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, Waleria Torres,MS,PhD.  A friendly discussion about points of principle, that may be important for gender dysphorias evaluation and treatment, and also for intersex.

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:


  • Who we, humans, are?                                                                                                                                                                     
  • What is the real gender of someone, who may define it?                                                                       
  • Is it the gender identity?                                                                                                                                                                               
  • The genitals?                                                                                                                                                                                               
  • The chromosomes or gonads?                                                                                                                                                                      
  • Could someone learn to be a boy or a girl?

THESE ARE THE REAL QUESTIONS….

Before these questions, we need to answer:

  • Are we animals or are we not animals?
  • Are we primates, as a result of Nature diversity and evolution?
  • Are we special God’s creatures, or we are primates that have a very developed neural system?
  • Was Descartes right making a radical split between body (res extensa) and mind (res cogitans)?
  • Are really correct our medical and psychological points of view, so Cartesian ones?
  • Perhaps, may not our difficulties start in those base philosophic questions? Truly ontological ones?
  • REALLY ARE NOT OUR DIFFICULTIES BASED IN OUR POINTS OF PRINCIPLE?

    So, my POINT OF VIEW is a little bit different from all you explained in that paper over which we will base our debate.  I think my commentaries may be interesting, because I don’t agree with almost nothing in that paper. So, I, perhaps, have something to add, another point of view to add to the overall question of gender.

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 6 pounds 5 ounces.

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 Hospital of Buffalo and the

Departments of Psychiatry and Pediatrics, University at

Buffalo School of Medicine and Biomedical Sciences.

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 Riley Hospital for Children in Indianapolis, Indiana.

Dr. Jorge Daaboul is an assistant professor of pediatrics in

the Division of Pediatric Endocrinology at the University

of Florida, College of Medicine. Dr. Daaboul has studied

ethical issues that impact the early decision making in

children with intersex conditions.

Martin T. Stein, M.D.

Professor of Pediatrics

University of California San Diego

Children’s Hospital San Diego

San Diego, California

 

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 India and Pakistan, in Mohenjodaro and Mergharth excavations of pre-Vedic cultures, probably Drawidian, they discovered a lot of typical female ornaments for ears  etc.. with more than 8000 years. The same occurred in Egypt, in pre-dynastic Egypt, in Naqada culture, some 7000 years ago. Women, in all cultures, like to feel beautiful and desirable, etc… independent of culture, but dependent of ... what? Gender identity...! They feel women, and they intend to feel beautiful women... due to their inner self perception. So gender expression and gender identity are related... and are not related only when there are external factors acting... as for example fear and shame.

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 Brazil, but the universities here denied that possibility to me.

 

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 Brazil, a TV channel asked me to show some intersex and hermaphrodites, to interview them in a talking show. I said them, NO! It is impossible, it would be very aggressive against them! They exist, I have a lot of patients that suffer that kind of sufferings, but they may never be socially exposed that way.

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<