SOGIESC dari Perspektif

Medis
“Learn, Unlearn, Relearn”
What is
SOGIESC?
Sex
Characteristics
 Sex
• Growing scrotum and testesCharacteristics
Primary Sex Characteristics Primary Sex Characteristics
• Growing vagina and uterus
• Hormones -> Sperm production • Hormones -> menstrual cycle
and growth Similarities
• Pubic hair Secondary Sex Characteristics
Secondary Sex Characteristics • Broadening hips
• Body hair • Oily skin,
acne, body • Breast growth
• Muscle mass • Female fat distribution
• Height, broad shoulders aroma
• Masculinized voice • Height
 Intersex
Conditions
Population
• 1.7–4%
• 0.05–1.7%

Names
• Disorders of sex development (DSDs), also known
as differences in sex development, diverse sex
development, and variations in sex
characteristics (VSC)

Causes
• Hormonal, gonadal, chromosomal, and other
bodily variations

• Jones, T. (2018). Intersex Studies: A Systematic Review of International Health Literature. SAGE Open, 8(2), 215824401774557. https://doi.org/10.1177/2158244017745577
• UN Free and Equal. (n.d.). Intersex Fact Sheet. Retrieved April 20, 2021, from https://www.unfe.org/wp-content/uploads/2017/05/UNFE-Intersex.pdf
 • Congenital adrenal hyperplasia
46, XX (1:10,000-18,000)
• Testosterone exposure during
intersex pregnancy (external/internal)
• Aromatase deficiency

• Problem with the testes: E.g. gonadal

dysgenesis
• Testosterone formation: inadequacy of
46, XY testosterone forming enzymes
• Using testosterone:
intersex • 5-alpha-reductase deficiency
(testosterone -> DHT)

Classificatio
• Androgen insensitivity syndrome
(receptors to male hormones)

• Both ovarian and testicular tissue (true

n
True gonadal hermaphroditism)
intersex • Chromosome and external genitals might
vary

Complex,
Undetermined • 45, XO; 47, XXY; 47, XXX
• García-Acero, M., Moreno, O., Suárez, F., & Rojas, A. (2020). Disorders of Sexual Development: Current Status and Progress in the Diagnostic Approach. Current Urology, 13(4), 169–178.
intersex •
https://doi.org/10.1159/000499274
Arnold, A. P. (2017). A General Theory of Sexual Differentiation. Journal of Neuroscience Research, 95(1–2), 291–300. https://doi.org/10.1002/jnr.23884
• Rey, R. (2017). Sexual Differentiation Endotext - NCBI Bookshelf. Endotext, 1–83. http://www.ncbi.nlm.nih.gov/pubmed/25905232
• Makiyan, Z. (2016). Systematization of ambiguous genitalia. Organogenesis, 12(4), 169–182. https://doi.org/10.1080/15476278.2016.1210749
• Wherrett D. K. (2015). Approach to the Infant with a Suspected Disorder of Sex Development. Pediatric clinics of North America, 62(4), 983–999. https://doi.org/10.1016/j.pcl.2015.04.011
• InterACT. (2021). Intersex Law & Policy, Media, and Youth Leadership. https://interactadvocates.org/
• MedlinePlus. (2019). Intersex: MedlinePlus Medical Encyclopedia. https://medlineplus.gov/ency/article/001669.htm
 Example
s

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., . . . Sheffield, J. S. (2014). Williams obstetrics (24th edition.). New York: McGraw-Hill Education.
Gender Identity and
Expression
 What is Gender?
• WHO: refers to the socially constructed roles,
behaviors, activities, and attributes that a
given society considers appropriate for men
and women.
Gender

Seen from binary model Male, Female

Transwoman/Transpuan
Cisgender
Seen from non-binary Seen from binary model
model Transman/Transpria
Transgender

Seen from non-binary Non-binary,

model genderqueer, and others

• Collazo, A., Austin, A., & Craig, S. L. (2013). Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice. Clinical Social Work Journal, 41(3), 228–237. https://doi.org/10.1007/s10615-013-0436-3/
• WHO. (2021). Gender. https://www.who.int/health-topics/gender#tab=tab_1
 Gender Expression Gender Identity
• How a person expresses or presents • Each person’s internal & individual
their gender. experience of gender (Sense of being a
• Behavior, appearance, body language, woman, a man, both, neither, or
voice, chosen name, pronoun, and anywhere along the gender spectrum).
many more. • Might = or ≠ from their birth-assigned
• For example: masculine, feminine, sex.
androgyny, etc. • For example: man, woman, transwoman,
transman, gender non-conforming

• Collazo, A., Austin, A., & Craig, S. L. (2013). Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice. Clinical Social Work Journal, 41(3), 228–237. https://doi.org/10.1007/s10615-013-0436-3/
• Collier, K. L., Van Beusekom, G., Bos, H. M. W., & Sandfort, T. G. M. (2013). Sexual orientation and gender identity/expression related peer victimization in adolescence: A systematic review of associated psychosocial and health outcomes. In Journal of Sex Research (Vol. 50, Issues 3–4, pp. 299–317). NIH Public
Access. https://doi.org/10.1080/00224499.2012.750639
• Bourns, A. (2019). Guidelines for Gender-affirming Primary Care with Trans and Non-binary Patients. https://www.rainbowhealthontario.ca/product/4th-edition-sherbournes-guidelines-for-gender-affirming-primary-care-with-trans-and-non-binary-patients/
 Biological Basis of Gender
Identity
• Monozygotic female and male twins:
39% chance, digozygotic female and male Genes

twins: 0%
• Longer CAG repeats in AR gene → AR
protein binding to co-activator↓ → less
effective testosterone signaling → Biological
Incomplete masculinization of the brain Basis of
Gender
• Older brother >> (alterations in Identity
androgen) → 40% natal
Neuroanatomy Hormones

• Roselli, C. E. (2018). Neurobiology of gender identity and sexual orientation. In Journal of Neuroendocrinology (Vol. 30, Issue 7, p. e12562). Blackwell
Publishing Ltd. https://doi.org/10.1111/jne.12562
• Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, et al. Gender Identity Disorder in Twins: A Review of the Case Report
Literature. J Sex Med. 2012 Mar 1;9(3):751–7.
• Hare L, Bernard P, J Sánchez F et al. Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. 2009;1–4.
• Dowshen N, Nguyen GT, Gilbert K, Feiler A, Margo KL, Stroumsa D. Improving Transgender Health Education for Future Doctors/Stroumsa Responds. Am J
Public Health. 2014 Jul;104(7):e5–6.
 First Observed Neurobiological
Differences: Cisgender vs. Transgender
Individuals

• Bed nucleus of the stria terminalis (BNST/BSTc) of

MtF trans individuals = smaller average size = more
similar to cisgender female vs. cisgender male
• Area related to sexual behavior, extension of
amygdala (related to stress response, fear, social
behaviors)
• Not influenced by sex hormones in adulthood,
Independent of sexual orientation

A: heterosexual man; B: heterosexual woman; C: homosexual man;

• Zhou, J. N., Hofman, M. A., Gooren, L. J. G., & Swaab, D. F. (1995). A sex difference in the human brain and its relation
D: male-to-female transsexual to transsexuality. Nature, 378(6552), 68–70. https://doi.org/10.1038/378068a0
• Lebow, M. A., & Chen, A. (2016). Overshadowed by the amygdala: The bed nucleus of the stria terminalis emerges as
key to psychiatric disorders. In Molecular Psychiatry (Vol. 21, Issue 4, pp. 450–463). Nature Publishing Group.
https://doi.org/10.1038/mp.2016.1

AH, Anterior hypothalamus
BNST
aINS, Anterior insula
OFC, Orbitofrontal cortex
SPL, Superior parietal lobe
IPS, Intraparietal sulcus
cAMY, central amygdala
New Theory of Gender Dysphoria
Incorporating the Distress, Social
Behavioral, and Body-Ownership Networks
DLPF, dorsolateral prefrontal cortex
LS, lateral septum
MCC, mid-cingulate cortex
A biology/symptom-based Approach
mPOA, medial preoptic area;
PAG, periaqueductal gray;
Teg, tegmentum;
VPM, ventral premotor
• Gliske, S. V. (2019). A new theory of gender dysphoria incorporating the distress, social behavioral, and body-ownership
cortex.
networks. ENeuro, 6(6). https://doi.org/10.1523/ENEURO.0183-19.2019
 Depathologization of Trans
Individuals
DSM-III DSM-III-R DSM-IV & IV-TR DSM-V
WHO through ICD-10
(1980) (1987) (1994 & 2000) (2013)

• Psychosexual • Disorders usually • Sexual and Gender • Gender Dysphoria

Disorders: First evident in Identity Disorders: • GD in children
• Transsexualism. Infancy, • GIDC • GD in
• GID of Childhood, or • GID in Adolescents or
Childhood. Adolescence. adolescents or Adults.
• Atypical GID • Transsexualis adults • Other Specified
m • GIDNOS GD
• GID of • Unspecified GD
childhood
• GID of
adolescence and
adulthood
• GIDNOS

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
• Beek, T. F., Cohen-Kettenis, P. T., & Kreukels, B. P. C. (2016). Gender incongruence/gender dysphoria and its classification history. International Review of Psychiatry, 28(1), 5–12. https://doi.org/10.3109/09540261.2015.1091293
• WHO releases new International Classification of Diseases (ICD 11). (n.d.). Retrieved May 26, 2019, from https://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases-(icd-11)
Sexual
Orientation
 What is Sexual
• American
Orientation
Psychiatric
Asexual-
romantic

(APA): Sexual orientation refers to an

Association Polysexual- Bisexual-

enduring pattern of emotional, romantic

romantic

romantic and/or sexual attractions to

men, women or both.
Sexual/Roma
• Seen as spectrum Pansexual-
romantic
ntic
Orientation
Graysexual-
romantic

• For examples:
• Heterosexual
• Homosexual/ Homosexua Demisexual
l-romantic -romantic
Gay/Lesbian
Heterosexu
• Bisexual al-
romantic

American Psychological Association. (2011). Sexual orientation and gender identity. https://www.apa.org/topics/lgbtq/sexual-orientation
 Kinsey Scale
Heterosexual-Homosexual Rating
Scale

• Drs. Alfred Kinsey, Wardell Pomeroy, and Clyde Martin

• First published in Sexual Behavior in the Human
Male (1948): showed people did not fit into exclusive
heterosexual or homosexual categories.
• An official Kinsey “test” does not exist -> The Rating | Description

Kinsey
originalresearch team assigned a number based on a
1 | Exclusively heterosexual
2 | Predominantly heterosexual, only incidentally homosexual
person’s sexual history. 3| Predominantly heterosexual, but more than incidentally homosexual
3 | Equally heterosexual and homosexual
4 | Predominantly homosexual, but more than incidentally heterosexual
• Changing public perception of sexuality and 5 | Predominantly homosexual, only incidentally heterosexual
6 | Exclusively homosexual
considered part of the most successful and influential X | No socio-sexual contacts or reactions

scientific books of the 20th century.

Limitations
• It doesn’t account for differences between romantic and sexual
orientation + asexuality
• Many are uncomfortable identifying with (or being identified as) a
number on a scale
• Kinsey Institute. (2019). Prevalance of Homosexuality study. https://kinseyinstitute.org/research/publications/kinsey- • It assumes that gender is binary
scale.php • It reduces bisexuality to a point between homosexuality and
• Galupo, M. P., Mitchell, R. C., Grynkiewicz, A. L., & Davis, K. S. (2014). Sexual Minority Reflections on the Kinsey Scale and the
heterosexuality
Klein Sexual Orientation Grid: Conceptualization and Measurement. Journal of Bisexuality, 14, 404–432.
https://doi.org/10.1080/15299716.2014.929553
 Genes

• Twin studies in Sweden (Långström N, et al. 2010): Variations controlled by

genes 40% in gay men, 20% in lesbian women.
• First genetic studies: Xq28 (Hammer, et al., 1993).
• No genetic loci in world-wide significance to detect homosexuality – closest
marker located in the same region of chromosome 8 in men.
• Epigenetics?

Biological Basis Hormones

• Sexual differentiation effects, but not observed in a lot of individuals

of Sexual (Hormones are not the only factor)

• Women with CAH -> more same sex activity

Orientation Neuroanatomy

• 3rd interstitial nucleus of the anterior hypothalamus (INAH3) in homosexual

men is smaller than in heterosexual men and has a similar size in
homosexual men and women
Animal Studies (in hundreds of species) • Elements of the anterior and preoptic area of the hypothalamus is part of a
• Sexual partner preferences tests and recording: time core neural circuit for sexual preferences.
spent alone or interacting with the same or opposite
sex stimulus animal
Maternal Immune Response

• Fraternal birth order (FBO) effect -> Some mothers develop antibodies
against a Y-linked factor (higher antibody titers to neurolignin 4 (NLGN4Y),
• Roselli, C. E. (2018). Neurobiology of gender identity and sexual orientation. In Journal of Neuroendocrinology (Vol. extracellular protein for synaptic functioning -> male brain development ->
30, Issue 7, p. e12562). Blackwell Publishing Ltd. https://doi.org/10.1111/jne.12562
• Långström N, Rahman Q, Carlström E, Lichtenstein P. Genetic and environmental effects on samesex sexual behavior: development of sexuality
a population study of twins in Sweden. Arch Sex Behav. 2010;39:75–80. [PubMed: 18536986] • Occurrence increases by approximately 33% with each older brother
• Hamer DH, Hu S, Magnuson VL, Pattatucci AML. A linkage between DNA markers on the X chromosome and male
sexual orientation. Science. 1993;261:321–327. [PubMed: 8332896]
• Poeppl TB, Langguth B, Rupprecht R, Laird AR, Eickhoff SB. A neural circuit encoding sexual preference in humans.
Neurosci Biobehav Rev. 2016;68:530–536. [PubMed: 27339689]
 The “Homosexual”
Diagnosis

DSM-II
DSM-I DSM-III DSM-III-R

(1973)
• Paraphilia • Sexual • Ego-dystonic • Dropped
Orientation Homosexuality
Disturbance

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
• Drescher, J. (2015). Out of DSM: Depathologizing Homosexuality. Behavioral Sciences, 5(4), 565–575. https://doi.org/10.3390/bs5040565
 Conversion Therapy in
Religious Practices:
Indonesia
• Ruqyah (for Muslims), Pastoral Counseling (for Christians), Shamans (Dukun)

Professional Practices:

• Psychiatrists, psychologists: cis-hetero-normative gender norms

• Statements from the Indonesian Psychiatric Association (2016)

Cultural Practices:

• Media (TV Shows; "Be A Man")

Government Practices:

• Raids: transwomen, gay men Other Influencing Factors:

• Character building, social rehabilitation program under the Ministry of Social
Affairs (Bina Karakter) – People with “Social Welfare Problems”, “Immoral
• Economic factors: financial
Lifestyle” • Self-stigmatization
• Type of violence: raids, hair cutting, stripped naked, hosed down, abuse • Environment
• Discriminatory laws: proposed bill for Family Resilience Law (RUU Ketahanan
Keluarga)

• Asia Pacific Transgender Network. (2021). Conversion Therapy Practices Against Transgender Persons in India, Indonesia, Malaysia and Sri Lanka - APTN - Asia Pacific Transgender Network. https://weareaptn.org/2021/03/31/conversion-therapy-practices-against-transgender-persons- in-
india-indonesia-malaysia-and-sri-lanka/
• Mallory, C., Brown, T. N. T., & Conron, K. J. (2018). Conversion Therapy and LGBT Youth Executive Summary.
• South China Morning Post. (2021). Retrieved Sep 14, 2021, from https://www.scmp.com/week-asia/people/article/3130861/exorcisms-and-corrective-rape-inside-indonesias-controversial-lgbt
 Bugis, Sulawesi Selatan: Bissu,

THANK Oroane, Makunrai, Calalai, Calabai

YOU!

Toraja: Burake Tambolang, Burake Tattiku Reog Ponorogo: Warok dan Gemblak
Sharing
Kasus
Asia Pacific Transgender Network. (2021). Conversion Therapy Practices Against Transgender Persons in India, Indonesia, Malaysia and Sri Lanka - APTN - Asia Pacific Transgender Network. https://weareaptn.org/2021/03/31/conversion-therapy-practices-against-transgender-persons-in-
india-indonesia-malaysia-and-sri-lanka/
Pertanyaan
• Apa saja kekerasan yang dialami beliau?
• Apa saja dampak yang dapat terjadi dari tindak kekerasan tersebut?
• Apa tindakan yang bisa dilakukan?
Ariel (nama samaran)
• 40 tahun
• Pria gay in the closet
• Menikah dengan Yanti (nama samaran)
dengan harapan bisa "sembuh”,
melindungi nama baik, dan dianggap
“normal”
Ariel bertanya kepada istrinya,
apakah bisa bila tidak
selingkuh lagi. Istri berkata
"Saya tidak bisa janji"
Akhirnya Ariel bercerai dengan
Yanti, setelah pernikahan 9
tahun
Sulit sekali bagi Ariel untuk bisa
berhubungan seksual dengan
Yanti
Merasa tidak bahagia dalam
pernikahannya, Yanti selingkuh
dengan mantan pacarnya
Perpisahan baik, tetapi sampai
sekarang belum bisa open
status kepada mantan istrinya
Yanti berusaha semaksimal
mungkin untuk bisa membuat
suaminya tertarik, termasuk
berdandan, memakai pakaian
yang bagus
Meski sayang dengan sang istri,
Ariel tidak dapat berhubungan
badan dengan istrinya
Ariel merasa dikutuk Tuhan
Pertanyaan
• Bagaimana pendapatmu terhadap kisah ini?
• Apa yang seharusnya dapat dilakukan?
Discrimination from the Basis of
SOGIESC
Health

Education

Misunderstanding of
Economy
SOGIESC
Stigma/Discrimination

+ Toxic understanding that one

group is better than another, Law
Patriarchy, Religious Beliefs, etc

Society