GENDER BASICS:
By Lynn Conway
Copyright @ 2000-2005, Lynn Conway.
This page is mirrored from Lynn Conway's "TG/TS/IS Information" webpage, with permission from the author.
[version of 5-05-05]
Gender is the most fundamental part of one's identity as a human being. The very first question everyone asks about us is "Is it a boy or a girl?"
Important though it is, most people never think much about gender. They have no idea what causes their sense of being a boy or a girl, a man or a woman. Having never suffered mis-gendering, they take their gender for granted like the air that they breathe, never giving it a second thought. It is an unquestioned birth privilege to have a gender.
Conventional wisdom says that people are either boys who grow up to become men, or they are girls who grow up to become women. There are only two possibilities, and you are either one or the other. It's obvious at birth from your "genital sex", and that's all there is to it! However, as we will see, reality is not that simple.
What makes us a boy or a girl? What determines our gender identity?
During early pregnancy, a fetus that has male genes (XY chromosomes) usually develops into a boy with male genitals. It develops into a girl with female genitals if it has female genes (XX chromosomes). This happens well over 99% of the time. Doctors and parents look at an infant's genitals at birth, and simply declare it to be a boy or a girl.
Those declared to be boys usually grow up into men having a male gender identity, and those declared to be girls usually grow up into women having a female gender identity. Again, it all seems pretty straightforward.
Although more than 5% of all men and women will grow up to be gay, and will seek love partners of the same gender as themselves, they too usually have normal male and female gender identities as men and women, respectively.
Intersex conditions - including intersex babies whose gender is ambiguous at birth:
Although most infants appear to be either normal boys or normal girls, various genetic and developmental effects can lead in some cases to infants having ambiguous genitalia, so that even the doctors can't be sure whether it's a boy or a girl. In other cases, the genitals look correct for one gender, but aren't consistent with the infant's genes. In yet other cases the child's genes are something more complex than just XX or XY, and the child's gender identity and physical gender trajectory as they mature may be difficult to predict in advance. Children having these genital and/or genetic variations are called "intersexed". Intersexed babies are produced in about one in every 1000 births.
For example, in about one in 13,000 births an XY (genetic male) fetus is unresponsive to fetal male hormones, and develops genitals that look like a girl's, except for a lack of internal reproductive organs. These XY "complete androgen insensitivity syndrome" (cAIS) infants are simply declared to be girls and are raised as girls. Although they cannot bear children, they often develop into slender, attractive women who have a female gender identity. It's rumored that a number of beautiful models have been cAIS girls.
In other births, a "partial androgen insensitivity syndrome" (pAIS) results in the external genital appearance may lie anywhere along the spectrum from male to female. (See the Androgen Insensitivity Syndrome Support Group (AISSG) website for more information about AIS conditions). Incredibly, many of these girls are never told about the true nature of their conditions, because their doctors and families feel such shame and embarrassment about thes "terrible secret" that these girls have male genes. Instead they are usually told things like "you didn't develop any female internal organs, and thus can't have babies", and often discover the truth about themselves by accident later in life (for example, read Sherri's Story on the AISSG website).
Our society is almost completely unaware of the existance of cAIS girls, and this had led to many problems for them. For example, for more than thirty years the International Olympic Committee (IOC) has conducted genetic "gender-testing" on all women athletes to make sure that they were "really female" (this was done to prevent "sex changes" from competing). In quite a number of cases these tests turned up cAIS girls, identified them as "males", and disqualified them from competition. These were truly tragic mis-identifications, since the presence of the Y chromosome in AIS girls does not make them males either genitally or in gender identity, nor does it confer any strength advantage to them. These mis-genderings were often made public, resulting in total humiliation for the women involved.
In a significant recent reversal of this dreadful policy, the IOC dropped all such gender-testing, starting with the summer games in 2000. Then on May 17, 2004, the IOC announced that postoperative transsexual women and men will be allowed to compete, after meeting certain conditions, starting with the summer games in 2004. Therefore, discrimination against particpation by IS and TS people in the Olympics is finally over.
For an overview of the many categories and prevalence of intersex conditions, see the Intersex Society of North America's page entitled "How Common Are Intersex Conditions?". For extensive historical and medical information about intersex conditions and about social and medical reactions to those conditions, see the excellent textbooks Intersex in the Age of Ethics and Hermaphrodites and the Medical Invention of Sex, by Prof. Alice Dreger, Ph.D., of Michigan State University:
The existence of XY (genetic male) intersex infants who have female genitals and who grow up to have female gender identity (the cAIS girls), was one of many early-known facts of intersexuality that led scientists years ago to recognize that gender identity IS NOT determined directly by having XY vs XX genes. Instead, they theorized that gender identity must be neutral at birth, and is determined later in early childhood by one's genitalia and upbringing. The leading proponent of this theory was John Money of Johns Hopkins University.
According to this theory, a child having a vagina and raised as a girl will grow up to have a female gender identity, independent of her genes. Similarly, it predicted that a child having a penis and raised as a boy would grow up to have a normal male gender identity, independent of his genes. If the child's gender identity didn't turn out according to this scheme, psychologists and psychiatrists assumed that something "went wrong" in the child's upbringing, or that the child was mentally disturbed or delusional in some way (i.e., "mentally ill"). Correction to any gender identity problems were sought through psychiatry, on the assumption that this "mental disturbance" could be reversed.
The practice of "surgically correcting" the genitals of intersex infants to make them "normal":
By the 1960's, advances in plastic surgery combined with the "Genitals + Upbringing" theory of gender identity led physicians to recommend "corrective" surgeries on many types of intersexed infants. The idea was to make the genitals look cosmetically correct for a boy or girl, and then raise the child in the corresponding gender, believing that the child would grow up to have a correspondingly normal gender identity.
John Money of Johns Hopkins University, who gradually became the medical community's dominant authority-figure in "gender-identity studies", was the leading advocate of such treatments. A believer in behaviorist psychology, in which the mind of the infant is thought to be a blank slate having no inherent personality characteristics, John Money theorized that gender identity was solely the product of upbringing and socialization.
The motive for doing "corrective" surgeries on infants was to solve the "social emergency" caused by an intersex birth. The very existence in nature of many intersex babies, with their many variations of genitalia, breaks down the strict male-female gender dichotomy of our culture. Thus the existance of intersex babies brings into question many deep religious and legal strictures. Parents and doctors are under incredible social pressure to eliminate these variations. John Money provided a theoretical rationale which validated intersex infant "corrective" surgeries, and made them appear to be "scientifically sound".
Since it was easier to surgically "make a girl" than to "make a boy", it frequently happened that XY intersexed boys having small or missing penises were turned into girls. The fact that sensitive genital tissue was lost in the process didn't deter the surgeons, because for many years our society did not openly recognize that most women have strong sexual feelings and a capacity for orgasm. If the infant was turned into a girl, doctors didn't worry about whether she would later have strong erotic genital sexual feelings and enjoy lovemaking; they only worried about whether she would function sexually for her male partner's pleasure.
Surgeries on intersexed infants have been done for many years now, with a frequency of about 1 in every 2000 births. In most cases the surgeries create girls. Amazingly, there was never any organized scientific follow-up to see how these cases turned out!
Even in the early years of these surgeries, there were people urging caution, most notably a young researcher named Milton Diamond, now a Professor at the University of Hawaii. While still a graduate student, Diamond made an audacious challenge to Money's theories in a 1959 paper entitled "A Critical Evaluation of the Ontogeny of Human Sexual Behavior". Diamond's insights were based on his own observations in animal experimentation. He further marshaled "evidence from biology, psychology, psychiatry, anthropology, and endocrinology to argue that gender identity is hardwired into the brain virtually from conception" (see As Nature Made Him, p.44).
However, the notions that human beings had "advanced beyond the influences of biological evolution in matters of sexuality", and that one's sexuality and gender were socially constructed, had already been deeply imprinted in the medical community. Under the influence of the gender prophet" John Money, this view dominated medical and psychological thinking for the remaining decades of the 20th century. Infant intersex surgeries were performed by the thousands during those decades, and again without any follow-ups. Only as the century was closing did awful questions begin to arise, as occasional rare follow-ups revealed things hadn't turned out as Money predicted.
How these attempted "corrections" reveal that old theories of gender identify formation were wrong:
In recent years, many intersex people have "found each other" via the internet and begun to compare notes about their situations. As a result, it's become clear to intersex people themselves that many of the "corrective" surgeries didn't work out according to their doctors' theories. Instead, many intersex people were left genitally maimed by those infant genital surgeries. Many were also suffering from gender identity crises, because of having undergone arbitrary gender reassignments based on what it was "easiest for the surgeons to do".
Under pressure from intersex activists, especially the newly formed ISNA, follow-up studies have finally begun on infants who were "surgically corrected" over the years. The first such study, of 25 genetically XY boys who had missing penises as infants (cloacal exstrophy syndrome) and who had been surgically turned into girls and raised as girls, revealed that all 25 developed MALE gender identities.
Those kids, although raised as girls, had all exhibited the rough and tumble play of boys when young. By their teens, each of these kids insisted against all evidence of their female genitalia and upbringing that they were boys, and wanted to be changed into boys. Many of them desperately sought girlfriends, just as might any other teenage boys.
Instead of reversing their innate gender identities and turning these intersex boys into girls, the infant surgeries effectively turned them into the equivalent of female to male transsexuals! Many of these boys have since undertaken hormonal and social gender reassignment from female to male. Tragically, the effects of their infant genital surgeries preclude the surgical reconstruction of male genitalia and in many cases even preclude them from experiencing sexual pleasure and orgasm.
More lessons from the intersexed about gender identity:
These recent studies call into question the entire existing practice of genital surgery on intersexed infants.
The studies then do something even more awesome: They turn on its head the theory that genitals and upbringing determine gender identity, triggering a paradigm shift in the medical community's overall thinking about the underlying nature of gender identity. The personal experiences of intersex people who have traveled different gender trajectories (some "corrected" as infants, and some not) are now becoming more widely known about, and are helping build a deeper understanding of the many variations in gender identity that are independent of one's physicality.
For example, in intersex conditions such as XY-Turner mosaic (mixed gonadal dysgenesis) a child may appear have normal male genitalia at birth and be raised as a boy, but then not masculinize at puberty and instead remain slight and feminine appearing. These teens can face great difficulties if their condition goes undiagnosed and/or if they do not become aware of good options for treatment. If they do not have a well-established male gender identity, they may face a difficult choice of whether to undertake testosterone treatments to masculinize and become men, or undertake estrogen treatments and genital surgeries to become women. In some cases, XY-Turner teens have female gender identities and if given a choice in the matter will chose reassignment as females.
The article "What do children know?", by Jane Spalding tells the compelling story of such a child who was raised as a boy, but who had a female gender identity and who sought hormonal and surgical reassignment as a female during her twenties. The existence of such cases further refutes John Money's proclamation that genitalia and upbringing establish gender identity:
Misguided by Money's theories for many decades, the medical profession has caused the irreversible physical maiming of thousands upon thousands of intersex babies. For compelling insights into the traumatic life experiences of an intersex person who was surgically "corrected" at birth, and who grew up without ever being told what had been done, see the recent interview of Cheryl Chase in Between the Lines: coming to terms with children born intersexed, by Victoria Tilney McDonough.
Cheryl was the founding Director of the Intersex Society of North America (ISNA), and the early leader of the movement to end shame, secrecy and unwanted genital surgeries for people born with atypical reproductive anatomies. ISNA is working to end the idea that intersexuality is shameful or freakish. In the U.S. alone, five children are subjected to harmful, medically unnecessary sexual surgeries every day. ISNA urges physicians to use a model of care that is patient-centered, rather than concealment-centered. For more insight into these issues, see the Discovery Channel documentary "Is it a Boy or a Girl?", which was produced with ISNA participation.
Cheryl Chase, Founding Director of ISNA
"When an intersex baby is born, the default is usually to
perform surgery," says Cheryl Chase, who was surgically
"reassigned" female when she was 18 months old.
"Doctors want to 'fix' what is not right, then slap a diaper
on the baby, close the file, and send it off into it's life."
The theory that gender identity is socially constructed is finally shattered:
The breakaway from John Money's paradigm escalated rapidly after the scientific community learned that Money had suppressed for many years clear evidence that his theories were wrong. The final straw was the highly publicized case of "John/Joan", presented in the book As Nature Made Him: The Boy Who Was Raised as a Girl, by John Colapinto.
Decades ago, John Money had advised the parents of an infant boy who had lost most of his penis in a medical accident to have the boy surgically changed into a girl - under the theory that "she" would then grow up to be a normal girl instead of an "abnormal boy". This was a very noteworthy case for scientific researchers because the child was born with an identical twin who could serve as a basis of comparison in the study of gender development. As a first step, the child was castrated and the rest of his penis removed. He was then raised as a girl. However, clearly exhibiting an innate gender identity as a little boy, "she" began to declare that "she" was "really a boy" and rebelled against efforts to make "her" behave like a girl. At puberty, still unaware of "her" childhood surgery, she resisted her parent's and physician's efforts to feminize her with estrogen and further surgeries. Eventually, she underwent gender transition to become male, much as would an FtM transsexual. In this case, raising a boy-child with female genitals as a girl clearly did NOT alter the child's inborn sense of his own true gender.
Over many decades, John Money continually referred to the John/Joan case as a victory, fabricating facts to indicate that this case had been a "complete success". Money never "allowed" anyone to get close to "Joan" to learn more details about her life, begging off any contact in the name of "privacy". The case gradually became so legendary that it became the cornerstone of support for Money's entire theory of gender.
And then the shattering news came down, in the revelations that John Money knew full well that the infant's reassignment had not worked at all. And worse yet, he had deliberately concealed this counter-evidence to his theories for decades - decades during which thousands more infants had been subjected to infant intersex surgical maimings. Fittingly, it was Professor Milton Diamond, the scientist who'd bravely challenged Money as a young graduate students decades earlier, who uncovered the deception.
Professor Diamond had always been suspicious of Money's results. Over the years he had tried in numerous research studies and papers to persuade others to at least consider the possibility that gender identity was inborn. However, his efforts were to no avail, given Money's intellectual dominance of the field.
Finally, in the early 1990's, Diamond managed to track down the child "Joan", now presumably a grown woman, whose case had been the foundation of Money's entire viewpoint. Wanting to simply confirm what had or had not happened to her, Diamond had stumbled into the incredible fact that "she" had never felt like a girl at all, and was now a married man!
Diamond and a colleague, Sigmundson, then worked tirelessly to document what had happened in this case, and they wrote a journal paper to reveal the results. The paper was so controversial that many research journals simply turned it down! So great was the influence of Money and the knee-jerk buy-in into his now established paradigm of thought about gender identity. The various journals simply could not believe the evidence that was staring them in the face!
The paper, "Sex Reassignment at Birth: Long Term Review and Clinical Implications" by Milton Diamond & H. Keith Sigmundson, was finally published in 1997 in the Archives of Pediatric and Adolescent Medicine. There was a firestorm of reaction in the media and the research community to its astonishing news. John Money was publicly revealed to have falsified evidence and suppressed counter-evidence in the case that was the cornerstone of his entire theory of gender identity. Within two years the writer John Calapinto's published a detailed account of the overall story, bringing it to the public at large.
Professor Diamond has since won important awards for his work. Director of the Pacific Center for Sex and Society at the University of Hawaii, he has written widely on issues of gender identity and intersex surgical interventions. I highly recommend his papers to you (see for example Sex and Gender are Different: Sexual Identity and Gender Identity are Different and An Emerging Ethical and Medical Dilemma: Should Physicians Perform Sex Assignment on Infants with Ambiguous Genitalia? ).
[ Note to trans readers (1-31-05): You can help Professor Diamond in his current research by retrieving the questionnaire at the following webpage, filling it out, and e-mailing it (or snail mailing it) to him at the indicated addresses: ]
The refutation of John Money's theories is finally leading to a paradigm shift not just in the scientific community, but also in the medical community - although progress there will be slower, given the lingering influence of Money's views among medical "elders". It is also leading to legal assaults on the continuation of infant genital surgery by "traditional surgeons". See in particular the recent article in the Yale Law Review which outlines the emerging understandings of the medico-legal issues in this area.
The theory that prenatally established brain and CNS structures determine innate gender feelings and gender identity:
Well now, if it isn't the genes that determine gender identity (cAIS girls disprove that), and if it isn't the genitals and upbringing that determine it (cloacal exstrophy boys disprove that), then what the heck does determine a person's gender identity?
Scientific evidence has been growing that somehow certain brain-structures in the hypothalamus (the BSTc region) determine each person's core gender feelings and innate gender identity. These structures are "hard-wired" prenatally in the lower brain centers and central nervous system (CNS) during the early stages of pregnancy, during a hormonally-modulated imprinting process in the central nervous system (CNS).
It appears that if those brain and CNS structures are masculinized in early pregnancy by hormones in the fetus, then the child will have male percepts and a male gender identity, independent of whether the genes or genitalia are male. If those structures are not masculinized in early pregnancy, the child will have a female percepts and a female gender identity, again independent of the genes or genitalia. As in the case of intersex infants having ambiguous genitalia, there are undoubtedly many degrees of cross-gendering of brain and CNS structures, so that while some infants are completely cross-gendered others are only partially cross-gendered.
More recent research indicates that the brain begins to differentiate in embryonic males and females even earlier, possibly before embryonic sex hormones come into play, and under mechanisms still not yet understood - with gender identity then becoming a complex effect of the interaction between earlier brain differentiation and later embryonic hormones. For more on this emerging research, see: "Brain development: The most important sexual organ", in Nature magazine, January 29, 2004 (Nature 427, 390 - 392)
That is why it is possible for some children to have gender identities inconsistent with their genes. In cAIS cases, for example, those girl's brain structures are likely insensitive to the masculinization effects of fetal testosterone, as were their genitals. Therefore, they develop the brain structures and gender identity of females, even though they are XY genetically.
That is also why it is possible for some children to have gender identities inconsistent with their genitalia and upbringing. In the case of the boys with cloacal exstrophy ("micropenises"), their brain-structures and CNS presumably did masculinize under the influence of fetal testosterone, leading to later male gender identities even though they had been surgically "turned into girls" as infants and raised as girls.
Those recent cloacal exstrophy observations are already having a profound impact in the medical research community. They are to the science of gender much like the Galileo's observations of the moons of Jupiter.
These are dramatic, unprecedented, undeniable observations that shift the previous paradigm of thought, and do so in an area of science that had been subject to much misinformation and taboo. In Galileo's case, the shift was from an 'earth-centered universe' to a 'sun-centered universe'. In the cases here, the shift is away from a 'genitals + upbringing' theory of gender identity to a 'CNS neurobiological developmental' theory of gender identity.
The implications of this paradigm shift are far reaching, especially for those who suffer from cross-gender identities. Instead of those gender feelings being considered to be "psychological", they can now be understood as being "neurological" in nature.
Listen carefully to the conclusions of William Reiner, M.D., a pediatric clinician and researcher at The Johns Hopkins Hospital, based on his work with intersex children (Reiner is now an investigator in the Cloacal Exstrophy follow-up study, which now confirms these conclusions):
It is amazing that psychiatrists completely missed all of this in the past, and so long assumed that gender identity was neutral at birth and later established by social interactions. Mis-gendered people themselves have long reported their problem not as one of THOUGHTS, but of cross-gendered percepts and BODY FEELINGS - as a little child the gendered feelings of how your body wants to move, how you respond to being touched, how aggressive or cuddly you are, how you interact with other little children. Then, after puberty, one's feelings upon being sexually aroused, and whether those deep urges are male (mounting urges) or female (urges of being manipulated and penetrated).
One doesn't "think up" these CNS-produced male/female gender and sexual feelings, one simply perceives them! The basic perceptual mechanisms involved are hard-wired, and cannot be changed by psychiatric means any more than one could permanently change one's sense of feeling hot into that of feeling cold and vice-versa.
Whatever in-utero process produces it, a person's gender feelings and gender identity are at the very core of their being. Gender identity is fixed, immutable and irreversible by any known medical or psychological means. We also now know that there is only one method for determining your gender identity. We have to ask YOU! Your gender is a percept: You are the only one who knows for sure what it is, and no one else can tell you what it is.
The story of John/Joan obtained early public notice in an article by John Colapinto in The Rolling Stone on Dec. 11, 1997 entitled "The True Story of John/Joan". Here's an excerpt from the last page of that article:
" - - - His story has shaken to its foundations the edifice constructed on John Money’s theories from the 1950s. And it has exposed a central flaw in a theory that has held sway for most of the 20th century. It was Sigmund Freud who first stated that a child’s healthy psychological development as a boy or a girl rests largely on the presence, or absence, of the penis – the notion central to Money’s theory of sexual development and the ultimate reason that John Thiessen was converted to girlhood in the first place. It is a notion that, today, has also been called into question by neurobiological research that, in the sexual realm, is leading scientists toward the conclusion that, as Dr. Reiner puts it, "the most important sex organ is not the genitals; it’s the brain - - - "
Gender "theorist" who claimed that gender identity is socially constructed.
Purveyed his views by personal dominance of his field and by falsification and suppression of research data contrary to his views.
Professor of anatomy and reproductive biology who shattered Money's long-held theory that gender identity is socially constructed.
His work instead strongly suggests that gender identity is biologically innate.
"In the end it is only the children themselves who can and must identify who and what they are. It is for us as clinicians and researchers to listen and to learn. Clinical decisions must ultimately be based not on anatomical predictions, nor on the 'correctness' of sexual function, for this is neither a question of morality nor of social consequence, but on that path most appropriate to the likeliest psychosexual developmental pattern of the child. In other words, the organ that appears to be critical to psychosexual development and adaptation is not the external genitalia, but the brain."
William Reiner, M.D., To Be Male or Female--That is the Question, 151 Arch Pediatr. Adolesc. Med. 225 (1997)].
