Gratitude

Testosterone (Part 2): Assumptions and Questions

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prescriptions

————
Part 1: Drugs and Doses
~ Part 2 in the Testosterone series ~
————

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

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

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

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

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

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

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

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

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

More Mirror Magic

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more-mirror-magic

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

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

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

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

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

Still cheating.

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

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

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

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

Ambiguous Androgyny (Part 3): What You See

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

now-you-see-me-4

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

now-you-see-me-1

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

Ambiguous Androgyny (Part 2): Deconstructing an Optical Illusion

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

The Prestige

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

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

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

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

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

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

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

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

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

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

 “…yourself in the mirror?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3D Character Model

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

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

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

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

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

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

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

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

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

My body is my Prestige.

Abracadabra.

Prestige On Stage

————

References

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

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

Our Whole Foundation Cracks

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Sand Dunes

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

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

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

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

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

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

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

/ TomCat / 2 Comments

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

————
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. 

Proximity and Power

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Boxing (1)

I begin by skipping rope.

tap     tap     tap     tap     tap

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

tap   tap   tap   tap   tap

Faster now. 400.

tap  tap  tap  tap  tap

Faster still. 600.

tap tap tap tap tap

The rope just a blur. 800.

taptaptaptaptap

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

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

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

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

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

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

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

Jab
Crack

Jab
Crack
Cross
Crack

Breath
Shuffle back
One two
Rear hook
Crack

Breath
Head flicks
Sweat flies

Jab
Crack
Cross
Crack
Jab
Crack
Uppercut

Breath
Shuffle forward
Breath
Sweat drips
Breath

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

Breath
Breath
Breath

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

Boxing is not about masculinity.

Boxing is a dance.

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

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

Not A Simple Question

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Ashes

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

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

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

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

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

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

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

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

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

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

Unrelenting Darkness

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Unrelenting Darkness (1)

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

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

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

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

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

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

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

A Perplexing Dichotomy

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Perplexing Dichotomy

I had coffee with a friend this week and we were both wearing long-sleeve shirts with the sleeves rolled up past the elbows and our forearms resting on the table fairly close together. And I could not stop looking at his arms, distracted to the point that I had to work really hard to follow the conversation and force myself to look up and make eye contact. There was just an excruciating… rightness… about the way his arms were put together, the heavy sturdiness of his wrists and knuckles, the forearm muscles bunched up just below the skin, the veins so stark and prominent (only men’s veins look that way, I’ve never seen it even in very lean and fit women), his tattoos somehow emphasizing all of those things even more. It wasn’t a conscious comparison, it wasn’t sexual or even aesthetic attraction, it was just a painfully heightened awareness of how completely right that body was and an overwhelming ache to live inside a body like that.

This is the same way I feel whenever I see men of similar age and similar physical build as me: my brother (especially when he walks around the house shirtless, that ache becomes a knife through my spine), one of the male construction workers in the cafe as I write this (the way his shirt snugs mockingly over broad masculine shoulders, the mesmerizing peak of his Adam’s apple bobbing as he laughs with his coworker, another knife through my spine), male squash players (god, how their bodies cut me to shreds!), random men walking down the street, narrow hips in jeans, square jaws, deep resonant voices, all slashing, slashing, slashing away at me all the time, the pain mixed with a vicarious pleasure in imagining what it would be like to live inside those bodies.

So of course, with all of that, how could I possibly consider transitioning to any point but “all the way”? How could I ever be satisfied with less than what those men look like?

But then. Sometimes I feel so incredibly at home in this body that I have, especially when I exercise, every movement a genderless fusion of form and function. Yesterday I ran on the treadmill for the first time in months, sprint intervals at maximum speed. I could see my reflection in the windows in front of the row of treadmills and somehow it didn’t bother me at all, because I felt such an effortless and elegant lightness in my running body – I felt the way my legs stretched with each stride and the contact of my feet on the belt and the expansion of my chest with every breath – and I was overwhelmed by a glittering fragile heartbreaking gratitude for this body.

And in that moment I wondered why I’m considering transition at all… the thought of injections and scalpels and drugs seems like such a gruesome fate for that graceful running girl, like seeing a cheetah stretched out mid-sprint on the savannah while imagining her body splayed open on a necropsy table, organs weighed and measured and her beautiful wild life reduced to blood glistening on stainless steel. Could I really do that to myself? But how can I deny the lifelong compulsion for physical masculinity that has driven me to near starvation and lingers like a spectre in every mirror image? This is the most perplexing and painful dichotomy…

“Who in the world am I? Ah, that’s the great puzzle!”
– Alice (Alice’s Adventures in Wonderland, 1865)