More recently, “gender identity disorder” has been created to replace “ transsexualism” as a diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). But science is no more certain today why some people feel so acutely uncomfortable in the sex they were assigned at birth than it was in Hirschfeld’s time—nor why their number seems to be increasing.
Statistics on transsexualism and transgenderism are notoriously unreliable; in the case of transgenderism (a broad and variously defined category) they are mere guesswork. However, it is possible to track the number of people requesting sex-reassignment surgery and to make some general estimates of prevalence (the number of cases of a given condition present in a given population during a given time) based on those figures.
According to the fourth edition of the DSM (DSM-IV), about 1 in 10,000 people seek sex-reassignment surgery (SRS) in the United States every year, and approximately 1 in 30,000 men and 1 in 100,000 women will undergo SRS at some point during their lives. This is believed to be a very conservative estimate, based on SRS statistics that are decades old. Professor Lynn Conway of the University of Michigan suggests that the DSM-IV figures are off by at least two orders of magnitude and that “the prevalence of SRS in the U.S. is at least on the order of 1:2500, and may be as much as twice that value. Therefore, the intrinsic prevalence of MtF transsexualism here must be on the order of ≈ 1:500 and may be even larger than that.” A group of researchers in the Netherlands recently estimated the prevalence of transsexuality to be 1 in 11,900 males and 1 in 30,400 females; this estimate was based on the number of Dutch citizens seeking services compared with the general population.
Legal scholar Julian Weiss has pointed out that “gender identity disorders” are probably far more common than previously suspected, on the basis of four general observations. First, unrecognized gender problems are occasionally diagnosed when patients are seen with anxiety, depression, substance abuse, and other psychiatric conditions, which often serve to mask the underlying gender issue. Second, many individuals who meet the diagnostic criteria for “gender identity disorder” never present themselves for treatment (this category includes the great majority of cross-dressers, professional female impersonators, and gender-variant gay people). Third, the intensity of some people’s feelings of gender-related discomfort fluctuates throughout their lifetimes, and does not always achieve a sustained “clinical threshold” requiring treatment. Finally, gender-variant behavior among female-bodied persons is “invisible” in a way that gender-variant behavior in male-bodied persons is not. On the most basic level, this is exemplified by the relative ease with which women can don men’s clothing.
The number of people self-identifying as transgendered or transsexual and seeking services (hormone therapy and/or surgery) has certainly risen in every decade since Christine Jorgensen brought the issue to the public’s attention, in 1952. Gunter Dorner, a German en-docrinologist who has devoted his career to studying the effects of hormones on the brain, has postulated a fourfold increase in the incidence of transsexualism over the past forty years in the former East Germany. Is Dorner correct? No one knows. But if various forms of gender variance are indeed on the increase, as seems to be the case, what might be the cause of this phenomenon? Dr. Paul McHugh, former chief of psychiatry at Johns Hopkins School of Medicine and a noted opponent of sex reassignment surgery, believes that gender variance is a fad or a “craze” driven by the media and the Internet. McHugh’s views are the flip side of the postmodern “performativity” argument that gender is a cultural construction and that the body is a text upon which individuals are free to inscribe their gender of choice. In this view, gender-queer people are revolutionaries helping to dismantle an oppressive system—and their numbers are increasing, as more and more people challenge the tyranny of the gender binary.
Others believe that greater public tolerance and acceptance, combined with the increased ability to connect with others online and in person, is responsible for the increasing visibility and political activism of gender-variant people. “Twenty or forty or fifty years ago, you couldn’t have had a meeting like this one,” Professor Milton Diamond told me at the 2003 annual meeting of the International Foundation for Gender Education. The majority of the meeting’s participants were cross-dressed men, a group that remains the most heavily closeted of sexual minorities and the most persecuted. “A meeting like this would have been broken up by the police,” Diamond said. Then too, he pointed out, “Many of these individuals think that they are the only ones in the world, and they don’t think that there is a solution, and when they find a solution or find a safe haven somewhere, they utilize it. Many of these activities are like support groups in their own way. They don’t call them that, but that’s what they are.”
Without denying the influence of social factors in helping more people come out, as a science writer I can’t help being interested in biological explanations for what seems to be a pronounced increase in the number of gender-variant people in the world today. An enormous quantity of man-made chemicals has been released into the environment since the chemical revolution began after World War II. According to researchers who have studied their effects, “many of these chemicals can disturb development of the endocrine system and of the organs that respond to endocrine signals in organisms indirectly exposed during prenatal and/or early postnatal life; effects of exposure during development are permanent and irreversible.” Some scientists and transpeople argue that the buildup of these endocrine-disrupting chemicals in the environment has begun to produce the same kind of effects on human sexual differentiation that have already been observed in wildlife and laboratory animals. In this view, a previously rare collection of endocrine-mediated anomalies is becoming more common as a result of the bioaccumulation of these chemicals, many of which are stored in fat and transmitted to the developing fetus through the placenta in pregnancy.
The strongest evidence for a possible biological basis for gender variance comes from research on the effects of the drug diethylstilbe-strol (DES). DES is a synthetic estrogen developed in 1938. Between 1945 and 1970, DES and other synthetic hormones were prescribed to millions of pregnant women in the mistaken belief that they would help prevent miscarriages. DES was even included in vitamins given to pregnant women, and in animal feed. Use of DES during pregnancy was discontinued in the United States in 1971, when seven young women whose mothers had taken DES during pregnancy were found to be suffering from a rare vaginal cancer. Since then, research on animals and human epidemiological studies have proved that DES causes myriad health problems in both males and females exposed to the drug in the womb, including structural damage to the reproductive system. Animal research has also shown that DES and other estrogenic chemicals affect the development of sex-dimorphic brain structures and behavior in animals. Laboratory animals exposed to hormones at critical stages of development in utero exhibited behaviors associated with the other sex after birth. Only in recent years have some researchers begun to note higher-than-expected rates of transgenderism in DES sons and daughters. The moderators of an online discussion group for the XY children of DES mothers surveyed subscribers in 2002 and discovered that 36.5 percent of the forum’s members were either preoperative or postoperative transsexuals, while another 14.3 percent defined themselves as transgendered. An update taken on the five-year anniversary of the group showed that since 1999, between one-quarter and one-third of the members of the DES Sons Network had indicated that gender identity and/or sexuality issues were among their most significant concerns. These data have not yet found their way into the scientific literature, however, and the combined cohort studies of DES children have thus far failed to ask a single question related to gender identity. This epidemiologic failure baffles DES “sons” who are now daughters and who are aware of the increasing public health concerns about chemicals that bind to the estrogen receptor in humans and animals.