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. 

Ambiguous Androgyny (Part 1): Recognizing an Optical Illusion

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

“Gender Identity” Needs To Disappear

Box Man (1)

I have spent much of the past two years researching gender dysphoria and exploring what it means to be transgender. This process has often been frustrating and confusing, as I have had considerable difficulty reconciling my intense physical dysphoria related to the female aspects of my body with the absence of any internal sense of “gender identity”. But after this prolonged immersion in the online trans community, in-depth review of the scientific literature on trans issues, and personal experience with transgender support groups and mental health professionals, the most prominent source of my chronic confusion has become apparent.

The “gender identity” concept, typical transgender narratives, and the criteria for diagnosis of gender dysphoria all depend on gender stereotypes – stereotypes which are increasingly irrelevant in modern society and which research overwhelmingly suggests are cultural constructs with limited biological underpinning. “One of the first steps to liberating people from the cage that is gender is to challenge established gender norms.” (Reilly-Cooper 2016) I think the dependance of “gender identity” discourse, trans narratives, and gender dysphoria diagnostic criteria on these gender norms actually serves to reinforce outdated and restrictive stereotypes rather than dismantle or challenge those stereotypes.

Much of this post will directly quote statements made by other authors in scientific review papers or online articles (bold indicates my own added emphasis). My goal here is not to simply repeat what has already been so eloquently stated elsewhere. I refer readers to the sources referenced at the bottom of this post for more thorough discussion of various related issues.

Instead, I wish to organize these statements within a coherent framework. This framework demonstrates a troubling and self-reinforcing cycle: the concept of “gender identity” relies on problematic gender stereotypes, the typical trans narrative relies on “gender identity” as an explanation and justification for choices regarding transition, and the diagnostic criteria for gender dysphoria use conventional gender norms as the frame of reference for assessment and diagnosis. In a clinical context, trans people are thus motivated to present their experiences in a way that aligns with opposite-gender norms to facilitate diagnosis of gender dysphoria and gain access transition options. But aligning themselves with cross-gender stereotypes necessarily (and paradoxically) requires acknowledgment of the restrictive and oppressive nature of those stereotypes which are associated so strongly (but unjustifiably) with biological sex. To counter this contradiction, trans people then invoke the concept of a discrete and inborn “gender identity” to assert the legitimacy of their experience.

(Note: This is a lengthy post with dense content. However, my conclusions are carefully derived from in-depth analysis of the concepts and research outlined throughout this post, so I encourage readers to work their way through my arguments slowly and sequentially to fully understand my final conclusions).

(1) “Gender Identity” Concept

“Gender identity is a highly problematic concept.” (Hird 2003)

Typical trans narratives strongly emphasize behaviors and preferences that align with cross-gender stereotypes as evidence of an intrinsic “gender identity”, based on a faulty assumption that there are inherent qualitative differences between men and women to support the existence of those stereotypes in the first place. The conceptualization of “gender identity” as an innate internal property is the “crucial tension at the heart of gender identity politics”. (Reilly-Cooper 2016)

“In this research, ‘gender identity’ is characterized as a sense of oneself as male, female, or indeterminate, whereas ‘gender role’ is characterized as behaviors, personality traits, and interests that society applies to these aspects, and the way that people are measured against stereotypical attributes.(Davy 2015) But is it really possible to separate “gender identity” from those “stereotypical attributes” that constitute “gender role”? To what extent do those “stereotypical attributes”, and the values and judgments that society assigns to those attributes, contribute to the development of “gender identity”?

I think “gender identity” is best understood as a constructed cognitive self-perception arising from internalized cultural gender stereotypes. “Gender variance may be conceptualized, as gender variant people apparently already do, as a multidimensional or sometimes idiosyncratically conceptualized, multicategorical construct. (Cohen-Kettenis 2009) “It is clear from feminist research that behaviors are not intrinsically masculine or feminine, but change through time and in different spaces… Gender constructionist research suggests that biological imperatives are few in the human, and consist only of procreative imperatives. Other behavioral aspects such as sartorial preference, aggression, empathy, and intelligence, among a number of other characteristics, are not sex specific and are often adaptable recent research situates behavioral sex differences firmly within a social role model… This unresolved debate weakens any possibility of arguing that there is something inherent in masculine and feminine behaviors. (Trans) people have never been subjects of an independent masculine or feminine type, and combinations of what is deemed masculine or feminine at any one time can be found within all humans, albeit performed with different intensities.” (Davy 2015)

Indeed, research regarding the development of identity during childhood consistently describes “gender identity” as an aspect of self-perception that develops and evolves over time in response to many internal and external factors. Factors contributing to the construction of gender identity include genetics, hormones, socialization, and progressive cognitive understanding of gender. (Hines 2011, Reiner 2011) “Gender development is multidimensional, and developmental processes involved in each dimension are likely to differ.” (Hines 2011) Gender identity is an evolving sense of self as one sex or the other.” (Reiner 2011) Evidence suggesting that “gender identity” develops and changes over time in response to many different factors directly contradicts the commonly held belief that “gender identity” is an innate and immutable property. The low rate of persistence of childhood gender dysphoria into adolescence also contradicts the idea that “gender identity” is an inborn and unchanging entity.

Gender identity is woven pervasively throughout identity.” (Reiner 2011) It is also clear that “gender identity” is simply one of many facets of identity which develop over time. Therefore, “gender identity” cannot be regarded as something discrete and separate from overall identity, and “gender identity” cannot be regarded as immune to the internal and external factors contributing to the ongoing development of overall identity.

“The precise mechanisms of gender identity development are complex, the interactions of the mechanisms poorly understood, and the outcomes not entirely clear, except that children and adolescents nearly always dichotomize.” (Reiner 2011) This tendency to dichotomize “gender identity” reflects persistent societal adherence to opposing gender stereotypes. Gendered socialization and the influence of this socialization on cognitive understanding of gender are major factors contributing to the development of “gender identity”. Socialization factors also gain in importance, as parents and then peers and eventually teachers encourage children to engage in gender-typed play. The child also begins to develop the understanding that he or she is male or female, and this knowledge produces motivation to imitate the behavior of others of the same sex.” (Hines 2011) As described above, this gendered socialization occurs despite the overwhelming evidence demonstrating that gender stereotypes have limited biological underpinning and that behaviors, preferences, personality traits, and cognitive functioning are not sex-specific attributes. (Hines 2011, Davy 2015) It is well established that societal gender stereotypes vary widely across different cultures and across different historical time periods (Hird 2003). This argues against any innate human “gender identity” giving rise to subsequent behaviors and preferences stereotypically associated with biological sex. Rather, it supports the idea that socially constructed gender norms give rise to individual “gender identity”.

I think the biggest weakness of the “gender identity” concept is that it is promoted as being real, immutable, and innate (endogenous) yet it remains so vague and poorly defined by those who claim to experience it. “The [trans] advocates’ websites rarely offer any indication of what feeling like a man or a woman is like.” (Davy 2015) Attempts to describe what “feeling like a man” or “feeling like a woman” means invariably fall back on conventional societal (exogenous) masculine or feminine stereotypes. This creates a frustratingly circular logic: “gender identity” is a property that is supposedly experienced internally (and therefore cannot be denied by an external perspective) but which cannot be defined in any way separate from externally imposed gender norms.

This has been extremely perplexing for me. This is why I have tried very hard to describe my experience of gender dysphoria in a concrete and clearly defined way that does not depend on reference to an internal “gender identity”. My previous blog posts (here, here, and here) have recounted the distressing thoughts and emotions that arise in response to seeing or touching the female secondary sexual characteristics of my body. This is the only way I can explain my experience without resorting to dichotomous gender stereotypes.

I do not know WHY my female anatomy generates such intense distress for me. I only know that it DOES. It would certainly be convenient to say that my physical dysphoria is secondary to a mismatch between my anatomy and my “gender identity”. But I fail to understand the concept of “gender identity” and I refuse to align my personal preferences and behaviors and interests with problematic and oppressive gender stereotypes for the sake of convenience. My female body (and the irrational but undeniable distress arising from my perception of it) and my human personality (my preferences, behaviors, and interests) are two separate things. “Gender is the value system that ties desirable (and sometimes undesirable?) behaviours and characteristics to reproductive function. Once we’ve decoupled those behaviours and characteristics from reproductive function – which we should – and once we’ve rejected the idea that there are just two types of personality and that one is superior to the other – which we should – what can it possibly mean to continue to call this stuff ‘gender’? What meaning does the word ‘gender’ have here, that the word ‘personality’ cannot capture? (Reilly-Cooper 2016)

Some might argue that my claiming an absence of “gender identity” merely represents an “agender” or “non-binary” identity along a “gender spectrum”. But those terms are simply variations on the original “gender identity” concept, and therefore remain inapplicable. Rebecca Reilly-Cooper presents an excellent series of arguments explaining why the conceptualization of gender as a spectrum is not really any more progressive or inclusive than a gender binary with two opposite poles. Rather, the concept of gender as a spectrum is illogical. I encourage readers to review her essay in full but will summarize her conclusions here: “If gender identity is a spectrum, then we are all non-binary, because none of us inhabits the points represented by the ends of that spectrum… Once we recognize that the number of gender identities is potentially infinite, we are forced to concede that nobody is deep down cisgender, because nobody is assigned the correct gender… at birth. In fact, none of us was assigned a gender… at birth at all. We were placed into one of two sex classes on the basis of our potential reproductive function, determined by our external genitals. We were then raised in accordance with the socially prescribed gender norms for people of that sex. We are all educated and inculcated into one of two roles, long before we are able to express our beliefs about our innate gender identity, or to determine for ourselves the precise point at which we fall on the gender continuum. So defining transgender people as those who at birth were not assigned the correct place on the gender spectrum has the implication that every single one of us is transgender; there are no cisgender people. The logical conclusion of all this is: if gender is a spectrum, not a binary, then everyone is trans. Or alternatively, there are no trans people. Either way, this a profoundly unsatisfactory conclusion, and one that serves both to obscure the reality of female oppression, as well as to erase and invalidate the experiences of transsexual people. The way to avoid this conclusion is to realize that gender is not a spectrum. It’s not a spectrum, because it’s not an innate, internal essence or property. Gender is not a fact about persons that we must take as fixed and essential, and then build our social institutions around that fact. Gender is socially constructed all the way through, an externally imposed hierarchy, with two classes, occupying two value positions: male over female, man over woman, masculinity over femininity.” (Reilly-Cooper 2016)

(2) Typical Transgender Narratives

As a highly pathologized, stigmatized, and marginalized community, trans people are placed in a very difficult position with respect to how they describe their experience. In a clinical context, trans people must present their narrative in a way that meets the established diagnostic criteria for gender dysphoria (criteria which are based on “cross-gender identification” and evidence of behaviors and preferences stereotypically associated with the “other sex”) in order to gain access to transition therapies. In a public context, trans people must present their stories in a way that is understandable to society at large, in order to promote awareness and acceptance. Because gender stereotypes are so deeply woven into the fabric of our society, describing trans experiences in terms of strong preferences for opposite-sex stereotypes arising from an innate “gender identity” allows a publicly palatable and understandable (albeit oversimplified and problematic) narrative to emerge from within an already well-established gender framework.

“Research has suggested that adult transpeople often think that if they do not express stereotypical masculinities and femininities… they will not fit the model that may steer them to the transitioning healthcare pathways… many transpeople are reluctant to relay anything to gender clinic psychiatrists that might be viewed as different from the perceived “correct” trans narrative. In previous research, I have demonstrated that transpeople tend to tailor their clinical narratives because they realize that psychiatrists have the power to stop their transitioning process… transpeople retrospectively claim to have participated in stereotypically gendered play and behaviors when they have sought transitioning technologies, and have often interspersed expected gender inflections into their clinical narratives… These inflections seem inevitable because the diagnostic criteria expect cross-gendered play and behaviors to be performed prior to the granting of transitioning technologies…  the clinically expected expressions of gender do not correspond well to gender role play or leisure pursuits apparent in contemporary society.” (Davy 2015)

The typical or “correct” trans narrative seems to include these main elements: strong retrospective emphasis on the early onset of gender dysphoric feelings in childhood which persisted into adolescence and adulthood, gender dysphoric feelings arising primarily from discomfort with societal gender stereotypes, assertion of a supposedly intrinsic and fixed “gender identity”, and physical dysphoria portrayed as a secondary consequence of a primary mismatch between the brain’s “gender identity” and the body’s “assigned sex”. To put it more simply, the typical trans narrative says: from a young age my personality and preferences did not align with conventional binary gender roles and gender stereotypes, therefore I must have a cross-gender or non-binary “gender identity”, therefore I must be transgender, therefore I am trapped in the wrong body, therefore my body needs to be changed to align with my “gender identity”. “Transpeople have often defined their trans gender identities through a ‘‘wrong body’’ narrative.” (Davy 2015)

Typical trans narratives not only emphasize the concept of an innate “gender identity”, they also imply that this cross-sex “gender identity” is the result of pre-natal biological factors. “Trans advocates’ essentialist claims of gender dysphoria seem to assume that society will be more accepting of transpeople if they are understood to have been ‘‘born this way”… [due to] the relative power that biogenetic discourses maintain in society and particularly in medicine.” (Davy 2015) The etiology of gender dysphoria is not clearly understood, but one of the most common theories is that exposure to altered levels of sex hormones during fetal development leads to “sex-atypical cerebral programming that diverges from the sexual differentiation of the rest of the body”. (Hoekzema 2015) However, “no evidence thus far has linked normal variability in the early hormone environment to gender dysphoria.” (Hines 2011) Additionally, people with disorders of sexual development (intersex conditions) that do cause abnormal exposure to sex hormones in utero overwhelmingly maintain a “gender identity” that aligns with the sex they were assigned at birth, rather than with the sex that their pre-natal hormone exposure more closely mimics (Hines 2011, Reiner 2011). “The majority of intersex people identified their gender as their sex assigned at birth.” (Reiner 2011) For example, female fetuses (XX chromosomes) with congenital adrenal hyperplasia have a genetic defect in adrenal enzyme pathways that leads to accumulation of androgens (such as testosterone) in the fetus’ body and causes pre-natal virilization of the female genitals. These infants are assigned female at birth. Despite high levels of pre-natal androgen exposure and masculinized genitalia, 97% of women with CAH identity as female from childhood into adulthood (Hines 2011). Male fetuses (XY chromosomes) with androgen insensitivity syndrome have normal testes and normal androgen production but lack androgen receptor molecules, which means that testosterone produced by the testes has no effect on the developing fetus. Androgen insensitivity impairs the masculinization of male genitalia in the developing fetus and the development of male secondary sexual characteristics during puberty. These XY individuals are often raised as females (particularly in cases of complete androgen insensitivity) and maintain a female “gender identity” despite having a male chromosomal configuration. (Reiner 2011) These examples provides strong evidence that “gender identity” is influenced more strongly by socialization and external gender expectations than internal biological factors like sex hormone exposure or sex chromosomes.

The typical trans narrative centers around a supposedly innate “gender identity” as an explanation for their discomfort in the body and the social role associated with their biological sex and as justification for their choices regarding transition. But as I outlined above, the concept of “gender identity” as a fixed internal property has no logical or scientific basis and relies entirely on an external frame of reference (societal gender stereotypes). “Trans advocates’ essentialist claims of gender dysphoria… and the desire to transition to a particular gender tend to mirror the simplistic dualisms from biological research, in which masculinity and femininity are regarded as natural, rather than socially constructed, characteristics.” (Davy 2015) So the emphasis on, and continued perpetuation of, the “gender identity” concept by trans advocates only serves to reinforce outdated and oppressive stereotypes.

(3) Gender Dysphoria Diagnostic Criteria

“Gender dysphoria is not always a straightforward diagnosis. This can be ascribed to the fact that international classifications are quite general and have significant short-comings, there are no objective criteria, and gender dysphoria can present in a great diversity of forms, situations, and experiences.” (Fabris 2015)

Most of the medical and psychological research regarding gender dysphoria has been based on diagnostic criteria in the American Diagnostic and Statistical Manual of Mental Disorders (DSM). I have focused on articles published since 2000, which usually refer to the diagnostic criteria for gender identity disorders in the DSM-IV and DSM-IV-TR (published in 1994 and 2000, respectively) or the criteria for gender dysphoria in the DSM-5 (published in 2013). However, some recent studies still refer to the criteria for gender identity disorders in the WHO International Statistical Classification of Diseases, the ICD-10 (published in 1993).

With respect to the DSM criteria, there is a glaring lack of validity studies or evidence supporting inter-rater reliability in the diagnostic process (Cohen-Kettenis 2009). It has been suggested that validity of the DSM diagnostic criteria can be inferred from studies evaluating sex reassignment as a treatment procedure. “Sex reassignments based on DSM diagnoses primarily resulted in satisfying results, in terms of alleviating the discomfort about one’s sex or the ‘gender dysphoria.’ Although diagnosis and response to sex reassignment are not very closely connected, and the reported findings are certainly no ‘‘proof’’ of the correctness of the diagnosis, they suggest that the elements of the DSM diagnosis are clinically useful.” (Cohen-Kettenis 2009) However, in the studies referenced by that statement, most of the subjects underwent “complete” sex reassignment. So the inferred clinical utility of DSM criteria may only apply to those who desire all aspects of sex reassignment, which is not representative of the transition goals of all trans people. “Indeed, clinicians in gender identity clinics are increasingly confronted with treatment goals other than complete sex reassignment.” (Cohen-Kettenis 2009) So the utility of the existing diagnostic criteria is, at best, limited to a subpopulation of the diverse transgender community.

One of the primary criticisms regarding the diagnostic criteria for gender identity disorder in the DSM-IV and DSM-IV-TR was the inability of the criteria to reflect the diversity of gender variance. “A problem with the current criteria is that gender identity, gender role, and gender problems are conceptualized dichotomously rather than dimensionally. For instance, the DSM-IV text states that adults with gender identity disorder are preoccupied with their wish to live as a member of the other sex, manifested as an intense desire to adopt the role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Within the gender identity disorder criteria, a concept such as ‘‘cross-gender identification’’ also assumes that there are only two gender identity categories, male and female.” (Cohen-Kettenis 2009) I have previously discussed my frustration that even supposedly dimensional (rather than dichotomous) scales used to measure the intensity of gender dysphoria (such as the GIDYQ-AA) leave little room for non-binary responses, and interpretation of the questions on the survey relies heavily on the reader’s alignment with stereotypical roles behaviors associated with men and women.

Prior to publishing the updated version of the DSM (DSM-5) in 2013, a workgroup was developed to revise the gender identity disorder criteria. One of the biggest revisions was a change in diagnostic terminology from gender identity disorder to gender dysphoria, to emphasize the distress associated with gender variance as being a form of psychopathology rather than gender non-conformity being considered pathological in and of itself. The goal of the workgroup was to revise the criteria in a way that would help destigmatize trans people while maintaining a diagnostic category that medical insurance companies would accept to provide financial support for transition treatments. (Davy 2015)

However, despite those revisions, the current DSM-5 criteria for gender dysphoria remain problematic. “The diagnostic framework in the DSM-5 for all transpeople continues to be underpinned by essentialist, heteronormative assumptions that situate binary sexes – male and female – with corresponding genitalia as the anchor from which gender dysphoria is judged… I would argue that the criteria proposed by the DSM-5 are derived from stereotypes applied in the gender identity clinics serving transpeople, rather than empirically developed from biological imperatives.(Davy 2015)

Particularly disturbing is the fact that the research and clinical experience taken into account in revising the DSM-5 diagnostic criteria was based heavily on trans peoples’ clinical narratives, which (as I described above) are often tailored with added gender inflections to align more closely with the previously established criteria in order to gain access to transition options. “The DSM-5 Workgroup has disregarded the plethora of work in feminist social science which criticizes the inherency of gender roles, gender identities, and sex differences, as well as research in transgender studies that depicts non-dysphoric transpeople, desires for different embodiments, non-conventional transitioning trajectories, and sexualities. In the pre-publication reports, the Workgroup considered only the views and evidence derived from sexological research. As such, the review reflects a form of expert clinical consensus based on transpeople’s tailored narratives and questionable ideas around masculinity and femininity.(Davy 2015)

Such a narrow-minded approach to developing diagnostic criteria based on increasingly irrelevant and biologically unjustified gender stereotypes creates a self-perpetuating cycle: trans people present their experiences in ways that align with the criteria, and the criteria are then perceived as being reinforced and validated by their alignment with trans people’s narratives. “The criteria used to diagnose gender dysphoria help psychiatrists to determine whether someone is experiencing distress about incongruence with their experienced gender through a gender normative frame… Arguably, this leads to the situation where transpeople must express incongruent behavior and demonstrate to the psychiatrist that they have most often preferred activities that are traditionally gendered and opposite to those gender norms applied to their assigned sex at birth. Within the DSM-5, these traditional gendered expressions seem to be required in spite of the lack of stark behavioral differences between the genders in Western societies today.” (Davy 2015)

And the ongoing emphasis on “gender identity” as part of the typical trans narrative and as a core diagnostic criterion further reinforces restrictive societal stereotypes. “[Most gender clinic psychiatrists] adhere to gender identity as both ‘‘real’’ and fixed. This adherence then facilitates the continued use of highly stereotyped notions of gender to provide the framework for assessing and treating transsex individuals.” (Hird 2003)

Neither the diagnostic framework nor the professionals involved in the diagnostic process seem to recognize these problems. “Most of the clinicians seemed to take the view that individual solutions are to be sought rather than societal change – there was little suggestion that society requires any change… the clinician’s job is not to reinforce gender boundaries defined by society.” (Hird 2003)

(4) Transition as Self-Determination

I have outlined the major issues regarding the concept of “gender identity”, typical transgender narratives, and the criteria for diagnosis of gender dysphoria. I have expressed my concern that the continued dependence of “gender identity”, trans narratives, and diagnostic criteria on traditional gender norms serves to reinforce restrictive and damaging stereotypes.

My conclusion is that an inborn, immutable, intrinsic “gender identity” DOES NOT EXIST. “Gender identity” is a cognitive aspect of self-perception constructed from internalized societal gender stereotypes. The idea of an innate “gender identity” is a crutch that trans people are forced to use to legitimize their experience in the face of a society that revolves around these oppressive gender stereotypes and a psychiatric establishment that retains these troublesome stereotypes as the frame of reference for assessment and access to transition options.

A self-determination and human rights model of trans identities views the diagnostic use of stereotypical gendered expressions associated with boys/men and girls/women as erroneous, and that they have little to do with actual contemporary gender identity formations. Accordingly, any gendered expressions, regardless of which birth-assigned sex one is given, should not act as criteria for diagnosing transpeople.” (Davy 2015)

For those who argue that inclusion of gender variance under the umbrella of psychiatry is necessary to allow access to medical and legal transition options, I would point out that some countries have already set a precedent where this is not the case. “Psychiatric involvement in healthcare pathways and legal assistance for those people who want to have a different body and/or corrected legal gender assignment should not be a requirement. They have succeeded in securing this in France, Denmark, Argentina, and Malta. In these countries, transpeople are legally recognized and are given access to healthcare services despite psychiatry being removed as the gatekeeper, because of transpeople demanding healthcare and legal recognition through a self-determination model of gender variance.” (Davy 2015)

“The solution is not to reify gender by insisting on ever more gender categories that define the complexity of human personality in rigid and essentialist ways. The solution is to abolish gender altogether. We do not need gender. We would be better off without it. Gender as a hierarchy with two positions operates to naturalize and perpetuate the subordination of female people to male people, and constrains the development of individuals of both sexes… You do not need to have a deep, internal, essential experience of gender to be free to dress how you like, behave how you like, work how you like, love who you like… The solution to an oppressive system that puts people into pink and blue boxes is not to create more and more boxes that are any colour but blue or pink. The solution is to tear down the boxes altogether.” (Reilly-Cooper 2016)

“Gender identity” needs to disappear. “Transition” should be removed from a gender context and the term “transgender” should be rendered obsolete. Instead, the medical, legal, and social aspects involved in “transition” should be viewed – simply and respectfully – as a human right to self-determination. “Assuming an inner-self who desires such a transformation, gender transitions are thus situated in a non-essentialized experiential framework, anchored in self-determination.” (Davy 2015) People – ALL people, not just trans people – should be free to modify their physical attributes, adopt social roles, and pursue interests that align with their personal preferences and desires. We are all of us “transitioning” all the time, as we learn and grow and adapt to an ever-changing world. “Transition” (in a transgender context) is just one of many ways that people strive for self-expression that makes them feel comfortable. “Transition” (in a human context) is an ongoing process for each of us to create an authentic self in this vast ocean of human diversity.

“If there’s no meaning in it, that saves a world of trouble, you know, as we needn’t try to find any.”
– The King (Alice’s Adventures in Wonderland, 1865)

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References

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

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

Fabris B, Bernardi S, Trombetta C. Cross-sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3): 269-82. 

Hines M. Gender development and the human brain. 2011. Annual Review of Neuroscience 34: 69-88. 

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

Hoekzema E, Schagen SE, Kreukels BPC, et al. Regional volumes and spatial volumetric distribution of gray matter in the gender dysphoric brain. 2015. Psychoneuroendocrinology 55: 59-71. 

Reilly-Cooper R. Gender is not a spectrum. 2016. Aeon. Accessed online 2016-07-10. (Quotes in this post were extracted from the Aeon article. However, a similar essay also appears on the author’s personal blog More Radical With Age“Gender is not a binary, it’s a spectrum: some problems”, January 2016).

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. 

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

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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 in the Gender Dysphoria Diagnosis series ~ 
Part 5
: GIDYQ-AA Full Text

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DSM-5

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

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

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

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DSM-III (1980)

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

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

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

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DSM-III-R (1987)

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

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

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

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

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

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ICD-10 (1993)

Gender Identity Disorders (F64)

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

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

Gender Identity Disorder of Childhood (F64.2)

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

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

Other Gender Identity Disorders (F64.8)

Gender Identity Disorder, Unspecified (F64.9)

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

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

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

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

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

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

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

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

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

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

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

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DSM-V (2013)

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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Jantina Cow

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

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

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

Jantina Dress

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jantina Rope Ladder

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

Jantina Dirtbike

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

Jantina Peter Pan

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

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

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References

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

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

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

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

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

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

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

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

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

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

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Full text of the GIDYQ-AA (male and female versions) available in Part 5.
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For several months I have been seeing a psychiatrist who specializes in working with transgender people. The initial assessment was a comprehensive three hour interview which began with me filling out the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). The GIDYQ-AA was developed in 2007 as a dimensional measure of gender dysphoria (dimensional referring to a concept of gender as a spectrum rather than two opposite poles) (Deogracias 2007). Among populations of heterosexual and nonheterosexual university students and clinic-referred patients with a diagnosis of gender identity disorder (the old term for what is now called gender dysphoria), the questionnaire showed “strong evidence for discriminant validity in that the gender identity patients had significantly more gender dysphoria than both the heterosexual and nonheterosexual university students.” (Deogracias 2007) Further experimental evaluation of the GIDYQ-AA showed similar results and reinforced the utility of the questionnaire in the assessment of patients with gender identity concerns (Singh 2010).

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

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

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

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

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

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

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

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

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

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

The only questions I could answer with any confidence were:

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

Not Applicable

Not Applicable

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

Gender Bender Award Graphic

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)

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References

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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.

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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.