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Journal ArticleDOI

Occurrence of phantom genitalia after gender reassignment surgery.

01 Jan 2007-Medical Hypotheses (Elsevier)-Vol. 69, Iss: 5, pp 1001-1003

TL;DR: It is predicted that male-to-female transsexuals will be much less likely to experience a phantom penis than a "normal" man who has had his penis amputated for another reason, and that the same will be true of female- to-male transsexuals who have had breast removal surgery.

AbstractTranssexuals are individuals who identify as a member of the gender opposite to that which they are born. Many transsexuals report that they have always had a feeling of a mismatch between their inner gender-based "body image" and that of their body's actual physical form. Often transsexuals undergo gender reassignment surgery to convert their bodies to the sex they feel they should have been born. The vivid sensation of still having a limb although it has been amputated, a phantom limb, was first described by Weir Mitchell over a century ago. The same phenomenon is also occurs after amputation of the penis or a breast. Around 60% of men who have had to have their penis amputated for cancer will experience a phantom penis. It has recently been shown that a significant factor in these phantom sensations is "cross-activation" between the de-afferented cortex and surrounding areas. Despite this it also known that much of our body image is innately "hard-wired" into our brains; congenitally limbless patients can still experience phantom sensations. We hypothesise that, perhaps due to a dissociation during embryological development, the brains of transsexuals are "hard-wired" in manner, which is opposite to that of their biological sex. We go on to predict that male-to-female transsexuals will be much less likely to experience a phantom penis than a "normal" man who has had his penis amputated for another reason. The same will be true of female-to-male transsexuals who have had breast removal surgery. We also predict that some female-to-male transsexuals will have a phantom penis even although there is not one physically there. We believe that this is an easily testable hypothesis, which, if correct, would offer insights into both the basis of transsexuality and provide farther evidence that we have a gender specific body image, with a strong innate component that is "hard-wired" into our brains. This would furnish us with a better understanding the mechanism by which nature and nurture interact to link the brain-based internal body image with external sexual morphology. We would emphasise here that transsexuality should not be regarded as "abnormal" but instead as part of the spectrum of human behaviour.

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Journal ArticleDOI
01 Dec 2008-Brain
Abstract: Transsexuality is an individual's unshakable conviction of belonging to the opposite sex, resulting in a request for sex-reassignment surgery. We have shown previously that the bed nucleus of the stria terminalis (BSTc) is female in size and neuron number in male-to-female transsexual people. In the present study we investigated the hypothalamic uncinate nucleus, which is composed of two subnuclei, namely interstitial nucleus of the anterior hypothalamus (INAH) 3 and 4. Post-mortem brain material was used from 42 subjects: 14 control males, 11 control females, 11 male-to-female transsexual people, 1 female-to-male transsexual subject and 5 non-transsexual subjects who were castrated because of prostate cancer. To identify and delineate the nuclei and determine their volume and shape we used three different stainings throughout the nuclei in every 15th section, i.e. thionin, neuropeptide Y and synaptophysin, using an image analysis system. The most pronounced differences were found in the INAH3 subnucleus. Its volume in thionin sections was 1.9 times larger in control males than in females (P 0.117) and females (volume P > 0.245 and number of neurons P > 0.341). There was no difference in INAH3 between pre-and post-menopausal women, either in the volume (P > 0.84) or in the number of neurons (P < 0.439), indicating that the feminization of the INAH3 of male-to-female transsexuals was not due to estrogen treatment. We propose that the sex reversal of the INAH3 in transsexual people is at least partly a marker of an early atypical sexual differentiation of the brain and that the changes in INAH3 and the BSTc may belong to a complex network that may structurally and functionally be related to gender identity.

252 citations


Journal ArticleDOI
TL;DR: It is concluded that the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIV.
Abstract: The categorization of gender identity variants (GIVs) as “mental disorders” in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of “impairment” and “distress” for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of “sex reassignment surgery” as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking “disorder” out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that—as also evident in other DSM categories—the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

169 citations


Journal ArticleDOI
TL;DR: A comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking and research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.
Abstract: Purpose of reviewResearch on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconfor

97 citations


Book
17 Jan 2011
TL;DR: One of the big puzzles in human evolution is the relatively sudden emergence between sixty thousand and a hundred thousand years ago of a number of traits the authors regard as uniquely human: fire, art, constructed shelters, body adornment, multicomponent tools, and more complex use of language.
Abstract: ion might work for bouba-kiki, but how do you explain metaphors that combine very abstract concepts like “it is the east, and Juliet is the sun” given the seemingly infinite number of such concepts in the brain? The surprising answer to this question is that the number of concepts is not infinite, nor is the number of words that represent them. For all practical purposes, most English speakers have a vocabulary of about ten thousand words (although you can get by with far fewer if you are a surfer). There may be only some mappings that make sense. As the eminent cognitive scientist and polymath Jaron Lanier pointed out to me, Juliet can be the sun, but it makes little sense to say she is a stone or an orange juice carton. Bear in mind that the metaphors that get repeated and become immortal are the apt ones, the resonant ones. In doggerel, comically bad metaphors abound. Mirror neurons play another important role in the uniqueness of the human condition: They allow us to imitate. You already know about tongue protrusion mimicry in infants, but once we reach a certain age, we can mime very complex motor skills, such as your mom’s baseball swing or a thumbs-up gesture. No ape can match our imitative talents. However, I will note as an interesting aside here, the ape that comes closest to us in this regard is not our nearest cousin, the chimpanzee, but the orangutan. Orangutans can even open locks or use an oar to row, once they have seen someone else do it. They are also the most arboreal and prehensile of the great apes, so their brains may be jam-packed with mirror neurons for allowing their babies to watch mom in order to learn how to negotiate trees without the penalties of trial and error. If by some miracle an isolated pocket of orangs in Borneo survives the environmental holocaust that Homo sapiens seems hell-bent on bringing about, these meek apes may well inherit the earth. Miming may not seem like an important skill—after all, “aping” someone is a derogatory term, which is ironic given that most apes are actually not very good at imitation. But as I have previously argued, miming may have been the key step in hominin evolution, resulting in our ability to transmit knowledge through example. When this step was taken, our species suddenly made the transition from gene-based Darwinian evolution through natural selection —which can take millions of years—to cultural evolution. A complex skill initially acquired through trial and error (or by accident, as when some ancestral hominid first saw a shrub catching fire from lava) could be transmitted rapidly to every member of a tribe, both young and old. Other researchers including Merlin Donald have made the same point, although not in relation to mirror neurons. 3 THIS LIBERATION FROM the constraints of a strictly gene-based Darwinian evolution was a giant step in human evolution. One of the big puzzles in human evolution is what we earlier referred to as the “great leap forward,” the relatively sudden emergence between sixty thousand and a hundred thousand years ago of a number of traits we regard as uniquely human: fire, art, constructed shelters, body adornment, multicomponent tools, and more complex use of language. Anthropologists often assume this explosive development of cultural sophistication must have resulted from a set of new mutations affecting the brain in equally complex ways, but that doesn’t explain why all of these marvelous abilities should have emerged at roughly the same time. One possible explanation is that the so-called great leap is just a statistical illusion. The arrival of these traits may in fact have been smeared out over a much longer period of time than the physical evidence depicts. But surely the traits don’t have to emerge at exactly the same time for the question to still be valid. Even spread out, thirty thousand years is just a blip compared to the millions of years of small, gradual behavioral changes that took place prior to that. A second possibility is that the new brain mutations simply increased our general intelligence, the capacity for abstract reasoning as measured by IQ tests. This idea is on the right track, but it doesn’t tell us much— even leaving aside the very legitimate criticism that intelligence is a complex, multifaceted ability which can’t be meaningfully averaged into a single general ability. That leaves a third possibility, one that brings us back full circle to mirror neurons. I suggest that there was indeed a genetic change in the brain, but ironically the change freed us from genetics by enhancing our ability to learn from one another. This unique ability liberated our brain from its Darwinian shackles, allowing the rapid spread of unique inventions—such as making cowry-shell necklaces, using fire, constructing tools and shelter, or indeed even inventing new words. After 6 billion years of evolution, culture finally took off, and with culture the seeds of civilization were sown. The advantage of this argument is that you don’t need to postulate separate mutations arriving nearly simultaneously to account for the coemergence of our many and various unique mental abilities. Instead, increased sophistication of a single mechanism—such as imitation and intention reading—could explain the huge behavioral gap between us and apes. I’ll illustrate with an analogy. Imagine a Martian naturalist watching human evolution over the last five hundred thousand years. She would of course be puzzled by the great leap forward that occurred fifty thousand years ago, but would be even more puzzled by a second great leap which occurred between 500 B.C.E. and the present. Thanks to certain innovations such as those in mathematics—in particular, the zero, place value, and numerical symbols (in India in the first millennium B.C.E.) , and geometry (in Greece during the same period)—and, more recently, in experimental science (by Galileo)—the behavior of a modern civilized person is vastly more complex than that of humans ten thousand to fifty thousand years ago. This second leap forward in culture was even more dramatic than the first. There is a greater behavioral gap between pre–and post–500 B.C.E. humans than between, say, Homo erectus and early Homo sapiens . Our Martian scientist might conclude that a new set of mutations made this possible. Yet given the time scale, that’s just not possible. The revolution stemmed from a set of purely environmental factors which happened fortuitously at the same time. (Let’s not forget the invention of the printing press, which allowed the extraordinary spread and near universal availability of knowledge that usually remained confined to the elite.) But if we admit this, then why doesn’t the same argument apply to the first great leap? Maybe there was a lucky set of environmental circumstances and a few accidental inventions by a gifted few which could tap into a preexisting ability to learn and propagate information quickly—the basis of culture. And in case you haven’t guessed by now, that ability might hinge on a sophisticated mirror-neuron system. A caveat is in order. I am not arguing that mirror neurons are sufficient for the great leap or for culture in general. I’m only saying that they played a crucial role. Someone has to discover or invent something—like noticing the spark when two rocks are struck together—before the discovery can spread. My argument is that even if such accidental innovations were hit upon by chance by individual early hominins, they would have fizzled out were it not for a sophisticated mirror-neuron system. After all, even monkeys have mirror neurons, but they are not bearers of a proud culture. Their mirror-neuron system is either not advanced enough or is not adequately connected to other brain structures to allow the rapid propagation of culture. Furthermore, once the propagation mechanism was in place, it would have exerted selective pressure to make some outliers in the population more innovative. This is because innovations would only be valuable if they spread rapidly. In this respect, we could say mirror neurons served the same role in early hominin evolution as the Internet, Wikipedia, and blogging do today. Once the cascade was set in motion, there was no turning back from the path to humanity.

92 citations


Journal ArticleDOI
TL;DR: This book seeks to convey recent insights into the workings of the human mind, as gleaned from studies of some of the more perplexing and counterintuitive deficits (or excesses) that can result from brain injury (or amputation).
Abstract: This book is aimed squarely at the popular science market and, presumably because of this, presents neurology as an exhilarating voyage into the ‘twilight zone’. It seeks to convey recent insights into the workings of the human mind, as gleaned from studies of some of the more perplexing and counterintuitive deficits (or excesses) that can result from brain injury (or amputation). Though co-authored by Ramachandran (a psychologist with a medical background) and Blakeslee (a science writer and journalist), it is written entirely in the Ramachandran first person. The book largely comprises vignettes of Ramachandran’s encounters with various patients suffering from a diverse array of unusual neurological deficits. As such, it runs close to Oliver Sacks’ territory, and the authors seem happy to trade on this overlap. Nevertheless, the book is a highly original and personal statement of Ramachandran’s position on innumerable issues. This is both its strength and its weakness. Each chapter covers a different topic, the only commonality being the seemingly bizarre and paradoxical nature of the neurological deficits described. The description of Ramachandran’s celebrated work on referred sensation in patients with amputated (phantom) limbs is an early highlight of the book. Although referred sensations—that is, feelings in phantom limbs generated by touch elsewhere on the body—have been described before, Ramachandran’s insightful contribution relates them to the somatosensory ‘homunculus’ in the brain and to recent electrophysiological discoveries about neural plasticity. The subsequent chapter on ‘treatment’ of referred phantom limb pain—the patient views a mirror-reflection of their intact limb moving, apparently at the location of the amputated limb—is less successful. No systematic study of the effectiveness of this treatment has yet been done, and there is no clear notion why the mirror intervention should work. As with much of the book, we are in uncertain and speculative territory, although the journey is certainly a thought-provoking one. The chapter on unconscious processing in the visual system emphasizes the different potential uses of vision—control of immediate action versus recognition of objects—and is superb. Unlike the other chapters, it provides an overview of a large body of research by many groups, summarizing both the areas of consensus and the remaining controversies. It integrates important findings on healthy subjects with those from patients, and offers many fundamental insights into visual perception. This chapter stands headand-shoulders above the rest, which may reflect Ramachandran’s particular expertise in vision research (plus the fact that the visual system has been studied most extensively). Although it would be unfair for any criticism to stem from such an exceptional chapter, this highlight does cast something of a shadow over the remainder of the book. It is the only chapter to shift the focus from Ramachandran’s own studies to the field as a whole, and as any writer will admit, it is easier to be objective about other people’s work than one’s own. Staying with the visual theme, the authors next address visual ‘filling-in’ of the blindspot which every normal person has in each eye. This leads to the perception of something where there is in fact no retinal input, a venerable topic to which Ramachandran has made important new contributions. A somewhat forced analogy is made with pathological hallucinations in braindamaged patients (Charles Bonnet syndrome). It is well-known that such hallucinations can be restricted to particular regions of the visual field. The new claim here is that the hallucinations must therefore be due to the influence of backprojections, from higherto lower-level visual areas. Although this is certainly one interesting possibility, it does not as yet seem to be a certain conclusion, a comment that applies to many other intriguing claims in this provocative book. I found the authors to be the least convincing on the subjects that I know best (neglect and anosognosia), which is perhaps inevitable given their maverick tendency to dismiss orthodox views. The discussion of unilateral neglect focuses on Ramachandran’s observation that some, but not all, neglect patients reach towards their ‘good’ ipsilesional side even when what is seen there is a mirrorreflection of an object whose true location lies on the impaired contralesional side. However, many interpretations seem possible for this (for example, motor rather than perceptual neglect; frontal deficits in overriding prepotent response tendencies). Moreover, journalistic comments such as “mere confrontation with a mirror flips these patients into the twilight zone” seem more sensationalist than revealing about the plight of neglect patients. The section on anosognosia (unawareness of deficit after brain damage)—for example, patients with left hemiparesis after right-hemisphere stroke often have no insight into their inability to control the affected limbs—may be the most controversial part of an unashamedly controversial book. Ramachandran takes a neo-Freudian view, arguing that patients actively deny information that they possess about their deficit due to putative differences in ‘processing style’ between the cerebral hemispheres. The left hemisphere supposedly seeks to maintain the status quo, whereas the normal right hemisphere seeks to ‘rock the boat’ in true Ramachandran style. If so, anosognosia may offer unique insights into the confabulatory style of the conservative left hemisphere. However, as yet the evidence seems insufficient to rule out a more cautious interpretation. Anosognosia for hemiparesis after large right parietal/frontal lesions may arise simply because the affected structures subserve ‘body image’, and so the patient lacks new information about the disruption to their movements. This would certainly explain why anosognosia is typically restricted just to body movement and position. But no doubt Ramachandran would think that I myself am stuck in conservative left-hemisphere denial here. © 1999 Nature America Inc. • http://medicine.nature.com

81 citations


References
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Journal ArticleDOI
Abstract: Although there is a vast clinical literature on phantom limbs, there have been no experimental studies on the effects of visual input on phantom sensations. We introduce an inexpensive new device--a 'virtual reality box'--to resurrect the phantom visually to study inter-sensory effects. A mirror is placed vertically on the table so that the mirror reflection of the patient's intact had is 'superimposed' on the felt position of the phantom. We used this procedure on ten patients and found the following results. 1. In six patients, when the normal hand was moved, so that the phantom was perceived to move in the mirror, it was also felt to move; i.e. kinesthetic sensations emerged in the phantom. In D.S. this effect occurred even though he had never experienced any movements in the phantom for ten years before we tested him. He found the return of sensations very enjoyable. 2. Repeated practice led to a permanent 'disappearance' of the phantom arm in patient D.S. and the hand became telescoped into the stump near the shoulder. 3. Using an optical trick, impossible postures--e.g. extreme hyperextension of the fingers--could be induced visually in the phantom. In one case this was felt as a transient 'painful tug' in the phantom. 4. Five patients experienced involuntary painful 'clenching spasms' in the phantom hand and in four of them the spasms were relieved when the mirror was used to facilitate 'opening' of the phantom hand; opening was not possible without the mirror. 5. In three patients, touching the normal hand evoked precisely localized touch sensations in the phantom. Interestingly, the referral was especially pronounced when the patients actually 'saw' their phantom being touched in the mirror. Indeed, in a fourth patient (R.L.) the referral occurred only if he saw his phantom being touched: a curious form of synaesthesia. These experiments lend themselves readily to imaging studies using PET and fMRI. Taken collectively, they suggest that there is a considerable amount of latent plasticity even in the adult human brain. For example, precisely organized new pathways, bridging the two cerebral hemispheres, can emerge in less than three weeks. Furthermore, there must be a great deal of back and forth interaction between vision and touch, so that the strictly modular, hierarchical model of the brain that is currently in vogue needs to be replaced with a more dynamic, interactive model, in which 're-entrant' signalling plays the main role.

962 citations


Journal ArticleDOI
01 Sep 1998-Brain
TL;DR: It is suggested that patients with phantom limbs provide a valuable opportunity not only for exploring neural plasticity in the adult human brain but also for understanding the relationship between the activity of sensory neurons and conscious experience.
Abstract: Almost everyone who has a limb amputated will experience a phantom limb--the vivid impression that the limb is not only still present, but in some cases, painful. There is now a wealth of empirical evidence demonstrating changes in cortical topography in primates following deafferentation or amputation, and this review will attempt to relate these in a systematic way to the clinical phenomenology of phantom limbs. With the advent of non-invasive imaging techniques such as MEG (magnetoencephalogram) and functional MRI, topographical reorganization can also be demonstrated in humans, so that it is now possible to track perceptual changes and changes in cortical topography in individual patients. We suggest, therefore, that these patients provide a valuable opportunity not only for exploring neural plasticity in the adult human brain but also for understanding the relationship between the activity of sensory neurons and conscious experience. We conclude with a theory of phantom limbs, some striking demonstrations of phantoms induced in normal subjects, and some remarks about the relevance of these phenomena to the question of how the brain constructs a 'body image.'

920 citations


01 Jan 1998

700 citations


"Occurrence of phantom genitalia aft..." refers background in this paper

  • ...Notwithstanding this malleability there is undoubtedly also a hard-wired, innately specified scaffold for body image; patients with congenital absence of both arms may also experience vivid phantoms [6,12,13]....

    [...]

  • ...Often repeated use of this procedure can cause the patient’s phantom arm to vanish [6,7,9,11]; indicating the remarkable malleability of body image....

    [...]


Journal ArticleDOI
12 Oct 1995-Nature

614 citations


Book
01 Jan 1998

339 citations


"Occurrence of phantom genitalia aft..." refers background in this paper

  • ...After removal of a hand, the region of the somatosensory cortex that is de-afferented is ‘‘taken over’’ by afferents that normally innervate the adjacent face portion of the map [6–9]....

    [...]

  • ...Although phantoms are often paralysed, some can be visually ‘‘resurrected’’ by use of a parasagital mirror positioned vertically in front of the patient so that the reflection of the normal (say left) hand appears optically superimposed on the phantom [6,7,9–11]....

    [...]

  • ...Often repeated use of this procedure can cause the patient’s phantom arm to vanish [6,7,9,11]; indicating the remarkable malleability of body image....

    [...]