More Scientific Study on Transgenderism Could save lives

Transgenderism is something that we should be talking more about, because it is a word that is increasingly used in the media and in pop culture. We read a lot about Transgender stars and politicians, but what does it really mean to be transgender? In recent years, we have seen a rise in the prevalence of transgender people in the public eye. On one hand, this has been a positive step forward for transgender people, because it has enabled the public to further understand them and to see that they are indeed capable of functioning in society and that they deserve our respect. We have seen a rise in the number of transgender people finding employment, as well as some improvements in the healthcare for such individuals. Essentially, being in the public eye is beneficial because it enables transgender people to gain the kinds of rights, freedom and respect that every individual should have. This increasing awareness has also led to an increase in hate crimes (Stotzer, 2008) and an overall confusion amongst the public about what it means to be transgender to begin with. With notoriety comes a wave of ignorance, and many people are frightened of the things that they do not understand. Often times, the people committing acts of violence against transgender people are members of their own family. By better understanding who transgender people are and what their experiences are we can continue to promote public awareness and ultimately increase the chances of happy healthy lives for this poorly understood group of individuals.

Being transgender is challenging and isolating. Transgender people have an extremely high suicide rate and there are many tragic stories of misunderstood people who truly suffer as a result of who they are. As the issue becomes more prevalent in the media, it is more important than ever that we continue to educate and work to better understand it.

“This heightened awareness has been beneficial to the transgender community. Not only are role models becoming more visible, but there is also a growing interest in better serving the community. For instance, the American Medical Association voted to support health insurance coverage of transgender people and to oppose any discrimination by insurance companies regarding transition-related treatments. Employers are increasingly providing employment protection based on gender identity or expression, and many are providing coverage for transition-related treatments. Thus, important entities are taking steps to include transgender people within the American family (Sanchez 2012).”

While transgender has become a buzz word at many social medial outlets, not many of us really understand what it is. Does it matter if we know or not? "We risk losing everything and everyone when we transition," says Kassidy Graham, a transgender woman and cast member of New Girls on the Block, a Discovery Life series about transgender people. "Some of us lose jobs that we are good at, loved ones we care about, are evicted from the homes we live in, and face a crippling depression that can often lead to suicide (Alcindor, 2015)."

Understanding something can make us more empathetic while erasing ignorance and fear. In addition, more scientific research means having more productive ways for doctors and psychologists to help their transgender patients in the future. So promoting knowledge on what it means to be transgender is key to easing the suffering that many transgender people currently face. Let's ask the questions that we might be afraid to or not know how to ask. Is this a matter of someone choosing an identity? What are the biological mechanisms behind it, or is it a psychological and social issue? Is it similar to being homosexual? Is it something that can be treated? Is it a personality or an identity disorder? What is the difference between a drag queen, a cross dresser and a transgender person? What kinds of medical procedures are required and why are those procedures important for transgender people? What happens to transgender people if their gender is not acknowledged and they do not get acknowledgement or medical treatment to aid them in transition? What IS transgender to begin with?

This article strives to give a basic understanding of the science behind transgenderism and will discuss the various theories behind its cause on a biological and genetic level. Understanding its biological mechanisms is important, because better scientific understanding not only erases ignorance about transgender people, but it also gives us better hope in the future of being able to provide them with the right kind of medical care. This article will also discuss the basic misconceptions behind transgenderism and try to explain the challenges of being transgender, thus communicating the importance of accepting people who have it. Ultimately, this article is advocating for continued public education on transgenderism and a better medical, political, educational and sociological infrastructure to meet their needs and embrace them as happy and healthy members of our communities.

"Knowledge is power.”-Francis Bacon

Everyone is born with a biological sex. It is true that some people are actually born both biologically male and female, however, that is not what it means to be transgender. That is a hermaphrodite, and these people will usually discover their gender as either male or female, because almost everyone is born with a gender. By biological sex, we are referring only to the genitalia. Gender is different from biological sex, because gender is a person's sense of being male or female. In many ways, gender role is something that we learn from society. Girls wear dresses and boys like cars, and other such stereotypes are examples of learning gender roles from society. Current understandings of gender point to the fact that it is something that we are born with, and it is something that we are biologically geared for. A transgender person is a person who is born with genitalia that do not match up with their sense of gender. Most transgender people know from a very young age that something is 'off', and most of them cannot reach satisfaction or fulfillment in life unless they are able to transition to the other gender by means of hormones or even surgery. There are many kinds of gender. Some people will dress like the opposite sex as a drag queen or a cross dresser. This is different however, because a person is only truly transgender if they actually live their entire life (or wish that they lived their entire life) as a person of the opposite sex. Just because a man sometimes wears women's clothes does not mean that he is transgender, and it does not mean that the does't still feel like and identify as a man. Transgender is something that a person has consistently for their entire life. People who truly have it are born with it, and it is not a choice.

How do parents handle it when their child is showing signs of being transgender? Parents are encouraged to allow their child to dress and act as the gender of their choice, knowing that eventually the child might desist, or decide that they are not transgender after all. This is perfectly normal. Being transgender can be very stressful for a child, so it is important that families are educated about transitioning and how to deal with a child that has gender issues.

Studies that have reported on mental health issues in gender-dysphoric children diagnosed before puberty have described some evidence of psychological problems. Fifty percent of children referred to the Dutch gender clinic had greater than or equal to 1 associated disorder, with 31% having an anxiety disorder (Herbert, 2011). While some data does exist, there is not an impressive set of long term data for childhood transitioning, especially for female to male transgender people. Male to female transgenderism has been significantly more studied. Only two studies exist to date on adolescent transitioning of female to male patients, one showed that female to male transitions are more likely to actually take place. That is to say that by the time the child is between 10-13, they actually decide to go through with transitioning and hormone treatment.

“The data from the gender clinic in The Netherlands suggest that gender dysphoric girls referred in childhood are less likely to remit than boys. 5 In that study, of 77 children referred in childhood, only 18 were girls, and 14 consented to follow-up. Surprisingly, 9 girls (64%) persisted with gender dysphoria and 5 girls desisted, a higher percentage of persistence than for the boys at follow-up (Herbert, 2011).”

The other study had very conflicting results.

“In contrast, a study from the gender clinic in Toronto, Canada, that included 25 girls evaluated in childhood found very different results. At the initial assessment, 60% met criteria for GID, and 40% were subthreshold for this diagnosis. 6 At follow-up, only 12% (3 girls) were judged to have GID or gender dysphoria, a much different rate of persistence compared with the Dutch study (Herbert, 2011)”

There are two main conclusions that we can draw from this. For one thing, it is poignant that there are only two studies existing about adolescent transition that focus on both male and female transitioning. Most studies focus on male to female, and this discrepancy in the numbers represents the amount of interest that science has invested into helping female to male transgender people. This blatant lack of data makes it challenging for physicians and mental health care workers to determine who is actually going to and needs to transition. It is said that between the ages of 10-13 most adolescents will have a crucial turning point where they either remit or decide to go through with a transition. Why is it important that there is more data on transitioning children and adolescents? It is important so that physicians can better understand who needs to transition, as an optimal transition does occur in adolescents. Transitioning with hormones when one is not actually going to make a life time commitment to that gender can have devastating effects later in life, and not transitioning when you need to can also have devastating psychological effects.

We need to focus research and attention particularly on adolescents, because this is their crucial time to make a transition if they are going to do so. It is considerably more difficult to transition as an adult. During puberty, people obviously go through a change that makes their biological sex apparent for the rest of their lives, and these changes are irreversible. Women develop breasts and hips, while men's faces change shape, facial hair develops etc. If a person who is transgender goes through this transition into the wrong gender, the results can be very hard on that person for the rest of their lives, and these cases often end in tragedies like suicide. However, it is also important to transition into another gender only when you are really committed to and programmed into this other gender for life. The truth is that many adolescents do indeed remit, or ultimately decide that they are comfortable with their biological gender after all. Basically, transgenderism can simply be a phase that children experience up until puberty, which they ultimately drop because they were not truly transgender after all. It is normal that some children might have a lengthy phase like this, however, it is important to understand that true transgenderism is not a phase that someone grows out of. This remittance occurs upwards of half of the time, so it is crucial that doctors are able to diagnose as accurately as possible. Further research and understanding of this sensitive time could give physicians the tools to truly help those who need it, while holding off on those who are not ready for hormone therapy in which they would go through puberty as their non-biological gender.

Why is it so important that doctors are able to diagnose transgender people in a timely fashion? The national suicide statistics say it all.

"About 50% of transgender youth will have at least one suicide attempt by their 20th birthday (Hass, Ann)".

This simple statistics sums up why it is so important that we learn to better understand and support transgender people. Interestingly, some people transition in adolescence (preferable) and some people transition later in life. This is most likely due to the fact that people who transition when they are younger are usually from minorities or lower economic brackets, while people who transition in their middle age are usually white and from more affluent backgrounds. Experts believe that this is due to the fact that the two groups have different expectations to conform to.

“Given that early transitioners typically come from lower socioeconomic backgrounds and from racial/ethnic minority groups, they may not feel the pressure to adhere to traditional ideals regarding success in the United States. Thus, they have less to lose by coming out."

What kinds of treatment do transgender people get from society, and what is it that makes them feel so isolated? A study by the American Foundation for suicide prevention came up with some of the following statistics.

“Respondents who experienced rejection by family and friends, discrimination, victimization, or violence had elevated prevalence of suicide attempts, such as those who experienced the following: — Family chose not to speak/spend time with them: 57% — Discrimination, victimization, or violence at school, at work, and when accessing health care • Harassed or bullied at school (any level): 50-54% • Experienced discrimination or harassment at work: 50-59% • Doctor or health care provider refused to treat them: 60% • Suffered physical or sexual violence: — At work: 64-65% — At school (any level): 63-78% — Discrimination, victimization, or violence by law enforcement • Disrespected or harassed by law enforcement officers: 57-61% • Suffered physical or sexual violence: By law enforcement officers: 60-70 — Experienced homelessness: 69%”

The isolation and alienation that many transgender people feel is beyond the realm of what most of us can even begin to comprehend. They are ostracized from their own families, they are subjected to violence and struggle with employment etc. The statistics speak for themselves, and clarify exactly why so many transgender people attempt suicide at some point in their lives, especially when they are young.

How prevalent is transexuality, and what are the biological mechanisms that cause it? Most likely, one of the most limiting factors in understanding it is the fact that many cases are not discussed or acknowledged properly. A lot of people are not comfortable coming forward or are unable to diagnose themselves. Also, a lot of doctors are not properly equip to understand transgender people, and so the are also unable to diagnose or help them. In the US, an epidemiological study has never been conducted. There are estimates, and these estimates vary throughout the world. Without a proper scientific investigation on the matter, it is difficult to say how many people are actually effected.

“In terms of prevalence, no epidemiological study of transsexualism has been conducted in the United States." The American Psychiatric Association

Clearly, it is hard to say just how many people are effected, however, these varying statistics show us that the number is probably severely underestimated. When we see that 50% of transgender adolescents who we are aware of have attempted suicide by the time they are 20, it is obvious that we need to do what we can to diagnose and support afflicted individuals people. It's also clear that a lot of people who are undiagnosed may be suffering greatly. The actual suicide and suicide attempt rate may be considerably higher, considering the limited data that we have.

Biologically speaking, scientists have not been able to pinpoint one particular marker that denotes a person as transexual. However, it is clear that transexual people are born as they are into their gender. An old theory was that gender is a socially learned thing, and that with the proper conditioning a child would simply learn to be a boy or a girl. This theory was tragically disproven for the final time by a man by the name of David Riemer. David was born as a boy and lost his Penis at around 7 months due to a poorly performed circumcision that required the rare procedure of cauterization. Doctors who believed in the theory that transsexualism was merely a product of psychological conditioning and traumatic experience, also believed that gender was essentially something which is learned through social conditioning. They encouraged David's parents to give him an orchiodamy (to give him female genitalia) )and to raise him as a girl. He went through a barrage of 'preparations' to teach him to be a girl throughout his childhood, and was not even informed of his male biological birth until he was an adolescent. At the age of 15, he decided to transform back into a man, however this was not without severe psychological impact. David grew to be a victim of chronic depression, he struggled in relationships and financial matters, and finally committed suicide at the age of 38. This case was particularly influential, because it showed doctors that gender was not something that a person can simply learn or decide upon, but that it is a fixed thing that people are born with.

The understanding of Gender has come a long way. In the past there was not a whole lot of talk about the flexibility of gender and it was not a question that greatly concerned the public or science. Only over the course of the last century have trans people started speaking up and becoming politically active. This in turn has turned our eyes towards an issue which has surely been present for all of our history, but that has only recently gained real attention or scientific research. For the longest time, science did believe that the causes of transgenderism were due to psychological issues. It was thought that children must go through some particular trauma in order to get a personality disorder in which they believe they are of the opposite gender. However, David's sad case finally shattered that idea for scientists and doctors. The notion that transgenderism is caused by some sort of personality disorder or that it has psychological roots is now passe thanks to recent scientific research and interest in the psychological community. Over the course of the last 10-15 years scientists have begun to study what they now believe comes down to something which is caused by biology; something that people are born with and that we should not attempt to change. This shift from seeing transgenderism as a psychological disorder to something with a biological origin is important because it enables us to further understand why it is important that we do not deny them. Transgenderism is not a psychological disorder or a choice.

There have been numerous studies into the biological groundings for gender, and many of these studies find that gender is indeed a biologically programmed trait (which may be independent of biological sex) but there is to date no particular marker that can 'predict' trangenderism. This could be seen as a good thing or a bad thing. It could be dangerous to have one certain gene linked to transgenderism, because this could leave room for labeling, over simplification or even for hasty diagnosis. On the other hand, searching for causes could be beneficial because it could help doctors to further understand what their patients are dealing with, and to help them appropriately. Here are the four main biological attributions to transgenderism at this point in time. As you can see, not all of these studies have been conducted within the last five years as is preferred for scientific evidence. However, this reflects the limited interest and evidence in the field. As far as scientists can tell at this point in time, transgenderism is probably related to androgen receptors, brain structure, brain function and all of these things are somehow related to prenatal androgen exposure.

Androgen receptors: The androgen receptor is activated by the binding of "secondary male sex characteristics. Hare et al. found that male-to-female transsexuals were found to have longer repetitions of the gene, which reduced its effectiveness at binding (Hare, 2009).

Brain structure: In 2002, a follow-up study by Chung et al. found that significant sexual dimorphism (variation between sexes) in BSTc did not become established until adulthood. Chung et al. theorized that either changes in fetal hormone levels produce changes in BSTc synaptic density, neuronal activity, or neurochemical content which later lead to size and neuron count changes in BSTc, or that the size of BSTc is affected by the failure to generate a gender identity consistent with one's anatomic sex (Chung, 2002).

Brain function- Berglund et al. (2008) tested the response of MTF transsexuals to two sex pheromones: The researchers' conclusion was, that in terms of pheromone activation, MTF's occupy an intermediate position with predominantly female features. The MTF transsexual subjects had not undergone any hormonal treatment at the time of the study, according to their own declaration beforehand, and confirmed by repeated tests of hormonal levels. (Berlgrund, 2007)

Prenatal Androgen exposure-Prenatal androgen exposure, the lack thereof, or poor sensitivity to prenatal androgens are commonly cited mechanisms to explain the above discoveries. Schneider, Pickel, and Stalla (2006) found a correlation between a generally accepted marker for prenatal androgen exposure and male to female transsexualism. MTF transsexuals were found to have a higher digit ratio than control males, but one that was comparable to control females (Schneider, H; Pickel, J; Stalla, G (2006).

However, all of these studies were pioneers in the field, and much more needs to be done in order to come to a better understanding of the biology behind transgenderism. Important to note is that while transgender people do have brains which look different on a scan and which show a melding of specific male or female traits, it is also true that the brain grows with experience, so some of these differences may be attributed to the person's life experience. Thus it is difficult to pinpoint exactly what the cause is at this point in time and to reach any particular conclusion would be hasty.

It is important to discuss these biological grounds for transgenderism, because a better understanding of them would mean that doctors would better be able to help their patients. Also, proper health insurance coverage and care is often based on a medical reason, and these biological and genetic grounds provide that. This said, even if transgenderism were to be a psychological issue and not a biological one, when we consider the stress and the suicide rates associated with transgenderism it does not matter what causes it, so much as it is important that we work harder to understand and support people who live with it.

Ultimately, one can see that transgenderism is something that people do not choose, but something that they are born with. We need to strive to embrace transgender people and to support them, because the stakes are very high for those who are not able to transition or to be accepted by their communities. Also, we should be thankful to those who have dedicated their time to researching this condition, because this research brings doctors and mental health professionals closer to understanding the severity and the urgency with which these patients need proper assistance and medical attention. We need to acknowledge that there is not nearly enough research in the field, and in order to really help people, we need to further investigate the mechanisms behind transgenderism. Considering the fact that only two studies have been conducted about females transitioning to males, it is obvious that the information we have to date is inconsistent and lacking. Amongst the public, the most important thing that we can work to understand is that transgenderism, while it may feel foreign to us, is not something that people can change, and we need to accept it. The best thing that can happen, is further public education and more scientific research so that transgender people can ultimately be accepted as worthwhile members of the human community who have access to appropriate healthcare, and who are ultimately able to assimilate into the workplace and into our social spheres.

Sources and further reading

1. Alcindor, Y. (2015, ). Transgender people find hope: Jenner could shine light on group's struggles. USA TODAY

2. Boylan, J. F. (2014, ). Transgender, schlumpy and human: Op-ed. New York Times

3. Chung, WC; De Vries, GJ; Swaab, DF (2002). "Sexual differentiation of the bed nucleus of the stria terminalis in humans may extend into adulthood". The Journal of neuroscience 22 (3): 1027–33. HYPERLINK "http://en.wikipedia.org/wiki/PubMed_Identifier"PMID HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/11826131"11826131

4. Erickson-Schroth, L. (2013). Update on the biology of transgender identity. Journal of Gay & Lesbian Mental Health, 17(2), 150

5. Berglund, H.; Lindstrom, P.; Dhejne-Helmy, C.; Savic, I. (2007). "Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids". Cerebral Cortex 18 (8): 1900–8. HYPERLINK "http://en.wikipedia.org/wiki/Digital_object_identifier"doi: HYPERLINK "http://dx.doi.org/10.1093%2Fcercor%2Fbhm216"10.1093/cercor/bhm216. HYPERLINK "http://en.wikipedia.org/wiki/PubMed_Identifier"PMID HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/18056697"18056697.

6. Herbert, S. E. (2011). Female-to-male transgender adolescents. Child and Adolescent Psychiatric Clinics of North America, 20(4), 681.

7. Hare, L; Bernard, P; Sanchez, F; Baird, P; Vilain, E; Kennedy, T; Harley, V (2009). HYPERLINK "http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402034""Androgen Receptor Repeat Length Polymorphism Associated with Male-to-Female Transsexualism". Biological Psychiatry 65(1): 93–6. HYPERLINK "http://en.wikipedia.org/wiki/Digital_object_identifier"doi: HYPERLINK "http://dx.doi.org/10.1016%2Fj.biopsych.2008.08.033"10.1016/j.biopsych.2008.08.033. HYPERLINK "http://en.wikipedia.org/wiki/PubMed_Central"PMC HYPERLINK "http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402034"3402034. HYPERLINK "http://en.wikipedia.org/wiki/PubMed_Identifier"PMID HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/18962445"189624

8. Knowlton, B. (2010, January 6). U.S. job site bans bias over gender identity. New York Times, A15

9. Lombardi, E. (2001). Enhancing transgender health care. American Journal of Public Health, 91(6), 869-872. doi:10.2105/AJPH.91.6.869

10. Sánchez, F. J., & Vilain, E. (2012). Transgender identities: Research and controversies. () Oxford University Press. doi:10.1093/acprof:oso/9780199765218.003.0004

11. Stotzer, R. L. (2008). Gender identity and hate crimes: Violence against transgender people in Los Angeles County. Sexuality Research & Social Policy, 5, 43–52. (p.54)

12. Schneider, H; Pickel, J; Stalla, G (2006). "Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure". Psychoneuroendocrinology 31(2): 265–9. HYPERLINK "http://en.wikipedia.org/wiki/Digital_object_identifier"doi: HYPERLINK "http://dx.doi.org/10.1016%2Fj.psyneuen.2005.07.005"10.1016/j.psyneuen.2005.07.005. HYPERLINK "http://en.wikipedia.org/wiki/PubMed_Identifier"PMID HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/16140461"16140461.

13. Haas, Ann. (2014). Suicide Attempts among Transgender and Gender Non-Conforming Adults. American Foundation for Suicide Prevention. The Williams foundation.

14. What engenders a transgender? (2014). Alive