Sunday, May 20, 2007

My Three Shrinks Podcast 21-R: Chris Kraft on Gender Issues

[20] . . . [21] . . . [22] . . . [All]

This podcast is a special treat, in that we have a guest expert on sexual disorders, Chris Kraft, PhD, who is the head of the Johns Hopkins Sexual Behaviors Consultation Unit and the Center for Sexual Health. He is talking about intersex disorders. Also, our friend, Victor, is a guest.

May 20, 2007: #21 Chris Kraft

Topics include:
  • Intersex disorders: This is where one is born with ambiguous genitalia, and one is raised a gender which is different from one's genetic gender. It is a rare condition. Dr. Kraft discusses the many complications that this can cause. This is part of an answer to Zoe Brain's question, continued from last week's podcast.
  • What is a "mother"? A Maryland court has determined that a surrogate mother can have her name removed from a baby's birth certificate, like fathers have been capable of for years. Can a child be born with no parents on its birth certificate?

EDIT: While I do have the "Happy Hour" CD, I could not find King Missile's 1992 hit, Detachable Penis, on iTunes or eMusic (eMusic does have a nice Karaoke version, however, in case you want to sing this at the corner pub). The band's video is posted on YouTube. (John, Dave, Chris & Roger: hope you don't mind me using the song.)  Thanks for the idea, Lily.  And, yes, the "-R" in the title indicates that Dinah Revised my original title, which had the same title as the song.

Find show notes with links at:
This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from

Thank you for listening.


Zoe Brain said...

Hi there! It's Zoe (rhymes with Joey rather than Edgar Allan Poe)

Gosh. In all my born days I never expected to have a podcast dedicated to me! Thanks, I'm really stunned, and appreciative.

Many thanks to your special guest too. I hope that surgical intervention on IS kids will be more conservative in future.

Pending some breakthrough in MRI or our understanding of gender identity formation and structures in the brain, the best thing really is to allow IS kids to tell us what gender they are.

By all means pick a gender, then raise the child as that, but be prepared to backtrack. The Intersex Society of North America is a good source on this matter.The prevalence of IS is at most 1-2% with the broadest possible definition, and 1 in 1000 is closer in practice - 0.1%, of which 1/5 have genetic cross-gendering, call it 0.02%, as your guest stated.

The prevalence of TS is often quoted as 1 in 30,000, based on extensive surveys of Swedish (not Dutch) psychiatrists in the 1960s.

Recent surveys of numbers of Sex Reassignment Surgical procedures performed in the US put a lower bound of prevalence as 1 in 2500. ( Conway )

The Surgeon who performed my surgery deals with upwards of 50 SRS patients from the USA per year according to his business manager. In the month I was there, I met 7 women from the US in for SRS. There are many more like him in Thailand, and the number of US patients annually would be as a minimum 500, and probably more like 1000. Add that to the US total, and the anomaly becomes manifest.

My GP has assisted in 30 transitions over 5 years, and the other General Practice in the city which provides services to TS people have assisted somewhat more. This in a city of 300,000 people. "Anecdote" is not the singular of "Data", but the "1 in 30,000" figure doesn't stand up, it's out by an order of magnitude.

Many thanks for an interesting podcast. Even the latter part was germane, as we required medical intervention for my son to be conceived.

Midwife with a Knife said...

Oh! An ob-gyn topic! Kind of. :)
I really loved this podcast. Fun topic. Sex! Sex! Sex! :)

The chromosomes are not helpful for determination of sex in disorders of ambiguous genitalia.

Where I was trained, in terms of pediatric gynecology, we first find a diagnosis, and try to explain the diagnosis (testicular feminization, Mullerian agenesis, congenital adrenal hyperplasia, 17-hydroxylase deficiency, etc) to the parents. Generally, even if there's ambiguous genitalia, you can usually tell with a good exam or some tests what their actual gender is supposed to be.

Also, we generally make any necessary surgical interventions (i.e. for urethral obstruction) as minimal as possible.

And, we usually tell parents to wait to assign the gender until puberty. Most of the disorders of ambiguous genitalia don't really require surgery anyway.

But we know relatively little about these disordes. They're so rare, it's difficult to really do great studies with respect to outcomes in terms of quality of lives for individuals. So, at least in terms of pediatric gynecology, we really don't have a great standard of care. Currently, at least where I trained, the focus was on avoiding as much harm as possible.

When we do neo-vaginas on kids with vaginal agenesis, we usually don't do it until they either need a vagina for menstruating or need a vagina for sexual intercourse. The surgeries are kind of cool. Plastic surgeons put in tissue expanders in the labia, and the non-hair bearing area of the labia are flapped up to create the vagina. They also use ileal or colonic mucosa in some cases.

IVF couples don't need psychiatric evals any more. But in my experience, the IVF nurses who do a lot of the care for these patients do a good job at keeping an eye out for psychiatric complications (fortunately serious psychiatric complications are uncommon. Psychiatric/mood side effects that are more mild are relatively common).

(Sorry for the long comment)

Dinah said...

Zoe Brain--
Glad you're moved.
Thanks for the inspiration. Dr. Kraft is a lot of fun and it was great to introduce him to my co-bloggers and have his wise insights on this fascinating topic. Roy's comment: "How could you not like someone named Chris Kraft?"

MWWAK-- Thanks for the added info and the perspective from another discipline. It adds a lot, if only you'd been here to podcast with us!

Roy said...

Next time we have Chris on, we'll have to invite MWWAK, too. We can use Talkshoe for that.

Zoe, our pleasure. Thank you for all the great info, and for helping us get educated about a topic that doesn't come up too often clinically (at least, for me). But, as a consult-liaison psychiatrist, it is important for me to understand these issues.

Oh, and folks, please Digg us (I think you would need a Digg account, but aren't we worth it?)

mythusmage said...

I first learned that Zoe was ... unique ... when I read these words way back in the late 1970s, "These are the voyages of the starship Brillo. Her 5 year mission to seek out new life and new civilizations. To boldly go where no dragon has gone before!"

Anonymous said...

Cool! So Zoe was Alan of A&E Brainstorm? (thx, Google)

NeoNurseChic said...

Haven't yet listened to the podcast, but this has already come up in the NICU setting as well. I once saw a baby that had a uterus, but no ovaries, and a penis, but not testicles. So it had the functional organs, but nothing hormonal or sex-producing. I was told that if the baby has a uterus, then it is female. However, I don't believe anything was being done to the child to formally declare one sex or the other. It is my feeling that this is very difficult - and I wouldn't want to live with the guilt of worrying if I picked the wrong one - but that it will declare itself as time goes on. Even as infants, you can generally tell if the child is male or female.

Quite an interesting topic, and I'm looking forward to hearing the podcast!

Take care,
Carrie :)

Midwife with a Knife said...

There was one other thing I want to add. Kleinfelter's syndrome and Turner's syndrome are not on the gender identity disorder spectrum.

Individuals with those problems identify as their phenotypic sex. In fact one of the most distressing things for them is that the don't develop secondary sexual characteristics at puberty like their peers. They are phenotypic males (KS) and females (TS), but since they have abnormal numbers of sex chromosomes, they don't develop normally.

Oh, and I need to correct an error, that I made. In the ambigous genitalia world, a karyotype is absolutely critical for the work up (differentiating testicular feminization from a salt wasting form of congenital adrenal hyperplasia, for example is crucial for the health of the child). I just meant that we don't typically use the chromosomes in these kiddos to tell parents that their baby is a boy or a girl. We try to assign gender by phenotype, but parents are encouraged to entertain a certain degree of flexibility around gender roles (perhaps all parents should have a degree of flexibility) and tell the parents that the kid will sort of delcare him or herself wrt gender.

Roy and Dinah: Thanks. That's very flattering, but you know, I'm no expert on this stuff. :)

Midwife with a Knife said...

And what is this "Digg it" thing? Just curious.

Roy said...

MWWAK ("not an expert"): This hasn't stopped us.

Digg? is a site where folks post news items, website pages, blog posts, and other internet links, and where others can vote, or "digg", the posted links. Digg visitors can vote a thumbs up or thumbs down on the stories... the more positive diggs a story has, the quicker it rises to the top of the whole list of stories.

A highly Dugg story can get thousands of hits in a matter of hours.

DrivingMissMolly said...

Hmmm, interesting.

This has been the best sounding podcast EVER! I love the clear voices and the lack of background noise!

Clink--Do you want to (secretly) go to law school?

Roy--You're falling down on the job! "Detachable Penis" by King Missile would have been perfect for this podcast! Kidding. Sorry.

I've read that more and more people are going to Thailand to have their sex-change surgeries. Part of it is cost and part of it is their desire to skip all of the required psychiatric steps.

I wonder what is going to happen when we have a bunch of people who regret their sex change, sorry, gender reassignment?

There was a case in Texas (Bexar county,Christie Lee Littleton case) where she was married, but upon the death of her hysband, she was denied the ability to sue her husband's doctor for wrongful death because she was not a biological female. Here's the URL;

There is something that really bothers me. Everytime I watch a documentary on gender reassignment it seems like most of the profiled people who want to become female are very much into the trappings of femininity. I hope that I do not sound too ignorant, but these women are more girly than the average woman, it seems. To me, this begets the question; Do they want to be women because of the "trappings" of femininity? Is that their predominant view of it? Maybe it is just the perspective of the shows, but they spend an inordinate amount of the program showing these woman getting waxed, plucked, taking hormones, voice lessons, walking lessons, and getting breast augmentation. Is that what being a woman is being reduced too? To be fair, the other woman they profiled on this program is an OB/Gyn and was married and has kids. He, at one point, was voted the "hottest doctor" on the floor! Now, she works to help other transgendered people. She's pretty, but also warm and caring. This is a view of femininity that I am more comfortable with. Not all of us wear thigh high boots!

I shuddered when I thought of a birth certificate without a mother's name. It just totally creeps me out.

Growing up in California, we had neighbors who had a son who was transgendered. I think he was in his teens/early twenties. Talk about confusing! I swear that one day he'd be waxing the car without a shirt and the next he'd be all dolled up to go out. Of course, whenever it appeared to my parents that I was going to ask them a question regarding James/Desiree, I was immediately shushed. I think she eventually had the surgery. Sometimes she'd pick us up from school. She was very nice and I wish her the best. I cannot begin to imagine the hell people like her go through.


Zoe Brain said...

Anonymous :

You'd think after 30 years the "Brillo" incident would have been consigned to the Dustbin of History.

But yes, 30 years ago I was a Sophomore, and so Sophomorish humour is only to be expected. Besides which, it really happened, a very weird Role Playing Game (D&D) indeed.

Not so odd that all my Roleplaying characters but one were female. Though about half had to acquire a "girdle of sex change" for that. I could never see why that was considered a cursed item.

Now I can. The thought of reverting is Nightmarish. Would I rather die? No, I have a young son to parent, and besides which, others who have worse fates - quadraplegia for example - manage to live fulfilling lives. I'd need significant help though. I've never taken any anti-depressants, but I think I'd need them.

Getting back to FRP... the one character that wasn't female was so incredibly ugly they wore a mask all the time. "Mordred the Foul" tried to be a Parfit Gentle Knight despite the hideous appearance, and lived a life of lonely solitude, not bemoaning his fate, but trying to make the best of an impossibly awful situation. Trying to have an inner beauty to counteract the outer ugliness.

And no, it never occurred to me that this was a bit of a giveaway. Hindsight makes things so much clearer, doesn't it?

I often think that group fantasy roleplaying games could be useful diagnostic tools in psychology, but I'm such an ignorant novice, I could easily be wrong. But I digress...

I did an A to Z transformation, yes. And I didn't rename my blog: my son is the A.E.Brain now.


Every woman is different, and that applies to those born with XY chromosomes too.

Some are really girly, others not.

I'm a Geek Girl, that stereotype or social template is one I'm comfortable living in. The first time I attended a meeting of the "women in technology and communication", I felt I'd come home at last. My other girlfriends were nice people, but not the most technically minded. I had no idea if I was really a woman or not, or some ersatz, too masculinised after so many years of male hormones to ever be "normal".

But when I joined the WITChes - for the first time in my life, I was with people who thought like me. All my doubts and fears dissolved, it was wonderful, being where I belonged at last. Just a very ordinary female Engineer, just like the others. So obvious even my deepest rooted insecurities dissolved.

I'd like to be more feminine than I am, I just haven't had the time to learn. I want to have a manicure one day, and a makeover, and to look Good once in my life. I've been fortunate with my face, less so with my ribcage - still that of a rugby player. No matter how I might want to look like Gabrielle, I never will. I might make a passable Xena though.

I'm still finding my look. Unlike Susan Stanton and Christine Daniels, my financial resources are limited. Somewhat less than $20k per year before tax. PhD stipends are subsistence only.

My friends tend to be SF fans and the like, very few of them could be called fashion-conscious. Like most other women struggling with menopause or PCOS (only even more so), those of us who are transsexual are really insecure about our appearance. Some of us who transition late will always cause stares, whispers, and sometimes beatings and arrest. Not of our attackers, of us.

A little insecurity is only sensible - just don't let it run your life.

Finally, Christine Daniels said it best in her blog :
That question has literally billions of potential answers, all of them correct. Being a woman in 2007, in my view, is having the ability to set your own agenda, to carve out your own well-defined niche, to travel a road less littered by billboards touting Revlon and L’Oreal if you desire.

Countless others revel in the so-called “trappings” of hair, makeup, shoes, dresses and purses. Stop by any mall on a Friday or Saturday and witness the timeless ritual of a woman declaring her independence by bringing home a pair of shoes that speaks to her and her only.

Perhaps it’s best not to think so deeply about this stuff, and just let you, me and all women live to our potential as women -- whatever that might mean to you, whatever that might mean for me.


Every transsexual’s story is unique, but one thing we share is an excruciating longing for acceptance that is beyond the scope on any non-trans person.

So allow us our few extra minutes in front of the makeup mirror.

We have earned them.

We never had a girlhood, you see.

Finally, it helps to have a sense of perspective. Being TS is... not so good. Any syndrome with such an awful suicide rate (and what, 70% who attempt it?) is obviously not a terrific thing to have.

But there's objectively far worse. It's probably just an F type brain and an M type hormone balance that causes depression no SSRI drug will touch. Objectively, there's worse situations, subjectively... I don't know. I had it easier than most.

mythusmage said...


I keep bringing up Brillo because the story is funny. It's a wonderful parody of tons of stuff, and it all happened (so to speak) for real.

Folks, you want a bit of cognitive dissonance consider this; that an RPG session is a bit of fiction that actually happens. A bit of make believe that's also true.

Just when you thought you had the world figured out.

Roy said...

Dang! You are right. Had I thought of adding Detachable Penis, I would have. I happen to have it in my iTunes library. Next time, I'll tighten my thinking cap ;-)

DrivingMissMolly said...
This comment has been removed by the author.
Rach said...

Great podcast as usual guys! By far, the clearest soudning one - whatever you're doing vis-a-vis sound/ volume, keep doing it!

Rach (who is on vacation again... and starting to go stircrazy!)

Zoe Brain said...

I've come to the conclusion that I'm far too young and innocent to be reading these comments.

That's my story and I'm sticking to it, anyway.

Actually, I really *am* like Bree in "Transamerica".

Roy said...

I remixed the podcast with bits of the King Missile song placed in strategic locations. What do you think? Should I release it?

(I don't want it to come off like we are making fun, or insensitive, or anything like that... we just try to find humor on all of life's difficulties... makes it easier to deal with touchy subjects, IMHO.)

Zoe Brain said...

Roy - a sense of humour is a necessary survival skill during Transition.

Also, isn't the whole idea of "changing sex" so embarrassing and hilarious? Ok, tragic too, but you really have to see the funny side of it.

So by all means, change the sound track.

Dinah said...

Thanks for the insight, Zoe.


dinah said...

Huh? Dinah didn't say this. Someone out there is impersonating me!

Roy said...

Oops. Didn't realize I was signed in as you. I was signed in to our general ShrinkRapBlog account, which Dinah uses, as well. We're gonna have to get you your own so this doesn't keep happening.

Gerbil said...

Since I'm always late on downloading and listening to podcasts, I wound up with the "remix."

Sheer genius, Lily. (And expert mixing, Roy.)

I listened on my way to work today--and broke out in a huge grin while on the train. Thankfully, strange behavior on public transit is de rigeur around here; so no one paid my random mirth any mind.

Sarebear said...

Woohoo, I get to listen to two 'casts in a row. This one was good, but I can't get that detachable penis out of my head.

Yes, I know how that sounds.

Cause it's in my HEAD!!!

The earworm, not the penis. Would this one be a penisworm? I guess if your penis was issuing forth music, or something, the same song over and over . . .

Ok, I'm up WAY too late, and I'm way silly.

But you already knew that . . . . hope y'all didn't just spit all over your monitors! Lizards don't like that . . .

Anonymous said...

good podcast!
additional info on gender-neutral pronouns (they do exist, though not widely used):

also, i have a downloaded mp3 copy of the song "detachable penis" and i have the artist listed as "butthole surfers".


Becomeparents said...
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