While most people take identification with their body for granted, conditions such as phantom limb pain, alien hand syndrome, and xenomelia suggest that the feeling of bodily congruence is constructed and susceptible to alteration. Individuals with xenomelia typically experience one of their limbs as over-present and aversive, leading to a desire to amputate the limb. Similarly, many transgender individuals describe their untreated sexed body parts as incongruent and aversive, and many experience phantom body parts of the sex they identify with (Ramachandran, 2008). This experience may relate to differences in brain representation of the sexed body part, as suggested in xenomelia (McGeoch et al., 2011). We utilized magnetoencephalography imaging to record brain activity during somatosensory stimulation of the breast—a body part that feels incongruent to most presurgical female-to-male (FtM)-identified transgender individuals—and the hand, a body part that feels congruent. We measured the sensory evoked response in right hemisphere somatosensory and body-related brain areas and found significantly reduced activation in the supramarginal gyrus and secondary somatosensory cortex, but increased activation at the temporal pole for chest sensation in the FtM group (N = 8) relative to non-transgender females (N = 8). In addition, we found increased white matter coherence in the supramarginal gyrus and temporal pole and decreased white matter diffusivity in the anterior insula and temporal pole in the FtM group. These findings suggest that dysphoria related to gender-incongruent body parts in FtM individuals may be tied to differences in neural representation of the body and altered white matter connectivity.
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Gender dysphoria is diagnosed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) on the basis of an individual’s dysphoria about the discrepancy between the gender they identify with versus the gender assigned to them at birth. This dysphoria is sometimes treated through hormones and surgery to align the body’s appearance with the individual’s gender identity.
It is unlikely that transgender individuals willfully construct these representations. While some phantom sexed body parts are welcome, others can conflict with gender identity, as seen in the case of a recurrent, unwanted phantom penile erection after sex reassignment surgery removing the penis (Namba et al., 2008). Indeed, phantom limbs in amputees are often characterized by severe and chronic pain and thus unlikely to be willfully constructed.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Andersson, J. L. R., Jenkinson, M., & Smith, S. (2007). Non-linear registration aka spatial normalisation. FMRIB Analysis Group Technical Report. Retrieved from http://www.fmrib.ox.ac.uk/analysis/techrep/tr07ja2/tr07ja2.pdf.
Aurbach, E., Heller, L., & Eagleman, D. M. (2009). Plasticity of somatosensory cortex after surgical body recontouring. Society for Neuroscience Annual Meeting Abstracts, 39, 25.
Baier, B., & Karnath, H. O. (2008). Tight link between our sense of limb ownership and self awareness of actions. Stroke, 39, 486–488.
Bao, A.-M., & Swaab, D. F. (2011). Sexual differentiation of the human brain: Relation to gender identity, sexual orientation and neuropsychiatric disorders. Frontiers in Neuroendocrinology, 32, 214–226.
Behrmann, M., Geng, J. J., & Shomstein, S. (2004). Parietal cortex and attention. Current Opinion in Neurobiology, 14, 212–217.
Berglund, H., Lindström, P., Dhejne-Helmy, C., & Savic, I. (2008). Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. Cerebral Cortex, 18, 1900–1908.
Blanke, O., Mohr, C., Michel, C., Pascual-Leone, A., Brugger, P., Seeck, M., … Thut, G. (2005). Linking out-of-body experience and self processing to mental own-body imagery at the temporoparietal junction. Journal of Neuroscience, 25, 550–557.
Blanke, O., Ortigue, S., Landis, T., & Seeck, M. (2002). Stimulating own-body perceptions. Nature, 419, 269–270.
Brang, D., McGeoch, P. D., & Ramachandran, V. S. (2008). Apotemnophilia: A neurologic disorder. NeuroReport, 19, 1305–1306.
Brugger, P., Lenggenhager, B., & Giummarra, M. J. (2013). Xenomelia: A social neuroscience view of altered bodily self-consciousness. Frontiers in Psychology, 4, 204. doi:10.3389/fpsyg.2013.00204.
Burke, S. M., Cohen-Kettenis, P. T., Veltman, D. J., Klink, D. T., & Bakker, J. (2014). Hypothalamic response to the chemo-signal androstadienone in gender dysphoric children and adolescents. Frontiers in Endocrinology, 5, 1–10. doi:10.3389/fendo.2014.00060.
Carruthers, G. (2008). Types of body representation and the sense of embodiment. Consciousness and Cognition, 17, 1302–1316.
Case, L. K. (2013). How the body can feel wrong: Sensory processing and neural body representation in transsexuality and anorexia nervosa. Retrieved from ProQuest Dissertations and Theses database (UMI No. 3601113).
Cheyne, D., Roberts, L. E., Gaetz, W., Bosnyak, D., Weinberg, H., Johnson, B., … Deecke, L. (2000). EEG and MEG source analysis of somatosensory evoked responses to mechanical stimulation of the fingers. In C. Aine, Y. Okada, G. Stronik, S. J. Swithenby, & C. C. Wood (Eds.), Advances in biomagnetism (pp. 1130–1133). New York: Springer.
Cohen-Kettenis, P. T., & Gooren, L. J. (1999). Transsexualism: A review of etiology, diagnosis, and treatment. Journal of Psychosomatic Research, 46, 315–333.
Cornwell, B. R., Carver, F. W., Coppola, R., Johnson, L., Alvarez, R., & Grillon, C. (2008). Evoked amygdala responses to negative faces revealed by adaptive MEG beamformers. Brain Research, 1244, 103–112.
Craig, A. D. (2009). How do you feel—Now? The anterior insula and human awareness. Nature Reviews Neuroscience, 10, 59–70.
Dale, A. M., Liu, A. K., Fischl, B. R., Buckner, R. L., Belliveau, J. W., Lewine, J. D., & Halgren, E. (2000). Dynamic statistical parametric mapping: Combining fMRI and MEG for high resolution imaging of cortical activity. Neuron, 26, 55–67.
Davis, S. A., & Meier, S. C. (2013). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health, 26, 113–128.
De Preester, H., & Tsakiris, M. (2009). Body-extension versus body-incorporation: Is there a need for a body-model? Phenomenology & Cognitive Sciences, 8, 307–319.
Decety, J., & Lamm, C. (2007). The role of the right temporoparietal junction in social interaction: How low-level computational processes contribute to meta-cognition. The Neuroscientist, 13, 580–593.
Devue, C., Collette, F., Balteau, E., Degueldre, C., Luxen, A., Maquet, P., & Brédart, S. (2007). Here I am: The cortical correlates of visual self-recognition. Brain Research, 1143, 169–182.
Di Noto, P. M., Newman, L., Wall, S., & Einstein, G. (2013). The hermunculus: What is known about the representation of the female body in the brain? Cerebral Cortex, 23, 1005–1013.
Dijkerman, H. C., & de Haan, E. H. (2007). Somatosensory processes subserving perception and action. Behavioural Brain Science, 30, 189–201.
Dutton, L., Koenig, K., & Fennie, K. (2008). Gynecologic care of the female-to-male transgender man. Journal of Midwifery & Women’s Health, 53, 331–337.
Erickson-Schroth, L. (2013). Update on the biology of transgender identity. Journal of Gay & Lesbian Mental Health, 17, 150–174.
Fink, G. R., Marshall, J. C., Weiss, P. H., Stephan, T., Grefkes, C., Shah, N. J., … Dieterich, M. (2003). Performing allocentric visuospatial judgments with induced distortion of the egocentric reference frame: An fMRI study with clinical implications. Neuroimage, 20, 1505–1517.
First, M. B. (2005). Desire for amputation of a limb: Paraphilia, psychosis, or a new type of identity disorder. Psychological Medicine, 35, 919–928.
Fischl, B., Sereno, M. I., Tootell, R. B., & Dale, A. M. (1999). High-resolution intersubject averaging and a coordinate system for the cortical surface. Human Brain Mapping, 8, 272–284.
Frot, M., & Mauguière, F. (1999). Timing and spatial distribution of somatosensory responses recorded in the upper bank of the sylvian fissure (SII area) in humans. Cerebral Cortex, 9, 854–863.
Fujiwara, N., Imai, M., Nagamine, T., Mima, T., Oga, T., Takeshita, K., … Shibasaki, H. (2002). Second somatosensory area (SII) plays a significant role in selective somatosensory attention. Cognitive Brain Research, 14, 389–397.
Garolera, M., Coppola, R., Muñoz, K. E., Elvevåg, B., Carver, F. W., Weinberger, D. R., & Goldberg, T. E. (2007). Amygdala activation in affective priming: A magnetoencephalogram study. NeuroReport, 18, 1449–1453.
Giummarra, M. J., Bradshaw, J. L., Nicholls, M. E., Hilti, L. M., & Brugger, P. (2011). Body integrity identity disorder: Deranged body processing, right fronto-parietal dysfunction, and phenomenological experience of body incongruity. Neuropsychology Review, 21, 320–333.
Gizewski, E. R., Krause, E., Schlamann, M., Happich, F., Ladd, M. E., Forsting, M., & Senf, W. (2009). Specific cerebral activation due to visual erotic stimuli in male-to-female transsexuals compared with male and female controls: An fMRI study. Journal of Sexual Medicine, 6, 440–448.
Guillamon, A., Junque, C., & Gómez-Gil, E. (2016). A review of the status of brain structure research in transsexualism. Archives of Sexual Behavior, 45, 1615–1648. doi:10.1007/s10508-0160768-5.
Hahn, A., Kranz, G. S., Küblböck, M., Kaufmann, U., Ganger, S., Hummer, A., et al. (2014). Structural connectivity networks of transgender people. Cerebral Cortex, 25, 3527–3534.
Hamada, Y., Okita, H., & Suzuki, R. (2003). Effect of interstimulus interval on attentional modulation of cortical activities in human somatosensory areas. Clinical Neurophysiology, 114, 548–555.
Hilti, L. M., Hänggi, J., Vitacco, D. A., Kraemer, B., Palla, A., Luechinger, R., … Brugger, P. (2013). The desire of healthy limb amputation: Structural brain correlates and features of xenomelia. Brain, 136, 318–329.
Hoechstetter, K., Rapp, A., Meinck, H. M., Weckesser, D., Bornfleth, H., Stippich, C., … Scherg, M. (2000). Magnetic source imaging of tactile input shows task-independent attention effects in SII. NeuroReport, 11, 2461–2465.
Inano, S., Takao, H., Hayashi, N., Abe, O., & Ohtomo, K. (2011). Effects of age and gender on white matter integrity. American Journal of Neuroradiology, 32, 2103–2109.
Johansen-Berg, H., & Rushworth, M. F. S. (2009). Using diffusion imaging to study human connectional anatomy. Annual Review of Neuroscience, 32, 75–94.
Komisaruk, B., Wise, N., Frangos, E., Liu, W. C., Allen, K., & Brody, S. (2011). Women’s clitoris, vagina, and cervix mapped on the sensory cortex: fMRI evidence. Journal of Sexual Medicine, 8, 2822–2830.
Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology, 41, 96–100.
Kranz, G. S., Hahn, A., Kaufmann, U., Küblböck, M., Hummer, A., Ganger, S., … Lanzenberger, R. (2014). White matter microstructure in transsexuals and controls investigated by diffusion tensor imaging. Journal of Neuroscience, 34, 15466–15475.
Kruijver, F. P., Zhou, J. N., Pool, C. W., Hofman, M. A., Gooren, L. J., & Swaab, D. F. (2000). Male-to-female transsexuals have female neuron numbers in a limbic nucleus. Journal of Clinical Endocrinology and Metabolism, 85, 2034–2041.
Lin, Y. Y., & Forss, N. (2002). Functional characterization of human second somatosensory cortex by magnetoencephalography. Behavioural Brain Research, 135, 141–145.
Lin, C. S., Ku, H. L., Chao, H. T., Tu, P. C., Li, C. T., Cheng, C. M., … Hsieh, J. C. (2014). Neural network of body representation differs between transsexuals and cissexuals. PLoS ONE, 9, e85914. doi:10.1371/journal.pone.0085914.
Lindgren, T. W., & Pauly, I. B. (1975). A body image scale for evaluating transsexuals. Archives of Sexual Behavior, 4, 639–656.
Luders, E., Sánchez, F. J., Tosun, D., Shattuck, D. W., Gaser, C., Vilain, E., & Toga, A. W. (2012). Increased cortical thickness in male-to-female transsexualism. Journal of Behavioral and Brain Science, 2, 357–362.
Manzouri, A., Kosidou, K., & Savic, I. (2015). Anatomical and functional findings in female-to-male transsexuals: Testing a new hypothesis. Cerebral Cortex. doi:10.1093/cercor/bhv278.
Mauguière, F., Merlet, I., Forss, N., Vanni, S., Jousmäki, V., Adeleine, P., & Hari, R. (1997). Activation of a distributed somatosensory cortical network in the human brain. A dipole modelling study of magnetic fields evoked by median nerve stimulation. Part I: Location and activation timing of SEF sources. Electroencephalography and Clinical Neurophysiology/Evoked Potentials Section, 104, 281–289.
McGeoch, P. D., Brang, D., Song, T., & Lee, R. R. (2009). Apotemnophilia: The neurological basis of a ‘psychological’ disorder. Nature Precedings. Retrieved from http://precedings.nature.com/documents/2954/version/1.
McGeoch, P. D., Brang, D., Song, T., Lee, R. R., Huang, M., & Ramachandran, V. S. (2011). Xenomelia: A new right parietal syndrome. Journal of Neurology, Neurosurgery and Psychiatry, 82, 1314–1319.
Meltzoff, A. N., & Moore, M. K. (1983). Newborn infants imitate adult facial gestures. Child Development, 54, 702–709.
Morgan, R., & Rochat, P. (1997). Intermodal calibration of the body in early infancy. Ecological Psychology, 9, 1–23.
Moseley, G. L., Gallace, A., & Spence, C. (2012). Bodily illusions in health and disease: Physiological and clinical perspectives and the concept of a cortical ‘body matrix’. Neuroscience and Biobehavioral Reviews, 36, 34–46.
Namba, Y., Sugiyama, N., Yamashita, S., Tokuyama, E., Hasegawa, K., & Kimata, Y. (2008). Phantom erectile penis after sex reassignment surgery. Acta Medical Okayama, 62, 213–216.
Prosser, J. (1998). Second skins: The body narratives of transsexuality. New York: Columbia University Press.
Ramachandran, V. S. (2008). Phantom penises in transsexuals: Evidence of an innate gender specific body image in the brain. Journal of Consciousness Studies, 15, 5–16.
Ramachandran, V. S., & McGeoch, P. D. (2007). Occurrence of phantom genitalia after gender reassignment surgery. Medical Hypotheses, 69, 1001–1003.
Rametti, G., Carillo, B., Gómez-Gil, E., Junque, C., Zubiarre-Elorza, L., Segovia, S., … Guillamon, A. (2011a). The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. Journal of Psychiatric Research, 45, 949–954.
Rametti, G., Carrillo, B., Gómez-Gil, E., Junque, C., Segovia, S., Gomez, Á., & Guillamon, A. (2011b). White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. Journal of Psychiatric Research, 45, 199–204.
Richards, C., & Barrett, J. (2013). The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual. Annals of the Royal College of Surgeons of England, 95, 93–95.
Rothemund, Y., Schaefer, M., Grüsser, S. M., & Flor, H. (2005). Localization of the human female breast in primary somatosensory cortex. Experimental Brain Research, 164, 357–364.
Savic, I., & Arver, S. (2011). Sex dimorphism of the brain in male-to-female transsexuals. Cerebral Cortex, 21, 2525–2533.
Schöning, S., Engelien, A., Bauer, C., Kugel, H., Kersting, A., Roestel, C., … Konrad, C. (2010). Neuroimaging differences in spatial cognition between men and male-to female transsexuals before and during hormone therapy. Journal of Sexual Medicine, 7, 1858–1867.
Smith, S. M., Jenkinson, M., Johansen-Berg, H., Rueckert, D., Nichols, T. E., Mackay, C. E., … Behrens, T. E. (2006). Tract-based spatial statistics: Voxelwise analysis of multi-subject diffusion data. Neuroimage, 31, 1487–1505.
Smith, S. M., Jenkinson, M., Woolrich, M. W., Beckmann, C. F., Behrens, T. E. J., Johansen-Berg, H., … Matthews, P. M. (2004). Advances in functional and structural MR image analysis and implementation as FSL. NeuroImage, 23, S208–S219.
Smith, S. M., Johansen-Berg, H., Jenkinson, M., Rueckert, D., Nichols, T. E., Miller, K. L., … Behrens, T. E. (2007). Acquisition and voxelwise analysis of multi-subject diffusion data with tract-based spatial statistics. Nature Protocols, 2, 499–503.
Soares, J. M., Marques, P., Alves, V., & Sousa, N. (2013). A hitchhiker’s guide to diffusion tensor imaging. Frontiers in Neuroscience, 7, 31. doi:10.3389/fnins.2013.00031.
Soleman, R. S., Staphorsius, A. S., Cohen-Kettenis, P. T., Lambalk, C. B., Veltman, D. J., van Trotsenburg, M. A., … Kreukels, B. P. (2014). Oestrogens are not related to emotional processing: A study of regional brain activity in female-to-male transsexuals under gonadal suppression. Cerebral Cortex, 26, 510–516.
Staphorsius, A. S., Kreukels, B. P., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E., … Bakker, J. (2015). Puberty suppression and executive functioning: An fMRI study in adolescents with gender dysphoria. Psychoneuroendocrinology, 56, 190–199.
Tsakiris, M. (2010). My body in the brain: A neurocognitive model of body-ownership. Neuropsychologia, 48, 703–712.
Tsakiris, M., Costantini, M., & Haggard, P. (2008). The role of the right temporo-parietal junction in maintaining a coherent sense of one’s body. Neuropsychologia, 46, 3014–3018.
Tsakiris, M., Hesse, M. D., Boy, C., Haggard, P., & Fink, G. R. (2007). Neural correlates of body-ownership: A sensory network for bodily self-consciousness. Cerebral Cortex, 17, 2235–2244.
van Dijk, M. T., van Wingen, G. A., van Lammeren, A., Blom, R. M., de Kwaasteniet, B. P., Scholte, H. S., & Denys, D. (2013). Neural basis of limb ownership in individuals with body integrity identity disorder. PLoS ONE, 8, e72212. doi:10.1371/journal.pone.0072212.
Yamashiro, K., Inui, K., Otsuru, N., Urakawa, T., & Kakigi, R. (2011). Temporal window of integration in the somatosensory modality: An MEG study. Clinical Neurophysiology, 122, 2276–2281.
Zhou, J. N., Hofman, M. A., Gooren, L. J., & Swaab, D. F. (1995). A sex difference in the human brain and its relation to transsexuality. Nature, 378, 68–70.
Zhu, Z., Disbrow, E. A., Zumer, J. M., McGonigle, D. J., & Nagarajan, S. S. (2007). Spatiotemporal integration of tactile information in human somatosensory cortex. BMC Neuroscience, 8, 1. doi:10.1186/1471-2202-8-21.
Zubiaurre-Elorza, L., Junque, C., Gomez-Gil, E., Segovia, S., Carrillo, B., Rametti, G., & Guillamon, A. (2013). Cortical thickness in untreated transsexuals. Cerebral Cortex, 23, 2855–2862.
Zucker, K. J., & Cohen-Kettenis, P. T. (2008). Gender identity disorder in children and adolescents. In D. L. Rowland & L. Incrocci (Eds.), Handbook of sexual and gender identity disorders (pp. 376–422). New York: Wiley.
We thank Dr. Mingxiong Huang, Dr. Roland Lee, and Dr. Tao Song for support in collecting the MEG data and Dr. Eric Halgren and Burke Rosen for assistance in processing the MEG data. We thank Zack Taich, Dave Deriso, and Radhika Gosavi for assistance in carrying out the study and Rachel Case for assistance in preparing the figures. This work was supported by the University of California, San Diego, through an Academic Senate Award (2011) and through general support of several of the authors while the study was conducted. This work was also supported by research funds from Herb Lurie. Finally, the first author thanks NCCIH for support during the preparation of the manuscript. The views presented in this paper are solely those of the authors and do not necessarily reflect views of the National Center for Complementary and Integrative Health.
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Case, L.K., Brang, D., Landazuri, R. et al. Altered White Matter and Sensory Response to Bodily Sensation in Female-to-Male Transgender Individuals. Arch Sex Behav 46, 1223–1237 (2017). https://doi.org/10.1007/s10508-016-0850-z
- Gender dysphoria
- Body image
- Body representation
- Gender identity
- Parietal lobes