The Riddle of Gender Page 4
Though the first scientific study of gender variance was published in Germany nearly a century ago, scientific understanding of the causes of what are today classified as “gender identity disorders” remains sketchy. Did transvestites (people who wear the clothes and sometimes adopt the lifestyle of the other sex) exist before the German sexologist Magnus Hirschfeld introduced them into the clinical literature in 1910? Undoubtedly. But prior to Hirschfeld, transvestites were believed to be a kind of homosexual—a category that itself had been only recently created. (Hirschfeld was the first to note that transvestites were usually heterosexual.) Similarly, though Hirschfeld included case studies of people born male who clearly expressed female gender identities, he didn’t identify transsexuals as a separate diagnostic category. British sexologist Havelock Ellis, who had experience with both transvestites and transsexuals, wanted to call members of both groups “eonists,” after the Chevalier d’Eon, a nomenclature that never caught on. It remained for the American physician Harry Benjamin to clarify the distinction between transvestism (today called cross-dressing) and transsexuality in his 1966 book, The Transsexual Phenomenon, and for a professional organization in Benjamin’s name to establish Standards of Care for treatment of transsexuality, in 1980.
More recently, “gender identity disorder” has been created to replace “ transsexualism” as a diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). But science is no more certain today why some people feel so acutely uncomfortable in the sex they were assigned at birth than it was in Hirschfeld’s time—nor why their number seems to be increasing.
Statistics on transsexualism and transgenderism are notoriously unreliable; in the case of transgenderism (a broad and variously defined category) they are mere guesswork. However, it is possible to track the number of people requesting sex-reassignment surgery and to make some general estimates of prevalence (the number of cases of a given condition present in a given population during a given time) based on those figures.
According to the fourth edition of the DSM (DSM-IV), about 1 in 10,000 people seek sex-reassignment surgery (SRS) in the United States every year, and approximately 1 in 30,000 men and 1 in 100,000 women will undergo SRS at some point during their lives. This is believed to be a very conservative estimate, based on SRS statistics that are decades old. Professor Lynn Conway of the University of Michigan suggests that the DSM-IV figures are off by at least two orders of magnitude and that “the prevalence of SRS in the U.S. is at least on the order of 1:2500, and may be as much as twice that value. Therefore, the intrinsic prevalence of MtF transsexualism here must be on the order of ≈ 1:500 and may be even larger than that.” A group of researchers in the Netherlands recently estimated the prevalence of transsexuality to be 1 in 11,900 males and 1 in 30,400 females; this estimate was based on the number of Dutch citizens seeking services compared with the general population.
Legal scholar Julian Weiss has pointed out that “gender identity disorders” are probably far more common than previously suspected, on the basis of four general observations. First, unrecognized gender problems are occasionally diagnosed when patients are seen with anxiety, depression, substance abuse, and other psychiatric conditions, which often serve to mask the underlying gender issue. Second, many individuals who meet the diagnostic criteria for “gender identity disorder” never present themselves for treatment (this category includes the great majority of cross-dressers, professional female impersonators, and gender-variant gay people). Third, the intensity of some people’s feelings of gender-related discomfort fluctuates throughout their lifetimes, and does not always achieve a sustained “clinical threshold” requiring treatment. Finally, gender-variant behavior among female-bodied persons is “invisible” in a way that gender-variant behavior in male-bodied persons is not. On the most basic level, this is exemplified by the relative ease with which women can don men’s clothing.
The number of people self-identifying as transgendered or transsexual and seeking services (hormone therapy and/or surgery) has certainly risen in every decade since Christine Jorgensen brought the issue to the public’s attention, in 1952. Gunter Dorner, a German en-docrinologist who has devoted his career to studying the effects of hormones on the brain, has postulated a fourfold increase in the incidence of transsexualism over the past forty years in the former East Germany. Is Dorner correct? No one knows. But if various forms of gender variance are indeed on the increase, as seems to be the case, what might be the cause of this phenomenon? Dr. Paul McHugh, former chief of psychiatry at Johns Hopkins School of Medicine and a noted opponent of sex reassignment surgery, believes that gender variance is a fad or a “craze” driven by the media and the Internet. McHugh’s views are the flip side of the postmodern “performativity” argument that gender is a cultural construction and that the body is a text upon which individuals are free to inscribe their gender of choice. In this view, gender-queer people are revolutionaries helping to dismantle an oppressive system—and their numbers are increasing, as more and more people challenge the tyranny of the gender binary.
Others believe that greater public tolerance and acceptance, combined with the increased ability to connect with others online and in person, is responsible for the increasing visibility and political activism of gender-variant people. “Twenty or forty or fifty years ago, you couldn’t have had a meeting like this one,” Professor Milton Diamond told me at the 2003 annual meeting of the International Foundation for Gender Education. The majority of the meeting’s participants were cross-dressed men, a group that remains the most heavily closeted of sexual minorities and the most persecuted. “A meeting like this would have been broken up by the police,” Diamond said. Then too, he pointed out, “Many of these individuals think that they are the only ones in the world, and they don’t think that there is a solution, and when they find a solution or find a safe haven somewhere, they utilize it. Many of these activities are like support groups in their own way. They don’t call them that, but that’s what they are.”
Without denying the influence of social factors in helping more people come out, as a science writer I can’t help being interested in biological explanations for what seems to be a pronounced increase in the number of gender-variant people in the world today. An enormous quantity of man-made chemicals has been released into the environment since the chemical revolution began after World War II. According to researchers who have studied their effects, “many of these chemicals can disturb development of the endocrine system and of the organs that respond to endocrine signals in organisms indirectly exposed during prenatal and/or early postnatal life; effects of exposure during development are permanent and irreversible.” Some scientists and transpeople argue that the buildup of these endocrine-disrupting chemicals in the environment has begun to produce the same kind of effects on human sexual differentiation that have already been observed in wildlife and laboratory animals. In this view, a previously rare collection of endocrine-mediated anomalies is becoming more common as a result of the bioaccumulation of these chemicals, many of which are stored in fat and transmitted to the developing fetus through the placenta in pregnancy.
The strongest evidence for a possible biological basis for gender variance comes from research on the effects of the drug diethylstilbe-strol (DES). DES is a synthetic estrogen developed in 1938. Between 1945 and 1970, DES and other synthetic hormones were prescribed to millions of pregnant women in the mistaken belief that they would help prevent miscarriages. DES was even included in vitamins given to pregnant women, and in animal feed. Use of DES during pregnancy was discontinued in the United States in 1971, when seven young women whose mothers had taken DES during pregnancy were found to be suffering from a rare vaginal cancer. Since then, research on animals and human epidemiological studies have proved that DES causes myriad health problems in both males and females exposed to the drug in the womb, including structural damage to the reproductive system. Animal researc
h has also shown that DES and other estrogenic chemicals affect the development of sex-dimorphic brain structures and behavior in animals. Laboratory animals exposed to hormones at critical stages of development in utero exhibited behaviors associated with the other sex after birth. Only in recent years have some researchers begun to note higher-than-expected rates of transgenderism in DES sons and daughters. The moderators of an online discussion group for the XY children of DES mothers surveyed subscribers in 2002 and discovered that 36.5 percent of the forum’s members were either preoperative or postoperative transsexuals, while another 14.3 percent defined themselves as transgendered. An update taken on the five-year anniversary of the group showed that since 1999, between one-quarter and one-third of the members of the DES Sons Network had indicated that gender identity and/or sexuality issues were among their most significant concerns. These data have not yet found their way into the scientific literature, however, and the combined cohort studies of DES children have thus far failed to ask a single question related to gender identity. This epidemiologic failure baffles DES “sons” who are now daughters and who are aware of the increasing public health concerns about chemicals that bind to the estrogen receptor in humans and animals.
“There are millions of us who were exposed to DES. And millions more exposed to DDT, DDE, dioxin, and God knows whatever else is out there that is estrogenic,” says Dr. Dana Beyer, a transgendered physician who serves as co-moderator of the DES Sons Network. “You look at DES and say, ‘If that can mimic estrogen, there must be other things out there. What are people eating? What are they exposed to in the water supply? Five million people were exposed to DES in this country alone. Globally, there are many millions more. And we’re still alive and kicking and suffering from the effects. Plus there probably will be third-generation effects and maybe fourth- and fifth-generation effects.”
Efforts to establish the etiology, or cause, of transsexuality and other forms of gender variance have most often focused on psychological rather than organic causes—this is not surprising, since gender identity disorders are classified as psychiatric, not medical, conditions. Many psychiatrists have attempted to root gender nonconformity in an unstable home environment, abusive or disturbed parents, gender confusion in the family, and other social factors. This line of research has not been very successful, however, as relatively few individuals who grow up in disturbed circumstances of any kind exhibit gender anomalies. As early as 1973, a psychologist working with cross-gendered clients noted that “there is no more psychopathology in the transsexual population than in the population at large, although societal response to the transsexual does impose almost insurmountable problems.”
For that reason many transgendered people reject “pathologiza-tion” and would like to see the gender identity disorders removed from the Diagnostic and Statistical Manual of Mental Disorders in the same way that homosexuality was removed from the DSM. Others argue that this step would have disastrous effects for transsexual people. Rusty Moore, a professor at Hofstra University, in New York, says that transsexuality is “a part of human variation just like having a club-foot is human variation. So people have surgery to correct clubfeet or cleft palate and that gets paid for by medical reimbursement. But in the meantime, until that medical reclassification takes place, our biggest legal protection is what we already have, the DSM. Because that’s the only thing that stops the people that are out to get us.”
Some who believe that transgenderism and transsexuality are biologically based argue that the condition known as “gender identity disorder” ought to be removed from the DSM and reclassified as a congenital endocrinological disorder. “Somewhere the hormones that are secreted either by the brain or by the testes in response to the brain—the fetal hormonal system—are messed up. The end result is the morphological phenomenon, the brain anatomy or hypothalamic anatomy,” says Dr. Dana Beyer. For that reason, “we’re thinking of trying to push a new name for this: Benjamin’s disorder. So that when a baby is born or when a child is growing up and comes and says, ‘You know, Mommy says that I’m a boy, but I think I’m a girl,’ the doctor would say, ‘Okay, let’s rule out Benjamin’s disorder.’ Let’s figure out what’s going on here, rather than telling the parents the kid is crazy, delusional. The assumption is that you are psychotic or have some kind of mental abnormality. That’s the problem with the DSM. If we can make this a congenital anomaly just like cleft palate and cleft lip, or any of the physical intersex conditions, that shifts everybody’s perspective.”
In The Normal and the Pathological, a study that traces the development of the concept of pathology in medicine, the historian of science Georges Canguilhem pointed out that “an anomaly or mutation is not in itself pathological.” Canguilhem carefully delineated the distinction between anomaly and pathology. “An anomaly is a fact of individual variation which prevents two beings from being able to take the place of each other completely,” he writes. “But diversity is not disease; the anomalous is not the pathological.” This concept was articulated in various ways by many of the transgendered people with whom I have spoken over the past three years.
“There’s an idea that people have subconsciously inculcated about how gender and the body work, and when someone says, ‘I’m doing it a little differently,’ it’s like ‘No, you’re wrong.’ But no, we’re just doing it differently than you,” says historian Susan Stryker. “It’s a privilege to not have to think about how you are embodied,” she says, comparing gender privilege to race privilege and pointing out that normatively gendered people don’t have to think about gender “in the same way that white people never have to think about race.” According to Stryker, transgendered people must question basic assumptions about what it means to be male or female, and the relation of gender to the body, in the same way that other minority groups must examine and reject the assumptions that create their oppression. “I didn’t have the privilege of having my body communicate who I am to other people without some kind of interventions. Transsexuals are subject to a double standard. People say, ‘You’re essentializing gender because you think it’s all in the genitals.’ Well, no, I don’t. It’s about my sense of self, and being able to communicate my sense of self to other people the way everybody else does.”
The concept of “gender” as applied to human beings is itself a fairly new concept. Until the middle of the twentieth century, scientists recognized only biological sex, and though a determination of “sex” was usually based on the appearance of the genitals at birth, scientific discoveries complicated this simple picture as early as the eighteenth century. In cases of ambiguous genitalia, the gonads (testicles or ovaries) were used to establish sex until the discovery of Barr bodies (inactivated X chromosomes in female cells) in the mid-twentieth century. Then chromosomes became the new litmus test for sex—but by that point, it had become increasingly clear that there were persons, rare though they might be, whose sense of themselves as men or women was in distinct contrast to the results of chromosome testing. The terms “gender role” and “gender identity” as descriptions of a person’s innate sense of self were born in the 1950s, and very quickly the word “gender” became a synonym for sex, although transgendered people today (and throughout history) have made it clear that this is a misconception. Sometimes, they say, the body lies.
CONVERSATION WITH BEN BARRES, M.D., PH.D.
Dr. Barres is Professor of Neurobiology and Developmental Biology at Stanford University. He graduated from the Massachusetts Institute of Technology, obtained an M.D. from Dartmouth Medical School, completed a neurology residency at Cornell, and obtained a Ph.D. from Harvard Medical School. He studies interactions between glia and neurons in the brain, and is internationally known for his work. He is in his late forties, but his bearded baby face makes him look much younger. I interviewed him in his office at Stanford University, which was cluttered in the way a scientist’s office is usually cluttered, with books and papers. He was wearing shorts, a T-shirt, and
tennis shoes and looked like he had just come from his lab. I asked him to speak from his perspective as both a scientist and a transman.
Q: Do you feel comfortable sharing some of the details of your personal story?”
I think that I have the typical story. All the transsexuals I talk to have exactly the same story. It gets boring after a while. As early as I can remember, I thought that I was a boy. I wanted to play with boys’ toys, play with my brother and my brother’s friends and not my sister. I was always being given girls’ toys, like Barbie. But I never wanted to play with dolls. I wanted to go and beat up on boys. I remember one year my brother got Rock ’Em, Sock ’Em Robots, and I was so jealous. And I remember at Halloween I was dressing up as an army man, or I was a football player. And it just seemed so natural to me, but looking back now I think, “My god, what must my parents have been thinking?”
Q: Did they think that you were a tomboy?’
I guess so. I remember that I beat up the biggest bully in grade school. Came home with broken glasses from fighting the boys in the street. Got mud all over me and played with trucks. I had a great time. It became a problem only when I got to the age where the boys realized that they shouldn’t be playing with girls. It was at some point in grade school, around nine or so, when it became clear that the boys didn’t want to play with girls anymore. And I’d go over to my friend’s house to play and I remember at one point the parents said, “I don’t think that it’s right for you to play with him anymore,” and I was like “Why not?” I didn’t understand it. I was just having a good time playing. You know, if I had been gay, I think that I might have had a lot of hazing from the other boys, about wanting to play with girls, but…