Sex and Sensibility

The State of the Art - Gender Identity and the Brain

European Society for Endocrinology Conference 2018

Symposium S30.3

Abstract : Brain structure and function in gender dysphoria

The concept of gender identity is uniquely human. Hence we are left with the phenomenon of men and women suffering from Gender Dysphoria (GD) also known as transsexualism to study the origins of gender identity in humans.
It has been hypothesized that atypical levels of sex steroids during a perinatal critical period of neuronal sexual differentiation may be involved in the development of GD. In order to test this hypothesis, we investigated brain structure and function in individuals diagnosed with GD using magnetic resonance imaging (MRI). Since GD is often diagnosed in childhood and puberty has been proposed to be an additional organizational period in brain differentiation, we included both prepubertal children and adolescents with GD in our studies.
First, we measured brain activation upon exposure to androstadienone, a putative male chemo-signal which evokes sex differences in hypothalamic activation (women > men). We found that hypothalamic responses of both adolescent girls and boys diagnosed with GD were more similar to their experienced gender than their birth sex, which supports the hypothesis of a sex-atypical brain differentiation in these individuals.
 At the structural level, we analyzed both regional gray matter (GM) volumes and white matter (WM) microstructure using diffusion tensor imaging. In cis-gender girls, larger GM volumes were observed in the bilateral superior medial frontal and left pre/postcentral cortex, while cis-gender boys had more volume in the bilateral superior-posterior cerebellum and hypothalamus. Within these regions of interest representing sexually dimorphic brain structures, GM volumes of both GD groups deviated from the volumetric characteristics of their birth sex towards those of individuals sharing their gender identity. Furthermore, we found intermediate patterns in WM microstructure in adolescent boys with GD, but only sex-typical ones in adolescent girls with GD.
These results on brain structure are thus partially in line with a sex-atypical differentiation of the brain during early development in individuals with GD, but might also suggest that other mechanisms are involved. Indeed, using resting state MRI, we observed GD-specific functional connectivity in the visual network in adolescent girls with GD. The latter is in support of a more recent hypothesis on alterations in brain networks important for own body perception and self-referential processing in individuals with GD.

Professor Julie Bakker, who led the research at the University of Liege in Belgium, said: “Although more research is needed, we now have evidence that sexual differentiation of the brain differs in young people with GD, as they show functional brain characteristics that are typical of their desired gender.”

“We will then be better equipped to support these young people, instead of just sending them to a psychiatrist and hoping that their distress will disappear spontaneously.”

Gloucester County School Board v. G.G - interACT: Advocates for Intersex Youth, et al.

Gloucester County School Board v. G.G - interACT: Advocates for Intersex Youth, et al. (Pdf)
Some highlights: This is, as far as I'm aware, the first court case involving Transgender where the binary nature of "physiological sex" has been challenged. Universally, Intersex people  have always been dismissed as inconsequential, rare one in a zillion cases of no importance. Or against sincerely held Religious belief, so their very existence denied, as it goes against what is still being taught in backwards and creationist biology classes.

    This case raises issues central to amici's mission as advocates for intersex youth. Petitioner maintains that the word “sex” in Title IX must refer only to an Individual’s so-called “physiological” sex, rather than the sex with which an individual identifies and lives every day. This is so, Petitioner argues, because “physiological” sex—purportedly unlike gender identity—is binary, objective, and self-evident. The intersex youth for whom amici advocate are a living refutation of this argument.

    Petitioner’s simplistic view of “physiological” sex is demonstrably inaccurate as a matter of human biology. Moreover, it demeans many thousands of intersex youth by erasing their bodies and lives and placing them outside the recognition of the law. Physicians who treat individuals with intersex traits recognize that the key determinant of how individuals navigate sex designations in their lives is their gender identity—their internal sense of belonging to a particular gender.

    Amici Have a strong interest in ensuring that The Court does not endorse Petitioner’s misguided View of “physiological” sex, and in seeing the Court interpret Title IX in a way that respects all children.

This brief argues that in cases of Intersex, Gender Identity is the only feasible way of determining anyone's sex. Rather than relying on handwaving and assertion, or religious texts, it shows that scientifically, there is no bright, distinct touchstone reliant on objective facts other than Gender Identity. It may not be perfect, but it's by far the best there is.

    Notably, the legal system has struggled for decades to answer the definitional question that Petitioner simply begs. By the time Title IX was enacted, courts well recognized that “(t)here are several criteria or standards which may be relevant in determining the sex of an individual.”
    M.T. v. J.T., 355 A.2d 204, 206–08 (N.J. App. Div. 1976) (listing chromosomes, external genitalia, gonads, secondary sex characteristics, and hormones, as well as gender identity).

     Commentators have noted the “variability of standards that courts employ” in making such determinations.

     Even courts in the same jurisdiction have disagreed about how to determine sex when physiological features do not align.

         Petitioner and its amici also assert that “physiological” sex has the virtue of being an “objective” classification. Pet. Br. at 32; McHugh Br. at 3–6, 12–13.

    Gender identity, they suggest, is “fuzzy and mercurial,” id. at 8, while “physiological” sex simply is. But the foregoing discussion should make clear that this assertion is similarly flawed. An intersex student’s "physiological” sex may depend entirely on which Physiological trait one chooses to privilege. Indeed, because of the diversity of medical perspectives, trained experts can and do disagree on the “correct” sex to assign to an intersex child.

    Interpreting “sex” to refer to a student’s gender identity would avoid (or at least mitigate) these problems. Unlike “physiological” sex, all parties appear to agree on what gender identity means: it is “[an] individual’s ‘innate sense of being male or female.’” Pet. Br. at 36; cf. Resp. Br. at 2 (similar). It is not subject to competing definitions depending on which expert or court is consulted. Moreover, unlike “physiological” sex, a student’s gender identity by definition cannot be subject to differences in medical opinion: each student is the ultimate arbiter of their own gender identity, as they (and they alone) experience it first-hand.

Moreover, at the time Congress passed Title IX, they either knew, or should have known, that Intersex people exist.

    Accordingly, when Congress enacted the provision at issue here, it knew—or, at minimum, should have Known—that not all students could be straightforwardly categorized as “male” or “female” based on Their anatomy alone. Congress could not have believed otherwise without ignoring millennia of Western history, science, and law.

Certainly by the time the Americans with Disabilities Act was passed, they knew.

So, how does this situation affect Intersex kids? One example. A kid with XX/XY mosaicism, one of the syndromes that can cause a partial, apparent natural sex change.

    (I) was in a boys’ restroom, and someone saw that I went in there, and then complained to my counselor, who then said “Well, you can’t use the boys’ restroom, so you have to use the girls’ restroom.” And I was like “ok, fine, whatever.” But ... there (were) athen complaints that I was using the girls’ restroom. And I was told, “Well, you can use the nurse’s restroom.”

    Now, ... the nurse was on the complete opposite side of the entire building .... So if I was in the middle of class, I would have to leave, and I would be gone for 10-15 minutes, so of course my teachers didn’t like that. So I was told “You can’t use the nurse’s restroom .... There is a single-stall restroom in the special education area, which is near where your classroom(s) are, so you can use that one.” And I was like “fine, ok.” And I used that one for a bit and was then told that I couldn’t use that one....

    At that (point)... I was told “Well, you don’t Have a full school schedule, so you can just hold It.” So yeah, for the last semester, at least, I just wasn’t allowed to use the restroom at the high school at all.

Unfortunately... It has been since February 2016 the Republican National Committee dogma  that, and I quote

A person’s sex is defined as the physical condition of being male or female, which is determined at conception, identified at birth by a person’s anatomy, recorded on their official birth certificate, and can be confirmed by DNA testing;

What do we do when not merely a major political party, but the one controlling the House, the Senate, the Presidency, a large majority of state governorships and legislatures, soon to be the Supreme Court and a majority of Federal judicial appointments, when this party has as an article of Faith something as counterfactual as "Pi = 3" or "The Earth is Flat"?

In Summary

Too many times I've seen assertions in Op-Eds and comments that "there is no evidence for a biological origin for transsexuality". Sometimes it's "no evidence whatsover",  sometimes "no convincing evidence", "no peer-reviewed evidence". The impression is given that there's only one or two papers written by pay-for-comment idealogues in vanity press publications, if anything, and probably not even that.


The truth is rather different. Evidence Supporting the Biologic Nature of Gender Identity Saraswat et al, Endocrine Practice: February 2015, Vol. 21, No. 2, pp. 199-204.

Objective: To review current literature that supports a biologic basis of gender identity.

Methods: A traditional literature review.
Results: Evidence that there is a biologic basis for gender identity primarily involves (1) data on gender identity in patients with disorders of sex development (DSDs, also known as differences of sex development) along with (2) neuroanatomical differences associated with gender identity.

Conclusions: Although the mechanisms remain to be determined, there is strong support in the literature for a biologic basis of gender identity.

 "Strong support" - like there's "Strong support" for the theory that the Earth isn't flat. It's about as close to certainty as you'll find in any scientific publication.

Ethical Guidelines Related to Mental Health Care

For the record...

Mental health professionals need to be certified or licensed to practice in a given country according to that country’s professional regulations (Fraser, 2009b; Pope & Vasquez, 2011). Professionals must adhere to the ethical codes of their professional licensing or certifying organizations in all of their work with trans- sexual, transgender, and gender-nonconforming clients.

Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long-term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965).

Such treatment is no longer considered ethical.

If mental health professionals are uncomfortable with, or inexperienced in, working with transsexual, transgender, and gender- nonconforming individuals and their families, they should refer clients to a competent provider or, at minimum, consult with an expert peer. If no local practitioners are available, consultation may be done via telehealth methods, assuming local requirements for distance consultation are met.

 From the WPATH Standards of Care v7(PDF)

Mental Health of Transgender Children Who Are Supported in Their Identities

Mental Health of Transgender Children Who Are Supported in Their Identities Olsen et al Pediatrics March 2016

CONCLUSIONS: Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.

 It's not GID per se that causes the horrific suicide rates in Trans kids. It's the combination of lack of supportive treatment and persecution - and even kids with a supportive environment havce elevated anxiety about that.

"Bathroom Bills" and other transphobic legislation kills kids. We have the proof of that.

Limits on Neuroplasticity - and the infamous BSTc layer

I found a wonderfully informative site I wasn't aware of, by an author whose talents at conveying complex concepts to a lay audience exceed my own. Even though I'm the one who's supposed to have a Grad Cert in Science Communication from the ANU.

It's Liz - Day by Day, a blog that apparently started as a record of Transition, but has since become an excellent resource on the science of Sex and Gender.

A bit like this blog, though I started it many years before my own atypical and non-volitional transition. (Zoe kicks herself again for not doing it earlier, not having the courage to).

Anyway, from this site, a graphic illustration of one area of the brain where women tend to have one structural pattern (OK, we've not found any exceptions, just degrees) and men another.

As they say, sometimes a picture is worth a thousand words.

Now onto Neuroplasticity - the quality of the brain to change its structure due to environment.

A good article on the limits to it is Equal ≠ The Same: Sex Differences in the Human Brain

"But wait," argue the anti-sex difference authors, "the brain is plastic"-that is, molded by experience. One group of authors uses the word plasticity in the title of their paper three times to make sure we understand its importance.²⁹ (As someone who has studied brain plasticity for more than 35 years, I find the implication that it never occurred to me amusing.) By the plasticity argument-also made explicitly by neuroscientist Lise Eliot in her book Pink Brain Blue Brain-small sex differences in human brains at birth are increased by culture's influence on the brain's plasticity.³⁰ Eliot further argues that we can avoid "troublesome gaps" between the behaviors of adult men and women (a curious contradiction, by the way, of the view that there are no behavioral differences between the sexes) by encouraging boys and girls to learn against their inborn tendencies.

It is critical to understand where the fallacies in this argument lie. First, it is false to conclude that because a particular behavior starts small in children and grows, that behavior has little or no biological basis. One has only to think of handedness, walking, and language to see the point. Second, this argument presupposes that human "cultural" influences are somehow formed independent of the existing biological predispositions of the human brain. But third, and most important, is the key fallacy in the plasticity argument: the implication that the brain is perfectly plastic. It is not. The brain is plastic only within the limits set by biology.

To understand this critical point, consider handedness. It is indeed possible, thanks to the brain's plasticity, to force a child with a slight tendency to use her left hand to become a right-handed adult. But that does not mean that this practice is a good idea, or that the child is capable of becoming as facile with her right hand as she might have become with her left had she been allowed to develop her natural tendencies unimpeded. The idea that we should use the brain's plasticity to work against inborn masculine or feminine predispositions in the brains of children is as ill conceived as the idea that we should encourage left-handed children to use their right hand.

29 Fine, C. et al. Plasticity, plasticity, plasticity. . . and the rigid problem of sex, Trends in Cognitive Sciences November 2013, Vol. 17, No. 11.
30 Eliot, L., Pink Brain, Blue Brain: How Small Differences Grow Into Troublesome Gaps -- And What We Can Do About It, 2009; HMH Publishing.

It wasn't always like this....

And standing there as big as life,
And smiling with his eyes,
Joe says, "What they can never kill,
Went on to organise.

-- Joe Hill

From

Royal College of Psychiatrists – (UK)

16 April 2002

Trans People in the New NHS

Historical context:

From the 1930s to the 1960s, Trans people were understood to experience a congenital physical condition, and after appropriate clinical intervention, they had full civil liberties in their real sex. Their Birth Certificates could be corrected, they could marry if they wished, and live otherwise ordinary lives. In the late 1960s, however, two events contributed to a massive change in that status. First – and ironically at the point at which gay men were decriminalised in the UK, in 1967 – in the USA, John Money announced that he had solved the dilemma of whether nature or nurture decide our gender.

One of a pair of twin boy babies had accidentally been penectomised during circumcision, had been reassigned as female, never told of his reassignment, and brought up as a girl. Money, a self-styled ‘missionary of sex’ announced that, after long-term follow up, the girl had successfully adjusted to her new role and that it was, therefore, nurture and not nature that decided the gender of people. Incredibly, on the basis of one single case, that view became the dominant one. It was clear by analogy that Transsexualism was not congenital, and that Trans people should respond to nurture if it was persistent enough and firm enough.

Second, in 1970, the case of Corbett v Corbett ‘criminalised’ Trans people by removing civil status recognition from them. The effect of that trial was comparable to the effect of the trials of Oscar Wilde and of Radclyffe Hall: it produced ‘a brilliantly precise image’ of the Trans community, a ‘grafting of a narrow set of cultural signifiers’ onto an ostensibly homogenous body of Trans people. In the public imagination, Trans people would always be Trans women [so that Trans men became invisible] and Trans women would always be, in the judge’s terms, ‘a pastiche of femininity’, a sort of teapot-elegant drag-queen, a kind of figure of fun. Equally seriously, Trans people were no longer allowed to correct their Birth Certificates, could not marry, could not adopt, were sent to the wrong sex prison [where Trans women at least were routinely raped by male inmates and warders alike] and it became the norm for them to be dismissed from employment as soon as their condition was disclosed, whether at diagnosis or later. With further irony, in 1980, as homosexuality was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Registered Mental Illnesses (DSM), Transsexualism was placed in it, to confirm by medicine this new edict of the law.

The first response of the UK Trans community was to feel crushed, and the second was to organise.

... in 1998, in the USA, Professor Milton Diamond discovered the real outcome of John Money’s iconoclastic research: the child who had been reassigned as a girl had never been happy in the female gender role; he had always experienced his gender as male, despite his female rearing, and female hormone treatment, and as soon as he was able he had reassigned to his male identity. John Money’s findings for his research were revealed as being grossly inaccurate at best, but not before a generation of tertiary specialists had been at least misdirected by someone who, for many of them, had been their mentor and pre-eminent amongst them. From the point of view of Trans people, of course, a generation of patients had been inadequately and inhumanely treated.

Largest Study to Date: Transgender Hormone Treatment Safe

Largest Study to Date: Transgender Hormone Treatment Safe

Cross-sex hormone treatment of transgender adults leads to very few long-term side effects, according to the authors of the largest study to date to examine this issue.
More than 2000 patients from 15 US and European centers participated in the retrospective study, called Comorbidity and Side Effects of Cross-Sex Hormone Treatment in Transsexual Subjects, and nearly 1600 received at least 1 year of follow-up, the authors reported.
"Our results are very reassuring," principal investigator Henk Asscheman, MD, PhD, who heads HAJAP, his clinical research company in Amsterdam, the Netherlands, told Medscape Medical News. "There are mostly minor side effects and no new [adverse events] observed in this large population."
Speaking at ICE/ENDO 2014 last week, where he presented the initial results of the research, Dr. Asscheman said the data confirm findings from smaller studies published in the past decade.
"The take-home message," he said, "is that when using the guidelines from the Endocrine Society ["Endocrine Treatment of Transsexual Persons"], you are not going to see a lot of comorbidities with cross-sex hormone treatment."
 

The Social Construction of Sex

The Social Construction of Sex - Pacific Standard: The Science of Society - Alice Dreger

This, then, brings us to the issue of gender identity. Gender identity can be described as the internal feeling of being a boy, girl, man, woman, or something else. Is gender identity socially constructed—that is, are people taught to feel like one or the other?

When I started doing intersex work,I thought so. I thought we were taught to feel, act, and behave like girls and boys. But I don’t think that anymore. That is to say, sure we’re taught these things, but many of us probably get our core gender identities as much from our biological origins as we do from our gender educations. I’ve met too many people who, in spite of careful gender educations—sometimes even intensive gender educations—just clearly felt the gender assigned to them was the wrong one. I’ve also seen a lot of evidence from intersex that prenatal hormone levels correlate with gender-type behaviors, gender identities, and even sexual orientation. (Correlate, not cause! But correlations can be useful clues to causal factors.)

...

On this note, let me just say this: People who think gender identities, gender roles, and sexual orientations are all socially constructed are the most naive biological determinists I’ve ever seen. They think all human brains are completely without structure when it comes to these things; we all have empty slates in our skulls at birth. No, we don’t! Really!
In fact, I think we can’t know that much about any individual person’s biology without a huge amount of study on that person—and even then, it’s hard to know much. (I think the same is true about an individual person’s social history.) In this sense, I’m much less of a strict biological determinist than the social constructivists people incorrectly lump me with. I happen to think that, for any given child, we can’t predict with certainty what gender identity or sexual orientation she or he will grow up to have, even if the child is raised in a very sex-role-strict culture. Some will go against our best guesses and educational attempts—we know that again from cross-cultural studies, where transgender, lesbian, bi, and gay children and adults show up again and again.

Yup. That sums it up pretty well.

Scientists Discover Children’s Cells Living in Mothers’ Brains - Scientific American

Scientists Discover Children’s Cells Living in Mothers’ Brains - Scientific American

Women may have microchimeric cells both from their mother as well as from their own pregnancies, and there is even evidence for competition between cells from grandmother and infant within the mother.

It's more complicated than most people think. Our bodies are not static, they are performance art. We are not defined completely by our DNA.

Methodological Questions in Childhood Gender Identity ‘Desistence’ Research

Methodological Questions in Childhood Gender Identity ‘Desistence’ Research from Kelley Winters

Satisfaction with Genital Surgery and Sexual Life of Adults with XY Disorders of Sex Development:

Satisfaction with Genital Surgery and Sexual Life of Adults with XY Disorders of Sex Development

Koeler et al, Jnl Clin Endoc Metab Vol 97 Issue 2, February 1, 2012.

Results:

Dissatisfaction with function of the surgical result (47.1%) and clitoral arousal (47.4%) was high in XY,DSD partially androgenized females after feminization surgery. Dissatisfaction with overall sex life (37.5%) and sexual anxieties (44.2%) were substantial in all XY,DSD individuals. Problems with desire (70.6%), arousal (52.9%), and dyspareunia (56.3%) were significant in XY,DSD complete females. 46,XY partially androgenized females reported significantly more often partners of female (9.1%) or both sexes (18.2%) and dyspareunia (56.5%) compared with controls. Individuals with complete androgen insensitivity syndrome stated significant problems with desire (81.8%), arousal (63.6%), and dyspareunia (70%).

Conclusions:

Care should be improved in XY,DSD patients. Constructive genital surgery should be minimized and performed mainly in adolescence or adulthood with the patients' consent. Individuals with DSD and their families should be informed with sensibility about the condition. Multidisciplinary care with psychological and nonprofessional support (parents, peers, and patients' support groups) is mandatory from child to adulthood.

While I'm not real thrilled with the "XY, DSD" terminology, a nose by any other name would smell. The point is, don't surgically change Intersex kids unless it's immediately medically (not socially) necessary

A Huge Update

The page Transsexual and Intersex Gender Identity has just been updated with a similar list of references of equal size, and very little overlap.

The list is at http://www.cakeworld.info/home/transsexualism/what-causes

DMRT1 prevents female reprogramming in the postnatal mammalian testis

Another one for the reference library: DMRT1 prevents female reprogramming in the postnatal mammalian testis Matson et al Nature 476, 101–104 (04 August 2011)

Sex in mammals is determined in the fetal gonad by the presence or absence of the Y chromosome gene Sry, which controls whether bipotential precursor cells differentiate into testicular Sertoli cells or ovarian granulosa cells¹. This pivotal decision in a single gonadal cell type ultimately controls sexual differentiation throughout the body. Sex determination can be viewed as a battle for primacy in the fetal gonad between a male regulatory gene network in which Sry activates Sox9 and a female network involving WNT/β-catenin signalling². In females the primary sex-determining decision is not final: loss of the FOXL2 transcription factor in adult granulosa cells can reprogram granulosa cells into Sertoli cells². Here we show that sexual fate is also surprisingly labile in the testis: loss of the DMRT1 transcription factor³ in mouse Sertoli cells, even in adults, activates Foxl2 and reprograms Sertoli cells into granulosa cells. In this environment, theca cells form, oestrogen is produced and germ cells appear feminized. Thus Dmrt1 is essential to maintain mammalian testis determination, and competing regulatory networks maintain gonadal sex long after the fetal choice between male and female. Dmrt1 and Foxl2 are conserved throughout vertebrates^{4, 5} and Dmrt1-related sexual regulators are conserved throughout metazoans³. Antagonism between Dmrt1 and Foxl2 for control of gonadal sex may therefore extend beyond mammals. Reprogramming due to loss of Dmrt1 also may help explain the aetiology of human syndromes linked to DMRT1, including disorders of sexual differentiation⁶ and testicular cancer⁷. 

Time to get my genes re-tested.

Identification of de novo copy number variants associated with human disorders of sexual development. Tannour-Louet et al PLoS One. 2010 Oct 26;5(10):e15392.

Disorders of sexual development (DSD), ranging in severity from genital abnormalities to complete sex reversal, are among the most common human birth defects with incidence rates reaching almost 3%. Although causative alterations in key genes controlling gonad development have been identified, the majority of DSD cases remain unexplained. To improve the diagnosis, we screened 116 children born with idiopathic DSD using a clinically validated array-based comparative genomic hybridization platform. 8951 controls without urogenital defects were used to compare with our cohort of affected patients. Clinically relevant imbalances were found in 21.5% of the analyzed patients. Most anomalies (74.2%) evaded detection by the routinely ordered karyotype and were scattered across the genome in gene-enriched subtelomeric loci. Among these defects, confirmed de novo duplication and deletion events were noted on 1p36.33, 9p24.3 and 19q12-q13.11 for ambiguous genitalia, 10p14 and Xq28 for cryptorchidism and 12p13 and 16p11.2 for hypospadias. These variants were significantly associated with genitourinary defects (P = 6.08×10(-12)). The causality of defects observed in 5p15.3, 9p24.3, 22q12.1 and Xq28 was supported by the presence of overlapping chromosomal rearrangements in several unrelated patients. In addition to known gonad determining genes including SRY and DMRT1, novel candidate genes such as FGFR2, KANK1, ADCY2 and ZEB2 were encompassed. The identification of risk germline rearrangements for urogenital birth defects may impact diagnosis and genetic counseling and contribute to the elucidation of the molecular mechanisms underlying the pathogenesis of human sexual development.

Note:

• incidence rates reaching almost 3%
• the majority of DSD cases remain unexplained.
• Most anomalies (74.2%) evaded detection by the routinely ordered karyotype

Another for the Reference Library

Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study -- Marco Colizzi,Rosalia Costa, Orlando Todarello Psychoneuroendocrinology, Volume 39, January 2014, Pages 65-73,

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

50,000 Deaths

Paper Prepared for the National Center for Health Care Technology

on the Social and Ethical Aspects of Transsexual Surgery
By Janice G. Raymond
Assistant Professor of Medical Ethics and Women's Studies
Hampshire College/University of Massachusetts
Amherst, Massachusetts
June, 1980

The subject of transsexualism, whether raised in the public forum or in the academic or medical communities, has been viewed generally as a medical issue that requires hormonal and surgicalintervention. Several assumptions accompany this profile of transsexualism.

1. That the transsexual is a person who is trapped in the body of the wrong sex. Thus we have the popular definition of a transsexual as a "female mind in a male body."[1] This results in the perception of transsexualism as a disease or as disease-like and thus a medical problem. In many cases, a "cure" can only be effected through radical intervention such as specialized hormonal treatments and sex conversion surgery.
2. That it is possible to transsex, i.e., to change one's sex through such medical intervention.
3. That it is a therapeutic necessity and a reasonable and humane treatment to perform surgery on those individuals who have undergone rigorous preoperative psychological evaluations and who can truly "pass" as members of the opposite sex. Furthermore, proof of the surgery's efficacy is that over 90% of those who have undergone transsexual operations report that their lives are healthier and happier.

The aim of this paper is to analyze these assumptions and, in so doing, to address the much-neglected social and ethical issues surrounding transsexual surgery. Transsexualism is an important medical ethical issue that raises questions that go far beyond the transsexual context -- questions of bodily mutilation and integrity, medical priorities, unnecessary surgery, the inevitable issue of the medical model in general, as well as definitions of maleness and femaleness, and the boundaries of such. Scholars will also find that transsexualism touches the parameters of many of the academic disciplines in such a way as to raise fundamental questions about the territorial imperatives of biology, psychology, medicine, and the law, to name but a few. Questions about the causes of transsexualism and the proper methods of treatment have been hitherto restricted to the domains of psychology and medicine. But as an ethicist, I would maintain that these issues of causation and treatment are often embedded with social values and philosophical beliefs -- values and beliefs about the so-called natures of womenand men, for example.
Historically, one could say that some people have always felt "trapped" in the wrong body, in the wrong skin, and in the wrong period of time. But this feeling never certified them as members of the "right" body, skin, or period of time. For example, persons who felt "trapped" in black skin were never encouraged to undergo a pigmentation change. Ultimately, it was recognized that such "trapped" feelings were encouraged by a society that oppressed and discriminated against black people, and that it was the society that needed changing, not the individual black. In the same way, to acknowledge that a man who feels trapped in his native-born body is a transsexual (and ultimately, through hormonal and surgical intervention, a woman), is to ignore the social causes and ramifications that surround the issue. Indeed, one must ask why it is possible in this society that persons could even talk about a "female mind in a male body."
If transsexualism is a disease, then does desire qualify as disease? As Thomas Szasz has asked, does the old person who wants to be young suffer from the "disease" of being a "transchronological" or does the poor person who wants to be rich suffer from the "disease" of being a "transeconomical?"[2]
Transsexualism as disease raises many deeper issues about the medical model in general and the ways in which transsexualism has come to the defined as legitimate medical territory. Within the last century, more and more areas of life have come to be defined as medical and technical problems. This is most evident, of course, in the mental health realm where all sorts of behaviors have been categorized as diseases, and then treated by drugs, surgery, and other medical-technical means. My point here is to affirm that more and more personal, moral, and now social problems are defined as medical problems when they are actually human and social conflicts. Approaching these conflicts from a diagnostic and disease perspective prevents the person who is dissatisfied with his sex from seeing the issue in an alternative framework. Specifically, persons who think they are transsexuals are not encouraged presently to see this desire as arising from the social constraints of masculine and feminine role-defined behavior. Thus a man who wishes to be emotional or non-aggressive is encouraged to think of himself as a woman instead of as a man who is trying to break out of the masculine role.
The ultimate effect of defining transsexualism as a disease, and as a medical problem, is to encourage persons to view other persons (especially children) who do not live out proper and appropriate sex role behavior as potential transsexuals. Thus, for example, for the boy who likes to play with dolls or the girl who wants to be a truck driver, these behaviors can be interpreted as transsexual behavior instead of as non-stereotypical behavior that helps to break down sex roles. Thus the classification of transsexualism as a disease or as a therapeutic category relegates non-stereotypical sex-role behavior to the medical realm.
It is important to understand that doctors here are not curing a disease. They are actually engaged in the political and social shaping of masculine and feminine behavior. Several facts bear out this contention. Here especially, I note the role of the so-called gender identity clinics and private therapists who foster and reinforce stereotyped behavior. Persons wishing to change sex come to these clinics or go to individual therapists to receive counseling and ultimately to be referred for treatment and surgery. It is a primary requirement of these centers that men who wish to be transsexed must prove that they can "pass" as "true women" in order to qualify for treatment and surgery. "Passing" requirements evaluate everything from an individual's feminine dress, to feminine body language, to so-called feminine positions in intercourse. Most clinics require candidates for surgery to live out opposite sex-roles and rigidly defined stereotypical behavior for periods of six months to two years. Thus the role of these clinics and clinicians in reinforcing sex-role stereotypes is significant and, as I have tried to show above, one that has consequences that reach far beyond the transsexual issue. I would suggest that what we are witnessing here is a "benevolent" form of behavior control and modification. It is not inconceivable that gender clinics, in the name of therapy, could become potential centers of sex-role control for non-transsexuals--e.g. children whose parents have strong ideas about the kind of masculine or feminine children they want their offspring to be.
The ultimate effect of viewing the desire to live as a member of the opposite sex as a disease or as a medical category is that a social and ethical issue becomes transformed into a therapeutic and medical-technical problem to be solved by "passing" requirements, hormone therapy, and sex conversion surgery. Medicine focuses on the surgical construction of desired genitalia. Artifacts of silicone breasts, artificial vaginas, and the like come to incarnate the essence of femaleness which the transsexual so desperately desires.[3] Since the general result of sex conversion surgery is that the transsexual becomes an agreeable participant in a society which encourages conformity to rigid sex role behavior, then ultimately the medical solution becomes a "social tranquilizer." Sexism, and its foundation of sex-role stereotyping, is reinforced.
Transsexual surgery also enables doctors to gain medical knowledge about the manipulation of human sexuality that probably could not be acquired by any other medical procedures. In what other medical situation could a penectomy be done upon a healthy penis and an artificial vagina inserted into a chromosomal male? What we also witness in the transsexual context is a number of medical specialties combining to create transsexuals -- urologists, gynecologists, endocrinologists, plastic surgeons, and the like. The proliferation of treatments that has been generated to take care of the "disease" is remarkable. These range from the initial and basic operative procedures undergone by all transsexuals to highly specialized forms of secondary cosmetic surgery such as eye, nose, and chin operations.[4] Not coincidentally, hormone therapy and surgery are expensive.[5]
The terminology of transsexualism becomes an issue in this context. For by its very existence, the word perpetuates the notion that transsexualism is a state of being, and that there is a group of people who will continue to need the surgery because they are "born" transsexuals. Until the surgery was popularized, in the aftermath of the Christine Jorgensen case, the specific need of surgery for a group of persons known as transsexuals was not evident (although, of course, some people may have felt that they wished to change sex). The extent to which the popularization and availability of surgery has generated a wider need for it is obscured by the terminology of transsexualism itself.
Finally, treating transsexualism as a disease and making it medical territory have also masked the fact that a unique group of medical consumers has been created by medicine itself. The terminology of transsexualism disguises the reality that transsexuals prove they are "real" transsexuals by conforming to the canons of a medical institution that evaluates them on the basis of their being able to pass as stereotypically masculine or feminine, and that ultimately grants surgery on this basis. Once sex-role dissatisfaction is given the name of transsexualism, institutionalized in gender identity clinics, and treated by hormone therapy and surgery, the category of transsexualism functions to explain and order very valid dissatisfactions with sex-role stereotypes.
The terminology of transsexualism raises the inevitable question of is it possible to change sex, i.e., to transsex? To answer this, it is necessary to discuss various meanings of the word SEX, a word that has both a dismaying multiplicity and ambiguity of meanings. John Money has distinguished various definitional levels of the word SEX that are helpful in assessing whether it is biologically possible to cross sex.[6] Chromosomal sex determines biological maleness or femaleness, contrary to popular opinion that anatomical sex is determinative. Normal males have a chromosomal pattern of XY with normal females being XX. There are some individuals who are born with chromosomal anomalies in which surgery is often used to bring the anomalous person in line with the anatomical characteristics that become most dominant, or else the developing anatomical characteristics are altered in line with the sex in which the child has been reared. The pattern of sex chromosomes is present and unchangeable in every body cell, including blood cells. Chromosomal sex can, however, conflict with anatomical sex.
Anatomical sex refers to primary and secondary sex characteristics. Primary characteristics include the testes in the male and the ovaries in the female. Secondary anatomical sex characters include the penis, scrotum, prostate, hair distribution, and a deeper voice in the male; and the clitoris, vulva, uterus, vagina, breasts, a wide pelvis, female voice, and hair distribution in the female. Transsexual surgery alters anatomical sex through hormonal and operative procedures.
Genital or Gonadal sex is the collective term for the tests in the male or the ovaries in the female.
Legal sex is designated most often by genital sex, although this is not actually defined in the codes. It is in this area that errors of sex do occur, since the obstetrician or mid-wife may be deceived by the apparent genital sex. Endocrine or Hormonal sex is determined by androgen in the male and estrogen in the female, supplied by not only the sex glands, but also by the pituitary or adrenal glands. Endocrine sex is mixed to certain extents since, for example, the testes as well as male adrenals, produce certain amounts of estrogen.
Psychological sex or the word gender are terms used in much of the literature to designate attitudes, traits, characteristics, and behavior that are said to accompany biological maleness or femaleness. I would prefer the term psychosocial sex to indicate the all-important factor that such attitudes, traits, characteristics, and behavior are socially influence and orchestrated.
Historical sex is a term that I would add to this already lengthy list of distinctions. History is important, in this context, because there is a certain constellation of events that attend the sex into which one is born. For example, menstruation for a girl is a biological happening, but it is also a historical event around which cluster a certain set of very different yet also very similar collective female experiences. Men do not have a history of menstruation nor the experiences which surround its onset, its monthly occurrence, or its demise.
What significance does this delineation of the various terminologies of sex have in answering the question of is it possible to change sex? Beginning in order with the list of sex distinctions, the most important reality is that it is biologically impossible to change chromosomal sex. If chromosomal sex is taken as the bottom line of maleness or femaleness, the male who undergoes sex conversion surgery is NOT female.
Anatomically, transsexualism does take place, but anatomical changes also happen in what is commonly termed plastic surgery. Transsexual surgery alters genital or gonadal sex most intrinsically. For example, it is possible to remove a woman's ovaries or a man's testes through this surgery, and it is also possible to construct an artificial vagina in a man whose penis and testes have been removed. The question then becomes how much value one would give to this kind of alteration in terms of changing the totality of a person's sex. George Burou, a Casablancan physician who has operated on over 700 American men who wanted to become women, expressed the superficiality of changing genital sex in this way: "I don't change men into women. I transform male genitals into genitals that have a female aspect. All the rest is in the patient's mind."[7] Furthermore, a change in genital sex does not make reproduction possible.
Endocrine or hormonal sex is the most susceptible to alteration, but this is done without surgical intervention. Hormonal intake of opposite-sex hormones have certain anatomical effects resulting in, for example, breast for men or a redistribution of body hair for both women and men. Hormonal treatments must be lifelong, however, for most of the anatomical effects to be prolonged.
In law, it is possible to transsex; that is, it is possible to change one's legal sex. However, the whole area of legal sex has been one of contention for the transsexual who wishes to have sex conversion surgery validated by a corresponding change of sex on official papers such as birth certificates, social security, drivers' licenses, and the like.
If it is impossible to change basic chromosomal structure, then it is necessary to take a more in-depth look at not only the terminology but also the reality of transsexualism? Can we call a person a transsexual, biologically speaking, whose anatomical structure and hormonal balance have changed, but who is still genetically XY and XX? If chromosomal sex is not the bottom line, what are we really talking about when we say that a person is a biological male or female?
Is there any such enduring reality as biological maleness or femaleness?
Obviously, there is more to maleness or femaleness than chromosomal make-up. Feminists have been arguing this for years, and I am not re-affirming the biology is destiny argument. In fact, it is transsexuals and defenders of the surgery who are asserting a new form of biology is destiny. For what they are ultimately saying is that it is impossible to change male or female behavior, traits, characteristics, and the like UNLESS one also changes one's body. Transsexuals define themselves by exclusive reference to the body of the sex they want to be. This is a new variation on the theme of biology is destiny. What transsexuals and those who support the surgery affirm is that persons are irrevocably determined by what body they are born with. In the transsexual context, persons desiring the surgery become enfettered by both the unwanted body of their chromosomal sex (which they reject) and the body of the opposite sex for which they are willing to undergo painful and mutilating surgery. Ultimately, the transsexual and the medical community which supports surgery give the message that the body is all-important, that it does guide one's destiny, and that all else is body-bound.
Chromosomal sex is the enduring reality which determines biological maleness or femaleness. This can never change. What is more significant in determining the totality of maleness or femaleness, however, is what I have called historical sex. No man can have the history of being born and located in any culture as a woman. He can have the history of wishing to be a woman and of acting like a woman, but this is the history of one who DESIRES to be a woman, not of one who is a woman. Surgery may confer the artifacts of outer and inner female organs, but it cannot confer the history of being born a woman in this society.[8]
History, of course, is not static. All of us make changes in both our personal and social history. I am not advocating that history should determine the boundaries, life, and location of the self. However, there are aspects of anyone's personal and social history that cannot be changed. For example, a person who is born into a particular class cannot change that history. He can change his class attitudes, habits, and complex of behaviors that accompany a certain class typology. Likewise, in the transsexual context, a man cannot change his history of having grown up male. Men who want to change masculine attitudes, habits, and complex of behaviors should not take on the bodies of women but rather should try to change their unwanted history in their own bodies.
To summarize, it is impossible to change sex, i.e., to transsex, because it is impossible to change not only the chromosomes of one's native-born sex but also much of the personal and social history that accompanies biological maleness and femaleness.
Proponents of transsexual surgery claim that the only way of treating those individuals who find themselves to be born into "the wrong sex," and who have undergone rigorous preoperative screening procedures, is ultimately through sex conversion surgery. It is emphasized that many persons who think they might be candidates for surgery are weeded out through these stringent evaluations, and only those who can truly "pass" as women (or men) are referred for surgery.
For this small number of individuals, transsexual surgery is not only a therapeutic necessity but a reasonable and humane treatment. Furthermore, the majority of postoperative reports of transsexuals testify that the surgery has been proven effective and efficacious and is therefore no longer experimental. They cite the fact that 90% of those persons who have undergone surgery report that their lives are happier and healthier.[9]
These reports, however, do not explore the deeper social issues, nor do they question a satisfaction that is achieved at the expense of never investigating the underlying social and ethical issues. They do not state that after surgery the transsexual fits into a role-defined world better than most native-born women who live out their feminine roles.
Critics of this position maintain that it would be an overwhelming burden on both the transsexual and the therapist to attack so large a problem as sex-role socialization in the therapeutic, never mind social, context. Therefore, it is easier, to confront the problem within role limits, making use of a ready-made social structure that created transsexualism initially. While proponents of transsexual surgery may admit that it would be preferable to modify society's attitudes toward masculine and feminine behavior, they emphasize that in the immediacy of the therapeutic moment, the task of social change is impossible. Faced with the personal crisis of a gender-disturbed individual, they opt for ignoring or relegating the social effects to a secondary place.
However, in the name of dealing with an individual crisis, it is important to note that this kind of therapy does not foster genuine individualism. Current transsexual therapy and surgery promote an individualism that serves a role-defined society. Thus, it is more accurate to say that these are solutions that promote the values of social conformity.
To use another example: Many oppressed people use heroin to make life tolerable in intolerable conditions. Heroin usage is a highly effective yet dangerous treatment for dissatisfaction and despair. Recently, black leaders have drawn attention to heroin as a pacifier of black people. The contentment and euphoria produced by the drug diffuses the critical consciousness of the users.
Although there are many real differences between the users of heroin and the recipients of transsexual surgery, the analogy is appropriate in at least one significant way. Transsexual surgery produces satisfaction and relief for the transsexual at the expense of muting his or her critical consciousness of the ways in which such surgery reinforces sex role behavior. Thus transsexuals are not encouraged to ask how their own socialization conditioned not only their choice of surgery, but also their motivation to choose.
It is in this sense that transsexual surgery can be said to be experimental surgery. Transsexuals are seeking surgery to relieve gender discomfort and dissatisfaction. Within the context of a roledefined society, the surgery is narrowly successful at doing this for some
transsexuals. But there is no evidence to prove that the surgery "cures" the deeper problems which lead many persons to seek the surgery. In other words, sex conversion surgery cannot bestow upon the transsexual the sense of self that he or she lacks. Furthermore, there is evidence, at least in some postoperative cases, that transsexuals themselves have come to realize this, but too late. Meyer and Hoopes, as early as 1974, noted that a group of their patients had reacted self-destructively after surgery. These reactions included multiple and serious suicide attempts, drug abuse, and serious physical complications.[10] Randall in an earlier study, reported on four cases (out of 29) in which postoperative adjustment was worse than before the operation. The behavior included suicide, suicidal impulse, moral depravity, and a wish to reverse the effects of the operation.[11]
One of the first well-known physicians to work in the areas was Charles Ihlenfeld, an endocrinologist, who was a co-worker and protege of Harry Benjamin. Ihlenfeld left the field after helping one hundred or more transsexuals change sex because as he reported to have said: "Whatever surgery did, it did not fulfill a basic yearning for something that is difficult to define. This goes along with the idea that we are trying to treat superficially something that is much deeper."[12]
Finally, Johns Hopkins terminated transsexual surgery in 1979 after conducting a study of fifty transsexuals which showed that there was no significant difference in successful life adjustment between those who underwent transsexual surgery and those who did not. The study was the first to compare postoperative transsexuals with an unoperated group of persons who wanted the surgery. The study, initially reported in the ARCHIVES OF GENERAL PSYCHIATRY and in the press release issued by Johns Hopkins which appeared in newspapers across the country said, among other things: "Physicians have to ask themselves if transsexual surgery is medically necessary. To say that this type of surgery cures psychiatric disturbance is incorrect. We now have objective evidence that there is no real difference in the transsexual's adjustment to life in terms of jobs, educational attainment, marital adjustment, and social stability."
On physical grounds alone, there is a substantial amount of evidence to confirm that sex conversion surgery is experimental. Transsexual treatment is far from established as a safe medical procedure. In some instances, it has been known to cause cancer. In 1968, W. Symmers reported two cases of carcinoma of the breast in which the transsexuals died. He suggested that the malignance was entirely due to the hormonal imbalance created by castration plus the massive does of estrogen received.[13] There are several other studies that have investigated the correlation between male-to=constructed female transsexualism and cancer.[14]
This paper has argued that the issue of transsexualism is an ethical one that has profound social and moral ramifications. Transsexualism itself is a deeply moral question rather than a medicaltechnical answer. In concluding, I would list some suggestions for change that address the more social and ethical arguments I have raised in the preceding pages.
While there are many who feel that morality must be built into law, I believe that the elimination of transsexualism is not best achieved by legislation prohibiting transsexual treatment and surgery but rather by legislation that limits it and by other legislation that lessens the support given to sex-role stereotyping, which generated the problem to begin with. Any legislation should be aimed at the social conditions that initiate and promote the surgery as well as the growth of the medical-institutional complex that translates these stereotypes into flesh and blood. More generally, the education of children is one case in point here. Images of sex roles continue to be reinforced, at public expense, in school textbooks. Children learn to role play at an early age.
Nonsexist counseling is another direction for change that should be explored. The kind of counseling to "pass" successfully as masculine or feminine that now reigns in gender identity clinics only reinforces the problem of transsexualism. It does nothing to develop critical awareness, and makes transsexuals dependent upon medical-technical solutions. What I am advocating is a counseling that explores the social origins of the transsexual problem and the consequences of the medicaltechnical solution. It would raise questions such as the following: is individual gender suffering relieved at the price of role conformity and the perpetuation of role stereotypes on a social level? In changing sex, does the transsexual encourage a sexist society whose continued existence depends upon the perpetuation of these roles and stereotypes? These and similar questions are seldom raised in transsexual therapy at present.
I am not so naive as to think that these measures would make transsexualism disappear overnight, but they would at least pose the existence of a real alternative to be explored and tried. Given encouragement to cultural definitions of both masculinity and femininity, persons considering transsexual surgery might not find it as necessary to resort to sex conversion surgery.
Public education must also be emphasized. Up to this point, the transsexual and the transsexual professionals have been the sources of information for the general public. The mere existence of the postoperative transsexual, moreover, and the fact of the surgery's availability permit people to restrict their thinking about sex role dissatisfaction to these medical-surgical boundaries.
One way in which education about transsexualism has reached the general public is through the media. Famous transsexual personages such as Jan Morris or Renee Richards appear in widely circulated magazines and on television talk shows. Thus transsexualism becomes "media-ized" in certain prejudicial ways, which contribute to public opinion that surgery is indeed the solution to gender dissatisfaction. Different perspectives on the issues of transsexualism need to receive more attention and publicity. We need to hear more from those men and women who, at one time, thought they might be transsexuals but decided differently -- persons who successfully overcame their gender crises without resorting to medicine and surgery.
We need to hear more also from professionals such as endocrinologist Charles Ihlenfeld who, after helping many to change sex, left the field. Finally, we need to listen to persons, such as feminists, who have experienced sex role dissatisfaction but did not become transsexuals.
In the final analysis, it is important to remember that transsexualism is merely one of the most obvious forms of gender dissatisfaction and sex-role playing in a role-defined society. It is one of the most obvious because, in the transsexual situation, we have the stereotypes on stage, so to speak, for all to see and examine in an alien context. What can be overlooked, however, is that these same stereotypical behaviors are lived out every day in "native" bodies. The issues that this paper has highlighted should by no means be confined to the transsexual context. Rather they should be confronted in the "normal" society that spawned the problem of transsexualism to begin with.
Footnotes

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1. Since the preponderance of those seeking the surgery and those undergoing it are men, my consistent references throughout this paper are male pronouns and examples. According to international medical literature, only one out of four persons who requests and obtains surgery is female. I also use male references, because I do not want to contribute to a false affirmative action mentality which represents transsexualism as a human problem. It is very clearly a male phenomenon.
2. See Thomas Szasz, review of THE TRANSSEXUAL EMPIRE: THE MAKING OF THE SHE-MALE by Janice G. Raymond, New York Times Book Review, June 10, 1979, p. 11.
3. The medical literature on transsexualism is a good example of the way in which the medical model has confined the questions raised by this issue to a narrow and fetishized field of inquiry. Such literature is replete with photographs, plates, and anatomical drawings of sexual organs. Interestingly, these photographs seldom show the whole person. They center on the genitalia. The narrow area of the chemical and surgical specialties commands attention here in such a way that the primary problem often is represented as how to construct a vagina, for example, in an aesthetic a way as possible.
4. A "salvation by surgery" ethic is created by the initial transsexual procedures. Secondary operations are often sought by the transsexual, usually for esthetic reasons and/or to correct real or psychologically felt complications. This cosmetic surgery frequently has nothing to do with refashioning the genitalia. Rather such surgery is undertaken in the hope of conforming the postoperative body more to fashionable and stereotypical feminine body images. Many transsexuals resort to an immense amount of polysurgery to fit themselves to the prescribed body measurements and gestalt of a curvaceous feminine figure.
5. 1978 figures estimated that, on the average, the male-toconstructed female operation and hospital stay alone can cost from $3,000 to $6,000. The female-to constructed male operation involves a series of several operations before the results are achieved and costs up to $12,000. There are, of course, many other expenses besides the surgery and hospital bills.
6. See John Money, "Sex Reassignment as Related to Hermaphroditism and Transsexualism," in Richard Green and John Money, eds., Transsexualism and Sex Reassignment (Baltimore: Johns Hopkins University Press, pp. 91-93 (1969).
7. For this reason, I use the term "male-to-constructed female" to indicate that only a superficial change does take place, that while transsexuals are stereotypically feminine, they are not fundamentally female, and that it is impossible to change sex. Thus transsexuals do not convert from male to female but from male-to-constructed female.
8. What of persons born with ambiguous sex organs or chromosomal anomalies that place them in a biologically intersexual situation? It must be noted that practically all of them are altered shortly after birth to become anatomically male or female and are reared in accordance with the societal gender identity and role that accompanies their bodies. Persons whose sexual ambiguity is discovered later are altered in the direction of what their gender rearing has been (masculine or feminine) up to that point. Thus those who are altered shortly after birth have the history of being practically born as male or female and those who are altered later in life have their body surgically conformed to their history. When and if they do undergo surgical change, they do not become the opposite sex after a long history of functioning and being treated differently.
9. Percentages vary slightly but most authors doing postoperative follow-up report that "the majority of" or "most of" the transsexuals they surveyed are satisfied, both with the results of the surgery and with their own state of being after the operation.
10. Jon K. Meyer and John H. Hoopes, "The Gender Dysphoria Syndromes: A Position Statement on So-Called Transsexualism," Plastic and Reconstructive Surgery, 54 (October 1977): 455ff.
11. John Randall, "Preoperative and Postoperative Status of Male and Female Transsexuals," in Richard Green and John Money, Transsexualism and Sex Reassignment (Baltimore: Johns Hopkins University Press, 1969), p. 373.
12. "A Doctor Tells Why He'll No Longer Treat Transsexuals," The National Observer, October 16, 1976, p.14.
13. W. Symmers, "Carcinoma of the Breast in Transsexual Individuals after Surgical and Hormonal Interference with Primary and Secondary Sex Characteristics," British Medical Journal, 2 (1968):83. Symmers reported on two cases of transsexuals who came to autopsy with carcinoma of the breast.
14. J. Hoenig et al., in their article, "The Surgical Treatment for Transsexuals" (Acta Psychiatra Scandinavia, 47 [May 1974]:106- 36), state that surgical treatment to increase breasts in male transsexuals should not be undertaken, especially if such treatment is followed up with estrogen therapy, since there is a risk of malignancy. Other studies that have investigated the correlation between male-to-constructed-female transsexualism and cancer are: The Veteran's Administration Cooperative Urological Research Group "Treatment and Survival of Patients with Carcinoma of the Prostate, Surgery, Gynecology, and Obstetrics, 124 (1967):1011.
15. A. Hanash, et. al., "Relationships of Estrogen Therapy for Carcinoma of the Prostate to Atherosclerotic Cardiovascular Disease: A Clinicopathologic Study," Journal of Urology, 103 (1970):467.
16. D. Bailar and D. P. Byar, "The Veteran's Administration Cooperative Urological Research Group: Estrogen Treatment for Cancer of the Prostate: Early Results with Three Doses of Diethylstilbestrol and Placebo," Cancer, 26 (1970):257.

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SOURCE: National Center for Health Care Technology
Division of Medical and Scientific Evaluation 5600 Fishers Lane Room 17A-29, Parklawn Building Rockville, MD 20857
As the result of this paper, existing governmental policy was changed so that it

effectively eliminated federal and some states aid for indigent and imprisoned transsexuals. It had a further impact on private health insurance which followed the federal government's lead in disallowing services to transsexual patients for any treatment remotely related to being transsexual, including breast cancer or genital cancer, as that was deemed to be a consequence of treatment for transsexuality.

-- Transsexual, Transgender and Intersex History : Entry on Janice Raymond.
A very, very conservative estimate of the number of additional deaths that resulted is 50,000. The amount of additional misery - incalculable.

I'll be writing a post in future discussing the numerous factual inaccuracies, omission of significant details, "spin" and other Academic sins that bedevil this paper, along with scientific findings made since this paper was written that debunk it. Those the author cannot be blamed for, unless it's for the sin of hubris, asserting as fact what is conjectured, without sufficient disclaimers. Something I have to watch in myself when writing for a popular audience, though not in Academic papers. There, Good Science and Academic Honesty demands sufficient room for doubt, while in a popular context, may cloud the issue and inevitably lead to misinterpretation.
I will include some other words from the author, in her book "The Transsexual Empire". A work where she makes no attempt to hide her real agenda.

"All transsexuals rape women’s bodies by reducing the real female form to an artifact, and appropriating this body for themselves. "

The transsexually constructed lesbian-feminist feeds off woman’s true energy source, i.e. her woman-identified self. It is he who recognises that if female spirit, mind, creativity and sexuality exist anywhere in a powerful way it is here, among lesbian-feminists

I contend that the problem with transsexualism would best be served by morally mandating it out of existence

And a similar quote:

I hope to see the very concept of Jewry completely obliterated.

-- Heinrich Himmler, Memo March 23 1941. Quoted in "Murderous Science" - Page 48 - by Benno Müller-Hill - History - 1998

A few of the more obvious errors:

Let’s look at the statements that sex is defined by chromosomes. XY is male, XX is female, and that chromosomes are unchangeable.

A 46,XY mother who developed as a normal woman underwent spontaneous puberty, reached menarche, menstruated regularly, experienced two unassisted pregnancies, and gave birth to a 46,XY daughter with complete gonadal dysgenesis. — J Clin Endocrinol Metab. 2008 Jan;93(1):182-9

CONCLUSION: Donor-derived cells are capable of composing endometrium in recipients, even those of the opposite sex. — Bone marrow-derived cells from male donors can compose endometrial glands in female transplant recipients by Ikoma et al in Am J Obstet Gynecol. 2009 Dec;201(6):608.e1-8

That is, an XX woman can end up with an XY body, even her ovaries. Anatomy is everything, chromosomes irrelevant.

Now one can define sex as purely chromosomal; or depending on height, as “men are taller than women” so everyone above average height is *by definition* male, or anything else. Hair colour. Length of fingers. Whatever. Some definitions make more sense than others. No single metric is accurate enough to be sufficiently useful. Base it on reproductive capacity, and many will be of neither sex, and a handful of both.

Sex in that sense is socially constructed, though based on objective biological facts. Which facts are chosen though, that varies.

This whole ideology is based on a false premise. “The Earth is Flat, therefore…..”

As for the idea that Transsexuality is a social construct about gender performance, with no biological component:

Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. by Berglund et al Cerebral Cortex 2008 18(8):1900-1908;
Male–to–female transsexuals have female neuron numbers in a limbic nucleus. Kruiver et al J Clin Endocrinol Metab (2000) 85:2034–2041
A sex difference in the human brain and its relation to transsexuality. by Zhou et al Nature (1995) 378:68–70.
A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. by Garcia-Falgueras et al Brain. 2008 Dec;131(Pt 12):3132-46.

And so on and so on. The facts don’t support this notion, no matter how ideologically comforting it may be. Again, no matter how strong your religious or ideological commitment, no matter how damaging you may think the notion is to your beliefs about what is right or just; no matter how much you may think that the notion, if widely held, would destroy society and cause misery and chaos – the evidence is that the Earth is not Flat.

More trenchant commentary on this, and scans of the document, at ENDABlog.

Calling Google Scholar...

Google's good, but not perfect. The number of people linking to sites with egregious nonsense about my personal details written by agenda-driven Kooks has boosted their credibility.

No matter.

A bigger problem is that Google Scholar isn't tracking my work very well. Only 60% of my papers are listed. So here's a definitive list that their webcrawlers should understand. With luck.

 Using Meta-Genetic Algorithms to tune parameters of Genetic Algorithms to fi nd lowest energy Molecular Conformers
ZE Brain, MA Addicoat  
Proceedings of the 12th International Conference on the Synthesis and Simulation of Living Systems

Simulation Case Study - ^x_tUML in agile development
A Vincent, AE Brain  
Proceedings of the Asia-Pacific Simulation and Training Conference SIMTECT 2004

Optimization of a genetic algorithm for searching molecular conformer space
ZE Brain, MA Addicoat
The Journal of chemical physics 135 (17), 174106-174106-10

Optimization of a Genetic Algorithm for the Functionalization of Fullerenes
MA Addicoat, AJ Page, ZE Brain, L Flack, K Morokuma, S Irle
Journal of Chemical Theory and Computation 8 (5), 1841-1851

Using a Meta-GA for parametric optimization of simple GAs in the computational chemistry domain
MA Addicoat, ZE Brain
Proceedings of the 12th annual conference on Genetic and evolutionary computation

Meta-Genetic Algorithms, Molecules, and Supercomputers
MA Addicoat, ZE Brain
Poster, SC10 Conference on High Performance Computing, Networking, Storage and Analysis

EFFICIENCY OF AN OPTIMIZED EVOLUTIONARY ALGORITHM FOR LOCATING MINIMUM ENERGY CONFORMERS
MA Addicoat ZE Brain
Proceedings Ninth Triennial Congress of the WORLD ASSOCIATION OF THEORETICAL AND COMPUTATIONAL CHEMISTS WATOC 2011

 Please go fetch, there's a good robot. 

Another part of the puzzle

Increased Cortical Thickness in Male-to-Female Transsexualism Luders et al, Journal of Behavioral and Brain Science, 2011

Abstract:

Background: The degree to which one identifies as male or female has a profound impact on one’s life.
Yet, there is a limited understanding of what contributes to this important characteristic termed gender identity.
In order to reveal factors influencing gender identity, studies have focused on people who report strong feelings of being the opposite sex, such as male-to-female (MTF) transsexuals.

Method: To investigate potential neuroanatomical variations associated with transsexualism, we compared the regional thickness of the cerebral cortex between 24 MTF transsexuals who had not yet been treated with cross-sex hormones and 24 age-matched control males.

Results: Results revealed thicker cortices in MTF transsexuals, both within
regions of the left hemisphere (i.e., frontal and orbito-frontal cortex, central sulcus, perisylvian regions, paracentral gyrus) and right hemisphere (i.e., pre-/post-central gyrus, parietal cortex, temporal cortex, precuneus, fusiform, lingual, and orbito-frontal gyrus).

Conclusion: These findings provide further evidence that brain anatomy is associated with gender identity, where measures in MTF transsexuals appear to be shifted away from gender-congruent men.