Dysmorphia comes from the Greek, morphe or “form.” By the time it filtered into the English language in the late 19th century, the meaning of the word had morphed into dysmorphia or ugliness. Two centuries later it is used for those who look at themselves in the mirror and hate what they see, either that their body is too fat or too thin, ugly or inadequate. It can also mean not recognizing the gender in the mirror as the one you know within.

Is transgenderism a choice or a medical condition? What does the neuroscience tell us? Some seem to believe that changing gender is a willful choice. In January, the Supreme Court ruled 5–4 to allow President Donald Trump to curtail the military service of transgender individuals. The Pentagon last year reported that there are 8,980 service members who identify as transgender.

A study from the American Society of Plastic Surgeons claimed that more than 3,200 gender reassignment surgeries were performed in 2016 in the United States. Marie Crandall of the Department of Surgery at the University of Florida College of Medicine says that more of these surgeries are now covered by Medicaid or Medicare.

As the number of people changing gender increases, so does discrimination. A midterm ballot question in Massachusetts initiated by an evangelical Christian group, would have, if successful, removed transgender rights in that state. It failed.

Before we examine the neuroscience let’s look at what ancient belief systems tell us. Judaism lists six genders. Atlanta rabbi Joshua Lesser says that an examination of Judaism’s sacred texts shows that a simple “male” and “female” binary is “inaccurate.” The six genders are:

Zachar: A person with male characteristics

Nekeivah: A person with female characteristics

Androgynos: A person with male and female characteristics (149 references to this in Mishna and Talmud; 350 in classical Midrash and Jewish law codes)

Tumtum: A person with indeterminate characteristics (181 references in Mishna and Talmud; 335 in classical Midrash and Jewish law codes)

Ay’lonit: A person classified as female at birth, develops male characteristics at puberty and is infertile (80 references in Mishna and Talmud; 40 in classical Midrash and Jewish law codes)

Saris: A person classified as male at birth who develops female characteristics at puberty and/or lacks male characteristics (156 references in Mishna and Talmud; 379 in classical Midrash and Jewish law codes)

Native Americans believe there are five genders: “female,” “male,” “two spirit female,” “two spirit male,” and “transgendered.” “LGBT Native Americans adopted the term “two spirit” from the Ojibwe language in Winnipeg, Manitoba, 1989,” Duane Brayboy writes in Indian Country Today. “The Navajo refer to Two Spirits as Nádleehí (one who is transformed), among the Lakota [the term] is Winkté (a male who behaves as a female), Niizh Manidoowag (two spirit) in Ojibwe, Hemaneh (half-man, half-woman) in Cheyenne, to name a few.”

Christianity lacks this specificity. Carol Shedd, a devout 89-year-old Episcopalian in Wellesley, Massachusetts says that Christians who oppose transgender individuals, “forget the teaching in Genesis 1:26–27 that all human beings are created in the image and likeness of God, there are no exceptions.” Gordon D. Kaufman, a Mennonite and Harvard Divinity Professor writes in his book, “In the beginning … Creativity”: “One reason we humans have found it so difficult to understand creativity [Kaufman’s term for God] is because we have all too often thought of nature as in a kind of harmony, a balance; but that is a mistake. All systems are in some respects out of balance, and sometimes the present order gives way to a new better-adapted order … The tipping point is that instant when what had been ordinary quantitative change suddenly leads to qualitative change.” He quotes philosopher Mark Taylor who wrote, “Life continues only as long as things are out of balance.”

Toby Kell, a retired senior radiologist in Needham, Massachusetts (one of the world’s top gender reassignment clinics is in Boston) says about 10 percent of babies are born with misleading sexual organs. “You may find a child born with female organs, but a large knob where the clitoris should be. The gender identification of babies can be challenging, sometimes a child has the genitalia of both sexes, or the outer appearance of one gender while carrying internal organs of another. Doctors assign one gender and hope for the best.”

Although this field of neuroscience is in its infancy, what we do know, is that the old argument of nature versus nurture, shows that nature most often has the last word. The genitals and the brain acquire masculine or feminine traits at different stages of development in utero. Shawna Williams writing in The Scientist notes that “human studies have found that, in several regions, the brains of trans people bear a greater resemblance to those of cis people [those who accept the gender they were born with] who share the trans subjects’ gender than to those of the same natal sex.” However, there are also studies of transgender people that contradict this. Research in Spain initially suggested that cortical thickness might be the determining factor, before realizing that there was no consistent pattern across the brain.

Ivanka Savic, a neuroscientist at the Department of Women and Children’s Health at the Karolinska Institute in Sweden and a visiting professor at UCLA, found with colleagues, Sarah M. Burke and Amir H. Manzouri, in research published in Clinical Psychopharmacology and Neuroscience that, “After controlling for sexual orientation, the transgender groups [studied] showed sex-typical [their italics] FA-values.” Fractional anisotropy (FA) can be used to measure white matter connections in the brain that differ between the sexes. The researchers say, “The only exception was the right inferior fronto-occipital tract, connecting parietal and frontal brain areas that mediate own body perception. Our findings suggest that the neuroanatomical signature of transgenderism is related to brain areas processing the perception of self and body ownership, whereas homosexuality seems to be associated with less cerebral sexual differentiation.”

The Netherlands probably leads the field in transgender research and surgery with children as young as 12, supported by their parents, opting for gender reassignment surgery. The Amsterdam university medical center treats 98 percent of Dutch transsexuals and two decades ago started commencing sex reassignment procedures before adulthood. Males were treated with anti-androgens first and with estrogens a few months later and females received progesterone to stop menstrual bleeding before going on to androgens. It was found that in the years post-surgery these young people “were socially and psychologically … not very different from their peers” and sometimes better.

Some of the criteria behind operations on the young is that bone mass and brain development are active during puberty; testosterone, as an example, accelerates the development of masculine features in a person who feels female. “Early treatment may result in a final height for MtFs [Male to Females] that is in the normal female range. For FtMs, a timely administration of oxandrolone may result in acceptable male height. Effects of suppression of the hormones of puberty on brain development are currently studied, and not known yet.”

Research by Georg S. Kranz and twelve fellow neuroscientists of the Netherlands Institute for Neuroscience found that, “All available evidence points towards a biologically determined identity. In [transgender] people you would say there was a mismatch in the testosterone milieu during the development of the body and then during development of the brain, so that the body was masculinized and the brain was feminized, or the other way around.”

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