Body maps and gender dysphoria

Gender dysphoria, the distressing mismatch someone feels between their gender identity and the sex they were assigned at birth, is slowly finding the recognition it deserves, with more countries and health services enabling assistance to transgender people. This progress has been made through both the incredible efforts of trans-rights activists, and by a better scientific understanding of this condition.

One popular scientific narrative for gender dysphoria has been the claim that such people have brains which do not fit their assigned gender. I.e. transgender people who were assigned male at birth actualy have more “feminine” brains, and vice versa. While this narrative does benefit from a certain elegant simplicity, making it more understandable to the layperson and possibly helping more people becoming acceptant of trans rights, it does have some significant issues, both scientific and ethical.

On the ethical level, many trans activists have openly spoken against such an explanation, because it does tend to lead to an automatic assumption of “we only accept such people because their brains are that way”. To put it otherwise, they ask “so if it turned out person X didn’t actually have a ‘mismatched brain’, then we wouldn’t accept their gender dysphoria distress as valid and requiring proper support?” Which is actually a very good point to make. While we should aim to use science to understand different aspects of reality, science shouldn’t be a veiled “appeal to nature”, a form of “well, it’s nature which made the brains of these people this way, so I guess supporting them is OK…” Our attitude should simply be: people are distressed, helping their distress does not in any way infringe on the rights and wellbeing of others, so they should be supported in resolving their distress.

Furthermore, still on the ethical level, the “mismatched brain” model does tend to be strongly connected to the ideas of gender essentialism, of the significant, clear inborn differences in personality, thinking, etc. between the males and females of homo sapiens. And gender essentialism is an attitude strongly corelated with transphobic attidutes. So in trying to support trans people with this idea we might actually be inadvertently working against them.

Which brings us to the scientific issues with this explanation. While the concept of a gender dimorphic, “male” and “female” brain has been strongly promoted for over a century now, with numerous goalposts moved along the way and claims of trans people having brains more similar to their perceived gender, rather to their assigned-at-birth gender, the last 25+ years of neurology research have slowly but steadily lead to a simple understanding: the dimorphic brain idea is simply false. (For a better description of this issue, check out this systemic review.) There is no such thing as a “male” or a “female” brain. The intergender variation is pretty much nonexistant in comparison to the intragender variation and the mosaic brain model is by far our best current understanding  of the issue.

Which would suggest that no, people experiencing gender dysphoria were not born with the “brain of the wrong gender”.

That being said, is the neurological explanation completely invalid? Should gender dysphoria be limited to a social issue, to people being forced into two socially constructed models of gender, while their actual inner experience is far more diverse?

In many cases I would say: yes. However, for some trans people, I would position an additional neurological level. Despite popular beliefs, a large number of transpeople are happy with a social level change in their gender expression. Based on 2011 data, only 61% of trans people overwent medical transition (typically receiving hormonal treatment for a certain level of body modification), and just 33% transitioned surgically. 14% of trans women and 72% trans men claimed they did not want a full genital reconstruction surgery. Now these scores can be artificially low, both due to changing attitudes and the issues with costs and availability of medical transition, and cost, availability and possibly unsatisfying options of a surgical transition. Even so, the desire for surgery or even medical treatment is not uniform for everyone. The specific level of change needed is different for different trans people. What could be the reason for this?

My hypothesis is that for these seeking more complex transition options, there will often be a significant neurological factor, located not in a generic “male” or “female” brain, but with a very specific part of the brain, our internal bodymap/body schema. Connected mainly with the activity of the so-called “cortical homunculus” in the parietal lobe (although, as all neurological processes, it is a far more distributed affair in reality), our bodymaps appear to be pretty much inate and present from birth (even in other primates). While life experience can modify both these maps and their experience, the basic schemas appear to be inbuilt. Furthermore, there are some interesting reports suggesting that the shape of the schemas is inborn. For example, Vilyanur Ramachandran, in his work on phantom limbs, mentions working with a student who was born without an arm, who nonetheless experienced a “phantom” of that arm. Later research also seems to confirm the presence of phantom limbs in people with congenitally absent limbs (for example here). So the first piece of the puzzle is this: we have inborn body maps, which do not necessairly fit how our body developed, even at birth. They are based on some inborn blueprint, although possibly modified by experience, rather then being built up out of pure sensory experience.

This does not, however, explain all of the observed effects. Not every person born without a limb experiences a phantom of that limb. Furthermore, the people with phantom limbs of their congenitally missing arms or legs were not, typically, reporting any significant distress over the mismatch between their body map and their actual body. Here we must refer to a couple of other neurological hints. More specifically, to the rare cases of body integrity dysmorphia and somatoparaphrenia. Such patients tend to feel that a part of their body, for example their arm or leg, is not a part of their body, but “an alien thing”, “a dead man’s hand”, etcetera. Some even seek amputation of said limbs and actually appear to experience a significant increase in their wellbeing after such an operation takes place. This is usually explained as a damage to the body map of the patient, making them feel as if a significant part of their body does not belong to them. The interesting point for us is this- the lack of a bodypart which should be there, based on the innate body map seems to be far less distressing than the presence of a bodypart which is experienced as externous and unfitting. This does seem to make sense form an evolutionary perspective (although obviously such evolutionary explanations are always only ad hoc stories).  Our ancestors, not just human but animal, would be prone to loosing lesser and larger bodyparts throughout their lives, and still manage to not only survive, but, to a point, thrive. So adapting to a missing bodypart makes perfect sense. However additional, unexpected bodyparts are a somewhat less common occurance. If they appear, they will usually either be the result of a developmental problem – which tends not to be something increasing survival & reproductive fitness – or possibly of a kind of cancer or other similar disease (for example, the “human tree disease” caused by a combination of chronic HPV and individual genetic predispositions). As such they are not something to become easily accustomed to, and would better serve us as a cause for alarm.

Here we should point out that reports of distress with one’s own body tend to be far more common in case studies of gender dysphoria, than distress with not having the desired body. It’s “I’m living in a wrong body” rather than “I’m not living in the right body”. This might be, of course, just bias on the side of people writing the reports, or a kind of a narrative preference, but it could also be a small point for the perspective described.

Here also the difference between AFAB and AMAB trans people becomes quite interesting. Far more AMAB trans people than AFAB trans people were interested in full genital surgery. This might be due to the fact that the hormonal treatment for AFAB gender dysphoria leads to a significant growth of the clitoris, making it somewhat similar to the penis (and in fact using the same tissue and nervous connections as the glans penis), which might fit the expected body map far more than the  presence of an external penis for AMAB trans people. Obviously, this is at this point just conjecture and would require further study.

So to sum up, the hypothesis I would like to put forward is this: a significant part of people who are suffering the most from gender dysphoria are born not with a “wrong brain”, but they are born with an innate body map which does not fit their developed body. Furthermore, for a part of such people, this mismatch is a source of significant distress, furthermore it is a far more distributed issue than in the case of the typical somatoparaphrenia patients. You can amputate a leg or and arm, but you can’t really amputate the whole body. (Although, possibly, the distribution might also cause a certain dilution of the suffering, as compared to the suffering from somatoparaphrenia, hence the typically less severe reactions. Than again, suicidal attempts caused by distress connected to severe gender dysphoria might be considered a form of a “general amputation” of the body.) This mismatch becomes more significant in adolescence, when the hormonal changes lead to further differentiation from the innate body map. As such, for such people, hormonal and surgical interventions would be an extremely useful way of reducing or even removing their distress.

It should be said that this differentiation, if true, does not make a certain group of transpeople more “valid” transpeople. It would not mean that you are “properly” trans only if your bodymap does not fit your body, and not if you are uncomfortable with other aspects of your assigned gender, such as the social or identity aspects. In both cases we have the issue of distress connected to invalid and externally enforced norms and schemas of gender, it’s simply that in one case there is also a comorbid neurological aspect which makes the whole experience more distressing.

As always, I would be grateful for comments, criticism, case studies and research connected to the proposed idea, etc.

And, in case this was not clear to anyone reading this, I’d like to clearly state that trans men are men, trans women are women, non-binary identities are valid, gender isn’t binary and trans rights are human rights and should be protected. Anyone who would try to use this text as an excuse for abusing trans people clearly did not understand anything I wrote.