What You Can Change _. And What You Can't - Martin E. Seligman [75]
As radical as surgery is, long-term follow-up of hundreds of patients suggests that while far from ideal, it is the treatment of choice. Most patients are much happier and adapt fairly well to their new lives, living comfortably in their new bodies, dating, having intercourse, and marrying. Any children, of course, are adopted, since no surgery can transplant viable internal sex organs. Those patients who do poorly psychologically are the ones who have had the poorest surgical results.4
The origin of sexual identity. Of the entire nosology, transsexualism is the deepest disorder. I know of no other psychological problem so intractable. We do not know how to change the psyche to conform to the body, so as a last resort we change the body to conform to the psyche. The depth of this disorder reflects the fact that sexual identity is the core layer of sexuality, and perhaps the very core of all of human personality.
Why is sexual identity so deep? I want to go well beyond the data to present a theory of the origin of sexual identity. My speculation is that most of sexual identity—both normal and transsexual—comes from an unknown hormonal process in the second to fourth months of pregnancy.
I start with a simplified version of how a fetus becomes male or female. The embryo has both potentials. Very early, both sets of internal organs—male and female—are present. The fetus would always go on to become female but for the next, crucial step: Two masculinizing hormones are secreted from the male fetus’s testes. The female internal organs then wither, the male internal organs grow, and the external male organs develop. In the absence of the masculinizing hormones at this stage, the male internal organs wither, and female internal and external organs develop. All this happens roughly at the end of the first trimester.5
I want to speculate that there is something else happening at this stage: The masculinizing hormones have a psychological effect. They produce male sexual identity (or, in their absence, female sexual identity). They also guide the development of the corresponding sexual organs, but this is a separate process. In this theory, sexual identity is present in the fetus. There is no way of asking a fetus if he feels like a male or a female, however, so this is not an easy theory to test. But there are four startling “experiments of nature” in which sexual identity is dissociated from sexual organs—all of which support my thesis.
You already know about two of them: MF transsexuals and FM transsexuals. In this theory, some as-yet-unknown disruption of the sexual-identity phase, but not the organ-development phase, takes place. For the MF transsexual, the psychological phase of masculinization does not occur, but the other phase—the masculinization of the sexual organs—goes normally. For the FM transsexual, the psychological phase goes awry, and masculinization occurs; the other phase—feminization of the sexual organs—goes normally, and herein may lie the tragedy.
There are two mirror-image conditions that show remarkable parallels to the two transsexualisms and that are much better understood—the adrenogenital syndrome (AGS) and the androgen-insensitivity syndrome (AIS). They may be the key to understanding transsexualism.
The adrenogenital syndrome has a profound effect on the 46XX fetus (a chromosomally normal female): It bathes her in masculinizing hormones. As a result, she is born with the internal organs of a female (since they were differentiated before the bath), but she is also born with what seems to be a penis and scrotum. The penis and scrotum look convincing, but they are actually an enormously enlarged and penile-shaped (foreskin and all) clitoris. The scrotum contains no testicles. Many AGSs are declared boys and raised as boys. Since the hormonal bath continues,