Gender Dysphoria Diagnosis (Part 4): DSM and ICD Diagnostic Criteria

————
Part 1: GIDYQ-AA Personal Reflection
Part 2: Psychological Benefits of Diagnostic Confirmation 
Part 3: Childhood Gender Non-Conformity
~ Part 4 in the Gender Dysphoria Diagnosis series ~ 
Part 5
: GIDYQ-AA Full Text

————

DSM-5

I frequently mention the diagnostic criteria for gender identity disorder and gender dysphoria in my posts, and I reference numerous research studies that also refer to these criteria. The diagnostic criteria are outlined in successive editions of the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the WHO International Statistical Classification of Diseases (ICD).

I thought it might be helpful to post all the different versions of the diagnostic criteria related to transsexualism, gender identity disorder, and gender dysphoria so that readers have more context for my previous posts. Presenting all the versions of the diagnostic criteria in chronological order also illustrates the evolution of these criteria over time.

The criteria posted below were extracted from hardcopies of the most recent DSM editions (DSM-IV-R and DSM-5) and an online ebook of ICD-10 accessed through a university server. I was unable to obtain hardcopies or online versions of earlier DSM editions so I have included here the abbreviated diagnostic criteria from the DSM-III and DSM-III-R as listed in the appendix of a review article discussing gender identity disorder diagnostic criteria. (Cohen-Kettenis 2009)

————

DSM-III (1980)

Transsexualism (302.5x)
A. Sense of discomfort and inappropriateness about one’s anatomic sex.
B. Wish to be rid of one’s own genitals and to live as a member of the other sex.
C. The disturbance has been continuous (not limited to periods of stress) for at least 2 years.
D. Absence of physical intersex or genetic abnormality.
E. Not due to another mental disorder, such as Schizophrenia.

Sub-classification by predominant prior sexual history:
1 = asexual
2 = homosexual (same anatomic sex)
3 = heterosexual (other anatomic sex)
4 = unspecified

Atypical Gender Identity Disorder (302.85)
This is a residual category for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder.

————

DSM-III-R (1987)

Transsexualism (302.50)
A. Persistent discomfort and sense of inappropriateness about one’s assigned sex.
B. Persistent preoccupation for at least 2 years with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.
C. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) (302.85)
A. Persistent or recurrent discomfort and sense of inappropriateness about one’s assigned sex.
B. Persistent or recurrent cross-dressing in the role of the other sex, either in fantasy or actuality, but not for the purpose of sexual excitement (as in Transvestic Fetishism).
C. No persistent preoccupation (for at least 2 years) with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex (as in Transsexualism).
D. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

Gender Identity Disorder Not Otherwise Specified (GIDNOS) (302.85)
Disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples:
1. Children with persistent cross-dressing without the other criteria for Gender Identity Disorder of Childhood.
2. Adults with transient, stress-related cross-dressing behavior.
3. Adults with the clinical features of Transsexualism of less than 2 years’ duration.
4. People who have a persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex.

————

ICD-10 (1993)

Gender Identity Disorders (F64)

Transsexualism (F64.0)
A. The individual desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormonal treatment.
B. The transsexual identity has been present persistently for at least two years.
C. The disorder is not a symptom of another mental disorder, such as schizophrenia, nor is it associated with chromosome abnormality.

Dual-Role Transvestism (F64.1)
A. The individual wears clothes of the opposite sex in order to experience temporarily membership of the opposite sex.
B. There is no sexual motivation for the cross-dressing.
C. The individual has no desire for a permanent change to the opposite sex.

Gender Identity Disorder of Childhood (F64.2)

For girls:
A. The individual shows persistent and intense distress about being a girl, and has a stated desire to be a boy (not merely a desire for any perceived cultural advantages to being a boy), or insists that she is a boy.
B. Either of the following must be present:
(1) persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g. boys’ underwear and other accessories;
(2) persistent repudiation of female anatomic structures, as evidenced by at least on of the following:
(a) an assertion that she has, or will grow, a penis;
(b) rejection of urinating in a sitting position;
(c) assertion that she does not want to grow breasts or menstruate.
C. The girl has not yet reached puberty.
D. The disorder must have been present for at least 6 months.

For boys:
A. The individual shows persistent and intense distress about being a boy, and has an intense desire to be a girl or, more rarely, insists that he is a girl.
B. Either one of the following must be present:
(1) preoccupation with stereotypical female activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games, and activities;
(2) persistent repudiation of male anatomical structures, as indicated by at least one of the following repeated assertions:
(a) that he will grow up to become a woman (not merely in that role);
(b) that his penis or testes are disgusting or will disappear;
(c) that it would be better not to have a penis or testes.
C. The boy has not yet reached puberty.
D. The disorder must have been present for at least 6 months.

Other Gender Identity Disorders (F64.8)

Gender Identity Disorder, Unspecified (F64.9)

————

DSM-IV (1994) and DSM-IV-TR (2000)

Gender Identity Disorder
A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:
(1) repeatedly stated desire to be, or insistence that he or she is, the other sex
(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games and pastimes of the other sex
(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion towards rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Sexually Attracted to Neither

Gender Identity Disorder Not Otherwise Specified (302.6)
This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include:
1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria.
2. Transient, stress-related cross-dressing behavior.
3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex.

————

DSM-V (2013)

Gender Dysphoria in Children (302.6)
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6 of the following (one of which must be Criterion A1):

  1. A strong desire to be of the other gender or an insistence that he or she is the other gender.
  2. In boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
  3. A strong preference for cross-gender roles in make-believe or fantasy play.
  4. A strong preference for the toys, games, or activities typical of the other gender.
  5. A strong preference for playmates of the other gender.
  6. In boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities.
  7. A strong dislike of one’s sexual anatomy.
  8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:
With a disorder of sex development (eg. a congenital adrenogenital disorder such as 255.2 congenital adrenal hyperplasia or 259.50 androgen insensitivity syndrome).
Coding note: code the disorder of sex development as well as gender dysphoria.

Gender Dysphoria in Adolescents and Adults (302.85)
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested at least two of the following:

  1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).
  2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
  4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
  5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
  6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:
With a disorder of sex development (eg. a congenital adrenogenital disorder such as 255.2 congenital adrenal hyperplasia or 259.50 androgen insensitivity syndrome).
Coding note: code the disorder of sex development as well as gender dysphoria.

Specify if:
Post-transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen – namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (eg. penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

————

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed, Text Revision). 2000. Washington, DC: American Psychiatric Association.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). 2013. Arlington, VA: American Psychiatric Association.

Cohen-Kettenis PT, Pfafflin F. The DSM diagnostic criteria for gender identity disorder in adolescents and adults. 2010. Archives of Sexual Behavior 39(2): 499-513. 

World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders  Diagnostic Criteria for Research. 1993. Geneva, Switzerland: WHO. Accessed online. 

Gender Dysphoria Diagnosis (Part 3): Childhood Gender Non-Conformity

————
Part 1: GIDYQ-AA Personal Reflection
Part 2: Psychological Benefits of Diagnostic Confirmation 
~ Part 3 in the Gender Dysphoria Diagnosis series ~
Part 4: DSM and ICD Diagnostic Criteria 
Part 5
: GIDYQ-AA Full Text

————

Jantina Cow

That’s me. A child dressed in baggy boy’s clothes, peeking out from underneath shaggy bangs – hair longer than she wanted but parentally forbidden from getting it cut – playing with her heifer calf named John. A child who knew she was a girl but desperately wanted to be a boy instead.

In a previous post, I discussed my overwhelming doubts about whether or not I truly have gender dysphoria given how atypical my experience seems to be in comparison to the more commonly portrayed trans narratives and the established diagnostic criteria. My experience since puberty has been predominantly characterized by intense physical dysphoria regarding female body characteristics, in the absence of any cognitive gender identity. So I didn’t consider myself “transgender” and I didn’t even know that gender dysphoria (formerly called gender identity disorder) was an established phenomenon or that transition options existed until two years ago – I just thought I had a very unusual and very severe body image disturbance. I have also previously described the powerful relief and peace I felt after having the gender dysphoria diagnosis confirmed by a specialist.

But despite the relief, acceptance, and confidence that followed after receiving expert confirmation of gender dysphoria, I found that after a couple of months those familiar doubts started creeping back in. Contributing to this resurgence of doubt was my ongoing difficulty understanding the significance of my childhood gender experience with respect to my current adult gender experience. Throughout my exploration of the trans community and investigation of transition options over the past two years, I have never been sure to what extent my obvious childhood gender non-conformity (obvious in memory and in family photos) and my distinct childhood desire to be a boy would necessarily add support to an adulthood diagnosis of gender dysphoria. I kept asking myself: how relevant is my childhood gender non-conformity?

Jantina Dress

That’s me too. A child posing awkwardly in a dress, a child forced into that dress by her rigidly insistent mother, a child hating that dress with a feisty little rage because dresses are impractical and frivolous garments, a girl who wanted to be a boy and resented being forced into a conventional girl’s uniform, but pulling off an admirably convincing smile to please her father holding the camera.

Typical trans narratives on personal blogs and from high-profile trans advocates usually emphasize that they “knew” they were the “opposite” gender since they were extremely young.

“As a child I knew everyone was telling me that I was a boy but I felt like a girl.” Laverne Cox 

“Ever since I could form coherent thoughts, I knew I was a girl trapped inside a boy’s body. There was never any confusion in my mind.” Jazz Jennings

“For me, I tend to refer to my childhood as one of a transgender child. When I was four and began asserting myself as the girl I knew myself to be… all I knew was that my internal sense of gender, what spoke to my soul, did not align with my body. But my prepubescent body had not grown into this battle I had to fight against.” Janet Mock

“As far back as four or five I felt like a boy and wished I was a boy.” Chaz Bono

“My earliest memories were that of wanting to be a girl even before I learned to spell.” Jade Starr

Most trans people seem to interpret early childhood behaviors and preferences that align with opposite-sex stereotypes as incontrovertible evidence of their gender dysphoria. But research suggests that childhood gender non-conformity is relatively common. “Surveys report that 2-5% of children aged up to seven, as reported by their parents, ‘behaves like opposite sex’ and 1-2% ‘wishes to be of opposite sex.'” (Kaltiala-Heino 2015) And among these gender non-conforming children, only a small minority (ranging from 2-37% in various studies) will retain gender dysphoric feelings into adolescence (Kaltiala-Heino 2015, Smith 2014, Steensma 2013, Wallien 2008). “The evolution of a gender nonconforming child is unpredictable, and it is therefore impossible to determine whether the condition will persist into adolescence or adulthood.” (Meriggiola 2015)

And of course, assessment of whether a child’s behavior is “gender non-conforming” is based on a troubling frame of reference: cultural gender stereotypes and the sexist attitudes associated with deviation from those stereotypes. “Cultural issues likely play a major role in whether a child’s behavior is perceived as gender atypical. Consultations due to gender identity are generally more often sought for boys than girls, which may suggest greater gender variation in boys, but also that effeminate behaviors in boys are perceived as more of a problem than tom-boyishness in girls… that natal boys were more commonly bullied because of gender presentation suggests that effeminate characteristics in boys are less tolerated than masculine self-presentation in girls.” (Kaltiala-Heino 2015)

Research also shows that childhood gender non-conformity is more often associated with adolescent and adult non-heterosexual sexual orientations than with gender dysphoria and transgender identity. “Another issue regarding the psychosexual outcome of children with gender identity disorder is the relation between the child’s gender atypicality and sexual orientation in adulthood. Early prospective follow-up studies indicated that a high rate (60-100%) of children (mostly boys) with gender dysphoria had a homosexual or bisexual sexual orientation in adolescence or adulthood and no longer experienced gender-dysphoric feelings… in accordance with retrospective studies among adult homosexuals, who recalled more childhood cross-gender behavior than heterosexuals. Adult individuals with childhood gender dysphoria are thus much more likely to have a nonheterosexual sexual orientation than a heterosexual sexual orientation.” (Wallien 2008)

In light of that information, I have always been uncomfortable with the strong emphasis that many trans people place on their childhood gender non-conformity. It left me feeling very unsure about how to integrate my own childhood experience into my current perspective regarding a diagnosis of gender dysphoria. And their emphasis also makes me deeply uncomfortable because it perpetuates the idea to the general public (who likely don’t know the statistics regarding low rates of persistence of childhood gender dysphoria into adolescence but who seem to have an exaggerated perception of the association between childhood gender non-conformity and future homosexuality) that childhood cross-sex behavior means their kid is trans or gay. These ideas potentially lead to inappropriate suppression of that behavior by the parents (if parents are homophobic or transphobic and believe they can prevent their kid “becoming” trans or gay). “There is evidence that some clinicians and parents have offered or requested treatment for children with gender identity disorder, in part, to prevent the development of homosexuality.” (Davy 2015) Or these ideas may lead to premature medical or psychological intervention (if parents are supportive of their child’s cross-gender interests but perhaps somewhat misguided and overenthusiastic in pursuing early transition). And clinical experience suggests that it is often the parents’ concern about their child’s gender non-conformity that leads to psychological assessment, rather than the child’s own distress about their gender non-conformity. “Parents of children with gender identity disorder are often ‘unable to cope’ with gender uncertainty… parents most often bring their children to clinical attention… in these cases, it is the parents whose children do not adhere to normative expectations of gender performance who experience ‘distress’.” (Hird 2003) I felt so confused and conflicted about all of this, and I have therefore intentionally avoided discussing my childhood gender experience in any great detail on my blog until now.

Laverne Cox has spoken out about the psychological advantages of puberty suppression in adolescents with gender dysphoria, a procedure which scientific evidence strongly supports as having substantial therapeutic benefit and which allows for more satisfying physical transition outcomes (Smith 2014, Kaltiala-Heino 2015, Meriggiola 2015). But Laverne Cox also promotes transitioning in early childhood, “With transition, the earlier the better. I think if your child knows that they are transgender – and we usually know – then it is life-saving.” I think that is an extremely irresponsible statement for an influential transgender advocate to make, given the existing evidence about the unpredictable psychosexual outcomes in gender non-conforming children.“Medical interventions are not warranted in pre-pubertal children.” (Kaltiala-Heino 2015) Research about the management of gender dysphoria in children recommends a supportive but cautious monitoring approach, with further assessment and consideration of puberty suppression if gender dysphoria does in fact persist past the onset of puberty. “The percentage of transitioned children is increasing and seems to exceed the percentages known from prior literature for the persistence of gender dysphoria, which could result in a larger proportion of children who have to change back to their original gender role, because of desisting gender dysphoria, accompanied with a possible struggle… the clinical management of children with gender dysphoria in general should not be aimed to block gender-variant behaviors.” (Steensma 2013)

To summarize the results of numerous studies: childhood gender dysphoria seems to be associated with an increased likelihood of future homosexual or bisexual orientation, and childhood gender dysphoria may or may not (and usually does not) persist into adolescence. “In clinical practice, gender-dysphoric children and their parents should be made aware of [these outcomes] and, if this would create problems, be adequately counseled.” (Wallien 2008) But of course, childhood “gender non-conformity” may simply represent the beautiful freedom and remarkable creativity inherent in children’s innocent pastimes viewed through an adult lens of social gender stereotypes. Childhood “gender non-conforming” behavior may also be a vital process in the development of their individual identity, not something that requires any parental intervention whatsoever. Let them be kids. Let them figure out for themselves who they are. “It is with seasoned modesty that we emphasize, to different degrees, the changeability of children during growth and development… what children desire of themselves as children is rarely what satisfies them as adults.” (Reiner 2011)

Revisiting the scientific literature on these topics has also had substantial personal relevance, allowing me to reframe my own childhood and adolescent experiences in a way that gives me more confidence in a current diagnosis of gender dysphoria and gives me a deeper understanding of assorted fragments of my increasingly coalescent story.

Knowledge of the factors associated with persistence versus desistance of childhood gender dysphoria into adolescence is limited (Steensma 2013). However, from this limited research, it has been demonstrated repeatedly that one of the most important factors associated with higher rates of persistence of gender dysphoria from childhood into adolescence is the intensity of childhood gender non-conformity or cross-sex identification. “Presentation [of gender dysphoria] is heterogeneous in childhood, with some children exhibiting extreme gender non-conforming behaviors accompanied by severe discomfort and other children showing less intense characteristics. Not all adolescents with gender dysphoria experience symptoms in early childhood, but those who do often present with more extreme gender non-conformity.” (Smith 2014) “Taken together, the prior research suggests that persistence of childhood gender dysphoria is most closely linked to the intensity of the gender dysphoria in childhood and the amount of gender-variant behavior.” (Steensma 2013) My childhood gender non-conformity WAS extremely intense, with a very strong and persistent desire to “be a boy” (in the context of a childish understanding of gender and a naive perception of masculine and feminine stereotypes) and drastic efforts (within a child’s limited scope of control) to create a boyish physical appearance through choice of clothing and hairstyle. The above research lends major relevance to the intensity of my childhood gender dysphoria, rather than the mere presence of it. Which adds diagnostic value to that aspect of my own story, and also allows me to understand the significance of my childhood experience without perpetuating the troublesome misconceptions about childhood gender non-conformity that I described above.

In terms of persistence of childhood gender dysphoria into adolescence, I now understand the significance of my own response to the physical changes accompanying puberty. Gender dysphoria which intensifies with the onset of puberty usually persists… At puberty, the development of secondary sexual characteristics can lead to increased distress, sometimes leading to severe extremes such as depression, anxiety, self-harm, suicidal tendencies, substance abuse, and high-risk sexual behaviour. Reactions to early pubertal changes have a high diagnostic value.” (Meriggiola 2015) Several other studies also reinforce the “high diagnostic value” of teenagers’ response to development of secondary sexual characteristics in early puberty (Smith 2014, Steensma 2013, Wallien 2008). In contrast to cognitive gender identity (which I suppose I would have described as “wishing to be a boy” when I was a child, but which seemed to fade away at the onset of puberty), my physical dysphoria increased dramatically in response to early pubertal changes. I was so intensely distressed by my budding breasts and broadening hips and my first few periods, that I immediately initiated a regime of strict dietary restriction and excessive exercise to starve away all traces of physical femaleness. These behaviors quickly progressed to full-blown anorexia nervosa, which persisted for the next six years. In retrospect, this experience now has high diagnostic value and is strongly consistent with gender dysphoria.

Not only do reactions to early pubertal changes have “high diagnostic value”, there is also diagnostic value associated with the response to puberty suppression. “Treatment with a GnRH analog [puberty suppression] is thought to be a diagnostic aid as well as a therapeutic intervention for this age group because stopping the progression of the physical changes of puberty would be expected to partially alleviate gender dysphoria symptoms in true gender dysphoria. The first prospective study of psychological outcomes in adolescents… showed a statistically significant improvement in behavior, emotional problems, and general functioning after puberty suppression.” (Smith 2014) I experienced intensified body aversion at the onset of puberty, but through extreme and prolonged starvation I basically created my own puberty suppression protocol (which ideally should have been achieved with appropriate drugs under medical supervision but I wasn’t aware of those options at the time so I did what I could on my own to suppress my confusing physical dysphoria). Anorexia virtually halted further pubertal development: the drastic weight loss induced amenorrhea which lasted from age 13 to 19 and prevented any further increase in chest and hip size, so that I floated through my teenage years in a rail-thin, nearly pre-pubescent, and highly androgynous body. During those years, my eating disorder was its own source of distress (food-related thoughts were incessant and abnormal eating behaviors were pronounced). But that all seemed such a small price to pay to achieve a tenuous and provisional satisfaction and comfort with a less feminine body, a “partial alleviation of gender dysphoria” secondary to “stopping the progression of the physical changes of puberty”. Which aligns precisely with the description in the above study. Once again, this evidence provides very definitive support for a true diagnosis of gender dysphoria in my case.

When I was 19, I experienced my first episode of major depression and I gained nearly 100lbs over a nine-month span. Menstruation resumed, acne worsened, my chest and hips increased in size, and my body basically went through normal puberty after a six-year starvation-induced delay. Following the weight gain and further pubertal development at 19 years old, my body became more feminine and my physical dysphoria escalated to a previously unprecedented intensity, to the point that I could no longer tolerate the sight of myself and began avoiding mirrors and showering in the dark. Moving uncomfortably through the next five years in a much heavier and more feminized body, I would often reflect on my androgynous teenage thinness with an excruciating sense of loss tainting all of those fond memories, a desperate feeling of hopelessness of ever regaining such a genderless and comfortable body. Only in the past year, after having lost some of the weight that I gained six years ago and developing a much more rigorous weightlifting routine to increase my upper body muscle mass, have I been able to create a more satisfying and comfortably androgynous appearance without depending on a dangerously low body weight. So now, when I reflect on my teenage body, those memories are no longer pained by desperation and loss. Instead, those memories have become just one more part of my story that now makes sense. I have finally let go of those last remnants of doubt: I DO have gender dysphoria. Atypical gender dysphoria, sure. But “atypical” tends to be my typical way of life.

Jantina Rope Ladder

That’s me. A skinny teenager sweating in the heat of August summer, her smile genuine this time from the satisfaction of building a rope ladder from sawed-off poplar branches to scale the walls of a hay bale fortress. I can still feel the comforting looseness of those tattered jeans around my narrow hips. I can feel the freedom and lightness and vitality in that slender androgynous body. It is only the slightest rise of my pectoral topography through the kid-sized purple T-shirt that hints at the biological truth I tried to deny.

Jantina Dirtbike

That’s me. A scrawny kid taking her first solo ride on her brother’s dirtbike, a little wobbly and a little cautious and a lot exhilarated. I can still feel the weight of my brother’s heavy boots on my feet, still feel the wind snatching my breath away as I tossed caution aside and revved up into top speed, still remember how alive I felt in that slim boyish body.

Jantina Peter Pan

And that’s me too. A lean little nymph leaping so lightly across the scattered hay bales, her favorite green Peter Pan sweater billowing around her weightless self. In the moment before the jump, I felt like I could fly, I felt alive inside my body, and I trusted my body to do what I wanted it to do. So all the muscles in my legs contracted, my feet pushed down hard against the hay, and then, recklessly, I tossed my stick-thin Peter Pan body up… and up… and up… towards a genderless Neverland in the dusky evening sky.

“Lastly, she pictured to herself… how she would keep, through all her riper years, the simple and loving heart of her childhood; and how she would gather about her other little children, and make their eyes bright and eager with many a Wonderland of long ago; and how she would feel with all their simple sorrows, and find a pleasure in all their simple joys, remembering her own child-life, and the happy summer days.”
– Lewis Carroll (Alice’s Adventures in Wonderland, 1865)

————

References

Davy Z. The DSM-5 and the politics of diagnosing transpeople. 2015. Archives of Sexual Behavior 44(5): 1165-76. 

Hird MJ. A typical gender identity conference? Some disturbing reports from the therapeutic front lines. 2003. Feminism and Psychology, 13: 181–199. 

Kaltiala-Heino R, Sumia M, Työläjärvi M, et al. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. 2015. Child Adolescent Psychiatry and Mental Health 9: 1-9. 

Meriggiola MC, Gava G. Endocrine care of transpeople part I. A review of cross-sex hormonal treatments, outcomes and adverse effects in transmen. 2015. Clinical Endocrinology 83(5): 597-606.

Reiner WG, Townsend Reiner D. Thoughts on the nature of identity: disorders of sex development and gender identity. 2011. Child and Adolescent Psychiatric Clinics of North America 20(4): 627-38. 

Smith KP, Madison CM, Milne NM. Gonadal suppressive and cross-sex hormone therapy for gender dysphoria in adolescents and adults. 2014. Pharmacotherapy 34(12): 1282-97. 

Steensma TD, McGuire JK, Kreukels BP, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. 2013. Journal of the American Academy of Child and Adolescent Psychiatry 52(6): 582-90. 

Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. 2008. Journal of the American Academy of Child and Adolescent Psychiatry 47(12): 1413-23. 

Gender Dysphoria Diagnosis (Part 2): Psychological Benefits of Diagnostic Confirmation

————
Part 1: GIDYQ-AA Personal Reflection
~ Part 2 in the Gender Dysphoria Diagnosis series ~
Part 3: Childhood Gender Non-Conformity
Part 4: DSM and ICD Diagnostic Criteria
Part 5: GIDYQ-AA Full Text
————

Unicorn

In a previous post, I described the intense relief and peacefulness that I felt after receiving confirmation of a diagnosis of gender dysphoria from an experienced psychiatrist. Confirmation of the diagnosis helped reduce the overwhelming doubt and uncertainty (what’s wrong with me? do I really have gender dysphoria? or is this something else?) and helped me move towards acceptance. Acceptance of gender dysphoria facilitated the freedom to start considering transition options without being constantly tugged backwards by relentless nagging doubt regarding the diagnosis itself.

From my personal experience, it seems that most trans people have a strong intrinsic sense of their own gender identity and most trans people feel much more confident than I did in aligning themselves with the established criteria for gender dysphoria and in pursuing transition. My psychiatrist, who specializes in working with transgender people, told me that most of his patients are confident regarding their transition goals and just need help accessing resources to transition when they initially present to his clinic. One study described a group of adolescents referred for assessment at a gender clinic in Finland: “During the assessment process, 72% (34/47) of the applicants were sure about feeling they were of the opposite sex to their natal and about pursuing sex reassignment, but 28% (13/47) were not sure about their feelings regarding gender identity and/or sex reassignment.” (Kaltiala-Heino 2015) Those results support my anecdotal impressions that the majority of trans people feel certain about their gender identity and transition goals.

But even for trans people who are more certain of their gender identity and transition goals than I was, the potential psychological benefit derived from diagnostic confirmation of gender dysphoria should not be underestimated.

A prospective study published in 2014 evaluated the psychological response to different steps in gender reassignment therapy in people with gender identity disorder (GID) (the old term for what is now called gender dysphoria). “To our knowledge, it is the first publication that focuses on the effects of the separate parts of the sex reassignment therapy.” (Heylens 2014)

The study recruited participants from a population of patients who applied for sex reassignment therapy at a Gender Clinic in Belgium. These patients had not previously received a diagnosis of GID and had not initiated any medical aspects of transition (such as hormone therapy or surgery) prior to applying to the Gender Clinic. A total of 82 patients agreed to participate in the study after giving informed consent, however 12 were excluded from the study because they did not meet the criteria for GID (they were instead given the diagnosis of GID-NOS, gender identity disorder not otherwise specified), another 12 patients were excluded from the study because they did not undergo “full treatment (hormonal and surgical)” due to psychiatric/medical comorbidities (3 patients) or personal preferences regarding transition goals (9 patients), and 1 patient was excluded from the study because they committed suicide during follow up. This left 57 patients in the study (46 MTFs and 11 FTMs) diagnosed with GID who completed all steps (hormonal and surgical) in the gender reassignment process.

Supporting the results of many previously published articles, this study showed that, “Sex reassignment therapy does influence the level of psychopathology in GID patients, with significant reduction in anxiety, depression, somatization, psychoticism, interpersonal sensitivity, hostility, and overall psychoneurotic distress… after treatment, the majority of patients indicated that they have a better mood, are happier, and feel less anxious than before. They also seem to be more self-confident and encounter a better body-related experience, indicating a less distorted self-image than before treatment.” (Heylens 2014)

Of particular relevance here, the results from this study showed that out of all the steps involved in gender reassignment therapy, confirmation of the GID diagnosis and initiation of hormone treatment were associated with the greatest psychological benefit. “The most important effect seemed to result from the confirmation of the diagnosis and the initiation of hormone therapy.” (Heylens 2014) The results strongly suggest that diagnostic confirmation of GID is, in itself, a very important and affirming step for patients.

However, based on the participant exclusion criteria, I think the results of this study may actually underestimate the positive psychological effects of diagnostic confirmation. The study excluded patients who did not strictly meet the GID criteria (an excluded group which may have included some non-binary trans people with less definitive cross-sex identity) and excluded patients who did not complete all steps of the gender reassignment process (the majority of whom chose not to based on personal preferences regarding transition). This suggests that the final population of patients in this study (those who received a formal diagnosis of GID and went on to complete all the steps in transitioning to the opposite sex) may have had a relatively high degree of certainty regarding their gender identity and transition goals compared to a broader population of patients (such as those with a GID-NOS diagnosis or patients who desired some but not all aspects of transition). The authors partially acknowledge this bias when they discuss the limitations of their study: “On the whole, our study population is a selected group that is not fully representative for the larger group of gender dysphoric people: they all fulfilled criteria for GID and were eligible for SRS. This perspective might certainly have an influence on the level of psychoneurotic distress. If there had been less certainty, at the end of the diagnostic phase and after initiation of hormonal treatment, about receiving SRS, results could have been different.”

Yet even in this population of gender dysphoric patients with potentially greater confidence and certainty regarding transgender identity and transition goals compared to a more diverse group, it is clear that the confirmation of the diagnosis (GID) by a professional was one of the most important steps in the transition process with respect to psychological improvements. “We found that the biggest decrease in psychological dysfunctioning is caused by initiation of hormone therapy or confirmation of the diagnosis by a professional caregiver. This finding was consistent with the subjective feeling of most treated patients and suggests that recognition and acceptance of the GID play an important role in the transition process.”

Recognition and acceptance. Isn’t that what we all want?

“If you’ll believe in me, I’ll believe in you.”
– The Unicorn (Through the Looking-Glass and What Alice Found There, 1871)

————

References

Heylens G, Verroken C, De Cock S, et al. Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. 2014. Journal of Sexual Medicine 11(1): 119-126. 

Kaltiala-Heino R, Sumia M, Työläjärvi M, et al. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. 2015. Child Adolescent Psychiatry and Mental Health 9: 1-9. 

Our Whole Foundation Cracks

Sand Dunes

A few nights ago I finally told my sister that I’m planning to start testosterone in a couple of months. I had predicted that her response might be surprise, or confusion, or neutral acceptance, or even a gentle “I’ve suspected for a while, I’m glad you finally told me.” But what she actually said caught me totally off guard: “Wow, that’s so exciting!!!” She seemed genuinely enthusiastic and excited about me starting testosterone. Of course, it was a huge relief to know that she’s supportive and I felt a surge of gratitude. But her excitement on my behalf also served as an uncomfortable reminder of my own lack of excitement at the prospect of starting testosterone.

For me, starting testosterone is no more exciting than starting an antidepressant: it’s just a pharmaceutical treatment, with no guarantee of benefit, aimed at managing a disorder that I wish I didn’t have. Except that with testosterone, unlike most other medications, the effects are systemic, irreversible, and impossible to hide past a certain point.

My sister also commented, “I am a bit surprised… all this time I just assumed that you were a girl who liked short hair and wore boys’ clothes.” I told her how badly I wish that was the case, how badly I wish that I could just be comfortable living in a female body. I don’t think that desire represents internalized transphobia. No, it’s just a painful recognition that it would be so much easier, so much less confusing, so much less distressing for me to feel comfortable in the body I already have.

It is not my intention to pathologize or medicalize gender dysphoria, which for most trans people seems to be a matter of identity rather than a “diagnosis” or a “disorder”. So I am speaking only for myself here. But I have ransacked every crack and crevice of my brain, searching desperately for any hint of “gender identity” – searching for something that would resemble what others have described as a “feeling” or “internal sense” of “being male” or “being female” or even being somewhere in between – and I have been unable to find anything like that.

In fact, I have no clear understanding of self-identity even beyond gender. I have no internal sense of “being me”. I – well I think we, as humans – are constantly changing and evolving as a result of gaining self-awareness, acquiring knowledge, and adapting to the influence of other people and external circumstances. Amidst this constant chaos, I cannot isolate a stable “identity” for myself. I simply recognize patterns in my thoughts, behaviors, and preferences, some of which have remained relatively stable over time and some of which seem to shift and change as easily and as often as sand dunes in a desert. Across this ever-changing landscape, I have a hard time understanding who or what I am. Perhaps, with time and further exploration, I might find out who I am. Or perhaps I will just learn to live with the uncertainty.

“[We are] incapable of certain knowledge or absolute ignorance. We are floating in a medium of vast extent, always drifting uncertainly, blown to and fro; whenever we think we have a fixed point to which we can cling and make fast, it shifts and leaves us behind; if we follow it, it eludes our grasp, slips away, and flees eternally before us. Nothing stands still for us. This is our natural state and yet the state most contrary to our inclinations. We burn with desire to find a firm footing, an ultimate, lasting base on which to build a tower rising up to infinity, but our whole foundation cracks.”
– Blaise Pascal (Pensées, 1688 – english translation)

Gender Dysphoria Diagnosis (Part 1): GIDYQ-AA Personal Reflection

————
~ Part 1 in the Gender Dysphoria Diagnosis series ~
Part 2: Psychological Benefits of Diagnostic Confirmation
Part 3: Childhood Gender Non-Conformity
Part 4: DSM and ICD Diagnostic Criteria
Part 5: GIDYQ-AA Full Text
————

GIDYQ-AA Panorama

————
Full text of the GIDYQ-AA (male and female versions) available in Part 5.
————

For several months I have been seeing a psychiatrist who specializes in working with transgender people. The initial assessment was a comprehensive three hour interview which began with me filling out the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). The GIDYQ-AA was developed in 2007 as a dimensional measure of gender dysphoria (dimensional referring to a concept of gender as a spectrum rather than two opposite poles) (Deogracias 2007). Among populations of heterosexual and nonheterosexual university students and clinic-referred patients with a diagnosis of gender identity disorder (the old term for what is now called gender dysphoria), the questionnaire showed “strong evidence for discriminant validity in that the gender identity patients had significantly more gender dysphoria than both the heterosexual and nonheterosexual university students.” (Deogracias 2007) Further experimental evaluation of the GIDYQ-AA showed similar results and reinforced the utility of the questionnaire in the assessment of patients with gender identity concerns (Singh 2010).

The GIDYQ-AA (female version) is displayed in its entirety above.

I had no knowledge of the GIDYQ-AA prior to my first appointment with the psychiatrist. My attempt to fill out the questionnaire at the beginning of the session left me more anxious, more confused, and more frustrated than ever, intensifying my pre-existing doubt that I had gender dysphoria or that I deserved to consider myself “transgender.”

Question 04: Have you felt, unlike most women, that you have to work at being a woman?
Answer: No, I don’t work at being a woman whatsoever. But almost every adult female does have to work at being a woman in our society. It takes my mother 90 minutes every morning to get dressed and put her makeup on before work, so I’d say she is working a lot harder at “being a woman” than I am and yet she has no gender identity confusion.

Question 05: Have you felt that you were not a real woman?
Answer: What does “real woman” even mean? How can I possibly capture my uncertainty within the check-box options of “Always, Often, Sometimes, Rarely, or Never”?

Question 06: Have you felt, given who you really are (e.g. what you like to do, how you act with other people), that it would be better for you to live as a man rather than as a woman?
Answer: How are behavioral preferences that overlap with opposite-gender stereotypes even remotely relevant to deciding whether to physically transition?

Question 10: Have you felt more like a man than a woman?
Answer: No, I never feel like a man or a woman, I just feel like a person with a brain that refuses to accept my existing female body.

Question 15: Have friends or relatives treated you as a man?
Answer: What does it mean to be “treated as a man”? Like what, if someone has difficulty opening a new jar of pickles, they’ll call me over to help? Or if someone’s car breaks down, they’ll expect me to know how to fix it?

Question 17: Have you dressed and acted as a man?
Answer: What does “dressing as a man” mean? Men wear clothes. Some of those clothes are traditional suit-and-tie business attire. Some of those clothes are drag queen costumes. But the clothes don’t make the body underneath any more or any less masculine. And what does ”acting as a man” mean? See response to question 15.

Question 26: Have you thought of yourself as a man?
Answer: What does “man” mean? Beyond the physical differences between men and women, I cannot come up with a consistently accurate and consistently differentiating definition of “man” versus “woman”.

Question 27: Have you thought of yourself as a woman?
Answer: What does “woman” mean? I’m so frustrated and confused that I’m about to cry and I am DONE answering these ridiculous questions.

The only questions I could answer with any confidence were:

Question 02: Have you felt uncertain about your gender, that is, feeling somewhere in between a woman and a man?
Answer: Yes, I definitely feel uncertain about my gender. But I don’t feel “in between” a woman and a man. I feel like gender identity is simply not applicable to me.

Question 20: In the past 12 months, have you disliked your body because it is female (eg. having breasts or having a vagina)?
Answer: Always, every minute of every day, since I was 12 years old.

So after ten minutes of wrestling with the questionnaire, I gave up and handed it back to the psychiatrist. He seemed surprised that I left so many questions blank. I tried to explain my confusion but he didn’t seem to understand how I could possibly have difficulty answering any of those questions. He told me that other trans patients typically complete the survey in a few minutes with no trouble.

The authors who originally developed the GIDYQ-AA established a cut-off score of 3.00, which was reliable in differentiating people with gender dysphoria from cisgender controls (Deogracias 2007). Months after that first appointment, I read a copy of my psychiatrist’s initial assessment report, which stated, “Tom’s GIDYQ-AA scaled score was 3.19 which is slightly above what one would expect for a transgender individual. Of note however, Tom had a great deal of difficulty answering these questions, leaving half of the rating scale blank and seemed to be rigidly stuck on the concepts of “male and female” so much that he could not answer the questions. As a result, I am not confident in the reliability of Tom’s score.”

I was glad that the psychiatrist acknowledged the unreliability of my score. But I was frustrated by his statement that I was rigidly stuck on the concepts of male and female. From my perspective, it was the questionnaire itself that was rigidly stuck on concepts of “man” and “woman”. The questionnaire seemed to assume participants’ alignment with stereotypical and binary concepts of gender. The authors who developed the GIDYQ-AA stated, “Gender identity often is conceptualized in a bipolar, dichotomous manner with a male gender identity at one pole and a female gender identity at the other pole. Individuals who have an uncertain or confused gender identity or who are transitioning from one gender to the other, however, do not fit into this dichotomous scheme… We developed a new measure which was designed to assess gender identity (gender dysphoria) dimensionally. In developing this measure, we conceptualized gender identity/gender dysphoria as a bipolar continuum with a male pole and a female pole and varying degrees of gender dysphoria, gender uncertainty, or gender identity transitions between the poles.” (Deogracias 2007) However, as I’ve described above in my answers to some of the GIDYQ-AA questions, I found that the questionnaire offered very little acknowledgment or inclusion of “varying degrees of gender dysphoria, gender uncertainty, or gender identity transitions.”

During the initial assessment, my conversation with the psychiatrist quickly moved away from the GIDYQ-AA. At the end of the initial interview, he told me that most of the trans patients he sees come in for their first appointment knowing that they want to transition and requesting referrals to start hormones and be placed on the waiting list for surgery. He asked me what I would like from him moving forward. I explained that my biggest difficulty so far was believing whether I actually have gender dysphoria, given how different my experience seems to be compared everything I’ve read from trans people and compared to his descriptions of other trans patients. I said I thought it would be helpful to have someone with extensive experience in this area tell me whether or not they think I truly have gender dysphoria, and if not, then what other possibilities might explain this extreme discomfort with my body. I told him that my differential diagnoses included:
1) a gender-centered variation of the body image disturbances that accompany an eating disorder
2) a generalized form of body dysmorphic disorder (such as muscle dysmorphia)
3) an extremely intense and unusual form of vanity
4) gender dysphoria with purely physical distress and absent gender identity

The psychiatrist seemed surprised by my request and told me that most of his other trans patients would consider it very stigmatizing to be told by an “expert” what diagnosis they do or do not have. He said that his other trans patients say they know themselves better than anyone, they are sure of how they feel regarding gender, and they just need help accessing resources to transition. I had no idea what to say in response to that, so I just repeated my explanation that I don’t feel like I have any sense of gender identity, all I know is that I am excruciatingly uncomfortable in this female body and that I’m very uncertain and confused about all of this. He remained hesitant to deliver any diagnosis following the first appointment.

During my second appointment, I repeated my request for a diagnosis or at least an exploration of other possibilities. He reluctantly shared his opinion that I do indeed have gender dysphoria. In his initial assessment report (which I read several months later), he wrote, “Although I did not share with Tom yet my diagnostic impressions with regards to his gender as this would interfere with therapeutic exploration of the topic, from my perspective he certainly would meet criteria for gender dysphoria given his strong desire to rid himself of the primary and secondary feminine sexual characteristics as well as stated desire for more masculine ones. There was no evidence to suggest Tom’s symptomology being due to body dysmorphia disorder nor by an eating disorder alone. From my perspective, Tom appears to also struggle with major depressive disorder, social anxiety disorder, and anorexia nervosa (in partial remission)… At this time, Tom is still questioning with respect to his gender identity and I suspect more exploration of this will be needed prior to him making decisions regarding transitioning either medically or socially.” Any lingering doubts I had following his verbal confirmation of gender dysphoria were dispelled by reading his report, which was incredibly thorough, accurate, and well-justified. I also appreciated his recognition that more exploration would be needed prior to transitioning medically or socially. Since then, I have continued to explore these issues during my discussions with him as well as through conversations with friends, ongoing self-reflection, and my commentary on this blog.

When the psychiatrist confirmed his impression that I truly do have gender dysphoria, I felt immediate and astonishingly intense relief. It felt like I had finally accumulated enough objective evidence that I could start to believe it myself. In the days afterwards, I often found myself thinking, “Gender dysphoria IS part of my story! And I’m okay with that!” It felt like a brand new realization every time.

Following that second appointment, basking in the glow of that relief, I stepped out of the office into a chill November evening, streetlights pricking the silent darkness, snow falling gently all around. It was a breathtakingly beautiful night. I was the only person out and I felt entirely alone. And for the first time I could remember, I was content to be alone with myself. I also felt completely and profoundly… peaceful… that’s the best word I can think of to describe it. Just utterly at peace with everything. I don’t think I’ve ever felt anything quite like that.

“And now, who am I?”
– Alice (Through the Looking-Glass and What Alice Found There, 1871)

————

References

Deogracias JJ, Johnson LL, Meyer-Bahlburg HFL, et al. The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. 2007. The Journal of Sex Research 44(4):370-79. 

Singh D, Deogracias J, Johnson LL, et al. The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults: further validity evidence. 2010. The Journal of Sex Research 47(1): 49-58. 

The Boy with the Crooked Smile

Crooked Smile

My fellow patients on the psychiatric unit are certainly an interesting cast of characters. Of course I wonder about their stories, I wonder what combinations of pain and circumstance and bad luck (and maybe good luck too?) have brought them here. And for all of them, I harbor a detached empathy, an impersonal hope that they can find their way back to their lives. Even so, I try as much as possible to avoid interacting with the other patients. Most of the time I lack the energy for superficial conversations. And I lack the imagination required to use small talk as a shield from the reality of our situation, the fact that we’re all here on the psych ward, that the locked unit doors are under video surveillance, that we’re all under the influence of the many multicolored pills we swallow every morning. My personal rainbow is red, white, and yellow.

I avoid the other patients too because many of them seem to have lost appropriate social inhibitions along the way, often spewing rude and abusive comments that I get so tired of deflecting and increasingly less willing to tolerate. I also get so tired of other patients asking my name, mispronouncing it, mispronouncing it again when I correct them, and eventually just inventing their own bastardized version of my three easy syllables because my name is too much effort for them. And finally, I avoid the other patients out of a desperate instinct of self-preservation – it takes all my strength to remain focused on my own therapeutic goals, and I just can’t afford to be distracted by caring too much about anyone else on the unit. They are here for their problems, I am here for mine – I can’t forget that.

Though I intentionally maintain this safe detachment from the other patients, I cannot help but watch them all with involuntary interest. There’s The Watchman, always lurking at the end of the hall where the lights are dimmest, his dark restless eyes seeming always to be fixed on me, the hood of his black sweater drawn up around his face like the cowl of a vigilant monk. And old Abraham Lincoln – the resemblance really is uncanny – who never seems to leave the spindly chair by the courtyard windows, his lanky body folded up like an oversized praying mantis. Sleeping Beauty, who emerges from her room only rarely and wears her hospital gown like an elegant cascading dress, floating through the hallways with a radiant self-absorption and a distended pregnant belly preceding her quiet footsteps. Eyebrows, whose bushy black brows dominate his placid face and create an expression of perpetual confusion, his eyebrows dancing up and down to punctuate each spoken word, each sideways glance, each bite of food. Santa Claws, with his leering eyes and scraggly food-littered beard, his leather Harley Davidson jacket and fingers decked out with silver skulls, hands so grotesquely swollen that the rings are nearly buried by the bulging flesh, his long and fungally discolored toenails scraping the floor like ugly claws. Serene, with coiffed gray hair and deep grooves running down from the corners of her mouth like a ventriloquist’s dummy, who complains endlessly about the smell of dust, who marches back and forth across the same few feet of floor holding her diaper in place with both hands, often shouting at nobody in particular, “I just want peace of mind! You have peace of mind! Why can’t I have peace of mind? I used to be a spiritualist, you know. I used to be able to enter the spirt world but I can’t anymore. I just want peace of mind!” (We all ignore her outbursts, no-one here has peace of mind). And there’s The Howler, heard but never seen beyond one brief glimpse of a bare torso twisted across a mattress on the floor of the high-obs room, his chillingly inhuman screams filtering through the corridors at all hours of the day and night.

All of these patients I regard with a carefully cultivated detachment. Except for Cody.* I am drawn to him with a startling and shattering compassion that slices through my cautious distance and makes my heart ache. I don’t know why. Perhaps it is his physical resemblance to my brother – same endearingly disheveled hair, same ice-blue eyes, same roguish youthful handsomeness, same lingering hint of unwashed masculine musk. Perhaps it is my own selfish desire to inhabit such an effortlessly narrow-hipped, broad-chested body, the masculine alignment of his bones and muscles so achingly appealing to my girl-trapped brain.

Or perhaps it is that Cody’s demons are more outwardly obvious than most other patients on the ward. He cannot hide his battles with monsters I can’t even imagine. His blue eyes rarely register the real world around him, focused instead on high invisible shelves that he stretches up to reach, invisible barriers on the floor that he probes carefully with dirty bare feet, invisible companions sitting in the empty chairs beside him. All of his movements are slow and tense and deliberate, coherent only in a separate world the rest of us can’t see. And all these movements are narrated by his ceaseless whispering, too quiet to hear the words themselves, just a soft susurration like butterfly wingbeats. Occasionally he is interrupted from these explorations of his invisible world – quite suddenly his entire body stiffens, his head snaps to the side, his mouth stretches in a soundless scream, and a series of tremors rattle through his rigid slender body until – just as suddenly – his body stills, he blinks, looks around dazedly, and resumes whispering.

Perhaps I am drawn to Cody by a powerful but unfamiliar protective instinct – a parental sort of protectiveness, perhaps, although in my case neither maternal nor paternal – an irrational hope that if I could just fold him in my arms and shield him from the world (real and invisible) then I could somehow absorb his pain and leave him whole. Even if it killed me. I wonder if this is how my parents feel when they watch my struggle with depression. I wonder if I underestimate how hard this might be for them, how strong the instinct to protect and shelter, if this boy I barely know can draw such fierce protectiveness from my cautious heart.

But I think, more than anything, I am drawn by Cody’s smile. I have seen it only once, walking past him in the hallway. He was engaged in a repetitive pulling motion, as though he were dragging something heavy up towards his chest, his whispers seemingly directed at the evidently irksome object. As I walked closer, his hands stilled and his whispers faded and his bright blue eyes met mine – and I could see the crystal clarity suddenly alive behind the blue. The ghost of a smile tugged at the corner of his mouth – a tiny crooked smile climbing up and crinkling the corners of his eyes as his head dipped in a respectful nod of recognition. A thready filament of connection hovered between us for a moment – the flash of recognition in his eyes heartbreaking and unmistakable – until suddenly the thread snapped, his eyes dropped downwards, his whispering resumed, and just like that – with all the finality of a guillotine blade – his moment of awareness was abruptly severed.

So now whenever his path crosses mine, I find myself searching his face for that crooked smile, that awareness, that flash of recognition, searching with a desperate selfish reckless caring that takes my breath away. I see you, Cody. I’m here. I know you’re there too. But he remains lost in his world of whispered things.

But he left me one more smile. After breakfast one morning, he shuffled into the dining room two hours late but I’d asked the nurse to save his tray. He attempted to eat at first but quickly lost track of his fork, his gaze drifting off, his whispering more fervent, and began lifting invisible items up off the floor. As he leaned down, the bunching of the muscles in his back was visible through the gap of his hospital gown – hard knobs of vertebrae protruding between the trailing strings he didn’t finish tying – that gap in his gown a green-rimmed sliver of heart-wrenching vulnerability. Then his attention shifted to his paper menu and, slowing picking up a nearby pencil, he began writing. Eventually he abandoned his writing and drifted away – whispering and shuffling – and I could see the scrap of paper he’d left behind. It was a list of names, I’m not sure who they are, scrawled in the overlarge and messy handwriting of a child. Near the bottom, the “r” in Tyler – with unexpected whimsy – was drawn as a stick figure with arms outstretched. Below the names, he wrote two statements: “walking sucks run” and “40 like steves as you say” – not quite nonsense, not quite sense – followed by a pencilled crooked smile. I see you, Cody. I know you’re there too.

*Not his real name.

A perfect smile is more appealing but it’s funny how
My shit is crooked, look at how far I done got without it
I keep my twisted grill, just to show them kids it’s real
We ain’t picture perfect but we worth the picture still
– J Cole (Crooked Smile, 2013)

Not Applicable

Not Applicable

A friend sent me that photo of an intake form for a youth program. The list of check-box options in the gender section is highlighted, and the form also provides space for chosen name and preferred pronouns. Compared to so many of the forms and surveys that I fill out on a regular basis, the form in that photo shows an impressive list of gender options – far more inclusive than the standard “M” or “F”, and much more specific in the options offered than even the more ambitious forms that provide “other” in addition to the lonely M and and rigid F.

Some online arenas offer even more inclusive gender options, Facebook for example. Users were originally offered four gender options: male, female, private, or < no answer >. In February 2014, Facebook added a “custom” gender option for users in the United States, which included at least 58 different pre-populated gender options. This update also allowed users to choose their preferred pronouns. Facebook’s decision to expand their list of gender options was highly praised by the trans and genderqueer communities as a milestone of recognition and a beacon of hope. When this change was implemented for users in the United Kingdom in June 2014, the list of gender options had grown to more than 70. In August 2014, Facebook added gender-neutral options to describe family members. In February 2015, Facebook broadened their gender horizons once more, allowing an essentially infinite number of gender identity descriptors by providing a free-form field for users to fill in the blank.

Well done, Facebook. Here’s a round of virtual applause. Compared to paper forms, online forms have more versatility because they are not restricted by physical space. Given the physical restrictions that apply to paper documents, I very much respect the inclusive efforts made by the authors of the form pictured above. They also deserve a round of virtual applause.

Gender: check all that apply. Okay. Reading all the options listed on the intake form, I tried to imagine which ones I would check if I were filling out the form myself. I quickly became confused and frustrated. Every single one of those check-boxes could, perhaps – if stretched a little here and shrunk a little there – apply to me. And yet every single box feels as awkward and ill-fitting as an outgrown T-shirt. Nor was there any combination of boxes that could approximate a more accurate answer. After much fuming and deliberation, I eventually decided that I would check only one box: “other”. And then, on that inviting blank line, I would write “not applicable”.

Not applicable. These words are a defiant slogan for so much of the uncertainty in my life. Not applicable. These words are my defensive withdrawal from the identities it seems that other people understand and claim so easily. Not applicable. These words are a burden of crushing doubt and a window to a world of limitless possibility.

Gender: check all that apply. Gender: fill in the blank. Gender: why is it even included on so many forms? Asking for a person’s gender on a form, seems, in many ways, as irrelevant as asking for their favorite color. Color and gender are both vast supersets that include an infinite number of items, making it impossible – even ridiculous! – to attempt to define the answer within a finite series of boxes or on a single blank line.  Like favorite color, gender is constant and permanent in some people and fluid and changeable in others. Like favorite color, gender means quite a lot to some people and very little to others. And, like knowing someone’s favorite color, knowing someone’s gender tells you nothing about who they really are and merely conjures up in your own mind your perception of the label they chose. Some might argue that gender is directly relevant on forms related to medical or reproductive issues. I argue that even in a medical context, gender isn’t relevant – what IS relevant is the presence or absence of certain organs and the concentration of certain hormones in the bloodstream – haven’t feminists and LGBT advocates been fighting so hard for so long to challenge rigid binary assumptions that tie gender to biology? I would like to see Facebook’s increasingly inclusive effort taken one step further to remove gender entirely from the available fields on a user profile.

It has taken me a long time to develop this provisional (dis?)comfort with the words “not applicable”. And here’s a difficult confession: I don’t understand what gender identity is, I don’t know what it’s supposed to feel like, and I’m beginning to suspect that I don’t even have a gender identity. The chronic physical distress associated with the female features of my body remains the only indicator of gender dysphoria. When I first started exploring gender and considering transition to a more masculine body, I felt so confused and alienated by statements that surfaced so incessantly from famous trans people:

My brain is much more female than I am male. That’s what my soul is.” Caitlyn Jenner

I didn’t have to learn how to act like a man because in my head I’d always been one.” Chaz Bono

“I knew in my heart and my soul and my spirit that I was a girl.” Laverne Cox

“When I was four and began asserting myself as the girl I knew myself to be…” Janet Mock

Similar sentiments echoed from many FTM and MTF blogs. So often it seemed that even in trans discourse, the definitions of “man” and “woman” and “male” and “female” hinged on outdated stereotypes regarding socialized preferences and behaviors. I was left more bewildered than ever, wondering if I even deserved shelter under the trans umbrella given my lack of gender identity. This statement finally resonated with my own aching and unlabeled nonidentity:

“That really begs the question: what is a man? And what is a woman? And how much of that is societal bullshit anyway? None of the labels fit me. None.” iO Tillet Wright

Then I thought that reading about the experiences of people who identify as agender, bigender, genderfluid, genderqueer, and various other non-binary terms might feel more comfortable. But still I felt so estranged from those perspectives. I could not understand what often seemed like such an aggressive gender neutrality:

“I tend to paint my nails if I feel like I am going to be particularly expected to behave like a man. It creates a dissonance with expectations that I enjoy… I shop in the men’s and women’s sections, cobbling together a look that could confound the most attuned gender-assignment identifier from a few feet away.” Rae Spoon

It has never been my intent or my desire to deceive anyone with my androgyny. I also could not relate to the conviction that seemed to characterize many non-binary genders:

My gender is not all that unique or special. My gender is not all that queer or all that different. My gender is not rebellious. My gender is not something you should be jealous of… My gender is not about hating binaries. Really, the binaries are hating my gender. My gender is not about how limiting the binary is, and it’s not about liberating myself or anyone else from any binary… My identity is not about men or women. It’s about me, about how I understand myself, how I live my life, how others understand me, and what makes sense.” Kae

That statement sounds so enviously confident. But I don’t know what any of it means. It became more and more apparent for me that existing labels were, as ever, not applicable.

The comments about gender that have most accurately captured my own confusing experience come not from the trans or genderqueer community, but from insightful people on the autism spectrum. (Jack 2012)

“I was sailing blind through a world full of gender signals.” – Jane Meyerding

“I’ve never seen any purpose for genders. They don’t reflect anything real, since they take “this sex is likely to do this” and turn it into a set of rules, making “likely” into “has to”… and I don’t identify as either because of that. It’s arbitrary and doesn’t fit anything about me.” – BlackjackGabbiani

“i don’t consider myself to have any sort of “internal” gender identity whatsoever – it always feels like “gender” is simply not a valid category in which to place myself. When i see “gender” as a tick-box category on a form, i feel similarly to if, on a form asking for details of a vehicle, it asked for “miles per gallon” when my vehicle was powered by something completely different (and that can’t be measured in gallons), like say solar electricity – i just don’t really consider myself to belong to the category of beings that have gender.” – Shiva

The absence of gender identity, the utter inapplicability of gender as a concept for me, is so eloquently described in those comments. The article also describes how disorienting and painful this experience can be.

“For some autistic people, gender does not easily serve as an available resource for identity… for some individuals, gender disorientation can be emotionally painful and having a term to describe oneself can be tremendously important… the malign persuasion in question here might be the fact that lacking a term or word with which to identify might persuade people that they do not fit, that they are anomalous.” (Jack 2012)

“I’m upset because I feel like there’s no word to describe my gender expression. It’s probably silly to be upset about not having a word for something, but because I don’t feel represented in either straight or queer communities, I do have a desire to articulate what it is that I am.” – Amanda Forrest Vivian

However, even those statements do not incorporate the intense and distressing incongruence between my female body and my brain’s resistance to that body. This physical discomfort combined with the absence of any cognitive gender identity feels impossibly bewildering.

For me, “not applicable” extends even beyond gender to other areas that serve as important aspects of identity for most people. Most standard forms don’t ask respondents to classify their sexual orientation, but those that do almost universally fail to include “asexual” as an option. For example, one study described the survey used to gather data on a large population: “Sexual orientation was assessed with the question: “Which of the following best describes your feelings? (1) completely heterosexual (attracted to persons of the opposite sex), (2) mostly heterosexual, (3) bisexual (equally attracted to men and women), (4) mostly homosexual, (5) completely homosexual (gay/lesbian, attracted to persons of the same sex), or (6) unsure. Respondents were categorized according to their orientation identity as reported in that question.” (Roberts 2012) Had I filled out that questionnaire, I suppose I could have chosen “unsure”, but, in this context, unsure implies not an absence of sexual attraction but simply indecision regarding the other available options. In fact, only 3 out of 8968 respondents chose “unsure”, a mere 0.03%.

A different study specifically investigating the prevalence of various sexual orientations in the British population did include a category to represent asexuality. “The measure of sexual attraction was introduced as follows: “I have felt sexually attracted to…” Six options followed: (a) only females, never to males; (b) more often to females, and at least once to a male; (c) about equally often to males and females; (d) more often to males, and at least once to a female; (e) only males, never to females; and (f) I have never felt sexually attracted to anyone at all.” (Bogaert 2004) The results of the study showed that 1.05% of 18 876 respondents reported being asexual (“I have never felt sexually attracted to anyone at all”). The authors explain, “This rate [of asexuality] is very similar to the rate of same-sex attraction (both exclusive same-sex and bisexuality combined: 1.11%). However, binomial tests indicated that there were more gay and bisexual men than asexual men, and more asexual women than lesbian and bisexual women.” (Bogaert 2004)

Despite this data suggesting that asexuality is not only relatively common (1%) but actually more common than homosexuality and bisexuality among women, asexuality remains largely ignored as a legitimate sexual orientation. I am still hesitant and uncertain about claiming an asexual and aromantic identity, but these words seem like the best available descriptors for my experience. A big part of my difficulty in accepting an asexual or aromantic orientation with any confidence is that there is so much lingering uncertainty: how do you definitively confirm the absence of sexual and romantic attraction without really knowing what those things feel like? An asexual blogger eloquently described this distressing uncertainty:

“Perhaps the most insidious part of this is that, to some degree, asexuality is a provisional identity. Unlike other sexual orientations, which at least have a frame of reference for what sexual attraction feels like, asexual people must rely on guesswork. When other people figure out their orientations, they can look at specific incidents of attraction and behavior. But asexual people have to look for a void – how do you find a void? How can you know sexual attraction isn’t present, if you have no frame of reference for distinguishing it? You have to compare yourself to other people and make your best guess.”  – Anagnori

The authors of the first study that did not include asexuality in the survey (Roberts 2012) note that in their study, “People “unsure” of their feelings were excluded.” Somehow I feel like that exclusion of people who are uncertain about their sexual identity extends beyond the parameters of that particular study and applies broadly to the world at large. Sexual orientation: check all that apply. Sexual orientation: fill in the blank. Sexual orientation: not applicable.

Our culture emphasizes romantic love as a central pillar of happiness and the foundation of family structure. Our culture considers sexual attraction one of the most fundamental traits of being human – indeed, of being animal. Our culture pathologizes the absence of sexual attraction as a medical or psychological disorder. Our culture, while it has become somewhat more inclusive and more accepting of gender diversity, remains doggedly adherent to indefinable and irrelevant distinctions between “men” and “women”. Our culture insists that, while gender can sometimes bend the rules, it can never disappear. When these core beliefs and assumptions comprise the infrastructure of our society, being agender, asexual, and aromantic – imperfect descriptors for me but no better words exist – is an experience of profound invisibility. In most of the categories that my world deems important, I remain: not applicable.

“It’s exactly like a riddle with no answer!”
– Alice (Through the Looking-Glass and What Alice Found There, 1871)

————

References

Bogaert AF. Asexuality: prevalence and associated factors in a national probability sample. 2004. The Journal of Sex Research 41(3):279-287.

Jack J. Gender copia: feminist rhetorical perspectives on an autistic concept of sex/gender. 2012. Women’s Studies in Communication 35:1-17.

Roberts AL, Rosario M, Corliss HL, et al. Childhood gender nonconformity: a risk indicator for childhood abuse and posttraumatic stress in youth. 2012. Paediatrics 129(3):410-41

————

This post was awarded Tiffany’s Gender-Bender Award for May 2016.

Gender Bender Award Graphic

Proximity and Power

Boxing (1)

I begin by skipping rope.

tap     tap     tap     tap     tap

The rope taps briskly against the floor, slow at first as I warm up, calf muscles clenching and protesting before they ease into the rhythm. I count to 200.

tap   tap   tap   tap   tap

Faster now. 400.

tap  tap  tap  tap  tap

Faster still. 600.

tap tap tap tap tap

The rope just a blur. 800.

taptaptaptaptap

Until, breathless, I stop and toss the rope aside. 1000.

I roll my shoulders, loosen up. Start shadow boxing at the darkened studio window, my reflection jabbing back at me with the familiar unfamiliarity that haunts my mirror image. But this time I don’t try to fit those female fragments into a coherent structure – I ignore the body and watch the motion, each movement detached and isolated, mechanical and yet alive with a deceptive hidden power. And I can feel the gratitude snaking through those fluid lines of chest and shoulder, gratitude for this gift of graceful motion.

I pause to wrap my wrists and knuckles. Slip my hands into well-worn gloves, bite down on the velcro strap, jerk my head back to tighten the cuff – the sweaty synthetic taste of it somehow grounding. I turn my back to the window. Now it’s just me, my body, and the bag.

The bag is old and tattered. Several layers of tape mend tears in the fabric. Formerly cylindrical, the sides have been flattened by a decade of heavy beating. I have gained precision in my aim and timing, trying to land my punches on the flat faces as the bag rocks and rotates.

Boxing has been described as a romance of masculinity and as the most dramatically masculine sport. Certainly boxing can be an avenue of aggression and anger and violence. But this – right here, this moment – this has nothing to do with masculinity. This has nothing to do with anger. This has nothing to do with violence. It has everything to do with peace: finding peace in the strength and stamina of a beautiful body that my brain so often refuses to accept.

I am the only female-bodied person in the gym. I can hear loud groans and heavy grunts from the men lifting weights across from me, perhaps from genuine exertion but more likely from their sense of entitlement, their unquestioned privilege to demand attention and invade even the auditory space. But my space – my sweaty ring around the swaying bag – is silent up until the split second of contact.

The sound of each strike cracks the silence. The impact of each punch echoes through my body as I pull back to hit again. The lyrics of this music thrum through my mind and hum through my muscles.

Jab
Crack

Jab
Crack
Cross
Crack

Breath
Shuffle back
One two
Rear hook
Crack

Breath
Head flicks
Sweat flies

Jab
Crack
Cross
Crack
Jab
Crack
Uppercut

Breath
Shuffle forward
Breath
Sweat drips
Breath

Lean in
Leap back
Duck
Jab
Crack
Jab
Crack
Jab
Crack
Cross
Crack

Breath
Breath
Breath

The bag is swinging wildly now. I must have fallen just a little out of tempo. Thinking too much. My body knows what to do if my mind doesn’t interfere. I step forward, cradling the heavy bag in my arms, letting my body absorb its momentum, ushering it gently back to stillness. I hear a cranky metallic clank from the chain suspending the bag. I stay there for another second, my face pressed against the fabric, a rough seam digging into my cheek. Then I shuffle backwards, tap the bag with one curled glove – respect, dear friend – and begin again.

Boxing is not about masculinity.

Boxing is a dance.

Boxing is a dance
of proximity and power,
of precision and peace,
of silence and space,
of gratitude and grace.

Our lives
Are better left to chance
I could have missed the pain
But I’d have had to miss
The… dance…
– Garth Brooks (The Dance, 1989)

The Madam and the Gentleman

The Madam and the Gentleman (1)

I was inspired to write a Genderland version of The Walrus and the Carpenter (Lewis Carroll, Through the Looking Glass and What Alice Found There, 1871). 

The madam and the gentleman
Were walking through the trees.
Or were there two gentlemen?
Two madams, possibly?
So matched were they in character
And wit and empathy.

It was only where the leaves
Grew sparse that you could see
His breadth, her breasts, such superficial
Difference in anatomy.
But still their voices rose and fell
In lovely harmony.

Said he to her, “My dear, it’s grand
To have a friend at last.
I hate to let myself remember
Such a lonely past.”
Joining hands, they walked along,
Barefoot on the grass.

Said she to him, “It cost your rib
To make me as I am.
So to you, I give a name – I think
It should be Adam.”
They shared a smile, hand in hand,
The gentleman and madam.

The sun began a slow descent
A wind blew through the trees
Said he to her, and pulled her close,
“I shall call you Eve.”
Their arms around each other dulled
The coolness of the breeze.

Side by side they passed the night
And woke to beads of dew
Shining softly on their skin.
He said, “I dreamed of you.”
They stood and shook the dewdrops off.
She said to him, “Me too.”

“We are together when we dream
And also when we switch
To consciousness,” said she to him.
“I can’t tell which is which.
Both are paradise, it seems
I am pleasantly bewitched.”

Awake and warming in the sun
They wandered hungrily
Along a narrow winding path
And found an apple tree
With burdened branches stretching out
As far as they could see.

They marvelled at their fortune.
“What good luck,” he said.
He reached and plucked an apple
From just above her head.
It hung there, heavy in his hand,
Shiny, ripe, and red.

She reached too but pulled back, startled
By a toothy emerald grin.
Along the bough, a serpent slithered
Small and green and thin.
It said, “Go on and take a bite
One bite is not a sin.”

“But,” it hissed, “if you do bite
This is what I’ll do…”
Its restless tail twitched back and forth.
“I’ll make a list of rules
That will divide your perfect pair
Into a separate two.”

Said she to him, “I shall not bite
For us, I really daren’t.”
But he pressed the apple to his lips
His appetite inherent.
The serpent hissed in satisfaction,
Its victory apparent.

Hunger sated, horror dawned, he said
“What have I done, my dear?
I’ve consigned us to convention
For all the coming years.”
She sadly sighed and shook her head
And shed a bitter tear.

To him, the snake said, “You must always:
Defend your fragile pride.
All your affection and compassion
You will be forced to hide
Behind anger and aggression and
Your bulging muscle size.”

To her, the snake said, “Your rules are:
You cannot upstage him.
Be meek and mild and obliging
So you do not enrage him.
And above all, mark my words,
Your beauty must engage him.”

The serpent, sly and treacherous,
Alive for centuries,
Hissed and blinked its beady eyes
The better for to see
These two friends lose each other
In archaic binary.

Said she to him, “How can we now
Ever stand a chance?”
They felt the weight of expectation
Pushing them askance.
Resigned and rueful, their eyes met
In a final silent glance.

Now the madam and the gentleman
No longer hand in hand,
A sneaky snake that whispers lies
To a woman and a man,
And a poisoned apple tree are all
That’s left of Genderland.

Not A Simple Question

Ashes

There are numerous articles and blog posts discussing the many ignorant, intrusive, and inappropriate questions that are all too often aimed at transgender people. These articles are on popular websites (Everyday Feminism, BuzzFeed, Astroglide, Huffington Post, Cosmopolitan, Autostraddle), as well as on personal blogs written by trans people (janitorqueer, American Trans Man, Matt Kailey’s Tranifesto). There are even artistic projects devoted to this issue (A Series of Questions). There are differences within the trans community regarding willingness or unwillingness to answer these types of questions, depending on their relationship with the asker, the context in which the questions are asked, their desire for privacy, and the extent to which they want to educate others. I will not rehash what has already been discussed so extensively on other sites.

But, from here in my small corner of the internet, I would like to add something to this ongoing conversation. This is a question that I have not seen mentioned in any of the existing articles, but one which I have heard multiple times and have always found difficult to deal with:

“Which is harder, coming out as gay or coming out as transgender and going through transition?”

In my more generous moments, I want to believe that people who ask this question are making an honest attempt to use an experience they think they understand (coming out as gay) to provide a frame of reference to help them understand an experience that seems more foreign (coming out as trans and going through transition). In a neutral frame of mind, I might view this question as the idle curiosity of an interested audience. But I cannot ignore the dismissive presumption inherent in that question, the way those words reflect a simplistic desire to neatly rank and categorize unfamiliar experiences along a linear scale of difficulty, the way those words erase the incredible diversity of individual experiences with the assumption that one person can speak for everyone who is gay and everyone who is trans.

So whenever someone asks me that question, I feel an odd mixture of anger and resentment conflicting with my effort to be tolerant and give them the benefit of the doubt regarding their intentions. I could choose not to answer the question. But so far I have always chosen to answer, because my desire to be understood exceeds my desire to disengage.

“Which is harder, coming out as gay or coming out as transgender and going through transition?”

This is what I say to people who ask me this question: I think the question is irrelevant and impossible to answer. Each person’s situation is so different. The challenges each individual faces and the distress they experience are dependent on so many complicated factors: their social support system, their home and work environments, their personality, concurrent physical or mental illnesses, economic status, race, perceived gender, the list is long. And I think perhaps one of the most powerful factors influencing LGBT experiences is a person’s own acknowledgement and acceptance of their sexuality or gender identity. The internalized homophobia and transphobia generated by a lifetime of societal conditioning can create such deeply entrenched and overwhelming shame – shame like a slow-burning bonfire that eats away at the edges of your soul until you are entirely consumed by the raging heat.

Speaking only for myself: the constant physical dysphoria that comes from living in a female body with a brain that resists this body so intensely – this incongruence made so glaringly evident in every mirror, every motion, every moment – and the physical effects of the hormonal and surgical aspects of transition are a notable difference between my experience and the experiences I’ve heard gay friends describe. The physical aspects of gender dysphoria and my fears and uncertainties about the medical aspects of transition are more disturbing to me (though no less important) than my fears about the social repercussions of transitioning.

Speaking once more for myself: despite the physical distress that is so painful, my journey so far has allowed me to accept gender dysphoria, authentically and shamelessly, as part of who I am. My shame has stopped burning and now I sift through the ashes to reassemble the charred pieces of myself. And though my landscape still looks bleak and scorched, I get to decide where I go from here. This acceptance has given me an extraordinary freedom that many trans people and gay people have not yet achieved if they remain burdened with shame or denial. For this part of my experience, I have the utmost gratitude.

“You ought to be ashamed of yourself for asking such a simple question.”
– The Gryphon (Alice’s Adventures in Wonderland, 1865)