D

Sex and Gender

Sex vs. Gender

  • Sex: Biological and physiological characteristics defining men and women (physical).
  • Gender: Socially constructed roles, behaviors, activities, and attributes a given society considers appropriate for men and women.
  • Sex is biological (male and female), while gender is masculine and feminine.

Chromosomal Determination of Sex

  • Human cells typically have 23 pairs of chromosomes.
  • Sex is determined by the 23rd pair of chromosomes.
  • Typically, women have XX chromosomes.
  • Typically, men have XY chromosomes.
  • Anomalies can occur where individuals are not strictly XX or XY.
  • An XY individual may phenotypically appear female.

Embryonic Development of Male Characteristics

  • Up to approximately six weeks post-conception, all embryos have a dual duct system: Wolffian and Mullerian ducts.
  • Wolffian ducts develop into male structures.
  • Mullerian ducts develop into female structures.

Process of Masculinization:

  1. Requires a Y chromosome.
  2. The Y chromosome contains the SRY (Sex-determining Region Y gene).
  3. The SRY region releases the HY antigen.
  4. HY antigen turns fetal gonads into testes.
  5. Testes secrete two hormones:
    • Testosterone: masculinizes male reproductive and physical structures (derived from the Wolffian duct system).
    • MIS (Mullerian Inhibiting Substance): disintegrates the Mullerian ducts.
  • For a male to develop, both a Y chromosome and testosterone are necessary.
  • If the body doesn't process testosterone, an XY individual may appear female.
  • In the absence of a Y chromosome and testosterone, Wolffian ducts disintegrate.
  • Mullerian ducts develop into female reproductive structures.
  • Mnemonic: M for Mom; Mullerian ducts become female reproductive structures.

Undifferentiated Tissue

  • Embryos are sexually undifferentiated up to six weeks.
  • Substantial differences between male and female development become visible around the seventh or eighth week.

Homologous Structures:

  • Structures with the same origin.
    • Genital tubercle becomes either the clitoris (female) or the glans of the penis (male).
    • Labia majora (female) are created from the same tissue as the scrotum (male).
  • Early tissue is undifferentiated, developing into either female or male structures based on developmental events.

Intersexuality and Redefining Sex

  • The traditional view of binary sex (male or female) implies those not fitting typical definitions are defective or incomplete.
  • Redefining sex can mean not being a damaged version of male or female but complete in itself (neuter).
  • This involves lacking gonads of either sex (testicles or ovaries), resulting in no sex hormone production (except minimal amounts from adrenal glands).
  • Consequently, there's absence of a penis, vagina, breasts, or internal sex organs.

Social Challenges

  • Lack of comprehension/comfort with those who don't fit into traditional gender roles.
  • Prejudice includes the idea that those who are neither male nor female don't exist or aren't real.

Personal Experience:

  • Initially assigned female at birth, but rejected this label early on.
  • At 15 or 16, experts suggested surgical addition of a penis, which was rejected.
  • Lack of sexual interest or a sex drive.
  • Chromosome test refusal at 14 due to potential misuse of results.
  • At 18, tried to change birth certificate to neuter but was initially denied. Legal battle ensued for two years.

Anomaly vs. Disorder

  • The term "anomaly" is preferred over "disorder" to reduce negative connotations. Acknowledges existence on a continuum of biological sex.

  • Intersex: Current term for individuals with sexual anomalies (previously "hermaphrodite," now considered outdated/offensive).

  • Some individuals have reclaimed the term hermaphrodite to indicate power.

Dimorphic vs. Bimodal Continuum View

  • Dimorphic View: Suggests two distinct biological sexes with no overlap. Recognizes variability within each gender (gonad size, genital morphology, chromosomes, hormones) but no overlap between sexes.
  • Bimodal Continuum: Biological sex exists on a spectrum with two peaks (male and female) and overlaps where intersex individuals lie. Blacklist (2000) suggested approximately 2% of the population falls into this intersex overlap.

Chromosomal Anomalies

  • Identified via karyotype (analysis of 23 chromosome pairs).

Turner Syndrome (XO)

  • Individuals have only one X chromosome.
  • Variability exists; some may have one X chromosome or one X chromosome and a portion of another X chromosome.
  • Characterized by non-functioning or absent ovaries.
  • Typical uterus, cervix, and fallopian tubes but no ovaries.
  • Underdeveloped external reproductive structures (genitals) leading to minimal breast development and no menstruation.
  • Learning disabilities related to visual-spatial skills.

Klinefelter Syndrome (XXY)

  • Individuals have two X chromosomes and one Y chromosome.
  • Possess testes but are sterile.
  • Internal reproductive structures are typical male.
  • Small penis and testes with some breast development.
  • Female secondary sex characteristics develop during puberty (wider hips also feminization occurs during puberty).
  • Associated learning disabilities, particularly speech and language development.

XXX Syndrome

  • Individuals appear as typical females; may be taller than average.
  • Typically no unusual physical features.
  • Typical sexual development; fertile.
  • Increased risk of learning disabilities and delayed speech/language skills.

XYY Syndrome

  • Supernumerary Y syndrome.
  • Males may be taller than average, but typically no unusual physical features.
  • Increased risk of learning disabilities, delayed development of speech/language skills, and motor skill delays.
  • Typically fertile.

Ovotestis Syndrome

  • Formerly known as true hermaphroditism.

  • Individuals have both ovarian and testicular tissue.

  • Tremendous variability in appearance; can have one ovary and one testicle or look like a typical female with testicular tissue associated with the ovaries.

  • All listed chromosomal anomalies are the result of chromosomal mutations; not inherited.

Hormonal Anomalies

  • Occur due to atypical concentrations of sex hormones, impacting sexual morphology.

Androgen Insensitivity Syndrome

  • XY chromosomes (typical male).
  • Body incapable of processing testosterone (an androgen).
  • Shallow vagina.
  • External appearance lacks typical male structures.
  • Gonads are undescended (internal) testes.
  • Develops female secondary sex characteristics at puberty (breast development, curved hips). However, are sterile due to lack of ovaries.
  • Vagina is shallow and "blind" (doesn't open into a cervix/uterus); no cervix or uterus.

Congenital Adrenal Hyperplasia (CAH)

  • XX chromosomes (typical female).
  • In utero exposure to greater-than-typical amounts of androgens causing masculinization of genitalia.
  • Enlarged clitoris, resembling a small penis.
  • Has ovaries and is fertile.
  • Develops female secondary sex characteristics at puberty and menstruates, unlike those with Androgen Insensitivity Syndrome (those individuals do not menstruate because they do not have ovaries or a uterus).
  • Past treatments involved surgical removal/reduction of the clitoris which can prevent orgasms during sex.

Ethical Considerations

  • Growing belief that surgery on intersex children should be delayed until the child is old enough to make their own informed decisions.

Gender Schema Theory (Sandra Bem)

  • Expanded view of gender roles during the 1970s.
  • Challenged the notion of gender existing on a single continuum.
  • Gender roles exist on two continua (femininity and masculinity).

Continua:

  • Y-axis: Continuum of femininity.

  • X-axis: Continuum of masculinity.

  • Individuals exist at some point on both of these continua.

Categories:

  • Feminine: High in femininity, low in masculinity.

  • Masculine: High in masculinity, low in femininity.

  • Androgynous: High in femininity and high in masculinity. Demonstrates greater flexibility in thought and associated with potential for greater psychological well-being.

  • Undifferentiated: Low in masculine and feminine traits; do not show consistent use of sex-type behavior.

  • Sex-typed: Identifies with their gender and acts according to societal roles.

  • Cross-typed: Gender role is opposite to that person's sex.

Case Study: Gender Neutrality Theory

  • Dr. John Money believed a baby is essentially neutral for the first two years of life, and their upbringing determines whether they feel masculine or feminine.

DSM-5 Definitions

  • Gender assignment (natal gender): Initial determination of male or female at birth.
  • Gender identity: An individual's identification as either male, female, or a continuum.
  • Cisgender: Gender identity is congruent with gender assignment. What you think of inside your brain is congruent with what others have assigned you at birth.
  • Gender atypical (gender non-conforming): A person's gender identity, gender role, or gender expression is not statistically characteristic of the individual's assigned gender.
  • Transgender: Broad spectrum of individuals who transiently or permanently identify with a gender different from their assigned gender.
  • Transsexual: An individual who seeks or has undergone a social transition from male to female or female to male. May or may not involve hormone treatment and/or genital surgery (no physical transition per se).
  • Gender dysphoria: The distress that an individual experiences due to the incongruence of the expressed gender and the assigned gender.

Gender Dysphoria:

  • Not all transgender individuals experience gender dysphoria (myth).
  • Shift away from identity being the problem to distress being the problem.

Diagnostic Criteria for Gender Dysphoria in Children:

  • Marked incongruence between one's experienced/expressed gender and assigned gender of at least six months duration.
  • Strong desire to be of the other gender or insistence he/she is the other gender or some alternative different from assigned gender also must be present.
  • Clinically significant distress or impairment in social, school, or other functioning.

Diagnostic Criteria for Gender Dysphoria in Adolescents/Adults:

  • Marked incongruence between one's experience or expressed gender and assigned gender that lasts for at least six months.
  • Associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Treatment of Gender Dysphoria

  • Attempt to bring the body in line with the mind.
  • Organization for gender reassignment: WPATH (World Professional Association for individuals with gender dysphoria).
  • Goal: To provide clinical guidance for health professionals to assist transsexual, transgender, and gender non conforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves to maximize overall health.

A Summarization of the WPATH Standards of Care

  • Used a guideline for healthcare professionals, mental health screened used to determine best care for an individual.
  • Guidelines used for hormone changes and/or surgeries, may see patients needing psychological, hormonal, or surgical treatments to achieve satisfaction.
  • Criteria to get a prescription for hormones, must have these 3 present, then one referral of documentation of assessment is needed (1 letter):
    • Persistent, well-documented gender dysphoria
    • Capacity to make a fully informed decision and consent for treatment
    • Age of majority of a given country (18 in the USA)
Hormone Therapy (Estrogen or Testosterone):
  • effects of taking Testosterone is irreversible.
    • Double Mastectomy: One letter is needed (not a prerequisite to be on hormones for surgery, just that assessment/letter from a mental health professional is needed to ensure other mental/health conditions are maintained.)
    • Vaginoplasty/Phalloplasty: (Two letters are required from a mental heath professional for these and they require two referrals).
      • Medical technology much more advanced with Vaginoplasty
      • 12 continuous months of hormone therapy undertaken prior to any surgery.
      • Continuous months of living in a gender role that is congruent with their gender identity (referred to as Real life test by WPATH). This is to ensure mental stability and understanding of gender, since undergoing is irreversible.