Aspects

Introduction

Seven aspects of sex and gender

It is vital to distinguish several aspects of "gender" and "sex". The following classification is one of a number that are or have been customary in the psychiatric and other literature.

1. Genetic sex

2. Hormonal sex

3. Anatomical sex

4. Developmental sex

5. Sexual orientation

6. Psychological gender (psychological sex)

7. Sociological gender (sociological sex)

The point of listing these areas of sex and gender is that while they are in some people integrated into a seamless whole, they can under some circumstances be remarkably distinct and independent.

For example: A person may be genetically male, hormonally female, anatomically either, developmentally female, have a homosexual or heterosexual orientation, possess a female psychological gender, yet be socially accepted as male or any other combination of the seven factors.

(Note: The word "sex" is generally used for physical, hormonal, physiological, neurological and reproductive functioning, while "gender" most often refers to the categorisation by oneself or others of whether a person is "male" or "female" in their social role or psychological identity).

The distinctions between genetic sex, hormonal sex, anatomical sex, developmental sex, sexual orientation, psychological gender and social gender are usually not known to people troubled about sex and gender. They are frequently not clearly outlined or fully explored by therapists. As a result, considerable confusion between sex and gender is often present.

It is vital that all who are concerned with issues of sex and gender be fully informed about the distinctions between these aspects of the issue. Above all, it is essential that individuals contemplating genital surgery be given the opportunity to explore all of these factors fully and clearly.

Genetic

Genetic aspects

This refers to the chromosomal composition of the individual. Human beings are normally born with either two X sex chromosomes, or an X and a Y chromosome. Males are born with an "XY" sex chromosome complement, while females are born with the "XX" chromosome complement. Rare variants include those with additional or deleted chromosomes (eg, XYY or XYYY).

The determination of anatomical sex and physical development is dictated by the genes on these chromosomes. This development in turn substantially determines the hormonal balance of the individual during gestation, childhood and adulthood. Hormonal and other factors then heavily influence "gender" (ie, the psychological and social identification of the person as male or female) and sexual orientation (ie, whether the person is attracted to males or females).

Variations in chromosome complement may have profound effects on adult life, behaviour and fertility (eg, the reported increased incidence of aggression, criminal activity and imprisonment in individuals with additional male, or Y, chromosomes)

Endocrine

Hormonal aspects

If genetic sex is the initial biological determinant influencing sex and gender, the resulting hormonal balance, interacting with the anatomical sex of the person, may be regarded as the next step up towards the ultimate observed sex and gender of the individual.

While the genetic factor (the possession of an XY chromosome pattern by boys, and an XX pattern by girls) largely determines hormonal and anatomical sex, sometimes other factors impinge on the final genetic expression of sex and gender.

Unusual influences may increase or decrease the secretion of male or female hormones during gestation, childhood, adolescence and adulthood. The earlier the influence of hormonal variations, the greater the influence on subsequent sexuality, gender and orientation. The result may be variations in anatomical structure, and variations in the amount of aggression, nurturing and other features usually (but not exclusively) associated with "male" and "female" sex and gender.

Pysiology

Physical aspects

Just as hormones influence the development of anatomy, so anatomy in turn profoundly influences the secretion of hormones. The development of testes determines the high levels of testosterone in males, that of ovaries the secretion of oestrogens and progestogens in females. Both are regulated by, and in turn influence, the pituitary gland and hypothalamic area of the brain. Surges of hormones from all these sources occur both during intrauterine development and during adolescence.

If there are unusual influences on gene expression, or if there is an unusual chromosomal pattern, anatomical sex may not be as clear-cut as is usually expected. There exist some individuals whose anatomical sex at birth is difficult to determine. Currently, there exists a small social movement to have intersexual states recognised as rare but accepted sexual categories of people.

It is true that in all cases there either is, or there isn't, a Y chromosome present, so that chromosomally, no one is truly intersexual. However, at birth this may not be clear from the visible anatomy of the child, and people with a Y chromosome may be raised as girls, while people without a Y chromosome may be raised as boys, contrary to their chromosomal sex.

The masculinisation of a person without a Y chromosome (chromosomally female) is usually the result of intrauterine exposure to high male hormone levels. In addition to masculinising the genitalia, this may also increase the probability of later male behaviours and characteristics, so that the person is indeed somewhat masculine in childhood and adult life.

In the minds of some, this may justify the child being accepted and raised as male. Sometimes surgery is performed to attempt to further the appearance of male anatomical structure, including removal of ovaries and obliteration of reproductive capacity, with the administration of testosterone later in life to strengthen other male characteristics. The person may live as a male, and love as a male, with greater or lesser success. The individual can, however, never be "male" in the sense of reproduction.

Similarly, the reverse may be true of an individual who is born with indeterminate anatomical sex, but this time with a Y chromosome, and therefore genetically male. The anatomical femininity may be matched by some degree or hormonally based femininity, and the child may be raised as female, and even have surgery to remove male genital features, including testes and reproductive capacity. The person may live and love as a female, with greater or lesser success, but once again will never be "female" in the sense of reproduction.

Upbringing

Sex of rearing

Given the genetic, hormonal and anatomical sex at birth and throughout childhood, the ultimate expression of sexuality and reproduction is substantially influenced by social and cultural factors.

Included in and central to the developmental aspect of sexuality is the awakening of sexual drive, and the consequent dramatic change in mood, energy levels, sexual interest in others, aggression, rivalry and participation in adult activities and social processes.

In many ways, sexual orientation (hetero- or homosexual) is an expression of this development of sexual activity. The onset and unfolding of sexuality under this heading is mediated by the male and female sex hormones. Without their presence, adult sexuality does not emerge.

"Social gender" as described in point 7. below is intimately involved in this developmental aspect of sexuality. In the Western world, certain features of dress, makeup, hair and appearance are associated with being "male" or "female" from an early age. Some of these behavioural patterns are only adopted with the development of adult sexuality and drives. For example, certain types of makeup and dress are only adopted by women on the approach of adulthood. However, elaborate dress and makeup were not always the prerogative of women, are becoming less so now, and are currently by no means so in all cultures. There have been times of extraordinary beauty and elaboration of European adult male dress and appearance, while among the Masai, for example, adult male self-decoration is the rule today. Social expressions of sexual development and biological sexual activity may therefore be said to be strongly culturally influenced.

Some developmental features of male and female sexuality and gender do, however, appear to be strongly influenced by the biological factors of genetics, anatomy and hormones.

While a few consider expressions of sex and gender to be socially determined, and almost independent of biological factors, there is overwhelming evidence that many aspects of human sexual identity and functioning are dependent on biology.

For example olfactory sensitivity to macrocyclic musk compounds and related odours is said to be about 200 times greater in women than in men (except during menstruation). According to some studies, multitasking capability is on average substantially greater among women. Other studies have suggested that attention span is on average longer in males. Throwing and catching ability have been found in some studies to differ between the sexes. Visuospacial capabilities based on maps and internal models may be greater in men than women, while similar capabilities based on observation and land-marking have recently been reported to be equal or greater in women than men. Language skills are found by most studies to be greater in women than men, with total linguistic production per day in women about twice that of males. Childhood differences between boys and girls in nurturing and relationships versus object-oriented play has been shown to exist extraordinarily early in development, too early for social factors to be likely to play a part. The examples are many.

While there has been vigorous argument (often emotionally or polemically based) on such matters, the most pronounced differences between males and females have been repeatedly correlated with differences in hormone levels, anatomical structure and other biological elements. There is no doubt, however, that educational, social and cultural encouragement powerfully reinforces such differences, and may be entirely responsible for some of them.

Developmental sexuality therefore represents the most intricate combination of biological and "non-biological" factors. Among the latter, psychological and social gender are the most salient.

Orientation

Sexual orientation

This refers to which sex a person is attracted to. Obviously, most males are mainly attracted to females, and vice versa.

There has been much debate over the relative contribution of biology and culture to sexual orientation. Much of this has reflected the political needs of different groups at different times. When biological deficiency was regarded as grounds for discrimination or rejection, homosexuals were declared biologically unsound, and homosexuality was rejected or regarded as a constitutional "illness". In response, more compassionate approaches emphasised that the person was not innately "defective", but had been led into homosexuality by environmental factors such as relationships with parents, early sexual experiences, or by other influences. When this became regarded as grounds for supposing that homosexually was acquired, unnatural and curable, the compassionate view came to be that people should not be forced, and that sexual orientation was after all biologically based, innate, and not the individuals "fault".

Most students of this debate who are not politically involved would today accept that a combination of biological predisposition and life experience is often present, and that the "causes" of homosexual orientation may be very different in different individuals.

Both biological and psychological research confirms that both factors may play a part. Early initiation in sexual experience often profoundly influences subsequent sexual preferences. Early experience of homosexuality, especially if pleasurable, may predispose to further seeking of this type of experience. At the same time, brain studies have shown differences in certain brain areas between homosexual and heterosexual individuals – with consequent debate as to whether these brain differences are innate or acquired.

Homosexual behaviour in males is common. The range of reported experience in this area may be listed as follows:

- A substantial proportion of heterosexual men have had homosexual experience (up to 70% in some studies)

- A considerable proportion men have alternated and regard themselves as "bisexual"

- Many men occasionally engage in homosexual behaviour but classify themselves as heterosexual

- A small proportion of males are, and regard themselves as, exclusively homosexual (originally estimated at 4%)

- Somewhat different proportions exist among women, but the same pattern applies.

There are additional complications in considering sexual orientation in individuals with psychological or social gender roles that are opposite to their anatomical or biological sex. Is an anatomical male who feels psychologically to be female, and is attracted to males, homosexual or heterosexual? Anatomically he is homosexual. In terms of gender, she is heterosexual.

Psychological

Self perception

It has been proposed that the word "gender" be reserved for the psychological and social assignment of male and female roles, as opposed to the genetic, anatomical, hormonal, developmental, behavioural and reproductive elements of sex.

Under this convention, "sex"refers to anatomy and sexual functioning, and "gender" refers to whether or not an individual feels to be, or considers himself or herself to be, male or female. According to this choice of usage, "gender" is in part a categorisation issue. It is an issue about which category - "male" or "female" - the individual assigns himself or herself to, or society assigns them to.

While most categorisation issues are intellectual, gender identification is a more profound matter. It impinges fundamentally on personal identity, a core element in mental stability and health. It has such an impact on self-esteem that for many people being a "good example of a male", or a "good example of a woman" largely determines their self-worth.

Clearly, the classification of oneself as "male" or "female" often involves specific criteria, and can involve elements of stereotype. While criteria for maleness or femaleness vary between individuals, families, clans, social classes, generations and cultures, there always will be some form of criteria - this is simply entailed in the fact that the delineation of gender by oneself and by others must involve features or hallmarks that signify the distinction between the two gender categories. Such criteria are mostly learned, not innate (eg, wearing dresses, having long hair etc). Disturbances of gender identity, therefore, inevitably involve learned attributes of gender, and cannot be considered to be wholly, or in the opinion of some even largely, innate.

Descriptions of gender identity disorder in DSM-IV-TR and other works emphasise elements that make it obvious that this disorder involves learning processes, and is not innate. Attachment to stereotypical and culturally determined aspects of gender roles is emphasised. Other features of the condition clearly involve learned elements - the desire in boys with this diagnosis "to have a vagina" for example, clearly requires that the patient first learns that there is such a thing as a vagina.

While psychological gender identity is internal to the person, it is heavily influenced by social interactions and acceptance of their preferred gender by others - in other words, by social gender.

To a great extent, psychological gender is imputed. That is, in whatever gender a child is raised, there will be a strong tendency for the child to assume the psychological gender ascribed from birth. This has been shown in the case of children born with indeterminate anatomical sex. If a genetically female child is considered to be "male" at birth, and is treated as such, then the child will consider itself to be "male" to a considerable degree, at least until psychological, functional or physical traits of the opposite sex begin to prevail. Similarly, a genetically male child considered "female" will ascribe femaleness to itself, at least until more male features emerge, perhaps beginning at the age of four or above, becoming more pronounced at adolescence. Even then, the child may still adhere to the initially ascribed gender, but regard herself as a "tomboy" but still female

On the other hand, it is possible that psychological gender is not wholly socially determined. Some people are deeply convinced that their gender is opposite to their anatomical sex, even if they appear to have been raised in a way that is completely consonant with their biological sex. This is reported to be the case in "gender dysphoria" or "gender identity disorder", where it is said that the individual may have the conviction that they are "a woman trapped in a man’s body" or "a man trapped in a woman’s body."

That this can happen spontaneously was hailed in the early days of gender identity writing as something of a discovery. However, the notion of being trapped in the body of the "wrong" sex is now so widespread among individuals concerned about gender that it is no longer possible to determine to what extent such a notion is implanted, and to what extent it arises spontaneously.

It is very doubtful indeed whether innately having a psychological gender opposite to anatomical sex yet has the force of accepted scientific reality. However, the person concerned may well have a sense of conviction about the matter, as may carers or therapists.

Social

Perception of others

Social gender is the assignment and acceptance of one’s gender role by others. It will determine whether the word "he"or "she" is used for the individual concerned. With that assignment come a large number of expectations regarding experience, appearance, behaviour, speech, work, family duties, reproduction and many other aspects of life{1}.

These expectations may vary widely among different sections of the community in which the person lives. Women may have a particular set of expectations of men, while males may have completely different expectations of the behaviour of their own kind. The young may have different expectations from the old. For example, older people may see nobility, responsibility and courtesy as male, and demureness and sweetness as female, while younger people may see daring and defiance as male and allure and charm as female.

Needless to say, expectations and criteria for being respected in male and female gender roles may vary even more sharply between different cultures. The criteria for social gender assignment are partly social constructs, and change with time. Social standing, however, can be very drastically influenced by even the slightest departure from the gender norms of the day in a given community.

Social gender may not always accord with psychological gender or anatomical or genetic sex. This is illustrated in the following examples:

A woman may feel "female", but be treated somewhat as a male in certain environments (eg, in a truck-driving or other so-called "male" course in which she is the only woman). Similarly, fully male identified men may be treated as effeminate in a culture in which their speech or manners are considered womanly (eg, British males with West End London accents in some male environments in the USA).

Less commonly, a person who is (anatomically) female may feel "male", but be treated as a woman, on the grounds of appearance and behaviour, while a person who is (anatomically) male but who feels "female" may still be treated as having a male social gender role. This is the situation in "gender dysphoria".

Ultimately, however, the social acceptance of a person’s gender role in the present social climate is likely to be substantially influenced by the role they play in reproduction. No matter how far the individual may go in considering themselves or persuading others that they belong to a particular gender, it is at present likely that society - rightly or wrongly - will consider that the ultimate reality of their gender hinges on whether they can (or do) father or bear a child.

In the short term, the collective response of society in this matter is not much open to manipulation or direction. Over a longer period, writing and polemics may alter collective views, and may already have begun to so. At present, however, collective social response is something of a "given". Anatomical males tend to be seen as of male gender, while anatomical females are seen as of female gender.

The entire issue of "gender dysphoria," "gender identity disorder" and "gender reassignment surgery" hinges on the contrasts and continuities between genetic, hormonal, anatomical, reproductive and developmental and behavioural sex, and psychological and social gender roles. However, the capacity to reproduce, and the role taken in this activity, continue to have a fundamental impact on the issue.