Vol. 176 September 1, 2017 Sexual Anatomy, Gender Identity, and Orientation

September 1, 2017

“Sexual orientation means ‘who you go to bed with’.
Gender identification means ‘who you go to bed as’.”

 -Norman Spack, MD, Pediatric Endocrinologist,
Chief of Gender Management Service, Childrens Medical Center, Boston

Discussion about transgender people is back on the front page since President Trump tweeted his wish, and then ordered the Defense Department, to ban the enlisting of transgender persons and to ban transgender soldiers from continuing to serve in our armed forces. The ACLU notes that there are currently about 8000 transgender U.S. soldiers.

The appearance of your genitals at birth, if anatomically correct, tells everyone in the delivery room what you are; “sexual anatomy”. “It’s a boy, or it’s a girl” are the first three words an infant “hears”. In the first decade of life we begin to think of ourself as a boy or as a girl; “gender identification”. In our second decade, as we approach and go through puberty, we begin to realize that we are attracted to boys or girls, or both; “sexual orientation“. These three terms are often confused and intermixed in our discussion. which can make rational, unemotional consideration of new policy, laws, and societal changes very difficult.

When do children begin to identify themselves as a boy or a girl? (1)
Studies show that it can be as early as third grade. (7-9 yo.) By then, most children associate themselves with one or the other sexes and understand that it is permanent; “girls grow up to be women and boys grow up to be men.”

What about “cross-gender” play which is very common at young ages?
By age 2 years all children know sex stereotypes (“women are associated with lipstick”,”boys don’t wear pink tutus”) ). It is remarkable that transgender children understand and accept the same stereotypes as their peers. Studies show that “cross-gender” play (“boys wearing dresses”, “girls excelling as tom-boys”) is very common in pre-school children, is normal, and is temporary in most children. 

Where are all these transgender children?
Everywhere. Since 2007 when Childrens Hospital started its Gender Management Service as part of their Sexual Disorders and Dysfunctions Clinic, they have treated about 200 transgender children, 95% of whom came from within 150 miles of Boston.

What causes transgender identification, nature or nurture?
Both probably. No one really knows. One twin study revealed that of 23
identical same-sex twin pairs, one twin in 9 of the pairs was identified as transgender. No twin in the 21 fraternal same-sex twin pairs were transgender. The suspected genetic basis of this is completely unknown. In 1895 an article in Scientific American expressed concern that riding bicycles threatened women’s health. In 1948 only 32% of adults believed women should wear slacks in public. (1)

What is the “treatment”? (2)
The Dutch taught us that the best time to change a person’s gender is before the onset of puberty (10-12 yo. in girls and 12-14 yo. in boys).

Dr. Spack and others thought that was a pretty young age for the patients (and their families) to make such a life-changing and permanent decision. Therefore, the U.S. standard of care is to delay puberty to buy some time.

At age 12 years after extensive psychometric testing of gender identification by a multi-specialty team, treatment with appropriate sex hormones that block progression of puberty of the “birth gender” is started. This puberty “blockage” is reversible and is continued for years.

At age 16 after the repeat of extensive psychometric testing of gender identification, the decision to move on to irreversible body-changing sex hormone treatment is considered. . If the decision is to NOT GO on with the change, that hormonal treatment is stopped and normal puberty appropriate to the “birth gender” occurs. If the decision is to proceed with a change, treatment with different sex hormones appropriate to the “affirmed gender” is started. The goal is to achieve the physical appearance of the “affirmed gender”. This treatment is usually very successful (“girls develop normal sized breast and have normal heights”).

After age 18 years and years of hormonal therapy, surgical reconstruction of genitalia can be considered. (Male-to-female surgery is much easier and can be successful enough to “fool a gynecologist”.)

Are there any barriers to treatment?
Yes. Very expensive (about $1000 a month for several years of hormonal treatment), misunderstanding about the reversibility of early treatment, and continued classification in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) of “Gender Identification Disorder” as one of a dozen “Sexual Disorders and Dysfunctions” (which exempts the treatment from most insurance plans). Note: Homosexuality was removed in 1973 from the DSM-III as a mental health disorder as it is NOT amenable to psychiatric therapy. Neither is transgender identity. There is no evidence that people can be talked out of, or therapized away from, their transgender identity.

What if the transgender child is not treated?
In the scheme of things the number of transgender children is limited. But, of the 100 patients seen by the Gender Management Service by 2012, 20% had performed self-mutilation and 10% had attempted suicide. Other studies have documented a much higher-than-average suicide rate in persons with gender identity issues.

So, gender identity can trump anatomy,
and sexual orientation can be completely unrelated to either.

This can get a bit confusing, but have no fear, it may even get harder to keep track of the players without a scorecard.
ew research is focussing on “nonbinary” children. These children  see themselves as in the middle of the spectrum and neither male nor female.

1. Scientific American, “Everybody has a stake in the new science of sex and gender”, September 2017
2. TED talk, Norman Spack, MD



Vol. 131 September 1, 2015 Current, Recurrent Controversies

September 1, 2015


“Anachron’s Law:
There is no myth which is so irrational that no one will believe it.
Anachron’s Corollary:
There is no truth which is so obvious that everyone will accept it.”
George Hammond

“How Much Is That Pill In The Window?”:
It costs either $2.6 BILLION or $1.4 BILLION to develop a new drug depending on which report you believe… the Tufts Center for the Study of Drug Development (supported in large part by drug companies) or Jeffery Avorn, MD of the Division of Pharmacoepidemiology and Pharmoeconomics of Harvard Medical School. The discrepancy is important since the high price of drugs is becoming a hot topic in this pre-election year. Read this NEJM article to get a glimpse of the smoke and mirrors used in such calculations (how to calculate capital costs?, what is a “self-originated” drug?, how much of R&D costs are covered by public tax money (NIH grants)?, what are R&D and what are marketing costs?, etc.). (1)

  • 80% of new compounds fail to meet expectations and are abandoned during development. This, of course, raises the calculated cost of developing the successful ones.
  • Both reports agree that the time required for new drug approval by the FDA has decreased to the point where it as fast as, or faster than other countries.

“Gadar” is faulty :
Ten years of research has not appreciably advanced our understanding of what makes people gay according to a “state-of-the-art” review of research into sexual orientation held every five years in a remote location. This year’s conference was held at the University of Lethbridge in Western Canada. The sharp dichotomy between nature (genetics) versus nurture (cultural) causes, the focus of numerous “twin studies” in many countries over many years, has been significantly blurred. The search for the “gay gene” has been tempered by the realization that at least 150 genes are involved in determining “something as simple as your height.” (2)

A new concept, the “environment of the womb”, has recently received greater research interest, but data remains inconclusive. The “environment of the womb” swirls with all sorts of different, and changing, levels of hormones and proteins for 9 months, and researchers  continue to look for its effects on the fetus – “epigenetics”. “Genes are the ingredients of grandma’s apple pie. Epigenetics is the recipe of how she actually makes it.” (2)

The scarce support of sexual orientation research is due in large part to societal controversies  (hence the remote locations for conferences to reduce easy access for “Spotlight Investigative Teams” roaming for hot topics). I wonder if such research is even worth it at all. Any research conclusion will likely be ignored by those people with the strongest negative opinions about sexual orientation because many have clearly shown no acceptance of scientific evidence about anything.

“Low-T” is another manufactured diagnosis:
Despite the lack of scientific evidence showing any benefits, 2.2 million men were prescribed testosterone in 2013 for “age-related hypogonadism”, a brand new diagnosis limited to aging men and apparently coined in response to a demand for testosterone prescriptions. Most of the men are 40 to 64 years old, and one-third of them had never had their actual testosterone blood level checked prior to the prescription. The authors of this report suggest that direct-to-consumer marketing for the improvement of “low-T symptoms” is a major reason for this wide-spread, increasing usage. The FDA has identified a “weak signal” that testosterone usage has adverse cardiac effects, and is concerned … so they have… “recommended some drug label revisions”. (3)

“Lingering Lyme”:
The CDC notes that one in five patients treated for Lyme disease may develop a persistent syndrome of fatigue and other symptoms known as “post-treatment Lyme syndrome”, and no one knows what causes it. It is NOT cured by continuous long-term antibiotics. There is new laboratory animal evidence that some of the organisms causing Lyme go into a “dormant state” when under antibiotic attack. They are NOT resistant to the antibiotic. The cell metabolism function that is attacked by the antibiotic just shuts down temporarily when the antibiotic is present, and so the organism survives. The researchers found that reintroducing the same antibiotic in the lab animal after a time off antibiotics subsequently killed these “persister” organisms. This is a new direction of inquiry in Lyme disease, but not everyone believes in “persisters” and “pulsed antibiotics”. They won’t believe, and shouldn’t, until all four of Koch’s postulates  for establishing a link between a disease and an organism are met. (4)

“Water, Water Everywhere…but not needed”:
The persistent myth that 8 glasses of water will keep you healthy was apparently initiated by readers of a 1945 Food and Nutrition Board recommendation that people need 2.5 liters of water a day. BUT, the readers ignored the next sentence that read “most of that quantity is contained in prepared food” … like fruits, vegetables, juice, coffee, tea, and even beer. Prospective studies have failed to find any benefit on skin elasticity, kidney function, “healthy appearance”, disease-free state, or mortality in those healthy people who increase their water intake. A recent study using a urine osmolality of 800 mOsm/kg (a measure of concentration) as the “normal” value in children concluded that more than half of 4,000 symptom-free, healthy children were “dehydrated”! It would seem that we should throw that particular “normal” standard out the window … or at least into the crapper. (5) Water is good for you, but, let’s face it, you really don’t need take a water bottle with you in the car when you go to pick up the mail.

1. “The $2.6 Billion Pill – Methodologic and Policy Considerations”, Jeffery Avorn, MD, NEJM 372;20, May 14, 2015 .
2. “What Makes People Gay?- Revisited” , Neil Swidey, Boston Globe Magazine, August 23, 2015,
3. “Testosterone and ‘Age-Related Hypogonadism’ – FDA Concerns”, NEJM 378;8, Aug 20, 2015
4. “Lingering Lyme”, Scientific American, Sept. 2015, pg.17
5. “The Persistent Health Myth of 8 Glasses of Water A Day”, Aaron J. Carroll, MD, NY Times, Aug. 25, 2015, pg. A3

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