Our mascotPapers presented at the 2nd International Congress on Sex & Gender, June 19-22, 1997

The Multi-Dimensionality of Gender

Carl W. Bushong, Ph.D., LMFT, TSC / TGIP

When we speak of gender, in a context other than language, it is a recent concept in our culture, both lay and professional. In 1955, John Money, Ph.D. first used the term "gender" to discuss sexual roles, adding in 1966 the term "gender identity" while conducting his gender research at Johns Hopkins. In 1974, Dr. N.W. Fisk provided our now familiar diagnosis of Gender Dysphoria. Previously, one's sexual role was considered one of two discrete, non-overlapping congenital attributes--male or female determined by one's external genitals. These two mutually exclusive categories allowed for no variation. Of course, we acknowledged the cultural differences in sexual roles, but there still could be only two modes of expression.

Now we see one's gender as a continuum, a blending, analogous to a "gray scale." But, our distribution of gender is bimodal, that is, most people are lumped at the two ends (see graphic) with only a minority in the middle. The great majority will see themselves as either male or female with all that implies.

But, my review of current research and experience with gender dysphoric, gay and traditional clients has led me to see gender not as a bimodal male or female dichotomy but as a matrix--a possible mix of male/female orientation within the same individual. Several researchers have developed theories of how the brain develops prenatally along sexual lines arising from androgen mediation. Dr. Milton Diamond concludes from his research that the brain has four stages of gender imprinting. The first is Basic Sexual Patterning such as aggressiveness vs. passivity. Second comes Sexual Identity (gender identity), third, the Mating Centers develop (sexual orientation), and fourth, the Control Centers for sexual equipment such as orgasm.

Gunter Dörner in Germany, using his research with rats, sees only three stages. He believes that first the Sex Centers develop giving typical male and female physical characteristics, then the Mating Centers (sexual orientation) and then the Gender Role Centers which are similar to Diamond's "Basic Sexual Patterning."

As a psychotherapist, I don't presume to enter into the discussion of what develops in what order and how. I take a more pragmatic stance and seek to observe what behaviors are linked, or independent from one another. From this research and observation, I have developed a list of five semi-independent attributes of gender. Not as a fixed dogma, but as a working theory, a map if you will, to help us understand this complex often hotly emotional issue of gender. Consider sexual identity/behavior springing from five semi-independent attributes.

These five attributes are:

Genetic-------------------------------------------------

Our chromosomal inheritance.

Physical Appearance---------------------------------

Our primary and secondary sexual characteristics.

"Brain Sex"--------------------------------------------

Functional structure of the brain, along gender lines.

Sexual Orientation------------------------------------

Love/sex object, "Love Maps."

Gender Identity----------------------------------------

Our subjective gender, our sexual Self-Map, how we feel ourselves to be: male or female.

It is my contention that it is possible for an individual to view oneself and function as male or female to varying degrees in each of the five sub-categories independent of the others. For example, an individual may be XX female (chromosomal female), physically female, have a "female brain," be heterosexual but see her(him)self as male--or any other combination. One can be either male or female in each of the five sub-categories independent of each other. If we use "F" for female identity/function, and "M" for male identity/function and one through five for the semi-independent attributes listed above we could describe each individual according to their particular breakdown:

1M 2M 3M 4M 5F

A Gender Dysphoric, Morphological Male

1M 2M 3M 4F 5M

A Homosexual Male

1F 2F 3M 4F 5F

A Dominant, But Heterosexual, Even Feminine, Female

Since each of these independent attributes is graded, it is easy to see the possible combinations and degrees number in the thousands. With regard to gender, we can be in a category of one--ourselves.

Perhaps only individuals who are homogeneously male or female at the highest degree in all five attributes could convincingly describe themselves as only a single gender-- the rest of us are a matrix.

Like our genetic and physical gender, our gender identity, sexual orientation, and brain sex, expression usually remains constant from childhood throughout one's life.

Distribution Graph


The Five Sub-Categories

Genetics

The first sub-category, Genetics, is only beginning to be understood. What mechanism and to what degree does genetic influences effect one's expression of gender? We do know that besides the traditional XX chromosome of a typical female and the XY of a typical male, that there are other combinations such as XXY, XYY, and XO.

A XXY combination results in 47 rather the 46 chromosomes. This condition is called Klinefelder's syndrome and occurs in one in every 500 births. Individuals with Klinefelder's are sterile, have enlarged breasts, small testicles and penis, and a eunuch body shape much like the "Pat" character on "Saturday Night Live." They show little interest in sex.

Another 47-chromosome occurrence is XYY Syndrome. In this syndrome, the hormonal and physical appearance of the individual are evidenced as a normal male, but behavior is effected. Typically, XYY Syndrome people are bisexual or paraphilic (pedophilia, exhibitionism, voyeurism, etc.), and show very poor impulse control.

Where Klinefelder's and XYY Syndrome are examples of an extra chromosome, Turner's syndrome is a case of a missing sex chromosome. These individuals possess 45 chromosomes (written as XO), are unable to develop gonads, and are free of all sexual hormones, except that crossing over from the mother during fetal life.

Turner's Syndrome people have external sex organs approximating a female, and their behavior is characterized as hyper-feminine, baby care oriented, and showing very poor spatial and math skills. The Turner's personality, free of all influence from testosterone, tends to be in direct opposition to the typical set of "Tom Boy" traits.

Physical Gender

Turner's Syndrome relates well to our second category of Physical Gender--that being our primary and secondary sexual characteristics. To discuss this aspect of gender we need to examine hormonal involvement, in particular testosterone. All sexual differentiation, physical, mental, and emotional are produced by hormones which may be amplified and/or specified by one's social environment During fetal life, the amount present, or the absence of testosterone determines our sexuality--physically, mentally and emotionally. There are key times or periods during development when the fetus will go towards the male or the female depending on the level of testosterone. These windows of opportunity may be only open for a few days and if the needed level of testosterone is not present, a basic female orientation develops regardless of the testosterone levels before or after this critical period, and the resulting sexual imprint.

The first critical period is at conception when the presence of the SRY gene (Sex-Determining Region of the Y chromosome) will determine our physical gender. The SRY gene is normally found on the short arm of the Y chromosome, but can detach making for a XY female (the Y missing its SRY gene) or a XX male (the SRY attaching to the X).

The SRY gene causes the fetus to release TDF (Testes Determining Factor) which turns the undifferentiated gonad into testes. Once testes have formed, they release androgens such as testosterone, dehydrocorticosterone, and anti-mullerian hormone.

Before the release of TDF, the developing fetus has two tiny structures, the mullerian and wolffian ducts, and two small-undifferentiated gonads, neither testes nor ovaries. Without the influence of TDF and testosterone, the gonads form into ovaries and the mullerian duct forms into the female internal sex organs, the wolffian duct disappears and the external sexual tissue becomes the labia major, clitoris, labia minor and clitoral hood. With the influence of TDF, the gonads become testicles and the wolffian duct forms the male internal sex organs, the mullerian ducts dissolve and the external tissue develop into the penis, scrotum, penile sheaths and foreskin. In other words, without testosterone all fetuses develop into females. Adam springs from Eve, not Eve from Adam.

As the primary sexual differentiation proceeds towards our physical gender, sometimes deviations occur. These anomalies are sometimes called "experiments of nature." One such "experiment" is a condition termed congenital adrenal hyperplasia (CAH) when the female fetus releases a steroid hormone form her adrenal glands which resembles testosterone. The resulting child often has confusing genitals ranging from deformed female genitals to an appearance of male genitals. If the child is raised as male, following any "adjusting" surgery and given male hormones at puberty, the individual develops as a "normal" but sterile male with XX chromosomes. On the other hand, if the infant is surgically corrected to female and given female hormones, there is a 50/50 chance of lesbian expression.

Another revealing "experiment of nature" is Androgen Insensitivity Syndrome. In this case, there is a normal amount of testosterone circulating in a XY chromosome fetus, but each cell of its body is unable to react to it. This is similar to Turner's Syndrome in that neither the mullerian or wolffian ducts mature and the external genitalia develops into an approximation of normal female genitals, but differs in that TDF stimulates the gonads into becoming functioning testicles in a XY chromosome body. The child is raised as a girl and is seen as a normal female until she fails to menstruate because she has no uterus. If her testes produce enough estrogen, she develops into a completely normal appearing, sterile female with XY chromosomes and internal testicles.

Dr. Simon LeVay, in his book, "The Sexual Brain," argues that one's brain receptors for hormones may also play a significant role in our gender development. Dr. LeVay writes, "There is much to recommend...that there are intrinsic, genetically determined differences in the brain's hormone receptors or in the other molecular machinery that is interposed between circulating hormones and their actions on brain development. First, this would provide a mechanism that involves hormone-induced brain differentiation but does not require there to be differences in the actual levels of hormones. Second, since there are several different receptors involved (including the androgen receptor, the estrogen receptor, and at least two " estrogen-related" receptors), there is opportunity for selective effects on different brain systems."

Now we must leave the comfortable arena of biology and development and enter the more rocky, emotional and even political arena of psychology, anthropology, and sociology. An arena where deduction, speculation and circumstantial evidence is more evident than "hard fact."

The third, forth and fifth attributes all reside in the brain and there is controversy on both a congenital vs. environmental level and on a developmental one. It is still argued by some that sexual orientation is a choice and there is no difference in the mental abilities of men and women. Others argue that the evidence, both direct and circumstantial, is becoming overwhelming that these stands are incorrect.

Brain Sex

Because of the controversy over whether significant differences in brain structure do exist between the genders, I will confine my discussion of the "Brain Sex" attribute to some behavioral differences that have been noted between morphological male and female infants and children. At all times keep in mind that Physical Gender does NOT always indicate "Brain Sex" Gender. And, while these differences are the norm, they are not absolute. Individual children may differ.

Even a few hours after birth, significant behavioral differences are noted between morphologically normal boys and girls. Newborn girls are much more sensitive to touch and sound than their male counterparts. Several day old girls spend about twice as long looking back at an adult face than boys, and even longer if the adult is speaking. A girl can distinguish between the cries of another infant from other extraneous noises long before a boy. Even before they can understand language, girls do better at identifying the emotional context of speech.

Conversely, during the first few weeks of infant life, boys are inattentive to the presence of an adult, whether speaking to the infant or not. However, baby boys tend to show more activity and wakefulness. At the age of several months, girls can usually distinguish between the faces of strangers and people they know--boys usually do not demonstrate this ability.

As infants grow into children, the differences seem to intensify and polarize. Girls learn to speak earlier than boys and do a better job of it. Boys want to explore areas, spaces and things, girls like to talk and listen. Boys like vigorous play in a large space where girls like more sedentary games in smaller spaces. Boys like to build, take things apart, explore mechanical aspects of things and are interested in other children only for their "use" (playmates, teammates, allies, etc.). Girls see others more as individuals--and will likely exclude a person because they're "not nice," and will more readily include younger children and remember each other's names. Girls play games involving home, friendship, and emotions. Boys like rough, competitive games full of "ëzap, pow' and villainy." Boys will measure success by active interference with other players, preferring games where winning and losing is clearly defined. In contrast, girl play involves taking turns, cooperation and indirect competition. Tag is a typical boy's game, hopscotch is a girl's game.

Sexual Orientation

If "Brain Sex" is controversial, the fourth attribute of Sexual Orientation is ever more so. Although there is public and political controversy, the overwhelming majority of medical and psychological practitioners agree that sexual orientation may prove to be mainly congenital, or at least firmly established in early childhood. The term "Sexual Orientation" is a bit misleading. It is more an erotic or love orientation in that Sexual Orientation determines the physical gender we find attractive, with whom we fall in love, and have romantic as well as sexual fantasies.

From experiments with animals, "experiments of nature" in humans, and genetic and neurological studies come a consistent, though still circumstantial, stream of evidence that indicates one's sexual orientation is largely hormonally determined by the presence or uptake of testosterone at key periods in fetal development, and possibly even beyond. As we have seen with congenital adrenal hyperplasia (CAH), female fetuses exposed to testosterone-like agents develop a 50/50 chance of a lesbian versus heterosexual orientation if raised as girls. Studies of identical twins also indicate that when one twin shows homosexual or lesbian expression, there is a 50/50 chance of homosexual or lesbian expression in the other twin--whether raised together or apart.

The remaining 50% of determination may be continued hormonal development, environmental considerations or a combination. One interesting consideration with determination may be during our early postnatal development since the fetal stage for human babies is not completed during gestation, but continues for a year or more outside the womb. And during this critical time after birth, we have the highest level of testosterone present, excluding the onset of puberty--with many brain receptors to receive this powerful hormone. At any rate, between the ages of three and six years, one's erotic orientation is very likely established but may not be acted upon for decades, if at all.

It is also interesting that sex- atypical traits (in regards to one's physical gender) seen in children destined to become gay or lesbian, are more evident than in adults who are gay or lesbian. One possible explanation is that the increased levels of androgens and estrogens at puberty stimulate the development of more sex-typical traits in adults.

Gender Identity

The last of our five attributes, Gender Identity, is the last to be identified, and the least understood and researched. Gender identity is one's subjective sense of one's own sex. Like pain, it is unambiguously felt but one is unable to prove or display it to others. One's subjective gender is just as real and immalleable as one's physical gender but unfortunately not recognized in our culture. When one's Gender Identity does not match their Physical Gender, the individual is termed Gender Dysphoric. Like minority Sexual Orientation, Gender Dysphoria is not pathological, but a natural aberration occurring within the population. As with minority sexual orientation, the percentage of the population having gender dysphoria is in dispute, with estimates ranging between one in 39,000 individuals up to three percent of the general population. My experience leads me to feel that the higher figure (3%) is closer to the actual prevalence.

Gender dysphoric individuals have been described, either by themselves or by others, as falling into three distinct groups: crossdressers, transgenderists and transsexuals.

Crossdresser

Those individuals with a desire to wear the clothing of the other sex but not to change their sex are termed crossdressers. Most crossdressers view themselves as heterosexual men who like to wear women's clothing in private or in public, and may even occasionally fantasize about becoming a woman. Once referred to as a transvestite, crossdresser has become the term of choice.

Transgenderist

Transgenderists are men and women who prefer to steer away from gender role extremes and perfect an androgynous presentation of gender. They incorporate elements of both masculinity and femininity into their appearance. Some persons may see them as male, and by others as female. They may live part of their life as a man, and part as a woman, or they may live entirely in their new gender role but without plans for genital surgery.

Transsexual

Men and women whose gender identity more closely matches the other physical sex are termed transsexual. These individuals desire to rid themselves of their primary and secondary sexual characteristics and live as members of the other sex.

Transsexuals are diagnostically divided into the sub-categories of Primary or Secondary. Primary transsexuals display an unrelenting and high degree of gender dysphoria, usually from an early age (four to six years of age). Secondary transsexuals usually come to a full realization of their condition in their twenties and thirties, but may not act on their feelings until they are much older. Typically, secondary transsexuals first go through phases that would be self-assessed as being a "crossdresser or transgenderist."

A New View of Gender

While the above categories are the generally accepted classifications both within the gender community and among helping professionals, during my work with gender folk I have come to the belief that there is only one cause and one conflict--but there are many reactions and adjustments to it. I have gradually come to the conclusion that one's coming to terms with the conflict between one's subjective knowledge of their gender and one's need to be "normal" fosters the conflict in all gender folk. I also feel that for most physically male gender folk, the male persona is an artificial construction produced by the early adolescent individual (age 12 to 15) in order to fit in and be like everybody else. For the F/M person, there is a separate and different, but still consistent pattern.

Physically Male/Subjective Female Individual (M/F)

Because a child's greatest desire is to be normal (like everybody else), the great majority of M/F individuals create an artificial self which meets this goal. They are often so successful at this that they not only fool everyone else but themselves as well -- at least part of the time, in some way.

Once created, M/F gender folk live in their male role -- a 3-D personality with its own goals, likes and dislikes, values, hobbies, etc. Although indistinguishable from the "real thing," it isn't themselves. It is an artificial creation for them to be able to fit in. This is achieved at the expense of denying, locking away, their natural female subjective gender. Their desire to be "normal" has denied them their natural selves. But, as the nagging reality of the deception becomes harder and harder to suppress, one has to express their true subjective gender somehow, in some way.

For most, dressing is the obvious compromise. If one cannot be female, one can at least express femininity. But the more one expresses one's true self, the desire for more becomes greater. Some individuals continue expressing themselves more and more, others panic and purge only to start again later.

One's gender identity classification (crossdresser, transgenderist, transsexual, etc.) is due to each individual's adjustment to first the conflict between one's subjective gender (Self-map) and their need to be "normal," and later to the conflict between one's subjective gender and their "male persona." There is no objective "best solution," only a subjective, personal best solution.

After years or decades of living, working and building within their male persona, it is often too "expensive" to give up the life, perks, family, etc., one has built up--in order to go back to basics and have an emotionally 12 year old girl grow up--and live in a once male 40+ year old body.

However far one is able to go toward dismantling the male persona and allowing their female subjective gender to develop, one generally seems to have the following three levels of transition:

1. Recognition that one's Self Map (subjective gender) is different from one's Physical Gender --This can take the form of seeing one's self as a "woman trapped in a man's body," a need to express one's "feminine side," etc. This stage is mainly concerned with physical/surface changes such as crossdressing, passing, makeup, wigs, etc. In this first part, many gender folk don't even venture from their own home and often have a juvenile (before age 15) and later, an adult phase. The so called "Primary Transsexual" is an individual who never constructs a male persona and therefor never accepts their male genitals or challenges their female Self Map/subjective gender.

2. Accepting one's Self-Map (Subjective Gender)--This stage is more varied than the first and consists of changing one's life to fit one's Self-Map. These changes may only involve bringing one's significant other and loved one's into their dressing behavior and expanding their activities ("crossdressers") or continuing to express their Self Map and dismantle their male persona by starting hormones, electrolysis and public dressing. One develops towards a "comfort level" with one's subjective gender and its conflict with their male persona.

3. Becoming one's True Self -- This is the last but unfortunately least experienced part of transitioning. This is the stage when that little child trapped inside an artificial persona in order to fit in breaks free, grows up and has their own life -- often with markedly different values, temperament and interests.

It has been my observation that the female subjective self needs little help in growing up and developing if the overpowering weight of the male persona is removed from it. The M/F individual has spent years, decades developing, reinforcing and living in their male role. Dismantling the male persona takes a great deal of time, effort and outside help. In those individuals identified as "transsexual," their subjective sense of happiness and success is directly parallel with the degree they have dismantled their male identity, not on their age, physical size, hormones, surgery, etc. Another interesting aspect of a female subjective gender with a male physical gender is the concept of Sexual Orientation. To classify a M/F individual as either homosexual or heterosexual would be equally false. If one views their gender as that established by their subjective gender, then having sex with a physical/ subjective female would make them homosexual (lesbian). But, if one viewed their actions from their physical gender, they would be committing a heterosexual act. In other words, no matter which gender they have sexual relations with, they are simultaneously committing both a homosexual and heterosexual act.

I believe this example illustrates the need for us to see our gender as a matrix of male/ female expression and not as an either/or classification based on the appearance of our physical genitalia.

Physically Female/Subjective Male Individual (F/M)

The F/M individual is much simpler than the M/F one. With F/M, there is no conflict or confusion over sexual orientation. --They are overwelmingly attracted to physical females, but not as a female themselves, but as a male. There is little, if any attempt to create a "female persona" and "crossdressing" behavior, if it appears at all, has different goals and practice.

Unlike the long transition required with M/F's, F/M's seem to need little help beyond understanding their condition, accepting it and help in correcting their physical gender to accommodate their subjective one.

In male-subjective/physical gender and female-subjective/physical gender individuals, males are generally the simple ones and females, the most complex. It may be that one's subjective gender is a major component in this complexity or the lack of it.


References

Benjamin, H..The Transsexual Phenomenon: A Scientific Report on Transsexualism and Sex Conversion in the Human Male and Female. New York, Julian Press, 1966.

Buhrich, N., Bailey, J.M. and Martin, N.G.Sexual orientation, sexual identity, and sex-dimorphic behaviors in male twins. Behavior Genetics, 21:75-96, 1991.

Diamond, M. Human sexual development: biological foundations for social development. Human Sexuality in Four Perspectives. Beach, F.A. (ed.), Baltimore, Johns Hopkins Press, 38-61, 1977.

Dittman, , R.W., Kappes, M.E. and Kappes, M.H.Sexual behavior in adolescent and adult females with congenital adrenal hyperplasia. Psychoneuroendocrinology, 1991.

Docter, R.F.Transvestites and Transsexuals: Toward a Theory of Cross-Gender Behavior. New York, Plenum Press, 1988.

Dörner, G. Hormones and sexual differtiation of the brain. Sex, Hormones and Behaviour, CIBA Foundation Symposium 62, Amsterdam, Excerpta Medica, 1979.

Dörner, G.Sexual differentiation of the brain. Vitamins and Hormones. 38:325-73, 1980.

Dörner, G.Sex hormones and neurotransmitters as mediators for sexual differentiation of the brain. Endokrinologie, 78. 129-38, 1981.

Dörner, G.Sex-specific gonadotrophin secretion, sexual orientation and gender role behaviour. Endokrinologie, 86. 1-6, 1985.

Fisk, N.M.Gender dysphoria syndrome: (The how, what, and why of a disease). In Proceedings of the 2nd Interdisciplinary Symposium on Gender Dysphoria Syndrome. (D.R. Laub and P Gandy, eds.). Division of Reconstructive and Rehabilitation Surgery, Stanford University Medical Center, 1974.

Kaplan, A.G.Human sex hormone abnormalities viewed from an androgenous perspective: a reconsideration of the work of John Money. The Psychobiology of Sex Differences and Sex Roles. Parson, J. (ed.). Hemisphere, 81-91,1980.

Kimura, D., and Harshamn, R.Sex differences in brain organization for verbal and non-verbal functions. Progress in Brain Research. De Vreis, GJ. it al. (eds.), Amsterdam, Elsevier, 423-40, 1984.

Kimura, D.Are men's and women's brains really different? Canadian Psychol., 28(2). 133-47, 1987.

LeVay, Simon. The Sexual Brain. Cambridge, Mass.: MIT Press. 1993.

Moir, A., and Jessel, D.Brain Sex: The Real Difference Between Men and Women. New York, Dell Publishing, 1989.

Money, J.Gay Straight, and In-Between: The Sexology of Erotic Orientation. New York, Oxford University Press, 1988.

Money J., and Ehrhard, A.A.Man and Woman, Boy and Girl: The Differentiation and Dimorphism of Gender Identity from Development to Maturity. Baltimore, Johns Hopkins Press, 1972.

Money, J., Schwartz, M., and Lewis, V.G.Adult erotosexual status and fetal hormonal masculinization and demasculinization: 46,XX congenital virilizing adrenal hyperplasia and 46, XY androgen insensitivity syndrome compared. Psychoneuroendocrinology, 9:405-414, 1984.

Stein, S. Girls and Boys: The Limits of Non-Sexist Rearing. London, Chatto and Windus. 1984.


About the Author --

Carl W. Bushong holds a doctorate in clinical psychology, and has been in private practice since 1977. Dr. Bushong is the Director of the Tampa Gender Identity Program (TGIP), where a full range of transgender services are provided using his Informed Choice method--the individual uses their own decision-making capabilities after being provided with the necessary information and feedback to do so. In other words, the patient is ultimately in charge of the decision-making process--and has access to the facilities and expertise of a well-trained gender team.

Tampa Gender Identity Program offers a comprehensive blend of gender based services--providing counseling, medical, hormonal, electrology and other services that deal extensively with gender identity and related life-style issues.

For further information, contact:

Carl W. Bushong, Ph.D., LMFT TSC / TGIP
PO Box 273107
Tampa, FL 33688-3107
Telephone: (813)884-7835
E-mail: nu-woman@intnet.net (E-mail Subject: Attn: Dr. Bushong)
WEB: http://www.nu-woman.com/tgip.htm


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