5280 Magazine this March features a striking article, "Second Nature" by Maximillian Potter, about Lucia, a ten year old in Boulder who has a strikingly M2F transgender identity.
Dr. Deborah Holden, a child clinical psychologist and a developmental neuropsychologist who has been practicing since 1980. In her Denver office, Dr. Holden saw Luc twice a week for about a month, administering a variety of emotional, developmental, and behavioral tests. . . . There was never a session where Luc walked in and stated that he wanted to be a girl. "He didn't use those exact words," Holden says, "but he definitely expressed feeling an urgent need to present himself to the world as female. Luc had a very specific idea of how he wanted to dress and present himself, and that was as a female. He wasn't arrogant about it, but he was very determined." Holden has seen more than 100 kids with gender issues, and in her clinical opinion, only eight to 10 of those children had "true gender confusion." Only two of those select cases were gender dysphoric to the point where she discussed with the parents the possibility of allowing the child to begin transitioning. Lucia "is the most clear" case of gender dysphoria Holden's seen.
The Rocky Mountain News today, meanwhile, reports on the equally striking case of 15 year old M2F Melaina who was inspired to talk to reporters about her case after a story about a 7 year old transgender student in Douglas County was reported.
At age 2, Melaina recalls playing with Barbies and her favorite toy, a kitchenette. When she played house in pre-school, "I would always want to be the mom."
Melaina says she never struggled with her identity. But her mother, Michelle Benzor-Marquez, cannot say the same.
When Melaina was around 8 years old, she was allowed to wear light-colored lip gloss and a little blush, but only at home. Melaina's hair grew longer, little by little, but her mom had the stylist chop it off one day in sixth grade. Melaina cried the whole 20 miles to her grandmother's home.
Benzor-Marquez hoped Melaina was gay because she figured the world could better handle that than transgender.
"I know people think it's wrong to be transgender," said Melaina, who on a recent day was dressed in black jeans and a black and gold striped blouse with decorative bow. "But God made everyone different in his own way, and you can't change that. It's not a choice." . . .
In fall 2006, the Bill Reed Middle School psychologist had a meeting with Benzor-Marquez. Melaina, known then as Manuel, was being teased and harassed.
"I had to come out and say, 'My daughter is transgender,' " Benzor-Marquez recalled.
This was the first time she ever said the word - and the first step toward fully acknowledging her daughter's situation.
In the earlier reported case of the 7 year old in Douglas County who was originally presented to classmates as a boy and has returned to school this year as a girl:
"She's happy," the mother said. "She's excited to be back in school. Loves her teacher." . . . Forty people from across the country have contacted the Douglas County School District about the situation and the majority "voiced concerns," said spokeswoman Whei Wong. Twenty of those families are local. . . . "No parent has asked that the student not be allowed to enroll," added.
Transgender identities are rare. The highest credible estimate of the number of people who have a transgender identity suggests that 99.8% of people have a cisgender identity (i.e. do not have transgender identities). The lowest credible estimate of the number of people who have a transgender identity suggests that more than 99.99% of people have a cisgender identity.
The DSM-IV (1994) quotes prevalence of roughly 1 in 30,000 assigned males and 1 in 100,000 assigned females seek sex reassignment surgery in the USA. The most reliable population based estimate of the incidence occurrence is from the Amsterdam Gender Dysphoria Clinic. The data, spanning more than four decades in which the clinic has treated roughly 95% of Dutch transsexuals, gives figures of 1:10,000 assigned males and 1:30,000 assigned females.
In September 2007 however, Olyslager and Conway presented a paper at the WPATH 20th International Symposium demonstrating that the data from this and similar studies actually implies much higher prevalence rates, with minimum lower bounds of 1:4,500 assigned males and 1:8,000 assigned females across a number of countries worldwide. They also present other evidence suggesting the actual prevalence might be as high as 1:500 births overall.
(One transgender advocacy group in the U.S., the National Center for Transgender Equality, has an estimate that as few as 99% to 99.7% of Americans are cisgender using a broad defintion of a transgender identity and admittedly patchy numbers as a basis for their estimate.)
Almost all credible sources agree that transgender identities are less common than homosexual sexual orientations, and further that people assigned a male gender identity at birth are more likely to have a transgender identity than people assigned a female gender identity at birth by something on the order of a two to three to one margin.
There are differences of opinion regarding how fixed childhood transgender inclinations tend to be, as the 5280 article explains:
Dr. Kenneth Zucker, believe that most transgender children are going through a "phase." Zucker is psychologist-in-chief and head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto, and during the past 30 years he has treated about 550 preadolescent gender-variant children. Based on his studies, Zucker says, 80 percent to 85 percent grow out of the phase, and only 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex. Zucker advocates counseling preteens with gender dysphoria to live according to their biological sex. "My approach," Zucker says, "has been to try to understand what might be the factors, of which I am sure there are many, that are causing a child to be so unhappy about their gender identity in relation to their birth sex, and then to make therapeutic attempts to help the child feel more comfortable in the gender identity that would make it more consistent with the biological sex, so as to avoid the path toward sex reassignment [surgery]." In other words, as Zucker sees it, more often than not a preadolescent's mood disorder causes the gender dysphoria—not the other way around, as Dr. Holden had diagnosed Luc. Zucker believes that if the mood disorders are adequately addressed then the gender dysphoria will go away.
Then there are the experts like Dr. Edgardo Menvielle who believe, simply put, that many transgender youth grow into transgender adults. Menvielle heads the Children's Gender and Sexuality Advocacy and Education Program at Children's National Medical Center in Washington, D.C., and oversees a support network comprised of some 300 families.
The debate is more than academic, because if one ends up ultimately seeking medical treatment for sex reassignment, there are definite benefits to early "puberty blocking and replacement therapies." According to a leading Boston practioner of these treatments, Dr. Spack, reported upon in the 5280 article:
"You'll find," Spack says, "that many people want to wait until a child is about 16, after puberty, to do any kind of hormone therapy. But by 16, the average female has been menstruating for four years, and the average male is 90 percent of adult height, not to mention facial hair. All of these things are, by that point, irreversible changes. If we can give a transgender child time, if we can delay puberty for a child, for a child like Lucia, why don't we do that?"
In addition to the psychological cost of foregoing hormonal treatment, there is a high financial price to pay to make those physical changes as an adult. It costs a small fortune for the painful procedures and operations: The only way to address the male Adam's apple would be to have it surgically shaved. And an M2F person would likely spend approximately $120,000 over a lifetime on hair removal. The cost of a M2F genital reassignment surgery, compared to hair removal, is a relative bargain at about $25,000.
It is clear that the overwhelming majority of people who are serious enough about their desires to seek medical treatment to cause them to more closely physically resemble their perceived gender identity do not regret their choice, although there is wide divergence in these estimates as well:
It is claimed that Meta-reviews of post-operative transsexuals prior to 1991 reveal a rate of serious regrets of less than 1% for transsexual men and less than 2% for transsexual women, while studies published after 1991 have reported a decrease in the rates for both . . . [other sources] suggests that 3-18% of them come to regret switching gender.
A Boston program that has handled 50 cases of sexual reassignment for people under age 21 reports no regrets.
A Biological Basis Is Likely
There is also some evidence of a biological basis for transgender identities that is quite distinct from the more heavily studied biological basis for homosexuality (which itself is better understood and appears to be biologically different in origin than female homosexuality):
The strongly connected and sexually differentiated hypothalamus, septum, bed nucleus of the stria terminalis (BST), and amygdala are implicated in sexually dimorphic patterns of reproductive and nonreproductive behaviors. Gender identity (i.e. the feeling to be male or to be female) is an important trait of a subject. Transsexuals experience themselves as being of the opposite sex, despite having the biological characteristics of one sex. In line with the hypothesis that in transsexuals sexual differentiation of the brain contrasts with that of the genetic and physical characteristics of sex, our group has recently found that the size of the central subdivision of the BST (BSTc) was within the female range in genetically male-to-female transsexuals. In that study the, BSTc was defined on the basis of its vasoactive intestinal polypeptide innervation, which is probably mainly derived from the amygdala. A crucial question resulting from that study was, therefore, whether the difference according to gender in the BSTc is based on a neuronal difference in the BSTc itself or rather a reflection of a difference in innervation from the amygdala. . . . Regardless of sexual orientation, men had almost twice as many somatostatin neurons as women (P < 0.006). The number of neurons in the BSTc of male-to-female transsexuals was similar to that of the females (P = 0.83). In contrast, the neuron number of a female-to-male transsexual was found to be in the male range. Hormone treatment or sex hormone level variations in adulthood did not seem to have influenced BSTc neuron numbers. The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.
In the case of both male homosexuality, and transgender identity development, some in the field think that there is a biological basis that has an important component after conception and prior to birth. For example, in the case of transgender identity development, some in the field think that the biological distinction described above "is mediated by diminished and excessive androgen levels respectively in utero and neonatally."
In hindsight, of course, this is a very sensible place to look for a cause of identities whose remarkability is precisely the fact that some aspect of gender identity, be it sexual attraction or a sense of self, differs from more obvious physical manifestations of gender which are generally rooted in that individual's XY or XX chromosome pair (or in some cases more than two X/Y chromosomes, although that is not a leading cause of either identity).
One of the leading physicians in the sex reassignment field, based in Trinidad, Colorado, whose patients are themselves overwhelmingly adults, offers strong indications that a transgender identity has a biological basis that manifests in most cases by early childhood:
Trinidad sex change surgeon Marci Bowers said about 95 percent of those she has operated on told her they remember identifying with the opposite sex as young as 4 or 5 years old.
"They (the kids) are hard- wired that way," Bowers said. "Don't get caught up on the genitalia. It's the child's internal concept of their self-identity. They know who they are."
I leave the topic with the parting thought that the phenomena of transgender identity, which appears real, has a deep, but hard to discern meaning about who we are as people, what gender is, and what neurodiversity means to our society.