Gender is a set of expectations about men and women that are sometimes violated.

Transcription

1 4 Chapter Gender is a set of expectations about men and women that are sometimes violated.

2 Sex and Gender Differences I n this chapter we discuss how men and women differ from each other. First we describe the origins of the physical differences that have been the topics of previous chapters: differences in the structures and functions of the genitals, reproductive tract, and other parts of the male and female bodies. This is essentially a biological issue. We then turn to mental and behavioral differences between men and women differences that are collectively referred to as gender. We summarize what is known about gender differences, with special emphasis on those that involve sexuality. Gender differences, like physical sex differences, are infl uenced by biological processes, such as the differing hormonal environments that males and females experience before birth. They are also affected by the way our parents treat us in infancy and childhood, by social pressures, and by our own efforts to make sense of the world. In other words, gender differences result from a delicate interplay of nature and nurture. The quest to understand this web of causation is not merely of theoretical interest. It is also deeply relevant to social policy, affecting how we educate our children, how we treat wrongdoers, and how we develop a more just society.

3 96 CHAPTER 4 Figure 4.1 Human chromosomes Women and men have the same autosomes (chromosome pairs 1 22) but different sex chromosomes: Women have two Xs, men have one X and one Y (as shown here at the lower right). sex chromosome Either of a pair of chromosomes (X or Y) that differ between the sexes. X chromosome A sex chromosome that is present in two copies in females and one copy in males. Y chromosome A sex chromosome that is only present in males. SRY A gene located on the Y chromosome (Sex-determining Region of the Y chromosome) that causes the embryo to develop as a male. Müllerian duct Either of two bilateral ducts in the embryo that give rise to the female reproductive tract. Wolffian duct Either of two bilateral ducts in the embryo that give rise to the male reproductive tract. anti-müllerian hormone (AMH) A hormone secreted by the testicles that prevents the development of the female reproductive tract. Genes and Hormones Guide Sex Development Sex chromosomes and genes are the primary arbiters of sex. Recall that every individual (with rare exceptions) possesses a pair of sex chromosomes in the nucleus of every cell in her or his body. One of these chromosomes is inherited from the person s mother, via her ovum, and is always a large X chromosome. The other is inherited from the person s father, via his sperm, and is either an X chromosome or a much smaller Y chromosome. An embryo that possesses two Xs develops as a female; an embryo with one X and one Y develops as a male (Figure 4.1). Thus, the father s genetic contribution to the embryo determines its sex. In 1990, a sex-determining gene called SRY, located on the Y chromosome, was identified as the switch, whose presence or absence sends sexual development along a male or female pathway. Many more genes, linked together in complex networks, are required for the formation of the gonads the ovaries in females or the testicles in males (Wilson & Davies, 2007). Female and male reproductive tracts develop from different precursors At about 6 weeks after conception, early in the development of the gonads, two pairs of ducts run from the gonads to the outside of the embryonic body at the future site of the external genitalia (Figure 4.2). One pair, the Müllerian ducts, are the precursors of the female reproductive tract. The other pair, the Wolffian ducts, are the precursors of the male reproductive tract. Notice that embryos of both sexes begin with a pair of both kinds of ducts. Thus, male development involves eliminating the Müllerian ducts and promoting the development of the Wolffian ducts, while female development involves eliminating the Wolffian ducts and promoting the development of the Müllerian ducts. Male embryos eliminate the Müllerian ducts by means of anti-müllerian hormone (AMH). This hormone, secreted by the developing testicles, diffuses to the nearby Müllerian ducts and causes them to degenerate. Beginning at about 3 months after conception, the testicles secrete testosterone. This hormone diffuses down the Wolffian ducts, triggering each one to develop into an epididymis, vas deferens, and seminal vesicle. Testosterone also promotes development of the prostate gland, although this gland is not derived from the Wolffian ducts.

4 Sex and Gender Differences 97 Müllerian duct Gonads Figure 4.2 Development of the male and female reproductive tracts from different precursor structures the Wolffian and Müllerian ducts. (The male and female gonads have a common origin and do not belong to either duct system.) (See Web Activity 4.1.) Wolffian duct Müllerian duct degenerates under influence of AMH. Müllerian duct develops into oviduct, etc. Male Female Müllerian duct Testicles Ovaries Müllerian duct Wolffian duct Wolffian duct develops into vas deferens, etc., under influence of testosterone. Wolffian duct Wolffian ducts degenerate in the absence of testosterone. Testicles Ovaries Fimbria Vas deferens Seminal vesicle Oviduct Uterus Vagina In female embryos, the absence of testosterone causes the Wolffian ducts to degenerate. The absence of AMH allows the Müllerian ducts to persist and to develop into the oviducts, uterus, and the deeper part of the vagina. Although the development of the female reproductive tract is the default pathway, in the sense that it goes forward in the absence of hormonal instructions to the contrary, it is an active process that is guided by many genes in the developing tract. Female and male external genitalia develop from the same precursors The external genitalia of both females and males develop from the same early tissues. As shown in Figure 4.3, at about 4 weeks postconception the embryo s anogenital region consists of a slit known as the cloaca. The cloaca is closed by a membrane. It is flanked by two urethral folds, and to the side of each urethral fold is a raised region named the genital swelling. At the front end of the cloaca is a small midline protuberance called the genital tubercle. By 2 weeks later, the urethral folds have fused with each other near their posterior (rear) end. The portion behind the fusion cloaca The common exit of the gastrointestinal and urogenital systems; in humans it is present only in embryonic life. urethral folds Folds of ectodermal tissue in the embryo that give rise to the labia minora (in females) or the shaft of the penis (in males). genital swelling Regions of the genitalia in the embryo that give rise to the labia majora (in females) or the scrotum (in males). genital tubercle A midline swelling in front of the cloaca, which gives rise to the glans of the clitoris (in females) or penis (in males).

5 98 CHAPTER 4 Figure 4.3 Development of the male and female external genitalia from common precursor structures. In males, the urethral folds fuse at the midline to form the penile shaft and enclose the urethra. In females, they remain separate, forming the labia minora. Genital tubercle Cloaca (covered by membrane) 4 weeks Genital swelling Urethral fold 6 weeks Urogenital sinus (covered by membrane) Anal fold Glans Urethral groove Urethral fold Scrotal swelling Male High testosterone 5 months Perineum Anus Female Low testosterone Genital tubercle Urethral fold Genital swelling Urethral opening Glans Shaft of penis Scrotal septum Scrotum Birth Perineum Anus Hood of clitoris Glans of clitoris Urethral opening Labia majora Labia minora Hymen anal fold The posterior portion of the urethral fold, which gives rise to the anus. urogenital sinus The common opening of the urinary and genital systems in the embryo. point, called the anal fold, eventually becomes the anus. The region of the fusion itself becomes the perineum. (Even in adults, the line of fusion is visible as a midline ridge or scar, which can be seen most easily with the help of a hand mirror.) During the fetal period, the region in front of the fusion point, which includes the opening of the urogenital sinus, gives rise to the external genital structures in both sexes. As with the internal reproductive tracts, the female external genitalia develop by default; that is, in the absence of hormonal or other external signals. The genital swellings develop into the labia majora. The urethral folds develop into the labia minora, the outer one-third or so of the vagina, and the crura (deep erectile structures) of the clitoris

6 Sex and Gender Differences 99 (see Chapter 2). The genital tubercle develops into the glans of the clitoris. Remnants of the cloacal membrane persist as the hymen. The vagina, therefore, develops from two different sets of tissues. The outer portion of the vagina, which develops from the urethral folds, is more muscular and more richly innervated than the inner portion, which develops from the Müllerian ducts. In male fetuses, the presence of circulating testosterone, secreted by the testicles, is required for the normal development of the genitalia. The urethral folds fuse at the midline, forming the shaft of the penis and enclosing the urethra. If this midline fusion is incomplete, a condition called hypospadias results, in which the urethra opens on the underside of the penis or behind the penis (Baskin, 2004). The genital swellings also fuse at the midline, forming the scrotum. The genital tubercle expands to form the glans of the penis. The prostate gland and probably the homologous paraurethral glands in females develops from tissue beneath the urethral folds. Thus, the same embryonic structures that become the labia majora in females become the scrotum in males. The structures that become the labia minora in females become the shaft of the penis in males. The structure that becomes the glans of the clitoris becomes the glans of the penis in males. Why isn t female development driven by secretion of estrogens from fetal ovaries in the same way that male development is activated by testosterone from fetal tissues? The answer is probably that fetuses of both sexes are exposed to estrogens coming from the mother s body. Thus, estrogens would not be an effective signal for guiding fetal development in one sex only. hypospadias An abnormal location of the male urethral opening on the underside of the penis or elsewhere. The gonads descend during development In fetuses of both sexes, the gonads (ovaries and testicles) begin their development in an area near the kidneys and later move downward. By about 10 weeks postconception they are positioned near the top of the pelvis. In females, the ovaries remain in this position for the remainder of fetal life, but after birth they gradually descend in the pelvis and end up on either side of the uterus. In males, the testicles move even greater distances (Figure 4.4). At 6 to 7 months postconception they descend into the pelvis, and shortly before birth they move down into the scrotum. As each testicle enters the scrotum, it draws various structures with it, including the vas deferens, blood vessels, and nerves which make up the spermatic cord. The connection between the pelvic cavity and the testicles is usually sealed off after the testicles descend. (A) (B) Testicle Kidney Testicular artery Kidney Epididymis Direction of descent Scrotal swelling Aorta Ureter Bladder Vas deferens Penis Vas deferens Epididymis Testicle Ureter Aorta Testicular artery Bladder Spermatic cord Figure 4.4 Descent of the testicles (A) Before descent, at 10 weeks, a fibrous cord (shown here in blue) attaches each testicle to the region of the scrotal swelling. (B) As the fetal body grows, this attachment pulls the testicle into the scrotum. Note how the vas deferens (green) and the testicular artery (red) are pulled after the testicle, so that the vas deferens comes to loop over the ureter (the tube, shown here in orange, that carries urine from the kidney to the bladder). Scrotum

7 100 CHAPTER 4 cryptorchidism Failure of one or both testicles to descend into the scrotum by 3 months of postnatal age. puberty The transition to sexual maturity.? FAQ My son s testicles did descend, but they re not there anymore. What happened? The testicles of male infants and toddlers may spend quite a bit of time pulled upward and out of sight by the cremaster muscle. That s not a matter of concern so long as they did complete their original descent. In 2% to 5% of full-term newborn boys, one or both testicles have not yet arrived in the scrotum. In many of these boys, the tardy testicles will arrive within a few weeks after birth, but if they are still no-shows when the boy reaches 3 months of age, the condition is considered abnormal and is termed cryptorchidism. About 1% to 2% of boys have this condition. Usually, the missing testicles have been held up somewhere along the path of their fetal descent most commonly in the groin. Cryptorchidism is associated with lowered fertility and with an increased risk of testicular cancer after puberty. Undescended testicles can often be surgically moved into the scrotum; this procedure is best done before 2 years of age (Lim et al., 2003). Correction of cryptorchidism improves the prospects for fertility but does not eliminate the increased risk of cancer. Once they are in the scrotum, however, the testicles can be monitored by regular self-examination, thus increasing the likelihood that any developing cancer would be detected at an early stage. Puberty is sexual maturation Most prenatal sex development occurs during weeks 8 through 24 of fetal life, when testosterone levels are high in male fetuses. A second surge in testosterone production (to adult levels) occurs in boys for the first 6 months of postnatal life: Further maturation of the male genitals occurs during this half-year period (Wilson & Davies, 2007). After that, sex hormone levels remain low in both sexes until puberty, the transition to sexual maturity. At the onset of puberty both testicles and ovaries begin secreting sex hormones at levels sufficient to initiate reproductive maturity, and the bodies and brains of girls and boys begin to transform into those of women and men. Because of the great impact of this transformation on psychosexual development, we postpone most of our discussion of puberty to Chapter 10. The brain also differentiates sexually Although the basic organization of the brain is very similar in men and women, early hormonal influences do produce some sex differences in brain structure, function, and chemistry. Here are some examples: Men s brains are about 10% larger, on average, than those of women. This overall size difference is proportional to the overall difference in body size between the sexes, however, and probably has no great functional significance. The two cerebral hemispheres are about the same size in women, but in men the right hemisphere is usually slightly larger than the left (Savic & Lindstrom, 2008). Certain regions within the cerebral cortex are also larger in one sex or the other (Raznahan et al., 2010). It is possible that some of these size differences underlie the differences in cognitive skills between women and men, as described later in this chapter. A brain structure called the amygdala is involved in the encoding of emotionally laden experiences into memory in both sexes, but men use the right amygdala for this task, whereas women use the left amygdala (Canli et al., 2002). Men s brains produce serotonin a neurotransmitter involved in the regulation of mood at a rate 52% higher than women s brains (Nishizawa et al., 1997). In the case of another neurotransmitter, dopamine, it s the other way around (Cosgrove et al., 2007). Such differences could offer a partial explanation for differences in the prevalence of certain mental disorders

8 Sex and Gender Differences 101 in the two sexes: Depression, for example, is twice as common in women, whereas alcoholism is twice as common in men (World Health Organization, 2011). The difference in circulating androgen levels in the two sexes (higher levels in males than in females) is the main driver of sexual differentiation in the brain, as in the rest of the body (Davis et al., 1995). Sex differences in the size of a brain structure might not result from early developmental processes alone, however. Dutch researchers reported that, when young adult transexuals were treated with hormones of the other sex as part of their sex-reassignment process, the overall size of their brains changed partway toward that of the other sex: The brains of male-to-female transexuals became smaller, and those of female-to-male transexuals became larger (Hulshoff Pol et al., 2006). This surprising finding suggests that a person s hormonal status in adulthood has an ongoing influence on brain size. disorders of sex development Medical conditions producing anomalous sexual differentiation or intersexuality. Klinefelter syndrome A collection of traits caused by the possession of one or more extra X chromosomes in a male (XXY, XXXY). Turner syndrome A collection of traits caused by the possession of one X and no Y chromosome. XYY syndrome A collection of traits caused by the possession, in a male, of an extra Y chromosome. Sex Development May Go Awry Given the complexity of the genetic and hormonal cascade that guides sex development, it is perhaps surprising how regularly it leads to the normal end product a healthy, fertile woman or man. Yet deviations from stereotypical female or male development do sometimes occur. Pediatricians call these deviations disorders of sex development (Lee et al., 2006). The following are some examples of these disorders. Chromosomal anomalies affect growth and fertility The standard sets of sex chromosomes are XX (female) or XY (male). Other combinations are possible. They can arise during cell divisions in the production of ova or sperm, or during the first cell division after fertilization. Embryos with abnormal numbers of sex chromosomes are very common, but the great majority die early in development. Among those that survive, the following are the most common anomalies: Klinefelter syndrome (XXY, XXXY). About 1 in 1000 live-born babies possesses one or more extra X chromosomes. These individuals are male because they possess a Y chromosome with its SRY gene, which masculinizes their bodies. In adulthood they may have some breast development and feminine body contours, however, with sparse body and facial hair. They are also generally taller than average. They have a low sperm count and are usually infertile. Turner syndrome (XO). About 1 in 4000 live-born children has one X chromosome and no Y chromosome. They are girls, since they lack the Y chromosome and its SRY gene. These girls tend to be short, with a characteristic broad chest and neck. They lack normal ovaries, and without medical assistance they do not enter puberty and are infertile. They may suffer from some cognitive deficits but they are not intellectually disabled (Ross et al., 2000): Women with Turner syndrome have excelled in a variety of careers (Figure 4.5). XYY syndrome. About 1 in 1500 babies possesses one X chromosome and two Y chromosomes. They are male, but they may have genital anomalies and low fertility. They also tend to have low intelligence. Perhaps for this reason, they are overrepresented among convicted criminals (Gotz et al., 1999; Briken et al., 2006), but most XYY men are behaviorally normal.? FAQ Will a man with Klinefelter syndrome pass it on to his children? No. He will need medical assistance to become a father, but any children he does have will almost certainly be normal girls or boys.

9 102 CHAPTER 4 Figure 4.5 Turner syndrome Dr. Catherine Ward Melver is a geneticist at Children s Hospital in Akron, Ohio, and president of the Turner Syndrome Society. Her short stature (4 feet 8 inches, or 142 cm) is a feature of Turner syndrome. triple-x syndrome A collection of traits caused by the possession, in a female, of three X chromosomes rather than two. intersexed A person whose biological sex is ambiguous or intermediate between male and female. gonadal intersexuality The possession of both testicular and ovarian tissue in the same individual. androgen insensitivity syndrome (AIS) The congenital absence of a functional androgen receptor, making the body unable to respond to androgens. congenital adrenal hyperplasia (CAH) A congenital defect of hormonal metabolism in the adrenal gland, causing the gland to secrete excessive levels of androgens. Triple-X syndrome (XXX). About 1 in 2000 newborns possesses three X chromosomes. These babies are girls. They develop mild cognitive deficits and their fertility is low, but many XXX females go undiagnosed. Although these chromosomal anomalies cannot be corrected, hormonal and other medical treatments, as well as counseling, can often help a great deal. Some of these individuals can become parents with the help of assisted reproductive technologies (Chapter 8). The gonads or genitals may be sexually ambiguous Some disorders of sex development cause the gonads or the genitals to end up in a state that is intermediate between the sexes or has some features of both. Persons affected by such conditions may be referred to as (or describe themselves as) intersexed. Here are some examples: Gonadal intersexuality. In this rare condition, which is also called true hermaphroditism, the person possesses both ovarian and testicular tissue either on different sides of the body or in gonads that contain mixtures of the two tissues. The cause is not usually known, but chromosomal anomalies may be to blame. The appearance of the external genitalia varies, but most persons with this condition look like women and identify as such. They are usually infertile. Androgen insensitivity syndrome (AIS). This is a genetic condition in XY individuals in which androgen receptors are defective or absent. AIS embryos develop as female because the body fails to respond to the testosterone secreted by the testicles. People with AIS lack the reproductive tract of either sex: They possess a shallow, blind-ending vagina, and they are infertile. Persons with complete AIS look like and identify as women, but people with partial androgen insensitivity have a more variable appearance and self-identification. Congenital adrenal hyperplasia (CAH). In this genetic condition, the fetus s adrenal glands secrete abnormally large amounts of androgens

10 Sex and Gender Differences 103 during the latter part of fetal life. In XX fetuses, which otherwise would develop into normal girls, the condition causes a partial masculinization of the genitals: The clitoris is often enlarged, for example, and the labia may be partially fused in the midline (Figure 4.6). Most of these children are raised as girls, but some children with very marked masculinization are raised as boys. For many children with ambiguous genitalia, the cause is not known. Whatever the cause, however, treatment of these children raises a host of difficult ethical questions. Should the genitals be surgically altered early in life to normalize them, with the hope of sparing the child or the child s family from embarrassment? What should the child be told, and as which gender should the child be raised? Partly in response to activism by people with intersexed conditions, there has been a movement away from early surgery, unless it is medically essential. The idea is to postpone irreversible decisions until affected children are able to make known their own gender identity and participate in the decisionmaking process. The secrecy and denial that often surrounds these cases is harmful to children s psychological development and self-acceptance, according to the testimony of intersexed people (Box 4.1). Enlarged clitoris Fused labia Figure 4.6 Partial masculinization of genitalia in a girl with congenital adrenal hyperplasia. Gender is a Central Aspect of Personhood The word gender, as used in this book, means the entire collection of mental and behavioral traits that, to a greater or lesser degree, differ between males and females. Thus, gender consists of all those things that make females and males different, aside from the primary and secondary sex traits. Some traits are highly gendered : That is, they are markedly different between the sexes. An example is a person s subjective sense of femaleness or maleness, a trait called gender identity. The great majority of females have a secure identity as females, and the great majority of males have a secure identity as males. Transexual and transgender people are exceptions but they form a very small percentage of the population. An example of a trait that is highly gendered, but less so than gender identity, is that of sexual orientation the direction of an individual s sexual attractions. Most men are predominantly attracted to women, and most women are predominantly attracted to men, but several percent of the population do not fit this pattern. Verbal fluency is a trait that is much more weakly gendered than gender identity. On average, girls outperform boys on tests of this cognitive skill, but it takes the testing of large numbers of children, and the application of statistical tests to the results, to demonstrate the difference. In our discussion of gender, we first review the aspects of mental life that are known to be gendered to a greater or lesser degree. We then discuss theories about how gender differences arise. gender The collection of psychological traits that differ between males and females. gender identity A person s subjective sense of being male or female. sexual orientation The direction of an individual s sexual feelings; sexual attraction toward persons of the opposite sex (heterosexual), the same sex (homosexual), or both sexes (bisexual). transgender A person who identifies with the other sex. Gender identity might not match anatomical sex In its simplest conception, a person s gender identity is his or her response to Do you feel as if you are a woman or a man? or some similar question. More than 99.9% of people will give an answer that is consistent with their genital anatomy. Yet rare individuals give a discordant answer to that question: anatomical women who say they feel like men and anatomical men who say they feel like women, as well as others for whom neither female nor male satisfactorily describes how they think about themselves. The existence of these transgender persons, discussed in greater detail later in the chapter, makes us realize that there must be something more to gender

11 104 CHAPTER 4 box 4.1 Personal Points of View My Life With Androgen Insensitivity Syndrome Katie Baratz Dalke, who recently graduated from the University of Pennsylvania Medical School, wrote this essay for Discovering Human Sexuality. By all accounts, I was a perfectly healthy and normal baby girl, thriving under the love and attention of my family and constantly seeking opportunities to sing, dance, and try on my mother s dresses and jewelry the more sparkles, the better! My family s world changed forever when I was 6. That year, I collapsed in the shower with a painful lump in my groin. Convinced I had a hernia, my parents, both doctors, took me to the hospital. But when surgeons operated, they found a testicle that had started descending. Tests soon showed that instead of the typical XX chromosomes found in girls, I had the XY chromosomal complement of boys. The doctor told my stunned parents that I had Complete Androgen Insensitivity Syndrome. He assured them that I would grow up normally, fall in love, and have a family through adoption, but they shouldn t tell me that I had XY chromosomes and testicles. My parents did decide to tell me, but gradually. As a young girl, they showed me an anatomy book and told me that the Katie Baratz Dalke uterus was the nest inside a woman where the baby grew. I didn t have one, but I could adopt a baby that would grow in my heart and be part of my family. I learned about periods and knew I wouldn t get them. Although I was sad that I wouldn t be able to become pregnant and felt different from my girl friends, I thought that was it until I turned 16. That year, my sister came home from school with a biology project. Everyone in her class was assigned a condition to research, and she randomly drew AIS. Mom and Dad, it sounds a lot like Katie, she said at dinner one night. And gender role The expression of gender identity in social behavior. cognitive Related to the aspects of the mind that process knowledge or information. identity than simply reporting on one s genitals. Gender identity is a central and stable aspect of who we are our personhood. The way we express gender identity in gendered behavior everything from what clothes we wear and how we walk and talk, to what sex we claim to be is called our gender role. Although self-identified transgender persons are quite uncommon, research indicates that gender identity may have a more blurred distribution in the general population than is captured by a simple male female dichotomy. If, for example, people are asked to rate their own masculinity/femininity on a scale in comparison with other persons of the same sex, responses are quite spread out: Some women rate themselves as about as feminine as other women, some as more feminine, and some as more masculine, and the same for men (Lippa, 2008). We will revisit this spectrum of subjective masculinity/ femininity when we discuss the topic of sexual orientation (see Chapter 12). Figure 4.7 Mental rotation task From the four images at right, the subject is asked to select the two objects that could be rotated in space to match the object shown at left. Men generally outperform women in this kind of task. Women and men differ in a variety of cognitive and personality traits Some sex differences are seen in aspects of mental life having to do with perception, motor performance, reasoning, judgments, knowledge, and memory collectively referred to as cognitive traits. For example, men outperform women in some visuospatial skills, such as the ability to mentally rotate three-dimensional objects (Figure 4.7), hit targets accurately, and navigate through

12 Sex and Gender Differences 105 there s a woman with Mom s name on the support group website. My parents looked at each other. They d wanted to wait until I was 18, but there was no going back now. They told me and my brother and sister everything. My dad finished up by saying, You re still our girl. I was devastated and angry, feeling betrayed by my parents and my own body. Looking back, I know those emotions came from a fear of what was wrong with me, plus the eternal conflict of adolescence: someone else deciding what s best for you. High school was grim. I went through puberty very late, and was taller and thinner than most of the boys all the way through senior year. I had horrible insomnia and tons of anxiety that sometimes veered into depression. I felt as if all of my girl friends were living a life I couldn t access, one marked by the common experiences of periods, dating, and an effortless transition to womanhood. I, on the other hand, had to take estrogen pills to develop a womanly figure, and I had to use a vaginal dilator for 30 minutes a day so that I could comfortably have sex. College was better. I found a therapist I loved and began to feel recognized by my classmates for my talents and interests rather than my body. I started to tell my story to friends and a few boyfriends, who were constantly supportive, encouraging, and loving. Speaking of love in my senior year, I met Sam, a runner and English major with a romantic streak. We started talking, and before I knew it, he was courting me with chocolate-covered strawberries and Marilyn Monroe movies. Shortly after we began dating, I knew that it was time to tell him about my AIS. He listened patiently and assured me that nothing about my genes or gonads changed the way he felt about me. Four years later, we were married on an unseasonably warm New Year s Eve, surrounded by our friends, family, and yes, lots of sparkles. We are beginning our lives together and planning to adopt our children, although I still feel pangs of sadness when I think about how much I d like to be able to have children biologically. I m also really involved in the AIS community. It feels incredible to help others with the pain I went through it was only after finding the AIS Support Group, the summer before college, that I realized AIS could be part of my life without dominating it, and that the loneliness I d felt abated. Ultimately, I want to be an advocate for people like me. It s hard to convince doctors to change how they handle such cases if you re not their peer, so I recently graduated from medical school with a masters in Bioethics and am beginning a residency in Psychiatry. As a psychiatrist, I hope to help people cope with having conditions like AIS, and to help doctors find the best way to treat them. space (Peters et al., 2007; Lippa et al., 2010). Women outperform men on tasks involving memorization of the location of objects (Figure 4.8), fine manipulation, and some verbal skills, such as verbal memory and fluency (Kimura, 1999; Rahman et al., 2003a). These sex differences are moderate to large in size, * but they are smaller than obvious physical differences between the sexes, such as the difference in average height. Many other cognitive skills show small differences between the sexes. Other sex differences have to do with feelings, attitudes, goals, interests, values, and behaviors (including sexual behavior) traits that loosely cluster under the term personality. Notable among these traits is aggressiveness: Males score higher than women on written tests of aggressiveness, show more verbal and physical aggression in real-life situations, and personality The collection of mental and behavioral traits, especially those related to emotions and attitudes, which characterizes an individual. * For statistics buffs, they show effect sizes (d) of about Figure 4.8A Test of object location memory Study this picture for 1 minute and try to impress upon your memory the position of every item you see. Then look at Figure 4.8B on p (From Silverman & Eals, 1992.)

13 106 CHAPTER 4 are more likely to commit violent crimes, both in the United States and across most cultures (Archer, 2004). Women are more likely to express aggression through indirect, nonphysical means, such as malicious gossip (Hess & Hagen, 2006). Another personality difference has to do with interests, and this is one of the strongest gender differences, statistically speaking. Women are more interested in peoplerelated activities and occupations; men have more thing-related interests (Lippa, 2005). One cross-cultural study, based on data from 23,000 men and women in 26 cultures, found robust cross-cultural gender differences in six personality factors: Men scored higher in factors named assertiveness and openness to ideas, while women scored higher in agreeableness, warmth, openness to feelings, and neuroticism (Costa et al., 2001). There may be differences in the moral sense of Figure 4.8B Test of object location memory Having memorized women and men. According to Harvard psychologist Carol Gilligan, author of an influential 1982 Figure 4.8A as best you can, look at this picture and identify all the pairs of objects that have swapped places. Women typically do better than men at book, In a Different Voice (Gilligan, 1982), women s this task. (From Silverman & Eals, 1992.) moral universe is based on caring, whereas men s is based more on justice and rules. Some scientific support for this point of view comes from studies in which women and men s values are surveyed by means of written questionnaires. When women and men are asked to rate the desirability of a variety of traits, the traits rated higher by women include sensitive, kind, understanding, affectionate, helpful, and sincere. When asked to choose the more desirable of two traits, such as cooperative versus competitive, patience versus determination, and helping versus being in charge, women tend to choose the more caring alternative. This sex difference has been observed both in the United States and in several Asian countries (Stimpson et al., 1991). A meta-analysis suggests that sex differences in moral reasoning exist but are small in magnitude smaller than the differences in moral reasoning that exist between cultures (Jaffee & Hyde, 2000). Wanton violence is predominantly a male activity. Differences in sexuality include attitudes toward casual sex, jealousy, and frequency of masturbation More directly relevant to the overall subject of this book are sex differences related to sexuality. Here we summarize these differences. We will expand on some of them in later chapters. Men and women have marked differences in their attitudes toward casual or uncommitted sex. Men express far more permissive attitudes than women regarding casual sexual encounters, are more desirous of engaging in such encounters, and make more attempts to do so. This is true not just in the United States, but also in over 50 nations where men and women have been surveyed (Schmitt, 2005; Lippa, 2009). Asked in a U.S. random-sample survey how they would feel after a one-night stand, men were more than three times as likely as women to say they would feel satisfied, while women were more than twice as likely as men to say they would feel regret or shame (Esquire, 2007).

14 Sex and Gender Differences 107 Women and men tend to seek different things in their sex partners. Women are attracted to older partners, men to younger ones. Women are more concerned than men with their partners status or wealth; men are more concerned than women with their partners physical attractiveness. These differences exist across cultures in Chinese college students just as much as in American students, for example (Toro-Morn & Sprecher, 2003). Of course, there are any number of exceptions to these generalizations men who adore powerful older women, for example, and women who are drawn to penniless but handsome youths. But in a statistical sense, the differences hold up very consistently. Men are more interested in visual sexual stimuli generally, including pornography, and are more sexually aroused by such stimuli, than are women (Janssen et al., 2003). Not surprisingly, most pornography is oriented toward consumption by men. Men and women both experience jealousy, but they tend to experience different kinds of jealousy (Buss, 2000). Women are more likely than men to experience emotional jealousy that is, to fear that their male partner may commit himself emotionally to a different woman. Men, in contrast, are more likely than women to experience sexual jealousy to fear that their female partner is being physically unfaithful to them. Concerning actual sexual behavior, far and away the largest difference is that males masturbate more than females, beginning at puberty (Oliver & Hyde, 1993; Gerressu et al., 2008). Males also report more frequent sexual intercourse, a younger age at first intercourse, and a larger number of total sex partners than do females, but these differences are in the small to moderate range. Of course, heterosexual sex partners should balance between the sexes: Men and women should have the same mean number of different partners of the other sex. The apparent sex difference in this measure has a number of potential explanations, which could include sampling problems. It s more likely, however, that men consciously overstate their number of partners and/or women understate them. Thus, one study reported that the sex differences in number of reported partners nearly disappeared when the subjects thought that their truthfulness was being monitored by a polygraph (Alexander & Fisher, 2003). It seems likely that women s lesser interest in casual sex and multiple partners limits how many partners heterosexual men have. If so, we would expect that men who desire sexual contact with other men would have more partners than heterosexual men do. And in fact, several studies have reported exactly that: Gay men have more casual sex partners and more total partners than straight men (Laumann et al., 1994). It s not that there s anything psychologically unusual about gay men in this regard it s just that they re seeking sex partners in a more willing population. With regard to all these sex differences in cognition, personality, and sexuality, there is still controversy about their magnitude and meaning. Psychologist Janet Hyde has argued that sex differences, if they exist at all, are usually too small to be of any practical significance but are often exaggerated in the popular imagination a tendency that she believes has negative consequences both in the workplace and in personal relationships (Hyde, 2005). Others say that Hyde ignores some large and well-replicated differences, which need to be taken into account by those concerned with education and public policy (Lippa, 2006). Many gender differences arise early in life Very young children behave as if they know the difference between female and male faces. This has been demonstrated by preferential looking experiments: For example, 3- to 4-month-old infants spend longer looking at a face of a woman if they have previously been looking at faces of men (Quinn et al., 2002). By 6 months this discrimination becomes more robust and includes the ability to distinguish between female and male voices.

15 108 CHAPTER 4 Figure 4.9 Gender constancy (A) A 2-year-old child may think that a man who puts on a long-haired wig has become a woman. (B) By 3 to 4 years of age, the child knows that a person s sex is a fixed attribute. (A) Man Man (B) Woman Man in a wig 2-year-old 3 to 4 years 2-year-old 3 to 4 years gender constancy A child s understanding that sex is a fixed attribute. Figure 4.10 Toy preference test A child is placed within a circle of toys and his or her play behavior is videotaped. Later, observers measure the amount of time the child spends playing with toys generally preferred by girls and those generally preferred by boys. Figure 4.12 shows examples of data from this kind of study. Although they distinguish between the sexes, very young children probably do not understand that sex is a fixed attribute of individuals. Before about 3 years of age, a child is likely to think that a man who puts on a long-haired wig has become a woman (Kohlberg, 1966). Gender constancy the realization that the sex categories are permanent and that a man in a wig is still really a man (Figure 4.9) appears by about 3 to 4 years of age (Bem, 1989). What about children s sense of their own sex? It appears that most children can identify their own sex and categorize themselves with other same-sex children by 2 to 3 years of age (Fagot, 1985; Stennes et al., 2005). This is usually before the age of gender constancy, so children apparently go through a 1- to 2-year period in which they know their own sex but do not know that they are unable to change it. Boys and girls show quite marked differences in behavior from a young age. Even before birth, male fetuses are more active than females, and this difference in activity level increases during childhood (Campbell & Eaton, 1999). By 18 months of age, toy preferences begin to diverge (Figure 4.10): Boys prefer toy vehicles, toy weapons, balls, and construction toys, while girls prefer dolls and toy kitchen implements (Berenbaum & Snyder, 1995; Serbin et al., 2001). Boys engage in more rough-and-tumble play and aggression than do girls (Maccoby & Jacklin, 1987; Maccoby, 1998). By 4 years of age most boys prefer to play with boys, and most girls with girls. This segregation by sex is universal across cultures and is most marked when adults are not present (Fabes et al., 2003). At the same age, girls and boys play is governed by different moral rules: Girls appeal to social conventions ( The teacher will be angry if we don t play nicely ), while boys are more likely to refer to principles of justice ( Hands off the car, it s mine! ) (Tulviste & Koor, 2005). These different styles

16 Sex and Gender Differences 109 of conflict resolution, along with boys greater physical aggressiveness, may be the main reasons why the sexes segregate in the first place: Girls find themselves disadvantaged in mixed-sex groups because boys ignore their verbal arguments and grab all the marbles, so the girls withdraw (Powlishta & Maccoby, 1990; Maccoby, 1998). With respect to motor skills, by 2 to 3 years of age boys show greater throwing accuracy and girls show finer control of hand musculature (Kimura, 1999). By elementary school age, differences in cognitive traits begin to emerge; at this age, girls are slightly better at calculating than boys. Boys superiority in mental visuospatial tasks, such as mental rotation, appears by the age of 9 to 12 (Kerns & Berenbaum, 1991) and in problem-solving tasks by about age 14 (Hyde et al., 1990). This male superiority in visuospatial and problem-solving skills does not translate into better classroom performance, however: Girls tend to get better grades than boys in most subjects and across most age levels. Biological factors influence Gender So far, we have attempted to describe gender differences without drawing any conclusions about how these differences arise. We now turn to the topic of causes. It turns out that researchers have taken a wide variety of approaches to this topic and have viewed gender through the lenses of several different disciplines. We begin by discussing the biological approach. Evolutionary forces act differently on females and males The field of evolutionary psychology investigates how gender characteristics have been molded by a long period of human and prehuman evolution. During this period, the struggle to survive and reproduce has favored the spread of genes that predispose their owners to certain sex-specific traits and behavior patterns. Here are three examples of how evolutionary psychology attempts to explain aspects of women s and men s sexual strategies (Buss, 2003). COGNITIVE SKILLS Evolutionary psychologists believe that cognitive differences between the sexes have arisen because of a long-standing division of labor between women and men. Because of their greater physical strength, it is argued, men have always taken a leading role in hunting, warfare, and exploration; while women, because of their biologically mandated role in pregnancy and breast-feeding, have taken a leading role in activities near the home site. Over many generations, such a division of labor might well have favored the spread of genes for different cognitive skills in the two sexes, such as the greater throwing and navigating skills of men and the greater hand and finger dexterity of women. INTEREST IN CASUAL SEX Men s greater interest in casual sex can be explained in terms of evolutionary processes. The cost of fathering a child when stripped to its biological essentials is minimal. In theory, therefore, a man can have hundreds of offspring if he impregnates many different women and walks away from Boys and girls traditionally learned different tasks, but this division of labor during human evolution may have fostered genes for different cognitive skills in the two sexes.

17 110 CHAPTER 4 each. Women, however, have to invest so much time and resources into pregnancy and infant care that they are very limited in the total number of offspring they are able to have. Therefore, one can argue, genes evolved that promoted men s interest in casual sex and women s choosiness about whom they mated with. JEALOUSY Women have always been certain of the identity of their children: Any child to whom a woman gave birth was necessarily her genetic offspring. A man, however, could not be certain which children were his: Even in a supposedly monogamous relationship, there was always the risk that his partner might have sex with someone else and that he might end up helping to rear a child that was not genetically his own. According to David Buss, this difference between the sexes, persisting over countless generations, led to the spread of genes promoting the different styles of jealousy in women and men described above. Men s sexual jealousy served to reduce the likelihood of rearing someone else s child; women s emotional jealousy served to reduce the likelihood that their male partners would abandon them and leave them without resources to rear their children (Buss, 2000, Harris, 2003). To the extent that these evolutionary theories about cognitive skills, interest in casual sex, and jealousy are correct, one might expect that nonhuman species (especially those closely related to us) would exhibit some of the same gender-differentiated traits that humans do, even without the benefit of human culture. As one test of this idea, Gerianne Alexander and Melissa Hines presented male and female vervet monkeys with the same kinds of toys that they had previously used to test children s toy preferences (Alexander & Hines, 2002). The monkeys preferences were uncannily similar to those of humans: Male monkeys played more with model cars and balls, for example, and female monkeys played more with dolls (Figure 4.11). Male and female monkeys played about equally with items that appeal to both boys and girls, such as picture books and stuffed dogs. Similar results have been obtained more recently with rhesus monkeys (Hassett et al., 2008). Since the monkeys had not seen the test items previously, they could hardly have learned to prefer some toys to others. Probably, some internal process of brain differentiation influences toy preferences in both human and nonhuman primates. It s not that there s an innate representation of the concept car or of any other toys in the brain, of course. Rather, children and monkeys choose toys that facilitate the behaviors they like to engage in, such as active movement in the case of males. (A) (B) Figure 4.11 Monkeys show humanlike toy preferences. (A) A female vervet monkey plays with a doll. (B) A male monkey plays with a toy car. (From Alexander & Hines, 2002.)

18 Sex and Gender Differences 111 Experiments demonstrate a role for sex hormones Earlier in this chapter we mentioned the structural and functional differences between the brains of women and men. These differences result, at least in part, from differences in circulating levels of sex hormones during fetal life, at puberty, and during adult life. So do hormones contribute to the psychological differences between the sexes? Experiments in animals certainly suggest so. Biologists have altered the hormonal environment of fetal rats and monkeys by adding testosterone to a female fetus, for example, or by blocking the action of a male fetus s own testosterone. In postnatal life the treated females behave in many ways like males, and vice versa (Goy et al., 1988). Although it would obviously be unethical to conduct such experiments in humans, biologists can take advantage of experiments of nature in which a similar situation has occurred spontaneously. One example is the condition of congenital adrenal hyperplasia (CAH). As mentioned earlier in this chapter, girls with CAH are exposed to abnormally high levels of testosterone-like hormones (androgens) that are secreted by their adrenal glands during part of their fetal life. Psychologists have found that some, but not all, of the behavioral traits of these girls are shifted in the masculine direction. The CAH girls engage in more rough-and-tumble play than other girls, for example, and they prefer boys toys to girls toys (Berenbaum & Snyder, 1995) (Figure 4.12). The differences persist into adult life, affecting such things as hobby interests and career choices (Berenbaum & Bailey, 2003). Women with CAH are also more proficient than other women at spatial tasks at which males typically excel (Puts et al., 2008). These observations indicate that the high androgen levels experienced by female CAH fetuses influence their gender characteristics after birth. Observations on other experiments of nature lend further support to the idea that prenatal hormones influence gender (Box 4.2). But do these results say anything about normal children? To address this question, researchers have estimated testosterone levels in healthy fetuses by measuring levels of the hormone in the amniotic fluid or in their mother s blood (Hines, 2006; Knickmeyer & Baron-Cohen, 2006). The children born of those pregnancies were studied at various ages after birth. It turned out that fetal testosterone levels predicted a variety of gender characteristics in these children, even within a single sex. The lower a girl s testosterone levels prenatally, for example, the more strongly she would prefer girls toys over boys toys when she was 3 years old. It s difficult to study adults with the same methodology, because of the long time interval involved. To get around this problem, biologists have looked for anatomical markers in adults that may reflect their degree of testosterone exposure prenatally. One marker that has attracted a great deal of attention is the ratio of the length of the index finger (second digit, or 2D) to the length of the ring finger (fourth digit, or 4D) the so-called 2D:4D ratio (Figure 4.13). Men typically have a lower 2D:4D ratio than women, and several lines of evidence suggest that this difference comes about as a result of the higher testosterone levels that males typically experience during fetal life (Breedlove, 2010). Researchers have found that the 2D:4D ratio correlates with many gendered characteristics, even within one sex. A Canadian group, for example, reported that men with lower (more male-typical) ratios are more aggressive than men with higher ratios (Bailey & Hurd, 2005). These kinds of findings suggest a relationship presumably a causal one between the brain s exposure to androgens before birth and a variety of gendered characteristics in childhood and adult life. None of the biological findings allow the conclusion that prenatal hormones determine a person s gender characteristics, however. They suggest an influence an influence that may be quite strong for some characteristics and quite Play time (seconds) Boys Girls Toy type Normal boys Normal girls CAH girls Neutral Figure 4.12 Hormones and play Exposure to androgens during fetal life influences choice of toys during childhood. Normal boys, normal girls, and girls with congenital adrenal hyperplasia (CAH) were observed while playing with toys. The toys available included those generally preferred by boys (e.g., trucks) and those generally preferred by girls (e.g., dolls), as well as gender-neutral toys. The toy preferences of the CAH girls were more like those of boys than like those of non-cah girls. (After Berenbaum & Snyder, 1995.) 2D 4D Figure 4.13 Finger-length ratio and gender The 2D:4D ratio is the length of the index finger divided by the length of the ring finger. The ratio is typically lower in men than women, but it also varies with gender characteristics within each sex. (D = digit)

19 112 CHAPTER 4 box 4.2 Biology of Sex Eggs at Twelve In the early 1970s Julianne imperato-mcginley, an endocrinologist at Cornell Medical School, heard stories about a remote village in the Dominican Republic where girls were changing sex at puberty sprouting a penis and testicles and well-developed muscles just like regular men. Intrigued, she led an expedition to the village. She found that the stories were true. in fact, the phenomenon was so common that the villagers had a name for these children: guevedoces, meaning eggs [testicles] at 12. Imperato-McGinley discovered that the affected children were chromosomally male (XY) but carried a genetic mutation called 5a-reductase deficiency, which made them unable to convert testosterone to the more potent androgen dihydrotestosterone (DHT) (Imperato-McGinley et al., 1974). DHT is required for the normal prenatal development of the male genitals. Thus, although the affected children had testicles, the testicles did not descend, and their genitals looked at least to casual inspection like those of girls. As a result, they were usually raised as girls. At puberty, however, their greatly increased levels of circulating testosterone triggered enlargement of their rudimentary penis and scrotum; their testicles descended, the voice lowered, and the general body build and musculature became that of an adolescent male. What particularly interested imperato-mcginley was the affected individuals gender development. The great majority of these children shifted from a female to a male gender identity at or soon after puberty (Imperato-McGinley et al., 1979). The transition typically took place over a period of several years subjects felt that they passed through stages of not feeling like girls, then feeling like men, and finally being convinced that they were men. How should this finding be interpreted? Just giving a normal prepubertal girl large doses of testosterone to induce male secondary development would not make her feel like a man. Therefore, it was not just the increased testosterone levels at puberty that induced a male gender identity in the children studied by Imperato-McGinley. Rather, in her interpretation, it was the combination of prenatal testosterone exposure, which had its typical masculinizing effect on the brain, with the rise in testosterone at puberty. Together, these hormonal effects nearly always overrode any effects of being reared as a female. Imperato-McGinley s conclusions were criticized for a number of reasons. it was suggested, for example, that the children she studied were not really reared as female, but as a kind of intersex. it is true that, as the syndrome became well known in the area, infants who had the syndrome were recognized by careful inspection of the genitalia at birth, and it was expected that Julianne Imperato-McGinley they would change sex. But imperato-mcginley also reported on 18 children who were raised in the full belief that they were, and would always remain, female. Of these children, 17 developed a male gender identity during puberty (and were sexually attracted to women), and 16 completely changed their public gender role to male. More recently, similar clusters of cases have been found in other isolated communities around the world. Again, most of the affected girls take on a male gender identity at puberty (Imperato-McGinley et al., 1991). The observations on 5a-reductase deficiency leave many loose ends. What were the gender characteristics of the affected individuals during childhood? What would have happened if the children s brains were flooded with testosterone at puberty, but their bodies for some reason had remained female would they have accepted their continued female identity, or would they still have transitioned to a male identity, becoming in essence transexuals? And what if the whole syndrome were sex reversed: What if it were a matter of boys developing women s bodies at puberty? Would they be as accepting of membership in the female sex which has lower status in many of the affected communities just as the 5a-reductase-deficient girls were accepting of membership in the privileged male sex? The remarkable individuals studied by imperato-mcginley do not provide all the answers to these questions, but they do support the general notion that sex hormones, both before birth and at puberty, powerfully influence a person s gender. 5a-reductase deficiency The congenital absence of the enzyme 5a-reductase, which converts testosterone to dihydrotestosterone.

20 Sex and Gender Differences 113 Figure 4.14 Babies enter a gendered world. Eva and Nicholas have been dressed in the pink and blue outfits that our culture deems appropriate for infant girls and boys, respectively. weak, or totally absent, for others. Thus, there is plenty of room for other factors to play a role. These may include nonhormonal biological processes, such as aspects of brain development that are controlled directly by genes (Ngun et al., 2011), as well as a variety of social and learning factors that we discuss next. Life Experiences influence Gender Newborn girls and boys enter a world that imposes gender on them from the very beginning (Figure 4.14). Psychologists have discerned a variety of ways in which interactions among individuals, their families, and larger social groups help create and strengthen gendered traits. Gender is molded by socialization The earliest social influences on a child s gender comes from the family. Children are exposed to myriad inputs from their parents and siblings that could influence gendered attitudes and behaviors. Parents may influence children s gender by the way they dress them, by the way they decorate their rooms, by the toys they provide, by the way they attend to, reward, or punish their children s behavior, and by the activities that they initiate with them. Some parents take great pains to encourage gender conformity by these various methods, while others take a more lenient stance. Even if they do not set out to influence a child s gender, parents and siblings may do so simply by virtue of acting as role models. OBSERVING SOCIALIZATION Here s just one example of a study in which the influence of family members (older siblings, in this case) on children s gender was demonstrated and measured (Rust et al., 2000). A British group of psychologists examined the gender-related behaviors and interests of over year-old children; the researchers reduced the data for each child to a single measure of masculinity/ femininity. Some of the children had older siblings of the same or the other sex. As can be readily seen in the data (Figure 4.15), those children who had an older sibling

21 114 CHAPTER 4 Figure 4.15 Influence of siblings on gender (A) Older siblings act as gender role models. (B) The Pre-School Activities Inventory (PSAI) score is a measure of gender-typical activities and interests in which male-typical traits score higher and female-typical traits score lower. This figure shows the PSAI score for 5542 British 3-year-olds, broken down according to whether they are singletons or have an older brother or sister. The children s gender traits are slightly shifted in the direction of the sex of their older sibling. (After Rust et al., 2000.) (A) (B) PSAI score Female Male 0 Has older brother Singleton Has older sister of the same sex were more gender typical than were children who had no sibling (singletons). Conversely, children who had an older sibling of the other sex were less gender typical than the singletons. These data indicate that the presence of same- or opposite-sex siblings does influence a child s gender characteristics to an appreciable degree. The influence was modest in size: A child s own biological sex was a much stronger predictor of its gender-related traits than was the sex of its older siblings. Girls with older brothers, for example, were far more feminine than any boys, even boys with older sisters. Parents are presumably in a stronger position than siblings to influence children s gender characteristics. This influence was illustrated in a study by researchers at the Johns Hopkins University (Pappas et al., 2008). They reported on 40 individuals who, as a result of a variety of intersexed conditions, were born with ambiguous genitalia. Although the genitalia of all the children had roughly the same anatomical appearance, those individuals whose parents raised them as boys became increasingly masculine through adolescence and adulthood, whereas those who were raised as girls became increasingly feminine. REWARDS AND PUNISHMENTS Studies such as the ones just described indicate that social interactions influence gender but don t pinpoint the exact mechanisms. One possible influence is the way family members use rewards, punishments, or withdrawal of rewards with any given child. Under these circumstances children learn from trial and error, often discovering how their behaviors lead to rewards or avoid punishments. In one study focusing on these learning processes, psychologist Robert Fagot and his colleagues studied interactions between parents and their 18-monthold infants and then followed the infants for about a year afterward. They found that the infants whose parents reacted to their behavior in the traditional fashion (rewarding or approving of gender-typical behavior and punishing or disapproving of gender-atypical behavior) learned to make gender distinctions earlier than other infants and exhibited more traditional gender-specific behavior (Fagot et al., 1992). Studies of this kind support the notion that gender-related traits are influenced by rewards and punishments.

22 Sex and Gender Differences 115 IMITATION Gender-typical behavior is also influenced by a child s observing and imitating the behavior of parents or older siblings, and not just by reward and punishment (Bandura, 1969; Bussey & Bandura, 1984; Grace et al., 2008). A child might first imitate both parents, but be rewarded most for observing and imitating the same-sex parent. In one study, Walter Mischel tracked the eye movements of children while they were watching films featuring male and female characters. In accordance with the theory of observational learning, the children attended more to the same-sex characters in the films than they did to the characters of the other sex. Such behavior could easily lead children to become better acquainted with, and imitate, the behaviors typical of their own sex. And the tendency of children to play with other children of their own sex, mentioned earlier, offers another way in which they can observe and learn gender-typical behavior, this time from their peers (Paechter & Clark, 2007). The media, particularly television, offers much for children to imitate in the gender domain (Figure 4.16). One study conducted in the 1970s took advantage of a unique opportunity to examine the effects of the media. A group at the University of British Columbia focused on a small Canadian town with the fictitious name of Notel (Kimball, 1986). This town received television broadcasts for the first time in The researchers wanted to know what the effect of television would be on the town s children. Before the broadcasts began, Notel s children had gender-related attitudes that were significantly more flexible than those of children in two comparable towns that already had television. By 2 years after the beginning of television transmissions, the attitudes of Notel s children had become much more stereotypical and comparable to those of children in the other towns. The girls had particularly marked changes in their attitudes toward peer relationships, while the boys showed marked changes concerning future occupations both in the direction of greater gender rigidity. All in all, the Notel study demonstrated a powerful effect of television in promoting stereotypical gender attitudes. Of course, it s possible that television promotes more flexible attitudes to gender today than it did in the 1970s.? FAQ Can I raise my child gender free? Not unless you re willing to refer to your child as it. But you can avoid imposing your gender expectations on him or her. LANGUAGE The language we speak is another cultural influence on gender, but one that we re barely aware of. We mentioned earlier that children acquire a knowledge of their own sex by 2 to 3 years of age, but this age actually varies according to the language environment that children are exposed to. Children in Hebrew-speaking households, for example, know their own sex about a year earlier than children in Finnish-speaking households. That s because Hebrew grammar emphasizes gender: Even the Hebrew word for you varies according to whether one is addressing a male or a female. Finnish grammar, on the other hand, doesn t specify gender at all. English falls in between, and correspondingly, children in English-speaking households learn their sex at an intermediate age (Guiora et al., 1982; Boroditsky, 2011). GENDER LEARNING FROM RULES Language also facilitates the learning of gender roles by means of verbally communicated rules (Baldwin & Baldwin, 2000). When a boy gets hurt and begins to cry, his older brother or father may state the rule: Big boys don t cry. The message is very clear, though the boy may need several months of additional learning before he can control his tears in a Figure 4.16 The media influence gender. Because overweight women, such as the character played here by Mo Nique, are often portrayed as losers in love, girls may learn to imitate thin actors.

23 116 CHAPTER 4 broad range of situations. Many girls learn that they are allowed to cry, and they may even get extra attention (a social reward) when they cry. Thus, these social rules help children learn that crying is much more acceptable for females than males. Swearing provides an opposite example: In many households, teenage girls are told more firmly than teenage boys that they should not swear. Gender rules are communicated not just by family members but also from many other social sources. As an example, Kathleen Denny, a graduate student in sociology at the University of Maryland, compared the messages conveyed by the U.S. Girl Scout and Boy Scout handbooks (Denny, 2011). There were consistent differences. The girls book placed more emphasis on group activities, artistic expression, and unstructured inquiry ( Take turns holding different colors up to your face [to] decide which colors look best on each of you. ), whereas the boys book placed more emphasis on science, learning facts from books, and solo activities ( draw a floor plan of your home ). The girls book encouraged aspiration and effort ( I will do my best to be ), whereas the boys book encouraged self-assuredness ( A Boy Scout is ). Scouting manuals provide just one example of the countless different messages conveyed to girls and boys, and each individual is influenced by a unique subset of all these rules. box 4.3 Personal Points of View The Boy Who Was Raised as a Girl Bruce and Brian Reimer were monozygotic twins born in Winnipeg, Canada, in When the twins were 7 months old they developed phimosis, a common condition in which the foreskin of the penis becomes constricted (see Chapter 3). The parents were advised to have the twins circumcised, but during Bruce s operation, an accident with the electrocautery machine led to the complete destruction of his penis. The parents were understandably devastated and at a loss as to what to do. Eventually they brought Bruce to sexologist John Money at the Johns Hopkins Medical School. Based on his earlier studies of children born with ambiguous genitalia, Money believed that children developed a male or female gender identity according to whether they were reared as girls or boys. Since it would not be possible to refashion a normal penis for Bruce, Money recommended that he be surgically transformed into, and reared as, a girl. He told the parents that as long as they treated the child as a girl, she would become a feminine, heterosexual woman. The parents followed Money s advice. They immediately changed Bruce s name to Brenda and dressed and treated her as a girl. When Brenda was 2 years old, her sex reassignment was completed: Her testicles were removed, and a rudimentary vagina was constructed from the scrotal skin. Her parents dedicated themselves to rearing Brenda and Brian as sister and brother. Money saw the parents and the twins from time to time David Reimer ( ) and advised the parents on the appropriate ways to treat Brenda that would best encourage her femininity. As the years went by, Money reported in detail on the case in lectures, papers, and books. He claimed that Brenda was developing as a normal girl, apart from a certain tomboyishness. While Brian copied his father, Brenda copied her mother, wrote Money (and colleague Anke Ehrhardt) in a 1971 book (Money & Ehrhardt, 1971): Regarding domestic activities, such as work in the kitchen and house traditionally seen as part of the female s

24 Sex and Gender Differences 117 Rule-based gender learning is often backed up by the promise of rewards or the threat of punishments or reinforced by the social aura of respected role models. The key feature of this form of learning, however, is that rules allow for the acquisition of general concepts that children can apply to a broad range of circumstances, including those that they have not previously encountered. In that way rules contribute to the creation of durable attitudes and opinions about gender that may be passed down from generation to generation. The weight of evidence supports the belief that socialization powerfully influences gender development. But, as with the biological approach, socialization can t explain everything. For one thing, some children are remarkably resistant to gender socialization. For example, children who become gay or transgender often violate some or many gender norms in rather dramatic ways, yet there is no evidence that these children are encouraged or trained to become gender rebels. And some children who are born as one sex but reared as the other may fiercely oppose this kind of reassignment, as if they somehow know which sex they ought to be (Box 4.3). It therefore seems unlikely that a complete account of gender development can be made in terms of either socialization or biology, and in fact few if any present-day workers in the field would make such a claim. role, the mother reported that her daughter copies her in trying to help her tidying and cleaning up the kitchen, while the boy could not care less about it. Brenda chose dolls as presents, while Brian chose model cars. The case became widely cited, both in the popular press and in academic circles, as evidence for the malleability of gender. This dramatic case provides strong support for [the idea] that conventional patterns of masculine and feminine behavior can be altered, reported Time magazine in It also casts doubt on the theory that major sexual differences, psychological as well as anatomical, are immutably set by the genes at conception (Colapinto, 2000). The normality of [Brenda s] development can be viewed as a substantial indication of the plasticity of human gender identity and the relative importance of social learning and conditioning in this process, stated the influential Textbook of Sexual Medicine (Kolodny et al., 1979). The case illustrated the overriding role of life experiences in molding human sexuality, according to the 1985 edition of the neurobiology textbook Principles of Neural Science (Kandel & Schwartz, 1985). Eventually, Money reported that he had lost contact with the Reimer family. it took detective work by University of Hawaii sexologist Milton Diamond (Diamond & Sigmundson, 1997), and later by journalist John Colapinto (Colapinto, 2000), to discover what had happened to Brenda. it seems that she was never successfully socialized into a feminine gender identity in the way that Money had claimed. Rather, she rebelled against it at every stage. Although a female puberty was induced by means of treatment with estrogen, Brenda loathed her developing breasts. By the age of 15 she had changed her name to David and was dressing as a boy. David had a double mastectomy, testosterone treatments, and a phalloplasty (reconstruction of a penis). He was always sexually attracted to women, and he eventually married, engaged in coitus with the aid of a prosthesis, and adopted children. Sadly, David killed himself in 2004 at the age of 38. The exact reason for his suicide is not known, but possible causes include the breakup of his marriage, financial difficulties, the earlier death of his twin brother Brian, and of course his traumatic childhood (Chalmers, 2004). The case of Bruce, then Brenda, then David Reimer suggests a conclusion different from the one drawn by John Money: Prenatal development seems to strongly influence gender identity and sexual orientation even when rearing conditions, genital anatomy, and pubertal hormones all conspire to produce the opposite result. This conclusion has been reinforced by the study of genetically male children with a condition in which the external genitalia fail to develop. Although surgically reconstructed as girls and reared as such, all are male-shifted in their gender characteristics, and nearly half of them insist they are boys or men (Reiner, 2004). It s been a monstrous failure, this idea that you can convert a child s sex by making over the genitals in the sex you ve chosen, said the author of that study. If we as physicians or scientists want to know about a person s sexual identity, we have to ask them (Dreifus, 2005).

25 118 CHAPTER 4 gender schema A collection of ideas about gender that influences perception and judgment. sexual scripts Socially negotiated roles that govern sexual behavior. Cognitive developmental models emphasize thought processes Cognitive psychologists believe that studying gender development requires getting inside children s minds to see how they think about gender. Children actively seek to make sense of the social world in which they live, and in the process they gradually develop a gender identity and acquire gender stereotypes (Martin & Ruble, 2010). One influential thinker in this area was Harvard psychologist Lawrence Kohlberg ( ). Kohlberg laid great weight on the concept of gender constancy, discussed earlier in this chapter the realization by young children that male and female are fixed attributes of individuals (Kohlberg, 1966). This realization of gender constancy becomes an organizing principle that motivates the child to develop stereotypical ideas about the characteristics of males and females such as that males are strong but cruel and that females are fearful but affectionate and to make his or her own behavior correspond to those stereotypes. Behavioral traits such as aggressiveness in boys may result from the boy s desire to demonstrate his gender attributes, according to this school of thought (Ullian, 1981). One problem with this approach to the topic, however, is that at least some gender-differentiated traits emerge before children realize the constancy of gender. Thus, purely cognitive models have been challenged by more integrative models that combine evolutionary predispositions, socialization, and cognition (Bussey & Bandura, 1999). (A) (C) (B) (D) GENDER SCHEMAS An offshoot of cognitive developmental theory that is relevant to socialization is the gender schema theory developed by Sandra Bem (Bem, 1981). A gender schema is a simplified framework of ideas about gender that influences perceptions, judgments, and memories. Under the influence of socialization, most children develop highly polarized schemas of masculinity and femininity, so that perception is based on either/or logic either masculine or feminine, but nothing in between. A variety of studies support the idea that gender schemas influence children s perceptions and memories. In one study (Figure 4.17), children were shown pictures of boys and girls performing tasks that were either consistent with gender stereotypes (e.g., girls cooking) or inconsistent with those stereotypes (e.g., girls sawing wood). When tested a week later on their recollection of the pictures, children tended to make mistakes that eliminated conflicts with stereotypes they might recall that they saw boys, rather than girls, sawing wood, for example (Martin & Halverson, 1983). In a more recent study, Timothy Frawley of Mercyhurst College asked 1st-graders to recall a story they had listened to (Frawley, 2008). The children changed the story to align with stereotypes: Children reported that a fearful girl cried (although she did not do so in the story) and that a boy who had cried in the story did not do so but was happy instead. Figure 4.17 Influence of gender stereotypes on children s memories Children recall images of gender-typical activities (A, B) accurately, but their memories of images showing gender-atypical activities (C, D) may be distorted to make them fit gender stereotypes. (After Martin & Halverson, 1983.) SEXUAL SCRIPTS Another variation on cognitive developmental models is the sexual script theory of John Gagnon and William Simon (Simon & Gagnon, 1986). As the word script suggests, this theory asserts that sexual behavior is a form of role-playing, influenced by scripts that we have learned. People are especially reliant on sexual scripts when interacting with prospective partners that they don t know very well. As we ll describe in more detail in Chapter 7, first encounters between

26 Sex and Gender Differences 119 heterosexuals have traditionally been organized according to gendered scripts governing such matters as what it means to invite someone out for a drink, who pays, and how the man and woman negotiate any sexual interactions. Scripts can change over time under the influence of culture. Early in the 20th century, for example, oral genital contact was a form of sex that men largely received from prostitutes and in transient relationships. Now, however, it has become a common and acceptable sexual practice between young adults who are hooking up or dating, and both males and females give oral sex to their partners (Reece et al., 2010). Thus, men and women today follow different scripts about oral sex than their grandparents did. Scripts, according to Gagnon and Simon, influence not only sexual dealings among people, but also the psychosexual development of individuals. They noted that postpubertal boys masturbate a great deal more than do girls, as we mentioned above, whereas girls early sexual experiences tend to be with partners. As a consequence, script theory suggests, the meaning of sex for males becomes embedded in the notion of the male s own sexual pleasure, whereas for females it becomes embedded in the notion of relationships. Some brain scientists are critical of purely cognitive models of mental development. That s because consciousness doesn t necessarily have access to the neural circuitry that underlies our feelings and motivations, or to the processes that modify that circuitry in the face of our life experiences. Joseph LeDoux, for example, has stressed the importance of delineating the invisible inner workings of the brain as a basis for understanding mental development and emphasized that the self consists of more than what self-aware organisms are consciously aware of (LeDoux, 2002). Gender Development is interactive Gender researchers, like researchers in most other areas, tend to invest themselves in certain approaches to their subject, perhaps due to the training they have received. Some are interested in biological theories, some in socialization, and so on. Yet it is unlikely that something as complex as human gender could be fully explained by any single approach. It s more probable that nature and nurture interact in the development of gender-related traits. Take, for example, a childhood trait such as toy preference. The observations of atypical toy preference in CAH girls strongly suggest that prenatal hormone exposure contributes to the gender difference in this trait. However, many parents give boys and girls gender-specific toys before the age at which gender-specific play emerges sometimes as early as 9 months (Pomerleau et al., 1990). Furthermore, children whose parents give them gender-specific toys are more likely to prefer and play with such toys than children who are given a mix of toys (Eisenberg et al., 1985; Katz & Boswell, 1986). Thus, it seems probable that there is an additive effect of biological predisposition and socialization on the development of toy preference. Another complicating factor is that the influence of socialization is not unidirectional, but can pull people in opposite directions at the same time. Concerning the male disposition to commit sexual violence, for example, some social forces strongly encourage such violence and others strongly discourage it (Figure 4.18). Given all these complexities, it will remain for future generations of researchers to fully tease out the web of causation that establishes gender. Transgender People Cross Society s Deepest Divide The term transgender is used in a broad way to encompass all individuals who have the anatomy of one sex but the gender identity of the other. The term transexual (also spelled transsexual) is used for the subset of transgender individuals who seek to change their body into that of the other sex by medical means (i.e., hormone transexual (or transsexual) A person who identifies with the other sex and who seeks to transition to the other sex by means of hormone treatment and sexreassignment surgery. Transexuals can be male-to-female (M-to-F) or female-to-male (F-to-M).

27 120 CHAPTER 4 Figure 4.18 Social influences work in contradictory ways. (A) Video games may encourage sexual violence. In Grand Theft Auto: Vice City, a man has sex with a prostitute and then beats her to death to get his money back. (B) The criminal justice system may restrain sexual violence: No one wants to join the 65,000 rapists who are serving long prison sentences. (A) (B) treatment and sex-reassignment surgery). This transition may be in either direction: male to female (M-to-F) or female to male (F-to-M). Transgender and transexual people have existed in most perhaps all human societies (Box 4.4). We focus first on transexuals and then take a look at the broader population of transgender people. gender dysphoria The unhappiness caused by discordance between a person s anatomical sex and gender identity. trans man (or transman) A female-to-male transexual. trans woman (or transwoman) A male-to-female transexual. Transexuals are of more than one kind Imagine yourself waking up one morning in a body of the other sex. Very likely you would be shocked and would move heaven and earth to get back into your right body. That is the kind of mental experience transexuals deal with on a daily basis, unless and until they undergo sex-reassignment procedures and transition to the other sex. The unhappiness caused by discordance between anatomical sex and gender identity is called gender dysphoria. Most F-to-M transexuals (also called trans men) share a similar life history. Even as very young girls they say they are boys or insist that they want to become boys, and they try to express their masculine identity in their clothing, hairstyles, friendships, activities, and career plans. Of course, this usually puts them on a collision course with the gender expectations of family, peers, and the world at large. As they enter puberty they resent the developing signs of womanhood and may seek to hide them by, for example, binding their breasts. In adulthood they seem quite masculine in many respects, and they are usually sexually attracted to women, but they do not identify as homosexual or lesbian. Rather, they identify as heterosexual men. The well-known expression man trapped in a woman s body describes them quite aptly. M-to-F transexuals (or trans women), on the other hand, fall into two contrasting types with different life histories. The first kind, who we may call classical M-to-F transexuals, are pretty much the opposite of the F-to-M transexuals just described. As young boys they say that they are girls or insist that they want to become girls, and they try to dress as girls and to play with girls. They dislike the man s body that puberty gives them and may try to pass (be identified by others) as women. Feminine mannerisms, gait, and conversational style seem to come naturally to them and often they are more feminine than many females. They are usually sexually attracted to men, but they identify as heterosexual women, not as gay men. They are women trapped in men s bodies. M-to-F transexuals of this type often seek sex reassignment in their teen years or young adulthood as soon as they are legally allowed to do so or as soon as they can raise the money to pay for it.

28 Sex and Gender Differences 121 box 4.4 Cultural Diversity Transgenders in Cross-Cultural Perspective Transgender men and women have probably existed in all human societies. in many societies, they have been given special names and accorded a special status often, a spiritual or sacred one. Throughout Polynesia, for example, there existed a class of M-to-f transgenders known as mahus. There was typically one mahu per village. The mahu dressed in female (or a mixture of female and male) attire, engaged in women s activities, and had sex with conventional men. He was attached to the village headman s household and performed sacred dances. He was traditionally accorded high status, and families encouraged or even trained one of their sons to become a mahu. from time to time, a European explorer or trader took a fancy to a mahu and brought her to his ship for sex, only to be shocked by the discovery of his male anatomy. There still exists a comparable group of M-to-F transgenders in northern india and Pakistan. Known as hijras, they cut off their genitals and work as religious dancers or as prostitutes serving men. Thailand has an especially large and visible community of M-to-f transgenders, who are known as kathoey (Figure A). Some have undergone sex reassignment. Kathoey are well accepted in the entertainment field and in some jobs typically held by women, but they face discrimination in male occupations. F-to-M transgenders have also been described in many societies. According to legend, female warriors known as Amazons battled the Greeks during the Trojan War (Figure B), and the word amazon has come to mean a tall, athletic or strongwilled woman. in the 16th century ce an explorer described female warriors among the Tupinamba indians of northeastern Brazil: There are some Indian women who determine to remain chaste: they have no commerce with men in any manner, nor would they consent to it even if refusal meant death. They give up all the duties of women and imitate men, and follow men s pursuits as if they were not women. They wear the hair cut in the same way as the men, and go to war with bows and arrows and pursue game, always in company with men; each has a woman to serve her, to whom she says she is married, and they treat each other and speak with each other as man and wife. The Amazon River was named after these women. (A) Thai transgenders (kathoey) participating in a beauty pageant In several native cultures of north America, rituals conducted at or before puberty gave a boy the option to choose between the status of a conventional male and that of a two-spirit (male female) person, or berdache (Williams, 1986). Among the Tohono O odham indians of the Sonoran Desert, for example, a boy who preferred female pursuits was tested by being placed within a brushwood enclosure, along with a man s bow and arrows and a woman s basket. The enclosure was then set on fire. if, in escaping the flames, the boy took with him the bow and arrows, he became a conventional man, but if he took the basket, he became a berdache. The berdaches wore special clothes fashioned from male and female attire, practiced mostly female occupations, and engaged in sexual relationships with conventional men. They were often shamans (healers who derived their curative powers from their knowledge of the spirit world), chanters, dancers, or mediators. In the 19th and 20th centuries some white American women successfully passed as men, in order to express a transgender identity or to take advantage of opportunities available only to the male sex or for a combination of both reasons. Some such women served as soldiers in the Civil War. Murray Hall, an influential new York politician of the 1880s and 1890s, married two women but was discovered to be a biological woman herself after she died. More recently, the bandleader Billy Tipton was thought to be a man, even by his girlfriends and at least one of his adopted children. As with Hall, Tipton s female sex was discovered at the time of his death, aged 74, in continued

29 122 CHAPTER 4 continued box 4.4 Westernization has led to considerable suffering for transgender persons in traditional societies. Under British influence, the once-honored hijras of india came to be despised. Spanish conquistadors killed many of the transgenders they encountered in Central America. in Colorado in 2001, a self-described two-spirit navajo youth, fred Martinez, Jr., was beaten to death by an 18-year-old white man, who boasted to friends that he had beat up a fag. Sources: Williams, 1986; Katz, 1992; Middlebrook, 1998; Quittner, mahu A man who took a female gender role in Polynesian society and performed ritual dances. hijra A member of a class of male-to-female transexuals in northern India and Pakistan. (B) Mounted Amazons fighting Greeks at the siege of Troy (from a Roman sarcophagus) kathoey Male-to-female transgenders in Thailand. two-spirit person In Native American cultures, a person with the spirit of both a man and a woman; a transgender person. Also called berdache. transvestism Wearing clothes of the other sex for purposes of sexual arousal. Sometimes applied to cross-dressing for any reason. autogynephilia A form of male-tofemale transexuality characterized by a man s sexual arousal at the thought of being or becoming a woman. Another kind of M-to-F transexual, however, is much less well known to the general public (Freund et al., 1982; Blanchard, 1993). During childhood, these boys are only mildly gender nonconformist, or not at all. When they grow up they are usually sexually attracted to women, so they are heterosexual with respect to their birth sex. However, their interest in women takes an unusual course, being colored with fetishistic elements. In particular, they are erotically aroused by wearing women s clothes a trait known as heterosexual transvestism. Eventually, this kind of ideation may progress to the point that they are aroused by the idea, not merely of being in women s clothes, but being in a woman s body and possessing female genitals. In other words, their desire to become a woman is fueled by the sex drive and by the desire to incorporate the object of their attractions into themselves, rather than by having a female gender identity as such. Feminine mannerisms, gait, and conversational style do not necessarily come naturally to these transexuals, and so they may take lessons on how to act like a woman. They tend to seek sex reassignment later in life, often after they have been heterosexually married and fathered children. A Canadian sexologist, Ray Blanchard, gave this second developmental pathway the name autogynephilia, meaning being attracted to oneself as a woman. Some sex researchers believe that most or all M-to-F transexuals who are sexually attracted to women are autogynephilic, which would make them at least as numerous as classical M-to-F transexuals (Bailey, 2003). Others don t find a close correlation between a M-to-F transexual s sexual orientation and whether or not that person displays characteristics of autogynephilia (Veale et al., 2008). Among M-to-F transexuals themselves, some have strongly opposed the concept of autogynephilia (James, 2004). Others have embraced the concept and added important details to its theoretical underpinnings (Lawrence, 2004). The cause or causes of transexuality are not well understood. Because, as discussed earlier, gender is influenced by biological factors such as prenatal hormones, many researchers suspect that such factors also lie behind transexuality. Consistent with this idea, there have been reports of differences in brain structure between transgender persons and conventionally gendered persons of the same birth sex (Rametti et al., 2011; Rametti et al., 2011).

30 Sex and Gender Differences 123 Changing sex is a multistage process No form of psychiatric treatment can bring a transexual person s gender identity into concordance with their biological sex. In fact, any attempt to do so would be experienced as a violation of personhood. Therefore, doctors and therapists have followed a different strategy, helping transexual people to achieve their dream of changing their anatomical sex and their social gender role (Figure 4.19). Transexuals call this process transitioning, and it may take several years to complete. From the perspective of the professionals who help people transition, the process has four major elements (World Professional Association for Transgender Health, 2008). The first element is psychological and physical evaluation. This may include psychotherapy, with the goal of probing the client s history, mental health, motivation, and education about the sex-reassignment process and the inevitable limitations of the results. The second element is known as the real-life experience. For this, the client lives and interacts with others as a member of the other sex for a period of time usually 1 to 2 years, but sometimes less. The idea is to ensure that the client can function well in the desired gender role. The third element is hormone treatment to initiate the process of bodily change. M-to-F transexuals are treated with estrogens, often in combination with androgen-blocking drugs. The effects of this treatment include changes in body fat distribution to a more female pattern, a decrease in the frequency of erections, and possibly a cessation of ejaculations. The breasts may enlarge, sometimes to a degree that makes later breast augmentation surgery unnecessary. Estrogens do not abolish facial hair or reverse baldness, however. The M-to-F client often has to undergo a lengthy process of beard removal by electrolysis or laser treatment. F-to-M transexuals are given androgens, which cause a beard to grow, though sometimes only a very thin one. The voice deepens, and the body fat distribution changes in a male direction. Because hormones do not remodel the skeleton, however, the general body shape may remain similar to that of the client s original sex. Ideally, the real-life experience precedes the hormone treatment, because not all the effects of hormone treatment can be reversed if the client decides not to go ahead with the transition. In practice, however, hormone treatment is often started early because it may be difficult to undertake the real-life experience without such treatment. The fourth element of transitioning is sex-reassignment surgery. For a M-to-F transexual, the key procedures are removal of the penis and testicles, construction of a vagina, labia, and clitoris (Figure 4.20), and augmentation of the breasts. Other procedures that may be performed include surgery on the vocal cords (to raise the pitch of the voice), liposuction to the waist, reduction of the Adam s apple, and various procedures to feminize the appearance of the face. Figure 4.20 The vulva after sex-reassignment surgery The clitoris is constructed from the top surface of the penis with its nerve supply intact and may therefore be capable of triggering orgasm. The clitoris and adjacent labial tissue are covered with mucosa derived from the penile urethra, giving them a pink color. The remainder of the penile skin, including the glans, is inverted to form the vagina. Often, additional skin must be grafted from other areas to make the vagina deep enough for coitus. (Courtesy of Eugene A. Schrang, M.D.) Figure 4.19 Chastity Bono, daughter of U.S. entertainers Sonny and Cher, transitioned to Chaz Bono in Chaz identified as a lesbian before transitioning. transitioning Changing one s physical sex and social gender. real-life experience A period of living in the role of the other sex as a prelude to sex reassignment. sex-reassignment surgery Surgery to change a person s genitals or other sexual characteristics.

31 124 CHAPTER 4 Figure 4.21 Transformation of the clitoris into a small penis by hormone treatment and surgery (metoidioplasty). This procedure is a simpler, less invasive, and less expensive alternative to the construction of a large penis usable for penetrative sex (phalloplasty). This F-to-M transexual also had a scrotum constructed from labial skin, with testicular implants. metoidioplasty Surgical contruction of a small penis from a clitoris.? FAQ How much does sexchange surgery cost? Anything from $10,000 to $150,000 and higher the latter being for procedures that include construction of a functional penis or complex facial surgeries. Going overseas (e.g., to Thailand) for surgery is a less expensive alternative. For a F-to-M transexual, surgery can include removal of the breasts, ovaries, oviducts, uterus, and vagina. (The breasts may be removed before the real-life experience if they are large enough to make passing as a man impossible.) In addition, a scrotum and penis may be constructed (i.e., scrotoplasty and phalloplasty). Construction of a penis that looks natural, contains a functioning urethra, and can be made to have an erection (with the aid of a pump/ reservoir system or some kind of stiffening device; see Chapter 14), is a very costly multistage process, and the results are far from ideal. Frequently, the new urethra develops narrowings (strictures) or unwanted openings to the outside (fistulas), which necessitate further surgery. Urinary tract infections can occur. Furthermore, there is major scarring in the body region that is used as the source of graft tissue. Because of the expense and the imperfect results, many F-to-M transexuals forgo a phalloplasty. In some clients, the clitoris can be enlarged by hormonal treatment and surgery to produce a small penis. This procedure is called metoidioplasty (Figure 4.21) (Hage, 1996). This is not generally usable for coitus, but it may be capable of erection and orgasm, and the procedure may also be psychologically and socially beneficial in confirming a male identity. Even with this simpler procedure, however, complications requiring further surgery are common. Postoperative transexuals have to make many practical decisions (for example, whether to be open about the sex change or to conceal their past), and they face all kinds of personal and social challenges. Even getting an amended birth certificate may be a struggle. Establishing sexual and affectional relationships is often difficult. Postoperative transexuals who can pass as members of their new sex have to deal with the problem of whether and when to let their prospective partners know about their history. When a heterosexual man finds out that his female partner was born a male, he may refuse to accept the reality of the sex change and may therefore reject the woman and possibly even assault her. Luckily, there are also people who are willing to accept transexuals as truly belonging to the sex with which they identify, or who are even specifically attracted to transexuals. Some transexuals remain in relationships that existed prior to their transition. Not all transexuals who wish to change sex do so via the official route just described. Some pursue another strategy (Denny & Bolin, 1997): They learn about sex reassignment through peer networks, obtain hormones on the black market, and, when they feel they are ready for surgery, go straight to a private surgeon. Of course, such self-medication carries significant risks (Moore et al., 2003). The long-term outcome of sex-reassignment surgery is mostly good. In one survey of 232 postoperative M-to-F transexuals, the overwhelming majority were well satisfied and felt that the surgery had greatly improved the quality of their lives (Lawrence, 2003). Some studies have reported that a significant proportion of postoperative transexuals are depressed or regret having undergone the transition (Eldh et al., 1997; Levine & Solomon, 2009). Better preoperative counseling and postoperative support would no doubt improve these outcomes. Among the factors that correlate with long-term satisfaction are young age at reassignment, good general psychological health, a body build that permits passing as the other sex, good family and social support, and the success of the surgical procedure itself. Most experts now believe that a transexual s sexual orientation, and whether they are autogynephilic or not, are not useful predictors of the success of sex reassignment and should not therefore be used as criteria for accepting or rejecting a person for medical assistance with the process. Because age at treatment seems to be so important, some centers (especially in Europe) are now treating children at or before puberty (Box 4.5).

32 box 4.5 Controversies How Should We Treat Gender- Dysphoric Children? In the past, children boys especially who acted in a gendernonconformist fashion or who expressed a wish to be the other sex suffered taunting and isolation at the hands of their peers and were subjected to persistent and sometimes traumatizing efforts by parents and therapists to normalize their behavior. In more recent times some parents have taken the opposite tack, respecting and even celebrating gender variance in their children. In 2010, for example, a Seattle-based mother, Cheryl Kilodavis, published a picture book titled My Princess Boy about her 4-yearold son Dyson, who likes to wear traditional pink girls clothes and sparkly jewelry. Kilodavis s mission is to accept and celebrate the unique person within us all. Many schools have become more willing to accommodate the needs of gender-dysphoric children, and a few have actually allowed such children to enroll and participate as members of the other sex (Santiago, 2006). In addition, there has been a move, especially in Europe, to facilitate sex reassignment at increasingly early ages. Because puberty produces undesired changes in gender-dysphoric children changes such as the appearance of beards or breasts that may be difficult to reverse at a later time some such children are being given drugs that postpone the onset of puberty. Then, when the child is considered old enough to make a mature decision, hormonal and surgical procedures may be instituted to induce a puberty of the kind appropriate to the child s self-declared gender. This was the path chosen by the parents of nicole Maines, a new England child who was born one of two identical twin boys, but who always identified as a girl. They helped her legally change her name from Wyatt to nicole when she was in 5th grade. At the age of 11 she was started on puberty-blocking drugs. By 2011, when the twins were 14, her brother was halfway through a typical male puberty, but nicole was 5 inches shorter than him and quite different in facial appearance and manner (see figure). it is expected that she will start taking estrogens in 2012 in order to induce an adult feminine physique, and that she will have genital sex-change surgery later in her teens. i think everything s going to turn out pretty well for me, she told the Boston Globe (English, 2011). This kind of approach could certainly ease the psychological path to sex transition for children who are destined to become transexual adults, but not all experts believe that it is the best Thanks to puberty-blocking drugs and her feminine manner, 14-yearold Nicole Maines has a radically different appearance from that of her once-identical twin brother Jonas. strategy. The reason is that, as many studies have shown, the majority of gender-dysphoric children lose their gender dysphoria as they transition through puberty, even without any treatment (Drummond et al., 2008; Wallien & Cohen-Kettenis, 2008). They may well become gay adults (see Chapter 12), but only a minority maintain their desire to change sex. it would seem counterproductive to support and facilitate a child s crossgender identity, and to take medical steps toward a sex change, if that child would eventually have become perfectly happy with his or her birth sex. Thus, Kenneth Zucker, who directs a gender-identity clinic at Toronto s Center for Addiction and Mental Health, believes that it is better to encourage gender-dysphoric children to accept their birth sex and not to look forward to an eventual transition (Zucker, 2005). This controversy could be resolved if it were possible to identify the persisters those children who will remain gender dysphoric after puberty and who therefore might truly benefit from support in their cross-gender identity and from an early sex change. To some extent, this may be possible. According to a longitudinal study by a Dutch research group, the persisters are the most radically gender-dysphoric children the ones who truly believe that they are the other sex, rather than merely wanting to be the other sex (Steensma et al., 2011). Whether this distinction is clear enough to justify selection of children for early treatment, however, is an unresolved issue. Perhaps the wisest course at present is for parents to love and support their gender-nonconformist child and for schools to protect them from bullying, but not to positively encourage or facilitate the child s desire to change sex until such time as this desire seems permanent. One problem that affects most transexuals is the expense of transitioning. Governments and insurance companies provide little or no assistance in most cases. (Medicaid does sometimes pay for sex-reassignment surgery, however.) How is a teenager or young adult to raise the money? For the majority, the expense of sex reassignment imposes a frustrating waiting period that may last for many years. A few try to raise the money through prostitution; transgender prostitutes are much in evidence in some large cities (see Chapter 17).

33 126 CHAPTER 4 Some transgenders do not want surgery The traditional view of transexuality is medical: Transexuals have a problem that needs to be treated in order to make them well. Not all transgender people accept this medical model. To some, it is society that has a problem with gender-variant people, and it is society that needs to be treated. Certainly, some Americans have an aversion to transgender people, who are victimized by abuse and hate crimes at a much higher rate than are lesbians and gay men. Could it be that the desire to change one s genital anatomy represents the internalization of these hostile attitudes? Kate Bornstein (Figure 4.22), a gender theorist who is herself a postoperative M-to-F transexual, put it this way: Figure 4.22 Kate Bornstein, a trans woman, believes that social pressures force people into impossible-tolive-up-to gender categories. Scan this or Go to the Discovering Human Sexuality Companion Website at sites.sinauer.com/ discoveringhumansexuality2e for activities, study questions, quizzes, and other study aids. People think that they have to hate their genitals in order to be transsexual. Well, some transsexuals do hate their genitals, and they act to change them. But I think that transsexuals do not naturally hate their birth-given genitals I ve not seen any evidence of that. We don t hate any part of our bodies that we weren t taught to hate. We re taught to hate parts of our bodies that aren t natural like a penis on a woman or a vagina on a man. (Bornstein, 1994.) To some extent Bornstein s point of view is supported by anthropological research. In the native culture of Samoa, for example, transgender persons (called fa afafine) rarely desire sex reassignment, because it is socially acceptable to possess a penis and yet live in a gender role that is not male (Vasey & Bartlett, 2007). Many transgender Americans do not seek sex reassignment either, for a wide variety of reasons. They may not see any contradiction between living as a woman while possessing the genitals of a man, or vice versa. They may not have the money, they may be put off by the less than ideal results, or they may be perfectly satisfied with cross-dressing and passing as a person of the other sex. This choice also gives them the option of switching between male and female roles. They may even get satisfaction from not passing from being recognizable as a gender outlaw or genderqueer rather than trying to deceive everyone. This is how one 18-year-old trans man, who has had a mastectomy but no genital surgery, put it: Some transmen want to be seen as men they want to be accepted as born men. I want to be accepted as a transman my brain is not gendered. There s this crazy gender binary that s built into all of life, that there are just two genders that are acceptable. I don t want to have to fit into that (Quart, 2008). Transgenders and transexuals struggle for awareness and acceptance Transgender adults have had a difficult struggle to gain recognition as a group distinct from lesbians and gay men. Of course, the introduction of sex-reassignment surgery in the 1960s, with all the attendant publicity, did educate the public about the phenomenon of transexuality, but it also prompted most people to accept the medical model of transexuality, which, as just mentioned, is rejected by some transgenders. One factor that has hampered the advancement of transgender people is that they are relatively few in number. Thus, their political activism has generally taken place under the umbrella of the much larger gay rights movement. In fact, transgender persons participated in the Stonewall Rebellion the 1969 riot in New York that was a key event in the modern gay rights movement (see Chapter 12). Still, like bisexuals, transgenders have fought to clarify their separate identity. In gay rights and gay pride marches and parades, transgender people form their own contingents, and these events now usually carry names such as March for Lesbian, Gay, Bisexual, and Transgender Equality. Transgender role models are beginning to appear, such as Victoria Kolakowski of California, who was elected as the nation s first transgender trial judge in 2010 (Sheridan, 2010).

34 Sex and Gender Differences 127 (A) (B) Legal protections for transgender people lag behind those for gays and lesbians, even though the transgender population is at greater risk of violence and discrimination. An attempt to introduce a federal Employment Non-Discrimination Act, with protections for transgender people, failed in On the positive side, the first-ever Congressional hearings devoted to transgender issues were held in the following year. Only 16 states have statutes that provide transgender people with protection from discrimination, and only 13 states currently include gender identity in their hate crime statutes (The District of Columbia offers both kinds of protection). One notorious case that was prosecuted as a hate crime was the murder of 17-year-old Gwen (born Edward) Araujo of Newark, California, in 2002 (Figure 4.23). According to trial testimony, four men had sex with Araujo and then killed her after they discovered she was anatomically a male. Two of the men pleaded guilty to manslaughter and two were convicted of murder, but the jury rejected the hate-crime enhancement. Figure 4.23 Transgender teen Gwen Araujo (A) and three of the men who beat her to death (B). Summary Sex is usually determined by the sex chromosomes: The XX pattern causes female development, and the XY pattern causes male development. The key player in male development is the gene SRY, on the Y chromosome, which induces the embryo s genital ridges to become testicles. In the absence of SRY, the genital ridges become ovaries. The male and female internal reproductive tracts develop from different precursors the Wolffian and Müllerian ducts. In XY embryos, the testicles secrete anti-müllerian hormone (AMH), which causes the Müllerian ducts to regress, and androgens, which cause the Wolffian ducts to develop further and produce the male internal anatomy. In XY embryos lacking functional androgen receptors (a condition called androgen insensitivity syndrome), neither the male nor the female reproductive tract develops. In XX embryos (normal females), the lack of AMH allows the Müllerian ducts to develop further, and the lack of androgens allows the Wolffian duct to regress, producing the female internal anatomy. The external genitalia of the two sexes develop from common precursors. The urethral folds give rise to the labia minora in females and to the shaft of the penis in males. The genital swellings give rise to the labia majora in females and the scrotum in males. The genital tubercle forms the external portion of the clitoris in females and the glans of the penis in males. Male-typical development of the external genitalia requires the presence of testosterone and its conversion to 5a-dihydrotestosterone (DHT). In female fetuses that are exposed to high levels of androgens (as in congenital adrenal hyperplasia), the external genitalia are partially masculinized. Some sexual differentiation of the brain occurs prenatally high levels of androgens drive male-typical brain development, and low levels permit female-typical development. At puberty and thereafter, estrogens become important in establishing and maintaining female-typical body structure and function and also influence the brain. Disorders of sex development include chromosomal anomalies such as Klinefelter syndrome (XXY) and Turner syndrome (XO), as well as genetic conditions that affect sex hormone production (e.g., congenital adrenal hyperplasia) or the body s sensitivity to sex hormones (e.g., androgen insensitivity syndrome). The proper treatment of children with ambiguous genitalia is a subject of controversy. continued