The Great Escape


The Great Escape

Welcome to the World of Gender Fluidity

March/April 2016


Andrea sits across from me in my office, twisting her hands in her lap. Her 5-year-old child, a biological boy, has progressed from insisting he’s a girl to refusing to go to kindergarten in “boy clothes.” He’s profoundly depressed, one of the saddest kids I’ve ever seen.

Gently, I ask her, “When did you first notice that your child was different?”

Andrea takes a long breath. “When Brandon was 2 and a half, we took him to a football game,” she says. “About halfway through, I pointed to the football players and said to him, ‘Maybe when you grow up, you’ll be like those guys.’ Brandon swiveled and pointed to the cheerleaders. ‘No, I want to be like them.’”

Fifteen-year-old DJ ambles into my office wearing a pink tee, ripped jeans, earrings in both ears, and hair shorn to a semibuzz cut. Dispensing with preliminaries, my new client announces, “I’m agender and pansexual.” Assigned female at birth, DJ declares a preference for the neutral pronoun “they,” and explains their identity to me. “I don’t think of myself as any gender, and I don’t think of other people that way either,” DJ says. “I don’t really notice gender.” DJ is contemplating top surgery—a double mastectomy and chest reconstruction—but is uninterested in taking male hormones.

The next day Marina comes in. Now in her early 50’s, she transitioned surgically from male to female about 10 years ago. Like Brandon, Marina (then Martin) had felt like a girl from an early age. Unlike Brandon, Martin had parents who were horrified by their son’s gender nonconformity. His attempts to express it were quickly beaten out of him, and his gender dysphoria remained hidden for decades. When Martin first entered my office 15 years ago, he reported a history of secretly hoarding female clothes and being nearly immobilized by shame. Married with two young daughters, he eventually left his wife and transitioned to Marina, after heartbreaking pain for everyone involved.

Admittedly, my clinical practice is a little unusual. I direct the Institute for Personal Growth (IPG), a large private group practice in New Jersey, which, since 1983, has specialized in what’s now called sex-and-gender-variant people. We started working with lesbians and gay men, and as the LGBTQ community has grown, we’ve expanded to include everyone in that big-tent tribe—from trans and kinky to gay, lesbian, and bisexual. Along the way, I’ve evolved personally as well as professionally. In 1973, I identified as lesbian, and now I just call myself queer. Queer can signify many attributes, but in my case, it’s shorthand for “I’m a bisexual lesbian mother who’s kinky and nonmonogamous, and was extremely gender atypical as a child.”

This may be a lot to take in. If so, I get it. A couple of decades ago, the only “transsexual” most people knew about was Renée Richards, the transwoman who made the news in 1976 by attempting to enter the US Open Tennis Championships as a woman. Fast forward to 2016 and a transgender teenager, Jazz Jennings, has her own TV show on TLC. And Becoming Nicole, a book that follows the experience of parents whose son, deep in his young heart, knows that he’s a girl, is a New York Times bestseller. But how do people like Jazz and Nicole know that they’re the wrong gender? And what does knowing something like this mean for our deeply held assumptions about males and females, about opposite sexes?

In the therapy world, these questions abound. Unless you graduated in the last few years, you were probably trained to view gender variance as pathological. For many years, merely feeling a sense of incongruence between one’s internal sense of gender and one’s body was enough to earn the DSM diagnosis of gender identity disorder (GID). Not until 2013 did the psychiatric establishment adjust its attitude, declaring in the DSM-5 that gender variance is in itself normal and renaming GID as gender dysphoria, emphasizing distress as the salient feature of the diagnosis. Meanwhile, changes proposed for the World Health Organization’s International Classification of Diseases remove “gender incongruence” from the psychiatric section and place it in a section on sexual health. Treatments for children that were once first-line behavioral interventions to promote gender-conforming behavior are now illegal in several US states and Ontario.

In the age of Caitlin Jenner, any therapist who deems transgender people mentally ill is clearly politically incorrect. Secretly, though, many of us may wonder how anyone who wants to alter his or her body so drastically could not be disturbed. Even if we don’t believe that, we may wonder what forces could compel a person to change in a way that courts widespread revulsion and rejection from family and society, loss of employment and housing, and even physical violence. Where do these folks get the courage to come out?


Shunned and Shamed: A History

When I came out as lesbian in 1975, shortly after homosexuality was removed from the DSM, the gay community could be downright hostile to gender-variant people. Among lesbians, butch-femme was considered a politically regressive imitation of patriarchal roles. Gay men had an uneasy relationship with gender nonconformity: drag queens were revered but “queeny” men—those whose manner marked them as effeminate—were considered a bad image for the gay activist movement. Biological males transitioning to female were labeled fake women and mistrusted, even hated, by the lesbian community. And as far as we knew, biological women who wanted to become men didn’t even exist.

By and large, transsexuals were hidden from sight in the larger culture. In her memoir, No Way Renée, Renée Richards describes a part of the transition process known as woodworking. In the 1970s and early 1980s, among the requirements for obtaining hormones and surgery from many university-based sex-change clinics was giving up one’s previous identity and life, which often included moving to another part of the country. Professionals believed that a transsexual’s only chance for relationship and community lay in pretending to be a biological woman. “You merged into the woodwork after your transformation,” wrote Richards, “and you tried to lead a new life without people knowing what your previous life had been.” Such clandestine circumstances eliminated any possibility of a transgender or transsexual community.

Even as a therapist interested in gender nonconformity in the 1980s, I now realize how clueless I was about the inner experience of gender-variant people. I remember working with a lesbian named Sally who called herself Sal and made every effort to look like a guy. She told me she loved making love to her very feminine partner, but that she bound her own breasts and wouldn’t allow her genitals to be touched. The gay-affirmative sex therapist in me chalked that up to internalized homophobia without seeing the obvious: Sal was profoundly uncomfortable in her female body. In 1990, seven years after terminating therapy, Sal called me to tell me about his transition—and to point out the prejudices that wouldn’t allow me to consider that a woman like her might actually be a transman. “I told you I wished I were a man, felt like I should have been born a man. You didn’t listen.”

Sal was right—in my mind, female-to-male transgender people (FtMs) didn’t exist. Looking back, I can think of many clients who were self-identified butches whom I may have unwittingly disaffirmed by my blindness. Today, transmen—biological females transitioning to male—are at least as common as transwomen. And I’m embarrassed by my old views.


The Internet as Healer

So what’s changed since the days when transgenderism was considered a rare disease, found almost exclusively in genetic males?

One important answer is the Internet and the connections it allowed people to make. My Italian American mother drew her connection identity from her immigrant parents, her extended family, and the Italian neighborhood that surrounded her. But those of us who differ greatly from our parents and immediate community often have a harder time. If the traits that make us different are the aspects of self that we feel define us most strongly, and especially if our family of origin rejects us for those traits, we search out others like us. We go out in a quest for our tribe—the community of support that allows us to feel validated and protected—and indeed we’re more affirmed and shielded from harm when we’re together.

Until the mid-1990s, trans people had no tribe. Between their exclusion from the gay community and the requirement that they “go stealth” if they surgically changed their bodies, they were largely alone, often burdened by a sense of deviance, shame, and self-hatred. With the advent of the Internet, and with it the explosion of trans-dedicated chatrooms and listservs, and later, websites and blogs, trans people began to communicate with each other and experience the validation that can only come with numbers. The transgender community, both virtual and real, exploded. Many became activists on behalf of greater rights for, and acceptance of, trans folks, and gradually, the gay community embraced the trans tribe as a partner. In the late 1990s, the T was added to LGB, which both reflected and facilitated a huge coming-out party for transgender people.

Back then, I recall asking Ashley, a 15-year-old who’d been assigned male at birth but identified as female, what made her think she was transgender. She immediately replied, “I saw it on the Internet. I read stuff. I went to trans websites, and chatted with other trans and genderqueer kids. And that’s when it all came together for me.”

Today, Ashley can see trans people portrayed sympathetically on TV (Orange Is the New Black and Transparent) and on film (The Dallas Buyers Club and The Danish Girl). She can see them as guests on news and interview shows (Laverne Cox and Janet Mock), or as hosts of their own reality shows (I Am Cait and I Am Jazz). Ashley can also be exposed to nonbinary people of her own generation. Miley Cyrus has publicly come out as genderqueer as well as pansexual, while Will Smith and Jada Pinkett-Smith’s son, Jaden, wore a dress to his senior prom and is the face of Louis Vuitton’s Spring Women’s Wear collection.

But in the 1990s, for the most part, there was just the Internet.


Parents Rebel

While the Internet was inviting trans individuals into a larger tribe, parents were getting into the act, too. As the Boomer generation became parents, child-raising practices began to change, putting a stronger emphasis on becoming more attuned to kids’ needs. Around the same time, gender norms were beginning to loosen. Even so, supporting a child’s nontraditional gender choices was no easy matter. In 1983, my partner Nancy and I gave birth to a son, Cory. When he was 4 or 5, he became passionate about wearing a pink skirt. Nancy and I were torn. On one hand, we’d been chanting the mantra of gender equality since he’d been in the womb. And it certainly wasn’t a shocker: we knew plenty of gay men who loved skirts and dresses.

But we were already vulnerable as lesbian parents. Among my colleagues, the prevailing wisdom about gender-variant boys was that they were the product of sissifying mothers. How would Cory’s choices play out as the child of two mothers widely believed by the general public to be invested in producing gay children? We felt we couldn’t risk allowing him to go out in public in a skirt, even in our semi-gayborhood in Jersey City, New Jersey. There was zero social support for a boy who dressed like a girl.

Luckily, that summer we had another option: an extended vacation on Fire Island. Cory wore his pink skirt every day in the gay communities of the island, and he was a big hit. As it happened, by the fall he’d lost interest in wearing skirts. But if he’d been transgender and had clung to his need to express his gender nonconformity, we’d have had to keep this part of him private—which would’ve caused him terrible pain. Social transition was an unheard-of concept in an era when it was considered pathology-inducing even to allow a child like Cory to play with dolls at home.

Once again, the Internet played a pivotal role in offering tribal support to the transgender community—in this case, the parent community. By the mid-1990s, mothers and fathers of gender-nonconforming kids began to find each other in online newsgroups, chat rooms, and message boards. Unwilling to follow the advice of traditional therapists who warned against gender-identity permissiveness, these parents sought out more forward-thinking mental health professionals, who themselves were beginning to find their place on the Web. The late 1990s saw the birth of gender-affirmative therapy, a model that views gender variance as normal and healthy. More therapists began to see social intolerance, not gender diversity, as the problem, and to include advocacy as part of their role as clinicians.

But make no mistake about it: the uptick in visibility for gender-variant young children is largely the result of parental passion and initiative. In 2010, when Cheryl Kilodavis was raising a young son who favored dresses, she wrote a children’s book about him, My Princess Boy, and started a foundation to promote acceptance of gender diversity in schools. Both the market for gender-affirmative therapy and the impetus for antireparative therapy laws that prohibit attempts to change gender identity have come from mainstream parents with modern views, not just—or even mainly—sympathetic clinicians or trans healthcare activists.


What’s It Like to Feel This Way?

Still, confusion persists. When I train psychotherapists on gender issues, the most common response is “I just don’t get it. How can someone not ‘feel like’ their gender? How can someone born a guy ‘know’ what a woman feels like?”

Most of us are what’s now known as cisgender: we feel no sense of dissonance between our sense of who we are and the sex listed on our birth certificate. A cisgender person has an assigned gender that matches his/her body, a subconscious sex and gender identity that are concordant, and gender expression—ways they show that they’re male or female—that’s more or less conventional. Others relate to them in a way that matches their own sense of gender. For most of us, these aspects of gender are so harmonious that we don’t even realize they’re distinct elements.

By contrast, transgender people experience a profound sense of dissonance. They don’t feel like their assigned gender. Try this experiment: imagine waking up tomorrow morning and discovering that your body is that of the “opposite” sex. Intriguing as it might be for a while, most of us would feel that our body is lying, that it’s a mask hiding our true self. Trans people feel this way about the bodies they actually have.

If you’ve ever been misgendered—called sir if you’re female or ma’am if you’re male—it was probably a somewhat jarring experience. You may have even felt offended. Imagine these feelings intensified a hundred times and occurring multiple times a day. And imagine that each time you were misgendered in public, or were perceived as transgender, you could be taunted, beat up, or worse. It’s not hard to imagine how your life could be crazy-making, even despair-making. According to a 2011 survey in the United States, 41 percent of trans people had attempted suicide, as compared to 4.6 percent in the general population. A 2015 Canadian study found that more than a third of transgender adolescents had tried to kill themselves.

I’ve seen transgender people break the law and risk their health to obtain and use illegal female hormones because the sense of congruence they experienced was as essential as life itself. For others, it’s not hormones or surgery that made the difference, but simply the freedom of gender expression that emerged when others viewed them the way they viewed themselves. But while finding an affirming tribe has become easier for younger trans people, many older individuals have spent a large part of their lives without the support necessary to experience gender congruency.

Tony, for instance, came to see me 10 years ago, when he was in his mid-40’s. From toddlerhood, he’d battled feelings that he was female, but had hid them from his deeply religious Catholic parents. He grew up in a small town in Maryland where everyone knew each other’s business. In his 20’s, attending college in another state, he enrolled in a gender-change clinic and took female hormones for long enough to develop breasts. Then, when his father died and his mother became ill, he returned home to care for her and felt he had no choice but to revert to a masculine persona. He stopped taking hormones, submitted to a double mastectomy to remove his breast tissue, and spent 20 more years living as a male. His mother’s death and a midlife depression jolted him into taking stock of his life. Today, at 55, Tony is Tanya. Though she regrets her lost years, she feels comfortable in her body and is coming to terms with her past decisions. “I feel bad, but I couldn’t do that to my mother. She’d never have understood,” she says. “I just focus now on how fulfilled I feel. I finally feel like myself.”

Twenty-five years ago, all my transgender clients were 40 or older, most of them having suffered greatly, along with their families, in order to be themselves. Today, my trans clients are all under 30, and they’re in therapy to take a closer look at their gender identity and how they need to define and express it, or to gain support for coming out to loved ones. They also come in for the commonplace reasons that propel people into treatment—depression, anxiety, and life stress in all its forms.


Wait: Gender Isn’t Binary?

Gender-diverse people are found in many cultures throughout history. What varies is how they’re treated: whether they’re stigmatized, accepted, or even integrated as a third gender, as they are in eight non-Western countries. Thanks to anthropologists, archaeologists, and sociologists who are now peering through a queer lens, we’re learning just how common gender diversity is.

Thanks to the same queer lens, we’re learning from biologists like Joan Roughgarden about gender expansiveness in animals, like the female spotted hyena that’s physically and socially dominant and has a clitoris so enlarged it’s called a pseudopenis, and the New Jersey sunfish, which includes two versions of male and one of female. In other words, in nature, gender isn’t always binary.

Until pretty recently, we tended to divide the world into males and females, along with a few “mistakes”—intersex and transgender people. But now we’re learning that there’s no such thing as the opposite sex. In reality, most sex-linked characteristics exist in both males and females, although some characteristics predominate in women and others in men. This is true of not only psychological traits, but also physical ones. Think of height, for example. Or hirsuteness. My Aunt Philomena had a moustache her whole life, while my father couldn’t grow one. But since we tend to ignore and minimize characteristics that don’t align with assigned gender, we certainly don’t think of people like my aunt or father as genderqueer.

But gender is pretty blurry even on the physical level, as biologist Anne Fausto-Sterling has pointed out in her influential book Sexing the Body. According to the Intersex Society of North America, an estimated 1 in 100 people are born with a reproductive or sexual anatomy that doesn’t fit the typical definition of female or male. But male and female bodies that aren’t intersex are also much more similar than different. In fact, our biological sex is so complex, with so many variations, that a February 2015 Nature article by Claire Ainsworth declared, “Almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body.” Ainsworth goes on to quote John Achermann, a London researcher and endocrinologist, as saying, “I think there’s much greater diversity within male or female, and there is certainly an area of overlap where some people can’t easily define themselves within the binary structure.”

This perspective fits with what scientists are learning about the “transgender brain”—that it resembles both the male and female brain. Scientists in Spain and the Netherlands have used MRIs to examine the brains of transgender teens and adults both before and after hormone treatment. They’ve found that in some ways, trans brains resemble the brains of the gender they experience themselves to be more than the gender assigned at birth.

For centuries, Western cultures have polarized the sexes, but biologists are now suggesting that a gender continuum is a more accurate model. This would demand that we literally see people differently. Think about it: what’s the first thing you notice about a person? What’s the first thing you ask about a baby? We organize our encounters with others around to binary genders.

Yet if our binary system of gender is inadequate, so is our language. Throughout this article, I use male and female pronouns. There are those who advocate gender-neutral language or pronouns to designate gender other than female or male, such as the pronoun they used in the singular. Others prefer new pronouns like hir and ze. Although it’s sure to throw copyeditors for a temporary loop, using this kind of language might help the gender spectrum emerge more clearly. Perhaps it’s already happening: in January 2016, the singular pronoun they was designated the American Dialect Society’s Word of the Year.


The Queer Revolution

In the LGBTQ community, gender boundaries have always been considered permeable. Think butch/femme and lipstick lesbians, drag queens and slender, boyish twinks. But these designations still reflected a binary model. In a single generation, a new paradigm has emerged that’s variously called a gender spectrum, a gender continuum, and a gender web. In the 1990s, the umbrella term transgender came into widespread use within the LGBTQ community. It was meant to include all categories of people who felt gender discordant—not only transsexuals, but also those who felt neither male nor female, those who felt both, and those whose inner experience of gender varied from their assigned sex but were content with a nontraditional gender expression and didn’t want to change their bodies. Aided in no small part by the Internet, these groups evolved into a tribe.

Today, it’s common to see lesbian couples in which one or both partners is a transwoman. We see some lesbians evolve into transmen with cisgendered female partners who remain in the relationship. We see gay men coupled with gay transmen. The LGBTQ community has already succeeded in separating gender from genitalia in a big way.

This new community has rejected old categories and created new identities. Few people under the age of 40 describe themselves as transvestites, cross-dressers, or transsexuals. Many describe themselves as genderqueer—a term that connotes feeling neither entirely male nor entirely female. Others use the term gender fluid. Lee, an 18-year-old assigned male in the adolescent group we run at IPG, was coming to terms with his lifelong sense of gender incongruence. “I’m gender fluid. There are times when I feel totally male, and want to be perceived that way, and other times when I feel completely feminine.”

Even traditional transgender people—those who undergo full hormonal and surgical procedures to create bodies that conform to their inner sense of gender—are defying gender norms. Caitlyn Jenner is old-school: her version of female mirrors the gender norms she grew up with. But increasingly, trans people request only partial medical intervention. Michael, a former client who still keeps in touch, has taken male hormones and lived as a man for more than 15 years, yet he’s never had surgery, so he still has breasts and female genitals. From time to time, he considers it, particularly chest reconstruction, but for many years, his partner has been a bisexual woman who loves his gender-blended body.

When Michael and Diana decided to have children, they agreed he’d be an egg donor for Diana, who’d carry the child. To accomplish this, he had to discontinue hormone treatment for an extended period of time, and he found his sense of physical discordance returned. He didn’t feel right again until he resumed taking testosterone. He’s still on the fence about whether he’ll ever want surgical intervention, but he now knows the importance of testosterone to his sense of gender congruence. For the moment, he has a nonbinary body.

Transgender people with unconventional gender expression, people who feel someplace in between male and female, and those who feel like neither one, boggle our minds far more than the Caitlyn Jenners of the world. We may not understand Bruce Jenner’s deep need to transition, but at least Caitlyn doesn’t challenge our ideas about men and women. It’s the in-between people who freak us out most. If there are more than two genders, what does that mean for everything based on the binary gender system, from laws and traditions to personal beliefs and behavior?


The Path of Therapy

There came a point in my own clinical work when I got it about being transgender. The journeys of clients like Martin/Marina and Tony/Tanya showed me that gender dysphoria was an urgent, unstoppable need to achieve authenticity in the face of family conflict, social obstacles, and intense personal pain. I remembered my own childhood, which included battles with my mother over my determination to wear pants and cut my hair short. I cried when I realized I was developing breasts. It was easy to imagine what would’ve happened had I not grown to like my young woman’s curvy body. But it may have been seeing the gender-variant college students who started to fill our practice in the late 1990s that clinched it for me. Teenagers like Ashley faced a future with far fewer obstacles than the older trans people I’d seen—a future that actually looked pretty normal.

That’s when I truly understood the parallels between the gay and trans struggles. In the 1970s and early ’80s, my practice was full of lesbians and gay men who’d grown up before the Stonewall riots, before homosexuality was removed from the DSM. Their stories were terrible and desperate, not unlike the lives of my older transgender clients. Then, as homosexuality became more accepted, gay people started coming out at earlier and earlier ages, and they came out to a world where they were deemed normal, not mentally ill, and where they were embraced by a strong community. And I got it. That was exactly what was happening with gender-variant people—and what continues to happen now. As therapists, we need to support this transformation.

For a starting place, we can look to the guidelines of the World Professional Association for Transgender Health (WPATH), which asserts that gender variance is normal and that mental health professionals have the responsibility to affirm the self-determination of transgender clients, except in the case of minors. If you rarely see gender-variant clients, I suggest that you refer any considering medical intervention to a therapist who’s a gender specialist, as the issues are complex and the science is changing rapidly.

But you may well get trans clients who’ve already figured this out, who may be thoroughly posttransition, or whose path is clear to them. If your practice includes lesbian and gay clients, you can’t avoid seeing trans people. Transwomen attracted to women—heterosexual before transition, lesbian after—tend to partner and live within the queer community. Many transmen identified as lesbians before they explored gender identity, and their female partners often stay with them after transition. Even if you don’t work with many gay people, your heterosexual clients almost certainly have a transgender child, relative, neighbor, or child’s classmate—whether they know it or not. It was once true that very few people knew a gay person, or at least knew that they knew. Now everyone does. Soon it’ll be the same for trans people.

How should you handle trans clients clinically, or approach issues of gender variance with parents? First, don’t assume their gender choices are inherently problematic or look for reasons why they’re gender variant. They are who they are, and like any client, they need your acceptance and respect. Second, educate yourself. Third, don’t assume that gender issues are relevant to therapy. Many trans- or gender-variant people come into therapy for exactly the same reasons everyone else does: depression or anxiety, relationship issues, loss, trauma, the whole gamut. These problems are sometimes caused or exacerbated by minority stress, the extra pressures and burdens engendered by being a member of any stigmatized group. Despite growing cultural acceptance, many transgender men and women are murdered each year simply because they’re gender variant.

If you work with adolescents, especially college kids, you’ll increasingly see teens who identify as something other than cisgender. As we’ve discussed, this doesn’t necessarily mean that they want medical intervention. But some trans teens will insist that they want the puberty blockers and cross-gender hormones recommended at various stages of adolescence.

What to do here? Research indicates that most young people who identify as transgender as teens don’t desist in that identification. But that doesn’t mean that every teen who asks for medication should be recommended for medical intervention. The vital task here is to honor the adolescent’s affirmed gender while helping that young person explore what that means for them.


The Shape of Things to Come

As social acceptance continues to grow, will we see an increase in the number of people claiming a trans or otherwise gender-nonconforming identity? Will we see a corresponding increase in those requesting body modification? The answer to the first question is unquestionably yes: as understanding and support expand, more people will come out. But the answer to the second question remains to be seen. As trans people change the definition of identity, some are making idiosyncratic choices with surgery and hormones. Some will modify their gender presentation, but not their bodies. Others will modify their bodies to create nonbinary bodies that match nonbinary identities. Tanner, the 20-year-old son of a friend, takes a low dose of testosterone and presents as male, but doesn’t plan to have either top or bottom surgery.

Perhaps the future is already here, in the shape of Millennials. Their support for gay marriage is merely the tip of the iceberg. Many of them have an entirely different paradigm for not only sex and gender diversity, but identity itself. They often define both their gender identity and their sexuality precisely and idiosyncratically, while characterizing their identity as a work in progress. And it’s not just trans and gay people who are doing this. In writing this article, I asked my son Cory, who once pined for a pink skirt, to describe himself as he is now, in his early 30’s.

“Gender is pretty easy,” he texted. “I’m a cismale who likes to range in presentation from fairly butch to slightly gender-bendy. Nobody would ever think I was trans, but lots of people think I’m gay, depending on the day. Sexuality is more complicated. For convenience, I say I’m bisexual and heteromantic. But sexuality, at least for me, has far more dimensions than that.”

There’s one thing for sure: the boundaries between male and female are getting fuzzier and fuzzier. In some ways, transgender and gender-nonconforming people reflect a larger cultural trend. Women can fight in combat, men are stay-at-home parents, and gender expression and identity are exploding into forms and flavors we never imagined. If these shifts continue, the cry of my parents’ generation in the ’60s and ’70s—“You can’t tell the boys from the girls!”—may become true. And as a society, that’s a profound change in the implicit rules of what’s normal—a change all of us, in one way or another, will have to come to terms with.


Unpacking Gender

Some Definitions

Affirmed gender: The gender you experience yourself to be. It may or may not be congruent with your assigned gender and physical body.

Agender: A person who experiences themselves as neither male nor female.

Assigned gender: Whether we’re designated “boy” or “girl” at birth. Assigned gender is generally based on the appearance of external genitalia. Also called biological sex, natal sex, or sex assigned at birth.

Cisgender: Someone whose gender identity is congruent with their assigned gender or assigned sex at birth.

Genderqueer: A term used by people who are nonbinary, or experience themselves as in between the categories of man and woman. They may also characterize themselves as gender fluid, bigender, or agender.

Gender dysphoria: A profound discomfort produced by a sense of incongruence between one’s assigned gender and one’s body, gender expression, and/or gender identity.

Gender expression: The way we show our gender to the world: the clothes we wear, the activities we choose, our mannerisms.

Gender fluid, Bigender: Someone who experiences and defines themself to be both a man and a woman, either at the same time or at different times.

Gender identity: The gender a person identifies with, independent of assigned gender, assigned sex at birth, or gender expression. Gender identity may or may not have a biological component.

Medical transition: Undertaking the hormonal and/or surgical interventions necessary to transform one’s body to one’s affirmed gender.

Social transition: The changes necessary to live as one’s affirmed gender without any body modification or medical intervention. For example, an assigned male might choose a feminine name, use female pronouns, and dress and express themself in typically female ways.

Transgender: This term is sometimes used to refer to the entire spectrum of non-cisgender people, and other times to describe only those who transition socially and medically to another gender. The terms trans and TGNC (transgender and gender nonconforming) are also used to denote the whole spectrum.

Transgender man, Transman: A transgender person who was assigned female at birth but identifies as a man.

Transgender woman, Transwoman: A transgender person who was assigned male at birth but identifies as a woman.

***

Margaret Nichols, PhD, has been a licensed psychologist and AASECT Certified sex therapy supervisor working in the LGBTQ community for 35 years. She founded the New Jersey Hyacinth AIDS Foundation and is the founder and president of the Institute for Personal Growth. Her recent publications include chapters in textbooks Principles and Practice of Sex Therapy and Systemic Sex Therapy. Contact: mnichols@ipgcounseling.com.

Tell us what you think about this article by emailing letters@psychnetworker.org. Want to earn CE hours for reading it? Visit our website and take the Networker CE Quiz.




Read 4718 times
Comments - (existing users please login first)
Your email address will not be published. Required fields are marked *

Name *
E-mail Address *
Website URL
Message *
8 Comments

Monday, March 14, 2016 1:32:32 PM | posted by Lisa
"But that doesn’t mean that every teen who asks for medication should be recommended for medical intervention. The vital task here is to honor the adolescent’s affirmed gender while helping that young person explore what that means for them." I applaud PN for taking on this timely issue, but I feel that something important is being lost in the way it has been addressed. Something is going on, and it is very concerning. I large number of young people -- especially teen age girls -- are coming out as trans after intense internet binges on sites such as reddit, tumblr, or YouTube. These young women often suffer from social anxiety, depression, aspergers, or in some cases, bipolar disorder. The coming out is happening in peer groups. In some cases, whole friend groups "come out" together. While I am supportive of transgendered people receiving the medical care and human rights that are their due, I am very concerned about a social contagion phenomenon. The current transgender trend among young people -- which is many cases is getting uncritical support among therapists -- puts distressed young people on a path that may lead to serious surgeries and life-long medical treatment. Puberty blockers and cross-sex hormones are being prescribed off-label to children and teens at increasingly young ages without adequate knowledge about potential long-term consequences. Once a young person has gone through their teen years presenting as their affirmed gender, whether on hormones or not, surgery may seem like a natural next step. Transition will always remain on option once a young person reaches adulthood. One cannot undo a surgery that removed healthy organs, or get back one's ability to have biological offspring. I am disappointed in my fellow therapists who have embraced a well-meaning social justice agenda that precludes their using their critical and diagnostic expertise. Our role should be to do as we always would when someone comes in with important questions that lead to major consequences -- to help them explore without judgment -- not to blindly affirm.

Tuesday, March 15, 2016 7:30:15 PM | posted by margaret
I agree, it would be unprofessional to uncritically affirm a child or youth's gender without careful evaluation, which can rarely be done quickly. But while I share your concern about teens adopting trans identity because somehow it is perceived as socially desirable, in practice I know of no gender affirming therapists who are not cautious- a trans identity has to be 'persistent, consistent, and insistent' and takes time. I am more concerned about therapists who are untrained in this specialty than I am about the colleagues I know and work with.

Wednesday, March 16, 2016 12:52:36 AM | posted by Maria Gonzales
In 1990, seven years after terminating therapy, Sal called me to tell me about his transition—and to point out the prejudices that wouldn’t allow me to consider that a woman like her might actually be a transman. “I told you I wished I were a man, felt like I should have been born a man. You didn’t listen.” Sal was right—in my mind, female-to-male transgender people (FtMs) didn’t exist. Looking back, I can think of many clients who were self-identified butches whom I may have unwittingly disaffirmed by my blindness. Today, transmen—biological females transitioning to male—are at least as common as transwomen. And I’m embarrassed by my old views. It is wise to be cautious when making generalizations regarding gender. We may unintentionally marginalize gender "non-conforming" men and women (who do not identify as transgender) in our efforts to affirm people in the transgender community. There are times when it i difficult to guess a person's gender identity,especially when they have an androgynous name or "nickname". I have known women named Billy, Jimmy and Johnny - spelled Billie, Jimmi, Johnnie. All identified comfortably as women yet, they looked as if they could identify as men. The great majority of "butch" lesbians do not identify as transgender and many feel very differently about gender that many transmen. A lesbian who wears masculine clothing, very short hair and has a rugged appearance may identify as female as much as a very traditionally feminine woman. Such a woman's perpective on gender will most often be one that rejects gender stereotypes. She may have similar feeling to Sal, perhaps even an identical perspective when she was younger that "she should have been born a man" or that "life would have been easier had she been born a man" but ultimately, she may come to terms with what she comes to understand as sexism and realizes that she finds empowerment in reclaiming was tit means to be female on her own terms. She may experience body dysphoria and have a very similar life history to Sal's yet still persist in embracing a female identity. How do I know? I know because I live this truth. One of my closest friends transcend FtM just a year ago. He and I shared 20 years of friendship - as lesbians. We were "buddies" and our friendship is just as strong today. Our histories are very similar, our experiences of dyshporia are almost identical yet we have taken different paths to wholeness. With the use of people coming out as "transgender" I fond that not only am I routinely mistaken to be male (which is nothing new) but I must often repeat my name and gender pronouns to help people fully accept that yes, I am female. Clerks have apologized to me in cities like S.F. and Seattle, confiding that they find it is often less hurtful to "affirm" people who look like me was "male" as transmen are often visibly troubled when they are "mis-gendered". And so it is, after many years of working got come to terms and learn to love myself and my female body, I now find that I must clarify my gender in some way in new environments at least once per day. For me, it is a nuisance but not an unbreakable burden. For my friend, the issue is more painful. He recognizes and shares my view that "gender is a social construct" but finds that after fighting to survive (for 30 years) in world that does not respect him and treat him as an equal to men, it made more sense for him to transition and live as a man in order to finally claim his place in the world. Ironically, we still share parallel experiences and similar battles we just reach a little further from other sides of the fence to connect these days.

Wednesday, March 16, 2016 6:13:23 PM | posted by Nienna
Well, yes but I hear the above views are controversial, that not everybody agrees with them, and that in particular, the radical feminists don't. I don't know how to deal with this issue socially because of that. Disbelievers I've met have got really offended with me for asking what pronouns they prefer, when it's turned out that they just prefer fashions associated with the opposite sex. So, how do we keep both the trans people and the rad femmes and the other non-trans-believing gender non conformers happy? How do I and us generally keep polite to everyone? I'm not a rad fem, but I'm not convinced by all this new gender stuff either. I have no religious objections; I'm secular. But, I'm close to fifty and I remember when I was young, how stridently it was said by activists in the gay community that sexual orientation was unchangeable, that people who were gay or lesbian, (there was little mention of bisexuals in those days), were so for life, yet something believed much more often now which I do totally accept is that sometimes people's sexual orientations do change, and in fact there are a lot of grey areas as regards sexual orientation. So, can it really be said, once trans always trans? Or, in 25 years approx, or whenever, will people similarly be saying, well actually that's not true, tons of people are trans but change to vis, it happened to me and me and me and me .... (or vice versa)? Because if not people should not be getting rid of healthy organs. And, yes I do have great concern over the thought of that and the effects of hormones and especially on young people. Re the above, I feel the loss of fertility and/or a healthy natural body has got to be a worse loss than the loss of not having a medically altered and sterile body which socially looks like the opposite sex of the person or androgynous. So I cannot feel medicalising is wise and don't feel society should be going down this road.

Sunday, March 20, 2016 11:06:19 AM | posted by Karen
It was with a mix of anticipation and trepidation that I opened up this month's issue of The Networker. At the risk of being censored, as well as sounding like a Neanderthal, I have some very basic, but urgent questions. Firstly; Are not all mental health professionals also bound by the Hippocratic Oath, "First Do No Harm?" If that is true, how is colluding with children and parents to administer mind and body altering hormones and surgeries perfectly acceptable? What if, as Margaret Nichols mentioned, upwards of 70% of children change their minds and eventually accept their male and female bodies as is? How easy would it be for them to then revert back? And for the parents to say "Whoops?" What would happen if instead of believing they are "born into the wrong bodies" we helped them to understand that there is no scientific evidence for a male or female brain? (See Science Mag.org, November 30, 2015.) What if we were to encourage both sexes to dress however they like (weather permitting,) play with whatever toys they wanted, and aspire to be whatever they like? Wouldn't it be kinder and more honest if we taught that you are actually born male or female, and that these sexes encompass a wide variety of thoughts, feelings and behaviors? How are we doing these children and adults a service if we have to suspend our own disbelief in order to agree that they are "who they say they are?" What if we remembered as professionals that there is a psychiatric condition known as "assumption" which disallows any questioning of that person's belief system? Would we enable a 90 pound anorexic to obtain liposuction because she believed she was fat? Would we do the same for a person with Body Integration Disorder who wanted to cut of parts of themselves? By challenging the language to say "assigning a gender at birth, are we using Orwellian Newspeak? Didn't Firstwave Feminism teach us that gender is a social construct? How are we helping anyone if we deny objective reality? As a therapist with almost 30 years experience, much of dealing with body dysmorphic disorder, I find the author's viewpoints deeply troubling. I have no doubt that she is a caring and compassionate practitioner. Yet I cannot help but wonder if our field has succumbed to such openness of belief that we have lost our bearings and our boundaries.

Sunday, March 20, 2016 10:12:02 PM | posted by Third Way
Unfortunately there are a lot of people out there just blindly affirming people's genders without any kind of exploration. In some cases, even suggesting there could potentially be other causes to people's gender issues is seen as transphobic. I don't really think it is people with a lot of experience like yourself that is doing this so much, but there are a lot of people out there who just get four hours of training and are taught that the only thing you need to for people with trans issues is to affirm their genders and eliminate all sources of oppression. Any other mental health issues are seen as automatically be not caused by the gender issues, even though some of the kids / young adults have obvious trauma issues that seem directly related. Particularly young people considering ftm transition with issues of internalized misogyny or feelings of unsafeness around men. I have seen so many stories from mothers who have their natal daughters announce seeming out of nowhere that they are trans, and see a therapist who after one session affirms them as trans and announces their other issues can't possibly be the cause of their gender issues. All this with no assessment whatsoever. Whatever else, these issues deserve to be treated with serious gravity. There is something wrong if assessment for approval for hormones is less involved than assessments for depression! Also, it is often seen as "bigoted" or "transphobic" to even question these ideas to the point that people with critical perspectives feel afraid to reveal themselves publicly. You'll notice this issue doesn't contain any critical perspectives for example. Here is some great further reading around these issues: http://alicedreger.com/gendermad http://thirdwaytrans.com/2015/12/18/social-justice-and-gender-therapy/ http://4thwavenow.com/2015/08/22/exiles-in-their-own-flesh-a-psychotherapist-speaks/ http://4thwavenow.com/2016/02/29/tumblr-snags-another-girl-but-her-therapist-mom-knows-a-thing-or-two-about-social-contagion/

Tuesday, April 5, 2016 1:43:25 AM | posted by Maria
The sharp rise in people coming forward as identifying as "transgender" is reminiscent of a time in the late 80's and early 90's when many trauma survivors were identifying as having "Multiple Personalities" or later, it was known as "Dissociative Identity Disorder". Some readers may have been practicing therapists at the time and can recall the issues that arose from this chaotic time, including the "Satanic Panic" that resulted in numerous (successful) lawsuits. A wave of class action lawsuits arose when claims of "False Memory Syndrome" that allegedly resulted from psychotherapist's "leading questions." Clinics like "The Healing Place, in Laguna Beach were closed down over night and it seemed like a wild fire of litigations that resulted in multiple clinic closures, heavy penalties, fines, suspensions and even revoked licenses. http://io9.gizmodo.com/a-brief-history-of-satanic-panic-in-the-1980s-1679476373 www.fmsfonline.org (False Memory Syndrome Foundation) A Psychotherapist needs sharp intuition paired with outstanding listening skills, excellent training and extremely high integrity to help patients with the complex and intricate issues of identity. One must be very careful to never ask "leading questions" one must listen carefully without "guiding" a patient in any one particular direction.

Wednesday, February 22, 2017 6:42:04 AM | posted by FightingToGetHerBack
My child with autism who suddenly announced she was transgender (after knowing several at her school her are trans) she was "affirmed" by a therapist who did not question her beliefs. We were pushed into accepting her transition because of a therapist like Margaret Nichols who falsely claimed we would be encouraging suicide if we did not support transition. We were pushed into using hormones and told they were perfectly safe. Thank God, we didn't listen. Thank God, I found the truth: that most of the approach to treating transgender children is POLITICALLY motivated and has no basis in sound psychology or medicine. I find the views of Margaret Nichols horrifying. I hope any therapist who reads this will probe further to question her assertions and faulty reasoning. (Does she really think that there is no social contagion effect going on? This defies common sense.) My daughter's beliefs -- which have been strongly supported by someone we trusted to help guide my daughter to the truth -- have now been reinforced so much so that we are at a loss as to how to help our daughter see the truth. Thanks to a therapist like Margaret Nichols, my daughter is still convinced she is a boy and is counting down the days until she turns 18 so she can find another therapist like Margaret Nichols to recommend she begin taking testosterone.