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Gender Dysphoria- Looking Beneath the Controversy

Clinical Psychologist, Ethelwyn Rebelo, gives a broader understanding of Gender Dysphoria (feelings of identification with the opposite gender and discomfort with one's own assigned sex that results in significant distress or impairment) and the biology behind it.

In the 1970’s there was a little boy who became known as “John” although this was not his real name. After a circumcision accident, he was turned into a girl, known as “Joan” in the media. (His real name had been David Reimer). Despite regular articles in academic journals reporting on the case and indicating that the sex change had been a phenomenal success, years later “Joan” decided to become “John” again.

This case was managed by a psychologist called, John Money, who for years had been considered to be the expert on sex-change operations. The John/Joan case was a dream-come-true for any sex-change researcher in that there was a ready made control for the experiment. John/Joan was an identical twin and his development could therefore be measured against that of his brother.

Money was greatly motivated by the need to confirm feminist arguments that viewed political and social equality for women as justifiable only and fundamentally if it could be argued that babies are born as blank slates in terms of gender identity and sexual orientation. Money’s agenda, noble though it may have been, however blinded him to indications that the case was not progressing as successfully as he wanted it to.

Eventually it emerged that John as Joan had always felt herself to be trapped in the wrong body and that she had suffered an immense amount of distress in terms of trying to understand her feelings and with fitting in with other girls. She obtained relief when her parents eventually told her the truth of what had happened to her in infancy and she was assisted into transtioning back into her original male sex.

The book on the John/Joan Case by John Colapinto

I myself worked with a little boy whose entire genitalia had been sliced off with a razor at eighteen months of age for muti purposes and left to die in a field in Soweto. Happily some children playing nearby found him and he was swiftly transported to Chris Hani Baragwanath Hospital, where after much discussion and counselling with his family, it was agreed to conduct a sex-change operation and turn him into a little girl. This child came to see me at the hospital child psychiatric clinic at the age of five. She was very unhappy being a girl, hated wearing girl’s clothes, became very angry if she was given girl’s toys and felt very strongly that she she was really a boy. This, despite the best efforts of the child’s mother to guide her into femininity. Having learned the John/Joan case lesson, the therapeutic team agreed that it would be best to allow him to be a boy and that hormones and surgery would be undertaken later to masculinise him.

What lack of understanding caused these mistakes to be made? As I have indicated, the assumption that Money and the surgeons at Chris Hani Baragwanath Hospital based their decisions on, was that a child is born as a blank slate and that it is only the conventions of society that direct him or her into either a conventional male or female direction. We now know that this is not the case. This does not mean that women are cognitively inferior in relation to men, that they are not as good at becoming rocket scientists or artists or politicians, or that their oppression or domination is justified. It does mean however that a person’s gender identity and sexual orientation is heavily influenced by biological factors.

In this blog, however, I will focus on gender identity.

Research in the last few decades has revealed that genetics alone does not determine biological sex and gender identity; prenatal hormonal influences play an important role.

In experiments with animals, the gonadal hormones that prenatally determine the development of genitalia have been found to also influence the development and functioning of the brain with regard to sexual characteristics and orientation.

In essence and very simply put: in the case of normal development, a testosterone surge masculinizes the fetal brain of a genetic male, but does not feed the fetal brain of a genetic female. Later in pregnancy, the sexual differentiation of the fetal brain takes place.

If a genetic male in utero has problems with his testosterone receptors, that male will not develop into a boy, he will be born looking like a girl. If his little body is able to produce testosterone but not make use of it, he will be born with an intersex condition known as Complete Androgen Insensitivity Syndrome. In such cases, parents and midwives are unaware of the fact that the perfect little girl before them is genetically male. They will begin to realise that something is wrong when she never starts menstruating, when she does not develop hair under her armpits and when she appears to be infertile. These girls who may be quite beautiful with lovely skin because the unused testosterone in their bodies converts to estrogen. Despite being genetically male, they always identify as female and have a female heterosexual orientations. Clearly all such girls are subject to a variety of ideologies, cultures, societies, expectations and emotional traumas, but interestingly they always adopt a female gender identity and heterosexuality.

In instances where the little genetic male in utero has a body that is able to partially use some of the testosterone it generates, then a baby with ambiguous genitalia is born. This is known as Partial Androgen Insensitivity Syndrome and matters may be more uncertain with regard to gender identity and sexual orientation.

Gonadal dysgenesis in 46XY individuals who have Swyer syndrome ensures that they are also born with unambiguous female genitalia, looking like females.


Jamie Lee Curtis

Nicole Kidman

Conversely, if there is a problem with the baby’s adrenal glands so that they do not produce cortisol, mineralocorticoids result in a surge of testosterone (something which should happen only to fetal males), these baby girls are then born with clitorisis that are so large they sometimes look like penises and therefore they may be registered as boys at birth. Such babies are known as having Congenital Adrenal Hyperplasia. In these cases 95% of these genetic girls identify as female and 5% have gender dysphoria and identify as male. This is at least 10 to 20 times more frequent than in a control population of female-to-male transgenderism. So exposure to the testosterone in utero increases the probability of babies developing gender dysphoria.

The differentiation of the sexual organs is settled in early pregnancy, while the sexual differentiation of the brain occurs as a result of the organising effect of sex hormones on the brain in later pregnancy. In puberty, the brain circuits that have been organised in the womb are then activated by the sex hormones. It has therefore been hypothesised that transgender individuals experienced a difference in hormonal surges in utero with one sex hormone developing their sex organs and another sex hormone impacting on their brain development.

There are many types of Intersex conditions and I will not be discussing them all in this blog. However another fascinating, although rather distressing type is known as 5-Alpha-Reductase Deficiency. These individuals are also genetically male but are born with normal appearing female genitalia and are usually raised as girls. In puberty they experience a bombshell as they suddenly begin to develop male characteristics. Despite the fact that these children were initially raised as girls, 60% of them eventually choose to live as heterosexual males. This is probably due to the organising effect of testosterone on early brain development and the activating effect of testosterone in puberty.

Jeffrey Eugenides in his wonderful novel: “Middlesex” which deals with main character who has this condition, begins his story as follows:

”I was born twice: first, as a baby girl, on a remarkably smogless Detroit day in January of 1960; and then again, as a teenage boy, in an emergency room near Petsokey, Michigan, in August of 1975.”

Whether transgender individuals are brain intersexed or not still has to be conclusively proved, although a mass of research finding are slowly accumulating which suggest a biological basis for such cases.

It also must be noted that gender dysphoria in itself does not always lead to a need to transition. Children who experience gender dysphoria do not all grow up with gender identity difficulties, although many may turn out to have same-sex sexual orientations. Research has revealed that during puberty, those whose gender dysphoria will persist have a very different experience of their bodily changes to those whose gender dysphoria will resolve. While perhaps initially dreading the development of their secondary sexual characteristics, those whose dysphoria comes to an end, do not experience the increased masculinisation or feminisation of their bodies as distasteful. Moreover, they tend to enjoy the pleasures of their emerging sexuality. Individuals who continue to feel dysphoric, on the other hand, experience an increased aversion towards their bodies and become more determined to transition medically or find their continued attraction to same-sex partners as confirmation of their cross-gender identification.

Once a person persists into adulthood with a certain sense of gender identity it is usually stable. Where the onset of this adult gender identity is in early childhood it is acknowledged that attempts to alter gender identity so as to bring it in line with birth characteristics are ineffective. Psychotherapy and psychiatry aimed at changing a person’s gender identity, where there is no evidence of psychosis, has been unsuccessful and hence it is now considered unethical for mental health professionals to attempt this. Useful psychotherapeutic enterprises include facilitating self-understanding, assistance with coping with difficulties; and providing individual and family support.

Altering the body has been found to be more effective in treating the distress of transsexual individuals. Hence, sexual reassignment surgery has emerged as a popular form of treatment.

Some people say: “God created Adam and Eve not Adam and Steve.” Such people do not really understand the various combinations that is in fact created.

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