The State of the Art - Gender Identity and the Brain

European Society for Endocrinology Conference 2018

Symposium S30.3

Abstract : Brain structure and function in gender dysphoria

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

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

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

The Six Genders in Classical Judaism

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

This description from Trans Torah/Rabbi Elliot Kukla:

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

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

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

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

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

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

Largest Study to Date: Transgender Hormone Treatment Safe

Largest Study to Date: Transgender Hormone Treatment Safe

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

Mistaken Gender: 5-Alpha Reductase Hermaphroditism and Biological Reductionism in Sexual Identity Reconsidered

Another for the reference library. Also.. a bit too close to home, the way some were treated.

Mistaken Gender: 5-Alpha Reductase Hermaphroditism and Biological Reductionism in Sexual Identity Reconsidered Gilbert Herdt, Academic Room 2012

Hermaphroditic infants are sex-assigned as kwolu-aatmwol, not as male. Those assigned as female are mistaken as normal females. Hermaphrodism is regarded as a sad and mysterious quirk.

The kwolu-aatmwol, unless distinguished as a shaman or war leader, is quietly disparaged. Yet several kwolu-aatmwol are well known in local history, and one of them, now deceased, was famed both as shaman and fight leader. The kwolu-aatmwol is therefore not rejected or frozen out of daily and normative social contacts, and may indeed rise to distinction through special achievements, as Sakulambei has done. Nor do Sambia feel disgust regarding these liminal beings. Still, Sambia is a sexually polarized society, and parents do not want infants to be hermaphroditic: the intersexed infant may be killed at birth by women, the men believe (Herdt 1981). If it passes as female, however, it is sure to survive.

Consequently, at birth, women carefully check the infant's sex to ensure that it is not kwolu-aatmwol. When discovered at birth, the child is reared in the direction of masculinity, but not unambiguously; rather, it is referred to as kwolu-aatmwol or male, because parents know that their infant will not change into a female. Sometimes the kwolu-aatmwol as a child is teased and humiliated by peers for having "no penis." If parents feel ashamed or rejecting of the child, the mental health outcome is poorer (Herdt and Davidson 1988).

Five of the fourteen kwolu-aatmwol were reared as females. Two of these are still alive.

One late adolescent continues to live as a female, though she is unmarried, physically larger than a normal female, and is now known to be a kwolu-aatmwol. The other living subject is an older adult who was reportedly reared ambiguously as a female.

Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial | BMJ

Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial Schierbeck et al BMJ 2012;345:e6409

Conclusions After 10 years of randomised treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, without any apparent increase in risk of cancer, venous thromboembolism, or stroke.

They used bio-identicals you see, not cheaper, artificial estrogen-like compounds as with other studies.

Not Quite Another One...

Girl is born looking like a Boy. She tries to be a Boy. Fails, but can fake it well. She has to to try to have some kind of normal life. Later, she finds out her body isn't as male as everyone (including her) thought. She's in-between, so can live as the woman she always was, without feeling like some kind of sex pervert. Her partner takes in her stride the fact that she married another girl, the person matters, not the physical shape, and they all live happily ever after, giving thanks that due to an unusual biological situation, two gals could have children together. Rare, but it happens.

From the Denver Post:

Five years ago, when Steve and Debbie Crecelius awaited results of his kidney stone ultrasound, they weren't expecting earth-shattering news. But what the technician told them rocked their world. "She said, 'You're female,' " said Steve, a prominent local photographer who has worked with clients ranging from Harrison Ford to the city of Glendale. The medical discovery that he is intersex — born with a mix of anatomical sex traits, so biological gender cannot be classified as either male or female — led to a flood of revelations that would refine and redefine their 25-year marriage. When they got home, Debbie forced a conversation that Steve feared would cost him his wife and family. "There's something I've always wanted to talk to you about," she said, explaining that she'd always known that he had female traits.....

No change of external appearance, just the revelation that her body wasn't completely male. That was enough. We need to educate people, especially Trans people, to realise that Trans people aren't "sex perverts" as is the popular belief. That whether someone is classically Intersex, with a mixed reproductive anatomy, or classically Transsexual, with a mixed neurological anatomy, or even if they just have a cross-sexed gender identity due to other causes - not that any have been identified - they're who they feel they are. They don't have to pretend.

It happens

Boy turns to girl – without surgery - Yahoo!7

Ryan McKenna always felt like a girl trapped inside a boy's body, but unlike many who suffer from gender identity disorders, Ryan didn't need surgery to become the female he believed he truly was. As a child Ryan's mum Julie found small lumps on his chest, before a doctor said Ryan probably had high oestrogen levels, but would likely grow out of it over time. At school, Ryan preferred hanging out with girls, and described himself as 'dress mad'. Ryan is affected by a hormonal imbalance which can affect growth, fertility and behaviour. The imbalance can pose serious psychological problems for those affected, but with support from loved ones, these issues can be overcome.

Seems Plausible

Sex and Gender Evaluation TEST RESULTS

S.A.G.E. Test Results

Your Raw Score is: 660, which indicates that overall you are Feminine

Your appearance is Feminine

Your brain processes are mostly that of a Female person.

You appear to socialize in a feminine manner.

You believe you have major conflicts about your gender identity.

You indicated you are physically Intersexed to some degree.

ANALYSIS:

Since you indicated you were born with an Intersex condition, it is likely that this has caused you some degree of gender conflict because society in general is not accepting or understanding of gender ambiguity. Since it is difficult to live in a purely androgynous gender role, please check the most appropriate analysis below.

NOTES:

Your answers indicate you have altered your physical appearance to look like the opposite sex.
Your Answers indicate your psychological state has likely prevailed since you were quite young.

ANALYSIS AS Male:

Male to Female Transsexual, either post-operative or in transition

NOTES:

Your answers indicate you have altered your physical appearance to look like the opposite sex.
Your Answers indicate your psychological state has likely prevailed since you were quite young.

ANALYSIS AS Female:

No conflicts, you appear to fully accept your physical sex and gender identity.

NOTES:

Your answers indicate you have altered your physical appearance to look like the opposite sex.
Your Answers indicate your psychological state has likely prevailed since you were quite young.

DMRT1, FOX and SOX

Following on from a previous post, from DMRT1 prevents female reprogramming in the postnatal mammalian testis by Marson et al, Nature (2011)

Sex in mammals is determined in the fetal gonad by the presence or absence of the Y chromosome gene Sry, which controls whether bipotential precursor cells differentiate into testicular Sertoli cells or ovarian granulosa cells [1]. This pivotal decision in a single gonadal cell type ultimately controls sexual differentiation throughout the body. Sex determination can be viewed as a battle for primacy in the fetal gonad between a male regulatory gene network in which Sry activates Sox9 and a female network involving WNT/β-catenin signalling [2]. In females the primary sex-determining decision is not final: loss of the FOXL2 transcription factor in adult granulosa cells can reprogram granulosa cells into Sertoli cells [2]. Here we show that sexual fate is also surprisingly labile in the testis: loss of the DMRT1 transcription factor [3] in mouse Sertoli cells, even in adults, activates Foxl2 and reprograms Sertoli cells into granulosa cells. In this environment, theca cells form, oestrogen is produced and germ cells appear feminized. Thus Dmrt1 is essential to maintain mammalian testis determination, and competing regulatory networks maintain gonadal sex long after the fetal choice between male and female. Dmrt1 and Foxl2 are conserved throughout vertebrates [4,5] and Dmrt1-related sexual regulators are conserved throughout metazoans [3]. Antagonism between Dmrt1 and Foxl2 for control of gonadal sex may therefore extend beyond mammals. Reprogramming due to loss of Dmrt1 also may help explain the aetiology of human syndromes linked to DMRT1, including disorders of sexual differentiation [6] and testicular cancer [7].

[1] Koopman, P., Gubbay, J., Vivian, N., Goodfellow, P. & Lovell-Badge, R. Male development of chromosomally female mice transgenic for Sry. Nature 351, 117–121 (1991)

[2] Uhlenhaut, N. H. et al. Somatic sex reprogramming of adult ovaries to testes by FOXL2 ablation. Cell 139, 1130–1142 (2009)

[3] Raymond, C. S. et al. Evidence for evolutionary conservation of sex-determining genes. Nature 391, 691–695 (1998)

[4] Loffler, K. A., Zarkower, D. & Koopman, P. Etiology of ovarian failure in blepharophimosis ptosis epicanthus inversus syndrome: FOXL2 is a conserved, early-acting gene in vertebrate ovarian development. Endocrinology 144, 3237–3243 (2003)

[5] Raymond, C. S., Kettlewell, J. R., Hirsch, B., Bardwell, V. J. & Zarkower, D. Expression of Dmrt1 in the genital ridge of mouse and chicken embryos suggests a role in vertebrate sexual development. Dev. Biol. 215, 208–220 (1999)

[6] Tannour-Louet, M. et al. Identification of de novo copy number variants associated with human disorders of sexual development. PLoS ONE 5, e15392 (2010)

[7] Turnbull, C. et al. Variants near DMRT1, TERT and ATF7IP are associated with testicular germ cell cancer. Nature Genet. 42, 604–607 (2010)

This diagram from the body of the article might help explain what was done, and what the effects were. For more details, see the full article, available through library sibscription.



I have a personal interest in such matters of course. In my own case, 3BHDD is a really good explanation of everything except for the rapidity of the change. That remains unexplained. This may have something to do with it, or it might not. More data needed, though activation/deactivation of Foxl9/Sox2 seems likely to play a role. DMRT1? No idea, though I don't see how it could. We're still guessing, but every little bit of information helps. There's one case being looked at by the Mayo clinic - a more complete change than mine - where this genuinely might be the cause, even if it's not involved in my own case. Weird stuff happens.

Why I Blog

A snippet from Reddit

Willblaze wrote:
So Im suppose to be some mystical mind reader? I dont know shit about any of this stuff, Im just an average hetero guy that has no run-ins with any trannsexuals. I never said it was anyones responsibility to teach me anything, I stated I didnt fucking know, and Im a human and make mistakes just like anyone else. Reread my comment and stop being such a fucking child. It has nothing to do with being sheltered, how the fuck do you know what type of surroundings I've grown up in. I live in the south of USA, so I NEVER see people like this.

ZoeBrain wrote:
Um.. I think you probably do - you just don't realise it.

BTW Congrats on admitting you don't know. That shows intelligence and intellectual honesty, and mere lack of knowledge is easily fixed.

OK, I better back up my statement of "you probably do" with some evidence. I know plenty of trans women in the South. Texas, Alabama, Georgia, North and South Carolina... but that doesn't help much.

To see what Trans women actually look like, some pretty, some pretty dreadful, have a look at these URLs.

http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSgallery1.html
http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSgallery2.html
http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSgallery3.html
http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSgallery4.html

There are Trans men too. Quite a few.

http://ai.eecs.umich.edu/people/conway/TSsuccesses/TransMen.html

OK, now just to expand your horizons a bit... in addition to Trans people, there are some who change sex naturally. In some parts of the world, the mutations that cause that are more common than the CCR1 mutation that causes red hair.

See http://www.usrf.org/news/010308-guevedoces.html

Most such changes are FtoM. Some (not due to 5ARD or 17BHDD but 3BHDD or rarer conditions) are MtoF.

Here's one such woman. No cosmetic surgery. She used to look male.

Now she's not the prettiest - she was 52 when that shot was taken. But I don't think it would have occurred to you that her change from looking male was just 5 years earlier, would it?

WillBlaze wrote:
bannana should take tips from people like you. Thank you for being a mature adult about the situation and also going out of your way to educate me. Im not proud of how I looked and I felt like an asshole about the things I said after they were pointed out to me how it was offensive. I wish I could give you many upvotes. The links really show me how I could see someone and have no idea at all. And the trans-men part? Wow, just wow. If I was talking to one of them at a bar I would have no idea at all, unless maybe the voice gives them away? Another subject I dont know very well... but if I just saw them at a bar I would think "thats a man" without a second thought on the matter.

Again, thank you for helping me understand this whole thing. Its a world I never have had any experience in. So instead of hurling childish insults at me and have the problem unresolved if not worsened, you resolve the problem and educate.

Music to my ears.

Not Alone

I've just had word from someone on the other side of the world of someone else with the same kind of syndrome as I have.

>80% similarity. Timing, weight loss, the works. Some minor differences, and we've got to check blood test results re lipids and androgens, but it's close, really close from the data we have already.

While there are less than 100 natural MtoF changes on record, none of them really matched what happened to me in 2005 (apart from the obvious MtoF bit). Not until now.

We'll be comparing clinical notes. With n=2, we should be able to get a far better handle on the biology of this syndrome.

The AMA on the Origins of Sexual Orientation and Gender Identity

Click to start the presentation in a new window.



Money Quote:

"Sexual Orientation and Gender Identity are conferred during the first 12 weeks of gestation, and they are irreversible"

There are some blatant contradictions which Dr Kate O'Hanlan struggles with - but that's really the fault of the constraining binary language; homosexual or heterosexual. In fact, Biology doesn't conform to a strict binary, and the edges blur between those two extremes. Someone in the minority near the divide can be "pushed over" one way or the other - usually towards behaviourally exclusive heterosexuality (regardless of feelings) due to societal pressure, but being abused as a child, or less commonly as an adult, can cause a push the other way. When the trauma is particularly strong, such as rape trauma resulting in a pathological fear of men, or extreme religious pressure to "resist their inner demons", they can become fanatics. The extreme Right-Wing Religious Homophobic politician who's caught with his pants down is now so common it's a cliche.

Or, untraumatised, they can remain happily Bisexual, or Asexual.

A similar case applies when it comes to Gender Identity, that minority who are bigendered can be pushed one way or the other, or remain androgenous or neutrois. How large those minorities are is another matter, but 1 in 3 seems a good estimate.

This accounts for all of the observed facts; that both gender identity and sexual orientation are inherent, congenital, and unchangeable for most intents and purposes, for a few they are not quite, if the person is traumatised enough. For the rest, the trauma does the same amount of damage, but has no other effect whatsoever.

Untitled Picture

Yes, it weirds me out too. Siblings? Couples? Photoshops? MtoF? FtoM? I don't know. Supposedly they're couples.. though my bet's on siblings. Eye colour and earlobe shape differ.

Priceless

The Class of '75.

Well, it wasn't quite like that for me... I've had no cosmetic surgery... but, well, see my previous post.

The Gendered Self - A Personal View

From Anne Vitale's e-book, the Gendered Self : Further Commentary on the Transsexual Phenomenon ($5.95 USD and worth a lot more)

Given the nature of the condition and the ability of some children to conceal it, it may be possible that most children with gender dysphoria are never diagnosed as such. The undiagnosed children cope by sticking rigorously to the role expected of them.
...
Little is known about gender dysphoric boys who privately struggle to fit into their expected gender role. With no apparent problem, (many adult GID clients report being exceptionally well behaved as children) they simply go unobserved by clinicians studying gender variant behavior. Yet from interviewing adults with gender dysphoria, I can report that the problem, although lacking the current intensity, was as real for them then as it is now.

The underlying feelings most often stated were of detachment and confusion, a sense of not really fitting in, even though family and teachers consistently rewarded them for their artificially affected behavior. One of the most common areas of confusion was the original sex assignment process itself. Although adults may think it simplistic, many children are completely perplexed as to why some children are assigned as boys and others as girls.

Given a tendency toward privacy and modesty in our society, many children, especially those without siblings, often have no way of knowing that there is a physical difference between themselves and those differently assigned

Andrea, a 35-year-old male-to-female, post-operative transsexual recalls that she was completely perplexed over her assignment as male until at age seven her sister was born. While watching her mother change her sister’s diaper, she learned for the first time that her assignment as a boy was based on a real physical difference. Although it cleared up part of the confusion, she realized even at that early age that her identity concerns were far more complicated and serious then she had first thought.

It is common for clients to report thinking in childhood that gender assignment was based on parental preference and therefore open for redress. Girls are especially aggressive in their insistence that they are really boys. Indeed, many are so insistent that they go on to act for all intents and purposes as though they are boys, a pattern they carry into adulthood.

For cloistered gender dysphoric boys it was in the area of peers and activities, especially sports, that the problem was most noticeable. Unable or uninterested in competing in organized boys’ activities and having been shuffled decidedly away from playing with the girls, many became reclusive. To add to their confusion, and counter to behavior typically reported in openly gender dysphoric boys, many cloistered boys actually preferred solo play with boys’ toys and had little or no interest in girls’ toys. For example, I have heard more than one long-time post-op male-to-female transsexual speak fondly of having spent countless hours playing with an Erector Set or a Lionel model train set-up that their father had helped them build. Others described designing and making detailed model airplanes, race cars and sailing ships. The more academic of this group report little or no interest in sports and rough-and-tumble play. To avoid castigation from their peers, they report spending a lot of time reading and studying.

My close family would instantly recognise that stereotype as being a perfect description of me when young.

I'll quote two segments from previous posts of mine, one poetic, one autobiographical, that shows just how accurate Dr Vitale's description is. No wonder I was considered an "open and shut case", despite the "hormonal issues that perplexed the situation" as an examining psychiatrist put it.

1967
====

Pardon Me.
I need to see someone.
I don't know who decides these things.
But you see, there's been a silly mistake.
I didn't complain before
But I'm now nearly 10.
It's getting really late.
I don't mind being in Loddon House
Though Thames or Kennet are OK too.
If I have to change
To either, I don't mind.
And as for A Class well,
I'm good at maths.
No complaints.
But you see
They put in me in the Boys
And Boy things just aren't me.
The Boy clothes I wear
Mean Girls won't play with me.
I'm so alone,
I spend my playtime
In the Library
Alone
Different
Lonely
I don't fit in
At all.
There's been a mistake, you see.
I know my parents
Wanted a Boy.
Maybe that's why it was done
The assignment incorrect
To Boy and not to Girl.
A Natural mistake
To make
No blame.
But haven't I been good?
Done everything required?
Never been naughty
Over much.
I think I've earned the right
To go in with the Girls
And soon
Before my teens begin.
I need to see
Someone in charge
Who decides these things.
Please help.

You know you're in a bad way when you can't read the last few lines of a poem you yourself wrote, without tearing up. Not for yourself, but for all the other earnest young pre-teen girls today, doing their best to be biddable and polite, with a naive faith in the ability of the kindly adults around them to fix the situation.

In 1967... the attempted "fix" might have meant electro-convulsive therapy, and possibly removing parts of the brain.... certainly "operant conditioning" using rewards and punishments... torture by any other name. Not the Abu Ghraib Guantanamo faux-torture, actual electrodes and actual beatings. I didn't know that then, I just thought that when things became obvious in my teens there would be some upheaval and readjustment, that's all. Inconvenience.

Now for the second part.

Up until age 5, I was a child. No real concept of gender.

At 6, I went to school, and noticed something was wrong. I was dressed as a boy, I looked like a boy, but I didn't think like "other boys". I still liked toy guns, and Meccano rather than dolls, but I was different.

At 7, I knew I wasn't a boy, but didn't know what I was. I thought boys were puerile, and girls too silly and sissy. A classic Tomboy in retrospect.

At 8, I got to play hopscotch with other girls, and I felt at home. They thought like I did, they cried like I did. I still didn't see myself as more than an honourary girl though. Even if my favourite toy car was Lady Penelope's pink Rolls-Royce.

At 9, more by a process of elimination than anything else, I realised I was female. Boys could just as well have been an alien species. Girls were just like me, in feelings and values.

At 10, I was in a boys boarding school then, and I was able to make up boardgames of astounding complexity when it rained. I had my own secret garden in the nearby woods, with flowerbeds I'd planted. I could sit and read amidst the flowers, and was terribly happy. It was then I picked the name Zoe, and planned what I was going to do with my life. I wanted children, a husband, the white picket fence etc, but also to be a Rocket Scientist and to travel the world, things that Wives and Mothers Just Did Not Do in the 60's.

Even though it had been obvious since age 7 that I’d never be “svelte” or “petite”, that I’d be the girl “with the wonderful personality”. I didn’t cry about that – much. And not where anyone could see me. I was more worried about the practical problems I'd be having when I started having a female puberty. And vaguely concerned that boys didn't interest me at all. I was no naive I thought that was part of the package of being a girl. Was I a defective one?

It came as a terrible shock when I learnt that boys and girls are born looking different, and that my body was boy.

I dislike being an instance of a stereotype, but reality is, whether I like it or not.

"Damn! I have recently learned that I am
But a creature that moves
In predestinate grooves.
I'm not even a bus. I'm a tram."

Although I'm technically Intersexed, the whole "natural sex change" business yada yada - my childhood was indistinguishable from that of other transsexual women. I'm both TS and IS. Or IS and formerly TS.

From the Author's page:

Based on the author's first hand experience in treating over 500 gender dysphoric individuals over the last quarter century, The Gendered Self is the story of what it is like to be born into and to live out one's life as a transsexual in a cissexual world.

The book starts by showing how the developing brain is genderized in utero and how that process can go awry leaving affected individuals sex/gender incongruent.

The author goes on to show that although hormonal and surgical means is the current treatment of choice for sex/gender incongruency, we have come to learn that with Genital Reassignment Surgery life takes a turn wherein the individual is permanently consigned to a parallel universe: not male, not female but a bio-sociological combination of both. It is a world where the absurd becomes ordinary and the ordinary becomes absurd. Transsexualism is a life long existential dilemma that challenges the very nature of psychological survival. Nietzsche famously said that "what does not kill you makes you stronger". As The Gendered Self shows, surviving transsexualism and living a meaningful life is certainly a testament to that.

A final word. Something I wrote three years ago.

Something that illustrates how "It is a world where the absurd becomes ordinary and the ordinary becomes absurd."

You get used to it. You get too used to it. You tell yourself that the situation is unusual, you have to make allowances, and if you're not very careful, you get to believe that you deserve it, because of the myriad little ways you get humiliated or mistreated in every country on Earth. Some places, name change is trivial. Other places, it requires a court hearing, and a bigoted judge can refuse you permission simply because he doesn't approve of "that kind of thing". Some places, changing birth certificate is trivial if you're post op. Some places it's even possible if pre-op. Some places it's impossible. Some places it's possible even if pre-op, but not if you're married (like the UK). It's Legal Insanity.

You tell yourself that compared with people with Lung cancer, you have it easy. But the comparison is unjust: for changing sex, while psychologically uniquely stressful and medically risky, is not the problem. The problem is not even the violence, for anyone can be unlucky (Ok, so you're seventeen times as likely to be unlucky, so maybe it's a problem after all). The problem is those who argue that you're insane (so don't deserve treatment), or not insane (so don't deserve treatment). That you're as mad as a meataxe, as much as a psychotic schizophrenic, yet unlike a psychotic schizophrenic don't qualify as disabled under the "Americans with Disabilities Act", because there's a special exemptive clause just for your condition (see Donna Rose Dec 20 2007 8:30am). That you're gay, especially if attracted to the opposite sex, but don't qualify for legal protection under any clauses that protect gays in any event. That in order to get treatment for your insanity, you must get two specialist psychiatrists to put their reputations on the line, in writing, to say that you're sane. You get used to the inconsistency. If there's a disadvantage, it applies, if there's a mitigation, it doesn't.

You become so used to making allowance for others feelings - for all you want to do is have something like a normal life too - that in order to save minor inconvenience or some disquiet in others, you accept the most objectively appalling treatment of yourself. Treated in so many ways - though which ones depend on where you are - as a 4th class citizen, unless you make a conscious effort not to, you believe that you are a 3rd class citizen who just has to put up with a few inconveniences.

Instead of the 2nd class citizen you are because you're a woman. Actually, come to think of it, maybe I shouldn't accept that state of affairs either as "normal", just because it has been since time immemorial.

"The Gendered Self may be purchased through Lulu.com. It is available immediately as a PDF file download for $5.99 USD or in paperback for $14.99 USD. eReader formats to be available soon."

One thing though about Transition. Even if you don't get a natural assist from a weird metabolism - it's easier than the alternative.

Jumping Through Hoops

A little window into my world.

Transition - the process of changing one's social role from one sex to the other - is something that the medical profession only helps with conditionally. Contrary to popular belief, it's not something just anyone is allowed to do.

Note the word "allowed".

Someone can get plastic surgery to enlarge or reduce breast size just by paying for it. Someone can get a hysterectomy on demand, or even have testes removed. But to get legal access to hormones, and later, surgery, that's a different matter. The medical profession insists on having a "gatekeeper" role (for the patient's own good of course), treating them as being incompetent to make their own decisions.

The situation is self-contradictory; on one hand, any psychiatric illness that would affect the patient's competence to make their own decisions is an immediate disqualifier. That's the first thing that's checked. So they have to be competent, or they can't proceed. But then they're treated as if they're not.

When the "gatekeeper" is reasonable, rational, and competent themselves, this is no big deal. But not all are. Some insist on unreasonable conditions, and unless the patient acts in accordance with their stereotyped beliefs, they will withhold treatment, refuse it.

This has led many feminists to label trans women as fakes, as men who denigrate women by acting some Doris-Day stereotypical role, presumably for some kind of sexual thrill. They don't know, or don't care, that this act is just one more humiliating indignity forced upon trans women in order to be authorised necessary medical treatment.

This was almost universal in the past. But it still happens. Here's an article detailing one patient's experience, not in the 50s, but in 2009.

In early 2009 I was finally given my assessment for suitability to go on the waiting list for sex reassignment surgery. Yes, that’s right, I would be assessed as to whether or not I was suitable to wait in line for further assessment.
...
I wear black. I like wearing black. I was told that women do not wear black....The woman doing the assessment was wearing black. Nothing but black. She told me that women wear bright colours. Pink was the only colour she could name.

The psychologist actually assumed I had short hair – either she was blind, or stupid – and said that women have long hair. On having it pointed out to her that I have long hair, and was wearing it tied back due to the wind, she said that women never wear their hair like that. She certainly didn’t, since her hair was about an inch long...

I was wearing a skirt. It’s hard to miss this on anyone, more so when someone is sitting cross-legged. She assumed I was wearing trousers. In her strange view of the world, women never wear trousers: they only wear skirts – and not long skirts, not even when it’s cold out. They wear short skirts. Knee length is still a long skirt. Mid-thigh is apparently the universal dress code for women. Unless they wear dresses, of course. No woman ever wears trousers. I’m sure the astute reader will see where this is going… Yes, she was wearing trousers.

The ever more ridiculous and outdated stereotypes continued: Women all wear make-up. But not subtle make-up. They trowel it on, so that it is clearly visible. It must be noticeable, or they’re not wearing make-up. No, she wasn’t wearing make-up either. I personally don’t. I’m very poor and could not afford any make-up if I wanted to wear it. Since I was raised by parents who were both feminist enough to think that make-up is something that women are not required or expected to do, I certainly don’t feel any pressure to bother. But the notion that maybe it’s sexist to require women to wear make-up was flatly disavowed by the psychologist. She said that all women wear the stuff, all the time. Except her, of course.

Then there was my lack of high heels. You see, all women wear high heels (except for certain psychologists)....I was told I should wear high heels. Even though I often cannot find any that actually fit.

On hearing that I’m attracted exclusively to women (there was a flat demand to know my sexual orientation) she said that only men are attracted to women. I asked her if she had not heard the term lesbian. She repeated what she said, so I think the answer was “no”. I guess lesbians are just too cutting edge.

I had very little of this. Mostly because I was in the hands of a competent medical team, but also because I didn't quite fit the usual Transsexual situation. Had I been confronted with these kinds of demands, I would have sought another psych, because I'd have no confidence in the professional competence of anyone who behaved like that. And if there'd been none available, I would have proceeded anyway, via less formal means if available, otherwise by playing the sub in their little sublimated BDSM game if need be. "Single minded" doesn't really cover it, "implacably determined" does.

It was pointed out to me by the psychs that there were options now I hadn't considered before. That I could wear makeup if I wanted to. Or heels, or frills, or whatever. But... that's not really me, and never was. Maybe it should be, a bit. Having 47 years of hiding, of being deathly afraid that someone would find out my Dark Secret, that's left me with some psychological hangups in this area. But nothing major, and nothing I can't fix myself, in time. I enjoy wearing ear-rings, having long nails, and have discovered the joys of a little Chanel No 5. If my body looked more attractive, maybe I'd do more... but it doesn't. The point is, that's not exactly a dominating concern in my life, I'm more involved in writing up my PhD thesis and preparing the courses I'll be teaching next year. Bringing up my son is more important still.

I wasn't called on to play the performing seal, to jump through hoops on command. If I had to, if there was no other alternative, I would have. You can only be humiliated by someone if you give them permission though, and I would have withheld that.

Vaginal Appearance and Construction

So today I'm going to talk about Lady Bits. With as much delicacy as I can, but because this is the kind of thing every woman should know. Every woman, including standard factory models.

None of us can be certain we won't get some cancer, requiring radiotherapy or radical surgery. And all of us should be warned about pursuing some ideal, via cosmetic surgery, because we don't "look normal".

Ok, some of us don't, but unless you're Transsexual or Intersexed, you almost certainly do. "Normal" covers a wide range.

So what if reconstruction is necessary, due to a congenital problem, accident, or cancer treatment? Genital Reconstruction Surgery is one of the more difficult surgical procedures. Complications are common. Female genitalia is easier to construct than male, but that doesn't mean it's easy.

From The pitfalls of vaginal construction Davies, M. C., Creighton, S. M. and Woodhouse, C. R. BJU International (2005), 95: 1293–1298.

Fourteen patients had complex congenital anomalies of the lower genital tract and 11 of these had associated anomalies of the urinary and gastrointestinal system; four were XY females. The 15 patients had had 31 vaginal procedures, including ileal vaginoplasty, mobilization of perineal skin flaps and split-skin grafting. Three patients required osteotomies to increase pelvic outlet diameter. The commonest complications were stenosis (six patients) and fistula formation (four). Eight patients are now sexually active; the remaining seven have not attempted sexual intercourse.
...
Complications are common and can be major; most patients require many repeat operations to achieve a patent vagina. Unfortunately at present, this is the only option for this group of young women to achieve a functional vagina. Patients with complex congenital anomalies of the reproductive and genital tracts are increasingly surviving into adulthood, and the numbers of these patients is likely to increase in the future.

I think they could learn from the best specialist surgeons, such as Brassard and Suporn. Suporn has performed perhaps 2,000 of these procedures - without a single case of fistula, and usually using a male or somewhat male initial configuration.

One thing - female genitalia varies. From Female genital appearance: ‘normality’ unfolds. Lloyd, J., Crouch, N. S., Minto, C. L., Liao, L.-M. and Creighton, S. M. (2005), BJOG: An International Journal of Obstetrics & Gynaecology, 112: 643–646

Population Fifty premenopausal women having gynaecological procedures not involving the external genitalia under general anaesthetic.

Methods A cross sectional study using digital photography and measurements of the external genitalia.

Main outcome measures Clitoral size, labial length and width, colour and rugosity, vaginal length, distance from clitoris to urethral orifice, distance from posterior fourchette to anterior anal margin.

Results A wide range of values were noted for each measurement. There was no statistically significant association with age, parity, ethnicity, hormonal use or history of sexual activity.

Conclusion Women vary widely in genital dimensions. This information should be made available to women when considering surgical procedures on the genitals, decisions for which must be carefully considered between surgeon and woman.

The Numbers:

Clitoral length (mm)	5–35
Clitoral glans width (mm)	3–10
Clitoris to urethra (mm)	16–45
Labia majora length (cm)	7.0–12.0
Labia minora length (mm)	20–100
Labia minora width (mm)	7–50
Perineum length (mm	15–55
Vaginal length (cm)	6.5–12.5
Tanner stage (n)	IV 4
	V 46
Colour of genital area compared with surrounding skin (n)	Same 9
	Darker 41
Rugosity of labia (n)	Smooth 14
	Moderate 34
	Marked 2

On a personal note.... I'm Tanner Stage III. But otherwise I could have been one of the study group. I'm a scientist, and no-one who's been through what I have can retain any shreds of maidenly modesty. But there are limits, even for me. My OB/Gyn has need to know more, but no-one else.

Under Reported

From Reddit:

Reddit, your opinion on what a man-turned-woman (naturally) should do. : self

Nearly two years ago, my father was diagnosed with a rare genetic condition - what it is exactly, doctors are not sure of, possibly a mutation of Klinefelter syndrome - in which his endocrine system started producing more estrogen than testosterone. This resulted in a massive reversal of his gender - he now has softer and smoother skin, actual breasts, curvy hips, the whole nine yards. This was not something he willing underwent - it entirely occurred naturally and without warning....

I've always suspected my unusual syndrome is under-reported.

Hormone Therapy for Transition

HORMONE THERAPY IN TRANSSEXUAL PATIENTS - If your Endo is clueless, this will help. That is, if you want to transition.

I Forgot

Every 4th of May, I've been reporting on my transition. A summary of the previous year.

I forgot this year. And I've just realised, some eight days later.

Guess that means it's complete.

Now I'll have to go back, and insert a backdated post, and a new one tomorrow summarising what happened this year.

What was I blogging about on that day, 8 days ago? My anger at girls being excluded from seeing a Rocket Scientist. Pure Feminism. Yes, I guess I've 'trans'ed now. I'm on the other side. This side. Gosh.

Life is what happens to you while you're busy making other plans.

A song for my son, Andrew.

Good night, Scampasaurus.