Previously, a discussion of the controversy over J. Michael Bailey's book on transgenders, "The Man Who Would be Queen," focused on problems finding the line between science and opinion in research on human biology. It is also interesting to speculate where the feelings come from that spur the decision to become transgendered (even for those of us who are not specialists in this area and have no scientific credibility backing up our positions).

As social animals, humans learn early on the rules to navigate society. Proper understanding and navigation of social norms is essential for humans to live satisfying lives, and in general, to reproduce. Rules governing gender roles, although they may vary from culture to culture, are a large subset of these.

It is clear to anyone watching children develop and begin to navigate the social waters that gender roles are a big area of focus for them. For instance, through observation, small children build a list of rules for identifying a male versus a female, and are very good at this with adults at a young age (<2). The genders of children themselves are much harder to identify, of course, because they lack secondary sex characteristics until puberty, so children and adults use other cues such as hairstyle and clothing to decide whether a child is a girl or a boy. When the signals are mixed, it seems to faze children more. If a girl has short hair and is not wearing girly clothes, another toddler may ask over and over "it's a she?" each time the girl is referred to as one.

A child also understands early in development that he or she is either a boy or girl (based on constant references by family and friends), and tailors his or her behavior to the correct gender, which shows that he or she understands the rules governing gender roles. All the sex-associated behavioral traits that parents insist must be inborn, may not be at all (the scientific jury is still out on most of these). Humans are designed to figure out this crucial part of living in a society at as early an age as possible, so whether or not they are, sex-associated traits can seem to be "genetic."

But what of the children who know they are a certain sex, but are not comfortable mimicking the behavior they see associated with that sex? (Why this happens in genetically unambiguous males and females is not always known and for another discussion.) They may feel caught in a trap. A boy (such as someone that I do currently know) who loves pink and frilly things either learns early on to suppress his own feelings, or is forced to suppress them by his family -- perhaps because they fear it means he is gay. If one stands back for a moment, the condemnation of a preference for a color by one sex that has been arbitrarily designated as being owned by the other sex is ludicrous, but of course occurs. If that boy is continually given the idea that there is something wrong with him because of his aesthetic preferences, then how is he going to feel about himself as he grows up? Society has already decided, at age 4, that there is something wrong with him, so it is likely he will believe it. This could play out any number of ways as the boy grows up, but one way that seems possible is that the boy will decide he really is supposed to be a woman, because he likes things that society tells him only women are allowed to like.

Society forces values and behaviors on us that we either accept, and become assimilated, or reject, and become an outcast or fringe member. Why do some men want to become women? Bailey says it is either because they are gay, and want to attract men, or because they find the thought of themselves as a female sexual object erotic. This either-or is what many transgenders have objected to, because surely people are more complex than the pigeonholers would have. What if a third (of likely several more) reason is that male-to-female transsexuals are just men who want to be able to wear dresses and enjoy pink, which society says they cannot do as men ("cross-dressing" being generally a fringe activity)?

I did find one study which is interesting in light of this theory (Winter S , Udomsak N (2002) Male, Female and Transgender : Stereotypes and Self in Thailand. Int. J. Transgenderism 6,1, http://www.symposion.com/ijt/ijtvo06no01_04.htm). The authors concluded with the following summary:

Participants overall expressed gender-trait stereotypes very similar to those of non-transgenders (both in their own country and internationally), notwithstanding that differences were found on a small number of traits.

Apart from a few traits, participants' actual self-concepts tended (in terms of their own gender-trait stereotypes) to be stereotypically female. Their ideal self-concepts were far less so, with several stereotypically male traits being frequently endorsed, and female traits being rejected.

As a corollary, the traits that participants wished to acquire tended to be broad-ranging, while those that they wished to lose were female-stereotyped.

The "ideal self-concept" and the "actual self-concepts" were not congruent. One might interpret this to mean that in an ideal world, we are all allowed to express our mix of stereotypically "male" and "female" traits, but in fact society has told these male-to-female transgenders that what they have are all the stereotypical "female" traits; therefore, they must be females trapped in male bodies. Why did they wish to lose "female" traits? My guess is that individuals such as these who cannot be neatly pigeonholed into their society's image of one gender or another are demonstrating it.

There are other individuals who are especially harmed by our either-or mentality of men and women. These are people with ambiguous genitalia, often due to recessive mutations. Some of these have an extra chromosome, such as people appearing to be males with an XXY genotype. (In humans, sex-determining chromosomes are labeled X and Y; females have two X chromosomes, and males have one X and one Y. Other species have different sex determination systems.) Others just don't produce enough of certain hormones when genitalia are developing. The latter is the subject of Jeffrey Eugenides's Pulitzer prize-winning novel "Middlesex," a story told from the point of view of a genetic male who is raised as a female for the first 14 years of his life. Behind the engrossing plot and the witty writing is a commentary on what gender really means, and how most of us have a very narrow view of what behavioral and appearance traits are acceptable in our society - and probably most societies.

This narrow view may make some biological sense, because really everything is about reproduction, and in a sexual species that means getting together with the right person in order to be able to reproduce, and in a social species that means learning the rules that tell you how to identify the sex of others, behave in a way that will make you attractive to members of the opposite sex. But as an intelligent and self-aware species it would be nice if we could transcend some biological imperatives to acknowledge the natural variation in gender identidy that does indeed occur (for whatever reason), and accept that full variation as part of the entire human experience.

Labels: gender, humans, sex, sociality

A long term academic controversy boiled up into the New York Times recently. There are dozens of these all the time in every field, but this one, regarding Dr. J. Michael Bailey, who in 2003 published "The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism" obviously made the mainstream press because of its topic.

The portrayal of the controversy is a typical rehash pitting the Nasty Scientist Who Misuses His Credentials To Promote An Unsubstantiated Viewpoint versus the Knee Jerk PC Crowd Who Doesn't Want To Hear The Uncomfortable Truth.

My disclaimer up front is that I have not read the book, just a lot of commentary by both its supporters and detractors. For my purposes this is enough. The existence of the controversy itself brings to mind two separate questions. The first is a question about how we go about conducting science and promoting its results, especially when the research involves human subjects (which by default produce data that are complex and difficult to interpret). The second is a question about the relationship between gender identity issues and society, and will be addressed in the next post.

Any academic discussion of sexual identity will become quickly polarized, because people view statements written in generalities as personal attacks. This is why a book such as this provokes much more emotional responses than controversial books or papers about other health issues. The crux of this controversy is that proponents of the book maintain that any transsexuals who were offended by it just don't want to hear the truth about themselves, while the offended transsexuals are insulted that anyone else would presume to know more than they about their motivations. It is clear from reviews on both sides that Dr. Bailey goes somewhat out on a limb by claiming that there are only two motivations for transsexuals, and every transsexual falls into one of the two groups. It is not surprising that transsexuals who believe they fit one of the categories like the book, and those who do not believe such do not. But what truly matters is whether this book is actually science or merely opinion.

Certainly it is wise to be suspicious of those making sweeping claims about human biology based on their invariably self-selected, self-reporting sample. Such a book, if it purports to be true science, should be absolutely clear in its justification of research methods (e.g. at the minimum, general acceptance of those methods by others in the field), and equally up-front about the assumptions that were made in the analysis of the data. All data analyses, statistical or not (and I have no idea if Bailey used statistics or not), involve assumptions, that if violated, undermine the conclusions the author is drawing.

There is a widespread problem of those with scientific credentials claiming authority in areas such as this that are notorious for requiring many assumptions and inferences that cannot be directly confirmed through observation or experiment. An example of a field outside the realm of human biology is paleontology, in which scientists notoriously cling to their personal theories with a vigor less known in other areas of geology and biology. The reason is that there is a clear limit on what we can ever know about plants and animals that went extinct millions of years ago, no matter how many more fossils are discovered. Thus the field is rife with assumptions and inferences that can never be disproved.

The field of human biology is similar. Our knowledge of how the brain works is growing, and may sometime be sufficient to make well supported generalizations, but the more we learn, the more we discover how little we really know. Every individual is a unique combination of genes and environment, with no way to replicate his or her singular experience (except in the limited case of identical twins-reared apart studies). So even sincere attempts at conducting scientifically rigorous, unbiased research are extremely limited in their real scientific utility. Overlaid on top of this is the problem of distinct personalities conducting the research, with biases (quite strong when the subject is our own species) either blatant or in most cases more subtle and difficult to detect, and the reception of results also by distinct personalities with their own biases. Rigorous scientific methods are a distinct improvement over exhortations from those claiming to converse with a higher being, but even their results are often far from black and white.

Is Dr. Bailey's book science? I cannot answer that question without reading it. But my own bias is that little health research to do with humans is worthwhile at the present time. Its larger potential value is that it will lead to more interesting questions to ask in the future, when we may have better technologies for understanding the interactions between genes and environment that create the deeply complex bags of water and chemicals that we are.

Labels: gender, health, humans

Although evidence is purely anecdotal, it appears these days that most children sleep a lot less than children of generations past. The majority of parents I encounter (certainly not all) seem to put their children to bed around the time they go to bed, which means a lot of kids out there may be getting only eight hours of sleep or less. Data presented in Weissbluth (2003), however, show that although total sleep per day declines with age until 14 years (in teenagers it creeps back up again), the median amount of sleep needed by children never drops below about 9.5 hours by this age. At 4, median sleep time is 12.5 hours, and the 10th percentile is 10.5. So although 10% of 4-year-olds out there may need less than 10.5 hours of sleep, one encounters many more than that who are getting less.

There seems also to be some correlation between sleep disorders and ADHD (attention deficit-hyperactivity disorder) (Gau et al., 2007; Hora das Neves 2007), although the nature of this correlation is not yet well understood, if it is even real (Sadeh et al., 2006). Medical studies relying on self- (or parental-) reported data, which many of these seem to be, are unreliable at best.

There are, however, suggestions by some that some of the people labeled as ADHD may instead be suffering from poor sleeping. This may be caused by sleep disorders such as sleep apnea. But most articles on the subject, even those advocating treatment of sleep disorders before treatment of the ADHD itself, seem to assume that sleep problems are one of the symptoms of ADHD.

What if the reverse is true, that years of sleep deprivation has caused ADHD? Weissbluth (2003) seems to be one of the few authors suggesting this link. All of us know that in the short term, sleep deprivation makes people irritable, unable to concentrate, and even often hyperactive. What if kids are growing up sleep-deprived for years? Might that not be a cause of sleep disorders?

What's worse is that the popular drug for controlling ADHD, Ritalin, is a stimulant, and kids on it sleep less than those on an alternative non-stimulant ADHD drug, atomoxetine. (Sangal et al., 2006). Are we making our kids lives worse in the long run by addressing only the short-term behavioral problems?

It can be difficult for parents to sleep-train their children, and many never do. Their child is in an endless cycle of exhaustion followed by a crash. The easiest way to sleep-train a baby is to put her down and let her cry until she falls asleep. Most kids will only cry for a long time for 2-3 nights, and then they understand that it is their sleep time, and they learn to put themselves to sleep. Failure to teach a child to get to sleep on his own can lead to a lifetime of sleep problems. It is crucial for the developing brain to get an adequate amount of sleep, which is when the brain processes new knowledge and experience. Babies and small children have a lot of new information to process, and they need to sleep a lot, often for longer than they are awake. It is not a stretch to imagine subtle (or not so subtle) developmental brain damage occurring in children who are chronically sleep-deprived because their parents will not force them to go to bed before they are exhausted. Obviously ADHD is a complicated issue, and it is likely to have many causes, ranging from genetic to environmental. But the first question any parent of a hyperactive kid should ask is, does my child get enough sleep?


References

Gau, S.S.F., Kessler, R.C., Tseng, W.L., Wu, Y.Y., Chiu, Y.N., Yeh, C.B. & Hwu, H.G. (2007) Association between sleep problems and symptoms of attention-deficit/hyperactivity disorder in young adults. Sleep 30:195-201.

Hora das Neves, S.N. & Reimao, R. (2007) Sleep disturbances in 50 children with attention-deficit hyperactivity disorder. Arquivos De Neuro-Psiquiatria 65:228-233.

Sadeh, A., Pergamin, L. & Bar-Haim, Y. (2006) Sleep in children with attention-deficit hyperactivity disorder: A meta-analysis of polysomnographic studies. Sleep Medicine Reviews 10:381-398.

Sangal, R.B., Owens, J., Allen, A.J., Sutton, V., Schuh, K. & Kelsey, D. (2006) Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep29:1573-1585.

Weissbluth, 2003. Healthy Sleep Habits, Happy Child. Ballantine Books, New York.

Labels: ADHD, brain, health, humans

Before there were washing machines to process cloth diapers, let alone disposable diapers, children in Western societies were toilet trained significantly earlier than they are now, usually by around a year old. Similarly, the great majority of children today living in non-Western societies are also toilet trained by a year. The pattern largely reflects parental convenience; age at toilet training has increased in societies in which the ease of diapering has increased. A Chinese colleague of mine has noted that as disposable diapers have become more readily available in China, toilet training is becoming delayed there as well.

This is all quite understandable. There are many time pressures on parents, and the multitude of choices we make every day about child-rearing will inevitably factor in parental needs. There is nothing wrong with this; those who advocate a purely child-centered approach to child rearing can end up with extremely self-centered children who will have trouble functioning in the real world. And a parent who never considers her own needs can end up stressed in a way that impacts a child negatively.

The problem with current toilet-training philosophy is that choice has essentially been removed by the mainstream media and medical establishment. In the U.S., we now live in a world in which it does not occur to most people to train their children early, even though it is common practice elsewhere. Why is this so?

Early toilet-training advocates such as Dr. Linda Sonna and Laurie Boucke (see references below) have traced the current late-training trend mainly to a paper published in the journal Pediatrics by Dr. T. Berry Brazelton, who was famous for a time for his child-rearing advice. This paper (Brazelton, T.B., 1962. A child-oriented approach to toilet training. Pediatrics 29:121-128) became the basis for the now widespread idea that early toilet training causes psychological damage to a child, despite the fact that Brazelton's research was supported by Proctor & Gamble, which produces Pampers. (Back then it was not required to report conflicts of interest in a published paper, so there is no hint of the affiliation in the original version.)

The problem with the paper is that it essentially sets up a straw man; Brazelton compares punitive and coercive techniques used by advocates of early training in the early 20th century, known then and now for potential damage, to waiting until a child is 2 before initiating toilet training. This is an apples and oranges comparison, because he does not examine the outcome of non-coercive early training, which is used successfully by most people around the world.

An underlying assumption of Brazelton's paper, one that is still commonly believed today, is that children do not have voluntary control of their sphincter muscles until they are 18 months or older. Anyone who has had a toilet-trained 10-month-old can tell you that this is simply untrue. What Brazelton and today's "experts" ignore is the fact that babies have been trained since birth not to exercise control, because they are wearing diapers and their parents do not care where or when they urinate or defecate. Brazelton asserts without any basis that "there is little innate in the child that leads him to want to be clean and dry" when in fact there is strong evidence from babies who are never diaper trained that in infancy they do have an instinct not to wet their bedding or clothes, and they do alert their caregiver that they need to go. Again, babies that have been in diapers for a few months lose this awareness of their bladder and bowel.

The most absurd statement Brazelton makes, which reveals his narrow agenda, is the following: "The developmental energy invested in learning to walk on his own is freed after 15 to 18 months and can be transferred to the more complex mastery of sphincter control and toilet training." According to Brazelton, we must wait to toilet train until age 2 because learning control of two muscles, one each controlling bladder and bowel release, is more complex than learning to walk, which involves the use of dozens of muscles.

The paper was essentially instruction for doctors on how to brainwash parents not to toilet train their children when they wish to, but to wait until a child is about 2 and is physiologically "ready," based on his incorrect assumptions. In the intervening decades, this idea of "readiness" has been transformed to mean, in the mainstream media, that your child will decide one day that she wants to be toilet trained. Some parents are lucky enough that this indeed happens. For many however, toilet training is a struggle because after being conditioned for 2-3 years that the place to urinate and defecate is the diaper, the child is told that he must forget this conditioning. You try the reverse right now, as you sit reading: urinate in your pants, just as an experiment. Can't do it, can you? Conditioning is a powerful behavioral control.

Disposable diapers are indeed a convenience, really a luxury. Cloth diapers are viewed as more environmentally correct, but their use generates many gallons of wastewater, as well as quantities of detergent and bleach released into the environment. Parents should be aware that there is indeed a third option: eliminating the use of diapers as early as possible. At a minimum, I strongly recommend bowel training, which we achieved almost instantly with our daughter at 9 months when we gave her the opportunity to sit on a potty at the appropriate time. The methods for this are fairly straightforward, and are discussed in detail in the recommended books below. There are also resources available at the Elimination Communication store. For some it is a matter of convenience to wait until their child can complete the whole toilet process by himself. But it also takes time, a lot of money, and produces a lot of waste to change diapers for years. All pediatricians should make parents aware that non-coercive early toilet training is a choice that many families make successfully.

Labels: health, humans