Eating Disorder

Forever Incomplete

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forever-incomplete

In a previous post, I mentioned that I used to draw. Most of my earlier artwork was done during high school from 2006 – 2008. I usually drew animals. I preferred colored pencils. I reluctantly tried different styles and different drawing materials (pencil, acrylic paint, watercolor, charcoal, ink etching) for art class assignments.

High school art class deadlines forced me to keep drawing frequently for three years, but after graduation I only finished a handful of pictures. Eventually, I completely stopped drawing. Art was simply too frustrating and too painful for me to continue. I was too perfectionistic for the process to ever be enjoyable. I would get so angry while drawing that my family often had to physically restrain me from tearing my work to shreds. Before I ever started a picture, I spent hours drawing a 1cm by 1cm grid on the reference photo and enlarging the grid proportionally on the blank white paper so that I could copy each detail meticulously. After the grid was complete, the drawing process felt like a never-ending series of mistakes that required constant erasing and smudging and adjustment. So I hated drawing. But I felt compelled to do it because I received so many compliments on the end results.

My last attempt at drawing was during second year vet school in 2011. It was a picture of a cow and her calf, shown above, intended as a gift for one of my professors. I became so enraged halfway through the drawing that I tore up the reference photo and threw my box of colored pencils across the room. After cleaning up the scattered paper fragments and shattered rainbow lead, I stuffed the half-finished picture back in a folder and promised myself I would never draw again. That drawing will remain forever incomplete. And I was artless for the next five and half years.

In all my previous artwork, I had never drawn people. Partly because I assumed I would never have the skill to draw a person perfectly. But mostly because I was so uncomfortable with my own appearance – discomfort arising from gender dysphoria and resulting in anorexia – that I refused to consider any attempt at drawing a human face or body. But I harbored a secret desire to be able to draw portraits with enough skill to capture a person’s resemblance and facial expression.

During my time on the psychiatric unit over the past few months, I finally decided to try drawing again. But I knew I had to do something differently to avoid returning to the same frustrating perfectionistic habits. And following the radical improvements in body image, I wondered if I could now try drawing people. So I broke all my old rules.

No pencil. No eraser. No grid. No animals.
Human faces. Drawn freehand. With pen.

This process has been far more enjoyable than I ever imagined. I now find myself looking forward to drawing with more excitement that I ever believed would be possible for me. I think my portrait efforts are a reflection of my progress in creating a more positive perception of my current appearance. And, in some ways, these portraits have been very helpful in contributing to acceptance and appreciation for human faces, including my own.

My drawings have become an incredibly important aspect of how I cope with body dysphoria, so I will start posting them here on Genderland. This ongoing active acceptance of my appearance is a process that will remain forever incomplete.

“Every portrait that is painted with feeling is a portrait of the artist, not of the sitter.”
– Basil Hallward (The Picture of Dorian Gray, Oscar Wilde, 1890)

Ambiguous Androgyny (Part 3): What You See

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Part 1: Recognizing an Optical Illusion
Part 2: Deconstructing an Optical Illusion
~ Part 3 in the Ambiguous Androgyny series ~
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now-you-see-me-4

Following the radical shifts in perspective after the mirror experiment, I have been working through several new considerations.

The first consideration is an important caveat: all of these recent realizations – a more positive and more realistic body image, a concrete image of my ideal body to help guide transition choices, and increased gratitude and acceptance for my body – all of these realizations apply very specifically to my body as it currently exists. Had I attempted that mirror experiment at any other time over the past 10 years, I think I would have aborted the attempt within a few minutes because the disgust, self-loathing, and confusion generated by seeing my mirror reflection would have been intolerable.

But now, I am fitter, stronger, and physically healthier than I have ever been before. This is not to suggest that accepting your body is only possible if you meet externally imposed standards of fitness or conform to conventional expectations of attractiveness. Absolutely not. I am only saying that the increased muscularity and decreased body fat associated with a rigorous exercise routine are changes that have allowed me to finally feel comfortable in my own body.

This also is the first time that I have achieved a degree of androgyny sufficient to alleviate most of my physical dysphoria while also maintaining a healthy body weight. This is not to suggest that expression of androgyny excludes bodies that are thinner or heavier than mine. Absolutely not. I am only saying that finding a way to create a comfortably androgynous appearance for myself, without resorting to a dangerously low body weight, is a much healthier and more sustainable approach than my teenage anorexia.

I think it is also important to acknowledge that much of my gratitude for my current body comes from realizing that I have won the genetic lottery. As an XX individual, I consider myself incredibly lucky to have a body that is capable of looking this androgynous without medical or surgical intervention so far. I have made considerable effort, through my workouts and my diet and my clothing choice and my haircut, to create this appearance. But that effort is only one small part of the story. I am lucky that I have the metabolism to lose weight relatively easily and maintain low body fat. I am lucky that I have the anabolic capacity to build muscle mass fairly easily in response to the effort I put in at the gym. I am lucky that my facial features are naturally androgynous. I am lucky that my chest has always been flat and has become even flatter after thousands of pushups and thousands of bench press reps. I cannot take credit for those factors. I can only be grateful for them.

The second consideration is that maintaining my body in a way that feels comfortable for me will require consistent ongoing effort. I have several options about what kind of effort this might be. I could continue my current diet and exercise routine. I could proceed with medical options including testosterone and mastectomy. I could work towards greater internal acceptance of the aspects of my body that I cannot control. All of these possibilities represent ongoing effort. All of these options come with advantages and disadvantages.

My daily workouts require a considerable investment of time and energy. Having started a new combination of medications to manage the debilitating fatigue of depression and having adjusted my lifestyle to incorporate an early morning exercise routine, the time and energy costs are no longer prohibitive barriers.

My diet requires constant awareness of calories, grams of protein, grams of fat. My diet also requires active tolerance of the often intrusive nature of this awareness. Many of my food-related thoughts and behaviors are habits deeply ingrained from a decade of disordered eating, and I do not recommend these strategies to anyone else. But I have accepted that these thoughts and behaviors are unlikely to disappear entirely. And while I don’t think the improvements in body image will lead to any immediate changes in my approach to food, these thoughts and behaviors become much more tolerable in the context of acceptance and gratitude instead of disgust and self-loathing.

Now that my ideal body is more clearly defined in my mind, I feel better able to evaluate the many different options for testosterone moving forward. Because I have realized that my goal is not complete physical masculinization but rather minor masculinizing adjustments to my current body, I think I would prefer to start on a low dose of testosterone so that physical changes occur very gradually. At this point, I have one particularly prominent question: In an XX person, would long-term administration of low dose testosterone ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of testosterone? Or would long-term administration of low dose testosterone lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of chronic administration of high doses of testosterone in FTMs or describing the effects of short-term administration of low doses of testosterone in women (including the effects of exogenous testosterone administered to treat various medical conditions as well as the effects of endogenous testosterone in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose testosterone in female-bodied people without concurrent medical issues. I have only found a handful of anecdotal descriptions on personal blogs from trans people taking low doses of testosterone. But this is an important question for me, so I will continue my investigation.

The third new insight is that greater acceptance and comfort with my how my body LOOKS has been followed by much greater awareness of how my body FEELS. Prior to the mirror experiment, I was so detached from my body that I had very little awareness for how it felt. When prompted by my psychiatrist to identify physical sensations associated with certain emotions, I was completely unable to do so. The only time I ever felt any meaningful physical awareness was during exercise, as I have described with respect to running and boxing.

But since that mirror experiment, I seem to have developed an intensely heightened awareness of so many daily physical sensations. A shower used to be just a shower. Now a shower is a thousand individual drops of water, each one hitting my skin and trickling down my body. Applying hand lotion used to be just a necessary task. Now I am aware of how the knuckles and metacarpals and tendons of one hand feel inside the palm of my other hand. Clothing used to be just a set of pants and shirts and underwear. Now I am aware of how different types of fabric feel against my skin, aware of the pressure as a shirt stretches across my shoulder, aware of the gentle tension of cuffs around my wrists. Going outside used to be a retinal adjustment from dark hallway to sunny doorway. Now this transition is not just a visual adjustment but also a physical awareness of the change in temperature from hallway to door, an awareness of how the shadows feel when they dance across my skin as the sunshine chases them away. Waking up in the morning used to be an abrupt termination of a dream replaced by real-life thoughts. Now waking up is an immediate awareness of my whole body stretched out on the mattress, an awareness of the light weight of sheets and blankets surrounding me.

“You used to be much more… muchier. You’ve lost your muchness.”
– The Mad Hatter (Alice’s Adventures in Wonderland, 1865)

I really can’t describe this feeling any better than The Hatter. Being inside my body now is much more muchier. There’s so just much muchness.

I had been living with my parents before I was admitted to hospital but was unable to move back in with them after discharge, so one of the priorities was finding a place to live after discharge. Up until the mirror session, I had been thinking only in terms of apartments and rent and location. But now, I finally understand that I can live HERE, in my own body. It feels like authentic inhabitation of a home I didn’t even realize that I had.

The last new realization is also the most powerful. I previously described watching how women shift their interpretation of my appearance from male to female when they see me in public washrooms. I recently had the opportunity to observe this perceptual reversal in a dentist’s waiting room instead of a womens’ washroom.

I sat down in the waiting room to fill out a general history form, which required that I list my current medications. An elderly man sitting nearby saw me writing and said, “Whattaya doin’? Writin’ down the names of all your girlfriends?” His tone and posture seemed to suggest that he was making a conspiratorial joke, but I did not find his questions humorous at all. I was annoyed by the interruption, astonished by his presumption, and curious about his assumptions.

I was wearing jeans and a loose-fitting blue sweater, with my backpack on the floor beside me. I thought it most likely that his attempted joke hinged on the string of assumptions that I am male, straight, teenage, and obsessed with girls. I also considered the possibility that he perceived me as female and assumed that I am lesbian because I have short hair. I won’t list all the problematic stereotypes associated with those assumptions, but I will say that I have encountered all of them on multiple occasions before.

I continued writing without looking up from the page, and said, “No, I’m writing down my medications.” And then, because I was both intensely curious and intensely irritated, I looked up and asked him, “Do you think I’m male or female?” He frowned, and I watched his eyes roam up and down my body, eventually returning to my face. He finally said, uncertainly, “Ooooh… I guess… you’re actually female?” So it seems that he had indeed made that first series of assumptions: male + straight + young = girl-crazy. And while his assumption that I was a boy provided some validation of my physical androgyny, his comments also demonstrated incredible ignorance. So I shrugged, unwilling to definitively confirm either maleness or femaleness. But because he now saw me as female, I said, “Doesn’t mean I don’t have girlfriends.” He let out a short uncomfortable chuckle, and then stood up and moved to the chair as far away from me as possible.

And you know what? I did not feel the slightest hint of guilt about being the source of his discomfort. Nagging guilt about the discomfort that my appearance causes other people has plagued me in the past. But not anymore. Because I have achieved not only an authentic inhabitation of my body, I have also achieved an authentic acceptance of my ambiguous androgyny.

This here? What you see when you look at me?
This is not a deliberate deception.
This is not an intentional illusion.
It is authentic ambiguity.

It is not a palmed card.
It is not a crafty shuffle.
It is not a false cut.
It is an ace worn proudly on my sleeve.

now-you-see-me-1

“So come close. Get all over me. Because the closer you think you are, the less you’ll actually see.”
– J Daniel Atlas (Now You See Me, 2013)

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

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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
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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)

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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 1): GIDYQ-AA Personal Reflection

/ TomCat / 2 Comments

————
~ 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
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GIDYQ-AA Panorama

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

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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. 

I Doubt It

/ TomCat / Leave a comment

I Doubt It Shower (1)

I had been dealing with depression for several years before I started exploring gender transition options. Of course, the distressing incongruity between my female body and my brain’s non-female body map had been extreme and persistent since puberty, but I tried so hard for so long to suppress those feelings, to attribute them to the body image disturbances that characterize anorexia nervosa or dismiss them as an unusual form of gender-centered vanity. So it was not until more recently – thanks in large part to perceptive suggestions from an observant friend – that I learned about gender dysphoria and started considering transition in a personal context.

When I first became aware of these options, I felt an immediate and expansive euphoria, an ebullient optimism that inflated me with such promising possibility. I believed that I had finally found The Answer to so many of my life’s uncertainties. I believed that transitioning – in a straightforward black-and-white line, from ugly A to perfect B, from female to male (whatever I thought those words meant then) – was The Solution that would fix all of my problems.

Buoyed by this excitement I began researching transition options, poring obsessively over online trans forums and frantically downloading research papers from PubMed. Very quickly I encountered cautionary statements – in scientific studies and trans peoples’ own stories – urging those of us considering transition to have realistic expectations about how transition may affect our life and reminding us that transitioning will not solve every problem.

“Overall, participants’ evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. It was described as a ‘‘challenge’’ or a ‘‘long and difficult road’’ that was worth taking because of its positive implications on future life, at the end of which not everything was different or better without limitations.” (Rupin 2015)

“Don’t expect transitioning to solve all of your problems. Transitioning is not a panacea – it won’t solve all of your problems. If you were prone to anxiety before coming out, you’ll probably still have to deal with it afterwards. At some point in my transition, I came to terms with the fact that living as my true gender wouldn’t magically fix everything. And it felt really good to let go of that impossible expectation.” – Annika

So I started to examine my own expectations about transitioning. This process began very gradually, my original optimism tempered but preserved. But as I delved ever deeper into myself, as I came to recognize – with a terrifying emptiness – that I do not have any cognitive sense of gender identity (just the physical distress associated with female anatomy), and as my long-standing depression spiralled ever further out of control, I started asking myself with a haunting and repetitive urgency: how much does gender dysphoria contribute to my depression? How much can I expect transitioning to alleviate this complex distress? These questions quickly gathered a frightening momentum, eliminating one by one every hopeful expectation I had about transition, culminating in a crushing avalanche of doubt about whether my gender dysphoria was even worthy of continued acknowledgment.

So often I would reach the end of the day and reflect on the past 16 hours, wondering what would have been better if I had lived the day inside a male body. Usually the answer that I gave myself was that very little would have changed, perhaps a few accidental mirror glimpses – always that initial flash of confusion as my brain works to reconcile reality with expectation – those mirror glimpses might have been less unpleasant, sure, but nothing else would have been any better. So why bother with transition then? Why bother with all this gender nonsense at all?

But in the moments when depression loosens – ever so slightly – its death-grip on my mind, in the moments when I feel a lucid clarity open up like a window to the world, I wonder if perhaps I underestimate how deep this dysphoria extends, if I underestimate how extensively the brain numbs itself to daily pain after a lifetime of unabated agony. And in these moments I can relive the day with more precision, sailing through the same sequence of events, but this time in a masculine vessel. It seems a lot would have been better.

On the squash court –
The squeak and shriek of sneakers on shiny varnished floor –
I could have worn shorts without feeling so self-conscious of my girl hips, I would not have been so painfully aware of my small shoulders dwarfed by the broad backs of male opponents, I would not have felt such desperate pressure to overcompensate with wins to prove that I deserve to play among men.

Standing outside in the summer sun –
The far-off chirp of cheerful birds and the low buzz buzz of busy bees –
I could have escaped my sweat-sticky sweater, an all-season mask concealing the feminine swell of my chest, and I could have instead felt the sun kiss the skin on my bare arms, I could have let my eyes wander as they wished without so consciously averting my gaze from the girl-shaped shadow on the ground.

In the shower –
Warm rivulets of water draining down over all the parts that I pretend do not exist –
I would not have had to cloak myself in darkness, I could have soaped my bristly legs without thinking automatically that I should shave them, and stepping out afterwards I could have wrapped the towel around my waist and seen my face and my bare chest in the mirror and not had to look away.

Driving in my car –
My hand on the shift stick and wind breezing in through the open window –
I would not have had to angle the rearview mirror just so to avoid that quarter-slice of girl-face when I glanced upwards, I would not have had to tug my jacket down low enough to hide the width of my hips in the seat, and I could have sung along more freely with the radio with a deeper voice vibrating through the lines of my jaw.

Pulling on my pants in the morning –
The rustling of fabric and the brisk zip of the fly in chilly pre-dawn dimness –
The flatness of the crotch would not have been such a mocking emptiness, the snugness of the pants over my hips and thighs would not have been such an excruciating reminder, and when I looked down I would have seen a man in jeans instead of a girl in men’s jeans.

Sitting typing like I am now –
Quiet clickety clack, clickety clack, rat a tat tat –
I would not have to feel the tight X of bra straps across my back, I would not have to notice how my wrists and fingers on the keyboard seem so slight and feminine, and I would not have to be afraid of seeing my face reflected back at me in the laptop screen.

With all of that, how is it possible that I still doubt whether I should transition? Such doubt this is! It only seems to multiply as my mind paces the same well-worn path through the same worn-out questions. This doubt is an aggressive beast that feasts on self-reflection.

“Do you suppose,” the Walrus said,
“That they could get it clear?”
“I doubt it,” said the Carpenter,
And shed a bitter tear.
– Tweedledee (Through the Looking Glass and What Alice Found There, 1871)

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References

Ruppin U, Pfäfflin F. Long-term follow-up of adults with gender identity disorder. 2015. Archives of Sexual Behavior 44(5):1321–1329.

Mirror Ghost Girl

/ TomCat / Leave a comment

Woman Looking at Reflection

Something I’ve noticed over the past few months is a shift in how I manage physical dysphoria. For the past five years, after gaining a lot of weight which accentuated my female anatomy, I coped almost exclusively though avoidance: showering in the dark, avoiding mirrors, deleting photos of myself, wearing baggy clothes, etc, basically pretending that my body didn’t exist.

But after a rigorous workout routine for the last 8 months, I have lost weight and built muscle and restored some of the physical androgyny that made me feel more comfortable as a scrawny teenager. I am able now to tolerate seeing my body or my reflection or my image in photos with less disgust. With this has come a shift from avoidance to compulsive body-checking and self-monitoring. Instead of avoiding mirrors, I now find it extremely difficult to pull my eyes away from my reflection.

This fascination (or perhaps obsession) seems motivated partly by simple astonishment and gratitude that I can actually tolerate seeing myself. But it is also motivated by a constant effort to reconcile that body as my own, which feels completely incomprehensible and beyond my power of imagination. The person I see in the mirror – the face, the body, the clothes – is all very familiar and recognizable, but in the detached non-self way that a close friend’s or sibling’s appearance is familiar and recognizable. When I see myself in a photo or in the mirror, I often notice myself thinking, “I suppose if I HAD to have a female body and could choose to look like someone, maybe it wouldn’t be so bad to look like her.” And then I remind myself that I DO look like her, that it’s actually ME in the mirror or the picture. But my mind remains unconvinced, and I continue to stare at those reflections and images of myself with the unsettling mixture of curiosity, frustration, and disorientation that comes with trying to unravel a particularly puzzling optical illusion.

The other part of this is that when I see my reflection or even just look down at my body, my appearance seems to change dramatically within the space of just a few minutes or hours. Sometimes it looks like I’ve gained 20lbs since morning and in my mind I immediately start making sweeping restrictive changes to my diet, only to see myself later in the day with the impression of almost unhealthy leanness and then erase all the dietary changes I just made.

More often it doesn’t look like weight gain or loss, it seems instead like a generalized skeletal reconfiguration, like all the ratios and proportions of my body (waist to hip ratio, width of my shoulders, angles of my face) have shifted to create subtle but – to me – obvious and unsettling differences in my appearance. My image remains familiar and recognizable, but constantly different, like looking in the mirror and seeing various digitally altered versions of your friend or sibling. Even when I mentally account for the differences in clothing, lighting, mirror distortion, etc, I can still see very clearly all the structural changes in my appearance.

This feels like a new experience that has emerged in the past few months, probably because it has been so long since I was actually able to see myself without immediate revulsion and withdrawal. Sometimes I feel like I’ve gone completely insane… I know with certainty that it is not physiologically or anatomically possible for any human body to change that much in such a short period of time. I know this. I remind myself of that over and over. Yet what I keep seeing with my own eyes, right there in front of me, incontrovertible visual evidence, is this shape-shifting mirror-ghost of a body that I cannot imagine I actually inhabit.

“What a strange thing a mirror is! And what a wondrous affinity exists between it and a man’s imagination!”
– George MacDonald (Phantastes, 1858)