Gendercare Gender Clinic Debate
We are
starting now (2003) a discussion or Debate about Gender Identity (GI)
and Gender Dysphorias (GD), mainly related to intersex (Isex), but not only for
intersex. That discussion started some time ago,
between Tom Mazur, PsyD, the chairman of the HBIGDA Intersex Committee, and myself,
That discussion started as Tom one day sent me a copy of one paper of him and
co-workers about one very disturbing situation of intersex
(one aphallia situation-a boy with testicles and no
penis), asking what I would do if I had a case like that. And I answered him,
with my general ideas about that subject.
Up until today, Tom doesn't answer me my commentaries (he has a lot of work to
do), but surely as soon as possible he will answer, and we will publish his
answer, and we will continue exchanging our ideas.
Now I asked him: may I, Tom, publish our debate in Gendercare? He answered me:
yes!
Could I suggest others to also say us their opinions? He answered me: yes!
So, here we are, with his paper (in black letters), my first answers (in gray
ones), and waiting more answers from Tom.
Below is one form. If you would like to send us your opinions about these
subjects, give us your name, email that we could be in touch with you if
necessary, your professional status (MD,MS,PsyD,BS,PhD,
or other, etc), personal gender status (no gender problem, gender dysphoric, intersex, transsexual,
etc), and your opinion. We will publish the serious opinions, and those that
really show interest in that subject.Nothing
aggressive will be published.
Thank you!
Dr.Torres/Gendercare
Debate:
Gender Identity (GI) and Intersex (Isex): the possibility of the generation of a Gender
Dysphoria (GD) situation.
Hi Tom!
I will try to put,
in the middle of the text,
my commentaries. My English is not
good, so pardon me a lot of English serious
mistakes.
My comments will be always
in gray, I will show you my ideas
about each particular comment or phrase,
you wrote or your co-workers
did.
I hope, after it, you will understand
really what is my idea about
that theme.
First of all, I think it is not a medical, nor a psychological, nor social or familiar problem only, but is a question of life,
of possible happiness of someone.
If we make a mistake, the consequence
will remain forever as a torture. In possible
intersex, transsexual, or any other
situation, what is in
debate here is life, is possibility of life, or a perennial
desiring for death.
I wrote in Portuguese, some
time ago: “No medical doctor,
no psychologist, no psychiatrist,
no anthropologist or sociologist, if never lived that
reality, could really understand what is a gender dysphoria” .
Because gender
dysphoria may be a continuous destructive process, sometimes with no
hope.
You
may feel sometimes yourself as a kind of a “Frankenstein”, or “ET”, or “Edward Hands of Scissors”
as one existential syndrome.
Most of people
think these situations as medical, social, familiar, psychological but we don’t remember, first of all,
it is an existential, so ethical and
philosophical problem.
In my point of view, we
have big
PHILOSOPHICALS questions to answer:
THESE ARE THE
REAL QUESTIONS….
Before these questions, we need to answer:
Thank you for
your patience with my bad English Tom,
Waleria
A Newborn Infant with a Disorder of Sexual
Differentiation
CASE:
Following
an uncomplicated 38 weeks pregnancy, a normal labor, and delivery with Apgar scores 8
and
9 at 1 and 5 minutes, respectively, a newborn was delivered with a birth weight
of
The physical examination was unremarkable, except for complete absence
of the penis. The scrotum
appeared normal with bilateral palpable gonads of normal size. A voiding cystourethrogram demonstrated a
normal bladder without uretero-vesical reflux; the
contrast study revealed that urine partially emptied into the
rectum and colon. The urethral meatus was positioned
at the anterior anal verge. Karyotype was 46 XY. This
is
the third child for this couple. They have a 4-year-old boy and a 6-year-old
girl.
To which sex should this infant be assigned? Accompanying decisions
concern disclosure of information to
patient and family (what should be disclosed about the condition and its
treatment and when?); surgery to
have
the genitalia match the sex assignment, or alternatively, female genital
anatomy (what should be done
and
when?); psychological support of the patient and family (who should provide it
and what model of care
should be followed?); and involvement of other family members and friends
(should they be told, and if so,
what
should they be told and when?). J
Dev Behav Pediatr 24:115
–119, 2003. Index terms: ambiguous
genitalia, sex differentiation, intersex, biomedical ethics, penile agenesis.
As almost all intersex
situations, that also is a disgusting one.
Dr. Martin T. Stein
This
challenging case is a rare condition that will not be
encountered by most
pediatricians. However, it represents a
dramatic example
of other more common conditions
discovered in the
newborn period associated with ambiguous
genitalia. Primary
care pediatricians are often the first
to
recognize the structural abnormalities in the external
genitalia and the
first to speak to the parents about the
condition. A knowledge of genetic and endocrinological
principles that
modulate fetal sex differentiation is essential
but
insufficient to provide comprehensive information to
the parents.
The influence of fetal sex hormones on gender
identity and the
incorporation of principles of patient rights
and patient
autonomy are additional areas of knowledge
required to guide
therapeutic decision making.
That last phrase,
for me, is the most important, perhaps, in that paper:
The influence of
fetal sex hormones on gender identity…. the incorporation of principles of
patient rights….. and patient autonomy.
Those 3 aspects,
for me, are the most important in all gender dysphorias
situations, intersex or any other: remember the
hormone action during pregnancy….... respect the patient’s rights and respect
the person autonomy.
Understand the
first, and recognize the second and the third, that is the way, surely, to
understand better all those situations.
But who is the
patient? The child, the baby, the intersex
or gender dysphoric, AND NOT its family.
A
variety of new concepts about newborns with intersex
conditions have
surfaced in the medical and bioethical
literature. They
reflect recent knowledge about the complexity
of gender identity
and gender role, bioethical considerations,
and the
influence of patient advocacy groups.
Gender identity
and gender role. And the influence of patient advocacy
groups.
As you will see,
I think the most part of our difficulties start when we mix up gender identity
with gender role playing in society, as a point of principle. And all the time,
we were mixing them up, in the past 50 years.
Another note is: why need the
patients to have advocacy groups? Surely because they feel as
victims of someone, or something. Only someone that thinks he has
rights, fight with an advocacy group. And if he has rights, and need to fight,
is because someone or something gave-up, in some situation, his rights (pardon
me my English. Those things are complex to explain in Portuguese… for me in a
foreign language is almost impossible! But I will try)
These
recent considerations are of interest to developmentalbehavioral
pediatricians in that
they focus on critical aspects
of
subsequent developmental outcomes.
Drs. David Sandberg and Tom Mazur are pediatric
psychologists who
specialize in the care of children and
adolescents with
endocrine disorders. They are members of
a
comprehensive clinical management team in pediatric
endocrinology at the
Children’s
Departments
of Psychiatry and Pediatrics, University at
Drs.
Sandberg and Mazur are involved in clinical research
on the
psychological adaptation of individuals with a
variety of
endocrine-related conditions and their families.
Dr. Erica Eugster is
a clinical associate professor of
pediatrics in the
section of pediatric endocrinology at
the
Dr. Jorge Daaboul is
an assistant professor of pediatrics in
the Division
of Pediatric Endocrinology at the University
of
ethical issues
that impact the early decision making in
children with intersex conditions.
Martin
T. Stein, M.D.
Professor
of Pediatrics
Children’s
Hospital San Diego
I would like to thank Martin Stein, for that so interesting introduction.
So correct, so perfect introduction to the problem.
Drs. David E. Sandberg and Tom Mazur
Don’t
be fooled—this rare case has more to teach than you
might think!
The infant is born with the extremely rare
condition of
penile agenesis (also known as aphallia).
Mortality
is high, because of associated urinary and gastrointestinal
tract problems;
however, complex forms of these
associations are
absent in this particular infant. Although
rare, the
case illustrates common challenges in the clinical
care of
patients with disorders of sexual differentiation
(‘‘intersex’’), in whom there is discordance among sex
chromosomes, gonads,
sex hormones, and phenotypic sex
(internal reproductive structure and external genital
appearance).
Thank you Tom for your words here. I like very much that
concept of different tissues, different aspects discordance, that generates intersexuality and also all dysphorias.
All dysphoria shows a discord, a lack of inner harmony.
Until
the mid-1950s, medical management of individuals
with intersex conditions was guided by the belief that an
individual’s ‘‘true
sex’’ could be revealed through examination
of internal
anatomy. It was assumed that a person’s
identification as male
or female would naturally conform to
‘‘true sex.’’
That “True Sex” concept is very important. I think it is more important than
we think today. Not as we considered in the past, thinking true was only
genital anatomy. That idea to resume sex as genitals, saying
that is true, is one of the most enrooted concepts in humam mind, because is inside us for millions of years, or
almost some cents of thousands of years, but it is not necessarily true. My MS
sexology dissertation was about it, but unfortunately, it is only in
Portuguese. But I think, we need really to find a
“true sex”, because each of us has a true sex, or live a true gender state:
male, female or androgynous, but surely, existentially for each of us, it is
true. Nowadays, we prefer to consider there exists a
"gender space", where humans live. The limits of that gender space
are Male(M) and Female(F), and we exist between these
limits.
Based
on reports suggesting that this assumption
was
incorrect, guidelines were changed, and sex assignment
decisions were
based on the principle of ‘‘optimal gender,’’
which
considered multiple aspects of outcome, most
prominently potential
for complete sexual functioning.3
That “Optimal Gender”, in my
philosophical point of view, is a good one, but may be used to disrespect the
autonomy and the right of each human being to exist in harmony as feels its
life and its sex and gender reality. The "Optimal Gender" is the
gender condition the patient feels and express. I prefer we consider the “True
sex”, or "Optimal Gender" not as something determined by genital
condition only, nor derived from a doctor's point of view or family's point of
view, but ONLY as one existential condition based on the PATIENT'S POINT OF
VIEW.
I think that
constructivist point of view, of social and anthropological construction of
gender identity as gender role playing and gender dichotomy as only a cultural
and ideological construction, is a very hard reduccionism,
reducing the human being as an object (reification), and not recognizing the
human rights of all humans as
persons, as a whole, with its autonomy.
This
approach, which stood largely uncontested until
recently,
Thank the Heavens, now it is changing!
is predicated on two
assumptions:4 (a)
‘‘gender
identity’’ (i.e.,
identification of self as either girl/woman or
boy/man)
is not firmly established at birth but rather is the
outcome of
rearing sex; and (b) stable gender identity and
positive
psychological adaptation require that genital
appearance match
assigned sex, which often calls for
reconstructive genital
surgery.
Tom, these two points of principle, are not “scientifical”, based in research and evidence, but
ideological, based in pre-conceptions. Based in Freud’s & Fliess
ideas, in XIX century! Based not in science, but in ideologic
points of principle!
That is the first
big problem of that old point of view: these two ideologic
principles. See, all the time, we have philosophical and ideological principles
in question, and never true science.
It is essential to distinguish
between gender
identity and other aspects of gender-related
behavior, which
may be influenced by prenatal hormones.
This
includes ‘‘gender role,’’ which refers to behaviors that
differ in
frequency or level between males and females in
this culture
and time (such as toy play or maternal interest),
and ‘‘sexual
orientation,’’ which refers to sexual arousal to
individuals of the
same sex (homosexual), opposite sex
(heterosexual), or both sexes (bisexual).
Here there is a very interesting mistake, also an ideological mistake.
And subreptitiously, the developers of these old
ideas, introduced
more “points of principle”, with no scientifical
evidences.
Money’s work, and later also Erhardt & Meyer-Bahlburg
paper (1980-Science), defined as Points of Principle, that the patterns of
playing are related to gender role playing, and not to gender identity. That is
never reasonable. If a cat miaw, it may not be a dog.
History and arqueology shows us also, that is not
true. In
Money &
fellows established, as another point of principle, gender identity was not
related to sexual hormones during gestation, but “gender roles”. That point of
principle, is also not scientific, but ideological. That was their definition,
but not the reality. And they based that conclusion, in the point of principle
that non human primates or mammals, had NOT a core
identity. Primatologists
today show chimpanzees (Pan trogloditas) and bonobos (Pan paniscus) have
surely a core identity.
All gender dysphoric victim shows all the time, during first
childhood, its inner tendencies, with its playing patterns. LATER, with not so
small age, the family, the others start interfering in that playing patterns,
and pressed to not show an unexpected or undesired gender identity &
expression, the child starts changing to a more palatable to others gender role
expression. A lot of victims show it through their anamnesis, and explain that situation
very well. And good science is based on evidences, through the external answer
of the patient, and not based on our personal models and ideologies.
So, there are
gender identity and gender roles. But surely, the hormones are important for
gender identities, and never for gender roles. Gender roles are truly role
playing… something socially constructed. Gender identity is inner feeling,
brain derived. Hormones may act on our brains, but not on our garments!
What feels in us?
Our brains!
Our selves are
the virtual creation of our brains!
The hormones may
act not in society, but in the children’s brains, so they may be important for
gender identities and never in gender role playing only, dissociated from the
brain expression as gender identity.
Those papers in
the 70’s and 80’s where very distorted ideological papers, and never were based
in scientifical evidences, but in the inner ideas of
the authors.
They fought
against a lot of evidences, from Imperato McGuinley, from Dorner, from Gorsky, from Swaab, etc, using
only ideological Points of Principles. Fortunately, now, we are not being so
misled by those points of principles.
The
clinical approach to disorders of sexual differentiation
(‘‘optimal
gender policy’’) has recently been
criticized from several
perspectives. First, the notion of
gender
‘‘neutrality’’ at birth has been challenged as a result
of a widely
publicized case.5 The
individual in this case
has a 46, XY
karyotype and was born with normally
formed male
genitalia. After a circumcision accident at the
age of 7
months left him without a penis, the child’s
gender was
reassigned, but not until 17 months, and the
child was
subsequently reared as a girl. This individual
(referred to as ‘‘John/Joan’’) has been studied extensively
as an adult.6 He reports having been
uncomfortable as a
girl
(‘‘gender dysphoric’’) and, starting at age 14 years,
began to live
as a male. He received a mastectomy and
began
testosterone replacement therapy in adolescence
followed shortly
after by phallic reconstruction. At age 25,
he married
and adopted the woman’s children. The gender
dysphoria and
ultimate sex reassignment of this individual
is believed
by some to have been predictable from
experimental studies
in animals in which exposure to
androgens during
sensitive periods of early brain development
is
associated with male-typical brain and behavioral
development.7
That David Reimer history is very
impressive. Surely, happened a scientific manipulation
of the results. The patient was all the time disrespected, because the ideas,
theories and ideologies were more important than reality. The Points of
Principle, were only ideological but not scientifical
ones.
Although
animal experimental research has
shown a
relation between prenatal androgen exposure and
sex-dimorphic
behavior, such studies have not examined
‘‘gender
identity’’ per se.8
That is a very important ideological
point of principle: Animals don’t have any identity, so they can't have gender
identity. That is a philosophical, ideological "absolutely old" point
of view. That is not science researching and evidence but bad ontology. On the
contrary, today, Damasio’s works in neurobiology, and
a lot of works in primatology from de Waal (see Bonobo, the forgotten ape, de Waal& Lanting,
1997, U California
Press) and a lot of others (mainly Walraven et
al,1995 ; Westergaard & Hyatt, 1994), show all
primates, including man, have a “core identity”, and in that core identity,
they show they feel male or female, they feel one gender identity. Obviously not as humans, but as someone. What we call male
or female primate behaviour, is their gender identity
expression. To ignore that humans are primates, was good for 1 or 2 centuries
ago... not nowadays when we see in a systemic way, we are a part of Nature as all
primates also are.
Each animal, each
organism, really each closure, organic closure, is a someone
and not a something. And
each one, in its own way, feels female or male. That is gender
identity. That surely is gender identity in man and other primates, and other
mammals.
When the animal shows its sexual answers through a lot of situations (as
a "behavior"), as the little child, they are showing and expressing
their gender identity, surely. Why not? So, all scientific evidences point
that way, and don’t agree with those old ideological Points of Principle.
The
impact of the John/Joan
case for
clinical practice is also tempered by the report of
another child
with a traumatic amputation of the penis with
considerably
different outcome.9
Are you sure, that "other
victim" will not one day say he suffered torture from family and doctors?
Or perhaps that other, and much other victim's had not
the same courage and the same chance to publish the misleading
"therapies" they suffered! After Colapinto's
book about David Reimer ("John/Joan") the big difference is, all old
idea was onbiously accepted as “science”, because
David’s results reported by Money and his co workers (those two old books) were
not real and and were used to give the experimental
background for these old “points of principle”. During a lot of time, during
the sixties, seventies and eighties……but now, when truth appeared, the castle
dismantled.
Today what we may say?
Sometimes, perhaps, may be, sex of
rearing may be important. But surely we may say, it is
not the determining factor to generate gender identity.
All those ideological points of principle
dismantled. We need now, to study hard, BASED IN SCIENCE AND EVIDENCES and
never more in our ideological points of principle, what is truly important in
gender identity determination.
As new “points of principle”, more
scientifically based ones, we have now:
1st: Gender identity is the
expression of our brains. We are the virtual construction of a self, from our
brains and body in one environment. Descartes was not correct (See Damasio’s “Descartes Error” and posterior papers). There is
no self, and no gender identity, without a neural brain behind. So, let’s
understand our brains, and discover how and when gender identity is formed in the
brain.
2nd: The gestational hormones
circulation, action, and activation, mainly testosterone and its metabolites,
play an essential role in that process. We are not sure how it works, but we
have a lot of evidences among other animals (Gorsky, Dorner, Swaab, Pfaff, etc), non
human primates (Resko, Bonsall,
Michael, Sholl, etc) human cadavers (Dorner, Swaab, Gorsky, McEwen, LeVay, etc) and
alive humans (Kawamura, etc), that gestational hormones are very important in
the human and other animal’s brains, in systems surely related to gender
identity (Newman,2000).
3rd: As the genital tissues
may have conformation problems, including cross gendered problems, as intersex conditions, why not the brains, as another part of
the body, could not have the same kind of problems?
4th: We know, today, thru
primates results (Bonsall, Michael, Resko, Roselli, etc), that in our
brains and our genitals, the hormone action IS NOT THE SAME! We have a lot of
results about that. So, if the processes involved are different, and the agents
are also different, why not could have different results, sometimes? Why a very
interesting study in that way never was developed? Why not?
5th: Another
interesting scientifical evidence: who masculinizes the genitals is DHT. Who masculinizes
the basal brain IS NOT DHT, but testosterone. And there may happen
a differential activation of the androgen receptor, by DHT and T (Pinsky& Kaufman, Gottliebe,
etc). So it is possible (only possible), that sometimes, in some transsexual
situations (not necessarily all), could happen a good action of DHT in the
genital tissue, but a not so good of T in the brain! No one, up until now,
studied that possibility, seriously. I tried to study it in
Tom I don’t know how is formed the gender
identity. Surely, a lot of inputs contribute in that existential formation. But
what I am sure is, that formation happens in the brain, mainly during pregnancy
(Clark,et al, 1988). After
birth…society, family, etc, modulate and limit gender identity expression and
living. And all that problem generates a lot of
existential problems, for all intersex, transsexuals
and all gender dysphorics, that live that kind of
discord as its inner reality. Others live not the inner discord, but their
brains are not absolutely sexed, as perhaps are not their genitals. What is
important to say is, we live not in an absolutely
sexed universe. The duality of the sexed hypothesis is not the reality but the
limits of a "gender space". "Normals"
are very simple and very sexed, as a default value, as M or F. Gender dysphorics may be, mainly transsexuals, an inner
discordance... a part goes to the M, others to the F... and only the self may
define if it is very sexed or mild sexed, and what is the prevalence M/F, if
there is a prevalence. Most TS have a strong prevalence, in discord with the
genitals. But some ISx may be much more
less sexed... as their genitals, their brains & minds may be not
very sexed. That may erect a special gender identity condition, in a point
between the M/F limits... and we sometimes may not be sure at what level will
be the "default" gender identity. Only the patient will define that
point set up, if any. The present case patient is not a real ISx, but a situation that probably all is more M than F...
so we may not decide for the baby... we may NOT do the simplest surgery to
change as a F... we need to wait the free and complete expression of the
child... probably here a more M than F.
As
an adult, the individual
maintains a female
gender identity, although she
exhibits
masculine occupational and recreational interests
and a
bisexual orientation.
A
second challenge to the ‘‘optimal gender’’ policy
comes from intersex individuals themselves, who are angry
about their
treatment.10
Here I think it is important to split
between the dysphoric or intersexual, and its family
and parents. The victim here, the patient here, for me, is the child, never the
family. So, what the intersex say? Wait please!
Because if you make a mistake, for you will be only statistics, books and
papers…. for the family will happens something disgusting and boring…. but for us,the gender dysphorics,
intersexual or transsexual, we will live a hell!
A lot of assigned
at childhood intersex remain insensible, anorgasmic….truly destroyed. They remain as gender dysphorics (MtF or FtM), and
sometimes, even without a gender dysphoria, they have a sexual dysphoria,
because they feel assexed people, without pleasure, without possibilities.
They hide themselves.
Here in
Why?
Because all they
need, is respect, and the right to be themselves, in
their way of living and suffering. What we may do for them? We may do, what
Money don’t did: respect their feelings. Their
feelings are more important than their families, than their schools and
neighbors, then their relatives, I say, even, for me their feelings are more
important than Law. Because our laws, sometimes are very
stupid and ignorant, because we are stupid and ignorant. But they may
not pay the price of our stupidity and ignorance.
They
object to the fact that they
were either
not informed or misinformed about their
condition, they
are still unable to obtain accurate information
about their
condition and treatment, and they feel
stigmatized and
shamed by the secrecy surrounding their
condition and its
management. Many also attribute poor
sexual function
to damaging genital surgery and repeated
and
insensitive genital examinations, both of which were
performed without
their consent.
Those are a mix up of feelings, between the victims and their families.
Finally,
social constructionists have challenged the entire
enterprise of
medical management of intersex cases by
arguing that
medical practices are rooted in history,
language,
politics, and culture, and therefore are not
universal
scientific facts.10 Thus,
the ‘‘correction’’ of an
intersexed
infant’s genitals is less a medical emergency than