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. 

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)

Never Just Black

Never Just Black

This past October 31 marked the first time I dressed up for Halloween in over half a decade. For years I had avoided dressing up and declined my friends’ Halloween party invitations because I could not tolerate the way that a costume would draw more attention to my physical appearance. I wanted my female face and female body to remain as invisible as possible. But thanks to my workouts and weight loss and more frequent male pronouns from strangers, I finally felt physically comfortable enough to consider a Halloween costume. When my manager encouraged employees to dress up at work, I wanted, for once, to be a good sport and join the fun instead of hiding behind lame excuses for my lack of Halloween spirit.

So I called my sister from a dollar store the day before Halloween, needing her help to navigate the dizzying rainbow array of pretty paints and powders. This was the first time I had ever worn real makeup and I had no idea what I was doing. “So you’ll probably want to go for the pencil eyeliner, it’s easier to work with than the liquid brush which can get kinda messy if you don’t have a lot of practice… but maybe get both and see which one you like better?” she said. She doesn’t wear cosmetics on a regular basis, but she has a lot of practice doing stage makeup from her days in ballet and cheerleading. “And you should probably get some lip liner to give your lips a defined outline, especially if you’re going with cheap lipstick which tends to smear.” All excellent advice. $15 and a few hours later, she coached me through my clumsy first attempts at applying all these products. My face was raw and red from rubbing off all my mistakes. But if I was going to dress in drag – compared to my usual androgynous attire, wearing makeup and a tight T-shirt and a short skirt seemed as deliberately flamboyant and exaggeratedly feminine as drag costumes – well, I was damn well going to do a good job of it.   

Despite the frustration of several failed attempts, I ended up enjoying the process of painting my face. As an artist (many years ago), black was always my favorite color. Black – pure, plain, unadulterated black – is dull and flat and lifeless. But black enhanced with hints of other colors – it becomes an enchanting dark dimension. So in my artwork, black was never just black. And on my face it was the same, purples and reds blending beautifully into the black eyeshadow and black lipstick.

The fact that I had so much fun with my costume was unexpected. Also unexpected was the way this makeup mask made my mirror image temporarily comfortable. Usually when I catch a glimpse of my face in a mirror, a flash of unsettling unfamiliarity floods those first few moments. But with such ostentatious makeup, that feeling of detachment from my own reflection suddenly had a perfectly coherent explanation, which made me feel strangely comfortable with the unfamiliarity of that painted face staring back at me.

“A large rose tree stood near the entrance of the garden: the roses growing on it were white, but there were three gardeners at it, busily painting them red.”
– Lewis Carroll (Alice’s Adventures in Wonderland, 1865)

Zero Dollar Haircut

Zero Dollar Haircut (Final)

As I get closer to my appointment to start hormone therapy, I have been forced to confront one of my biggest fears regarding testosterone: hair loss, also known as male-pattern baldness or androgenetic alopecia. I have been reluctant to admit this fear of hair loss, even to myself, because it seems like such a minor and superficial concern compared to so many other aspects of hormone therapy and gender dysphoria. I have been uncomfortable accepting that this fear is largely driven by vanity. I would like to think I am above such petty obsession with external appearance. But the intensity of my fear of hair loss suggests otherwise. So I have investigated strategies to prevent – or at least minimize – the extent of hair loss while taking testosterone.

Androgenetic alopecia affects approximately 50% of cisgender men by age 50 and approximately 90% of cisgender men in their lifetime (Kabir 2013). One study demonstrated that among Caucasian cisgender men, androgenetic alopecia was present in approximately 50% of those 30-35 years old, 60% of those 36-40 years old, and 70% of those 40-45 years old (Shankar 2009).  Androgenetic alopecia is less prevalent, but still relatively common, among cisgender men of other ethnicities (Feinstein 2015). Men with visible hair loss are perceived as older and less physically and socially attractive (Mella 2010). The prevalence of androgenetic alopecia in female-to-male transpeople (FTMs) is similar to that for cisgender men, occurring in approximately 50% of FTMs after 13 years on a physiologic dose of testosterone (Fabris 2015, Gooren 2008, Meriggiola 2015).

Androgenetic alopecia is influenced by hormonal factors. Testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase. DHT has five times greater affinity for androgen receptors than testosterone. Hair follicles in the scalp produce 5-alpha-reductase which converts testosterone (produced elsewhere in the body) into DHT (which acts locally in the scalp). When DHT binds to androgen receptors on hair follicles, it results in a shortened anagen phase (the phase of hair growth) and decreases hair follicle size. This ultimately results in follicular miniaturization and the growth of shorter, thinner hair shafts. As more and more follicles undergo miniaturization, hair coverage of the scalp progressively decreases (Kabir 2013). Genetic factors also play a role. Androgenetic alopecia seems to be highly heritable, with complex polygenic inheritance and variable penetrance. Hair loss is more extensive in men with a genetic predisposition for greater numbers of androgen receptors on hair follicles and/or increased sensitivity of follicles to the effects of DHT (Kabir 2013).

One strategy to minimize hair loss that has been mentioned occasionally in articles about testosterone therapy is concurrent administration of finasteride. Finasteride selectively inhibits the 5-alpha-reductase enzyme, which decreases the concentration of DHT in the scalp and in the blood by approximately 60-70%. Because it reduces the amount of DHT, finasteride prevents or reverses hair follicle miniaturization as demonstrated in scalp biopsy studies (Mella 2010). Finasteride can be taken orally at a recommended dose of 1mg/day; studies have not demonstrated greater improvement in hair growth at higher doses (Mella 2010). Reported side effects of finasteride in cisgender men include decreased libido, erectile dysfunction, and ejaculation dysfunction; all of these side effects are very rare (Mella 2010). Presumably, erectile and ejaculation dysfunction would be of little concern in transgender men, even those who have had phalloplasty (given the current anatomical limitations of that surgery). Side effects of finasteride that are relevant for transmen include slowed or decreased growth of facial hair and body hair, and slowed or decreased clitoromegaly (TransHealth UCSF 2016). The blog American Trans Man has a post describing finasteride in more detail (Beards, Baldness and What’s in Your Pants).

Since I was a small child, my hair has been the source of great pride for me and much friction between my mother and I. For years I begged her to let me cut it short, but she refused on the grounds that it would make me “look like a boy.” She didn’t seem to understand that looking like a boy was precisely what I wanted. When she finally and reluctantly relented in 2006 and allowed my 14 year old self to get a short haircut, my hair became one of the first and one of the most important ways for me to exert some small measure of independence from my parents. Now that I am 24, my haircut is one of the only healthy ways I can modify my body and create a more masculine physical appearance to ease chronic physical dysphoria. (Obsessive exercise, excessive dietary restriction, self-induced vomiting, and painfully tight clothing are other strategies that I rely on to maintain a sufficiently masculine appearance but obviously I do not recommend these strategies).

For me, short hair is not just about gendered physical appearance. It is also about practicality. I hated long hair! I hated having to wash all that hair every evening in the shower. I hated having to towel-dry the soggy dripping mass. I hated how it took so long and hurt so much to comb out all the knots. I hated the way long tendrils of hair would end up everywhere – everywhere! – coiled in the shower drain, stretched out on my pillow, draped across my keyboard, poking out between the pages of a textbook like a tiny thready bookmark. I hated putting my hair in a ponytail, always conscious of the irritating tension, unsettled by how the sleek flatness of the pulled-back hair left my face so stark and open, like a picture without a frame. But I also hated leaving my hair free from the ponytail elastic, when it became a heavy hanging curtain that obscured my view and insisted on creeping into the corners of my mouth, my hands perpetually occupied in batting it away.

When I got it cut short, all those long-hair annoyances vanished. Then the only problem was that to maintain a shorter style, haircuts become necessary more frequently. The one advantage of long hair was that I only needed a haircut once or twice a year. My short style required a trim every eight weeks. I hated haircuts. I hated the inconvenience of having to schedule an appointment or waiting as a walk-in with nothing to do but browse through battered People magazines. I hated that I always gave the stylists the same description of what I wanted and got different cut every time.

I scrupulously avoided developing a long-term relationship with any of my hairdressers, taking pains to visit different salons on a rotating basis. Because once you’re beholden to one particular stylist then that’s it for you! No longer are you free to walk in whenever you choose – you have to make an appointment that works with their schedule, which is a chafing restriction of freedom for a busy person. No longer are you free to fend off small talk – you have to engage cheerfully and energetically to preserve this superficial relationship on good terms. After all, they are wielding sharp instruments in the vicinity of your jugular veins. No longer are you free to tip according to the quality of service – you now feel compelled to tip extra to ensure ongoing consistency in the style they deliver, tip extra to appear appreciative that they remember the random details of your life that they’ve extracted from you during reluctant small talk.

How I hated salon small talk! My silent salon-chair prayer: I’m paying you to cut not talk, so please, leave me be, focus on my hair, I don’t have anything to say. But stylists are relentless conversationalists, far more skilled in the art of superficial niceties than my awkward introverted self, leaving me always feeling two steps behind in a complicated and unwanted dance. “Ohmygod, has anyone told you how much you look like Miley Cyrus? No. No, they haven’t. But we’re both female-bodied and we both have short hair so yeah, we’re, like, totally twins. Please. Do shut up. So do you have any plans for the weekend, hon?” No. Well yes, but not plans I want to share with you. “Are you planning any fun vacations this summer, sweetheart? Gonna travel somewhere nice?” No. I don’t take vacations and I don’t travel. And if I say so, this is just going to get more awkward. “Are you excited for grad? Have you picked out your prom dress yet?  You must be so excited!” No. I graduated from high school eight years ago and when I did, I wore pants. And, worst of all, “So where do you work?” Usually I avoided that question by being deliberately vague. But if, caught off guard and overwhelmed by social anxiety, I admitted the truth – that I recently graduated from veterinary school – I would inevitably hear about her friend’s cousin’s English Bulldog – or maybe she’s a French Bulldog? you know I never can remember the difference, dear – anyway, she has terrible dermatitis and do you think it could be a food allergy and should he try feeding her a strict diet of carrots and cottage cheese?

What I hate most of all – with a cold, hard, brittle anger – is the fact that women’s cuts cost more than men’s cuts irrespective of style and complexity. This is true even at bargain hair salons (Ultracuts: women’s cut $17.95, men’s cut $15.95), with the price differences exaggerated in higher-end salons (Euphoria: women’s cut $35-55, men’s cut $30-35). What epic bullshit this is! Not only is this pricing unfair and discriminatory, it is completely ridiculous considering that many women’s haircuts require little more than snipping a half-inch off the ends while men’s haircuts typically involve more extensive shaping and require the use of multiple tools (scissors, clippers, texturizers).

With all of these frustrations, the hair salon ordeal eventually became untenable. So I finally tried – with excitement and trepidation – to cut my hair myself. It was awkward and slow at first, trying to align the movements of my hands with the reverse image in the mirror, trimming conservatively in case of mistakes, making a hairy mess all over the bathroom counter. But I my system perfected now: #3 clipper guard (3/8 inch) on the sides, #4 guard (1/2 inch) to taper the sides into the top, scissor cut the top and bangs with practiced precision… and then the back, usually a #6 guard (3/4 inch) to leave it long enough to create a wide fauxhawk, but sometimes I let the back grow out for a few months into a baby rat tail (my dad says this looks like a mullet – business in the front, party in the back – but I say it’s a party in the front AND a party in the back).

I love cutting my hair. I love the feeling of accomplishment and competence when I see the finished product – damn girl, you did that! I love how it looks exactly as I had envisioned. I love the way the messy locks have a cocky character all their own, the way they frame my face in a way that feels so right. I love having the freedom to give myself a trim as soon my hair crosses my threshold of intolerable shagginess. I love the way the clippers feel moving across my scalp, the way the soothing vibration seems to penetrate all the way through to my brain. I love the way it feels when clumps of hair – spiky little dark brown mice – drop from the clipper blades onto my bare shoulders. I don’t even mind sweeping up these scattered clumps with my hands, flushing them down the toilet, vacuuming the bathroom afterwards. And I love how my mother hates my haircut. Perfect.

It is tempting to romanticize my hairstyle preference as an essential means of expressing some intransigent gender identity. I could perhaps pretend that my gender-non-conforming haircut has some important political significance, that it is a follicular feminist statement. If it were any of these things, my fear of hair loss would have a lovely self-righteous justification. But if I’m honest, I’d say my hair has no real significance beyond this simple fact: I love it. I love how it looks. I adore the feeling of my fingers running through the fresh-buzzed stubble. I enjoy the way the wind chills my exposed ears and naked nape, the way the breeze ruffles the hair on top like a friendly hand. If this is vanity, then fine – I’ll own that. I am vain. We all are, in different ways for different reasons. So I will explore the option of finasteride with an authentic shameless vanity.

Cordless hair clippers: $49.95
Haircut: $0
My hair my way: *priceless*

“Your hair wants cutting!”
– The Mad Hatter (Alice’s Adventures in Wonderland, 1865)

————

References

Fabris B, Bernardi S, Trombetta C. Cross‐sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3):269-282.

Feinstein RP. Androgenetic alopecia. 2015. Medscape Drugs and Diseases. Accessed online 26-04-2016.

Gooren LJG, Giltay EJ. Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females. 2008. Journal of Sexual Medicine 5(4):765-776.

Kabul Y, Goh C. Androgenetic alopecia: update on epidemiology, pathophysiology, and treatment. 2013. Journal of the Egyptian Women’s Dermatologic Society 10: 107-116.

Mella JM, Perret MC, Manicotti M, et al. Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review. 2010. Archives of Dermatology 146(10):1141-1150.

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.

Shankar K, Chakravarthi M, Shilpakar R. Male androgenetic alopecia: population-based study in 1,005 subjects. 2009. International Journal of Trichology 1(2):131-133.

TransHealth UCSF. Primary care protocol for transgender patient care: hormone administration. Accessed online 26-04-2016.

Unrelenting Darkness

Unrelenting Darkness (1)

I recently spent three weeks hospitalized in a psychiatric unit for treatment of depression. In clinical terms, I have severe chronic treatment-resistant major depressive disorder, a mouthful of words to describe a debilitating disease that has affected the trajectory of my entire adult life. My pharmaceutical history reads like a drug compendium, A to Z by generic name: aripiprazole, bupropion, caffeine, citalopram, clonazepam, desvenlafaxine, dexamphetamine, lisdexamphetamine, lorazepam, mirtazapine, oxazepam, trazodone, tryptophan, venlafaxine, vortioxetine, zolpidem, zopiclone. Over the past year in therapy, I have turned my soul inside out looking for answers, finding only a buzzing hive of angry stinging questions. But effort means nothing in the face of this monster. My brain just keeps attacking itself over and over, with ever shorter reprieves between recurrent nightmare episodes.   

My time in hospital was frustrating, necessary, and marginally helpful. I worked hard to create realistic expectations for myself after discharge and I was prepared to tolerate the distress arising during the initial readjustment to real life. But coming home from hospital has been unlike anything I have ever experienced before… I feel empty, hollow, completely gutted, broken beyond repair with a skull full of ugly scars, so far beyond hopeless that there are no words to describe this degree of detachment and despair. Since then I have been going through the motions of daily life, but that is truly all they are – mechanical motions performed perfunctorily to pass the time. I still adhere to the hospital schedule because it is the only structure I can cling to in the shattered remnants of my world: breakfast at 8:00, lunch at 12:00, dinner at 17:00, one pill at 19:30, another at 21:00. And when I’ve reached the end of each endless day, I have to fight through the night to snatch a few hours of disturbed and broken sleep.

I feel like I held on to my last shred of sanity while I was in the hospital, because I was focused on the short-term goal of getting discharged and because a smoldering filament of rage kept me connected, somehow, to the outside world. But now I have no goals, no anger, nothing, I’m just drifting in a completely meaningless void while the world keeps moving around me.

This depression feels like a brain tumor that has been growing for six years, slowly at first but ever faster as the malignancy multiples, gradually taking up more and more space inside my head and slowly choking off pieces of who I am. It has strangulated my motivation, eroded my energy, killed my capacity for hope. All I am left with now – and for how much longer I don’t know – is the capacity for gratitude, and a raw and feral intelligence caught in a leg-hold trap, thrashing ferociously and trying to chew off its leg to escape but unable to gnaw through the bone. And this toxic neoplasia continues growing faster than my acceptance of it, an escalating arms race, a Cold War in my brain.  There are no surgical options for treatment, no chemotherapy, not even any palliative means to ease this excruciating pain.

My psychiatrist, my sister, my friends – friends! such an inadequate word to describe these people that I love so fiercely – they encourage me so often to find things to be hopeful for. I try – I do – I try so hard – with infinite gratitude for their kindness and support – but I cannot manufacture authentic hope. It’s like being naked in a winter wind, trying to imagine what warmth feels like – even if you can conjure up the most vivid memory of hot summer sun, it will not prevent you from freezing to death.

I think the most powerful emotions are gratitude and hopelessness.  They both have the ability to eclipse all semblance of rational thought. They both leave me breathless in the wake of their intensity. And the two can coexist in a devious kind of harmony, like brilliant fireworks bursting in an unrelenting darkness.

Sometimes the curiosity
Can kill the soul but leave the pain
And every ounce of innocence
Is left inside her brain.
Shinedown (Her Name is Alice, 2010)

Twin

Twin

My parents have a small herd of Black Angus cows, small enough that they still name every calf born in the spring. Choosing names for the calves was always so much fun when we were children… until the year my younger sister named her steer calf Isabelle. I was shocked and horrified by her callous disregard for the unspoken but unquestioned rule that boys get boys’ names and girls get girls’ names, no matter what species of creature they are. I cried for a while, then tried to talk her out of such a ridiculous decision. But when she refused to change her mind, I promptly named my heifer calf John out of spite. So there, little sister.

It wasn’t until much later that I really started to question why our world divides first names into male and female, why we insist on saddling such innocent syllables with a gendered connotation. It began to feel so strange to hear expectant parents proudly recite two separate lists of possible names for their unborn baby, names for a girl and names for a boy, those two prenatal lists already hinting at a more sinister set of stereotypes settling into place while the fetal cells diligently divide and differentiate.

Had I been born with a tiny infant penis, a urethral ticket to a world of privilege, my name would have been Benjamin. Instead I was given the female name my parents found in a quiet grassy cemetery, my pregnant mother strolling with my father, visiting the graves of relatives, falling in love with my name on a headstone one row over. It is a beautiful lyrical name, it means “purple flower”, and it is so rare in North America that most online baby name databases do not even recognize its existence. It is a name that has garnered many compliments when I first introduce myself, a name that has been mispronounced a dozen different ways in a dozen different accents, a name that is more deeply and more permanently a part of me than a tattoo or a scar. I am neither proud of this name nor ashamed of it, I regard it with the neutral allegiance of 24 years of involuntary companionship. I withhold my name here only out of concern for privacy.

But as I explore the world of gender, I wonder if perhaps I have outgrown this name. Considering a name change comes with a confusing mixture of emotions: sadness about leaving one name behind, excitement at the prospect of choosing another, guilt that I am erasing the name my parents put so much love and thought into, fear that by choosing a male name I am simply reinforcing the gender binary that has been so damaging and restrictive my whole life. I want to make it clear that for me, gender dysphoria is an almost purely physical distress, centered around my body and the problematic anatomy that my brain resists so emphatically. For me, names and pronouns are merely a matter of semantics, relevant only to the extent that a stranger’s “sir” or “he” validates the masculinity of my physical appearance. The main reason I have considered changing my name is that, depending on the extent of my transition (which at this point remains uncertain), a female name will become confusingly incongruent with a male body in most public circumstances. Adopting a unisex or male name will make it simpler for me and for other people. Of course, the simplest thing is not always the right thing, so I continue to reflect on my motivations for choosing a new name. For many of my friends, my first name is irrelevant anyway, as they refer to me by my last name (McMurray) or by nicknames derived from my last name (mcmurr, Mac).

The list of names that I considered was drawn mostly from my favorite fictional characters: Peter (Pan), Jeremy (Finch), Dirk (Pitt), Owen (Meany), Jack (Reacher), Max (Rockatansky). But I kept circling back towards the name I used online for years before I even acknowledged transition as a possibility: Tom Sparrow. As a child I was intrigued by a story my parents told me about their wedding. They had a guestbook for guests to sign their name and record where they were visiting from. After the wedding, my parents found a signature in the book from someone they hadn’t actually invited, a Tom Sparrow from New York, New York. My dad suspected that his best man had written the pseudonym as a joke, but I always liked imagining that this itinerant stranger, Tom Sparrow, had actually crashed their wedding. And this story resonated deeply with my younger self because, like Tom Sparrow the wedding ghost, I so often felt like an invisible guest at someone else’s party. Tom Sparrow… the name was a quick little bird flitting restlessly through the thread of my thoughts. (I only recently found out that the name in the wedding guestbook was actually Todd Sparrow, I must have misheard it the first time my parents told the story, but it’s too late now because Tom has solidified in my mind over so many years).

So I tried using the name Tom in the few circumstances where people knew about my gender journey and did not already have a nickname for me. With one friend I started signing off my emails as Tom (thereafter double checking the name at the bottom of all my emails to avoid any awkward mistakes). I asked my psychiatrist to call me Tom. I introduced myself as Tom in therapy groups. The name Tom felt so strange and foreign in writing and out loud, so I gave myself nearly a year to get used to it. But the foreignness never waned and Tom continued sounding silly and contrived. Eventually – frightened by the mounting feeling of detachment from my name, frustrated by my continued uncertainty regarding transition, and struggling with severe depression related to other life circumstances – I stopped signing my emails to my friend and requested that my psychiatrist not call me any name at all. This namelessness was comforting initially, like the reassuring anonymity of a dial tone.

But namelessness was not sustainable forever, so I tried Thomas instead of Tom. And very quickly Thomas felt right. I’m not exactly sure why… perhaps the single syllable of Tom was too abrupt and harsh and Thomas has a softer sibilance, perhaps the formal tone of Thomas commanded more of my respect, perhaps I reached a more authentic acceptance of gender dysphoria and could then commit more fully to this aspect of transition, perhaps it was simply the passage of time and a thousand self-reflections that softened the shape of a new name.

So for now, I am Thomas, to myself (sometimes), to my psychiatrists, and to friends who don’t already have their own name for me – those cheerful nicknames that carry all the shared history of an ongoing friendship.

Thomas means “twin”, which has an appealing symmetrical symbolism. You see, I am twins in one body. I am two sexes, male and female – separated by time and perception, biology and convention – inevitably intertwined until death do us part.

“I know my name now. That’s some comfort.”
– Alice (Through the Looking-Glass and What Alice Found There, 1871)

Falling Out of the Closet

Falling Out of the Closet (1)

Lately I have found myself quite often on the verge of coming out to my sisters and close friends about my gender dysphoria and transition considerations. Perhaps I feel like I owe them some honesty in return for their generous support while I was recently hospitalized for treatment of depression. Perhaps I feel an increasing urgency to share my fears and excitement with them as time ticks closer to the date of my appointment to discuss starting testosterone. Perhaps I have simply grown tired of constantly editing what I say and cropping out so much of myself around them that the prospect of finally dropping these pretences feels so incredibly enticing. I don’t know exactly why I feel this inner pressure to come out to certain people, but I must acknowledge that this pressure is strong and sometimes almost unbearable.

But even stronger than that pressure is a vague and deeply unsettling discomfort that has so far kept me from coming out to them. I have had many opportunities to tell them and I am reasonably confident that their responses will be supportive. But this mysterious reluctance always mutes the coming out speech that I’ve rehearsed so often in my mind. The only way I can describe it is that sharing my gender journey with anyone I haven’t already told feels like I’m losing control of my story, like my voice is getting drowned in an increasingly crowded conversation. Twice I have discussed my gender issues in a group (one a transgender support group and the other an interpersonal therapy group), and the group setting ramps up my discomfort to an extreme, like I’m not just losing control of my story but that the group members have actually stolen my rough draft and are busy making red-ink edits on words they barely understand. So I have inevitably withdrawn the gender topic from the groups that I’ve attended.

When I first started exploring gender identity and transition options more than 18 months ago, coming out to my closest friends felt so simple and natural, like taking a framed picture off the wall and revealing the hook that held it up – something that they had known must be there, even without seeing it, something unquestionably necessary to the suspension of that hanging frame, but which, when glimpsed for the first time, seemed stark and unexpected in an unsurprising way. With these friends, my gender journey is a constantly evolving conversation, not just one dramatic and irreversible leap out of the closet. I am continually amazed and grateful for their patient curiosity and acceptance. They allow me to explain my experience and explore my uncertainties, acknowledging the difficulties I encounter without claiming tritely to have “been there too” and without dismissing it as something so unusual and so weird that they “just can’t relate” – irritating responses that I’ve heard all too often from other people. These friends also allow the urgency and enormity of my gender issues to ebb and flow with time, accepting this process as a non-linear progression.

Sometimes with peripheral acquaintances, people I’ve just met or barely know, I come out to them quite quickly, almost carelessly, tossing this huge disclosure at them like a handful of nearly worthless coins, a defiant challenge to test whether this is something that might interfere with a budding friendship still in its fragile infancy, unwilling to invest the energy in developing a doomed relationship. This is maybe not the best approach, just a pattern I’ve noticed with myself.

I am most afraid of coming out to my parents. Because I am currently living at home with them, this fear prowls behind every familiar doorway in the house that I grew up in. One of my friends had an extremely traumatic experience coming out to his family many years ago – he said that when he came out to his parents, he did so very abruptly which may have contributed to their feeling shocked and overwhelmed, and he did so while struggling immensely with his own questions and uncertainties which may have facilitated their unfortunate belief that they could exert their parental influence to control his choices. So with my parents I have tried to approach coming out slowly and strategically, setting up several steps in advance and thinking several moves ahead, laying tentative groundwork for future possibilities, like a delicate chess match. I frequently bring up trans issues in the news and media to discuss with them, edging ever closer to the truth while keeping the discussion neutral and impersonal, referring to transgender people as “them” and not “us” – not yet.

On some level, I think my father already knows the truth. Over the past few years he has become much more open-minded and more tolerant, able to re-evaluate the many restrictive ideas his generation grew up believing. Since I was a kid he has always accepted and supported my obvious gender non-conformity. So I have played a gentle match with him, his Pawns relenting peacefully one by one, and his white King waiting in a patient stalemate while my dark Knights rein back heavy horses.

My mother has perhaps begun to suspect the truth as well, although her fear and prejudice slam the door on those suspicions and cut off any opportunity for reflection. I am often ashamed at the bitter depth of my resentment towards her, resentment built up by the years of hated dresses and ponytail hair she forced onto me, resentment maintained by the irrational childlike fear and guilt I still feel around her. With her I play a much more timid game, time and again caught off guard by her aggressive, reckless, unpredictable moves. But I have tried to practice being more assertive in our inconsequential daily duels, practicing for the inevitable big discussions. My front-line Pawns remain defensive, trying mostly just to minimize losses while they repeatedly withdraw and regroup before bravely inching forward once again, encroaching incrementally on her imposing Queen, until – eventually, explosively – checkmate, mother.

One of my friends – with his ever-sparkling insight – told me, “I know that I never felt ready to come out. It just sort of happened because the pressure and anguish of staying hidden just overwhelmed me and I fell out of the closet. I would trust your inner voice here… hopefully the time will feel right, or it won’t and you’ll just fall out of the closet and pick up the pieces and carry on.” His idea of falling out of the closet – as a necessity more than a choice – resonated so strongly with me. It is an eloquent description of how it has so often felt when I have discussed my gender journey with others. But I am working hard to give myself permission NOT to feel pressure to come out to anyone else right now, to keep writing my own rough draft, to be okay with falling out of the closet and picking up the pieces if that is the way it eventually has to happen.

“Fancy what a game of chess would be if all the chessman had passions and intellects, more or less small and cunning; if you were not only uncertain about your adversary’s men, but a little uncertain also about your own; if your Knight could shuffle himself on to a new square on the sly; if your Bishop, in disgust at your Castling, could wheedle your Pawns out of their places; and if your Pawns, hating you because they are Pawns, could make away from their appointed posts that you might get checkmate on a sudden. You might be the longest-headed of deductive reasoners, and yet you might be beaten by your own Pawns. You would be especially likely to be beaten, if you depended arrogantly on your mathematical imagination, and regarded your passionate pieces with contempt.”
– George Eliot (Felix Holt, the Radical, 1866)