Aetiology

Introduction

Theories on the cause of gender identity problems

Bio-psycho-social theories dominate most informed discussions of aetiology of many types of emotional instability and psychiatric illness. In the on going ‘nature-nurture’ debate about the origins of gender differences and Gender Identity Disorders there are many and varied perspectives all equally supported by evidence and passionately upheld by theorists who maintain they each hold the ‘truth’ about gender development, gender roles and ‘deviations’ from the norm such as Homosexuality and Gender Identity Disorders{1}.

In summarizing the aetiology of Gender Identity Disorders, it must be stressed that all precipitating and pre-disposing factors such as biology, mannerisms, family rearing patterns, peer rejection and rigid cultural stereotypes will probably not create disturbance in gender identity unless they exist in an interrelating fashion{2}. For example a boy whose prenatal development determined a somewhat female appearance and docile temperament is not bound to any particular adult sexual pattern or gender identity configuration. The probability of such ‘deviations’ occur when his mother, if she happens to be of a particular personality, will treat him as an extension of herself which further feminises his identity. If the father is withdrawn, absent or abusive, the chances of feminization are further increased. Peer rejection and labelling leading to stigmatisation, will then ‘cement’ the feminine core gender identity increasing the likelihood of the development of a transgendered lifestyle. It can be seen in this scenario no one factor is totally determining{3}, which supports the biopsychosocial etiological theory that views transsexualism as a personality disorder{4}.

Biological

Biological Theories

The Biological Model of gender development is adopted more readily by those in the scientific and medical profession, especially the area of Genetics and Endocrinology.

There have been many speculations about physiological causes of Gender Identity Disorder, but generally it has been found that there is no evidence of biological aetiology{5}. (Annon, 1975). Although there would be a consensus as to the physiological action of hormones on the body of the foetus and the brain to a certain extent, there is debate over the measure to which the brain is ‘wired’ for a cognitive, affective and behavioural outcome specific to sex. The Biological Model of gender development is largely rejected by many psychologists, social researchers, sociologists and anthropologists{6}. Money, for example, found that of most psychological deviants studied, sissies, tomboys, transvestites, transsexuals, homosexuals and bisexuals appeared to be normal on all of six physiological tests used. (Breecher, 1969).

A number of studies have centered on the sexual behavior of animals but gender identity is a more complex and distinctly human phenomenon with no experimental analogs in animal research{7}.

It has been suggested that the belief that gender identity is biologically determined is often an indication that Transsexuals do not want to question the origins of their condition or explore its causes and development. Ross states "Such individuals are often unwilling to accept any responsibility for their gender dysphoria and will not entertain any attempts to change it." (Walters, 1986:20) Ross also suggests that professionals who believe that Gender Identity Disorders are biologically determined may also attempting to justify the continuation of Sex Reassignment Surgery without a close examination of the psychological basis for each individual’s condition{8}.

Psychological

Psychological theories

Whilst there is no good evidence to suggest a biological basis for transsexualism{9}, it has been known for some time that there are a number of psychological factors which may contribute to a patient’s request for sex reassignment and these need not necessarily occur in childhood{10}. Transsexualism is medically classified as a mental illness along with other personality disorders{11}. Many find it difficult to view gender identity disorder as anything other than a psychological disturbance{12}, calling attention to the fact that a large number (up to 70 per cent) of individuals who present for gender reassignment may be able to give up their request for surgical procedures and come to terms with their gender dysphoria{13} indicates that the disorder is not biologically determined and that psychodynamic considerations in many cases may determine the request for surgery{14}.

Psychological components of sexual identity are frequently independent of one another, and disturbances of some or all may lead to individuals presenting as transsexuals{15}. Contributing factors to gender dysphoria include varying disorders of parental rearing practices{16}, sexual abuse or incest{17},psychopathology, psychological disturbances or lack of ego development, social and environmental factors, object losses or separations and general stressors such as the break up of relationships, aging, or inability to function in the appropriate masculine or feminine role{18}.

Gender dysphoria may be an attempt to ward off decompensation and psychological breakdown that occurs from a lack of core identity and defective self-identity. Individuals from a sex-role rigid society may feel that they do not fit into the more stereotyped roles and thus assume that, if they did not fit in the role of one sex, they must belong to the other{19}. It is also not uncommon for homosexuals living in an anti-homosexual society to request gender reassignment in an attempt to legitimize their same-sex object preference{20}. Many see transsexualism as a delusion of psychotic proportions requiring long term psychiatric treatment{21}, which has been shown to be effective for those individuals willing to under go it{22}. This group views sex reassignment surgery as complicity with the psychosis and therefore both inappropriate and ineffective.

Sometimes the desire for sex reassignment is simply a cry for help, an expression of psychological pain stemming from a long history of anxious attachments, generalized anxiety, social phobia, intimacy dysfunction, depression, loneliness and despair{23}.

Social

Socio-Cultural theories

There is no consensus as to the precise role our physiological make-up plays in the construction of gender identity. The Socio-cultural model investigates the psychological, social and cultural world of the individual in order to see ‘the bigger picture’ of gender identity, gender roles and gender confusion and concludes that the subjective sense of gender identity is to a large extent determined by the psychosocial environment of a person, which couched in a cultural setting is a malleable entity. The model also suggests that psychosocial influences play a very significant role in the aetiology of Gender Identity Disorders.

Many who study gender disorders have come to see gender identity as a rather subjective entity referring to the inner feelings of maleness and femaleness. In essence it is the gender of the inner self; that part of an individual that is not seen; the individual’s perception of himself or herself. It is not necessarily related to anatomical sex and is independent from sex role. (Rattnam et al, 1991) The idea that gender identity is not necessarily related to anatomical sex suggests that gender identity can develop independently from biological prescriptions which although do have significant bearing on development, only serve to predispose rather than pre-determine.

Social Learning Theory with its emphasis on modelling and reinforcement and Cognitive Developmental Theory with its focus on children as active thinkers about their social worlds, are the major contemporary approaches to development of sex-typing. A great deal of understanding about gender development can also be gained from the Psychodynamic Theories which although have focused mainly on abnormal behaviour, give us insight into the motives, drives and relational conflicts of the individual, many of which are unconscious. The ‘indirect’ model many adhere to demonstrates that, within a social cognition framework, biological sex-related characteristics interact with a social context and situational factors to produce different behaviours.

Whether identity and concept of self defines behaviour, whether choices are made based on cognitions, or whether learnt behaviour and labels solidify and define gender identity, are questions still debated by psychologists and sociologists. The approach one takes will determine how research data is interpreted. It can be suggested that the emergence of gender identity and role is a complex process incorporating facets of all of the above theories in a dynamic interplay between the unconscious, cognitive, emotional and behavioural components of an individual’s psychosocial development. Incorporating aspects of a variety of theories allows us to view the human being as the multi- faceted creature that he/she is; capable of being ‘determined’ by social and psychological forces, labelled, behaviourally conditioned, but also able to make objective free choices. Let us therefore view research studies from a position that considers the various perspectives so we are able to gain greater understanding of the dynamic interactive process of human socialisation.

Psycho-Social

Psycho Social theories

The theory held by some psychologists and social theorists is that biology provides a ‘blank slate’ of neural circuitry on which experience inscribes orientation{24}. (Byrne, 1994) Gender Identity must be learned through culture and relationships and any deviations such as homosexuality and Transsexuality reflect a disruption in social learning, imprinting, conditioning and psychodynamic developmental processes{25}.

Indeed, the theoretical underpinnings of the study of Gender Identity Disorders are rooted mainly in Pychodynamic Theory and Social Learning Theory. From the first perspective, Gender Identity Disorders are caused by conscious or unconscious rearing of the child in opposition to his anatomical gender and are based on the widely accepted work of Stoller. (Bockting and Coleman (Eds), 1992) With the latter theory tremendous importance is placed on early experience of social conditioning and learning of behaviours. Both psychoanalytic and social learning theories agree that Gender Identity Disorders are directly related to a weak or reversed gender identity. (Dworetsky, 1982)

These perspectives are explored in detail in most of the texts on Gender Identity Disorder and the nature of Gender Dysphoria. Ross, who has written the chapter on origins of transsexuality in Walter’s book Transsexualism and Sex Reassignment explains to us that "....the persistent and consistent wish of being a member of the opposite sex over a long period of time is not due to one single cause but significant interactions between variables.". (Walters, 1986:187) He concludes "present evidence strongly suggests the great majority of Gender Dysphorics... result from the various disorders of parental rearing patterns, psychopathology and psychological disturbances or lack of ego development, social and environmental factors, object losses or separation, general stressors or lack of core gender identity." (Walters, 1986:25) Others, likewise have speculated that gender disorders stem from psychodynamic formulations, imprinting, conditioning, abnormal parent-child relationships, close association with the parent of the opposite sex, lack of attachment to and identification with peers of the same sex during childhood and cultural influences. (Rattnam et al, 1991) Of course, as mentioned earlier, many theorists consider that these factors may be interacting with the predisposing factors of hormonal or genetic influences which are yet to be discovered, as well as inborn physical and character traits.

Sanda Davis, a modern American psychotherapist who works primarily in the area of Gender Identity Disorder and understands it as a result of the process of Introjection, approaches it in a similar way one would diagnose and treat Multiple Personality Disorder

She defines an Introject, a psychoanalytic term, as an "active mental impression of outside people" existing as "packages of information imprinted on the real person’s mind, which activate a multiple of cognitive, emotional and physical processes." (Davis, 1995:75) The introject which is imprinted through the impact of an overpowering person or people, reflects in its structure, the perceived characteristics of the external object and has a self-image and self definition. The degree of Gender Dysphoria is proportionate to the degree of emotional and personal significance of the dynamic elements imprinted, and also to the degree of expansion of the female introject in the male’s internal and external life. The strength of the introject is also relative to the defeated state of the traumatised person, who has been numbed, confused and weakened to the point of learned helplessness.

Bio-Social

Bio-Social theories

Some theorists maintain that biological factors do not wire the brain for orientation but they pre-dispose towards certain personality traits that influence the relationships and experiences that ultimately shape sexuality. (Byrne, 1994) Others, whilst accepting that gender development occurs as a synthesis of biology and socialisation, place more emphasis on the socialisation aspect.

For example in a review of the current literature on the biological differences in gender, Berk found that generally girls show more rapid early verbal development and are more emotionally sensitive, dependent and compliant, whilst boys are advantaged in spatial and mathematical abilities and are more aggressive. He concludes "The disparities are small...Biological facts operate in some differences but it only makes it slightly easier for one sex rather than another to acquire attributes. Both boys and girls can learn all of them through socialisation." (Berk, 1991:555) Similarly, Deux in a 1985 study concluded that gender accounts for 5% of individual differences among children in any characteristic, leaving most to be explained by other factors. (Berk, 1991)

This approach has been largely developed by Dr. John Money who is the Associate Professor of Medical Psychology and Paediatrics at the Johns Hopkins Hospital in Washington D.C and is the director of its office of Psychohormonal Research. (Berk,1991) He would suggest that there are hormonal influences that act on the brain to set up supposed neural pathways to receive postnatal, social, and gender identity signals but after birth the biological program shifts to one of psychosexual conditioning and gender identity now becomes largely a matter of social biography. Money and Ehrhardt, admit that of the two, social factors are the most influential part of gender identity differentiation and pre-natal hormonal factors only ‘predispose’. (Raymond, 1989)

Likewise Marcus et al in 1985 put forward the theory that suggests in regard to boys, pre-natal hormone levels influence the organisation of the nervous system so as to induce frequent displays of excitement, anger and anxiety which will have the likelihood of turning into aggression in the presence of an environmental condition. Parsons (1982) also suggests that androgens promote higher levels of activity which only serve to pre-dispose a male to aggression, depending on rearing.(Berk, 1991)

In relation to Gender Identity Disorder this theory is confirmed by the findings of Chon-Kettenis and Gooren in 1992 that when transsexuals were administered androgens they did not report higher levels of anger or aggression, but only increased sexual motivation and arousability. (Bockting and Coleman (Eds), 1992) We can suggest socialisation did not provide the environment for individuals who became transsexuals to develop an expression of the male biological pre-disposition toward aggression.

Bio-Psycho-Social

Bio-Psycho-Social theories

There is evidence to suggest that biological differences do slightly pre-dispose individuals for different gender related characteristics and so social sex-role prescriptions are not just purely culturally based{26}. Traditional sex-roles have polarised the expectations for male and female, expanding the differences found through biological research way out of proportion. These findings give us reason to believe in the enforcement of equal rights and opportunities for men and women in education, media, vocation, politics and science, but do not give us permission to ‘transcend’ sex in the establishment of a healthy gender identity. In regard to deviations from the norm in the form of transgenderism, we can suggest that more than just cultural norms are being violated. Those who consciously or unconsciously raise their boys, or encourage those who do, in a way that encourages cross gender identification are, it can be argued, violating the physical ‘being’ of the person, contradicting and stunting their ‘destiny’ as a male.

It must be argued that, even if society is enculturated with ‘exaggerated’ sex-role prescriptions, it is vitally important for an individual growing up in society to feel a ‘gender -sameness’ with others, especially in childhood and adolescence. Regardless of whether normal biological variations in an individual cause him to be less ‘culturally’ masculine, it is important that he know he is a male. To jeopardise an individual’s psychosocial developmental process so that he is unable to achieve a secure gender identity alongside others, ‘predisposes’ him for a life of confusion and unhappiness. G.I. Rekers holds that "Failure to achieve precise gender identification may impair the development of a mature, complex, self identity where as the mature normal adult accepts gender identity as a given quality and elaborates other attributes." (Benner (Ed), 1992) Although it can be argued that the transgender issue is both a problem of society in that its gender norms are too rigid, it can also be viewed as a problem originating from childrearing practice that sabotage gender identification.