Gender identity

Nature versus nurture

Although the formation of gender identity is not completely understood, many factors have been suggested as influencing its development. In particular, the extent to which gender identity is determined by nurture (social environmental factors) versus biological factors (which may include non-social environmental factors) is at the core of the ongoing debate in psychology known as "nature versus nurture".^[22][23] There is increasing evidence that the brain is affected by the organizational role of hormones in utero, circulating sex hormones and the expression of certain genes.^[23]

Social factors which may influence gender identity include ideas regarding gender roles conveyed by family, authority figures, mass media, and other influential people in a child's life.^{[24][clarification needed]} The social learning theory posits that children furthermore develop their gender identity through observing and imitating gender-linked behaviors, and then being rewarded or punished for behaving that way, thus being shaped by the people surrounding them through trying to imitate and follow them.^[25][26]

Large-scale twin studies suggest that the development of both transgender and cisgender gender identities is due to genetic factors, with a small potential influence of unique environmental factors.^[27]

Case of David Reimer and contrasting case

The neutrality of this section is disputed. (August 2021)

This section may primarily relate to a different subject, or place undue weight on a particular aspect rather than the subject as a whole. (December 2024)

Further information: Nature versus nurture

A well-known example in the nature-versus-nurture debate is the case of David Reimer, born in 1965, otherwise known as "John/Joan". As a baby, Reimer went through a faulty circumcision, losing his male genitalia. John Money advised Reimer's parents to raise him as a girl. Reimer underwent sex reassignment surgery at seventeen months and grew up as a girl, dressing in girl clothes and surrounded by girl toys. In the early 1970s, Money reported that Reimer's sex reassignment to female was a success, influencing the academic consensus toward the nurture hypothesis, and for the following 30 years, it became standard medical practice to reassign intersex infants and male infants with micropenises to female.^[28]

John Money was instrumental in the early research of gender identity, though he used the term gender role.^[29] He disagreed with the previous school of thought that gender was determined solely by biology. He argued that infants are born a blank slate and a parent could be able to decide their babies' gender.^[30] In Money's opinion, if the parent confidently raised their child as the opposite sex from earlier than age two, the child would believe that they were born that sex and act accordingly.^[31] Money believed that nurture could override nature.^[30]

After Reimer tried to commit suicide at age 13, he was told that he had been born with male genitalia. Reimer stopped seeing Money, and underwent surgery to remove his breasts and reconstruct his genitals.^[32] In 1997, sexologist Milton Diamond published a follow-up, revealing that Reimer had rejected his female reassignment, and arguing against the blank slate hypothesis and infant sex reassignment in general.^[33]

Diamond was a longtime opponent of Money's theories. Diamond had contributed to research involving pregnant rats that showed hormones played a major role in the behavior of different sexes.^{[31][page needed]} The researchers in the lab would inject the pregnant rat with testosterone, which would then find its way to the baby's bloodstream.^[30] The females that were born had genitalia that looked like male genitalia. The females in the litter also behaved like male rats and would even try to mount other female rats, proving that biology played a major role in animal behavior.^{[31][page needed]}

One criticism of the Reimer case is that Reimer lost his penis at the age of eight months and underwent sex reassignment surgery at seventeen months, which possibly meant that Reimer had already been influenced by his socialization as a boy. Bradley et al. (1998) report the contrasting case of a 26-year-old woman with XY chromosomes whose penis was lost and who underwent sex reassignment surgery between two and seven months of age (substantially earlier than Reimer), whose parents were also more committed to raising their child as a girl than Reimer's, and who remained a woman into adulthood. She reported that she had been somewhat tomboyish during childhood, enjoying stereotypically masculine childhood toys and interests, although her childhood friends were girls. While she was bisexual, having had relationships with both men and women, she found women more sexually attractive and they featured more in her fantasies. Her job at the time of the study was a blue-collar occupation that was practiced almost exclusively by men.^[34] Griet Vandermassen argues that since these are the only two cases being documented in scientific literature, this makes it difficult to draw any firm conclusions from them about the origins of gender identity, particularly given the two cases reached different conclusions. However, Vandermassen also argued that transgender people support the idea of gender identity as being biologically rooted, as they do not identify with their anatomical sex despite being raised and their behaviour reinforced according to their anatomical sex.^[35]

Biological factors

Several prenatal biological factors, including genes and hormones, may affect gender identity.^[22][40] It has been suggested that gender identity is controlled by prenatal sex steroids, but this is hard to test because there is no way to study gender identity in animals.^[41] According to biologist Michael J. Ryan, gender identity is exclusive to humans.^[42]

In a position statement, the Endocrine Society stated:^[14]

The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed "gender identity disorder." Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Social and environmental factors

Social scientists tend to assume that gender identities arise from social factors.^[55] In 1955, John Money proposed that gender identity was malleable and determined by whether a child was raised as male or female in early childhood.^[56][57] Money's hypothesis has since been discredited,^[57][58] but scholars have continued to study the effect of social factors on gender identity formation.^[57] In the 1960s and 1970s, factors such as the absence of a father, a mother's wish for a daughter, or parental reinforcement patterns were suggested as influences; more recent theories suggesting that parental psychopathology might partly influence gender identity formation have received only minimal empirical evidence,^[57] with a 2004 article noting that "solid evidence for the importance of postnatal social factors is lacking."^[59] A 2008 study found that the parents of gender-dysphoric children showed no signs of psychopathological issues aside from mild depression in the mothers.^[60] It has also been suggested that the attitudes of the child's parents may affect the child's gender identity, although evidence is minimal.^[61]

Definitions

The terms gender identity and core gender identity were first used with their current meaning—one's personal experience of one's own gender^[1][16]—sometime in the 1960s.^[85][86] To this day they are usually used in that sense,^[8] though a few scholars additionally use the term to refer to the sexual orientation and sexual identity categories gay, lesbian and bisexual.^[87] Gender expression is distinct from gender identity in that gender expression is how one chooses to outwardly express their gender through one's "name, pronouns, clothing, hair style, behavior, voice or body features."^[88] It is thus distinct from gender identity in that it is the external expression of gender but may not necessarily portray a person's gender identity and may vary "according to racial/ethnic background, socio-economic status and place of residence."^[89]

Early medical literature

In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called "inverts", and they were portrayed as having an interest in knowledge and learning, and a "dislike and sometimes incapacity for needlework".^[90] During the mid-1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed.^[91][92] The aim of this therapy was to push children back to their "correct" gender roles and thereby limit the number of children who became transgender.^[90]

Freud and Jung's views

In 1905, Sigmund Freud presented his theory of psychosexual development in Three Essays on the Theory of Sexuality, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the phallic stage, at which point gender identity became ascertainable.^[93] According to Freud, during this stage, children developed an Oedipus complex where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child's power to appease sexual impulses.^[25] In 1913, Carl Jung proposed the Electra complex as he both believed that bisexuality did not lie at the origin of psychic life, and that Freud did not give adequate description to the female child (Freud rejected this suggestion).^[94]

1950s and 1960s

During the 1950s and '60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homosexuality (which was viewed as a mental disorder at the time). In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersex and transsexual individuals. Psychoanalyst Robert Stoller generalized many of the findings of the project in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden, in 1963.^[95] Behavioral psychologist John Money was also instrumental in the development of early theories of gender identity. His work at Johns Hopkins Medical School's Gender Identity Clinic (established in 1965) popularized an interactionist theory of gender identity, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book Man and Woman, Boy and Girl (1972) became widely used as a college textbook, although many of Money's ideas have since been challenged.^[96][97]

Butler's views

In the late 1980s, gender studies scholar Judith Butler began lecturing regularly on the topic of gender identity, and in 1990, they published Gender Trouble: Feminism and the Subversion of Identity, introducing the concept of gender performativity.^[98] Butler argues that the traditional view of gender is limiting in that it adheres to the dominant societal constraints that label gender as binary. In scrutinizing gender, Butler introduces a nuanced perception in which they unite the concepts of performativity and gender.^[99]

Medical field

Transgender people sometimes wish to undergo physical surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina or breasts.^[100] In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants, and recommends that the procedure be only conducted when medically necessary.^[101] Today, gender-affirming surgery is performed on people who choose to transition so that their external sexual organs will match their gender identity.^[102]

In the United States, the Affordable Care Act provided that health insurance exchanges would have the ability to collect demographic information on gender identity and sexual identity through optional questions, to help policymakers better recognize the needs of the LGBTQ community.^[103] In 2020, however, the Trump administration finalized a rule that "would remove nondiscrimination protections for LGBTQ people when it comes to health care and health insurance" in the Affordable Care Act and extends to "regulations pertaining to access to health insurance."^[104] This rule "is one of the many rules and regulations put forward by the Trump administration that defines "sex discrimination" as only applying when someone faces discrimination for being male or female, and does not protect people from discrimination on the basis of sexual orientation or gender identity."^[104]

Gender dysphoria and gender identity disorder

Gender dysphoria (previously called "gender identity disorder" or GID in the Diagnostic and Statistical Manual of Mental Disorders or DSM) is the formal diagnosis of people who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex:^[105][106] "In gender identity disorder, there is discordance between the natal sex of one's external genitalia and the brain coding of one's gender as masculine or feminine."^[85] The DSM (302.85) has five criteria that must be met before a diagnosis of gender identity disorder can be made, and the disorder is further subdivided into specific diagnoses based on age, for example gender identity disorder in children (for children who experience gender dysphoria).

The concept of gender identity appeared in the third edition of the DSM, DSM-III (1980), in the form of two psychiatric diagnoses of gender dysphoria: gender identity disorder of childhood (GIDC), and transsexualism (for adolescents and adults). The 1987 revision of the manual, DSM-III-R, added a third diagnosis: gender identity disorder of adolescence and adulthood, nontranssexual type. This latter diagnosis was removed in the subsequent revision, DSM-IV (1994), which also collapsed GIDC and transsexualism into a new diagnosis of gender identity disorder.^[107] In 2013, the DSM-5 renamed the diagnosis gender dysphoria and revised its definition.^[108]

The authors of a 2005 academic paper questioned the classification of gender identity problems as a mental disorder, speculating that certain DSM revisions may have been made on a tit-for-tat basis when certain groups were pushing for the removal of homosexuality as a disorder. This remains controversial,^[107] although the vast majority of today's mental health professionals follow and agree with the current DSM classifications. In recent years, however, there has been a "growing chorus of voices contesting the pathologization of transgender lives and the dominance of medical-scientific narratives about trans experience."^[109] As such, in 2019, the World Health Organization removed gender dysphoria from the mental illness chapter and moved it instead to the sexual health chapter, changing the term "Gender Dysphoria" to "Gender Incongruence," thereby removing gender dysphoria as a pathological mental illness.^[110]

International human rights law

The Yogyakarta Principles, a document on the application of international human rights law, provide in the preamble a definition of gender identity as each person's deeply felt internal and individual experience of gender, which may not correspond with the sex assigned at birth, including the person's sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other experience of gender, including dress, speech and mannerism. Principle 3 states that "Each person's self-defined [...] gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom. No one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilisation or hormonal therapy, as a requirement for legal recognition of their gender identity."^[111] Principle 18 states that "Notwithstanding any classifications to the contrary, a person's sexual orientation and gender identity are not, in and of themselves, medical conditions and are not to be treated, cured or suppressed."^[112] Relating to this principle, the "Jurisprudential Annotations to the Yogyakarta Principles" observed that "Gender identity differing from that assigned at birth, or socially rejected gender expression, have been treated as a form of mental illness. The pathologization of difference has led to gender-transgressive children and adolescents being confined in psychiatric institutions, and subjected to aversion techniques – including electroshock therapy – as a 'cure'."^[113] The "Yogyakarta Principles in Action" says "it is important to note that while 'sexual orientation' has been declassified as a mental illness in many countries, 'gender identity' or 'gender identity disorder' often remains in consideration."^[114] These Principles influenced the UN declaration on sexual orientation and gender identity. In 2015, gender identity was part of the United States Supreme Court case Obergefell v. Hodges in which marriage was no longer legally restricted to be only between man and woman.^[115]

Binary gender identities

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While academic usage of terms man and woman began to diverge at the same time, and become more restricted to concepts related to gender,^[120] this distinction was not universal (and still is not) even in academic usage, and even less so in more informal writing or in speech, which often conflate the two.^[121][122]

Non-binary gender identities

Some people, and some societies, do not construct gender as a binary in which everyone is either a boy or a girl, or a man or a woman. Those who exist outside the binary fall under the umbrella terms non-binary or genderqueer. Some cultures have specific gender roles that are distinct from "man" and "woman." These are often referred to as third genders.