Thursday 25 June 2015

Gender Identity and the Brain - a Round-Table

Six months ago Charlie Rose and his colleague, Nobel Prize-winning brain scientist, Eric Kandel, began planning their latest instalment of the Charlie Rose Brain Series dealing with gender identity and the brain. In the time since, we met the most famous transgender person in the world — Caitlyn Jenner. In a fascinating hour-long episode, Charlie moderates a brilliant discussion on the topic, joined by: Ben Barres, chair of neurobiology at Stanford University, Norman Spack of Boston Children’s Hospital, Catherine Dulac of Harvard University, Melissa Hines of University of Cambridge, and Janet Hyde of University of Wisconsin. Kendel opens the discussion with the introduction: “This is a marvelous topic, and I like it in particular because it shows how brain science can be a liberating influence in our life.”

Thursday 11 June 2015

The Six Genders in Classical Judaism

More Than Just Male and Female: The Six Genders in Classical Judaism — SOJOURN

This description from Trans Torah/Rabbi Elliot Kukla:

Zachar/זָכָר: This term is derived from the word for a pointy sword and refers to a phallus. It is usually translated as “male” in English.

Nekeivah/נְקֵבָה: This term is derived from the word for a crevice and probably refers to a vaginal opening. It is usually translated as “female” in English.

Androgynos/אַנְדְּרוֹגִינוֹס: A person who has both “male” and “female” sexual characteristics. 149 references in Mishna and Talmud (1st-8th Centuries CE); 350 in classical midrash and Jewish law codes (2nd -16th Centuries CE).

Tumtum/ טֻומְטוּם A person whose sexual characteristics are indeterminate or obscured. 181 references in Mishna and Talmud; 335 in classical midrash and Jewish law codes.

Ay’lonit/איילונית: A person who is identified as “female” at birth but develops “male” characteristics at puberty and is infertile. 80 references in Mishna and Talmud; 40 in classical midrash and Jewish law codes.

Saris/סריס: A person who is identified as “male” at birth but develops “female” characteristics as puberty and/or is lacking a penis. A saris can be “naturally” a saris (saris hamah), or become one through human intervention (saris adam). 156 references in mishna and Talmud; 379 in classical midrash and Jewish law codes.

Wednesday 10 June 2015

Caitlyn Jenner's Debut in Vanity Fair Spotlights Transgender Issues

Caitlyn Jenner's Debut in Vanity Fair Spotlights Transgender Issues

If you want to read just one article that explains all the major issues, medical, social, and legal - this is it.

Friday 5 June 2015

McHugh's "Surgical Sex" Revisited

In which Dr Paul McHugh's 2004 article Surgical Sex is rebutted by.... Dr Paul McHugh's 2004 article Surgical Sex.

Why did Johns Hopkins stop performing sex reassignment surgery? The obvious reason is that their surgeon left, and wasn't replaced. They now refer patients to other surgeons after assessing suitability. The surgery is now no longer a "research" effort, but part of mainstream medical practice.
But there's more to it than that.

From McHugh's work, Psychiatric Misadventures :
I happen to know about this (sex-reassignment surgery) because Johns Hopkins was one of the places in the United States where this practice was given its start. It was part of my intention, when I arrived in Baltimore in 1975, to help end it.
Verdict first, trial afterwards.

The Meyer study McHugh commissioned in support of his pre-determined aim, and used as the primary evidential basis for the conclusions in Surgical Sex  was, well, it has figures on a scale of -8 to 5 with values of 19. For a scathing critique of just some of the more obvious nonsense that means it should never have passed even the most cursory peer review, due to the ridiculous figures in it, see
Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991 Friedemann Pfäfflin, Astrid Junge (Translated from German into American English by Roberta B. Jacobson and Alf B. Meier),
Chapter 3: Follow-up studies in chronological order : Meyer & Reter, 1979 Dept. of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
"The tables and figures shared by the authors do not seem serious because after the scoring table a maximum of only eight minus and five plus points can be achieved, but in the results table (p. 1014) a range from -18 to +19 points is given. How these figures came about remains totally in the dark....One asks the question how it came about that a renowned professional publication published such opaque figure material."
Junk Science from the "Dark Age of Psychiatry".

McHugh adduces in support of his secondary thesis, that genes determine sexual identity, an article by Reiner,
Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth
by Reiner and Gearhart, N Engl J Med. 2004 January 22; 350(4): 333–341.
McHugh writes:

"Reiner concluded from this work that the sexual identity followed the genetic constitution. "

Reiner did no such thing. He stated that sexual identity followed the hormonally-directed path in foetu.
1 in 300 men aren't 46,XY, they do not have a "male" genetic constitution (as McHugh puts it). Some women do. Genes are only important in that they *usually* (not always) cause a specific hormonal environment in the womb.

It's important to make the distinction because hormonal environment during pregnancy can change, resulting in mixed anatomy, part female, part male. It can also be completely out of synch with "genetic constitution", resulting in XY females and XX males.

This explains the situation, and why McHugh's claim that "genetic constitution" dictates "sex identity" is very obviously a misinterpretation of the evidence.
Sexual Hormones and the Brain: An Essential Alliance for Sexual Identity and Sexual Orientation Garcia-Falgueras A, Swaab DF Endocr Dev. 2010;17:22-35 

The fetal brain develops during the intrauterine period in the male direction through a direct action of testosterone on the developing nerve cells, or in the female direction through the absence of this hormone surge. In this way, our gender identity (the conviction of belonging to the male or female gender) and sexual orientation are programmed or organized into our brain structures when we are still in the womb. However, since sexual differentiation of the genitals takes place in the first two months of pregnancy and sexual differentiation of the brain starts in the second half of pregnancy, these two processes can be influenced independently, which may result in extreme cases in trans-sexuality. This also means that in the event of ambiguous sex at birth, the degree of masculinization of the genitals may not reflect the degree of masculinization of the brain. There is no indication that social environment after birth has an effect on gender identity or sexual orientation.

Note that McHugh got it partly right -
"Male hormones sexualize the brain and the mind."
"Having looked at the Reiner and Meyer studies, we in the Johns Hopkins Psychiatry Department eventually concluded that human sexual identity is mostly built into our constitution by the genes we inherit ..."
WRONG - this contradicts the previous statement, that it's hormonal environment that's the issue
" ... and the embryogenesis we undergo."
Correct again.

Moving outside the field of psychiatry, let's look at physical anatomy. If embryogenesis and hormonal environment rather than "genetic constitution" is key, if "male hormones (in the womb) sexualise the brain and the mind" as McHugh says, then there has to be physical, objectively measurable evidence of this.

If genetic constitution is key - as McHugh also says, contradicting himself, it is impossible for "genetic males" to have female brain structures.
If hormonal environment is key, then we'd observe female brain structures in all those with a female sex identity, and only those with a female sex identity, regardless of genetic constitution.
The experiment to determine which is correct is simple.

 A sex difference in the human brain and its relation to transsexuality. by Zhou et al Nature (1995) 378:68–70.
   Our study is the first to show a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones
Note the date. 1995. Twenty years ago. Nine years before McHugh's article.
In terms of what this means for patients.... here's McHugh again.
"Proper care, including good parenting, means helping the child through the medical and social difficulties presented by the genital anatomy.... This effort must continue to the point where the child can see the problem of a life role more clearly as a sexually differentiated individual emerges from within. Then as the young person gains a sense of responsibility for the result, he or she can be helped through any surgical constructions that are desired. Genuine informed consent derives only from the person who is going to live with the outcome and cannot rest upon the decisions of others who believe they “know best.”
ABSOLUTELY! This applies to both Transsexual and Intersex children. Those who believe they "know best" because of religious conviction or whatever should not be allowed to mandate un-necessary treatment, or prevent necessary treatment. Moreover, as sexual identity is based on biology, and biology is anything but a strict binary, the sexual differentiation may not be binary either. Some will be most comfortable conforming to a binary model, while others will find that model neither comfortable nor appropriate. Similarly, surgical options should be offered, but never required. The patient may be fine with having unusual genitalia - their body, their choice.

 Back to McHugh again...
" I have learned from the experience that the toughest challenge is trying to gain agreement to seek empirical evidence for opinions about sex and sexual behavior, even when the opinions seem on their face unreasonable. One might expect that those who claim that sexual identity has no biological or physical basis would bring forth more evidence to persuade others. But as I’ve learned, there is a deep prejudice in favor of the idea that nature is totally malleable. "
 Again, completely agree in all respects. The problem is that McHugh states that
  1. Sexual Identity results from hormonal factors (true)
  2. Sexual Identity instead results from "genetic constitution" (false)
and also
  1. Sexual Identity always without exception results from biological factors (true)
  2. Sexual Identity in Transsexuals is a "mental illness" with no physical basis (false)
Bottom line:

Male–to–female transsexuals have female neuron numbers in a limbic nucleus. Kruiver et al J Clin Endocrinol Metab (2000) 85:2034–2041
"The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions"