An Introduction to: PROFESSOR MILTON DIAMOND, PhD
In addition to Professor Diamond's undoubted expertise in the field of sexology, this kindly, soft-spoken man has also earned the trust of those transgenders with whom he has come into contact. His advocacy for transsexual and intersex people is helping to turn the tide of medical opinion away from the notion of medical and surgical intervention to "correct" nature's "mistakes", and toward a greater understanding of biodiversity and an individual's right to exist and make decisions for themselves.
FIRST - DO NO HARM
I was born in the Bronx, New York, in 1934 to European Jewish parents who immigrated from the Ukraine right after the First World War They settled in New York, married, and I was the youngest of three kids. In those days the Bronx was a neighbourhood for people who had worked themselves out of the ghetto of the Lower East Side, and my lather and mother owned a small corner grocery store.
I got the name of Mickey because when I got into my teenage years, about ten or twelve - something like that, I was living in an Irish neighbourhood, and I donít think the kids there knew the name Milton, so it was easier for them to call me Mickey and it stuck.
My father had a genius for taking over stores which were on the verge of collapse, building them up (with our help), reselling them for a profit, and moving on to a better location, so from the time I was a pre-schooler it seemed to me that we never stayed in one place for long. Unfortunately the neighbourhoods which offered the greatest business opportunities were not exactly academically inclined or given to "neighbourliness", and some of my earliest recollections of elementary school were of becoming mixed up in rumbles and other street adventures not of my making.
We moved to upper Manhattan during my second year of junior high school, and by that time my peers were under the impression that gang fights were a sanctioned team sport and thought that school was a waste of time. Apart from the occasional "Zip Gun" firearms were rare, but knives were popular and any excuse was a good excuse to pick a fight.
Although I had enjoyed my schooling up until then, I started to feel an aversion to the fights and other negative influences at the school, and began to play hooky. I spent most of my time wandering around the streets, going to museums, or reading in the park. My parents' insistence that I should get a good education as a means to achieving anything I wanted to do in America, just didn't seem to make a great deal of sense at the time.
Some friends told me that they were taking a test to enter a special high school, and since it provided a legitimate excuse to avoid school for a day, I decided to take the test as well. I had no idea what it was all about, but that test was a major turning point in my scholastic life. I was admitted to the Bronx High School of Science, and although it meant travelling from Manhattan to the Bronx every day, it proved to be well worth while.
Camaraderie among my peers now replaced combativeness: it was fun to compete with each other to see who knew the most trivia, while at the same time keeping up with the adult world, sports, and extracurricular activities. Although I still had to return home to the "gang" neighbourhood to work in the family store and get my homework done, it was now the school which provided relief from stress and an adverse environment. My experience at the Bronx High School of Science convinced me that my future would be hi science, and that my preferred occupation would be teaching.
I entered college in January 1951, when the possibility of being drafted for the Korean War was a reality which all male college students faced. Joining the Reserved Officers Training Corps (ROTC) offered a way to stay in school and also obtain the small stipend it provided to help pay for my tuition, with the promise of a GI Bill in the future to help finance graduate studies.
My choice of college was uncomplicated. Coming from a poor family meant that the only possibility was the subsidised City College of New York (CCNY) - now the City University of New York. I enrolled as physics major, but as with most universities, one was required to take courses outside one's major area, so I took biology courses and non-physics electives.
I found my physics major courses engrossing, and as I passed beyond the basic biology courses into more electives such as genetics and comparative anatomy, I found the area so fascinating and stimulating that I realised I wanted to somehow integrate biology into my physics interest. I switched my major to biophysics, and as far as I am aware, I was the first student to graduate from CCNY with that subject as an undergraduate major.
Although I had completed all the required courses and was eligible for graduation in January, 1955,1 was not yet twenty-one, which was the minimum age at which I could be commissioned. Since the ROTC would pay for further schooling, I decided to remain in school for an additional semester so that I would be of age when I graduated, and could receive my second lieutenant's bars.
During this "extra" semester I took endocrinology and animal behaviour as additional biology electives, and was fortunate that my teacher for both courses was William Etkin, whose knowledge of endocrinology and behaviour was extensive -with some of his publications as valuable today as they were then. He was an inspiring teacher and our discussions both in and after class led to our becoming good friends.
I loved the courses and the subject matter, and it was then that I realised that this was the direction in which I wanted to go. I wanted to understand behaviour and its underlying mechanisms. Before I had the opportunity to pursue this ambition further however, I had a debt to repay to Uncle Sam.
As a biophysics major I was eligible to join either the infantry or engineers, and it took me about three seconds to make that choice. I married before going to Japan, and my wife and I lived off-base just outside Tokyo in a Japanese neighbourhood. My assignment in Japan was as a topographic engineering officer involved in the analysis and production of maps.
We enjoyed our Japanese experiences so much, that I renewed my two-year military contract for a further year and seriously considered making the topographic service my career: my first professional publications were on cartography and mapping. While I was stationed in Japan however, I met regularly with animal behaviour researchers at Tokyo Kyoiku Daigako (Tokyo Teachers' College), and these experiences would later prove to be quite significant.
I asked Professor Etkin to recommend the best schools at which to pursue the interface of behaviour and hormones, but in his old-school manner he recommended not schools but individuals with whom to study. One of those individuals was William C. Young at the University of Kansas, who accepted my application, and so it was that we left the sophisticated environs of Tokyo for the rural environment of Lawrence, Kansas.
At the time, I would have preferred to major in psychology or zoology, but Young was an anatomist. I hadn't realised that the only behaviours in which he was interested were associated with reproduction, and that he was researching different endocrinological aspects of sexual behaviour. It seemed that this aspect of my training came about without any real choice on my part.
The graduate school requirements of the University of Kansas also required a minor area of study, and against Young's advice (who would have preferred my minor to be biochemistry) I chose experimental psychology where I came under the wing of Professor Ed Wike, who also became my friend and mentor. I found the combination of anatomy, endocrinology and psychology very enjoyable and beneficial, and this period was to set the stage for the rest of my career.
My PhD is actually in anatomy and psychology. I received my doctorate in 1962, and my first job was teaching at the University of Louisville, School of Medicine. After four or five years there, we came to live in Hawaii, so that I could take up a position at the new medical school which was developing here.
In the states you sort of go up in the ranks from instructor, to assistant professor, associate professor, and then professor. I got my professorship here in Hawaii about fifteen years or so ago, and I am presently a Professor of Anatomy and Reproductive Biology. That's my official title: I consider myself primarily a sexologist. At the Medical School, I teach sex and neuro-anatomy, and basically those are my two main areas of interest and responsibility.
Apart from my life in medicine I enjoy folk music, and play both guitar and banjo. Photography is another keen interest of mine, and I look upon it as a challenge to take the best photograph that I possibly can.
On the Development of Sexuality and Gender Identity
Chromosomal sex, internal accessory reproductive structures, hormonal sex, secondary sexual characteristics, gonadal sex and external genital morphology, all vary far more than most people realise. So do people's notions of "masculinity", "femininity", "gender identity", "sexual identity", and "sexual preference or orientation".
Our society traditionally supports a two-sex model, in which males are expected to have an X and a Y chromosome, testes, a penis and internal systems for expelling urine and semen from the body. Women are supposed to have two X chromosomes, ovaries, and internal structures to transport urine and ova to the outside world, as well as a system to support pregnancy and foetal development.
In addition to this biological model, there are also a number of recognisable secondary sexual characteristics which societies use to define males and females as being either "masculine" or "feminine" in appearance.
In any discussion of sexuality, it is extremely important to realise that definitions of "masculine" or "feminine" (even for the description of traits) is often affected by retrospective judgements involved in establishing the original categories. The conclusion, for instance, that roundness or softness are feminine traits, whereas angularity and hardness are masculine, is a judgement based on the findings that most males have physical features which can be categorised as hard and angular and related to muscular activity, and by contrast, most females have characteristics classifiable as soft and round, which can be related to childbearing and nurturing.
Is mounting behaviour and aggressive sexuality considered to be masculine in a particular society? Is being mounted or being sexually submissive considered to be feminine? We can certainly choose items which will reflect such sex differences, but those choices, while they may be reality-oriented, are essentially idiosyncratic and may be subject to contrary opinion.
We also have to consider subtle observer bias in the definition of male versus female behaviour characteristics. To some observers, masculinity or femininity of an individual may be considered to be reflected in the choice of an out-of-the-home career, or preference for a domestic role. Choice of a career might be seen to be an indication of masculinity. Alternatively, the desire to have or spend time with children might be considered an index of femininity.
For individuals in open societies the "smorgasbord" of choice is wide since so many different patterns, sex roles and gender roles are possible, and indeed are seen cross-culturally. Many families or situations however do not allow free choice and this stifles attempts at individual expression. The presence of overly rigid forces (such as parents or others) therefore often thwarts the emergence of natural tendencies.
The developing child observes the world around them, and notes whether or not they are like other children in the category to which their families and other members of their community have assigned them. As long as they feel that they are part of the appropriate group, there is no reason for them to question their gender. Problems arise however, when a child feels that they are not like the others, or they feel a greater affinity for those of the opposite gender group
The strength of those feelings determines how the child will react. If a boy feels strongly enough that he is a girl rather than a boy, he begins to envision himself becoming a girl and a woman, and similarly, if a girl strongly identifies herself as being a boy, she sees herself becoming a boy and a man.
This is a fairly big conceptual leap for a child, and there is often a period of confusion. When a boy, for instance, experiences alienation from the sex allotted to him, and the only other category of child he knows is "girl", then it will occur to him that he might be one of those.
Usually there is a period of doubt during which the child wonders how to reconcile these awkward feelings, particularly if he or she believes that any revelation regarding their preferred gender may get them into trouble with their family, schoolmates, and the community in which they live. Consequently, children will not necessarily tell their parents (or anyone else) about these thoughts, but may express their feelings behaviourally.
In the same way that a child may believe in the tooth fairy or Santa Claus, he or she may come to expect that it will only be a matter of time until they grow up to be the man or woman they believe themselves to be. When it becomes obvious that this is not going to happen, the child begins to seek ways and means of bringing about the desired change.
For most people sexual and gender identity are sufficiently in concert to satisfy ego needs and overcome any doubt as to one's own sex and appropriate role in society. For some individuals however, this is not the case, and needless to say, intense feelings of conflict and discomfort develop from this dichotomy.
Fluidity of language means that there is a difference in the way that scientists and laypersons use terms. In the sexology field, several of us have tried to standardise the use of terms, but many people prefer their own usage.
I prefer to use gender to refer to social and societal contexts and sex to refer to medical and biological contexts. For instance, male and female are biological (sex) terms, while boy and girl, or man and woman are social (gender) terms. Following on from that, the distinctions I make between sexual identity and gender identity, as concepts, are crucial to understanding any explanation I may give relating to aspects of transsexuality and intersexuality.
For the typical individual, sexual identity and gender identity mean the same thing. He or she is viewed in society as a boy or girl, man or woman. That is their gender identity. They also see themselves as biological males or females respectively. That is their sexual identity. To the typical person, there is no conflict between sexual and gender identity, although the terms involved refer to different things.
Now consider the way identity is perceived by a transsexual. The typical person sees how he or she is viewed by society, either as a man or woman and recognises that as his or her gender identity; it conforms to the individual's sex as male or female. But the female individual, who thinks she should live as a man, recognises male as her sexual identity. For her, gender identity and sexual identity are in conflict. To reconcile those differences a transsexual says "change my body, not my mind".
She knows that society interacts with her as a woman because that is the way she looks, but she would prefer that it interacts with her as a man. She therefore chooses to have surgery to make the body conform to the mind. A male body type will comfort her by giving her the feeling of being the male she desires to be, and assist the world in treating her as a man, the gender identity she prefers. Her sexual identity, or how she is viewed by society, will then match her gender identity.
It should be noted that some people use the term gender to replace the term sex because they are sex phobics. To such persons, gender seems "clean" while sex is viewed as "dirty".
In the 1970s Virginia Prince popularised the term transgender to describe people like herself, who prefer to live as the opposite gender without undergoing surgery. Typically, the only things the transgenderist wants to change are features of their gender rather than their sex.
Since that time the term has become more and more inclusive, and these days is often used as an umbrella term to describe transsexuals, transvestites, drag queens, so-called gender benders and others.
At this point it might be useful to introduce the term sexual orientation. This refers to the type of person with whom one wants to have erotic and love relations. Most typical males are oriented towards females and vice versa, but many people are attracted to members of their own sex. Gender identity is a separate issue to sexual orientation, and transsexuals have the same range of preferences as the rest of the population.
To get away from the confusion and social taboos when terms such as heterosexual and homosexual are used, I prefer to use the terms androphilic (male loving) and gynecophilic (female loving) to describe the preferred love interest, with ambiphilie (both loving) replacing the term bisexual.
Certainly, different terms need to be used for intersexed individuals. For instance, what would be homosexual or heterosexual for an intersexed person who has both male and female biology? And whose view would prevail - the transsexual's or the onlooker's, when considering the individual's partner before and after sex-reassignment surgery?
In dealing with nomenclature, another issue is how the term gender identity disorder (small letters) is viewed as a general term in popular language, and how Gender Identity Disorder (capital letters) is seen as a medical condition. GID (formerly known as gender dysphoria) is a constellation of thoughts and behaviours that is still used by the scientific and medical communities to identify transsexuals only.
One of the major components which separate the GID transsexual from the members of all other groups subsumed under the term "transgendered", is that only the transsexual feels he or she is rightly a member of the opposite sex, and persistently wants surgery and hormones to effect a sex reassignment. Some people feel that the word "disorder" has negative connotations, but in the medical definition, the term reflects the psychological distress which the transsexual usually shows.
While drag queens, transvestites and others might show some aspects of gender confusion or disorder, they don't fit the medical definition of GID, and although these people may dispute society's restrictions on their freedom of expression, their condition usually doesn't reach the level of intensity seen among transsexuals. They also don't need the medical community's assistance in effecting any change in their life roles and behaviours.
In terms of "passing", it has been suggested to me that it is cruel to expect someone to live as the opposite sex for one year prior to going onto hormones, particularly if the person can't easily pass as their chosen gender when cross-dressed. These concerns are well understood, and a frequent topic of discussion among therapists who try to adhere to the standards-of-care (SOC) proposed by the Harry Benjamin International Gender Dysphoria Association (HBIGDA)-now>( WPATH ).
This professional society which was named for the physician who first extensively studied transsexuality, recommends a standard-of-care for transsexuals which requires that an individual must live for up to two years as their chosen gender as a "real life test". The problem being addressed is how to protect the individual and the professional in the interaction and decision making process. The recommendations are not written in stone, and therapists interpret them differently, with the result that some are more liberal in implementing those guidelines than others.
A therapist may consider hormones at an earlier stage for someone who cannot pass easily as their chosen gender, than they would for someone who is able to pass easily. There is a big difference between a male wishing to live as a woman, or a female wishing to live as a man, than actually living the life. The "real life test" allows the individual to try the life out before too many irreversible changes occur. The administration of hormones can induce changes which are difficult to reverse, so they are frequently given after the individual has at least some real life experience in, and feels comfortable with, their chosen gender.
Personally, I do think that caution is warranted, and would not feel comfortable if all the safeguards of the standards-of-care were removed. Doing away with them would certainly make it easier to transition, but that is not always a good thing. I've probably seen several hundred transsexuals who have satisfactorily made the change, and who now seem a lot happier and more satisfied with their lives than they were before the sex reassignment.
I have however, also seen a couple of people who had sufficient money to bypass the system and have their operations done in other countries, and were very unhappy with the result. They found out too late that their lives hadn't changed as they had hoped, and they couldn't easily go back to living as they had been. I admit that the number of people who are disillusioned with the outcome is very small, but I think it does offer a warning not to bypass the test and evaluation procedure.
People make all sort of decisions about their surgery. There are female-to-males (F2M) who only have a hysterectomy and their breasts removed, and don't have penile reconstruction, for example, and they are happy with that. Others want the penis reconstructed. Some male-to-females (M2F) have their penis and testicles removed, almost all them have extensive depilatory treatments, and some go on to have their Adams' apple shaved or jaw reconstructed. Each person makes a decision for him or herself as to how much surgery he or she wants, or can afford.
I have been asked if there are individuals who have simply chosen to change their sex for social reasons, and I think that it's a good question. I guess that anything is possible, but personally I don't think that an individual would go through sex reassignment surgery and switch gender just for social reasons unless the stakes were extremely high. Frankly I can't even begin to imagine how high that might have to be.
Certainly a male might think, if he was homosexually oriented, that it could be easier to attract a male if he were attired or built like a woman, but he would have to be willing to accept all the other things that go with being a woman and transitioning. He must accept the surgery, the stigma and other social and medical features of transsexualism. And the "real life test" should soon convince him that the anticipated benefits are unlikely to come about. Also, the typical male homosexual or lesbian appreciates his or her genitals and doesn't want to give them up.
I don't think that anyone wakes up in the morning and decides that they're going to be a transsexual just to attract a certain type of partner or to live a certain lifestyle. Individuals, I believe, change their gender to have it conform to their "brain sex". Making the choice to live the life of a transsexual is not a flippant decision.
The incidence of intersexuality may well be as high as one in one hundred people. Since twins occur once in every eighty births, the frequency of intersex is approximately the same as twinning.
The majority of such conditions are not noticeable - an individual may have an intersex condition but neither he/she, the parents or a physician would be aware of it without specific testing. For about one in two thousand people or two in three thousand people however, the condition is apparent, due to the genitals which are "ambiguous" - that is to say, it is difficult to tell whether the person is male or female. Therefore, one in one hundred people may have an intersex condition, but only approximately one in two thousand will have one which is apparent at the time of birth.
Intersex people have recognised combinations of male and female biological characteristics, and often the person with an intersex condition has genitals which are ambiguously male or female. Because genitals develop from a common precursor, intermediate morphology is not uncommon, but the popular notion of two complete sets of male and female genitals in the one person is not possible.
Intersex is basically a condition in which individuals have both male and female biological traits. They might have a genetic condition of XY which is typically male but look like a female, or have the female chromosome XX but possess male genitalia. They may also have both male and female gonads - a testis and an ovary. In addition to having both male and female features in their body, an intersex person may also manifest these traits in their behavioural preferences.
Apart from the presentation of the patient, diagnostic methods would include genetic testing, endocrine testing and receptor testing - in other words, can the body respond to the individual's hormones, are there androgen receptors, oestrogen receptors etc.
For some newborn infants, surgery is required right away, but usually they have conditions for which I would consider immediate surgery to have mostly negative repercussions. Gonadectomy, for instance, removes essential hormones from the individual and in the case of intersex conditions and particularly Androgen Insensitivity Syndrome (AIS), they have a bad problem with osteoporosis. If gonads were left in, there would be less of a problem.
Essentially what is being done is cosmetic in most cases. Parents are counselled to act quickly because it is a social emergency. People need to take their time and understand all of the problems involved. Only in congenital adrenal hyperplasia (CAH) is there a need for emergency diagnosis, because individuals who have this are salt losers - and there is some small contention even with regard to that group.
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