Evidence on the biological nature of gender identity

Gender identity disorder affects as many as 1 in 100 people. Varying etiologies for the disorder have been suggested but none proven indefinitely. Gender-affirming medical therapies (hormonal and surgical) have been met with resistance by physicians who perceive that gender identity can be changed with psychiatric treatment. The physicians’ perception on transgender identity has significant implications in medical care of the transgender patient.

Multiple studies set out to identify evidence of gender identity having biological basis by examining disorders of sex development. Meyer-Bahlburg et al. found that among individuals with 46 XY genotype (these individuals born with congenital abnormalities including penile agenesis, cloacal exstrophy, and penile ablation) 78% were assigned as females and only 15 were raised as males. The risk of questioning gender identity was higher in the female assigned 46 XY individuals while the male assigned patients were more comfortable with their gender identity. Reiner and Gearhart et al. identified similar results where most individuals with XY genotype who underwent female gender reassignment surgery later identified as males and all subjects presented strong masculine characteristics regardless of gender assignment. Dessens et al. examined gender identity in patients with congenital adrenal hyperplasia (adrenal glands produce excess androgens) in 46 XX patients. The majority of female assigned patients (63%) changed their gender identity later in life.

Despite evidence for biological basis in gender identity disorders there are gaps in evidence-based guidelines for the care of the transgender patient. As a result, transgender medicine is underrepresented in the medical community. The principle of justice affirms that patients are entitled to fair distribution of healthcare resources, autonomy the right to make informed decisions regarding treatment with clinicians, while non-maleficence/beneficence uphold minimizing harm and providing care to benefit the patient; however transgender patients are less likely to have health insurance, access to medical services, and the option for treatments they desire. Do you think that transgender medicine needs reform? If so, to what extent? Should insurance companies cover gender-affirming therapies on the grounds of medical necessity rather than elective therapies?

[1] Hann M, Ivester R, Denton D. Bioethics in Practice: Ethical Issues in the Care of Transgender Patients. Oscher J 17(2): 144-145, 2017.     

[2] Saraswat A, Weinand J, Safer J. Evidence Supporting the Biologic Nature of Gender Identity. Endocrine Practice 21: 199–204, 2015.