Transhealth – how to talk to patients about pronouns

Transgender authors share their experiences of healthcare and the important messages they’d like doctors to know

Two articles published on the bmj aim to help doctors treat patients who request support with their gender identity.

Firstly a practice pointer on how to refer to gender clinic, and secondly a What Your Patient Is Thinking article about trans people’s experiences in the healthcare system.

In this podcast, two of the authors of that patient experience article, Emma-Ben and Reubs, join us to discuss identity, pronouns and what genderqueer means.

More information

Environmental Endocrine Disruption Crisis of Epidemic Proportions

AutismOne Conference 2017

Presented by Leslie Carol Botha, WHE,
uploaded on SlideShare. Watch it full screen.

Endocrine Disruptors

Sex and gender : you should know the difference

1. The dictionary
2. The intersection of sex and gender: lessons learned and improving LGBT health care
3. A call to action

Embryos do not have a “gender”; rather, they have a “sex.” Gender refers to social and cultural distinctions between sexes, not biological ones. An embryo’s “maleness” or “femaleness” should therefore be defined by its biological sex (i.e., sex chromosome pair).

We recognize that “sex” and “gender” are often synonyms in regular speech. But, as reproductive medicine specialists who might tout services in “gender selection/determination” or even care for patients who are transgender, it is imperative that we dictate the use of the proper terminology, not just among ourselves, but also during dialogue with patients, policymakers, and other stakeholders. Failing to do so may have unintended consequences that we will attempt to point out.

1. The dictionary, World Health Organisation (WHO), American Congress of Obstetricians and Gynecologists (ACOG), Food and Drug Administration, American Society of Reproductive Medicine (ASRM), and personhood

The rise of “gender,” and its interchangeability with “sex” is well documented both in academia and in the public arena, as is its criticism. Ultimately, while various academic specialties define the terms differently, it is important for us to reflect on current definitions to guide our call to action.

  • The Oxford English Dictionary defines “sex” as “either of the two main categories (male and female) into which humans and many other living things are divided on the basis of their reproductive functions.
  • The WHO defines “sex” as the “biological and physiological characteristics that define men and women.” The WHO further defines “gender” as the “socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for men and women.”
  • In the 2011 Committee Opinion on “Healthcare for Transgender Individuals,” the ACOG defines “sex” as the “designation of a person at birth as male or female based on anatomy and biology”.
  • Prior to 2011, the FDA used the term “gender” to refer to the physiological differences between male and female but changed position, distinguishing “sex” as a biological classification and “gender” as a “person’s self-representation as male or female, or how that person is responded to by social institutions”.
  • The ASRM Ethics Committee uses the term “sex” when discussing selection/determination of embryos. This 2015 document replaced two documents titled “Sex selection and PGD [sic]” and “Preconception gender selection for nonmedical reasons” from 2008 and 2004, respectively. Currently (at the time of this writing), on the ASRM website, the terminology remains “Gender/Sex Selection,” implying that the two terms are synonyms and highlighting the evolution of the Ethics Committee’s sensitivity to distinguishing between these two terms.

A recent PubMed query identified 51 scientific publications with the term “gender selection” in the title. This term is inaccurate because we are unable to determine the gender of an embryo, or a neonate for that matter, only its chromosomal sex. For those clinics, physicians, and/or laboratories offering couples the option of choosing embryos based on sex chromosomes, the term “sex selection” or “sex determination” should be used instead.

While one could take this academic convention further, we will concede our efforts beyond the embryo stage and stop short of calling for “gender reveal” celebrations to be renamed “sex reveal” celebrations. We understand that parents may have ingrained convictions about the future gender identity of a fetus.

Furthermore, ASRM should consider, perhaps within its Ethics Committee document on sex selection, formally adopting definitions of sex and gender that are in step with its peer organizations. Doing so may be important in further policy refinements and testimony preparation when ASRM or individual members testify regarding personhood measures. Admittedly, using the terms interchangeably is a nuance that might escape most policymakers, but consistently referring to an embryo’s sex is more aligned with ASRM’s stance on personhood measures.

2. The intersection of sex and gender: lessons learned and improving LGBT health care

It is important to take a moment to highlight the origin of the medical community’s wariness of exerting a paternalistic force in “gender determination.” Beginning in the 1950s and continuing for many decades, physicians promoted the assignment of “gender” at birth for intersex infants or those with ambiguous genitalia. This often involved “genital corrective surgeries” to attempt to match the anatomy to the assigned gender. Examples include clitorectomies in virilized XX infants with congenital adrenal hyperplasia and removal of a micropenis in XY infants with creation of a neovagina. Many children with a Y chromosome were assigned a female gender, given that it was easier to create a vagina than a functional penis. Initial protests to this approach came from intersex advocacy groups, citing a lack of long-term data and significantly high levels of psychological stress in those subjected to nonconsensual surgery.

In the late 1990s, the issue entered the mainstream media with the case of David Reimer, an XY infant who underwent gender reassignment surgery at 22 months old after a circumcision procedure resulted in inadvertent penile amputation. He was raised from that point on as female but struggled with gender dysphoria and transitioned to living as a male at the age of 15. He suffered from depression and committed suicide at the age of 38.

The interplay between sex and gender is complex and involves genetic, hormonal, and sociocultural factors. The principles of patient autonomy and nonmaleficence dictate that we, as physicians, should not assign gender. Based on this philosophy, and given our ability with embryo biopsy and aneuploidy screening, we believe that one can “select” and/or “determine” only the sex of an embryo. The gender cannot be determined until later.

Finally, this distinction has consequences as it relates to our care of LGBT patients and our position as proponents and providers of assisted reproductive technologies. We are often involved in the care of transgender and gender-nonconforming patients. This may include hormonal management during transition or assistance in fertility preservation or family building. We should welcome these patients, and understanding a distinction between biologically defined “sex” and one’s self represented “gender” is the first step in improving their health care experience.

3. A call to action

In summary, we call on our peers and stakeholders to use, and advocate for, the use of “sex” instead of “gender” when discussing the chromosomal makeup of an embryo in academic, public policy, and lay-media settings. We also recommend adopting definitions similar to our complimentary medical societies and mainstream health care agencies and attempting to have our literature to conform to the above.

Our field has long pushed beyond the social stigmas of infertility, miscarriage, menopause, and sexual dysfunction to provide compassionate care for our patients. This issue provides an opportunity for us to continue in that tradition.

Sources and DES Studies

Sexual Differentiation of the Brain

Hormones and sexual differentiation of human behavior

Includes Gonadal hormones and sexual differentiation of human behavior : Effects on psychosexual and cognitive development.

by Akira Matsumoto, 1999.

Sexual difference in the brain has long been one of the more intriguing research areas in the field of neuroscience. This thorough and comprehensive text uncovers and explains recent neurobiological and molecular biological studies in the field of neuroscience as they relate to the mechanisms underlying sexual differentiation of the brain.

Attempts have been made to clarify sex differences in the human brain using noninvasive techniques such as magnetic resonance imaging. Sexual Differentiation of the Brain thoroughly examines these techniques and findings, providing an up-to-date, comprehensive overview written by leading researchers in the field.

Chapter 14

Gonadal hormones and sexual differentiation of human behavior: Effects on psychosexual and cognitive development

Melissa Hines is a DES Daughter who has substantial research experience investigating impact of prenatal DES exposure in females and subsequent impact on gender and sexual orientation. She has several books which further investigate these themes of “brain gender”.

Contents
  1. Introduction and Overview
  2. Core Gender Identity
  3. Sexual Orientation
    1. Genetic Females
      1. CAH
      2. DES
    2. Genetic Males
      1. Androgen Insensivity Syndrome (AIS)
      2. Enzymatic Deficiencies
      3. Exposure to DES or Progestins
  4. Gender Role Behaviors
    1. Childhood Play Behavior
    2. Cognitive Abilities
  5. Summary and Conclusions
    References

Man and woman, boy and girl

The differentiation and dimorphism of gender identity from conception to maturity

The differentiation and dimorphism of gender identity from conception to maturity.

Baltimore : Johns Hopkins University Press, 1972 book that combines experimental and clinical data in this report on human development and the relation of sexual differentiation and social roles.

In Man and Woman, Boy and Girl, John Money and Anke Ehrhardt offer a comprehensive account of sexual differentiation using genetics, embryology, endocrinology and neuro-endocrinology, psychology, and anthropology. Their multidisciplinary approach to gender identity avoids the old arguments over nature versus nurture. Money and Ehrhardt focus instead on the interaction of hereditary endowment and environmental influence. Money and Ehrhardt’s work will lead many readers to the conclusion that the differences between man and man, or woman and woman, can be as great as between man and woman.

This was required reading in my human sexuality class in college. I thought it was well presented and researched. It defies some of the gender role and gender identification theories by explaining the gender spectrum in very graphic terms. It will make some people VERY uncomfortable, but it makes a valid point I believe, there are many ways to define gender and how individuals identify with their gender. It does not support the popular theory that we are born genetically predisposed to a particular sexual orientation. Instead the book suggests that regardless of how male or how female you may be genetically you may choose which sex you prefer in your physical or emotional relationships. Blasphemy to some, but it goes a long way to clearing up some of the ambiguity about gender roles and gender identification.

Jonathan Van Voorhees, August 4, 2015.

Trans Day of Remembrance

80% of trans people have experienced domestic violence abuse

November 20th is the Transgender Day of Remembrance. We remember all who have lost their lives from acts of transphobic violence.

This event serves as a memorial, a protest, an opportunity for reflection and a chance to see old friends and meet new ones.

MORE INFORMATION

X chromosome dosage compensation and sex-biased gene expression relashionship

Sex-Biased Expression of the Caenorhabditis elegans X Chromosome is a result of Both X Chromosome Copy Number and Sex-Specific Gene Regulation

Abstract

Dosage compensation mechanisms equalize the level of X chromosome expression between sexes. Yet the X chromosome is often enriched for genes exhibiting sex-biased, i.e. imbalanced expression. The relationship between X chromosome dosage compensation and sex-biased gene expression remains largely unexplored. Most studies determine sex biased gene expression without distinguishing between contributions from X chromosome copy number (dose) and the animal’s sex.

Sex-Biased Expression of the Caenorhabditis elegans X Chromosome is a result of Both X Chromosome Copy Number and Sex-Specific Gene Regulation, Genetics, NCBI pubmed/27356611, 2016 Jun 29.

Here, we uncoupled X chromosome dose from sex-specific gene regulation in C. elegans to determine the effect of each on X expression. In early embryogenesis, when dosage compensation is not yet fully active, X chromosome dose drives the hermaphrodite-biased expression of many X-linked genes, including several genes that were shown to be responsible for hermaphrodite fate. A similar effect is seen in the C. elegans germline, where X chromosome dose contributes to higher hermaphrodite X expression, suggesting that lack of dosage compensation in the germline may have a role in supporting higher expression of X chromosomal genes with female-biased functions in the gonad. In the soma, dosage compensation effectively balances X expression between the sexes. As a result, somatic sex-biased expression is almost entirely due to sex-specific gene regulation. These results suggest that lack of dosage compensation in different tissues and developmental stages allow X chromosome copy number to contribute to sex-biased gene expression and function.

DES-related studies

Nonbinary: now a legal gender in the United States

US Court Allows a Person to Choose Neither Sex

On June 10, 2016, a Multnomah County Circuit Court Judge for the State of Oregon granted Jamie Shupe’s petition to change the legal sex/gender marker from female to nonbinary. This is understood to be the first order from a United States state court to recognize “non-binary” as a legal gender/sex identifier as part of a legal sex change procedure.

Oregon Court Allows a Person to Choose Neither Sex, nytimes, JUNE 13, 2016.

Oregon law does not specifically limit gender choices to male or female. Instead, the law allows a judge to order a legal change of sex and enter a judgment indicating the change of sex of a person if the court determines that the individual has undergone surgical, hormonal or other treatment appropriate for that individual for the purpose of gender transition and that sexual reassignment has been completed.

Other countries already federally recognize genders other than male and female—including Australia, Denmark, Nepal, and New Zealand.

The Evidence of the EDCs Effect on Gender: the DES Situation

Are EDCs blurring issues of gender?

Introduction

Although scientists have postulated a wide range of adverse human health effects of exposure to endocrine-disrupting chemicals (EDCs), the nexus of the debate is the concern that prenatal and childhood exposure to EDCs may be responsible for a variety of abnormalities in human sexuality, gender development and behaviors, reproductive capabilities, and sex ratios. Scientists today are asking hard questions about potential human effects: Do EDC exposures impair fertility in men or women? Can they cause sexual organ malformations, stunted reproductive development, or testicular or breast cancer? Do fetal exposures to EDCs alter sex phenotypes? Do they change later gender-related neurobiological characteristics and behaviors such as play activity and spatial ability? Could such exposures even be involved in the etiology of children born with ambiguous gender?

Are EDCs Blurring Issues of Gender?, Environnement Health Perspectives, NCBI PubMed PMC1281309, 2005 Oct.

EDCs include a spectrum of substances that can be loosely classified according to their known or suspected activity in relation to sex hormone receptors and pathways. The most-studied and best known are the environmental estrogens, which mimic estradiol and bind to estrogen receptors (ERs). ER agonists include the pesticide methoxychlor, certain polychlorinated biphenyls (PCBs), bisphenol A (BPA; a high production volume chemical used to make polycarbonate plastic), pharmaceutical estrogens such as diethylstilbestrol (DES) and ethinyl estradiol, and phytoestrogens, which occur naturally in many plants, most notably in soybeans in the form of genistein and related substances. There are a few known ER antagonists, or antiestrogens. Antiandrogens, or androgen receptor (AR) antagonists, include the fungicide vinclozolin, the DDT metabolite p,p′-DDE, certain phthalates (a group of chemicals used to soften polyvinyl chloride plastics), and certain other PCBs. And there are other types of EDCs that affect particular endocrine targets. The various EDCs differ greatly in their potencies relative to natural hormones, and in their affinity for target receptors. Some have been shown to act via non–receptor-mediated mechanisms, for example by interfering with hormone synthesis.

In many well-documented cases of high-level fetal exposures to known EDCs such as DES, certain PCBs, and DDT, the answer to the question of whether exposure is associated with gender-related effects is clearly yes. But high-level exposures such as these are relatively rare and isolated. The debate today centers on low-dose exposures—generally defined as doses that approximate environmentally relevant levels—and the idea that low-dose intrauterine exposure to some EDCs during certain critical windows of development can have profound, permanent impacts on subsequent fetal development and adult outcomes.

Critics of this idea maintain that thus far there is no credible evidence to suggest that low-dose exposures cause any adverse human health effects. But if low-dose exposures were confirmed to be the threat that proponents of the concept insist they are, public health would clearly be at risk, regulatory agencies’ risk assessment approach would need to be revised, and certain common chemicals—including some that are massively produced and economically important—would likely disappear from the marketplace.

In a June 2000 EHP review article on human health problems associated with EDCs, Stephen Safe, director of the Center for Environmental and Genetic Medicine at Texas A&M University, concluded that

“the role of endocrine disruptors in human disease has not been fully resolved; however, at present the evidence is not compelling.”

Frederick vom Saal, a developmental biologist at the University of Missouri–Columbia, disagrees, particularly in light of the research that’s been presented in the years since that review. He says

“The jury is not out on human effects. In terms of the amount of information we have in animals and the amount of information we have in humans, clearly there is a huge difference, but that’s a lot different than saying the jury is out on whether EDCs influence humans.”

One thing both scientists might agree on, though, is that right now there are still more questions than answers.

Evidence of Effects: the DES situation

The Global Assessment further states that the only evidence showing that humans are susceptible to EDCs is currently provided by studies of high exposure levels. There is, in fact, clear evidence that intrauterine EDC exposures can alter human reproductive tract development and physiology. The most thoroughly characterized example is DES, the synthetic estrogen prescribed to millions of pregnant women in the United States and elsewhere from the 1940s to the 1970s to prevent miscarriage. The drug is known to have caused a rare form of vaginal cancer in thousands of daughters of women who took DES, as well as a variety of adverse reproductive tract effects in both the daughters and sons of those women.

The DES situation could be seen as a worst-case scenario for prenatal EDC exposure—the deliberate delivery of a potent estrogenic chemical in high doses. Viewed another way, it has provided researchers a rare opportunity to study the effects of prenatal EDC exposure in a relatively controlled fashion, with a well-defined population and well-characterized exposure to a single potent agent.

Over the course of her research, Newbold has developed a mouse model of DES exposure that has proven extremely useful in studying the effects of DES and other environmental estrogens, particularly those outcomes that may be manifested only later in life. She says

“With the experimental model, there are a lot of questions we can ask with DES that will tell us about the weaker environmental estrogens. We can change the timing of exposure and the amount of exposure, and we can look at different target tissues.”

The animal model has replicated numerous abnormalities reported in DES-exposed humans, and has also predicted some human outcomes.

“We have published documentation [see, for example, the October 1985 issue of Cancer Research and volume 5, issue 6 (1985) of Teratogenesis, Carcinogenesis, and Mutagenesis] that a number of the reproductive anomalies seen in DES-exposed mice, such as retained testes and abnormalities in the oviduct in females, were also later reported in DES-exposed humans,”

says Newbold.

More DES DiEthylStilbestrol resources

DiEthylStilbestrol Gender Identity Controversy

“a very good possibility that DES is was caused me to be trans…”

Video published on 11 June 2016 by DES Daugther Network channel via Dion Lim 5/6/11pm weeknight anchor/reporter at WTSP/CBS .

It was a pill meant to prevent miscarriages…

Can a drug manipulate gender identity, cause people to be trans, asks Dion Lim?
Well, I know many DES sons who can confirm that yes, it did happen.

More DES DiEthylStilbestrol Resources