Professor Louis Gooren runs the Dutch national clinic for gender dysphoria (when people feel that they are in the wrong body and want to be the opposite sex). This clinic is the largest in the world and Professor Gooren has been in Australia as a Visiting Professor for Concord Hospital’s Clinical Week in Sydney.
IF I WERE to say to you that there’s a clinic which is prepared to see five-year-olds who seem to be showing signs of gender dysphoria, (feeling they’re in the wrong body and want to be the opposite sex) and that this clinic countenances giving these children hormonal therapy when they’re a bit older, you’d probably be shocked, and think it’s some mad trendy affair in California.
Well, you’d be wrong. It actually happens at a highly-respected centre for endocrinology, the study of hormones, and it’s director has been in Australia for Concord Hospital’s Clinical Week in Sydney. He’s Professor Louis Gooren, from the Free University of Amsterdam.
Louis Gooren: I had an interest in sex hormones, so I started working with the transsexual community in the mid-‘70s to be precise, in ’74. For me it was an experiment as well, and it worked well; both parties liked one another. And since then I’ve treated 2,200 transsexuals. The annual inflow is very constant, we see 150 new subjects per year, of whom about 90 undergo hormonal and surgical treatment per year. It remains very, very stable over time.
Norman Swan: So what’s your definition of transsexualism?
Louis Gooren: Transsexualism is the incorrigible feeling to belong to the other sex. I mean you have a male body, intellectually you recognise that, but you don’t feel it’s yours. You feel it’s a mistake; your feeling is to belong to the other sex, and in that way you cannot be corrected. No-one can convince you it should be otherwise. There’s no way out for transsexuals then to adapt the body to the mind.
Norman Swan: And you talk about diagnosis. How do you diagnose? Are you talking about making a physical diagnosis here of transsexualism?
Louis Gooren: No, not yet, it may come in the future, when we understand more about the brain physiology of transsexualism. But now we have to rely on the self report of the transsexual, and that alarms a lot of medical people, it alarms a lot of lay people. How can you trust people in this regard? I can tell you from working over 25 years with transsexuals, that no-one does it for fun. And everyone who thinks reasonable about this, who would go to a doctor and have the doctor tamper with his or her genitalia? There’s absolutely no attraction in this. So it’s only genuine transsexuals that seek this type of help.
Norman Swan: And you say you see them as experimental subjects, I mean it’s obviously with their consent, and they’re willing to be part of that. What sort of studies do you do?
Louis Gooren: Well we have an interest in finding out why people become transsexual, and let me tell you immediately that I still don’t know, after 25 years, and seeing more than 2,000 transsexuals. But in our understanding of the functions of sex in animals, we know now that it’s not enough to have egg cells and sperms and the appropriate gonads, you also need the brain programming to act like a male rat or a male horse or a male peg, or a female rat, a female horse or a female pig. And that seems to be the case with the human race too. You need a brain programming to live like a man and to act like a man. So I mean, it’s not enough to have a penis and sperm cells, you need a programming of your brain to bring them into the female vagina to meet with an egg cell, and the other way around for women.
So what we usually do in human life, is to assign someone born with a penis to the male sex, and someone born with a vagina to the female sex. And that’s all right, I mean no need to change that practice. But we know from our scientific investigations that the brain differentiation has not yet taken place at that stage. It takes place after birth.
Norman Swan: Environmentally or genetically? Because there’s been a huge debate about that.
Louis Gooren: We don’t know. I think it’s a kind of biological automatism, because it almost never goes wrong. If it would depend on the environment I would be inclined to believe, and I can only say ‘inclined’ to believe, that there would be more mishaps. But nearly all this, this goes all right. The brain differentiation is almost always in accordance with the genital criterion, so if you have a penis it’s almost certain that you have a male brain differentiation. Say only in 60 to 70 males in a country like Holland of 16-million, that it goes otherwise.
Norman Swan: And how many females?
Louis Gooren: About one-third of the total population of transsexuals, so we see 150 patients with gender problems per year, and two-thirds are men and one-third are women.
Norman Swan: The one area of confusion, before we get to the biology of this, is between sexual preference and sexual identity, and the degree to which they overlap.
Louis Gooren: There’s no overlap. Sexual identity is ‘Do you identify yourself as a male or as a female?’ and sexual preference is the person you like to have sex with. And these are two entities in one person, the two separate things in one person, to take up the example of sexual orientation. Homosexuals, meaning male or female, have no problem in accepting their body as it is, and that’s exactly the problem of transsexuals; they cannot accept their biological body as it is.
Norman Swan: So you can have a male who identifies himself as a female, and is attracted to females?
Louis Gooren: That happens.
Norman Swan: So in fact when the sex change operations occur, they’re effectively lesbian?
Louis Gooren: Yes, right, that happens. But what we are trying to do with transsexuals is to reconcile their own image of themselves to their outer experience, and that’s what is our task. Actually we don’t worry very much about their sexual orientation, that’s something they must resolve in privacy.
Norman Swan: And before we get to hormones, let’s talk about the brain. It’s hugely controversial, this whole issue of brain sex, can you tell about somebody their sexual orientation from looking at their brains and their brain function? Can you tell about their sexual identity? What have you found?
Louis Gooren: We have found, and this was in post-mortem studies, that a certain nucleus in the hypothalamus, which is one of the older parts of the brain in terms of evolution, has certain sex differences. The sex differences are minimal; the vast majority of the brain is identical in men and women, but there are certain areas in the hypothalamus that differ between men and women. One of those areas is the brain nucleus of the stria terminalis, that’s a technical term, but it refers to a certain part of the brain, that is different in men and women in terms of size, in terms of number of cells, in terms of chemistry of that part. And we found in the brains of male to female transsexuals, or males that had adopted the female role, it was identical to the type of nucleus found in ordinary women. And the other way around, but our studies are less advanced in the female to males. In two brains of females to males we have found that this part of the brain is differentiated in a male way.
Norman Swan: So you’ve circumstantial evidence that that is cause and effect, that that region of the brain might well –
Louis Gooren: Well at least we see a correlate, but we don’t know what comes first, the identity and then the brain nucleus, or first the brain nucleus and then the identity, but at least we find it correlates; we find at a certain level a different organisation in the brains of transsexuals in comparison to non-transsexuals.
Norman Swan: Now the hypothalamus carries out some very basic functions in the body, to do with regulation, regulation of temperature, appetite, hormones. What’s this bit of the brain doing?
Louis Gooren: No-one knows really. Most of our information on the brain does come from mishaps in the brain. In experimental animals it’s easy, you simply eradicate that nucleus and see what functions fail. But you cannot do that in a human subject. Now all the information that we have on human subjects, come generally from all the medical things that go wrong in a body. If that particular area has a tumour in it and doesn’t function any more, what function is missing. But this information we don’t have with regard to the sex differences in the brain.
Norman Swan: You’ve also, being an endocrinologist, looked at the hormones in transsexuals. What do you find?
Louis Gooren: We find very interesting things. That’s easy to say, but what do I mean? It may be interesting for your audience to know that the findings of what hormones do in transsexuals are very relevant for the general public. Now there is big talk about what hormones do for male and female bones, and in transsexuals you can very precisely study what the male hormones do in female bones, and what female hormones do in male bones.
Norman Swan: This comes from the therapy rather than the pre-treatment situation?
Louis Gooren: Right, that’s right.
Norman Swan: Before we get to the therapy for people with transsexualism, what about the natural state? Is there any difference in hormones between transsexuals and non-transsexuals?
Louis Gooren: There is none, there is absolutely no difference between transsexuals, homosexuals and heterosexuals.
Norman Swan: So when you treat, say a man who believes himself to be a woman and you’re now going through the process of turning him into a woman both hormonally and physically eventually, just give us an idea of the cocktail of hormones that person receives, and what does the woman receive who wants to become a man?
Louis Gooren: It’s relatively easy. For a person who is a man and wants to become a woman, you give a hormone that suppresses his testosterone, and then you add a feminising hormones, an oestrogen. And in female to males you only give an androgen, that’s to masculinise the body.
Norman Swan: So it’s almost as if you’ve got an experimental situation here of testing out these hormones and of course these hormones exist already in males and females but in different proportions.
Louis Gooren: Right.
Norman Swan: Well just play it out for us then, testosterone in a woman; what have you found that it does?
Louis Gooren: It does a large number of things. We have been very carefully studying the effects on bones, and what you see is that the bone metabolism changes, the bone turnover becomes faster. They lose bone faster, but they gain bone faster and the net result is the same, they maintain bones. But the oestrogen does a much better job in the males. It’s much more easy to preserve bone mass in males receiving oestrogens, than in females receiving androgens. And there’s a lesson to learn: now we know that in the general male population, oestrogens are terribly important for preservation of the bone mass. Say with declining testicular function with ageing, we must take care that there are sufficient oestrogens around to keep male bones healthy in old age. And that’s an important message.
Norman Swan: Your point is that if you want to protect the bones, you’ve actually got to give some oestrogen as well, testosterone’s not good enough.
Louis Gooren: Yes.
Norman Swan: What about coronary heart disease? Because you’re talking about people who are genetically male or genetically female. Does oestrogen in men protect against coronary heart disease?
Louis Gooren: It doesn’t seem to. I mean we were impressed with our results and females receiving androgens, how little effect they had on all kinds of risk factors in terms of cardiovascular disease. So it’s the whole story that androgens are responsible for a high level of cardiac disease in men, must be revised probably. It’s other factors, maybe lifestyle factors.
Norman Swan: In effect then, what you’re saying is that apart from effects or lack of effects on bone, you’re not seeing, and the obviously masculinising thing such as growing facial hair and gaining a bit of muscle, you’re not seeing any of the nasty side effects.
Louis Gooren: Not many.
Norman Swan: What about cancer?
Louis Gooren: No, we have not seen hormone-related cancers in transsexuals. There are cancers in transsexuals, but –
Norman Swan: Not more than in the general population.
Louis Gooren: No.
Norman Swan: The interesting corollary of that is to do with – we’re talking about just before the Olympics, where people get very upset about the idea of androgens, basically male-type hormones, to build muscles, and the whole steroid phenomenon in gymnasia where people say, ‘Look, these are dangerous drugs.’ The implication is that maybe they’re not as dangerous as people suggest.
Louis Gooren: You’re talking about different dosages of hormones. Many of these athletes stuff themselves with hormones, they use, say, ten times the recommended dose for treatment of men who are testosterone deficient. And there’s another entry into the problem. I mean if you compete in sports, you must compete fairly, you must not get an unfair advantage over other people; these are two things to keep in mind when you address this issue.
Norman Swan: What then have you learnt, apart from what you just said, about the treatment of osteoporosis, of bone disease, from your work?
Louis Gooren: What we have learned is if men are testosterone-deficient and you’ve replaced them with hormones like the androgens we do, you have to carefully look into the situation of the bones, whether it’s enough, and whether maybe you have to add oestrogens to keep the bones strong and healthy.
Norman Swan: And in women, because some endocrinologists would use male hormones in women to build the bone when they’re getting desperate.
Louis Gooren: Yes, it has a different action in comparison to oestrogens, but it seems that oestrogens are capable of keeping the bones relatively strong.
Norman Swan: Would you then say that it’s been overplayed, the role of male hormones in women, particularly elderly women, as a treatment for osteoporosis?
Louis Gooren: It could be, it could also be another way of treatment that you say I limit the amount of oestrogens and I give some androgens in addition to keep the bones healthy, but these are extremely delicate and difficult issues and it’s hard being able to give a simple yes or no answer.
Norman Swan: Do transsexuals who’ve been treated have shorter life spans?
Louis Gooren: Not that we know of, but we need much longer follow-up of the transsexuals, but in say, over the 25 years I’ve been treating transsexuals, there’s no increased mortality, no increased death rates, and no increased disease rates.
Norman Swan: Let’s come the full circle, talking about the people themselves who have gender dysphoria. You treat people quite young; how young?
Louis Gooren: Well we get to see people at the age of five, six, seven.
Norman Swan: Five, six, seven?
Louis Gooren: Yes. And your listeners should not panic, we are not giving hormones to these young kids. But they are followed up and they are able to tell their story, and they have the certainty when their problem is serious, they will receive treatment when they are older. And what we know now of our limited experiences, that not all these children who show cross-sex behaviour, I mean the girls that like to play football or boys who are rather sissy, and like to sit down with a bit of embroidery and not playing with the boys, do become transsexuals, that’s certainly not the case. Some become homosexual, but the children have the certainty when they are transsexual when they turn out to be transsexual in the future, that they are treated. It requires many, many years of follow-up and I would say five, six years, and you get to know something about someone if you follow-up someone five or six years. And the most courageous we have done is to give hormones to pubertal children, that are not hormones that belong to the other sex, but hormones that block their own pubertal development. So if you think you are a girl and you go through male puberty and you become big and tall with big bones and a big jaw and get hairy, that bit can be spared with the type of hormone treatment we give. We are not inducing female sex characteristics at that age.
Norman Swan: You’re just holding back the male ones.
Louis Gooren: Yes.
Norman Swan: How often do you do that?
Louis Gooren: Not very often, say five, six cases per year.
Norman Swan: Give me a typical story that leads you to be confident about doing that and advising the parents accordingly. How dysphoric does the child have to be?
Louis Gooren: Very dysphoric. I mean some children start out not to behave ever as a person of the biological sex they seem to belong to, and they always behave like people of the other sex. They become extremely squeamish when they are put in a category of the biological sex. Parents see that, and mostly the parents are the biggest supporters of these interventions. They say, ‘It’s hopeless, we cannot fit our child into the category of sex you would think the child belongs to.’
Norman Swan: If you take the 2,000-odd people that you’ve treated; on average, what age do they tell you they first felt as if they were the opposite sex?
Louis Gooren: Almost invariably they tell you that they started fairly early in life, and it waxed and waned for some of them, and certainly puberty was hell for them. They really become someone who they were not. I mean if you are man and you think you are a woman and you get these big bones and big jaws that most Caucasians get, and the hairiness that most Caucasians get, it’s really becoming the person you are not, and that’s really very terrible for people. And to undo these things later in life comes at enormous cost and enormous pain, so it may handicap you all your life. I mean we’re all subject to the tyranny of the eye; we judge people by what we see. And if you see a woman big jaws and big hands and big feet, however gentle you are, you have an association. This can be spared if you treat early. And I recognise the responsibility that we have by being very, very careful. But these decisions are not taken overnight, these are decisions of five, six years of follow-up of the subject.
Norman Swan: And if you made a mistake, can you stop the treatment and then go into puberty, even at the age of 20, 21?
Louis Gooren: Yes, you can revert it, but we have not seen cases like that in our pubertal cases. As I said before, the parents are mostly the biggest supporters of the decision to treat these children because they know their children well.
Norman Swan: Do they end up very tall? Because one of the things that happens in puberty is that the epiphyses, the growth plates at the bends of the bone, close over, so you stop growing, and that’s under hormonal control, so when you stop puberty, do you then get a kind of unlimited growth happening, these people are very tall?
Louis Gooren: Not unlimited growth, and we have other small endocrine tricks to stop that growth by giving say rather inactive hormonal compounds that stop that growth. And ideally, we would like to see the boys who become girls to be a bit smaller and girls who become boys to be a bit taller. So the average difference in the western world between men and women is not centimetres.
Norman Swan: It’s loaded stuff, isn’t it.
Louis Gooren: It is. And some people would claim that we take the position of the Creator.
Norman Swan: Or the Patriarch?
Louis Gooren: Yes, but that’s not true; our aim is to help people.
Norman Swan: Do you have women in your clinic as well, women therapists, female doctors and so on?
Louis Gooren: Oh yes. The therapist who looks after these younger children is a lady, and has children herself. She’s extremely careful and responsible and everyone is welcome to visit her clinic and see how careful she is. Holland is a nice place, but people are looking over your shoulder, the government is, the health inspector is, the media are, and rightfully so, I mean people have the right to know. But we are able to defend what we do, because we don’t make overnight decisions and we ourselves are very conservative. You would not believe it, but –
Norman Swan: I believe it.
Louis Gooren: Very kind of you.
Norman Swan: Louis Gooren, who’s Professor of Endocrinology at the Free University of Amsterdam. And he tells me that the long-term follow-up of these children that they treat in puberty shows they adapt quite well, because when they come to adulthood, they actually don’t look like men or women, so the endocrinal help they need is less.
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