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Professor Milton Diamond, Phd
Transsexuality, Intersexuality, and Ethics
Milton (Mickey) Diamond, PhD is a Professor in the Department of Anatomy and Reproductive Biology at the John A Burns School of Medicine at the University of Hawaii in Manoa, and is Director of the Pacific Center for Sex and Society.
Professor Diamond’s lengthy career has involved teaching, clinical activities and research—particularly in the fields of sexual behaviour, reproduction and the understanding of sexual development. Invitations to present his findings have been received from Australia, Asia, Britain and Europe, as well as throughout the United States.
Dr Diamond was invited to be a keynote speaker at the Fifth International Congress on Sex and Gender during 2002 in Perth, Western Australia. Before fulfilling that engagement, Dr Diamond and his partner, Dr Constance Brinton-Diamond, travelled through several Australian states giving lectures to enthusiastic audiences at various universities and organisations—including the rather stunned inhabitants of outback Queensland.
Currently, Dr Diamond teaches, conducts research and mentors medical and graduate students. He has produced several acclaimed television and radio series, eight books and well over one hundred articles and chapters. He is also a regular consultant for various agencies, institutions and individuals and has received awards too numerous to mention here.
The scope of Professor Diamond’s research work was largely unknown to the general public until the ‘John/Joan’ case (as it is known in the medical literature) created a storm of controversy. As a result of this case the whole area of intersex management came under scrutiny.
Eventually, encouraged by Mickey Diamond and author John Colapinto, David Reimer—the subject of that appalling experiment—came forward to tell his harrowing story and won widespread respect and admiration for his courage and indomitable spirit.
Apart from his life in research and teaching, Mickey enjoys folk music, photography, reading, travelling and good conversation.
First—Do No Harm
My PhD is actually a combined degree in anatomy and psychology. I received my doctorate in 1962 at the University of Kansas and my first job was teaching at the University of Louisville School of Medicine. After five years, we left Kentucky and came to live in Hawaii where I had been invited to take up a position at the new medical school that was developing here.
In the academic world of the United States one works his way up in the ranks from instructor to assistant professor, associate professor and then professor. Currently, I’m a Professor of Anatomy and Reproductive Biology. While that is my official title, I consider myself primarily a sexologist. At the medical school I teach medical sexology and neuroanatomy and basically those are my two main areas of research and teaching interest.
On a personal level, I was born in the city of New York in 1934 to European Jewish parents who emigrated from the Ukraine right after the First World War. They met in New York, married, and I am the youngest of three children. My father and mother owned a small corner grocery store where we all worked.
I got the name of Mickey when I was about ten or twelve. I was living in a neighbourhood where the kids found it easier to call me Mickey than Milton. The name stuck. Unfortunately, the neighbourhood was not one where my peers were academically inclined. A gang culture was more the norm and some of my earliest recollections of middle school were of becoming mixed up in rumbles and other street adventures not of my making.
During this period I started to feel an aversion to the fights and other negative influences at school. I began to find alternatives and often played hooky. Most of the time I wandered around the streets, went to museums, or read in the park. My parents’ insistence that I should get a good education as a means of achieving anything I wanted to do in America just didn’t make a great deal of sense at the time.
Some friends told me that they were taking a test to enter a special high school and since it provided a legitimate excuse to avoid school for a day I decided to take the test as well. That test turned out to be a major turning point in my life. I was admitted to the Bronx High School of Science and, although it meant travelling from Manhattan to the Bronx every day, it proved to be well worth while.
Camaraderie among my peers now replaced combativeness. It was fun to compete with each other to see who knew the most trivia while at the same time keeping up with the adult world, sports and extracurricular activities. My experience at the Bronx High School of Science convinced me my future would be in science teaching and research.
I entered college in January 1951 when the possibility of being drafted for the Korean War was a reality that all male college students faced. My choice of college was uncomplicated. Coming from a poor family meant that the only possibility was the subsidised City College of New York (CCNY)—now the City University of New York.
I enrolled as a physics major but, as with most universities, one was required to take courses outside a major area. The electives I chose were biology and philosophy courses.
I also joined the Reserve Officers Training Corps (ROTC). This offered a way to stay in school and also obtain the small stipend the Corps provided to help pay for my tuition. It also promised the GI Bill in the future—a promise of funds to help finance graduate studies.
I found my physics major courses engrossing but as I passed beyond the basic biology courses into more electives such as genetics and comparative anatomy I found the area particularly fascinating and stimulating. I then realised I wanted to somehow integrate biology into my physics interest and switched my major to biophysics. As far as I am aware, I was the first student to graduate from CCNY with that subject as an undergraduate major.
Although I had completed all the required courses and was eligible for graduation in January 1955, I was not yet twenty-one—which was the minimum age at which I could be commissioned. Since the ROTC would pay for further schooling, I decided to remain in school for an additional semester so that I would be of age when I graduated and could receive my second lieutenant’s bars.
During this extra semester I took endocrinology and animal behaviour as additional biology electives and was fortunate that my teacher for both courses was William Etkin, whose knowledge of endocrinology and behaviour was extensive (some of his publications are as valuable today as they were then). He was an inspiring teacher and our discussions both in and after class led to our becoming good friends.
I loved the courses and the subject matter and realised that I wanted to understand behaviour and its underlying mechanisms. Before I had the opportunity to pursue this ambition further, however, I had a debt to repay to Uncle Sam. I chose to do that in the Corps of Engineers and was assigned to Tokyo, Japan, as a topographic engineering officer involved in the analysis and production of maps.
I married just before going to Japan and my wife and I lived in a traditional Japanese environment off the military base. We considered our time in Japan as our honeymoon. We enjoyed our Japanese experiences so much that I renewed my two-year military contract for a further year and seriously considered making the topographic service my career. My first professional publications were on cartography and mapping.
As it came time for me to leave military service, I asked Professor Etkin to recommend the best schools at which to pursue the interface of behaviour and endocrinology. In his old-school manner he recommended not schools but individuals with whom to study.
One of those individuals was William C Young at the University of Kansas, who accepted my application—and so it was that we left the urban environs of Tokyo for the rural environment of Lawrence, Kansas.
At the time, I would have preferred to major in psychology or zoology but Young was an anatomist. Anatomy was thus the discipline I was to follow. Once under Young’s tutelage I came to realise that the only behaviours in which he was interested were those associated with reproduction and that he was researching different endocrinological aspects of sexual behaviour. This aspect of my training came about without any real choice on my part.
The graduate school requirements of the University of Kansas also required a minor area of study and I chose experimental psychology where I came under the wing of Professor Ed Wike, who also became my friend and mentor. I found the combination of anatomy, endocrinology and psychology very enjoyable and beneficial, and this period set the stage for the rest of my ‘academic career and my work in understanding sexual development.
The David Reimer (John/Joan) Case
Highly significant and relevant to my interest in development was the situation presented by the David Reimer (John/Joan) case. It had been widely reported in the 1970s that David (a male twin), following a circumcision accident, had been successfully transformed from the boy he was declared at birth into a happy girl with aspirations of entering womanhood. This case was presented to the world to demonstrate the so- called power of nurture to overcome nature and to bolster the associated management of intersexed children.
It was this challenge, contrary to all the other evidence I knew to be available, which drove me to find out the truth for myself. With the eventual cooperation of H Keith Sigmundson—the psychiatrist who had originally been in charge of David’s local care—in 1995 I was able to meet this now famous twin and convince him to share his story.
With this culmination of nearly fifteen years of searching I felt a huge sense of accomplishment—not only for myself but also for all those researchers who had worked on the topic and found pieces of the puzzle of sexual development.
As it turned out, David is a male individual who was raised and treated (as far as can be determined) as a girl. He had been castrated and given female hormones to induce breast growth and a female-looking body. Where his penis had been, his genital region was reconstructed to have a female-appearing vulva.
Despite all these surgical, endocrine, and social efforts to convert David to a girl and woman, he came instead to feel that he was a boy—a male ‘as nature made him’—and not a female/girl as he was raised.
I believe that some biological predisposition to male-being told him he was a not a female; that he was different to all those girls he knew and more like the boys he knew. It is the same sort of predisposition that tells the majority of us we are male or female while telling transsexuals and intersexuals who and what they are—or ought to be.
It occurred to me that David’s story was similar to those of intersexed or transsexed persons who came to feel they were reared in the wrong gender and subsequently switched genders. It also led me to consider what the true outcome to his treatment might mean for countless thousands of intersexed children whose management would no longer be based on erroneous information.
Imagine for a moment that you are a paediatrician and you are presented with a newborn baby in whom the genitals are ambiguous—no vagina or penis, or some combination of both. How would you advise the parents? Do you think the child, if it is male, would have the greatest chance of happiness being brought up as a boy—or as a girl?
Would growing up without a typically functioning penis be so difficult that it would be better to bring up this child as a girl and then give him appropriate surgical and hormone treatment? Or would you consider his life as a male the most crucial factor—in which case it might be better to help him adjust to the loss of his penis, with an attempt to construct a new one later? What about bringing up a female with a phallus? Such cases are not exactly common but they force us to carefully consider what are the major influences on sexual development.
On The Development of Sexuality and Gender Identity
Our society traditionally supports a two-sex model. This is one in which men are expected to be males with an X and Y-chromosome, testes, a penis and internal systems for expelling urine and semen from the body. Women are conjectured to be females and have two X-chromosomes, ovaries and internal structures to transport urine and ova, as well as a system to support pregnancy and foetal development.
In addition to this basic model there are also a number of recognisable secondary sexual characteristics that cultures use to define men and women as being either ‘masculine’ or ‘feminine’ in appearance. While these expectations are generally met, there is more variation in how these sex and gender characteristics combine than is often recognised.
Chromosomal sex, internal accessory reproductive structures, hormonal sex, secondary sexual characteristics, gonadal sex and external genital morphology, all can vary. So do people’s notions of ‘masculinity’, ‘femininity’, ‘gender identity’, ‘sexual identity’, and ‘sexual preference’ or ‘sexual orientation’.
In any discussion of sexuality, therefore, it is extremely important to realise that definitions of ‘masculine’ and ‘man’ or ‘feminine’ and ‘woman’ (even for the description of traits) are often affected by retrospective judgements involved in establishing the original categories. And these definitions vary with different cultures.
The conclusion, for instance, that roundness or softness are feminine traits whereas angularity and hardness are masculine traits is a judgement based on the findings that most mature males have physical features that can be categorised as hard and angular and related to muscular activity. By contrast, most mature females have characteristics classifiable as soft and round, which can be related to child-bearing and nurturing.
One can certainly choose characteristics that will reflect sex differences but those choices, while they may be reality-oriented, are often
idiosyncratic and can be subject to contrary opinion. Is mounting behaviour and aggressive sexuality considered masculine in a particular society? Is being mounted or being sexually submissive considered feminine?
We also have to consider observer bias in the definition of male versus female behaviour characteristics. To some observers, the masculinity or femininity of an individual is reflected in the choice of an out-of-the-home career, or preference for a domestic role. Choice of an adventurous and dangerous career is seen to be an indication of masculinity. Alternatively, the desire to have or spend time with children is considered an index of femininity.
For individuals in open societies, the ‘smorgasbord’ of choice is wide since so many different patterns, sex roles and gender roles are possible, and indeed are seen cross-culturally. Many families or situations, however, do not allow free choice and this stifles attempts at individual expression. Therefore, the presence of overly rigid forces such as parents or religion often thwarts the emergence of natural tendencies.
Social forces outside the family such as education and occupational requirements or legal strictures can also be powerful modifiers of preferred behaviours.
The developing child observes the surrounding world and notes whether or not he or she is like other children in the category to which their families and other members of their community have assigned them—boy or girl. As long as they feel that they are part of the appropriate group there is no reason for them to question their gender. And indeed, only a minority of children challenges their gender assignment.
Problems arise when a child feels unlike others of the group, or feels a greater urge to belong to the opposite gender group. This can occur regardless of whether the child is appropriately masculine or feminine.
The strength of those feelings determines how the child will react. If a young boy feels strongly enough that he is a girl rather than a boy, he begins to envision himself becoming a girl and maturing into a woman. Similarly, if a girl strongly identifies herself as being a boy, she sees herself becoming a real boy and then a man.
In the same way that a child believes in the tooth fairy or Santa Claus, he or she may come to expect that it will only be a matter of time until they grow up to be the man or woman they want to be. When it becomes obvious that this is not going to happen automatically the child seeks ways and means of bringing about the desired change.
To change one’s gender, even in thought, is a big conceptual leap for a child and while the idea may come as an epiphany there is often a period of confusion. When a boy, for instance, experiences alienation from the gender allotted to him, and the only other category of child he knows is ‘girl’, it is only slowly that it will occur to him that he might be one of those—or should be.
Usually there is a period of doubt during which the child wonders how to reconcile these awkward feelings, particularly if he or she learns that any revelation regarding the preferred gender may set them at odds with their family, schoolmates and the community in which they live. Consequently, children will not necessarily tell their parents (or anyone else) about these thoughts. They may, however, express their feelings with appropriate or inappropriate behaviours.
The way most people see their bodies (their sexual identity) and the way they recognise that society sees them—or the way they want society to
see them (their gender identity)—are sufficiently in concert to satisfy ego needs and overcome any doubt as to their own sex and appropriate role in society. For some individuals this is not the case. For such persons, intense feelings of conflict and discomfort develop from this dichotomy.
Fluidity of language means that there is a difference in the way that scientists and laypersons use terms. In the sexology field several of us have tried to standardise the use of terms but many people prefer their own usage. Before proceeding, I think it advantageous to clarify at least four definitions I observe.
In academic discourse I prefer to use GENDER to refer to social and societal contexts and SEX to refer to medical and biological contexts. For instance, male and female are biological (sex) terms, while boy and girl, or man and woman are social (gender) terms. This facilitates
understanding that males can act like girls and grow to be women and females can act like boys and grow to live as men.
Following on from that, the distinctions I make between SEXUAL IDENTITY and GENDER IDENTITY, as concepts, are crucial to understanding my discussion of transsexuality and intersexuality.
For the typical individual, sexual identity and gender identity coincide. He or she, as a male or female (in sexual identity) is viewed in society as a boy or girl, man or woman. That is their gender identity. To the typical person there is no conflict between sexual and gender identity—although the terms involved refer to different things.
Now consider how a transsexual perceives identity—for instance, the female who knows she has a female body but who thinks she should live as a man. This person recognises her sex (identity) is female but also recognises she is a male in her mind. She sees being a man as her suitable gender. That is her gender identity. For her, gender identity and sexual identity are in conflict (how she is and how she wants to be are in conflict). To reconcile those differences this individual says ‘I want to/must live as a man. To best permit me to do so, change my body not my mind’.
She knows that society interacts with her as a woman because that is the way she looks and her anatomy confirms it, but she would prefer that society interact with her as a man. As she gets older, if finances and her social situation allow, she chooses to have medical assistance (usually surgery and hormone therapy) to have her body conform to her mind.
A male body type will comfort her by giving her the sense of being the male she desires to be and assist the world in treating her as a man—the gender identity she prefers.
In the 1970s Virginia Prince promoted the term ‘transgender’ to describe people like herself, who accept themselves as males (or females) but who prefer to live as the opposite gender without undergoing surgery. ‘Typically, the only things the ‘transgenderist’ wants to change are features of their gender rather than their sex. These changes are usually in behaviour patterns or in social manifestations of gender such as choice of clothing. They might choose to augment these changes with hormonal body modification.
To Prince, the term transgender could be applied to anyone who deviates from the norm in gender patterns without requiring or desiring surgery. The term, for Prince, thus excluded transsexuals. Since the 1970s, however, the term has become more and more inclusive. These days it is often used as an umbrella term to describe transsexuals, transvestites, drag queens, so-called gender benders and others.
At this point, it might be useful to introduce the term SEXUAL ORIENTATION. This refers to the type of person with whom one wants to have erotic and love relations. Usually, males are oriented towards females and vice versa, but many people are attracted to members of their own sex.’
Sexual orientation is a separate issue to gender identity and transsexuals have the same range of preferences in a partner as do the rest of the population. For these partner preferences—to get away from the confusion and social taboos when terms such as heterosexual and homosexual are used—I often prefer to use the terms AN]JROPHILIC (male loving), GYNECOPHELIC (female loving), and AMBIPHILIC (both loving) for bisexual.
These different terms are of particular value in discussing transsexual and intersexed individuals. For instance, what would be homosexual or heterosexual for an intersexed person who has both male and female biology? And whose view would prevail—the transsexual’s or the onlooker’s—when considering the individual’s partner before and after sex reassignment surgery?
In dealing with nomenclature, another issue is how gender identity disorder (small letters) is viewed as a general expression in popular
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