arrFiles=new Array();arrFiles[0]=new Array("http://www.gendercare.com/library/debate.html","A Newborn Infant with a Disorder of","Cliente Normal Cliente 2 267 2003-06-10T09:06:00Z 2003-06-10T09:06:00Z 18 7407 42222 Uso Particular 351 84 51851 9.2812 21 0 0 Hi,We are starting now a discussion or Debate about Gender Identity (GI) and Gender Dysphorias (GD), mainly related to intersex (Isex), but not only for intersex. That discussion, that ideas exchanging, 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 don \'t answered 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 discussion, or debate, or exchanging of ideas, 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 red ones), and waiting more answers from Tom.Below is one form. If you would like to send us your opinions about those 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!WalSee another DEBATE related with those subjects, named: Transsexual GD (Gender Dysphoria) may be related to MAIS (minimum androgen insensitivity syndromes), sometimes?And see here another very interesting and special one, about Bailey \'s book about transsexualism, based in a paper by M.Italiano:Bailey \'s \"at it again \"-the omission and distortion of BSTc findingsDebate: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 thetext, my commentaries. My English is not very good, so pardon me a lot ofEnglish mistakes.In between your paper text, always in red, I willshow you my ideas about each particular comment or phrase, you wrote and theothers also.I hope, after it, you will understand reallywhat are my ideas about those subjects.First of all, I think it is not a medical,nor a psychological, nor social or familiar problem, but is a question of life,of living, of possible happiness of someone. If we make a mistake, theconsequence may remains forever as a torture. In those gender dysphoriassituations, intersex, transsexual, or any other situation, what is in debate islife, is possibility of life, or a perennial desiring for death.I wrote in Portuguese, some time ago: Nomedical doctor, no psychologist, no psychiatrist, no anthropologist  or sociologist, if never lived that reality,could really understand what is a gender dysphoria. Because gender dysphoriamay be a continuous destructive process, sometimes with no  hope. You feelyourself a kind of “Frankenstein”, or “ET”, or “Edward hands of scissors” asone existential syndrome.Almost all the time, we think those situations as medical, social,familiar, psychological but we don’t remember, first of all, it is anexistential, so ethical and philosophical problem.In my point of view, we have a big PHYLOSOPHICAL problem, and to solveit we will need to solve first that question: Who we, humans, are? What is the real sex (or gender) of someone? Thegender identity? The genitals? The chromossomes or gonads? The rearing? Thegender role playing in society?Phylosophically, what is the real sex ofsomeone? THAT IS THE REAL QUESTION.Before that question, we need to answer:Are we animals or are we not animals? Are weprimates, as the others? Are we special God’s creatures, or we are animals thathave a very developed neural system?And another question: Was Descartes rightmaking a radical split between body (res extensa) and mind (res cogitans)? Arereally correct our medical and psychological points of view, so Cartesian ones?Perhaps, may not our difficulties start inthose base questions, philosophic ones? Truly ontological ones? REALLY ARE NOTOUR DIFFICULTIES BASED IN OUR POINTS OF PRINCIPLE?So, my POINT OF VIEW is a little bitdifferent from all you explained in that paper.  I think my commentaries may be interesting, because I don’t agreewith noone that commented that situation, here, in that paper. So, I, perhaps,have something to add, another point of view to add to the overall question ofgender.WaleriaA Newborn Infant with a Disorder ofSexual DifferentiationCASE: Following an uncomplicated 38 weekspregnancy, a normal labor, and delivery with Apgar scores 8and 9 at 1 and 5 minutes, respectively, a newborn was delivered with abirth weight of 6 pounds 5 ounces.The physical examination was unremarkable, except for complete absenceof the penis. The scrotumappeared normal with bilateral palpable gonads of normal size. A voidingcystourethrogram demonstrated anormal bladder without uretero-vesical reflux; the contrast studyrevealed that urine partially emptied into therectum and colon. The urethral meatus was positioned at the anterioranal verge. Karyotype was 46 XY. Thisis the third child for this couple. They have a 4-year-old boy and a6-year-old girl.To which sex should this infant be assigned? Accompanying decisionsconcern disclosure of information topatient and family (what should be disclosed about the condition and itstreatment and when?); surgery tohave the genitalia match the sex assignment, or alternatively, femalegenital anatomy (what should be doneand when?); psychological support of the patient and family (who shouldprovide it and what model of careshould be followed?); and involvement of other family members andfriends (should they be told, and if so,what should they be told and when?). JDev Behav Pediatr 24:115 –119, 2003. Index terms: ambiguousgenitalia, sexdifferentiation, intersex, biomedical ethics,penile agenesis.As all intersex situations, that also is adisgusting one.Dr.Martin T. SteinThischallenging case is a rare condition that will not beencounteredby most pediatricians. However, it represents adramaticexample of other more common conditionsdiscoveredin the newborn period associated with ambiguousgenitalia.Primary care pediatricians are often the firsttorecognize the structural abnormalities in the externalgenitaliaand the first to speak to the parents about thecondition.A knowledge of genetic and endocrinologicalprinciplesthat modulate fetal sex differentiation is essentialbutinsufficient to provide comprehensive information totheparents. The influence of fetal sex hormones on genderidentityand the incorporation of principles of patient rightsandpatient autonomy are additional areas of knowledgerequiredto guide therapeutic decision making.That last phrase, for me, is the mostimportant, perhaps, in that paper: The influence of fetal sex hormones ongender identity…. the incorporation of principles of patient rights….. andpatient autonomy.Those 3 aspects, for me, are the mostimportant in all gender dysphorias situations, intersex or any other: rememberthe hormone action during pregnancy….... respect the patient’s rights and respect the personautonomy.Understand the first, and recognize thesecond and the third, that is the way, surely, to understand better all thosesituations.But who is the patient? The child, the baby,the intersex or gender dysphoric, AND NOT its family.Avariety of new concepts about newborns with intersexconditionshave surfaced in the medical and bioethicalliterature.They reflect recent knowledge about the complexityofgender identity and gender role, bioethical considerations,andthe influence of patient advocacy groups.Gender identity and gender role. And theinfluence of patient advocacy groups.As you will see, I think the most part ofour difficulties start when we mix up gender identity with gender role playingin society, as a point of principle. And all the time, we are mixing them up,in the next 50 years.Another note is: why need the patients to have advocacy groups? Surely becausethey feel as victims of someone, or something. Only someone that thinks he hasrights, 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 (pardonme my English. Those things are complex to explain in Portuguese… for me in aforeign language is almost impossible! But I will try)Theserecent considerations are of interest to developmentalbehavioralpediatriciansin that they focus on critical aspectsofsubsequent developmental outcomes.Drs. David Sandberg and TomMazur are pediatricpsychologistswho specialize in the care of children andadolescentswith endocrine disorders. They are members ofacomprehensive clinical management team in pediatricendocrinologyat the Children’s Hospital of Buffalo and theDepartmentsof Psychiatry and Pediatrics, University atBuffaloSchool of Medicine and Biomedical Sciences.Drs.Sandberg and Mazur are involved in clinical researchonthe psychological adaptation of individuals with avarietyof endocrine-related conditions and their families.Dr. Erica Eugster is a clinical associate professor ofpediatricsin the section of pediatric endocrinology attheRiley Hospital for Children in Indianapolis, Indiana.Dr. Jorge Daaboul is an assistant professor of pediatrics intheDivision of Pediatric Endocrinology at the UniversityofFlorida, College of Medicine. Dr. Daaboul has studiedethicalissues that impact the early decision making inchildrenwith intersex conditions.MartinT. Stein, M.D.Professorof PediatricsUniversityof California San DiegoChildren’sHospital San DiegoSanDiego, CaliforniaI would like to thank Martin Stein, forthat so interesting introduction. So correct, so perfect introduction of theproblem.Drs.David E. Sandberg and Tom MazurDon’tbe fooled—this rare case has more to teach than youmightthink! The infant is born with the extremely rareconditionof penile agenesis (also known as aphallia).Mortalityis high, because of associated urinary and gastrointestinaltractproblems; however, complex forms of theseassociationsare absent in this particular infant. Althoughrare,the case illustrates common challenges in the clinicalcareof patients with disorders of sexual differentiation(‘‘intersex’’),in whom there is discordance among sexchromosomes,gonads, sex hormones, and phenotypic sex(internalreproductive structure and external genital appearance).Thank you Tom for your words here. Ilike very much that concept of different tissues, different aspectsdiscordance, that generates intersexuality and also all dysphorias. All dysphoriashows a discord, a lack of inner harmony.Untilthe mid-1950s, medical management of individualswithintersex conditions was guided by the belief that anindividual’s‘‘true sex’’ could be revealed through examinationofinternal anatomy. It was assumed that a person’sidentificationas male or female would naturally conform to‘‘truesex.’’That “True Sex” concept is veryimportant. I think it is more important than we think today. Not as weconsidered in the past, thinking true was only genital anatomy. That idea toresume sex as genitals, saying that is true, is one of the most difficultconcepts in humam mind, because is inside us for millions of years, or almostsome cents of thousands of years. My MS sexology dissertation was about it, butunfortunately, it is only in Portuguese. But I think, we need really to find a“true sex”, because each of us has a true sex: male, female or androgynous, butsurely, existentially for each of us, it is true.Basedon reports suggesting that this assumptionwasincorrect, guidelines were changed, and sex assignmentdecisionswere based on the principle of ‘‘optimal gender,’’whichconsidered multiple aspects of outcome, mostprominentlypotential for complete sexual functioning.3That“Optimal Gender”, in my philosophical point of view, is a way to non respectthe autonomy and the right of each human being to exist, and exist as feels itslife and its sex and reality. I prefer we continue looking for the “True sex”,not anymore as a genital condition, but as one existential condition.I think that constructivist point of view,of social and anthropological construction of gender identity as gender roleplaying 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.Thisapproach, which stood largely uncontested untilrecently,Thank the Heavens, now it is changing! is predicated on two assumptions:4 (a) ‘‘genderidentity’’(i.e., identification of self as either girl/woman orboy/man)is not firmly established at birth but rather is theoutcomeof rearing sex; and (b) stable gender identity andpositivepsychological adaptation require that genitalappearancematch assigned sex, which often calls forreconstructivegenital surgery.Tom, those two points of principle, arenot “scientifical”, based in research and evidence, but ideological, based inpre-conceptions. Based in Freud’s  &amp;Fliess ideas, in XIX century! Based not in science, but in ideologic points ofprinciple, too!That is the first big problem of that oldpoint of view: those two ideologic principles. See, all the time, we havephilosophical and ideological principles in question, and never true science. It is essential to distinguishbetweengender identity and other aspects of gender-relatedbehavior,which may be influenced by prenatal hormones.Thisincludes ‘‘gender role,’’ which refers to behaviors thatdifferin frequency or level between males and females inthisculture and time (such as toy play or maternal interest),and‘‘sexual orientation,’’ which refers to sexual arousal toindividualsof the same sex (homosexual), opposite sex(heterosexual),or both sexes (bisexual).Here there is a veryinteresting mistake, also an ideological mistake. And subreptitiously, thedevelopers of those ideas,  introducedmore “points of principle”, without any scientifical evidences.Money’s work, and later alsoErhardt  &amp; Meyer-Bahlburg paper(1980-Science), defined as Points of Principle, that the patterns of playingare related to gender role playing, and not to gender identity. History andarqueology shows us, that is not true. In India and Pakistan, in Mohenjo –daroand Mergharth excavations of pre-Vedic cultures, probably Drawidian, theydiscovered a lot of typical female ornaments for ears  etc.. with more than 8000 years. The same occurred in Egypt, inpre-dynastic Egypt, in Naqada culture, some 7000 years ago. Women, in allcultures, like to feel beautiful and desirable, etc… independent of culture,but dependent of gender identity.And they established, as another point ofprinciple, gender identity was not related to sexual hormones during gestation,but “gender roles”. That point of principle, is also not scientific, butideological. That was their definition, but not the reality.And they based thatconclusion, in the point of principle that any non human primate or mammal, hada core identity. Primatologists today show chimpanzees and bonobos have surelya 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 playingpatterns, and from gender identity expression, the child starts changing to agender role expression. A lot of victims show it thru their anamnesis, andexplain very well it. And good science is based on evidences, thru the externalanswer of the patient, and not based in our internal models and ideologies.So, there are gender identity and genderroles. But surely, the hormones are important for gender identities, and neverfor gender roles. Gender roles are truly role playing… something sociallyconstructed. Gender identity is inner feeling.What feels in us?Our brains!Our selves are the virtual creation of ourbrains!The hormones may act not in society, but inthe children’s brains, so they may be important for gender identities and neverin gender role playing.Those papers in the 70’s and 80’s where verydistorted ideological papers, and never were based in scientifical evidences,but in the inner ideas of the authors.They fought against a lot of evidences, fromImperato McGuinley, from Dorner, from Gorsky, from Swaab, etc, using onlyideological Points of Principles. Fortunately, now, we are not being so misledby those points of principles.Theclinical approach to disorders of sexual differentiation(‘‘optimalgender policy’’) has recently beencriticizedfrom several perspectives. First, the notion ofgender‘‘neutrality’’ at birth has been challenged as a resultofa widely publicized case.5 Theindividual in this casehasa 46, XY karyotype and was born with normallyformedmale genitalia. After a circumcision accident at theageof 7 months left him without a penis, the child’sgenderwas reassigned, but not until 17 months, and thechildwas subsequently reared as a girl. This individual(referredto as ‘‘John/Joan’’) has been studied extensivelyasan adult.6 Hereports having been uncomfortable as agirl(‘‘gender dysphoric’’) and, starting at age 14 years,beganto live as a male. He received a mastectomy andbegantestosterone replacement therapy in adolescencefollowedshortly after by phallic reconstruction. At age 25,hemarried and adopted the woman’s children. The genderdysphoriaand ultimate sex reassignment of this individualisbelieved by some to have been predictable fromexperimentalstudies in animals in which exposure toandrogensduring sensitive periods of early brain developmentisassociated with male-typical brain and behavioraldevelopment.7ThatDavid Reimer history is very impressive. Surely, happened a scientificmanipulation of the results. The patient was all the time disrespected, becausethe ideas, theories and ideologies were more important than reality. The Pointsof Principle, were only ideological but not scientifical ones. Althoughanimal experimental research hasshowna relation between prenatal androgen exposure andsex-dimorphicbehavior, such studies have not examined‘‘genderidentity’’ per se.8That isa very important ideological point of principle: Animals don’t have anyidentity, so they cant have gender identity. That is a philosophical,ideological point of view. That is not science researching and evidence. On thecontrary, today, Damasio’s works in neurobiology, and a lot of works inprimatology from de Waal (see Bonobo, the forgotten ape, de Waal&amp; Lanting,1997,  U California Press) and a lot ofothers (mainly Walraven et al,1995 ; Westergaard &amp; Hyatt, 1994), show allanimals, including man, have a “core identity”, and in that core identity, theyshow they feel male or female, they feel one gender identity. Obviously not ashumans, but as someone.Each animal, each organism, really eachclosure, organic closure, is a someone and not a something. And  each one, in its own way, feels female ormale. That is gender identity. That surely is gender identity in man and otherprimates, and other mammals.When the “animal shows its sexual answersthru a lot of situations, as the little child, they are showing and expressingtheir gender identity, surely. Why not? So, all scientific evidences point thatway, and don’t agree with those old ideological Points of Principle. Theimpact of the John/Joancasefor clinical practice is also tempered by the report ofanotherchild with a traumatic amputation of the penis withconsiderablydifferent outcome.9The big difference is, all old idea was accepted as “science”,because David’s results reported by Money and his co workers (those two oldbooks) gave the experimental background for those “points of principle”. Duringa lot of time, during the sixties, seventies and eighties……but now, when truthappeared, the castle dismantled. Today what we may say?Sometimes, perhaps, may be, sex of rearing may be important. Butsurely we may say, it is not the determining factor to generate genderidentity.All those ideological points of principle dismantled. We need now,to study hard, BASED IN SCIENCE AND EVIDENCES and never more in our ideologicalpoints of principle, what is truly important in gender identity determination.As new “points of principle”, more scientifically based ones, wehave now:1st: Gender identity is the expression of our brains. Weare the virtual construction of a self, from our brains and body. Descartes wasnot correct (See Damasio’s “Descartes Error” and posterior papers). There is noself, and no gender identity, without a neural brain behind. So, let’sunderstand our brains, and discover how and when  gender identity is formed in the brain.2nd: The gestational hormones circulation, action, andactivation, mainly testosterone and its metabolites, play an essential role inthat process. We are not sure how it works, but we have a lot of evidencesamong 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 hormonesare very important in the human and other animal’s brains, in systems surelyrelated to gender identity (Newman,2000).3rd: As the genital tissues may have conformationproblems, including cross gendered problems, as intersex conditions, why notthe brains, as another part of the body, could not have the same kind ofproblems?4th: We know, today, thru primates results (Bonsall,Michael, Resko, Roselli, etc), that in our brains and our genitals, the hormoneaction IS NOT THE SAME! We have a lot of results about that. So, if theprocesses involved are different, and the agents are also different, why notcould have different results, sometimes? Why a very interesting study in that way never was developed? Why not?5th: Another interesting scientifical evidence: whomasculinizes the genitals is DHT. Who masculinizes the brain IS NOT DHT, buttestosterone. And there may happen a differential activation of the androgenreceptor, by DHT and T (Pinsky&amp; Kaufman, Gottliebe, etc). So it is possible(only possible), that sometimes, in some transsexual situations (not necessarilyall), could happen a good action of DHT in the genital tissue, but a not sogood 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 thatpossibility to me.Tom I don’t know how is formed the gender identity. Surely, a lot ofinputs contribute in that existential formation. But what I am sure is, thatformation happens in the brain, mainly during pregnancy (Clark,et al, 1988).After birth…society, families, etc, modulate and limit gender identityexpression and living. And all that problem generates a lot of existentialproblems, for all intersex, transsexuals and all gender dysphorics, that livethat kind of discord as its inner reality. Asan adult, the individualmaintainsa female gender identity, although sheexhibitsmasculine occupational and recreational interestsanda bisexual orientation.Asecond challenge to the ‘‘optimal gender’’ policycomesfrom intersex individuals themselves, who are angryabouttheir treatment.10Here Ithink it is important to split between the dysphoric or intersexual, and itsfamily 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 amistake, for you will be only statistics, books and papers…. for the familywill happens something disgusting and boring…. but for us,the genderdysphorics, intersexual or transsexual, we will live a hell!A lot of assigned at childhood intersexremain insensible, anorgasmic….truly destroyed. They remain as genderdysphorics (MtF or FtM), and sometimes, even without a gender dysphoria, theyhave a sexual dysphoria, because they feel assexed people, without pleasure,without  possibilities.They hide themselves. Here in Brazil, a TVchannel asked me to show some intersex and hermaphrodites, to interview them ina talking show. I said them, NO! It is impossible, it would be very aggressiveagainst them! They exist, I have a lot of patients that suffer that kind ofsufferings, but they may never be socially exposed that way.Why?Because all they need, is respect, and theright to be themselves, in their way of living and suffering. What we may dofor them? We may do, what Money don’t did: respect their feelings. Theirfeelings are more important than their families, than their schools andneighbors, then their relatives, I say, even, for me their feelings are moreimportant 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 ourstupidity and ignorance. Theyobject to the fact that theywereeither not informed or misinformed about theircondition,they are still unable to obtain accurate informationabouttheir condition and treatment, and they feelstigmatizedand shamed by the secrecy surrounding theirconditionand its management. Many also attribute poorsexualfunction to damaging genital surgery and repeatedandinsensitive genital examinations, both of which wereperformedwithout their consent.Those are a mix up of feelings, betweenthe victims and their families.Finally,social constructionists have challenged the entireenterpriseof medical management of intersex cases byarguingthat medical practices are rooted in history,language,politics, and culture, and therefore are notuniversalscientific facts.10 Thus, the‘‘correction’’ of anintersexedinfant’s genitals is less a medical emergency thanitis the adoption of medical technology to support a culturalimperativeto view the sexes as dichotomous. Supporters ofthispoint of view contend that such beliefs result inunnecessaryand damaging surgery.I don’t agree with their ideologicpoints of view, but I agree with the results. Wait the child manifestation.Assign a “preliminary” sex, a social rearing in one sex, in a very androgynousand light way… the child need to show who he/she is, and if we respect and loveand permit it, it will happen…. Because the brain is there…. And it will showthe inner reality. Only after a free and express solicitation of the child, Ithink , a “final sex” may be defined, including genitally. And improve yoursurgeries, please! To live without erotic and sensual possibilities, surely istoo hard! Respect the autonomy of the victims!Howshould a decision regarding sex assignment bereachedin the present case? Until recently, most childrenwithaphallia would receive a female sex assignment.That surely is the worse decisionpossible. Why? Because possibly the brain had not the same genital problems, weare not sure.What I suggest to do today in thataphallia  situation?Possibly the brain is male. Startrearing, in a light way, as a male. And wait. One day, if we know how toobserve the child really, not in front of others, but when alone (the genderdysphoric lives all the time hiding from others – based in that characteristicI propose the development of Gendercare Game-Tests for diagnosis of dysphoriain little children). Playing our game, the child feel alone, and showitself…and we receive electronically the results, thru the web. So, after timeor our test (to gain some years), we may decide who he/she is. And ask them,what they would like to be…etc..Only after that process, until we have abetter brain diagnostic, if we will have one one day, we could, respecting thechild as a person, with a life and a future, see if we will adapt a surgery ornot (good quality surgeries, please!)Accordingly,the testicles would be removed and genitalsurgeryperformed to create the outward appearance offemalegenitalia, that is, labia and clitoris. Surgicalconstructionof a vagina might be performed at this timeorbe postponed until adolescence. A feminizing puberty(developmentof breasts and feminine body) would beachievedthrough the administration of estrogen therapybeginningin the early teenage years. It has been thought thatthisapproach would maximize the individual’s psychologicaladaptation,including gender identity, body image, andsexualfunction.That would be a very dangerous situationfor the child. And a lot of times, as a lot of other gender dysphorics, withshame and fear, they never will openly admit their sufferings. I am sure, themost part of the “good” feminization solutions that way, are not real, but isan inner torture for the victim. Ashamed, fearing life, parents, and all, theyclose in themselves, as the gender dysphorics most part of the time do. Conversely, delaying or avoiding surgicalconstructionof female external genitalia would potentiallyjeopardizethe formation of an unambiguous gender identitybecauseof the incongruence between gender rearing andgenitalappearance.That is not true. That is a Myth. A myththat now need to be reviewed, as soon as possible. An alternative decision might be to rearthisinfant as a male (consistent with his gonadal sex)becauseprenatal testosterone has presumably ‘‘organized’’thebrain, foreclosing identification as a female. Phalloplastymightthen be considered, although the challenges ofthisoption are daunting and it has only rarely beenattempted.The option of not attempting to provide thechildwith a phallic structure would potentially jeopardizestablegender identity formation.A lot od FtM transsexuals live thatreality. They are men, they feel they are men, and live as men, and play malegender roles in society. But don’t have male genitals, because the surgeriesare not so surely good, and the good ones are so expensive. BUT SURELY THEY AREMUCH MORE HAPPY LIVING AS MALES WITH PROBLEMS, THAN AS FEMALES. Because theyare males, they always were males.Giventhe dearth of systematic information on long-termoutcomein individuals with aphallia and other formsofintersexuality, how should this clinical problem beresolved?How are the parents to be involved in thedecision?What information do they need to make informedFirst we were too impressed by ourpoints of principle, ideological ones. Then we are impressed by medicineprinciples. Then, by society, and now respecting too much the families. Surely,dialectically we are improving a little. But THE MOST IMPORTANT WE AREIGNORING: THE CHILD’S RIGHTS. The child as one whole human being, not the partof a family. That is the main idea: respect the human being, as a child. It isnot important what is good for our ideas. Or the Law, or society. Nor thefamily and parents. What is important is the human being, and the baby is awhole, an human being. Let’s start respecting it. How?We have a lot to do:1st: scientifical research of thebrains and gender identity, thru fMRI, molecular biology, hormone action andexpression, etc.2nd: start changing social andlaw principles: Genitals don’t define sex, nor society and role learning. Noone learns to be a boy or a girl, but what someone may learn is to play thefemale or male gender role, society suggest you would live. So we need to startestablishing “preliminary sex assignment”, that later, in intersex andtranssexual cases, could be reviewed and corrected.(some decades ago, I was a horse farmer,also. As a hobby, I had Arab horses, very good champions in Brazil, from Egyptlineage. When a foul had birth, we send to the Stud Book, the “preliminaryregistration”. Here, obviously the problem is not sex, but lineage. More orless 2 to 3 years later, an expert from the Stud Book analyses the stallion ormare, to see if it  is a true Arab ornot. The horse shows who he is , by his characteristics, measures, etc.. If allis ok, we have the final registration document, if not, that animal is notconsidered a pure breed Arab. And the preliminary registration is changed, andthe animal is a “mixed arab”, or even nothing.)If the arab horses, as the throughbreed  and Andaluzian horses have that right, whynot could have that possibility our law to protect our children?decisionson behalf of their child? Rare as this case is, it hasmuchto teach us. Questions emerge regardless of whethertheinfant is assigned a gender and reared as a boy or as agirl.(We acknowledge Dr. Sheri Berenbaum’s constructivecommentson a draft of this commentary.)DavidE. Sandberg, PH.D.PediatricPsychiatry and PsychologyChildren’sHospital of BuffaloTomMazur, Psy.D.PediatricEndocrinologyChildren’sHospital of BuffaloBuffalo,New YorkREFERENCES1. Grumbach M, Conte FA. Disorders of sexdifferentiation. In: WilsonJD, Foster D, eds. Williams Textbook of Endocrinology. 9th ed.Philadelphia, PA: WB Saunders; 1998:1303– 1425.2. Melton L. New perspectives on the management ofintersex. Lancet.2001;357:2110.3. Money J. SexErrors of the Body and Related Syndromes. Baltimore,MD: Paul H. Brookes Publishing Co.; 1994.4. Zucker K. Intersexuality and gender identitydifferentiation. AnnuRev Sex Res.1999;10:1– 69.5. Colapinto J. As Nature Made Him. New York, NY:HarperCollinsPublishers; 2000.6. Diamond M, Sigmundson HK. Sex reassignment atbirth. Long-termreview and clinical implications. Arch Pediatr Adolesc Med. 1997;151:298– 304.7. Goy RW, McEwen BS. Sexual Differentiation of the Brain.Cambridge, MA: MIT Press; 1980.8. Collaer MA, Hines M. Human behavioral sexdifferences: a role forgonadal hormones during early development? Psychol Bull. 1995;118:55–107.9. Bradley SJ, Oliver GD, Chernick AB, Zucker KJ.Experiment ofnurture: ablatio penis at 2 months, sex reassignmentat 7 months, anda psychosexual follow-up in young adulthood. Pediatrics.1998;102:e9.10. Kessler SJ. Lessons from the Intersexed. New Brunswick, NJ:Rutgers University Press; 1998.Dr.Erica EugsterThiscase represents one of the most difficult situationsfacedby parents and health care professionals involved inthecare of infants born with an intersex condition. See, all expectation is over health careprofessionals and family….AND THE VICTIM? The child is not a human being, butonly a parent’s property, or a family’s part?Unlikemanyother conditions that result in undervirilization of ageneticmale, the 46, XY infant with isolated aphallia waspresumablyexposed to normal levels of male testosteroneduringintrauterine life. A major concern revolves aroundtheeffect of prenatal androgen exposure on ‘‘masculinization’’ofthe brain and ultimate gender identity.If all our body parts and tissues may befemale or male, and not only the genitals: why not the brain? The brainmasculinization, or not, is a reality for all other primates and all mammalsstudied…. Are we not mammals? Not animals? Not primates? Are we Jupiter’s idea,or created by the Jewish and Christian God? Or by Allah? Or by the AfricanYoruba Gods? Or by Brahma, Vishnu and Shiva?Whatcan we learn from the literature regarding sexassignmentandoutcomes in similar cases? Congenitalabsenceof the penis is extremely rare, with fewer than 100casesreported. Although female sex-reassignment and earlybilateralorchiectomy historically have been consideredstandard-of-carefor these patients, follow-up studies focusprimarilyon success of surgical procedures rather thanpsychosexualdevelopment and function.1 Inthe few casereportsof aphallia in which a male gender was assigned,2limitedinformation is available regarding psychologicaladaptationand long-term satisfaction.I fear those “long term satisfactionsurveys”. Money manipulated all the time the “long term satisfaction” of DavidReimer. That tendency was not Money’s but is human, our tendency. Our ideas anttheories absorb us in a way, that at the minimun possibility we say, it isconfirmed! She is a very helpful female!But a lot of times, men think their womenwere also very happy, until the day they flew with the neighbor, or ask fordivorce. And vice versa.So, I don’t believe really in those“studies”, mainly because I know how a gender dysphoric may hide the reality,for dozens of years, and sometimes for life.Anotherstrategy is toattemptto extrapolate from similar populations of 46, XYpatientswith apparently normal early prenatal testicularfunction,such as those with micropenis or traumatic penileloss.Although there are reports of normal male genderidentityand fulfilling heterosexual activity in such patients,3femalegender role and satisfaction with sex-of-rearing havealsobeen reported in a small number of individuals.4Truly,very small amount….and please, remember Imperato MacGinleys data from CostaRica!Afew sensationalized cases of extreme gender dysphoriaandpatient groups advocating a moratorium on earlygenitalsurgery have encouraged the medical community torecognizethe critical need for long-term outcome data onintersexpopulations.For her they were sensationalized,because she was not among them. That sort of disrespect, today, is no moreacceptable, please!  However, the few existing studies oftheclaims made by intersex support groups have beenlimitedby small sample size and selection bias.5Hereshe shows her ideological bias.Therefore,wefind ourselves currently in a situation with far morequestionsthan answers. How, then, should we begin toaddressthis challenging case?Oncethe medical diagnosis has been established, parentsofan infant with intersex should be given a comprehensiveandexplicit explanation of normal and abnormal sexualdifferentiation.Considering the paucity of scientificallyvalidatedoutcome data in the management of intersex, allavailableinformation should be shared, including that whichhasbeen highly publicized and is arguably biased. Aconsistentsource of dissatisfaction among adult intersexuals,evenamong those for whom the psychosexual outcomeappearsfavorable, has been the lack of disclosure bymedicalprofessionals (and often parents) regarding theirdiagnosisand treatment. The perceived secrecy can beexperiencedas shame. The ideal time at which to establish acultureof full disclosure is in the initial discussions withparents.At that time, information should be provided aboutthediagnosis and options regarding sex assignment andsurgery.Surgical options for this challenging case includethetechnically difficult phalloplasty6 orthe easier vaginoplasty.7–8 Each procedure is associated with short-and longtermcomplications.All options should be considered in thecaseof the infant with aphallia. If the child is reared male,thereis the potential for endogenous steroidogenesis andfertility,whereas if the child is reared female, hypogonadismandinfertility are guaranteed.Athird option promoted by patient advocacy groupswouldbe to rear the child as either a boy or as a girl, butdefergonadectomy and genital surgery until the child canindependentlyprovide informed consent.9 However,earlygonadectomyshould be considered in cases of a female sexassignmentin light of the postnatal rise of testiculartestosteronethat may further masculinize sex-dimorphicregionsof the brain. Gender-validating surgery has longbeenconsidered crucial to the development of uncomplicatedgenderidentity. However, a widely publicized casereportof a boy with traumatic amputation of the penisrearedas a girl after feminizing genital surgery10 and theexampleof physically normal transsexuals who request sexreassignmentillustrate that genital appearance consistentAll her preoccupations are with societyand family. For her, the child is more one thing than one person. Truly she isliving in the xxth or even the xIxth century, ideologically and ethically.withrearing gender is not a guarantee against the developmentofgender dysphoria later in life.Inlight of contemporary controversy, few would hazardtheassertion that there is an absolute ‘‘right’’ or ‘‘wrong’’answerregarding optimal sex assignment in this case.Nonetheless,honesty and empathy go far in establishing anatmosphereof trust within which the parents may becomefullparticipants in the decision-making process. This goalcanbe facilitated by the inclusion of a mental healthprofessionalin the clinical care team. Necessary qualificationsofsuch a team member would be knowledge regardingtheprocess of physical sexual differentiation and itsdisorders,psychosexual development, and the potentialcontributionsof the social environment and biology toindividualvariability. In addition, this team member wouldhavemore general knowledge and experience in caringforchildren with congenital health problems and theirimmediateand extended families. This behavioral specialistcanprovide psychoeducational counseling at the time ofdiagnosisto support the objective of fully informed consentformedical management, including surgical decisions. Thementalhealth specialist would be available to parents and tothechild to provide on-going support to address inevitableconcernsregarding the correctness of the sex assignmentdecisionand to provide the parents with the skills to deliverdevelopmentallyappropriate education to the child regardinghis/hercondition and treatment. Although not yetsupportedby controlled studies, such a comprehensiveclinicalcare model holds the promise of enhanced quality oflifefor the affected individual and his/her family.EricaEugster, M.D.ClinicalAssociate Professor of PediatricsRileyHospital for ChildrenIndianapolis,IndianaREFERENCES1. Hendren WH. The genetic male with absent penis andurethrorectalcommunication: experience with 5 patients. J Urol. 1997;157:1469– 1474.2. Ciftci AO, Senocak ME, Buyukpamukcu N. Male genderassignmentin penile agenesis: a case report and review of theliterature. J PediatrSurg. 1995;30:1358–1360.3. Reilly JM, Woodhouse CRJ. Small penis and the malesexual role.J Urol. 1989;142:569–572.4. Wisniewski AB, Migeon CJ, Gearhart JP, Rock JA,Berkovitz GD,Plotnick LP, Meyer-Bahlburg HF, Money J. Congenitalmicropenis:long-term medical, surgical and psychosexual follow-upof individualsraised male or female. Horm Res. 2001;56:3–11.5. Dayner J, Witchel SF, Lee PA. Assessing care ofintersex patients:initial survey results. Pediatr Res. 2002;51(pt2):119A. Abstract.6. Ochoa B. Trauma of the external genitalia inchildren: amputation ofthe penis and emasculation. J Urol.1998;160:1116–1119.7. Creatsas G,Deligeoroglou E, Makrakis E, Kontoravdis A,Papadimitriou L. Creation of a neovagina followingWilliamsvaginoplasty and the Creatsas modification in 111patients withMayer-Rokitansky-Kuster-Hauser syndrome. Fertil Steril. 2001;76:1036– 1040.8. Krege S, Walz KH, Hauffa BP, Korner I, Rubben H.Long-termfollow-up of female patients with congenital adrenalhyperplasia from21-hydroxylase deficiency, with special emphasis onthe results ofvaginoplasty. BJU Int. 2000;86:253– 258.9. Diamond M, Sigmundson HK. Management ofintersexuality.Guidelines for dealing with persons with ambiguousgenitalia. ArchPediatr Adolesc Med. 1997;151:1046 –1050.10. Colapinto J. As Nature Made Him. New York, NY:HarperCollinsPublishers; 2000.Dr.Jorge J. DaaboulThiscase serves as a model for the current debate on themanagementof the child with ‘‘ambiguous genitalia’’ or, tousethe term that has acquired wide currency in the last fiveyears,with intersex. In the 1950s, a management strategyforchildren with intersex was formulated that included earlysexassignment with early surgical correction to assureconsonancebetween the assigned gender and the physicalappearanceof the child. To assure gender-appropriateparenting,parents were often not fully informed of thechild’scondition because it was felt that if the parents hadanydoubts about the child’s gender, they might send thechildmixed signals, resulting in an insecure genderidentity.1 With small modifications, this managementstrategyremained in place until the mid 1990s and is stillacceptedin many centers in the United States and aroundtheworld.2,3Inthe mid 1990s, social scientists, a number of intersexactivists,and some physicians called for a revision of thismanagementstrategy. The debate focused on managementstrategycontinues to this date. It has led physicians to bemoreopen and share more information with patients abouttheircondition and about the consequences of medicaland/orsurgical therapy. However, the focus of managementhasremained fixed on determining which medical and/orsurgicalinterventions will yield an optimal outcome foreachintersex condition. The general feeling is that thecurrentdebate on intersex will be resolved when theappropriateoutcome studies are done and that, when thesedataare generated, physicians will, in effect, be able to useanalgorithm to determine a child’s sex of rearing and theappropriatemedical and surgical interventions that the childwillrequire to make her/him a well-adjusted individual withasecure gender identity and adequate sexual function.AlthoughI believe that studies are important andnecessaryto establish the efficacy of the various medical,surgical,and psychological interventions that are used inthemanagement of the child with intersex, I believe that thedatawill yield results that confirm an enormous variabilityinhow individuals with identical intersex conditionsdeveloppsychologically. Even the limited studies available(e.g.,behavioral characteristics of girls with congenitaladrenalhyperplasia4) point to widely divergentoutcomes.Thereare conditions, such as complete androgen insensitivitysyndrome,where outcomes are almost universallypredictable.But for most intersex conditions, the psychologicaloutcomewill be so variable that, for each specificcase,the outcome will be unpredictable.Therefore,the current medical model with its focus ondiagnosisand medical-surgical treatment does not assure thebestpossible outcome for children with intersex conditions.Theappropriate care model is one in which the focus isshiftedaway from the precise medical diagnosis and towardstheparents’ conception of what their child has, what theybelievetheir child’s gender to be, and how they see theirchild’sfuture in the context of their family and of society.Eachset of parents, with their unique sociocultural beliefsandbackgrounds, would then make all decisions regardingthecare of their child. These decisions will be unique to eachfamilyand will reflect each family’s unique perspective ontheincredibly complex issues of sex and gender. This taskshouldbe facilitated by health care professionals expert inthefield of family counseling and child development whoare,in addition, familiar with intersex conditions.5Toapply this reasoning to the challenging case, there isno‘‘right’’ medical-surgical procedure for the infant withaphallia.Rather, after informing the family of what isknownand not known about the outcomes of this condition,thecaregiver should explore with the family members theirfeelingsabout what they believe is best for their child andrespecttheir decision.Insummary, it is my opinion that when all the outcomedataon intersex are collected and analyzed we will discoverthatthere will be no one answer or management protocolperintersex condition, but rather many answers, eachuniqueto a given family.Dr.Jorge really understandonly ethics for the parent \'s and family point of view, and never the child \'s. I can \'t agree, in that, with him. Sorry, Tom, but I am too tired. To write in a foreignlanguage for me is hard, and I am really not so young (to don’t say I amfeeling really old!)Thank you , dear friend.Let’s believe in science and evidences?Let’s respect the victims?Let’s change our philosophical andideological points of principle?Thank you,Waleria Torres,MSPS.I wrote two books about that subject, butunfortunately, only in Portuguese. “Domage”! About that particular aphallia case, as I said, what I wouldsuggest would be:1.Wait;2. Start preliminary, rearing in a lightway, as a boy.3.Observe;4. Do the Gendercare Game-test with 3-4-5years old.5.Observe;6. With 6,7 we hope we could be sure who thechild is, and start maintaining the sex of rearing, or not.7. After necessarily corrections, reassignlegally the child.JorgeDaaboul, M.D.AssistantProfessor of PediatricsDivisionof Pediatric EndocrinologyDepartmentof PediatricsUniversityof Florida, College of MedicineGainesville,FloridaREFERENCES1. Money J. SexErrors of the Body and Related Syndromes. Baltimore,MD: Paul Brookes Publishing Co; 1994.2. Lifshitz F. Pediatric Endocrinology. New York, NY:Marcel Dekker,Inc; 1996:296.3. Sperling M. Pediatric Endocrinology. Philadelphia,PA: W.B.Saunders Co; 1996:449–450.4. Meyer-Bahlburg HF. Gender and sexuality in classiccongenitaladrenal hyperplasia. Endocrinol Metab Clin North Am. 2001;30:155– 171.5. Daaboul J, Frader J. Ethics and the management ofthe patientwith intersex: a middle way. J Pediatr EndocrinolMetab.2001;14:1575– 1583.Dr.Martin T. SteinChildrenwho are born with intersex conditions bringenormouschallenges to the fields of developmentalendocrinologyand child development. The commentariesthataccompany this case emphasize contemporary socialandethical issues that have not always been considered intheearly medical decision-making process. In addition,culturaldifferences with regard to the acceptance of intersexconditionsmay not conform to those of Western society andshouldbe taken into consideration.1Thecontemporary dialogue on an approach to the childwithan intersex condition is a credit to our colleagues inpediatricendocrinology who have responded to recentscientificdiscoveries (both biological and psychological)andthe concerns of patients and their families. Dr. RobertBlizzard,in a recent commentary in Pediatrics, wrote:‘‘Thereexists a series of conundrums regarding genderassignment,gender identity, gender role, and sexualpreferencethat need solving before we can be comfortableinproviding reasonable answers to the questions posed byparentsof intersexed patients and those of the patientsthemselves.’’2Thisis an area in which a developmental-behavioralpediatriciancan contribute in significant ways. With anemphasison the interactions between biological andpsychosocialaspects of child development, the issuesraisedby the birth of a child with an intersex conditionareparticularly suitable to the clinical perspectives of adevelopmental-behavioralpediatrician. The commentariesinvitean interdisciplinary approach that should be seen asanopportunity for participation.REFERENCES1. Kuhnle U, Krohl W. The impact of culture on sexassignment andgender development in intersex patients. Perspect Biol Med. 2002;45:85– 103.2. Blizzard RM. Intersex issues: a series ofcontinuing conundrums.Pediatrics.2002;110:616– 621. Commentary.Challenging Case 119For the black words Copyright © Lippincott Williams &amp; Wilkins.For the red ones Copyright © for Gendercare.com Gender Clinic. Unauthorized reproductionof this article is prohibited.M.Italiano, researcher, opinion:Hello to all contributors thus far, May I add that there is very little evidence for a theory of gender identity formation based upon genital appearance. I have tremendous respect for Dr. Meyer-Bahlburg and others who seem to believe this, but I believe they are taking a misguided approach. They often compare how long those with ambiguous genitalia are left in that state and try tocorrelate this with gender identity development. It is misguided, because although they controlfor the degree of genital ambiguity (Prader scale), the years/months without surgical intervention, and even achieve good estimates for prenatal androgens, they often omit other criteria. For example, they often compare XY male pseudohermaphrodites with XX female pseudohermaphrodites. This is a big mistake, as it is now known that there is a differentialexpression of androgen receptors in the human brain between males and females.Likewise, the SRY gene on the Y chromosome is expressed in the human brain. Also the DAX-1gene on the X chromosome is expressed in the human brain. DAX-1 regulates the androgen receptor (AR). So, when these researchers compare XX CAH persons who have very masculnized external genitals with XY 5 Alpha reductase deficiency individuals, who have far more feminine external genitals, theybelieve the 5 Alpha RD individuals should do just as well as, or even better than, the CAH individuals with a female gender assignment. However, this I believe is a big mistake, as they haven \'t accounted for: 1) The likelihood that the XX CAH persons will have less AR numbers/distribution in certain areas of the brain. 2) That SRY gene will be expressed in the brains of the XY 5 Alpha RD individuals, but will be absent from the brains of the XX CAH individuals. (SRY also interacts with steroidogenic factor 1.) 3) That DAX-1 gene will have greater expression in the XX CAH persons, as there are two X chromosomes in these individuals when compared with their 5 Alpha RD counterparts. The DAX-1 gene, which is located on the long arm of the X chromosome, inhibits AR function. Another problem is the comparing of several types of male pseudohermaphrodititeswith each other based upon genital ambiguity (Prader scale) and common social environments. Dr. Jean Wilson has found that 70% of 5 Alpha RD persons when they are assigned as female,renounce this assignment and demand a change to male, whereas only 50% of persons with 17 Beta-Hydroxysteroid dehydrogenase do so. This, I believe adds further support to the \"Torres-Jurberg hypothesis \" regarding ligand selective activity of AR, because 5 Alpha RD persons \"only \" have a problem with androgen ACTION, in that they don \'t convert T to DHT. They have \"plenty \" of T. However, the 17 B-HSD persons have a problem not with the androgen ACTION, but with the androgen PRODUCTION, and produce less T than the 5 Alpha RD individuals. Therefore, with less T production, it is not surprising that fewer 17 B-HSD persons (only 50%) request a change to male assignment when compared with 5 Alpha RD individuals (70%). Furthermore the third type of male pseudohermaphroditism, CAIS individuals who havea failure of AR ACTION at T and DHT, seem to present even less for a gender change to malewhen assigned as female. Thus, to compare all three types amongst themselves based upon common socialenvironments and degree of genital masculnization as determined by the Prader scaleseems to be futile. It does not take into account the mechanics involved. For intersexed individuals with ambiguous genitalia, we have 2 HUGE problems: 1) We can \'t predict their gender based upon their genital appearance. 2) We can \'t undo the nerve damage AND the functional damage by well-intentioned surgeries. It is simply \"rolling the dice \" and playing a \"gambling game \". Can the surgeons ever admit they \'ve made a mistake in their ways of thinking? The only answer is that they MUST. They should not be allowed to wait until more patients come forth tell them first. This has happened far too much throughout history.Would you like to say us your opinion about those subjects?","null","null","");arrFiles[1]=new Array("http://www.gendercare.com/library/hbigda-sc6.html","HBIGDA \'s SOC, Version 6th, Commented by Wal Torres ","Library TheHarryBenjaminInternational GenderDysphoriaAssociation \'s StandardsofCareforGender IdentityDisorders,SixthVersion February, 2001	Committee Members: Walter Meyer III M.D. (Chairperson), Walter O.	Bockting Ph.D., Peggy Cohen-Kettenis Ph.D., Eli Coleman Ph.D., Domenico DiCeglie	M.D., Holly Devor Ph.D., Louis Gooren M.D., Ph.D., J. Joris Hage M.D., Sheila	Kirk M.D., Bram Kuiper Ph.D., Donald Laub M.D., Anne Lawrence M.D., Yvon	Menard M.D., Jude Patton PA-C, Leah Schaefer Ed.D., Alice Webb D.H.S., Connie	Christine Wheeler Ph.D.	This is the sixth version of the Standards of Care since the original 1979	document. Previous revisions were in 1980, 1981, 1990, and 1998. Table of Contents: Introductory Concepts Epidemiological Considerations Diagnostic Nomenclature The Mental Health Professional Assessment and Treatment of Children and Adolescents Psychotherapy with Adults Requirements for Hormone Therapy for Adults Effects of Hormone Therapy in Adults The Real-Life Experience Surgery Breast Surgery Genital Surgery Post-Transition Follow-Up I. Introductory Concepts	The Purpose of the Standards of Care. The major purpose of the Standards	of Care (SOC) is to articulate this international organization \'s professional	consensus about the psychiatric, psychological, medical, and surgical management	of gender identity disorders. Professionals may use this document to understand	the parameters within which they may offer assistance to those with these	conditions. Persons with gender identity disorders, their families, and social	institutions may use the SOC to understand the current thinking of professionals.	All readers should be aware of the limitations of knowledge in this area	and of the hope that some of the clinical uncertainties will be resolved	in the future through scientific investigation.	The Overarching Treatment Goal. The general goal of psychotherapeutic, endocrine,	or surgical therapy for persons with gender identity disorders is lasting	personal comfort with the gendered self in order to maximize overall	psychological well-being and self-fulfillment.	The Standards of Care Are Clinical Guidelines. The SOC are intended to provide	flexible directions for the treatment of persons with gender identity disorders.	When eligibility requirements are stated they are meant to be minimum	requirements. Individual professionals and organized programs may modify	them. Clinical departures from these guidelines may come about because of	a patient \'s unique anatomic, social, or psychological situation, an experienced	professional \'s evolving method of handling a common situation, or a research	protocol. These departures should be recognized as such, explained to the	patient, and documented both for legal protection and so that the short and	long term results can be retrieved to help the field to evolve.	The Clinical Threshold. A clinical threshold is passed when concerns,	uncertainties, and questions about gender identity persist during a person \'s	development, become so intense as to seem to be the most important aspect	of a person \'s life, or prevent the establishment of a relatively unconflicted	gender identity. The person \'s struggles are then variously informally referred	to as a gender identity problem, gender dysphoria, a gender problem, a gender	concern, gender distress, gender conflict, or transsexualism. Such struggles	are known to occur from the preschool years to old age and have many alternate	forms. These reflect various degrees of personal dissatisfaction with sexual	identity, sex and gender demarcating body characteristics, gender roles,	gender identity, and the perceptions of others. When dissatisfied individuals	meet specified criteria in one of two official nomenclatures--the International	Classification of Diseases-10 (ICD-10) or the Diagnostic and Statistical	Manual of Mental Disorders--Fourth Edition (DSM-IV)--they are formally designated	as suffering from a gender identity disorder (GID). Some persons with GID	exceed another threshold--they persistently possess a wish for surgical	transformation of their bodies.	Two Primary Populations with GID Exist -- Biological Males and Biological	Females . The sex of a patient always is a significant factor in the management	of GID. Clinicians need to separately consider the biologic, social,	psychological, and economic dilemmas of each sex. All patients, however,	should follow the SOC. II. Epidemiological Considerations	Prevalence. When the gender identity disorders first came to professional	attention, clinical perspectives were largely focused on how to identify	candidates for sex reassignment surgery. As the field matured, professionals	recognized that some persons with bona fide gender identity disorders neither	desired nor were candidates for sex reassignment surgery. The earliest estimates	of prevalence for transsexualism in adults were 1 in 37,000 males and 1 in	107,000 females. The most recent prevalence information from the Netherlands	for the transsexual end of the gender identity disorder spectrum is 1 in	11,900 males and 1 in 30,400 females. Four observations, not yet firmly supported	by systematic study, increase the likelihood of an even higher prevalence:	1) unrecognized gender problems are occasionally diagnosed when patients	are seen with anxiety, depression, bipolar disorder, conduct disorder, substance	abuse, dissociative identity disorders, borderline personality disorder,	other sexual disorders and intersexed conditions; 2) some nonpatient male	transvestites, female impersonators, transgender people, and male and female	homosexuals may have a form of gender identity disorder; 3) the intensity	of some persons \' gender identity disorders fluctuates below and above a clinical	threshold; 4) gender variance among female-bodied individuals tends to be	relatively invisible to the culture, particularly to mental health professionals	and scientists.	Natural History of Gender Identity Disorders. Ideally, prospective data about	the natural history of gender identity struggles would inform all treatment	decisions. These are lacking, except for the demonstration that, without	therapy, most boys and girls with gender identity disorders outgrow their	wish to change sex and gender. After the diagnosis of GID is made the therapeutic	approach usually includes three elements or phases (sometimes labeled triadic	therapy): a real-life experience in the desired role, hormones of the desired	gender, and surgery to change the genitalia and other sex characteristics.	Five less firmly scientifically established observations prevent clinicians	from prescribing the triadic therapy based on diagnosis alone: 1) some carefully	diagnosed persons spontaneously change their aspirations; 2) others make	more comfortable accommodations to their gender identities without medical	interventions; 3) others give up their wish to follow the triadic sequence	during psychotherapy; 4) some gender identity clinics have an unexplained	high drop out rate; and 5) the percentage of persons who are not benefited	from the triadic therapy varies significantly from study to study. Many persons	with GID will desire all three elements of triadic therapy. Typically, triadic	therapy takes place in the order of hormones ==&gt; real-life experience	==&gt; surgery, or sometimes: real-life experience ==&gt; hormones ==&gt;	surgery. For some biologic females, the preferred sequence may be hormones	==&gt; breast surgery ==&gt; real-life experience. However, the diagnosis	of GID invites the consideration of a variety of therapeutic options, only	one of which is the complete therapeutic triad. Clinicians have increasingly	become aware that not all persons with gender identity disorders need or	want all three elements of triadic therapy.	Cultural Differences in Gender Identity Variance throughout the World. Even	if epidemiological studies established that a similar base rate of gender	identity disorders existed all over the world, it is likely that cultural	differences from one country to another would alter the behavioral expressions	of these conditions. Moreover, access to treatment, cost of treatment, the	therapies offered and the social attitudes towards gender variant people	and the professionals who deliver care differ broadly from place to place.	While in most countries, crossing gender boundaries usually generates moral	censure rather than compassion, there are striking examples in certain cultures	of cross- gendered behaviors (e.g., in spiritual leaders) that are not	stigmatized. III. Diagnostic Nomenclature	The Five Elements of Clinical Work. Professional involvement with patients	with gender identity disorders involves any of the following: diagnostic	assessment, psychotherapy, real-life experience, hormone therapy, and surgical	therapy. This section provides a background on diagnostic assessment.	The Development of a Nomenclature. The term transexxual emerged into	professional and public usage in the 1950s as a means of designating a person	who aspired to or actually lived in the anatomically contrary gender role,	whether or not hormones had been administered or surgery had been performed.	During the 1960s and 1970s, clinicians used the term true transsexual.	The true transsexual was thought to be a person with a characteristic path	of atypical gender identity development that predicted an improved life from	a treatment sequence that culminated in genital surgery. True transsexuals	were thought to have: 1) cross-gender identifications that were consistently	expressed behaviorally in childhood, adolescence, and adulthood; 2) minimal	or no sexual arousal to cross-dressing; and 3) no heterosexual interest,	relative to their anatomic sex. True transsexuals could be of either sex.	True transsexual males were distinguished from males who arrived at the desire	to change sex and gender via a reasonably masculine behavioral developmental	pathway. Belief in the true transsexual concept for males dissipated when	it was realized that such patients were rarely encountered, and that some	of the original true transsexuals had falsified their histories to make their	stories match the earliest theories about the disorder. The concept of true	transsexual females never created diagnostic uncertainties, largely because	patient histories were relatively consistent and gender variant behaviors	such as female cross-dressing remained unseen by clinicians. The term \"gender	dysphoria syndrome \" was later adopted to designate the presence of a gender	problem in either sex until psychiatry developed an official nomenclature.	The diagnosis of Transsexualism was introduced in the DSM-III in 1980 for	gender dysphoric individuals who demonstrated at least two years of continuous	interest in transforming the sex of their bodies and their social gender	status. Others with gender dysphoria could be diagnosed as Gender Identity	Disorder of Adolescence or Adulthood, Nontranssexual Type; or Gender Identity	Disorder Not Otherwise Specified (GIDNOS). These diagnostic terms were usually	ignored by the media, which used the term transsexual for any person who	wanted to change his/her sex and gender.	The DSM-IV. In 1994, the DSM-IV committee replaced the diagnosis of	Transsexualism with Gender Identity Disorder. Depending on their age, those	with a strong and persistent cross-gender identification and a persistent	discomfort with their sex or a sense of inappropriateness in the gender role	of that sex were to be diagnosed as Gender Identity Disorder of Childhood	(302.6), Adolescence, or Adulthood (302.85).	For persons who did not meet	these criteria, Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6)	was to be used. This category included a variety of individuals, including	those who desired only castration or penectomy without a desire to develop	breasts, those who wished hormone therapy and mastectomy without genital	reconstruction, those with a congenital intersex condition, those with transient	stress-related cross-dressing, and those with considerable ambivalence about	giving up their gender status. Patients diagnosed with GID and GIDNOS were	to be subclassified according to the sexual orientation: attracted to males;	attracted to females; attracted to both; or attracted to neither. This	subclassification was intended to assist in determining, over time, whether	individuals of one sexual orientation or another experienced better outcomes	using particular therapeutic approaches; it was not intended to guide	treatment decisions.	Between the publication of DSM-III and DSM-IV, the term \"transgender \" began	to be used in various ways. Some employed it to refer to those with unusual	gender identities in a value-free manner -- that is, without a connotation	of psychopathology. Some people informally used the term to refer to any	person with any type of gender identity issues. Transgender is not a formal	diagnosis, but many professionals and members of the public found it easier	to use informally than GIDNOS, which is a formal diagnosis.	The ICD-10. The ICD-10 now provides five diagnoses for the gender identity	disorders (F64): Transsexualism (F64.0) has three criteria:	The desire to live and be accepted as a member of the opposite sex, usually	accompanied by the wish to make his or her body as congruent as possible	with the	preferred sex	through surgery and hormone treatment;	The transsexual identity has been present persistently for at least two years;	The disorder is not a symptom of another mental disorder or a chromosomal	abnormality. Dual-role Transvestism (F64.1) has three criteria:	The individual wears clothes of the opposite sex in order to experience temporary	membership in the opposite sex;	There is no sexual motivation for the cross-dressing;	The individual has no desire for a permanent change to the opposite sex. Gender Identity Disorder of Childhood (64.2) has separate criteria for girls and for boys. For girls:	The individual shows persistent and intense distress about being a girl,	and has a stated desire to be a boy (not merely a desire for any perceived	cultural advantages to being a boy) or insists that she is a boy;	Either of the following must be present: Persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing; Persistent repudiation of female anatomical structures, as evidenced by at least one of the following:	An assertion that she has, or will grow, a penis;	Rejection of urination in a sitting position;	Assertion that she does not want to grow breasts or menstruate.	The girl has not yet reached puberty;	The disorder must have been present for at least 6 months. For boys:	The individual shows persistent and intense distress about being a boy, and	has a desire to be a girl, or, more rarely, insists that he is a girl.	Either of the following must be present: Preoccupation with stereotypic female activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games, and activities; Persistent repudiation of male anatomical structures, as evidenced by at least one of the following repeated assertions:	That he will grow up to become a woman (not merely in the role);	That his penis or testes are disgusting or will disappear;	That it would be better not to have a penis or testes.	The boy has not yet reached puberty;	The disorder must have been present for at least 6 months. Other Gender Identity Disorders (F64.8) has no specific criteria. Gender Identity Disorder, Unspecified has no specific criteria. Either of the previous two diagnoses could be used for those with an intersexed	condition.	The purpose of the DSM-IV and ICD-10 is to guide treatment and research.	Different professional groups created these nomenclatures through consensus	processes at different times. There is an expectation that the differences	between the systems will be eliminated in the future. At this point, the	specific diagnoses are based more on clinical reasoning than on scientific	investigation.	Are Gender Identity Disorders Mental Disorders? To qualify as a mental disorder,	a behavioral pattern must result in a significant adaptive disadvantage to	the person or cause personal mental suffering. The DSM-IV and ICD-10 have	defined hundreds of mental disorders which vary in onset, duration, pathogenesis,	functional disability, and treatability. The designation of gender identity	disorders as mental disorders is not a license for stigmatization, or for	the deprivation of gender patients \' civil rights. The use of a formal diagnosis	is often important in offering relief, providing health insurance coverage,	and guiding research to provide more effective future treatments. IV. The Mental Health Professional	The Ten Tasks of the Mental Health Professional. Mental health	professionals (MHPs) who work with individuals with gender identity disorders	may be regularly called upon to carry out many of these responsibilities: To accurately diagnose the individual \'s gender disorder; To accurately diagnose any co-morbid psychiatric conditions and see to their appropriate treatment; To counsel the individual about the range of treatment options and their implications; To engage in psychotherapy; To ascertain eligibility and readiness for hormone and surgical therapy; To make formal recommendations to medical and surgical colleagues; To document their patient \'s relevant history in a letter of recommendation; To be a colleague on a team of professionals with an interest in the gender identity disorders; To educate family members, employers, and institutions about gender identity disorders; To be available for follow-up of previously seen gender patients.	The Adult-Specialist. The education of the mental health professional who	specializes in adult gender identity disorders rests upon basic general clinical	competence in diagnosis and treatment of mental or emotional disorders. Clinical	training may occur within any formally credentialing discipline -- for example,	psychology, psychiatry, social work, counseling, or nursing. The following	are the recommended minimal credentials for special competence with the gender	identity disorders: A master \'s degree or its equivalent in a clinical behavioral science field. This or a more advanced degree should be granted by an institution accredited by a recognized national or regional accrediting board. The mental health professional should have documented credentials from a proper training facility and a licensing board. Specialized training and competence in the assessment of the DSM-IV/ICD-10 Sexual Disorders (not simply gender identity disorders). Documented supervised training and competence in psychotherapy. Continuing education in the treatment of gender identity disorders, which may include attendance at professional meetings, workshops, or seminars or participating in research related to gender identity issues.	The Child-Specialist. The professional who evaluates and offers therapy for	a child or early adolescent with GID should have been trained in childhood	and adolescent developmental psychopathology. The professional should be	competent in diagnosing and treating the ordinary problems of children and	adolescents. These requirements are in addition to the adult-specialist	requirement.	The Differences between Eligibility and Readiness. The SOC provide	recommendations for eligibility requirements for hormones and surgery. Without	first meeting these recommended eligibility requirements, the patient and	the therapist should not request hormones or surgery. An example of an	eligibility requirement is: a person must live full time in the preferred	gender for twelve months prior to genital surgery. To meet this criterion,	the professional needs to document that the real-life experience has occurred	for this duration. Meeting readiness criteria -- further consolidation of	the evolving gender identity or improving mental health in the new or confirmed	gender role -- is more complicated, because it rests upon the clinician \'s	and the patient \'s judgment.	The Mental Health Professional \'s Relationship to the Prescribing Physician	and Surgeon. Mental health professionals who recommend hormonal and surgical	therapy share the legal and ethical responsibility for that decision with	the physician who undertakes the treatment. Hormonal treatment can often	alleviate anxiety and depression in people without the use of additional	psychotropic medications. Some individuals, however, need psychotropic medication	prior to, or concurrent with, taking hormones or having surgery. The mental	health professional is expected to make this assessment, and see that the	appropriate psychotropic medications are offered to the patient. The presence	of psychiatric co-morbidities does not necessarily preclude hormonal or surgical	treatment, but some diagnoses pose difficult treatment dilemmas and may delay	or preclude the use of either treatment.	The Mental Health Professional \'s Documentation Letter for Hormone Therapy	or Surgery Should Succinctly Specify: The patient \'s general identifying characteristics; The initial and evolving gender, sexual, and other psychiatric diagnoses; The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent; The eligibility criteria that have been met and the mental health professional \'s rationale for hormone therapy or surgery; The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance; Whether the author of the report is part of a gender team; That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.	The organization and completeness of these letters provide the hormone-	prescribing physician and the surgeon an important degree of assurance that	mental health professional is knowledgeable and competent concerning gender	identity disorders.	One Letter is Required for Instituting Hormone Therapy, or for Breast Surgery.	One letter from a mental health professional, including the above seven points,	written to the physician who will be responsible for the patient \'s medical	treatment, is sufficient for instituting hormone therapy or for a referral	for breast surgery (e.g., mastectomy, chest reconstruction, or augmentation	mammoplasty).	Two Letters are Generally Required for Genital Surgery. Genital surgery for	biologic males may include orchiectomy, penectomy, clitoroplasty, labiaplasty	or creation of a neovagina; for biologic females it may include hysterectomy,	salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty,	placement of testicular prostheses, or creation of a neophallus.	It is ideal if mental health professionals conduct their tasks and periodically	report on these processes as part of a team of other mental health professionals	and nonpsychiatric physicians. One letter to the physician performing genital	surgery will generally suffice as long as two mental health professionals	sign it.	More commonly, however, letters of recommendation are from mental health	professionals who work alone without colleagues experienced with gender identity	disorders. Because professionals working independently may not have the benefit	of ongoing professional consultation on gender cases, two letters of	recommendation are required prior to initiating genital surgery. If the first	letter is from a person with a master \'s degree, the second letter should	be from a psychiatrist or a Ph.D. clinical psychologist, who can be expected	to adequately evaluate co-morbid psychiatric conditions. If the first letter	is from the patient \'s psychotherapist, the second letter should be from a	person who has only played an evaluative role for the patient. Each letter,	however, is expected to cover the same topics. At least one of the letters	should be an extensive report. The second letter writer, having read the	first letter, may choose to offer a briefer summary and an agreement with	the recommendation.	Library V. Assessment and Treatment of Children and Adolescents	Phenomenology. Gender identity disorders in children and adolescents	are different from those seen in adults, in that a rapid and dramatic	developmental process (physical, psychological and sexual) is involved. Gender	identity disorders in children and adolescents are complex conditions. The	young person may experience his or her phenotype sex as inconsistent with	his or her own sense of gender identity. Intense distress is often experienced,	particularly in adolescence, and there are frequently associated emotional	and behavioral difficulties. There is greater fluidity and variability in	outcomes, especially in pre-pubertal children. Only a few gender variant	youths become transsexual, although many eventually develop a homosexual	orientation.	Commonly seen features of gender identity conflicts in children and adolescents	include a stated desire to be the other sex; cross dressing; play with games	and toys usually associated with the gender with which the child identifies;	avoidance of the clothing, demeanor and play normally associated with the	child \'s sex and gender of assignment; preference for playmates or friends	of the sex and gender with which the child identifies; and dislike of bodily	sex characteristics and functions. Gender identity disorders are more often	diagnosed in boys.	Phenomenologically, there is a qualitative difference between the way children	and adolescents present their sex and gender predicaments, from and the	presentation of delusions or other psychotic symptoms. Delusional beliefs	about their body or gender can occur in psychotic conditions but they can	be distinguished from the phenomenon of a gender identity disorder. Gender	identity disorders in childhood are not equivalent to those in adulthood	and the former do not inevitably lead to the latter. The younger the child	the less certain and perhaps more malleable the outcome.	Psychological and Social Interventions. The task of the child-specialist	mental health professional is to provide assessment and treatment that broadly	conforms to the following guidelines: The professional should recognize and accept the gender identity problem. Acceptance and removal of secrecy can bring considerable relief. The assessment should explore the nature and characteristics of the child \'s or adolescent \'s gender identity. A complete psychodiagnostic and psychiatric assessment should be performed. A complete assessment should include a family evaluation, because other emotional and behavioral problems are very common, and unresolved issues in the child \'s environment are often present. Therapy should focus on ameliorating any comorbid problems in the child \'s life, and on reducing distress the child experiences from his or her gender identity problem and other difficulties. The child and family should be supported in making difficult decisions regarding the extent to which to allow the child to assume a gender role consistent with his or her gender identity. This includes issues of whether to inform others of the child \'s situation, and how others in the child \'s life should respond; for example, whether the child should attend school using a name and clothing opposite to his or her sex of assignment. They should also be supported in tolerating uncertainty and anxiety in relation to the child \'s gender expression and how best to manage it. Professional network meetings can be very useful in finding appropriate solutions to these problems.	Physical Interventions. Before any physical intervention is considered, extensive	exploration of psychological, family and social issues should be undertaken.	Physical interventions should be addressed in the context of adolescent	development. Adolescents \' gender identity development can rapidly and	unexpectedly evolve. An adolescent shift toward gender conformity can occur	primarily to please the family, and may not persist or reflect a permanent	change in gender identity. Identity beliefs in adolescents may become firmly	held and strongly expressed, giving a false impression of irreversibility;	more fluidity may return at a later stage. For these reasons, irreversible	physical interventions should be delayed as long as is clinically appropriate.	Pressure for physical interventions because of an adolescent \'s level of distress	can be great and in such circumstances a referral to a child and adolescent	multi- disciplinary specialty service should be considered, in locations	where these exist.	Physical interventions fall into three categories or stages: Fully reversible interventions. These involve the use of LHRH agonists or medroxyprogesterone to suppress estrogen or testosterone production, and consequently to delay the physical changes of puberty. Partially reversible interventions. These include hormonal interventions that masculinize or feminize the body, such as administration of testosterone to biologic females and estrogen to biologic males. Reversal may involve surgical intervention. Irreversible interventions. These are surgical procedures.	A staged process is recommended to keep options open through the first two	stages. Moving from one state to another should not occur until there has	been adequate time for the young person and his/her family to assimilate	fully the effects of earlier interventions.	Fully Reversible Interventions. Adolescents may be eligible for puberty-delaying	hormones as soon as pubertal changes have begun. In order for the adolescent	and his or her parents to make an informed decision about pubertal delay,	it is recommended that the adolescent experience the onset of puberty in	his or her biologic sex, at least to Tanner Stage Two. If for clinical reasons	it is thought to be in the patient \'s interest to intervene earlier, this	must be managed with pediatric endocrinological advice and more than one	psychiatric opinion.	Two goals justify this intervention: a) to gain time to further explore the	gender identity and other developmental issues in psychotherapy; and b) to	make passing easier if the adolescent continues to pursue sex and gender	change. In order to provide puberty delaying hormones to an adolescent, the	following criteria must be met: throughout childhood the adolescent has demonstrated an intense pattern of cross-sex and cross-gender identity and aversion to expected gender role behaviors; sex and gender discomfort has significantly increased with the onset of puberty; the family consents and participates in the therapy.	Biologic males should be treated with LHRH agonists (which stop LH secretion	and therefore testosterone secretion), or with progestins or antiandrogens	(which block testosterone secretion or neutralize testosterone action). Biologic	females should be treated with LHRH agonists or with sufficient progestins	(which stop the production of estrogens and progesterone) to stop menstruation.	Partially Reversible Interventions. Adolescents may be eligible to begin	masculinizing or feminizing hormone therapy, as early as age 16, preferably	with parental consent. In many countries 16-year olds are legal adults for	medical decision making, and do not require parental consent.	Mental health professional involvement is an eligibility requirement for	triadic therapy during adolescence. For the implementation of the real-life	experience or hormone therapy, the mental health professional should be involved	with the patient and family for a minimum of six months. While the number	of sessions during this six-month period rests upon the clinician \'s judgment,	the intent is that hormones and the real-life experience be thoughtfully	and recurrently considered over time. In those patients who have already	begun the real-life experience prior to being seen, the professional should	work closely with them and their families with the thoughtful recurrent	consideration of what is happening over time.	Irreversible Interventions. Any surgical intervention should not be carried	out prior to adulthood, or prior to a real-life experience of at least two	years in the gender role of the sex with which the adolescent identifies.	The threshold of 18 should be seen as an eligibility criterion and not an	indication in itself for active intervention. VI. Psychotherapy with Adults	A Basic Observation. Many adults with gender identity disorder find	comfortable, effective ways of living that do not involve all the components	of the triadic treatment sequence. While some individuals manage to do this	on their own, psychotherapy can be very helpful in bringing about the discovery	and maturational processes that enable self-comfort.	Psychotherapy is Not an Absolute Requirement for Triadic Therapy. Not every	adult gender patient requires psychotherapy in order to proceed with hormone	therapy, the real-life experience, hormones, or surgery. Individual programs	vary to the extent that they perceive a need for psychotherapy. When the	mental health professional \'s initial assessment leads to a recommendation	for psychotherapy, the clinician should specify the goals of treatment, and	estimate its frequency and duration. There is no required minimum number	of psychotherapy sessions prior to hormone therapy, the real-life experience,	or surgery, for three reasons: 1) patients differ widely in their abilities	to attain similar goals in a specified time; 2) a minimum number of sessions	tends to be construed as a hurdle, which discourages the genuine opportunity	for personal growth; 3) the mental health professional can be an important	support to the patient throughout all phases of gender transition. Individual	programs may set eligibility criteria to some minimum number of sessions	or months of psychotherapy.	The mental health professional who conducts the initial evaluation need not	be the psychotherapist. If members of a gender team do not do psychotherapy,	the psychotherapist should be informed that a letter describing the patient \'s	therapy might be requested so the patient can proceed with the next phase	of treatment.	Goals of Psychotherapy. Psychotherapy often provides education about a range	of options not previously seriously considered by the patient. It emphasizes	the need to set realistic life goals for work and relationships, and it seeks	to define and alleviate the patient \'s conflicts that may have undermined	a stable lifestyle.	The Therapeutic Relationship. The establishment of a reliable trusting	relationship with the patient is the first step toward successful work as	a mental health professional. This is usually accomplished by competent	nonjudgmental exploration of the gender issues with the patient during the	initial diagnostic evaluation. Other issues may be better dealt with later,	after the person feels that the clinician is interested in and understands	their gender identity concerns. Ideally, the clinician \'s work is with the	whole of the person \'s complexity. The goals of therapy are to help the person	to live more comfortably within a gender identity and to deal effectively	with non-gender issues. The clinician often attempts to facilitate the capacity	to work and to establish or maintain supportive relationships. Even when	these initial goals are attained, mental health professionals should discuss	the likelihood that no educational, psychotherapeutic, medical, or surgical	therapy can permanently eradicate all vestiges of the person \'s original sex	assignment and previous gendered experience.	Processes of Psychotherapy. Psychotherapy is a series of interactive	communications between a therapist who is knowledgeable about how people	suffer emotionally and how this may be alleviated, and a patient who is	experiencing distress. Typically, psychotherapy consists of regularly held	50 minute sessions. The psychotherapy sessions initiate a developmental process.	They enable the patient \'s history to be appreciated current dilemmas to be	understood, and unrealistic ideas and maladaptive behaviors to be identified.	Psychotherapy is not intended to cure the gender identity disorder. Its usual	goal is a long-term stable life style with realistic chances for success	in relationships, education, work, and gender identity expression. Gender	distress often intensifies relationship, work, and educational dilemmas.	The therapist should make clear that it is the patient \'s right to choose	among many options. The patient can experiment over time with alternative	approaches. Ideally, psychotherapy is a collaborative effort. The therapist	must be certain that the patient understands the concepts of eligibility	and readiness, because the therapist and patient must cooperate in defining	the patient \'s problems, and in assessing progress in dealing with them.	Collaboration can prevent a stalemate between a therapist who seems needlessly	withholding of a recommendation, and a patient who seems too profoundly	distrusting to freely share thoughts, feelings, events, and relationships.	Patients may benefit from psychotherapy at every stage of gender evolution.	This includes the post-surgical period, when the anatomic obstacles to gender	comfort have been removed, but the person may continue to feel a lack of	genuine comfort and skill in living in the new gender role.	Options for Gender Adaptation. The activities and processes that are listed	below have, in various combinations, helped people to find more personal	comfort. These adaptations may evolve spontaneously and during psychotherapy.	Finding new gender adaptations does not mean that the person may not in the	future elect to pursue hormone therapy, the real-life experience, or genital	surgery. Activities:	Biological Males: Cross-dressing: unobtrusively with undergarments; unisexually; or in a feminine fashion; Changing the body through: hair removal through electrolysis or body waxing; minor plastic cosmetic surgical procedures; Increasing grooming, wardrobe, and vocal expression skills.	Biological Females: Cross-dressing: unobtrusively with undergarments, unisexually, or in a masculine fashion; Changing the body through breast binding, weight lifting, applying theatrical facial hair; Padding underpants or wearing a penile prosthesis.	Both Genders: Learning about transgender phenomena from: support groups and gender networks, communication with peers via the Internet, studying these Standards of Care, relevant lay and professional literatures about legal rights pertaining to work, relationships, and public cross-dressing; Involvement in recreational activities of the desired gender; Episodic cross-gender living. Processes:	Acceptance of personal homosexual or bisexual fantasies and behaviors	(orientation) as distinct from gender identity and gender role aspirations;	Acceptance of the need to maintain a job, provide for the emotional needs	of children, honor a spousal commitment, or not to distress a family member	as currently having a higher priority than the personal wish for constant	cross-gender expression;	Integration of male and female gender awareness into daily living;	Identification of the triggers for increased cross-gender yearnings and	effectively attending to them; for instance, developing better self-protective,	self-assertive, and vocational skills to advance at work and resolve	interpersonal struggles to strengthen key relationships. VII. Requirements for Hormone Therapy for Adults	Reasons for Hormone Therapy. Cross-sex hormonal treatments play an	important role in the anatomical and psychological gender transition process	for properly selected adults with gender identity disorders. Hormones are	often medically necessary for successful living in the new gender. They improve	the quality of life and limit psychiatric co-morbidity, which often accompanies	lack of treatment. When physicians administer androgens to biologic females	and estrogens, progesterone, and testosterone-blocking agents to biologic	males, patients feel and appear more like members of their preferred gender.	Eligibility Criteria. The administration of hormones is not to be lightly	undertaken because of their medical and social risks. Three criteria exist. Age 18 years; Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks; Either:	a documented real-life experience of at least three months prior to the	administration of hormones; or	a period of psychotherapy of a duration specified by the mental health	professional after the initial evaluation (usually a minimum of three months).	In selected circumstances, it can be acceptable to provide hormones to patients	who have not fulfilled criterion 3 - for example, to facilitate the provision	of monitored therapy using hormones of known quality, as an alternative to	black-market or unsupervised hormone use.	Readiness Criteria. Three criteria exist: The patient has had further consolidation of gender identity during the real-life experience or psychotherapy; The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality; The patient is likely to take hormones in a responsible manner.	Can Hormones Be Given To Those Who Do Not Want Surgery or a Real-life Experience?	Yes, but after diagnosis and psychotherapy with a qualified mental health	professional following minimal standards listed above. Hormone therapy can	provide significant comfort to gender patients who do not wish to cross live	or undergo surgery, or who are unable to do so. In some patients, hormone	therapy alone may provide sufficient symptomatic relief to obviate the need	for cross living or surgery.	Hormone Therapy and Medical Care for Incarcerated Persons. Persons who are	receiving treatment for gender identity disorders should continue to receive	appropriate treatment following these Standards of Care after incarceration.	For example, those who are receiving psychotherapy and/or cross-sex hormonal	treatments should be allowed to continue this medically necessary treatment	to prevent or limit emotional lability, undesired regression of	hormonally-induced physical effects and the sense of desperation that may	lead to depression, anxiety and suicidality. Prisoners who are subject to	rapid withdrawal of cross- sex hormones are particularly at risk for psychiatric	symptoms and self- injurious behaviors. Medical monitoring of hormonal treatment	as described in these Standards should also be provided. Housing for	transgendered prisoners should take into account their transition status	and their personal safety.	Library VIII. Effects of Hormone Therapy in Adults	The maximum physical effects of hormones may not be evident until two years	of continuous treatment. Heredity limits the tissue response to hormones	and this cannot be overcome by increasing dosage. The degree of effects actually	attained varies from patient to patient.	Desired Effects of Hormones. Biologic males treated with estrogens can	realistically expect treatment to result in: breast growth, some redistribution	of body fat to approximate a female body habitus, decreased upper body strength,	softening of skin, decrease in body hair, slowing or stopping the loss of	scalp hair, decreased fertility and testicular size, and less frequent, less	firm erections. Most of these changes are reversible, although breast enlargement	will not completely reverse after discontinuation of treatment.	Biologic females treated with testosterone can expect the following permanent	changes: a deepening of the voice, clitoral enlargement, mild breast atrophy,	increased facial and body hair and male pattern baldness. Reversible changes	include increased upper body strength, weight gain, increased social and	sexual interest and arousability, and decreased hip fat.	Potential Negative Medical Side Effects. Patients with medical problems or	otherwise at risk for cardiovascular disease may be more likely to experience	serious or fatal consequences of cross-sex hormonal treatments. For example,	cigarette smoking, obesity, advanced age, heart disease, hypertension, clotting	abnormalities, malignancy, and some endocrine abnormalities may increase	side effects and risks for hormonal treatment. Therefore, some patients may	not be able to tolerate cross-sex hormones. However, hormones can provide	health benefits as well as risks. Risk-benefit ratios should be considered	collaboratively by the patient and prescribing physician.	Side effects in biologic males treated with estrogens and progestins may	include increased propensity to blood clotting (venous thrombosis with a	risk of fatal pulmonary embolism), development of benign pituitary prolactinomas,	infertility, weight gain, emotional lability, liver disease, gallstone formation,	somnolence, hypertension, and diabetes mellitus.	Side effects in biologic females treated with testosterone may include	infertility, acne, emotional lability, increases in sexual desire, shift	of lipid profiles to male patterns which increase the risk of cardiovascular	disease, and the potential to develop benign and malignant liver tumors and	hepatic dysfunction.	The Prescribing Physician \'s Responsibilities. Hormones are to be prescribed	by a physician, and should not be administered without adequate psychological	and medical assessment before and during treatment. Patients who do not	understand the eligibility and readiness requirements and who are unaware	of the SOC should be informed of them. This may be a good indication for	a referral to a mental health professional experienced with gender identity	disorders.	The physician providing hormonal treatment and medical monitoring need not	be a specialist in endocrinology, but should become well-versed in the relevant	medical and psychological aspects of treating persons with gender identity	disorders.	After a thorough medical history, physical examination, and laboratory	examination, the physician should again review the likely effects and side	effects of hormone treatment, including the potential for serious, life-	threatening consequences. The patient must have the capacity to appreciate	the risks and benefits of treatment, have his/her questions answered, and	agree to medical monitoring of treatment. The medical record must contain	a written informed consent document reflecting a discussion of the risks	and benefits of hormone therapy.	Physicians have a wide latitude in what hormone preparations they may prescribe	and what routes of administration they may select for individual patients.	Viable options include oral, injectable, and transdermal delivery systems.	The use of transdermal estrogen patches should be considered for males over	40 years of age or those with clotting abnormalities or a history of venous	thrombosis. Transdermal testosterone is useful in females who do not want	to take injections. In the absence of any other medical, surgical, or psychiatric	conditions, basic medical monitoring should include: serial physical examinations	relevant to treatment effects and side effects, vital sign measurements before	and during treatment, weight measurements, and laboratory assessment. Gender	patients, whether on hormones or not, should be screened for pelvic malignancies	as are other persons.	For those receiving estrogens, the minimum laboratory assessment should consist	of a pretreatment free testosterone level, fasting glucose, liver function	tests, and complete blood count with reassessment at 6 and 12 months and	annually thereafter. A pretreatment prolactin level should be obtained and	repeated at 1, 2, and 3 years. If hyperprolactemia does not occur during	this time, no further measurements are necessary. Biologic males undergoing	estrogen treatment should be monitored for breast cancer and encouraged to	engage in routine self-examination. As they age, they should be monitored	for prostatic cancer.	For those receiving androgens, the minimum laboratory assessment should consist	of pretreatment liver function tests and complete blood count with reassessment	at 6 months, 12 months, and yearly thereafter. Yearly palpation of the liver	should be considered. Females who have undergone mastectomies and who have	a family history of breast cancer should be monitored for this disease.	Physicians may provide their patients with a brief written statement indicating	that the person is under medical supervision, which includes cross- sex hormone	therapy. During the early phases of hormone treatment, the patient may be	encouraged to carry this statement at all times to help prevent difficulties	with the police and other authorities.	Reductions in Hormone Doses After Gonadectomy. Estrogen doses in post-orchiectomy	patients can often be reduced by 1/3 to 1/2 and still maintain feminization.	Reductions in testosterone doses post-oophorectomy should be considered,	taking into account the risks of osteoporosis. Lifelong maintenance treatment	is usually required in all gender patients.	The Misuse of Hormones. Some individuals obtain hormones without prescription	from friends, family members, and pharmacies in other countries. Medically	unmonitored hormone use can expose the person to greater medical risk. Persons	taking medically monitored hormones have been known to take additional doses	of illicitly obtained hormones without their physician \'s knowledge. Mental	health professionals and prescribing physicians should make an effort to	encourage compliance with recommended dosages, in order to limit morbidity.	It is ethical for physicians to discontinue treatment of patients who do	not comply with prescribed treatment regimens.	Other Potential Benefits of Hormones. Hormonal treatment, when medically	tolerated, should precede any genital surgical interventions. Satisfaction	with the hormone \'s effects consolidates the person \'s identity as a member	of the preferred sex and gender and further adds to the conviction to proceed.	Dissatisfaction with hormonal effects may signal ambivalence about proceeding	to surgical interventions. In biologic males, hormones alone often generate	adequate breast development, precluding the need for augmentation mammaplasty.	Some patients who receive hormonal treatment will not desire genital or other	surgical interventions.	The Use of Antiandrogens and Sequential Therapy. Antiandrogens can be used	as adjunctive treatments in biologic males receiving estrogens, though they	are not always necessary to achieve feminization. In some patients, antiandrogens	may more profoundly suppress the production of testosterone, enabling a lower	dose of estrogen to be used when adverse estrogen side effects are anticipated.	Feminization does not require sequential therapy. Attempts to mimic the menstrual	cycle by prescribing interrupted estrogen therapy or substituting progesterone	for estrogen during part of the month are not necessary to achieve feminization.	Informed Consent. Hormonal treatment should be provided only to those who	are legally able to provide informed consent. This includes persons who have	been declared by a court to be emancipated minors and incarcerated persons	who are considered competent to participate in their medical decisions. For	adolescents, informed consent needs to include the minor patient \'s assent	and the written informed consent of a parent or legal guardian.	Reproductive Options. Informed consent implies that the patient understands	that hormone administration limits fertility and that the removal of sexual	organs prevents the capacity to reproduce. Cases are known of persons who	have received hormone therapy and sex reassignment surgery who later regretted	their inability to parent genetically related children. The mental health	professional recommending hormone therapy, and the physician prescribing	such therapy, should discuss reproductive options with the patient prior	to starting hormone therapy. Biologic males, especially those who have not	already reproduced, should be informed about sperm preservation options,	and encouraged to consider banking sperm prior to hormone therapy. Biologic	females do not presently have readily available options for gamete preservation,	other than cryopreservation of fertilized embryos. However, they should be	informed about reproductive issues, including this option. As other options	become available, these should be presented. IX. The Real-Life Experience	The act of fully adopting a new or evolving gender role or gender presentation	in everyday life is known as the real-life experience. The real- life experience	is essential to the transition to the gender role that is congruent with	the patient \'s gender identity. Since changing one \'s gender presentation has	immediate profound personal and social consequences, the decision to do so	should be preceded by an awareness of what the familial, vocational,	interpersonal, educational, economic, and legal consequences are likely to	be. Professionals have a responsibility to discuss these predictable consequences	with their patients. Change of gender role and presentation can be an important	factor in employment discrimination, divorce, marital problems, and the	restriction or loss of visitation rights with children. These represent external	reality issues that must be confronted for success in the new gender	presentation. These consequences may be quite different from what the patient	imagined prior to undertaking the real-life experiences. However, not all	changes are negative.	Parameters of the Real-Life Experience. When clinicians assess the quality	of a person \'s real-life experience in the desired gender, the following abilities	are reviewed: To maintain full or part-time employment; To function as a student; To function in community-based volunteer activity; To undertake some combination of items 1-3; To acquire a (legal) gender-identity-appropriate first name; To provide documentation that persons other than the therapist know that the patient functions in the desired gender role.	Real-Life Experience versus Real-Life Test. Although professionals may recommend	living in the desired gender, the decision as to when and how to begin the	real-life experience remains the person \'s responsibility. Some begin the	real-life experience and decide that this often imagined life direction is	not in their best interest. Professionals sometimes construe the real-life	experience as the real-life test of the ultimate diagnosis. If patients prosper	in the preferred gender, they are confirmed as \"transsexual, \" but if they	decided against continuing, they \"must not have been. \" This reasoning is	a confusion of the forces that enable successful adaptation with the presence	of a gender identity disorder. The real-life experience tests the person \'s	resolve, the capacity to function in the preferred gender, and the adequacy	of social, economic, and psychological supports. It assists both the patient	and the mental health professional in their judgments about how to proceed.	Diagnosis, although always open for reconsideration, precedes a recommendation	for patients to embark on the real-life experience. When the patient is	successful in the real- life experience, both the mental health professional	and the patient gain confidence about undertaking further steps.	Removal of Beard and other Unwanted Hair for the Male to Female Patient.	Beard density is not significantly slowed by cross-sex hormone administration.	Facial hair removal via electrolysis is a generally safe, time- consuming	process that often facilitates the real-life experience for biologic males.	Side effects include discomfort during and immediately after the procedure	and less frequently hypo- or hyper-pigmentation, scarring, and folliculitis.	Formal medical approval for hair removal is not necessary; electrolysis may	be begun whenever the patient deems it prudent. It is usually recommended	prior to commencing the real-life experience, because the beard must grow	out to visible lengths to be removed. Many patients will require two years	of regular treatments to effectively eradicate their facial hair. Hair removal	by laser is a new alternative approach, but experience with it is limited. X. Surgery	Sex Reassignment is Effective and Medically Indicated in Severe GID.	In persons diagnosed with transsexualism or profound GID, sex reassignment	surgery, along with hormone therapy and real-life experience, is a treatment	that has proven to be effective. Such a therapeutic regimen, when prescribed	or recommended by qualified practitioners, is medically indicated and medically	necessary. Sex reassignment is not \"experimental, \" \"investigational, \" \"elective, \" \"cosmetic, \" or optional in any meaningful sense. It constitutes very effective	and appropriate treatment for transsexualism or profound GID.	How to Deal with Ethical Questions Concerning Sex Reassignment Surgery. Many	persons, including some medical professionals, object on ethical grounds	to surgery for GID. In ordinary surgical practice, pathological tissues are	removed in order to restore disturbed functions, or alterations are made	to body features to improve the patient \'s self image. Among those who object	to sex reassignment surgery, these conditions are not thought to present	when surgery is performed for persons with gender identity disorders. It	is important that professionals dealing with patients with gender identity	disorders feel comfortable about altering anatomically normal structures.	In order to understand how surgery can alleviate the psychological discomfort	of patients diagnosed with gender identity disorders, professionals need	to listen to these patients discuss their life histories, and dilemmas. The	resistance against performing surgery on the ethical basis of \"above all	do no harm \" should be respected, discussed, and met with the opportunity	to learn from patients themselves about the psychological distress of having	profound gender identity disorder.	It is unethical to deny availability or eligibility for sex reassignment	surgeries or hormone therapy solely on the basis of blood seropositivity	for blood-borne infections such as HIV, or hepatitis B or C, etc.	The Surgeon \'s Relationship with the Physician Prescribing Hormones and the	Mental Health Professional. The surgeon is not merely a technician hired	to perform a procedure. The surgeon is part of the team of clinicians	participating in a long-term treatment process. The patient often feels an	immense positive regard for the surgeon, which ideally will enable long-term	follow-up care. Because of his or her responsibility to the patient, the	surgeon must understand the diagnosis that has led to the recommendation	for genital surgery. Surgeons should have a chance to speak at length with	their patients to satisfy themselves that the patient is likely to benefit	from the procedures. Ideally, the surgeon should have a close working	relationship with the other professionals who have been actively involved	in the patient \'s psychological and medical care. This is best accomplished	by belonging to an interdisciplinary team of professionals who specialize	in gender identity disorders. Such gender teams do not exist everywhere,	however. At the very least, the surgeon needs to be assured that the mental	health professional and physician prescribing hormones are reputable	professionals with specialized experience with gender identity disorders.	This is often reflected in the quality of the documentation letters. Since	fictitious and falsified letters have occasionally been presented, surgeons	should personally communicate with at least one of the mental health	professionals to verify the authenticity of their letters.	Prior to performing any surgical procedures, the surgeon should have all	medical conditions appropriately monitored and the effects of the hormonal	treatment upon the liver and other organ systems investigated. This can be	done alone or in conjunction with medical colleagues. Since pre-existing	conditions may complicate genital reconstructive surgeries, surgeons must	also be competent in urological diagnosis. The medical record should contain	written informed consent for the particular surgery to be performed. XI. Breast Surgery	Breast augmentation and removal are common operations, easily obtainable	by the general public for a variety of indications. Reasons for these operations	range from cosmetic indications to cancer. Although breast appearance is	definitely important as a secondary sex characteristic, breast size or presence	are not involved in the legal definitions of sex and gender and are not important	for reproduction. The performance of breast operations should be considered	with the same reservations as beginning hormonal therapy. Both produce relatively	irreversible changes to the body.	The approach for male-to-female patients is different than for female-to-male	patients. For female-to-male patients, a mastectomy procedure is usually	the first surgery performed for success in gender presentation as a man;	and for some patients it is the only surgery undertaken. When the amount	of breast tissue removed requires skin removal, a scar will result and the	patient should be so informed. Female-to-male patients might may have surgery	at the same time they begin hormones. For male-to-female patients, augmentation	mammoplasty may be performed if the physician prescribing hormones and the	surgeon have documented that breast enlargement after undergoing hormone	treatment for 18 months is not sufficient for comfort in the social gender	role. XII. Genital Surgery	Eligibility Criteria. These minimum eligibility criteria for various	genital surgeries equally apply to biologic males and females seeking genital	surgery. They are: Legal age of majority in the patient \'s nation; Usually 12 months of continuous hormonal therapy for those without a medical contraindication (see below, \"Can Surgery Be Performed Without Hormones and the Real-life Experience \"); 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion; If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery; Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches; Awareness of different competent surgeons.	Readiness Criteria. The readiness criteria include: Demonstrable progress in consolidating one \'s gender identity; Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).	Can Surgery Be Provided Without Hormones and the Real-Life Experience?	Individuals cannot receive genital surgery without meeting the eligibility	criteria. Genital surgery is a treatment for a diagnosed gender identity	disorder, and should undertaken only after careful evaluation. Genital surgery	is not a right that must be granted upon request. The SOC provide for an	individual approach for every patient; but this does not mean that the general	guidelines, which specify treatment consisting of diagnostic evaluation,	possible psychotherapy, hormones, and real-life experience, can be ignored.	However, if a person has lived convincingly as a member of the preferred	gender for a long period of time and is assessed to be a psychologically	healthy after a requisite period of psychotherapy, there is no inherent reason	that he or she must take hormones prior to genital surgery.	Conditions under which Surgery May Occur. Genital surgical treatments for	persons with a diagnosis of gender identity disorder are not merely another	set of elective procedures. Typical elective procedures only involve a private	mutually consenting contract between a patient and a surgeon. Genital surgeries	for individuals diagnosed as having GID are to be undertaken only after a	comprehensive evaluation by a qualified mental health professional. Genital	surgery may be performed once written documentation that a comprehensive	evaluation has occurred and that the person has met the eligibility and readiness	criteria. By following this procedure, the mental health professional, the	surgeon and the patient share responsibility of the decision to make irreversible	changes to the body.	Requirements for the Surgeon Performing Genital Reconstruction. The surgeon	should be a urologist, gynecologist, plastic surgeon or general surgeon,	and Board-Certified as such by a nationally known and reputable association.	The surgeon should have specialized competence in genital reconstructive	techniques as indicated by documented supervised training with a more experienced	surgeon. Even experienced surgeons in this field must be willing to have	their therapeutic skills reviewed by their peers. Surgeons should attend	professional meetings where new techniques are presented.	Ideally, the surgeon should be knowledgeable about more than one of the surgical	techniques for genital reconstruction so that he or she, in consultation	with the patient, will be able to choose the ideal technique for the individual	patient. When surgeons are skilled in a single technique, they should so	inform their patients and refer those who do not want or are unsuitable for	this procedure to another surgeon.	Genital Surgery for the Male-to-Female Patient. Genital surgical procedures	may include orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labiaplasty.	These procedures require skilled surgery and postoperative care. Techniques	include penile skin inversion, pedicled rectosigmoid transplant, or free	skin graft to line the neovagina. Sexual sensation is an important objective	in vaginoplasty, along with creation of a functional vagina and acceptable	cosmesis.	Other Surgery for the Male-to-Female Patient. Other surgeries that may be	performed to assist feminization include reduction thyroid chondroplasty,	suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction,	face-lift, and blepharoplasty. These do not require letters of recommendation	from mental health professionals.	There are concerns about the safety and effectiveness of voice modification	surgery and more follow-up research should be done prior to widespread use	of this procedure. In order to protect their vocal cords, patients who elect	this procedure should do so after all other surgeries requiring general	anesthesia with intubation are completed.	Genital Surgery for the Female-to-Male Patient. Genital surgical procedures	may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty,	scrotoplasty, urethroplasty, placement of testicular prostheses, and	phalloplasty. Current operative techniques for phalloplasty are varied. The	choice of techniques may be restricted by anatomical or surgical considerations.	If the objectives of phalloplasty are a neophallus of good appearance, standing	micturition, sexual sensation, and/or coital ability, the patient should	be clearly informed that there are several separate stages of surgery and	frequent technical difficulties which may require additional operations.	Even metoidioplasty, which in theory is a one-stage procedure for construction	of a microphallus, often requires more than one surgery. The plethora of	techniques for penis construction indicates that further technical development	is necessary.	Other Surgery for the Female-to-Male Patient. Other surgeries that may be	performed to assist masculinization include liposuction to reduce fat in	hips, thighs and buttocks. XIII. Post-Transition Follow-up	Long-term postoperative follow-up is encouraged in that it is one of the	factors associated with a good psychosocial outcome. Follow-up is important	to the patient \'s subsequent anatomic and medical health and to the surgeon \'s	knowledge about the benefits and limitations of surgery.	Long-term follow-up with the surgeon is recommended in all patients to ensure	an optimal surgical outcome. Surgeons who operate on patients who are coming	from long distances should include personal follow-up in their care plan	and attempt to ensure affordable, local, long-term aftercare in the patient \'s	geographic region. Postoperative patients may also sometimes exclude themselves	from follow-up with the physician prescribing hormones, not recognizing that	these physicians are best able to prevent, diagnose and treat possible long	term medical conditions that are unique to hormonally and surgically treated	patients. Postoperative patients should undergo regular medical screening	according to recommended guidelines for their age. The need for follow-up	extends to the mental health professional, who having spent a longer period	of time with the patient than any other professional, is in an excellent	position to assist in any post-operative adjustment difficulties.	Library","null","null","");arrFiles[2]=new Array("http://www.gendercare.com/library/wal_original1.html","	Gender Identity: a dynamical neuro-psychical process by Wal Torres & Pedro Jurberg ","Gender Identity: a dynamical neuro-psychical processBy Wal Torres# & Pedro Jurberg *# Wal was a MS in sexology candidate, at UGF-Rio, Brazil* Pedro Jurberg,PhD, is a neurobiologist from Instituto Oswaldo Cruz, Rio, Brazil.Copyright &copy; 2001 by Gendercare.com. All rights reserved.	Abstract: Since 1955 John Money introduced the concept of \"sex of rearing \" as the determining factor for gender identity erection. Some authors as Diamond, Imperato-McGinley, Reiner, Freitas; and now the true hystory of David Reimer described by Colapinto --- the twin transgenitalized by Money as he reported in 1972/75; show that \"sex of rearing \" may not be that determining factor. Based in the evidence of the neural differentiation of basal neural nucleus in the human brain, consequently there is a psychic differentiation in the human fetus; in the differentiated hormone action in genital and neural basal tissues organization (hypothalamus, stria terminallis and amygdalas); and in the possible hormone differential action in AIS (androgen insensitivity syndromes), we propose a new model for gender identity formation: by an autonomous neuro-psychical dynamic process that ends priming the gender identity in the human child (from gestation to 3 years of age).That gender identity can \'t change by social or cultural rearing factors, social identifications or any other social pressure against the child. If the social pressure is syncronous or lightly assincronous with the neuro-psychical gender identity--- lived by the child as a deep feeling to be a boy or a girl--- the identity naturally stabilizes in a steady state. If the pressure of society is hard against nature, will happen a disturbance, the child becoming insecure, neurotic, probably aggressive. If the pressure is too hard, may happen chaotic feelings of destruction, mainly self-destruction . So we propose a revision in our gender concepts and evaluation of gender dysphorias (not anymore as GID \'s, based in Money \'s model), based in a neuro-psychical paradigm and not only in a genital paradigm. We hope that understanding (the dysphorias as a neural discord --- so a somatic, biologic and organical congenital problem) will also help gender dysphorics legal and social integration. Today no clinic, lab or scientifical result show this possibility may not be true. Key-words: Gender identity/ brain \'s gender/ gender paradigm/ gender dysphorias/ hormones and gender/ intersex and transsex.	Freud, Money and the Myth	Based in Freud \'s concept of \"bisexuality \" of the psyché (see Freud	1905) --- really gender undifferentiation --- Money,Hampson,Hampson, 1955 proposed a social constructivist theoretical gender model, and a \"sex of rearing \" therapy for gender dysphorics. The child would \"learn to be a boy or a girl, as learns a language \" during the first childhood, gender being molded by the social rearing- that was Money \'s main idea.In 1966, two identical twins suffered circuncision, and one of them was mutilated, having his penis almost entirely lost (Money & Ehrhardt 1972; Money & Tucker, 1975; Diamond & Sigmundson 1997; Colapinto 2000). Money suggested the surgeons could reassign the genitals of the boy to the female, because the boy would learn to be a girl if its family, doctors and therapists would teach him continuously he was a girl--- and they agreed. The transgenital surgery was done, and they tried to teach the child to be a girl: he looked like a girl after the surgery, he was dressed with female clothes, was reared as a girl, with a girl \'s name, learning to play with girl \'s toys, learning girl \'s manners. The boy made an effort to be a girl: he don \'t knew what happened when he was a little baby. He tried hard and hard. But he was not a girl, he could not succeed.Later, they start giving him female hormone therapy. The boy took estrogens, developed breasts, and as he today says (Colapinto 2000), he was psychically submitted to a torture. He lived a terror situation each time he would need to go with his parents visit Money at the Johns Hopkins Hospital.With 14 he and his brother were informed about what happened when they were babies. They were shocked and he immediately start living as a boy, as he had the inner belief since his first childhood. His parents supported him. Later he get married with Jane, a normal woman; was transgenitalized to the male the best way possible, and took the name of David.During more than 40 years that history was not showed to sexologists, psychologists, psychiatrists, endocrinologists and general public. What the academy and the general public knew was only Money \'s version, and never David \'s version of the efficiency of \"sex of rearing therapy \". In 1994, Diamond found the twins - see Colapinto 2000 --- and Money started showing he was rethinking his \"sex of rearing \" ideas (Money 1994), recognizing for the first time the human brain was not gender undifferentiated as thought Freud, and could happen the dysphoria as a discord of gender between the neural and the genital biological organizations. Diamond 1996 and Diamond & Sigmundson 1997, started saying what really happened. But for David and other boys reared and reassigned as girls, and for a lot of others prematurely surgically reassigned based in sex of rearing \"therapy \", it was too late --- see the more than 1500 intersex dysphorics of Intersex Society of North America (Fausto-Sterling 2000, Nussbaum 2000). The same happens with other gender dysphorics, without any recognized genital malformation at birth ( \"transsexuals \").Now that the truth about David Reimer is spread thru books, papers and internet, we need to rethink gender identity formation, considering new points of principle. We intend to show how the identity and its gender may be primed in the neural system, in harmony with the genitals or in discord with them. And we intend to show how important is to study gender and gender problems. The human brain has a genderPhoenix showed the guinea pigs had a gender differentiated brain, organized by steroid hormones during a defined time (see Phoenix et al 1959). Later, other authors showed the same for primates (Resko et al 1988; Bonsall & Michael 1989). Some said hormones were important for animals, but not for gender identity of humans (Money & Ehrhardt 1972; Money & Tucker 1975; Ehrhardt & Meyer-Bahlburg 1981). Some said hormones were not important for gender identity, but perhaps only for gender roles! (Ehrhardt & Meyer-Bahlburg 1981).In humans some neuro anatomical organizational gender differences were discovered (see Swaab & Fliers 1985; Allen et al 1989; Zhou et al 1995; Kruijver et al 2000). All those differences were discovered in the hypothalamus, stria terminalis and amygdalas--- a neural basal system named by Newman 2000 as the Social Behavior Network -SBN.Zhou et al 1995 and Kruijver et al 2000 showed, in human stria terminalis, male nucleus are 1,5 times the female, and in normal and dysphoric females (female identities) those nucleus are female, and male in normal and dysphoric males (male identities); and no hormone or social condition could change that fact after birth. Those facts suggest the gender identity formation depends on neuro-anatomy of SBN basal systems, and the neural organization of the SBN depends on:I. The sexual hormones during SBN gender differentiation in fetal stage of human and other primates development (see Imperato McGinley et al 1979; Clark et al, 1988; Resko et al 1988; Bonsall & Michael 1989; Zhou et al 1995; Wilson 1999; Kruijver et al 2000).II. For humans and other mammal species the gender differentiation depends on the action of testosterone-T thru the androgen receptor- AR and not on the action of dihydrotestosterone-DHT (see Imperato McGinley et al 1979; Resko et al 1988; Bonsall & Michael 1989) or the aromatization of T (see Ogawa et al 1997,1998a and b,1999).III. For humans, the genital tract surely is only differentiated by DHT --- see Wilson et al 1980.The independence between neural and genital gender is a consequence of those arguments. So we may say it is possible to happen the organic, biological, somatic discord between neural and genital gender, with or without genital malformation. The relation between the neural and the psychical If the human fetus is neural gender differentiated, that neural differentiation needs to promote a psychical expression --- see Damasio 1994 --- so the child is necessarily psychically gender differentiated since its fetus stage. But how the neural organization becomes psychical translation and expression?Based in Damasio 1994, we may develop a model for gender identity formation simulation as a simple and first possibility--- certainly not the best, and surely not the last.Gender Identity Modeling and SimulationA good model is one that describes and simulates something with a desired precision. The precision of the simulation may be established and later measured and verified by control conditions. For the gender identity dynamical neuro-psychical formation model we establish here, we will use Damasio \'s neurobiological dynamics and as control conditions the dysphoric living and existence. If that model describes well a normal and a dysphoric gender identity formation, it will be a good model for that first stage of our proposal. We know very well that all simulation model is a reduction of our possible knowledge of all phenomena --- but we may develop knowledge only by reducing the reality to our models--- that is an episthemologic basic principle. Obviously we may be criticized because our model will be too simple and the neurobiology of Damasio is a knowledge still too incipient also; but surely as soon as possible other neuro-psychical models better than this one will be developed. That is only one of the models possible, and surely not the best: but its results show that for dysphoric \'s simulation it is a good first model for further developments. With the development of neurobiology and neuropsychology, new models better than this one will surely be developed, but even this so simple one show good results for the present moment of our development --- much better, for example, than the results showed by Money \'s social constructivist model.The model description and the simulation of a dysphoric identity formation is described as follows:I.At birth, the SBN is gender differentiated. May be organized as male or female (really other possibilities exists- as showed Colapinto 2000 in people that feels as androginous, without female or male identities --- but our model don \'t consider that possibility). In the future, new and better models will consider what now we ignore. II.The child always is exposed to an environment: as a fetus, its mother is its environment, and after birth, the world. III.The environment is continuously introducing, thru the senses, stimulous to the brain. As the inner visceral and tissue \'s sensations are also continuously sending internal stimulous to the brain. IV.Those stimulous to the fetus and the unconscient baby \'s brain is continuously stimulating autonomous answers of basal nucleus of the brain (see Damasio 1994). One of those systems is the gender differentiated SBN, that will answer autonomously a gender differentiated answer, depending only from its neural organization --- and not on the environment conditions (after the ending of the neural organization), or the genital conformation. V.That answer will be continuously retained by the memories --- priming emotional memories --- in the limbic system, unconsciously. VI.For example a female SBN will react autonomously with female-like answers: less aggressive, with more receptivity, more female sensibility --- in resume, autonomously in a female way. VII.The same way, the male SBN will react in a more aggressive way, more assertivity, more activity. All those answers end priming the emotional memory, since gestation and first childhood. VIII.Those gender differentiated answers will constinuously reinforce positively the memory of gender from the SBN, as a fetus and as a small child, just until 2,3 years of age, unconsciously. Later, that reinforcement will continue, forever. IX.The female brain of the little child will predispose the child to like to play and have female manners: to play dolls and house, have \"sissi \" feelings, because has a female SBN; and fight and play boyish toys, and develop male manners and feelings if had a male SBN. X.The genitals don \'t play nothing in that dynamic process that erects as a priming the gender identity as the feelings to be a girl or a boy. XI.One day the child with 4,5 or 6 will feel consciously that identity, those memories and natural gender differentiated answers it lives since it was a fetus, always as a continuous positive reinforcement, as a belief and self-recognition and inner sensation as a certainty to be a boy or a girl. XII.If it was a normal girl or boy, all will be in harmony with its genitals and rearing: that dynamical process is naturally lived and is not perceived. XIII.But if the child \'s SBN is in discord with its genitals, at that moment and later on it will start living the torture to feel one gender identity, being socially recognized by the other gender. That discord between nature and rearing will certainly interfere with the emotional stability of the child, since its 5,6 7 years old and later --- and the uneasiness with the genitals of the gender dysphoric will start.XIV. The dysphoric child will have the conscience of its situation and the courage to show others its reality, as a \"primary \" transsexual, for example.XV. Or may hide its reality, and try to live as a non dysphoric one, hiding for itself its sufferings. One day, may show its reality as a \"secondary transsexual \" --- really a dysphoric that show others its gender reality only later. XIV.That model, aplied to dysphorics show a very good and real simulation of their reality--- as themselves admit in a lot of testimonies --- and simulates very well all dysphoric feelings quoted in ICD-10, F.64.2, from World Health Organization-WHO, where are defined the dysphoric child \'s feelings.So, for our control conditions and criteria, even being a so simple model, based in so simple Damasio \'s neurobiological considerations, our model is a very good one for that moment and for the present stage of development of neuro-psychical possible translations.The influence of the social environmentIf the social environment and the sex of rearing is syncronous with the gender identity, and also the genitals naturally or surgically are in harmony, the child is normal, with no problem or dysphoria --- this way lives the great majority of humans. So nobody thinks in those dynamics, and seems if the genitals had automatically the power to promote masculinity or femininity in all systems and tissues. But some children are dysphorics: they had a gender discord between genital and SBN. In those situations, when the child start being conscient of itself, will perceive its feelings are in discord with its genitals, its name, its clothes, its social recognition. Starts the dysphoric feelings, that uneasiness with its body, its genitals, its social situation.The child likes dolls and play house, and has a boy \'s name, genitals, social and civil identification. All will recognize in her, not the girl she always was sure she was, but a boy: a \"gay boy \", an effeminate boy, a \"sissi boy \". That will hurt the inner feelings of the dysphoric girl. Or vice versa for a dysphoric boy, with a vagina, natural or made by a surgeon as David Reimer \'s .The social rearing can \'t change or form the gender identity, but may disturb the life of the gender dysphoric, if in assyncronicity with the neural gender identity. The social pressure in discord with the gender identity may cause neurosis and even psychosis and suicides.How may be primed the gender neural organization?Jeanne Imperato- McGinley et al 1979 had a very important idea: studying 5-alfa-reductase syndromes, they discovered that systematically, children with that kind of syndrome had gender problems.That syndrome means the enzime that metabolizes T in DHT don \'t works well. So, without DHT, the genital tract may not be masculinized and the genitals remain almost female. The children were reared as girls, and later, all around the world, in all cultures, after 7 they start showing they had male gender identities. Imperato-McGinley and her co-workers understood the neural system could be masculinized by T and not DHT as the genital tract, and be in discord. But in those days, the \"sucessfull experience \" of Money \'s twins don \'t gave the academy the opportunity to understand Imperato McGinley could be wright, and Money wrong. Later, Resko et al 1988; Bonsall & Michael 1989; Diamond 1996; Freitas 1998; Wilson 1999 had the same Imperato McGinley \'s idea in other dysphoric situations: testosterone may masculinize the SBN as DHT masculinizes the genital tract--- by two totally independent processes. The congenital organical gender discord is possible, even in humans. After Diamond & Sigmundson 1997 and mainly Colapinto 2000, we hope all will agree Imperato McGinley may be right: T may be the responsible for neural gender differentiation, and that differentiation remains forever, erecting the gender identity dynamically, priming it naturally and biologically by the living of the nervous system by a somato- psychical translation .Gender paradigm --- a question of Ethics and Science Who really is a boy or a girl? (Torres & Jurberg 2000).The best classification is decided by the genitals; the genitals and rearing; or the inner living of the certainty to be a boy or a girl? Something neuro-psychical, independent from the genitals and the social rearing? What is the best way to understand gender, and to choose the best referential for gender social classification today?In that subject, we need a revolution, as Copernicus and Kant made, for cosmologic and philosophic principles. We think it is ideological and ethically better to respect the human being as a person, with its autonomous self-recognition, as a closure. Ethically humans have autonomy as a human right. So, the real gender is the self- reference, the certainty to be a boy or a girl, and not what others think we are, by what they see when we are babies, in a heteronomous way. If we respect human autonomy, we will retain as gender referential the neuro-psychic neural gender organization, in harmony or not with the genitals. If not in harmony, we have today enough surgical technology and hormone therapy to correct the body to live the neuro-psychical reality in harmony, recognizing the neural (the self) prevails over the genital. Ethically the autonomous over the heteronomous.No scientifical result nor existencial situation disagrees with that paradigm today, in normal and gender dysphoric people. Why not change the civil law? Why not socially protect dysphoric children, respecting their autonomy as human beings? Respecting the way they see themselves, the way they feel and exists?Dysphorics have not GIDs- gender identity disorders, as thought Money, ICD-10 and DSM-IV psychiatrical standards. Their psychical problems --- if they have any --- are consequence of the hardness of society against their inner nature since they were little children, and not the responsible of the ethiology of the dysphoria (see Cohen et al 1997). GID \'s as any psychiatrical disorder in gender dysphorics is a myth --- as the efficiency of sex of rearing \"therapy \" was a myth.Sexologists, psychiatrists, psychologists, doctors, parents, pastors, priests, judges, authorities, governors: give the dysphorics a chance to be normal; being recognized, after its body corrections, as normal people. Then, and only then, they will live in harmony with themselves, with their bodies and papers, and with society; feeling they are, as the others, socially accepted and respected as citizens. Possibly, as the others, they will live and possibly be happy.Reference ListALLEN,LS; HINES,M; SHRYNE,JE; GORSKY,RA (1989)---Two sexually dimorphic cell groups in the human brain, Journal Neuroscience 9(2), 497-506, 1989;BONSALL,RW & MICHAEL,RP (1989)--- Pretreatments with 5alfa dihydrotestosterone and the uptake of testosterone by cell nuclei in the brains of male rhesus monkeys, Journal Steroid Biochemistry, 33(3),405, 1989;	CLARK,AS; McLUSKY,NJ; GOLDMAN-RAKIC,PS (1988)--- Androgen binding and metabolism in the cerebral cortex of the developing rhesus monkey, Endocrinology, 123(2),932,1988;COHEN, de RUITER,C; RINGELBERG,H; COHEN-KETTENIS,PT (1997)--- Psychological functioning of adolescent transsexuals: personality and psychopathology, Journal of Clinical Psychology, 53(2), 187-196, 1997;COLAPINTO,J (2000)--- As Nature Made Him --- Portuguese translation: Sexo Trocado- a história real do menino criado como menina, Ediouro, 2001;DAMASIO,AR (1994)---Descarte \'s Error--- Portuguese translation: O erro de Descartes,, Cia das Letras, 1996;	DIAMOND,M (1996)--- Prenatal predisposition and the clinical management of some pediatric conditions, Journal of Sex & Marital Therapy, 22(3) 1996;DIAMOND,M & SIGMUNDSON, HK (1997)--- Sex reassignment at birth: long-term review and clinical implications, Archives of Pediatric Adolescent Medicine. 151, 298-304, 1997;	EHRHARDT,AA & MEYER-BAHLBURG,HFL (1981)---Effects of prenatal sex hormones on gender related behavior---Science, v211, pp1312, 1981.	FAUSTO-STERLING,A (2000)---The Five Sexes, Revisited, The Sciences, 19-23,July/ August 2000;FREITAS,MC (1998)---Meu Sexo Real: a origem inata, somática e neurobiológica da transexualidade, Editora Vozes, 1998;	FREUD,S---3 ensaios sobre a teoria da sexualidade (1905), Ed. Stand. Bras., vol VII, Imago,1972;	GOTTLIEB,B; PINSKY,L; BEITEL,LK; TRIFIRO,M (1999)---Androgen Insensitivity, American Journal of Medical Genetics (Semin. Med. Genet.) 89: 210-217, 1999;	IMPERATO-McGINLEY,J; PETERSON,RE; GAUTIER,T; STURLA,E (1979)---Androgens and the evolution of male-gender identity among male pseudohermaphrodites with 5-alfa-Reductase deficiency, The New England Journal of Medicine, 300(22) 1233-1237, 1979;	KRUIJVER,FPM; ZHOU,JN; POOL,CW; HOFMAN,MA; GOOREN,LJG; SWAAB,DF (2000)--- Male to female transsexuals have female neuron numbers in a limbic nucleus, The Journal of Clinical Endocrinology and Metabolism, 85(5), 2034-2041, 2000;MIGEON,CJ; BROWN,TR; LANES,R; PALACIOS,A; AMRHEIN,JÁ; SCHOEN,EJ (1984)--- A clinical syndrome of mild androgen insensitivity, Journal of Clinical Endocrinology and Metabolism, 59(4), 672-678, 1984;MONEY,J; HAMPSON,JG; HAMPSON,JL (1955)---Hermafroditism: recommendations concerning assignmentt of sex, change of sex, and psychologic management, Bulletin of the Johns Hopkins Hospital 97, 284-300, 1955;	MONEY,J & ERHARDT,AA (1972)---Man and woman; boy and girl: The differentiation and dimorphism of sexual identity from conception to maturity, Johns Hopkins University Press, 1972;	MONEY,J & TUCKER, P (1975) --- Sexual signatures: on being a man or a woman, Portuguese translation as \" Os papéis sexuais \"by Editora Brasiliense, 1981;MONEY,J (1994)--- The concept of gender identity disorder in childhood and adolescence after 39 years, Journal of Sex & Marital Therapy, 20 (3), 163-177, 1994;	NEWMAN,SW (2000)--- The medial extended amigdala in male reproductive behavior: A node in the mammalian social behavior network, Annals of the New York Academy of Sciences, 242-257, 2000; NUSSBAUM,E (2000)--- A question of gender, Discover Magazine, Jan 2000; OGAWA,S; LUBAHN,DB; KORACH,KS; PFAFF,DW (1997)---Behavioral effects of estrogen receptor gene disruption in male mice, Proceedings of the National Academy of Sciences of the USA, 94,1476-1481, 1997;	OGAWA,S; ENG,V; TAYLOR,J; LUBAHN,DB; KORACH,KS; PFAFF,DW (1998b)--- Roles of estrogen receptor-alfa gene expression in reproduction related behaviors in female mice, Endocrinology, 139 (12), 5070, 1998b;	OGAWA,S; WASHBURN,TF; TAYLOR,J, LUBAHN,DB; KORACH,KS; PFAFF,DW (1998a)--- Modification of testosterone dependent behaviors by estrogen receptor-alfa gene disruption in male mice,Endocrinology, 139(12), 5058, 1998a;	OGAWA,S; CHAN,J; CHESTER,AE; GUSTAFSSON,JÁ; KORACH,KS; PFAFF,DW (1999)--- Survival of reproductive behaviors in estrogen receptor-beta gene deficient (?erko) male and female mice, Proceedings of the National Academy of Sciences of the USA, 96(22), 12887-12892, 1999;	PHOENIX,CH; GOY,RW; GERALL,AA; YOUNG,WC (1959)--- Organizing action of prenatally administered testosterone propionate on the tissues mediating mating behavior in the female guinea pig--- Endocrinology, 65, pp. 600-667, 1959;	QUIGLEY,CA; DeBELLIS,A; MARSCHKE,KB; EL-AWADY,MK; WILSON,EM; FRENCH,FS (1995)---Androgen receptor defects: historical, clinical and molecular perspectives, Endocrine Reviews, 16(3), 271-321, 1995;	RESKO,J; CONNOLLY,PB; ROSELLI,CE (1988)--- Testosterone 5-alfa-reductase activity in neural tissue of fetal rhesus macaques, Journal Steroid Biochemistry, 29(4), 429-434;	SWAAB,DF & FLIERS,E (1985)--- A sexually dimorphic nucleus in the human brain, Science 228, 1112;	TORRES,WF & JURBERG,P (2000)--- Ser homem ou ser mulher: a identidade neuro-psíquica de gênero como fator determinante, Scientia Sexualis, 6(3), 2000;TORRES,WF & JURBERG,P (2001)--- PAIS and MAIS ligand-selective and the organic ethiology of gender dysphorias, paper presented at the 15th World Congress of Sexology, that same volume, 2001;WILSON,JD; GRIFFIN,JE; GEORGE,FW (1980)--- Sexual differentiation: early hormone synthesis and action, Biology of Reproduction, 22, 9-17;WILSON,JD (1999)--- The role of androgens in male gender role behavior, Endocrine Reviews, 20(5), 726-737;1999;	ZHOU,JN; HOFMAN,MA; GOOREN,LJG; SWAAB,DF (1995)--- A sex difference in the human brain and its relation to transsexuality, Nature, 378, 68-70, 1995. Wal Torres is supported by CapesAny correspondence, send to:Wal Torres, Universidade Gama Filho, Rio, BrazilPaper Presented at the 15th World Congress of Sexology, Paris 2001","null","null","");arrFiles[3]=new Array("http://www.gendercare.com/library/wal_original2.html","	PAIS and MAIS Ligand-Selective and the Organic Ethiology of Gender Dysphorias by Wal Torres & Pedro Jurberg --- Torres & Jurberg Hypothesis","PAIS and MAIS Ligand-Selective and the Organic Ethiology of Gender Dysphorias By Wal Torres# & Pedro Jurberg *# Wal was a MS in sexology candidate, at UGF-Rio, Brazil* Pedro Jurberg,PhD, is a neurobiologist from Instituto Oswaldo Cruz, Rio, Brazil.Copyright &copy; 2001 by Gendercare.com. All rights reserved.	Abstract: Gender may not be defined anymore only by genitals and sex of rearing as determining factors: after David Reimer \'s revelation of the truth about what he suffered oppressed by sex of rearing \"therapy \", we need to renew our gender criterias. We propose the neuro-psychical identity as a new gender main criteria, and that gender is independent of the genital conformation because the sex hormone that determines genital external conformation is DHT, thru its action over the androgen receptor AR, but testosterone-T is the main responsible for the neural gender organization in humans. The gender discord between those two biological systems may occur, generating the dysphoria, naturally or thru a genital surgery (as in David Reimer \'s case). It is important to study the hormone-selective binding characteristics and expression (T-AR and DHT-AR) to know if that action in mild androgen insensitivity syndromes-MAIS and partial syndromes-PAIS explain some dysphoric situations in transsexuals (MAIS) and intersexuals (PAIS). A diagnosis test for children and youths may be developed, and gender understanding must be renewed. Key Words: Gender identity/ gender dysphorias/ androgen insensitivity syndromes/ intersex/ transsex.	The androgen receptor (AR) is a ligand-activated transcription factor that mediates male sexual development. AR binds the two biologically active androgens, testosterone(T) and dihydrotestosterone(DHT), with high affinity (Zhou et al 1995b). AR is not tissue or ligand specific, but its action is ligand dependent. There is a database (Gottlieb et al,1998) of AR mutations. Despite AR being not ligand specific, its action may be ligand-selective. Sometimes both ligands T and DHT are uneffective; sometimes DHT is less effective; sometimes T (Gottlieb et al, 1999) .	In PAIS and CAIS (complete AIS), the action of DHT-AR is abnormal (it generates genital malformations- levels 2 to 7 in Quigley \'s scale--- see Quigley et al 1995); in MAIS maybe there is no problem with DHT-AR (they don \'t show any genital malformation- level 1 in Quigley \'s scale), but possibly T-AR may have important abnormalities (they show undervirilization: gynecomastia, or small penis, and/or a dysphoria, etc.).The abnormalities in T-AR are less visible and less studied than DHT-AR, because they mediate--- during fetal stage--- \"more invisible processes \" (Zhou et al,1995b), in more invisible tissues.	Some genital malformation or intersex don \'t generate gender dysphorias. Gender dysphoria means \"to have an uneasiness with its genitals \". CAIS don \'t generate dysphorias, because all tissues remain female and there is no inner discord. Some PAIS and MAIS cases also don \'t generate dysphorias. Gender dysphorias happens when there is a gender discord between genital and neural tissues. That situation may happens: (1) When baby boys have their genitals mutilated, or micropenis, and are surgically transgenitalized to females and reared as girls. For example, the John/Joan case (David Reimer \'s), described by Nussbaum,2000;Diamond & Sigmundson,1997; Fausto-Sterling,2000; Colapinto,2000; (2) when happens the discord between the neural gender (male) with ambiguous (female like) genitals, as in Imperato McGinley \'s syndromes: recognized as girls, reared as girls in all cultures and continents, later they show they are boys; (3) some PAIS situations, when the genitals are more female, but the neural male (in most PAIS cases there is harmony between genital and neural gender, both female or male); (4) True hermafroditism when the genital option (by surgery decision made by adults: parents, psychiatrists or surgeons) is not in accord with the child neuro-psychical gender identity (showed later by the child expression and living); (5) \"transsexuals \", when the neural and genital gender are naturally in radical discord, without any visible genital external conformation problem. How we may evaluate those situations? What could be a good criteria?John Money \'s criteria (genital conformation and sex of rearing --- see Money & Ehrhardt 1972; Money & Tucker 1975) really isn \'t a good criteria: the true story of David Reimer show us John Money \'s model of gender identity formation was a fake and not the reality (see Diamond 1996; Diamond & Sigmundson 1997; Colapinto 2000; Fausto-Sterling 2000) --- Money and his co-workers wrote and published their opinions and not what the patient (David Reimer) really lived as gender identity, as truth-they ignored the patient \'s reality, publishing their opinions as truth and unfortunately being believed: they trapped doctors, sexologists and psychologists.	Considering: (a) Our neural organization has its congenital and irreversible gender determined in a neuroendocrinal way (Imperato McGinley et al, 1979; Bonsall & Michael 1989; Resko et al 1988; McEwen, 1994, Zhou et al, 1995a; Kruijver et al, 2000); (b) That gender neural organization generates in the foetus and baby a psychical gender identity as an emotional priming (see Damasio 1994; Torres & Jurberg 2000; and Torres & Jurberg in other article in this volume); and that (c) rearing, culture, hormones at puberty: modulate, inhibit or reinforce, but don \'t determine the gender of our identity (Imperato McGinley1979; Wilson,JD, 1999);	we propose as a 1st gender classification criteria: what determines the neural gender is prenatal T as what determines the external genitals gender is prenatal DHT: in humans as in other primates (Bonsall & Michael 1989, Resko et al, 1988).The gender identity is determined by the dynamic complex evolution and psychical expression of that neural differentiation (see the other article of Torres & Jurberg in this volume). To evaluate properly gender in transsexual and intersexual dysphorics it is important the selective action of T-AR and DHT-AR in PAIS and MAIS, researching functional activity and gene expression not only of DHT-AR and artificial steroids-AR, but also T-AR (see Gottlieb et al 1999).	What we may today do in mosaic situations? In the genital tract (DHT-AR action) we may know , but in the neural (T-AR)? We propose as a 2nd gender classification criteria: in complex situations: wait the child own manifestation thru its neural system of who it is, boy or girl: they have the best neural sensor possible: their selves .	Whe propose a 3rd gender classification criteria: When happens a dysphoria in a genetically male child, it would be important to study the child in the molecular level, with or without genital malformations , when it is feasible --- or wait and believe in the identity showed by the child.	Those 3 criterias may prevent dysphorias when there are genital malformations, and a test procedure to evaluate dysphorias in children may be developed. When malformations don \'t happen we may not prevent, but we may diagnosis soon (the child show a dysphoria between 5 to 8 years old if with liberty and no social repression --- as a \"sissi boy \" or \"effeminate gay boy \", for example), and correct the children as soon as possible--- beginning with 10 to 12 years old at least, before the child will be too traumatized by society (see Cohen et al, 1997) and the body structure defformed by hormones.	The ligand-selective test may prevent consequences. If not, we will need to wait that the victim show its identity freely, before any surgery and final legal gender classification is irreversibly d etermined. It is better to sacrifice family and society, delaying the social and civil legal decision --- as Freitas, 1998 proposed --- knowing that doing this way we will prevent some children sufferings.	The ethical position we support today is: don \'t define anymore gender in a rash, heteronomous and authoritary way, because that rash action may mutilate children, and originate dysphorias --- see David Reimer \'s and Cheryl Chase \'s stories and arguments (Fausto-Sterling 2000; Colapinto 2000). Therapists and surgeons know gender dysphorics by the outside only --- thinking they have problems to understand reality (see Mormont, Michel, Wauthy, 1995), when they are the only to really know and live themselves by the inside, knowing their true reality (see Freitas 1998).	Today, no result or fact is in contradiction with our 3 criterias; but first of al we need a positive confirmation of them from lab gene expression results in PAIS and MAIS intersex and transsex --- and to do that we need a molecular endocrinology lab to continue our project .	References:	ALLEN,LS; HINES,M; SHRYNE,JE; GORSKY,RA (1989)---Two sexually dimorphic cell groups in the human brain, Journal Neuroscience 9(2), 497-506, 1989;	BONSALL,RW & MICHAEL,RP (1989)--- Pretreatments with 5alfa dihydrotestosterone and the uptake of testosterone by cell nuclei in the brains of male rhesus monkeys, Journal Steroid Biochemistry, 33(3),405, 1989;	CLARK,AS; MAcLUSKY,NJ; GOLDMAN-RAKIC,PS (1988)--- Androgen binding	and metabolism in the cerebral cortex of the developing rhesus	monkey, Endocrinology, 123(2),932,1988;COHEN, de RUITER,C; RINGELBERG,H; COHEN-KETTENIS,PT (1997)--- Psychological functioning of adolescent transsexuals: personality and psychopathology, Journal of Clinical Psychology, 53(2), 187-196, 1997;COLAPINTO,J (2000)--- As Nature Made Him --- Portuguese translation: Sexo Trocado- a história real do menino criado como menina, Ediouro, 2001;DAMASIO,AR (1994)---Descarte \'s Error--- Portuguese translation: O erro de Descartes,, Cia das Letras, 1996;	DIAMOND,M (1996)--- Prenatal predisposition and the clinical management of some pediatric conditions, Journal of Sex & Marital Therapy, 22(3) 1996;DIAMOND,M & SIGMUNDSON, HK (1997)--- Sex reassignment at birth: long-term review and clinical implications, Archives of Pediatric Adolescent Medicine. 151, 298-304, 1997;	EHRHARDT,AA & MEYER-BAHLBURG,HFL (1981)---Effects of prenatal sex hormones on gender related behavior---Science, v211, pp1312, 1981.	FAUSTO-STERLING,A (2000)---The Five Sexes, Revisited, The Sciences, 19-23,July/ August 2000;FREITAS,MC (1998)---Meu Sexo Real: a origem inata, somática e neurobiológica da transexualidade, Editora Vozes, 1998;	FREUD,S---3 ensaios sobre a teoria da sexualidade (1905), Ed. Stand. Bras., vol VII, Imago,1972;	GOTTLIEB,B; LEHVASLAIHO,H; BEITEL,LK; LUMBROSO,R; PINSKY,L; TRIFIRO,M (1999) --- The androgen receptor gene mutation database, Nucleic Acids Research 26(1),234, 1998;GOTTLIEB,B; PINSKY,L; BEITEL,LK; TRIFIRO,M (1999)---Androgen Insensitivity, American Journal of Medical Genetics (Semin. Med. Genet.) 89: 210-217, 1999;	IMPERATO-McGINLEY,J; PETERSON,RE; GAUTIER,T; STURLA,E (1979)---Androgens and the evolution of male-gender identity among male pseudohermaphrodites with 5-alfa-Reductase deficiency, The New England Journal of Medicine, 300(22) 1233-1237, 1979;	KRUIJVER,FPM; ZHOU,JN; POOL,CW; HOFMAN,MA; GOOREN,LJG; SWAAB,DF (2000)--- Male to female transsexuals have female neuron numbers in a limbic nucleus, The Journal of Clinical Endocrinology and Metabolism, 85(5), 2034-2041, 2000;McEWEN,B (1994) --- How do sex and stress hormones affect nerve cells? Annals New York Academy of Sciences, 1-18, 1994;MIGEON,CJ; BROWN,TR; LANES,R; PALACIOS,A; AMRHEIN,JÁ; SCHOEN,EJ (1984)--- A clinical syndrome of mild androgen insensitivity, Journal of Clinical Endocrinology and Metabolism, 59(4), 672-678, 1984;MONEY,J; HAMPSON,JG; HAMPSON,JL (1955)---Hermafroditism: recommendations concerning assignmentt of sex, change of sex, and psychologic management, Bulletin of the Johns Hopkins Hospital 97, 284-300, 1955;	MONEY,J & ERHARDT,AA (1972)---Man and woman; boy and girl: The differentiation and dimorphism of sexual identity from conception to maturity, Johns Hopkins University Press, 1972;	MONEY,J & TUCKER, P (1975) --- Sexual signatures: on being a man or a woman, Portuguese translation as \" Os papéis sexuais \"by Editora Brasiliense, 1981;MONEY,J (1994)--- The concept of gender identity disorder in childhood and adolescence after 39 years, Journal of Sex & Marital Therapy, 20 (3), 163-177, 1994;	MORMONT,C; MICHEL,A; WAUTHY,J --- Transsexualism and Connection with Reality: Rorschach data, in Rorschachiana - Yearbook of the International Rorschach Society , Hogrefe & Huber Publishers, vol 20, pg 172-187, 1995; NEWMAN,SW (2000)--- The medial extended amigdala in male reproductive behavior: A node in the mammalian social behavior network, Annals of the New York Academy of Sciences, 242-257, 2000;	NUSSBAUM,E (2000)--- A question of gender, Discover Magazine, Jan 2000;	OGAWA,S; LUBAHN,DB; KORACH,KS; PFAFF,DW (1997)---Behavioral effects of estrogen receptor gene disruption in male mice, Proceedings of the National Academy of Sciences of the USA, 94,1476-1481, 1997;	OGAWA,S; ENG,V; TAYLOR,J; LUBAHN,DB; KORACH,KS; PFAFF,DW (1998b)--- Roles of estrogen receptor-alfa gene expression in reproduction related behaviors in female mice, Endocrinology, 139 (12), 5070, 1998b; OGAWA,S; WASHBURN,TF; TAYLOR,J, LUBAHN,DB; KORACH,KS; PFAFF,DW (1998a)--- Modification of testosterone dependent behaviors by estrogen receptor-alfa gene disruption in male mice,Endocrinology, 139(12), 5058, 1998a; OGAWA,S; CHAN,J; CHESTER,AE; GUSTAFSSON,JÁ; KORACH,KS; PFAFF,DW (1999)--- Survival of reproductive behaviors in estrogen receptor-beta gene deficient (?erko) male and female mice, Proceedings of the National Academy of Sciences of the USA, 96(22), 12887-12892, 1999;	PHOENIX,CH; GOY,RW; GERALL,AA; YOUNG,WC (1959)--- Organizing action of prenatally administered testosterone propionate on the tissues mediating mating behavior in the female guinea pig--- Endocrinology, 65, pp. 600-667, 1959;	QUIGLEY,CA; DeBELLIS,A; MARSCHKE,KB; EL-AWADY,MK; WILSON,EM; FRENCH,FS (1995)---Androgen receptor defects: historical, clinical and molecular perspectives, Endocrine Reviews, 16(3), 271-321, 1995;	RESKO,J; CONNOLLY,PB; ROSELLI,CE (1988)--- Testosterone 5-alfa-reductase activity in neural tissue of fetal rhesus macaques, Journal Steroid Biochemistry, 29(4), 429-434;1988;	SWAAB,DF & FLIERS,E (1985)--- A sexually dimorphic nucleus in the human brain, Science 228, 1112;	1985;TORRES,WF & JURBERG,P (2000)--- Ser homem ou ser mulher: a identidade neuro-psíquica de gênero como fator determinante, Scientia Sexualis, 6(3), 2000;TORRES,WF & JURBERG,P (2001) --- Gender Identity: A dynamical neuro-psychical process, paper presented at the 15th World Congress of Sexology, Paris, that same volume, 2001;WILSON,JD; GRIFFIN,JE; GEORGE,FW (1980)--- Sexual differentiation: early hormone synthesis and action, Biology of Reproduction, 22, 9-17;1980;WILSON,JD, GRIFFIN,JE, RUSSEL,DW (1993) --- Steroid e-alfa-redutase 2 deficiency, Endocrine Reviews, 14(5), 577, 1993;WILSON,JD (1999)--- The role of androgens in male gender role behavior, Endocrine Reviews, 20(5), 726-737;1999;	ZHOU,JN; HOFMAN,MA; GOOREN,LJG; SWAAB,DF--- A sex difference in the human brain and its relation to transsexuality, Nature, 378, 68-70, 1995(A); ZHOU,ZX ; LANE,MV; KEMPPAINEN,JÁ; FRENCH,FS; WILSON,EM--- Specificity of ligand-dependent androgen receptor stabilization: receptor domain interactions influence ligand dissociation and receptor stability, Molecular Endocrinology, 9(2), 208-218, 1995(B).Paris, June 2001	Universidade Gama Filho- Rio, BrazilWF Torres supported by Capes.	Presented at the 15th World Congress of Sexology, Paris 2001","null","null","");arrFiles[4]=new Array("http://www.gendercare.com/library/wal_original3.html","	Nossa Sociedade Neurótica e seu Modelo Distorcido de Realidade por Wal Torres (Martha Freitas), em homenagem ao Grupo Atobá-RJ","Nossa Sociedade Neurótica e seu Modelo Distorcido de RealidadeEscrito em homenagem ao Grupo Atobá do Rio de Janeiro em 2000 por Wal Torres# (Martha Freitas) # Wal nesse tempo era candidata ao MS em sexologia na UGF-Rio, BrazilConvidada pelo Atobá, escreveu esse capítulo de um livro que não foi editado.Copyright &copy; 2001 by Gendercare.com. All rights reserved.	Sempre que estive no Atobá falei sobre o bonobo, um macaco	descoberto neste final do século XX, que a meu ver foi uma	das maiores descobertas científicas de todos os tempos. Agora, neste momento, não tenho como não começar me referindo a ele. Nas florestas do Congo, existem dois tipos de macacos quase humanos: os chimpanzés (Pan trogloditas) e os bonobos (Pan paniscus). Nós e os bonobos somos descendentes dos chimpanzés. Dos bonobos nós somos primos. Nos diferenciamos dos chimpanzés há uns 4,5 a 5 milhões de anos, e os bonobos se diferenciaram deles há uns 2,5 milhões de anos, ou seja, eles são geneticamente mais \"modernos \" que nós. Mas à partir do chimpanzé eles evoluíram num sentido diferente de nós: nós evoluímos nossa inteligência, e eles ao que tudo indica desenvolveram sua sensibilidade e altruísmo.A sociedade chimpanzé é como a nossa: sexualmente a regra é a heterossexualidade, e sexo é feito para a procriação. Os machos são dominadores e violentos, entre eles e com as fêmeas. Todos, machos e fêmeas, parecem uns neuróticos. Existem guerras e lutas de extermínio. Parecem-se muito conosco, são nossos bisavós.A sociedade bonoba se desenvolveu de forma diferente. Eles tem sistematicamente um comportamento bissexual na natureza: na infância, os macaquinhos machos se relacionam entre si, sistematicamente. Idem as macaquinhas. Eles crescem numa sociedade que para nós seria \"libertina \", \"promíscua \", mas sem frustrações. Depois de crescidinhas, as meninas macacas se afastam da tribo, e procuram uma outra, e lá não se relacionam com os machos, mas com as fêmeas. Depois de transarem com quase todas as fêmeas, elas são \"aceitas no grupo \", e passam a transar também com os machos, além de por toda a vida transarem entre si, com muito mais frequência do que com os machos.Essa sociedade é extremamente pacífica, bem resolvida, sem conflitos e problemas, fazendo sexo e não se agredindo. Machos com machos, fêmeas com fêmeas, e machos com fêmeas. Uma sociedade a nossos olhos promíscua, imoral, desencaminhada? Mas aos olhos da natureza, equilibrada! A promiscuidade e a degradação não estarão em nossos olhos? Como em nossa sociedade está o desequilíbrio da violência?Ainda hoje a mulher ter prazer é considerada uma coisa indecente. Seria humilhante o prazer? O que teria valor seria o sofrimento? Somos, as mulheres que dão vazão à libido e à própria feminilidade, caracterizadas como \"vadias \". Até na música do funk. Como se o prazer fosse uma vergonha, uma imundície! Eu gosto de minhas primas bonobas. Elas são mais felizes que as chimpanzés, que apanham dos machos, se agarram neuroticamente às crias, dependem exclusivamente do humor dos machos; e aceitam naturalmente uma sociedade machista e violenta ao extremo, que não aceita o diferente, perscrutando as diferenças ao invés de realçar as semelhanças. A bonoba vive e deixa viver. Infelizmente, essas relações mais livres, na nossa cultura da opressão e do autoritarismo, do machismo e da prepotência..... a cultura da mediocridade ocidental, que dificulta o prazer e a descontração, que torna tudo difícil, porque tudo é tabu, nada que pode dar prazer é lícito: onde sofrer é bom e santo, ter prazer é mal e depravado. Na natureza existe continuamente a valoração do prazer e a fuga do sofrimento. Quem valoriza o sofrimento e o fazer o outro sofrer, depreciando na realidade o outro além do prazer, é nossa cultura neurótica, nossa cultura chimpanzé humanizada sob uma película de racionalidade, excludente do outro, do diferente.....colonizadora em todos os sentidos ..... escravizadora ...... opressora da minoria, ....... castradora do diferente.... desvalorizadora do que não conhece e não compreende.....destruidora do meio em que vive, da natureza que a sustenta....eliminadora arrogante do outro, do não si mesmo. Cultura que explora inapelavelmente o outro, esvaziando-o e destituindo-o de seus valores, suas verdades, suas crenças e sua maneira de ser no mundo....tornando o outro pagão, gentio, imundo, promíscuo, como por um decreto divino, .... considerado efeminado, portanto desvalorizado, se for sensível..... considerado animalizado se for instintivo e natural.... desconsiderado simplesmente por não ser eu mesmo, no meu egoísmo, egoísmo que se alia à prepotência, e ambos, travestidos em uma falsa \"revelação \" da divindade, que seria tacanha em sua \"pureza \" e \"santidade \". Auto-justificada, essa atitude se arvora em norma, em lei, em estatuto divino, social e humano. Isso sim, essa atitude intelectualmente promíscua é que transforma a divindade num chimpanzé, um macaco neurótico, violento e agressivo como nós, e assim fazemos da divindade alguém à nossa imagem e semelhança.Eu sonho com uma sociedade bonoba. Um mundo onde o prazer não seja pecado e o sofrimento não seja, \"de per se \", redentor. Onde não se imagine que o outro e o diferente tem que ser igual a nós, senão será \"gentio \", \"pagão \", inferior e necessariamente pior que nós, que recebemos a \"revelação \", como arrogantemente ousamos destruir o índio, escravizar o negro, perseguir o diferente na sua forma de amar e se apaixonar, maltratar o portador de deficiência, desprezar a mulher e o valor do feminino, chamando de puta a que nunca foi puta, e de santa a neurótica reprimida e repressora, ambas vítimas desse machismo dominador ocidental.Talvez o leitor tenha se assustado. É para se assustar mesmo, porque essa realidade é assustadora. Nós vivemos num mundo em que se valoriza o sofrimento, principalmente dos outros, e onde o prazer é considerado desprezível --- quando é dos outros. É o mundo da hipocrisia, em que as aparências valem mais que as realidades, e em que as realidades são tenebrosas---valoriza-se e deprecia-se invertendo os valores. No passado faziam o corpo sofrer (o corpo dos outros, principalmente das mulheres), para salvar a alma. Porque as almas deles que ditavam a lei já estavam salvas, por suas próprias normas. Eles eram iluminados, de acordo com suas regras. Eles se justificavam a seus próprios olhos, porque ditavam as regras. Essa dominação continua inalterada. Ela mudou, se travestiu, se disfarçou, ficou mais sutil e aumentou. Se aprofundou, se introjetou no inconsciente do mundo ocidental. Criou raízes ainda mais profundas, mudou de métodos: deixou a violência explícita, mas se tornou implicitamente violenta.Como se manipula a realidade? Como podemos definir o real?A realidade é \"em si \" incognoscível. O que fazemos, são modelos da realidade, nos quais acreditamos. Mas não conhecemos o real. Temos que estar conscientes disso. Inconscientemente, com muita facilidade identificamos o modelo com a realidade, e começamos a concluir e manusear o modelo como se ele fosse a realidade.Foi isso o que se fez na física até o início do século XX com a descoberta da gravitação universal por Newton, e anteriormente com a cosmologia de Ptolomeu. O modelo de Ptolomeu era um bom modelo para simular a movimentação da maioria dos astros.....para prever as estações do ano....ele simulava bem a realidade, ao nível de detalhe que se precisava e que se podia obter em seu tempo. O problema surgiu quando alguns fatos começaram a não ser explicados, e ele passou a ser questionado, por Galileu e Copérnico. Mas, na pretenção de conhecer a \"verdade \" e a \"realidade \", o poder dominante tentou impedir o surgimento de um modelo melhor porque poderia destruir os seus dogmas. Portanto, se abria mão da verdade e realidade, em função de dogmas particulares de uma forma de pensamento e de ser no mundo: o equívoco essencial do ser humano ao longo da história. Essa atitude repetimos no mundo da ciência, quanto aos problemas de gênero, quanto à vivência dos papéis de gênero e quanto à orientação sexual, até hoje.Newton, no dizer de Laplace, havia explicado tudo em física: nada mais havia a descobrir. A mesma atitude da defesa do dogma acima da realidade, devida à falta de compreensão de que o modelo jamais será a realidade.Com a pesquisa do muito pequeno, e do muito grande, se mostrou que a física de Newton era um modelo excelente, para uma escala da realidade, mas insuficiente para outras escalas. Depois Poincaré sugeriu seu importantíssimo conceito de que \"a escala faz o fenômeno \", que a maioria ainda hoje não compreende, e muito menos aplica.Na física do muito pequeno, do muito grande, e do mais ou menos, fica evidente, com a relatividade de Einstein e a incerteza de Heizenberg, que os fenômenos físicos: ou seja, a nossa possibilidade de apercepção da realidade, depende da escala. A relatividade, a gravitação de Newton e os quanta, são fenômenos feitos pelas diferentes escalas à partir da nossa, e portanto cada modelo desenvolvido para cada escala, simula imperfeitamente aquela escala. Como a realidade, mesmo física, em qualquer escala é incognoscível, não se pode, de forma alguma, falar em realidade: mas alguns insistem em manter uma realidade sua como absoluta, ou seja, querem continuamente impor sua forma de ser no mundo. Seu modelo como realidade, acima da própria realidade. É esse poder que hoje domina o mundo: tanto o capitalista ocidental; como o comunista chinês; como o mundo islâmico fundamentalista oriental. Hoje o mundo, ideologicamente se divide pelo menos nestes 3 grandes grupos, que procuram absolutizar os seus valores como realidade, não percebendo que não passam de modelos imperfeitos de uma realidade.As pessoas com problemas de gênero, são vítimas dessa insanidade. São estigmatizadas, não pela realidade, mas pelos sistemas de modelamento da realidade. A pessoa disfórica de gênero, como a pessoa transexual, é catalogada hoje em dia pela ONU, através da OMS, em seu catálogo de doenças, o CID-10 em vigor, como padecendo de uma \"desordem de identidade de gênero- GID \". Desordem, porque não se reconhecem de forma apropriada, porque tendo pênis não se reconhecem como meninos e mesmo tendo vaginas não se reconhecem como meninas. No sentido psicológico e psiquiátrico, eles \"fogem da realidade \", por um ou outro motivo desconhecido. Os \"especialistas \" insistem em afirmar que as causas psíquicas dessas \"desordens \" são ignoradas, e qualquer tratamento psicológico ou psiquiátrico é inefetivo para fazer com que essas pessoas, sejam crianças, jovens ou adultos, \"caiam na real \".Essa postura é absurda, do ponto de vista epistemológico.Corresponde a dizer que Einsten tinha um problema de \"desvio da realidade \", porque \"fugia da realidade \" de Newton, quando imaginava observar dados do muito grande, e Heizenberg tinha \"desvios de conduta \" e \"fuga da realidade \" por perceber no muito pequeno a incerteza. Einstein e Heizenberg se adaptavam plenamente à realidade que viviam e percebiam, \"mas não ao modelo então vigente \". Einstein e Heizenberg, se avaliados por psiquiatras e psicólogos, certamente seriam considerados, como o são os disfóricos transexuais, como psicopatas: ainda bem que naquele tempo essas duas categorias profissionais mal existiam, e eram ainda muito pouco influentes.Infelizmente, eles hoje em dia têm uma grande influência na OMS, ---e até hoje ainda não perceberam que não diferenciam seus modelos da realidade (ainda estão no século XIX, e como Laplace \"endeusou \" Newton, eles ainda \"endeusam \" Freud e assemelhados), e permanecem estigmatizando pessoas: por isso encheram, durante decênios, os manicômios de pobres pacientes, vítimas muitas vezes fabricadas por eles mesmos e por sua ignorância.O dia que o ser humano tiver mais consciência de que os fenômenos não são a realidade, mas os modelos imperfeitos que fazemos da realidade, e que a escala faz o fenômeno, então, e só então, nos aproximaremos efetivamente do que se pode conhecer da realidade. Mas aí teremos um conhecimento sempre particular, sob uma ótica e um ponto de vista, de forma complementar. Um conhecimento holista, sistêmico, em que por mais que somemos os pontos de vista, não atingiremos o todo, que sempre será hipercomplexo, além de nossas capacidades, a menos que reduzamos o conhecimento a fenômenos modelados, simulados, percebidos pelo que realmente são: percepções parciais e imperfeitas da forma como podemos perceber a realidade.Como podemos aplicar o conhecimento de Poincaré sobre escalas, no caso do gênero? Na física, reconhecer as escalas é fácil, mas no gênero?Proponho para o gênero 3 escalas de harmonia interna: a primeira, a da harmonia completa, em que a pessoa tem sua realidade genital e neuro-psíquica em harmonia interna: para ela é indiferente ser classificada pela identidade ou pelos genitais, pois está em harmonia: corresponderia ao modelo de Newton da física, onde percebemos a grande maioria dos fenômenos, assim também, a grande maioria das pessoas vivem os fenômenos de gênero e de sua vivência sexual, sob o ponto de vista, ou escala da harmonia : onde é indiferente o posicionamento do referencial, como é indiferente o posicionamento do referencial na física de Newton.Um outro grupo, correspondente à relatividade na física do muito grande, onde o tempo como se expande e o espaço se retrai e se encurva, se distorce, corresponderia à situação de gênero vivida pelo disfórico: a identidade se expande, adquire uma importância acima do comum, porque os genitais como que se distorcem, se deformam aos olhos do disfórico: precisam ser adequados à sua realidade, para que ocorra a harmonia interna. O gênero passa a ser determinado por um referencial específico, o referencial passa a ser importante, como em Einstein, quando não era importante em Newton. A importância do referencial do gênero como identidade, que é vivida pela pessoa, e centraliza sua vivência. Por outro lado os genitais deformados, precisam e podem ser corrigidos: porque toda pessoa humana, tem como pessoa o direito a uma vida em harmonia, consigo mesma e com a sociedade em que existe. Mas, compreendida a situação e corrigido o problema, a pessoa se sente normal, e assim precisa e deve ser social e juridicamente reconhecida.A outra escala do gênero, é a escala \"quântica \", ou da incerteza, que designamos como androginia: a pessoa não se define, quer internamente como identidade, quer genitalmente. Como nos quanta, existe uma incerteza: em situações e momentos ela é mais masculina, em outros feminina, e essa ambiguidade permanece sempre. Esse fenômeno é extremamente raro no mundo : estima-se que existam, para 6 bilhões de pessoas harmônicas, 24 milhões de disfóricas, e apenas 100 mil andróginas --- estimativa de Fausto-Sterling.E os homossexuais, gays, lésbicas, travestis (transgêneros), cross-dressers, drag queens e kings? Essas pessoas não têm qualquer problema que ultrapasse sua forma diferenciada de amar, de se mostrar, ou de ser no mundo. E conviver com o diferente, inclusive sexual, não passa de um dever humano --- já que ser diferente é um direito --- mas nossa neurose social e acadêmica ainda insiste, e mesmo o CID-10, em patologizar os cross-dressers e transgêneros, o que beira o ridículo do \"Malade Imaginaire \", de Molière.Tendo conhecimento e consciência dessa limitação humana quanto ao nosso possível conhecimento do real, jamais tornaremos a imaginar que, por não se adequar a um modelo, ou a uma forma de ser e compreender o mundo, Einstein, ou Heizenberg, ou uma pessoa disfórica, ou transexual ou andrógina ou com uma forma de amar homossexual, ou como uma forma de se mostrar transgênero ou como drag ou cross-dresser, poderia ter algum problema psiquiátrico. Portanto, a classificação dos problemas de gênero no CID precisa ser corrigida e os conceitos de \"desordens de identidade de gênero \" precisam ser esquecidos --- vide nosso anteprojeto de adequação do CID, no nosso site: www.gendercare.com onde apresentamos nosso anteprojeto integralmente para conhecimento público. Porque no caso dos problemáticos de gênero, como no passado \"os homossexuais \", como as \"mulheres histéricas \", como os \"masturbadores \", todos foram patologizados insanamente de forma estigmatizadora. Só que os problemáticos de gênero continuam estigmatizados: os homossexuais se livraram do CID, as \"histéricas \" se livraram de Freud, e os \"masturbadores \" se livraram de todos os anteriores, podendo ser pessoas normais.O disfórico de gênero, cada dia mais se reconhece, nasce com um problema de desarmonia biológica, da conformação genital com a organização neural de gênero. Essa organização gera, limita e condiciona dinamicamente a identidade de gênero, que independe do sexo de criação e do meio social na infância --- que são importantes como reforçadores positivos ou negativos da identidade, mas não como determinantes do fato gerador da identidade de gênero --- o fracasso de Money, relatado por Colapinto no caso dos gêmeos, não deixa dúvidas sobre o assunto, assim como o depoimento de milhares de manipulados pelos métodos de Money, da ISNA-Intersex Society of North America.Essa discordância gera o mal estar ou a disforia de gênero --- a sociedade classifica pela aparência genital, mas a pessoa se reconhece e se identifica com sua identidade neuro-psíquica --- e se instala, desde a mais tenra idade, o mal estar. A criança pode se mostrar como é --- como Roberta Close, por exemplo; ou se esconder ---- ter a disforia sofrendo em silêncio. As duas situações são difíceis de suportar: a primeira, do \"transexual primário \", pela discriminação social. As \"transexuais secundárias \" se protegem mais socialmente, mas sofrem intimamente: ....e um dia, tendo a oportunidade, elas aparecem.... e são ainda mais grotescas e estranhas, aos olhos dessa sociedade ignorante.Aos olhos de uma parte da \"ciência \", têm problemas com a realidade, e precisam ser \"tuteladas \" por sexólogos médicos, psiquiatras e psicólogos, mesmo após sua maioridade: precisam de avaliações de outros para saberem quem são, como débeis mentais, o que é uma atitude inconcebível. Tuteladas, discriminadas, estigmatizadas....ainda, quando operadas precisam ser lindas, femininérrimas, equilibradas, educadas, elegantes, inteligentes ....e ainda suportar serem consideradas \"transexuais masculinos \", \"homens operados \", no meio acadêmico e científico, e mesmo em provedores de internet, como a Terra Networks, da qual sou assinante, e por isso posso falar, que designou o papel de Cláudia Raia numa novela da Globo, como de \"um transexual \". ....e quando protestei, fizeram, como sempre, ouvidos de mercador .... Uma situação de tortura, de insanidade por parte das autoridades, dos governantes, da ONU, da OMS, .... uma fuga neurótica da realidade, se não psicótica, da parte deles, e não dos disfóricos. Porque eles continuam considerando seus falsos modelos a própria realidade, com a qual o disfórico tem que se adaptar.E o Atobá? O que esse blá-blá-blá todo tem a ver com os 15 anos do Atobá?Há 15 anos atrás, um atobá, um pássaro, que estava sendo morto e sacrificado por imbecis, foi salvo, resgatado, comprado por um grupo de rapazes com orientação preferencialmente homossexual em sua forma de amar. O pássaro foi salvo, tratado, depois liberto por eles. Eles tanto sabiam amar, que também amaram a pobre criatura e a libertaram. E foi um amor extremamente hetero que demonstraram pelo pássaro, que era muito diferente deles.Infelizmente, na mesma época um outro ser vivo, um rapaz com orientação homossexual do bairro, não teve a mesma sorte. Foi cruelmente morto, e ninguém o resgatou das mãos de seus algozes, nem tratou dele, nem o amou, nem o libertou.15 anos depois, apesar do exemplo do Atobá, Luiz Mott nos mostra a imbecilidade humana e brasileira, em seu livro sobre o assassinato de homossexuais no Brasil --- as fotos dos travestis serrados ao meio são de fazer chorar, das lágrimas escorrerem por terem vida própria, tal a imbecilidade dessa sociedade psicótica em que existimos.Uma sociedade que se diz civilizada, mas rejeita que os disfóricos de gênero possam ser corrigidos e integrados civil e juridicamente, como pessoas normais, estigmatizando-os perpetuamente, não importa o que façam. Que mata pessoas por sua diferente forma de ser no mundo, de se mostrar, ou de amar. Ou por padecerem de um mal congênito na organização neural de seus cérebros, em discordância com seus genitais. Que mutila crianças e bebês intersexuais, cirurgicamente fazendo-as disfóricas, esperando irresponsavelmente que elas \"aprendam a se adaptar aos seus genitais \". Uma sociedade que faz ouvidos de mercador para as vítimas, e que aceita impunemente as manipulações de dados científicos por parte do poderoso John Money. E tudo isso feito em nome de Deus, da moralidade e dos \"bons costumes \", ou em nome de uma \"ciência \".Por isso eu gosto e quero homenagear o Atobá. O atobá pássaro, e principalmente o Atobá grupo, o Atobá gente, que cuidou do pássaro, e o libertou. Porque este país precisa é de homens e de gente assim, como os do Atobá: homens de verdade, que tenham a coragem de amar e de libertar os cativos do próprio destino.Bibliografia Sugerida	COLAPINTO,J --- Sexo Trocado : a história real do menino que criaram como menina (2000), Ediouro 2001;FREITAS,MC---Meu Sexo Real: a origem inata, somática e neurobiológica da transexualidade, Editora Vozes, 1998;	FREITAS,MC --- Disforia com o corpo e não com o papel social; Anais do VII Congresso Brasileiro de Sexualidade Humana, 132-133, Rio de Janeiro 1999;MOLIÈRE --- Le Malade Imaginaire,(1672) ,GF Flammarion,1995;MOTT,L --- Violação dos Direitos Humanos e Assassinato de Homossexuais no Brasil, Editora do Grupo Gay da Bahia, 2000;TORRES,WF & JURBERG,P --- Ser Homem ou ser Mulher : a identidade neuro-psíquica de gênero como referencial, Scientia Sexualis 6(3) 2000;	Todos estão convidados a visitar nosso site na internet, e a se comunicar conosco por E-mail:http://www.gendercare.com","null","null","");arrFiles[5]=new Array("http://www.gendercare.com/library/wal_original4.html","	Ser Homem ou ser Mulher: a Identidade Neuro-Psíquica como Referencial por Wal Torres & Pedro Jurberg ","Ser Homem ou ser Mulher: a Identidade Neuro-Psíquica como Referencialpor Wal Torres# & Pedro Jurberg *# Wal era ainda mestranda em sexologia pela UGF-Rio, Brasil* Pedro Jurberg,PhD, é um neurobiólogo, pesquisador do Instituto Oswaldo Cruz, Rio, Brasil.Copyright &copy; 2000 by Editora Gama Filho. All rights reserved.Publicado neste site com autorização da UGF	Resumo Neste trabalho procuramos fazer uma análise crítica do paradigma de gênero hoje adotado na sociedade, e propomos um novo paradigma.Ser homem ou ser mulher não depende apenas de cromossomos, gônadas, produção endógena de hormônios sexuais e da conformação genital externa. O paradigma atual, baseado no conceito de que homens têm pênis e mulheres vaginas, e no \"sexo de criação \", ignora a gênero neuro diferenciação do feto humano e seu papel na formação da psiquê. Existem, nos humanos, núcleos neurais gênero diferenciados. Esses núcleos promovem reações autônomas a estímulos, que terminam por estampar na memória emocional do indivíduo vivências gênero diferenciadas. Cremos que tal diferenciação neural tem essa tradução psíquica, consolidada por essa dinâmica, que leva à formação da identidade neuro-psíquica de gênero --- a qual não está necessariamente em harmonia com a conformação genital e/ou a criação. O paradigma atual não leva em conta essa evidência, nem as estruturas sexuais dimórficas neurobiológicas, prendendo-se a velhos conceitos do século XIX. O tipo de criação e as identificações sociais interferem apenas à partir do momento em que a criança começa a tomar consciência de sua própria condição, inibindo ou reforçando sua crença de ser menino ou menina. Propomos a adoção de um novo paradigma que leve em conta essa diferenciação neuro-psíquica como melhor referencial na classificação de gênero. Também propomos uma nova compreensão da identidade de gênero e da autonomia individual de gênero, inclusive com a criação de um novo sistema de registro civil. Palavras Chave: Paradigmas de Gênero/ Identidade de Gênero/ Neuro-diferenciação de gênero/ Dinâmica da tradução do neural em psíquico/ Disforias de gênero.	Being a Man or a Woman: Neuro-psychic Gender	Identity as a Determining Factor in Gender Differentiation.Abstract:This paper tries to make a critical analysis of modern society \'s gender paradigm, as well as to propose a new one.Being a man or a woman is not a mere consequence of the individual \'s chromosomes, gonads, hormones and external genital conformation. The actual paradigm, based on the concept that men have penis and women have vaginas, and on sex of rearing, ignores the neural gender differentiation of the human fetus and its role on the building of the psyche. Humans have gender differentiated neural nuclei. These nuclei prompt autonomous responses to stimuli, which will eventually promote an emotional priming according to the gender differentiated neural experiences stored in the memory. We believe such neural differentiation has a psychic translation, consolidated by this dynamics, that leads to the building of one \'s neuro-psychic gender identity --- which is not necessarily in harmony with one \'s sex of rearing and/or genital conformation. Thus, gender dysphorias --- diverging genders in psyche and genitalia --- may occur. The present paradigm takes neither this evidence nor the neurobiological sexual dimorphic structures into consideration, clinging to old concepts of the XIX century. Rearing and social identifications only start interfering at the moment the child realizes its own condition, inhibiting or reinforcing its belief of being a boy or a girl. We propose the adoption of a new paradigm, one which takes this neuro-psychic differentiation into account as the best determining factor in gender classification.We also propose a new understanding of gender identity and gender autonomy, including the creation of a new system of civil registration.Key Words: Gender paradigms/ gender identity/ neuro-differentiation of gender/ neuro-psychic dynamics and translation/ gender dysphoriasIntrodução	O assunto é extremamente polêmico e contraditório. Sobre ele têm havido verdadeiras batalhas ideológicas no mundo da sexologia nos últimos 30 ou 40 anos (por um lado uma posição construtivista social: Money,Hampson,Hampson 1955; Money & Ehrhardt 1972; Money & Tucker 1975; Money 1994; Zucker 1996; Bradley & Zucker 1997; e por outro, a essencialista neuro-psíquica: Imperato McGinley 1979; Zhou et al 1995; Diamond 1996; Reiner 1997; Diamond & Sigmundson 1997; Freitas 1998; Wilson 1999; Kruijver et al 2000; como cronistas e comentaristas: DeLamater & Hyde 1998; Fausto-Sterling 2000; Colapinto 2000). O assunto toca o ser humano em sua realidade mais íntima: a formação da identidade humana e seu gênero, o ponto de partida da vivência subjetiva da sexualidade e objetiva do comportamento sexual. Se a matéria fosse outra, não relacionada a sexo e sexualidade, talvez já estaria esclarecido e certamente o assunto afetaria menos o estado emocional dos debatedores.Por outro lado, como toda luta ideológica, ela faz vítimas, geralmente inocentes. As vítimas são pelo menos de 14 a 15 milhões de portadores de alguma síndrome, quer de disforia de gênero, quer de androginia.A Harry Benjamin International Gender Dysphoria Association- HBIGDA considera que só de transexuais existem aproximadamente 4 milhões de disfóricos no mundo --- dados obtidos a partir de índices oriundos de levantamentos feitos na Holanda e em Singapura --- vide Cohen-Kettenis & Gooren 1999. De pessoas com intersexo estima-se que existam 102 milhões de pessoas no mundo --- estimativa conservadora que admite 1,7% da população mundial como intersexual --- outras estimativas admitem de 120 (2%) a 240 (4%) milhões --- vide Fausto-Sterling 2000. Destes, podemos admitir que 10% sejam ou tenham sido tornados disfóricos por cirurgias precipitadas de designação de gênero e \"sex of rearing \" (consideração também de Fausto-Sterling 2000), o que daria um total de 14,2 milhões de disfóricos no mundo ( estimativa obtida a partir de Fausto- Sterling 2000). No presente trabalho analisamos os paradigmas de formação de gênero, e propomos um novo, de acordo com descobertas recentes. Estes paradigmas serão analizados com base numa visão epistemológica, ética e ideológica, considerando-se os dados científicos e clínicos hoje em dia disponíveis.Uma questão epistemológica, ética, científica e ideológica Como podemos definir o melhor modelo para os dias de hoje?Precisamos considerar simultaneamente pelo menos 4 critérios, todos igualmente importantes: o critério epistemológico, porque um modelo visa explicar e, no caso, categorizar a realidade; o modelo também procura simulá-la baseando-se numa teoria ou em algumas teorias ou pontos de princípio; em segundo lugar o critério ético, fundamental neste caso pois o gênero categoriza a identidade, classifica a pessoa, visa discriminar em categorias o íntimo das pessoas. Quais os direitos que tem a pessoa sobre a sua classificação? Podem terceiros classificar uma pessoa à revelia de sua vontade? Pode a pessoa não ser autônoma na definição de sua identidade, não sendo agente do reconhecimento pessoal, mas paciente, sem sua reificação? Um terceiro critério que precisa ser considerado é o científico. Resultados científicos modernos indicam que um dos modelos é falso? Quando, como e por quê? Os pontos de princípio subjacentes ao modelo se mostram equivocados, a partir de novos resultados científicos modernos? Tratando-se de seres humanos, quando não podemos, por motivos éticos, realizar uma série de testes de laboratório, quais são os resultados clínicos? Esses resultados clínicos, quando manipulados e divulgados, têm o aval expresso das vítimas, efetivamente expressam os pontos de referência das vítimas ou expressam os pontos de vista e pontos de princípio dos pesquisadores? Nesse caso, essa manipulação de resultados perde todo valor científico! E os resultados clínicos humanos são coerentes com os resultados de laboratório em primatas não humanos? Uma incoerência nesse sentido pode evidenciar uma manipulação ideológica subjacente de resultados clínicos, quando os pacientes não expressam efetivamente seus sentimentos sobre sua identidade, se não se tomar as cautelas éticas necessárias --- o que hoje em dia ainda não é a prática comum nas pesquisas e em sua divulgação. Um quarto e último critério que temos que levar em consideração, é o ideológico; todos nós temos uma visão de mundo, de sociedade, de valores....mas esta visão está mascarando o modelo, tornando-o muito reducionista, anti-ético por desconsiderar a autonomia do paciente, nos levando a negarmos resultados científicos por não condizerem com nossa visão de mundo e de sociedade, entrando em choque com nossos valores?Um modelo de gênero visa explicar acontecimentos, classificar pessoas, justificar atitudes, promover leis, códigos, preceitos, construir inclusive o imaginário social sobre o assunto, criando e destruindo preconceitos, incluindo ou excluindo pessoas, permanecendo coerente com sua simulação da realidade. Como todo modelo embasado em ciência, ele pode vir a ser falseado pelos casos que exclui ou não consegue explicar, e assim se mostrar envelhecido, devendo ser substituído por um outro mais novo que necessariamente deve abranger as explicações e a simulação dos casos considerados pelo que foi falseado, e acrescentar outros que explique, simule e justifique, quando o outro ignorava, rotulava ou excluía. Para ter valor científico todo paradigma tem que ser falseável, ou seja, só terá valor se pudermos verificar que ele poderá vir a se mostrar falso com base em resultados experimentais ou clínicos, caso contrário o modelo não terá valor científico mas apenas ideológico --- esse conceito de uma teoria para ser científica ter que poder experimentalmente vir a se mostrar falsa, é de Popper --- para maiores detalhes vide Popper 1979. Alguns cuidados especiais devem ser tomados neste assunto tão polêmico:I.Cuidados epistemológicos: Até onde podemos reduzir um fenômeno para categorizá-lo e conhecê-lo ? Teoricamente devemos reduzí-lo o mínimo possível para que o conheçamos da maneira mais ampla. Mas alguma redução sempre é inevitável, porque para o ser humano, conhecer é reduzir. Mas sempre temos que ter consciência das reduções que fazemos nos nossos modelos, para conhecer. O grande problema nas nossas reduções não está na redução em si que é necessária sempre, mas na absolutização da redução, identificando-a com a verdade. Jamais podemos identificar o modelo, que sempre reduz a realidade ao cognoscível não passando de uma simulação da realidade, à própria realidade em si. Esse é o tipo de equívoco epistemológico que, ao longo da história, continuamente cometemos. II. Cuidados éticos: não se deve ignorar a pessoa humana como closura neuro-psíquica na aplicação de nenhum modelo em que esteja envolvido seu direito a se auto-referenciar --- me baseio na ética personalista. O ser humano deve ser compreendido como um organismo em contato perpétuo com um ambiente, que se auto-referencia nesse ambiente, de forma autônoma, como pessoa. Como agente de sua realidade e de sua identidade e, jamais, como paciente. Não podemos ignorar a compreensão das pessoas sobre si mesmas, sobre quem são, como se vêm, como se compreendem e como se sentem. Senão não serão pessoas, mas coisas. Não podemos classificar o outro como coisa, reificando-o; e ao mesmo tempo devemos respeitar sua auto-classificação como pessoa. O respeito pelo como o outro se auto-reconhece e como quer ser reconhecido são imprescindíveis em qualquer modelo teórico referente à identidade da pessoa humana, e com relação a qualquer atributo de sua identidade. Não é ético definir exogenamente modelos, sejam eles quais forem, e depois considerar herege, pecador, anormal ou psicopata quem não se adapta às nossas teorias ou pontos de princípio, simplesmente pela sua inadaptação à nossa maneira de simular a realidade. Na realidade nós mesmos, querendo absolutizar nosso modelo teórico identificando-o de maneira absoluta com a realidade, estamos evidenciando nossos desvios por não nos apercebermos bem da realidade. Devemos ter a consciência e o equilíbrio para percebermos que o desvio da realidade nesse caso está em nós e em nossa forma perversa de absolutizar o nosso modelo, e não no outro, no desadaptado. Um outro aspecto ético muito importante que precisa ser especialmente avaliado neste caso, é o critério de publicidade dos resultados clínicos: eles efetivamente expressam o ponto de vista da vítima, o que a vítima sente e se reconhece livremente, ou o que o pesquisador \"sugere \" (na realidade impõe --- geralmente a crianças, jovens ou pessoas naturalmente fragilizadas) como referencial teórico para a vítima, que não tendo condição muitas vezes de questionar, aceita a autoridade do terapeuta (um exemplo trágico mas típico de vício de publicidade foi o caso David Reimer --- que posteriormente será apresentado em detalhes ---vide Colapinto 2000). Estarão hoje em dia as Comissões de Ética preparadas para evitar radicalmente a manipulação dessas situações, garantindo efetivamente o direito do paciente, mesmo criança, jovem ou fragilizado social, de ser ouvido sobre sua realidade mais íntima que diz respeito à sua identidade, sem a intermediação possivelmente tendenciosa do pesquisador ou terapeuta ?III. Cuidado científico : não se pode ignorar resultados científicos neuro-biológicos e em endocrinologia molecular ligados às diferenciações de gênero em seres humanos, e mesmo em primatas não humanos quando não podemos, por motivos éticos, experimentar em humanos; principalmente quando obtidos em laboratórios de primeira linha, mormente quando se mostram coerentes com outras descobertas, e reprodutíveis. Também não se deve ignorar resultados clínicos de métodos adotados no passado e no presente, sejam eles positivos ou negativos com relação aos nossos pontos de vista, tenham eles resultados confirmadores ou não de nossos modelos.IV. IV. Cuidados ideológicos: sempre convivemos com uma visão cultural e social de mundo e de sociedade. Ela se reflete nos valores e manipulações --- jurídicos, políticos e de marketing --- instituídos por nós. Mesmo que, ideologicamente, exista o amadurecimento para um avanço dialético da história, nem sempre se terá no mesmo momento o amadurecimento político, e muito menos o jurídico. E pode-se manipular ideologicamente todo esforço de marketing, quer político, cultural, científico e social.Os Três ParadigmasDegladiam nessa arena ideológica três correntes principais de pensamento:A primeira, mais tradicional, atualmente adotada pela maioria dos países e por suas legislações, preserva a conformação genital como base de classificação de gênero e considera freudianamente a psiquê humana como gênero indiferenciada no nascimento e o reconhecimento dos genitais como fonte fundamental de auto-identificação (vide Freud 1905; Money & Ehrhardt 1972; Money & Tucker 1975). Ignora os processos neurais intra-uterinos e considera a influência e construção social a base da formação do gênero da identidade como um processo psico-social construído na primeira infância --- o \"sex of rearing \" de Money (vide Money & Ehrhardt 1972). Quem não se adaptar a esse paradigma automaticamente é visto pela academia (a partir da APA- American Psychiatric Association) como portador de uma patologia psíquica --- daí o conceito de GID- gender identity disorder (vide Mormont, Michel, Wauthy 1995). Esse paradigma atual chamaremos de modêlo atual heterônomo. Esse modelo heterônomo tradicional é profundamente reducionista e cai no equívoco de absolutizar sua redução da realidade identificando-a com a própria realidade. Reduz classificando e absolutiza como verdade sua classificação. E depois julga os que não se adaptam a ele, como se não se adaptassem à própria realidade (vide Mormont,Michel,Wauthy 1995).É anti-ético porque a pessoa (ainda como bebê) é classificada por outros à partir de critérios e categorizações determinados por outros, de forma autoritária. A pessoa não é agente mas paciente na definição de sua realidade e identidade. Posteriormente se ela não se adaptar a esses critérios, seja pelo motivo que for, ela que foi paciente e não agente de sua identificação e categorização passa a ser responsabilizada por sua inadaptação ao modelo. O modelo se torna a realidade absoluta. Essa absolutização de um modelo teórico, seja ele qual for, demonstra uma fuga da apercepção da própria realidade pelo detentor do modelo e não pelos que não se adaptam a ele. O detentor do modelo é principalmente a academia. É importante notar que mesmo que o modelo atual parecesse perfeito, sem no momento apresentar qualquer indício de falsidade, mesmo assim ninguém eticamente teria o direito de identificá-lo com a realidade, discriminando quem a ele não se adaptasse.É a- científico porque o modelo desconsidera inúmeras evidências neuro- biológicas em seres humanos e resultados clínicos --- mostrando evidentemente enormes debilidades e possibilidades de se mostrar falso em inúmeras situações --- a mais evidente sendo o caso da manipulação ideológica dos resultados obtidos com o tratamento de David Reimer, o gêmeo transgenitalizado de Money em 1967, que se dizia certamente aprenderia a ser menina --- e por isso a família aceitou a transgenitalização do bebê de 8 meses --- vide Money, Hampson, Hampson 1955. Posteriormente se publicou, propagou e propagandeou exaustivamente que o menino havia efetiva e inequivocamente aprendido a ser menina, confirmando o simulado pelo modelo teórico (vide Money & Ehrhardt 1972; Money & Tucker 1975) --- e essa informação científica se tornou um marco no sucesso desse modelo e passou a nortear a conduta médica, cirúrgica e psico-terapêutica a partir de então, até o final do século XX e início do XXI --- mas hoje o próprio personagem que se viu vítima desse modelo vem a público desmentir tudo o que foi publicado sobre ele, e mostrar que jamais aprendeu a ser menina (Diamond & Sigmundson 1997; Fausto-Sterling 2000; Colapinto 2000). Outros resultados confirmam a inadequação dessa terapia e dos pontos de princípio sobre os quais ela está alicerçada (Zhou et al 1995; Reiner 1996; Reiner 1997; Freitas 1998; Wilson 1999; Kruijver et al 2000; Fausto-Sterling 2000; Nussbaum 2000; Colapinto 2000). Classificar os portadores de disforias como portadores obrigatórios de psicopatias (GID), que é uma consequência do modelo teórico e não da realidade também tem se evidenciado ser clinicamente um equívoco (vide Cohen et al 1997). A manipulação da publicidade dos resultados no caso David Reimer (o gêmeo de Money) infelizmente não é um caso isolado nesse universo de \"sex of rearing \". Após a sua veiculação, milhares de outros casos de manipulação da informação de resultados clínicos de identidade de gênero têm aparecido na mídia (vide Fausto-Sterling 2000; Colapinto 2000). Em cada artigo científico em que terapeutas afirmam categoricamente que a criança ou jovem estava \"adaptado \" ou não a uma identidade de gênero, temos que levar em consideração \"sempre \" a possível manipulação ideológica da publicidade nesses casos, mesmo que inconsciente ou por desatenção do pesquisador, desde que a própria vítima não se manifeste publicamente--- as comissões de ética precisam ser alertadas sobre esse assunto--- sobre sua identidade. E mesmo quando se manifestam, podem ser manipuladas facilmente, como foi David Reimer, quando ainda era conhecido como \"Brenda \", que foi entrevistado na televisão quando criança, parecendo dar suporte a Money. Hoje, David diz que estava em pânico, e que dizia o que queriam que dissesse. As vítimas nunca se manifestam porque nunca são levadas em consideração pelo referencial teórico vigente, tanto que esse foi o tema mais importante levado a público por Cheryl Chase- fundadora e coordenadora da Intersex Society of North America-ISNA, ela mesma vítima desse modelo teórico, no encontro da Lawson Wilkins Pediatric Endocrine Society -LWPES, em maio de 2000, em Boston, quando Chase discursou para uma platéia de médicos sobressaltados sobre seu tema: Sexual Ambiguity- the patient centered approach (Ambiguidade sexual: o ponto de vista do paciente) --- vide Fausto-Sterling 2000.Mas esse modelo é ainda profundamente conveniente do ponto de vista ideológico. Mantém a posição da academia, típica de nossa cultura paternalista e autoritária ocidental. Respalda o \"status quo \" construtivista social dominante na psicologia e na antropologia, para não dizer em toda academia. Responsabiliza rotulando a pessoa inadequada---com \"desordem de gênero \" ou \"psicopatia marginal \": no caso geralmente a criança e o jovem---que na maioria das vezes não são ouvidos nos meios acadêmicos e científicos, nem sobre si mesmos---que não são respeitados como pessoas em nossa sociedade autocrática e são discriminados quando não se adaptam ao modelo a eles imposto sendo responsabilizados por sua inadaptação. Por outro lado, quanto à sua autonomia, incoerentemente são considerados como legalmente irresponsáveis por si mesmos, inclusive quanto às condições básicas de sua própria identidade. Discrimina os \"gays \", as \"sissi boys \", as \"mariquinhas \", os \"perversos \" e \"invertidos \" como se considerava politicamente correto há pouco tempo atrás --- atitude homofóbica (na realidade \"diferentesexualfóbica \") que começa a ser proibida terminantemente pelo Conselho Federal de Psicologia -CFP, mas que ainda é adotada pelo ideário social alimentado por anos de vigência dessa forma de fobia ao diferente de gênero que foi institucionalizada através das normas DSM desde 1952 (vide Simmons 1981)--- normas que derivaram desse modelo teórico. Mas mesmo ideologicamente este modelo começa a se tornar inconveniente, desgastado e obsoleto. Um segundo modelo, pós-moderno e hoje influente na área filosófica, é o que radicalmente considera o gênero um \"continuum \" e o determinismo da categorização da bipolaridade macho/ fêmea um construto reducionista da medicina, da psicologia e da sociologia. Se extingue o conceito de gênero e preserva-se apenas o conceito de identidade. Mostra-se que as grandes definições nas questões de gênero, como intersexo e transexo não passam de questões semânticas (vide Fausto-Sterling 2000) ---- um modelo autônomo, absoluto em sua autonomia e relativizante quanto à bipolaridade macho/ fêmea tradicional (um exemplo dessa forma de pensamento se encontra em Wilchins1997; e ele é alinhavado por Fausto-Sterling 2000 como possível modelo de gênero ideal).O modelo autônomo absoluto é profundamente não-reducionista e ético --- considera de forma absoluta a pessoa humana como agente de sua realidade e identidade; e cientificamente também se mostra profundamente interessante --- não contradiz nenhum resultado científico, pelo contrário, é o que mais considera os resultados científicos hoje conhecidos, de forma ampla e irrestrita, em todas as áreas da ciência, e em todos os resultados clínicos. Mas mesmo ético, humanista e abrangente é a-científico dentro do conceito de Popper 1979, porque não pode ser contradito cientificamente por abarcar tudo --- ele é tão radical na aceitação da autonomia do indivíduo, que não pode ser científica e experimentalmente considerado inverídico --- o que o invalida cientificamente. Por ser humanista demais, ele acaba por ser a-científico porque não falsificável.Por outro lado, do ponto de vista ideológico ele é difícil de ser implementado política e juridicamente. A sociedade estará preparada para um salto tão grande no reconhecimento do gênero, a ponto de respeitar a pessoa humana em sua identidade de forma tão completa que aceite a abolição da obrigatoriedade da dicotomia macho/ fêmea ? A consequente abolição dos conceitos de hetero, homo e bissexualidade nas inter-relações humanas? Uma reconceituação radical de matrimônio, família, sexualidade? Tudo isso sem uma base científica sustentável, mas como consequência apenas de uma posição humanista? A própria Fausto-Sterling duvida que esse modelo logo possa vir a ser considerado, do ponto de vista legal, mesmo que hoje já o seja no filosófico, mesmo nas sociedades ocidentais consideradas \"de primeiro mundo \".Um terceiro modelo, intermediário entre esses dois extremos, procura levar em consideração os genitais e a dicotomia macho/ fêmea, mas sem se limitar apenas a eles. Com base em resultados obtidos nas últimas décadas na neurobiologia, na neuro-psicologia e na endocrinologia molecular, sem dúvida de forma neo-determinista também em si reducionista, o gênero passa a ser definido pela vivência íntima da pessoa pelo seu auto-referenciamento como closura neuro-psíquica. As neuro-diferenciações cerebrais intra-uterinas organizadas pela ação (ou inação) de androgênios passam a ter uma importância fundamental. Sua dinâmica formadora do gênero da identidade e sua independência dos genitais passa a ser esclarecedora de muitos casos de disforias --- mesmo que não esgote o assunto. Corresponde a um modelo de transição entre a forma autoritária extremamente reducionista do primeiro e a liberalização ainda utópica absoluta do segundo --- um modelo autônomo, essencialista e bipolar (antes deste artigo este modelo ainda não havia sido formalmente apresentado na literatura, mas apenas alinhavado em Diamond 1996 e em Freitas 1998).Apresenta a maioria das vantagens do segundo, sem apresentar tantos inconvenientes. Talvez seja o modelo possível, o modelo da transição necessária, a redução possível, mas mesmo assim já constituindo um grande avanço com relação ao modelo heterônomo atual.Eticamente prioriza a autonomia da pessoa, mas restringindo-a à bipolaridade da categorização um tanto artificial de macho/fêmea --- atitude restritiva reducionista e teoricamente incorreta, mas que tendo bem compreendidas suas limitações passa a ser aceitável, desde que explícita e claramente respeite a identidade da minoria que não se adequa a essa categorização e não a exclua de forma alguma. Um reducionismo do possível para o momento e o futuro próximo, aceitável desde que não ignore suas limitações, e não se auto-absolutize.Cientificamente está de acordo com todos os dados conhecidos --- mesmo que não se aplique a extremos conhecidos de resultados clínicos. Por exemplo existem pelo menos 100.000 pessoas no mundo hoje em dia (vide Fausto-Sterling 2000), que consciente e amadurecidamente dizem ser andróginas, sem uma identidade de gênero definida como crença profunda de ser homem ou mulher --- na quase totalidade, casos de hermafroditismo e mosaicismos --- mas que se sentem felizes como andróginas, desde que sejam socialmente respeitadas como e pelo que são (vide Fausto-Sterling 2000; Colapinto 2000). Esse terceiro modelo tem a limitação de não considerar esses casos em seu aparato teórico, mas pode ter a abrangência de não ignorá-los e de não querer enquadrá-los na prática médica e jurídica preconizada pelo modelo para os outros casos em que a categorização bipolar se aplica. Em compensação, abarca 14,2 milhões de outros, os disfóricos de gênero, hoje em dia marginalizados pelo paradigma atual. É importante salientar que esse modelo é falseável --- bastará se encontrar provas científicas de que o cérebro humano não é diferenciado, por exemplo, ou que essa diferenciação nada tenha a ver com a identidade de gênero, ou que seja cientificamente impossível a discordância entre o gênero genital e o neural, para falseá-lo --- portanto plenamente científico, além de ético e humanista. Por outro lado , é naturalmente centrado, como ponto de princípio com base no próprio referencial teórico, no paciente, na autonomia da pessoa como agente de sua própria identidade, levando em consideração as necessidades de disfóricos e andróginos, como preconizado por Chase (em Fausto-Sterling 2000) e Freitas 1998.Ideologicamente esse modelo é aplicável hoje em dia, evidentemente com muitas resistências radicadas há milênios na sociedade e há séculos na academia --- não se enquadrando na ontologia cartesiana, até hoje filosoficamente incorporada na academia --- e dificuldades legais e jurídicas intransigentes na maioria dos países, principalmente nos de mentalidade acadêmica, política e jurídica conservadora, autoritária, paternalista e colonial como a nossa; mas já vem sendo implementado, se não na teoria pelo menos na pratica, paulatinamente, na Holanda e na Bélgica (Cohen-Kettenis & Gooren 1999). A Necessidade da MudançaA fragilidade demonstrada do paradigma atual, em todos os sentidos, se revela claramente quando se analisa os casos de disforias de gênero --- prejudicando algumas dezenas de milhões de pessoas no mundo. As principais situações em que podem ocorrer disforias de gênero, são:A----- Casos que classificamos de intersexo tipo 1 --- com anomalias genitais aparentes no momento do nascimento, que depois, naturalmente ou por adequações cirúrgicas equivocadas e imposição de \"sex of rearing \", venham a se mostrar disfóricas:. Síndrome de Imperato McGinley, onde ocorre uma radical falta de ação da dihidrotestosterona (DHT), o que impede a masculinização dos genitais externos, mas não ocorre obrigatoriamente falta de ação da testosterona (T). Esses meninos, ao nascerem, apresentam genitália ambígua, parecendo mais feminina que masculina. Tratados conforme o paradigma atual, foram criados e educados como meninas, em diferentes continentes e culturas, alguns passando por cirurgias de designação, outros não; a maioria deles após os 7 anos de idade mostram uma identidade e auto-referenciação masculina, e procuram uma redesignação física e social masculina, apesar das pressões sociais contra essa correção (vide Imperato McGinley et al,1979).	. Casos de síndromes parciais na recepção de androgênios (PAIS): Existem várias possibilidades, quando a atuação dos receptores de androgênios (AR) é hormônio-seletiva. Por exemplo podem haver casos em que a ação de DHT seja anormal, mas de T seja ou não normal. Nestes casos, podem acontecer disforias (vide Pinsky et al, 1984;Kaufman, Pinsky, Killinger, 1986; Pinsky & Kaufman,1987; Zhou et al, 1995B).	. Casos de hiperplasia adrenal congênita: mesmo a genitália ambígua sendo mais feminina, e designada como feminina, pode ocorrer a masculinização da auto-referenciação, a pessoa sentindo-se um homem (vide Quaglia,1980; Meyer-Bahlburg, Gruen, New, 1996; Reiner 1996).B ----- Casos de intersexo tipo 2 em que as crianças nasceram sem problemas de ambiguidade genital externa perceptível, mas que um dia, por um acidente e transgenitalização à revelia da expressa vontade da criança, ou por nascer com genitais normais na forma mas não no tamanho passando pelo mesmo tipo de tratamento, ou mesmo nascendo com os genitais aparentemente totalmente normais, venham a apresentar uma disforia de gênero:.Meninos normais que tiveram os pênis decepados em acidentes até os dois anos de idade, e foram designados como meninas; e meninos com micropênis, que são designados como meninas --- em ambos os casos as cirurgias de transgenitalização são efetuadas enquanto bebês, portanto sem a aprovação precípua deles mesmos. Por exemplo o caso dos gêmeos estudado desde 1967 pela Johns Hopkins (Money & Erhardt, 1972), quando foram efetuadas cirurgias de transgenitalização em um deles. O menino (John/ Joan, na realidade hoje David Reimer) foi criado como menina e apresentado como sucesso da terapia de \"sex of rearing \", como indutor eficiente do gênero da identidade (vide Money & Erhardt, 1972; Money & Tucker 1975). Mas agora, quando se fez o \"follow up \" do caso, se constatou que o menino criado como menina hoje em dia é David, foi transgenitalizado como transexual FM tendo passado por duas séries de inúmeras cirurgias de neofaloplastia e está casado com uma mulher, tendo três filhos adotivos, e feliz com sua condição atual por ser reconhecido como homem, apesar de ainda ter inúmeros problemas. Em sua biografia escrita em 2000 por John Colapinto, David mostra que se identificou como homem desde a infância, antes mesmo de saber de seu processo de transgenitalização cirúrgica, e diz ter sido torturado psiquicamente por anos pela terapia de \"sex of rearing \" (vide Colapinto 2000). Colapinto afirma que David, com 14 anos disse aos pais que se o levassem novamente até Money, ele se suicidaria --- à partir daí nunca mais viu Money. O paradigma atual não explica esses casos e ainda perversamente desqualifica e exclui socialmente as vítimas. Pelas revelações de David Reimer, sua aplicação ética e cientifica não mais se justifica em nenhum caso.	. Casos de transexualismo: pessoas algumas vezes cultas, mas evidentemente nem sempre; algumas doutores e mestres em vários ramos do conhecimento, outras vedetes e mesmo profissionais do sexo; que mesmo nascendo com os genitais com a conformação de um gênero, se auto-referenciam como sendo do outro gênero. Mesmo não apresentando problemas psicopatológicos --- conforme afirmam Cohen et al 1997 (e Masters & Johnson 1982 já reconheciam serem os disfóricos refratários à psicoterapia aplicada para induzí-los a se identificarem com seus genitais), o paradigma atual insiste em considerá-los como tendo que ser portadores de uma psicopatologia. No ideário social brasileiro e ocidental de uma maneira geral, essas pessoas são social e profissionalmente muito discriminadas, e a maioria delas termina trabalhando como profissional do sexo ou como profissional da indústria erótica, por exclusão social e consequente falta de oportunidade profissional --- o que é uma consequência do modelo teórico vigente, e um de seus aspectos mais perversos e anti-éticos. O Conselho Federal de Medicina- CFM em sua resolução 1482/97 reconhece que esses casos precisam ser tratados por cirurgias de transgenitalização --- esta é a prática preconizada pela HBIGDA, e adotada na maior parte do mundo ocidental --- vide Petersen & Dickey 1995. Explicar estes casos como uma psicopatologia, como uma GID, hoje em dia já se mostra não só ética mas mesmo clinicamente inconsistente.Colocamos os \"transexuais \" como intersexuais tipo 2, dentro da mesma problemática dos outros casos de disforia em \"intersexuais \". Essa mesma atitude tomou a OMS-Organização Mundial de Saúde, no CID-10 (Código Internacional de Doenças), ao classificar todos os portadores de disforias no item F64, tenham uma má formação genital visível (F.64.8) ou não (F.64.0 e F.64.2). Como diz Fausto-Sterling 2000, essas designações não passam de questões semânticas.	O sentido da mudança proposta: o gênero neural	1.Existem diferenças neuro anatômicas entre cérebros humanos, masculinos e femininos. Em humanos foram descobertas diferenciações de gênero em núcleos na região pré-óptica do hipotálamo: o SDN (sexually dimorphic nucleus), descoberto por Swaab & Fliers 1995; e os Inah-2 e 3 (interstitial nuclei of the anterior hypothalamus-nº2/3) , descobertos por Allen et al, 1989, em que os núcleos masculinos são aproximadamente duas vezes maiores que os femininos. Posteriormente também foram descobertos núcleos na estria terminal (BNST- bed nucleus of the stria terminalis) gênero diferenciados (Zhou et al, 1995A; Kruijver et al, 2000). Esses núcleos são 50% maiores em estrias masculinas que em femininas. Os pesquisadores verificaram nos dois estudos:	a) Que as estrias de disfóricas MF (male to female--mulheres disfóricas), têm características femininas em todos os casos estudados;	b) que estrias de um disfórico FM (female to male--homem disfórico), tem estria masculina;	c) que as estrias de homens com orientação homossexual e outros com orientação heterossexual, são igualmente masculinas, não havendo diferenças;	d) que essa diferença neuro-anatômica é determinada no período de gestação, e não é mais alterável por ingestão de hormônios e outras possíveis modificações durante a vida após o nascimento.	2. As diferenças neuro-anatômicas se encontram em núcleos gênero-diferenciados no hipotálamo, estria terminal e corpos amigdalóides no sistema denominado por Newman,2000 como Social Behavior Network (SBN).	3. Resultados com humanos e experiências realizadas com macacos rhesus indicam que a ação de masculinização nos núcleos e sistemas do SBN se dá pela ação de T e não de DHT (vide Imperato McGinley et al 1979---com humanos; e Bonsall, Rees,Michael,1989 ; Resko, Connolly, Roselli, 1988--- com rhesus).	4. Em primatas (humanos inclusive) e em roedores, a ação diferenciadora da auto-referência de gênero dos organismos se dá diretamente através da ação de T pela mediação de AR, e não através de aromatização (processo pelo qual T se metaboliza em estradiol, que passa a ativar os receptores de estrogênios-ER), que afeta a agressividade e capacidade de ejaculação, mas não o gênero em si (resultados obtidos à partir de ratos transgênicos: vide Ogawa et al, 1997, 1998 a ,1998 b, 1999).	5. Em primatas rhesus, por mapeamento dos tecidos cerebrais por autoradiografia foi verificado que (vide Bonsall, Rees, Michael,1983; Bonsall, Rees,Michael, 1986; Michael, Bonsall, Rees ,1986; Michael, Bonsall, Rees,1987; Clark MacLusky, Goldman-Rakic, 1988; Bonsall, Rees, Michael, 1989; Michael, Bonsall, Rees,1989; Bonsall, Zumpe, Michael 1990):	a) A ação dos androgênios no cérebro se dá na maioria dos tecidos, mas principalmente no SBN--- fato confirmado pelos dados neuro-anatômicos em humanos;b) Apenas no SBN ocorre intensivamente a metabolização de T em estradiol, por aromatização;	c)	No SBN a ação de DHT é insignificante se comparada à ação	de T (vide Resko, Connolly, Roselli, 1988; Bonsall & Michael,1989)	--- fato confirmado por Imperato McGinley et al 1979; Wilson 1999	em humanos;	d)	A ação de T, direta ou por aromatização, no SBN se dá no período pré-natal, praticamente não havendo mais ação após esse período (vide Clark, MacLusky, Goldman-Rakic,1988) --- fato coerente com os resultados de Zhou et al 1995; Kruijver et al 2000, obtido com humanos;	Esses resultados evidenciam:	1º- As diferenças neuro-anatômicas em cérebros masculinos e femininos em seres humanos mostram que o ser humano é gênero diferenciado em seu sistema neural por ocasião do nascimento. Esses resultados são obtidos com humanos e estão coerentes com os obtidos com outros primatas, mas independem deles.	2º Essas diferenças neuro-anatômicas em seres humanos, e a ação diferenciada de T e DHT descoberta em humanos (à partir de dados clínicos) e em macacos rhesus (por mapeamentos que eticamente não se pode fazer em humanos) mostram que o ser humano pode ter, por causas eminentemente orgânicas e intra-uterinas, o gênero do SBN em discordância com a conformação genital.3º Os resultados neuro-anatômicos em seres humanos disfóricos e não disfóricos, independentemente de sua orientação sexual, indicam que existe uma relação bi-unívoca entre neuro-anatomia do SBN e identidade de gênero, no ser humano.Essas conclusões estão bem embasadas em resultados com humanos, e são confirmadas pelos resultados com primatas não humanos, dentro de um contexto científico e filogenético. Além desses dados, outros tão modernos como estes em endocrinologia molecular evidenciam a existência de inúmeras mutações, em seres humanos, no gene receptor de androgênios- AR. Essas mutações, que já foram catalogadas às centenas (vide Gottlieb et al 1998), provocam reconhecidamente as síndromes de insensibilidade na recepção de androgênios-AIS, que pode ser parcial-PAIS e mínima- MAIS, com consequente ambiguidade genital ou não. A descoberta também da possibilidade da hormônio seletividade na ação de AR pode explicar a causa orgânica da disforia em humanos. Além disso, os resultados foram obtidos, todos, por renomadas equipes em renomados laboratórios, institutos de pesquisa e universidades, tanto na América do Norte (CIT- California Institute of Technology, University of Texas, North Carolina University, McGill University- Montreal, Oregon Regional Primate Research Center, Department of Psychiatry- Emory University School of Medicine-Atlanta e The Rockfeller University-New York) como na Europa (Department of Human Anatomy-Oxford University- England; Netherlands Institute for Brain Research e Department of Endocrinology- Free University-Amsterdam), e todos eles têm se mostrado reprodutíveis, não havendo portanto qualquer base científica ou epistemológica para refutá-los como inválidos (até o final de 1997, conforme o banco de dados, já haviam sido catalogadas 309 mutações AIS). A Tradução Psíquica do Gênero Neural	Se Descartes tivesse razão em sua ontologia, então um sistema não teria nada a ver com o outro. Mesmo que descobríssemos todos núcleos neurais diferenciados em seus mínimos detalhes ultra-estruturais (vide Raisman & Field, 1973) em cérebros masculinos e femininos, humanos ou não, nada disso teria algum valor para a psicologia, porque o neural e a psiquê seriam radicalmente independentes. Mas, em 1890, Willian James já antevia, e em 1994 Antônio Damásio mostrava com resultados experimentais, que Descartes não tem razão (vide Damásio 1994).	Indiscutivelmente existe uma inter-relação íntima do neural com o psíquico. Nós precisamos descobrir a relação existente entre esses sistemas porque só descobrindo essa tradução poderemos descobrir como funcionamos em nossa auto-referenciação (vide Cariani, 2000) e como influencia em nós nossa diferenciação neural de gênero --- essa relação bi-unívoca entre gênero da identidade e neuro-anatomia do SBN, descoberta nos anos 80 e 90 em seres humanos.	Questionava-se essa possibilidade, com base no \"sucesso indiscutível \" do construtivismo social na construção da identidade de gênero alardeado por Money. Mas hoje, vindo à tona a verdade sobre David Reimer e a impropriedade das assertivas de Money, fica ainda mais evidente a possibilidade que aventamos, e a necessidade da tradução que propomos. O neural pode ser considerado a estrutura do psíquico, como o psíquico a linguagem do neural --- vide Heimer et al, 1991; Damásio,1994; 1998. Temos que compreender que essa tradução não é uma redução simplificadora da realidade, mas a realidade ôntica mais profunda da vivência psíquica. Mesmo Eccles, cientista católico, conferencista da Pontifícia Academia de Ciências do Vaticano e prêmio Nobel de medicina, considera que o neural e o psíquico são onticamente inter-relacionados obrigatoriamente, tendo inclusive aventado um modelo \"quântico \" para essa tradução (vide Eccles 1989). Mas é evidente que essa tradução é extremamente complexa mesmo nos outros animais, quanto mais no homem, em que é hiper-complexa. Mas que onticamente está sempre interligada com o sistema neural, sendo inalienável dele, não há dúvida, e que essa compreensão nada tem a ver com uma visão reducionista do problema, também não. Com base nisso se alicerça o nosso conceito atual de morte. A morte cerebral, mesmo que não visceral, autoriza a remoção e os transplantes de órgãos --- porque subjacente a essa morte cerebral, neural, talâmica e hipotalâmica, que hoje a medicina e a academia consideram como efetiva, sabemos ser inegável a morte psíquica que a traduz, a morte do eu, do si mesmo. Neural, e portanto psiquicamente, aquele ser, aquele eu está morto, mesmo que se mantenham os órgãos vivos. Senão, em cada transplante e remoção de órgãos, teríamos que admitir que estaríamos cometendo um assassinato.Para tentar avaliar essa relação certamente teremos que definir modelos de simulação muito mais simples que a realidade --- aí sim, teremos que reduzir para compreender --- no modelar e simular a tradução, mas não na ontologia da tradução. O nosso receio do \"reducionismo \", como já foi dito e explicado, não advém da nossa intrínseca necessidade de reduzirmos a um modelo teórico para podermos compreender e simular, mas do nosso vício ideológico de querermos absolutizar nossos modelos, confundindo-os com a realidade.James,1890 já tentava modelar e recentemente Damásio,1994 consegue estabelecer modelos de tradução e mostra como se formam os sentimentos, as emoções e as racionalizações, à partir de modelos relativamente simples. O mesmo tipo de reações se dão na formação dos desejos, e outras reações a estímulos. Heimer et al, 1991 chega a propor uma abertura ideológica ampla para abrir caminho entre neurologia e psiquiatria, e mostra como pequenas diferenças neurais podem acarretar grandes diferenças psíquicas.	A identidade de gênero como crença profunda	Nosso ser é nossa crença mais profunda. Sabemos que existimos, que somos alguém. Podemos dizer que nossa auto-referência se molda desdeo início de nossa existência, desde o útero, num meio ambiente intra uterino em que, com a mãe, formamos um universo particular, e depois com a imersão num novo universo, esse processo tem continuidade e amadurece, vindo um dia a se tornar consciente. Nesse universo intra-uterino se organizam os sistemas neurais gênero-diferenciados que podem ser afetados pelo meio ambiente intra-uterino condicionado pelo estado emocional, imunológico e hormonal das mães.	Todos nós concordamos que a primeira infância produz marcas profundas em nosso ser. Muito mais profundas ainda terão que ser as experiências traumáticas vividas nesse universo do útero. Porque essa vivência é a base de tudo e a mais fundamental. Ela faz parte de nossa primeira \"construção \", e não é puramente genética e determinista: dela participa decisivamente o meio ambiente intra-uterino como contingência.O ser humano, para ser construído, precisa da proteção de um universo particular--- um útero--- tão sensível ele é para qualquer problema na construção. O útero e a placenta funcionam como filtros que protegem o feto de interferências externas. Mas ele estará sempre nesse meio ambiente que o protege na maioria das vezes, mas dependendo do estado emocional e de saúde da mãe, poderá se reverter essa proteção. Ele pode somatizar uma não masculinização neural se a mãe tiver um estado de stress muito forte e continuado, por produzir pouca testosterona nas células de Leydig, por interferências do sistema imunológico da mãe, por exemplo. O mesmo pode acontecer, se ela tiver um estado infeccioso (vide Ward & Weisz 1980; 1984; Anderson, Rhees, Kinghorn 1985; Anderson et al, 1986; Götz et al, 1993). Portanto, o feto humano, mesmo superprotegido, corre riscos que perpetuarão suas consequências principalmente no neural e no psíquico (vide Miller et al, 1999; Andersen et al, 1999).	Vivenciar essas realidades constrói o \"hardware \" que vai condicionar a conformação de nossa identidade como \"software \"; e dela também participará nossa inter-relação com as pessoas mais próximas de nós, neste \"outro universo \" para o qual um dia nascemos. Saímos do universo da construção do hardware, e entramos no universo da construção do software De uma maneira geral esse segundo universo tendo uma ação positiva ou reforçadora de nossa natureza, ou tendo ação negativa em antítese com nossa natureza pré-construída e limitante (vide Eccles 1989; Damásio 1994).	Neste trabalho não apresentaremos os detalhes do modelo de	simulação da dinâmica da identidade de gênero, que será apresentado em outro trabalho específico sobre o assunto.Cada ser humano adulto sabe ser homem ou mulher, como uma crença profunda (salvo casos muito especiais, que não podem ser ignorados, em que ocorre uma identidade andrógina--- vide Fausto-Sterling 2000; Colapinto 2000). Como a diferenciação do SBN participa na formação dessa crença? Procuraremos analisar a dinâmica do que ocorre numa criança disfórica de gênero do tipo 2 --- no caso uma menina (pois terá identidade feminina) com genitais masculinos --- quando se poderá evidenciar melhor os fatores que interferem nessa dinâmica. No caso de crianças normais, como ocorrem sempre reforços positivos, não se percebe com clareza a dinâmica do processo de formação do gênero da identidade. Mas essa modelação dinâmica será apresentada em outro artigo, por ser extensa e complexa.	A construção uterina de nossa estrutura neural condiciona todo o vir a se formar de nosso eu psíquico. Não poderia haver software sem hardware, e de forma alguma o software poderia independer do hardware. Também não faria sentido evolutivo, num assunto tão fundamental como o gênero (vide Damásio 1994), o hardware ser diferenciado, sem diferenciar o software.	Um Novo Paradigma	Qualquer paradigma é adequado conquanto explique todos os casos que se propõe explicar, e seja ético. Neste sentido o paradigma atual de gênero tornou-se inadequado mesmo explicando a maior parte dos casos, mostrando-se desgastado quando aplicado a uma série de situações de disforia e androginia (entre 14 e 15 milhões de pessoas no mundo conforme critérios já apresentados anteriormente) e equivocado ao desconsiderar a diferenciação neural de gênero e suas inevitáveis consequências na psiquê, e por ser a-ético, desconsiderando a autonomia da pessoa humana, em todas as situações. O próprio Freud, cujos pontos de princípio embasaram o modelo atual, sempre admitiu, demonstrando sua coerência e grandeza de espírito que, com o crescimento do conhecimento sobre as diferenciações sexuais, suas idéias poderiam ter que ser revistas (vide Freud, 1920). O paradigma freudiano precisa ser revisto, como ele mesmo previu. Money 1994, muito pressionado, finalmente flexibilizou seus pontos de princípio freudianos em sua base e construtivistas sociais em sua dinâmica até então inflexíveis, o que já era um sinal de que ele mesmo notava que suas idéias começavam a se mostrar equivocadas e insustentáveis, e Diamond 1996 faz um excelente e abrangente comentário sobre esse fato e suas consequências --- vide também Reiner 1997; Freitas 1998; Wilson 1999; Fausto-Sterling 2000; Colapinto 2000. Uma quantidade significativa de pessoas se sentem desadaptadas numa das coisas mais fundamentais que é o seu reconhecimento como homem ou mulher e que, por isso, são marginalizadas pelo paradigma atual, que as considera psicóticas (portadoras de GID \'s- CID-10, F.64.0) simplesmente por manterem suas crenças sobre si mesmas, apesar do modelo teórico vigente. Só este fato já julgamos ser importante para que procuremos um paradigma que contemple de forma mais abrangente a vida humana. O gênero do ser humano é um grande desconhecido fora da auto-referência do indivíduo. Portanto o enquadramento jurídico do gênero não deve poder estar em discordância com a auto-referenciação de cada (e de todo) ser humano, em nenhum caso, sem exceções. Um único registro no momento do nascimento, realizado por terceiros à revelia da pessoa como coisa definitiva e reificante certamente não é o sistema mais adequado. Propomos um sistema de registro em dois estágios: um provisório com base nos genitais ao nascer, e um posterior, com base na auto-referência do indivíduo, após seus 10 a 14 anos --- o sistema que hoje mais se aproxima de nossa proposta é o vigente na Holanda, onde se estabelece um segundo estágio de registro entre os 16 e os 18 anos de idade --- mas existe o reconhecimento acadêmico (vide Cohen et al 1997; Cohen-Kettenis & Gooren 1999) que o segundo estágio deve vir a ser antecipado. Só depois pode haver a classificação definitiva do gênero do indivíduo--- e mesmo assim, permitindo sempre um re-questionamento existencial, em casos extremos (de androginia existencial). Nos casos problema, uma profunda avaliação de gênero até os 10 a 14 anos se faz necessária. Para tanto é fundamental a qualificação de especialistas em avaliação do gênero e seus problemas --- Fausto-Sterling também considera fundamental essa formação e especialização, conforme citação dela em Colapinto 2000, à pg 259 da tradução brasileira --- embasados em novos \"insights \", num permanente desenvolvimento da compreensão do que é o gênero, como se desenvolve no sistema neuro-psíquico, como pode estar em discordância, como prevenir possíveis disforias, como não agredir social e juridicamente os disfóricos de gênero e os andróginos, e como, através de correções cirúrgicas e endócrinas, numa sociedade inclusiva, aceitá-los e integrá-los plenamente (sempre que essa vontade for expressamente adotada por eles --- vide Fausto-Sterling 2000; Colapinto 2000).	Para tanto, são necessários métodos precisos de diagnóstico.	Por isso, propomos um intenso programa de pesquisas na área das	disforias de gênero em sexologia, incluindo:	*** Programas de pesquisa na área de endocrinologia molecular,	estudando-se a ação hormônio-seletiva de AR nos casos de mulheres	disfóricas (geneticamente masculinas --- existencialmente femininas)	*** Programas de avaliação de diferenças em neuro-imagens, principalmente quanto à sincronicidade e assincronicidade em relações basais e corticais com o SBN.	*** Verificação da importância do estado emocional das mães de disfóricos de gênero durante sua gestação.	*** Desenvolvimento de testes lúdicos em crianças para avaliar reações expontâneas gênero diferenciadas (o método DAP--- \"draw a person \" de Machôver não tem se mostrado muito efetivo - por isso não tem sido muito utilizado- vide Petersen & Dickey 1995).	*** Desenvolver a cultura do respeito da autonomia do como o outro se vê quanto ao gênero.	Adendo:Mesmo entre eminentes sexólogos, médicos e psicólogos, existem ainda dificuldades na compreensão das diferenças entre homossexualidade, travestismo e transexualismo. Sabendo disso, vamos procurar comentar um pouco mais esse assunto, com base no paradigma proposto e no paradigma atual.Pelo paradigma atual, homossexualidade, travestismo e transexualismo são \"desordens \". No caso da homossexualidade, médicos (através do CID) e psicólogos (através do CFP) já começam a admitir que não se trata de \"desordem \", mas a norma DSM-IV dos psiquiatras americanos ainda mantém essa situação --- de qualquer forma a postura original deriva do paradigma atual. O primeiro, uma desordem na orientação sexual, como \"drive \"; travestismo, uma desordem de vivência de papel social de gênero; transexualismo uma desordem de identidade de gênero.Pelo paradigma que propomos, nenhum desses fenômenos classificamos como \"desordens \" de nenhuma espécie (no caso da homossexualidade, a OMS e o CFP efetivamente há algum tempo já adotaram essa mesma postura frente ao fenômeno, mas quanto ao travestismo e às disforias de gênero, ainda mantêm a postura original de considerá-las \"desordens \" de papel e de identidade, respectivamente).Homossexualidade deve ser diferenciada, antes de mais nada, em várias homossexualidades, tanto masculinas como femininas. O velho marquês de Sade já separava corretamente essas coisas, há muito tempo atrás (vide Sade, 1785). E não compreendemos nem as heterossexualidades como coisas ordenadas, nem as homossexualidades como coisas \"desordenadas \". Cada uma delas tem sua ordem própria, inclusive como mostra a natureza no comportamento sistematicamente bissexual entre os bonobos -Pan paniscus (vide deWaal & Lanting 1997), livremente no seu habitat na floresta, o hominíneo mais próximo do Homo sapiens sapiens; e o chimpanzé - Pan trogloditas por seu turno mostra um comportamento sistematicamente heterossexual, também livremente na floresta. Nenhuma das duas espécies pode ser catalogada como \"em desordem \" ou uma espécie \"dentro da ordem natural \" e outra \"fora da ordem natural \". Forçosamente, são duas espécies dentro da ordem natural, há pelo menos alguns milhões de anos. Essa diferenciação de ordem e desordem é puramente semântica e ideológica.A nosso ver o travestismo (um se vestir, um se mostrar como) de forma alguma é uma desordem de qualquer espécie, nem física, nem mental, nem psíquica, nem social. É uma postura social específica, muitas vezes conveniente, outras vezes prazerosa, outras vezes até necessária, algumas vezes rebelde. Qual executiva não se traveste masculinizando-se com terninhos e gravatinhas, numa empresa, numa reunião de Conselho ou de Diretoria? Será uma \"desordem \" motivada por alguma psicopatia ou sociopatia? O que choca não é o travestismo feminino, que na realidade é valorizado como uma demonstração de ascensão social, mas o masculino. Por quê? Pela ideologia dominante, que considera valor na mulher se masculinizar, e indecência o homem se feminizar. Se uma mulher resolver por uma cueca ela vai ficar uma gracinha, mas um homem com calcinha é ridículo. O problema está então na \"desordem \" de nossa ideologia machista introjetada e dominante, por ser parcial e manipuladora, e não em quem se traveste, por desejo ou por necessidade ou interesse.O transexualismo, como este artigo mostra, é uma disforia de gênero, um problema biológico e congênito; não uma \"desordem de identidade de gênero \", mas uma discordância entre dois sistemas biológicos: o neural e o genital. Mas o neural prevalece, porque determina o si-mesmo neuro-psíquico da pessoa. 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Correspondência: Toda correspondência deve ser encaminhada a Wal F Torres, Mestrado em Sexologia da Universidade Gama Filho-UGF.","null","null","");arrFiles[6]=new Array("http://www.gendercare.com/library/genderoriginal1.html","CORBETT vs. CORBETT: RE-EXAMINED -- M.Italiano paper","CORBETT vs. CORBETT: RE-EXAMINED	by M. ItalianoCopyright &copy; 2002 Gendercare.com. All rights reserved. It may be unusual for a British Lord to marry a Liverpool commoner.Given that the Liverpool commoner was a post-operative transsexual,it would be even more unusual for the British Lord not to believe that he \'d have an \"easy out \" from the marriage whenever and however he wanted, should he become displeased with it. Wouldn \'t a court anullhis marriage? The English High Court Of Justice was put to this test. On February 2, 1970, in so granting a decree of nullity to Arthur Corbett for his primary claim that his wife, post-operative transsexual April Ashley was a male at the time of the marriage, and for his secondary claim that she could not consummate the marriage, the court failed this test miserably. It also failed the transsexuals of England. However, a careful re-examination of the decision, known as Corbett vs. Corbett (otherwise Ashley), with a recapitulation of the details found in the judgement, delivered by Sir Justice Ormrod, leave no other conclusion: motives of bigotry, not those of scientific merit, or of sound logic were responsible for the outcome. Several distortions by the judge will be presented as re-examinations. RE-EXAMINATION #1: The judge restricts deliberations to 3 criteria, the chromosomal, gonadal, and genital sex as they were present AT birth IF congruent. -The law should adopt in the first place the first three of the doctors \' criteria, ie. the chromosomal, gonadal, and genital tests, and if all three are congruent sex for the purposes of marriage should be determined accordingly, and one should ignore any operative intervention.- (1) The word \"ignore \", basically places the person in theirpre-operative state. in other words, PAST TENSE STATES ARERELEVANT, but PRESENT TENSE STATES ARE IRRELEVANT. The mixingof these tenses by the judge can be seen in the following passage of his judgement: -The respondent has been shown to...to HAVE HAD testicles prior to the operation and therefore TO BE OF male gonadal sex; to HAVE HAD male external genitalia...therefore TO BE OF male genital sex.- (1) (Capitals added) The relating of past tense states to evaluate the presentstate, lacks sensibility. This is noted as such, by anotherjudge, in a seperate case dealing with sexual offence, whichJustice Ormrod claimed should be treated as marriage. Thejudge, Justice Mathews, writes: -How can the law sensibly ignore the state of those genitalia...simply because they were artificially created or were not the same as at birth?-(2) O \'Donovan(3), supports the decision on a moral basis, claimingthat a healthy biology in regard to the three criteria of sex listedabove is nature, can \'t be set aside by remodelling of the genitalia,which is art, and claims that this argument must be maintained as \"though the procedure were perfected \", and not \"claiming that thetechnique is still incomplete. \"(3) Following his argument, we would have to believe that ifhydrogen and oxygen atoms, which form water, if converted,by nuclear acceleration from sulfur and helium, shouldstill be regarded as sulfur and helium, since that \'s how theystarted out, and nature had intended them to be. Of course,if enough were collected, they would indeed form water.It \'s a case of an imposition of one \'s moralistic viewpoint,not of facts, although facts are used for the distortion.Perhaps they have to be used, and moreso, twisted, lest thedistorted viewpoint becomes more obvious. In other words, Ormrodconfuses the past with the present. But, even so, O \'Donovanclaims even worse. Even if we could get a PERFECT change, weought to still dismiss it, because of an imposed philosophy.That philosophy is this: It started out that way, thereforeit was intended to be that way. Therefore, \"case closed \".No more discussion or facts please! RE-EXAMINATION #2: Justice Ormrod could allow for an intersexed person \'s sex to be influenced by surgery, but not a transsexual \'s, although the end result could be the same. -Of course the real problem shall arise if all three criteria are not congruent. This does not arise in the present case and i must not anticipate, but it would seem to follow from what I have said that the greater weight would probably be given to the GENITAL TEST than to the other two.- (1) This is a tacit attack on transsexuals who have hadfeminizing surgery. The judge is allowing the law to makeexceptions for intersexed individuals in this passage. Byclaiming that the genital sex would probably be given greaterweight than the other two criteria in those born with anincongruity amongst the three, he coincidentally(???)avoidsproblems which would ensue, should the chromosomal sex be usedas the ultimate criteria (a problem the International OlympicCommitte is having(4), and a problem that another court had(5),which didn \'t correctly interpret the Corbett decision). Thus, a deliberate(???)loophole is created in the law forintersexuals. Nontheless, the judge hangs his own reasoning that \"the respondent has been shown to have had male genitalia...therefore to be of male genital sex \"(1), since the genitaliaof a post-operative male to female transsexual, can be no differentthan, for example an intersexed individual born with partialandrogen insensitivity syndrome and only mildly virilizedgenitalia after both have had feminizing genital surgery. In bothcases, the genitalia would be female, although imperfectly.Thus, the judge \'s contention that the genitalia IS of malegenital sex, after surgery, is inaccurate. RE-EXAMINATION #3: The judge claims that a vagina created by surgery is not adequate for consummation IF created in a transsexual. -I do not think that sexual intercourse using the completely artificial cavity...can possibly be described as \"ordinary and complete intercourse or as vera copula-of the natural sort of coitus. \" In my judgement it is the reverse of ordinary, and in no sense natural. When such a cavity has been constructed in a male, the difference between using it and anal or intra-crural intercourse is, in my judgement to be measured in centimetres.- Vaginal intercourse in non-transsexual women and intranssexuals with and without an artificially constructed vaginais also a difference to be measured in centimetres from anal orintra-crural intercourse. Furthermore, an angular differencein the vagina, based upon male/female sex differences in thepelvis is irrelevant, since there is more than 10% of overlapbetween males and females, even when the entire pelvis isconsidered.(6) RE-EXAMINATION #4: The judge doesn \'t consider hormonal sex to be biological. -having view to the essentially heterosexual character of the relationship called marriage, the criteria must, in my judgement, be biological, for even the most severe hormonal imbalance which can exist in a person with male chromosomes, male gonads, and male genitalia, cannot reproduce a person who is naturally capable of performing the essential role of a woman in marriage.- Not only is the essential role of a woman in marriage notdefined anywhere in the judgement, but the wife was givena hormonal test during the trial, but results were not permittedto be used in court, because it was not carried out undersupervision. Thus, we can assume that this \"non-biological \" and irrelevent test was ordered before the judge decided it to besuch, or was wastedly ordered after his mind was already made up(just to appease the council for the repondent???) This iscertainly interesting, in that, just shortly into the trial, thejudge asked the parties if they really needed to continue towaste taxpayers \' money! RE-EXAMINATION #5: The husband \'s medical witness, Sir John Dewhurst is in the judge \'s camp: word games and other twists. In an article in The Lancet(7), Dewhurst refers to JusticeOrmrod \'s excellent decision. In this report, he echoes Ormrod \'sstatement about vaginal intercourse being different from anal orintra-crural intercourse by centimetres if created in atranssexual. The absurdity of this is noted by Mills(8),Smith(9), and Denny(10). Perhaps, Dewhurst was returning the favor, as the judgereferred to a statement by Dewhurst, and used it in hisjudgement as follows: -The body in its postoperative state looke more like a female \'s than a male \'s as a result of very skillful surgery. To put it in the words of Professor Dewhurst, \"the pastiche of feminity was convincing. \" This I feel is an accurate descrition of the respondent.- It is obvious what Ormrod and Dewhurst are doing here.In acknowledging the body to appear more female than male (asa result of surgery), they are tacitly acknowledging that thewife \'s anatomical sex HAS changed. THUS, they must come upwith a pejorative word to cover for themselves (and theiragenda???) the word pastiche is used. How can we be sure thatthis word is used to signify bigotry in this case? This canbe clearly demonstrated by examining another paper wrtitten byDewhurst(11), where an intersexed person, born with a fullymasculinized penis and scrotum, had feminizing genital surgery.In this report(11), Dewhurst states \"The vulva showed littleabnormality. \" So, feminization of a penis and scrotum inan intersexed person results in a vulva showing little abnormality, whereas, feminization of a penis and scrotum in a transsexualresults in a pastiche. The usage of very different terminology,one positive, and the other pejorative, is clearly hypocritical,and indicative of one \'s own prejudices and biases. The onlyother explanation, of course, can be that of total ignorance,since later on in this same article, Dewhurst calls what he hadjust referred to as a fully \"masculinized penis \", with penileurethra, and states, \"the clitoris was removed \"!!!(11) CONCLUSION On careful re-examintaion of the Corbett vs. Corbett(otherwise Ashley) decision we are faced with five strikingdistortions found in the decision. Although, very commonlythe decision is claimed to be based exclusively upon thechromosomal make-up of the two partners, this is absolutelyFALSE. The marriage was anulled based upon three criteria(chromosoma sex, gonadal, AND genital sex) AS they werepresent AT birth, IF all three were congruent at birth. Re-examination #1, demonstrates that the judge used only factsfrom the past. In refusing to consider those facts in the presentstate, he was not able to reach a conclusion which pertained tothe present state. Re-examination #2, clearly shows how a loopholein the law can be created for certain individuals (intersexuals)and illustrates that the END RESULT, IF IN TRANSSEXUALS, doesNOT JUSTIFY THE MEANS, despite the fact that the end result can be the same (eg., the same genital sex in intersexual and transsexualpersons after treatment. Re-examintaion #3, demonstrates that oneis totally unable to clearly define what consummation is.Re-examination #4, presents a \"pick and choose \" category, wherecriteria, such as hormonal sex, which clearly makes up aclassification of one \'s sex, and is clearly biological, can bedismissed as not such, and be arbitrarily disregarded, by morethan one clever means, if one simply desires to do so.Re-examintaion #5, shows that things exist ONLY in regard tothe particular word or label which one CHOOSES to use to describethem at ANY GIVEN moment. It is clear, that under careful re-examination, the Corbettdecision has indeed failed miserably.REFERENCES 1) Corbett vs. Corbett (otherwise Ashley)(1970) 2 W.L.R. 1306, 2 All E.R. 33 (P.D.A.) 2) Unreported decision, Supreme Court of New South Wales, Court of Criminal Appeal, 31 October 1988, No. 436 of 1986. 3) Transsexualism and Christian Marriage, by Oliver O \'Donovan, 198, Grove Booklet on Ethics No. 48, Grove Books, Bramcote Notts. 4) Ferris, E.A. (1992) Gender verification testing in sports. British Medical Bull. Jul; 48 (3), 683-691. 5) In the marriage of C and D (falsely called C) (1979) 35 FLR 340. 6) Schwartz, J.H. (1993) What The Bones Tell Us. H. Holt, New York. 7) Dewhurst, C.J. (1970) Sex and Gender, The Lancet, March 7, 517. 8) Mills, I.H. (1970) Sex and Gender, The Lancet, March 21, 615. 9) Smith, D.K. (1971) Transsexualism, Sex Reassignment Surgery, and trhe Law. 56, Cornell Law Review, 963-1009. 10) Denny, D. (1994) Gender Dysphoria: A Guide To Research. Garland Publishing, New York. 11) Dewhurst, J. and Gordon, R.R. (1984) Fertility following change of sex: A Follow-up. The Lancet, December 22/29, 1461-1462.","null","null","");arrFiles[7]=new Array("http://www.gendercare.com/library/italiano_paper1.html","Postsurgical Changes in the Neovagina -- M.Italiano AEGIS paper","Postsurgical Changes in the Neovagina	by M. ItalianoThis article first appeared in the AEGIS (American Educational Gender Information Service)publication Transgender Treatment Bulletin in February 1998 1(2), page 8. It is reprinted by permission. Recent attempts at vaginoplasty for transsexuals have utilized a variety of techniques, including split-thickness and full-thicknessskin grafts, penile inversion procedures, and sigmoid-colon methods. Although the advantages and disadvantages of each continue to be debated, many stated advantages are are clearly exaggerated or are erroneous. For instance, Masters and Johnson \'s (1966) pioneering work on the artificially-constructed vagina clearly demonstrates that \"the method of creating an artificial vaginal barrel is incidental, since the functional reaction patterns of artificial vaginas are identical regardless of how they are constituted \" (p.101) This statement includes behavior during arousal and orgasm as well as lubrication, a subject steeped in controversy. Some surgeons opt for the use of sigmoid-colon methods in the belief that this provides an advantage of lubrication secreted by colon mucosa. Other surgeons employ mucosal flaps from the urethra to supplement penile inversion for the purpose of providing lubrication. They believe lubrication can \'t be achieved by the use of skin grafts or penile inversion. This is untrue. There is much to be learned from nontranssexual women who have had surgery for \"inadequate \" vaginas. From months to sometimes years afterskin grafting, the graft loses all of its skin properties and adapts to its environment, becoming a mucosa which takes on \"the exact cytology, gross and microscopic, of a normal vagina \" (Sherfey, 1973). Masters and Johnson state, \"Suffice it to say that on the basis of pure cytologic evaluation, it is impossible to differentiate the epithelial cells taken from the artificial vaginas of Subject \'A \' (when under the influence of adequate hormonal replacement) or Subject \'B \' from those of a normal vaginal mucosal smear \" (Masters & Johnson, 1961, p. 203). Some surgeons disagree, stating that the tissue is not mucosa, but only resembles mucosa. They are only partially correct, since the normal female vaginal tissue is not truly mucosa either. It is called mucosa only because it lines a body passageway. It contains no mucous-secreting glands (Fawcett, et. al., 1995). That is why lubrication is a transudate phenomenon, the source being dilation of the capillaries that surround the barrel and the subsequent squeezing out of fluid through the vaginal walls, which in normal and artificially constructed vaginas have been shown to be a functioning two-way membrane. (Masters & Johnson, 1966). Although Masters & Johnson note that production of lubrication usually takes longer in the artificial vagina, they also showed that some artificial vaginas are capable of lubricating as well and as rapidly as any normally constituted vaginal barrel and that two of their patients had \"lubricated, in fact, more effectively than many women with normally constituted vaginas \" (Masters & Johnson, 1966). Pierce et. al. (1956) demonstrated the conversion of skin to vaginal epithelium, which after twenty years, included normal vaginal PH levels, complete loss of hair, complete loss of pigment, complete loss of sweat glands, and normal vaginal epithelial glycogen levels. They proposed, \"the process is not one of metaplasia, for no new cell types are produced. Rather, there is alteration of existing cell layers and the loss of the skin organs. \" (p.6) Those post-operative male-to-female transsexuals who amuse themselves with the peculiar statement that they still have a penis, but that it \'s just turned inside-out should note that not only do they not have a penis, but they don \'t even have skin of the penis any more. The histology of the tissue has changed. It also responds to hormones in an identical way as does a normal vagina, with \"cyclic cornification and mucification \" (Sherfey, 1973). The presence of ovaries is not a necessity. For instance, \"The estrogenic and early luteal effects demonstrated by Subject \'A \' are obvious, and serve as a clinical indication of adequate steroid replacement in this surgically castrated female \" (Masters & Johnson, 1966, p. 203). More impressive is a recent report by Alessandrescu et. al. (1996), who did biopsies on twelve artificially constructed vaginas and found an epithelial structure identical to that of oa normal vagina. Two examples are shown in the form of pictures using electron microscopy. Although it may be suggested that transsexuals may respond differently than nontranssexual females with regard to the results of vaginoplasty, it is my opinion that the burden of proof that this is the case rests with the surgeons who employ such procedures as colon usage and mucosal flaps for the purposes they intend. Since the nature of their work is clinical and generally not investigative, they should at least advise their patients that future study may be necessary before the value of their technique can be substantiated. REFERENCES Alesandrescu, D., et. al. (1996). Neocolpopoiesis with split-thickness skin graft as a surgical treatment of vaginal agenesis: Retrospective review of 201 cases. American Journal of Obstetrics & Gynecology, 174(1), 131-138. Fawcett, D.W., et. al. (1994). Textbook of histology (12th ed.).New York: Chapman & Hall. Masters, W.H. & Johnson, V.W. (1961, May-June). The artificial vagina: Anatomic, physiologic, psychosexual function. Western Jourmnal of Surgery, Obstetrics, & Gynecology,69,192-212. Pierce, G.W., et. al. (1956, July). Changes in skin flap of a constructed vagina due to environment. American Journal of Surgery, 92,4-8. Sherfey, M. (1973). The nature and evolution of female sexuality. New York: Random House.","null","null","");arrFiles[8]=new Array("http://www.gendercare.com/library/italiano_paper2.html","TRINUCLEOTIDE REPEATS AND SEX DETERMINATION</B><BR>	by M. Italiano","TRINUCLEOTIDE REPEATS AND SEX DETERMINATION	by M. ItalianoCopyright &copy; 2002 Gendercare.com. All rights reserved. Recent advances in molecular biology have led to the identification of the SRY testis detemining gene (Sinclair, et. al., 1990; Koopman, et. al., 1991). Testicular tissue may occur in individuals lacking SRY (some XX males and most true hermaphrodites)(Pereira, 1991), and there are individuals who lack testicular tissuedespite the presence of an intact SRY (some XY females with gonadaldysgenesis) (Pivnick, 1992). These cases suggest other genes, X-linked and autosomal, which are actively involved in the primary (gonadal) sex determining pathway. Other data may require alternative molecular insights. For instance, it has been observed that XX males and XX true hermaphrodites often occur within the same family history (Skordis, et. al., 1987). In some cases, the mode of inheritance is known to be autosomal in nature. Since Lyonization can \'t explain this finding, it remains to be determined how a common genetic defect causes one member of a family to become a male with testes, and the other, a true hermaphrodite with testicular and ovarian tissue. (See discussion in Wachtel, 1994). This can easily be explained, however, if we consider trinuceotide expansion. Upstream to the translation site of certain genes there is an expanded region of trinucleotide repeats, which is unstable; it can expand to greater lenghts when transmitted to successive generations (Richards and Sutherland, 1992). Each subsequent generation can receive a chain of these repeats which is elongated more than that of its predecessor. When the number of repeats exceeds a particular limit, theyinterfere with the translation of the gene in question. (Yu, et. al., 1992). This can result in consequences such as disease, the severity of which is correlated with the number of repeats involved in the expansion. (Harley, H.G., et. al., 1993). It is suggested here, that trinucleotide repeats would cause sex reversal, the severity of which would also be correlated with the number of repeats in the expansion. Severity in this context apllies to the variability of partial sex reversal (XX true hermaphroditism) as opposed to complete sex reversal (XX male syndrome). This would explain the autosomally-linked familial pattern of sex reversal observed by Skordis, et. al. (1987), as well as that in American cocker spaniels described by Selden, et. al. (1978). In the latter study a true hermaphrodite whelped an XX male with unambiguoustestes. Assuming that the pup \'s testes were inherited from its mother, this could be explained by trinucleotide repeat expansion, in conjuntion with differential methylation patterns, which are usuallyderived from the female gamete (Harley, et. al., 1993; McConkie-Rosell, et. al., 1993; Yu, et. al., 1992). REFERENCES Harley, H.G., et. al. (1993) Size of the unstable CTG repeat sequence in relation to phenotype and parental transmission in Myotonic Dystrophy. Am. J. Hum. Genet., 53, 1164-1174.Koopman, P. et. al. (1991) Male development of chromosomally femal mice transgenic for SRY. Nature, 351, 117-121.McConkie-Rosell, A., et. al. (1993) Evidence that methylation of the FMR-1 locus is resonsible for sex variable phenotypic expression of the fragile X syndrome. Am J. Hum. Genet., 53, 800-809.Pereira, E.T. (1991) Use of probes for ZFY, SRY, and the Y pseudoautosomal boundary in XX males, XX true hermaphrodites, and an XY female. J. Med. Genet., 28, 591-595.Pivnick, E.K. (1992) Mutations in the conserved domain of SRY are uncommon in XY gonadal dysgenesis. Hum. Genet., 90, 308-310.Richards, R.I. and Sutherland, G.R. (1992) Heritable unsatble DNA sequences. Nature Genet., 1, 7-9.Seldon, J.R., et. al. (1978) Genetic basis of XX male syndrome and XX true hermaphrodites: Evidence in the dog. Science, 201, 644-646.Sinclair, A.H., et. al. (1990) A gene from the human sex-determining region encodes a protein with homology to a conserved DNA-binding motif. Nature, 346, 240-244.Skordis, N., et. al. (1987) Familial XX males coexisting with familial 46 XX true hermaphrodites in same pedigree.J. Pediatr., 110, 244-248.Wachtel, S.S. (1994) XX Sex Reversal in the Human. Chapter 12 in Wachtel, S.S. (edit.) Molecular Genetics of Sex Determination. Academic Press.Yu, S., et. al. (1992) Fragile-X syndrome: unique genetics of the heritable unstable element. Amer. J. Hum. Genet., 50, 968-980.","null","null","");arrFiles[9]=new Array("http://www.gendercare.com/library/italiano_paper3.html","	XY Female Pregnancy</B><BR>	by M. Italiano","XY Female Pregnancy	by M. ItalianoCopyright &copy; 2002 Gendercare.com. All rights reserved. SUCCESSFUL PREGNANCIES IN HUMAN XY FEMALES: THE XY (and z of) FEMALE CLASSIFICATION We were taught in grade school that a person \'s sex is ultimately determined and defined by one \'s sex chromosomes. If you have an XX chromosome type, your \"true sex \", is female. If you have an XY chromosome type, your \"true sex \" is male. Recent evidence, though, demonstrates that this is far from being the truth(1) Althoug some people cite XY persons with androgen insensitivitysyndrome, who are externally female and have female secondary sexual characteristics, to support a classification of some XY individuals as females,(2) still, because they have testes and no uterus or tubes, others are not convinced that they should be classified as females, but still classify them as males (3), or use the term male pseudohermaphrodite. The doing away with sex testing in the Olympics provides insight into the problems of defining sex on the basis of chromosomes.(4) However, another syndrome, XY gonadal dysgenesis or the XY sex reversal syndrome(1) is convincing enough, to require that even some persons with a normal Y chromosome must be regarded as female.Why? Because XY human females have been known to give birth.(5,6,7,8)It is now known that it is not the Y chromosome per se that definesmaleness, but it is a complex interaction with X and Y chromosomal genes and gene products with genes and gene products on non sex chromosomes, that defines maleness.(9,10) In other words, it is XY, plus z(z being a variable of any number of additional circumstances). A disturbance with any of these genes, or possibly environmental influences, may cause an XY person to become a female with a uterus and ONLY female anatomy, who is capable of giving birth. Although these females have ovarian tissue which degenerates prematurely(11),when they are provided with donor eggs, their giving birth to single pregnancies(5,8), twin pregnancies(6), and even more than one successive pregnancy(7), leaves us with a new indisputable fact: XY can sometimes equal female.REFERENCES1) Lopez-Lopez, M. (1998) Genetic heterogeneity and phenotypic variability in 46,XY sex reversal. (Article in Spanish). Rev. Invest. Clin., Mar-Apr;50(2):171-176.2) Ahlquist, J.A.O. (1994) Gender Identity in Testicular Feminization. Response 1 Phenotypically, anatomically, legally, and socially female. Brit. Med. J., Apr; 308(16):1041-1042.3) Greer, G. (1999) The Whole Woman. Doubleday Publications., U.K.4) Stephenson, J. (1996) Female Olympians \' sex tests outmoded. J. Amer. Med. Assoc., 276:177-178.5) Frydman, R. et. al. (1988) Pregnancy in a 46 XY patient. Fertil. Steril., 50:813-814.6) Sauer, M.V., et. al. (1989) Successful twin pregnancy after embryo donation to a patient with XY gonadal dysgenesis. Amer. J. Obstet. Gynecol., 161:380-381.7) Kan, A.K.S., et. al. (1997) Two successful pregnancies in a 46, XY patient. Hum. Reprod.,12(7):1434-1435.8) Selvaraj, K., et. al. (2002) Successful pregnancy in a patient with a 46, XY karyotype. Fertil. Steril., Aug.; 78(2):419-420.9) Raymond, C.S., et. al. (1999) A region of human chromosome 9p required for testis development contains two genes related to known sexual regulators. Hum. Mol. Genet., June; 8(6):989-996.10) Tommerup, N., et. al. (1993) Assignment of an autosomal sex reversal locus (SRA1) and campomelic dysplasia (CMPD1) to 17q24.3-q25.1. Nature Genetics, 4:170-174.11) Cussen, L.J. & MacMahon (1979) Germ Cells and Ova in Dysgenetic Gonads of a 46-XY Female Dizygotic Twin. Amer. J. Dis. Child., April; 133:373-375.","null","null","");arrFiles[10]=new Array("http://www.gendercare.com/library/italiano_paper4.html","Bailey \'s  \"at it again \"-the omission and distortion of BSTc findings</b><BR><BR>by M.Italiano","Bailey \'s \"at it again \"-the omission and distortion of BSTc findingsby M.ItalianoCopyright &copy; 2003 Gendercare.com. All rights reserved. It seems that J. Michael Bailey, author of the new book, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism (1), perhaps the worst book ever written on transsexualism, is at it again. In writing what he considers a scientific, yet popular, treatment of the subject, Bailey omitted from his book, some of the most important transsexual data to date- two Dutch reports (2, 3), which indicate that male to female transsexuals have a female sized brain structure. Have no fear, though. After this inconceivable omission, Bailey has tried to cover for himself, by a brief treatment of these reports, in an apparently updated section of his website, which addresses some of the criticism his new book has received (4). His treatment of the brain studies in his website is almost as bad as his book. For instance, in trying to maintain his claim that there are two seperate types (and ONLY two!) of transsexualism- a \"type of gay man \" (Bailey \'s own words- pg.178 in his book) (Type 1), or a heterosexual man with misdirected heterosexuality in the form of an SRS driven autoerotic \"paraphilia \", known as autogynephilia (type 2), he cites Anne Lawrence \'s report, where she interprets the data of the brain studies, to claim that the BSTc may actually be a marker for autogynephilic transsexuals (5). How does she do this? Of course, by assuming that the reports of the subjects in the Dutch paper are not to be believed (or perhaps, that they were lying). For instance, she claims that they were \"arguably all autogynephilic \" (5), even though two were reported as male-oriented (and thus would be considered, type 1- homosexual transsexuals) and one as oriented toward males and females (3). In order to suggest that they were autogynephilic instead of oriented toward males, as was indicated in the report, (ie., that the reports are not to be believed), a reference is given to a 1987 paper by Ray Blanchard (who coined the term autogynephilia), which showed that homosexual transsexuals secured hormones earlier than do autogynephilic transsexuals. WOW! Imagine, using ONLY ONE variable from a study of patients at the Clarke Institute of Psychiatry in Canada, to explain why the information presented about a group of patients in a totally seperate study from the Netherlands, should not be trustworthy. Not to mention, that this same Blanchard, also claimed that the homosexual transsexuals are early onset transsexuals and the autogynephilic transsexuals are late onset transsexuals. If Lawrence used THIS Blanchard variable instead, she would have difficulty, of course, with the fact that there was no size difference between the transsexuals who had early onset transsexualism (T2, T5, and T6) as opposed to those who were reported to have had late onset transsexualism (subjects T1 and T3) (3). Furthermore, it also would not square with the data that two early onset transsexuals (T2 and T5) were female oriented, whereas one early onset transsexual (T6) was male oriented (3). Nor would it square with the report that one late onset transsexual (T3) was reported as being female oriented and another late onset transsexual reported as being male oriented (T1) (3). Of course, again it may be suggested that all of this too, should be \"arguably \" contested. BUT, why shouldn \'t we call in to question Lawrence \'s \"arguable \" changing of the data being reported? Or, perhaps, moreso, why shouldn \'t we call into question, Bailey \'s use of Lawrence \'s data, and her fine reputation (she maintains an excellent resource for m to f transsexualism), for his own \"rescue \", when he does not carefully point out these important implications of the data in his website, and does not even cite the studies in the first instance, in his book! Surely, if we read the Dutch report carefully (3), it does seem to correlate not with a type of transsexualism, but with gender identity itself. Not only do we have male oriented transsexuals AND female oriented transsexuals co-existing as early onset transsexuals, thus showing heterogeneity within this group, but we also have male oriented transsexuals and female oriented transsexuals co-existing as late onset transsexuals, showing heterogeneity within this group also. Thus, we have heterogeneity WITHIN the two groups and a homogenous state BETWEEN the two groups. Further omissions by Bailey, who in his trite treatment of the BSTc studies, claims the BSTc studies as not being \"close to supporting the interpretations they have inspired \" (4) , is that the first female to male transsexual brain studied, actually has a male BSTc. Admittedly, it \'s only one subject, but this intriguing case, when compared with the control females, flies in the face of Bailey \'s conceived notions. Again, it \'s the \"easy way out \" for him to omit this data, which conflicts with his conclusions. In like manner, is his omission of a 7th male to female (T7) who, although did not transition (he was 84 in no later than 1999 when the paper was submitted), was nonetheless described as \"A nontreated individual with cross-gender identity feelings (T7) which were already present since his earliest childhood \" (3). Perhaps, the only consolation that this non-transitioner wasn \'t reported by Bailey, was that his late presentation, would have probably garnered him autogynephilic status, due to his age. Incidentally, this \"non-transitioner \" would have already been 37, when Christine Jorgenson received the pioneering operation. Bailey \'s claim that, \"The Dutch group was unfamiliar with (or ignored) the theory of autogynephilia \" (4), doesn \'t seem as accurate, as that Bailey, was unfamiliar with (or ignored) the BSTc studies. Certainly, he ignored them in his book. His statment, \"The study is thus irrelevant to the question of whether there are one, two, or more subtypes of transsexuals \" (4), seems to be his belief, and is probably supported by little scientific evidence itself, relying upon little more than Lawrence \'s disbelief of the data (5), as well as Bailey \'s own selective omission of other data (4). That the BSTc extends its sexual dimorphism into adulthood, of course, still does correlate with gender identity, although since it seems to occur later, may only be a developmental co-occurring phenomenon, with, perhaps, a related cause. This brain result, however, is not likely, as the Dutch authors point out, to be related to post-natal hormone levels. Certainly, the non-transitioningtranssexual, whom Bailey leaves out, would seem to discount Bailey \'s assumption that taking hormones influenced the BSTc. Bailey, claims of course, that the study does not rule out the possibility of post-natal hormonal influences on the BSTc (or even the influence of other factors on the BSTc). But, then again, anything may be a possibility. As Stoller once wrote in his book, Sex and Gender (6), \"Perhaps transsexualism is caused by the \"baleful influence of a two-headed turtle, upon whose back, the earth is carried. Try to disprove that one. \"If Bailey believes there are only two types of transsexuality, and that the brain structure which is uniquely involved in autogynephilic transsexualism, may also be found in other paraphilias, that is an unfortunate. Where would that leave the many homosexually related paraphilias peculiar to \"homosexual transsexuals \"? From his book (1), we would be lead to believe he would \"reason \" to \"blame \" it on INAH-3. I guess one \"paraphilic marker \" deserves company, which of course, leaves the question, what if both brain structures, the BSTc and INAH-3, were left \"un-masculinized \"? \" Well, it seems that we would certainly be in for a sequel. Could a sequel get any better than the original? Could it get any worse? Yes, indeed, it does seem, that Bailey is at it again.REFERENCES 1) Bailey, J.M. (2003) The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. Joseph Henry Press. 2) Zhou, J.-N., et. al. (1995) A Sex difference in the human brain and its relation to transsexuality. Nature, 338: 68-70. 3) Kruijver, F.P.M., et. al. (2000) Male to Female Transsexuals have Female Neuron Numbers in a Limbic Nucleus. J. Clin. Enddocrinol. Metab., Vol. 85, No. 6: 2034-2041.***Click the button and read the Kruiver et al full paper! 4) http://www.psych.northwestern.edu/psych/people/faculty/bailey/controversey.htm#brains 5) http://www.psych.northwestern.edu/psych/people/faculty/bailey/ages.htm 6) Stoller, R.J. (1975) Sex and Gender Vol. 2: The Transsexual Experiment. Jason Aaronson, N.Y.","null","null","");arrFiles[11]=new Array("http://www.gendercare.com/library/srs_results3.html","Italiano paper","Neoclitoris:Integration by M. ItalianoCopyright &copy; 2001 Gendercare.com. All rights reserved. Ulrich T. Hinderer (1), in 1974 was the first todevelop the sensate pedicle technique for itsapllication in intersex persons with ambiguousgenitalia with the preservation of a reduced clitoralglans based exclusively on the dorsal neurovascularbundle. He also is the first to suggest total excisionof the corpora cavernosa, including the crura toprevent dispareunia. The first respectable surgeons to use Hinderer \'stechnique for transsexuals in the 1980 \'s were TerrenceMalloy of Pennylvania Hospital (U.S.) and Ulrich T.Hinderer(Madrid, Spain) himself. While this was animprovement over using only some corpus spongiosum(which surgeons such as Stanley Biber of Trinidad,Colorado and Roberto Granato of New York, New Yorkwere using) or of reduced corporal tissue sewntogether(which surgeons such as Rodolphe Meyer of Switzerlandand Larry Lipschultz of Houston, Texas were using)for clitoral reconstruction, it hadn \'t shown adifference in the orgastic ability of the limitedsample studied by Lief and Hubschmann (2). Only 4 ofthe patients in this sample were orgastic. Two(50%)were from Biber (using only spongiosum) and theother two (50%)from Malloy (using the sensate pedicletechnique). So there was no demonstration of anadvantage of one technique over the other as far asachieving orgasmic capabilities, in this regard.Although Hage (3)found favor in Hinderer \'s technique,he did not investigate sexual function. Furthermore,in Hage \'s report, he suggests removal of the cavernosaand the crura to prevent painful intercourse.However, at least one other respeected surgeon, DonaldLaub, Sr. of Palo Alto, California, reported in adozen post-operative male to female transsexuals (4),that of the top 6 erotic aspects of male to femaleanatomy, the cura and cavernosal stumps were rated as3rd and 4th respectively, and were therefore notpainful, but highly pleasurable. So, with Laub \'stechnique, it appears that one can use the sensatepedicled technique and STILL retain parts of theerectile tissue bodies. In fact, the way the tissue isburied with the formation of scar tissue in this areamay be directly related to the issue of whether thepreservation of erectile tissue will be painful orpleasurable. Certainly, advocates of Hinderer \'stechnique, as used by Hage, Melman, Meltzer, Preecha,and others may be in direct contradiction to somerecent reports on the innervation of the phallus.Baskin, et. al. (5) and Yang, CC and Bradley, W.E.(6),have independently confirmed that the lateral andventral portions of the penile shaft were innervatedby branches arcading from the dorsal midline radiatingtoward the ventral surface. These branches were inboth reports, seen to penetrate the corpusspongiosum(thus its not imaginary that patients withthe spongiosum technique were orgastic) and at thejunction of the corpus spongiosum and the corpuscavernosum in the Baskin report. Thus, in anotherreport by Baskin, et. al.(7), they state \"The conceptof lifting the dorsal nerve off of the tunica at the11 and 1 o \'clock positions seems to be inconsistentwith the fact that the nerves fan out extensivelyaround the dorsal and lateral aspects of the clitoralbody. \" They also address the removal of erectiletissue in severely masculinized cases. They write \"Standard treatment was to amputate the erectilebodybof the clitoris at the pubic arch, leaving...theneurovascular bundle with a strip of dorsal tunica. Toour knowledge the long-term effect on sexual functionof removing this erectile tissue is unknown. Incontrast, leaving too much erectile tissue has beenreported to cause pain at puberty. A compromise may beto incise the corpora cavernosa on the ventral surfaceor bottom at the 6 o \'clock position and removeerectiletissue within the tunica to reduce the size of theerectile body, preserving some erectile tissue and allclitoral nerves. \" Thus, in a third paper by Baskin,et. al. (8), they sternly warn about the possibilityof the sensate pedicle technique and the likelihood ofdamage to nerves perforating the spongiosum, and thearea of the crural bodies on the ventral lateralsurface. Of course, Schrang \'s technique of keeping some ofthe corpora and the crura, and shortening thedorsal neurovascular bundle has great hope that the cut dorsal nerves will regenerate-likely false notionto a great degree. The technique which Petra mentioned about the entire dorsal bundle being retained with the looptechnique would probably be promising.Papageorgiou, et. al. (9) have a promising techniqueused in an intersexual of preserving both the dorsaland ventral pedicles. This may be applied totranssexuals by retaining the tunica, with its nerves,removing unnecessary erectile tissue, and folding thetunica. Also a fine technique, although not in itsproper location, is the technique of inverting theglans and putting it into the vagina with nervesintact as does Jalma Jurado (Brazil)(10). However,he does seem to use spongiosa tissue (urethral mucosa)in the place of the clitoris. This is not so unusual,since the normal female clitoris also containsspongiosa (11). Sava Perovic (Yugoslavia)(12)uses somenerve tissue in the place of the clitoris, as asensate pedicle type of technique, but ALSO uses theother part of the glans/nerves in an inverted forminto the vagina. Thus, he has a combination technique.Clearly the best techniques at clitoroplasty are beingdiscovered.REFERENCES 1)Hinderer, U.T. (1974) La Cirugia Plastica en eltratamiento del intersexo. Acta Soc. Endocrinol.Madrid 6: 39.2)Lief, H.I. & Hubschman, L. (1993) Orgasm in thepost-operative transsexual. Arch. Sex. Beh. Apr; Vol.22,(2): 145-55.3)Hage, J.J. (1993) A new method for clitoroplasty?Plast. Reconst. Surg. June; Vol. 91(7):1303-7.4)Laub Sr., D.R. (1997) Erotic Aspects of Male-to Female-Anatomy. Paper presented at the 15th HarryBenjamin International Gender Dysphoria association.5)Baskin, L. et. al. (1997) Neuroanatomical ontogenyof the human fetal penis. British J. Urol.Apr;79(4):628-40.6)Yang, C.C. & Bradley, W.E. (1998) Neuroanatomyof the penile portion of the human dorsal nerve of thepenis. British J. Urol. Jul;82(1):109-113.7)Baskin, L. et. al. (1999) Anatomical Studies of theHuman Clitoris. J. Urol. Sept., Vol. 162, 1015-1020.8)Baskin, l. (2000) Anatomy Of The NeurovascularBundle: Is Safe Mobilization Possible? J. Urol. Sept.,Vol. 164, 977-980.9)Papageorgiou, T. (2000) Clitoroplasty WithPreservation Of Neurovascular Pedicles. Obstet. andGynecol. Nov., Vol. 96, No. 5., Part 2, 821-823.10)Personal Communication from Wal Torres, Aug.,2002.(11)van Turnhout, Arjen A.V.M. (1995) The femalecorpus spongiosum revisited. Acta. Obstet. Gynec.Scand. Vol. 74: 767-771.12)Perovic, S.V. et. al. (2000) Vaginoplasty in maletranssexuals using penile skin and a urethral flap.B.J.U.Int. Nov., Vol. 86 (2): 843-50.","null","null","");arrFiles[12]=new Array("http://www.gendercare.com/library/srs_results4.html","Italiano paper","Neoclitoris:Integration part 2 by M. ItalianoCopyright &copy; 2001 Gendercare.com. All rights reserved. In my previous article (1), I made several points:1) The sensate pedicle clitoroplasty technique was developed by Ulrich T. Hinderer in 1974 for use in persons with ambiguous genitalia, and subsequentlyused in transsexuals in the 1980 \'s by several respected surgeons.2) This represented an improvement over using just corpus spongiosa tissue or just using fused, shortened corpora cavernosa stumps as previously used by some surgeons.3) That neither of these techniques have demonstrated a greater capacity for attaining orgasmamongst the limited studies performed.4) That despite claims that total removal of the corpora and crura are necessary to avoid pain, there is evidence to the contrary-even that the preservation of the crura and corpora cavernosa tissue may be a source of pleasure, and that the NV bundle, crura, and corpora can all be successfully used.5) That the sensate pedicle technique actually cuts and damages many nerves, and although good for the 1980 \'s, is in no way state of the art today. Further integration, with an exposition as to why the sensate pedicle technique is archaic, is presented. LIFTING MEANS CUTTING As previously mentioned (1), lifting the dorsal nerve off of the tunica albuginea, even from 11 to 1 O \'Clock, WILL cut nerves which extend around the lateral and ventral sides. Besides the referencesfor such cited in my previous article (1), an additional report by Baskin (2) found that \"the neuroanatomy was analogous in male and female patients, revealing an extensive network, not only at the 11 and 1 O \'Clock position, but completelysurrounding the ventral aspect of erectile bodies. \"Thus, it is irrelevant, if the sensate pedicle technique is performed on transssexuals or intersexuals. If the author warnsof cutting nerves in minor procedures, such as straightening the penis, how much more nerve cutting and nerve damage occurs in transsexuals and intersexuals? Cheryl Chase, director of ISNA, writes \"there really is no such thing as a \'neurovascular bundle \'...See the following article for an accurate anatomy. \"(3) Furthermore, the ventral mid-glans is also innervated by the dorsal neurovascular bundle (4), which is cut off by the sensate pedicle technique. It is not surprising that some of the NV bundle is often present in tissue samples after surgery. Lastly, not only the dorsal nerve innervates the glans, but it is also innervated by a branch of the perineal nerve.(4) Thus, it is bad enough to use the sensate pedicle technique. However, it is even worse for those, who in addition, insist on removing the corpora cavernosa and the crura. THE CORPORA CAVERNOSA A recent report by Colombel et. al. (5), demonstrates that the dorsal nerves are in direct communication with the branches of cavernous nerves of the penis. Andersson et. al. (6) also demonstrate a \"rich sympathetic, adrenergic innervation of the CC and the vasculature. The pelvic nerve plexus has parasympathetic and sympathetic roots. This ends in cavernous nerves which anastamose in 70% of the cases with the pudendal nerve in the penile root. \" Benoit et. al. (7) state, \"Thus, there are two neurovascular pathways destined for the penis that are topographically distinct. One is located in the pelvis and the other in the perineum. \" The functional balance between these remains unknown.In any event, the removal of cavernosal nerves interferes with the pelvic and/or with thepudendal nerve. Thus the total removal of the cavernosa is indefensable. Furthermore, the corpora cavernosa and prepuce are the only two features common to all primate genitalia. (8) THE CRURA The removal of the crura, may be even more harmful than the removal of the corpora. In a very recent report (8), Akman et. al. studied the nerve distribution under the pubic arch and the relationship of the nerves to the crural bodies, corporeal bodies, and urethra of the penis. Previous studies were only based on the penis distal to the pubic arch without total inclusion of the crural bodies. Beneath the pubic arch, the nerves to the penis were an extension of the dorsal neurovascualar bundleof the prostate. The nerves formed 2 bundles following a path just under the pubic arch in close proximity to the bone, superior to the urethra and medial to the origin of the crural bodies. The nerve bundles joined the corporeal bodies at the proximal origin, where the 2 crural bodies fused together. At this point perforating branches from the cavernosal nerves were documented. As the dorsal nerves joined the dorsal aspect of the corporeal bodies, they immediately began to fan out along the surface of the corporeal tissue to the junction of the urethral spongiosum. The authorsstate that a precise understanding of penile anatomy beneath the pubic arch and at the origin of the crural bodies is important for preserving neuronal structures. It is clear that the sensate pedicle technique is totally inadequate at preserving nerves in SRS. Furthermore, the total removal of the crura and corpora cavernosa further cut and damage nerves. HOW MUCH ERECTILE TISSUE SHOULD BE REMOVED? Shouldn \'t erectile tissue be removed to prevent painful erection?At least one SRS surgeon is able to retain some erectile tissue (the crura and some of the corpora) which actually is ranked among the most erotic places in 12 post-operative male to female transsexuals surveyedby this surgeon (discussed in reference 1). This would also be in accord with the recommendation by Baskin (also discussed at some length in reference 1). It is also in accord with the letter by Chase, mentioned above (3). Herein, she states \"Finally, the surgery is based on the premise that erectile tissue is unimportant and can be removed. Unlikely to be true. \" I posed the question of pain associated withnot excising all of the erectile tissue directly to Chase. She replied, \"Erection is painful if the erectile tissue is surgically relocated, scrunched down with stitches (like the pleats in a quilt), and surrounded with scar tissue. \" (9) So, the method of retaining erectile tissue is important. In an individual with ambiguous genitalia, a technique was used to preserve the corpora and both the dorsal AND ventral neurovascular pedicles. (10) A co-author of the paper writes, \"The corpora still function and erection occurs but I suspect...that there is very little direct vascular communication across the site of excised tissue, nevertheless there is erectile function due to the preserved vascular connections proximal to (and distal to) the site. \" (11) There was no painful erection in the report listed above (10). Also, it should be mentioned that there is no difference in either nitric oxide synthase localization (12) or the distribution of peptidergic nerve fibers (13) in the normal clitoris as opposed to persons with an ambiguous phallus. Finally, women don \'t masturbate by manipulating the glans. They do soby manipulating the shaft. (14) WHAT \'S IN A GLANS? For over a hundred years, anatomical research has confirmed that both the penile and clitoral prepuce are richly innervated, specific erogenous tissue with specialized encapsulated (corpuscular) sensory receptors, such as Meissner \'s corpuscles, Krause end bulbs, Ruffini corpuscles, and mucocutaneous corpuscles. (15) These receptors trasmitsensations of fine touch, pressure, proprioception, and temperature. The two primary sensory receptors in primate skin are free nerve endings and encapsulated or corpuscular receptors. Although free nerve nerve endings (itch, pain, and temperature receptors) are found in most skin, the encapsulated receptors are concentrated in regions that require specialized touch sensitivity. These include the external genitalia. (15) They have a capsule and an inner core composed of both neural and non-neural elements with the exception of the pinkus corpuscle, which is nontheless a genital sensory receptor associated with Merkel cells. The capsule of corpuscular receptors is a continuation of the perineurium and the core includes preterminal and terminal nerve fibres surrounded by laminated layers of modified Schwanncells (laminar cells), Meissner \'s and genital corpuscles have a complex branching of the nerves with the corpuscular core. (15) However, importantly, the Pacinian corpuscle has a single nerve through the core, which is surrounded by laminar cells to form an onion bulb configuration. (15) In humans, the glans penis has FEW corpuscular receptors and predominant free nerve endings, consistent with protopathic sensibility. Protopathic means a low order of sensibility (concioussness of sensation), such as to deep pressure and pain, that is POORLY localized. As a result, the GLANS PENIS HAS VIRTUALLY NO FINE TOUCH SENSATION AND CAN ONLY SENSE DEEP PRESSURE AND PAIN AT A HIGH THRESHOLD. THE PREPUCE HAS TEN TIMES MORE CORPUSCULAR SENSORY RECEPTORS THAN THE GLANS PENIS. (15,16) This is why circumcision has recently been under severe criticism. (15,17) The residual exposed glans mucosa becomes abnormally keratinized with an increase in the number of cell layers in glanular mucosal epithelium.(17) Foreskin restoration DOESN \'T regenerate encapsulated receptors, but re-covering of the corona results in a reverting of the epithelium to the normal squamous mucosa of the glans.(17) The point is that the only area of the human body which is LESS sensitive than the male glans is the sole of the foot!(16,17,18) The clitoral glans has MUCH more sensory receptors than even the male prepuce, which has ten times the amount of the male glans!(15,17) But, in uncircumcised male to female transsexuals, even this tissue has been lost to circumcision. Although the male glans and female glans may have some overlap in the amount of these receptors (19), only the corona of the glans is rich in these receptors. (15,16) The sensate pedicle technique, or any other which does not use coronal tissue for clitoral glans construction, is simply not based in an accurate understanding ofthe fact that the human male glans overall (except for the corona and the prepuce and ridged band which is removed at circumcision) is unlike the clitoral glans. In other human primates the male and female glans are comparable in sensory receptors. (15,16) Any male to female technique at clitoroplasty needs to conserve the coronal margin for neoclitoral construction. This would not be in contradiction to the preservation of the entire tunica albuginea, with nerves which fan out laterally and ventrally. It would not be in contradiction to the preservation of all of the crura and some of the corpora, which is necessary for maintaining nerve sensation of all pathways as well as erectile function, although the subalbugineal level, which is absent in the clitoris, may need to be removed, as it is related to the uniqueness of the male erection cycle which includes not only tumescence, but also rigidity.(20)REFERENCES 1) Neoclitoris:Integration (can be viewed at the Gendercare Library, following gendercare.com site: http://gendercare.com/srs_results3.html2) Baskin, L. (1999) Fetal genital anatomy reconstructive implications. J. of Urology Aug;162 (2):527-529.3) Personal Communication fro Cheryl Chase, Oct. 31, 2000.4) Yang, C.C. & Bradley, W.E. (1999) Innervation of the human glans penis. J. of Urol. Jan;161(1):97-101.5) Columbel, M. et. al. (1999) Caverno-pudendal nervous communicating branches in the penile hilum. Surg. Radiol. Anat. Vol. 21(4):273-276.6) Andersson, K.E. et. al. (2000) Sympathetic pathways and adrenergic innervation of the penis. Int. J. Impot. Res. Mar;12 Suppl. 1:S pages 5-12.7) Benoit, G. et. al. (1999) Supra and infralevator neurovascular pathways to the penile corpora cavernosa. J. of Anat. Nov;195 (Pt. 4), 605-615.8) Akman, Y., et. al. (2001) Penile anatomy under the pubic arch: reconstructive implications. J. of Urol. Jul;166 (1), 225-230.9) Personal Communication from Cheryl Chase, Nov. 1, 2000.10) Papageorgiou, T. et. al. (2000) Clitoroplasty with preservation of neurovascular pedicles. Obstet. Gynecol. Vol. 96 (5), Part 2 Nov., 821-823.11) Personal Communication from James H. Segars, Sept. 17, 2001.12) Burnett,A.L., et. al.(1997) Immunohistochemical Description Of Nitric Oxide Synthase Isoforms In Human Clitoris J. of Urol. Vol. 158, 75-78.13) Hauser-Kronberger, C., et. al. (1999) Peptidergic innervation of the human clitoris. Peptides Vol.20 (5):539-543.14) Kinsey, A. (1953) Sexual Behavior in the Human Female.15) Cold, C.J. & McGrath, K.A. (1999) ANATOMY AND HISTOLOGY OF THE PENILE AND CLITORAL PREPUCE IN PRIMATES. An evolutionary Perspective of the Specialized Sensory Tissue of the External Genitalia. Chapter 3 in Male and Female Circumcision, edited by Denniston, et. al. Kluwer Academic/Plenum Publishers, New York.16) Halata Z. & Munger, B.L. (1986) The neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis. Brain Research Vol. 371 (2),205-230.17) Cold, C.J. & Taylor, J.R. (1999) The Prepuce B.J.U. Int. Vol. 83, Suppl. 1, 34-44.18) von frey, M. (1984) Beitraege zur Physiologie des Schmerzsinns. Zweite Mitt. Akad. wiss. Leipzig Math naturwiss Kl Berlin Vol.46, 283-296.19) Personal Communication from John R. Taylor Oct. 4, 2000.20) Toesca, A., et. al. (1996) Immunohistochemical study of the corpora cavernosa of the human clitoris J. of Anat. Vol. 188, 513-520.","null","null","");fileNum=13;