Self Portrait #1

self-portrait-1-final

Drawing this self portrait was a fascinating experience.

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

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

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

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

self-portrait-1-laptop

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

Time: 6  hours

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

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

self-portrait-1-wip

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

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. 

The Boy with the Crooked Smile

Crooked Smile

My fellow patients on the psychiatric unit are certainly an interesting cast of characters. Of course I wonder about their stories, I wonder what combinations of pain and circumstance and bad luck (and maybe good luck too?) have brought them here. And for all of them, I harbor a detached empathy, an impersonal hope that they can find their way back to their lives. Even so, I try as much as possible to avoid interacting with the other patients. Most of the time I lack the energy for superficial conversations. And I lack the imagination required to use small talk as a shield from the reality of our situation, the fact that we’re all here on the psych ward, that the locked unit doors are under video surveillance, that we’re all under the influence of the many multicolored pills we swallow every morning. My personal rainbow is red, white, and yellow.

I avoid the other patients too because many of them seem to have lost appropriate social inhibitions along the way, often spewing rude and abusive comments that I get so tired of deflecting and increasingly less willing to tolerate. I also get so tired of other patients asking my name, mispronouncing it, mispronouncing it again when I correct them, and eventually just inventing their own bastardized version of my three easy syllables because my name is too much effort for them. And finally, I avoid the other patients out of a desperate instinct of self-preservation – it takes all my strength to remain focused on my own therapeutic goals, and I just can’t afford to be distracted by caring too much about anyone else on the unit. They are here for their problems, I am here for mine – I can’t forget that.

Though I intentionally maintain this safe detachment from the other patients, I cannot help but watch them all with involuntary interest. There’s The Watchman, always lurking at the end of the hall where the lights are dimmest, his dark restless eyes seeming always to be fixed on me, the hood of his black sweater drawn up around his face like the cowl of a vigilant monk. And old Abraham Lincoln – the resemblance really is uncanny – who never seems to leave the spindly chair by the courtyard windows, his lanky body folded up like an oversized praying mantis. Sleeping Beauty, who emerges from her room only rarely and wears her hospital gown like an elegant cascading dress, floating through the hallways with a radiant self-absorption and a distended pregnant belly preceding her quiet footsteps. Eyebrows, whose bushy black brows dominate his placid face and create an expression of perpetual confusion, his eyebrows dancing up and down to punctuate each spoken word, each sideways glance, each bite of food. Santa Claws, with his leering eyes and scraggly food-littered beard, his leather Harley Davidson jacket and fingers decked out with silver skulls, hands so grotesquely swollen that the rings are nearly buried by the bulging flesh, his long and fungally discolored toenails scraping the floor like ugly claws. Serene, with coiffed gray hair and deep grooves running down from the corners of her mouth like a ventriloquist’s dummy, who complains endlessly about the smell of dust, who marches back and forth across the same few feet of floor holding her diaper in place with both hands, often shouting at nobody in particular, “I just want peace of mind! You have peace of mind! Why can’t I have peace of mind? I used to be a spiritualist, you know. I used to be able to enter the spirt world but I can’t anymore. I just want peace of mind!” (We all ignore her outbursts, no-one here has peace of mind). And there’s The Howler, heard but never seen beyond one brief glimpse of a bare torso twisted across a mattress on the floor of the high-obs room, his chillingly inhuman screams filtering through the corridors at all hours of the day and night.

All of these patients I regard with a carefully cultivated detachment. Except for Cody.* I am drawn to him with a startling and shattering compassion that slices through my cautious distance and makes my heart ache. I don’t know why. Perhaps it is his physical resemblance to my brother – same endearingly disheveled hair, same ice-blue eyes, same roguish youthful handsomeness, same lingering hint of unwashed masculine musk. Perhaps it is my own selfish desire to inhabit such an effortlessly narrow-hipped, broad-chested body, the masculine alignment of his bones and muscles so achingly appealing to my girl-trapped brain.

Or perhaps it is that Cody’s demons are more outwardly obvious than most other patients on the ward. He cannot hide his battles with monsters I can’t even imagine. His blue eyes rarely register the real world around him, focused instead on high invisible shelves that he stretches up to reach, invisible barriers on the floor that he probes carefully with dirty bare feet, invisible companions sitting in the empty chairs beside him. All of his movements are slow and tense and deliberate, coherent only in a separate world the rest of us can’t see. And all these movements are narrated by his ceaseless whispering, too quiet to hear the words themselves, just a soft susurration like butterfly wingbeats. Occasionally he is interrupted from these explorations of his invisible world – quite suddenly his entire body stiffens, his head snaps to the side, his mouth stretches in a soundless scream, and a series of tremors rattle through his rigid slender body until – just as suddenly – his body stills, he blinks, looks around dazedly, and resumes whispering.

Perhaps I am drawn to Cody by a powerful but unfamiliar protective instinct – a parental sort of protectiveness, perhaps, although in my case neither maternal nor paternal – an irrational hope that if I could just fold him in my arms and shield him from the world (real and invisible) then I could somehow absorb his pain and leave him whole. Even if it killed me. I wonder if this is how my parents feel when they watch my struggle with depression. I wonder if I underestimate how hard this might be for them, how strong the instinct to protect and shelter, if this boy I barely know can draw such fierce protectiveness from my cautious heart.

But I think, more than anything, I am drawn by Cody’s smile. I have seen it only once, walking past him in the hallway. He was engaged in a repetitive pulling motion, as though he were dragging something heavy up towards his chest, his whispers seemingly directed at the evidently irksome object. As I walked closer, his hands stilled and his whispers faded and his bright blue eyes met mine – and I could see the crystal clarity suddenly alive behind the blue. The ghost of a smile tugged at the corner of his mouth – a tiny crooked smile climbing up and crinkling the corners of his eyes as his head dipped in a respectful nod of recognition. A thready filament of connection hovered between us for a moment – the flash of recognition in his eyes heartbreaking and unmistakable – until suddenly the thread snapped, his eyes dropped downwards, his whispering resumed, and just like that – with all the finality of a guillotine blade – his moment of awareness was abruptly severed.

So now whenever his path crosses mine, I find myself searching his face for that crooked smile, that awareness, that flash of recognition, searching with a desperate selfish reckless caring that takes my breath away. I see you, Cody. I’m here. I know you’re there too. But he remains lost in his world of whispered things.

But he left me one more smile. After breakfast one morning, he shuffled into the dining room two hours late but I’d asked the nurse to save his tray. He attempted to eat at first but quickly lost track of his fork, his gaze drifting off, his whispering more fervent, and began lifting invisible items up off the floor. As he leaned down, the bunching of the muscles in his back was visible through the gap of his hospital gown – hard knobs of vertebrae protruding between the trailing strings he didn’t finish tying – that gap in his gown a green-rimmed sliver of heart-wrenching vulnerability. Then his attention shifted to his paper menu and, slowing picking up a nearby pencil, he began writing. Eventually he abandoned his writing and drifted away – whispering and shuffling – and I could see the scrap of paper he’d left behind. It was a list of names, I’m not sure who they are, scrawled in the overlarge and messy handwriting of a child. Near the bottom, the “r” in Tyler – with unexpected whimsy – was drawn as a stick figure with arms outstretched. Below the names, he wrote two statements: “walking sucks run” and “40 like steves as you say” – not quite nonsense, not quite sense – followed by a pencilled crooked smile. I see you, Cody. I know you’re there too.

*Not his real name.

A perfect smile is more appealing but it’s funny how
My shit is crooked, look at how far I done got without it
I keep my twisted grill, just to show them kids it’s real
We ain’t picture perfect but we worth the picture still
– J Cole (Crooked Smile, 2013)

Zero Dollar Haircut

Zero Dollar Haircut (Final)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

————

References

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

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

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

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

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

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

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

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

Falling Out of the Closet

Falling Out of the Closet (1)

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

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

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

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

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

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

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

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

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