Testosterone (Part 2): Assumptions and Questions

prescriptions

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

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

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

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

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

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

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

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

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

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)

Reflection on Reflection #1

Reflection on Reflection #1

“There are things known and there are things unknown, and in between are the doors of perception.”
– uncertain origin*

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*Commonly attributed to Aldous Huxley.

This quote does not actually appear in Huxley’s work but is often assumed to originate from his book, The Doors of Perception (1954). The Doors of Perception is a philosophical essay reflecting on the experience of taking mescaline, titled in reference to a statement from William Blake: “If the doors of perception were cleansed, everything would appear to man as it is, infinite.” (The Marriage of Heaven and Hell, 1790).

The American rock band The Doors was named in reference to Huxley’s book. The quote above has also sometimes been attributed to co-founding band members Jim Morrison and Ray Manzarek, although it was likely abbreviated from a comment made by Manzarek in an interview for Newsweek: “There are things you know about,” says 25-year-old Manzarek, whose specialty is playing the organ with one hand and the bass piano with the other, “and things you don’t, the known and the unknown, and in between are the doors – that’s us. We’re saying that you’re not only spirit, you’re also this very sensuous being. That’s not evil, that’s a really beautiful thing. Hell appears so much more fascinating and bizarre than heaven. You have to ‘break on through to the other side’ to become the whole being.” (Newsweek, 1967, This Way to Egress)

It is unclear who rephrased Manzarek’s statement into the wording displayed above, or why this quote is most often attributed to Huxley despite not appearing in his published work. This is one of those things unknown.

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 3): Childhood Gender Non-Conformity

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

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Jantina Cow

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

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

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

Jantina Dress

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jantina Rope Ladder

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

Jantina Dirtbike

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

Jantina Peter Pan

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

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

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References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

Our Whole Foundation Cracks

Sand Dunes

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

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

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

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

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

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

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

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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.