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.