Understanding Gender Dysphoria, page 9
Also, many studies involving transsexuals are based on post-mortem samples in which the person had been actively involved in cross-sex-typed behavior and had been utilizing feminizing hormone therapy in ways that may very well affect the regions under investigation. This is particularly true when referencing studies of the very neuroanatomical brain differences under discussion. As Zhou et al. acknowledged, “As all the transsexuals had been treated with oestrogens, the reduced size of the BSTc could possibly have been due to the presence of high levels of oestrogen in the blood,”41 though they argue against that interpretation of their findings. What is needed, say critics, is research that utilizes a control group that would “exclude the possibility that the feminization of the BSTc in MtFs was due to hormone treatment, especially estrogen therapy, received for transsexualism.”42
Some of the most influential studies today are based on observed differences in brain structure, whether that has to do with the number of cells present or the volume of cells in specific neuroanatomical regions of the brain.43 These are essentially studies of morphology or brain structure, which is a rather limited way of conceptualizing the brain and potential observable differences. Beyond morphology or structure, there are also issues with brain activity, connectivity, load and efficiency that often go overlooked in a nearly exclusive focus on structure.44
Most proponents of a nature model for the etiology of gender identity concerns focus on the brain-sex theory and frequently point to the studies primarily of morphology: the size and shape of the brain region or cells. This points to one kind of sex difference, and it is real. But the study of morphology is only one of many possible ways to look at neurology. There is also activity—which area of the brain is more active in certain tasks? There is also connectivity and ways to assess whether there are gender differences in connectivity and what these mean. Then there is load, which is more like bandwidth or the thickness of the circuit. Finally, there is the question of efficiency. How efficient is the circuitry—is it highly mylenated, and are there significant differences in efficiency?
Also, when we consider research on identity, it is hard to imagine it being located in the hypothalamus. Self-concept is not rooted there but rather in the cortex.45 Further, the whole idea of locating this sense of identity is problematic; as one expert in neurobiology shared, it is like finding a brain region for being a Democrat or a Republican; like finding a brain region for being an Asian American or being an animal-rights activist.46
It seems that any research on gender identity would also need to consider how the parietal lobe would be involved, as it is related to understanding one’s body, as well as the frontal lobe for organizing self-awareness, let alone the temporal lobe for getting at sexuality. That there have been noted differences in the morphology of the brain in small samples is interesting, but it raises several other questions for future research.
There appears to be reason to at least take a step back and look at the larger picture here, to gain some perspective on what is being argued for and how best to conceptualize it.
I want to discuss a couple of alternatives to the brain-sex theory that have been a part of the larger discussion. They are Blanchard’s typology of clinical presentations and models based more on social learning as well as contributions from biology in the form of temperamental differences.
Blanchard’s Typology
There is a group of researchers and clinicians who do not make strong claims about etiology but rely on and advance a typology of transsexuality first introduced by Ray Blanchard. Blanchard suggested what to some are controversial47 but distinct subtypes of transsexuals based on sexual attraction/orientation, such as male-to-female androphilic type, which he contrasts with a male-to-female autogynephilic type. The former is more of a “classic” presentation that is often referred to as the “homosexual” type because the person is a biological male who is attracted to males. (The attraction is for a male who is attracted to him as a woman, however.) These are “persons who typically transition at a younger age, report more sexual attraction to and sexual experience with males, are unlikely to have married or to have been biologic parents, and recall more childhood femininity.”48
The autogynephilic type is described more like a fetish. In this case proponents assert that the biological male finds the idea of himself as a woman sexually arousing. These are persons who “typically transition at an older age, report more sexual attraction to and sexual experience with females, are more likely to have married and to have become biologic parents, report more past or current sexual arousal to cross-dressing or cross-gender fantasy, and recall less childhood femininity.”49
Another common presentation in Blanchard’s typology would be the biological female who experiences herself as male (or female-to-male, FtM type).50 They are biologically/genetically female at birth but feel that they are male in their gender identity. This person would not typically be attracted to males and may have tried to enter into a same-sex relationship. However, same-sex relationships often do not meet their needs for intimacy, as they want to be close to a female who is drawn to them as a male.
Other clinical presentations based on sexual orientation include the bisexual type (with a history of sexual arousal to the same and opposite sex) and the asexual/analloerotic type (with no or little arousal pattern).51
Many of the research studies that supporters of Blanchard’s typology cite were conducted between the mid-1980s and mid-1990s and include data on many more transsexuals:
Blanchard’s studies reported data on hundreds of transsexual males (that is, males who hoped to become or had become women), as well as other individuals who were male with respect to birth sex and did not desire sex reassignment surgery, but who sometimes presented themselves, or thought of themselves, as female. Participants in these studies were representative of gender patients in Canada, and were probably also quite similar to patients seen in the United States and Western Europe. Blanchard’s goal was to make sense out of the diversity of patients that gender clinics saw.52
The main point in this review is that for many clinicians and theorists, the fact that there is an observable typology based upon sexual attraction/orientation suggests a more complicated pathway(s) for the etiology of gender identity concerns than is found in the brain-sex theory. Again, proponents of Blanchard’s typology do not tend to take a position on etiology, but those who have advanced the brain-sex theory and others, particularly several transgender advocates, have been critical of Blanchard’s typology and, in particular, autogynephilia.
Limitations. The primary concern I see raised by critics or opponents of Blanchard’s typology is the distinction between the two types of male-to-female transsexuals: the androphilic type and the autogynephilic type. Recall that the androphilic MtF is believed to have a homosexual orientation, to have childhood experiences in common with what has been reported by adult homosexuals looking back on their childhood, and to express themselves in the more classic case of transsexualism (that is, “I am a woman trapped in the body of a man”). In contrast, the MtF autogynephilic type is described more like a fetish. It refers to a biological male who has a history of sexual arousal to the idea or fantasy of himself as female. It is this presentation that has been the primary concern. Most critics of Blanchard’s typology tend to express support for the brain-sex theory and view Blanchard’s typology as “unfalsifiable”:
It is unfalsifiable (note: any trans woman who reports that she doesn’t fit the classifications is explained by the “theory” as being a “liar”). Furthermore, the scheme has no predictive capabilities. Thus it is thus untestable.53
Proponents of Blanchard’s typology present this criticism as reflecting a kind of denial:
Few nonhomosexual transsexuals publicly identify as autogynephilic, and most neither admit a history of sexual arousal to the idea of being a woman, nor accept that such arousal was a motivating factor for their transsexualism. Indeed, although most public transsexual activists appear by their histories and presentations to be nonhomosexual MtF transsexuals, they have generally been hostile toward the idea that nonhomosexual transsexualism is associated with, and motivated by, autogynephilia.54
Here is the problem with “denial” at this point in the argument: ironically, by framing the criticism as denial we are left with support for the criticism that had been raised. That is, Blanchard’s typology is at risk of being untestable if those who do not report a corresponding history are said to not be admitting the history, proponents of Blanchard’s typology presuppose.
Also, it is unclear with Blanchard’s typology whether the claim that cross-dressing is associated with sexual arousal (or had taken on a fetishistic quality) is referring to the present or the past in each case. It is possible that cross-dressing had at one time been associated with arousal or had taken on a fetishistic quality, perhaps during adolescence, but does not have that quality later in one’s life.
In any case, it may be helpful to be aware of these controversies. Further, it should be noted that the DSM-5 has moved away from specifiers that focus on sexual attraction or orientation.55 The current preference is to discuss early and late onset Gender Dysphoria, which I will cover later.
Multifactorial Models with an Emphasis on Psychosocial Factors
The other major explanatory framework comes from those who do advance multifactorial models that give greater weight to early psychosocial factors in childhood. Proponents begin with the assumption that the psychosocial environment is important. That is, basic concepts from cognitive theory and social learning theory are in play simply in the formation of one’s gender identity. These are concepts that go back to Stoller56 and Kohlberg57 and of one’s “core gender identity” or “fundamental sense of belonging to one sex.”58 That is, there is a cognitive process by which a child comes to know and understand his or her sense of gender and associated behaviors. There is a role that parenting and observational learning plays in terms of what is witnessed, modeled, and reinforced by parents, a broader family and kinship network, and one’s peer group.
Meyer-Bahlburg59 identifies several risk factors thought to be associated with the development of gender dysphoria. In addition to the prenatal sex hormone considerations associated with the brain-sex theory, these include (for biological males who are gender dysphoric) feminine appearance, inhibited/shy temperament, separation anxiety, late in birth order, sensory reactivity and sexual abuse. Also, associated risk factors related to parents include preference for a girl, parental indifference to cross-gender behavior, reinforcing cross-gender behavior, encouragement of “extreme physical closeness with boys,” insufficient adult male role models and parental psychiatric issues.60
Veale and colleagues61 review numerous studies on family and rearing environment and related considerations. Parental factors cited in the literature include less warm/emotionally distant fathers (although some studies do not show this difference), parental wishes for a girl (among MtF transsexual persons) and increased maternal involvement and parental support for gender variant behavior.62 Higher reports of emotional, physical and sexual abuse have also been documented among gender-variant persons.63
These findings are primarily correlational. An experience or a quality may frequently occur with the phenomenon. For example, “Increased insecure attachment has been noted in boys” who are gender dysphoric.64 So this different attachment pattern has been associated with gender dysphoria in boys. We would be speculating at causation (due to the design of the research), but is it possible that it is one of several considerations that contribute to gender dysphoria? It is also possible that gender dysphoria can contribute to difficulties with attachment.
Peer group interactions have also been noted by those who look at psychosocial influences on gender dysphoria. For example, boys who are gender dysphoric demonstrate “preferential adoption of cross-gender pretend play, and cross-dressing. Fear and avoidance of other boys can be striking. . . . A likely consequence of their preference for girl playmates is the continuous rehearsal of female role skills and habits, and a lack of development of male role skills and habits. The avoidance of contact with boys also implies a lack of peer group reinforcement for male-typical behavior; such peer-group reinforcement has been documented from middle preschool age on.”65
But does that mean that nurture plays a role in gender dysphoria? In their review of this literature, Cohen-Kettenis and Gooren66 identify the potential for a pathway to exist related to parental psychopathology and gender identity concerns, but they are correct in noting that those correlations should not be taken as causal, and that there are different explanations that could account for higher levels of psychopathology in parents who are coming to see a specialist in gender identity. What Cohen-Kettenis and Gooren did not see was much evidence that gender dysphoria is the result of a failure to identify with the same-sex parent.
Zucker and Bradley67 proposed a theory that gender dysphoria may result from children who are more anxious and sensitive to others and who have a different response to tensions in the marriage or conflicts surrounding gender, as well as possible psychopathology on the part of their parents. Zucker has elsewhere discussed whether parents are preoccupied or otherwise distracted and unable to respond to or shape gender expressions.
Proponents of psychosocial models that look at the relative weight of psychosocial factors are not saying that these are the exclusive cause but rather that there are multiple factors that may make a contribution:
A multifactorial model of gender development can take into account biological predisposing factors, precipitating factors, and perpetuating (maintenance) factors. Because so much is still not even known about normative gender development, . . . clinicians, patients, and their families vary in how much weight (or variance) each of these factors is given. At one extreme, some would argue that biological factors account for the bulk of the variance; at the other extreme, some would argue that psychosocial factors are most influential. . . . the propensity for practicing clinicians (and clients) to utilize dichotomous “either/or” paradigms in conceptualization is a common problem that should be avoided.68
Limitations. The limitations here are that many of the studies are correlational in design, so that they suggest a relationship between gender identity conflicts and other psychosocial considerations. However, it is often unclear which is the cause. For example, if a person was looking into parent-child relationships, we have to ask the question, does the parent’s reaction, for example, come in response to gender atypicality, or does the gender atypicality elicit a specific parental response?
In the cases I have seen of young children, I have been impressed by the salience of their presentation, of their gender atypicality and, in some cases, extreme gender incongruence at a rather young age. Anecdotally, while parental interactions may clearly reinforce or maintain certain expressions of gender identity, the expressions that seemed so salient at age four or five did not appear to me to be the result of the parental interactions, modeling or attachment but rather the cause of parental concern.
Reflections on etiology. As I look over the limitations to the existing research, as well as what we know and what we do not know about causation at this point, it seems wise to consider any model of causation with some humility, almost holding it in an open hand with an understanding that we may know more in the years to come that will help us understand this topic better than we do today. I am also impressed by the amount of hostility directed at adherents of specific theories. There is a need not only for good research in this area, but a kind of open discussion that is not reduced to personal, ad hominem attacks.
It seems warranted that whatever model we work from today, it would ideally reflect a weighted interaction among multiple contributing factors—contributions that come from both nature and nurture. The contributions could take many forms, some of which we have discussed, and, as I have suggested, they would be weighted differently for different people. There may also be other factors in play that we have yet to identify. An appropriate amount of humility can be found in saying, We don’t know what causes gender dysphoria.
As we consider a weighted interactionist model of some kind, I am reminded of two important concepts: equifinality and multifinality. Equifinality says that there could be multiple pathways to the same outcome. It seems reasonable, given the range of experiences of gender identity concerns (that I believe reside along a continuum), that there are likely many possible pathways to the same outcome if that outcome is the umbrella term transgender or gender incongruence or gender identity concerns. The outcome of transsexuality as a most extreme experience of gender dysphoria may indeed best be explained by the brain-sex theory, but I would not want to hold that out as a unifying theory that has to explain all experiences of transsexuality.
Multifinality says that a group of people could have the same factors as part of their history but have different outcomes.69 Not every child who experiences a push from nature will end up experiencing gender identity conflicts. It seems as though other variables need to be in the mix, and it is difficult to say with great confidence what those are.
Something like the brain-sex theory could be in play for some experiences of transsexuality. But what if the various factors were weighted differently for different people? Would we then be able to account for other experiences of gender identity concerns along a continuum? Would a broader model that allows for the possibility of the brain-sex theory but is not limited to it provide for a more nuanced understanding that helps us understand the heterogeneity of presentations?
I tend to agree that our current understanding of etiology simply does not provide us with an “empirically grounded detailed theory of the mechanisms and process of gender identity development.”70 This seems like a reasonable conclusion to draw at this time. It would be premature to stand behind any one model that then makes exclusive proclamations about the determinants of gender identity concerns. I suspect that a weighted interactionist model of etiology would consider contributions from both nature and nurture, from both biology and environment without giving too much weight at this point to any one unifying theory. This means not being sold on the brain-sex theory while simultaneously demonstrating an openness to the theory as more research in this area is provided.
