On the Medicalization of Gender
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, a professor of cinema and digital media at the University of California, Davis, who has made several dozen musical recordings of synthesizer compositions and collaborations with the Kronos Quartet, John Zorn, and performance artist diva Justin Bond. Ostertag outs himself as a transgressive “queer” who came of age in the countercultural music scene of 1970s New York. He admits that he takes medications for HIV and depression, but with much ambivalence. Anticipating that his arguments are likely to draw the ire of transsexual critics, he presents his bona fides at the outset to fend off criticism that he is transphobic or anti-medicine. His doubts about the use of sex hormones led him to a broader project of examining the history of their discovery and commercial exploitation for diverse purposes, such as rejuvenation, boosting masculinity and femininity, birth control, athletic doping, and “curing” homosexuality. The second large topic of the book is a review of neuroscience research on the neurological basis of gender and sexual orientation.

Ostertag claims that he’s the first to gather all of these issues into a concerted critique of the medical construction of transsexualism. However, this terrain was covered, albeit two decades ago, by Bernice Hausman in Changing Sex: Transsexualism, Technology, and the Idea of Gender (1995). Ostertag doesn’t seem to be aware of Hausman’s work, though it received a lot of attention at the time for its seeming hostility toward transsexualism along traditional feminist lines as well as its skepticism of medical technologies such as hormones. What he presents is not so much new scholarship on the history of sex hormones as an able survey of the scholarship by medical historians, neuroscientists, and biochemists.*

In the late 19th century, European medical researchers hypothesized that the gonads (ovaries and testes) were the source of different chemical factors responsible for the physical and psychological traits differentiating male and female animals. Early experiments involved simply castrating animals, transplanting gonads, or injecting gonadal extracts. Testicular extracts and surgeries reputed to boost masculinity and vigor in men became popular in the early 20th century. The transplantation of “normal” (heterosexual) testes was even attempted as a treatment for male homosexuality. The isolation of the actual chemicals started in the 1930s. They became classified as female “sex hormones” (the estrogens) and male hormones (the androgens). In the body, they are synthesized from a common chemical foundation, cholesterol, which is one of a larger class of chemical structures, the steroids. Biochemists subsequently discovered that cholesterol is converted through a complex cascade of chemical reactions into hormones serving three broad endocrine functions: in addition to the “sex steroids,” there are the mineralocorticoids, involved in salt and fluid balance, and the glucocorticoids (such as cortisol) that affect metabolism and immune responses).

What also became evident, after the sex steroids were identified, is that they were not so neatly “sexed.” Like the other steroid hormones, the sex steroids circulate throughout the body, affect a variety of tissues (not just the gonads), and are not limited to one sex or the other. Furthermore, the sex steroids are synthesized not solely in the gonads but also in the adrenal cortex (small endocrine organs attached atop the kidneys), the liver, and fat cells. Indeed, fat cells can convert androgens into estrogens, just as the gonads do. One of the reasons overweight men develop “man boobs” (gynecomastia) is the conversion of testosterone to estradiol in fat tissue. Scholars have long pointed out that the terms “male hormone” or “female hormone” in reference to androgens and estrogens are a misleading historical vestige. All of the sex steroids are important to the healthy development and functioning of bones, bone marrow, fat tissue, and muscles in females and males. Yet they are particularly responsible for the development of the gonads, adolescent sexual characteristics, and reproductive cycles. So while the “sex hormones” are not exclusive to one sex or the other, their delicate balance is important to sexual health and development.

Interwoven in the discovery of the naturally occurring steroids is the elaboration of synthetic sex steroids. Since the 1930s, pharmaceutical companies have tried to find uses for both natural and synthetic steroids. Both androgens and estrogens were deployed to treat homosexuality: the former produced more randy homosexuals; the latter caused feminization (leading mathematician Alan Turing to depression and suicide). Marketing testosterone to healthy men failed in the mid-20th century, but androgens started being used illicitly in the late 1960s for muscle building. The “female hormones” would find a lasting use for oral birth control, but had many failed applications. For example, diethylstilbestrol (DES), a synthetic (non-steroidal) estrogen synthesized in 1938, was marketed to relieve symptoms of menopause or to help prevent miscarriages. It was later found to increase cancer rates not only in the women who used it but also in their daughters and sons.

Ostertag often slips into tabloid-style exposés of Big Pharma’s sins: its deceptive marketing; its keenness to promote ineffective or even harmful uses of medications; its complicity in exploiting and promoting gender stereotypes; its relentless pursuit of profit. While I share his suspicions (even as I write prescriptions), this nefarious history of sex hormones is slightly irrelevant. It does not change the fact that empirically the sex steroids do affect physical changes in the body that some adults, whether transsexuals or body builders, willingly choose. After almost a century of clinical experience with these drugs, there is substantial data on their health risks. The website of UCSF’s Center for Excellence in Transhealth has an extensive discussion of medical (and surgical) care and the risks and benefits—given the limits and quality of available scientific evidence. Trans people considering medical interventions do indeed need to be informed on their own and with their doctors’ guidance when balancing potential physical health risks against potential psychosocial benefits (which in turn can have physical health benefits).

The lengthy chapter on brain organization theory is interesting, but also beside the point. Whether or not there’s a neurological basis for gender identity does not change the psychological, experiential reality that people (cisgender, transgender, genderqueer, or otherwise) have of a gender identity. Whether it has a biological basis or is shaped by developmental and cultural factors also does not really matter. In raising the issue, Ostertag is implicitly relying on the “ex-gay” conversion therapy argument that sexual orientation is not biologically hardwired but psychologically based. While many transgender people (just as many gay people) like to believe they were “born this way,” it’s an unsubstantiated, inadequate, and unnecessary basis for their gender or sexual identity. Perhaps the main rhetorical value of Ostertag’s chapter on brain organization theory is to remind us how wobbly the “born this way” claim is.

The book’s conclusion, I think, really gets to Ostertag’s core anxieties. He is unhappy that the trans community has embraced medicalization by relying on hormones and surgery. Perhaps the problem is that he conflates “my community, the queer community” with the gay male community and its battle in the 1970s to depathologize homosexuality and remove the diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the “T” has been included in the past two decades in the “LGBT community,” transsexuals’ political battles are not the same as gay men’s. The trans community has long struggled with the issue of inclusion in the DSM, never more so than during the period when the Fifth Edition was being prepared (2013). Transgender people who want medical interventions (and insurance coverage) need a diagnostic code to justify the medical care. The committee revising the “Gender Identity Disorder” diagnosis arrived at the Solomonic decision to rename it “Gender Dysphoria” and place it in a chapter of its own—apart from fetishism, premature ejaculation, and male erectile dysfunction.

As I mentioned, Ostertag is candid about his own medical history and reliance on antidepressants and HIV medications. He is thoughtful about the constructedness of “depression” as a diagnosis and alludes to the checkered history of antidepressants and Big Pharma’s profit motive in these. I can add that precisely how and where in the brain all psychiatric medications work to generate their clinical benefits remains speculative. The Prozac (fluoxetine) package insert describing “mechanism of action” is characteristic of other psychiatric medications: “Although the exact mechanism of Prozac is unknown, it is presumed to be linked to its inhibition of CNS neuronal uptake of serotonin.” Despite the huge unknown, antidepressants in large numbers of studies empirically help a majority of people who take them for depression. Even Ostertag has to admit that, despite his huge misgivings, he takes antidepressants “because I experience my life as nearly unbearable without them.” So is he just projecting on trans people his own ambivalence about being dependent on HIV and depression medications and enriching Big Pharma? Or does he worry that doctors are not adequately informing and monitoring their transgender patients? Or that transgender people are engaged in “gender transition” out of postmodern playfulness, unlike himself, who has no choice but to depend on medications for his health?

Perhaps Ostertag should have started by questioning his use of “gender transition.” He uses the term throughout his book as synonymous with sex hormone treatment. He notes that there is much evolution and controversy around the terms for trans identities and medical care, but “gender transition” is a particularly dusty one. As one indication of this, it’s the term the U.S. Department of State uses in explaining its policy on granting passports under a new name and gender. A physician must attest whether an applicant’s “gender transition” is complete or “in process,” without explaining the distinction. More accurately, the term is applied to a person’s transitioning gender role presentation in public or in the workplace. This “gender transitioning” does not need to coincide with hormone therapy. Just as problematical is the use of the term “gender reassignment surgery” as a politically correct substitute for “sex reassignment surgery.” The former term is inaccurate, since surgery and hormones do not reassign but instead confirm the gender that a person has already embraced. For this reason, the more current term is “gender affirming” hormones or surgery.

Eventually, Ostertag gets to what may really be gnawing at him: “giving hormone blockers to young children.” He is a bit sweeping in using the label “hormone blockers,” referring to a protocol developed at a gender clinic in Amsterdam to carefully assess gender dysphoric adolescents and administer a gonadotropin releasing hormone (GnRH) analogue after puberty has started in order to arrest the development of secondary sex characteristics. GnRH treatment is usually continued until age sixteen, when the individual can consent (in the Netherlands) to cross sex hormones. Widely called the “Dutch Protocol,” it was found to be successful in the small group of 55 adolescents that they followed for seven years. It relieved their gender dysphoria, depression, anxiety, and body dissatisfaction, and improved their likelihood of completing high school and going to college. Nevertheless, the GnRH protocol is still controversial, since there is limited experience with it. Even experts wonder: how stable is transgender identification in a teenager? Could the treatment itself (for psychological or neurological reasons) reinforce trans identity? What could be the long-term health effects?

Finally, another area of uncertainty in transgender care is the approach to gender variant pre-adolescent children. This is technically out of Ostertag’s purview, since it does not involve any hormone use. It used to be that a “tomboy” girl or an effeminate boy would be aggressively, often punitively, coaxed to be gender conforming in an effort to prevent homosexuality. A friend of mine from medical school recalled as a child being sent to a camp specifically aimed at butching up “sissy boys.” This approach has (mostly) fallen out of favor in the U.S., particularly after its early promoter, psychologist George Rekers, was caught hiring a male escort in 2010. Many states have started banning sexual orientation “conversion therapy,” particularly for children.

Given that the research literature still indicates that the majority of “gender variant” children will grow up to be gay or bisexual rather than transsexual, should there be any behavioral interventions with them to encourage or redirect their gender behavior? Will a “gender affirming” approach reinforce an alternative gender identity? Are attempts to normalize gender variant behavior without encouraging a cross-sexed identity a form of gender conversion therapy? As yet, there is no professional consensus on these questions, but they are highly contentious. The controversy highlights the fact that behavioral interventions are still taken every bit as seriously as hormonal ones in the shaping of gender and sex. So, while Sex Science Self does not always seem to be on target in its deployment of historical evidence, it is a legitimate and earnest expression of cultural anxieties (particularly in the gay community) about the prominence of transgender issues and the role of the pharmaceutical-industrial complex in the medical construction of gender.

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*       Historians include Nelly Oudshoorn, Chandak Sengoopta, Elizabeth Watkins, and John Hoberman. His medical history of transsexualism condenses the work of Joanne Meyerowitz, Deborah Rudacille, and Susan Stryker. His chapter on brain organization theory largely relies on Brain Storm (2010), by Rebecca Jordan-Young. Longtime readers of these pages may recall my essays on most of these authors’ books.