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

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

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

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

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

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

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

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

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

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

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

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

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

The only questions I could answer with any confidence were:

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

Not Applicable

Not Applicable

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

Gender Bender Award Graphic

Not A Simple Question

Ashes

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

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

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

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

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

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

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

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

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

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

Zero Dollar Haircut

Zero Dollar Haircut (Final)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

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

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)

I Doubt It

I Doubt It Shower (1)

I had been dealing with depression for several years before I started exploring gender transition options. Of course, the distressing incongruity between my female body and my brain’s non-female body map had been extreme and persistent since puberty, but I tried so hard for so long to suppress those feelings, to attribute them to the body image disturbances that characterize anorexia nervosa or dismiss them as an unusual form of gender-centered vanity. So it was not until more recently – thanks in large part to perceptive suggestions from an observant friend – that I learned about gender dysphoria and started considering transition in a personal context.

When I first became aware of these options, I felt an immediate and expansive euphoria, an ebullient optimism that inflated me with such promising possibility. I believed that I had finally found The Answer to so many of my life’s uncertainties. I believed that transitioning – in a straightforward black-and-white line, from ugly A to perfect B, from female to male (whatever I thought those words meant then) – was The Solution that would fix all of my problems.

Buoyed by this excitement I began researching transition options, poring obsessively over online trans forums and frantically downloading research papers from PubMed. Very quickly I encountered cautionary statements – in scientific studies and trans peoples’ own stories – urging those of us considering transition to have realistic expectations about how transition may affect our life and reminding us that transitioning will not solve every problem.

“Overall, participants’ evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. It was described as a ‘‘challenge’’ or a ‘‘long and difficult road’’ that was worth taking because of its positive implications on future life, at the end of which not everything was different or better without limitations.” (Rupin 2015)

“Don’t expect transitioning to solve all of your problems. Transitioning is not a panacea – it won’t solve all of your problems. If you were prone to anxiety before coming out, you’ll probably still have to deal with it afterwards. At some point in my transition, I came to terms with the fact that living as my true gender wouldn’t magically fix everything. And it felt really good to let go of that impossible expectation.” – Annika

So I started to examine my own expectations about transitioning. This process began very gradually, my original optimism tempered but preserved. But as I delved ever deeper into myself, as I came to recognize – with a terrifying emptiness – that I do not have any cognitive sense of gender identity (just the physical distress associated with female anatomy), and as my long-standing depression spiralled ever further out of control, I started asking myself with a haunting and repetitive urgency: how much does gender dysphoria contribute to my depression? How much can I expect transitioning to alleviate this complex distress? These questions quickly gathered a frightening momentum, eliminating one by one every hopeful expectation I had about transition, culminating in a crushing avalanche of doubt about whether my gender dysphoria was even worthy of continued acknowledgment.

So often I would reach the end of the day and reflect on the past 16 hours, wondering what would have been better if I had lived the day inside a male body. Usually the answer that I gave myself was that very little would have changed, perhaps a few accidental mirror glimpses – always that initial flash of confusion as my brain works to reconcile reality with expectation – those mirror glimpses might have been less unpleasant, sure, but nothing else would have been any better. So why bother with transition then? Why bother with all this gender nonsense at all?

But in the moments when depression loosens – ever so slightly – its death-grip on my mind, in the moments when I feel a lucid clarity open up like a window to the world, I wonder if perhaps I underestimate how deep this dysphoria extends, if I underestimate how extensively the brain numbs itself to daily pain after a lifetime of unabated agony. And in these moments I can relive the day with more precision, sailing through the same sequence of events, but this time in a masculine vessel. It seems a lot would have been better.

On the squash court –
The squeak and shriek of sneakers on shiny varnished floor –
I could have worn shorts without feeling so self-conscious of my girl hips, I would not have been so painfully aware of my small shoulders dwarfed by the broad backs of male opponents, I would not have felt such desperate pressure to overcompensate with wins to prove that I deserve to play among men.

Standing outside in the summer sun –
The far-off chirp of cheerful birds and the low buzz buzz of busy bees –
I could have escaped my sweat-sticky sweater, an all-season mask concealing the feminine swell of my chest, and I could have instead felt the sun kiss the skin on my bare arms, I could have let my eyes wander as they wished without so consciously averting my gaze from the girl-shaped shadow on the ground.

In the shower –
Warm rivulets of water draining down over all the parts that I pretend do not exist –
I would not have had to cloak myself in darkness, I could have soaped my bristly legs without thinking automatically that I should shave them, and stepping out afterwards I could have wrapped the towel around my waist and seen my face and my bare chest in the mirror and not had to look away.

Driving in my car –
My hand on the shift stick and wind breezing in through the open window –
I would not have had to angle the rearview mirror just so to avoid that quarter-slice of girl-face when I glanced upwards, I would not have had to tug my jacket down low enough to hide the width of my hips in the seat, and I could have sung along more freely with the radio with a deeper voice vibrating through the lines of my jaw.

Pulling on my pants in the morning –
The rustling of fabric and the brisk zip of the fly in chilly pre-dawn dimness –
The flatness of the crotch would not have been such a mocking emptiness, the snugness of the pants over my hips and thighs would not have been such an excruciating reminder, and when I looked down I would have seen a man in jeans instead of a girl in men’s jeans.

Sitting typing like I am now –
Quiet clickety clack, clickety clack, rat a tat tat –
I would not have to feel the tight X of bra straps across my back, I would not have to notice how my wrists and fingers on the keyboard seem so slight and feminine, and I would not have to be afraid of seeing my face reflected back at me in the laptop screen.

With all of that, how is it possible that I still doubt whether I should transition? Such doubt this is! It only seems to multiply as my mind paces the same well-worn path through the same worn-out questions. This doubt is an aggressive beast that feasts on self-reflection.

“Do you suppose,” the Walrus said,
“That they could get it clear?”
“I doubt it,” said the Carpenter,
And shed a bitter tear.
– Tweedledee (Through the Looking Glass and What Alice Found There, 1871)

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References

Ruppin U, Pfäfflin F. Long-term follow-up of adults with gender identity disorder. 2015. Archives of Sexual Behavior 44(5):1321–1329.

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)

Falling Out of the Closet

Falling Out of the Closet (1)

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

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

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

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

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

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

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

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

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

A Perplexing Dichotomy

Perplexing Dichotomy

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

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

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

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

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

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

New York Times Trans Voices

The New York Times has an ongoing editorial series about transgender experiences (Transgender Today), with an online section for submissions from trans people to share their own stories (Trans Voices).

I found that most of the stories in that series described the experience of gender dysphoria in terms of social gender roles and traditional gender stereotypes, without much reference to the physical distress that is so prominent for me. The blog American Trans Man has an excellent series of posts describing body dysphoria (What Does Body Dysphoria Feel Like?), but I did not see my own experience represented there either.

So I wrote this piece in an attempt to describe my profoundly physical dysphoria, which was challenging within the 400 word limit. I submitted my story to the New York Times online in June 2015, however it was not accepted for publication. My original submission is below.

————

I am not a woman. And I do not know what it means to feel like a man. But I do know this: my brain believes my body should be male. I know this too: living with a female body is a thousand daily torments, a relentless rain of knife-sharp wounds, a constant cacophony of noise in my mind and a disorienting disconnection from my physical self.

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. The soft, hesitant, distinctly female voice that emerges from my mouth feels like some kind of cruel deception. The shape of my shadow, a perfect hourglass,  is a barbed and bitter insult. Menstruation brings with it a dark and bloody tidal wave of despair, an overwhelming urge to claw open my own abdomen and rip out the offending uterus with my bare hands. For years I have showered with the lights off so I don’t have to see this foreign female body naked, but even in the darkness I feel a surge of revulsion when my soapy hand slips between my legs or slides quickly over my chest. A kaleidoscope of images now… the absurd roundness of these girl-hips, the obscene feminine heaviness of my upper thighs, the fragile slenderness of my fine-boned hands, the ugly narrowness of my unmuscled shoulders, the terrible width of my flared iliac crests cradling a soft smooth belly, the raw red ring around my ribs from a too-tight sports bra… all inescapable, all excruciating, all wrong. WRONG! WRONG! WRONG! The same refrain always buzzing in my head, the same anxiety always crawling just below my skin.

All this I know, every minute of every day.

But I do not know what comes next. I am confused. I am terrified. I am drifting on a sea of fear and uncertainty, paralyzed by indecision. I feel a desperate urgency to make a choice, to finally find some peace.

Testosterone, mastectomy, hysterectomy. Those are the options that could tear my life apart. Those are the options that might mold parts of me into a more masculine form. But is that where I want to go? Will that ever be enough to stifle these sirens screaming in my brain? What does silence sound like?

————

“Take care of the sense, and the sounds will take care of themselves.”
– The Duchess (Alice’s Adventures in Wonderland, 1865)