Principles of Transgender Medicine and Surgery

Randi Ettner, Stan Monstrey, Eli Coleman, Randi Ettner, Stan Monstrey, Eli Coleman

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317514596
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

A practical guide to state-of-the-art treatments and health care knowledge about gender diverse persons, this second edition of Principles of Transgender Medicine and Surgery presents the foremost international specialists offering their knowledge on the wide spectrum of issues encountered by gender diverse individuals. In this handy text, professionals of all types can get important information about various aspects of transgender health care for a full spectrum of clients, from childhood to advanced age. Key topics addressed include medical and surgical issues, mental health issues, fertility, the coming out process, and preventive care. This essential text is extensively referenced and illustrated, and instructs both novice and experienced practitioners on gender-affirming care.

1Theories of the Etiology of Transgender Identity

Randi Ettner and Antonio Guillamon

Introduction

Ever since the beginning of time, human beings have sought to understand the physical world and one another. Ancient people told tales, or “myths, ” passed down orally, which were humanity’s earliest answers to the mysteries of the unknown.

In these cosmogonic myths, supernatural beings possessing human motives created the world and other natural phenomena. They also served to explain the genesis of sickness and cure. Often, solemn recitation of the creation myth was enough to cure an illness, as symbolic return to the origins allowed for the “rebirth” of the patient. Mythmakers of all religions and cultures recognized that unseen forces needed to be heralded to make a sterile womb fertile or to cure a body or mind (Eliot, 1976).

The scientific revolution that occurred in 16th- and 17th-century Europe heralded the dawn of modern science and a revolution in physics. Theories replaced beliefs, and printing facilitated the dissemination of knowledge. The medical profession made great strides in understanding the human body and the pathophysiology of disease. But human beings and their behavior do not easily capitulate to taxonomy, and in the absence of observable disease or organ deficiency, one must settle for theory—the modern equivalent of myth—to explain enigmatic phenomena. Such is the case with gender incongruity, the most misunderstood area of human behavior.

Historical Background

Historical accounts of people engaging in cross-gender behavior date back to Biblical times. The Old Testament expostulated against such displays (Deuteronomy 22:5) and Ovid, a first-century bc poet, referred in verse to the “stuff from a mare in heat, ” a reference to conjugated estrogen, which is derived from pregnant mares (Taylor, 1996). But prior to the middle of the 20th century, the phenomenon of gender transition was unknown in the Western world.

In 1910, Magnus Hirschfield, a German sexologist, published Die Transvestism, a monograph describing cross-gender behavior, but as early as 1877, Krafft-Ebing referenced case histories in the medical literature (Pauly, 1992). In 1921, Harry Benjamin, a German physician living in New York, and Eugen Steinach observed that vasoligation (ligation of the vas deferens) had a restorative effect in elderly men, an observation that presaged the use of hormone replacement in the aged. Benjamin was keenly interested in Steinach’s experiments, in which he “changed the sex” of animals, via castration and implantation of the opposite-sex glands (Schaefer & Wheeler, 1987b). Benjamin spent the next decade of his life providing endocrine therapy to geriatric patients. In 1948, an incident occurred that shifted the focus of Benjamin’s career, earning him a place in history and changing the lives of countless people.

It was the referral from famed sex researcher Alfred Kinsey of a 23-year-old man, Van, who presented a unique situation: Van claimed he wanted to change his sex. Van and his mother pleaded with Benjamin for help. The mother related that, at age 3, Van spontaneously began dressing in girl’s clothing. He continued this throughout grade school, and special toilet arrangements were made. Psychiatrists assured the parents that this highly intelligent child would outgrow this behavior, but he didn’t. When the high school refused to make accommodations, Van left, remained at home, and performed housework. He insisted that he be treated as a female, and became extremely agitated when he wasn’t. Van refused to accept that change was impossible, and he was institutionalized by the courts a year prior to meeting with Harry Benjamin.

Benjamin urged Van to go to Germany, where recorded accounts of sex reassignment surgeries appeared in the literature as early as 1930. Van made three trips to Europe, which culminated in the surgical construction of a neovagina from skin of the thigh. Van changed his name to Susan, moved to Canada, and was never heard from again (Schaefer & Wheeler, 1987b).

But it wasn’t until 1952, when U.S. citizen Christine Jorgensen underwent surgery in Denmark, that media reports of “sex-change surgery” captured the public’s attention. She became Benjamin’s seventh patient, and lifelong friend (Schaefer & Wheeler, 1987a). Christine Jorgensen deconstructed prevailing beliefs about gender immutability, as Harry Benjamin reconstructed a taboo area of behavior into a medical specialty.

Psychoanalytic Theories

Ms. Jorgensen’s fame rose rapidly, as did opposition to the surgery. The “Christine operation” generated legal, religious, and moral controversy. But the psychiatric community struck the most damaging blow by challenging the very legitimacy of the condition (Ettner, 1999).

A 1978 article in the Journal of the American Medical Association stated “most gender clinics report that many applicants for surgery are actually sociopaths seeking notoriety, masochistic homosexuals, or borderline psychotics” (Belli, 1978). The reigning psychoanalytic model regarded transsexualism as a psychiatric disorder. Those desiring surgery were proclaimed to be delusional, obsessive, or otherwise severely disturbed. The cause of the “disorder” was attributed to serious object relations disturbances: an inability of mother and child to separate, leading to dysregulation of intrapsychic boundaries and an attempt, on the part of the patient, to incorporate an alternate persona (Gilpin et al., 1979; Lothstein, 1979; Macvicar, 1978; Moberly, 1986; Ovesey & Person, 1976). Some theorized that this was a psychotic process (Socarides, 1978), while others conceptualized it as a type of borderline syndrome. Lothstein (1984) described the severely dysphoric patient as being unconsciously motivated to “discard bad and aggressive features” and incorporate “a new idealized perfection.”

Tragically, this conflation of gender dysphoria, homosexuality, and psychopathology often resulted in the institutionalization of people who required medical and surgical treatment. Many were subjected to electroshock or other aversion therapies when psychoanalysis failed to “cure” them (Shtasel, 1979).

Early Biological Theories

Some researchers, intent on replacing “emotional controversy by rational assessment of facts, ” rejected the psychoanalytic theories, and probed for a biological basis of the condition (Vogel, 1981). Roentgenological examination of skulls (Lundberg, Sjovall, & Walinder, 1975), screening for anomalous hormonal milieus (Gooren, 1986; Kula, Dulko, Pawlikowski, et al., 1986), cytotoxicity assay inspection of h-y antigen status (Eicher et al., 1980, 1981; Engel, Pfafflin, & Wiedeking, 1980; Spoljar, Eicher, Eiermann, & Cleve, 1981), and quantitative electroencephalograph analysis were among the once-promising attempts at identifying an organic marker. Despite the failure of these investigations, some researchers remained convinced that a yet-unknown change in hormonal-dependent brain structure was implicated (Gooren, 1990).

Oddly enough, psychologists provided indirect support for this position. Through the use of reliable, objective psychometric testing, they documented that transgender individuals lacked the rampant psychopathology supposedly fundamental to the condition. In fact, several studies concluded that surgical applicants demonstrated a “notable absence of psychopathology” (Cole, O’Boyle, Emory, & Meyer, 1997; Greenberg & Laurence, 1981; Leavitt, Berger, Hoeppner, & Northrop, 1980; Tsushima & Wedding, 1979). With the advent of the internet, databases became accessible for meta-analyses. Large-scale studies designed to provide quantitative epidemiological data found no evidence that child-rearing practices accounted for the development of the phenomenon (Buhrich & McConaghy, 1978).

Rapid advances in technology led to increasingly sophisticated theories and investigation into the etiology of the condition. By the 1990s, a theory emerged known as “gender transposition.” Evidence of a link between steroid hormones, brain structure, and animal sexual behavior (Dorner, Poppe, Stahl, et al., 1991) was extrapolated to suggest a switch of hormone-induced cephalic differentiation at a critical gestational stage might likewise occur in humans (Elias & Valenta, 1992; Giordano & Giusti, 1995) The theory proved to be reductionistic, and was ultimately abandoned (Coleman, Gooren, & Ross, 1989).

Environmental Theories

As psychoanalytic theory lost its foothold, two movements, both reactions to Freudian doctrine, arose in concert. The first was the theory of radical behaviorism. Psychologist B. F. Skinner asserted that free will was an illusion, and that behavior—even complex human behaviors—was the consequence of environmental reinforcement histories. The infant was a tabula rasa—a blank slate. Simultaneously, the French philosopher Michel Foucault was espousing what would become known as the theory of social constructionism. Foucault, like Skinner, insisted that there is no fixed human nature. He proposed that sex and gender are social constructs imputed on to bodies. Heavily influenced by Foucault, and empowered by the view that constricted societal roles could be surmounted, the social construction of gender—the belief that people learn to become men or women—germinated. Gender was regarded as performance; i.e., people do gender: “In social interaction, throughout their lives individuals learn what is expected, act and react in expected ways, and they simultaneously construct and maintain gender order” (Butler, 1990). By the 1970s, a majority of scientists, most notably John Money, regarded socialization as the sine qua non of gender identity formation.

Anatomical Post-Mortem Studies

In 1995, Zhou, Hofman, Gooren, et al. reported that autopsied brains of male-to-female transsexual individuals differed in comparison to heterosexual and homosexual non-transgender men’s brains. This groundbreaking study identified an area of the hypothalamus, the bed nucleus of the stria terminalis (BSTc), wherein the volume of the central sulci was comparable to that of control females, and unlike the greater volume found in control male brains. The findings were widely publicized, and The New York Times reported the study was “casting new light on perplexing issues of sexual identity” (Angier, 1995).

Clearly, exploring the landscape of the brain offered tantalizing clues to consciousness and identity. But the study raised additional questions. What if the volume differences found in the BSTc were the result of hormone use? A subsequent study was designed to address that issue. Kruijver et al. (2000) quantified the number of somatostatin neurons in the BSTc, rather than using volume as a metric. Neuron numbers of heterosexual males, homosexual males, lesbian women, transsexual women, males and females with sex steroid disorders, a transsexual man...

Table of contents

• Cover
• Half Title
• Endorsement
• Title Page
• Copyright Page
• Table of Contents
• List of Contributors
• Foreword
• Preface
• Introduction
• 1 Theories of the Etiology of Transgender Identity
• 2 Worldwide Prevalence of Transgender and Gender Non-Conformity
• 3 An Overview of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People
• 4 Primary Medical Care of Transgender and Gender Non-conforming Persons
• 5 Preventive Care of the Transgender Patient: An Evidence-Based Approach
• 6 Mental Health Issues
• 7 Psychotherapy with Transgender People
• 8 Developmental Stages of the Transgender Coming-Out Process: Toward an Integrated Identity
• 9 Sexual Function in the Transgender Population
• 10 Hormone Treatment of Adult Transgender People
• 11 Gender Dysphoria in Children and Adolescents
• 12 Transgender Youth: Endocrine Management
• 13 Disorders of Sex Development (DSD): Definition, Syndromes, Gender Dysphoria, and Differentiation from Transsexualism
• 14 Male-to-Female Gender Reassignment Surgery
• 15 Female-to-Male Gender Reassignment Surgery
• 16 Understanding Sexual Health and HIV in the Transgender Population
• 17 Reproduction and Fertility Issues for Transgender People
• 18 Care of Aging Transgender and Gender Non-Conforming Patients
• 19 Transgender Health Care and Human Rights
• Index