Gender Identity: From Dualism to Diversity (2007)

©2007 by Cathy Pittman & Dallas Denny

Source: Denny, Dallas, & Pittman, Cathy. (2007). Gender identity: From dualism to diversity. In M. Tepper & A.F. Owens (Ed.), Sexual Health, Vol. 1, Psychological Foundations, pp. 205-229. Westport, CT: Praeger.

This draft  differs in small ways from the printed version. I was unable to scan the printed pages without breaking the book’s spine. The chapter appears here courtesy of Praeger Publishers.

 

 

Gender Identity

From Dualism to Diversity

Dallas Denny and Cathy Ann Pittman (Endnote 1)

 

As we go about our daily lives, we assume that every human being is either a male or a female. We make this assumption for everyone who ever lived and for every future human being. Most people would admit that the cultural trappings of males and females have varied over place and time, but that nevertheless, there is something essentially male and something essentially female.

—Kessler & McKenna, 1978, p. 1

 

Almost from inception, the sex of an expected child is a subject of conversation and speculation by friends, co-workers, and family. When the baby is born, the first words spoken by those in attendance will nearly always be, “It’s a boy!” or “It’s a girl!”(Endnote 2). The infant will be assigned a sex, male or female, generally as the result of a hasty visual inspection of the external genitalia (Kessler, 1988, chapter 3).

This assignment of sex will in most cases last throughout life, and will have a profound effect on the way the individual is treated by her family and society (Cooper, 1999; Mercurio, 2003) (Endnote 3). The child will be given a name, and gendered pronouns will be used accordingly. Her assigned sex will determine almost every aspect of her life, including the clothing she will wear, her playmates, her speech and behavior patterns, and even her hopes and dreams. Rigid expectations will be placed on her interests, her career, and her sexual orientation and behavior (Burke, 1996).

For most of us, this assignment of male or female seems natural and easy. Our bodies match our internal sense of masculinity or femininity, and our families and societies reinforce our own beliefs. We feel confident and secure in our sense of being male or female, and we assume others are similarly comfortable with their own sex of assignment.

For some people, however, sex assignment is problematic. For any of a variety of reasons, their sex of assignment does not match their inner views of themselves. The rigid expectations placed on them by society can and do cause external conflict and inner pain.

In this chapter we will talk about the development of the child in the womb, the assignment of sex at birth, and what happens thereafter. In particular, we will discuss gender identity—the sense of oneself as male or female, man or woman—and gender role—the expectations society places on individuals on the basis of their sex of assignment. We will begin with a discussion of the way in which sex is assigned in American society, and follow with background information on intersexuality and transsexualism because we will use these conditions to inform the ensuing discussion of gender identity and its formation. We include also a discussion of the newly-developed term transgender and the community it defines. We will draw upon these definitions and discussions in the last sections of our paper.

 

General Discussion

Sex Assignment

When a baby is born, the attending obstetrician or midwife will generally make an immediate assignment of sex. This announcement is based upon a visual and tactile inspection of the infant’s genitalia. If a penis and scrotum are visualized, the baby will be pronounced a boy. If inspection reveals labia and a vagina, announcement will be made that the child is a girl. In a small percentage of cases this determination will be difficult to make.

The prime indicator of sex is the length of the phallus. If the non-erect phallus is 2.5 cm in length or longer, it will typically be labeled a penis and the baby will be assigned to the male sex. If the phallus is less than .9 cm in length, it will be labeled a clitoris and the infant will be assigned to the female sex (Kessler, 1988, Chapter 3). A phallus between .9 cm and 2.5 cm in length will pose a social and medical quandary. Is it a “micropenis” or an “enlarged clitoris?” Should the baby be assigned to the male or female sex? (Kessler, 1998, p. 43).

Another indicator of sex is the position of the urethral meatus. In males, it is typically at the tip of the penis. In females, the phallus (clitoris) does not include a urethral tube. Yet another indicator is the tissue which comprises the scrotum in males and the labia in females. Is it fused (scrotum)? Is it unfused (labia)? Is it partially fused (undetermined)? (See Money & Erhardt, 1972, p. 44, for a pictorial representation of these variations.)

Any difficulty in determining the sex of the infant will lead to a medical and social crisis (described in Kessler, 1998, chapter 3). Parents will be concerned about the well-being of their child and anxious about what to tell enquiring well-wishers. Physicians will be anxious to determine that the health of the child will not be negatively effected, and to quickly assign a sex in order to diminish the anxiety of the parents.

In cases in which a visual determination of sex cannot be easily made, the medical team can perform a variety of tests to check other determinants of sex: internal genitalia, chromosomal makeup, hormonal state. Almost always, after such tests the physician in attendance will assign either the male or female sex and the “ambiguous” external genitalia will be interpreted accordingly. Even when other markers of sex are available, however, they are sometimes ignored in favour of the visual genital determination (Kessler, 1990).

In some instances—for example, in the salt-wasting form of congenital adrenal hyperplasia—medical intervention is necessary in order to save the baby’s life, but in the majority of cases, there is no pressing medical need to provide treatment.

 

Intersexuality

The term intersex is applied when a person’s reproductive anatomy does not clearly fit the definitions of male and female (see FAQ posted at the website of the Intersex Society of North America, www.isna.org). Intersexuality persons often have genitalia which are intermediate between male and female anatomy, but in some cases, the external genitalia are unambiguously male or female in form. Some cases of intersexuality are apparent at birth, but in other cases an individual’s intersexuality may remain unknown or even unsuspected until puberty (cf Imperato-McGinley, et al., 1974, Quigley & French, 1994) (Endnote 4).

The causes of intersexuality are many and varied, but all affect the developing fetus in ways that alter the formation of the genitals. In some cases, intersexuality develops as a result of gross variations in the structure of the chromosomes. Individuals with Klinefelter syndrome, for instance, have two X or more (female) chromosomes and one Y (male) chromosome (Jacobs & Strong, 1959) (Endnote 5). They are assigned as male at birth, but as adults Klinefelter men typically have hypogonadism (underdeveloped testes) and low levels of testosterone. They are often infertile and may develop gynecomastia (see Klinefelter, 1979, for a description of the syndrome). Most Klinefelter men have male gender identities, but seem to be at increased probability for transsexualism (cf Overzier, 1958).

Turner syndrome occurs when there is but a single X chromosome; this can occur in some or all cells (Hall & Gilchrist, 1990). Individuals with Turner syndrome are assigned and raised as female, and develop gender identities as female. Physical characteristics of women with Turner syndrome include short stature and incomplete ovarian development (see Turner, 1938 for the initial description of the syndrome, and Saenger, et al., 2001 for a contemporary discussion of diagnosis and medical management).

Chromosomal mosaicism occurs when cells exhibit a variety of types of sex chromosomes: the individual’s karyotype can include both XX and XY cells, or can include combinations of XY (male), XX (female), XO (Turner), XXY, XXXY, and XXXY (Klinefelter and its variants), XXX, and XYY (“Supermale”) sex chromosomes (Money & Ehrhardt, 1972, pp. 29, 39; for a thorough description of the genesis of chromosomal mosaicism, see http://www.medgen.ubc.ca/wrobinson/mosaic/). Some individuals with mosaicism are assigned as females at birth, others as female.

In other cases, the effect of one of more genes can result in intersexuality. The genes in question may either be on one of the austosomal chromosomes or on the sex chromosomes. The latter is the case in Androgen Insensitivity Syndrome, in which the lack of an enzyme prevents an XY individual’s cells from responding to testosterone, the male masculizing hormone. In the complete form and in some cases of the incomplete forms of AIS, the infant is born with labia and a vagina and is pronounced a female and raised accordingly. Typically, the discovery of intersexuality does not happen until puberty, when the AIS girl fails to menstruate or develop axillary and pubic hair (Endnote 6). Treatment typically consists of administration of estrogens (a female hormone) to induce breast development, surgical excision of the undeveloped internal testes to reduce the risk of cancer, and plastic surgery or an aggressive course of mechanical dilation to increase vaginal depth (Groveman, 1997; Shah, et al., 1992).

Although women with the complete form of AIS are genetic males, they are raised as girls and develop firm gender identities as females. Discovery of their genetic status at puberty can be shocking and disconcerting to AIS women and can cause them to wonder if they are “really” women, but their gender identities typically remain unchanged.

Variations in fetal hormonal levels can also result in intersexual genitals. We should note that dependent upon hormonal influences, both XX and XY fetuses have the ability to form unremarkably male or female external genitalia. This is because both male and female genitals develop from the same fetal tissue (see Money & Ehrhardt, 1972, chapter 3). Under the influence of testosterone, this tissue will grow into a penis with a urethral canal, and pre-labial tissue will fuse into a scrotum. In the absence of testosterone, a clitoris will form and the labia will remain unfused. Consequently, some XX babies are born with external genitalia which appear to be unremarkably male, and some XY babies are born with external genitalia which appear to be unremarkably female. If testosterone is at low levels, or available only intermittently, undifferentiated genitals will result. This can happen because of fluctuations in the mother’s hormonal levels, as a result of medications the mother has taken, or for mechanical reasons (see Money & Ehrhardt, 1972 and Money).

Congenital adrenal hyperplasia is a genetic condition which affects both males and females. The fetus’ adrenal glands circulate high levels of testosterone both before and after birth (see Money & Erhardt, 1972, chapter 6). The syndrome is more readily apparent in girls than in boys because the external genitalia of females with CAH are masculinized before birth (the internal genitals are not affected). The condition can be fatal if undiagnosed, and is treated in both girls and boys by administration of corticosteroids, which reduce testosterone levels (Money & Ehrhardt, 1972, Chapter 6) (Endnote 7). Because they show symptoms associated with salt loss, most babies with CAH are clinically diagnosed soon after birth. Consequently, females, even those with fully masculinized external genitalia, are usually assigned to the female sex. (Money & Erhardt, 1972, Chapter 6, p. 97). Some masculinized females, however, have been assigned to the male sex and raised as boys (Endnote 8).

Girls with CAH are frequently given surgery to feminize their genitals; this often happens at an early age (Golombok & Fivush, 1994, p. 44, Money & Erhardt, 1972, Chapter 6). As adults, most CAH women have firm gender identities as female. Studies have found that as children, they tend to engage in active and aggressive play, much like boys (Hines & Kaufman, 1994). As adults, they tend to be somewhat masculine in dress, appearance, and demeanour and to be sexually attracted to other women (Collaer & Hines, 1995; Federman, 1987; Zucker, et al., 1996). “This toyboyism” is believed to be due to masculinization of the brain by testosterone during the fetal period (Money & Erhardt, 1972, p. 98-103).

In 1974, Imperato-McGinley, et al. reported a hereditary condition known as 5-alpha reductase deficiency in children in several villages in the Dominican Republic. The condition was later reported in New Guinea and Saudi Arabia (Hyde, et al., 2001). In 5-ARD, a genetic male individual lacks an enzyme which transforms testosterone to dihydrotestosterone, the most potent of the androgens. Children with 5-ARD are born with ambiguous but predominantly female-appearing genitalia, and in the remote villages in which the first cases were found, they were usually designated female and raised as such. At puberty, what has until then been considered a clitoris enlarges and became a functional penis and the testicles, which were previously in the body cavity, descend from the inguinal canals into the scrotum. The teen then undergoes normal male-type puberty: the voice deepens, some degree of facial and body hair develop, and the body becomes muscular. In most cases subjects which have until then been considered to be girls spontaneously reassign themselves to the male sex.

In most types of intersexuality, the individual has either testicular or ovarian tissue—however undeveloped—but not both. This is known as pseudohermaphroditism. True hermaphroditism is a rare condition in which an individual has both ovarian and testicular tissues; this is usually the result of XX/XY mosaicism (Money, 1968, chapter 7). The types of intersexuality described above, and most others, are examples of pseudohermaphoridism (Endnote 9).

 

Transsexualism

Gender dysphoria is a clinical term used to describe the emotional suffering, dissatisfaction, and sense of discomfort felt by some people in the disparity between their biological sex and their gender identity (Fisk, 1973; Seil, 1996). This dysphoria is arguably the defining characteristic of transsexualism, a condition in which an individual wishes to live in the role of the non-natal sex, and often does, via a process called sex reassignment (Money, 1972) (Endnote 10).Unlike intersexuals, transsexuals typically have unambiguously male or female bodies and genitalia. They seek to change their sex solely because their gender identities are not congruent with their assigned sex (Endnote 11).

Although a discussion of sexual orientation is beyond the scope of this paper, we would like to note that the sexual orientations of transsexuals run the same gamut as those of nontranssexuals. Some transsexuals are attracted to individuals of the same natal sex, and remain so even after sex reassignment. Others are attracted to individuals of the non-natal sex. Some are attracted to both, some to neither, and some to other transsexuals (Lev, 2004, pp. 74-76). Transsexualism is, at its root, a question of personal identity rather than an issue of sexual orientation.

 

Transgender

In the 1990s, the term transgender came into use to describe the constellation of individuals whose gender identities and modes of gender expression vary from binary norms (Israel & Tarver, 1997, pp. 8-9). Bornstein (1994, p. 141) considers the word short for “transgressively gendered.” Its umbrella covers all gender-variant people, including transsexuals (Endnote 12).

Transgender is an important term because unlike most other labels in use with gender-variant people, it originated not within the medical community, but from gender-variant people themselves (Denny, 1999). Transsexuals and other gender-variant people have been heavily “colonized” by the medical community (Bolin, 1988). This means that the definitions of the “types” of transgendered people and most of the published writing was done by physicians and mental health professionals rather than by transgendered people themselves (Denny, 1995, Spring) (Endnote 13). Consequently, transsexualism and other forms of gender variability have been and in some circles still are considered to be a form of mental illness (cf DSM IV-TR, McHugh, 1992).

In recent years, trangendered persons of all stripes have come to reject the idea that there is something wrong with them and have begun to work to devise a lexicon that does not pathologize them and develop healthy models of medical treatment and self-expression (see Denny, et al., 2001; Green, & Cole, in this volume). Increasingly, they are fighting, with some success, for their legal rights (Currah, et al., 2000). Moreover, they have succeeded in changing the public discourse about gender. The introduction of the term transgender and the developing model of healthy gender variability has begun to replace the earlier pathology-based medical model which fixed the stigma of gender variability on the individual and to cause scholars and activists to look beyond binary gender norms (Endnote 14, 15).

 

Sex and Gender

For most of human history, sex and gender were considered synonymous terms. Gender seems to have been originally used to describe grammatical categories of masculine, feminine, and neuter (American Heritage Book of English Usage, 1996). By the 1900s, gender was being used in print to “designate psychological, social, and cultural aspects of maleness and femaleness” (Kessler & McKenna, 1978, p. 7). Over the past fifty or so years, however, sex and gender have begun to evolve into separate terms with separate meanings.

This distinction between sex and gender has been an important one in feminist and postmodern writings. Beginning in the 1960s, the second wave of feminists rejected prevailing notions that women were limited in their abilities and opportunities because of their reproductive biology (Bem, 1993, p. 1; and see Freud, 1931) (Endnote 16). As they argued that their reproductive abilities need not determine their roles in society, they began to use the term gender as distinct from sex.

In the 1950s, researchers at Johns Hopkins University also made a distinction between human sex and gender (cf Money, Hampson, & Hampson, 1955). They considered sex to be biological, and gender to be psychological, and began to apply the distinction to their work with transsexuals and intersexed individuals (cf Money, 1969, Money & Ehrhardt, 1972).

In contemporary usage, sex has increasingly come to refer to our biological status, typically as a male or female (and occasionally as intersexed). Gender has increasingly come to refer both to our inner sense of ourselves as male and female (or, for some, as both, or as neither), and to our gender roles in society. Certainly, the terms are still often used interchangeably, even in scientific discourse (cf Hubbard, 1998; Kessler & McKenna, 1978, p. 7). While some writers argue that the terms should be considered synonymous (cf Maccoby, 1988), others (for instance, Deux, 1985; Unger, 1979, and most transgender activists; cf Bornstein, 1994) argue that they should be considered separate and distinct.

Sex, then, is our biological status as male, female, or intersexed, and gender is our sense of self and our social role as male, female, or intersexed. Male and female relates to our sex; man and woman, and masculine and feminine attributes are gender terms. Our gender identity is our sense of ourselves as a man or a woman. Statements such as “I am a boy” or “I am a woman” are reflections of our gender identity (Golombok & Fivush, 1994, p. 3). Our gender role is the set of behaviors and behaviors expected of us by our culture (Kessler & McKenna, 1978, pp. 11-12) (Endnote 17).

Our biological sex is represented by our physiological and anatomical characteristics, which arise from multiple determinants that impact body and brain (Lev, 2004, p. 80). We can be classified as male or female because we have, respectively, a penis or a vagina, XY or XX chromosomes, testicles or ovaries (Hubbard, 1998). Money (1969) lists as many as nine determinants of sex: chromosomes, gonads, fetal hormonal state, internal morphology, external morphology, neural (hypothalamic) state, assignment and rearing, pubertal hormonal state, and gender identity.

In many and perhaps most cases, these criteria of sex are consistent. That is, an individual has XY chromosomes, a penis, testicles, testosterone predominant in the bloodstream, and a masculine gender identity and role—or conversely, an individual has XX chromosomes, a vagina, ovaries, estrogen predominant, and a feminine gender identity and role. In other cases, the criteria of sex are not consistent. An AIS woman may have a vagina and a feminine gender identity, but undeveloped internal testicles and an XY chromosomal makeup. An individual with congenital adrenal hyperplasia may have XX chromosomes and ovaries, but male-like external genitals and a feminine gender identity (Golombok & Fivush, p. 40). Transsexuals almost always have bodies that are unarguably male or female, but their gender identities do not match those bodies.

 

Gender Identity

Most of us take our gender identity for granted. We usually don’t even think about it. It is easy to be male or to be female. We “feel” male or female and think of ourselves as male or female. Mind and body are in synchrony and our presentations or expressions of our sex and gender fit easily into the context of our particular social and cultural norms. Some people, however, experience anguish, distress, and societal persecution because their gender identities do not match their biological sex.

How does gender identity develop? When does it develop? Why do some people develop gender identities which are at odds with their gender roles? What can transsexualism and intersexuality tell us about the formation of gender identity?

There are any number of theories about the formation of gender identity, and a considerable amount of research—although not nearly enough to give us a clear picture of what is going on. A thorough discussion of the issue would require one book, and perhaps several, so we give only the briefest highlights here.

 

Biological and Social Influences on the Development of Gender Identity

Any number of studies with non-human animals have demonstrated that hormonal manipulations can result in profound changes in sexual behavior (see Money & Erhardt, 1972, Chapter 5 for some examples of this). In mammals as unrelated as rats and monkeys, introduction of testosterone in the fetal period results in females with male-like brain structures and sexual behavior; conversely, blocking or removal of testosterone results in female-like brain structures and sexual behavior. Moreover, there appear to be critical (now more often called sensitive) periods in fetal development when the presence or absence of testosterone has greater influence than at other times (Money & Ehrhardt, 1972, pp. 58-59; see also Bradley, & Zucker, 1997).

Humans cannot, of course, ethically be subjected to experimental manipulations of hormones—but intersex conditions and transsexualism can shed light on the development of gender identity (Endnote 18). Virilizing syndromes like congenital adrenal hyperplasia have been shown to result in a higher than usual amount of masculine gender identity and lesbianism in females, and it has been observed that Klinefelter Syndrome, with its XXY chromosomal pattern, results in a higher than usual incidence of crossdressing and transsexualism in males. Money (see Money & Ehrhardt, 1972, pp. 108-116) concluded that girls with the complete form of androgen insensitivity syndrome had interests and patterns of behavior which were more stereotypically feminine than XX women: they “pretty much conformed to the idealized stereotype of what constitutes femininity in our culture.” (pp. 111-112). This was presumably because their brains had not been masculinized by small levels of testosterone, as happens in XY women (Endnote 19).

Golombok & Fivush (1994) devote three chapters to psychological and social theories of gender identity development. They begin with psychoanalytic perspectives, including Freud’s (1931/1967) developmental approach, with its oral, anal, and phallic stages, and post-Freudian theories such as Erikson’s (1968/1974), which replaces Freud’s “penis envy” with “womb envy,” and Chodorow’s (1978), which argues that the development of gender identity begins with the infant’s attention to the breasts of the mother (chapter 4).

Social learning theory is arguably the most plausible environmental argument for the formation of gender identity. It holds that behavior is acquired through reinforcement and modeling, as the individual observes others and is instructed by his parents and others (for summaries, see Golombok & Fivush, 1994, and Bem, 1993). Cognitive theories of gender development focus on the active involvement of the individual, who constantly tries to make sense of his environment. As the individual matures, her reasoning abilities improve; Golombok & Fivush (1994, chapter 6) note Piaget’s (1966) and Kohlberg’s (1969) theories of moral reasoning, which divide this intellectual growth into developmental stages, and gender schema theory, which amounts to the internalization by the child of society’s stereotypes about gender (Bem, 1993, p. 138).

Certainly, any number of studies have shown that from early infancy, boys and girls are treated differently. Baby boys are surrounded by blue items, and baby girls by pink (Endnote 20). Boy babies tend to be held with their faces pointing away from the adult, and girl babies with their faces pointing toward the adult. Boys’ toys are quite different from those of girls: think Hot Wheels vs. Barbie. Boys and girls, and later, men and women, are differentially reinforced for different types of behavior. They are rewarded for “sex-appropriate” dress, speech, mannerisms, interests, and career choices, and negatively enforced for “sex-inappropriate” choices (Endnote 21). Additionally, boys are encouraged to use other boys and men as social role models, and girls to use other girls and women as models. Eventually, according to the various environmental theories, these experiences, and the internal process of them by the growing child, result in the formation of a gender identity.

We know far too little about the complex interplay of biology and environment to state definitely which is “more important,” in gender identity development, or even how they interact. Moreover, much existing research is subject to differing interpretations. This is especially true in the social sciences, due to the inherent difficulty in controlling extraneous variables (cf Townsend, 1953, pp. 12-15, Edwards, chapter 1). Because of the complexity of research with human subjects, it is often impossible to determine whether observed differences in behavior in males and females are due to, for instance, internal differences in temperament and interests, or to external influences like parental instruction and role modeling. We can only refer the reader to the discussions by Golombok & Fivush (1994) and Bem (1993), and to their sources.

 

At What Age Does Gender Identity Form?

For many years, prevailing scientific wisdom held that neonates are psychosexually neutral (cf Lev, 2004, pp. 356-357). Gender identity depended on the sex to which the infant was assigned and raised. It was formed and permanently fixed during the first years of life and was thereafter resistant to change: “… There is a period of time in the young child’s life before which she or he is too young to have a gender identity, and after which whatever gender identity has developed cannot be changed.” (Kessler & McKenna, 1978, pp. 9-10). Money (1969, p. 92) noted “Gender identity differentiation is particularly active in the three or four years after language acquisition until school age. It finally reaches its full expression with adolescent sexual maturity.” Money & Erhardt (1972, p. 176) set 18 months as the age after which a child’s gender should not be reannounced. Earlier, Money had set this age at 2 years and 3 months (Money, Hampson, & Hampson, 1957) (Endnote 22).

Money’s 1957 paper with the Hampsons and a 1961 paper by the Hampsons were of critical importance. These researchers suggested that gender identity was formed by a process of imprinting similar to that observed by Lorenz (1935) with the formation of affectional bonds in goslings (Endnote 23). Moreover, they considered that the child is born in a state of sexual neutrality and that gender identity is almost entirely a result of the gender of assignment and subsequent rearing (Hoenig, 1985a, pp. 22-23) (Endnote 24). Gender identity was independent of the maleness or femaleness of the child, and entirely dependent upon the individual’s early experiences and her private interpretation of them.

On the basis of this theory, Money, a pediatric psychologist, made a recommendation to surgeons and endocrinologists at Johns Hopkins that they could “surgically steer intersexual newborns into whichever sex, boy or girl, they wished” (Colapinto, 2000, p. 32). Consequently, surgery on intersexual infants and children became commonplace in North America (see Kessler, 1994, chapter 2, for a discussion of the theory of “intersexuality management”).

 

“Natural” Attitudes About Sex

There are in fact unspoken and generally unconscious assumptions held about sex and gender by most people throughout the Western world. These attitudes, described by Garfinkel (1967, pp. 122-128) and summarized by Kessler & McKenna (1978, pp. 113-114; see the table) maintain: that there are two and only two sexes, as determined by possession of a penis or a vagina, that these two sexes are fixed and permanent and cannot be changed; and that they are “natural,” meaning that they exist independent of human thought or culture. Any exception to these dualistic “rules” is “unnatural” and not to be taken seriously (Endnotes 25, 26, 27).

In recent decades, sociologists, anthropologists, and feminist and queer scholars have asked whether these “natural” attitudes about sex are natural at all. Kessler & McKenna (1978) take the position that gender is not a natural attribute at all, but a social construction; so do Foucault (1980), Butler (1990, 1993), and others. Transgender and intersex activists and scholars have questioned binary male/female norms of gender and sex, pointing out that many people just don’t fit comfortably into either of the available categories (see Bornstein, 1994; Boswell, 1991-1992; Feinberg, 1992; and Kessler’s, 1994 introductory section). For instance, Fausto-Sterling (1993) has delineated five different sexes (Endnote 28). Increasing numbers of people are beginning to construct their personal gender in ways outside the binary, and this is having a profound effect in academe and in the political arena (Boswell, 1998). Indeed, some writers consider the change in thinking so profound as to constitute a transgender paradigm shift (in the Kuhnian [1963] sense; see Denny, 1995). Clearly, many people believe that conventional beliefs about human sexuality no longer explain their realities.

We cannot begin in the 12,000 words we have been allotted to build a comprehensive case for either the adequacy or inadequacy of “natural” attitudes toward sex and binary views of gender. We have space enough for only a brief discussion of the challenges intersexuality and transsexualism pose to natural attitudes about sex and theories of gender identity development.

 

Challenges to “Natural” Attitudes about Sex

Natural attitudes about sex assume that there are two and only two sexes and that they can be easily determined. We do, in fact, make everyday binary gender attributions about others, based upon that person’s visible secondary sex characteristics and manner of presentation, our knowledge of how he is viewed by others, and his presumed genital anatomy and chromosomal makeup (Kessler & McKenna, 1978, p. 2). Usually, we have no direct knowledge of either his genitals or chromosomes (Endnote 29). Kessler & McKenna (1978, pp. 153-155) note that we assign cultural genitals to others based on our assumptions about their genitals. Such assumptions may or may not be the same as their genitals. The actual genitals, may be in fact, intersexed, or may belong to a transsexual. The individual we assume to have a penis may be a female-to-male transsexual who has not had genital reconstructive surgery and consequently does not have a penis, or an individual with partial AIS with genitalia that cannot easily be classified as male or female. It is, in fact, sometimes difficult to definitively determine someone else’s sex.

Kessler & McKenna (1978, pp. 1-2) note that there is no single anatomical or behavioral characteristic which is “always and without exception” true of one sex. Males can cry, and females can be stoic. Females can be aggressive, and males passive. High voices do not always belong to females, or low voices to males. Both males and females can have facial hair, or may lack it. Not all males produce sperm, and not all females produce eggs. Not all females and capable of bearing children. Moreover, the various determinants of sex may not be congruent. Chromosomes may tell one story, and external genitalia another, as may the internal and external genitalia. Gender role and identity may be inconsistent with external genitals and chromosomes.

Is one or another of Money’s (1969) multiple determinants of sex the “true” marker of sex? If so, then what does one do when that marker is called into question? If one considers, for instance, chromosomal status to be the true identifier of sex, with XY designating male and XX designating female, is a woman with Turner Syndrome (XO) “half-female” because she does not have a second X chromosome? Is a Klinefelter-variant man with XXXY chromosomal makeup more “female” than an XX woman simply because he has more X chromosomes? There is the human element to consider, as well. Should a woman with the complete form of AIS be considered a man simply because she has an X chromosome and a Y chromosome? Should the facts that she has a vagina and breasts, has lived in the female role for her entire life, has always considered herself to be a woman and is considered a woman by others, and is statistically likely to be more feminine than XX women be disregarded in favor of chromosomal reductionism?

Natural attitudes about sex hold that genitals are the essential signifiers of sex. Males have penises, and females have vaginas. The external genitals of many intersexuals, however, are intermediate in form and so neither clearly male nor female. The assignment of intersexual infants into male or female categories is often the result of a best determination based on external genitalia and laboratory results (Endnote 30). An unassigned phallus “becomes” a penis or clitoris, according to the sex assigned. According to “natural” attitudes, the phallus was always one or the other. Moreover, the infant is “actually” the member of one sex or the other, independent of the assignment made by the medical team or her gender identity, when she becomes older.

When should a neonate’s phallus be considered a penis rather than a clitoris? At 4.0 cm in length? At 2.6 cm? When it conducts urine? What if a 5.0 cm penis is attached to an infant who has been determined to have XX (female) chromosomal makeup? What about men who have lost their penises to war wounds, car accidents, cancer, or angry wives with knives? They have lost the “definitive determinant” of maleness. Should they be considered no longer male (and hence, by “natural” rules, female) simply because they have lost their penises?

Because it involves surgical change of genitalia and reassignment of gender roles, transsexualism violates several of the natural attitudes—at least the second and fifth, according to Kessler & McKenna (1978, p. 114) (Endnote 31). At the same time, transsexualism, as it was socially constructed in the second half of the twentieth century, can be viewed as reinforcing Garfinkel’s natural attitudes because it involves a reassignment from one binary pole to the other, rather than a migration to a third gender (pp. 114-115) (Endnote 32). Transsexuals have, in fact, been villainized for being as likely as anyone else to hold natural attitudes about sex (cf Billings & Urban, 1982; Raymond, 1979). They have in effect been blamed for adherence to the model they have been required to follow in order to gain access to the medical technologies they must have in order to change their bodies (Bolin, 1988; Denny, 1992). Many contemporary transsexuals subscribe wholeheartedly to the transgender model, as initially formulated by Boswell (1991, 1992) and Feinberg (1992).

Critics have claimed that transsexuals do not actually change sex. This is a topic for another paper, but we will say that regardless of whether or not there is a change of biological sex, transsexuals—at least the ones who pass convincingly as members of the non-natal sex—certainly achieve a cultural change of sex. Arguments about chromosomes and whether surgical neovaginas are not in fact inside-out penises (see Raymond, 1979; Wilchins, 1997, p. 117) are not as important to most transsexuals as the relief they achieve by modifying their bodies and living in a gender role which they find natural and comfortable.

 

What Intersexuality and Transsexualism Can Tell Us About the Development of Gender Identity

Because intersexuality often involves identifiable and unusual hormonal conditions in utero, intersexual births can reveal much about the effects of hormones on developing fetal tissue; this includes not only the internal and external genitals, but the brain. We know, for instance, that unusually high levels of testosterone in congenital adrenal hyperplasia in females results not only in masculinization of the external genitalia, but in behavioral changes. Women with CAH are, on average, more masculine in appearance and behavior than other girls and more likely to be sexually attracted to women (Federman, 1987). This gives us a window into the effects of testosterone on the fetal brain (Money & Erhardt, 1972, p. 98-103). Similarly, women with complete AIS have more stereotypically feminine interests than do XX women (Money & Ehrhardt, 1972, pp. 108-116), presumably because of the lack of testosterone on their brains.

Because intersexual infants are quickly assigned into one or the other of the two commonly acknowledged genders, researchers have had occasional opportunities to study how the children have adapted to their assigned genders. Money and his fellows at Johns Hopkins University were able to report outcomes of children with various intersexual conditions (cf Money, 1987a; Money, et al., 1986). Money & Ehrhardt (1972, chapter 8) report on three matched pairs with CAH, “concordant for diagnosis but discordant for sex of rearing;” that is, one of each pair was assigned as male, and one as female (p. 152). They concluded that while prenatal hormonal levels have an influence on personality traits, the three cases “wreck the assumption that gender identity as male or female is preordained by the sex (XX, or XY) chromosomes” (p. 161). More recently, Reiner & Gearhart (2004) reported contrary findings: about 60% of a small group of XY infants with cloacal exstrophy who were assigned as female later reverted to the male role (see Dreifus, 2005) (Endnote 33). In general, however, follow-up studies have been few and limited by small numbers of subjects (Endnote 34).

Another of Money’s matched pairs catapulted the nature vs. nurture question to the forefront of sex research and “became the index case for surgical alteration of intersexed children for the next thirty years” (Lev, 2004, p. 116; See Donahoe & Hedrin, 1976). In 1966, one of a pair of identical twin boys suffered complete ablation of his penis when a medical machine malfunctioned during circumcision; his twin was not injured. The grieving parents sought medical help, eventually consulting John Money at Johns Hopkins University. Money suggested that the injured child be reassigned as female and raised accordingly. Castration and vaginoplasty were performed and the child’s sex was “reannounced” at about two years of age. Her new name was to be Brenda Reimer.

Money’s initial report of this case was presented in 1972, when Brenda was six years old, with her identity disguised (Colapinto, 2000, p. 65; the case is also reported in Money & Ehrhardt, 1972). Over the next ten or so years, Money spoke about the case frequently and his latest published follow-ups indicated that “Joan” was developing as a typically feminine young girl with a typical feminine gender identity (Money, 1975; Money & Tucker, 1975). He later claimed that “Joan” was lost to follow-up.

Milton Diamond—whose 1975 paper was critical of Money’s theory of psychosexual neutrality at birth—had longstanding doubts about Money’s positive evaluation of “Joan’s” outcome. In 1997, he and Keith Sigmundson published an article in Archives of Pediatric and Adolescent Medicine, revealing that “Joan” herself had had longstanding doubts as to the appropriateness of her gender assignment. At age 14, she had reassigned herself as male. Since his testicles and penis had been surgically removed, “John” began taking testosterone to masculinize his body and underwent mastectomy and plastic surgery to build a penis. He later married and adopted his wife’s children (Endnote 35).

The “John/Joan” case almost immediately came to be viewed as a refutation of Money’s theory of psychosexual neutrality at birth. Intersex activists have used the case—with some success—to bolster their ongoing efforts to convince pediatric surgeons to refrain from performing plastic surgery on intersexual infants. Journalist John Colapinto reported on the case in an article in Rolling Stone, and later a book (2000); he made a convincing argument that Money had withheld information about David’s outcome and behaved strangely in his contacts with the Reimer family (Endnote 36).

Evidence from individuals with 5-alpha reductase deficiency provides additional evidence in opposition to Money’s theory of psychosexual neutrality at birth. Eventually, societies learn to recognize neonates with the syndrome and promptly assign them to the male sex, but in cases in which the children have been raised as female, most of them spontaneously reassign themselves as male when their bodies and genitals masculinize at puberty (Herdt, 1990; Imperato-McGinley, et al., 1974).

There has been no shortage of attempts to find biological links for the incongruent gender identities of transsexuals (see Hoenig, 1985a, 1985b, for a review) (Endnote 37). Because most transsexuals have unremarkable genitalia, we know that any prenatal hormonal influences will be more subtle than is the case with intersexuals; nevertheless, some have argued for a critical period for the development of gender identity (Hoenig, 1985a, p. 26).         A number of writers have claimed that transsexualism is caused by environmental factors, most frequently citing smothering mothers and weak or absent fathers (Endnote 38). For example, Stoller, a Freudian, believed male-to-female transsexualism occurs when the male child does not adequately separate from his mother (1975, pp. 38-55). Stoller describes mothers of male-to-female transsexuals as, depressed, bisexual, and, paradoxically, “feminine in a boyish manner” (1968, pp. 94-95). Other theorists blame fathers (cf Nicolosi, 1991). Yet others cite social learning and cognitive-behavioral causes, or erroneously conflate transsexualism with homosexuality . Data do not convincingly support any of the behavioral theories (see Lev, 2004, chapter 4, for a review).

 

Conclusion

Our interpretation of the scant data suggest that when XY intersexuals are sexually reassigned as females, gender identity is congruent in about half of the cases. Children who are reassigned in the first months of life and raised unambiguously as girls are more likely to have congruent gender identities than those reassigned after age two and those whose receive social messages that they are “really” boys. With regard to transsexualism, we conclude that the cause or causes of a gender identity that does not match the body are not definitely known. We consider it likely that in both intersexuality and transsexualism, gender identity develops as a result of a complex interplay of biological and social factors (Endnote 39).

With regard to the “natural” rules of gender, we hope we have given enough examples to show that they are woefully inadequate to represent the realities of intersexuals and transsexuals, and nontranssexual transgendered people. We must either dismiss those who do not comfortably fit into binary gender norms as aberrations and refuse to take them seriously or consider that the natural rules of gender are perhaps not so natural after all. Perhaps it is time for our society to move from the artificial dualism which has shamed, disempowered, and stigmatized intersexual and gender-variant individuals to an appreciation of the diversity of gendered bodies and identities. Perhaps it is time to rewrite the “natural” rules.

 

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Endnotes

Endnote 1: The first author would like to thank Dr. Sandra Cole for her loan of books from her personal collection.

Endnote 2: For the past several decades, it has been possible to determine the sex of a child in utero by use of ultrasound technology. This is beginning to have profound social effects In some cultures which value male children, this prenatal sex determination has led to selective abortion of large numbers of female fetuses (cf Nisher & Jones, 1997). In the United States, fewer children with Down syndrome are being born (Will, 2005).

Endnote 3: For an entertaining fictional account of the tensions that can arise when an infant’s sex remains unannounced, see Gould, 1980).

Endnote 4: The number of live intersex births is not known. Blackless, et al (2000) put the rate as high as 17 in 1000. Intersex advocacy groups report the following incidences: Androgen Insensitivity Syndrome Support Group (http://www.medhelp.org/www/ais/): 1 in 65,000 live male births (citing Jagiello & Atwell, 1962). Klinefelter Syndrome Support Group (http://www.klinefeltersyndrome.org/), 1 in 500 live male births. Turner Syndrome Society of the United States (http://www.turner-syndrome-us.org), 1 in 2500 live female births. The incidence of 5-Alpha Reductase Deficiency has not yet been established. True hermaphroditism is rare; only 500 cases have been reported (P&S Medical Review, August, 1996). See also Sax, 2002.

Endnote 5: Humans have 23 pairs of chromosomes. Twenty-two of these pairs are called autosomal chromosomes. The 23^rd pair are the sex chromosomes, which are of two types: X (female) and Y (male). Males have one X chromosome and one Y chromosome; females have two X chromosomes. These are designated as XX and XY, respectively.

Endnote 6: The lack of secondary sexual hair patterns is a result of the complete inability of the individual with AIS to respond to testosterone; it is in fact testosterone which causes axillary and pubic hair in XX women (for more information, see the website of the Androgen Insensitivity Syndrome Support Group at http://www.medhelp.org/www/ais/.

Endnote 7: Prolactin-induced pseudohermaphroditism, another common cause of masculinization of female genitals, is caused by the mother’s ingestion of prolactin during fetal development (Money & Ehrhardt, 1972, p. 9).

Endnote 8: The reader may find it curious that male infants with feminized or ambiguous external genitalia have in recent decades been medically reassigned as males in considerable numbers, while female infants with masculinized external genitalia have been much less likely to be reassigned as male. We suspect this is due to phallocentric attitudes of medical personnel.

Endnote 9: Dreger, et al. (2005) argue for the replacement all words with the root “hermaphrodite “ (e.g. pseudohermaphroditism, “true” hermaphroditism) because they needlessly stigmatize intersexuals and their families.

Endnote 10: Sex reassignment does not occur quickly, but as the result of a process of resocialization and medical interventions with hormones and plastic surgery. Consensual guidelines, the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, regulate this process (Meyer, et al., 2001). Transsexuals are required to consult mental health professionals in order to obtain authorization for initiation of hormonal therapy and genital sex reassignment surgery. Eligibility for genital SRS additionally requires a “Real Life Experience,” a period of not less than one year in which the transsexual must live and work (or go to school) full-time in the non-natal gender role. These standards were formulated to safeguard transsexuals and those who provide services to them. (To obtain a copy of the SOC and learn about the Harry Benjamin Association, visit www.hbigda.org).

Endnote 11: The Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision of the American Psychiatric Association sets the incidence of transsexualism as 1:30,000 for natal males, and 1:100,000 for natal females.

Endnote 12: Some transsexuals like the term transgender; others don’t, as they consider they have little in common with nontranssexual gender-variant people like crossdressers and drag kings and queens (Lev, 2004, p. 6).

Endnote 13: Intersexual people have been similarly colonized. They did not become a significant part of the discourse of intersexuality until the 1990s, when Cheryl Chase founded the Intersex Society of North America. See www.isna.org.

Endnote 14: Transgendered people face discrimination daily and are often victims of hate crimes (see www.gender.org/remember for a shocking list of transsexuals and other transgendered people who have been murdered).

Endnote 15: The transgender model shifts the pathology that has been imposed upon transgendered people to the society that rejects and persecutes them.

Endnote 16: If the feminist movement has a theme, that theme is “Biology is not Destiny” (cf Friedan, 1964).

Endnote 17: Money (1987b) has argued of late that gender identity and role are inextricably interrelated.

Endnote 18: In fact, intersexuals and victims of circumcision accidents have been called “natural experiments,” and at least one such individual has been unethically manipulated throughout his life (see Colapinto, 2000).

Endnote 19: Alternation of hormonal levels can happen due to gross changes in chromosomal structure, as with Klinefelter syndrome, because of single or multiple alleles (genes) on the sex chromosomes or autosomal chromosomes, as with AIS and CAH, or because of exogenous introduction of hormones, as with prolactin-induced pseudhermaphroditism. It is the cocktail of hormones that result that guides fetal development.

Endnote 20: Curiously before the middle of the twentieth century, blue was the color for girls, and pink the color for boys ( cf Paoletti & Kregloh, 1989). According to the June, 1918 issue of Ladies Home Journal, “Pink [is] a more decided and stronger color [and] more suitable for the boy.. while blue, which is more delicate and dainty, is prettier for the girl.” (Quote from http://www.songdog.net/blog/archives/000994.html, citing the website “Gender Specific Colors.” Gender Specific Colors was not accessible as of 24 March, 2006.) See Morris, 1995, pp. 142-143) for a different view.

Endnote 21: What is considered “appropriate” changes across cultures, across social class, and with time. See Lurie, 1981 for a discussion of sartorial styles.

Endnote 22: One child development textbook notes that by age three, most children can state whether they are a boy or a girl on the basis of clothing and hairstyles, but do not understand that sex is constant and does not change until they are five or six years of age (Mussen, Conger, & Kagan, 1969, pp. 502-503).

Endnote 23: Lorenz, investigating observations made by fellow ethologist Oskar Heinroth, discovered that during their first two days of life, geese formed permanent bonds with their parents; however, when Lorenz substituted himself for a parent, he found that the goslings permanently “imprinted” on him, treating him as if he were the “perfect parent” (Gould, 1982, p. 50). As adults, they would court humans and ignore other geese. Lorenz called the two-day period in which the imprinting occurred a critical period.

Endnote 24: Milton Diamond, then a graduate student, believed that biology, rather than environment, played the primary role in the development of gender identity. His 1965 paper in The Quarterly Review of Biology is a masterpiece of synthesis from a wide range of disciplines. See Colapinto, 2000, chapter 2, for additional discussion of the work of Money and the Hampsons and Diamond.

Endnote 25: In contemporary Western society, views of human sexuality have been restricted by the reductionistic and mechanistic Cartesian/Newtonian world view, which tends to divide just about everything into two categories: day and night, white and black, fat and thin, male and female. As a result of this dualistic perspective, humans have been considered to come in but two “types,” male and female. The scientific term for this is dimorphism, which is Latin for “two forms” (Blackless, et al., 2000, Lev, 2004, chapter 3). Sex is seen as either male or female, gender as either man or woman, gendered behavior as either masculine or feminine. Males and females are believed to be completely different from one another, as if they were different species, or even from different planets (cf Gray, 1992, who applied a “Mars” versus “Venus” analogy to male and female styles of communication). Rigid binary boundaries allow for little variability or flexibility in our expressions of sexuality.

Endnote 26: This is known as an “essentialist” or “reductionistic” position. The line of thinking that rejects the essentialist views of sex and gender is known as postmodernism or deconstructionism.

Endnote 27: Throughout their book, Kessler & McKenna (1978) use the term gender to refer to the biology of the individual. We have used the term “natural attitudes about sex” rather than “natural attitudes about gender,” as they do. We should point out, however, that those who hold such “natural attitudes” usually do not acknowledge that sex and gender are separate and distinct from one another. Consequently, we consider “natural attitudes” about sex to extend to gender.

Endnote 28: Male, female, male pseudohermaphroditism, female pseudohermaphroditism, and true hermaphroditism. Fausto-Sterling’s five-sexes theory has been criticized (see Fausto-Sterling’s, 2000, for her discussion of the reaction to her 1993 paper, and the Traditional Values Coalition’s “Gay Urban Myth: Exposed: The Claim that Hermaphroditism is a Separate Sex” at http://traditionalvalues.org/urban/six.php), but the real issue is not exactly how many genders there are, but that the binary gender system is clearly inadequate to define everyone’s gender (see Bornstein, 1994; Rothblatt, 1994).

Endnote 29: Most of us, in fact, do not actually know our own chromosomal makeup.

Endnote 30: Rather than by the discovery of some “natural essence” of maleness or femaleness.

Endnote 31: Transsexuals themselves violate the last of the natural rules, because they do not find their natal assignment of sex “natural” at all. In fact, many transsexuals are repelled by their bodies and social roles. It is their gender identities as members of the non-natal sex that they consider natural.

Endnote 32: The model of transsexualism developed by Benjamin (1966) required reassignment from one sex to the other (male to female, or female to male). Although Benjamin developed a Likert-type scale showing variations in gender identity (pp. xxx), the model itself did not acknowledge them.

Endnote 33: Cloacal exstrophy is a complicated birth defect in which the abdominal viscera form outside of the abdominal cavity (Digital Urology Journal, http://www.duj.com/cloacal.html).

Endnote 34: Intersex activists rightly consider this lack of longitudinal data outrageous, since thousands of intersexual infants and children have had genital surgery under the “tabula rasa” theory of gender identity introduced by Money.

Endnote 35: David Reimer committed suicide in May, 2004, two years after the suicide of his twin brother (David Reimer, 38, subject of the John/Joan case, dies, New York Times).

Endnote 36: It is perhaps not inevitable that Brenda chose to reassign her sex to male. Bradley, et al. (1998) reported a similar case, in which the assignment from male to female was made at six months of age. As an adult, the subject retained a female gender identity and expressed no interest in reassignment to the male sex. About 40% of the infants reassigned from male to female reported in Reiner & Gearhart’s 2004 study grew up with female gender identities.

Endnote 37: With some success. For example, Zhou, et al. (1995) discovered that the bed nucleus of the stria terminalis of the hypothalamus had a lower volume in male-to-female transsexuals than in either nontranssexual men or women. BSTcs of nontranssexual men were found to be 44% larger than in nontranssexual women.

Endnote 38: Bolin, 1988, pp. 56-58, calls these “mother-blame” theories.

Endnote 39: We believe that gender identity is but loosely related to masculine or feminine behavioral traits or to sexual orientation. Green’s (1987) longitudinal study of a cohort of extremely feminine young boys showed that most grew up to be gay men; there was only one (probable) transsexual in the bunch. CAH women with masculine appearance and behavior usually have unambiguous gender identities as females.