09/01/2016 02:39 pm ET Updated Sep 02, 2017

Professor Mickey Diamond: "Nature Loves Variety; Unfortunately, Society Hates It"

I have for the past four years writing my columns avoided the issue which has, to a large degree, overdetermined my life - my life as an intersex person. There are a number of reasons for this - the complexity of the issue, the involvement of endocrine disruptors in the genesis of the condition which few still want to acknowledge, its causation of the most traumatic time of my life, and the political difficulty in dealing with intersex in the context of the growing acceptance of trans rights.

Starting with the last - the success of the trans rights movement - I see sufficient progress that the old tension between the two communities in the U.S. has resolved sufficiently that it's time for the two to coexist, and there is no better underpinning to that political marriage than recognition that being trans is a form of human intersexuality. One example - now that we have open trans military service, the team that brought that about, led by Aaron Belkin, is turning its attention to intersex persons.

I believe there is no better time to discuss this than with the upcoming publication of Transsexuality in Theology and Neuroscience: Findings, Controversies and Perspectives, ed. by Gerhard Schreiber (Berlin and Boston: Walter de Gruyter 2016).

I can see this evolution in our civil rights movement also helping to elevate the issue of endocrine disruption and its impact on sexual development into greater public consciousness. Efforts have been made, from those by Deborah Rudacille in her 2003 book, The Riddle of Gender, to the recent broadcast by Dion Lim at the Tampa affiliate of CBS News earlier this year. Endocrine disruptors (EDCs), the first and best studied of which is Diethylstilbestrol (DES), have profound effects on human health and development. Of greatest concern to me has been DES's impact on sexual development, leading to intersex conditions, including transsexualism, as well as an increase in homosexuality, both male and female. DES exposure has also impacted me by causing renal failure and septic shock, and months of treatment that can be considered nothing but rape and torture, with resulting depression and PTSD. If that wasn't already enough, it also probably caused both my mother's breast cancers, with all the consequences from those experiences.

Intersex conditions are far more complex than basic transsexualism (I am not including the newer phenomena of genderqueer and non-binary identities), but I believe it's time to begin the effort. The chapter in the aforementioned book called "Transsexualism as a Form of Intersex," by our greatest basic science researcher on the subject, Professor Mickey Diamond, is the ideal source material. It is the distillation of a lifetime of work on his part which was last published in more primitive form in the 2006 paper, Atypical Gender Development - A Review. The title of this column is Mickey's favorite aphorism
- "Nature loves variety; unfortunately society hates it."

Here is Mickey's abstract of the chapter:

This paper attempts to demonstrate that there are significant natural in-born sex differences found between the brains of those called transsexual people and others. It does so by showing the differences are due to normal genetic, hormonal and environmental forces that lead eventually to differences in the transsexual person's brain. This development brings with it feelings of dysphoria regarding one's gender identity. It is such feelings that lead to a desire for sex/gender change. These brain differences are sufficient enough to conclude that persons with a transsexual condition are intersexed. Simultaneously it is recognized that many intersexed persons will switch from their assigned gender, yet many will not.

Professor Diamond begins by touching on the biological underpinnings of transsexualism, quoting a paper from Coolidge, Thede and Young from 2002 where they reported a strong heritable component, and then referencing a paper of his from 2013 where he detailed his long years of studying twins, both monozygotic (identical) and dizogytic (fraternal), which points to a genetic component. I can personally recall being told by him of a set of trans triplets!

Mickey then discusses some basic human embryology, focusing on the temporal development of genitals vs. the brain. He concludes, "It thus is clear that the brain and genitals can develop independently and under different forces," the main force being androgens, known as the primary male sex hormone. He quotes Professor William Reiner, formerly of Johns Hopkins, who famously proved the existence of human gender identity in 2004, saying,

The etiology of gender identity may be neither obvious nor easily conceptualized. Yet what is obvious is that the presence of androgen is critical. It is the determining factor in the development of [...] behavioral sexual dimorphism in humans--genital structure, [...] male-typical behaviors, masculinization of the brain [...].

The Professor continues by defining sex and various terms relating to both trans persons as well as those who are intersex, either visibly or in an occult manner, explaining that "intersex" has been categorized by the medical profession since 2006 as Disorders of Sexual Development (DSD), or, as some prefer, Variations of Sexual Development (VSD). He describes various intersex conditions, such as Klinefelter's Syndrome (47XXY, at times with a trans identity), Androgen Insensitivity Syndrome (raised as female and with a female gender identity), Congenital Adrenal Hyperplasia (masculinized women, quite often lesbian-identified), and 5-alpha reductase deficiency (common in the Dominican Republic) and 17-beta hydroxysteroid dehydrogenase deficiency (common in Gaza) (raised as girls but masculinized at puberty).

He then briefly describes the history of the discovery of sexual dimorphism (sex differences) in mammalian brains, including humans, led by Drs. Gorski, Hofman, and Swaab, and then moves on to the anatomical differences in the hypothalamus of the human brain in transsexual persons discovered by Drs. Zhou, Swaab and Kruijver. Dr. Diamond concludes,

This work supports the paradigm that, for transsexual persons, sexual differentiation of the brain and genitals may go in opposite directions and points to a neurobiological basis of transsexualism and the accompanying gender dysphoria.

Other findings have piled up over the years, showing that brain anatomy correlates with gender identity, not sex assigned at birth. Studies performed by Swaab, Garcia-Falgueras, Bao, Simon, Yokota, Rametti, Zubiarre-Elorza, Taziaux, Govier and Luders, including further brain anatomy measurements with increasingly sophisticated instrumentation, dichotic listening and oto-acoustic emission measurements, kisspeptin expression, various olfactory tests, and even dental measurements, all add to the literature which demonstrates that trans persons reflect their brain sex, or gender identity, and not their genital anatomy.

Mentioning the 2013 paper by Saraswat (Evidence Supporting the Biologic Nature of Gender Identity) and the recent book by Bevans, The Psychobiology of Transsexualism and Transgenderism, Diamond concludes,

To this investigator there seems evidence enough to consider trans persons as individuals intersexed in their brains and scant evidence to think their gender transition is a simple and unwarranted social choice.

That is the bottom line. This investigator is not just any investigator, but a leading world authority (in contrast to Paul McHugh), who recognizes that being trans is a natural, biological phenomenon, a form of human intersex development, where the sex of the brain, manifest in many different regions, differs from genital anatomy. That is a literal definition of "intersex," and while it might not seem politically relevant, it has the potential to be.

There is NO dispute within medicine that intersex persons exist. There may be embarrassment, though that has been fading, and a reluctance to discuss and study the phenomenon by physicians and researchers who are uncomfortable with their own sexuality, but the existence of, and the science underpinning, the multitude of intersex conditions is not in dispute. Even right-wing religious fundamentalist extremists like Professor Paul McHugh do not deny the existence of human intersexuality or the existence of gender identity.

They run into problems with trans persons when they try to reconcile the science with their faith. Since the intersex political movement in the U.S. has been quiet for the past decade and, even when storming the American Academy of Pediatrics garnered little media attention, the likes of McHugh just ignored that phenomenon. They have not ignored the trans experience, though, with McHugh on the attack since 1975.

Reconceptualizing transness as intersex interferes with their denial of science fact and undermines their assaults on trans persons, and particularly trans children and adolescents. Paul McHugh would never dare to shame a child born intersex, nor to claim that "God doesn't make mistakes" when it comes to such children. The reactionary fundamentalists have no problem, however, making such claims about trans persons, simply because being trans is an occult form of intersex. And just as we find it easier to marginalize the brain-disabled compared to others whose infirmity is visible to the human eye, so do the fundamentalists find it easier to condemn trans persons whose intersexuality is often confined just to the brain. Well, God doesn't make mistakes with trans persons, either. Believers can just check their Bible for confirmation.

Making this case, with due concern to maintaining the rights of those born genitally intersex and preventing any reconstructive surgery prior to the age of consent, will help educate the American population, and add confidence to federal judges, and possibly the Justices as well, when they decide cases dealing with trans persons. Equal protection means just that, and it includes the trans and, more generally, the intersex population. Just because you can't see the differences doesn't mean they don't exist, and just as you'd accept differences that are visible to you the obligation continues even when they're not discernible.

After all, when you know something to be true about yourself, you expect others to take your word for it, respect your dignity and not subject you to an MRI. Trans persons deserve the same consideration.