You think your phantom limb is bad, check out my phantom erection!
For Friday Weird Science, there is really nothing better than a good case report. And you guys are getting a GOOD one this week. Partially because it’s really good, and partially because I have just returned from the bachelorette party of a dear friend. So you now get to meet FUN Scicurious! And see how devoted Sci is? She’s so devoted she’s blogging to you in a dubious mental state! It’s because I care. And because, though last week I got to say “vagina”, this week I get to say “penis”. Hehehe.
Namba, et al. “Phantom erectile penis after sex reassignment surgery” Acta Medical Okayama, 62(3), 2008.
Also, I will warn you, I’ll describe stuff, but you probably don’t want to see the pictures. If you do want to see them, check the paper out for yourself.

Sexual reassignment
In all that I have ever read on sexual reassignment surgery, it appears to be easier to go from male to female (or hermaphrodite to female, in some cases), than to go from female to male or hermaphrodite to male. There are a lot of complications with both operations, of course, but it seems that male to female is generally less problematic. After all, it’s a lot easier to take stuff away, than to put stuff there that wasn’t there in the first place, let alone making something that wasn’t there in the first place actually functional. On the other hand, going from male to female, there are probably a lot of problems with sensitivity of the new vagina, the ability to use the muscles that surround it (if they have those), etc. But suffice to say that both operations are incredibly difficult.
This case study concerns a 52 year old who was diagnosed as a male to female transsexual, and then had his penis and testicles removed, and a vagina a clitoris were created. After the operation, she (the authors refer to the patient consistently as ‘he’, but I think it’s more polite to refer to someone as the the gender with which they identify) complained to clitoral hypersensitivity and a sensation known as “phantom erectile penis”.
A bit about phantom limbs
The first reported “phantom limb” phenomenon was described in 1871 by Weir Mitchell (oooh, that would make a GREAT Giant’s Shoulders, I need to keep that in mind…). Basically, this is the sensation that the limb is still there following amputation. Most people might think of this as merely spooky, but it can really disrupt people’s lives. Sometimes the phantom limb is in constant pain, and no pain killer will work. Sometimes the phantom limb itches horribly, and it wouldn’t matter where you scratched. For a lot of good stuff on phantom limb, I highly recommend Ramachandran’s ‘Phantoms in the Brain: Probing the Mysteries of the Human Mind’. This was the book that got me in to neuroscience, it’s very well written and incredibly cool.
When most people think of phantom limbs, they think of phantom arms or legs, maybe fingers. Probably no one thinkgs of a phantom penis. And the phenomenon is very rare. It was first described in 1951, and can result from either amputation of the penis for medical or traumatic reasons (got bit off?) or due to transitions from male to female. The transition from male to female, however, produces phantom penis far more often than penile loss due to trauma.
As far as we know currently, phantom limb works like this: For every part of your body, you’ve got sensory cortex and motor cortex (two different areas), devoted to that part specifically. This is not even counting the supplementary motor areas and other brain regions that can affect movement or sensation. But the motor and sensory cortex are the ones we’re concerned with now. The primary motor and sensory cortical areas are on either side of the central sulcus (a groove which splits the front and back of your brain), and each one has a specific map to it, called a homunculus (latin for “little man”). These homunculii are mapped out according to how much representation each area of your body gets in your brain. Areas that are very sensitive to touch, say, will get a lot more area devoted to them than those that are less sensitive.
homunculus.jpg (image courtesy of Mind Hacks)
As you can see from the picture above, certain things get a LOT more area devoted to them than others. Your hands and fingers, for example, are very sensitive and get a lot of representation. Proportionally, so do the genetalia. So there are a lot of neurons coming up from the genitalia to the cortex. When you cut off the penis and testicles, those neurons don’t carry sensory information anymore, and that area of the brain just isn’t getting all the stimulation that it’s used to. When that happens, and your brain realizes that the condition is permanent, things will start to change. The thing your brain hates most is a wasted neuron. So the brain undergoes changes in its cortical remapping, and sensory information from surrounding areas (say, the new clitoris) will come up to that area of the cortex, a phenomenon called “cross-activation”.
The Case Report
Following sexual reassigment surgery, it’s apparently pretty common to suffer from some phantom penis and phantom erectile syndrome for the first few weeks, while everything settles and cortical remapping takes place. However, in this case, the patient continued to experience the sensation of an erection for over 6 months after surgery. I can imagine that this quickly got annoying. After all, there’s nothing the poor woman can ever DO about it!
The authors performed a second surgery. It turns out that, to perform a male to female transition, you take the penis off, but you leave most of the underlying anatomy intact, the corpus spongiosum, the external urinary, etc. This meant that the nerves going up to the brain were still there, too, and could still be stimulated by the friction and stimulation from nearby areas.
What they had to do was go back in and scoop the extra parts out. Literally. This is very difficult, as the woman still has to be able to pee, and so the urethra has to remain intact, and that’s a tall order considering that the urinary and ejaculatory systems share a duct in the male. But they did do it. By scooping out the underlying tissue, they got rid of all sensory nerves going from the former penis to the brain, which allowed remapping to eventually take place, and the woman stopped suffering from phantom erectile penis.
Hehe. Phantom erectile penis. Try to say that ten times fast. Without smiling. Knew you couldn’t.
And I think it’s about time to put the data together on the post about masturbation and nasal congestion! I will hopefully be presenting the data graphs and stats soon.
Namba, Y, Sugiyama, N, Yamashita, S, Tokuyama, E, Hasegawa, K, Kimata, Y. (2008). Phantom erectile penis after sex reassignment surgery Acta Medica Okayama, 62 (3), 213-216

39 Responses

  1. Scar Wars – The Phantom Penis

  2. Scar Wars – The Phantom Penis

    Tryin’ to get some Wookie…

  3. …and that’s a tall order considering that the urinary and ejaculatory systems share a duct in the male.
    Female urinary and ejaculation systems also share the same duct.

  4. What’s really interesting is the sensation many F-to-Ms report before surgery, of having a phantom penis. After meta or the full 9 yards (or more likely, 9cm), the map becomes coherent.
    Another interesting phenomenon reported by some M-to-Fs is the lack of a body-image including external genitalia. This can and does lead to many painful accidents in childhood involving zippers. Such women have no problems after surgery, and appear to be orgasmic at a higher rate, even if anorgasmic before. Basically, the device drivers are pre-installed.
    Now if only there was some good science on this, some randomised studies rather than just a heap of anecdotal evidence… or even studies involving cases with 5alpha-reductase-2 deficiency (5alpha-RD-2) and 17beta-hydroxysteroid dehydrogenase-3 deficiency (17beta-HSD-3) whose genitalia changes from a somewhat feminine to a somewhat masculine configuration.

  5. Sometimes Dr. Isis gets phantom penis envy.

  6. Tricky, you are indeed correct, I’m a moron at 1am.
    emoryk, I really want to retitle my post now. How much you wanna bet that that was something Anakin lost when he went through that lava and came out as Darth Vader? I’d have a lot of inner anger, too.
    Zoe Brain: totally cool! I didn’t know that at all! It really brings to mind the question of how cortical mapping (in F to M) could produce that kind of sensory innervation when there is no physical basis for it. Are these people who report this actually XY with female external genetalia, or are they XX?

  7. The imagery associated with the words “scoop the extra parts out” is actually pretty disturbing. Like a pumpkin or something.

  8. Vagina pumpkins sound like a fantastic idea.
    I didn’t realize that the question of female ejactulation was solved…someone should update wikipedia so that I don’t live in darkness.

  9. Mostly 46xx, though one guy I know is a 90% 46xx / 10% 46xy mosaic. You get such minor Intersex conditions a lot in TS people. Not the majority, but still 10-100 times the rate in the general population.
    Most Intersexed people don’t have “gender issues”, and can get quite upset at the implication that they do. But again, depending on the exact nature of the syndrome they have, 10-100 times the rate in the general population.
    As an example, 10% of the 46xx people with CAH identify as male, and 30-50% of those with 46xy chromosomes and 5ARD or 17BHDD identify as female.
    There’s an article on this subject at BiGender and the Brain, but it would be good to have the input of a professional neurologist rather than an amateur like me who’s been thrust into the middle of the situation.
    We still have no idea what happened in my case in May 2005. It’s now been seriously suggested by both a specialist psych and a specialist endo that it may be “conversion syndrome”, but that sounds too much like Black Magic and JuJu to me. Doing the “boy act” for 47 years was unbelievably, insanely stressful, but I just don’t believe that the human body can change like that due to totally bottled-up psychic stress. I mean, what’s next? Limb regeneration? That would be easier, biologically speaking!
    So I remain extremely sceptical, and think it’s more likely an unidentified genetic whoopsie, like hundreds of other syndromes still not well understood.

  10. However, in this case, the patient continued to experience the sensation of an erection for over 6 months after surgery. I can imagine that this quickly got annoying. After all, there’s nothing the poor woman can ever DO about it!
    No mirror box treatment? That would get an Ig Nobel hands down (so to speak).

  11. “the authors refer to the patient consistently as ‘he’, but I think it’s more polite to refer to someone as the the gender with which they identify”
    Perhaps so, but it seems to me that if scientific journals should strive for accuracy rather than politeness, then calling some dude who gets his pecker lopped off “he” rather than “she” would be the way to go.
    Fascinating post, though I’m rather startled that doctors would resort to such radical surgery to treat what seems to be a mental illness rather than physical. Or am I mistaken and is the transsexual condition the result of some kind of developmntal defect of the reproductive or endocrine system as with intersexed individuals? WTF?!??

  12. excerpted from:
    Severence Pain
    Jonathan Vos Post
    Sometimes after amputation the patient thinks he feels a phantom limb, same time, same place,
    same channel, where there is pale air only. A man with a splinter
    underneath his fingernail was driving to a doctor to extract it
    when a car crash cut his arm off. After the pain
    of the accident, he ached incurably from
    the phantom splinter in his
    phantom hand.
    [12 sep 74]

  13. Jomega:
    Yes, there is some evidence that transgenderedness has a physical basis, that there is actually a mismatch between the brain and the body, the brain developing along lines more typical of one sex, while the body exhibits the opposite sex.
    Even if it weren’t, gender reassignment surgery has a much higher rate of success, in terms of patient satisfaction, than any psychological treatment yet found.

  14. I have an uncle that had half of an index finger crushed (irrepairably) (sic?) in an industrial accident. At the time of the accident his fingernails were caked with a mixture of grit, dirt, grease, etc. To this day (this happened some 20+ yrs ago), he relates that he can STILL feel the grime beneath that (nonexistent) fingernail!

  15. jomega – it was theorised quite early on that there was a physical basis for Transsexuality. It had all the characteristics of a biological rather than psychiatric condition, but there was no evidence. Well, no evidence other than that nothing else fit.
    Surgery was originally offered purely on a harm-minimisation basis. Nothing else worked, not psychotherapy, cognitive therapy, psychotropic drugs, aversion therapy using nausea-inducing drugs and electrodes attached to eyeballs and genitals, ECT, leucotomy and lobotomy… All of the above (plus exorcism, spirit release therapy and the like, the psychs got quite desperate) were about as effective at curing it as they are at curing congenital deafness.
    Then in the mid-90’s, evidence started coming in, first from autopsies, then (later) fMRI scans of living subjects.
    The BiGender and the Brain article above has lots of links, but here’s a few.
    Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. by Berglund et al
    A Sex Difference in the Human Brain and its Relation to Transsexuality by Zhou et al.
    Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus by Kruijver et al
    fMRT zur Diagnose bei Transsexualitaet geprueft and for the Teutonically-challenged, a translation of the conclusion:

    Radiologists can now confirm what transsexuals report – that they feel “trapped in the wrong body” – on the basis of the activation of the brain when presented with erotic stimuli. There is obviously a biological correlation with the subjective feelings.

    And so on and so on. All the samples are necessarily too small for comfort individually, but they’re all consistent, and when put together are quite convincing. The contrary hypothesis, that there is no biological basis, that these are a long series of hundreds of coincidences, is pure conjecture.
    Unfortunately there’s too much hand-waving in the details. We have good evidence for correlation, but none for causation. We have conjectures and anecdotal evidence, but until we know enough to show, for example, what causes people to be left-handed, right-handed, or ambidextrous, we can only surmise. BTW Transsexuals have a very high rate of ambidexterity. That should tell us something, but we have little idea what.

  16. Paper Hand: Thanks. Your answer already has new questions oozing from my brain. I’m off to go look shit up now!

  17. jomega – look at my post on Oct 10 – BiGender and the Brain has the links you’re looking for, or most of them.

  18. jomega –
    There have been numerous studies to corroborate a physical basis to transgender identity in those who identify as such. It is by no means a mental problem, nor, I think, is anything a problem for them other than the fact that their physical sex doesn’t match up with their gender expression.
    I think you’re a bit of a transphobe, in any case.
    – a neuroscience student who is also an ally

  19. Easy there, Katherine, jomega’s gonna go look stuff up. It’s a difficult concept for many people to grasp, especially since a lot of the information about it isn’t really in the public eye.
    Zoe Brain: thanks so much for all the info! I only started learning about transgender operations when I read “Sexing the Body” by Anne Fausto-Sterling, but I was very affected by her descriptions, and I’m excited to know how much more info is out there! I will definitely be checking out your blog!

  20. “the authors refer to the patient consistently as ‘he’, but I think it’s more polite to refer to someone as the the gender with which they identify”
    Indeed it is; it would in fact have been polite to refer to the patient as “she” thoughout, since (barring exceptional circumstances such as being an Arab prince with more money than God) gender reassignment surgery is not done until long after the patient has begun identifying as female (for MTF transsexuals).
    Interesting article, though. I find the phantom pain rather surprising, since as I understand it the surgery is not so much cutting off the penis as turning it inside out – some internal matter is necessarily removed, but as much of the surface (and the nerves leading to it) is left in place as possible… I would expect a “phantom erection” to be, and to be perceived as, a hardening of the clitoris.

  21. I wonder if, a la Phantoms in the Brain, rather than scooping out underlying tissue in a procedure that was bound to increase risks of scarification, infection, and (important re: genital surgery) loss of sensation, they had instead employed Ramachandran’s mirror therapy. A bit of Our Bodies, Ourselves inspired hand mirror and flashlight time each day, if successful, would have offered a cheaper and possibly more satisfying result.
    As an aside, re: comments about hardening of the clitoris, my understanding from MTF transsexuals I have known is that b/c it is constructed of tissue from the glans, the constructed clitoris does indeed harden and enlarge when aroused.

  22. Erm, if there’s an actual physical brain malfunction, then could someone please direct me to the appropriate research? Because some lucky sod would have just discovered the gender gene or gender brain bit and why aren’t the misogynistis shouting this from the rooftops? My beef with transgenderism is the definition:
    Transgenderism is the unsubstantiated belief that a normal healthy sane person is born with a genderized brain which correctly matches their biological sex, while transfolk are born with a mis-matched gendered brain and body.
    Even though they usually don’t express their belief in quite such explicit terms, it isn’t possible to define transgenderism to their satisfaction without also defining “normal healthy sane biological female”. So a healthy sane biological female has a female gendered brain which is different from a male gendered brain; and as a result of those brain differences, a female gendered brain will therefore be less good at some tasks then a man’s.
    If gender is real then you my dear have a very pink girly brain which is genetically incapable of performing well that which only biological males are good at and you deserve your unequal pay because you in fact cannot perform that job as well as a man. Or perhaps you should just stay home and take care of the babies, because your genderized brain is rilly good at that.
    The other question is why are we allowing the mentally ill to operate in a professional capacity as therapists?
    And if the rule is that one’s self-identity must be honored without question, then everyone needs to lick my boots pronto, because I think I’m the Queen of England.

  23. mAndrea’s reputation precedes her.
    If I may quote from her monomaniacally anti-trans blog,

    If the transgendered are going to claim that ‘subjective life experience’ proves that the underlying ideology guiding that life experience is valid, then the following are true as well: The life experience of pedophiles proves that sex with children is beneficial to pedophiles and as a consequence society should be looking for ways to mitigate the harm to children who are raped by pedophiles so that the benefit to pedophiles can continue. The life experience of females who have been raped by every male relative they know proves that all men are rapists and as a consequence all men should be leashed. The life experience of rapists prove that rape is good. The life experience of transitioning proves that transitioning is good. The life experience of alcoholics proves that they feel relief and more relaxed when other people stop trying to take away their bottle.

    Not that she’s comparing transsexuals to pedophiles, rapists, and alcoholics, (nudge nudge wink wink).
    m Andrea has quite a name for transphobia. Whether that name is justified or not, I leave to others to decide, as I can’t be objective. Her blog – and her posts on other blogs – is not quite 100% vituperatively critical of anything trans, but is over 95%. She has an obsession about the issue.
    This is from PART TWO: Deconstructing Transgenderism for non-radical feminists also on her blog.

    But all along feminists have been insisting that the differences between men and women are minor; and also insisting that because those differences are minor, then segregating jobs and other skillsets is discrimination. But darlings, when those differences become worth switching body parts over, then those differences become major, and then gender discrimination becomes not only reasonable but acceptable. It ceases to be discrimination at all, and becomes instead a normalized condition of womanhood.

    Sexism and it’s close friend misogyny are propagated by the idea that women are very different from men, and have very different skillsets which conveniently are not as shiny as the skillsets belonging to men.
    We know men will take advantage of any opportunity to normalize gender discrimination because that is the over-whelming pattern. Until vanilla feminists are willing to seriously argue that sexism is permanently eradicated, then we can expect that pattern to continue in some form, and so it behooves a person not blinded by fairy lights to look for ways men will subvert women’s status. And darlings, transgenderism is as great an opportunity for subversion of women’s status as the sexual liberation was back in the 60’s.

    Transsexuality cannot have a biological cause, because if it did, it would undermine Feminist Theory. Undermining Feminist Theory causes repression, persecution, and injustice. Therefore Transsexuality as a biological condition cannot be allowed to exist, and in the words of the Feminist Janice Raymond,

    “I contend that the problem of transsexualism would be best served by morally mandating it out of existence.”

    This is about politics, not Science. It’s about the post-modernist view of science (and every other activity) as being nothing but tools in a power-game, with only an insignificant correspondence to any objective reality.

  24. I’ll try to answer m Andrea’s points as best as I may.
    First, there is no such thing as a “male brain” and a “female brain”.
    Human brains have a set of characteristics, characteristics which lead to behaviour patterns.
    Some of these characteristics are sexually dimorphic – that is, the majority of males tend to conform broadly to one cluster of values in any one characteristic, and the majority of females tend to conform broadly to another set. It’s entirely usual to have a female whose characteristics will usually be “typically female”, but with some that will be “typically male” or somewhere in the middle.
    Analogies are always suspect, but it’s like saying “Men are taller than women”. Well, no, they’re not. Most men tend to be taller than most women, but there’s plenty of women who are taller than most men, and plenty of men who are shorter than most women.
    The one area of the brain that appears to be cross-gendered in transsexuality is the lymbic nucleus. We know that other parts are almost never cross-gendered, and yet other parts are usually cross-gendered to a greater or lesser degree. “Gendered” meaning “more typically found in females than males” or vice-versa. Worse, some parts are quite sensitive to sex-specific hormones, and others are not. Changing hormonal balance, either by pregnancy or hormone replacement therapy, causes gross neuroanatomical effects in some structures, though not the lymbic nucleus.
    How that leads to the formation of a cross-gendered Gender Identity is not proven, but Milton Diamond’s Biased-Interaction Theory has passed every test thrown at it. Certainly it describes my own case with amazing accuracy.
    Women in our society tend to have different talents, different emotional responses, and different behaviours in some respects than men. This is biologically caused, often by hormonal cycles, or may be due to typically gendered neurology.
    But all of these are “tendencies”. Discriminating on the basis of appearance rather than actual observed behaviour and talents in an individual is illogical and in many cases unjust. It is the very definition of unreasonable prejudice.
    Moreover, most of what we think of “gendered behaviour” is purely a social construct, with no biological basis whatsoever. Feminist Theory which insists on no significant inherent difference is mostly correct. 75%? 80%? 90%? Something like that.
    Western Society tends to value certain talents more than others. For example, actuarial accountants make a lot more than paramedics. Plumbers make a lot more than Rocket scientists. All of them make more than Kindergarten teachers.
    The latter is caused by a distortion of the market. m Andrea is spot on when she talks about the Patriarchy. It exists, it’s repressive, and we can even quantify the degree of repression now. it is no coincidence that the areas where more women are likely to be more talented than most men are under-valued in monetary and status terms.
    This has changed to some degree – in InfoTech, it’s women who tend to have talents that put them in the higher-paying analyst and management positions rather than the lower-paid programming jobs. But a woman doing the same job as a man is likely to be paid 15-30% less .
    So yes, those of us researching the genuine sexually dimorphic differences in human cognition had better be extremely careful that our work is not misinterpreted by others to further an odious and contrary-to-reality political agenda. We have a responsibility to see that it doesn’t. To that extent, m Andrea is right.
    To the extent that she denies the biological realities, she is wrong. To the extent that she uses her considerable intellect and wit to denigrate, insult, oppress, and devalue women belonging to a minority group even more denigrated, insulted, oppressed and devalued than her own relatively privileged one, she is dangerously wrong, and in a moral sense. Though she does it from the highest of motives, you know, can’t make an omelette and all that. The needs of the many outweigh the needs of the few. They’re not *really* women anyway, they’re part of the oppressive class, so deserve all they get.

  25. Thank you very much, Zoe. That was the first time I have ever heard a transgendered person acknowledge sexism as a serious and on-going issue. In all my readings of transfolk or interactions with same, your comment was the absolute first to go beyond a disclaimer — as opposed to an actual acknowledgment. We have progress!
    I would never deny the biological differences between males and females, else my first “sexism is inherent” proof would never have been developed. My contention HERE is that under normal circumstances, one’s birth body is capable of expressing any and every type of internal character which one may possess; and as such, one’s internal character is independent of physical bodies.
    Transgenderism insists that internal character must be physically matched to a biological sex.
    Zoe, proving that physiological differences exist among biological sex does not prove that specific internal characteristics are limited mostly to one sex, nor does it prove the absence of cultural conditioning, nor does it prove a requirement to switch body parts, not does it prove transfolk are mentally healthy.
    See how logically male my brain works? Yet, if you were to meet me in person you’d think I look like a barbie doll, I am so adorable and squishy. My brain does not match my body AT ALL, according to your own rules of how things should be; and while these sexist rules enrage me, my solution is to encourage society into accepting people for who they are on the inside — not force the body into ancient notions of gender roles.
    My issue with transgenderism is how it is classified. Do people with mental disorders become licenced therapists? Alcoholics run 12-step programs to encourage others to stop, but we don’t tolerate their false propaganda regarding the health benefits of binge drinking.
    If the assertion is that gender is real, then the thing from which gender itself originates needs to be found, because it’s completely idiotic to pass laws based on unfounded assumptions, and which fuel an increase in sexism — see my last post for proof. The logical argument is contained only within the first section and the last.
    Aother implicit assumption is that males have the ability and/or desire to cease sexist behavior; and this cessation will continue even in the presence of yet more stimulation. PROVE IT.

  26. This is a Science blog, and the last few posts illustrate the difference between CP Snow’s “Two Cultures”.
    Those here aren’t cynics, but they’re sceptics, so any views expressed here are expected to “put up or shut up”, to give references, and usually quantitative data too. Numbers.
    The dielectical tricks of distorting what others have to say won’t work. That’s why I asked you to correct me in my interpretation of what you said. And why I stressed “tendencies” and “judging the individual”.

    See how logically male my brain works? Yet, if you were to meet me in person you’d think I look like a barbie doll, I am so adorable and squishy. My brain does not match my body AT ALL, according to your own rules of how things should be;

    A perfect example (with added snark) of the kind of thing that won’t wash in these circles, not when my post above showing what I actually said is visible for all to see. Nothing about arrogant “rules”. I know you’re from a different culture, not used to this, but it’s the way Science works.
    Or rather, is supposed to work, being a human activity it doesn’t always measure up to the ideal. The Post-Modernists aren’t completely wrong.
    Moving right along.
    Regarding mental illness… how quickly you forget!
    Here‘s a paper from 1996, only 12 years ago. A selection:

    Typically, gender-narcissistic females would complain that their femininity was a “handicap,” the role of wife and mother was “demeaning,” and their reproductive organs were “disgusting” or “a monthly pain.”

    They reported a generalized anger about what they saw as “men’s attitudes toward them,” which contrasted with the more positive reports of those in the control group. Some of the former made no distinctions between “good” and “bad” men, while others, utilizing the defense mechanism of splitting, saw some men, generally heterosexual men, as all-bad (inherently sexist) and some men, generally homosexual men, as all-good (nonsexist). At the same time, they generally idealized women, citing their moral superiority. I interpreted this as their projecting negative judgments about their femininity onto men while erecting a narcissistic armor of female grandiosity. Many made men the scapegoats for their inner conflicts about their femininity, vocalizing sentiments that have become common among militant feminist circles such as, “Men are the cause of all the problems of women.” Thus, they were competitive with men, rather than cooperative, wielding the attitude expressed in the song lyric,”I can do anything better than you’can.”

    It’s not so long ago that views like yours were pathologised as a mental illness too. It’s a cliche, but it is genuinely one of the tools of the Patriarchy, to ensure “the proper order” is maintained. See also Drapetomania.
    You’re using the exact same tools too, denying narratives etc. All the things you so rightly rail against when they’re done to women – or rather, some women, the right kind of women. Those that conform to your own rules of how things should be. Those who don’t say My brain does not match my body AT ALL so to speak. That may show you the scope of the problem. Men, in my experience, have no idea what “male privilege” means, and will deny its existence due to that lack of awareness. Just like you. In this particular context, you’re not just an ally of the Patriarchy, a tool, you’re an integral part of it. I wonder if you’ll ever realise that? No matter.
    As regards Sexism – you obviously don’t have much experience with TS women. We are acutely aware of the “demotion” we take in transition. OK, technically I’m Intersexed rather than Transsexual, my transition a matter of natural change rather than therapeutic measures, but close enough. I didn’t want to give up male privilege, but now that it’s happened, the sheer relief is enormous, and worth the cost, at least, in my case.
    One metric of that cost, because we can quantify it now with measurements, is given in Before and After: Gender Transitions, Human Capital, and Workplace Experiences by Schilt K, Wiswall M in The B.E. Journal of Economic Analysis & Policy
    MtoF transitioners get a 33% pay cut. FtoM transitioners get a 1.5% pay rise. This shows that Sexism has an even more severe effect than Transphobia, by about 10%.
    Yes, 90% of the oppression that women get from the Patriarchy, Transsexuals get too. Transsexual women get all that, plus the oppression for being women as well. Worse, some in the Feminist movement cast them out, so they don’t even have the normal supportive resources.
    You should also remember that perhaps 9 in 10 TS women are “stealth”. You’d be astonished at how many in the various Feminist movements, both Vanilla and RadFem, have to be careful about others finding out their medical history.
    Lots of TS women talk about Sexism, and fight it. They just don’t all reveal that they’re TS, because of attitudes like, well, yours.
    My apologies to all for aiding and abetting the change of subject, from hard science to Gender Politics.

  27. @scicurious. I would hypothesize that a phantom penis in an F2M would occur via a similar mechanism to phantom sensation in any other congenitally-absent limb. (Brugger 2000)
    One would therefore expect that prosthesis use could relieve the problem in the same way as is known for other limbs. (Giummarra 2007) F2Ms often report from childhood, spontaneously ‘packing’ their underwear with any suitably sized cylindrical object.
    In the reverse case, where a M2F feels a phantom penis (when presumably she never felt the need for a penis in the first place), I’d hypothesize that perhaps the majority of the brain developed along female lines, but wherever the body map is encoded (no citation, I’m handwaving here) got encoded ‘male’. Alternately, we know things like mirror training can relieve phantom limb pain and also that you can hide someone’s real limb and twist a prosthetic limb (that the subject can see) into an uncomfortable position and the subject can feel pain – so maybe some M2F women just ‘trained’ themselves into feeling a penis.
    Brugger et al., 2000 P. Brugger, S.S. Kollias, R.M. M�ri, G. Crelier and M.-C. Hepp-Reymond, Beyond re-membering: phantom sensations of congenitally absent limbs, Proc. Natl. Acad. Sci. U. S. A. 97 (2000), pp. 6167�6172
    Melita J. Giummarra, Stephen J. Gibson, Nellie Georgiou-Karistianis, John L. Bradshaw, Central mechanisms in phantom limb perception: The past, present and future, Brain Research ReviewsVolume 54, Issue 1, , April 2007, Pages 219-232.

  28. I believe the classic work comparing cis and trans brains is still Kruijver et al. 2000, despite the small sample (so they limited their conclusions to trans women):
    This drew on earlier work by Zhou et al., members of the same team:

  29. No apologies needed, Zoe. Thanks for supplying so much information!
    And David and Marja, those are excellent links! I might try and put up some more stuff on phantom limb (though maybe not phantom penis) sometime soon, it seems people are interested.

  30. Zoe, the intersexed get a free pass in my book, perhaps I should have mentioned that. Transfolk have normal chromsomes, comprise .007% of the population, and literally only a handful of those are intersexed. The intersexed organizations are strongly opposed to body modification surgery.
    The idea that hard science should exclude everything but numbers is a patriarchal concept. Economists use that technique constantly when they ignore the high cost paid by the environment and disenfranchised groups in their relentless search for profits. You will find interesting a book review to be posted after permission is granted. It has nothing to do with medicine, but the sign of true intelligence is the ability to apply the lessons learned from one field to another, and I’m sure the scientisty folks can manage. To say that medical science should ignore the cost paid by half of humanity for the benefit of .007% is insane and cruel and proves my point that males are incapable of non-sexist behavior.
    Besides that, the thing which drives a person to seek body modification surgery is not proven to be the identical thing from which gender itself orignates, which is also still unproven.
    It is entirely appropriate to support the rights of people who are suffering from mental disorders — it’s a health issue like any other, one which receives undeserved stigma and ridicule. But discrimination of any kind is based upon the idea that some group is inherently “different” or “inferior” from another group. Equality cannot be granted to those who are truly inferior, their rights must be attained on the basis “in spite of” their handicap. Females are not handicapped, unless one considers that a male human is the default.
    The transfolk are claiming that the non-transgendered are defective, if you follow the logic to the end. One cannot be both healthy and non-healthy at the same time, though it is possible to be slightly one or the other (which would technically be non-healthy). One cannot say that it is healthy to possess the desire to switch body parts while at the same time also say that it is healthy to possess satisfaction with one’s birth body. While both of those actions are an expression of one’s right to bodily autonomy, they both cannot be the highest state of health; one must by default be more healthy than the other.
    Also, it is postmodernism which attempts to eliminate the possiblity of any concept ever attaining the status of falsehood or invalidation — which is anathema to logic — so to ever use that term in reference to myself displays a profound lack of insight.
    Again, Zoe, it is the classification of transgenderism which is at issue. Either it is a mental illness, or it is not.

  31. “One cannot say that it is healthy to possess the desire to switch body parts while at the same time also say that it is healthy to possess satisfaction with one’s birth body. While both of those actions are an expression of one’s right to bodily autonomy, they both cannot be the highest state of health; one must by default be more healthy than the other.”
    Two opposite conditions can both be healthy. Being a woman is healthy [for women]. Being a man is healthy [for men]. The desire to treat cancer is healthy – if one has cancer. The desire not to treat cancer is healthy – if one does not have cancer, or if one does but finds the costs and side-effects outweigh the benefits.
    Would you suggest that any of these are more healthy? Would you suggest that any are less healthy?
    I do not consider the mismatch between [parts of] my brain and [parts of] my body a healthy condition; I consider my desire to treat it healthy.

  32. m Andrea – it’s true that Gender Identity Disorder is in the DSM-IV-TR, the manual of diagnosing psychiatric illnesses. It is a psychiatric illness in that context.
    The code is 302.85 for adults, and 302.6 for children, or if there is any non-neurological Intersex condition involved. You may give a “free pass” to the Intersexed, but the Patriarchy and psychiatric establishment do not. Any distress caused by a mismatch between reality and arbitrary assignment is considered a psychiatric illness.
    But so is having been raped – the codes there are 995.81 (if raped as an adult) and 995.5 (if raped as a child).
    In fact, it’s not the biological cause that is the psychiatric illness, but the anxiety, depression and other sequelae resultant from the biological cause that requires treatment. For some, putting an end to the underlying cause, be it repeated physical abuse or brain/body mismatch, can affect a complete cure. For others, psychotherapy may be needed, or at least, an end to the Patriarchal system of stigma and shame that further victimises the victims.
    It wasn’t that long ago that the idea of having rape victims have a say in their own treatment was anathema too. The arguments both for and against are identical.
    It’s not true that Intersex organisations are against surgery. They are against *involuntary* surgery, surgery without consent. They believe that until the patient can tell us what gender they are, surgical intervention should be minimal, and aimed at preserving urinary, sensate and reproductive functionality, not mere socially-acceptable cosmesis, that will leave the child transsexual in at least 10% of cases, possibly 30%.
    I have no idea where you get the 0.007% figure from. There is much confusion about the exact definition of “Intersex”, that may account for it. Using the most inclusive definition, where the soma is neither 100% male nor 100% female, the incidence is 1.7% (See Fausto-Sterling et al).
    While this may be technically true, the majority of such cases would only be detectable through extensive lab tests, they are essentially asymptomatic, though many compromise fertility. Others are asymptomatic at birth, only developing symptoms later – such as sex reversal, as in my case.
    At the other extreme is Leonard Sax’s definition, which excludes many syndromes recognised by all Intersex groups as being Intersex conditions. His figure is 0.02%. But to get to this low figure, he has to exclude Kleinfelter Syndrome (47xxy not 46xy or 46xx) and other conditions. Even though some 47xxy people have fathered children, and other 47xxy people have given birth.
    I tend towards the inclusive definition myself, while admitting the difficulties. However, I can’t be objective about it.
    Regardless of the incidence, if it is deemed desirable on Utilitarian grounds that a minority suffer “for the greater good”, we should be honest about it. We should not seek to minimise the size of the group affected, nor bury or ignore scientific evidence just to feel less guilty.
    The evidence from Kruiver, Zhang et al has already been mentioned. Now that is open to reasonable attack on the grounds of lack of replication – not that attempts have been made to replicate it that have failed, but that no attempts have been made. It is open to attack on the grounds of small sample sizes, though the sample size is not insubstantial compared to the universal set.
    But to that evidence, I’d add that of Berglund – “Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids” – Bentz – “A common polymorphism of the SRD5A2 gene and transsexualism.” – Kerlin “Prenatal Exposure to Diethylstilbestrol (DES) in Males and Gender-Related Disorders: Results from a 5-Year Study ” and “The Presence of Gender Dysphoria, Transsexualism, and Disorders of Sexual Differentiation in Males Prenatally Exposed to Diethylstilbestrol: Initial Evidence from a 5-Year Study” – and especially Krause – “Geschlechtsspezifische Differenzen der Hirnaktivitaet in der fMRT bei Normalprobanden im Vergleich mit transsexuellen Probanden”. For the teutonically challenged, that’s “Gender differences in brain activity between normal volunteers compared with transsexual subjects in functional magneto-resonance imaging”.
    We’re not sure what the exact mechanism is or mechanisms are that cause transsexuality. It appears to be the combination of an atypical hormonal environment in the womb, combined with a genetic pre-disposition. We’re now confident though that we know what transsexuality is. A (partly, mostly or completely) male brain in a (partly, mostly, or completely) female body, or the reverse.
    If you give the Intersexed a “free pass”, they qualify too. Unless you restrict your definition of “Intersexed” unreasonably, or deem all these papers – none of which have been contradicted – to be a long chain of individual 1 in a million coincidences.
    Going beyond the dry, dusty numbers inherent in Science, I’ll quote the Full Bench of the Family Court in Australia, back in 2003, when the data was far more scanty, but still overwhelming:
    “There should be no escape for medical and legal authorities that these definitions (of male and female) ought to be corrected and updated when new information becomes available, particularly when our outdated definitions bring suffering to some of our fellow human beings.”

  33. Zoe, the intersexed get a free pass in my book, perhaps I should have mentioned that.
    And this is where you, along with the mental health establishment who consider being IS a contraindication to the GID diagnosis, give the game away.
    According to you and the DSM, I am mentally ill. So next month, I go and get my chromosomes tested, and it turns out I’m XXY*. Nothing whatsoever about my life history, thoughts, feelings, behaviors, anything that makes up the diagnostic criteria for any kind of mental illness, changes in the slightest. Only now I get a “free pass” from you and the psych establishment and am no longer mentally ill.
    Oh, but it gets better. Some XXY individuals live as men, some as women. But both are considered exempt by you and the psych establishment from being diagnosed as mentally ill. Logically, if we follow you and the psych establishment, one of those two sub-groups must be mentally ill, but which one? Oh wait, there’s that “free pass” to rescue us from the tyranny of following assertions to their logical conclusions, whew!
    This may explain part of your confusion:
    Transgenderism insists that internal character must be physically matched to a biological sex.
    Nope. There is a huuuuuuuge range of opinion under the “transgender” umbrella. Even if you restrict yourself to transsexuals, quite a small subset of the transgendered, there’s no insistence on any particular course. The majority of female-to-male transsexuals don’t get SRS because their version is way more expensive and the current results aren’t really that good (which, aside, is why it’s often assumed that male-to-females are three times as common, they’re usually counting by surgery rates which greatly undercounts female-to-males).
    it wasn’t necessary to change legal documents and
    there wasn’t the risk of getting killed if the wrong person somehow inadvertently found out a la Tyra Hunter and
    the sexual options for women with penises weren’t (in my opinion) limited and unattractive
    then I probably wouldn’t have bothered with surgery.
    *As far as I know, I have no chromosomal abnormalities.

  34. Ooh wait! It gets even better!
    David Reimer had no intersexed conditions, so he can’t get your free pass.
    He did have the insistence that his internal character needed to be matched to a biological sex.
    Did David Reimer suffer from the mental illness of transgenderism?
    Why or why not?

  35. m Andrea, I think you’re laboring under a misconception about what drives transsexuals to seek body modification. I can’t fault you for it, because most transsexuals seem to labor under similar misconceptions. I think it stems from the fact that our language lumps a whole bunch of often-correlated but in fact causally-distinct things under the labels of “male/masculine” and “female/feminine.” It makes it hard sometimes to even think clearly about all this, let alone talk about it. As I’m sure you’ve experienced as a feminist writer.
    So here’s the deal, as I see it. There are two parts to it: self-identification, and body map. I’m not sure if they’re causally distinct from each other, but I suspect they might be. I think both are usually factors in transsexualism, though.
    Self-identification is which gender one perceives oneself to be–male or female. It’s not based in the slightest on preferences for one or the other set of traditional gender role behaviors, nor anything else I can quite pin down. Zoe points to Diamond’s research about how you figure it out based on comparing your emotional reactions to things and your ways of thinking about things to those around you; I suppose that could be it. At least, I haven’t noticed any glaring ways that contradicts my own experience. In any case, I know from personal experience that one can perceive oneself as female and still be more interested in numbers and guns than in gossip and babies (my very feminine-looking accountant mother comes to mind), or perceive oneself as male and still be more interested in poetry and dance than in machinery and sports (my very masculine-appearing actor father comes to mind). I grew up in this environment that completely contradicted traditional sex/gender stereotypes, and was explicitly raised to believe in the feminist ideals of equal opportunity, being judged on individual merits rather than stereotypes, and the idea that there was no type of work that was strictly “women’s work” or “men’s work.” Because of what I saw around me, I had no trouble accepting those ideals, either. In spite of all that, somehow you just “know” which one you are, and you seek role models of the same gender who seem to share your interests and values. For about 99.9% of the non- or only-subtly-intersex population, give or take a factor of two, your gender matches your body’s sex, so you naturally go through life assuming that’s how you figured it out, but cases like David Reimer prove pretty conclusively otherwise. As I said, I guess Diamond’s theory is as good as any we’ve got for now.
    Anyway, identifying yourself as one gender while the rest of the world identifies you as the other is an incredibly frustrating way to grow up. You don’t feel you fit in with those who see you as being like them, and those who you see as being like yourself, don’t agree and exclude you in subtle and not-so-subtle ways. Then there’s the fact that you more or less automatically absorb and internalize all the messages that society throws at you for your self-identified gender, like everyone else does, and they’re there at your disposal whether you buy into them or not, but there are consequences for not behaving in the ways expected of the gender others see you as, so you spend your life having to consciously learn and practice those things that don’t come “naturally” in order to fit in. All because your body doesn’t match their expectations for the gender you self-identify as.
    If that were all there was to it, then “simply” changing society to truly accept that gender identity isn’t tied to body sex–that some women have penises and some men have vulvas–might obviate the need for surgery. But even if that were practical (a long-term project if ever there was one), and even if society didn’t promote idealized images of male and female bodies for us all to aspire to, that’s not all there is to it. There’s the body map part, too.
    By “body map” I don’t necessarily mean the actual brain-body map that’s involved in phantom limb syndrome, but I strongly suspect that’s got something (possibly quite a lot, maybe everything) to do with it. But whether it does or not, the transsexual has this feeling (which I suspect is causally separate from gender self-identification) that the body isn’t right, that she or he has wrong-shaped genitals and a wrong-shaped body, a feeling that gets amplified when the sexually dimorphic hormone-induced changes of puberty start happening.
    So, you have this (often rather severe) body discomfort along with the (also often rather severe) social discomfort caused by the way others treat you because of this (wrong) body, even in milieus where misogyny and misandry and sex stereotyping aren’t issues. Either of these alone might or might not be tolerable enough to forego the risks and financial burdens of surgery and the anticipated social and financial costs of transphobia and (for MtFs) misogyny, but together they usually combine to make even those risks and costs a good trade-off.
    Now, if you have evidence to back up the idea that either the gender self-identification or the mismatched body map are entirely non-biological (i.e. purely “psychological”) in origin, I’m open to considering it and seeing how it affects my understanding. I’ve looked and haven’t found any myself, but that doesn’t necessarily mean it doesn’t exist.
    The fact remains, though, that there’s no known way to change gender self-identification (cognitive-behavioral techniques can only help you learn to suppress or ignore the feeling, and only temporarily at best) or to alleviate the body discomfort without surgery. And if there were–well, how would that be different, morally, from psychologists or psychiatrists “helping” you be rational and accept things the way they are instead of constantly banging your head against a brick wall working to change the world for what you (but not they) consider “the better?”
    I guess the point I’m trying to get across, m Andrea, is that when you get to the core of the issue, transsexualism isn’t a threat to feminist philosophy at all; it’s only that, like most in the general population, most transsexuals don’t really “get” the distinction between what’s necessarily and essentially different between men and women, what’s just statistically more likely to be associated with one or the other but can’t be relied upon in any individual, and what’s merely socially constructed to support the patriarchal social order. It’s only this misunderstanding of what it’s really all about that makes it *appear* threatening to feminist philosophy.
    I’ll follow Zoe’s lead and apologize for participating in turning this scientific thread toward gender politics. I am quite interested in what the underlying neurobiology of transsexualism might be, but I’ve seen these arguments come up enough times and in enough places, and the issues raised important enough, that I felt the need to offer an alternate point of view. Thanks for your patience and indulgence.

  36. most transsexuals don’t really “get” the distinction between what’s necessarily and essentially different between men and women,
    To judge from the muddled, and muddy, arguments coming out of m_Andrea and other anti-trans feminists, I would argue that they don’t “get” the distinction you allude to.

  37. For what it’s worth, before reading this article and all the comments, I too thought transexuals were mentally ill. I also gave the intersexed a pass.
    It’s obvious now that the gender isn’t so simple. And that’s okay.

  38. Another piece of evidence has come in after this post was written that gives additional credence to the “hormones plus genetic pre-disposition” theory.
    Androgen Receptor (AR) Repeat Length Polymorphism Associated with Male-to-Female Transsexualism
    Results: A significant association was identified between transsexualism and the AR allele, with transsexuals having longer AR repeat lengths than non-transsexual male controls (p=0.04). No associations for transsexualism were evident in repeat lengths for CYP19 or ERβ ?genes. Individuals were then classified as short or long for each gene polymorphism based on control median polymorphism lengths in order to further elucidate possible combined effects. No interaction associations between the three genes and transsexualism were identified.
    Conclusions: This study provides evidence that male gender identity may be partly mediated through the androgen receptor.

    The Australian and American team examined three sex hormone genes. They found male-to-female transsexuals tended to have a longer version of the androgen receptor gene, which could reduce testosterone action.”It is possible that a decrease in testosterone levels in the brain during development might result in incomplete masculinisation of the brain in male-to-female transsexuals,” Associate Professor Harley said.But it was highly likely that other genetic factors were also involved in this form of transsexualism, he said.

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