Self Portrait #2

self-portrait-2-final-1

Materials: ballpoint pen (black) + black fine-point Sharpie marker + Staedtler colored pencils

Time: 20  hours

Reference: photo of myself taken August 14, 2016. I look tired, because it was taken very early in the morning. And I look sad, because I’d said an indefinite goodbye to someone I love two days before. I took this photo because I realized that I’d never drawn sadness.

Comments: it was very difficult for me to complete this sketch. My style has improved a lot since I first started drawing portraits, but increased skill creates higher expectations, and I was disappointed to feel my old paralyzing perfectionism emerging once more. And drawing my own sadness meant that I was reminded – over and over – of the reasons for that sadness. Fighting perfectionism and embracing sadness for the duration of this drawing was emotionally exhausting. But I found that I was more comfortable drawing a self portrait this time. After my first self portrait, I said I liked my eyes and my hair and my collarbone. After my second self portrait, I realized – with great surprise! – that I actually like my whole face.

self-portrait-2-wip

“She was a genius of sadness, immersing herself in it, separating its numerous strands, appreciating its subtle nuances. She was a prism through which sadness could be divided into its infinite spectrum.”
– Jonathan Safran Foer (Everything is Illuminated, 2003)

Testosterone (Part 2): Assumptions and Questions

prescriptions

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Part 1: Drugs and Doses
~ Part 2 in the Testosterone series ~
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After a long process of clarifying my transition goals, I was finally able to create a prescription plan to help achieve a more androgynous appearance without complete masculinization. I initially felt confident about my plans for hormone therapy. However, in the weeks leading up to my appointment with a new family doctor who could provide these prescriptions, I began to feel more uncertain about starting testosterone – I wondered whether recent improvements in body image could be sustained without drugs, and I was concerned about potential side effects even on low doses of T and finasteride.

I also felt anxious that the doctor may not understand or support my atypical transition goals. In my experience, people’s ignorance of gender dysphoria can often lead to misunderstanding or hostility and judgment. But people’s knowledge of gender dysphoria, from personal or professional experience, can also create frustrating barriers to understanding and acceptance. Other trans people, whose experience aligns more closely with typical trans narratives, often respond defensively or dismissively to my uncertainty about gender identity and my ambivalence about pursuing medical transition options. Medical professionals, whose work with other trans patients informs their perspective on gender dysphoria, often convey wildly inaccurate assumptions about my experience. These assumptions usually become evident in their well-intentioned attempts to demonstrate knowledge and acceptance. But these assumptions do not make me feel accepted; they make me feel invisible.

When I arrived for my appointment, it was immediately apparent that the doctor had made some problematic assumptions. He assumed that I wanted to achieve maximum masculinization as quickly as possible – before I had even mentioned my transition goals, he delivered several warnings about the risks of taking too much testosterone and several reassurances that I should start seeing physical changes very soon on standard doses. He assumed that he would have to educate me about hormone therapy – he interrupted me constantly to deliver very basic information that I already knew. And he assumed that I would trust his opinion – he emphasized the fact that he had worked with “lots” of trans patients to support his recommendations, with little reference to specific clinical experiences or published literature.

His inaccurate assumptions and his tendency to interrupt meant that it took much longer than necessary for me to explain my situation. Eventually, in an abbreviated and fragmented fashion, I was able to describe my transition goals. He said that my experience is “atypical” and admitted that he doesn’t have many patients who want to transition slowly and partially. But by the end of the appointment, he seemed to understand my perspective and he was supportive of my desire to proceed cautiously (or potentially not even start T right away). He gave me the prescriptions I requested: 1.25g/day Androgel and 1.25mg/day finasteride.

I mentioned my concern about T potentially causing mood fluctuations (less likely with lower doses and transdermal formulations). He cheerfully reassured me that mood issues aren’t a problem in patients on much higher doses of injectable T, so he would expect no changes in mood on the dose of Androgel that I requested, although I might experience slightly increased energy on T. While that information was somewhat comforting, I wondered if there may be some bias in his clinical experience which could lead to underestimation of the effects of T on mood. I have previously described how trans people may tailor the information they share with doctors who control access to transition options. If someone is desperate to continue hormones but experiences negative mood side effects, they might be motivated to withhold that information from the doctor to avoid being told to decrease the dose or discontinue hormones.

I also mentioned my fear that T could cause increased appetite and significant weight gain. Even if the weight gain was related to a desirable increase in muscle mass, these sides effects would be very difficult for me to cope with due to a long history of disordered eating. He again cheerfully reassured me that weight gain is usually minimal even on higher doses of T, typically characterized by a slight increase in muscle mass with concurrent decrease in body fat so that the number on the scale may remain stable or increase by only a few pounds. He said that people who do experience significant weight gain after starting T are generally gaining weight for reasons other than the hormones, so if I maintained the same exercise and diet routine after staring T then I shouldn’t expect much change in weight and appetite. Changes in body weight can be assessed more objectively than changes in mood, so it seems that clinicians’ observations of weight changes are less likely to be biased by selective disclosure from patients.

Finally, I asked him whether long-term use of low-dose T would eventually lead to complete masculinization (just on a much slower timeline than higher doses) or whether it would allow partial masculinization to a stable endpoint that could be sustained and non-progressive over time. The doctor was very confident in saying that it would be the latter (partial non-progressive masculinization). But I have found no published evidence to support either conclusion, and the doctor admitted that he has “very few” patients who elect to start on a low dose of T (let alone maintain a low dose of T indefinitely) so it seems that his clinical experience with respect to this question would be relatively limited. [Several weeks later, I discussed the same question with a psychiatrist who specializes in working with transgender people. The psychiatrist said that the endocrinologists he’s worked with believe long-term low-dose T would eventually (over decades) lead to complete masculinization, which directly contradicts the family doctor’s response to my question. It seems there are no definitive answers available].

So I left the appointment with two prescriptions and more questions than answers. My instinctive desire for certainty grappled with my relentless tendency for skepticism. I was grateful that I had been given the prescriptions I requested, grateful that I had the freedom to move forward with hormone therapy whenever I wanted – a freedom that many trans people do not have. But as I reviewed the prescriptions and the lengthy consent form outlining all potential risks and side effects, I still found myself questioning more intensely whether this drugs are truly right for me, or whether I could find a way to be comfortable in this XX body without hormonal or surgical intervention.

“We make all sorts of assumptions because we don’t have the courage to ask questions.”
– Miguel Ruiz (The Four Agreements: A Practical Guide to Personal Freedom, 2001)

Testosterone (Part 1): Drugs and Doses

drugs

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~ Part 1 in the Testosterone Series ~
Part 2Assumptions and Questions
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When I initially reviewed the literature on hormone therapy for FTMs over a year ago, I hoped to find quick and easy answers about testosterone. At that time, I had a simplistic and optimistic belief that gender dysphoria was the main issue contributing to depression and other life issues, so I felt a desperate urgency to start medical transition as soon as possible. But because I was still so unsure about my own transition goals, my research felt disorganized and overwhelming and served only to magnify the intensity of my uncertainty.

But after resolving my chronic confusion with the concept of “gender identity,” deconstructing many of my own illusions about my appearance, creating a more concrete mental image of my “ideal” body, and gaining a greater measure of acceptance of my current body, I was finally able to consider hormone therapy with more clarity. As I described previously, my “ideal” body does not align with that of typical cisgender men. Rather, my “ideal” body would have somewhat more masculine facial features and a slightly more masculine silhouette than my current female frame (broader shoulders, more upper body muscle mass, wider waist, narrower hips), but would otherwise be more androgynous than masculine. So I revisited my old research with this new lens, and I was able to create what seemed to be an optimal hormone therapy plan to accomplish my desired physical changes.

It is beyond the scope of this post to summarize all of the published information regarding hormone therapy for FTMs. I present here my own tentative prescription plan with reference to information most relevant to my situation. I hope this may be valuable to others seeking to achieve slight and gradual physical masculinization outside standard FTM hormone therapy protocols. Recent publications have acknowledged increasing diversity in transition goals among gender dysphoric individuals. (Fabris 2006)

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Testosterone (T): 1-2g/day transdermal

Transdermal T is available as a gel or as a patch. I planned to consult with my prescribing physician about the availability and cost of those options in my area. Injectable (intramuscular) T formulations are most commonly preferred and prescribed for FTMs. (Simpson 2006, Meriggiola 2015) However, compared to the various injectable T formulations, transdermal T has several advantages with respect to my own transition goals.

First, transdermal formulations are associated with more stable serum T concentrations over time that mimic the physiologic secretion of T in cisgender men. (Simpson 2006, Meriggiola 2015) Intramuscular injections of T every 1-4 weeks cause supraphysiologic serum concentrations in the first few days after the injection, followed by a rapid decrease in T concentration. (Meriggiola 2015) Some studies report changes in energy and more pronounced mood swings associated with these rapid fluctuations in T concentration. (Simpson 2006, Meriggiola 2015) Mood changes include more frequent irritability, frustration/anger, and aggression as well as decreased positive and negative affect intensity. (Slabbekorn 2001, Simpson 2006) Maintaining a more consistent T concentration may help reduce mood changes, which is an important consideration for me given repeated episodes of severe depression.

Second, transdermal T may be associated with more gradual physical changes compared to injectable T. (Simpson 2006) “Transdermal formulations are recommended if slower progress is desired or for ongoing maintenance after desired virilization has been accomplished.” (TransHealth UCSF 2016). However, at comparable doses, transdermal and injectable T are associated with a similar overall degree of physical masculinization despite the slower progression of changes occurring with transdermal preparations. (Merrigiola 2015) Many FTMs hope to achieve pronounced physical masculinization as quickly as possible, but given my more conservative transition goals, I would prefer more gradual changes so that I have a longer period of time to evaluate whether the physical changes are truly desirable.

Third, transdermal T eliminates the requirement of giving myself intramuscular injections. I have an embarrassingly low pain tolerance, so I will admit that the prospect of injecting several millilitres of viscous oil into myself every few weeks is very unappealing.

Disadvantages of transdermal T in my situation include increased cost (my current health coverage is limited and does not include the off-label prescription of T for gender transition) as well as possibility for delayed cessation of menstruation (menstruation has always been a core source of body dysphoria for me and is one of the primary motivations to seek hormone therapy). (Simpson 2006) However, other studies have found that transdermal T induces amenorrhea on a similar timeline as injectable T. (Pelusi 2014)

The recommended maintenance dose range of transdermal T for FTMs who want to achieve considerable masculinization as quickly as possible is 2.5-10g per day. (Simpson 2006, Fabris 2015, Meriggiola 2015) A dose of 1-2g per day would likely allow even more gradual progress. Lower starting doses, such as 2.5g per day, are also recommended if there are concurrent psychiatric problems.(Simpson 2006)

Finasteride: 1mg/day oral

I previously discussed my desire to avoid hair loss by using finasteride concurrently with T. In addition to reducing male-pattern baldness in FTMs, finasteride can also be associated with slowed or decreased facial and body hair growth and slowed or decreased clitoromegaly. (TransHealth UCSF 2016) These effects are usually listed as disadvantages in articles about hormone therapy in FTMs. However, given my desire for only slight physical masculinization, these side effects are actually advantages because they align closely with my transition goals. The recommended dose of oral finasteride is 1mg/day. (Mella 2010)

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In the process of more seriously considering hormone therapy and trying to develop my own prescription plan, I returned to an important question from a previous post:

In an XX person, would long-term administration of low dose T ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of T? Or would long-term administration of low dose T 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 long-term administration of high dose T in FTMs or describing the effects of short-term administration of low dose T in women (including the effects of exogenous T administered to treat various medical conditions as well as the effects of endogenous T in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose T in female-bodied people without concurrent medical issues.

I want to achieve a sustainable, non-progressive, partial physical masculinization. But I am not sure to what extent this goal is possible, even with conservative use of low dose hormones.

The scientific literature regarding long-term outcomes of low dose T administration in healthy XX individuals is almost non-existent. The literature regarding the extent and timeline of physical and psychological changes on low dose T is also extremely limited. Virtually everything currently published in scientific journals about T-induced changes in FTMs describes study participants on doses of T that are 2-10 times higher than the doses I’m considering. (Fabris 2015, Meriggiola 2015, Slabbekorn 2001, Pelusi 2014) There are some anecdotal reports of the effects of low dose T on blogs and YouTube videos by transmasculine people, but their comments tend to be sporadic, unstructured, and inconsistent.

This scarcity of published information about the short-term and long-term effects of low dose T contributes to my chronic difficulty imagining a future version of myself. For those of us with atypical transition goals, most of the existing medical knowledge and established hormone protocols are simply not applicable. This creates a painful sense of isolation and confusion, as though I’m peering out at the rest of the world from behind a foggy looking-glass.

“It’s dreadfully confusing!” 
– Alice (Lewis Carroll, Through the Looking-Glass and What Alice Found There, 1871)

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References

Fabris B, Bernardi S, Trombetta C. Cross‐sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3): 269-282. Note: see Table 3 for an extensive summary chart regarding testosterone doses and formulations.

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. 

Pelusi C, Costantino A, Martelli V, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. 2014. Journal of Sexual Medicine 11(12): 3002-3011. 

Simpson AJ, Goldberg J. Trans Care: Hormones – A Guide for FTMs. 2006. Trans Care Project.Vancouver, BC, Canada. Accessed through Rainbow Health Ontario. Note: see page 5 for a brief summary chart regarding testosterone doses and formulations. 

Slabbekorn D, van Goozen SHM, Gooren LJG, et al. Effects of cross-sex hormone treatment on emotionality in transsexuals. 2001. International Journal of Transgenderism 5(3):2. 

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

Gender Dysphoria Diagnosis (Part 5): GIDYQ-AA Full Text

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Part 1: GIDYQ-AA Personal Reflection
Part 2: Psychological Benefits of Diagnostic Confirmation
Part 3: Childhood Gender Non-Conformity
Part 4: DSM and ICD Diagnostic Criteria
~ Part 5 in the Gender Dysphoria Diagnosis series ~
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The most commonly viewed post on this blog is Part 1 of this series: GIDYQ-AA Personal Reflection. The popularity of this post likely reflects considerable curiosity regarding the diagnostic process for gender dysphoria. Part 1 only listed a handful of questions from the questionnaire in the context of my personal reflection. It is nearly impossible to find a complete version of the GIDYQ-AA online without access to scientific journals through academic servers, so I thought it might be helpful for readers to dedicate a post to the full text of the GIDYQ-AA.

Below, I have recorded the Female Assigned at Birth and Male Assigned at Birth versions of the GIDYQ-AA in their entirety. I created my own GIDYQ-AA documents formatted for printing, including a table to record responses to questions and a section for scoring; these documents are available for download.  I also have a section describing the scoring process in detail. Finally, abstracts from the study describing initial development of the GIDYA-AA (Deogracias 2007) and from a study providing further evidence to support the validity of the GIDYQ-AA (Singh 2010) are also included.

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GIDYQ-AA Documents for Download

Female Assigned at Birth (Adult) Word
Female Assigned at Birth (Adult) PDF

Female Assigned at Birth (Adolescent) Word
Female Assigned at Birth (Adolescent) PDF

Male Assigned at Birth (Adult) Word
Male Assigned at Birth (Adult) PDF

Male Assigned at Birth (Adolescent) Word
Male Assigned at Birth (Adolescent) PDF

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GIDYQ-AA (Female Assigned at Birth) Full Text
Response options are “always,” “often,” “sometimes,” “rarely,” or “never.” Items 1, 13, and 27 were reversed scored. For adolescents < 18 years of age, the word woman was changed to girl. Items 1-2, 5-10, 16, and 24-27 were considered to be subjective indicators of gender identity/gender dysphoria. Items 3-4, 11, 13-15, and 17-19 were considered social indicators. Items 20-22 were considered somatic indicators. Items 12 and 23 were considered sociolegal indicators.

01. In the past 12 months, have you felt satisfied being a woman?
02. In the past 12 months, have you felt uncertain about your gender, that is, feeling somewhere in between a woman and a man?
03. In the past 12 months, have you felt pressured by others to be a woman, although you don’t really feel like one?
04. In the past 12 months, have you felt, unlike most women, that you have to work at being a woman?
05. In the past 12 months, have you felt that you were not a real woman?
6. In the past 12 months, 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?
07. In the past 12 months, have you had dreams? If NO, skip to Question 8. 
If YES, Have you been in your dreams?
 If NO, skip to Question 8. If YES, In the past 12 months, have you had dreams in which you were a man?
08. In the past 12 months, have you felt unhappy about being a woman?
09. In the past 12 months, have you felt uncertain about yourself, at times feeling more like a man and at times feeling more like a woman?
10. In the past 12 months, have you felt more like a man than like a woman?
11. In the past 12 months, have you felt that you did not have anything in common with either men or women?
12. In the past 12 months, have you been bothered by seeing yourself identified as female or having to check the box “F” for female on official forms (e.g., employment applications, driver’s license, passport)?
13. In the past 12 months, have you felt comfortable when using women’s restrooms in public places?
14. In the past 12 months, have strangers treated you as a man?
15. In the past 12 months, at home, have people you know, such as friends or relatives, treated you as a man?
16. In the past 12 months, have you had the wish or desire to be a man?
17. In the past 12 months, at home, have you dressed and acted as a man?
18. In the past 12 months, at parties or at other social gatherings, have you presented yourself as a man?
19. In the past 12 months, at work or at school, have you presented yourself as a man?
20. In the past 12 months, have you disliked your body because it is female (e.g., having breasts or having a vagina)?
21. In the past 12 months, have you wished to have hormone treatment to change your body into a man’s?
22. In the past 12 months, have you wished to have an operation to change your body into a man’s (e.g., to have your breasts removed or to have a penis made)?
23. In the past 12 months, have you made an effort to change your legal sex (e.g., on a driver’s licence or credit card)?
24. In the past 12 months, have you thought of yourself as a “hermaphrodite” or an “intersex” rather than as a man or woman?
25. In the past 12 months, have you thought of yourself as a “transgendered person”?
26. In the past 12 months, have you thought of yourself as a man?
27. In the past 12 months, have you thought of yourself as a woman?

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GIDYQ-AA (Male Assigned at Birth) Full Text
Response options are “always,” “often,” “sometimes,” “rarely,” or “never.” Items 1, 13, and 27 were reversed scored. For adolescents < 18 years of age, the word man was changed to boy. Items 1-2, 5-10, 16, and 24-27 were considered to be subjective indicators of gender identity/gender dysphoria. Items 3-4, 11, 13-15, and 17-19 were considered social indicators. Items 20-22 were considered somatic indicators. Items 12 and 23 were considered sociolegal indicators.

01. In the past 12 months, have you felt satisfied being a man?
02. In the past 12 months, have you felt uncertain about your gender, that is, feeling somewhere in between a man and a woman?
03. In the past 12 months, have you felt pressured by others to be a man, although you don’t really feel like one?
04. In the past 12 months, have you felt, unlike most men, that you have to work at being a man?
05. In the past 12 months, have you felt that you were not a real man?
06. In the past 12 months, 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 woman rather than as a man?
07. In the past 12 months, have you had dreams? If NO, skip to Question 8. 
If YES, Have you been in your dreams? 
If NO, skip to Question 8.
 If YES, In the past 12 months, have you had dreams in which you were a woman?
08. In the past 12 months, have you felt unhappy about being a man?
09. In the past 12 months, have you felt uncertain about yourself, at times feeling more like a woman and at times feeling more like a man?
10. In the past 12 months, have you felt more like a woman than like a man?
11. In the past 12 months, have you felt that you did not have anything in common with either women or men?
12. In the past 12 months, have you been bothered by seeing yourself identified as male or having to check the box “M” for male on official forms (e.g., employment applications, driver’s license, passport)?
13. In the past 12 months, have you felt comfortable when using men’s restrooms in public places?
14. In the past 12 months, have strangers treated you as a woman?
15. In the past 12 months, at home, have people you know, such as friends or relatives, treated you as a woman?
16. In the past 12 months, have you had the wish or desire to be a woman?
17. In the past 12 months, at home, have you dressed and acted as a woman?
18. In the past 12 months, at parties or at other social gatherings, have you presented yourself as a woman?
19. In the past 12 months, at work or at school, have you presented yourself as a woman?
20. In the past 12 months, have you disliked your body because it is male (e.g., having a penis or having hair on your chest, arms, and legs)?
21. In the past 12 months, have you wished to have hormone treatment to change your body into a woman’s?
22. In the past 12 months, have you wished to have an operation to change your body into a woman’s (e.g., to have your penis removed or to have a vagina made)?
23. In the past 12 months, have you made an effort to change your legal sex (e.g., on a driver’s licence or credit card)?
24. In the past 12 months, have you thought of yourself as a “hermaphrodite” or an “intersex” rather than as a man or woman?
25. In the past 12 months, have you thought of yourself as a “transgendered person”?
26. In the past 12 months, have you thought of yourself as a woman
27. In the past 12 months, have you thought of yourself as a man?

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gidyqaa-full-text

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GIDYQ-AA Scoring
The table at the bottom of the photo above shows how the questionnaire is scored. The scoring process is the same for the female-assigned-at-birth and the male-assigned-at-birth versions. I have summarized the scoring process in more detail below.

  1. Participant fills out the questionnaire, indicating how often each question applies to them (“always,” “often,” “sometimes,” “rarely,” or “never”).
  2. The number of X’s in each category (“always,” “often,” “sometimes,” “rarely,” and “never”) are added up. Items 1, 13, and 27 are reversed scored, which means that for those questions, an “always” response would actually be counted as “never” and an “often” response would actually be counted as “rarely.”
  3. The total number of responses in each category (including reverse scored items) are then multiplied by weighting factors: the number of “always” responses is multiplied by 1, the number of “often” responses is multiplied by 2, the number of “sometimes” responses is multiplied by 3, the number of “rarely” responses is multiplied by 4, and the number of “never” responses is multiplied by 5.
  4. The multiplied totals for each category are then added together to give the Raw Score.
  5. The Raw Score is then divided by 27 to give the Scaled Score. (Note: if participants left any items blank, the Raw Score is divided by the total number of items completed. For example, if a participant did not respond to 2 of the items on the questionnaire, the Raw Score would be divided by 25 instead of by 27 to give the Scaled Score).

Based on published studies evaluating the GIDYQ-AA, a Scaled Score less than 3.0 is strongly suggestive of gender dysphoria, while a Scaled Score greater than 3.0 is more likely to reflect the absence of gender dysphoria. However, no single questionnaire or scoring system can perfectly capture all of the variation in gender identity and personal goals (and I have previously discussed many of the problems that I think may interfere with the utility of the questionnaire), so scores on the GIDYQ-AA are not necessarily definitive and should not replace each individual’s sense of their own identity.

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“The present study reports on the construction of a dimensional measure of gender identity (gender dysphoria) for adolescents and adults. The 27-item gender identity/gender dysphoria questionnaire for adolescents and adults (GIDYQ-AA) was administered to 389 university students (heterosexual and nonheterosexual) and 73 clinic-referred patients with gender identity disorder. Principal axis factor analysis indicated that a one-factor solution, account ing for 61.3% of the total variance, best fits the data. Factor loadings were all >.30 (median, .82; range, .34-96). A mean total score (Cronbach’s alpha, .97) was computed, which 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. Using a cut-point of 3.00, we found the sensitivity was 90.4% for the gender identity patients and specificity was 99.7% for the controls. The utility of the GIDYQ-AA is discussed.” (abstract, Deogracias 2007)

“This study aimed to provide further validity evidence for the dimensional measurement of gender identity and gender dysphoria in both adolescents and adults. Adolescents and adults with gender identity disorder (GID) were compared to clinical control (CC) adolescents and adults on the Gender Identity=Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ–AA), a 27-item scale originally developed by Deogracias et al. (2007). In Study 1, adolescents with GID (n1⁄444) were compared to CC adolescents (n1⁄498); and in Study 2, adults with GID (n1⁄441) were compared to CC adults (n1⁄494). In both studies, clients with GID self-reported significantly more gender dysphoria than did the CCs, with excellent sensitivity and specificity rates. In both studies, degree of self-reported gender dysphoria was significantly correlated with recall of cross-gender behavior in childhood—a test of convergent validity. The research and clinical utility of the GIDYQ–AA is discussed, including directions for further research in distinct clinical populations.” (abstract, Singh 2010)

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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. 

Self Portrait #1

self-portrait-1-final

Drawing this self portrait was a fascinating experience.

Before I ever start a drawing, I spend a lot of time analyzing the face in the reference photo, observing the technical aspects of facial proportions and composition and contrast, and figuring out how to capture the emotion in their expression. It’s an intellectual and artistic analysis done from a detached, non-judgmental, keenly observant, and empathetic perspective. This process has completely changed the way I see my own face in the mirror. Now I see my face with so much more interest – what’s unique about her face? how would I capture her expression there? – now I see my face with so much more compassion.

Drawing my self portrait (titled #1 because I think there will be more!) was very strange at first, like an out-of-body experience, similar to my mirror experiments but more prolonged and more precise. I deliberately drew all the facial imperfections that have long been a source of self-consciousness for me: acne scars on my left cheek, the vein that so prominently traverses my left temple, right iris heterochromia.

After I finished the sketch, I realized that I actually like my eyes – they are very big, very expressive, and asymmetrically colourful. I also like my collarbones and the upper pectoral definition on my chest, the hard-earned result of thousands of pushups. And I’ve always loved my short, messy hair.

I never thought I would be capable of drawing my own face. My self portrait took six hours to complete… six hours staring at my face, after six years of showering in the dark and avoiding mirrors with pathological self-loathing.

self-portrait-1-laptop

Materials: ballpoint pen (black) + black fine-point Sharpie marker + Staedtler colored pencils

Time: 6  hours

Reference: photo of myself taken July 16, 2016 on the stairs at a city train station. I chose that photo because the lighting provided good contrast and the cautious, wary facial expression is characteristic of my chronic skepticism.

Comments: I sign most of my drawings as TM. But I have as many names as I do clothes, so when I started drawing again, I was initially unsure what my signature should be. Most commonly I go by Thomas or by my given name (which starts with J), so I decided to sign with a provisional TM. I can turn the T into a capital J with a single curved stroke of the pen if I want. I signed this self portrait with JM because my given name and the face I drew have been mine my whole life. Thomas is a newer addition.

self-portrait-1-wip

Irene Adler: Do you know the big problem with a disguise, Mr. Holmes? However hard you try, it’s always a self-portrait.
Sherlock Holmes: You think I’m a vicar with a bleeding face?
Irene Adler: No, I think you’re damaged, delusional and believe in a higher power. In your case, it’s yourself. And somebody loves you.
– BBC Sherlock (S02, E01 – A Scandal in Belgravia)

More Mirror Magic

more-mirror-magic

In my first mirror experiment, I was wearing a fitted tank top and baggy sweatpants, sitting cross-legged on a stainless steel shelf across from the mirror in my hospital bathroom. So my reflection focused on my face and upper body. I had intentionally chosen baggy pants and a cross-legged position to conceal my hips and thighs, which have long been a prominent source of body dysphoria. Perhaps that was cheating, a bit – after all, I had challenged myself to evaluate my mirror image as objectively as possible. Despite a little cheating, that mirror experiment generated so many important insights, allowing me to create a more positive and more realistic current body image as well as a more concrete idea of what my ideal body looks like to help guide transition choices.

Since then, I have repeated the mirror experiment countless times, for shorter periods. I pushed myself to continue stripping away the cognitive and physical illusions I have used for so long to detach myself from every aspect of my body. I pushed myself to look at my reflection wearing tighter pants, like jeans and workout capris. I pushed myself to change my position, sometimes sitting with my legs stretched out or dangling off the shelf, sometimes standing or leaning against the wall, legs apart and legs crossed. And I pushed myself to engage with my own image, not just in bathroom mirrors, but also in all the other reflective surfaces that bounce our selves back to us as we move through this fragmented world: the darkened window of a gift shop after closing, the smudged glass of a framed grad photo, the shiny plastic of a gas-station trashcan, the metallic blade of a new kitchen knife, the sleeping screen of an open laptop, the mysterious blackness of a stranger’s sunglasses or the familiar blue of a close friend’s eyes.

So my reflection has become a dynamic and ever-present companion. Reflection on reflection remains an intriguing process. And as I’ve expanded my mental library of my own reflected images, I have added incremental insights and deeper awareness to the major realizations from that first mirror session. These insights and awareness continue to solidify the growing comfort and gratitude for my body.

But this comfort and gratitude are continually challenged, often unexpectedly. Near the end of stay in hospital, I had finished my morning workout, taken a quick shower, towelled dry, and wrapped the disappointingly tiny hospital towel around my waist. I studiously avoided dropping my gaze low enough to risk seeing my bare chest. I stood with my back to the bathroom mirror and reached down for my stack of clean clothes. And I realized – in a heart-pounding moment of fear and curiosity, shame and acceptance, annoyance and awareness – that I was still cheating. So I straightened up and, in a clumsy bathroom pirouette with a frayed white-towel skirt, I turned around to the face the mirror without a shirt or bra.

I had not been able to tolerate the sight of my bare chest since I was in my early teens. When I turned around that morning, my eyes initially focused only on my face and arms and shoulders – anatomy which was comfortably familiar after previous mirror sessions – dancing deliberately away from the lower half of the mirror.

Still cheating.

So I forced my focus downwards and inwards. And – to my complete astonishment! – I felt only the mildest discomfort. I saw the unwanted female breasts. I felt disappointed by their presence. But behind them, I also saw the power in my pectoral muscles and I saw the gentle rise and fall of breaths moving through my chest.

Certainly, the presence of breasts was uncomfortable and undesirable. And if I could have snapped my fingers and created a flat male chest just like that, I would have done so without hesitation. But I knew that was impossible. And I know that getting a mastectomy will be a long, painful, and potentially expensive process that is also impossible in any short-term timeframe. So that moment of seeing my naked chest in the mirror helped me achieve a radical acceptance of those impossibilities and a neutral peace with my current reality.

I may decide to pursue top surgery in the future, but that choice – previously motivated by disgust and self-loathing – became less urgent and less desperate as I stood in front of the mirror. I am now less convinced that top surgery will ultimately be necessary, but I will be open to that option moving forward. I will also be open to this ongoing process of accepting what’s real and revising what’s ideal. And I will remain open to any further insights that my capricious mirror image chooses to share with me.

The time will come
when, with elation
you will greet yourself arriving
at your own door, in your own mirror
and each will smile at the other’s welcome –
– Derek Walcott
(Love After Love, from Collected Poems 1948-1984)

Forever Incomplete

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

————
Part 1: Recognizing an Optical Illusion
Part 2: Deconstructing an Optical Illusion
~ Part 3 in the Ambiguous Androgyny series ~
————

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)

Ambiguous Androgyny (Part 2): Deconstructing an Optical Illusion

————
Part 1: Recognizing an Optical Illusion
~ Part 2 in the Ambiguous Androgyny series ~
Part 3: What You See
————

The Prestige

“Are you watching closely?”
– Alfred Borden (The Prestige, 2006)

In my last post, I discussed how the analogy of an optical illusion – specifically, the multistable perception that arises when viewing ambiguous images – has given me a more concrete framework to understand my experience of body dysphoria. Optical illusions have been described as an experience where “expectations are violated”, so I had challenged myself:

Does this multistable perception of my mirror image indicate the presence of some problematic expectations that my ambiguous androgyny somehow violates? Is it possible for me to deconstruct this distressing optical illusion to create a more comfortable, more coherent, and more stable cognitive interpretation of my physical appearance?

Certainly, part of the optical illusion effect comes from gender dysphoria itself. The inexplicable but undeniable distress I feel in response to seeing my female anatomy, and the detachment from my physical appearance that developed as a means to cope with that distress, both contribute to difficulty recognizing my mirror image as an accurate reflection of myself.

But now I think there was a second layer to that illusion: my own expectations about what male and female bodies are supposed to look like. My physical androgyny, deliberately designed to minimize female traits and partially successful in reducing the intensity of body dysphoria, became an optical illusion because it did not match conventional expectations of “male body” or “female body” and generated mutually exclusive alternating interpretations of “boy” or “girl”. “The perception of multistable stimuli can be influenced by contextual properties of the image, including recognizability and semantic content.” (Leopold 1999) My ambiguously androgynous mirror reflection became an illusion by violating my gendered-body expectations and refusing to align with any recognizable gender pattern in my mind.

Which leads to the third layer of this illusion: the insidiously deceptive illusion of opposites. For so many years, I assumed that because my brain did not expect to see a female body, it must expect to see a male body instead. This was an appealing and self-reinforcing assumption because a “male” body is a concrete and easily visualized image. Dozens of male bodies cross my sightline each day. My mind catalogues all their physical similarities, an additive assimilation of biased data to create an increasingly narrow idea of what makes a man a man. This process provoked a constant self-loathing comparison of my female body to their male bodies and a vicarious idealization of stereotypical physical masculinity.

A couple of months ago, I had several long conversations about my ongoing disordered eating issues and my experience of body dysphoria with a new acquaintance. When I described the optical illusion effect associated with seeing myself in the mirror, he asked, “Would it be helpful to spend longer looking at yourself in the mirror, to try to acclimatize your mind to the mirror image?” I immediately dismissed his suggestion, telling him that spending more time in front of the mirror would only prolong the uncomfortable optical illusion sensation.

But over the next few days and weeks, I found my mind continually returning to his question. Everything I hear, every word I read, everything I see – all of it, all the time – it just keeps echoing around in my brain like a constant cognitive echolalia. Questions always echo loudest.

“Would it be helpful to spend longer looking at yourself in the mirror?”

 “…spend longer looking at yourself in the mirror?”

 “…yourself in the mirror?”

I started to reconsider my original dismissal. I tried to imagine spending a longer period of time in front of the mirror. Anticipating the same discomfort and confusion that has always plagued my reflection, I remained rigidly resistant to this prospect. Until I finally realized: I don’t need to look at my reflection LONGER, I need to look at it DIFFERENTLY. I should stop trying to force the optical illusion into a logical conclusion. Instead, I need to try to see past the deception and reveal my brain’s expectations. I should stop letting myself get distracted by the magician’s misdirection, lulled over and over into seeing the impossible while knowing that it is impossible. Instead, I need to ignore the magician’s diversions and focus on the cold hard mechanics of the trick to see how it’s actually performed.

So began the mirror experiment. With an odd mixture of anxiety and curiosity, I propped myself cross-legged on the stainless steel shelf across from the mirror in my hospital bathroom. I stared at myself in the mirror for an hour.

The first few minutes in front of the mirror were dominated by self-judgment. I felt so obnoxiously vain – with respect to Greek mythology, such intense focus on my reflected image is practically the definition of narcissism. But I was able to rationalize it by reminding myself that someone else had suggested this mirror experiment. After I let go of that self-judgment, the insights that arose during my time in front of the mirror were incredibly enlightening and completely unexpected.

As I stared at my reflection, I intentionally kept changing the lens through which I viewed my mirror image. I started with a third-person lens, trying to see myself neutrally, objectively, as an outsider. I wondered: What does my psychiatrist see when he looks at me? What do my friends see? What do strangers see? I revisited echoes from previous conversations, comments other people had made about my physical appearance.

“I see you as female right now because I’ve read your file and I know your age. You’re 24. But you don’t look like a 24-year-old man… probably based on the lack of facial hair. So if I just saw you on the street and didn’t know your age, I would assume you were an adolescent boy.” – a psychiatrist

“You think 80% of strangers read you as female and 20% read you as male? I dunno, McMurray… I think it’s closer to 50-50. Or maybe 60% would say you’re female, 40% male. There have been several times when we’ve had coffee where someone comes up to me after you’ve left and asked “Who was he?” or asked if you were my son.” – a friend

“Hey. I just wanted to say… you look so good in that tank top! Like, your shoulders are so jacked! Oh my god, I wish I had arms like that.” – an in-patient on the psychiatric unit

“Don’t take this the wrong way… but… your perception of yourself as ugly or unattractive is not exactly accurate… I think that might be an unrealistic and negative distortion. At least from my perspective.” – an acquaintance

Hearing those echoes and seeing the person in the mirror through this third-person perspective was like seeing an engaging snapshot of a stranger, appreciating their appearance and finding yourself curious about who they are and what their life is like. Such strict objectivity was surprisingly reassuring.

I mentally hit ⌘S to save an image of that objective snapshot, then discarded the third-person lens, toggled the microscope, slotted in a first-person filter, and reattached my “self” to the body in the mirror. As my first-person perspective came into focus, I felt the familiar flutter of distressing dysphoric confusion, but I hit ⌘S again. Then I opened up two Preview windows side-by-side to compare the third-person and first-person images.

Prior to this mirror session, I didn’t think that I had a distorted body image. I thought I saw myself realistically and just didn’t like what I saw. But this direct comparison of two different perspectives on my appearance illuminated several previously unrecognized negative distortions. I am not actually not as homely as I always thought, I am leaner and more muscular than I thought, I look physically fit and healthy. These realizations came with a deep sense of gratitude for my body and a brand new desire to treat this body kindly, no matter which gender its appears to be.

This direct side-by-side comparison also revealed a troubling cognitive sleight-of-hand: whenever I see myself, my mind immediately hones in on female anatomy and magnifies the size and significance of these female features while largely ignoring other aspects of my appearance. Being able to see myself in the third-person image without the mentally Photoshopped enhancement of physical femininity finally allowed me to appreciate how small and insignificant these female anatomical traits are on my own body.

The next step was to return to the original challenge I had set for myself: examine my expectations. I adjusted the microscope once more, retaining the first-person lens but changing the position of the focus to visualize the expectations underlying the outward appearance. It’s obvious that I do not expect to see a female body in the mirror, but do I really expect to see a male body instead? That’s an easy assumption, but is is accurate?

I have struggled for so long to create a tangible idea of my transition goals. Considering making masculinizing modifications to my body has always seemed appealing, but those options come with risks and side effects and I have been unable to clearly visualize the final outcome of these steps. So I have been overwhelmingly uncertain to what I extent I want to medically transition.

With the focus on my expectations, I opened up a third window in my mind: a CGI animation program. I imported the objective third-person image of myself and translated that into a 3D avatar that represents my current body. Then I started building an avatar to represent my “ideal” body. To do this, I had to disable the program’s automatic preset templates for “male” or “female” characters – templates generated from internalized expectations of what “men’s bodies” and “women’s bodies” are supposed to look like, expectations accumulated after nearly two and a half decades in a world that revolves around binary gender stereotypes. Without a 2D image or a preset template, I had to start from scratch on my “ideal” avatar, first building a basic genderless human body and then adding and subtracting anatomical features (a beard, a penis, a square jaw), adjusting ratios and proportions (broader shoulders, bigger deltoids, narrower hips), until my “ideal” avatar finally emerged with a startlingly concrete clarity. My “ideal” body seems to be one of nearly symmetrical androgyny: a lean and physically fit individual with moderate upper body muscle mass (prominent but not bulky), a smooth chest, a shoulder-to-hip ratio of about 1.2 to 1.4, a waist-to-hip ratio of about 0.8, and a well-defined jawline. Beard and penis not required.

3D Character Model

Having created realistic 3D models of my current body and my “ideal” body, I aligned these two avatars side-by-side on the screen. I reduced the opacity of both images to about 50% transparency and dragged the “ideal” avatar over top of the “current” avatar. And then I looked for discrepancies, trying to figure out where the two avatars differ. To my astonishment, it became clear that the differences between my real body and my ideal body are far more minor than I had previously believed! My ideal body has a slightly more masculine silhouette than my current body (broader shoulders, more upper body muscle mass, wider waist, narrower hips) and slightly more masculine facial features. Otherwise, my real and ideal avatars are almost identical.

This realization was profoundly reassuring. I finally have a concrete mental image of what I want my body to look like in the future – I have an avatar to project forward in time. I also have a much more positive and more realistic perspective on my current body, a much more authentic acceptance of my current appearance, and an overwhelming gratitude for my body. My androgynous appearance no longer seems ambiguous, because I no longer have to force it to align with expectations about what men and women look like. My androgynous appearance is now unambiguously, unequivocally, unashamedly my own. “In addition to being associated with perceptual transitions during multistability, activity in frontal and parietal cortex can also contribute to percept stabilization.” (Sterzer 2009) I think these cognitive contortions through the looking-glass have finally stabilized my perception of my mirror image in a way that could be comfortable and consistent over time.

My mind lingered for a few more moments, visualizing my real and ideal avatars, regarding them both with dawning respect and gratitude and affection, feeling a growing groundedness inside these bones and vessels and muscles that are my home for life. And then, ⌘S one more time – these images are worth saving, remembering, cherishing – one by one I closed all the windows I had opened in my mind. After the software was shut down, the microscope dismantled, the lenses stowed away, I found myself with nothing left between me and my mirror image. And it was in that one raw unguarded moment that I realized: I DON’T WANT TO KILL HER. I had just spent a very intimate hour with this girl – I had seen every subtle change in her expression, seen tears of gratitude welling up, watched a bemused little grin flicker across her face, I had watched her body shift and stretch, had seen the athletic strength and flexibility behind even the smallest adjustments in posture – and I could not bear the thought of killing her. Reattaching my “self” to that thought, I realized: I DO NOT WANT TO KILL MYSELF. More than two years of suicidal ideation – varying in urgency and intensity but relentless in its constant haunting presence – evaporated in that single second. Just like magic.

“Every great magic trick consists of three parts or acts. The first part is called The Pledge. The magician shows you something ordinary: a deck of cards, a bird, or a man. He shows you this object. Perhaps he asks you to inspect it to see if it is indeed real, unaltered, normal.

The Pledge is my female body: real, ordinary, medically unaltered.

 The second act is called The Turn. The magician takes the ordinary something and makes it do something extraordinary. Now you’re looking for the secret… but you won’t find it, because of course you’re not really looking. You don’t really want to know. You want to be fooled.

For years, my brain was stuck at the Turn, constantly creating illusions without really looking, desperately wanting to fool itself into seeing a body that matched my unchallenged expectations. I finally made those expectations disappear.

But you wouldn’t clap yet. Because making something disappear isn’t enough; you have to bring it back. That’s why every magic trick has a third act, the hardest part, the part we call The Prestige.”
– Cutter (The Prestige, 2006)

And now I’ve brought something back: a realistic perception of my female body, stripped of illusion and expectation, gently wrapped in gratitude and acceptance.

My body is my Prestige.

Abracadabra.

Prestige On Stage

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References

Leopold DA, Logothetis NK. Multistable phenomena: changing views in perception. 1999. Trends in Cognitive Sciences 3(7):254-264. 

 Sterzer P, Kleinschmidt A, Rees G. The neural bases of multistable perception. 2009. Trends in Cognitive Sciences 13(7):310-318.

Ambiguous Androgyny (Part 1): Recognizing an Optical Illusion

————
~ Part 1 in the Ambiguous Androgyny series ~
Part 2: Deconstructing an Optical Illusion
Part 3: What You See
————

my-wife-and-my-mother-in-law

Despite my detailed descriptions of the anatomic dysphoria associated with gender dysphoria, it has remained very difficult for me to explain my experience to other people in a way that is concrete and understandable to them. But the process of putting words to a such a vague yet distressing combination of thoughts and emotions has been extremely helpful for me, because it forces me to analyze my own perspective in a way that makes it more clearly defined in my own mind.

Anatomic dysphoria is often portrayed as the distress arising from a mismatch between physical attributes and an intrinsic cognitive “gender identity”. In a previous post, I described the problems with the concept of “gender identity” and argued against the idea that “gender identity” is an inborn, innate, and immutable property. So “gender identity” does not serve as a useful means of understanding my own experience. I have continued searching for other ways to conceptualize my physical dysphoria.

Re-reading previous posts on this blog and reflecting on the language that I use to describe my experience to others, I noticed that I commonly return to the analogy of an optical illusion:

“An accidental glimpse of this girl-face in the mirror feels like a baffling optical illusion, an odd reflection of a face I know so well but can never quite call my own.”

“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.”

I have also described the rapid and involuntary shifts in perception that occur when I view my physical image:

“My appearance seems to change dramatically within the space of just a few minutes or hours.”

And I have alluded to the deliberate cognitive process involved in attempting to interpret my mirror image in a way that is more coherent and less distressing.

 “…my reflection jabbing back at me with the familiar unfamiliarity that haunts my mirror image. But this time I don’t try to fit those female fragments into a coherent structure.” 

 I have found only sparse references to this optical illusion effect in the writing of other trans authors, but what they describe about seeing their reflection closely mirrors my own experience.

“I know that what happens between my eyes and my brain and the body in the mirror is like some sort of twisted optical illusion trick.”Malachi

 “Were the optical illusions I saw reflected really me?” – Grace Stephens

 “I have entered an ambiguous time in my transition. Like the color of the tiles in the checker shadow illusion, how my gender is perceived is often entirely context dependent… When I look in the mirror, sometimes I can see two different versions of myself, depending on which cues I focus on. When I focus on the cues that my brain interprets as ‘male’, I can see myself as I know myself to be, every week more aligned with my internal self-image. When I focus on the cues that my brain interprets as ‘female’, I feel dysphoric and upset.” It Doesn’t Have to Be This Way

“Every day, my face looks different… The feeling invoked when I look in the mirror is the same as when I view these [optical] illusions. They are confusing, disorienting, and unsettling. To me, these emotions are the defining characteristic of body dysphoria.” – Amy Dentata

In light of my personal experience and these sporadic references from other trans writers, I expanded my investigation of optical illusions. The results of my research suggest that using the analogy of an optical illusion to describe my experience of body dysphoria is extremely accurate.

One particular optical illusion that is especially relevant to my experience is the image called My Wife and My Mother-in-Law. This illusion closely aligns with my experience of anatomic dysphoria because it generates two very different interpretations of a human face based on unchanging physical features. The photo at the top of this post is my own drawing of this well-known illusion.

I recently used My Wife and My Mother-in-Law to help explain my experience of physical dysphoria to my psychiatrist. He admitted that he had seen the image before, but prior viewing does not detract from my explanation. I asked him what he saw when he looked at the picture. He said that his first impression is that of a young woman with her face turned away, but because he knows that an old woman’s face is also there, he can intentionally re-interpret the image to visualize the old woman. (The young woman’s chin becomes the old woman’s nose, and the young woman’s necklace becomes the old woman’s mouth). I asked him what he felt while looking at that image and seeing the young woman’s face alternate with the old woman’s face. He said he felt a brief and mild sensation of confusion and discomfort, but his mind naturally reset the lines back into the young woman’s face which restored a more neutral emotional response to the image. I explained that for me, the image never settles on one face or the other for very long, it constantly shifts back and forth between the young woman and the old woman, which makes the viewing experience very disorienting and confusing. Then I told him, “Imagine that the image doesn’t shift between young woman and old woman, but instead shifts between young woman and young man. Over and over and over. Imagine that the image never settles into a consistent comfortable interpretation. Imagine that you see this constantly alternating image every time you look down at your body, every time you look in the mirror, every time your reflection stares back at you from a cell phone screen or a darkened store window. Imagine that. That’s what my physical dysphoria is like, an optical illusion where my real image (young woman) and my brain’s expected image (young man) are constantly competing and my perception of the image is constantly changing to align with one or the other. I end up feeling disoriented and unsettled and completely detached from my own body.” He considered this – very carefully, very thoughtfully, as is his way – and then nodded. He truly seemed to have an accurate and empathetic understanding of my experience of anatomic dysphoria.

My Wife and My Mother-in-Law belongs to the class of optical illusions known as ambiguous images. (Podvigina 2015) Examples of other ambiguous images include the Rabbit Duck, Rubin’s Vase, Necker’s Cube, Winson Figure, and Spinning Dancer.

Many types of optical illusion create a perceived image that differs from the actual components of the figure based purely on the physical properties of the visual stimuli itself, properties such as shape, texture, contrast, and continuity of lines. These are often called literal optical illusions. Ambiguous images differ from literal optical illusions because the visual stimuli of ambiguous images allow multiple coherent cognitive perceptions to arise from the same image components. Literal optical illusions create a single inaccurate perception. Ambiguous images create multiple spontaneously shifting accurate perceptions – this experience is called multistable perception.

Multistable perception occurs when a static sensory stimulus is ambiguous and consistent with two or more mutually exclusive subjective interpretations; each interpretation is discrete and stable for a short period of time, but perception alternates between these different interpretations. (Leopold 1999, Eagleman 2001, Sterzer 2009, Schwartz 2012, Podvigina 2015)

[Note: multistable perception can occur in response to visual, auditory, olfactory, and tactile stimuli, but this phenomenon has been most extensively investigated with respect to visual sensory input. (Schwartz 2012) The rest of this post will focus exclusively on multistable perception in a visual context].

Characteristics of multistable perception include:

  1. Exclusivity: conflicting visual representations alternate but are never simultaneously present. There is no “average” or “combined” interpretation. (Leopold 1999, Schwartz 2012)
  2. Inevitability: alternations in perception are initiated spontaneously. (Leopold 1999, Schwartz 2012) The alternation process cannot be completely prevented, but alternations in perception are subject to limited voluntary control and may be influenced by the intention of the observer; control over the rate of perceptual alternation and stability of each percept improves with practice. (Leopold 1999, Sterzer 2009, Podvigina 2015)
  3. Randomness: durations of successive intervals of transiently stable percepts are unpredictable and characterized by sequential stochastic independence. The statistical properties of multistable alternations show similar distributions of dominance phases (which percept is dominant) across different types of stimuli and between individuals. (Leopold 1999, Schwartz 2012, Podvigina 2015)
  4. Dependence on awareness: perceptual reversals are very rare or even absent when observers do not know that alternative interpretational possibilities exist. (Podvigina 2015)

These traits of multistable perception also characterize my experience of anatomic dysphoria:

  1. Exclusivity: conflicting interpretations of my physical appearance seem to alternate but are never simultaneously present. I have been unable to achieve any consistent “average” interpretation of my physical features. My androgyny seems to be its own form of ambiguous image: androgynous ambiguity is consistent with two mutually exclusive interpretations – male and female – leading to multistable perception in my mind.
  2. Inevitability: these alternations in perception are initiated spontaneously. I cannot prevent them from happening whenever I see my body or my mirror image. I have limited voluntary control over which perception is dominant at any point in time.
  3. Randomness: the rate of alternation between conflicting perceptions of my physical appearance seems to be unpredictable and variable, which makes the experience confusing and unsettling.
  4. Dependence on awareness: perceptual reversals are very rare or even absent when observers do not know that alternative interpretational possibilities exist. I am constantly aware of multiple interpretations of my own appearance, so this trait is more obvious when I consider other people’s perceptions of my appearance. In situations where other people initially assume that I am either male or female, perceptual reversals occur only when the situational context later indicates that their interpretation of my sex may be inaccurate. The best example of this is when I’m standing alone in a public womens’ washroom. When women enter the washroom and first see me, their facial expression often indicates surprise (and sometimes alarm) because they interpret my appearance as male. Occasionally they ask me if I’m in the right washroom, but more often they step outside the washroom, check the sign on the door, and then, having confirmed that they are in a space designated for females only, they re-enter the washroom and re-evaluate my appearance. Now that they are aware of an alternative interpretation of my appearance, their facial expression shifts towards relief and acceptance as their mind realigns my features in a pattern recognizable as female. The Women’s Washroom Double-Take used to make me feel guilty for making someone else feel uncomfortable, but now generates more neutral interest as I observe their perceptual reversals in real-time.

“Ambiguous figures provide the experience of having one’s perceptual awareness switching between different options while at the same time remaining fully conscious that no physical stimulus change whatsoever underpins these vivid perceptual changes.” (Kleinschmidt 2012) This statement from an article reviewing the literature on multistable perception bears striking similarity to previous description of my own experience: “My appearance seems to change dramatically within the space of just a few minutes or hours… My image remains familiar and recognizable, but constantly different… 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.”

Unlike many optical illusions which create illusory perceptions primarily due to deficits in the visual system, ambiguous images (a form of multistable stimuli) are unique in allowing neural activity related to subjective conscious perception to be distinguished from neural activity related to objective physical stimulus properties. (Eagleman 2001, Sterzer 2009, Schwartz 2012) Evidence from several lines of empirical neuroscience (including functional magnetic resonance imaging and transcranial magnetic stimulation in humans and non-human primates) suggests that continuous processes in the frontal and parietal cortex are involved in constantly re-evaluating interpretations of sensory input and initiating changes in subjective perception, which results in the rapid and spontaneous perceptual alternations characteristic of multistable perception. (Leopold 1999, Sterzer 2009) These processes occur unconsciously during normal vision (almost all visual stimuli contain some degree of ambiguity that is rapidly and accurately resolved by this processing). This re-evaluation of perception only becomes consciously apparent when ambiguities in visual stimuli are maximized. (Leopold 1999, Eagleman 2001, Sterzer 2009) Multistable perception thus appears to be one component of an adaptive global process that generates a unified and coherent interpretation of the world, even though the information available to interpret is often fragmentary, conflicting, or ambiguous. (Sterzer 2009, Schwartz 2012) Multistable perception represents a kind of “stable instability” in subjective interpretation. (Schwartz 2012) And it seems that physical androgyny represents a particularly ambiguous image that is difficult for many people – myself and others – to interpret coherently.

The experience of multistable perception shows considerable individual variability. The rate of perceptual fluctuation tends to be consistent for a given person but varies by as much as an order of magnitude from one person to the next. (Leopold 1999, Schwartz 2012, Kleinschmidt 2012) Individual variation in the rate of perceptual alternation is associated with genetic factors, differences in brain structure (particularly in parietal lobe regions), and personal attributes including intelligence, creativity, and even mood disorders. (Leopold 1999, Kleinschmidt 2012, Podvigina 2015) Not only are there large individual differences in perceptual switch rates, there are also individual differences in preference for one percept over another – the preferred (dominant) interpretation of an ambiguous image is observed for a longer duration than the non-dominant interpretation over a period of spontaneous perceptual alternation. (Podvigina 2015) Certainly my personal experience aligns with this data. From my conversations with others regarding My Wife and My Mother-in-Law, it seems that I experience a much faster rate of perceptual reversal than most people: for me the image fluctuates very rapidly between the young woman’s face and the old woman’s face, while others describe something similar to what my psychiatrist described where perceptual switches occur less frequently and are more dependant on deliberate effort. It also seems that I experience less pronounced perceptual dominance than most people: I usually see the old woman’s face on first glance but during subsequent perceptual alternation it doesn’t feel like either face represents a more stable observation, while others generally describe that the perception of the young woman’s face is heavily dominant. So I wonder: do my individual characteristics associated with more rapid perceptual alternation and less pronounced perceptual dominance in response to multistable visual stimuli also contribute to my rapid shifts in perception and my difficulty maintaining a consistent interpretation of my own mirror image?

I think the optical illusion analogy is very valuable to help explain my experience of physical dysphoria. I have now refined this optical illusion analogy to refer more specifically to multistable perception that arises in response to viewing ambiguous images (particularly ambiguous images involving human faces). This new framework supports discussions with other people on the topic of anatomic dysphoria, and also provides a more concrete scaffold for me to construct a better understanding of my own experience.

Al Seckel, formerly considered one of the world’s leading authorities on illusions, referred to optical illusions as an experience where “expectations are violated” (TED, 2004). On my journey through Genderland thus far, I have radically re-evaluated personal and cultural expectations that I previously took for granted. I have deliberately distanced myself from restrictive and oppressive societal gender stereotypes and expectations. But now, I think I need to challenge myself even further. Does this multistable perception of my mirror image indicate the presence of some problematic expectations that my ambiguous androgyny somehow violates? Is it possible for me to deconstruct this distressing optical illusion to create a more comfortable, more coherent, and more stable cognitive interpretation of my physical appearance?

 “As much as I’d like to believe there’s a truth beyond illusion, I’ve come to believe that there’s no truth beyond illusion. Because, between ‘reality’ on the one hand, and the point where the mind strikes reality, there’s a middle zone, a rainbow edge where beauty comes into being, where two very different surfaces mingle and blur to provide what life does not: and this is the space where all art exists, and all magic.”
– The Goldfinch (Donna Tartt, 2013)

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References

Eagleman DM. Visual illusions and neurobiology. 2001. Nature Reviews | Neuroscience 2(12):920-926.

Kleinschmidt A, Sterzer P, Rees G. Variability of perceptual multistability: from brain state to individual trait. 2012. Philosophical Transactions of the Royal Society B: Biological 367(1591): 988-1000.  

Leopold DA, Logothetis NK. Multistable phenomena: changing views in perception. 1999. Trends in Cognitive Sciences 3(7):254-264. 

 Podvigina DN, Chernigovskaya TV. Top-down influences to multistable perception: evidence from temporal dynamics. 2015. International Scholarly and Scientific Research & Innovation 9(11):3849-3852.

 Schwartz J, Grimault N, Hupe J, et al. Multistability in perception: binding sensory modalities, an overview. 2012. Philosophical Transactions of the Royal Society B: Biological 367(1591):896-905. 

Sterzer P, Kleinschmidt A, Rees G. The neural bases of multistable perception. 2009. Trends in Cognitive Sciences 13(7):310-318.