Theories about causes

• Lifestyle choice
• Environmental effects
• Psychological theories
• Behavioural perspective
• Psychiatric perspectives
• Socio-cultural theories
• Biologically-based, multifactorial cause

OVER the years, researchers and clinicians have offered a range of different theories in an attempt to explain the ‘why’ of transsexualism (TS). Some of these theories have proved to be little more than moral judgements or guesswork. Others have resulted in the abuse of human rights of transsexual and transgender people. Many times, the social values of the day informed these theories and were genuine (if misguided) attempts to explain the phenomenon.

Lifestyle choice

In the past and even sometimes today, TS has been thought to be a lifestyle choice.

Many people cross-dress and masquerade, out of curiosity or a playful form of harmless enjoyment or for the entertainment of others, or as a playful form of self-exploration. This is not TS. This activity is not motivated by an overwhelming and persistent desire for permanent changes to their body.

The theory that TS is simply a lifestyle choice holds no relevance or relief for men and women experiencing the painful predicament of a body that has developed contrary to that of their innate-sex.

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Environmental effects

In recent times, environmental factors are increasingly thought to play some part in the development of TS.(1) These factors cast a wide net over a widespread range of endocrine disrupting chemicals (EDCs) in the environment. EDCs, which mimic oestrogen and/or disrupt androgen receptors are said to interfere with hormonally sensitive tissues in mammals, including human beings.(2)

EDCs are present in the water, food and the air as detergents, plastic wrappers, cosmetics, exhaust fumes, insect repellent and herbicides, including the presence of substances in the waterways which were originally present in birth-control pills and antibiotics. Many of these chemicals are fat soluble, building up in fat deposits of fish and animals, with those at the top of food chain (usually human) accumulating the highest exposure to EDCs.(3)

Between 1938 and the 1980s, the best known EDC(4) was prescribed to millions of pregnant women worldwide including Australia. DES (Diethylstilbestrol), in the form of a synthetic oestrogen, was prescribed to prevent pregnancy complications and miscarriage. By 1939, the drug was marketed under at least 400 different brand names. The wide range of prescribing and numerous forms of the drug makes it difficult to accurately assess the numbers of women and their children who have been exposed to DES.

DES has been implicated in anatomic and functional abnormalities in the male and female genitourinary and reproductive tract(5) of children exposed to the drug in utero and has been implicated in association with disorders of sexual differentiation(6) and even TS.(7)

There is ongoing debate(8) about the effects of DES and the endocrine effects(9) of EDCs. DES could be a contributing cause just as easily as any other EDC in the environment.(10)

At best, environment factors might currently stand to be only a part of a complex web of causality. There is no evidence they are a stand-alone cause for TS.

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Psychological/Psychiatric/Socio-cultural factors

Psychological and psychiatric theories focus either on the “nurture” aspects or the “mental illness” concept of the condition. Nurture refers to all the complex interactions of family dynamics, childhood trauma or child-rearing styles. The influence of the mental pathology perspective on this variation of sex development has seen TS listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), under the term ‘gender identity disorder’ (GID), where it still remains today.

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Psychological theories

Psychological theories align into two clear divisions.(11) Both start from the same premise: the transsexual person has failed to socialise properly into their ‘correct’ gender during childhood and adolescence, resulting in an adult who has a ‘gender identity disorder’ with an urge to ‘change sex’.

Either the individual has –

i) a sexual identity fixed at a young age and only treatable by assisting the individual to live as best they can within the pathology (eg mental illness, disturbance); or

ii) a sexual identity unfixed from childhood which remains ambiguous and potentially treatable with psychotherapy.

The first idea offers a childhood-compliance dynamic; the second one offers a childhood-conflict dynamic. Either way, from the viewpoint of psychology, TS is considered to be the result of emotional disturbance(12), an attempt ‘to ward off a paranoid psychosis’(13) or a deviation(14) from a “normal healthy” sexual identity.

In terms of female-to-male transsexuals, some researchers theorise “(female) transsexualism is a defence against trauma in childhood.”(15) Other researchers report patterns in these men’s families where mothers lack a cohesive self with an envy (and jealousy) of males, which is communicated to the child; an absence of the mother’s male partner to support her; the role of the father, encouraging masculinisation in his female child; and an alcoholic and/or abusive male parent.(16)

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Behavioural perspective

In the 1950s, the ‘theory of gender neutrality’ was strongly promoted by one man – John Money, a New Zealand born psychologist who worked at the John Hopkins Hospital in Baltimore, USA.(17)

Money developed a behavioural theory that nurture was solely responsible for the formation of a person’s gender identity. His theory was the basis of the wide-spread view that gender is simply a matter of childhood conditioning during a formative time period in infancy up until around two years after birth. In this period of time, Money theorised that a child is a blank slate on which nurture acted to create all aspects of a person including their gender.

In effect, Money’s theory proposed a child can be taught to be a boy or girl depending on how they are raised, what toys they are given to play with, clothes, names and pronouns and guidance received from parents. After approximately two years, the child’s gender would become fixed or consolidated.

It wasn’t until 1997, when Dr Milton Diamond (a medical researcher) bravely discredited Money’s theory(18) by persistently tracing the evidence in the John/Joan case. (See “the John/Joan case”)

Unfortunately, the behaviourist psychology of the 1950′s-80′s remains in many tertiary textbooks and seem to still hold a good deal of influence over much of what is theorised about matters of gender and sexual behaviour. Even though the John/Joan case was not about TS, the incident illustrates the harm in giving credence to the gender-identity formation theory.

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Psychiatric perspectives

Psychiatry assumes TS is a ‘mental illness’. This perspective, based in mental pathology, goes back over four decades and has shaped psychological and psychiatric perceptions of transsexual people so deeply that the term ‘gender identity disorder’ (GID) in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), is used to diagnose TS.

Psychiatry asserts a person’s gender identity develops primarily as a result of a learning process.(19) In the case of boys with TS, it is assumed their gender identity develops with incorrect ‘imprinting’ and ‘conditioning’.(20) Unfortunately, the treatment offered by psychiatry has a history of treating transsexual people with a view to making them ‘normal’ again.

Some of these strategies include ‘aversion therapy’(21), psychotropic medication, hormone treatment consistent with the individual’s birth sex and electroconvulsive therapy.(22) Despite these forms of treatment costing thousands of dollars, there have never been any reports of a permanent ‘cure’.(23)

There is research indicating that men and women with TS experience a higher incidence of depression and suicidal ideation than the general population. When treatment is inaccessible or extremely expensive, when the human rights of these men and women are denied and while social support for their medical condition is absent, it is not surprising that depression is evident. Depression is often a co-existing factor or natural outcome of a lifetime of ignorance from medical professionals, the social enviornment and their loved ones, there is no evidence, that depression causes the condition.(24)

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Socio-cultural theories

With the spectacular failure of John Money’s gender-identity formation theory, sociopolitical theorists continued to promote the belief that TS was simply the result of rigid gender expectations in society.(25)

These theorists proposed, if society were more accepting of differences in social role, dress and behaviour for men and women, then the phenomenon of TS would gradually fade as people would no longer feel compelled to alter themselves physically. Feminist theorists have often used this line of thinking to deny the existence of TS.(26)

The theory is well-meaning. There is little doubt society has many unfortunate restrictions and biases. However, it is as unhelpful in offering a solution as it would be to offer a socio-cultural theory for the pathology of Type 1 Diabetes or asthma.

Curiously enough, many of these socio-cultural theories are espoused by gender-variant individuals themselves.(27)

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Biologically-based, multifactorial cause

At this point in time, there is no laboratory test, such as a blood test or x-ray, to diagnose TS. The cause (aetiology) of this condition continues to be investigated by researchers around the world.

“What are you doing?”
“I’m looking for the watch I lost.”
“Where’d you lose it?“
“I lost it down the street.”
“Well, why are you looking here?”
“There’s better light here.”
– Milton Diamond, 2002

Prof Diamond’s example (above) describes the way research is often carried out. Researchers often start looking for answers “where the light is better”.

It is increasingly understood TS is not a mental disorder(28), a social difference (crossing the cultural norms of a person’s society or culture) nor a ‘lifestyle choice’ (cross-dressing or performance art). It is no longer confused with sexual orientation, deviation, gender roles or other gender related disorders and cannot be overcome by contrary socialisation, psychological or psychiatric treatments.(29)

In recent years, researchers have begun to associate the condition with a neuro-developmental process in the brain.(30) In this regard, the tools of psychiatry or psychology have a role as supportive measures for men and women in this situation, rather than as diagnostic tools or treatment to ‘erase’ their feelings.

A multifactorial model for investigating TS offers the most realistic flexible approach to date, to tease out the possible and complex aetiology of this baffling and fascinating human phenomenon. Current understanding of TS stems from a combination of developmental biological and physiological causes, such as “genetic, prenatal (before birth), hormonal, postnatal (after birth), social, and post-pubertal (after puberty) hormonal determinants”.(31)

There are many possible influences on foetal brain development including genetics,(32) in-utero hormones,(33) environmental influences,(34) ageing,(35) stress or trauma during pregnancy.(36) There is even some evidence from animal models(37) that exposure to anticonvulsant medication may increase the risk of subsequent gender dysphoria in humans.

Gender identity is not the exclusive domain of either nature or nurture.(38) Current thinking includes biological factors – Nature (genetic and hormonal from conception on), as well as social and environmental factors – Nurture.

In 1996, leading practicing clinicians in the field published this statement about TS:

“…the weight of current scientific evidence suggests a biologically-based, multifactorial aetiology for transsexualism.(39)

A follow-up investigation in 2004, agreed there was probably not one cause for TS, but pointed to the growing evidence for a multifaceted, biologically-based, causality(40) for this variation of sex development.

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References

1. Johnson, 2004.
2. Murray, Lea, Abramovich, Haites & Fowler, 2001; Vreugdenhil, Slijper, Mulder & Weisglas-Kuperus, 2002; Weiss, 2002; Hayes, Haston, Tsui, Hoang, Haeffele & Vonk, 2003; Cravedi, Zalko, Savouret, Menuet & Jégou, 2007.
3. de Blas, 2003: “One of the best documented cases of endocrine disruption is the feminisation of male fish in Britain”.; Milnes, Bermudez, Bryan, Gunderson, Guillette, 2005.
4. Swan, 2000; Toppari, 2002.
5. Rubin, 2007.
6. Toppari, 2002; Ohyama, 2004; Paris, Jeandel, Servant & Sultan, 2006.
7. For more information see Cochrane, nd. www3.telus.net/des1; Dictionary of Organic Compounds, in reference to diethylstilbestrol, cites adverse human health effects include: “Causes male impotence and transsexual changes particularly in offspring exposed in utero” (1996, p2175); Michel, Mormont & Legros, 2001; Johnson, (2004), “transsexualism is an unacknowledged endpoint of endocrine disruption” (p145); Kerlin, 2005.
8. Comment by Gierthy, 2002; Odum, et al., 2002; Titus-Ernstoff et al., 2003; Palmer, et al., 2005; Brouwers, Feitz, Roelofs, Kiemeney, de Gier & Roeleveld, 2006.
9. Brouwer, et al., 1999.
10. Kubo, Arai, Omura, Wantanabe, Ogata & Aou, 2003.
11. Michel, et al., 2001; Wallbank, 2004.
12. Wise and Meyer, 1980.
13. Socarides, (1970, p348).
14. Repressed homosexuality (Green, 1987; Socarides, 1969, 1970); masochism (Volkan & Masri, 1989); “overbearing mothers and absent fathers” (Stoller, 1968); separation anxiety or abandonment depression (Roback & Lothstein, 1986); ‘unconscious’ rearing of the child in the opposite sex by caregivers (Stoller, 1969, 1975); neurotism (Bozkurt, 2006), separation anxiety (Ovesey & Person, 1973); paranoid, borderline and narcissistic personality disorders (Greenberg, Rosenwald & Nielson, 1960; Golosow & Weitzman 1969; Moberley, 1983; Lothstein, 1988; Chiland, 2000).
15. Risman, 1982.
16. Stoller, 1972; Pauly, 1974a, 1974b; Lothestein, 1979.
17. Money presented himself as a doctor, implying he had a medical degree. He had a PhD in psychology, which enabled him to use the letters Dr in his name. He had no medical degree.
18. Diamond, 1997.
19. Compare with Money’s gender-identity formation theory.
20. Gooren, nd.
21. As recently as the early 1980′s, children with non-traditional gender identity presentation and behaviour were treated in psychiatric institutions with aversion therapy to reform conduct, appearance and mannerisms to be more appropriate to their apparent biological sex. See Scholinski, 1997 (now Dylan Scholinski) The last time I wore a dress: A memoir.
22. As recently as the 1970′s people were still being ‘treated’ with electro-convulsive therapy (ECT) and aversion therapy, without ‘success’.; Reid, 2004.
23. Lothstein, 1979; Playdon, 2000.
24. Hird, 2002.
25. King, 1984.
26. Daley, 1978; Raymond, 1979; Jeffery, 2004.
27. Feinberg, 1997.
28. Reid, 1990; Green, 1999; Haraldsen & Dahl, 2000; Elliot, 2001.
29. Green, 1999.
30. Allen & Gorski, 1991; Zhou, Hofman, Gooren & Swaab, 1995; Kruijver, Zhou, Pool, Hofman, Gooren & Swaab, 2000; Swaab, Chung, Kruijver, Hofman & Ishunina, 2001; Swaab, 2002; Besser, et al., 2004.
31. Money, 1994; Reid, di Ceglie, Dalrymple, Gooren, Green & Money, 1996; Besser et al., 2004.
32. Landen, 1999; Ostrer, 2000; Coolidge, Theda & Young, 2002.
33. Ostrer, 2000; Sinisi, Pasquali, Notaro & Bellastella, 2003; Sobel, Zhu & Imperato-McGinley, 2004.
34. Whitten, Patisaul & Young, 2002.
35. Swaab, Chung, Kruijver, Hofman & Hestiantoro, 2002.
36. Ward, Ward, Denning, French & Hendricks, 2002.
37. Dessens, Cohen-Kettenis, Mellenbergh, vd Poll, Koppe & Boer, 1999.
38. Gooren n.d.
39. Reid, di Ceglie, Dalrymple, Gooren, Green & Money, 1996.
40. Besser et al., 2004.
     

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page updated 21 June 2011