This series will explore the current research on gender identity issues with the help of Mark A. Yarhouse. There are numerous competing hypotheses concerning the genesis of gender dysphoria. Of course, much of the controversy comes, not simply from what the answer to the question is, but how to articulate the question itself. Prior to the DSM-IV, one spoke of “gender identity disorder,” such that the disorder had to do with the sense of incongruence between gender identity and biological sex. With the advent of the DSM-V and the shift from the label of “gender identity disorder” to “gender dysphoria,” however, theorists have attempted to de-pathologize gender incongruence and instead began to focus on the dysphoria experienced. According to this standard, it is the dysphoria itself that becomes insignificant more so than the incongruence.
The DSM-5 theorists attempt to direct focus away from questions of biological sex and instead focus on assigned gender. One of the symptoms of gender dysphoria reads “In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.” Whatever the case or emphasis may be, it is important to understand the emerging heterogeneity observed by clinicians, as well as the internal debates concerning the nature and genesis of transsexualism.
So Richard Carroll:
“The clinician is now confronted with an often-bewildering array of individuals with transgender experiences, including transsexuals, transvestites, she-males, queers, third sex, two-spirit, drag queens, drag kings, and cross-dressers. The phrase “transgender experience” is currently used to refer to the many different ways individuals may experience a gender identity outside of the simple categories of male or female. It should be remembered that there are many individuals who have blended genders in some way, who never seek treatment, and who may be very comfortable with their atypical gender identity.”
Indeed, different individuals may cross-dress for different reason. Some do so because they strongly identify with the opposite gender, and thus experience gender dysphoria, but this is not always the case. Some men, for example, rather than feeling profound discomfort with their own gender, instead merely experience sexual arousal from identifying as a woman or dressing like one. This is known as autogynephilia. Furthermore, there may be distinct causal or biolgical pathways responsible for these different experiences. It is therefore important to keep in mind that any two individuals who cross-dress may bear only a superficial resemblance to one another in terms of underlying structural, psychological or biological motives, in a manner similar to how emotional instability may be characteristic of a very wide array of mental disturbances. Violent oscillations between euphoria and dysphoria, for example, is characteristic of both bipolar disorder and borderline personality disorder, and yet one is mood disorder, whereas the other is a personality disorder, and both are markedly different in many fundamental respects.
Let us examine some of the competing theories concerning the origins of gender dysphoria. The most popular is that of the so-called brain-sex theory. According to this hypothesis, there are areas of the brain that differ greatly between men and women. These parts of the brain are known as “sexually dimorphic structures.” An individual’s “brain sex” has reference to “ways in which the brain scripts toward male or female dispositions or behaviors.” Diamond explains it thus:
“Since the brain is the organ determining or scripting male or female behaviors, the term brain sex is short hand to reflect on how an individual thinks and organizes the world; whether in a stereotypical male or female ways. It is certainly true that the brain is the most used sexual organ of the body and the term brain sex reflects its male or female disposition. It directs the individual to think and act more like a stereotypic male or like female.”
Scientists, according to this hypothesis, have established that testosterone not only differentiates genitalia in the womb, but also differentiates the brain accordingly. These take place during two distinct stages, however. Rather than occurring at the same point in fetal development, these theorists argue that there is a discrepancy that is as significant for the differentiation of the genitals as for the brain:
“As sexual differentiation of the genitals takes place much earlier in the development (i.e., in the first two months of pregnancy) than sexual differentiation of the brain ,which starts int he second half of pregnancy and becomes over upon reaching adulthood, these two processes may be influenced independently of each other.” There is therefore a possibility, they argue, that “a discrepancy may exist between prenatal genital differentiation and brain differentiation such that the external genitals develop, for example, as male while the brain develops as female.” From this perspective, the theorists are interested in prenatal hormonal exposure as a potential cause of gender dysphoria.”
Studies of handedness and finger length ratio have played a role in the study of in utero exposure of testosterone. Left-handedness is associated with certain levels of exposure to testosterone during certain critical stages in development. Indeed, while most left-handed individuals are not transsexual, an unusually large number of transsexuals are left-handed. Something similar has been hypothesized concerning the relation of gender identity with finger length. Theorists who emphasize this note that the ratio of the index finger and the ring finger is affected by exposure to testosterone in the womb and that the lower the finger length ratio, the greater the exposure. Men tend to have a lower ratio, and some studies suggest that there is evidence that the finger ratio of transsexual men resembles that of biological females.
Some studies emphasize study of neuroanatomical brain differences. Those who emphasize this argue that there are marked differences in brain structure or morphology between male-to-female transsexuals and non-transsexual males. The structure and morphology of the hypothalamus is particularly important when it comes to this issue. “Studies of the central subdivision of the bed nucleus of the stria terminalis (BSTc), an area of the hypothalamus, has been in the female range in terms of volume of cells and number of cells among male-to-female transsexuals.” These are all small studies, unfortunately, and many of the transsexuals who have undergone these studies have been in hormonal treatment for years, thus potentially altering the relevant parts of their brains.
Ray Blanchard has been particularly influential in generating distinct typologies of different “kinds” of transsexuals. For example, there is the male-to-female “autogynephilic” type in which the individual exhibits this preference as a kind of sexual fetish. Then there is the male-to-female “androphilic” type who is more of a “classic” transsexual who exhibits marked homosexual tendencies (a biological male with a sexual attraction to other biological males).
We have looked at some of the more neurobiologically based hypotheses concerning the genesis of atypical sex/gender identities. However, there are other hypotheses which emphasize psychosocial factors which may contribute to such. These psychologists emphasize the importance of cognitive and social learning theory in the formation of an individual’s gender identity. These draw on Stoller and Kohlberg and rely on the concept of a “core gender identity” or “fundamental sense of belonging to one sex.” The child comes to know his sense of gender and associated behaviors according to certain parenting styles, observational learning, broad family and kinship patterns, and so on. Meyer-Bahlburg, for example, identifies numerous risk factors associated with 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 behavior, reinforcing cross-gender behavior, encouragement of “extreme physical closeness with boys,” insufficient adult male role models and parental psychiatric issues.” In addition to this, Veale and colleagues suggest that parental factors include less warm or emotionally distant fathers, parental wishes for a girl, and an unusually high level of maternal involvement, as well as parental support for gender variant behavior. Gender-variant individuals have also been found, in some studies, to have been subject to sexual, physical and emotional abuse.
Cohen-Kettenis and Gooren hvae also explored the possibility of a pathway involved with parental psychopathology. They note that the correlation should not necessarily be seen as causal, however. Zucker and Bradley suggested that gender dysphoria may result in children who tend to be more anxious and sensitive. These children may also have different response to marital tensions or conflicts related to gender. Of course, proponents of psychosocial models acknowledge that other factors may be involved as well, and so they do not insist on the exclusivity of such pathways.