For those not familiar with the seemingly endless arguments over what should be classified in the DSM, HBS is a synonym for what is more commonly known as transsexualism.
Let me be clear about a couple of points here before I begin my critique of HBS advocacy.
First, I am not hostile to the research being done that HBS advocates have attached their position to. In fact, I am very much supportive of the research and its goals.
Second, while I find that research to be very promising and certainly intriguing indeed, it is far from conclusive. (I will substantiate this in more detail later)
Third, I recognize that regardless of any biological factors, being transsexual poses some unique challenges to the individual that may legitimately require assistance from mental health professionals.
(I) The Research
Much of the advocacy for HBS that I have found tends to rely on documents like this. It's actually quite a good document to read, and it is signed by practitioners with long and respected histories in treating transsexuals.
Where HBS advocacy is very prone to absolute statements such as:
Harry Benjamin's Syndrome (HBS) is a congenital intersexual condition that has a pre-natal developmental origin, and it involves the differentiation of the male and female gender identities in the brain. The estimated incidence of HBS is 1 in 100.000 live births.
Fair enough as a statement, but when one digs a little deeper into the foundational etiology being cited, it's nowhere near as clear as that.
For example, in discussing hormonal effects on the differentiation of the brain, we get the following:
Sexual differentiation of the mammalian brain starts during fetal development and continues after birth (Kawata, 1995; Swaab et. al., 2001). It is hypothesised that in humans, in common with all other mammals studied, hormones significantly influence this dimorphic development although, at present, the exact mechanism is incompletely understood. It is also postulated that these hormonal effects occur at several critical periods of development of the sexual differentiation of the brain during which gender identity is established, initially
during the fetal period, then around the time of birth; and also post-natally.
It's very important to recognize the caution in these statements. The terms "postulated" and "hypothesize" tell us that the researchers suspect that things go in this general direction, but have not yet found the kind of conclusive evidence that would make their suspicions conclusive.
Another piece that is regularly cited is Kruijver et. al. Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus.
Therefore, we determined in 42 subjects the number of somatostatin-expressing neurons in the BSTc in relation to sex, sexual orientation, gender identity, and past or present hormonal status.
These are interesting results, but the size of 'N' is excessively small (a common problem in studies involving transsexuals to begin with), and does not ask the question of whether this variance happens outside the transgender population with any significant frequency. (Or, for that matter, how common is the variance within the transgender/transsexual population?)
The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.
Their conclusions correctly state that the study's findings point to biological basis for transsexuals. Again, there is an appropriate caution expressed in their choice of wording. They are not claiming that they have found proof of cause, rather that they have further evidence that leans towards biological causes. The researcher's wording correctly, and wisely, avoids the logical error of confusing correlation with causation.
Like the recent study out of Australia that identified an interesting variance in the androgen receptor sites in transsexuals, all of these findings suggest strongly, but do not yet prove conclusively that there are biological underpinnings that explain transsexualism.
In fact, much of this evidence - even when aggregated - remains a fairly thin veneer of understanding of a very complex subject. Even if we identify a dozen or so common traits found in transsexuals, it is far from clear that such findings will provide us with anything beyond correlation. Correlation is important, but its not the only vector in understanding these issues.
We understand very little about the biology behind the development of the brain, much less how that biology influences the actual behaviour of the brain.
Unfortunately, the HBS advocacy draws some overly strong conclusions based on what is still very early stage research:
Gender identity is a purely neurological function, with no psychological factors appended.
I have to disagree with this statement. The evidence is far from being so conclusive about things. It certainly suggests biological underpinnings, but even there researchers are clearly being cautious in their conclusions. It would be premature to claim that there are absolutes here. If we consider the human body rationally for a moment, it's not too hard to recognize that it really is a collection of complex systems which interact with each other. I think that drawing such a hard and fast conclusion at this time is simply far too facile - and really suggests sloppy reasoning rather than honest insight.
As an aside, we know significant amounts about the biological causality related to much more drastic mental health concerns such as schizophrenia. This understanding does not change the validity of mental health practitioners' being involved in the treatment of schizophrenia's consequences - especially with respect to developing appropriate coping skills.
Harry Benjamin’s Syndrome is not an illness or a disorder, and we should not consider it such, but rather as a physiological variation of human sexual formation, as in the case of other Intersex Syndromes. When, on this page, we speak about "suffering" HBS, we refer to the suffering caused by the physical incongruence that people born with this condition experience, and not to a pathological explanation for HBS.
At present, it is not possible to diagnose this condition at the time of birth. Therefore, the children are raised in the gender role opposite to that of the neurological gender identity. This often leads to psychological problems unrelated with the HBS itself.
Unrelated? How can the consequences of prolonged, extreme distress not be seen as related to the source of the distress itself?
The process of adapting to life in a new gender role when one has already grown up in "the wrong one" is not trivial. In fact, some careful guidance and oversight of that process can be an extremely valuable part of the journey. Not all who choose to transition need that kind of guidance, but some will, and in general it is not a bad thing to have objective feedback handed to you during the process of making such major changes in life.
Is being transsexual an illness in the same sense as schizophrenia or bipolar disorder? Yes and no. To be sure, the consequences for the individual with the condition can be unquestionably severe - in the extreme. Can one treat the kind of depression that leads to suicide in transsexuals without that treatment addressing the fact of their transsexualism? I think not, and any approach which attempts to isolate one from the other is deeply flawed.
(II) The Politics of Gender
Here is where I take great exception to what is often claimed by HBS advocates. They seem to take a strongly separatist view of things - to the extent of being dismissive of those who do not fit into their narrow view of what is valid.
Consider the following from a comment :
And what similarities exist between a crossdresser and a transsexual? That is a ridiculous claim. They are totally distinct. And to compare the classification of "Intersex" with "transgender" is grasping at straws. Intersex is an objective term.
This is fairly classic of what I've seen in the past - whether it is the old "Primary Transsexual" versus "Secondary Transsexual" debates of years past, or the arbitrary hierarchy that evolved among various transgender groups where one subgroup "looks down on" the others. Transsexuals look down transgenderists, who in turn look down on crossdressers who in turn look down on ... and so on. I agree that each is distinct from the others to some degree (that is to say that a cross dresser certainly doesn't have the same driving need that pushes a transsexual to transition fully), but I also recognize that like the various Intersex conditions are distinct, but at the same time share certain common traits, so do the various cross-gender conditions. We already have an umbrella term for people whose gender identity and body are at odds with each other to some degree or another - 'Transgender'.
However, even among HBS advocates, the narrow, blinkered "we're different" narrative is beginning to be recognized as detrimental:
If you are going to have a HBS support group it should support not denigrate others. Even the Transgendered know that Crossdressers, Transgenderists, Transsexuals, Intersexed and Androgyne are all very different groups with different criteria. That doesn't mean they can't get along. Except for Real Transsexuals and the Intersexed no one else is interested in HBS.
Let me expand on this somewhat. As I discussed earlier, there is a growing body of research that points to biological roots that influence the probability that someone is transsexual. Putting aside, for a moment, my reservations about the completeness of that research or its conclusiveness, let's entertain some inferences based on that research.
Consider for a moment that there are several different bits of evidence that a transsexual's (MTF, at least) brain is 'female-differentiated', additionally, there is also more recent evidence which suggests that a transsexual may not respond to testosterone normally due to changes in the androgen receptor sites in the DNA. Let us further consider the reality that humanity is amazingly diverse - as evidenced by the sheer number of different InterSex conditions that have been identified.
Now, if someone is born with only some of the attributes that differentiate transsexuals from cissexual people, what do we find ourselves facing? Perhaps the individual becomes a crossdresser, or the influences are a little stronger and they choose to live full time, but do not pursue GRS. What combination of factors admits someone to this exclusive club of people with HBS? Is it some of the identifiable markers, or is it only all of them? For those that are arbitrarily excluded, how does one propose to deal with their needs for treatment?
There's a point here - and it is in fact the very issue that makes the term 'Transgender' valid in the first place. There has to be some kind of recognition that cross-gender identification exists on a continuum, and just because someone has 95% of the identified traits, but doesn't have the last 5% doesn't mean that they are not experiencing significant and valid dissonance from their lives.
In using exclusionary rhetoric, the advocates for HBS do themselves and others a significant disservice. They damage their own cause by arbitrarily delineating things along lines that may not actually exist. Even more sad is the fact that this line of advocacy also guarantees that many potential allies in the political world will be alienated and unwilling to advocate on behalf of HBS people - even if the evidence shows that HBS is actually a very broad condition.
Given the overall sparseness of the data being cited, it is all too probable that the condition now being called "Harry Benjamin Syndrome" will turn out to be much more subtle than merely accounting for transitioning transsexuals who pursue surgery.
(III) The Argument For Gender As A Continuum
In many respects, this is a variation on the reasoning about sexual identity that I covered in an earlier series of essays.
Fundamentally, humanity is very diverse in its expression of all things - and gender is no less diverse. Chances are that whatever factors that combine to result in transsexuals combine in different combinations with differing outcomes. Even if we come to complete biological models that explain things, I doubt that they will be as clear cut as "there are real transsexuals and then there's everybody else".
Anecdotaly, I know people who are 'manly men' (in the extreme); 'womanly women'; people who have transitioned across genders; others who discovered that they didn't need to transition after putting their toes in the waters; masculine women; men who were perfectly masculine before transition became perfectly average women post transition and those who fall somewhere in between. I know one lady who transitioned quite successfully after spending a long time identifying as a crossdresser. In short, there is a plethora of perfectly valid experiences.
Within the broad umbrella under the term transgender, it should come as no big surprise that there are many who feel varying degrees of need to transition. Some can get along quite nicely with occasional forays into cross-dressing; others find that they need to transition fully, including GRS. In between, we find all sorts of variations. Just as the kinds of scales that Kinsey created do not reflect the ambiguity of real human sexuality, absolutes do not describe the human experience of gender either.
Philosophically, I argue that logical models that require one to exclude data that is apparently related, without providing solid rational evidence why that data should be excluded are deeply flawed. Observationally, it's a lot more coherent to view human behaviour as analogous to a spectrum - although there are definable bands, the boundaries between the bands are not as clear cut on close inspection as one might first have thought. For example, the colours of light are expressed across a range of wavelengths. Similarly, people express their gender identity in a variety of ways as well. Not all transsexuals transition in their teens or twenties - either because they don't need to, or they are still struggling to find their milieu in the world.
If, for example, you wish to argue that crossdressers have no valid meaning in the world of HBS, then I am going to have to insist that you provide the science to back up that claim. In other words, you will be asked to prove that in general crossdressers possess none of the traits that you claim are key to the manifestation of HBS.
In this respect, I favour models which are broadly defined and generally elastic. This is a key feature of the model of Evolution that Darwin postulated in the 19th century. The strength of Darwin's model lies not in its detail, but rather in its ability to adapt readily to new data as it arrives. Darwin postulated that different species evolved from their forebears through a process of selection. He didn't limit the paths, in fact he didn't even try to do more than define what such a path might look like.
The logical model of a gender spectrum fulfils this very nicely, as such a model leaves open the likelihood that we will find that in fact gender identity - especially as it manifests in those who are members of the wide umbrella that is covered by the term 'transgender' - is a result of multiple attributes which intersect at the same time, and in varying degrees.
In general, an inclusive model will be much more semantically robust when subjected to scrutiny, because the model doesn't have to change much to accommodate new data. New data, on the other hand, must be scrutinized very carefully to understand how it fits into the model. (This is why Evolution infuriates its critics - it is such a simple, malleable model that it has yet to encounter a significant exception, but rather has been able to absorb the ever growing mountains of data that we keep adding)
To me, the long and short of all this is that while I support the research being done into the etiology of transsexualism (or HBS, if you prefer), I do not think that the evidence to this point comes anywhere near giving adequate reason to assume that what has been found does not apply in varying degrees to all of the transgender spectrum.