The term gender has a long history, with Greek roots signifying "birth, race, and family" and Latin roots signifying "birth, race, and kind." The psychologist John Money was among the first to use the term to refer to a person's felt identity as male or female, as distinguished from that person's biological sex traits (Money). The term also is used to refer to a person's nature or identity as male or female and to social aspects of sex such as the cultural roles of men and women.
Various biological traits distinguish male from female, but males and females are not distinct in categorical ways and the boundary between male and female is fluid rather than fixed: Human beings can exhibit atypical traits or intersexed conditions (Fausto-Sterling). Rather than having an XX or XY sex chromosome complement, for example, some people have an XXY or XYY complement. In some cases an individual may be born with only a single X chromosome. Some humans have indeterminate genitalia or both testicular and ovarian tissue. In regard to social roles male and female traits can overlap as well.
Gender Assignment of Newborns and Children
The sex of a newborn child is of keen interest to the parents, but some children are born with ambiguous genitalia, having both testicular and ovarian tissue, or genetic syndromes that confound a simple designation as male or female. The term gender assignment refers to practices that are used to discern and impose a gender identity on a newborn child. Suzanne J. Kessler has described how cultural ideals of sex influence the practice of gender assignment. She showed that some physicians have made decisions about gender assignment in accordance with the size and expected function of a child's genitalia rather than in accordance with more complex hormonal and genetic assessments (Kessler, 1990; 1998). If a male child was likely to have a very small penis, for example, some physicians and parents used surgery to assign a female identity to that child. Advocates of this kind of intervention argue that a secure gender identity depends on having appropriate sexual genitalia.
The gender assignment of John/Joan has received a great deal of attention (Colapinto, 1997). In 1966 a physician burned the penis of boy beyond repair during a circumcision that involved an electrocautery needle. Fearful of what the boy's life would be like, his parents took him Johns Hopkins University for evaluation. The psychologist John Money proposed gender reassignment from male to female on the assumption that the loss of the penis was so damaging that it would be better for the child to be raised as female; he also believed that gender identity can be shaped after birth. With the consent of the parents, in 1967 physicians removed the boy's testicles at the age of 22 months, repositioned the urethra, and induced a preliminary vaginal cleft. The parents selected a girl's name and began to treat and raise the child as female (Colapinto, 2000).
From 1972 on Money reported the child's gender assignment as successful. He said that the case showed that gender identity is plastic and can be shaped during early childhood. One's sense of self as male or female is not, he held, determined by anatomy, genetics, or prenatal history. Health practitioners translated that evidence into practice guidelines and encouraged gender interventions. One advocate said that the possibility of female sex assignment with genetic males "must be considered whenever the severity of the genital abnormality is such that it is likely to be extremely difficult or impossible to correct for normal adult functioning" (Baker, p. 266).
In fact, the gender reassignment of this child failed. The child consistently rejected female identification and exhibited male-typical interests and behaviors. Eventually the child refused further interventions, and at that point the family told the child the truth. The fourteen-year-old immediately reclaimed a male identity, adopted a male name, started male hormone treatments, underwent breast removal, and eventually was treated with phalloplasty, the construction of a penis. None of those events were reported in the professional literature until 1997. Thirty years passed between the beginning of this experiment and its publicly described failure (Diamond and Sigmundson).
Some commentators believe that that failure provides evidence that gender assignments do not work, but that conclusion is not fully supported by the evidence. Gender assignment in children has not been well studied, but even if this case failed spectacularly, other interventions might succeed. It also should be noted that the intervention made sense at the time of an unsettled debate about the extent to which gender identity can be influenced after birth. The unfortunate outcome has rightly forced broad reconsideration of gender assignment practices. Various commentators have noted that gender assignment can reinforce dubious notions such as the view that a person cannot be male unless he has a large and intact penis and that it is better for a child to grow up as a sterile female than as a male with a very small or damaged penis.
Some commentators have argued that gender assignment violates children's autonomy (Dreger, 1999). That argument is not convincing because newborns and very young children lack the cognitive powers that justify respect for people's choices. More convincing are worries that early gender interventions are not effective or work to the advantage of anxious parents, not to the benefit of the children. Concerns of this kind suggest that gender assignment in the case of ambiguous genitalia or intersex conditions at the very least should not be treated as inherently shameful or as a social emergency.
Physicians should propose gender interventions to parents only after a rigorous evaluation of the risks and benefits. Among other things, practitioners should advise parents that some individuals live happily with atypical genitalia or intersex conditions and that gender assignment can be carried out later on if that is desired by the child (Dreger, 1998). Parents need support as they think through decisions about gender interventions with their children, and this support should include nonpathologized images of intersex people. In the 1990s the Intersex Society of North America began its education and advocacy efforts to improve options for intersex people and their healthcare providers, and this group explicitly rejects a pathological view of intersexuality.
Gender Identity Disorders
Some people assert a gender identity that is at odds with their anatomy and genetic traits. The American Psychiatric Association (APA) treats some of those people as suffering from gender identity disorder (GID). GID sometimes is called gender dysphoria, and it occurs in children, adolescents, and adults. According to the APA, people with this disorder are characterized by a "strong and persistent crossgender indentification" (American Psychiatric Association, 2000, p. 581).
This preoccupation is said to pass into the pathological when there is strong and persistent cross-gender identification and clinically significant distress or impairment in social, occupation, or other important areas of function. The diagnosis is not applied to persons with cross-gender identification who have intersex conditions. To some extent gender identity disorder replaces what previously has been treated as transsexualism, a term that came into use in the 1940s. Although some commentators still use that term, transgenderism and cross-gendered identities have come into common use.
The prevalence of cross-gender identities has been poorly studied. There have been no studies of prevalence in the United States, although there have been some studies in smaller countries. According to those studies, cross-gender identities occur in 1 in 30,000 adult males and 1 in 30,000 adult females (American Psychiatric Association, 2000). There are various theories about why some people come to have cross-gender identities, although no single theory is accepted as conclusive. Researchers have explored prenatal hormonal exposure, birth order, genetics, brain structure, and various psychological and social learning theories (Green and Blanchard; Devor). Whatever the origins of crossgender identification are, there is a general pattern of development: People have a sense of dissatisfaction with their sex characteristics and assigned gender, conclude that that dissatisfaction would be alleviated by change and therefore pursue varying degrees of reassignment (Devor).
Adults with cross-gender identities differ in regard to expectations from medicine and how far they want to conform their bodies to a particular gender (McCloskey). Not everyone wants to assume every male or female trait. Transgendered men may elect to have testosterone treatment, excision of the breasts and genitals, reduction in thyroid cartilage to minimize the Adam's apple, and the construction of a vagina. Transgendered women may elect to have estrogen treatment, electrolysis of unwanted hair, and the construction of male genitalia. However, some transgendered people continue to value aspects of their originally assigned sex and want to keep them even as they add other transfomations. Also, not all instances of crossdressing or atypical gender expression represent cross-gender identities. Some men and women cross-dress for sexual reasons; this phenomenon is known in psychiatry as transvestism. In these instances there is no discordance between one's biological traits and one's desired gender identity. The issue here is gender expression rather than identity.
There are no specific clinical or psychological tests to diagnose cross-gendered identities; the diagnosis is made on the basis of the case presentation. Moreover, there are no pharmaceutical or surgical treatments for this condition. Generally, behavioral or psychosocial treatments are used to orient a person to a gender identity; no hormonal or pharmacological treatments are known. Some studies have shown that cross-gender identification can be reduced in children through a variety of psychological and social interventions (Green). Advocates of treatment with children focus their interventions on helping children become content with their birth sex. They counsel, for example, that "young children should be taught that sex is irreversible" (Green and Blanchard, p. 1658).
Some practitioners justify therapy for children to alleviate the distress associated with cross-gender identities and behaviors and prevent the emergence of a homosexual orientation in adolescence and adulthood (Rosen et al.). Critics have contested both of those goals. In 1996 the Human Rights Commission of the City and County of San Francisco condemned the use of the diagnosis of GID. According to that group, the diagnosis of GID in children is used to screen for homosexuality and stigmatize gender nonconformity. Others have defended the use of the diagnosis and therapy: "Whether or not someone else agrees, parents have the legal right to bring a child for therapy to modify behavior they disapprove of and with the goal of preventing a later behavior of which they disapprove" (Green and Blanchard, p. 1659). Those commentators compare this option to parents' rights with respect to their children's education, religion, and diet.
Parents have a prima facie right to choose on behalf of their children, but that right is tempered by the moral right of children to be protected from undue risk and useless treatments. For reasons of beneficence parents should not use therapies that bring more harm than good to their children. Medical ethics also recognizes that maturing adolescents deserve a degree of choice in regard to birth control practices, psychiatric treatment, and involvement in research even when those choices conflict with parental wishes. Gender therapies for maturing adolescents require much stronger justifications than do those undertaken with much younger children.
Harry Benjamin holds a central place in the scientific study of transsexualism or transgenderism. Benjamin was a German national who immigrated to the United States and published The Transsexual Phenomenon in 1966. In that book he offered the first comprehensive treatment guide for transsexuals. In late 1970s a group of healthcare professionals codified his approach in the Harry Benjamin Standards of Care. Among other things, those rules require that people who seek gender interventions:
- obtain a diagnosis of gender disorder;
- begin a relationship with a therapist;
- receive hormone therapy;
- live as cross-dressed for a sustained period; and
- after therapists authorize it, receive desired surgical interventions (Harry Benjamin International Gender Dysphoria Association).
These standards are observed widely in professional relationships with transgendered people. However, some commentators believe that the standards are paternalistic in the sense that they represent a degree of control over medical interventions that is not required elsewhere, for example, in cosmetic surgeries.
Transgender therapy has important implications for a person's social and legal status. The physician and tennis player Renee Richards, formerly Richard, gained the right to play in women's professional tennis as a transgendered woman (Richards). Other transgendered men and women have not been as successful in finding accommodation in society and the law. Individuals who undergo transgender therapy often face legal difficulties insofar as they may violate laws regarding cross-dressing and the use of public washrooms. Those people are sometimes restricted in their right to marry and have children. Prison housing also raises special problems because transgendered persons are especially vulnerable to mistreatment and violence. Some jurisdictions have adopted laws that prohibit discrimination against people having or being perceived as having a self-image or identity not traditionally associated with one's biological sex. Most jurisdictions have no such laws.
The Ethics of Transgender Interventions
Insofar as male-to-female transgenderism is more common than its opposite, some critics have seen in transgender therapy the extension of male privilege. Janice Raymond has argued that male-to-female transgenderism trivilalizes women because it treats femaleness as a trait that men may adopt as they wish. She characterizes female-to-male transgenderism as an attempt to bypass constraints on female participation in a male-dominated society (Raymond). Raymond would not ban transgender therapy, but she believes that a greater social emancipation of women would eliminate the reasons for seeking it. By contrast, other commentators believe that the origins of cross-gendered identities are ultimately beside the point: Those commentators think that the proper focus of interest in these identities is not prevention and treatment but social accommodation so that people may live in whatever modes of sex or gender expression they find desirable (Devor).
Some commentators object to gender interventions for adults on the grounds that medical interventions violate the natural law principle of bodily integrity. However, other commentators working within the same tradition have defended medical interventions on the grounds that they protect psychic health (Springer). It is also possible to argue on utilitarian grounds that if psychiatry has no meaningful treatment for cross-gendered identities, gender interventions can help people achieve happiness. Even commentators who defend a pathological interpretation of crossgender identities agree that "the most reliable conclusion is that the overwhelming majority of post-operative transsexuals are content with their decision to undergo sex reassignment" (Green and Blanchard, p. 1660). Utilitarian ethics not only advocates the greatest happiness for the greatest number of people, as in the philosopher John Stuart Mill's formulation, it also asserts the liberty principle, a principle of noninterference with individual pursuits insofar as they do not harm others. A case can be made that atypical gender choices do not intrude on the rights of others any more than atypical religious or political views do.
Defending atypical gender identities and expression in adults does not of course establish what priority gender interventions should have in a health-care system. Some critics argue that too little research has been done on ways to improve the surgical needs of transgendered people (Devor). Some people have found that private insurers and government health programs are unwilling to pay for interventions because the interventions are voluntary and do not cure an underlying disorder. Other commentators have argued that gender interventions meet an important psychic need, that they work, and that their limitations can be overcome through better selection standards (Gordon). Those commentators therefore argue that private insurers and the government should pay for gender therapies.
Gender, Identity, and Gender Expression
One of the striking aspects of recent medical history is the way in which affected parties have worked to mitigate injurious or harmful medical practices. For example, women's advocacy groups have helped reshape health-care practices that worked against the interests of women. Men and women with homosexual orientations have worked to change the medical perception of homosexuality as pathological (Bayer). People with AIDS have forced a reconsideration of problematic language and representations used to describe them (Treichler). In a similar way people with cross-gender identities and intersex conditions have challenged the assumptions behind diagnoses and treatments related to gender.
In 1993, participants at the International Conference on Transgender Law and Employment Policy issued the first version of the International Bill of Gender Rights. Among other things, that bill asserts the right of all people to self-definition in regard to gender and the right of free gender expression. It also asserts the right of people to control their bodies in regard to chemical, cosmetic, and surgical interventions as well as the right to receive competent and professional medical care. It also rejects the pathological interpretation of gender: "[I]ndividuals shall not be subject to psychiatric diagnosis or treatment as mentally disordered or diseased solely on the basis of a self-defined gender identity or the expression thereof" (International Conference). In the long run it is a goal of gender activists to move society away from the treatment and prevention of GID and toward acceptance of a much broader range of gender expression.
Gender activism generally rejects the idea that only people with a particular biological endowment may participate in masculinity or femininity. This approach is part of a larger critique of gender roles that are constructed from opposed conceptions of male and female (MacKenzie; Feinberg). A number of commentators point out that some societies have successfully incorporated more diffuse notions of gender identity and gender roles; Native American tribes are commonly cited examples (Williams; Jacobs, Thomas, and Lang).
This critique raises questions about whether gender assignment in children and the category of GID serve social rather than medical purposes. The APA has attempted to divest itself of responsibility for the enforcement of moral or political values: "Neither deviant behavior, e.g., political, religious, or sexual, nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflicts is a symptom of a dysfunction in the person" that generates persistent stress, disability, or significant risk of suffering, death, pain, disability, or loss of freedom (American Psychiatric Association, 1987, p. xxii). Some commentators believe that the stress suffered by children, adolescents, and adults with cross-gender identities is primarily social in nature and thus is primarily a social problem, not an issue to be addressed through diagnosis and treatment.
Some commentators wonder whether medicine will continue to identify cross-gender identifications as pathological or whether another view will prevail. Certainly, attention to the views and counsel of the people under discussion and resistance to easy slippage between biology and culture will help medicine and ethics serve human beings as the people they are rather than as the people society would have them be.
timothy f. murphy (1995)
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