When I address this audience as ladies and
gentlemen, it is not my first association that I am addressing a group of
human beings with vulvas and vaginas on the one hand, and a group with
penises on the other hand. This introduction, this approach might sound
abrupt, or even odd to you, but it brings us right to the core of the
matter.
When I address you as ladies and gentlemen,
I am referring to the kind of person - woman or man - that you became after
your birth, when your sex was determined by the criterion of the external
genitalia. This being established, your boyhood or girlhood, your manhood or
womanhood, became a matter of indirect evidence. Your genitalia are normally
not apparent or obvious in your social environment. Clues as to your being a
man or a woman come from indirect sources. When we group up, we develop a
sense of being a man or a woman, on which we hardly ever reflect. We are
what we are, either a man or a woman. For this sense of belonging to one sex
of the other the term gender identity has been coined. We communicate this
sense of belonging to the one sex and not to the other to the outside world
in our gender role. At the roots of this gender identity/role development
lies the criterion of the external genitalia, as determined immediately
after birth, but along the course of development of the gender
identity/role, the genital criterion is not the first association when we
talk about men and women in daily life. The reason why I am so elaborate on
this subject is that most legal systems pertaining to the determination of
sex pay absolute reverence to this one criterion of external genitalia,
while there are several criteria or characteristics of sex, such as the
genetic and the gonadal ones, the criteria of the internal and external
genitals and of the sexual differentiation of the brain. The latter one, the
sexual differentiation of the brain, is a rather new issue. I cannot say we
have a complete picture, but the scientific information can no longer be
ignored, and it goes without saying that it has relevance for the subject of
transsexualism.
What I said earlier about the relatively
loose connection between the genital criterion of sex on the one hand and
the gender identity on the other, is not at all new information. Let us have
a look at a very nice piece of tapestry made in Alsace (presently France) in
the 16th century. It is now in The Cloisters Museum in New York City. It
depicts the wise King Solomon. The lady in the picture has decided to put
his wisdom to the test. She has two flowers in her hand, one a false,
artificial one, the other a true flower. They look very much alike. The King
is asked whether he is able to tell which is the true one and which is the
false one. He says: "Wait and see to which one a bee will go. That is
the true one". The next question pertains to the sex of two children, a
pair of twins, one male, one female. They are dressed exactly the same. Can
the King distinguish the male twin from the female twin? He can, he throws
an apple at each of them. The girl twin will catch the apple with her knees
together leaning slightly backwards, whereas the boy twin will move his
knees apart, and move slightly forward to the King. Next they are asked to
throw the apple back to the King. The girl twin will throw the apple back
moving her arm in the lower half of a circle, whereas the boy will hurl the
apple back moving his arm in the upper half of a circle. The lesson to be
learnt here is that the wise King Solomon, in order to determine the sex of
the two twins, did not use the criterion of the genitalia. He could easily
have asked the children to lift their skirts. He did not! He relied on the
indirect information of the body language of both twins. Which is what we do
in our daily lives. Nothing new under the sun.
Let us now pay some attention to the
biology of becoming a man or a woman, or sometimes, and this is unfortunate,
becoming something in between. This slide shows the entrance of the
cathedral of San Gimignaiano in Tuscany (Italy), and God taking a rib out of
Adam, this creating Eve. This story undoubtedly applies to the first lady on
earth, but you in the audience have a different history of becoming men or
women.
At conception it was decided - let us
assume by the laws of chance - that your chromosomal pattern was 46,XY or
46,XX. Except for the chromosomes, there is no distinguishable difference
between a future boy and a girl in the first 6 weeks of development. After
the first 6 weeks, the indifferent gonad becomes a testis in the case of a
46,XY pattern, and an ovary in case of a 46,XX pattern. All the following
steps in the differentiation process are dependent on the hormones produced
by the testis before birth. The next step in the differentiation process is
that of the formation of the internal genitalia. These are completely
identical ducts in boys and girls. In the presence of testicular hormones
produced by the boy foetus, one pair of ducts will become prostate and
deferential duct, while the other pair goes into regression. In a girl
foetus, the development is the contrary: there are no testicular hormones,
so one pair does not develop, the other pair becomes the uterus and
oviducts. A couple of weeks later, the external genitalia develop from a
common principle. In the presence of testosterone, as is normal in a boy,
the external genitalia become a penis and a scrotum in a boy. In girls there
is no testosterone around, and the external genitalia develop into a vulva
and vagina.
It has always been assumed that the sexual
differentiation was completed with the formation of the external genitalia.
But it is NOT. Since the beginning of this century we have known that the
brain, too, undergoes a sexual differentiation. This has been firmly
established scientifically in lower animals, and it occurs relatively late
in development, in most species just before or shortly after birth. Let us
take the example of a rat. If a normally developed male rat is castrated on
the first day after his birth, his brain will have a female sexual
differentiation; if, by contrast, a female rat is given testosterone
immediately after birth, she will have a male sexual differentiation of her
brain. This implies that the female rat with her female genitalia will
copulate in the pattern of a male rate, and conversely, the male rat,
deprived of testosterone after birth, will assume the typical copulation
position.
What we see here is that male animals,
through hormonal manipulation, can be led towards female sexual patterns,
and conversely, female animals towards male sexual patterns. Again, this is
firmly established sexology of lower mammals such as the rat and the guinea
pig.
What do we know about man, the human
species? We know that the human brain, too, undergoes a degree of sexual
differentiation. Three areas of the brain have now been documented as being
sex-dimorphic. One of them is the so-called sex-dimorphic nucleus in the
lower part of the brain, the hypothalamus. Surprisingly, the sex difference
becomes manifest only 3 to 4 years after birth. This is amazing information.
Long after you were born and after your sex had been determined by the
criterion of the external genitalia, your brain still had a long way to go
to become sexually differentiated; it does not do so not before the age of 3
to 4 years. These scientific findings may shed light on the problem of
transsexualism where we find a contradiction between the genital sex on the
one hand and the gender identity on the other hand. To summarise the
previous information:
The slides are self-evident.
The process of sexual differentiation is
characterised by the following:
- sexual differentiation is a multi-step
process, not a one point decision;
- each step is characterised by a
bi-potentiality; each time the developing organism is at a bifurcation
of the male or female development;
- each step has a critical period in the
course of development. Only during a window of time can this particular
step take place. No backtracking;
- the sexual differentiation process has
not been completed at birth: the sexual differentiation of the brain
occurs between the age of 3 to 4 years.
So far I have described the orderly normal
sexual differentiation of becoming a boy or a girl, a man or a woman. It is
unfortunate that this process is liable to errors. In about 5 in every 1000
individuals this process has shown some errors. It is also a bit of an
admonition to those who always state: so God created man in His own
image: male and female created He them. Doctors can testify: in the vast
majority of cases with impeccable result, in about 5 in every 1000
individuals there are sex errors. The sexual differentiation has not
followed its normal course.
I will now show some of these sex errors,
and the list is by no means exhaustive. Two slides are self evident. It can
be concluded that there may be contradictions between the genetic sex on the
one hand and the other criteria of sex on the other hand.
In the clinical syndrome of androgen
insensitivity, for instance, all the cells of the body are intense to the
action of testosterone. While the first two steps of sexual differentiation
are normal (the chromosomes, the formation of the gonads) the other steps
follow the path of the other sex. These subjects are identified as girls at
birth and are raised as girls. They are infertile, they have no ovaries,
they have no uterus; but they do have testes. They are legally registered as
female and almost always engage in a marriage with a man.
Another example is the clinical syndrome of
the congenital virilising adrenal hyperplasia. If this occurs, the first
steps of sexual differentiation follow the pattern of a girl: a 46,XX
chromosomal pattern and ovaries, but due to abnormal production of androgens
by the adrenal, the external genitalia virilise, become more or less male,
depending on the degree of the severity of the disease. In severe cases,
these children are taken for boys at birth and raised as boys. They marry
women, but cannot become fathers because they have no testes. Instead, they
have ovaries.
Whereas the above clinical syndromes are
relatively easy to comprehend, some cases of hermaphroditism are difficult
to interpret. What can be done with these children at birth? A person cannot
grow up without a sex. What decision should be taken? A decision must be
taken! The social environment requires it, and the law requires it. What
criterion of sex must take precedence, certain predominances over others?
Would it be the genetic, the gonadal, or the external or internal genitals?
It has become accepted clinical practice to assign the baby to that sex in
which it will in all likelihood function best in childhood and adulthood, so
in general the criterion of the external genitalia prevails. It is medically
assessed to what sex the function of the external genitalia will lend
themselves best, sometimes after surgical corrections. It has particularly
been Dr. John Money who has built up a vast experience with this category of
children, and the policy described above has proved successful. It can be
summarised as follows: In a follow up of children with ambiguous genitalia
at birth for whom decisions had to be made as to sex assignment, sex of
assignment and rearing was more accurate than any other variable as a
prognosticator of the gender identity/role established in life. The other
variables were chromosomal and gonadal sex, sex hormones, and genital
anatomy.
Now back to transsexualism. It is likely
from the available evidence that in transsexuals the pattern of sexual
differentiation of the brain has not followed the pattern typical of that
sex: in other words, the nature of the chromosomes, the gonadal and genital
development are in contradiction with the brain sex; at least with the
sexual self-image of which we assume the substrate to be in the brain. There
is some evidence to confirm this assumption. In a collaborative study with
the Dutch Brain Research Institute, Professor Swaab could demonstrate in
postmortem investigations that in two male-to-female transsexuals the
sexual-dimorphic nucleus of the brain showed a similarity with the female
pattern. This was not the case in a third transsexual. The suprachiasmatic
nucleus was unusually large and showed a similarity with the pattern found
in homosexual men.
There are some interesting findings with
regards to brain functions. Women do better on verbal tasks than men; and
men, by contrast, do better than women on spatial ability. Men are better at
finding the way than the average women. Several studies indicate that
transsexuals show similarities in verbal and spatial performance with the
sex they view as their own.
In conclusion, there is now evidence which
needs further corroboration that in male-to-female transsexuals the sexual
differentiation of the brain is cross-sex to the other characteristics of
sex, and vice versa in female-to-male transsexuals.
Transsexualism manifests itself early in
life. On this slide you see two brothers of the same family. The younger boy
feels and presents himself to the world as a young man. His brother, a
future candidate for a sex change, is showing clear signs of cross sex
behaviour, look at the body angle. The next slide shows that this cross-sex
behaviour persists in time. Here you see the same person a couple of years
later, persisting in cross-sex behaviour.
I come to the end of my talk. As a
biomedical expert I arrive at certain conclusions and I arrive at certain
recommendations for legislators.
In summary, legal and sex assignment by the
criterion of the morphology of the external genitalia:
- is based on only one of the five
criteria of sex presently known; the other criteria are gonadal, genital
and brain sex;
- the criterion of the external genitalia
does not imply that chromosomal sex or the sex of the internal genitalia
are concordant;
- sexual differentiation of the brain is
not completed at the moment of birth. This takes place between the ages
of 3 to 4 years, well after birth;
- assignment to sex on the criterion of
external genitalia is an act of faith, but well founded and time-honoured.
Only 1 in 10,000-30,000 will be a false prognostication
- such an expedient practise does not
require a change;
- it works extremely well in daily life;
- in order to do justice to the rare
individuals in whom sexual differentiation of the brain postnatally has
not followed the path prognosticated, for example, by the external
genitalia, the law must make provisions. If we have the constitutional
right to be treated equally and the same by the law, the law must do
justice to the rare individuals in whom sex errors of the body occur.
This is a personal misfortune, but no ground for unfair treatment.
Ladies and Gentlemen.
I hope I have been able to communicate to
you that transsexualism is not an isolated phenomenon in the area of sex
errors of the body. It is one on a sliding scale. In some people you will
find contradiction between their genetic sex and the other variables of sex.
In other people between their genetic sex and gonadal sex on the one hand,
and their genital and brain sex on the other. Finally in transsexuals there
is a contradiction between the genetic, gonadal and genital sex on the one
hand, and the brain sex on the other. For all these people who have had the
misfortune to incur a sex error of the body in their development, solutions
have to be found. It is part of our anthropology, and of our human
existence, that we recognise only men and women in our social system, which
reflects on our personal status. In other words, there is no room for
intersexes, socially, legally and psychologically. Medical experience
teaches that being intersex makes a person subject to social abuse; such a
person becomes a freak. It would be absolute medical ignorance, medical
incompetence, even abuse NOT to rehabilitate a person with a sex error of
the body. Sex errors of the body cannot be corrected in the true sense of
the word. The only option is a rehabilitation to one sex or the other.
Rehabilitation does not pretend to be a cure. It is exactly what the word
says: rehabilitation makes the best of a condition that cannot be corrected
essentially and fundamentally.
The guiding principle in this
rehabilitation process is to assign a person with sex errors of the body to
the sex in which he/she will function best, psychologically, socially,
erotically, sexually. Again, I want to stress that reassignment of
transsexuals is a medical intervention on a sliding scale. It is not
essentially different from procedures in other sex errors of the body. The
same interventions including genital surgery are done in other cases of sex
errors of the body. This brings me to the issue raised in some of the legal
material I have been reading in this context: Can it really be done? Sex
reassignment in transsexuals? In other words: is the feminisation of the
body by hormones and the construction of a neovagina, a true authentic sex
change or is it a construct, an artefact, a modification only of the body?
My answer would be that it is as much a sex change as it is in other cases
of intersex. Many of the intersex cases will have contradictions between the
variable, the criteria of sex. Many will be unable to produce children; it
is a rehabilitation to the best of our ability, not a cure.
There can be no psychomedical ground not to
treat these people respectfully; we must provide them with reassignment
treatment which meets their needs. In the cases of intersex, and this is
particularly true of transsexualism, medical treatment does not bring
resurrection from one's ashes; it is not a cure. It is not a completely new
start, it is a rehabilitation process. We must accept the given fact of sex
errors of the body and continue from there. We must create the conditions
for successful rehabilitation to the male or female sex as much in cases of
transsexualism as in other cases of intersex subject.
The transcript of this speech (delivered to an
international audience of government representatives, lawyers, doctors and
transsexuals at the end of the three day conference) is taken from the
official proceedings, published by the Council of Europe. ISBN 92-871-2805-7
Citation: Closing
Speech at The Council of Europe: 23rd Colloquy on European Law:
Transsexualism, medicine and law. April 14-16, 1993 published on the
Internet by Press for Change, UK <http://www.pfc.org.uk/gendrpol/lgooren.htm>
