Thursday, August 9, 2012

Nature, Nurture, and Hormonal Transition

We are all constantly flowing with a complex mix of hormones. They cycle like tides, they interrelate in fascinating ways, and they are always shifting in response to our physical and social environments. Among these are the “sex steroids,” such as estrogen, progesterone, and testosterone. All of us, whatever our sex, normally produce both the “female” and “male” sex hormones—in fact, calling them “male” or “female” is very odd, considering that a man requires estrogen to produce viable sperm, and a female relies on testosterone for healthy muscle tone. It is the relative balance of estrogen and testosterone—not the absence of one or the other—that determines our secondary sex characteristics, such as the development of breast tissue or facial hair. This balance varies from person to person, because all sex characteristics exist on a spectrum (with some of us living in the middle intersex territory).

We like to tell a simple story in which people have a biological sex, over which is laid social gender (such as the clothing we wear, what we do with the hair on our heads and bodies, or what careers our society deems appropriate for us). Our physical makeup is presented as asocial and unchanging. In fact, we are naturally social beings, born to have our biological makeup affected by our social experiences. For example, humans are born with a capacity for language, but what language we learn depends on the society into which we are born. And the language we learn, in time, affects our brains. Depending on what phonemes are used in the language(s) we learn as children, we become capable of distinguishing some sounds and not others. If we learn a language in which compass-point direction is incorporated when referring to objects, we develop a much stronger innate sense of direction. If we learn to communicate in sign language, the centers of our brain recruited to produce communication develop quite differently. The brain is a “plastic” organ, shaped by social experience.

In my last post I critiqued the argument that having a trans identity should be understood as an intersex disorder of the brain, necessitating genital sex reassignment. I critiqued this argument because (1) I'm intersex and abhor the argument that it is “necessary” to surgically alter our genitals, and (2) the experience of the intersex community cautions that if there were indeed a medical test for some morphology deemed to represent a "trans brain," the result would be eugenic abortion. I got a lot of negative feedback on that post. Interestingly, some people thought it implied an argument against medical transition, which it is most assuredly not my intent (I've transitioned hormonally). My argument was only with the idea that the way to win civil rights is to champion a biological etiology for trans identity. As for etiologies of gender identity or sexual orientation, my take is that I'm sure they're incredibly complex, but also that they are as irrelevant as the etiology of identifying as a "cat person" versus a "dog person," or, less flippantly, the etiology of identifying with a particular religion. Many people affiliate with the religion (or lack thereof) their parents expect them too, but some do not, and either way, their religious identities should be respected, without needing to look for a biological etiology of religious preference to justify respect.

In any case, in this post I'd like to discuss the interrelationship of biology and social factors in hormonal transition.

In my own life, I've lived under four different hormone balances. First, I had the standard prepubertal hormonal milieu of low sex steroids. At puberty, my gonads kicked in and I developed secondary sexual characteristics—and because I had three gonads (two ovaries and an ovotestis), I developed a lot of them. In later adulthood, my internal reproductive organs were removed, and my sex steroid levels soon fell to almost nil (with less testosterone, estrogen or progesterone than what would be expected for a 90-year-old menopausal woman). And several years later I began hormone replacement therapy with testosterone, or “T,” leading to my living with typical male levels of T, unaccompanied by the usual male levels of estrogen or progesterone. I duly note that none of the three hormonal balances I have lived under as an adult are typical ones. What I can report on is what I experienced with a high, estrogen-dominant hormone load, what it's like to live with no sex steroids, and what changed when I went from no sex steroids to T alone.

There is no doubt that hormone replacement therapy has biological effects. When a person takes estrogen, “E,” (sometimes accompanied by progesterone, “P”) to gender transition, she develops breasts, deposits fat around the hips, and develops softer skin and ligaments. When a person undergoes HRT with T to transition, his voice changes, his phalloclitoris enlarges, and he grows more facial and body hair. But we often talk about other changes. In the contemporary U.S., we think of men as aggressive and dominant, and women as empathetic and emotionally labile, and we expect these conditions will develop with HRT. Often, friends and family worry that a trans man will become violent if he undergoes hormonal transition, or that a trans woman will become irrational. It's as if people see testosterone as the Hormone of War, and estrogen as the Hormone of Overwhelming Emotion (helpfully pictured in my little graphic above). In fact, the effects they produce are much less drastic.

Changes that follow HRT are real. But this does not mean that they are only biological, not social. Consider something simple, like voice. A few months after starting HRT, my voice changed. I was very happy about this, as I was never comfortable with my voice. Clearly, T precipitated changes in my vocal cords and larynx. But a lot of the changes in my voice over the course of my transition have been socially produced. First, there's the fact that I consciously chose to “work” at my voice so that I spoke out of a lower part of my register. It's extremely likely that this has affected my physical vocal apparatus, just as a singer's vocal cords are affected by voice training. But many of the changes in my speaking voice were not conscious, while hardly being biological. They emerged from my being perceived as a guy, without my much noticing what was happening.

Consider this: have you ever noticed that you can often guess the gender of the person a guy is speaking to on the phone by how he is talking? Men in the U.S. today tend to speak with a higher pitch and to articulate more clearly when speaking to women, while speaking in a more mumbled, lower range to other guys. “Hi, Mia. Oh, sure, I can meet you at 4 instead. See you then!” vs. “Hey, bro. Uh-huh. Yeah, well. See ya.” So I found myself on the receiving end of bro-talk, and as a result, the way I speak changed. My spouse teases me about my grunted, blasé “uh-huhs.” Social interactions changed the way my voice sounds. You can't tease out the physical sex and social gender effects, because they interact to produce my voice, but they are both there, each influencing the other. And both components are equally “real.”

So: even the embodied changes during HRT that seem physical and simple are both biological and social. The social effects on the more social aspects of our masculinity/femininity are almost certainly more pronounced. Let's consider the idea that men are more aggressive, that this must be biologially caused by T, and thus that HRT with T will make a person more dominant and violent. This belief is shaped by two things: first, by a cultural ideology shared by all patriarchal societies that men's dominance of society is natural, and secondly, by media reports on the phenomenon of “roid rage” in cis men who use T illegally to build muscle mass for sport or body building.

Let me talk about “roid rage” first. This occurs in people who abuse T because they take it in large and irregular doses, causing big hormone spikes. And hormone swings do make people irritable. This is seen, for example, in cis women who experience premenstrual mood swings, because the level of P rises, then falls abruptly before the menstrual period. I can report from my own experience that swings in P level made me much more irritable than changes in T level. Note, however, that we call a woman who is hormonally irritable “bitchy” rather than “raging,” and see her as less threatening. . . In any case, my experience on T has been that since my T level remains fairly constant as I use a moderate and regular dose, I don't “rage” at all. My irritability levels are no higher than they were when I was completely empty of sex steroids, and are much lower than they were under the three-gonad-circus levels I produced naturally before gonadectomy.

What's really interesting, though, is that my behavior has become a lot less dominating and aggressive than it was before my hormonal transition. I used to be very vigorously argumentative. As an academic who was read as a woman, I had to be quite assertive in order to have authority in a classroom or at a conference. It's part of our gender culture that men interrupt women, assuming greater authority in conversation, and engage in the phenomenon of “mansplaining” (i.e., explaining to a woman something she already knows in a patronizing manner). To avoid loss of social prestige as an academic, I was therefore very assertive in conversation, so as not to allow myself to be interrupted or to appear “weak” in the presentation of my ideas to (male) students or colleagues.

After some time on HRT, I found myself taken aback by how I was being perceived. People had become more reserved around me, and somehow more hesitant in conversation. I made a couple of female students cry when critiquing their comments. My behavior had not changed at all—but my social gender had. The level of dominance I'd asserted for many years was now coming across, not as simple authority, but as intimidating. I wonder if some people thought T had made me “mean,” or that I was acting in the gender-stereotyped manner cissexism claims to be characteristic of trans people. In any case, I had to consciously modify my behavior. It took me a while to retrain myself to be more restrained and gentle in my presentation. It was kind of amusing to learn how much more intimidating the assertive comments of a person who is 5'2” would be taken once he was understood as male—but also sad proof of the greater authority granted men in our society. Such is male privilege. . .

So: my take on the idea that T biologically induces rage and dominance is that it is pretty much bullpucky. Big fluctuations in the level of T can cause irritability, as do big swings in the level of E and P, but that's about it.

I don't mean to come across as saying that none of the changes that we associate with temperament and relate to sex hormones have any biological basis. One that I can speak to is crying. For many years, with my high hormone load being dominated by E and P, I cried a lot, and I hated it. The crying stopped when my gonads were removed, and did not resume when I started taking T, to my great relief. And I see that my friends on HRT with E cry much more easily. The thing is, this does not mean I don't get sad or frustrated any less often than I did in the past, or that they used to be emotionally insensitive and now are oversensitive. One of my trans women friends sees being able to cry when upset as one of the greatest gifts of HRT, because people will finally acknowledge the depth of her feelings. I am happy that I don't tear up easily anymore because I have always enjoyed being treated as having an emotional even keel. These relate clearly to gender roles, in which being emotionally expressive is valued in women and devalued in men. Hormones may affect how often we cry, but it's society that gives that great meaning.

Consider this: like crying, hiccups are also related to higher levels of estrogen. I used to get the hiccups a lot; now I don't. However, since hiccups are not burdened by any gender meanings in our society, nobody else has noticed or gives a fig leaf how often I hiccup. Also related to estrogen are more mobile bowels—people with high E suffer from irritable bowel syndrome a lot more than people with low E. A less irritable bowel is another thing I've enjoyed about my T-only hormonal balance that is clearly biologically-induced, but given no social meaning in my transition. The fact that I don't cry much anymore, however, has been remarked upon a lot, and is treated as highly significant.

So, the relationship between nature and nurture in producing “sex difference” is complex. What is clear is that since humans are such profoundly social beings, social forces shape even those things that are usually thought of as “purely biological,” like the effects of sex hormones. It's one of the things that makes understanding humans fascinating.

Friday, August 3, 2012

On Trans Gender Identity and the "Intersex Brain"

Once upon a time, in the fairly recent past, people often asked what made a person gay or lesbian—taking the perspective that homosexuality was a pathology that needed explanation. Various theories were proposed: psychological (could a domineering mother and passive father be the cause?); moral (was it a failure to embrace “traditional Christian family values”?); and biological (was there some hormone imbalance or brain abnormality at fault?).

Today, when someone comes out as lesbian, gay, or bisexual, the question of etiology is rarely raised. Lesbian, gay and bisexual rights advocates are much less likely to spend their time tossing back at the homophobic the questions, “What made you straight? When did you realize you were straight? Could you do something to change your heterosexuality if you tried?” Sexual orientation is generally treated as a fact, something that is not pathological and that requires no etiological explanation.

Back in the 20th century, however, many advocates for “gay rights” sought to find a physical cause for homosexuality. They hoped that finding proof that there was some immutable, biological reason for homosexuality, beyond the individual's control, would lead to greater social acceptance. In fact, it was political activism, not scientific discoveries, that led to the social shift to viewing LGB people as a minority deserving of protection from bigotry. But for a while, many “gay rights” activists were focused on finding proof that there was such a thing as the “gay brain,” and research on the topic persists today. The size of the hypothalamus of gay men has been argued to be more similar to straight women's than straight men's. It's been posited that straight men and lesbians have brains with a right hemisphere slightly larger than the left, while straight women and gay men have balanced brains.

Implicit behind these arguments is a belief that gay men are in some way effeminate, and lesbians masculine. But LGB activists scoff at this belief today—the idea that gender expression relates to sexual orientation now seems offensive and ridiculous. So while scientific research continues to look for ways in which gay male brains are “feminine” and lesbian brains are “mannish,” LGB rights advocates no longer pay much attention.

We've not come to this point, however, in the struggle for trans gender rights. Trans people today are making strides, but we're now in the position LGB people were decades ago. We face a great deal of discrimination and disgust from the cis gender population, and we are constantly asked, “What made you trans? Was it psychological trauma, is it that you don't respect traditional Christian family values, or is there something wrong with you medically?”

And just like lesbian, gay and bisexual people in the 20th century, trans people today face such virulent bigotry that many trans people hope finding scientific proof that there is some immutable, physical reason for trans gender identity, beyond the individual's control, will lead to greater social acceptance. Today many trans activists are eager to trumpet neurological studies that purport to show that the brains of trans men are more like the brains of cis men than of cis women, or that the brains of trans women are more like those of cis women than cis men.

It was the philosopher Descartes who first argued that the brain contains localized areas that control the body. He declared that the soul occupied the pineal gland—a theory sounds ridiculous today, when we know that the pineal glad is more prosaically the structure that secretes melatonin. But today, many trans people (it must be clear by now that I am not one of them) are looking for a brain structure housing gender identity. They argue that people are born with a “brain sex,” and that if this “brain sex” differs from the individual's genital sex, they suffer from an intersex condition that must be treated via gender transition.

I am deeply uncomfortable with this intersex theory of gender dysphoria. While I know from personal experience that it gives some trans people great comfort, and while I worry about seeking to demolish what others feel is their life raft, I want to lay out my objections.

My first objection is a scientific one: gender identity and gendered behavior are deeply complex. They are no more located in the hypothalamic unciate nucleus than the soul is located in the pineal gland. If many of ares of the brain are involved in something as comparatively simple as speech, how many more must be involved in matters as complex as sense of self?

A second objection relates to the entire field that Cordelia Fine names “neurosexism.” Basically, the entire field of neurological study of sex differences is pervaded by sexism and flawed by a teleological approach: “We know that men are good at math, logic and sport, while women are good at nurturing and communicating, so let's pin these to some brain differences we can locate.  This will show that politically-correct resistance to the idea of eternal gender roles is pointless.” By linking claims to trans rights to this body of science, we're tying ourselves to gender stereotypes and a regressive social agenda.

A third objection is that the brain is a very “plastic” organ, meaning that it changes over time. For example, when a deaf person communicates via sign language, different areas of the brain are “recruited” to process communication than just those used for oral speech. Furthermore, early and late learners of sign have different patterns of brain activation when they observe another person signing. In other words, the brain, like other parts of the body, is affected by life experience and use--it varies greatly from individual to individual, and for one individual over time. Even if we were to find that trans men resemble cis men in their patterns of brain use, this would not mean that such a similarity is inborn. It would just mean that trans people have life experiences similar to cis people who share their identified sex, cultural norms, and gendered behavior.  This is certainly proof that we experience our gendered identities and lives in the same way cis people do.  It is not proof that trans people are born with intersex brains.

Another objection I have is to the foundational premise at hand: that trans men and cis men are uniformly masculine in their gendered behavior and style, and hence distinct from feminine trans and cis women. In fact, there are plenty of men, cis and trans, who are nurturant parents, or who like the color pink, or who are bad at sports. There are many women, cis and trans, who are dominant athletes, have bad verbal skills, are excellent at spatial relations, or who hate primping. Furthermore, plenty of trans people are nonbinary in identity, which can't be explained in the least by this dyadic, reductionist framework.

I also object as someone who is intersex by birth to the framing of trans identity as an intersex condition. The difficulties faced by intersex people can indeed relate to gender identity, since children born intersex today are forcibly assigned a dyadic sex at birth, and often subjected to sex reassignment surgery to which they cannot consent. If the child grows up not to identify with the sex to which ze was coercively assigned, gender dysphoria results. But no test has ever been developed that can determine what the eventual gender identity of an intersex person will be—not in the brain, the chromosomes, the gonads or the genitals. And the issues intersex people face center on forced sex assignment in childhood--something which advocates of the intersex brain thesis tacitly support when they argue that since trans status arises from an intersex brain, it "must" be treated medically. Like many intersex people, I boggle resentfully at the idea held by some trans people that intersex people are “lucky,” have a privileged relationship to the medical community, or are free from stigma in our lives. The belief that being categorized as intersex would lead to advantages, which causes some trans people to frame trans identity as an intersex condition, is deeply flawed.

Finally, I would argue that this entire issue is a distraction. Remember that it was not the discovery of a brain area “causing” homosexuality that led to the relative successes of the LGB community in gaining civil rights. It was activism that led to those gains. The belief that if differences could be shown to be inborn, liberation would result, seems hopelessly naïve to me. Bear in mind that for many decades, scientists argued that women should not be permitted to vote or attend college because their brains were too small. More starkly, consider the Holocaust, which was founded on a belief in inborn racial inferiority.  Some intersex conditions can be detected prenatally, but this has not led to more widespread acceptance of intersexuality.  When these conditions are detected, doctors typically offer to terminate the pregnancy.

For all these reasons, I urge people not to hitch the wagon of trans rights to the idea of inborn, dyadic, neurological differences. Brains are extraordinarily complex and shaped by culture and experience over time. Gender identities are multiple, gender roles constantly evolving, and gender expression varies widely from individual to individual. Intersex people face huge obstacles, and framing us as the lucky group to be emulated denies our suffering.

The solution to transphobia is not neurology, but political activism.