We must acknowledge this Androgynal condition in man.
Thomas Browne, Pseudodoxia Epidemica
AT MEDICAL SCHOOL in the mid-1990s, my paediatric training took place in a Victorian hospital in Edinburgh called the ‘Sick Kids’. But it began before birth, so to speak, in the modern maternity unit a short stroll away across the park. It was there in the obstetric hospital that I was obliged to learn how to deliver babies, as well as gain an understanding of 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 its 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 – no metabolic or hormonal problems were 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 placed on the distinction was implicit even in the name bands we wrapped around the babies’ wrists. These were usually colour-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 and gonadal biopsies.
Later that day, I walked back across the park to the library at the Sick Kids and looked up ‘Disorders of sexual differentiation’ in the textbooks. ‘Ambiguity of the external genitalia at the time of birth causes great distress for the parents,’ 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 the vast majority of babies with ambiguous genitalia fall into two broad groups. Intersex babies could turn out to be genetically female – with two X chromosomes – but their clitorises had swelled to the size of small penises because of a hormonal condition generating unusually high levels of testosterone-like hormones (androgens) while still in the womb. But there were also genetic males – possessing 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 XY babies don’t sense androgens in their blood, they develop short, blind-ended vaginas with a clitoris instead of a penis.
There was a third category in the textbook – ‘true hermaphrodites’: these were 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 in which it could come about. The most likely is that a ‘male’ sperm carrying a single ‘Y’ chromosome, and a ‘female’ sperm carrying a single ‘X’ chromosome, fertilise an egg that has just divided, then those two fertilised eggs fuse together. The bodily tissues of these ‘true hermaphrodites’ are a tessellation 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 1950s that it was realised this phenomenon could lead to hermaphroditism.
The textbook said, in clear but insensitive style, that ‘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 had rare, ‘true’ hermaphroditism: a mosaic of male and female cells had given rise to elements of both sexes. As well as a penis and vagina, 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 1990s in Edinburgh, there wasn’t a great deal of sensitivity around gender ambiguity, and the possibility of raising Sam as neither male nor female – being dressed in green or red instead of pink or blue – didn’t appear to arise. The very nature of the English language seemed to demand a decision. ‘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 paediatric textbook: boys without male genitals (absent either because of a developmental anomaly, or consequent to an accident) could simply be raised as girls. But it was increasingly noted that in adolescence, 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 their enlarged clitorises reported high levels of preference for identifying as women. One study from 2005 put this proportion at 12 per cent, while the proportion of XY babies raised as girls, but who later identified as male, was lower at 5 per cent.
Modern medicine is only now getting to grips with 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 tells of the contribution of the playwright Aristophanes 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.
All three groups of these original, powerful beings began to threaten the gods, so 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. ‘This is my discourse of love,’ he says in the Symposium, ‘which, although different to yours, I must beg you to leave unassailed by the shafts of your ridicule.’
From the ancient world through to 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 sharing essential characteristics, and capable of changing sides. From the anatomies of Aristotle and Galen, to the speculations of Thomas Browne, for most of scientific history, transition between female and male was thought of not just as possible but as expected from time to time. Only about 200 or 300 years ago, with the hardening rationalism of the Enlightenment, did this fluidity give way.
Another Greek story, the myth of the prophet Tiresias, attests to a fascination with gender flexibility. As a young man, 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 struck them across their backs’. The female snake was killed, and Tiresias was transformed instantly into a woman. Snakes were symbolic of transformation because they periodically shed their skins, and in her new skin Tire-sias became a prostitute in Thebes, and later a mother. After seven years, she came upon mating snakes again, and this time struck the male, and was promptly returned to male form.
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 sex. As the only ancient transsexual, 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, perhaps says more about male anxieties than it does about sexual realities.
TARIK TOLD ME that he had known from a young age that he should have been born a girl. 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 in 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 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 by the sabbatical had given him his first opportunity to think about changing 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 moved on: momentum had gathered against the proposition that a boy without a penis should simply be raised as a girl – and vice versa. Elements of gender differentiation are deeply rooted in the brain and in hormones – there’s little doubt now that there’s more to a sense of gender identity than socialisation. Twin studies imply that the incidence of discontent with birth gender is higher in identical twins than it is in fraternal (non-identical) twins, which implies at least a partial genetic component. Other studies have found that chromosomal disorders that lead to reduced testosterone production in boys may result in increased desire for male-to-female transition.
Until recently, gender variance was considered a deviance. The first Diagnostic and Statistical Manual (‘DSM’) of the American Psychiatric Association, published in 1952, placed gender variance under the blunt heading ‘Sexual Deviation’. The second manual, published in 1968, retained the same classification, although by then the Kinsey Report on sexual behaviour in the United States had broadened awareness of sexual diversity. The third DSM, 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 criticised as excluding those entirely at ease in their adopted gender, and the more neutral term ‘variance’ is now proposed.
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 jaw line, penis and scrotum. He could barely bring himself to touch his genitals and found it easier to wash them quickly, in the dark.
Medical guidelines in both the UK and the US 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 transition. ‘For me, this is living authentically.’ With support from a local gender identity clinic he took the difficult step of telling his academic colleagues, his parents and his siblings, and began to live as ‘Teresa’.
Tiresias had switched gender at the strike of a snake – with the support of the clinic, I began the much slower process of effecting a comparable metamorphosis with prescription drugs. The first drug was finasteride, which inhibits the generation of the most potent form of testosterone within the body. It’s used to shrink the prostate, and in small doses it helps to retard male-pattern baldness. This was only partially successful – it isn’t a very effective treatment – 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 pituitary gland’s production of gonad-stimulating hormones and can shrivel the testes – it has the potential to cause flushing of the skin, a collapse of interest in sex and weakening of the bones. A few weeks after leuprorelin was established, we commenced oestrogen therapy. This feminises the body and promotes the development of breasts, but can bring on blood clots as well as subtly increase the risks of stroke, heart attack and breast cancer.
This all took a couple of years, and the final phase of transition to Teresa would be the most difficult: surgical removal of the testicles and parts of the penis, and then the creation of a blind-ended vagina using the penile skin. The physical transition proceeded in two stages – Teresa’s convalescence from each procedure took months. The body’s own power of healing can rebel against its new form: initially, trans women 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 and sutured down to resemble 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. She told me that her academic work was better than it had ever been. Oestrogen affects more than just the shape and hair distribution of the body: ‘My brain loves these hormones,’ another trans woman told me shortly after commencing oestrogen 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 immense challenges she faced: teasing and disapproval from her colleagues; disappointment and disbelief from her parents; harassment in the street; the need for ongoing hormonal treatment; her ceaseless battle with chest and facial hair. But her sleep now was restful, and the feeling of dread on awakening had gone.
EVEN THIRTY 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, 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 externalised. It was an absurd view in many respects, but it did allow for the possibility that gender exists on a spectrum, and that we all carry the potential for transformation.
This idea persisted from classical times to the medieval, and endured 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 jumping a ditch after some pigs, found that her vagina had ‘extruded’ into a penis, making her a man. The transformation was confirmed by a bishop and Marie was re-baptised ‘Germain’, and honoured 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 that Germain was an XY male, and the growth of his penis was not sudden but took place gradually over months; he probably 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 sequence is well described by the heroine/hero of Jeffrey Eugenides’s novel Middlesex: the heightened hormonal boost of puberty causes the growth of a penis and beard, descent of the testicles, as well as a deepening of the voice. This particular genetic condition is also relatively common in a genetically restricted community in the Dominican Republic, where those who experience it are known as huevedoces, or ‘testicles at twelve’.
Montaigne tells another gender transition story, about a woman called Mary who took to living as a man. Mary became a weaver in a distant town and fell in love with a woman whom he married, and with whom he lived ‘for four or five months, to [his wife’s] satisfaction’. But then someone from his home town recognised him and called in the authorities, who tried him as a woman. Mary was hanged for ‘using illicit devices to supply her defect in sex’. In the French society of the period, acts of God were permissible, but Mary’s transition was perceived as a matter of wanton choice.
In 1931 a German physician named Felix Abraham published a description of a new procedure, carried out by a Dr Gohrbandt in Berlin, on two individuals with 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 fifty-two at the time of her surgery – Abraham adds 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 a summary of his case for facilitating surgical transition:
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 [sic] indeed cause themselves very severe harm if the doctor does not fulfil their wishes.
Following the simple vaginoplasty of Gohrbandt, it wasn’t until the 1950s 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 1960s and 1970s. ‘I do not transform men into women,’ he announced 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 between the sexes. A postmortem study from Holland found that the hypothalamus of trans women shared neuronal characteristics with natal women. Whether these similarities pre-date or post-date the surgical transition (i.e. whether they were innate or consequent to behavioural or hormonal changes) wasn’t clarified by the study. But either way, in their ‘heads’ and in their ‘brains’, the trans women were identifiably women.
There is much still unknown about gender, sexuality and the developing brain. It’s becoming apparent that 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, or to contest the evident truth that elements of our identities shift ceaselessly through different social interactions.
The next few years are going to see a gathering appreciation of the many determining factors involved in the expression of gender identity, as well as improvements in surgical techniques. Many elements of transition thought impossible are now looking achievable: 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 it would be surprising if one isn’t announced within the next few years.
As a doctor, my role is to ease suffering and promote health; my interest in gender reassignment (or ‘confirmation’ as many trans men and women prefer it) is primarily whether it eases the distress of the patient consulting me, and helps them live their lives. Gender variance holds a mirror up to the polarisation of gender in our society, which instructs us relentlessly and emphatically to choose. It’s known now that forcing this choice can be harmful, and isn’t backed up by the scientific evidence – we all benefit from allowing elements of our identity to be in flux. In her book The Argonauts, Maggie Nelson quotes her partner’s impatience with the idea that anyone with an ambiguous expression of gender must be on a journey to one binary extreme or the other (‘I’m not on my way anywhere’), and points out that all of us are in ceaseless transition, irrespective of gender: ‘on the inside, we were two human animals undergoing transformation beside each other, bearing each other loose witness. In other words, we were aging.’
There is a gathering movement of people who feel that, for them, gender reassignment surgery may have been a mistake – that the medical profession’s checks and barriers to hormonal and surgical transition, though formidable, were for them insufficient. After twenty years living as a woman, ‘Elan Anthony’ detransitioned, like Tiresias, back to being a man. He calls his journey ‘third way trans’: ‘I couldn’t bond with people and eventually started therapy to work on why I couldn’t have relationships and why my body was so tense,’ he said in an interview with The Guardian. ‘I eventually realised that a lot of this had to do with trying to present myself as female, which was unnatural for my body.’ He’d been bullied as a boy, feeling himself at the bottom of a strict male hierarchy; through therapy he came to realise that his childhood identification as female reflected an unconscious need to escape. One of the greatest barriers faced by Elan was criticism within the trans community: ‘It is difficult being part of the psychological community that is so pro-transition right now, and being one of the few critics,’ he said, ‘but it feels like there are a lot more people speaking out about detransition, as well as more clinicians who are interested in looking at alternative ways to deal with dysphoria.’
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’. To undergo transition from one gender to another takes courage and determination, but in a polarised culture, so too does the occupation of an ambiguous, androgynous space. In the natural world, to occupy a space part-way between two genders is not just possible, it’s common. The testimony from science, medicine and people with fluid or ambiguous gender all indicate that the distance between Tiresias’s two lives needn’t be so great, and that sometimes the choice need not be quite so stark.