Historical and Modern Perspectives on Gender and Gender Identity

Early Medical Literature

In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called “inverts,” and they were portrayed as having an interest in knowledge and learning and a “dislike and sometimes incapacity for needlework.” During the mid-1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed. The aim of this therapy was to push children back to their “correct” gender roles and thereby limit the number of children who became transgender.

Psychodynamic Perspectives: Freud and Jung’s Views

In 1905, Sigmund Freud presented his theory of psychosexual development in Three Essays on the Theory of Sexuality, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the phallic stage, at which point gender identity became ascertainable. According to Freud, during this stage, children developed an Oedipus complex where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child’s power to appease sexual impulses. In 1913, Carl Jung proposed the Electra complex as he both believed that bisexuality did not lie at the origin of psychic life and that Freud did not give adequate description to the female child (Freud rejected this suggestion).

1950s and Beyond

During the 1950s and ’60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homosexuality (which was viewed as a mental disorder at the time). In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersex and transsexual individuals. Psychoanalyst Robert Stoller generalized many of the findings of the project in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden, in 1963. Behavioral psychologist John Money was also instrumental in the development of early theories of gender identity. His work at Johns Hopkins Medical School’s Gender Identity Clinic (established in 1965) popularized an interactionist theory of gender identity, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book Man and Woman, Boy and Girl (1972) became widely used as a college textbook, although many of Money’s ideas have since been challenged.

Butler’s views

Figure 1. Judith Butler is an American philosopher and gender theorist.

In the late 1980s, Judith Butler began lecturing regularly on the topic of gender identity. In 1990, they published Gender Trouble: Feminism and the Subversion of Identity, introducing the concept of gender performativity, arguing that both sex and gender are constructed.

Present views

Gender dysphoria (GD) exists when a person suffers discontent due to gender identity, causing them emotional distress. Researchers disagree about the nature of distress and impairment in people with gender dysphoria. Some authors have suggested that people with gender dysphoria suffer because they are stigmatized and victimized by society; if the society was more accepting of transgender identities and non-binary expressions of gender, they would suffer less and/or may not experience dysphoria at all. Other research into genetic variation, hormones, and differences in brain functioning and brain structures suggest evidence for the biological etiology of the symptoms associated with gender dysphoria; however, much of this research is preliminary and still controversial.

As you have read, in the past, gender identity development was mostly viewed through cognitive and behaviorist lens—arguing that struggles with gender identity developed from the environment or cognitive schemas. More recent research has been done to understand biological and influences on gender variances and how early social experiences may create lasting epigenetic changes related to sex differences. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior, but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.

For example, early postmortem studies of transsexual neurological differentiation was focused on the hypothalamic and amygdala regions of the brain. Using magnetic resonance imaging (MRI), some transgender women were found to have female-typical putamina that were larger in size than those of cisgender males.^[1] Some trans women have also shown a female-typical central part of the bed nucleus of the stria terminalis (BSTc) and interstitial nucleus of the anterior hypothalamus number 3 (INAH-3), looking at the number of neurons found within each.^[2]

Treatment for Gender Dysphoria

The World Professional Association for Transgender Health (WPATH) Standards of Care (Version 7 from 2011) are considered by some as definitive treatment guidelines for providers. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or surgical transition to the other sex. Clinicians’ decisions regarding patients’ treatment are often influenced by this standard of care (SOC). They are most widespread standard of care (SOC) used by professionals working with transsexual, transgender, or gender variant people.

Other standards of care (SOC) exist, including the guidelines outlines in Gianna Israel and Donald Tarver’s classic 1997 book Transgender Care. Several health clinics in the United States (e.g., Tom Waddell Health Center in San Francisco, Callen-Lorde Community Health Center in New York City, and Mazzoni Center in Philadelphia) have developed protocols for transgender hormone therapy following a harm reduction model that is starting to be embraced by increasing numbers of providers. Willingness to provide hormonal therapy based on assessment of individual patients needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.

Transgender transition services, the various medical treatments and procedures that alter an individual’s primary and/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.

Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual’s own expression of their identity, regardless of their biological gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.

Treatment

Figure  2. Some transgender individuals will undergo top or bottom surgeries, while others may choose not to have any surgery at all.

Today, gender affirming surgery is performed on people who choose to have this change so that their anatomical sex will match their gender identity. Transgender individuals sometimes wish to undergo this type of surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina, or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants since many adults have regretted that these decisions were made for them at birth.

Gender confirmation surgery (or gender affirming surgery) refers to any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity. Surgical procedures are usually preceded by hormone replacement therapy.

Some forms of gender confirmation surgery include

• bottom surgery, or surgery to alter the genitalia.
• top surgery, or surgery to alter the chest and breast tissue.
• facial reconstruction surgery, to alter the appearance of the face.

Those who plan to have surgery but not yet done so are often referred to as pre-op while those who have already had surgery are referred to as post-op. Those who do not wish to include surgery in their transition are referred to as non-op.

Sex reassignment surgery performed on nonconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case following a botched circumcision) when the individual’s sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed. Milton Diamond at the John A. Burns School of Medicine of the University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.

Psychological Treatments

Treatment for a person diagnosed with GD may include psychotherapy or to support the individual’s preferred gender through hormone therapy, gender expression and role, or surgery. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. This may include psychological counseling, resulting in lifestyle changes or physical changes resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries. Psychotherapeutic treatment of GD involves helping the patient to adapt. The goal of treatment may simply be to reduce problems resulting from the person’s transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing or counseling a spouse to help them adjust to the patient’s situation.

Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions. Attempts to alleviate GD by changing the patient’s gender identity to reflect birth characteristics have been ineffective.

Biological Treatments

Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual’s physical body and gender identity. Biological treatments for GD without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GD treatment, they often feel lost and confused when their biological treatments are complete.^[3]

Prepubescent Children

The question of whether to counsel young children to be happy with their sex assigned at birth or to encourage them to continue to exhibit behaviors that do not match their sex assigned at birth—or to explore a transgender transition—is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.^[4][5] Other clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.^[6]

Professionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender affirmation leading to gender affirming surgery will be in that person’s best interest.

Psychological and Social Consequences

Overall, psychotherapy, hormone replacement therapy, and gender affirming surgery together can be effective treating GD when the WPATH standards of care are followed. The overall level of patient satisfaction with both psychological and biological treatments is very high.

After gender affirming surgery, transsexual individuals (people who underwent gender affirming hormone therapy and gender affirming surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression, and hostility levels were lower after gender affirming surgery. They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. Many studies have been carried out to investigate satisfaction levels of patients after gender affirming surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing gender affirming surgery.

Although studies have suggested that the positive consequences of gender affirming surgery outweigh the negative consequences, it has been suggested that most studies investigating the outcomes of gender affirming surgery are flawed as they have only included a small percentage of gender affirming surgery patients in their studies. These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates, and low follow-up rates, which would indicate need for continued study.

Persistent regret can occur after gender affirming surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide. Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of gender affirming surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice, and stigmatizing behaviors. The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety, and post-traumatic stress.

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity, and reduce minority stress. Therefore, it is suggested that psychological support is crucial for patients after gender affirming surgery, which helps them feel accepted and to have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier gender affirming surgery processes.