He Who Fights With Monsters

falling-man

I have not been posting much writing lately.

I was hospitalized (for the second time) on a psychiatric unit from May 9 to August 12, 2016. As I alluded to in previous posts, my time on the psychiatric unit was incredibly valuable with so many radical improvements physically and psychologically. I was allowed to use my laptop during off-unit privileges and I wrote extensively – in notes to myself and messages to friends – about the changes and insights that developed during my hospitalization. I occasionally posted on this blog during that time, but most of my writing remained unposted because there was simply too much to process so quickly. I had expected to maintain my positive trajectory following discharge so I had planned to revise and post my writing here shortly after leaving the hospital.

But now, trying to retrospectively capture the enthusiasm and excitement in my old writing feels forced and hollow. Over the past few months, most of the major improvements have deteriorated as rapidly and radically as they arose, and I have been left to watch my mind disintegrate once again. As this decline has progressed, my despair has been considerably amplified by the knife-sharp awareness of just how much I had gained in hospital and how much I am in the process of losing.

So I have avoided writing altogether, instead posting my drawings and my poems and my photos which have taken on much darker undertones in recent weeks. It would, perhaps, be something of a delusion to think that anyone has noticed the change in the nature of my posts. Very few people visit this blog, and of those that do, I doubt that most of them have the patience or interest to read my writing in its entirety. My closest friends have often criticized my writing in my correspondence to them as being too lengthy, too distressing, or too rigorously academic. I have no reason to believe that my writing here would be perceived any differently by an online audience.

Is sharing these thoughts a desperate self-pitying bid for attention? No. Because any attention granted in response to such a plea would be quite superficial and quite meaningless, so it would be illogical to seek that kind of attention. No. This is simply an honest account of my current experience. I value authenticity above most other personal attributes. To me, authenticity – and her sister trait, vulnerability – represent extraordinary courage: the courage to “endure the sharp pains of self-discovery” in the process of understanding one’s own experience, and the courage to share this experience with others despite the risk of invalidation and rejection that plague every potential human interaction.

One of the most confusing patterns that I’ve noticed as my depression has worsened during recent months has been the withdrawal of many of my closest friends. Formerly close relationships have become strained, distant, and detached. I have been trying very hard to understand what has contributed to this widespread withdrawal. At first I believed that I was the common denominator, and I spent many sleepless nights trying to figure out what is so wrong with me that my friends are no longer willing to engage with me in ways that feel genuine. But now I wonder if it is less a problem with me, and more a problem with them. Perhaps the common denominator is their inability or unwillingness to tolerate the excruciating intensity of the sadness, loneliness, hopelessness, and meaninglessness that dominate my psychological landscape.

Unlike previous episodes of depression, my current experience is also dominated by anger, a towering and terrifying RAGE. Often this rage is directed at myself, rage like drops of blood attracting a predatory frenzy of depressive sharks. Sometimes this rage is directed at the world, rage like hand grenades exploding in the face of societal adherence to oppressive conventions that marginalize so many broken people. And sometimes this rage has no target, rage like a forest fire burning at the whim of wind and weather, the crackling searing heat omnivorous and destructive. But fires are essential for regeneration of forest vegetation. Maybe my rage is the first step towards some kind of psychological reintegration.

Direct feedback from my friends and my own observations during interactions with them suggests that humans are fundamentally distressed by intense emotions, especially anger, in themselves or in others. I am not sure why emotional intensity is so uncomfortable for them, and they have all been unable to coherently articulate the reasons behind their discomfort. But I wonder about several possible contributing factors.

1. I think many people retain a false and judgmental belief that intense emotion is necessarily the result of some kind of distortion or magnification on the part of the person expressing it. This belief may be the internalized result of an affect-phobic culture. This belief may also reflect the fragility of human egos finding comfort in a comparative notion that the absence of such painful intensity in themselves represents their own superior emotional regulation.

2. I think many people also believe that the expression of intense emotion necessarily implies a desire or expectation to reduce that intensity. Almost without exception, people automatically respond to someone else’s pain with advice and suggestions intended to help fix the problem or suppress the emotional intensity. I think this tendency reflects an unwillingness to accept their own powerlesssness. People seem largely unable to understand how their aggressive attempts to be helpful actually eclipse their capacity to empathize.

3. And I think that most people are afraid of truly empathizing with intense pain because doing so would require acknowledging their own innate potential to experience pain beyond their control. Such an acknowledgment would shatter illusions of personal agency. When somebody like me calmly and rationally outlines the meaninglessness and futility of life when all sense of purpose, satisfaction, and self-worth have been stripped away, people are forced to re-evaluate the framework they use to justify their own worth and purpose – they must then confront the threatening truth that these ideas are often built around tenuous and artificial self-delusions.

I have always tried very hard to avoid overwhelming my friends with the negative aspects of my experience. I have shared the fact of my depression with them, but I have intentionally minimized the severity of it, I have openly and deliberately invalidated myself in conversation with them, and I have often completely avoided mentioning my most distressing experiences. These behaviors represent my conflicted and evidently unsuccessful attempts to be authentic yet avoid provoking their discomfort. But as my depression becomes more debilitating and more painful, it becomes increasingly difficult for me to hide it. And as the intensity of my pain becomes more evident to them, the more uncomfortable they become and the more they withdraw from me. I have seen their faces fall, I have felt the cooling of the air between us, I have heard their static silence oozing through the speaker on my phone whenever I allow them to see a fraction of my truth. They cannot face my reality, so they retreat and withdraw. Their silence becomes deafening, and their absence suffocating.

“Wer mit Ungeheuern kämpft, mag zusehn, dass er nicht dabei zum Ungeheuer wird. Und wenn du lange in einen Abgrund blickst, blickt der Abgrund auch in dich hinein.”
– Friedrich Nietzsche (Aphorism 146, Beyond Good and Evil, 1886)

[Translation: He who fights with monsters should look to it that he himself does not become a monster.
And if you gaze long into an abyss, the abyss also gazes into you].

Depression is a monster. And I feel like an abyss. My existence is intensely painful. This pain is all-consuming, inescapable, and terrifyingly rational. I move from day to day accompanied by more distress than most people have ever known or even have the capacity to imagine. When I stop protecting them from me and allow them to glimpse the true extent of my hopelessness, they are horrified to find themselves gazing into the abyss. And they are even more horrified to find the abyss gazing back at them with a familiar face.

I never knew
I never knew that everything was falling through
That everyone I knew was waiting on a cue
To turn and run when all I needed was the truth
But that’s how it’s got to be
It’s coming down to nothing more than apathy
I’d rather run the other way than stay and see
The smoke and who’s still standing when it clears
Everyone knows I’m in
Over my head
Over my head
– Over My Head (Cable Car) (The Fray, 2005)

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.

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. 

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)

Present Tense

Clock (1)

Depression has a curious way of disturbing the passage of time.

On depression’s terms, time  s t r e t c h e s . . .  o  u  t  .  .  .  s   o   .   .   .   s    l    o    w    l    y    .    .    .    with a maddening and mocking languidness.

Remembering and sequencing the events of today becomes an overwhelming challenge, my mind trudging grudgingly through the heavy fog that clouds those recent memories. The last few days and weeks and even years are stacked haphazardly, an inseparable scatter of all things past.

More cruelly, depression amputates the future. Tomorrow and next year are equally incomprehensible. This missing sense of future is deeply unsettling. It is like losing your peripheral vision – only when it’s gone do you realize, with horror! – how casually you took it for granted, how much it used to guide your behavior and perception, and how without out it you feel lost in a narrow and distorted world.

I have also seen these wrinkles in time described by people with terminal physical illnesses. Most eloquent of these descriptions was written by Paul Kalanithi in the days leading up to his death from lung cancer:

“Verb conjugation became muddled. What tense was I living in? The future tense seemed vacant and, on others’ lips, jarring. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.”

The relentless suicidal ideation that accompanies depression seems, in many ways, very similar to the last months of a fatal physical disease. To outsiders, the most salient difference between those two is the illusion of choice.

I think that a coherent sense of future can also be a casualty of gender dysphoria, especially for those of us with uncertain transition goals and unpredictable transition outcomes.

I have had a hard time visualizing my future, as either female-perceived or male-perceived. Needless to say, this is a bit of a dilemma, as it can create the sense of moving into an enigmatic, inconceivable oblivion. Now, I don’t think it’s healthy to focus too much on the future, but I do think it’s normal to have some sort of future projection of yourself to hold onto – and I think that’s something that transgender people are plagued with – with not being able to visualize their future self during uncertain times, particularly when they are considering medical intervention.” – gendermagik

The point where depression and dysphoria intersect is a terrifying discontinuation of the mental and the physical, an inescapable Möbius strip of mind and body locked perpetually in the painful present tense.

The broken clock is a comfort, it helps me sleep tonight
Maybe it can stop tomorrow from stealing all my time
I am here still waiting, though I still have my doubts
I am damaged at best, like you’ve already figured out
– Lifehouse (Broken, 2007)

“You do not get the time back. Whatever time is eaten by a depression is gone forever. No matter how bad you feel, you have to do everything you can to keep living, even if all you can do for the moment is to breathe. Wait it out and occupy the time of waiting as fully as you possibly can. Hold on to time.”
– Andrew Solomon (The Noonday Demon, 2001)