The nature of the beast ~ a repost...

A letter I recently received from Dr Ecker, to whom many thanks:
Hi Zoe, 

Yes, we gave our presentation to 60 plus psychiatrists from the US, AU, FR, IT, EU, UK, Holland etc. 

We spoke for 2 1/2 hours on why cross gender identity was a normal inherited variation of humans. We showed how Transgender Brains think, smell, and hear like the opposite sex. We presented internationally accepted guidelines for hormonal treatment of transsexuals to be published Summer 2009. 

Here are my slides and with my participants' permission I shall send you theirs. We are now in print in the APA Syllabus and soon in the APA Journal this summer. I am checking if we were recorded. 

My greatest personal compliment came from Frank Kruijver, from Holland, whose research of the human brain in TSs started it all. He thought we have taken his work very far in our understanding of the human brain. Hope you can do something with this. Sid Ecker, M.D. 
I will indeed endeavour to "do something with this".

Starting with publishing it, broadcasting it as far and as wide as I can. This stuff needs to be known.

Dr Ecker is not a psychiatrist, he's a urologist, with very extensive clinical experience in observing the effects of hormonal treatment of a variety of patients, transsexual and otherwise. He has no particular axe to grind, but he has seen so much misinformation, he wants to set the record straight. To put some Science into the issue.

As the e-mail states, Dr Ecker was invited to give a presentation to the American Psychiatric Association as part of a seminar at their annual meeting. From their letter to him:
Symposium Title: The Neurobiological Evidence for Transgenderism

EDUCATIONAL OBJECTIVES:
The participants shall learn the current definitions of Transgenderism, Gender Identity, Gender Expression, Gender Role Behavior, Gender Dysphoria and Transsexualism and understand the Standards of Care (WPATH) for treatment. The neurobiological evidence for gender differences in the human brain and genetic inheritability of Transsexualism will be presented. Current US medical practices in the Treatment of GID in children, adolescents and adults will be discussed.

SYMPOSIUM ABSTRACT:
The topic of Gender Identity Disorder is one of great controversy in the world because of the diametrically opposite approach of treatment advocated in different medical centers. The prevalence and incidence of Transgenderism, which reflects the thinking and behavior of the opposite genetic sex, cannot be known because the non-dysphoric patient does not present for medical care for a multiplicity of reasons. What we can estimate and understand is the mild to severely dysphoric patient who seeks medical attention and is given a diagnosis of Gender Identity Disorder under DSM-IV-TR. The panel shall present the current scientific literature pertinent to our understanding of the concept of a male, female or transgender brain. They shall discuss the current research undertaken with Transsexuals, which lends evidence to genetic inheritance and biological causation. Finally they shall discuss the appropriate medical care that can help bring the patient’s physical being into congruency with their Brain Gender Identity. While treatment in the form of surgery or cross-hormonal medication has been denied to these individuals at certain prominent medical centers, the number of patients seeking help has increased. As more patients see the psychiatric community as a welcoming entity listening to their concerns, instead of trying to reverse or repair their Transgender thinking, they will be encouraged to allow psychiatry to join in the multi-disciplinary treatment of their condition. 

Title of Presentation: Brain Gender Identity

Abstract: 
Gender Identity is that innate sense of who you are in this world with reference to your sexuality and behavior, not necessarily corresponding to your genitalia and reproductive organs. Transgenders are atypical and “think” as the opposite gender. Certain areas of the brain have been shown to be sexually dimorphic. They are different in structure and numbers of neurons in males versus females. Protein Receptors for the sex hormones in different areas of the brain (limbic and anterior hypothalamic) must be present in sufficient numbers to receive those powerful hormones. There are androgen receptors (AR), Estrogen Receptors (ER), and Progesterone receptors (PRs). ARs or ERs are predominant at different times in different parts of the human brain. Hormone receptor genes have been identified in humans, which are responsible for sexually dimorphic brain differentiation in the hypothalamus. The groundwork in brain gender identity is gene-directed and takes place by forming male and female hormone receptors in the brain before the gonads and hormones can influence them. Multiple genes acting in concert determine our sexual identity. The human brain continues to make neurons and synaptic neuronal connections throughout life. This contributes to Gender Role Behaviors making individuals in the continuum of gender identity. Gender behaviors must be differentiated from gender identity (Hines). Gender Identity cannot be predicted from anatomy (Reiner). Brain gender identity is determined very early in fetal development, but gender expression, expressed as behaviors requires hormonal, environmental, social and cultural interactions, which evolve with time. One cannot deny the profound effects of Testosterone, Estradiol and other steroids on genital differentiation in-utero or their effects on behavior from birth or the physical and mental cross gender changes caused by exogenous hormones, but gender identity is determined before and persists in spite of these effects.

References:

1.DF Swaab, WC Chung, FP Kruijver, MA Hofman, TA Ishunina
Structural and functional sex differences in the human hypothalamus
Horm Behav. Sep, 2001; 40(2): 93-8. Review

2. DF Swaab
Sexual differentiation of the human brain: relevance for gender identity, transsexualism and sexual orientation
Gynecol Endocrinol. Dec, 2004; 19(6): 301-12. Review.

3.IE Sommer, PT Cohen-Kettenis, T van Raalten, AJ Vd Veer, LE Ramsey, LJ Gooren, RS Kahn, NF Ramsey
Effects of cross-sex hormones on cerebral activation during language and mental rotation: An fMRI study in transsexuals
Eur Neuropsychopharmacol. Mar 2008; 18(3): 215-21.

4.H Berglund, P Lindstrom, C Dhejne-Helmy, I Savic
Male to female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids
Cereb Cortex. Aug 2008; 18(8): 1900-8. 


A more complete list of his references is in this PDF file, at http://cs.anu.edu.au/~Zoe.Brain/BGI REF 3.pdf.

Now onto the powerpoint presentation itself: Brain Gender Identity, which I have mirrored at http://cs.anu.edu.au/~Zoe.Brain/BGI 3.3.2.ppt

I'll quote the first slide: 
Most of our information on the Neurobiology of sex comes from animal studies (Becker et al., 2005), but nearly all of what we know about variations in human sexuality, including hetero- and homo-sexuality, and disorders of gender identity (transsexualism) comes from clinical material, anecdotes or even fiction (the three overlap).
Herbert, J., (Brain, 2008)
And one of his meticulously reasoned conclusions, led to inescapably by the biology of foetal and post-birth neural development: 
Brain gender identity is determined very early in fetal development, but gender expression, expressed as behaviors requires hormonal, environmental, social and cultural interactions which evolve with time.
The Logic is immaculate, the conclusions obvious when presented so clearly.

While there are still pieces of the puzzle missing, and many details still to be determined, Dr Ecker has solved it - we now have the Big Picture, incomplete, but still recognisable. All the things I had observed and deduced had to be true on the basis of external observation, Dr Ecker now shows the chain of causality, what happens and when.

His exposition of the biology might even give me some clues as to my own anomalous situation, which genes and which proteins to look at - but this is of secondary interest to me. It's why I got into all this, but now I'm in, it's others I'm more concerned about.

Dr Ecker's first communication with me on the first of March was as follows: 
Hi Zoe, 

My name is Dr. Sidney W. Ecker, M.D., F.A.C.S. and it appears that I have made it to your informative blog. I would ask you to stay tuned for my Symposium at the American Psychiatric Association's 2009 Annual meeting in May as my abstracts and presentation is their property for publication at the moment.

http://pn.psychiatryonline.org/cgi/content/full/44/4/8

S10. The Neurobiological Evidence for Transgenderism
1. Brain Gender Identity Sidney W. Ecker, M.D.
2. Transsexuality as an Intersex Condition Milton Diamond, Ph.D.
3. Novel Approaches to Endocrine Treatment of Transgender Adolescents and Adults Norman Spack, M.D.

What I am trying to do is to logically sequence the scientific evidence to date that you quote and put it into an understandable form for my peers and eventually the public. My current Reference list for Brain Gender Identity is attached. This is certainly not "dogma" as Dr. Zucker claims, but like you I possess the ability and education to understand (biological) science. As a Urologist with a specific interest and expertise in Prostate Cancer, I have administered DES, Estrogens, LHRH agonists and Androgen Blockers to thousands of men for PCa. I make the analogy that these men voluntarily took female hormones to improve the quality of their lives much the same way TransWomen do. Do you need to fear death or be suicidal to take cross-gender hormones? Emphatically, No! Will they prevent eventual death in either scenario? No!!

After the meeting I shall send you my PowerPoint Presentation, but I must keep my powder dry for the moment.

You may publish my reference list, but I can't imagine anyone could access all these articles as I have from the National Library of Medicine's Reading Room. So we'll just have to wait to hear from the opposition and peer review.
Thanks for your Web blog.
Sid Ecker
Thank you, Dr Ecker. I'll help as much as I can.

20-year-old Sorrawee Nattee Crowned Most Beautiful Transsexual

http://www.asianbite.com/default.asp?display=2779

Sorrawee took the top prize at Miss Tiffany's Universe 2009 in the beach resort of Pattaya, beating off 29 other transsexuals and receiving a small Honda car, and 100,000 baht ($2,860) in cash on Friday night.

"I'm very excited," the 20-year-old from Thailand's southern Songkhla province said, touching the glimmering winner's crown with disbelieving fingers.

She appeared overwhelmed by hordes of photographers, camera crews and well-wishers, the scene played out before a live television audience of 15 million people.

In a nation obsessed with beauty pageants and famous for its sexual tolerance, this elaborate contest is taken every bit as seriously as the more traditional competitions.

The pageant had categories for Best Costume, Miss Photogenic and even Miss Unlimited Sexy Star. Dresses ranged from flowing white ensembles to shimmering red numbers and pink miniskirts. High heels were a must.

All contestants were born men, and organizers said they hoped to raise public awareness of transgendered issues.

When asked to name her hero, winner Sorrawee earned loud applause by naming her mother and father.

"She had smart answers and is very beautiful," Marut Sarowat, a television and stage director who was one of the judges, said of Sorrawee.

Everything goes well....

Gave up smoking. Hormones normalised at pre menopausal levels with no side effects. I feel quite different. normalised... it suggests I had it all right.

Starting to look "different". Next thing to dealing with that....

Court lets girl, 17, remove breasts

THE Family Court has allowed a 17-year-old girl to have her breasts removed so she can be more like a boy.

The teenager, code-named "Alex", was on court-ordered hormone medication from the age of 13 to prevent menstruation and breast development. She returned to the court in December 2007 asking for a double mastectomy to make it easier for her to pass as a boy.

The Chief Justice of the Family Court, Diana Bryant, decided it was in the teenager's best interests to have the surgery immediately rather than wait until turning 18.

The teenager had been diagnosed with "gender identity dysphoria", a psychological condition in which a person has the normal physical characteristics of one sex but longs to be the opposite sex.

Justice Bryant said: "In the end, it wasn't a particularly difficult issue because the only real issue was, 'Would he (Alex) have it at 17 or once he's 18?' Then, he doesn't need permission.

"So the issue was, 'Was there any likelihood he would change his mind in the meantime, and was it in his best interests to have it at that time?'

"Overwhelmingly, the evidence was that it was in his interests. And I made that order. I wanted to make it quickly so that he could have the operation straightaway."

But ethicist Nick Tonti-Filippini said mainstream medicine did not recognise hormone treatments and surgery as treatment for gender dysphoria. He said it was a psychiatric disorder qualifying under American guidelines as a psychosis because "it's a belief out of accordance with reality".

"What you are trying to do is make a biological reality correspond to that false belief."

The Chief Justice said Alex had not had any urgent plans to proceed with further surgery when he turned 18. She did not make Alex wait for the mastectomies until of age because the teenager had been living as a boy since the age of 13.

"Everyone was absolutely adamant that he wasn't going to change his mind. He was very comfortable . . . that he was going to continue on this path."

The written judgement is due to be published soon.

Justice Bryant said it was better for the teenager to have the surgery at 17 because this was an age where she would qualify for support from state social services.

This was also a crucial time in her development: "It's a year when he's really cementing his friendships with peers that will stand him in good stead for moving into university and the wider world, and it was very important to him that he be able to do that confidently as a boy."

Justice Bryant said having breasts constrained Alex socially. She had to avoid being hugged by friends, could not go to the beach and had to wear binding. "So it was quite an impediment to his social development, which everyone thought was very important." 

The decision was not irrevocable: "You can have prostheses and things. So if he changed his mind later on, it's reversible."
 

Justice Bryant said she heard evidence from medical experts and from Alex, her counsellor and an independent children's lawyer, and she called in the Office of the Public Advocate "because I wanted a contradictor". The vidence was overwhelmingly in favour of the surgery, she said. 

Mr Tonti-Filippini said he was also concerned that in previous Family Court cases involving gender dysphoria, the medical experts had been confined to a small group of Melbourne doctors who work with sex changes.
 

Mr Tonti-Filippini said a Melbourne man who had had sex-change surgery at 22 was now suing his doctors because he regretted the decision and felt they had not explored his doubts at the time.
 

The Family Court's 2004 ruling allowing Alex to take hormones provoked a debate about when children are old enough to make serious medical decisions. 

There was another furore about a Family Court ruling in 2007 allowing a 12-year-old girl code-named "Brodie", who also wanted to be a boy, to begin a course of puberty-suppressing hormones. The court was told 
that Brodie had threatened self-harm at the prospect of her periods starting.
 

It was later claimed by a relative that Brodie's mother had had postnatal depression and had "brainwashed" the child by buying her boy's clothing from the time she was a baby and fostering boyish behaviour. Brodie's father had opposed the hormone move.