Understanding Gender Dysphoria, page 21
7Ibid.
8Richard A. Carroll, “Gender Dysphoria,” in Principles and Practice of Sex Therapy, ed. Sandra R. Leiblum, 4th ed. (New York: Guilford, 2007), p. 479.
9Ibid.
10The DSM-5 identifies Transvestic Disorder as the primary condition in which cross-dressing is associated with sexual arousal. It is the experience of adolescent or adult males “for whom cross-dressing behavior generates sexual excitement and causes distress and/or impairment without drawing their primary gender into question. It is occasionally accompanied by gender dysphoria.” It is a condition rarely diagnosed in females (p. 458).
The proposed Guidelines for Psychological Practice with Transgender and Gender Non-Conforming Clients note that the reference to Transvestites, which they define as “someone who wears clothing, jewelry and/or make-up and/or adopts a gender role expression not traditionally associated with a person’s sex assigned at birth,” is “controversial and is considered pejorative and outdated by some community members and professionals, instead preferring the term cross dresser” (Guidelines for Psychological Practice with Transgender and Gender Non-Conforming Clients proposed by the American Psychological Association, p. 12, temporarily posted on http://www.apa.org, retrieved May 27, 2014).
11Let me acknowledge that many transgender people would not include those who perform drag under the transgender umbrella. While I am sympathetic with the distinction that people want to make between drag and gender incongruence, other experts in this area have also listed those who perform drag as part of the transgender community. See, for example, Carroll, “Gender Dysphoria,” p. 482.
The relationship between transgender persons and those who perform drag has recently been in the news with RuPaul receiving criticism for the use of the word “tranny.” In a commentary by Parker Marie Molloy that appeared in The Advocate, Molloy wrote directly to RuPaul and shared: “The fact of the matter, Ru, is that words do hurt, and when you continue to use words that are frequently used to dehumanize people like me, that are used as precursors for assault, after you’ve been informed how hurtful these words are, you’re no better than a racist who uses the ‘n word,’ the homophobe who calls gay men ‘faggots,’ or the misogynist who refers to his female coworkers as ‘bitches’” (Parker Marie Molloy, “It’s Time to Stop with the T Word,” The Advocate, February 20, 2014, www.advocate.com/commentary/2014/02/20/op-ed-its-time-stop-t-word).
12Cressida Heyes, “Identity Politics,” in The Stanford Encyclopedia of Philosophy, Spring 2012 ed., ed. Edward N. Zalta, http://plato.stanford.edu/archives/spr2012/entries/identity-politics.
13Heyes, “Identity Politics.”
14Ibid.
15Milton Diamond, “A Conversation with Dr. Milton Diamond,” by Dean Kotula, 2002, http://www.hawaii.edu/PCSS/biblio/articles/2000to2004/2002-conversation.html.
16Cindy Meston and Penny Frohlich, “Gender Identity Disorder,” http://homepage.psy.utexas.edu/HomePage/Group/MestonLAB/HTML%20files/Resources_msd _gender.htm.
17Dick F. Swaab and Alicia Garcia-Falgueras, “Sexual Differentiation of the Human Brain in Relation to Gender Identity and Sexual Orientation,” Functional Neurology 24, no. 1 (2009): 18.
18Meston and Frohlich, “Gender Identity Disorder,” http://homepage.psy.utexas.edu/HomePage/Group/MestonLAB/HTML%20files/Resources_msd_gender.htm.
19For example, R. Green and R. Young, “Hand Preference, Sexual Preference, and Transsexualism,” Archives of Sexual Behavior, 30 (2001), pp. 565-74.
20For example, B. Kraemer, T. Noll, A. Delsignore, G. Milos, and U. Schnyder, “Finger Length Ratio (2D:4D) in Adults with Gender Identity Disorder,” Archives of Sexual Behavior, 38 (3) (2009): pp. 359-63.
21Ibid. As the authors put it, “genetic females exposed to high levels of testosterone in utero (e.g., congential adrenal hyperplasia) rarely develop [gender dysphoria].” Furthermore, “prenatal exposure to antiandrogenic, androgenic, and estrogenic drugs rarely leads to [gender dysphoria] in either genetic females or males although some of these individuals display abnormal gender role behavior.”
The experience of gender dysphoria varies among those who have an intersex condition. In a helpful review of the data, Tom Mazur and his colleagues offered the following observations about intersex conditions and gender dysphoria:
(1) self-initiated gender change occurs in intersex syndromes and related conditions; (2) the prevalence of individuals who change gender varies by syndrome; (3) self-initiated gender change is not universal for any one syndrome or condition; (4) gender change is more frequent in XY persons than in those with an XX chromosomal pattern; (5) self-initiated gender change occurs in both directions, that is, male-to-female and female-to-male, although it more frequently occurs in the direction of female-to-male . . . ; and (6) there are no published reports of gender change in micropenis regardless of whether the person was assigned and reared as male or female. (From Mazur, Colsman and Sandberg, “Intersex,” p. 247.)
22For example, J. N. Zhou, M. A. Hofman, L. J. G. Gooren and D. F. Swaab, “A Sex Difference in the Human Brain and Its Relation to Transsexuality,” Nature 378 (1995): 68-70.
23For example, F. P. M. Kruijver, J. N. Zhou, C. W. Pool, M. A. Hofman, L. J. G. Gooren and D. F. Swaab, “Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus,” The Journal of Clinical Endocrinology & Metabolism 85, no. 5 (2000): 2034-41.
24Zhou, Hofman, Gooren and Swaab, “A Sex Difference in the Human Brain,” pp. 68-70.
25Kruijver et al., “Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus,” pp. 2034-41.
26Zhou, Hofman, Gooren and Swaab, “A Sex Difference in the Human Brain,” pp. 68-70.
27Wilson C. J. Chung, Geert J. DeVries and Dick F. Swaab, “Sexual Differentiation of the Bed Nucleus of the Stria Terminalis in Humans May Extend into Adulthood,” The Journal of Neuroscience 22, no. 3 (February 1, 2002): 1027-33.
28Ibid., p. 1031.
29Critics of the brain-sex theory, such as Anne Lawrence, are not convinced. They note that these findings do not fit with the experience of gender dysphoria tracing back to childhood for most people.
30Chung et al., “Sexual Differentiation,” p. 1032.
31See www.shb-info.org/sitebuildercontent/sitebuilderfiles/2_gooren_et_al.pdf.
32Milton Diamond, “Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation,” International Journal of Transgenderism 14, no. 1 (May 2013): 24-38.
33Milton Diamond, “Biased-Interaction of Psychosexual Development: ‘How Does One Know if One Is Male or Female?’” Sex Roles 55 (2006): 5899-6000. Available online at www.hawaii.edu/PCSS/biblio/articles/2005to2009/2006-biased-interaction.html.
34Ibid. I have not focused as much on genetic contributions, but these are often discussed with reference to twin studies. In a recent study of transsexuality among twins that combined a convenience sample with past (largely convenience) samples, a 20 percent concordance rate was reported for all monozygotic twin pairs, which was more common among male twin pairs (33%) than female twin pairs (23%). Diamond, “Transsexuality Among Twins,” pp. 24-38.
A relatively new topic in psychology and neuroscience is epigenetics, which considers whether any number of factors cause genes to be switched on or off in response to the environment. Proponents have turned to epigenetics to explain why one twin in a monozygotic twin pair might not be transsexual when the other twin is transsexual. See G. Dorner, F. Gotz, W. Rohde, A. Plagemann, R. Lindner, H. Peters and Z. Ghanaati, “Genetic and Epigenetic Effects on Sexual Brain Organization Mediated by Sex Hormones,” Neuroendocrinology Letters 22, no. 6 (2001): 403-9.
For research on transsexuality among non-twin siblings in which siblings (particularly brothers) of transsexual persons have a higher chance of being transsexual than the general population, see E. Gomez-Gill, I. Esteva, M. C. Almaraz, E. Pasaro, S. Segovia and A. Guillamon, “Familiarity of Gender Identity Disorders in Non-twin Siblings,” Archives of Sexual Behavior 39 (2010): 546-52.
35Diamond, “Biased-Interaction of Psychosexual Development,” www.hawaii.edu/PCSS /biblio/articles/2005to2009/2006-biased-interaction.html.
36Ibid.
37Ibid.
38Kruijver et al., “Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus,” pp. 2034-41; Zhou, Hofman, Gooren and Swaab, “A Sex Difference in the Human Brain,” pp. 68-70.
39Zhou, Hofman, Gooren and Swaab, “A Sex Difference in the Human Brain,” pp. 68-70.
40The Kruijver et al. study used the same six MtF transsexuals as were used by the Zhou et al. team and added one additional MtF transsexual. See Michael Bailey, http://gendertrender.wordpress.com/2012/11/21/what-many-transgender-activists-dont-want-you-to-know-and-why-you-should-know-it-anyway.
41Zhou, Hofman, Gooren and Swaab, “A Sex Difference in the Human Brain,” p. 70.
42See http://gendertrender.wordpress.com/2012/11/21/what-many-transgender-activists-dont-want-you-to-know-and-why-you-should-know-it-anyway.
43See also Eileen Luders, Francisco J. Sanchez, Christian Gaser, Arthur W. Toga, Katherine L. Narr, Liberty S. Hamilton and Eric Vilain, “Regional Gray Matter Variation in Male-to-Female Transsexualism,” NeuroImage 46 (2009): 904-7.
44William M. Struthers, personal communication, January 6, 2014.
45See an interesting study of regional blood flow changes among female-to-male transsexuals by Hideyuki Nawata, Koji Ogomori, Mariko Tanaka, Ryoji Nishimura, Hajime Urashima, Rika Yano, Koichi Takano and Yasuo Kuwabara, “Regional Cerebral Blood Flow Change in Female to Male Gender Identity Disorder,” Psychiatry and Clinical Neurosciences 64 (2010): 157-61.
46William M. Struthers, personal communication, January 6, 2014.
47Lawrence, in “Proposed Revisions to Gender Identity Disorder Diagnoses in the DSM-5,” argues that dissatisfaction with subtypes based on sexual orientation appears to be related to activism/nonscientific dissatisfaction with that particular typology.
48Anne A. Lawrence, “Factors Associated with Satisfaction or Regret Following Male-to-Female Sex Reassignment Surgery,” Archives of Sexual Behavior 32, no. 4 (2003): 300.
49Ibid. See also Anne A. Lawrence, “Transgenderism in Nonhomosexual Males as a Paraphilic Phenomenon: Implications for Case Conceptualization and Treatment,” Sexual and Relationship Therapy 24, no. 2 (2009): 188-206.
50Ray Blanchard, “Gender Identity Disorders in Adult Men,” in Clinical Management of Gender Identity Disorders in Children and Adults, ed. R. Blanchard and B. V. Steiner (Washington, DC: American Psychiatric Publishing, 1990), pp. 49-75; Ray Blanchard, “Gender Identity Disorders in Adult Women,” in Clinical Management of Gender Identity Disorders in Children and Adults, ed. R. Blanchard and B. V. Steiner (Washington, DC: American Psychiatric Publishing, 1990), pp. 77-91.
51Blanchard, “Gender Identity Disorders in Adult Men.” Among those who would fall into an autogynephilic presentation, Blanchard suggested a range of experiences: transvestic, anatomic, physiologic and behavioral. See also Anne Lawrence, Men Trapped in Women’s Bodies: Narratives of Autogynephilic Transsexualism (New York: Springer, 2013).
52See http://gendertrender.wordpress.com/2012/11/21/what-many-transgender-activists-dont-want-you-to-know-and-why-you-should-know-it-anyway.
53See http://ai.eecs.umich.edu/people/conway/TS/LynnsReviewOfBaileysBook.html.
54See http://gendertrender.wordpress.com/2012/11/21/what-many-transgender-activists-dont-want-you-to-know-and-why-you-should-know-it-anyway.
55For a discussion of this decision, see Lawrence, “Proposed Revisions to Gender Identity Disorder Diagnoses in the DSM-5,” p. 1258.
56Robert J. Stoller, “The hermaphroditic identity of hermaphrodites,” Journal of Nervous and Mental Disease, 139 (1964), pp. 453-57.
57Lawrence Kohlberg, “A Cognitive-Developmental Analysis of Children’s Sex-Role Concepts and Attitudes,” The Development of Sex Differences, ed. E. E. Maccody (Stanford, CA: Stanford University Press), pp. 82-173.
58Zucker, “Gender Identity Disorder in Children and Adolescents,” p. 468.
59H. F. L. Meyer-Bahlburg, “Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol,” Clinical Child Psychology and Psychiatry 7, no. 3 (2002): 360-76.
60Ibid., p. 363.
61J. F. Veale, D. E. Clarke and T. C. Lomax, “Biological and Psychosocial Correlates of Adult Gender Variant Identities: A Review,” Personality and Individual Differences 48 (2009): 357-66.
62For example, see P. T. Cohen-Kettenis and W. A. Arrindell, “Perceived Parental Rearing Style, Parental Divorce and Transsexualism: A Controlled Study,” Psychological Medicine 20 (1990): 613-20; M. Hogan-Finlay, Development of the Cross Gender Lifestyle and Comparison of Cross Gendered Men with Heterosexual Controls (PhD diss., Carleton University, Ottawa, Canada, 1995); R. L. Schott, “The Childhood and Family Dynamics of Transvestites,” Archives of Sexual Behavior 24 (1995): 309-27.
63Veale, Clarke and Lomax, “Biological and Psychosocial Correlates of Adult Gender Variant Identities,” 357-66; D. Gehring and G. Knudson, “Prevalence of Childhood Trauma in a Clinical Population of Transsexual People,” International Journal of Transgenderism 8 (2005): 23-30.
64Meyer-Bahlburg, “Gender Identity Disorder in Young Boys,” p. 364.
65Ibid.
66P. T. Cohen-Kettenis and L. J. G. Gooren, “Transsexualism: A Review of Etiology, Diagnosis and Treatment,” Journal of Psychosomatic Research, 46 (4) (1999), pp. 315-33.
67Kenneth J. Zucker and Susan L. Bradley, “Gender Identity and Psychosexual Disorders,” The American Psychiatric Publishing Textbook of Child and Adolescent Psychiatry, eds. J. Wiener and M. Dulcan (Washington, DC: American Psychiatric Publishing, 2004), pp. 813-35.
68Kenneth J. Zucker and Nicola Brown, “Gender Dysphoria,” in Principles and Practice of Sex Therapy, 5th ed., eds. Yitzchak M. Binik and Kathryn S. K. Hall (New York: Guilford, 2014), p. 243.
69Kenneth J. Zucker, “DSM-5: Call for Commentaries on Gender Dysphoria, Sexual Dysfunctions, and Paraphilic Disorders,” Archives of Sexual Behavior, 42(5) (2013), pp. 669-74.
70Meyer-Bahlburg, “Gender Identity Disorder in Young Boys,” p. 472.
71This seems consistent with theorists who believe that “the most likely developmental pathway to [gender dysphoria] will involve temperamental features coupled with a variety of psychosocial risk factors which in aggregate determine how far the child moves into the cross-gender area” (Ibid., p. 364).
Chapter 4: Phenomenology and Prevalence
1Richard A. Carroll, “Assessment and Treatment of Gender Dysphoria,” in Principles and Practice of Sex Therapy, 3rd ed., ed. S. R. Leiblum and R. C. Rosen (New York: Guilford, 2000), p. 369.
2American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Publishing, 2013), p. 452.
3Ibid.
4John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl (New York: HarperCollins, 2000).
5T. D. Steensma, R. Biemond, F. deBoer and P. T. Cohen-Kettenis, “Desisting and Persisting Gender Dysphoria After Childhood: A Qualitative Study,” Clinical Child Psychology and Psychiatry (2010): 1-18.
6Ibid., p. 5.
7Ibid.
8Ibid., p. 7.
9Ibid.
10American Psychiatric Association, Diagnostic Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Publishing, 2013), p. 452.
11See, for example, www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelines ontheRecognitionofSexandGender.aspx. Also, in 2013 Germany officially sanctioned the designation “indeterminate gender” on birth certificates for babies whose gender was unable to be assigned at birth.
12Steensma, Biemond, deBoer and Cohen-Kettenis, “Desisting and Persisting Gender Dysphoria After Childhood,” pp. 1-18.
13Ibid., p. 7.
14Ibid.
15Kenneth J. Zucker, “Gender Identity Disorder in Children and Adolescents,” Annual Review of Clinical Psychology 1, no. 1 (2005): 467-92.
16DSM-5, p. 455.
17Zucker, “Gender Identity Disorder in Children and Adolescents,” p. 473.
18See Kenneth J. Zucker and Susan J. Bradley, “Gender Identity and Psychosexual Disorders,” Focus 3, no. 4 (2005): 598-617.
19DSM-5, p. 454.
20J. R. Blosnich, G. R. Brown, J. C. Shipherd, M. Kauth, R. I. Piegari and R. M. Bossarte, “Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care,” American Journal of Public Health 103, no. 1 (2013): e27-e32; see also A. Bakker, P. J. M. van Kesteren, L. Gooren and P. Bezemer, “The Prevalence of Transsexualism in the Netherlands,” Acta Psychiatr Scand 87, no. 4 (1993): 237-38; G. DeCuypere, M. van Hemellrijck, A. Michel et al., “Prevalence and Demography of Transsexualism in Belgium,” European Psychiatry 22, no. 3 (2007): 137-41.
21K. J. Conron, G. Scott, G. S. Stowell, and S. J. Landers, “Transgender Health in Massachusetts: Results from a Household Probability Sample of Adults,” American Journal of Public Health, 102(1) (2012), pp. 118-22; Gary J. Gates, “How Many People are Gay, Bisexual, and Transgender?” The Williams Institute, April 2011, pp. 1-8. Available: http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf.
22Kenneth J. Zucker and Nicola Brown, “Gender Dysphoria,” in Principles and Practice of Sex Therapy, 5th ed., ed. Yitzchak M. Binik and Kathryn S. K. Hall (New York: Guilford, 2014), p. 238.
23Zucker, “Gender Identity Disorder in Children and Adolescents,” pp. 467-92.
24For a discussion of this, see Mark A. Yarhouse, Richard E. Butman and Barrett W. McRay, Modern Psychopathologies: A Comprehensive Christian Appraisal (Downers Grove, IL: InterVarsity Press, 2005), pp. 58-80.
25Zucker, “Gender Identity Disorder in Children and Adolescents,” p. 477.
26Ibid.
27Carroll, “Assessment and Treatment of Gender Dysphoria,” pp. 368-422.
