Friday 22 May 2009

Brain Gender Identity - a presentation by Dr Sidney Ecker, MD FACS

A letter I recently received from Dr Ecker, to whom many thanks:
Hi Zoe,

Yes, we gave our presentation to 60 plus psychiatrists from the US, AU, FR, IT, EU, UK, Holland etc.

We spoke for 2 1/2 hours on why cross gender identity was a normal inherited variation of humans. We showed how Transgender Brains think, smell, and hear like the opposite sex. We presented internationally accepted guidelines for hormonal treatment of transsexuals to be published Summer 2009.

Here are my slides and with my participants' permission I shall send you theirs. We are now in print in the APA Syllabus and soon in the APA Journal this summer. I am checking if we were recorded.

My greatest personal compliment came from Frank Kruijver, from Holland, whose research of the human brain in TSs started it all. He thought we have taken his work very far in our understanding of the human brain. Hope you can do something with this. Sid Ecker, M.D.
I will indeed endeavour to "do something with this".

Starting with publishing it, broadcasting it as far and as wide as I can. This stuff needs to be known.

Dr Ecker is not a psychiatrist, he's a urologist, with very extensive clinical experience in observing the effects of hormonal treatment of a variety of patients, transsexual and otherwise. He has no particular axe to grind, but he has seen so much misinformation, he wants to set the record straight. To put some Science into the issue.

As the e-mail states, Dr Ecker was invited to give a presentation to the American Psychiatric Association as part of a seminar at their annual meeting. From their letter to him:
Symposium Title: The Neurobiological Evidence for Transgenderism

The participants shall learn the current definitions of Transgenderism, Gender Identity, Gender Expression, Gender Role Behavior, Gender Dysphoria and Transsexualism and understand the Standards of Care (WPATH) for treatment. The neurobiological evidence for gender differences in the human brain and genetic inheritability of Transsexualism will be presented. Current US medical practices in the Treatment of GID in children, adolescents and adults will be discussed.

The topic of Gender Identity Disorder is one of great controversy in the world because of the diametrically opposite approach of treatment advocated in different medical centers. The prevalence and incidence of Transgenderism, which reflects the thinking and behavior of the opposite genetic sex, cannot be known because the non-dysphoric patient does not present for medical care for a multiplicity of reasons. What we can estimate and understand is the mild to severely dysphoric patient who seeks medical attention and is given a diagnosis of Gender Identity Disorder under DSM-IV-TR. The panel shall present the current scientific literature pertinent to our understanding of the concept of a male, female or transgender brain. They shall discuss the current research undertaken with Transsexuals, which lends evidence to genetic inheritance and biological causation. Finally they shall discuss the appropriate medical care that can help bring the patient’s physical being into congruency with their Brain Gender Identity. While treatment in the form of surgery or cross-hormonal medication has been denied to these individuals at certain prominent medical centers, the number of patients seeking help has increased. As more patients see the psychiatric community as a welcoming entity listening to their concerns, instead of trying to reverse or repair their Transgender thinking, they will be encouraged to allow psychiatry to join in the multi-disciplinary treatment of their condition.

Title of Presentation: Brain Gender Identity

Gender Identity is that innate sense of who you are in this world with reference to your sexuality and behavior, not necessarily corresponding to your genitalia and reproductive organs. Transgenders are atypical and “think” as the opposite gender. Certain areas of the brain have been shown to be sexually dimorphic. They are different in structure and numbers of neurons in males versus females. Protein Receptors for the sex hormones in different areas of the brain (limbic and anterior hypothalamic) must be present in sufficient numbers to receive those powerful hormones. There are androgen receptors (AR), Estrogen Receptors (ER), and Progesterone receptors (PRs). ARs or ERs are predominant at different times in different parts of the human brain. Hormone receptor genes have been identified in humans, which are responsible for sexually dimorphic brain differentiation in the hypothalamus. The groundwork in brain gender identity is gene-directed and takes place by forming male and female hormone receptors in the brain before the gonads and hormones can influence them. Multiple genes acting in concert determine our sexual identity. The human brain continues to make neurons and synaptic neuronal connections throughout life. This contributes to Gender Role Behaviors making individuals in the continuum of gender identity. Gender behaviors must be differentiated from gender identity (Hines). Gender Identity cannot be predicted from anatomy (Reiner). Brain gender identity is determined very early in fetal development, but gender expression, expressed as behaviors requires hormonal, environmental, social and cultural interactions, which evolve with time. One cannot deny the profound effects of Testosterone, Estradiol and other steroids on genital differentiation in-utero or their effects on behavior from birth or the physical and mental cross gender changes caused by exogenous hormones, but gender identity is determined before and persists in spite of these effects.


1.DF Swaab, WC Chung, FP Kruijver, MA Hofman, TA Ishunina
Structural and functional sex differences in the human hypothalamus
Horm Behav. Sep, 2001; 40(2): 93-8. Review

2. DF Swaab
Sexual differentiation of the human brain: relevance for gender identity, transsexualism and sexual orientation
Gynecol Endocrinol. Dec, 2004; 19(6): 301-12. Review.

3.IE Sommer, PT Cohen-Kettenis, T van Raalten, AJ Vd Veer, LE Ramsey, LJ Gooren, RS Kahn, NF Ramsey
Effects of cross-sex hormones on cerebral activation during language and mental rotation: An fMRI study in transsexuals
Eur Neuropsychopharmacol. Mar 2008; 18(3): 215-21.

4.H Berglund, P Lindstrom, C Dhejne-Helmy, I Savic
Male to female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids
Cereb Cortex. Aug 2008; 18(8): 1900-8.

A more complete list of his references is in this PDF file, at REF 3.pdf.

Now onto the powerpoint presentation itself: Brain Gender Identity, which I have mirrored at 3.3.2.ppt

I'll quote the first slide:
Most of our information on the Neurobiology of sex comes from animal studies (Becker et al., 2005), but nearly all of what we know about variations in human sexuality, including hetero- and homo-sexuality, and disorders of gender identity (transsexualism) comes from clinical material, anecdotes or even fiction (the three overlap).
Herbert, J., (Brain, 2008)
And one of his meticulously reasoned conclusions, led to inescapably by the biology of foetal and post-birth neural development:
Brain gender identity is determined very early in fetal development, but gender expression, expressed as behaviors requires hormonal, environmental, social and cultural interactions which evolve with time.
The Logic is immaculate, the conclusions obvious when presented so clearly.

While there are still pieces of the puzzle missing, and many details still to be determined, Dr Ecker has solved it - we now have the Big Picture, incomplete, but still recognisable. All the things I had observed and deduced had to be true on the basis of external observation, Dr Ecker now shows the chain of causality, what happens and when.

His exposition of the biology might even give me some clues as to my own anomalous situation, which genes and which proteins to look at - but this is of secondary interest to me. It's why I got into all this, but now I'm in, it's others I'm more concerned about.

Dr Ecker's first communication with me on the first of March was as follows:
Hi Zoe,

My name is Dr. Sidney W. Ecker, M.D., F.A.C.S. and it appears that I have made it to your informative blog. I would ask you to stay tuned for my Symposium at the American Psychiatric Association's 2009 Annual meeting in May as my abstracts and presentation is their property for publication at the moment.

S10. The Neurobiological Evidence for Transgenderism
1. Brain Gender Identity Sidney W. Ecker, M.D.
2. Transsexuality as an Intersex Condition Milton Diamond, Ph.D.
3. Novel Approaches to Endocrine Treatment of Transgender Adolescents and Adults Norman Spack, M.D.

What I am trying to do is to logically sequence the scientific evidence to date that you quote and put it into an understandable form for my peers and eventually the public. My current Reference list for Brain Gender Identity is attached. This is certainly not "dogma" as Dr. Zucker claims, but like you I possess the ability and education to understand (biological) science. As a Urologist with a specific interest and expertise in Prostate Cancer, I have administered DES, Estrogens, LHRH agonists and Androgen Blockers to thousands of men for PCa. I make the analogy that these men voluntarily took female hormones to improve the quality of their lives much the same way TransWomen do. Do you need to fear death or be suicidal to take cross-gender hormones? Emphatically, No! Will they prevent eventual death in either scenario? No!!

After the meeting I shall send you my PowerPoint Presentation, but I must keep my powder dry for the moment.

You may publish my reference list, but I can't imagine anyone could access all these articles as I have from the National Library of Medicine's Reading Room. So we'll just have to wait to hear from the opposition and peer review.
Thanks for your Web blog.
Sid Ecker
Thank you, Dr Ecker. I'll help as much as I can.


Anonymous said...

"The panel shall present the current scientific literature pertinent to our understanding of the concept of a male, female or transgender brain."

Does this mean they consider "transgender brains" to be something other than male or female?

Zoe Brain said...

Depends on your definition of male and female, and the context.

The evidence is that my brain is feminised in some respects, but likely hyper-masculinised in others. This doesn't thrill me, but we have to go where the evidence leads us.

I self-identify as female. Basically, I'm a woman with an unusual medical condition. A woman with a transgendered brain, if you like.

In this context - even if no others - it makes sense to talk about male, female, and transgendered as 3 distinct categories. Because neurologically, they are.

We shouldn't read too much into this : there's no implication of a "third sex".

On the other hand, some Intersexed people identify as neither male nor female, and it's likely that "third sex" might be a good description for them. It would be illuminating to study such people, to see the parts of the brain that differ from others who identify well with the binary model.

But in all of this - they are PEOPLE, not lab specimens. So while I'm really interested in their neuro-anatomy, the only person I know is giving full and informed consent is me. Others have a right to tell me to go jump in the lake.

Emily said...

Thank you very much for sharing that with us. I was particularly interested in the linguistic changes they mentioned. Before starting hormones, I had a most horrendous stutter which disappeared in a matter of days of starting the treatment. Quite a liberation, as I'm sure you can imagine!

Unknown said...

Zoe wrote: "We shouldn't read too much into this : there's no implication of a "third sex". "

Confusion arises because of a failure to distinguish medical sex from scientific sex. The two are obviously not the same - at least because medical sex comes in only two flavors and scientific sex, which reflects a drive for biological accuracy, necessarily comes in legion flavors.

It is too often forgotten that the purpose of medicine is to promote health, not to promote scientific accuracy (even though the latter is useful). That is why medical sex can be changed (it is changed at the end of a medically supervised transition, it should be changed at least in the paperwork at the start of transition if the aim is truly to promote health).

Such a change would imply that treatment is given on a same sex basis in the new sex, not on a transex basis. Or to express that in other words, transmen are disfigured men rather than mentally disordered women.

Autumn Sandeen said...

If you haven't already crossposted this to a PHB diary I can promote, then please consider it. :)

I'd put the letter above the fold, and the abstract below the fold. :)

Anonymous Woman said...

Will any thoughts contrary to the status quo at PHB be challenged?

Zoe Brain said...

Autumn - done.

Anon-T - I'm a right-wing neocon. As you can imagine, my comments frequently challenge the prevailing view on PHB, in the same way that sodium has a reaction with water.

Yes, I get challenged. Sometimes, I even change my mind as the result.

More often, others might reconsider their views instead.

But who does what doesn't matter as much as that the ideas be improved, regardless of originator.

I'm a scientist, and an engineer who works in safety-critical systems, yes, including Rocket Science. If you don't eat, live, and breathe this philosophy, the Rocket she's a go BOOM, the program she's a no work, and people die as the result.

That provides more than a little incentive for me to check my ego at the door, monstrously huge though it is. It's big enough to look after itself.

Anonymous Woman said...


However there's no maneuvering around what happened there. 'Challenged' was the wrong word. It should have been 'dismissed'.

Twice now online i have had the experience of being dismissed in a very strange, off-hand way. Not for having a contrary view, but having a view that *somehow* resembled in some way the view of so-called 'classic transsexuals' (Sandeen's words).

Perhaps i'm 'guilty' by association through link-listing? i just want to listen to all sides of something i'm a part of.

It's not ego. It's believing i was a part of a collective whole, and then having that belief wiped out by being slapped down for having a concern i felt strongly about.

Standing nails do get pounded down. But you harm the structure when you treat screws the same.

At any rate, i shouldn't have vented here. Sorry about that.

A supervisor i have would talk about a site he worked at in California that had something to do with rocket construction. He liked pointing out that there were no fire extinguishers, rally sites, emergency plans...nothing.

He said there was no popint, and explained that if something, *anything* went wrong, the entire complex and surrounding area would instantly be wiped off the map.

i'm going to have to ask him where and when that was...

Dyssonance said...

Try pounding *this* nail... bwahahahahaha

Zoe, I'll be presenting this in a week here in Phoenix, and probably in a conference in Phoenix as well.

Vocal transfolk are strong people with strong wills and high degrees of obstinacy.

throw two in a room and you'll either have best friends or mortal enemies. Not a whole lot of in between there, lol.

Anonymous said...

First, I wouldn't worry to much about the "hypermasculinized" thing so much. It's almost a sleight-of-hand thing if someone were to make that suggestion with that study, pointing to total brain volume more than anything else. Testosterone tends to swell tissue, period. It should come as no surprise in pre-treatment brains that brain tissue is swollen also. This little fact gives the study its sensational claim of "male" sized brains in MtF's. Hardly the damning evidence it was made out to be, and more along the lines of "the sky is blue".

The scope of the study does not include the brain structures that are more or less impervious to changes in hormone balance. Some things can be swayed to a degree, such as the "outer" parts, and some cannot. This includes the area that neuroscientists think contains our "sense of self".

The age of differentiation in various parts seems to be independent of hormones as well, the result of processes set in stone long before effects occur, as Kruijver and others have said. This silly notion that one can change "brain sex" by taking pills needs to be laid to rest once and for all.

At least some of the study's authors wants the reader to conclude that if the whole brain is "male" (by size), of course everything inside it is structurally "male" as well. This ignores fine structure, function and the more detailed work done by others.

The shift in grey-to-white matter ratios isn't nearly as important as the study tries to make it out to be either. Lesbian females and other "masculinized" people (according to the stereotype) show similar shifts *without* elevated levels of testosterone in adulthood.

Basically, the size of the "male" brain is most likely due to testosterone levels alone. Removing the hormone reduces the size. Organization of the "outer" brain has little to do with the subject matter at hand, and in any case this study in no way contradicts the "brain sex theory" of ts'ism. If someone were to imply that it does, that would be disingenuous.

Oh, and if you see Eric Vilain's name on something, better read the fine print on whatever it is.

sumptos devil s advocate said...

Go go Gadget go!!

Anonymous Woman said...

Truer words were never spoken about T.

i missed your site, Dyss.

Anonymous said...

I was hoping this was going to be compelling evidence, but all it seemed to be was a round-up of other studies that have happened, along with some hypotheses and conclusions...

Unknown said...

Certainly there is a third sex and many more. We must get beyond the dichotomy of male and female, XX and Xy because there exists at least 15 million people who are other. I show more than 10 known human variations of Chromosomal sex and there are more everyday as we discover variations in the Y chromosome like Swyer's Syndrome. We must see beyond the dichotomy of gender just as Harry Benjamin talked about 5 stages of Transsexualism and Anne Fausto-Sterling talked about 5 sexes. The numbers of human variations are staggering, no matter how you define sex. "Transgenders are Born to Think as Male and Female, they are neither solely, but both." It's the hardest concept to wrap your head around. That is what the accumulated scientific evidence shows to date. It took over 50 years for people to believe that "Smoking causes Lung Cancer" and we still don't know exactly why. So many factors involved.
The idea that there are normal human variations of sex and gender beyond the Biblical Dichotomy is something the world has to learn. "Facts do not cease to exist because they are ignored." Aldous Huxley. Thanks for your blog. Sidney Ecker, M.D.

Anonymous said...

lesbians seem to have male size brains from an unexpected source of testosterone courtesy of the homeopathy effect.
Mark Espeland at Wake Forest U in Winston Salem is considdering this hypothesis right now

lilacwoman said...

I'm not sure who I am addressing this to ... or if this will even be read.

The PPT suggests that gender behavior is manageable: "We may choose our behavioral expressions of our identity, but not our Gender Identity."

I would sell my soul to be able to manage my behavior. It is, after all, our behavior which is not acceptable and not that we identify as female or male.

Like others (I assume), my end came as an involuntary unraveling of my male persona I managed to maintain for +50 years. Even though I present female, I continue to look for reasons why I ultimately succumbed to the need to present and be validated as female ... even though physically I can never really be 'female'.

There is a question in this. Where can I get the evidence supporting the argument that we can 'choose' our behavioral expressions of our identity ... and is there guidance on regaining 'control' of behavior?

I had always been blessed with an iron willpower and ample intellect. Today, I am helpless to control the expression of my identity despite the penalties for such expression.

I suppose like many others, I think of myself as being the exception and that this is not real and that I will find a way out where others have failed.

And yes, in spite of all, I am the happiest I have been my whole life ... and yes, I know that my happiness is simply organic and can be contained in a testtube. I would choose to be unhappy if I could as I did for more than 50 years.

Always looking for answers and help, Sabrina Simon

PS. Anyone out there?

Zoe Brain said...

Yes, there are people out there, many of whom are in the same situation.

The behaviour Dr E was referring to is the "gendered behaviour" that is a social construct, nothing to do with instinct. That's most of it. Whether one wears a skirt or a kilt, for example. There's no neural circuit for preferring pink or blue.

But the feelings engendered when you hear a baby cry... that's another matter. One can suppress the natural reactions, for a while, until one day one can't.

SS - you're female. What you do about that, how you cope with it, is up to you. But you're not alone. May I suggest joining the Beginning Life forum? The link is on the left.

You're not alone you see. And people care.

Anonymous said...

Hi Zoe!

thanks for the info on 'Brain Gender Identity'

to answer others thoughts on 'behaviour control' etc.

although we now realize the brain gender is something that develops and 'finalizes' in life (unchangeable thereafter)...

we also have discovered the concept of the parts of the brain that in fact DO CHANGE (not the gender part of course), and these areas offer new horizons to all of us who had thought our 'thinking' was inflexible; we now know our 'preferences' (yes, sexuality) can be 'willed' by us or 'conditioned' by others. it is up to us to be 'aware' of this, that way we have a greater degree of control over our mental destinies.

neuralplasticity of our brains, means we can at will, with repetition, motivation, etc 'remap' new skills, likes, dislikes, passions, love, hate, fears, addictions...

thus it explains the 'reality' of many genuinely transgendered brained transsexuals who spend an immense amount of energies in 'hyper-masculinizing' ourselves in hopes of 'exorcizing' the 'femaleness' out of our heads and hearts... little do we know, we are fighting an impossible 'change' for the 'unchangeable' part of our brains... the 'gender' area of the brain; all the while we exhibit in our TS 'suppressed' gendered lives, 'learning' all the likes and dislikes of 'male thinking'... arming ourselves with 'macho' skills? being fearless?

add on top of that... the profound effect that Testosterone has on our 'drive'... 'macho drive' plus 'sexual drive'... wow... i no longer blame males for 'thinking nothing about sex'... a lot of that, perhaps 100% is due to Testosterone alone... (i might be exaggerating a bit; but now i am on estrogen and anti-androgens... i FEEL and THINK how different it is...)

our brains... both the 'finalized unchangeable gender' part as well the 'changeable' skills-preferences part combined is astounding... we as TG-TS are living proof of the two together in our 'gender struggled' lives...

i am m2f TS, and mAIS...

Stefanie Daniella Young-Yue
(aka SaintSuelle, aka, Saint Eve)
i am on FB