Some personal history: in medical school I was fascinated by issues which would now be called, "gender identity." As fate would have it I found myself in a medical school where the departments of endocrinology and pediatric endocrinology and pediatrics were essentially laboratories of biochemistry. The first report of five alpha reductase deficiency (5AR)was made by a fellow in endocrinology there, Julianne Imperato McGuinley. (This was what the book Middlesex was about.)
First there are people some call "trans genders" who may not feel they've been assigned the wrong sex, which some distinguish from "trans sexuals," who always have the feeling they have be assigned the wrong sex.
People with 5 AR are born with "ambiguous genitalia" i.e, when the mother asks, "Boy or girl?" the doctor is staring at the genitalia and he's not sure. The clitoris is large and might be a small penis and the testicles are not dangling in a scrotum but there might be lumps in the inguinal canals (groin) or in the abdomen which might be testicles. The urethra opens at the base of the clitoris/penis. So, the matter of sexual assignment is in doubt. In the Domican Republic, where this trait is common, whole villages named their kids the Spanish equivalent of "Pat" or "Robin" or "Terry"--gender neutral names, because they knew some of the little girls would sprout penises at age twelve.
The medical school had a Metabolic Research Unit (MRU) which received patients with 5RU and also got patients with 17 hydroxyprogesterone dehydrogenase deficiency (17OHPD), an enzyme which catalyzes the production of testosterone, and these patients are born with amibiguous or female genitalia, because they are first wave of testosterone which occurs in the "first puberty" in utero was diminished. Many of these people, with 46 XY chromosomes go through infancy and childhood feeling not like girls, chasing after their friends shooting toy guns, and acting like "tomboys." When puberty arrives, as is the case for the 5AR patients, a tidal wave of testosterone basically floods past the bottleneck and exposes these folks to enough testosterone to masculinize their genitalia and their skin and hair and muscles.
Both 5RU and 17 OHPD patients are "pseudohermaphrodites," i.e., their outward appearance (their "phenotype") do not match their chromosomes or their glandular tissues, i.e. they have intra adominal testes but not in a scrotum. On the outside, they look like girls; but on the inside they have testes.
Another group of pseudohermaphrodites were patients born with ambiguous genitalia who had Congenital Adrenal Hyperplasia, a condition in which various enzymes along the pathway to cortisol production were deficient and so finding the road to cortisol blocked the metabolities on that assembly line, that roadway to cortisol detoured to roadways to male hormone production. A ittle girl with 46 XX gets born with an enlarged clitoris and swollen labia, fused like a scrotum, and the question was whether she is a boy or a girl. Maria New, the great pediatric endocrinologist, used the laboratory of Ralph Peterson and together they figured out what was going on and were able to treat these patients and say these were girls whose ambiguous genitalia would regress once they were treated with cortisol. Sometimes surgery was necessary, but for the most part, these girls were successfully identified, treated and wound up leading normal lives as females.
In some cases of these infants, there were difficult decisions to be made regarding "gender assignment." Would a boy whose penis would never become much larger than a big clitoris ever be able to function as a male? Should "he" be assigned to the female gender and surgery be done to fashion a vagina?
The MRU also got people with testicular feminization, brought in for study. T fem patients have male chromosomes, 46 XY, but they have very unambiguous genitalia, on the outside: a clitoris, a vagina and nothing that looks like testicles. As they grow, they are frequently very pretty women, with no body hair, no pubic hair and luxurious scalp hair. But their vaginas end "blindly," and they have no cervix, no uterus and the gonads found in their pelvis are, under the microscope, typical testes. These people are "resistant" to testosterone, i.e. the receptors on their cells which make hair cells grow beard or pubic hair do not function; testosterone simply bounces off their cells. In utero, if there is no testosterone effect, the body develops along female lines, for reasons not entirely clear. These are pseudohermaphrodites of a different sort. It's not that they cannot make testosterone--their levels are often quite high--but unlike the 5RU or 17OHD patients, they cannot respond to these levels. This is a disorder of receptor function. These folks do not have "gender dysphoria" and have no doubt they are female and function as females, identify as femaies and feel female no matter what their chromosomes or gonads may be.
The same medical school had as chief of it's Westchester Division of Psychiatry, a very talented man named Paul McHugh, who had done important work in clarifying what is and is not schizophrenia. Turns out, as McHugh demonstrated, the sine qua non of that diagnosis is hearing voices--auditory hallucinations. With that, whatever serious disorder you may have, it's not schizophrenia. That observation has held up over time and now that genetic studies are starting to unravel schizophrenia, it's still in place.
So, it is in light of that experience, of seeing people who had some confusion about exactly what sex they are, I have faced the problem of "trans sexuals."
For that early, formative part of my career, I thought of all these patients with these biochemical "abnormalities," or "differences" as people with pathology, with a problem to be solved by the powers of medical science. This idea developed in no small part because these were "patients" presenting themselves, usually with their parents for a "solution" to their "problems" which could be defined in terms of enzymes, biochemistry and later genetics.
But now I am seeing people arrive in my office asking me to provide them with testosterone (if they are 46 XX and feel they are men in a woman's body) or estrogen (if they are 46 XY and feel they are women trapped in a man's body.) Some ask for support through "reconstructive" surgery, i.e., the removal of their testes and fashioning of a vagina.
And I do not know what to think.
I'm not even sure what the risks of raising the blood levels of a genetic woman to male levels. I'm got some idea what the risks of raising a genetic man's estrogen levels to a female range, but there are more unknowns there than knowns.
I have little doubt that homosexuality is not a disease, not a pathology. I do not doubt that most homosexuals are "born that way."
But even there, there is room for nuance. Paul McHugh wrote an amicus brief for the Supreme Court in which he noted studies which suggest just how plastic and fluid sexual preference can be over the lifetime of, most particularly, women. While he stopped short of calling homosexuality a choice, McHugh suggested that all human beings go through phases of variable attractions to their own and the opposite sex and many things beyond genetics or immutable biology influence sexual preference at different times over a lifespan.
Unfortunately, he was writing to oppose gay marriage. The legal basis for the argument was everyone agrees that under the 5th and 14th amendments, you cannot discriminate against a class of people who are born a certain way, say Black, and can do nothing to change that. But if people are not born gay, fixed gay, destined to be gay, then there is no "class" of biologically fixed gay people who can be considered an offended group by a law which forbids gay marriage.
It is a curious argument, in the sense that McHugh may be arguing gays are really no different from people who consider themselves exclusively heterosexual, so while we should not revile them for swinging just a little wider in one of life's arcs, neither do they qualify for special protection, since they aren't that different.
Fortunately, McHugh's argument did not carry the day, but it did taint the notion of his scientific objectivity when it comes to transgenders. On the other hand, while he did not claim homosexuality is a mental illness, he does say people who have "gender dysphoria" i.e. who seek help to change their sexuality, who have no definable biochemical reason for sexual confusion, are profoundly mentally ill.
McHugh became the chief of psychiatry at Johns Hopkins and after taking on that role Hopkins stopped all transgender sexual surgery. The reasons given had to do with follow up studies on the patients who had undergone transgender surgery. They had, in the Hopkins group, and in multiple other studies, a suicide rate of something like 20-30 times control groups. This suggested a rather extreme form of "buyer's remorse." In the Hopkins experience almost one out of three people who underwent transgender surgery committed suicide. It also suggests McHugh might be correct to assert these patients do not have, primarily "gender dysphoria" but a far more serious underlying pathology which resides in close proximity to depression.
So, I have to ask whether we are mixing apples and oranges to include homosexuals with transgenders with pseuohermaphrodites or people with definable biochemical abnormalities in the same group.
I wonder whether the Lesbian, Gay, Transgender alliance is one based in politics or simply in the common experience of being attacked because of your sexuality.
But is the sexual conflict of the transgender or trans sexual person really comparable to that of the homosexual or, for that matter, the pseudohermaphrodite?
One might argue that it's the experience of discrimination which matters, not the genetics. A mix race child is likely to be considered simply Black by racists to seek to deny her the use of a "whites only" bathroom. In that sense, it doesn't matter if she is different, genetically from others in her class, when that class is defined by the way she is treated by others. Surely, under the Third Reich, German, French and Polish Jews, half Jews, Roma and homosexuals all found themselves in the same cattle cars, no matter what their differences.
Next week I'll go to the Endocrine Society meetings where there will be sessions on these issues.
I'm hoping to attend with an open mind.
Confused, but hopefully open.
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