An Experimental Study of Body Image and Perception in Gender Identity Disorders

By Marone P., Iacoella S., Cecchini M.G., Ravenna A.R.
Cattedra di Psicofisiologia clinica - Prof. V. Ruggieri
University "La Sapienza" - Rome - Italy.

Citation: Marone P., Iacoella S., Cecchini M.G., Ravenna A.R., Cattedra di Psicofisiologia clinica - Prof. V. Ruggieri University "La Sapienza" - Rome - Italy (1998) An Experimental Study of Body Image and Perception in Gender Identity Disorders. IJT 2,3, http://www.symposion.com/ijt/ijtc0501.htm

• Introduction
• Subjects
• Instruments and Procedure
• Results
• Conclusions
• Tables
• Bibliography

In this work we present research regarding the perception and the degree of integration of the body image in a group of gender dysphoric individuals who were seen in the Division of Plastic and Reconstructive Surgery of San Camillo Hospital in Rome for sexual reassignment surgery.

The theoretical model used is an integrated psychophysiological model (Ruggieri, 1988) that describes the process of identity construction and clarifies some characteristic elements of transsexualism. Based on this model the formation of identity is the result of a continuous integration of psychophysical structures at different and more and more complex levels with the aim of constructing a cohesive self. The tendency towards increasing integration of psychic and physiological aspects of the self has its own dynamics and represents a maturational process. The first step of integration consists of the integrity of the bodily unity from the most simple biological level to the most complex; to this end there needs to be a continuous communication and accommodation of body perception, instinctive behavior, cognitive processes and emotions; thus the construction of the body image gives testimony to the level of integration achieved.

In summary, all the afferent information, somatesthetic, visual, acoustic, olfactory, gustatory, and visceral is decoded and integrated at a central level in associative areas of the parietal lobe and is resent to the periphery, producing a particular expressivity. In the process of constructing a body image global representations and representations of subunits alternate and/or coexist together. Synthesizing afferent information the subject succeeds at perceiving the body as a unit that transcends the simple collection of peripheral sensory input.

In this study we want to demonstrate how the various body parts are perceived by the transsexual person. We noticed certain perceptive styles, inhibitions, and peculiarities in the construction of the body image and concomitant intrapsychic and interpersonal experience that differ between male-to-female and female-to-male transsexuals.
Therefore, we examined how the visual and kinesthetic sensory information is distributed; which body areas are primarily perceived; how male-to-female and female-to-male subjects differ in body perception and which inhibitive processes impede body perception and consequently interfere with an adequate aggregated synthesis. In fact, increase and diminution of body sensations change a subject's body image (Tausk, 1983).
Many authors have talked about the preoccupation of transsexuals with wanting "to pass" by mastering the physical attributes and behavior of the desired gender. As early as ages 2 to 3 children with gender identity problems imitate the stereotypic behavior of the opposite sex, e.g. a boy wearing his mother's dress or applying make up or a girl playing with guns.
Furthermore, our clinical data highlight the intense preoccupation of transsexuals of both genders with the aesthetics of outward appearance, be it centered on the shape of the body, secondary sexual characteristics or dress code. It is striking, how the attention to these details can turn into an all consuming obsession of day to day life.
Often, this exasperating attention to outward appearance is in effect an overly concrete attempt to adapt to internal and external gender role expectations and serves the purpose of confirmation of the self around which a sense of personal identity is being constructed.
The body becomes the instrument of a practical act in which desires for an imagined idealized body and its imagined lacking parts must be realized.
In the psychophysiological model adopted by us, we can see how such activities represent senso-motorical explorations, that give a contribution to the construction of the body image and corresponding identity. The stronger the individual's need is to live in the desired gender role, the greater the determination to affect physical changes. Evidently, there is a circular relationship between peripheral information being integrated in a sense of gender identity and this sense of gender identity in turn influencing physical behavior.
A person's gender identity is subject to feedback from the social environment which can be confirming or challenging the person's inner psychological experience. Gender dysphoria is socially and emotionally complex and generates conflict with the external world.
The desperate projection to a future time when the body will finally express one's inner identity contributes to the construction of a body image based on disowning especially those discordant parts of the body that are outwardly visible. This negative attitude towards one's own body leads to a serious interference with establishing sexual relationships during adolescence.
Gender dysphoric persons who proceed to sex reassignment surgery have a desperate need to coincide the appearance of their physical self with their inner sense of gender identity in order to resolve the anxiety provoking conflict between perception and body representation.

Subjects
30 individuals with gender identity disorders, 15 male-to-female (average age: 26) and 15 female-to-male (average age: 27,9) who presented to the Division of Plastic and Reconstructive Surgery of San Camillo Hospital in Rome for gender reassignment surgery.

Instruments and Procedure
Body perception was studied with the Sensory Integration Body Imagery Test (Ruggieri V., 1993), a test that evaluates the degree of body perception by measuring the time employed by a subject in perceiving body parts (latency), it examines the kind of sensory modality used (visual and/or kinesthetic) and the intensity of perception. Both analytic and synthetic perceptions were examined. Latency is determined by processes of inhibition and/or excitation. It is interesting to analyze which body areas are more inhibited, conflictual or anxiogenous.

Results
The results show interesting gender differences in the intensity of the perception of body areas. In fact, we observed that the shortest latency for both groups is for the feet, while the longest latency in male-to-female subjects is for the whole body and in female-to-male subjects for the chest. In the latter group the latency decreases when the subject is asked to focus on the lower body, while it increases when looking at the upper body areas and the whole body. We could suppose that the long latency is due to the fact that these body areas are more visible and therefore more significant in interpersonal relationships and for one's own psychic identity. It seems common sensical that the more exposed areas of the body such as breasts, neck and face are primarily used to define either masculine and feminine gender.

The aesthetics of the body have signal character and indicate the belonging to a specific gender. However, in humans both sexes look more alike than males and females in many animal species were it not for the gender differentiating emphasis through the use of clothes, hair style, make up and jewelry (Lorber, 1995).
In female-to-male subjects the thorax causes particularly ambivalent reactions because of the prominent presence of breasts, as demonstrated in our tests by the high inhibition of perception of this body area. The highest latency is found in the perception of the thorax, whole body, neck, head and back. The perception of the remaining parts of the body shows even shorter latency than the perception of legs and feet.
In the male-to-female group, it is possible to observe a higher latency in the perception of the whole body, as if it were difficult to reintegrate the various body areas into a single unit. We hypothesize that anxiety in these subjects leads to the inhibition of perception of the whole body.
For us it is interesting to understand how in the process of body image construction global and analytic representations alternate and/or live together. In fact, through the amount of information from the periphery, the subject comes to a perception of the body as a unit, which is more abstract than the sum of sensory information from single districts. This unified perception of the body, which overrides the single sensory perceptual event, is a dynamic process that oscillates between global representations and partial representations (Ruggieri, Marone, Fabrizio, 1997).
Coming back to the intensity in the distribution of latency, we observe a high latency in the perception of the neck. In previously published research (Marone, Iacoella 1997), the males-to-females have a higher visual perception in the Sensory Integration Body Imagery Test than in the Body Perception Test, a test in which the perception occurs through a figure of the same biological sex as the subject. When male-to-female subjects are asked to compare themselves to a male body, they react with anxiety and try to overcome the dissatisfaction with their own body by readily identifying a "neck seen" as belonging to the female gender. The neck not only represents an important point of recognition for female identity, but beyond that embodies the change in the pitch of the voice.
In the previously cited research, the results demonstrate that females-to-males had statistically significant differences in the visual perception of the thorax, hands, genitals and legs, and in the kinesthetic perception of the head, arms, hands and legs. In these areas the intensity of perception in the Body Perception Test was significantly inferior to the perception in the Sensory Integration Body Imagery Test which amounts to an inhibition of perception of these body parts. In brief, for female-to-male subjects the head, thorax, arms, hands and legs seem as indispensable in the construction of a psychosexual identity as the genitals.
In contrast to females-to-males, the male-to-female group shows the highest latency in the perception of the genitals, attesting the conflictual character of this body area. Similarly, previous research (Marone, Iacoella, 1997) demonstrates the lowest intensity for the perception of the genitals in the female-to-male group and a high latency for the perception of the thorax and the genitals for the male-to-female group. Again, both research data and numerous clinical observations highlight the genital area as particularly charged and conflictual for male-to-female subjects, resulting eventually in the well known requests for surgical castration.
The psychological history of these subjects confirms these findings: breasts in female-to males and genitals in male-to-females are often carefully hidden or enhanced with prostheses, bec MtoF and for the FtoM. The body area more perceived with kinesthetic modality by MtoF are the glutei; the difference in respect of mean of FtoM is statistically significant; the MtoF, therefore, "feel" the glutei more than FtoM. This is the only statistical difference between the two groups. This area is
very important in terms of "clarity of perception" in construction of body image and in postural organization, and also in sexual behavior.
The body area more perceived with visual perceptive modality by MtoF are the legs.
The body area more perceived are the hands and the arms with kinesthetic and visual modality for FtoM. This is very interesting considering clinical data that show that these are very important in interpersonal contact and in sexual behavior.

Conclusions
Considering this first set of data it seems useful to observe, also in relation to research currently in progress with a matched control group, that the genitals, in both groups, are the areas perceived with the lowest intensity, while the glutei and legs for male-to-females and hands and arms for female-to-males are the areas perceived with the highest intensity. The latency in the upper parts of the body is almost always present with high intensity in relation to interpersonal reflection and adhesion to traditional schemes that assign specific signals of identification for male or female gender to some body areas. In reference to perception, it is possible to hypothesize that the areas perceived with major intensity are fundamental points, in terms of "clarity of perception" (Ruggieri, 1993), in the process of construction of the body image.
The body perception seems strongly inhibited when the model of reference suggests the biological sex of subject (Marone, Iacoella, 1997). It is possible to hypothesize that the figure so defined by the Body Perception Test leaves very little space for the subject to have a construction in accordance his/her imagination: the subjects perceive a particular area with construction of an image more coherently adequate to his/her body.
It is very important to underline that not only genitals contribute to the peculiarity of gender in the construction of a psychosexual identity: the body areas mentioned above seem just as important in the recognition of male or female identity.

Tables

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