Disordered Or Just Different? Myth, Science, and Sexuality

Disordered or Just Different? Myth, Science and Sexuality By Veronica Drantz, PhD Prepared for The Center For Inquiry/Chicago First Annual Spring Conference Dangerous Nonsense Exploring the Gulf between Science and its Imposters April 24, 2010

The Myth

Gamete-makers Are Not Binary!
Gametes are binary (eggs or sperm)
Organisms that make the gametes are not binary!

The Science
Development of genitalia in mammals
Did Eve come from Adam?
“ Organization – Activation” Mechanism

23 Pairs Human Chromosomes XX (Female), XY (Male) Figure 25-2 Karyotype of chromosomes from a normal male. The chromosomes have been stained with Giemsa's stain, which produces a characteristic banding pattern.

Genetic Sex Determination
Typical male has Y chromosome
Typical female has no Y chromosome
Figure 25-1 Basis of genetic sex determination. In the two-stage meiotic division in the female, only one cell survives as the mature ovum. In the male, the meiotic division results in the formation of four sperms, two containing the X and two the Y chromosome. Fertilization thus produces a male zygote with 22 pairs of autosomes plus an X and a Y or a female zygote with 22 pairs of autosomes and two X chromosomes. Note that for clarity, this figure and Figures 25–6 and 25–7 differ from the current international nomenclature for karyotypes, which lists the total number of chromosomes followed by the sex chromosome pattern. Thus, XO is 45, X; XY is 46, XY; XXY is 47, XXY, and so on.

Y Chromosome Has Testis-determining Region (Gene)
Is a sex-determining gene on the Y chromosome in placental mammals and marsupials
Initiates male sex determination
Located near tip of short arm of Y chromosome
Codes for SRY protein
SRY = Sex-determining region Y
aka testis determining factor = TDF
Causes gonad to differentiate into testis
SRY protein is DNA-binding regulatory protein
Acts as transcription factor
Initiates transcription of cascade of genes necessary for testicular differentiation

Sexual Differentiation of Internal Genitalia Figure 25-4 Embryonic differentiation of male and female internal genitalia (genital ducts) from wolffian (male) and müllerian (female) primordia.

Sexual Differentiation of External Genitalia Figure 25-5 Differentiation of male and female external genitalia from indifferent primordial structures in the embryo.

Sexual Development in Mammals Figure 25-6 Diagrammatic summary of normal sex determination, differentiation, and development in humans. MIS, müllerian inhibiting substance; T, testosterone; DHT, Dihydrotestosterone

Male Testosterone Levels Figure 25-8 Plasma testosterone levels at various ages in human males.

Mechanism of Steroid Hormone Action

There Is Only One Sex!
Mammalian body plan is inherently female
Male is altered female !!!
Every individual’s body plan is a variation on the female theme
Default (female)
Fully altered (male)
Partly altered (intersex)
Everyone falls on some point of the continuum from female (gynemorphic) to male (andromorphic)
This sexual body plan is organized by presence or absence of steroid hormones during the critical period of development
Sexual systems are activated later by steroid hormones during puberty

Sex Has Many Levels
Genetic Sex – Chromosomes (X & Y in mammals only)
Gonadal Sex – Ovaries/Testis
Hormonal Sex – Estrogen/Testosterone
Somatic Sex – Body anatomy/physiology
Psychological Sex - Sexual identity
and then there is
Sexual orientation
Primary sex characteristic

Core Sexuality – Nature or Nurture?
Genitalia are obviously inborn but what about sexual behavior?
Is the brain also organized by presence or absence of hormones before birth?

John Money Psychologist
Psychosexual "neutrality-at-birth“ theory
“ Sexual behavior and orientation as male or female does not have an innate, instinctive basis”
Money, J. Hermaphroditism, gender and precocity in hyperadrenocorticism: Psychologic findings. BULLETIN OF THE JOHNS HOPKINS HOSPITAL 96:253-264 (1955)
Postulate 1: Individuals are psychosexually neutral at birth
Postulate 2: Healthy psychosexual development is intimately related to the appearance of the genitals
No evidence to support this theory (s erious flaws in Money’s statistical and research methods
*Cappon D, Ezrin C, Lynes P. Psychosexual identification (psychogender) in the intersexed THE CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL 4:90-106 (1959)

Milton Diamond B iologist
“ Sexuality-at-birth" theory
Organization – Activation Mechanism - Prenatal genetic and hormonal influences predispose at birth to a male or female sexual identity
Inherent sexuality provides built-in "bias“ with which the individual interacts with environment; sexual behavior and thus gender role, are not neutral and without initial direction at birth
Biased-interaction theory of psychosexual development (also known as biased-predisposition theory of psychosexual development and same-different theory of psychosexual development)
Evolutionary view

1959 – Breakthrough at University of Kansas
Phoenix CH, Goy RW, Gerall AA, Young WC. Organizing action of prenatally administered testosterone propionate on the tissues mediating mating behavior in the female guinea pig. ENDOCRINOLOGY 65:369-382 (1959)
Milton Diamond
Youngest graduate student in Young’s lab
Felt Young et al were too cautious failing to link their animal findings to human situation
Decided to write essay challenging psychosexual neutrality theory

Diamond Versus Money
Diamond challenges Money - 1965
Diamond, Milton. A critical evaluation of the ontogeny of human sexual behavior. QUARTERLY REVIEW OF BIOLOGY 40:147 – 175 (1965)
Over the years, animal work accumulated showing “determining influence” of prenatal hormones
Money responds to challenge - December 28, 1972
Symposium of American Association for the Advancement of Science “Sex Role Learning in Childhood and Adolescence”
Man & Woman, Boy & Girl: the differentiation and dimorphism of gender identity from conception to maturity . Baltimore, MD: John Hopkins University Press, 1972. 311 p. (Depts Psychiatry and Pediatrics, John Hopkins Univ. Sch. Med., Baltimore, MD)

The David Reimer Story
John/Joan “Twins Case”
Same nature: Identical twins from same womb (same genetics and prenatal hormonal influence)
Different nurturing: Raised as different sexes
Money reported “Joan” to be a successful girl and woman
Touted as a success, this “Nurture Over Nature” case report became the foundation of standard care for treatment of certain intersex conditions, micropenis, and accidental penile amputation in infancy

How to Treat a Newborn With Ambiguous Genitalia or Mutilated Penis? Colapinto, John. As Nature Made Him - The Boy Who Was Raised As A Girl HarperCollins (2000)

Colapinto, John. As Nature Made Him - The Boy Who Was Raised As A Girl HarperCollins (2000)

N A T U R E N U R T U R E Colapinto, John. As Nature Made Him - The Boy Who Was Raised As A Girl HarperCollins (2000)

Joan/Brenda Becomes John/David
“ Joan’s turning point occurred at the age of 14, when she, on her own initiative, began living as a boy, John. John recalls how soon thereafter he finally learned the truth, “In a tearful episode following John’s prodding, his father told him of the history of what had transpired as an infant and why. John recalls: ‘All of a sudden everything clicked. For the first time things made sense and I understood who and what I was.’”
Beh HG, Diamond M. An Emerging Ethical and Medical Dilemma: Should Physicians Perform Sex Assignment on Infants with Ambiguous Genitalia? MICHIGAN JOURNAL OF GENDER & LAW 7: 1-63, 2000

John Money tells medical community that Joan/Brenda is a happy girl/woman and then claims to lose track of her
Milton Diamond finds Joan/Brenda living as David!
When David discovers his case was medically famous and that thousands of intersex babies had suffered his plight, he cooperated with Milton Diamond and “went public”
Milton Diamond, Ph.D. & H. Keith Sigmundson, M.D. Sex Reassignment at Birth: A Long Term Review and Clinical Implications. ARCHIVES OF PEDIATRIC & ADOLESCENT MEDICINE 151:298-304 (1997)
Money’s view is now discredited!
David Reimer (1965-2004)

Intersex People Curtis Hinkle - Founder Organization Intersex International

Intersexuality
Incidence: 1.7%*- 2.5%
Intersexual people are as natural as the rest of us
They are nature’s experiments to a physiologist – providing information about sexual development
Only in recent years have we been able to track intersexual people over their lifetime and find out about their sexual identity and orientation
They illustrate how no definition of female or male is always “satisfying”
* Fausto-Sterling, Anne. SEXING THE BODY: GENDER POLITICS AND THE CONSTRUCTION OF SEXUALITY. Basic Books (2000)

Barrett KE, Barman SM, Boitano S, and Brooks HL. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010) Disordered or Just Different?

Chromosomal Variants of Sexes 1/500 of the population have a karyotype other than XX or XY. Intersex Support Group International 1999-2001 Barrett, Kim E. Barman, Susan M. Boitano, Scott and Brooks, Heddwen L. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010) Figure 25-1 Basis of genetic sex determination. In the two-stage meiotic division in the female, only one cell survives as the mature ovum. In the male, the meiotic division results in the formation of four sperms, two containing the X and two the Y chromosome. Fertilization thus produces a male zygote with 22 pairs of autosomes plus an X and a Y or a female zygote with 22 pairs of autosomes and two X chromosomes. Note that for clarity, this figure and Figures 25–6 and 25–7 differ from the current international nomenclature for karyotypes, which lists the total number of chromosomes followed by the sex chromosome pattern. Thus, XO is 45, X; XY is 46, XY; XXY is 47, XXY, and so on. Figure 25-7 Summary of four possible defects produced by maternal nondisjunction of the sex chromosomes at the time of meiosis. The YO combination is believed to be lethal, and the fetus dies in utero.

Variations of Genetic Sexes
Nondisjunction of chromosomes
XO Female (Turner Female)
XXX Female (Superfemale)
XXY, XXXY etc. Male (Klinefelter Male)
XYY Male (Jacob’s Syndrome)
Translocation of SRY gene from Y to X chromosome
XY Female (Swyer syndrome): absence or mutation of SRY on Y produces females with gonadal dysgenesis
XX Male (XX Male Syndrome): SRY gene in one or both X chromosomes, produces infertile males

What If the Androgen Receptor Doesn’t Work? Barrett KE, Barman SM, Boitano S, and Brooks HL. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010)

Androgen Insensitivity Syndrome
AIS aka testicular feminization syndrome
Caused by mutations in the gene for the androgen receptor
X-linked recessive disorder
Male (46 XY) karyotype
Testes (abdominal or inguinal)
Male internal genitalia undeveloped
No uterus or other internal female genitalia

Complete Androgen Insensitivity Syndrome (CAIS)
Appear female at birth and are reared as girls
Unless there is known or suspected AIS in the family or inguinal testes are detected, these girls typically go undiagnosed until puberty
Vagina may be short and blind-ending and may or may not need elongation
Breast development occurs but pubic and axillary hair development is sparse or absent
When menses fails to occur a remedy is sought
Julia Child was a CAIS woman

Complete Androgen Insensitivity Syndrome Luria, Z., Friedman, S., and Rose, M.D. HUMAN SEXUALITY. New York: John Wiley & Sons, 1987. Forbes, C.D. and Jackson, W.F. A COLOUR ATLAS AND TEXT OF CLINICAL MEDICINE. England: Mosby-Wolfe (1993)

Partial Androgen Insensitivity Syndrome (PAIS)
Usually noticed at, or soon after, birth
Depending upon the degree of masculinization of the genitals, the child may be raised as a boy or a girl
AIS is an inherited condition
Recessive X-linked single gene syndrome
Manifests differently in children of the same parents; one child can be raised as a boy, another as a girl
59% PAIS were assigned as males (United Kingdom study, 16 years or younger)
Most published cases of clinical-psychiatric involvement seem to be related to subjects who were raised as females

AIS Grading Scheme
Grade 1: normal masculinization in utero
Grade 2: male phenotype with mild defect in masculinization (eg, isolated hypospadias)
Grade 3: male phenotype with severe defect in masculinization—small penis, perineoscrotal hypospadias, bifid scrotum or cryptorchidism
Grade 4: severe genital ambiguity— clitoral-like phallus, labioscrotal folds, single perineal orifice
Grade 5: female phenotype with posterior labial fusion and clitoromegaly
Grade 6/7 female phenotype (grade 6 if pubic hair present in adulthood, grade 7 if no pubic hair in adulthood)
Numbered I through 7 in order of increasing severity (more defective masculinization ) Adapted from Quigley CA, DeBellis A, Marschke KB, El-Awady MK, Wilson EM, French FS. Androgen Receptor Defects: Historical, Clinical, And Molecular Perspectives. ENDOCRINE REV, 1 6:282; (1995) with permission. In: Diamond, Milton and Watson, Linda Ann. Androgen Insensitivity Syndrome And Klinefelter’s Syndrome: Sex And Gender Considerations. CHILD ADOLESC PSYCHIATRIC CLIN N AM 13: 623—640 (2004)

Complete AIS & Gender Identity
39 subjects:
100% lived as women and believed that it was the best decision for them; however, this was not a simple solution for all
“ Acceptance of assignment does not mean that assignment has been correct. It just means that most are able to adapt and live with the handicap; however, they might have preferred other options”
* Indicates to me that androgen receptor is required for “alteration” of human gender identity brain region(s). Diamond, Milton and Watson, Linda Ann. Androgen Insensitivity Syndrome And Klinefelter’s Syndrome: Sex And Gender Considerations. CHILD ADOLESC PSYCHIATRIC CLIN N AM 13: 623—640 (2004) published statements from ALIAS, an AIS newsletter. Agree Disagree “ I don’t think I am any different in feeling than if I were born XX, feel very female.” 82%* 18% “ All my efforts over the years in presenting a female persona have left me completely exhausted. I might just as well have had a mastectomy, cut my hair short and lived as a celibate man. It would actually have been easier I think.” 10% 90% I have to “work at being a woman” 56% (dressing in a feminine way or using cosmetics or hair styles in a way to signal “female” unambiguously, altering selection of clothes; 30% did above much of the time) 44% Considered suicide 62% 38% Attempted suicide 23% 77%

Partial AIS & Gender Identity
18 subjects:
Often ambivalent about assigned gender
67% believed that the gender in which they were raised was best for them, whereas the others voiced reservations
“ Gender switch” occurred at mean age of 33, range 18-46)
* Now angry about castration, vaginal reconstruction surgery, and somatic feminization by estrogen treatment since puberty **Attempted before switching Diamond, Milton and Watson, Linda Ann. Androgen Insensitivity Syndrome And Klinefelter’s Syndrome: Sex And Gender Considerations. CHILD ADOLESC PSYCHIATRIC CLIN N AM 13: 623—640 (2004) PARTIAL AIS 8 raised as boys 4 live as women 10 raised as girls 2 live as men* Considered suicide 61% **Attempted suicide 17%

Simple Virilizing Congenital Adrenal Hyperplasia
The salient features of classical simple virilizing 21-OHD are prenatal virilization and progressive postnatal masculinization with accelerated growth and advanced bone ages but no evidence of mineralocorticoid deficiency
21-hydroxylase deficiency is most common form
Causes build-up of certain intermediate hormones along the pathway toward cortisol
Causes accumulation of 17-hydroxy progesterone and other hormones with androgenic properties

Two Types of Adrenogenital Syndrome
21  -hydroxylase deficiency
11  -hydroxylase deficiency
Figure 22-7 Outline of hormone biosynthesis in the zona fasciculata and zona reticularis of the adrenal cortex. The major secretory products are underlined. The enzymes for the reactions are shown on the left and at the top of the chart. When a particular enzyme is deficient, hormone production is blocked at the points indicated by the shaded bars . Barrett KE, Barman SM, Boitano S, and Brooks HL. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010)

Simple Virilizing CAH
Diagnosis at birth of a female with simple virilizing CAH usually is made immediately because of the apparent genital ambiguity
In female embryos causes androgenic stimulation that results in enlargement of the genital tubercle, fusion of the internal and external urethral folds and fusion of the labio-scrotal folds just as normal production of testosterone does in male embryos
Can result in a female infant having marked enlargement of the clitoris and fusion of the labioscrotal folds
This 'virilization' can cause an infant with a 46-XX karyotype to have the appearance of having hypospadias and cryptorchidism

Five Degrees of Virilization Affecting the Urogenital Sinus and External Genitalia in Females Hines M, Brook C., Conway, G.S. Androgen And Psychosexual Development Core Gender Identity, Sexual Orientation And Recalled Childhood Gender Role Behavior In Women And Men With Congenital Adrenal Hyperplasiz (CAH). J SEX RES, 41: 75-81 (2004)

Congenital Adrenal Hyperplasia (CAH) Luria, Z., Friedman, S., and Rose, M.D. HUMAN SEXUALITY. New York: John Wiley & Sons (1987) Forbes, C.D. and Jackson, W.F. A COLOUR ATLAS AND TEXT OF CLINICAL MEDICINE. England: Mosby-Wolfe (1993)

Frequency of CAH
Figure 4. Frequency of nonclassical and classical 21-hydroxylase deficiency in comparison with other autosomal recessive disease incidences
Hines M, Brook C., Conway, G.S. Androgen And Psychosexual Development Core Gender Identity, Sexual Orientation And Recalled Childhood Gender Role Behavior In Women And Men With Congenital Adrenal Hyperplasiz (CAH). J SEX RES, 41: 75-81 (2004)

Adrenogenital Syndrome Luria, Z., Friedman, S., and Rose, M.D. HUMAN SEXUALITY. New York: John Wiley & Sons (1987)

Sexuality of CAH Women
Recalled significantly more male-typical play behavior as children
Reported significantly less satisfaction with the female sex of assignment and less heterosexual interest
Results suggest those girls with CAH who show the greatest alterations in childhood play behavior may be the most likely to develop a bisexual or homosexual orientation as adults and to be dissatisfied with the female sex of assignment
Hines M, Brook C., Conway, G.S. Androgen And Psychosexual Development Core Gender Identity, Sexual Orientation And Recalled Childhood Gender Role Behavior In Women And Men With Congenital Adrenal Hyperplasia (CAH). J SEX RES, 41: 75-81 (2004)

Sexuality of CAH Women
The finding of greater same-sex fantasy among CAH women than among comparison women is consistent with the prenatal hormonal hypothesis*
However, most CAH women were categorized as exclusively heterosexual in fantasy and behavior*
"These results suggest that excess prenatal androgens predispose some women to the development of same-gender sexual orientation”**
“ However, because CAH is a relatively rare condition, and a majority develop a heterosexual orientation, CAH plays a minor role in the overall variability of women's sexual orientation within the general population”**
*Veniegas, Rosemary C. Biological Research on Women's Sexual Orientations: Evaluating the Scientific Evidence. J SOCIAL ISSUES, (2000)
**Pattatucci, A. M. L., & Hamer, D. H. Development And Familiality Of Sexual Orientation In Females. BEHAVIOR GENETICS, 25: 407-420 (1995)

Cloacal Exstrophy
Rare, complex defect of the entire pelvis and its contents
Occurs during embryogenesis
Associated with severe phallic inadequacy or phallic absence in genetic males
For about 25 years, neonatal assignment to female sex has been advocated for affected males

Cloacal Exstrophy Treatment of Genetic Males
Orchiectomy and construction of vulvae
Testes normal
Phallic atresia occurs despite the presence of normal prenatal androgen levels
At birth, female-sex assignment socially, legally, and surgically
Neonatal orchiectomy induces a hypogonadal endocrine disorder that precludes postnatal and pubertal androgen surges
Unique opportunity to assess prenatal androgen influences on sexual development in genetic males with female-sex assignment and feminized genitalia in a uniform population of patients
Reiner, William G. and Gearhart, John P. Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth. THE NEW ENGLAND JOURNAL OF MEDICINE, 350:333-341 (2004)

Cloacal Exstrophy Reiner, William G. and Gearhart, John P. Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth. THE NEW ENGLAND JOURNAL OF MEDICINE, 350:333-341 (2004)

Development of Male Sexual Identity in Cloacal Exstrophy
Prenatal androgens appear to be a major biologic factor
Results suggest that children who are born genetically and hormonally male may identify themselves as males despite being raised as females and undergoing feminizing genitoplasty at birth
Reiner, William G. and Gearhart, John P. Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth. THE NEW ENGLAND JOURNAL OF MEDICINE, 350:333-341 (2004)

The Sexual Brain

The Hypothalamus Integration of Neuroendocrine Activity and Genesis of Instinctive Drives & Behavior Barrett KE, Barman SM, Boitano S, and Brooks HL. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010) Figure 18-1 Human hypothalamus, with a superimposed diagrammatic representation of the portal hypophysial vessels.

Hypothalamic Functions: Homeostasis and Instinctive Drives & Behavior Barrett KE, Barman SM, Boitano S, and Brooks HL. GANONG’S REVIEW OF MEDICAL PHYSIOLOGY 23 rd ed. Lange Medical Books/McGraw-Hill (2010)

Hypothalamus & Limbic System: Genesis of Emotions & Emotional Expression Netter, Frank H. The CIBA COLLECTION OF MEDICAL ILLUSTRATIONS. Vol I. Nervous System. Part I. Anatomy & Physiology. New York: CIBA (1983)

Anterior Hypothalamus Governs Sexual Behavior in Mammals Figure 25-28 Loci where implantations of estrogen in the hypothalamus affect ovarian weight and sexual behavior in rats, projected on a sagittal section of the hypothalamus. The implants that stimulate sex behavior are located in the suprachiasmatic area above the optic chiasm (blue area), whereas ovarian atrophy is produced by implants in the arcuate nucleus and surrounding ventral hypothalamus (red). MB, mamillary body

Nucleus is grey matter region where nerve cells synapse
Some of these nuclei are sexually dimorphic, i.e., larger in typical males than typical females
Same Anatomy of Anterior Hypothalamus in All Mammals Paredes, Raul G., and Baum, Michael J. Role Of The Medial Preoptic Area/Anterior Hypothalamus In The Control Of Masculine Sexual Behavior ANNUAL REVIEW OF SEX RESEARCH (1997) Allen, L. S., Hines, M., Shryne, J. E., and Gorski, R. A. Two Sexually Dimorphic Cell Groups In The Human Brain. JOURNAL OF NEUROSCIENCE, 9: 497-506 (1989) Byne, William. The Medial Preoptic And Anterior Hypothalamic Regions Of The Rhesus Monkey: Cytoarchitectonic Comparison With The Human And Evidence For Sexual Dimorphism. BRAIN RESEARCH 793: 346-350 (1998)

Biology of Sexual Orientation
Anthropological evidence - gay people everywhere
“ Gay people have a different sensibility” Sandra Witelson, PhD

Same-sex Behavior In Nearly All Animals
Homosexuality & other sexually variant behaviors in animals is widespread
Bruce Bagemihl, Biological Exuberance: Animal Homosexuality and Natural Diversity , New York: St. Martin's Press ( 1999)
Examples of same-sex behavior can be found in almost all species in the animal kingdom — from worms to frogs to birds — making the practice nearly universal among animals
Bailey N, Zuk M. Same-sex sexual behavior and evolution TRENDS IN ECOLOGY AND EVOLUTION 24:439-446 (2009)

Brain Sexual Orientation Region
Simon LeVay compared anterior hypothalamus of cadavers of gay men versus straight men
INAH-3 = Third interstitial nucleus of anterior hypothalamus
Measured volume (thionin stain for nucleic acids)
Was 2+X larger in straight men than in gay men or women
Thus, INAH-3 is dimorphic with sexual orientation rather than genetically determined sex
Lends support to idea that sexual orientation has biological basis
LeVay, S. A Difference In Hypothalamic Structure Between Heterosexual And Homosexual Men. SCIENCE, 253: 1034–1037 (1991)

Sexual Orientation & INAH3 LeVay, S. A Difference In Hypothalamic Structure Between Heterosexual And Homosexual Men. SCIENCE, 253: 1034–1037 (1991)

2 nd Study of INAH3 & Sexual Orientation
Confirmed earlier findings
INAH3 contained significantly more neurons and occupied a greater volume in presumed heterosexual males than females
No sex difference in volume was detected for any other INAH
Trend for INAH3 to occupy a smaller volume in homosexual men than in heterosexual men
AIDS does not affect INAH3
NEW FINDING: no difference in the number of neurons within the INAH3 based on sexual orientation
Byne, William, Tobel, Stuart, Mattiace, Linda A., Lasco, Mitchell S., Kemether, Eileen, Edgar, Mark A., Morgello, Susan, Buchsbaum, Monte S., and Jones, Liesl B. The Interstitial Nuclei of the Human Anterior Hypothalamus: An Investigation of Variation with Sex, Sexual Orientation, and HIV Status. HORMONES AND BEHAVIOR, 40: 86-92 (2001)

Gay Sheep Brains
About 8% of rams are exclusively homosexual
Volume of ovine sexually dimorphic nucleus (oSDN) is 2X bigger in “female-oriented” rams than in “male-oriented” rams
This “duplicates” LeVay’s work on INAH3 of humans
Roselli CE, Larkin K, Resko JA, Stellflug JN, Stormshak F. The volume of a sexually dimorphic nucleus in the ovine medial preoptic area/anterior hypothalamus varies with sexual partner preference. ENDOCRINOLOGY 145:489-483 (2004)

Anterior Hypothalamus Is Activated by Sex Pheromones
Positron emission tomography (PET scans) of anterior hypothalamus while subjects smell sex pheromones
Berglund H, Lindstr ö m P, Savic I. Brain response to putative pheromones in lesbian women. PNAS PNAS 103:8269-8274 (2006) AND = progesterone derivative 4,16-androstadien-3-one EST = estrogen-like steroid estra-1,3,5(10),16-tetraen-3-ol (EST) Subject Activation of anterior hypothalamus Heterosexual males EST Homosexual males AND Heterosexual females AND Homosexual females EST

Is There a Genetic Basis to Sexual Orientation?
It has been suggested that homosexuality "runs in families," meaning that there may be a genetic underpinning to the development of sexual orientation
Studies have examined this issue by assessing one of following
Incidence of homosexuality in families
Similarity of sexual orientation between twins
Evidence for genetic markers among gay family members

Genetics of Gayness in Males
A genetic hypothesis posits that homosexuality runs in families and that genetic markers* for sexual orientation can be found among family members
Evidence for genetic markers for gay men and their gay brothers in the Xq28 region on the X chromosome
*Markers are regions or sections of DNA that are the same among family members, suggesting the presence of a gene
Hamer, D. H., Hu, S., Magnuson, V. L., Hu, N., & Pattatucci, A. M. A. Linkage Between DNA Markers On The X Chromosome And Male Sexual Orientation. SCIENCE, 261: 321-327 (1993)
Hu, S., Pattatucci, A. M., Patterson, C., Li, L., Fulker, D. W., Cherny, S. S., Kruglyak, L., & Hamer, D. H. Linkage Between Sexual Orientation And Chromosome Xq28 In Males But Not In Females. NATURE GENETICS, 11: 248-256 (1995)

Genetics of Lesbianism
The following findings are consistent with a genetic hypothesis:
Lesbians had significantly higher rates of lesbian sisters, daughters, and cousins through a paternal uncle than did heterosexual women
Pattatucci, A. M. L., & Hamer, D. H. Development And Familiality Of Sexual Orientation In Females. BEHAVIOR GENETICS, 25: 407-420 (1995)
Increasing rates of concordance of lesbianism from nonidentical twins to identical twin pairs
Bailey, J. M., & Benishay, D. S. Familial aggregation of female sexual orientation. AMERICAN JOURNAL OF PSYCHIATRY, 150: 272-277 (1993)
Bailey, J. M., Dunne. M. P., & Martin, N. G. Genetic And Environmental Influences On Sexual Orientation And Its Correlates In An Australian Twin Sample. JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY, 78: 524-536 (2000)
But lesbianism is not associated with the locus at Xq28
Hu, S., Pattatucci, A. M., Patterson, C., Li, L., Fulker, D. W., Cherny, S. S., Kruglyak, L., & Hamer, D. H. Linkage Between Sexual Orientation And Chromosome Xq28 In Males But Not In Females. NATURE GENETICS, 11: 248-256 (1995)

Biology of Sexual Identity Harry Benjamin's Syndrome (HBS) Estimated incidence of HBS is 1 in 100.000 live births

The Transsexual Brain
Background:
Investigation of genetics, gonads, genitalia or hormone level of transsexuals does NOT explain their status
In experimental animals, the same gonadal hormones that prenatally determine the morphology of the genitalia also influence the morphology and function of the brain in a sexually dimorphic fashion
This led to the hypothesis that sexual differentiation of the brain in transsexuals might not have followed the line of sexual differentiation of the body as a whole

MtF Brains
Six male-to-female transsexuals (T1-T6)
Searched for sexually dimorphic brain structure that was not influenced by sexual orientation (male-to-female transsexuals may be "oriented" to either sex with respect to sexual behavior)
Zhou, J.N. Hofman, M.A. Gooren, L.J. and Swaab, D.F.. A Sex Difference in the Human Brain and its Relation to Transsexuality. NATURE, 378: 68-70 (1995)

Bed Nucleus of the Stria Terminalis
“ Although there is no accepted animal model for gender identity alterations, the bed nucleus of the stria terminalis (BST) turned out to be an appropriate candidate to study” because BST
Plays an essential part in rodent sexual behavior
Has estrogen and androgen receptors
Is major aromatization center in developing rat brain
Receives projections mainly from the amygdala
Provides a strong input in the preoptic-hypothalamic region
Reciprocal connections well-documented between hypothalamus, BST and amygdala
Sex differences in the size and cell number of the BST have been described in rodents which are influenced by gonadal steroids in development
In humans a particular caudal part of the BST (BNST-dspm) has been reported to be 2.5 times larger in men than in women
The central part of the BST (BSTc) is characterized by its somatostatin cells and vasoactive intestinal polypeptide (VIP) innervation
Experimental endpoint: volume of the BSTc - based on its VIP innervation

Localization of the BSTc
Central part of the BST (BSTc) is characterized by
Somatostatin-producing cells
vasoactive intestinal polypeptide (VIP) innervation
Measured the volume of the BSTc on the basis of its VIP innervation

Bed Nucleus of the Stria Terminalis Figure 2 : Representative sections of the BSTc innervated by vasoactive intestinal polypeptide (VIP). A: heterosexual man; B: heterosexual woman; C: homosexual man; D: male-to-female transsexual. Bar=0.5 mm. LV: lateral ventricle. Note there are two parts of the BST in A and B: small sized medial subdivision (BSTm), and large oval-sized central subdivision (BSTc) Zhou, J.N. Hofman, M.A. Gooren, L.J. and Swaab, D.F.. A Sex Difference in the Human Brain and its Relation to Transsexuality. NATURE, 378: 68-70 (1995)

Bed Nucleus of the Stria Terminalis
Figure 3
The six transsexuals are numbered T1-T6
The patients with abnormal sex hormone levels are numbered S1-S4
M1 and M2: postmenopausal women

BSTc Volume Is Not Affected by Varying Sex Hormone Levels in Adulthood
S1: BSTc volume of a 46-year-old woman who had suffered for at least 1 year from a tumor of the adrenal cortex that produced very high blood levels of androstenedione and testosterone, was within the range of that of other women
M1, M2: Two postmenopausal women (aged over 70 years) showed a completely normal female-sized BSTc

Small-Sized BSTc in MtF Not Due to Estrogen Treatment
All the transsexuals had been treated with estrogens, so could the reduced size of the BSTc be due to high estrogen levels?
T2 and T3: both showed a small, female-like BSTc
T2 stopped taking estrogen about 15 months before death (since her prolactin levels were too high)
T3 stopped hormone treatment since a sarcoma was found about three months before death
S2: 31-year-old man who suffered from a feminizing adrenal tumor which induced high blood levels of estrogen, nevertheless had a very large BSTc

Small-sized BSTc in MtF Not Due to Lack of Androgens
All had been orchidectomized except for T4
S4 and S3: orchidectomized because of prostate cancer (one and three months before death respectively) - found that their BSTc sizes were at the high end of the normal male range
T4: single transsexual who had not been orchidectomized - ranged in the middle of the transsexual scores (Fig. 3)
Not only were five of the transsexuals orchidectomized, they all used the antiandrogen cyproterone acetate (CPA)
T3 & T6: A CPA effect on the BSTc does not seem likely, because T6 had not taken CPA for the past 10 years, and T3 took no CPA during the two years before death and still had a female-sized BSTc

MtF Has Female-sized BSTc!
Verified that the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc) is larger in typical men than in typical women
A female-sized BSTc was found in male-to-female transsexuals
The size of the BSTc was not influenced by sex hormones in adulthood and was independent of sexual orientation
This is the first study to show a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones

Figure 2. Representative immunocytochemical stainings of the somatostatin neurons and fibers in the BSTc
(a) a reference man
(b) reference woman
(c) homosexual man
(d) male-to-female transsexual
Note the sex difference regardless of sexual orientation
The male-to-female transsexual has a BSTc in the female range
Kruijver, Frank P. M., Zhou, Jiang-Ning, Pool, Chris W. Hofman, Michel A.,. Gooren, Louis J. G And Swaab, Dick F. Male-To-Female Transsexuals Have Female Neuron Numbers In A Limbic Nucleus. J CLIN ENDOCRINOL METAB, 85: 2034-2041 (2000)
2 nd Study: Somatostatin Results Parallel VIP Results

What’s Missing in the Sexual Identity Picture?
FtM
Has male sexual identity
Work so far predicts that BSTc of FtM should be same size as typical male’s

FtM Has Same Neuron Number in BSTc as Typical Male
Figure 1.
BSTc neuron numbers. Distribution of the BSTc neuron numbers among the different groups according to sex, sexual orientation, and gender identity. M, Heterosexual male reference group; HM, homosexual male group; F, female group; TM, male-to-female transsexuals
The sex hormone disorder patients S1, S2, S3, S5, S6, and M2 indicate that changes in sex hormone levels in adulthood do not change the neuron numbers of the BSTc
Note that the number of neurons of the FMT is fully within the male range

BSTc Neuron Number Is Not Related to Sexual Orientation
Whether the transsexuals were male oriented (T1, T6), female oriented (T2, T3, T5), or both (T4) did not have any relationship with the neuron number of the BSTc
The same holds true for heterosexual and homosexual men
This shows that the BSTc number of somatostatin neurons is not related to sexual orientation

Sexual Identity & INAH3

INAH3 & BSTc: Sexual Identity Versus Sexual Orientation
INAH3 volume may be related to sexual orientation
S LeVay A difference in hypothalamic structure between heterosexual and homosexual men S cience 30 August 1991:Vol. 253. no. 5023, pp. 1034 - 1037
INAH3 cell number may be related to sexual identity
BSTc cell number and volume both related to sexual identity
Garcia-Falgueras, Alicia, Swaab, Dick F. A Sex Difference In The Hypothalamic Uncinate Nucleus: Relationship To Gender Identity. BRAIN, (Nov 2, 2008)

INAH3 in Transsexuals
Method: Three different stainings throughout the nuclei in every 15th section, i.e. thionin, neuropeptide Y and synaptophysin
INAH3 volume and number of neurons of male-to-female transsexual people is similar to that of control females
The female-to-male transsexual subject had an INAH3 volume and number of neurons within the male control range ( even though the treatment with testosterone had been stopped three years before death)
No difference in INAH3 between pre-and post-menopausal women, so feminization of the INAH3 of male-to-female transsexuals was not due to estrogen treatment
Garcia-Falgueras, Alicia and Swaab, Dick F. A Sex Difference In The Hypothalamic Uncinate Nucleus: Relationship To Gender Identity. BRAIN, (Nov 2, 2008)

Copyright restrictions may apply. Garcia-Falgueras, A. et al. Brain 2008 0:awn276v1-276; doi:10.1093/brain/awn276 INAH3 number of neurons Garcia-Falgueras, Alicia, Swaab, Dick F. A Sex Difference In The Hypothalamic Uncinate Nucleus: Relationship To Gender Identity. BRAIN, (Nov 2, 2008)

Copyright restrictions may apply. Garcia-Falgueras, A. et al. Brain 2008 0:awn276v1-276; doi:10.1093/brain/awn276 INAH3 volume in thionin staining in different groups, according to their gender identity and hormonal changes in adulthood Garcia-Falgueras, Alicia, Swaab, Dick F. A Sex Difference In The Hypothalamic Uncinate Nucleus: Relationship To Gender Identity. BRAIN, (Nov 2, 2008)

Copyright restrictions may apply. Garcia-Falgueras, A. et al. Brain 2008 0:awn276v1-276; doi:10.1093/brain/awn276 Density of neurons in INAH3 in different groups: M = control male group; F = control female group; MtF = transsexual male-to-female group; CAScastrated male group; PreM = pre-menopausal women; PostM = post-menopausal women Garcia-Falgueras, Alicia, Swaab, Dick F. A Sex Difference In The Hypothalamic Uncinate Nucleus: Relationship To Gender Identity. BRAIN, (Nov 2, 2008)

Adult Hormones & INAH3
Castrated men had values intermediate between male and female controls
This data and S7 cannot be fully explained by activating affect of androgens on INAH3
Indicates there are also organizational effects of androgens during development of INAH3 morphology

INAH3 & BSTc Involved in Sexual Identity
Propose that the sex reversal of the INAH3 in transsexual people is at least partly a marker of an early atypical sexual differentiation of the brain
Appears to be a relationship of BSTc with sexual identity rather than with sexual orientation while INAH3 seems to have a relationship with both

MtF – Atypical Hypothalamic Response to Sex Pheromones
Data implicate that transsexuality may be associated with sex-atypical physiological responses in specific hypothalamic circuits, possibly as a consequence of a variant neuronal differentiation
Berglund H, Lindström P. Dhejne-Helmy C, Savic I. Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids CEREB CORTEX 0:bhm216v1-bhm216 (2007)

Genetics of MtF Transsexuality
Looked for potential differences in three genes known to be involved in sex development
Gene for the androgen receptor
Gene for estrogen receptor
Aromatase enzyme which converts testosterone to estrogen
Comparison of the DNA from the MtF transsexual participants with controls showed a significant link with a long version of the androgen receptor gene and transsexualism
Hare, Lauren and Harley, Vincent. BBC News–10/26/2008

Genetics of FtM Transsexuality
Gene variant for 17  -Hydroxylase*
Leads to higher than average tissue concentrations of androgens and estrogen hormones
These hormones may in turn influence early brain development
44% of FtM transsexuals carried it, compared with 31% of non-transsexual women
Proportion of MtF transsexuals with variant was similar to that in non-transsexual men
*Also called cytochrome P17
Tempfer, Clemens et al. 2008

Gene Variant for 17  -Hydroxylase in FtM

Homosexuality – How to Explain in Darwinian Terms?

Fa'afafine - Broadly Accepted Social Class in Samoa
Fa’afafine - males who have sex with males
Samoa - more like the setting in which humans evolved
South Pacific island nation
Relatively unwesternized
Traditional, tribally-based cultures
Tighter-knit families
Fewer anti-gay biases that alienate gays
Samoan culture characterized by a high degree of social tolerance towards fa'afine s
*Farran, Sue and Su’a, Alexander. Discriminating on the grounds of status: criminal law and Fa’afafine and Fakaleiti in the south pacific. Journal of South Pacific 9: 1-15 (2005)

Kin Selection Hypothesis’ Basic Prediction
Androphilic (“gay”) males should direct more altruistic behavior toward kin than gynephilic (“straight”) males
Vasey, P, Pocock, D . VanderLaan, D. Kin Selection And Male Androphilia In Samoan Fa'afafine. EVOLUTION AND HUMAN BEHAVIOR, 28: 159–167 (2007)

Fa’afafines Put “Significantly” More Effort Into Raising Nephews and Nieces
Childcare activities
Babysitting
Buying toys
Tutoring
Exposing the children to art and music
Contributing to daycare, medical and education expenses

Gay Men in Samoa Reproduce Through Kin Selection
Gay men put extra efforts into helping raise nephews and nieces (as compared to straight men)
This boosts the children’s chances of survival, and someday reproduction
These youths, even if not gay, might share with their aunt or uncle a few genes promoting homosexuality—ensuring a clutch of “gay genes” in every generation

Is Gender-atypical Behavior a Mentally Distressing Disorder?
This Samoan study afforded the “opportunity to examine whether gender-atypical behavior, gender-atypical identity, and sex-atypical identity, in and of themselves, cause distress in sex/gender variant individuals
Simultaneously controlling for the confounding effects of extreme societal intolerance towards such individuals

Transsexuality Not Distressing
Current DSM-IV TR: Transsexual diagnosis of GIDC
Do adult fa'afafine “recall a strong and persistent cross-gender identification in childhood, a sense of inappropriateness in the male-typical gender role, a discomfort with their sex, or distress associated with any of the above?”
Vasey and Bartlett concluded that “the diagnostic category of GIDC should not occur in its current form in future editions of the DSM, as there is no compelling evidence that cross-gender behaviors or identities, in and of themselves, cause distress in the individual.”
GIDC = Gender Identity Disorder in Childhood Vasey, P, Pocock, D . VanderLaan, D. Kin Selection And Male Androphilia In Samoan Fa'afafine. EVOLUTION AND HUMAN BEHAVIOR, 28: 159–167 (2007) Vasey, P., and Bartlett, N. H. What Can the Samoan "Fa'afafine" Teach Us about the Western Concept of Gender Identity Disorder in Childhood? PERSPECTIVES IN BIOLOGY AND MEDICINE, 50: 481-490 (2007)

Summary: What We Now Know About Core Sexuality
The biblical genesis story “explains” only typical men and typical women
The scientific story explains everyone!

“ Organization-Activation” Theory
“ The preponderance of evidence seems to indicate that the theory of organization-activation for the development of sexual behavior is certain for non-human mammals and almost certain for humans"
Milton Diamond. Clinical implications of the organizational and activational effects of hormones. HORMONES AND BEHAVIOR 55:621–632 (2009)

Organization-Activation Theory
“ The fetal brain develops during the intrauterine period in the male direction through a direct action of testosterone on the developing nerve cells, or in the female direction through the absence of this hormone surge. In this way, our gender identity (the conviction of belonging to the male or female gender) and sexual orientation are programmed or organized into our brain structures when we are still in the womb”
Garcia-Falgueras A, Swaab DF. Sexual hormones and the brain: an essential alliance for sexual identity and sexual orientation PEDIATRIC NEUROENDOCRINOLOGY 17: 22-35 (2010) Similar wording in: Garcia-Falgueras A, Swaab DF. Sexual hormones and the brain: an essential alliance for sexual identity and sexual orientation. PEDIATRIC NEUROENDOCRINOLOGY 17:22-35 (2010)

Critical Periods of Genitalia and Brain Are Different
“ However, since sexual differentiation of the genitals takes place in the first two months of pregnancy and sexual differentiation of the brain starts in the second half of pregnancy, these two processes can be influenced independently, which may result in extreme cases in transsexuality. This also means that in the event of ambiguous sex at birth, the degree of masculinization of the genitals may not reflect the degree of masculinization of the brain. There is no indication that social environment after birth has an effect on gender identity or sexual orientation”
Garcia-Falgueras A, Swaab DF. Sexual hormones and the brain: an essential alliance for sexual identity and sexual orientation PEDIATRIC NEUROENDOCRINOLOGY 17: 22-35 (2010)
Similar wording in: Garcia-Falgueras A, Swaab DF. Sexual hormones and the brain: an essential alliance for sexual identity and sexual orientation. PEDIATRIC NEUROENDOCRINOLOGY 17:22-35 (2010)

Three Dimensions of Sexuality
Somatic Morphology (X axis)
Sexual Identity (Y axis)
Sexual Orientation (Z axis)
Everyone occupies a point in this three-dimensional space! Gynemorphic Andromorphic Gynecentric Androcentric Gynephilic Androphilic

Sex Versus Gender
Sex  Gender
Sex is biological (gonads)
Gender is cultural
Gender “traits” differ from culture to culture and from time to time
Castor Semenya Controversy over whether this South African eighteen-year old should be allowed to compete as a woman after her victory in the women’s’ 800m race during World Championships in Berlin is continuing

Culture Determines How Sexual Differences Are Valued!
Muxe of Mexico
http://www.nytimes. com/slideshow/ 2008/12/07/ weekinreview/ 1207-MUXE_ index.html >
Five Genders of Indonesia (National Geographic)
http://www.youtube.com/watch?v=K9VmLJ3niVo
Fa'afines of Samoa (National Geographic)
http://www.youtube.com/watch?v=EronVtKYr0c

The “Binary Gender”
We live in a “binary gendered” culture
Two genders only
Man
Woman
Many cultures recognize more than two genders

NORTH AMERICA
Two-spirits – Native American Berdache – Illiniwek (Illinois) Muxes – Zapotec People, Oaxaca, Mexico
Thanks to Lorelei Erisis http://transprov.wordpress.com/2009/05/21/simple-list-of-third-gender-and-gender-variant-groups/

SOUTH AMERICA
Travestís – Brazil Bichas Viados Guevedoche – Dominican Republic Quariwarmi – Incan

EUROPE
The Sworn Virgin – Balkans Catamites – Ancient Greece Mollies – Modern England Tertium genus hominum (a third human gender) “eunuchs” – Ancient Eastern Mediterranean

AFRICA
Ashtime – Maale culture of Southern Ethiopia Mashoga – Swahili-speaking areas of the Kenyan coast, particularly Mombasa Mangaiko – The Mbo people, Democratic Republic of the Congo Sḫt (”sekhet”) – Middle Kingdom of Egypt (2000-1800 BCE)

MIDDLE EAST
The Kurgarûs – Sumer kur.gar.ra ur.sal Zenanas – Arab Xanith or Khanith – Oman

ASIA
lyha – Mohave Hijras – India, Pakistan & Bangladesh also known as: Aravani/Aruvani or Jogappa Hijira (alt. sp.) – India Sādhi Kotis Sadhin – The Gaddhi in the foothills of the Himalayas Basivi – Madras (area of India) Tritiya-prakrti (third-nature) – Indic culture of premodern India Ubhatobyanjanakas – Buddhist Vinaya Pandakas Kathoey – Thailand Pandaka – Ancient Buddhist Societies

ASIA-PACIFIC POLYNESIA
Fa’afafine – Samoa Polynesia Fakaleiti – Tonga Mahu Wahine – Hawaii Mahu Vahine – Tahiti Whakawahine – Māori Akava’ine – Cook Islands

INDONESIA
Waria Kwolu-aatmwol – “Sambia” community in the eastern highlands of Papua New Guinea PHILIPPINES bakla – Tagalog Bayot – Cebuano Agi – Ilonggo Bantut – Tausug) Binabae Bading Lakin-on

Dangerous Nonsense
What the medical profession has been and is still doing to sexually-variant peoples
Gay, lesbian, bisexual people
Intersex people
Transsexual people

Science Versus Anti-gay Quackery
“ There is no indication that social environment after birth has an effect on gender identity or sexual orientation”

Medical Profession’s Treatment of GLB People Homosexuality was removed from the list of mental disorders by the World Health Organisation in 1990 1952 (DSM-I) Sociopathic Personality Disorders 1968 (DSM-II) Sexual Deviation 1970 Gay rights activists storm APA annual convention 1972 APA annual meeting –first-ever panel of non-patient homosexuals” and Dr. Anonymous 1973 (DSM-II Revision) Deletion of Homosexuality Substitution of Sexual Orientation Disturbance (Homosexuality is not illness but supposedly discomfort with being persecuted as a homosexual is an illness) 1980 (DSM-III) Gender Identity Disorder (GID) and Ego-dystonic Homosexuality (formerly SOD) 1987 (DSM-III Revision) Homosexuality omitted entirely (Ego-dystonic homosexuality/SOD removed. It’s normal to not want to be persecuted & empirical data to support diagnosis is lacking) )-> 2000 (APA Position Statement) Ethical psychiatrists should stop conversion or “reparative therapies”

Anti-gay Quacks & Supporters – for Reparative Therapy
The American College of Pediatricians (ACP)
National Association for Research & Therapy of Homosexuality (NARTH)
Exodus International
The National Catholic Bioethics Center

Dangerous Nonsense From ACP
ACP is a southern anti-gay advocacy group angry at American Academy of Pediatrics (AAP) because AAP policy is against reparative therapy
April 2010 –launched anti-gay website and also sent letters promoting their propaganda to 10,00+ school superintendents across America
“… schools should not seek to develop policy which “affirms” or encourages these non-heterosexual attractions among students who may merely be experimenting or experiencing temporary sexual confusion ”

Medical Profession’s Treatment 0f Intersex People
Disordered or Just Different?
DSD = Disorders of Sexual Development
OII objects to “disorder” terminology
http://www.gopetition.com/petitions/solidarity-with-the-intersex-community.html
Milton Diamond sent letter to the Archives of Diseases of Childhood (7/27/2006) recommending Variations of Sex Development be used for intersex conditions instead of Disorders of Sex Development
http://adc.bmjjournals.com/cgi/eletters/91/7/554

Intersex Problems Are Socio-cultural
“ The basic problems faced by the intersexed are socio-cultural in nature and not medical and are a result of the dogmatic fundamentalism inherent in the current binary construct of sex and gender”
Curtis Hinkle - Founder Organization Intersex International http://www.gopetition.com/petitions/solidarity-with-the-intersex-community.html

Diamond’s Letter to Pediatricians
Variations of sex development inextricably involve sexual and gender identity, sexuality, and one's innate sense of self. Thus, the term disorder is far too narrow and too pathological to be accurate. We oppose its adoption in this instance. We suggest that the institution of medicine take a more humble and compassionate approach, recognizing that the institution of medicine does not act from a sphere of perfect knowledge nor hold a monopoly on classifying individuals. What medicine observes are variations in human sex development, it does not know the biological purpose of such variations , and there remains great controversy about how, whether or when to intervene. Terms such as error or disorders reveal an unwelcome arrogance in light of medicine's limited vantage. Medicine can do better. One way is to, instead, use the term Variation in Sex Development (VSD), a term that is without judgment and neither prohibits or ordains medical intervention
http://adc.bmj.com/content/91/7/554/reply#archdischild_el_2460?sid=437e97e7-049d-42c8-b60f-6d8d02dd31c1

Medical Profession’s Treatment of Intersex People
… in the event of ambiguous sex at birth, the degree of masculinization of the genitals may not reflect the degree of masculinization of the brain.”

OUTCOMES: Ambiguous Genitalia “Normalization” Surgery
John Money’s lab follows up on some of their intersex cases
Admit that follow-up studies are very limited; hence, the need for this study
Intersex types studied
46, XY
Quigley grade 2-4, average 3.5
AIS, gonadal dysgenesis, others
Turns out that roughly half were assigned/raised as boys, half as girls
Written questionnaire and physical exam
Pigeon; CJ, Wisniewski, AB, Gearhart JP, Meyer-Bah burg, HFL, Rock, JA, Brown, TR, Canella, SJ, Market A, Ngai KM, Money J, Berkovitz GD. Ambiguous Genitalia With Perineoscrotal Hypospadias in 46,XY Individuals: Long-Term Medical, Surgical, and Psychosexual Outcome PEDIATRICS 110:10p (2002)

23% of participants were dissatisfied with sex of rearing – indicating “general predictions cannot guarantee future gender development for any single case”
This figure could be as high as 44% (if all non-participating patients were also dissatisfied)
Migeon; CJ, Wisniewski, AB, Gearhart JP, Meyer-Bahlburg, HFL, Rock, JA, Brown, TR, Casella, SJ, Maret A, Ngai KM, Money J, Berkovitz GD. Ambiguous Genitalia With Perineoscrotal Hypospadias in 46,XY Individuals: Long-Term Medical, Surgical, and Psychosexual Outcome PEDIATRICS 110:10p (2002)

Majority (62% men, 67% women) sought counseling concerning condition
Mean surgeries: men 5.8; women 2.1
Half were dissatisfied with body image
Two-thirds were dissatisfied to some degree with sexual function
Researchers never asked: What if we did nothing?

“ Valuable Support?”
“ The birth of an intersex infant is often viewed as a major crisis by parents and other family members. In these instances, pediatric endocrinologists can offer valuable support by helping the parents to understand sex differentiation and medical/surgical options that are available for their child. Specifically, physicians should inform parents about 1) long-term cosmetic and functional outcomes associated with genital reconstruction , 2) the need for long-term sex hormone replacement , and 3) possibilities for reproduction”

Conclusions – Not Supported by Their Own Data
“ For infants with markedly ambiguous genitalia, including a small phallus and perineoscrotal hypospadias, sex of rearing should be decided by parents who have been thoroughly informed about their child’s medical and surgical options and have also been informed of available outcome data. Advances in medical and surgical procedures used to treat intersex conditions, along with better education and support provided to patients and their families, may further improve the quality of life experienced by individuals who are affected by syndromes of abnormal sex differentiation”

Poor Quality Medical Treatment of Intersex People
Over 50% are misdiagnosed!
Minto CL, Crouch NS, Conway GS, Creighton SM. XY females: revisiting the diagnosis BJOG: an International Journal of Obstetrics and Gynaecology 112:1407–1410 (2005)
Intersex people have their own physiology and health concerns that are not being addressed by physicians
Holterhus P-M, Bebermeier J-H, Werner R, Demeter J, Richter-Unruh A, Cario G, Appari M, Siebert R, Riepe F, Brooks JD, Hiort O. Disorders of sex development expose transcriptional autonomy of genetic sex and androgen-programmed hormonal sex in human blood leukocytes BMC GENOMICS 10:292 (2009)

OII Is Against “Genital Normalization” Surgeries on Infants
“ The basic problems faced by the intersexed are socio-cultural in nature and not medical and are a result of the dogmatic fundamentalism inherent in the current binary construct of sex and gender”
“ Some intersexed individuals are subjected to genital mutilation in childhood as a result of this totalitarian, sexist oppression”
Curtis Hinkle - Founder Organization Intersex International http://www.gopetition.com/petitions/solidarity-with-the-intersex-community.html

3 Recommendations at 1998 AAP National Meeting
General moratorium on sex assignment cosmetic surgery
Moratorium should not be lifted unless and until studies show outcomes are positive
Efforts should be made to undo effects of past physician deception and secrecy
Diamond, M. Sex, gender, and identity over the years: a changing perspective CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA 13:591-607 (2004)

Diamond, M. Sex, gender, and identity over the years: a changing perspective CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA 13:591-607 (2004) NEW STANDARDS OF CARE FOR INTERSEX PATIENTS American Academy Pediatricians year 2000 British Association Pediatric Surgeons year 2001 #1. General moratorium on sex assignment cosmetic surgery No surgical moratorium (In1999, AAP decided that surgical moratorium was “unrealistic” because it was hypothesized that parents would not accept it) No surgical moratorium #2. Moratorium should not be lifted unless and until studies show outcomes are positive Recognized need for more research and greater candor and honesty Recognized need for more research and greater candor and honesty #3. Efforts should be made to undo effects of past physician deception and secrecy No call back to families or individuals that had previous treatment No call back to families or individuals that had previous treatment Response to intersex birth “ Social emergency” Informed consent includes “possibility of non-operative management” Gender assignment All virilized females (CAH or maternal androgen) should be girls (because of retained fertility) Gender assignment on individual basis; may include cultural considerations Clitoral surgery Infants raised as girls “will usually require clitoral reduction” “ There is a strong case for no clitoral surgery in lesser degrees of clitoromegaly” Penile surgery PAIS infants “in whom a very small phallus mandates a female sex of rearing” should have testes removed The risk of malignant testicular changes in AIS is small

Reprehensible Pediatric Policy
2006 Consensus Statement replaces policy of year 2000
They chose term “ Disorders of Sexual Development”
They dismiss “sexual identity” issue: “Structure of the brain is not currently useful for gender assignment”
Factors they say influence their decision on gender assignment
Diagnosis
Genital appearance
Surgical options
Need for lifelong replacement therapy
Potential for fertility
Views of family
Circumstances relating to cultural practices
Collaboration with participants in International Consensus Conference on Intersex organized by Lawson Pediatric Endocrine Society and European Society for Paediatric Endocrinology Lee PA, Houk CP, Ahmed SF, Hughes IA. Consensus statement on management of intersex disorders PEDIATRICS 118:488-500 (2006)

No Controlled Clinical Trials
“ Long-term data regarding sexual function and quality of life among those assigned female as well as male show great variability”
“ There are no controlled clinical trials of the efficacy of early (  12 months of age) versus late (in adolescence and adulthood) surgery or of the efficacy of different techniques”
Lee PA, Houk CP, Ahmed SF, Hughes IA. Consensus statement on management of intersex disorders PEDIATRICS 118:488-500 (2006)

Pediatricians Use Parental Distress & Prejudice to Justify Damaging Surgery
“ It is generally felt that surgery that is performed for cosmetic reasons in the first year of life relieves parental distress and improves attachment between the child and the parents; the systematic evidence for this belief is lacking”

Let’s Follow Columbia’s Example
“ In 1998, Constitutional Court of Colombia, South America, ruled that sex reassignment of children would no longer be legal in that country
Parents cannot consent for children over 5 years because such children are deemed to have identified with a gender and are autonomous
The Court’s purported goal was ‘forcing the parents to put the child’s best interest ahead of their own fears and concerns about sexual ambiguity’”

Medical Profession’s Treatment of TransPeople Ignores Science
“… since sexual differentiation of the genitals takes place in the first two months of pregnancy and sexual differentiation of the brain starts in the second half of pregnancy, these two processes can be influenced independently, which may result in extreme cases in transsexuality”
“ There is no indication that social environment after birth has an effect on gender identity or sexual orientation”

DSM
DSM = Diagnostic and Statistical Manual of Mental Disorders
Published by the American Psychiatric Association
Standard classification of mental disorders used by mental health professionals in the United States

DSM Is Widely Used
Psychiatrists, other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, counselors
Researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers
Across clinical settings (inpatient, outpatient, private practice, etc.)

Transsexual People Are Not Mentally Disordered!
Transsexual persons have atypical brain structure and atypical brain function that correspond to their felt sexual identity.
Transsexual people are merely different. Difference does not equal disorder!
Therefore, the American Psychiatric Association should remove “Gender Identity Disorder” from its new version of the Diagnostic and Statistical Manual of Mental Disorders

Gender Identity Disorder (GID)
How can someone have GID or GIDC (GID in children) if sexual identity is innate?
How do you treat something that is not learned and cannot be changed?

Dr. Kenneth Zucker, PhD Ignores Science and Preys on Emotions!
Head of the child and adolescent gender identity clinic at Toronto's Centre for Addiction and Mental Health
Has “treated” “children with GID” since mid-’70s
Explains gender dysphoria in terms of “family noise”
Insecure mother-child relationship
Neglectful parents
Mother who wanted a daughter
Domineering sisters
Is in charge of APA committee making recommendations about GID for DSM revision!!!
Rosin H. “A Boy’s Life” in THE ATLANTIC November 2008 Fitzgibbons RP, Sutton PM, O’Leary D. The psychopathology of “sex reassignment” surgery: assessing its medical, psychological, and ethical appropriateness THE NATIONAL CATHOLIC BIOETHICS CENTER pp 97-125 (2009)

Zucker Dismisses Hard Data and Neuroscience As “Dogma”!
When referring to a poster that read: “Gender dysphoria is increasingly understood…as having biological origins,” and describes “small parts of the brain” as “progressing along different pathways,” Dr. Zucker is quoted as saying: “In terms of empirical data, this is not true. It’s just dogma, and I’ve never liked dogma. Biology is not destiny.”
Rosin H. “A Boy’s Life” in THE ATLANTIC November 2008

Zucker’s Misdiagnosis Assures “a Fix”
Richard Green did longitudinal study on the kind of children “treated” by Dr. Zucker and found these boys, without any treatment, grow up to be gay men
Dr. Zucker claims success at curing these male children when they come out as gay rather than trans! But they were gay all along! And Zucker gets paid for traumatizing these boys and their frantic families
Green R. The “Sissy Boy Syndrome” and the Development of Homosexuality THE INSTITUTION FOR SOCIAL AND POLICY ST. (1987)

APA Statement On GID & DSM Revision Process Is a Lie!
May 9, 2008 – “All DSM-V work group proposals will be based on a careful, balanced review and analysis of the best clinical and scientific data””
But in draft revision there is no mention of brain work, Reimer case, intersex studies, anthropological work, Green’s work – nothing of the hard science is mentioned or considered during revision process by Dr. Zucker’s committee!

Religious Bigots Lie by Ignoring the Science and Quoting the Quacks
Quacks give bigots ammunition
In reference to a biological origin for GID (transsexuality), the Catholic Bioethics Center says:
“… there is no scientific evidence to support this conclusion”
“ There is no evidence that gender identity confusion – a gender identity contrary to anatomical structure – is inborn” (quote attributed to psychoanalyst Charles Socarides who founded NARTH in 1992)
Fitzgibbons RP, Sutton PM, O’Leary D. The psychopathology of “sex reassignment” surgery: assessing its medical, psychological, and ethical appropriateness THE NATIONAL CATHOLIC BIOETHICS CENTER pp 97-125 (2009)

Transsexuals Are Still Crazy in USA but Not in France!
France has become the first country in the world to declassify transsexualism as a mental illness
World Health Organization and the American Psychiatric Association continue to list the condition as a mental illness, rather than a medical condition
Draft of DSM-V has been released
Gender Identity Disorder has been replaced with Gender Incongruence for DSM-V

Insult to Injury - Intersex People Now Can Also Have “Gender Incongruence”!
Special subtype of gender incongruence in DSD is recommended by Zucker’s committee for the DSM-V!
OII responds: “We see no need to further medicalise and stigmatize intersex people by referring to them as necessarily disordered (DSD) and where mistakes in assignment have been made, we see no value in medicalising and stigmatizing them further by applying another form of disorder called ‘gender incongruence’”
http://www.intersxualite.org/DSM5.html

The Truth Shall Set Us Free!
There’s plenty more “dangerous nonsense”
But there’s also plenty more science that will continue to happen
Now if we apply the scientific findings to our culture, the truth shall set us free!

Difference  Disorder
Everyone is born into the world as a unique “sexual somebody”
We do not learn our core sexuality; we discover it as we grow up and it unfolds
What we do learn is whether the culture will celebrate or persecute our sexuality
The culture needs to change and make a place for all the babies born into it
All of us, not just the Adams and the Eves, have the birthright to be who we naturally and innately are

The End

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Disordered Or Just Different? Myth, Science, and Sexuality

by Veronica Drantz on Aug 16, 2010

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Disordered Or Just Different? Myth, Science, and Sexuality — Presentation Transcript