13, 2014,http://www.slate.com/blogs/future_tense/2014/02/13/facebook_custom_gender_options_here_are_all_56_custom_options.html.
[13] André
Ancel, Michaël Beaulieu, and Caroline Gilbert, “The different breeding
strategies of penguins: a review,”Comptes Rendus Biologies 336, no. 1 (2013): 6–7, http://dx.doi.org/10.1016/j.crvi.2013.02.002.
Generally, male emperor penguins do the work of incubating the eggs and then
caring for the chicks for several days after hatching. After that point, males
and females take turns caring for the chicks.
[14] Jennifer
A. Marshall Graves and Swathi Shetty, “Sex from W to Z: Evolution of Vertebrate
Sex Chromosomes and Sex Determining Genes,” Journal
of Experimental Zoology 290
(2001): 449–462, http://dx.doi.org/10.1002/jez.1088.
[15] For
an overview of Thomas Beatie’s story, see his book, Labor of Love: The Story of One
Man’s Extraordinary Pregnancy (Berkeley:
Seal Press, 2008).
[16] Edward
Stein, The Mismeasure of
Desire: The Science, Theory, and Ethics of Sexual Orientation (New York: Oxford University Press,
1999), 31.
[17] John
Money, “Hermaphroditism, gender and precocity in hyperadrenocorticism: psychologic
findings,” Bulletin of the
John Hopkins Hospital 95, no.
6 (1955): 253–264, http://www.ncbi.nlm.nih.gov/pubmed/14378807.
[18] An
account of the David Reimer story can be found in John Colapinto, As Nature Made Him: The Boy Who Was
Raised as a Girl (New York:
Harper Collins, 2000).
[19] William
G. Reiner and John P. Gearhart, “Discordant Sexual Identity in Some Genetic
Males with Cloacal Exstrophy Assigned to Female Sex at Birth,” New England Journal of Medicine,
350 (January 2004): 333–341,http://dx.doi.org/10.1056/NEJMoa022236.
[20] Paul
R. McHugh, “Surgical Sex: Why We Stopped Doing Sex Change Operations,” First Things (November 2004),http://www.firstthings.com/article/2004/11/surgical-sex.
[21] American
Psychiatric Association, “Gender Dysphoria,” Diagnostic
and Statistical Manual of
Mental Disorders, Fifth Edition [hereafter DSM-5] (Arlington, Va.:
American Psychiatric Publishing, 2013), 452,http://dx.doi.org/10.1176/appi.books.9780890425596.dsm14.
[22] Ibid.,
458.
[23] Ibid.
[24] Ibid.,
452.
[25] Ibid.
[26] Ibid.,
454–455.
[27] Ibid.,
452.
[28] Ibid.,
457.
[29] Angeliki
Galani et al., “Androgen
insensitivity syndrome: clinical features and molecular defects,” Hormones 7, no. 3 (2008): 217–229, https://dx.doi.org/10.14310/horm.2002.1201.
[30] Perrin
C. White and Phyllis W. Speiser, “Congenital Adrenal Hyperplasia due to
21-Hydroxylase Deficiency,”Endocrine Reviews 21, no. 3 (2000): 245–219, http://dx.doi.org/10.1210/edrv.21.3.0398.
[31] Alexandre
Serra et al., “Uniparental
Disomy in Somatic Mosaicism 45,X/46,XY/46,XX Associated with Ambiguous
Genitalia,” Sexual Development 9 (2015): 136–143, http://dx.doi.org/10.1159/000430897.
[32] Marion
S. Verp et al., “Chimerism
as the etiology of a 46,XX/46,XY fertile true hermaphrodite,” Fertility and Sterility 57, no 2 (1992): 346–349, http://dx.doi.org/10.1016/S0015-0282(16)54843-2.
[33] For
one recent review of the science of neurological sex differences, see Amber
N.V. Ruigrok et al., “A
meta-analysis of sex differences in human brain structure,” Neuroscience Biobehavioral Review 39 (2014): 34–50,http://dx.doi.org/10.1016/j.neubiorev.2013.12.004.
[34] Robert
Sapolsky, “Caught Between Male and Female,” Wall
Street Journal, December 6, 2013,http://www.wsj.com/articles/SB10001424052702304854804579234030532617704.
[35] Ibid.
[36] Ibid.
[37] For
some examples of popular interest in this view, see Francine Russo,
“Transgender Kids,” Scientific
American Mind 27, no. 1
(2016): 26–35, http://dx.doi.org/10.1038/scientificamericanmind0116-26;
Jessica Hamzelou, “Transsexual differences caught on brain scan,” New Scientist 209, no. 2796 (2011): 1,https://www.newscientist.com/article/dn20032-transsexual-differences-caught-on-brain-scan/;
Brynn Tannehill, “Do Your Homework, Dr. Ablow,” The Huffington Post, January
17, 2014, http://www.huffingtonpost.com/brynn-tannehill/how-much-evidence-does-it_b_4616722.html.
[38] Nancy
Segal, “Two Monozygotic Twin Pairs Discordant for Female-to-Male
Transsexualism,” Archives of
Sexual Behavior 35, no. 3
(2006): 347–358, http://dx.doi.org/10.1007/s10508-006-9037-3.
[39] Holly
Devor, “Transsexualism, Dissociation, and Child Abuse: An Initial Discussion
Based on Nonclinical Data,”Journal of Psychology and Human Sexuality, 6 no. 3 (1994): 49–72, http://dx.doi.org/10.1300/J056v06n03_04.
[40] Segal, “Two Monozygotic Twin Pairs
Discordant for Female-to-Male Transsexualism,” 350.
[41] Ibid.,
351.
[42] Ibid.,
353–354.
[43] Ibid.,
354.
[44] Ibid.,
356.
[45] Ibid.,
355. Emphasis in original.
[46] J.
Michael Bostwick and Kari A. Martin, “A Man’s Brain in an Ambiguous Body: A
Case of Mistaken Gender Identity,”American Journal of Psychiatry, 164
no. 10 (2007): 1499–1505, http://dx.doi.org/10.1176/appi.ajp.2007.07040587.
[47] Ibid.,
1500.
[48] Ibid.,
1504.
[49] Ibid.
[50] Ibid.,
1503–1504.
[51] Giuseppina
Rametti et al., “White
matter microstructure in female to male transsexuals before cross-sex hormonal
treatment. A diffusion tensor imaging study,” Journal
of Psychiatric Research 45,
no. 2 (2011): 199–204,http://dx.doi.org/10.1016/j.jpsychires.2010.05.006.
[52] Ibid.,
202.
[53] Giuseppina
Rametti et al.,
“The microstructure of white matter in male to female transsexuals before
cross-sex hormonal treatment. A DTI study,” Journal
of Psychiatric Research 45,
no. 7 (2011): 949–954,http://dx.doi.org/10.1016/j.jpsychires.2010.11.007.
[54] Ibid.,
952.
[55] Ibid.,
951.
[56] Emiliano
Santarnecchi et al.,
“Intrinsic Cerebral Connectivity Analysis in an Untreated Female-to-Male
Transsexual Subject: A First Attempt Using Resting-State fMRI,” Neuroendocrinology 96, no. 3 (2012): 188–193,http://dx.doi.org/10.1159/000342001.
[57] Ibid.,
188.
[58] Hsaio-Lun
Ku et al., “Brain
Signature Characterizing the Body-Brain-Mind Axis of Transsexuals,” PLOS ONE 8, no. 7 (2013): e70808, http://dx.doi.org/10.1371/journal.pone.0070808.
[59] Ibid.,
2.
[60] Hans
Berglund et al.,
“Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When
Smelling Odorous Steroids, Cerebral
Cortex 18, no. 8 (2008):
1900–1908, http://dx.doi.org/10.1093/cercor/bhm216.
[61] See,
for example, Sally Satel and Scott D. Lilenfeld, Brainwashed: The Seductive Appeal of
Mindless Neuroscience, (New York: Basic Books, 2013).
[62] An
additional clarification may be helpful with regard to research studies of this
kind. Significant differences in the means of sample populations do not entail
predictive power of any consequence. Suppose that we made 100 different types
of brain measurements in cohorts of transgender and non-transgender
individuals, and then calculated the means of each of those 100 variables for
both cohorts. Statistical theory tells us that, due to mere chance, we can (on
average) expect the two cohorts to differ significantly in the means of 5 of
those 100 variables. This implies that if the significant differences are about
5 or fewer out of 100, these differences could easily be by chance and
therefore we should not ignore the fact that 95 other measurements failed to
find significant differences.
[63] One
recent paper estimates that 0.6% of the adult U.S. population is transgender.
See Andrew R. Flores et al.,
“How Many Adults Identify as Transgender in the United States?” (white paper),
Williams Institute, UCLA School of Law, June 30, 2016, http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf.
[64] Petula
Dvorak, “Transgender at five,” Washington
Post, May 19, 2012,https://www.washingtonpost.com/local/transgender-at-five/2012/05/19/gIQABfFkbU_story.html.
[65] Ibid.
[66] Ibid.
[67] American
Psychiatric Association, “Gender Dysphoria,” DSM-5,
455. Note: Although the quotation comes from theDSM-5 entry for “gender dysphoria” and
implies that the listed persistence rates apply to that precise diagnosis, the
diagnosis of gender dysphoria was formalized by the DSM-5, so some of the studies
from which the persistence rates were drawn may have employed earlier
diagnostic criteria.
[68] Ibid.,
455.
[69] Kenneth
J. Zucker, “Children with gender identity disorder: Is there a best practice?,” Neuropsychiatrie de l’Enfance et de
l’Adolescence 56, no. 6
(2008): 363, http://dx.doi.org/10.1016/j.neurenf.2008.06.003.
[70] Kenneth
J. Zucker et al., “A
Developmental, Biopsychosocial Model for the Treatment of Children with Gender
Identity Disorder,” Journal of
Homosexuality 59, no. 2
(2012), http://dx.doi.org/10.1080/00918369.2012.653309.
For an accessible summary of Zucker’s approach to treating gender dysphoria in
children, see J. Michael Bailey, The
Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism (Washington, D.C.: Joseph Henry Press,
2003), 31–32.
[71] Kelley
D. Drummond et al., “A
follow-up study of girls with gender identity disorder,” Developmental Psychology44, no.
1 (2008): 34–45, http://dx.doi.org/10.1037/0012-1649.44.1.34.
[72] Jesse
Singal, “How the Fight Over Transgender Kids Got a Leading Sex Researcher
Fired,” New York Magazine,
February 7, 2016, http://nymag.com/scienceofus/2016/02/fight-over-trans-kids-got-a-researcher-fired.html.
[73] See,
for example, American Psychological Association, “Guidelines for Psychological
Practice with Transgender and Gender Nonconforming People,” American Psychologist 70 no. 9, (2015): 832–864, http://dx.doi.org/10.1037/a0039906;
and Marco A. Hidalgo et al.,
“The Gender Affirmative Model: What We Know and What We Aim to Learn,” Human Development 56 (2013): 285–290, http://dx.doi.org/10.1159/000355235.
[74] Sara
Reardon, “Largest ever study of transgender teenagers set to kick off,” Nature 531, no. 7596 (2016): 560,http://dx.doi.org/10.1038/531560a.
[75] Chris
Smyth, “Better help urged for children with signs of gender dysphoria,” The Times (London), October 25, 2013, http://www.thetimes.co.uk/tto/health/news/article3903783.ece.
According to the article, in 2012 “1,296 adults were referred to specialist
gender dysphoria clinics, up from 879 in 2010. There are now [in 2013] 18,000
people in treatment, compared with 4,000 15 years ago. [In 2012] 208 children
were referred, up from 139 the year before and 64 in 2008.”
[76] Annelou
L.C. de Vries et al.,
“Young Adult Psychological Outcome After Puberty Suppression and Gender
Reassignment,” Pediatrics 134, no. 4 (2014): 696–704, http://dx.doi.org/10.1542/peds.2013-2958d.
[77] David
Batty, “Mistaken identity,” The
Guardian, July 30, 2004,http://www.theguardian.com/society/2004/jul/31/health.socialcare.
[78] Ibid.
[79] Jon
K. Meyer and Donna J. Reter, “Sex Reassignment: Follow-up,” Archives of General Psychiatry 36, no. 9 (1979): 1010–1015, http://dx.doi.org/10.1001/archpsyc.1979.01780090096010.
[80] Ibid.,
1015.
[81] See,
for instance, Paul R. McHugh, “Surgical Sex,” First
Things (November 2004),http://www.firstthings.com/article/2004/11/surgical-sex.
[82] Michael
Fleming, Carol Steinman, and Gene Bocknek, “Methodological Problems in
Assessing Sex-Reassignment Surgery: A Reply to Meyer and Reter,” Archives of Sexual Behavior 9, no. 5 (1980): 451–456,http://dx.doi.org/10.1007/BF02115944.
[83] Cecilia
Dhejne et al., “Long-term
follow-up of transsexual persons undergoing sex reassignment surgery: cohort
study in Sweden,” PLOS ONE 6, no. 2 (2011): e16885, http://dx.doi.org/10.1371/journal.pone.0016885.
[84] 95%
confidence interval: 2.0–3.9.
[85] 95%
confidence interval: 1.8–4.3.
[86] MtF
transsexuals in the study’s 1973–1988 period showed a higher risk of crime
compared to the female controls, suggesting that they maintain a male pattern
for criminality. That study period’s FtM transsexuals, however, did show a
higher risk of crime compared to the female controls, perhaps related to the
effects of exogenous testosterone administration.
[87] 95%
confidence intervals: 2.9–8.5 and 5.8–62.9, respectively.
[88] Ibid.,
6.
[89] Ibid.,
7.
[90] Annette
Kuhn et al.,
“Quality of life 15 years after sex reassignment surgery for transsexualism,” Fertility and Sterility 92, no. 5 (2009): 1685–1689, http://dx.doi.org/10.1016/j.fertnstert.2008.08.126.
[91] Mohammad
Hassan Murad et al.,
“Hormonal therapy and sex reassignment: a systematic review and meta-analysis
of quality of life and psychosocial outcomes,” Clinical Endocrinology 72 (2010): 214–231,http://dx.doi.org/10.1111/j.1365-2265.2009.03625.x.
[92] Ibid.,
215.
[93] 95%
confidence intervals: 68–89%, 56–94%, and 72–88%, respectively.
[94] Ibid.
[95] Ibid.,
216.
[96] Ibid.
[97] Ibid.,
228.
Lawrence S. Mayer and Paul R. McHugh, "Part Three: Gender
Identity," Sexuality and Gender: Findings from the Biological, Psychological,
and Social Sciences, The New Atlantis,
Number 50, Fall 2016, pp. 86-113.
