At medical school, in the mid-’90s, my pediatric training took place in a Victorian hospital in Edinburgh called the “Sick Kids.” But it began before birth, so to speak, at the modern maternity unit a short stroll away across a park lined with elm trees. It was there in Edinburgh’s Royal Infirmary that I was obliged to deliver 20 babies and learned about the many perils that attend the first few minutes of life. When I’d been signed off as competent to assist births, the next stage in training followed the newborn babies into an adjoining neonatal unit.
The babies we admitted were often mortally ill and critically underweight, but one day there was an unusual admission: a perfectly healthy nine-pound newborn. In the moments after birth, when the newborn’s parents had cried out to ask if it was a boy or a girl, the midwife had gasped, “I don’t know!” The baby had ambiguous genitalia, a small penis as well as a vagina. He or she was robust and feeding well—it was quickly established that the baby suffered no metabolic or hormonal problems causing the ambiguity. The only reason to stay in the hospital was to figure out whether she really was a he, or vice versa. The importance the medics placed on the distinction was implicit even in the name bands we wrapped around the babies’ wrists. These were usually color-coded pink or blue, but the new baby was given one of white. The parents were anxious and bewildered, and only became more so when the attending neonatologist began to speak of blood tests, scans, gonadal biopsies.
Later that day I walked back through those boulevards of elms to the library at the Sick Kids. “Ambiguity of the external genitalia at the time of birth causes great distress,” I read. “Sensitive explanation is vital.” It was estimated that one in 2,000 babies manifest some degree of genital ambiguity, and as regards the tests: “Complete diagnostic evaluation requires special expertise as it has to consider the long-term functional role of the individual as well as the precise gender.” The book went on to explain that intersex babies could turn out to be genetic females (with two X chromosomes), whose clitorises had swelled to the size of small penises because of a hormonal condition generating unusually high levels of androgens (testosterone-like hormones) while still in the womb. But there were genetic males (with an X and a Y chromosome), whose developing genitalia had proven partially insensitive to testosterone, or who hadn’t been able to generate adequate amounts of the hormone to physically differentiate. As human beings, our default form is female—if the bodies of male babies don’t sense androgens in their blood, they develop short, blind-ended vaginas. These two broad groups described the vast majority of babies with ambiguous genitalia.
There was a third category in the textbook: “true hermaphrodites,” babies born with both testicular and ovarian tissue, and small penises as well as wombs and vaginas. Highly improbable events had to coincide for this to happen, and there were several ways it could come about. One is that a “male” sperm carrying a single “Y” chromosome, and a “female” sperm carrying a single “X” chromosome, can fertilize an egg that has just divided, then those fertilized eggs fuse together. The bodily tissues of these “true hermaphrodites” are often a tessellated patchwork of male and female cells, and are known in medical jargon as “mosaics.” Mosaicism has been known since at least the 1930s, but it wasn’t until the late ’50s that it was realized this phenomenon could lead to hermaphroditism.
The assumption implicit in my training was that, as regards gender, we are born neutral—all of our gender-typical behaviors, whether male or female, are socialized. The textbook also said in clear but insensitive style: “A genetic male with functioning testes but feminized external genitalia is better reared as a girl.” I wondered how they could be so sure.
It took a few days to sort out all the blood tests and scans—days in which the parents, in the interests of neutrality, referred to the baby as Sam. Names might tolerate ambiguity, but the deeply gendered nature of language meant that no one could figure out which pronouns to use. “It” seemed grossly insensitive, but “he” or “she” might prove incorrect. Sam was gloriously oblivious, breastfeeding well and putting on weight.
When all the results were put together, they implied that Sam was one of the rare, “true” hermaphrodites: a mosaic of male and female cells had given rise to elements of both sexes. Sam had a womb as well as a fallopian tube leading from an ovary on the left side, but on the right there was a buried testicle and a vas deferens, the duct that in adulthood conveys sperm from the testicle to the urethra.
In the ’90s in Edinburgh, there wasn’t a great deal of sensitivity around gender ambiguity, and the possibility of raising Sam as intersex—being dressed in green or red instead of pink or blue—didn’t appear to arise. When the very nature of language insists on a decision, choosing gender-neutral clothes and toys was perhaps never going to be enough. “She’s a girl,” Sam’s mother decided finally, once we had explained the findings of the tests, “Sam is Samantha.” What would be done about her penis was left for a later decision. Her bald little head was immediately decorated with a flowery headband. Her cot-side filled up with pink cards, frilly blankets, and heart-shaped balloons.
Sam was
living, thriving proof that there’s more to men and women than X and Y
chromosomes, but modern Western culture, and in particular Western medicine,
often struggles with ambiguity and androgyny. Through most of the twentieth
century, medical orthodoxy held to the line articulated in my pediatric
textbook: Boys without male genitals (absent either because of a developmental
anomaly, or consequent to an accident) could simply be raised as girls. But in
adolescence it was increasingly noted that many of these individuals began to
express discomfort with the gender allocated to them. Early hormonal exposure
seemed to have a role in determining later identity. It was noticed, too, that
XX babies raised as boys, because of enlarged clitorises, reported high levels
of unease in being identified as boys. One study from 2005 put this proportion
at 12 percent, while the proportion of XY babies raised as girls, but who later
identified as male, was lower at 5 percent.
Science and statistical surveys are teaching us more about these fluid ideas of gender identity, but thousands of years ago, in the philosophy and mythology of the Greeks, these concepts were already being explored.Plato’s Symposium for instance tells of the playwright Aristophanes’s contribution to an earnest discussion about love. In the beginning there were three sexes, he says, not two: male, female, and androgynous. Each consisted of four hands, four feet, two sets of genitals and two faces gazing in opposite directions. Those beings wholly male came from the sun, those all female came from the earth, and those in whom male and female parts coexisted came from the moon.
When these original, powerful beings began to threaten the gods, Zeus split them down the middle “as you might divide an egg with a hair,” doubling their numbers but condemning each to search forever for his or her other half. Those who were once androgynous became heterosexuals, useful for breeding but prone to adultery. Those who were all-woman became lesbians and those who were all-man became homosexual men (“the best of boys and youths, for they have the most manly nature”). Aristophanes was a comic playwright, and seems to have anticipated being mocked for his ideas, though no one present did so. “This is my discourse of love,” he says, “which, although different to yours, I must beg you to leave unassailed by the shafts of your ridicule.”
As Plato’s story shows, there’s a long history in our culture of complex, flexible ideas of gender. From the ancient world through the Renaissance, there are plenty of examples in medical and other writings in which men and women are thought of less as opposites than as beings sharing essential characteristics. From the anatomies of the Greek physician Galen, to the speculations of the English physician Sir Thomas Browne, transition between female and male was thought of as not just possible, but expected from time to time. Only about 200 or 300 years ago, with the hardening rationalism of the Enlightenment, did this fluidity give way.
As scientific progress continues to forge new understanding of intersex conditions, as well as the separate issues of gender and sexuality, I’m convinced we’re returning to a more complex, fluid, and ultimately humane perspective which allows an expression of identities that have long existed but been repressed. I’ve witnessed surgical and medical techniques facilitate transition in a way that was unthinkable even 30 years ago, and I’ve begun to understand what Aristophanes only hinted at—that gender ambiguity represents a variance, not a deviance in our humanity.
Another Greek story, the myth of Tiresias, attests to a fascination with gender flexibility, and existed in many versions, the best known being the archaic poet Hesiod’s version. As a child, Tiresias was walking in the forest when he came upon a pair of mating snakes—a symbol of bisexuality and an omen of ill luck. Instead of rushing away from the misfortune, “He strake them overthwart the backs.” The female snake was killed, and Tiresias was transformed instantly into a woman. Snakes also symbolize transformation because they periodically shed their skins, and in her new skin Tiresias became a prostitute in Thebes, and later a mother. After seven years, she came upon mating snakes again, and this time struck the male, returning immediately to a male form.
The Roman poet Ovid follows the tale of Tiresias with a bawdy barroom story about Zeus and his wife Hera having an argument over whether men or women had the greatest pleasure during intercourse. As the only ancient trans person, Tiresias was called in to adjudicate, and testified that if sexual pleasure consists of ten parts, then women enjoy nine tenths and man enjoys one part only. It’s an odd tale, and given the assertion that only about one-third of women in Western culture reach climax during heterosexual intercourse, says more about male anxieties than it does about sexual realities.
Tarik told me he had known from a young age that he’d been born on the wrong side of Tiresias’s divide. He was neither straight nor gay, and he couldn’t remember ever being interested in sex. As a boy he’d been more interested in Barbie than Action Man, and was scolded for wearing his sister’s dresses. Outwardly he had been a calm and studious child, but a whirlwind of anxieties over his true gender identity gathered force through adolescence. He became an academic, and when we met three or four years ago, he was just beginning a long research sabbatical. The free time offered him his first opportunity to address his gender identity. “You’re the first person I’ve told,” he told me, sobbing. “I can’t go on like this.”
Since my time in medical school, neurodevelopmental research had begun to suggest gender identities are rooted in hormonal and somatic aspects of our bodies’ workings—my textbook’s assertion that a boy without a penis could simply be raised as a girl has now been shown to be wrong. Twin studies imply that the incidence of gender variance is higher in identical twins than it is in fraternal (non-identical) twins, which indicates a genetic component. Other studies have found that chromosomal disorders that lead to reduced testosterone result in an increased incidence of male-to-female transition. XY babies without a penis raised as girls show a relatively high incidence of gender variance, raising the probability that some hormonal, gendered imprint early in life may prove indelible as an adult.
Until recently, gender variance was considered a mental illness. The first Diagnostic and Statistical Manual of the American Psychiatric Association, published in 1952, placed it under the blunt heading “Sexual Deviation.” The second manual, published in 1968, retained the same classification, although by then there was a broadening awareness of diversity of sexuality and sexual behavior. The third, from 1980, created the new category “Gender Identity Disorders,” which was carried over into the fourth, from 1994. The fifth version, in 2013, has switched the term “disorder” for “dysphoria”—a state of mind that connotes suffering and distress. This term, too, has been criticized in the literature as excluding those entirely at ease in his or her adopted gender, and the more neutral term “variance” is now proposed as less stigmatizing.
Tarik was profoundly dysphoric; every morning he woke with a plunging feeling in his gut, knowing he faced another day of acting as a man. He was depressed, and his sleep was agitated and unrefreshing. His body disgusted him, particularly his chest hair and beard, his jawline, penis, and scrotum. He could barely bring himself to touch his genitals and found it easier to wash them quickly, in the dark. He’d never had sex, never masturbated, and told me he’d sometimes wake drenched in semen, as if his body was in rebellion against his sexlessness.
Medical guidelines in both the United Kingdom and the United States require living fully in the adopted gender role for twelve months or more before gender reassignment surgery. “I hate that expression, ‘living in a role,’” Tarik told me when we began to discuss his transition. “For me, this is living authentically.” With ongoing support from a local gender identity clinic he took the courageous step of telling his work colleagues, his parents, his siblings, and began to live as Teresa.
Tiresias had switched gender at the strike of a snake; I began to prescribe drugs for Teresa to effect a comparable metamorphosis. The first drug was finasteride, which inhibits the generation of the most potent form of testosterone within the body. In small doses, it helps to retard male-pattern baldness. This was only partially effective, and gave way after a few months to leuprorelin injections, initially monthly and then, once her body was used to them, once every three months. Leuprorelin inhibits the brain’s pituitary gland and can shrivel the testes—it has the potential to cause flushing, a collapse of interest in sex, and weakening of the bones. A few weeks after leuprorelin was established, we commenced estrogen therapy. This feminizes the body and promotes the development of breasts, but can be dangerous if given inappropriately (it can bring on blood clots as well as stroke, heart attack, and breast cancer). Given the risks involved, the idea that trans women would undertake these therapies purely as a “lifestyle” choice doesn’t bear scrutiny.
The final phase of transition to Teresa would be the most difficult: removal of the testicles and parts of the penis, and then the creation of a blind-ended vagina. Parts of the glans penis were carefully preserved with their nerve sensation still intact and used to create a clitoris—“clitoroplasty.” The physical transition proceeded in slow, painful stages—convalescence from each procedure took months. The body’s own power of healing can rebel against its new form: initially trans women may have to keep their newly created vagina open with the daily use of dilators and regular douching with antiseptic solution. Parts of the scrotal skin are infolded, then sutured down to create labia.
Once Teresa’s physical scars had healed, her dysphoria was replaced by euphoria. She went back to her position at the university and the quiet, studious life she’d had before transition. Her academic work was better than it had ever been. Estrogen can affect more than just the shape and hair distribution of the body: “My brain loves these hormones,” another trans woman told me shortly after commencing estrogen therapy. “It feels as if a missing cog has fallen into place.” Teresa remained uninterested in sex or in finding a partner. There were still many challenges she faced: teasing and disapproval from her colleagues; disappointment and disbelief from her parents; the need for ongoing hormonal treatment; her ceaseless battle with chest and facial hair. But her sleep was now restful, and her dread of awakening had gone.
Even 30 years ago the transition from Tarik to Teresa would have been improbable: Gender surgery was far more difficult to access, and it was rudimentary in terms of the procedures that could be offered. But though the science and the surgery to effect gender transition is a relatively recent phenomenon, classical medical ideas of gender and sexual differentiation prefigured it. They hinged on the assumption that male bodies were simply warmer than those of women, and the temperature of your mother’s womb determined whether you’d develop male or female sexual organs. According to Galen, writing in the second century, these organs were fundamentally the same: The scrotum was simply a womb turned inside out, and the penis was an extruded vagina. To transform a woman to a man, all that was necessary was to heat the pelvic organs, which would then “break free” and become externalized. It was an absurd view in many respects, but it allowed for the possibility that gender exists on a spectrum, and that we all carry the potential for transformation.
This idea persisted from classical times through medieval and past the Renaissance—the sixteenth-century French philosopher Michel de Montaigne and his surgeon contemporary Ambroise Paré both tell the story of a female swineherd, Marie, who, while energetically chasing after some pigs, “extruded” her vagina into a penis, becoming a man. The transformation was confirmed by a bishop, and Marie was rebaptized as Germain and honored by being made one of the king’s courtiers. It seems as if Germain was welcomed in his new form because he’d transitioned through an apparent act of God rather than through his own choice. It’s likely Germain was genetically male but had a hormonal condition that had diminished the conversion of testosterone to its most potent form and so developed feminine genitalia in the womb. The heightened hormonal boost that occurs at puberty caused the growth of the penis and beard, descent of the testicles, as well as a deepening of the voice—a sequence described by the heroine/hero of Jeffrey Eugenides’s novel Middlesex. (This particular condition is also relatively common in a genetically restricted community in the Dominican Republic, where those who experience it are known as guevedoces, or “testicles at twelve.”)
Montaigne also tells another contemporary story about a transgender person, Mary, who began to live as a man. He became a weaver and fell in love with a woman whom he married and lived with “for four or five months, to her satisfaction.” But someone from his hometown recognized him as Mary and called in the authorities, who tried him as a woman. Mary was sentenced to be hanged for “using illicit devices to supply her defect in sex.” Transition as an act of God was permissible, but French society of that period couldn’t countenance the idea that he, like Germain, had no choice about his gender identity: His decision to live as a man was not a whim but a reflection of his true identity.
Surgery that affects the expression of gender, too, has an old history: Castration to create eunuchs was practiced as far apart as ancient China, Persia, and Rome. But the first sex reassignment surgeries occurred less than a century ago. In 1931, a German physician named Felix Abrahampublished a description of a new procedure, carried out by a Dr. Gohrbandt in Berlin, on two individuals who suffered gender dysphoria. The first, Dora R., had tried repeatedly as a boy to amputate his penis. Abraham described the second, Toni E., as a “homosexual” and “transvestite” who had only ever felt comfortable in women’s clothing. Toni E. was 52 at the time of her surgery—Abraham adds poignantly that she had waited until the death of her wife before proceeding.
Gohrbandt’s “vaginoplasty” procedure involved the creation of a tunnel through the pelvic muscles from the perineum up to the abdominal lining. The new cavity was then packed with a rubber sponge coated with skin grafts taken from the thigh. Abraham concluded his case reports with an eloquent summary of the humanitarian case for transition, translated and republished in 1997 in the International Journal of Transgenderism:
One could raise an objection to this type of surgery, that it is some kind of luxury surgery with a frivolous character, because the patient possibly will return to the doctor after some time with new and greater demands. This cannot be excluded. It was not easy for us to decide on the described procedures, but the patients were not to be dismissed, but also were in a mental state that made it probable that self-mutilation, with life-endangering complications, could be possible. From other cases we have learned that transvestites indeed cause themselves very severe harm if the doctor does not fulfill their wishes.
After the simple vaginoplasty of Gohrbandt it wasn’t until the ’50s that Dr. Georges Burou in Morocco began to use inversion of the penile skin to create a vagina—a neater, and from the perspective of healing, more successful method of vaginoplasty. Hundreds of trans women are said to have passed through Burou’s clinic through the ’60s and ’70s. “I do not transform men into women,” he announced controversially in 1973. “I transform male genitals into genitals that have a feminine aspect. All the rest is in the patient’s head.”
In a sense, Burou could be said to have been correct: It’s now known that there are structures in the brain, constituting parts of the hormonal and emotional regulatory systems, that exhibit differences in neuronal numbers between the sexes. This was shown 20 years ago in a letter to the science journal Nature by a Professor Swaab in Holland: In postmortem studies, trans women had “female numbers” of neurons within these brain structures. A later study from California argued the chain of cause-and-effect was the wrong way around—it was through certain sexual behavior that brain structures altered over time, though this too has been disputed. Either way, in their heads and in their brains, trans women were demonstrably women.
It’s
astonishing how much is still to be studied and discovered about gender,
sexuality, and the developing brain. It’s becoming apparent there are critical
moments in the womb that determine whether we grow up identifying as male,
female, or somewhere in between, and neuronal structures within the brain come
to reflect these different positions. This isn’t to deny that the expression of
identity is enormously influenced by our individual contexts and cultures. The
next few years are going to see a gathering appreciation of the many
determining factors involved, as well as improvements in surgical techniques.
Many elements of transition recently thought impossible are now looking achievable. In 1999, the feminist academic Germaine Greer wrote, “No so-called sex-change has ever begged for a uterus-and-ovaries transplant; if uterus-and-ovaries transplants were made mandatory for wannabe women they would disappear overnight.” Yet there are reports that one of Gohrbandt’s patients in the ’30s, Lili Elbe, died attempting to receive a uterine transplant. This was more than two decades before even kidney transplantation became possible, and conflicting accounts suggest that Elbe died from an infection following a far more routine procedure of transition surgery. In any case, the last few years have shown Greer’s assertion to be incorrect: Uterine transplants have become technically possible and in 2014 a recipient of such a transplant gave birth. Though no trans woman has yet successfully received a uterine transplant, many have expressed the wish to do so, and the first is likely to be announced within the next few years.
As a doctor my role is to ease suffering and promote health; I’m less interested in the rights and wrongs of gender variance treatments than in whether they help the individual before me to flourish. Gender variance holds a mirror up to the polarization of gender in our own society, which instructs us relentlessly and emphatically to choose. Forcing this choice can be harmful and isn’t backed up by the scientific evidence. We are developing a greater understanding of gender variance and, in tandem, society is developing increasing tolerance toward gender ambiguity.
When in The Waste Land T.S. Eliot wrote of the pain of being trapped between two lives, tortured and unable to be fully accepted in either, the allegorical figure he chose was Tiresias: “throbbing between two lives … I Tiresias have foresuffered all.” The testimony from science, medicine, and gender variant individuals themselves all indicate that the distance between those two lives needn’t be so great, and that sometimes the choice need not be so stark.