Testosterone (Part 2): Assumptions and Questions

prescriptions

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

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

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

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

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

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

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

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

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

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
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The Prestige

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

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

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

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

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

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

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

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

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

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

 “…yourself in the mirror?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3D Character Model

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

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

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

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

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

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

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

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

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

My body is my Prestige.

Abracadabra.

Prestige On Stage

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References

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

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

Ambiguous Androgyny (Part 1): Recognizing an Optical Illusion

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~ Part 1 in the Ambiguous Androgyny series ~
Part 2: Deconstructing an Optical Illusion
Part 3: What You See
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my-wife-and-my-mother-in-law

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

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

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

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

“I continue to stare at those reflections and images of myself with the unsettling mixture of curiosity, frustration, and disorientation that comes with trying to unravel a particularly puzzling optical illusion.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Characteristics of multistable perception include:

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

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

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

“Ambiguous figures provide the experience of having one’s perceptual awareness switching between different options while at the same time remaining fully conscious that no physical stimulus change whatsoever underpins these vivid perceptual changes.” (Kleinschmidt 2012) This statement from an article reviewing the literature on multistable perception bears striking similarity to previous description of my own experience: “My appearance seems to change dramatically within the space of just a few minutes or hours… My image remains familiar and recognizable, but constantly different… I know with certainty that it is not physiologically or anatomically possible for any human body to change that much in such a short period of time. I know this. I remind myself of that over and over. Yet what I keep seeing with my own eyes, right there in front of me, incontrovertible visual evidence, is this shape-shifting mirror-ghost of a body that I cannot imagine I actually inhabit.”

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

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

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

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

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

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References

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

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

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

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

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

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

“Gender Identity” Needs To Disappear

Box Man (1)

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

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

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

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

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

(1) “Gender Identity” Concept

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

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

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

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

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

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

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

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

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

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

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

(2) Typical Transgender Narratives

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

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

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

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

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

(3) Gender Dysphoria Diagnostic Criteria

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

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

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

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

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

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

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

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

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

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

(4) Transition as Self-Determination

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

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

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

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

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Jantina Cow

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

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

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

Jantina Dress

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jantina Rope Ladder

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

Jantina Dirtbike

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

Jantina Peter Pan

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

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

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References

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

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

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

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

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

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

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

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

Gender Dysphoria Diagnosis (Part 2): Psychological Benefits of Diagnostic Confirmation

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Part 1: GIDYQ-AA Personal Reflection
~ Part 2 in the Gender Dysphoria Diagnosis series ~
Part 3: Childhood Gender Non-Conformity
Part 4: DSM and ICD Diagnostic Criteria
Part 5: GIDYQ-AA Full Text
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Unicorn

In a previous post, I described the intense relief and peacefulness that I felt after receiving confirmation of a diagnosis of gender dysphoria from an experienced psychiatrist. Confirmation of the diagnosis helped reduce the overwhelming doubt and uncertainty (what’s wrong with me? do I really have gender dysphoria? or is this something else?) and helped me move towards acceptance. Acceptance of gender dysphoria facilitated the freedom to start considering transition options without being constantly tugged backwards by relentless nagging doubt regarding the diagnosis itself.

From my personal experience, it seems that most trans people have a strong intrinsic sense of their own gender identity and most trans people feel much more confident than I did in aligning themselves with the established criteria for gender dysphoria and in pursuing transition. My psychiatrist, who specializes in working with transgender people, told me that most of his patients are confident regarding their transition goals and just need help accessing resources to transition when they initially present to his clinic. One study described a group of adolescents referred for assessment at a gender clinic in Finland: “During the assessment process, 72% (34/47) of the applicants were sure about feeling they were of the opposite sex to their natal and about pursuing sex reassignment, but 28% (13/47) were not sure about their feelings regarding gender identity and/or sex reassignment.” (Kaltiala-Heino 2015) Those results support my anecdotal impressions that the majority of trans people feel certain about their gender identity and transition goals.

But even for trans people who are more certain of their gender identity and transition goals than I was, the potential psychological benefit derived from diagnostic confirmation of gender dysphoria should not be underestimated.

A prospective study published in 2014 evaluated the psychological response to different steps in gender reassignment therapy in people with gender identity disorder (GID) (the old term for what is now called gender dysphoria). “To our knowledge, it is the first publication that focuses on the effects of the separate parts of the sex reassignment therapy.” (Heylens 2014)

The study recruited participants from a population of patients who applied for sex reassignment therapy at a Gender Clinic in Belgium. These patients had not previously received a diagnosis of GID and had not initiated any medical aspects of transition (such as hormone therapy or surgery) prior to applying to the Gender Clinic. A total of 82 patients agreed to participate in the study after giving informed consent, however 12 were excluded from the study because they did not meet the criteria for GID (they were instead given the diagnosis of GID-NOS, gender identity disorder not otherwise specified), another 12 patients were excluded from the study because they did not undergo “full treatment (hormonal and surgical)” due to psychiatric/medical comorbidities (3 patients) or personal preferences regarding transition goals (9 patients), and 1 patient was excluded from the study because they committed suicide during follow up. This left 57 patients in the study (46 MTFs and 11 FTMs) diagnosed with GID who completed all steps (hormonal and surgical) in the gender reassignment process.

Supporting the results of many previously published articles, this study showed that, “Sex reassignment therapy does influence the level of psychopathology in GID patients, with significant reduction in anxiety, depression, somatization, psychoticism, interpersonal sensitivity, hostility, and overall psychoneurotic distress… after treatment, the majority of patients indicated that they have a better mood, are happier, and feel less anxious than before. They also seem to be more self-confident and encounter a better body-related experience, indicating a less distorted self-image than before treatment.” (Heylens 2014)

Of particular relevance here, the results from this study showed that out of all the steps involved in gender reassignment therapy, confirmation of the GID diagnosis and initiation of hormone treatment were associated with the greatest psychological benefit. “The most important effect seemed to result from the confirmation of the diagnosis and the initiation of hormone therapy.” (Heylens 2014) The results strongly suggest that diagnostic confirmation of GID is, in itself, a very important and affirming step for patients.

However, based on the participant exclusion criteria, I think the results of this study may actually underestimate the positive psychological effects of diagnostic confirmation. The study excluded patients who did not strictly meet the GID criteria (an excluded group which may have included some non-binary trans people with less definitive cross-sex identity) and excluded patients who did not complete all steps of the gender reassignment process (the majority of whom chose not to based on personal preferences regarding transition). This suggests that the final population of patients in this study (those who received a formal diagnosis of GID and went on to complete all the steps in transitioning to the opposite sex) may have had a relatively high degree of certainty regarding their gender identity and transition goals compared to a broader population of patients (such as those with a GID-NOS diagnosis or patients who desired some but not all aspects of transition). The authors partially acknowledge this bias when they discuss the limitations of their study: “On the whole, our study population is a selected group that is not fully representative for the larger group of gender dysphoric people: they all fulfilled criteria for GID and were eligible for SRS. This perspective might certainly have an influence on the level of psychoneurotic distress. If there had been less certainty, at the end of the diagnostic phase and after initiation of hormonal treatment, about receiving SRS, results could have been different.”

Yet even in this population of gender dysphoric patients with potentially greater confidence and certainty regarding transgender identity and transition goals compared to a more diverse group, it is clear that the confirmation of the diagnosis (GID) by a professional was one of the most important steps in the transition process with respect to psychological improvements. “We found that the biggest decrease in psychological dysfunctioning is caused by initiation of hormone therapy or confirmation of the diagnosis by a professional caregiver. This finding was consistent with the subjective feeling of most treated patients and suggests that recognition and acceptance of the GID play an important role in the transition process.”

Recognition and acceptance. Isn’t that what we all want?

“If you’ll believe in me, I’ll believe in you.”
– The Unicorn (Through the Looking-Glass and What Alice Found There, 1871)

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References

Heylens G, Verroken C, De Cock S, et al. Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. 2014. Journal of Sexual Medicine 11(1): 119-126. 

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. 

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

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

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

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

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

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

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

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

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

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

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

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

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

The only questions I could answer with any confidence were:

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

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

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

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

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

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

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

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

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

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

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

————

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. 

Magnetic Resonance

This is my brain. You’ll have to take my word for that though – it looks so ordinary, doesn’t it? Just an ordinary brain – a vast and beautiful ecosystem of interconnectivity. The extraordinary complexity of it is somehow diminished by the flatness of the image, the deceptive simplicity of the gently undulating sulci and gyri.

A nurse leads me from the psychiatric unit down through the guts of the hospital to the MRI room. Scrub-clad staff shuffle softly past us, diligent and busy, unnoticed aboveground but vital to the round-the-clock function of this teeming facility. We pass the steamy laundry room, the fragrant kitchen, several silent storage vaults. The hallways are cast in pale fluorescent light with an occasional dull orange flash from the elevator displays. A stripe of faded blue tape splits the corridor in half, faint dusty footprints crisscrossing back and forth across the dividing line. We have entered an entirely different world down here – a dim basement fairy-tale world of medical equipment and quiet footsteps.

MRI stands for magnetic resonance imaging, a technique developed in the 1970s that uses magnetic fields and radio-frequency waves to create cross-sectional images of organs and tissues. I am getting an MRI of my brain as part of the work-up for chronic depression, to rule out possible organic causes such as inflammatory disorders, cerebrovascular anomalies, or brain tumors. All of these are very unlikely, but because my depression has been unusually severe, prolonged, and resistant to conventional treatments, my in-patient psychiatrist wants to explore the possibility of rare underlying causes.

So the nurse rolls my body into the machine and I lay as still as death – movement artifact can interfere with image quality – wth my head in a plastic cage, cranium cushioned by foam pads on either side. The loud mechanical clunking from the machine becomes a visceral thudding din that seems to penetrate right down to my bone marrow. I can force my body into stillness, but I cannot quell the restless activity in my mind as it dredges up fragments of conversations from what feels like a thousand lifetimes: who I was and who I am, things I’ve lost and things I’ve locked away, wise voices echoing in a chamber of despair.

“She is probably the best student I have worked with over the past 15 years I have been in academia.”

“People with great abilities naturally have great successes and great failures.”

“You expect people to behave in logical and predictable ways. But they don’t. Not everything is logical. And that expectation creates a lot of frustration and disappointment for you.”

“You wear your emotions on your sleeve, McMurray. You can’t hide your anger and frustration, even when it’s directed at yourself. That much emotional intensity is intimidating.”

“You are a solution that’s just waiting for a problem.”

“Remember we once talked about finding your way out of the darkness of a great forest?”

“That’s not how it works here, princess…”

Today my psychiatrist tells me that the MRI showed no abnormalities. I ask to see the images – not because I don’t believe him, but because I want to see this brain of mine. On the screen it looks so… grey and calm and normal. I had expected, at least, that the machine would have somehow captured the racing chaos of my thoughts, like headlight streaks in a long-exposure photo of a busy city during rush hour. Or I thought perhaps the image might show a rim of necrotic blackness devouring the grey matter, some kind of visible sign of the darkness in my mind. Or I even half-expected to see a nest of snarling demons ensconced in their cerebral lair, ghoulish grins like candid mugshots of the pain that grips my brain.

Staring at my brain on the screen, this restless mind once more starts sifting through the debris of recent conversations. The technician who said, “What’s a nice girl like you doing in a psychiatric unit?” The nurse who asked me about my suicidal intentions and then, after I described my list of lethal methods and the pros and cons ascribed to each, said, “You look really good right now. You seem calm and coherent.” The friends who have expressed their confusion and disbelief when I describe the severity of this depression, “But you sound so normal! You seem like your usual self!” Even my out-psychiatrist who admitted that I seem so composed and articulate during appointments that he initially questioned why we were considering readmission to hospital. My outward composure – sometimes the hard-won result of energy I can barely muster, sometimes simply the only way I know how to be – seems to mask the intensity of my internal pain. And this MRI image feels the same way: it looks perfectly ordinary, composed and coherent, while the agony remains entirely invisible.

“Forgetting pain is convenient, remembering it: agonizing. But recovering the truth is worth the suffering…”
– The Cheshire Cat (Alice: Madness Returns, 2011)

Unrelenting Darkness

Unrelenting Darkness (1)

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

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

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

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

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

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

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

Twin

Twin

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

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

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

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

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

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

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

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

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

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