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PAIS and MAIS Ligand-Selective and the Organic Ethiology of Gender Dysphorias
http://www.gendercare.com/library/wal_original2.html
PAIS and MAIS
Ligand-Selective and the Organic Ethiology of Gender Dysphorias
By Wal Torres#
& Pedro Jurberg *
# Wal was a MS in sexology candidate, at UGF-Rio, Brazil
* Pedro Jurberg,PhD, is a neurobiologist from Instituto Oswaldo Cruz, Rio,
Brazil.
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Copyright © 2001 by Gendercare.com. All rights reserved.
Abstract:
Gender may not be defined anymore only by genitals and sex of rearing as determining factors: after David Reimer's revelation of the truth about what he suffered oppressed by sex of rearing "therapy", we need to renew our gender criterias. We propose the neuro-psychical identity as a new gender main criteria, and that gender is independent of the genital conformation because the sex hormone that determines genital external conformation is DHT, thru its action over the androgen receptor AR, but testosterone-T is the main responsible for the neural gender organization in humans. The gender discord between those two biological systems may occur, generating the dysphoria, naturally or thru a genital surgery (as in David Reimer's case). It is important to study the hormone-selective binding characteristics and expression (T-AR and DHT-AR) to know if that action in mild androgen insensitivity syndromes-MAIS and partial syndromes-PAIS explain some dysphoric situations in transsexuals (MAIS) and intersexuals (PAIS). A diagnosis test for children and youths may be developed, and gender understanding must be renewed.
Key Words: Gender identity/ gender dysphorias/ androgen insensitivity
syndromes/ intersex/ transsex.
The androgen receptor (AR)
is a ligand-activated transcription factor that mediates male sexual
development. AR binds the two biologically active androgens, testosterone(T) and
dihydrotestosterone(DHT), with high affinity (Zhou et al 1995b). AR is not
tissue or ligand specific, but its action is ligand dependent. There is a
database (Gottlieb et al,1998) of AR mutations. Despite AR being not ligand
specific, its action may be ligand-selective. Sometimes both ligands T and DHT
are uneffective; sometimes DHT is less effective; sometimes T (Gottlieb et al,
1999) .
In PAIS and CAIS (complete AIS), the action of DHT-AR is abnormal (it generates
genital malformations- levels 2 to 7 in Quigley's scale--- see Quigley et al
1995); in MAIS maybe there is no problem with DHT-AR (they don't show any
genital malformation- level 1 in Quigley's scale), but possibly T-AR may have
important abnormalities (they show undervirilization: gynecomastia, or small
penis, and/or a dysphoria, etc.). The abnormalities in T-AR are less visible and
less studied than DHT-AR, because they mediate--- during fetal stage--- "more
invisible processes" (Zhou et al,1995b), in more invisible tissues.
Some genital malformation or intersex don't generate gender dysphorias. Gender
dysphoria means "to have an uneasiness with its genitals". CAIS don't generate
dysphorias, because all tissues remain female and there is no inner discord.
Some PAIS and MAIS cases also don't generate dysphorias. Gender dysphorias
happens when there is a gender discord between genital and neural tissues. That
situation may happens:
(1) When baby boys have their genitals mutilated, or micropenis, and are
surgically transgenitalized to females and reared as girls. For example, the
John/Joan case (David Reimer's), described by Nussbaum,2000;Diamond &
Sigmundson,1997; Fausto-Sterling,2000; Colapinto,2000;
(2) when happens the discord between the neural gender (male) with ambiguous
(female like) genitals, as in Imperato McGinley's syndromes: recognized as
girls, reared as girls in all cultures and continents, later they show they are
boys;
(3) some PAIS situations, when the genitals are more female, but the neural male
(in most PAIS cases there is harmony between genital and neural gender, both
female or male);
(4) True hermafroditism when the genital option (by surgery decision made by
adults: parents, psychiatrists or surgeons) is not in accord with the child
neuro-psychical gender identity (showed later by the child expression and
living);
(5) "transsexuals", when the neural and genital gender are naturally in radical
discord, without any visible genital external conformation problem.
How we may evaluate those situations?
What could
be a good criteria?
John Money's criteria (genital conformation and sex of
rearing --- see Money & Ehrhardt 1972; Money & Tucker 1975) really isn't a good
criteria: the true story of David Reimer show us John Money's model of gender
identity formation was a fake and not the reality (see Diamond 1996; Diamond &
Sigmundson 1997; Colapinto 2000; Fausto-Sterling 2000) --- Money and his
co-workers wrote and published their opinions and not what the patient (David
Reimer) really lived as gender identity, as truth-they ignored the patient's
reality, publishing their opinions as truth and unfortunately being believed:
they trapped doctors, sexologists and psychologists.
Considering:
(a) Our neural organization has its congenital and
irreversible gender determined in a neuroendocrinal way (Imperato McGinley et
al, 1979; Bonsall & Michael 1989; Resko et al 1988; McEwen, 1994, Zhou et al,
1995a; Kruijver et al, 2000);
(b) That gender neural organization generates in the foetus and baby a psychical
gender identity as an emotional priming (see Damasio 1994; Torres & Jurberg
2000; and Torres & Jurberg in other article in this volume); and that
(c) rearing, culture, hormones at puberty: modulate, inhibit or reinforce, but
don't determine the gender of our identity (Imperato McGinley1979; Wilson,JD,
1999);
We
propose as a 1st gender classification criteria:
What determines the neural gender is prenatal T as what
determines the external genitals gender is prenatal DHT: in humans as in other
primates (Bonsall & Michael 1989, Resko et al, 1988). The gender identity is
determined by the dynamic complex evolution and psychical expression of that
neural differentiation (see the other article of Torres & Jurberg in this
volume).
To evaluate properly gender in transsexual and intersexual dysphorics it is
important the selective action of T-AR and DHT-AR in PAIS and MAIS, researching
functional activity and gene expression not only of DHT-AR and artificial
steroids-AR, but also T-AR (see Gottlieb et al 1999).
What we may today do in mosaic situations? In the genital tract
(DHT-AR action) we may know , but in the neural (T-AR)?
We propose as a 2nd gender classification criteria:
In complex situations: wait the child own manifestation thru
its neural system of who it is, boy or girl: they have the best neural sensor
possible: their selves .
We propose a 3rd gender classification criteria:
When happens a
dysphoria in a genetically male child, it would be important to study the child
in the molecular level, with or without genital malformations , when it is
feasible --- or wait and believe in the identity showed by the child.
Those 3
criterias may prevent dysphorias
when there are genital malformations, and a test procedure to
evaluate dysphorias in children may be developed. When malformations don't
happen we may not prevent, but we may diagnosis soon (the child show a dysphoria
between 5 to 8 years old if with liberty and no social repression --- as a
"sissi boy" or "effeminate gay boy", for example), and correct the children as
soon as possible--- beginning with 10 to 12 years old at least, before the child
will be too traumatized by society (see Cohen et al, 1997) and the body
structure defformed by hormones.
The ligand-selective test may prevent consequences. If not, we will need to wait
that the victim show its identity freely, before any surgery and final legal
gender classification is irreversibly d etermined. It is better to sacrifice
family and society, delaying the social and civil legal decision --- as Freitas,
1998 proposed --- knowing that doing this way we will prevent some children
sufferings.
The ethical position we support today is:
Don't define anymore gender in a rash, heteronomous and
authoritary way, because that rash action may mutilate children, and originate
dysphorias --- see David Reimer's and Cheryl Chase's stories and arguments
(Fausto-Sterling 2000; Colapinto 2000). Therapists and surgeons know gender
dysphorics by the outside only --- thinking they have problems to understand
reality (see Mormont, Michel, Wauthy, 1995), when they are the only to really
know and live themselves by the inside, knowing their true reality (see Freitas
1998).
Today, no result or fact is in contradiction with our 3 criterias; but first of
al we need a positive confirmation of them from lab gene expression results in
PAIS and MAIS intersex and transsex --- and to do that we need a molecular
endocrinology lab to continue our project .
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Paris, June 2001
Universidade Gama Filho- Rio, Brazil
WF Torres supported by Capes.
Presented at the 15th World Congress of Sexology, Paris 2001
http://www.gendercare.com/library/wal_original1.html
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Copyright © 2001 by Gendercare.com. All rights reserved.
Abstract:
Since 1955 John Money introduced the concept of "sex of rearing" as the determining factor for gender identity erection. Some authors as Diamond, Imperato-McGinley, Reiner, Freitas; and now the true hystory of David Reimer described by Colapinto --- the twin transgenitalized by Money as he reported in 1972/75; show that "sex of rearing" may not be that determining factor. Based in the evidence of the neural differentiation of basal neural nucleus in the human brain, consequently there is a psychic differentiation in the human fetus; in the differentiated hormone action in genital and neural basal tissues organization (hypothalamus, stria terminallis and amygdalas); and in the possible hormone differential action in AIS (androgen insensitivity syndromes), we propose a new model for gender identity formation: by an autonomous neuro-psychical dynamic process that ends priming the gender identity in the human child (from gestation to 3 years of age).That gender identity can't change by social or cultural rearing factors, social identifications or any other social pressure against the child. If the social pressure is syncronous or lightly assincronous with the neuro-psychical gender identity--- lived by the child as a deep feeling to be a boy or a girl--- the identity naturally stabilizes in a steady state. If the pressure of society is hard against nature, will happen a disturbance, the child becoming insecure, neurotic, probably aggressive. If the pressure is too hard, may happen chaotic feelings of destruction, mainly self-destruction . So we propose a revision in our gender concepts and evaluation of gender dysphorias (not anymore as GID's, based in Money's model), based in a neuro-psychical paradigm and not only in a genital paradigm. We hope that understanding (the dysphorias as a neural discord --- so a somatic, biologic and organical congenital problem) will also help gender dysphorics legal and social integration. Today no clinic, lab or scientifical result show this possibility may not be true.
Key-words: Gender identity/ brain's gender/ gender paradigm/ gender dysphorias/ hormones and gender/ intersex and transsex.
Freud, Money and the Myth
Based in Freud's concept of "bisexuality" of the psyché (see Freud 1905) ---
really gender undifferentiation --- Money,Hampson,Hampson, 1955 proposed a
social constructivist theoretical gender model, and a "sex of rearing" therapy
for gender dysphorics. The child would "learn to be a boy or a girl, as learns a
language" during the first childhood, gender being molded by the social rearing-
that was Money's main idea.
In 1966, two identical twins suffered circuncision, and one of them was
mutilated, having his penis almost entirely lost (Money & Ehrhardt 1972; Money &
Tucker, 1975; Diamond & Sigmundson 1997; Colapinto 2000).
Money suggested the surgeons could reassign the genitals of the boy to the
female, because the boy would learn to be a girl if its family, doctors and
therapists would teach him continuously he was a girl--- and they agreed. The
transgenital surgery was done, and they tried to teach the child to be a girl:
he looked like a girl after the surgery, he was dressed with female clothes, was
reared as a girl, with a girl's name, learning to play with girl's toys,
learning girl's manners. The boy made an effort to be a girl: he don't knew what
happened when he was a little baby. He tried hard and hard. But he was not a
girl, he could not succeed.
Later, they start giving him female hormone therapy. The boy took estrogens,
developed breasts, and as he today says (Colapinto 2000), he was psychically
submitted to a torture. He lived a terror situation each time he would need to
go with his parents visit Money at the Johns Hopkins Hospital.
With 14 he and his brother were informed about what happened when they were
babies. They were shocked and he immediately start living as a boy, as he had
the inner belief since his first childhood. His parents supported him. Later he
get married with Jane, a normal woman; was transgenitalized to the male the best
way possible, and took the name of David.
During more than 40 years that history was not showed to sexologists,
psychologists, psychiatrists, endocrinologists and general public. What the
academy and the general public knew was only Money's version, and never David's
version of the efficiency of "sex of rearing therapy".
In 1994, Diamond found the twins - see Colapinto 2000 --- and Money started
showing he was rethinking his "sex of rearing" ideas (Money 1994), recognizing
for the first time the human brain was not gender undifferentiated as thought
Freud, and could happen the dysphoria as a discord of gender between the neural
and the genital biological organizations. Diamond 1996 and Diamond & Sigmundson
1997, started saying what really happened.
But for David and other boys reared and reassigned as girls, and for a lot of
others prematurely surgically reassigned based in sex of rearing "therapy", it
was too late --- see the more than 1500 intersex dysphorics of Intersex Society
of North America (Fausto-Sterling 2000, Nussbaum 2000). The same happens with
other gender dysphorics, without any recognized genital malformation at birth
("transsexuals").
Now that the truth about David Reimer is spread thru books, papers and internet,
we need to rethink gender identity formation, considering new points of
principle. We intend to show how the identity and its gender may be primed in
the neural system, in harmony with the genitals or in discord with them. And we
intend to show how important is to study gender and gender problems.
The human brain has a
gender
Phoenix showed the guinea pigs had a gender differentiated brain, organized by
steroid hormones during a defined time (see Phoenix et al 1959).
Later, other authors showed the same for primates (Resko et al 1988; Bonsall &
Michael 1989). Some said hormones were important for animals, but not for gender
identity of humans (Money & Ehrhardt 1972; Money & Tucker 1975; Ehrhardt &
Meyer-Bahlburg 1981). Some said hormones were not important for gender identity,
but perhaps only for gender roles! (Ehrhardt & Meyer-Bahlburg 1981).
In humans some neuro anatomical organizational gender differences were
discovered (see Swaab & Fliers 1985; Allen et al 1989; Zhou et al 1995; Kruijver
et al 2000). All those differences were discovered in the hypothalamus, stria
terminalis and amygdalas--- a neural basal system named by Newman 2000 as the
Social Behavior Network -SBN.
Zhou et al 1995 and Kruijver et al 2000 showed, in human stria terminalis, male
nucleus are 1,5 times the female, and in normal and dysphoric females (female
identities) those nucleus are female, and male in normal and dysphoric males
(male identities); and no hormone or social condition could change that fact
after birth.
Those facts suggest the gender identity formation depends on neuro-anatomy of
SBN basal systems, and the neural organization of the SBN depends on:
I. The sexual hormones during SBN gender differentiation in fetal stage of human
and other primates development (see Imperato McGinley et al 1979; Clark et al,
1988; Resko et al 1988; Bonsall & Michael 1989; Zhou et al 1995; Wilson 1999;
Kruijver et al 2000).
II. For humans and other mammal species the gender differentiation depends on
the action of testosterone-T thru the androgen receptor- AR and not on the
action of dihydrotestosterone-DHT (see Imperato McGinley et al 1979; Resko et al
1988; Bonsall & Michael 1989) or the aromatization of T (see Ogawa et al
1997,1998a and b,1999).
III. For humans, the genital tract surely is only differentiated by DHT --- see
Wilson et al 1980.
The independence between neural and genital gender is a consequence of those
arguments. So we may say it is possible to happen the organic, biological,
somatic discord between neural and genital gender, with or without genital
malformation.
The relation between the neural and the psychical
If the human fetus is neural gender differentiated, that neural differentiation
needs to promote a psychical expression --- see Damasio 1994 --- so the child is
necessarily psychically gender differentiated since its fetus stage. But how the
neural organization becomes psychical translation and expression?
Based in Damasio 1994, we may develop a model for gender identity formation
simulation as a simple and first possibility--- certainly not the best, and
surely not the last.
Gender Identity Modeling and Simulation
A good model is one that describes and simulates something with a desired
precision.
The precision of the simulation may be established and later measured and
verified by control conditions.
For the gender identity dynamical neuro-psychical formation model we establish
here, we will use Damasio's neurobiological dynamics and as control conditions
the dysphoric living and existence. If that model describes well a normal and a
dysphoric gender identity formation, it will be a good model for that first
stage of our proposal.
We know very well that all simulation model is a reduction of our possible
knowledge of all phenomena --- but we may develop knowledge only by reducing the
reality to our models--- that is an episthemologic basic principle.
Obviously we may be criticized because our model will be too simple and the
neurobiology of Damasio is a knowledge still too incipient also; but surely as
soon as possible other neuro-psychical models better than this one will be
developed. That is only one of the models possible, and surely not the best: but
its results show that for dysphoric's simulation it is a good first model for
further developments.
With the development of neurobiology and neuropsychology, new models better than
this one will surely be developed, but even this so simple one show good results
for the present moment of our development --- much better, for example, than the
results showed by Money's social constructivist model.
The model description and the simulation of a dysphoric identity formation is
described as follows:
I.At birth, the SBN is gender differentiated. May be organized as male or female
(really other possibilities exists- as showed Colapinto 2000 in people that
feels as androginous, without female or male identities --- but our model don't
consider that possibility). In the future, new and better models will consider
what now we ignore.
II.The child always is exposed to an environment: as a fetus, its mother is its
environment, and after birth, the world.
III.The environment is continuously introducing, thru the senses, stimulous to
the brain. As the inner visceral and tissue's sensations are also continuously
sending internal stimulous to the brain.
IV.Those stimulous to the fetus and the unconscient baby's brain is continuously
stimulating autonomous answers of basal nucleus of the brain (see Damasio 1994).
One of those systems is the gender differentiated SBN, that will answer
autonomously a gender differentiated answer, depending only from its neural
organization --- and not on the environment conditions (after the ending of the
neural organization), or the genital conformation.
V.That answer will be continuously retained by the memories --- priming
emotional memories --- in the limbic system, unconsciously.
VI.For example a female SBN will react autonomously with female-like answers:
less aggressive, with more receptivity, more female sensibility --- in resume,
autonomously in a female way.
VII.The same way, the male SBN will react in a more aggressive way, more
assertivity, more activity. All those answers end priming the emotional memory,
since gestation and first childhood.
VIII.Those gender differentiated answers will constinuously reinforce positively
the memory of gender from the SBN, as a fetus and as a small child, just until
2,3 years of age, unconsciously. Later, that reinforcement will continue,
forever.
IX.The female brain of the little child will predispose the child to like to
play and have female manners: to play dolls and house, have "sissi" feelings,
because has a female SBN; and fight and play boyish toys, and develop male
manners and feelings if had a male SBN.
X.The genitals don't play nothing in that dynamic process that erects as a
priming the gender identity as the feelings to be a girl or a boy.
XI.One day the child with 4,5 or 6 will feel consciously that identity, those
memories and natural gender differentiated answers it lives since it was a
fetus, always as a continuous positive reinforcement, as a belief and
self-recognition and inner sensation as a certainty to be a boy or a girl.
XII.If it was a normal girl or boy, all will be in harmony with its genitals and
rearing: that dynamical process is naturally lived and is not perceived.
XIII.But if the child's SBN is in discord with its genitals, at that moment and
later on it will start living the torture to feel one gender identity, being
socially recognized by the other gender. That discord between nature and rearing
will certainly interfere with the emotional stability of the child, since its
5,6 7 years old and later --- and the uneasiness with the genitals of the gender
dysphoric will start.
XIV. The dysphoric child will have the conscience of its situation and the
courage to show others its reality, as a "primary" transsexual, for example.
XV. Or may hide its reality, and try to live as a non dysphoric one, hiding for
itself its sufferings. One day, may show its reality as a "secondary
transsexual" --- really a dysphoric that show others its gender reality only
later.
XIV.That model, aplied to dysphorics show a very good and real simulation of
their reality--- as themselves admit in a lot of testimonies --- and simulates
very well all dysphoric feelings quoted in ICD-10, F.64.2, from World Health
Organization-WHO, where are defined the dysphoric child's feelings. So, for our
control conditions and criteria, even being a so simple model, based in so
simple Damasio's neurobiological considerations, our model is a very good one
for that moment and for the present stage of development of neuro-psychical
possible translations.
The influence of the social environment
If the social environment and the sex of rearing is syncronous with the gender
identity, and also the genitals naturally or surgically are in harmony, the
child is normal, with no problem or dysphoria --- this way lives the great
majority of humans. So nobody thinks in those dynamics, and seems if the
genitals had automatically the power to promote masculinity or femininity in all
systems and tissues. But some children are dysphorics: they had a gender discord
between genital and SBN. In those situations, when the child start being
conscient of itself, will perceive its feelings are in discord with its
genitals, its name, its clothes, its social recognition. Starts the dysphoric
feelings, that uneasiness with its body, its genitals, its social situation.
The child likes dolls and play house, and has a boy's name, genitals, social and
civil identification. All will recognize in her, not the girl she always was
sure she was, but a boy: a "gay boy", an effeminate boy, a "sissi boy". That
will hurt the inner feelings of the dysphoric girl. Or vice versa for a
dysphoric boy, with a vagina, natural or made by a surgeon as David Reimer's .
The social rearing can't change or form the gender identity, but may disturb the
life of the gender dysphoric, if in assyncronicity with the neural gender
identity. The social pressure in discord with the gender identity may cause
neurosis and even psychosis and suicides.
How may be primed the gender neural organization?
Jeanne Imperato- McGinley et al 1979 had a very important idea: studying
5-alfa-reductase syndromes, they discovered that systematically, children with
that kind of syndrome had gender problems.That syndrome means the enzime that
metabolizes T in DHT don't works well. So, without DHT, the genital tract may
not be masculinized and the genitals remain almost female. The children were
reared as girls, and later, all around the world, in all cultures, after 7 they
start showing they had male gender identities. Imperato-McGinley and her
co-workers understood the neural system could be masculinized by T and not DHT
as the genital tract, and be in discord. But in those days, the "sucessfull
experience" of Money's twins don't gave the academy the opportunity to
understand Imperato McGinley could be wright, and Money wrong.
Later, Resko et al 1988; Bonsall & Michael 1989; Diamond 1996; Freitas 1998;
Wilson 1999 had the same Imperato McGinley's idea in other dysphoric situations:
testosterone may masculinize the SBN as DHT masculinizes the genital tract--- by
two totally independent processes. The congenital organical gender discord is
possible, even in humans. After Diamond & Sigmundson 1997 and mainly Colapinto
2000, we hope all will agree Imperato McGinley may be right: T may be the
responsible for neural gender differentiation, and that differentiation remains
forever, erecting the gender identity dynamically, priming it naturally and
biologically by the living of the nervous system by a somato- psychical
translation .
Gender paradigm --- a question of Ethics and Science
Who really is a boy or a girl? (Torres & Jurberg 2000).
The best classification is decided by the genitals; the genitals and rearing; or
the inner living of the certainty to be a boy or a girl?
Something neuro-psychical, independent from the genitals and the social rearing?
What is the best way to understand gender, and to choose the best referential
for gender social classification today?
In that subject, we need a revolution, as Copernicus and Kant made, for
cosmologic and philosophic principles.
We think it is ideological and ethically better to respect the human being as a
person, with its autonomous self-recognition, as a closure. Ethically humans
have autonomy as a human right. So, the real gender is the self- reference, the
certainty to be a boy or a girl, and not what others think we are, by what they
see when we are babies, in a heteronomous way.
If we respect human autonomy, we will retain as gender referential the
neuro-psychic neural gender organization, in harmony or not with the genitals.
If not in harmony, we have today enough surgical technology and hormone therapy
to correct the body to live the neuro-psychical reality in harmony, recognizing
the neural (the self) prevails over the genital. Ethically the autonomous over
the heteronomous.
No scientifical result nor existencial situation disagrees with that paradigm
today, in normal and gender dysphoric people.
Why not change the civil law? Why not socially protect dysphoric children,
respecting their autonomy as human beings? Respecting the way they see
themselves, the way they feel and exists?
Dysphorics have not GIDs- gender identity disorders, as thought Money, ICD-10
and DSM-IV psychiatrical standards. Their psychical problems --- if they have
any --- are consequence of the hardness of society against their inner nature
since they were little children, and not the responsible of the ethiology of the
dysphoria (see Cohen et al 1997). GID's as any psychiatrical disorder in gender
dysphorics is a myth --- as the efficiency of sex of rearing "therapy" was a
myth.
Sexologists, psychiatrists, psychologists, doctors, parents, pastors, priests,
judges, authorities, governors: give the dysphorics a chance to be normal; being
recognized, after its body corrections, as normal people.
Then, and only then, they will live in harmony with themselves, with their
bodies and papers, and with society; feeling they are, as the others, socially
accepted and respected as citizens. Possibly, as the others, they will live and
possibly be happy.
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Wal Torres is supported by Capes
Any correspondence, send to:
Wal Torres, Universidade Gama Filho, Rio, Brazil
Paper Presented at the 15th World Congress of Sexology, Paris 2001
