Sunday, September 8, 2013

What it is like to be a Man

A Discussion on the Subjective Experience of Masculinity

This week someone* had the experience of treating a patient with gender identity dysphoria, that is, someone who is transgendered. The standard treatment for female to male is treatment with biweekly testosterone injections. I reviewed the consent form for such treatment. The major focus of the consent was explaining the physical changes that would occur when taking hormones. No mention was made, with the exception of increased libido, of psychological or mental effects of testosterone. I considered this, and was rather surprised. If I were a patient considering taking hormones, I would be most concerned with what it would do to my mind. Bodily changes are important, but not nearly as important as how it would affect my thinking and behavior.

But what does testosterone do to the mind? There is very little research on this question. The only research I’m aware of is the work by Paul Zak. He showed that men will behave differently when given testosterone in certain economic/psychological games (the study was restricted to men, because of concerns for affecting women’s hormonal systems). The game most affected by testosterone is called the Ultimatum Game. This game involves two players: player A is given $10 and can choose to give any amount is that to player B. Player B decides whether to accept the offer or, if the offer is too unfair, to nuke the whole pot so nobody gets any money. When given testosterone, player B is more likely to reject unfair offers. Such punishing behavior is critical, Zak argues. He discusses another experiment where two groups compete with each other. One group is allowed to, at individual expense, punish free riders, while the other group is not. The group that is allowed to punish is wildly successful and out-competes the group that is not allowed to punish. Zak sees testosterone as a driver toward enforcing laws and fighting free riders, two essential functions for a functioning society.

As far as I know, this is the major work done on the psychology of testosterone. Why aren’t more people interested in this question? I think because we are just beginning to emerge from behaviorism. Since the cognitive revolution, we’ve started to think that ideas might impact behavior, that psychological experiences might actually matter. I remember a comment in paper comparing motivation to pleasure. The authors noted that the early work in the field was done by behaviorists who did not collect data on subjective mental states; as a result, the conclusions of the early work could not speak help separate motivation from pleasure. I think a similar thing has happened with testosterone. No one asked, after Thomas Nagel, what is it like to be a man? So we must start from scratch.

What is it like to be a man? The difficulty with this question is that comparisons are hard to find. It is difficult to identify individual subjective experiences and attribute them to one’s sex. How can one know if a particular state is common to men and women, or is a direct result of being a man? Further, are there subjective states that only men have that women do not? Or is it a more fluid thing? I think the experience of transgendered people can speak to these questions. For those who experience gender identity dysphoria (the DSM diagnosis), they often report feeling like a man, even though they were born genetically, anatomically a woman. I’ve spoken about this question with Ben Barres, a female to male transgendered individual and a professor in neurobiology at Stanford. The emphasis of his experience was on the social conventions surrounding the genders (e.g. preferring to dress up like a soldier rather than a princess). Transgendered people often go through operations and take hormones to change their physical appearance. They often report this reduces an enormous amount of anxiety and depression, as they now look on the outside how they feel on the inside. The feeling of being a man is an understandably difficult thing to define or describe, but from transgendered people, we learned that part of what it means to be a man is to look like a man; there is a mental state that is somehow incompatible or conflicting with breasts.

But what is that state? I recently had insight into this question when I had a testosteroney day. I’ve heard some argue that men have hormonal cycles as women do, but have not seen good evidence to this effect. Nonetheless, I experience certain days that I can describe none other than testosteroney. I’ve had others describe states of mind with the very same word. On one such day, I was pondering this question. I began to note the things that I did differently, or how I thought differently. When driving to work, I noticed that I drove a little faster, took a little more risk, and was ruthlessly just in traffic etiquette (if someone wanted to cut in the traffic line, I normally let them; on this particular day, I did not). At work, I was confident with my supervisors and patients. On my breaks my mind wandered to projects, solving world problems, launching businesses, and responding to arguments; this is somewhat typical for me, but on this particular day, my own individual concerns were afforded almost no attention. I also noticed on that day that the oh-so-difficult Christian command to not look at a woman to lust after her was especially difficult. When I got home from work, I did not procrastinate and was very productive.

I began to ask myself: when else do I feel like this? In parallel with this, I recalled the tiny bits of research on testosterone and things that increase it. Do I feel like this when my team wins? Yes! Do I feel like this when I handle a gun? Yes! Do I feel like this when I drive fast? Yes! Beside the research I’m aware of, are there other times I feel testosteroney? Competitive activities, lifting weights and summiting a mountain all seem to give this feeling. They also tend to be enjoyed more by men than women (at least more frequently). For some reason, climbing on top of large piles of rocks seems to be a stupidity associated with my sex.

What about women? Can they feel testosteroney? Of course! They also produce testosterone, and whether it is literally increased or not under the circumstances is an empirical question that has not been asked. Perhaps it is the case that women cannot increase their testosterone to the same degree as men; men certainly have anatomy to suggest that they might experience testosterone rushes of greater magnitude. But this is just speculation, and experiments need to be done.

In this rambling essay, I think my conclusion is that we just simply need to hunker down and do this research. What frustrates me is that the experiments have not been done. This essay has focused on male hormones, mostly because I have direct access to their release. I would guess that women’s behavior and psychology is also affected by hormones (female friends assure me that my guess is secure and that female behavior is not constant through the month; I have not had the opportunity to make these observations myself). What do hormones do to our psychology? This is a critical question for medicine if we intend to continue using hormone therapy. Our patients ought to be told all the risks and benefits of a particular treatment, including the psychological. It is inexcusable that we do not have this information. Let’s get to work.

*Because of HIPAA, I cannot tell you whether that person was me or not. Also, if I were to divulge that I treated a patient from “Northern California,” I would be in violation of HIPAA; the punishment for such an offense is imprisonment. I’m not joking. If you think this is unjust, please work to reform HIPAA.

1 comment:

  1. Interesting post. I think one can learn about the effects of testosterone by learning how it plays out in body builders. Look at the rage episodes and moves into hypomania. Also in terms of trauma research, consider how girls with a history of trauma have 3-5x higher levels of hormones when she hits puberty and also finds herself mostly around boys.