Thesis

There have been many reviews on the comorbidities of gender incongruence in the literature. However studies like María Paz-Otero (2022), Marconi (2023) and Pele’s 2023 thesis primarily focus on the psychopathological correlates of GI and do not investigate related body-representation syndromes such as body integrity disorder or anorexia nervosa.The purpose of this document is to research and organize information to differentiate gender incongruence from its historical etiologies and related correlates. I will first clarify conceptually through a historical review of the study of human sexual development, tracing how the current clinical model emerged. I will then examine the limitations of proposed mechanisms (neuroanatomical, hormonal, and sociological)  in the existing literature. I will briefly touch on the physiological byproducts and sociology of transition which both may introduce bias in comorbidity research. Finally I will outline a possible explanatory model of gender as a status of body representations which tries to highlight these pitfalls by properly contextualizing gender within a sociological and cognitive framework.

Background

Inversion

The term transsexualism has a recent origination, starting from the theories of late 19th century German sexologists. Crucial to the modern conception of sexology is that of inversion. Prior to inversion, sexuality and gender was not seen as inherently linked together, with German  anatomist Meckel remarking in 1812 that it was possible to exist "a contrast between the orientation of an individual's sexual urge and the physical form”, but did not venture further to explore the exact relationship between the two. 

However, in its current form it was first conceptualized by Karl Heinrich Ulrichs, a civil servant and legalist who developed his own theories on the origin of homosexuality. As a type of legal apologia and public advocacy he developed an antecedent to inversion, explaining the reason why men felt attracted to other men is because they were anima muliebris virili corpore inclusa - “feminine souls confined by a masculine body”. He used the basic knowledge of sexual development known at the time, derived from embryology and case studies on hermaphroditism to argue that greek love was another natural form of hermaphroditism – a third sex with qualities of both, bisexuality. However his arguments backfired as they played into the sexual degeneration theory popular at the time for explaining onanistism, antinormophilia and antiphysical desires. 

Developments continued with Westphal formalizing his concept of conträre Geschlechts/Sexualempfindung which got translated to Italian and then English as “sexual inversion”. Deviant sexuality, gender identity, and intersex conditions all were classified as either the psychosexual or the physical variety of inversion. Krafft-Ebing further categorized sex inversion into a scale where on one side was inclinations of the other sex - effeminacy or the lack of femininity, all the way towards metamorphosis sexualis paranoica - a psychotic disorder which was characterized by delusions of changing into another sex. It took Hirshfield to further delineate between homosexuality and cross-sex behavior within his concept of seelischer transsexualismus. He adopted a very similar differentiation as Krafft-Ebing between organic and psychological disorders of sex. However he drew a further distinction within psychological disorders where homosexuality and transvestism (further to be known as simply transsexualism) were distinct types of psychological inversions, contrasted with physical inversions like hermaphroditism or gynandromorphism.

Hermaphroditism

Unfortunately, post-war developments would muddy the waters, especially for Anglophone sexology. Although the term intersexual was first coined in by Goldschmidt et. al in 1915, doctors like Cawadias, a Greek-born British homeopath known as London's leading sexologist, would adopt the term to refer to hermaphroditism. He, like Hirschfeld, would argue that everyone was of mixed sex nature or bisexual to a certain degree. On the other hand, he would reassert the existence of an intersexualism much like Westphal’s inversion that underlied homosexuality, transvestic behaviors, and transsexuality as part of variations of his sexomorphic impulse.When he states that “a male homosexual of intersexual origin was in fact an intersex who wanted to be a female” he harkens back to Ulrichs’ bisexual soul theories. 

Even with Harry Benjamin’s future, more pragmatic and evidence-based work, we are left with the legacy of a sexology that had undone even “dark-age” knowledge of human development. Cawadias, and likewise, Foucault builds upon this myth that medieval society was severely hostile to any sort of aberration in sex and only recovering from this after the early modern period. However from medieval jurisprudence upon the matter, we can see that what it criminalized was the breakdown of natural relations, such as the case of Laurence of Esclimont. Later 15th and 16th century French scholars like Riolan, leaning on an increasingly hippocratic tradition of medicine, reinterpreted its description of the exaggeratedly masculine partner not as part of the defense nor as indicative of the social usurpation that it presented but as evidence of the pseudohermaphroditism of penetrative women or tribades.

Thus it was from the movement away from Aristotelian medicine, which considered the hermaphrodite as mere bodily aberration, but a medicalized neo-Hippocratean model which operationalized the non-existence of perfect hermaphrodite to pathologize homosexuality. Cases like that of Marie le Marcis were only able to avoid the death penalty associated with sodomy with testimony of a sexologist. They would argue, sometimes against all evidence, that the defendant was hermaphroditic. Thus through prominent controversies like this model formed where homosexual and cross-sex behavior was associated with hermaphroditism. When Cawadias characterized his star patient Gina Turtle as having “dominant female characteristics”, it harkened back to aspects of medieval canonists like Huguccio who had devised methods to determine the ‘prevailing sex’ of a hermaphrodite. 

With Cawadias’s negation of the perfect hermaphrodite, he would complete the abandonment of Aristotelian sexual differentiation. In his arguments he uses the vestigial feature to argue that all women are “intersex” in Kleb’s “gonadal paradigm” accidentally, stumbling against the future Jost-paradigm which asserts that in fact it is males with vestigial female features, and not vise-versa. This reflects further in the medical fraud perpetuated by Gina. In the article it states that her genetic test turned up a “rare mosaic of chromosomes: a Y male chromosome (accounting for her deep contralto voice) coupled with the female chromosomal make-up of Turner's syndrome”. One must note that Turner syndrome is also known as 45 X monosomy, i.e. where only one X is present. Thus her rare mosaic is otherwise known as XY, the genotypic male sex chromosomes. Thus this phenomena of factious disorder involving intersex, as reported by Cadet in the literature, is not new nor is a result of purely with autogynephilia or Munchausen by Internet as has been variously suggested, but as a structural result of the reliance homosexuals and transsexuals have on the medical establishment for establishing the “naturalness” of themselves. 

Modern Etiologies

Modern models of transgenderism do not fare much better at differentiating gender dysphoria. As a move to reduce stigmatization, a reclassification was made away from transsexualism, then transgenderism, then from gender dysphoria as not to classify the mere condition of cross-sex desire as mental illness. However this new terminology comes with two main problems. First the conceptualization of gender incongruence: what does incongruence exactly mean and why can it result in dysphoria? Secondly, is it necessary or even sufficient to classify someone as transgender if they have gender dysphoria or incongruence? Given the many questions, assumptions, myths, and social stigmatization around transgender identity, it is not surprising that the field has an inadequate working model and has fallen into the same historical conceptual traps. 

The set of three main proposed etiologies - neuroanatomical sex, natal hormone transfer, and delusional erotic syndrome all trace their lineage in the early sexology of 19th century germanophone intelligentsia. With the advent of sex reassignment surgery, the medicalization of transgender identity naturally followed in this tradition. Harry Benjamin’s Sex Orientation Scale thus borrowed transsexual from Hirschfield and further tried to differentiate between transvestism and true transsexuals. He proposed a tentative etiology which proposed that true transsexuals had a female brain contrasted with the masculine brains of transvestites. Thus this was an explanation in search of a mechanism, following in the footsteps of earlier sexology searching for the basis of sexual attraction in disorders of sexual development.

Thus Blanchard’s typology, resting on the developments of Benjamin solidly sits in this post-behavorialist framework, having convinced itself that sexuality and gender identity have totally been separated from psychological and social factors. In the desire to delineate clearly the patients needed for medical intervention, it echoes the same flawed methodology as Benjamin. It flattens the possible etiologies for homosexuality and transsexualism into one category, mirroring Hirschfield’s classification of inversion – but completely without the psychopathological aspect. Blanchard finds himself in this contradiction, seeking to both explain fetishistic transvestism and delineate transsexualism and fails at both. Thus with our current model of gender identity and sexual attraction, it cannot account for fetishistic transvestites, transvestite homosexuals without transgender identity, and heterosexual transsexuals with paranoia of erotic origin. 

Brain Organization

According to the modern model of the etiology of homosexuality and transsexuality, they arise from hormone exposure in the womb to cross-sex hormones, resulting in a masculinized or feminized brain. Since neurodevelopment happens after sex organs, it is theorized that it is possible to have cross-sex biased brain development. However the extant literature shows mixed results about whether brain neuroanatomy matches gender identity. Joel et. al, an MRI study of 1,400 subjects, found that the sexual differentiation of brains is actually much less than expected and characterized the brain as a “mosaic” of differently sex biased structures. Furthermore a 2021 review found that both across 63 studies homosexuals and transsexuals did not have opposite-sex biased brains. 

Prenatal Hormone

Another thing we would expect from this model is the impact of prenatal hormone transfer in fraternal twins. This chart summarizes the existing twin studies as of 2022, looking for evidence of the heritability of GD and differences in DZ and MZ twins which would indicate hormonal transfer. Sasaki et. al explicitly was a test of prenatal hormone transfer theory of GD, with 4354 twins both fraternal and identical, and casts heavy doubt on the significance of hormonal transfer theory. Additionally, van Beijsterveld et. al (n ∼ 8,500) found that fraternal girls had lower levels of cross-sex attributes compared to controls, according to behavioral measures. 

Adrenal Disorder

Finally, Congenital Adrenal Hyperplasia has been suggested, by Bailey and others, as another natural experiment to prove that hormonal virilization in the womb can influence sexual attraction and gender identity. However there are inadequate studies done on the prevalence of GD in the CAH population. de Jesus et. al remarks that many studies have serious methodological issues: small cohort sizes, age discrepancies, and a lack of follow up which mean that the population itself is ill-characterized. If the utero-virilization of CAH can cause gender incongruence, studies should find correlates to virilization, subtype, and social factors. However with the existing study quality it is hard to draw any strong conclusions. 

Intersex Conditions

Modern theories of sexual and gender development have to take into account the interplay of biological variation with sociological factors. There is a difficulty in studying complex sex differentiated behaviors, as they are usually absent or minimal in animal models and difficult to independently produce in humans. This minireview goes into the various perinatal sex hormone exposures in animal models which produce sexual behavior, positing that it is a broader process of brain organization theory where cognitive and behavioral outcomes are part of sexual development. However as Jordan-Young points out, there are many confounding factors in the socialization of CAH females such as invasive medical intervention, physical correlates of CAH (such as genital development, body hair, and infertility) and comorbidities with endocrine-related mood disorders. 

Thus when it comes to approaching a more general overview of disorders of sexual development, evidence becomes quite sparse, with small sample sizes, conflicting behavioral metrics, and lack of adult and long-term follow-up. For table 1 in the review by Yang et al., which lists recommended gender assignment for individuals with DSD, all different conditions were marked with the lowest evidential criteria. Another, more comprehensive review tried to measure GID over a variety of DSDs and found that it was from 2 to 26%. This might suggest that DSDs might be linked to gender incongruence however, it's entirely possible that with enough refinements in the standard treatments for DSDs gender incongruence would fall to general population levels. 

Health Correlates

Transition introduces to the transfeminine individual a set of related oestrogen-dependent health impacts that are often not monitored properly. After the initial elimination of a testosterone-dominant system, estrogen monotherapy, if not done with sufficient monitoring, comes with problems related to high estrogen levels and low testosterone levels compared to cissexual baselines. Dosing too high for physiological estrogen levels can possibly cause estrogen tachyphylaxis and elevates SHBG levels, reducing feminization. 

Without proper androgen supplementation the musculature, the prostate, and other testosterone-sensitive tissues can atrophy, leading to skeletomuscular, sexual and urological side effects. A reduced prostate size might also contribute to incontinence, as suggested by A. Kuhn et al. Estrogen-dependent syndromes like Raynaud's and hypermobility are also dose sensitive and can modulate based on hormonal levels. These can be attenuated by androgen replacement through direct T supplementation, progesterone, and domperidone and non-stereoidal androgenic drugs like SARMs to an extent. 

Although the exact mechanism is uncertain, hormone-influenced gingivitis similar to pregnancy gingivitis is common. This can be worsened with eating disorders such as bulimia, a common comorbidity. High rates of smoking, alcohol consumption, and illicit drug use all can combine with other common comorbidities like psychogenic hygiene indifference and medical neglect. 

Neurodevelopmental

It has shown that there is an overlap between autism and gender incongruence. However studies like Kristensen show that genderqueer group has the highest AQ-10 average, which is not explored well and not necessarily explained by the negative result of the male brain thesis. However this result could be explained by a corollary of the WEIRD bias. An autism diagnosis is already socioeconomically biased to an affluent demographic with preexisting risk factors for autism, including older parental age. With other sociological factors like smaller family sizes, and socially liberal backgrounds with self-selected surveys this group is massively overpresented in the literature. We see this bias in studies like Warrier et al., where it disregards the lack of significance on the older LifeLines cohort as drop-out of more severe cases without actually testing it, even though this critique equally applies to the survey results equally where severe cases are self-selected out. Thus the demographic is more likely to have autism, be active on the internet, and feel freer from social pressure against identifying as queer resulting in being overpresented in surveys of younger queer people. 

This is differentiated from the historical urban queer diaspora from lower socioeconomic backgrounds who were conceptualized due to convenience bias. Accessibility to SRS had been opened up by Benjamin’s criteria to poorer and black trans women who had a chance to get surgery and assimilate, but also made them severely dependent on the medical field. Thus, much like earlier medical studies on syphilis, Blanchard and other sexologists used vulnerable populations for medical experimentation for their intrusive psychosexual theories in exchange for medical access. With this as a baseline we can tell the main differentiator between the clinical populations is simply the latter is self-selected from those who are more readily self-identify as transgender, and those forced to. 

Theory

There has been a speculated process of feedback between the body and the mental representation of the body that has been implicated in disorders such as anorexia nervosa and body integrity disorder. This theoretical framework has also applied to other distortions of internal body representation such as learned paralysis or alien limb syndrome. This behavioral and perceptual feedback loop has also been applied to gender as a status where virilization in CAH females leads to shifts in self perception in terms of gender and sexuality. This accords with case reports about a reported feeling of visceral self-alienation from one’s own body in sufferers of alien limb syndrome. There has also been a reported similar erotic component to BID although how sufficiently the case literature has disambiguated BID from its historical classification as paraphilia is sparse. 

Body schema, and the body in gender integrity disorder must be then integrated into a framework where the social is actually constructive in the proper sense of cognitive enactment. The socially extended mind applies cognitive processes to not only mental supplements in terms of physical or contextual memory, but social institutions as a subset of densely interactive processes that don’t merely mime mental processes but enact them. As a result, gender as a status can be framed as how sexual differentiation is given intelligibility through a virtualized body. It is properly understood as the exact equivalent to the material, it is as much as the body as the body can be itself. This gives proprioception much more significance as only a part of the internal modeling of the world the body does.

Gender

This topic has been addressed in philosophy of mind as representationalism, which diminishes the externality of mental processes. The enactive nature of this is the explicit rejection of a nativist view insofar as individuals are able to independently, through interaction with reality, determine the gendered body. Where the precondition of heteronormativity renders bodies legible, socially constructivist gender is an attempt to make up for a lack of agency in a structuralist framework by positing an immaterial force, much like Cawadias’ sexomorphic impulse, that imposes sex externally. However the conceptualization of gender presents a double-bind between the natural, a conformation to an authentic gender free from undue influence, and an hypervigilance of the social body created by accordance with pure expectation. 

Thus gender becomes more despotic as relativist self-regulation which produces a distinct form of sex that is cordoned off from itself properly (sex is not gender and gender is not sex). From this relativist framework, the hermaphrodite or the third sex, it follows, must have been the natural pariah, the Other which has a monstrous status within the normative dyad. Gender reifies this natural failure into an ersatz sex that substitutes for its blind spot, the anti-normative framework it takes as granted. The erotic, and thus the culture of sexuality disguises the fundamental power dynamic which restricts participation. Neoteny promises the same, a hyperfeminity which is totally removed from constitutive processes of society. However we must reject the spirit of gender correlationism clearly, there is no body outside descent.

With a virtual body we can constitute the parts which we consider separate: social and somatic incongruence into an integrated whole. Ramachandran’s study on cortical remapping of amputees can give us a sense of how the virtual body’s feedback is altered after somatic changes. For the amputee, it seems to scatter and duplicate the somatosensory maps according to proximity on the Penfield homunculus. However it was subtly noted that the thumb tended to have a correspondingly larger size than the rest of the fingers. With the role that the thumb plays in fine dexterity, it has been implicated as a proxy for neocortical development, and shown biomechanically to have a greater range of motion. This implies that not only innervation density  is represented but degree of freedom influences the size of the somatosensory maps. 

Sex

Sex as a sense is the structured synthesis of feedback onto the same virtual body. Sex, like animacy, are part of that active inference that the mind creates, modalities of reality that allow affordances to exist as such. Perception is not theory-neutral, and is synthetic, and cognitively penetrated by multiple sources of information, both conscious and unconscious. Arstila proposes that perceptual learning is the simplest mechanism where non-cognitive stimuli can influence cognitive ones without penetration. He argues against Siegel’s Thesis K saying that there are no such K-properties that the process creates and our ability to perceive gestalts are merely rearrangements of attention. However with recent advancements in computer vision and natural language, we can see that it is possible to conceptualize any sort of information as a modality, as long as you have enough of a dataset. Furthermore, when an NN grokks suddenly, what property it is approximating is the hidden information of the dataset, crypticity which is abstracted from variable causalities. Perceptual unitization instead does the same work as compressibility, it distills the minimal causal state into a basic quanta. 

Thus sex can appear to us as a perceptual fundamental, an unconscious, basic qualia that like the Müller-Lyer illusion is influenced by contextual experience in carpentered environments. Sex is specific degrees of freedom within the social realm, enacted affordances that are similarly sensorily magnified onto the virtual body. Thus dysphoria is the distress from trying to reconcile the incongruence, and can have such visceral and general effects merely coming from social feedback because of this intimate connection. We can see then that multiple subsets of dissociation and sudden moments of collapse are possible when there is a resonance between them. Brizzi et al. tries to integrate the free energy principle into theories about anorexia nervosa. Allocentric lock theory characterizes anorexia as a failure of the multimodal updating of a body matrix into either a dominant allocentric, exterior frame or a first-person egocentric one. The distress that results from the disembodiment of experiencing the body as one does not expect.

Conclusion

The antinormative as critical programme has failed by its own standards. The assertion that gender is either purely a language game or an immaterial inner-truth has disregarded the fact that the virtual is not optional scaffolding around some primitive. The relativist nature of such has reduced genuine exceptions to analogies for regulation, disguising the structural conditions it takes as given being themselves what produces the exception. The attempt to systematize them within a more rigorous legal and medical framework created monsters on the periphery instead of preserving extraneous cases as exce ption. It is exactly that tendency to read the logic backwards that whitewashes when failure happens. Thus in an actual study of sexology we must consider the catastrophe as such. Where it happens is an actual possibility of change.