Multi-Dimensionality of Gender
When we speak of gender, in a context other than language, it is a recent concept in our culture, both lay and professional. In 1955, John Money, Ph.D. first used the term "gender" to discuss sexual roles, adding in 1966 the term "gender identity" while conducting his gender research at Johns Hopkins. In 1974, Dr. N.W. Fisk provided our now familiar diagnosis of Gender Dysphoria. Previously, one's sexual role was considered one of two discrete, non-overlapping congenital attributes--male or female. These two mutually exclusive categories allowed for no variation. Of course, we acknowledged the cultural differences in sexual roles, but there still could be only two modes of expression.
Now we know that one's gender is on a continuum, a blending, analogous to a "gray scale." But, our distribution of gender is bimodal, that is, most people are lumped at the two ends (see graphic) with only a minority in the middle. The great majority will see themselves as either male or female with all that implies.
Probably more upsetting to our conventional view of gender than this fuzziness of gender roles is that we can be a MIX of male and female identities within the same individual. Several researchers have developed theories of how the brain develops prenatally along sexual lines arising from androgen mediation. Dr. Milton Diamond concludes from his research that the brain has four stages of gender imprinting. The first is Basic Sexual Patterning such as aggressiveness vs. passivity. Second comes Sexual Identity (gender identity), third, the Mating Centers develop (sexual orientation), and fourth, the Control Centers for sexual equipment such as orgasm.
Gunter DÃ¶rner in Germany, using his research with rats, sees only three stages. He believes that first the Sex Centers develop giving typical male and female physical characteristics, then the Mating Centers (sexual orientation) and then the Gender Role Centers which are similar to Diamond's "Basic Sexual Patterning."
As a psychotherapist, I don't presume to enter into the discussion of what develops in what order and how. I take a more pragmatic stance and seek to observe what behaviors are linked, or independent from one another. From this research and observation, I have developed the list of five semi-independent attributes of gender. Not as a fixed dogma, but as a working theory, a map if you will, to help us understand this complex often hotly emotional issue of gender. Consider sexual identity / behavior springing from five semi-independent attributes. These five attributes are:
|Genetic||Our chromosomal inheritance.|
|Physical Appearance||Our primary and secondary sexual characteristics.|
|"Brain Sex"||Functional structure of the brain, along gender lines.|
|Sexual Orientation||Love/sex object, "Love Maps."|
|Gender Identity||How we see ourselves: As male, female or a combination.|
It is my contention that it is possible for an individual to view oneself and function as male or female to varying degrees in each of the five sub-categories independent of the others. For example, an individual may be XX female (chromosomal female), physically female, have a "female brain," be heterosexual but see her(him)self as male--or any other combination. One can be either male or female in each of the five sub-categories independent of each other. If we use "F" for female identity/function, and "M" for male identity/function and one through five for the semi-independent attributes listed above we could describe each individual according to their particular breakdown:
1M ----- 2M ----- 3M ----- 4M ----- 5F
A Gender Dysphoric, Morphological Male
1M ----- 2M ----- 3M ----- 4F ----- 5M
A Homosexual Male
1F ----- 2F ----- 3M ----- 4F ----- 5F
A Dominant, But Heterosexual, Even Feminine, Female
Since each of these independent attributes are graded, it is easy to see the possible combinations and degrees number in the thousands. With regard to gender, we each can be in a category of one--ourselves.
Whether it's gender identity, sexual orientation, or brain sex, the expression usually remains constant from childhood throughout one's life.
Now, for a more detailed description and illustration of the five sub-categories of gender:
The first sub-category, Genetics, is only beginning to be understood. How and how much do genetic influences effect one's expression of gender? We do know that besides the traditional XX chromosome of a typical female and the XY of a typical male, that there are other combinations such as XXY, XYY, and XO.
A XXY combination results in 47 rather the 46 chromosomes. This condition is called Klinefelder's syndrome and occurs in one in every 500 births. Individuals with Klinefelder's are sterile, have enlarged breasts, small testicles and penis, and a eunuch body shape much like the "Pat" character on "Saturday Night Live." They show little interest in sex.
Another 47 chromosome occurrence is XYY Syndrome. In this syndrome, the hormonal and physical appearance of the individual are evidenced as a normal male, but behavior is effected. Typically, XYY Syndrome people are bisexual or paraphilic (pedophillia, exhibitionism, voyeurism, etc.), and show very poor impulse control.
Where Klinefelder's and XYY Syndrome are examples of an extra chromosome, Turner's syndrome is a case of a missing sex chromosome. These individuals possess 45 chromosomes (written as XO), are unable to develop gonads, and are free of all sexual hormones, except those crossing over from the mother during fetal life.
Turner's Syndrome people have external sex organs approximating a female, and their behavior is characterized as hyper-feminine, baby care oriented, and showing very poor spatial and math skills. The Turner's personality, free of all influence from testosterone, tends to be in direct opposition to the typical set of "Tom Boy" traits.
Turner's Syndrome relates well to our second category of Physical Gender--that being our primary and secondary sexual characteristics. To discuss this aspect of gender we need to examine hormonal involvement, in particular testosterone. All sexual differentiation, physical, mental, and emotional are produced by hormones which may be amplified and/or specified by one's social environment. During fetal life, the amount present, or the absence of testosterone determines our sexuality -- physically, mentally and emotionally. There are key times or periods during development when the fetus will go towards the male or the female depending on the level of testosterone. These windows of opportunity may be only open for a few days and if the needed level of testosterone is not present, a basic female orientation develops regardless of the testosterone levels before or after this critical period, and the resulting sexual imprint.
The first critical period is at conception when the presence of the SRY gene (Sex-Determining Region of the Y chromosome) will determine our physical gender. The SRY gene is normally found on the short arm of the Y chromosome, but can detach making for a XY female (the Y missing its SRY gene) or a XX male (the SRY attaching to the X).
The SRY gene causes the fetus to release TDF (Testes Determining Factor) which turns the undifferentiated gonad into testes. Once testes have formed, they release androgens such as testosterone, dihydrotestosterone, and anti-mullerian hormone.
Before the release of TDF, the developing fetus has two tiny structures, the mullerian and wolffian ducts, and two small undifferentiated gonads, neither testes nor ovaries. Without the influence of TDF and testosterone, the gonads form into ovaries and the mullerian duct forms into the female internal sex organs, the wolffian duct disappears and the external sexual tissue becomes the labia major, clitoris, labia minor and clitoral hood. With the influence of TDF, the gonads become testicles and the wolffian duct forms the male internal sex organs, the mullerian ducts dissolve and the external tissue develop into the penis, scrotum, penile sheaths and foreskin. In other words, without testosterone all fetuses develop into females. Adam springs from Eve, not Eve from Adam.
As the primary sexual differentiation proceeds towards our physical gender, sometimes deviations occur. These anomalies are sometimes called "experiments of nature." One such "experiment" is a condition termed congenital adrenal hyperplasia (CAH) when the female fetus releases a steroid hormone form her adrenal glands which resembles testosterone. The resulting child often has confusing genitals ranging from deformed female genitals to an appearance of male genitals. If the child is raised as male, following any "adjusting" surgery and given male hormones at puberty, the individual develops as a "normal" but sterile male with XX chromosomes. On the other hand, if the infant is surgically corrected to female and given female hormones, there is a 50/50 chance of lesbian expression.
Another revealing "experiment of nature" is Androgen Insensitivity Syndrome. In this case, there is normal amounts of testosterone circulating in a XY chromosome fetus, but each cell of its body is unable to react to it. This is similar to Turner's Syndrome in that neither the mullerian or wolffian ducts mature and the external genitalia develops into an approximation of normal female genitals, but differs in that TDF stimulates the gonads into becoming functioning testicles in a XY chromosome body. The child is raised as a girl and is seen as a normal female until she fails to menstruate because she has no uterus. If enough estrogen is produced by her testes, she develops into a completely normal appearing, sterile female with XY chromosomes and internal testicles.
Now we must leave the comfortable arena of biology and development and enter the more rocky, emotional and even political arena of psychology, anthropology, and sociology. An arena where deduction, speculation and circumstantial evidence is more evident than "hard fact."
The third, forth and fifth attributes all reside in the brain and there is controversy on both a congenital vs. environmental level and on a developmental one. It is still argued by some that sexual orientation is a choice and there is no difference in the mental abilities of men and women. Others argue that the evidence, both direct and circumstantial, is becoming overwhelming that these stands are incorrect.
Because of the controversy over whether significant differences in brain structure do exist between the genders, I will confine my discussion of the "Brain Sex" attribute to some behavioral differences that have been noted between morphological male and female infants and children. At all times keep in mind that Physical Gender does NOT always indicate "Brain Sex" Gender. And, while these differences are the norm, they are not absolute. Individual children may differ.
Even a few hours after birth, significant behavioral differences are noted between morphologically normal boys and girls. Newborn girls are much more sensitive to touch and sound than their male counterparts. Several day old girls spend about twice as long looking back at an adult face than boys, and even longer if the adult is speaking. A girl can distinguish between the cries of another infant from other extraneous noises long before a boy. Even before they can understand language, girls do better at identifying the emotional context of speech.
Conversely, during the first few weeks of infant life, boys are inattentive to the presence of an adult, whether speaking to the infant or not. However, baby boys tend to show more activity and wakefulness. At the age of several months, girls can usually distinguish between the faces of strangers and people they know--boys usually do not demonstrate this ability.
As infants grow into children, the differences seem to intensify and polarize. Girls learn to speak earlier than boys and do a better job of it. Boys want to explore areas, spaces and things, girls like to talk and listen. Boys like vigorous play in a large space where girls like more sedentary games in smaller spaces. Boys like to build, take things apart, explore mechanical aspects of things and are interested in other children only for their "use" (playmates, teammates, allies, etc.). Girls see others more as individuals--and will likely exclude a person because their "not nice," and will more readily include younger children and remember each other's names. Girls play games involving home, friendship, and emotions. Boys like rough, competitive games full of "'zap, pow' and villainy." Boys will measure success by active interference with other players, preferring games where winning and losing is clearly defined. In contrast, girl play involves taking turns, cooperation and indirect competition. Tag is a typical boy's game, hopscotch is a girl's game.
If "Brain Sex" is controversial, the fourth attribute of Sexual Orientation is ever more so. Although there is public and political controversy, the overwhelming majority of medical and psychological practitioners agree that sexual orientation may prove to be mainly congenital, or at least firmly established in early childhood. The term "Sexual Orientation" is a bit misleading. It is more an erotic or love orientation in that Sexual Orientation determines the physical gender we find attractive, with whom we fall in love, and have romantic as well as sexual fantasies.
From experiments with animals, "experiments of nature" in humans, and genetic and neurological studies come a consistent, though still circumstantial, stream of evidence that indicates one's sexual orientation is largely hormonally determined by the presence of testosterone at key periods in fetal development, and possibly even beyond. As we have seen with congenital adrenal hyperplasia (CAH), female fetuses exposed to testosterone-like agents develop a 50/50 chance of a lesbian versus heterosexual orientation if raised as girls. Studies of identical twins also indicate that when one twin shows homosexual or lesbian expression, there is a 50/50 chance of homosexual or lesbian expression in the other twin—whether raised together or apart.
The remaining 50% of determination may be continued hormonal development, environmental considerations or a combination. One interesting consideration with determination may be during our early postnatal development since the fetal stage for human babies is not completed during gestation, but continues for a year or more outside the womb. And during this critical time after birth, we have the highest level of testosterone present, excluding the onset of puberty--with many brain receptors to receive this powerful hormone. At any rate, between the ages of three and six years, one's erotic orientation is established but may not be acted upon for decades, if at all.
The last of our five attributes, Gender Identity, is the last to be identified, and the least understood and researched. When one's Gender Identity does not match their Physical Gender, the individual is termed Gender Dysphoric. Like Sexual Orientation, gender dysphoria is not pathological in itself, but a natural aberration occurring within the population. As with sexual orientation, the percentage of the population having gender dysphoria is in dispute, with estimates ranging between one in 39,000 individuals to three percent of the general population.
Although it is useful for psychotherapists and other behavioral scientists to use diagnostic nomenclature in order to describe an individual, we must remember that these categories are often fluid. An individual may see and express themselves for years as a crossdresser, then change their self-identity to a more transgendered or transsexual one. This change may be because the individual actually changes their self-view with age, or more information and experience lead to a clearer understanding of self.
Gender dysphoric individuals commonly, even frequently, have a sexual orientation markedly different from their gender identity, which suggests that the key periods of these formations occur at differing times. While gender dysphoric individuals display a wide gamut of incongruity and discomfort with their physical gender, three main groups have been delineated:
Those individuals with a desire to wear the clothing of the other sex are termed crossdressers. Most crossdressers are heterosexual men--one's sexual preference has nothing to do with crossdressing. Many men like to wear women's clothing in private or in public, and may even occasionally fantasize about becoming a woman. Once referred to as a transvestite, crossdresser has become the term of choice.
Transgenderists are men and women who prefer to steer away from gender role extremes and perfect an androgynous presentation of gender. They incorporate elements of both masculinity and femininity into their appearance. They may be seen by some persons as male, and by others as female. They may live part of their life as a man, and part as a woman, or they may live entirely in their new gender role but without plans for genital surgery.
Men and women whose gender identity more closely matches the other sex are termed transsexual. These individuals desire to rid themselves of their primary and secondary sexual characteristics and live as members of the other sex. Hormonal and surgical techniques make this possible, but it is a difficult, disruptive, and costly process, and must not be undertaken without psychological counseling, careful planning, and a realistic understanding of the likely outcome. Most transsexual people are born and first live as male.
Transsexuals are diagnostically divided into the sub-categories of Primary or Secondary. Primary transsexuals display an unrelenting and high degree of gender dysphoria, usually from an early age (four to six years of age). Secondary transsexuals usually come to a full realization of their condition in their twenties and thirties, and may not act on their feelings until they are much older. Typically, secondary transsexuals first go through phases that would be self-assessed as being a "crossdresser or transgenderist."
The outcomes of transsexuals vary greatly. There seems to be no significance in the outcome differences between primary and secondary transsexuals. Those who complete this gender reassignment process (the process of "transition") and have exercised due diligence throughout generally do very well for themselves and lead happy and fulfilling lives. Unfortunately, others who go through the process on a perfunctory basis may be unprepared to fully and comfortably assimilate into their new gender role. In conclusion, when we think of gender, we need to realize that many combinations in gender exist, and that they are all natural. Although most people are morphologically male or female, those who homogeneously fill all five gender categories as the same gender may be in the minority. The largest minority, but still a minority.
Carl W. Bushong, Ph.D., LMFT, LMHC
about the author
Carl W. Bushong holds a doctorate in clinical psychology, and has been in private practice since 1977. Dr. Bushong is the Director of the Tampa Gender Identity Program (TGIP), where a full range of transgender services are provided using his Informed Choice method--the individual uses their own decision-making capabilities after being provided with the necessary information and feedback to do so. In other words, the patient is ultimately in charge of the decision-making process--and has access to the facilities and expertise of a well-trained gender team.
Copyright 1995 Tampa Stress Center, Inc.
Source: Tampa Stress Center, Inc., PO Box 273107, Tampa, Florida 33688. Telephone (813)884-7835.
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Last Updated: 15 March 2016
Reviewed by Harry Croft, MD