The transgender spectrum: where do I fit? Part one

In this and next month’s columns I’ll be covering material from a workshop I gave recently at the Keystone Conference in Harrisburg, Pennsylvania. My goal was to generate dialogue about the transgender spectrum through presenting a theory and a number of therapy case vignettes that illustrate aspects of the theory.  We had a very lively discussion following my remarks, and I hope that it will continue to generate thinking in the readers of today’s column.

The notion of a spectrum of gender identity is one that has been taken as a given for a number of years in the transgender community and among professionals working in this field.  Although we have no formal research data to confirm or deny this theory, it is one that makes a great deal of sense to me from a clinical perspective, and is consistent with what we see with other human traits such as attractiveness or intelligence, that is, a continuum, rather than a binary. We don’t see just beautiful and ugly, or intelligent and stupid, but a range of presentations of these traits falling along a normal, bell-shaped curve.

Since I am a clinician and not a research scientist, I am going to base my remarks on what I have seen over the past couple of decades in conversation with transgender clients and their families.  However, I’d like to refer to a theory proposed recently by biologist and transgender activist Julia Serano in her book, “Whipping Girl”, called the “intrinsic inclination” model of human gender and sexual variation.  It has 4 basic tenets: 1) that sexual orientation, gender expression, and gender identity, (which she calls “subconscious sex” or “what sex my brain expects my body to be”) are determined independently of one another; 2) that these gender inclinations, as she refers to them, are intrinsic to each person and persist despite external influences and conscious attempts by the individual to purge, ignore, or suppress them; 3) these traits are multiply determined rather than being caused by any one factor such as genetics, hormones or environment, resulting in a continuous range of potential outcomes; and 4) the best way to describe the occurrence of these inclinations is with a bimodal distribution, with two overlapping bell curves representing each physical sex, such as that for height.  With the overlap, we can account for the fact that some women are more masculine in their gender expression than some men, although on the average males are more masculine than females.

The important and overarching element of Serano’s model is that it places exceptional outcomes such as transgender identities on a continuum of naturally occurring human variation rather than assuming they are biological or developmental errors. Because Serano’s model coincides nicely with the amazing diversity I have seen in my own work, I feel comfortable using it to justify the notion of a spectrum of gender identity.  The model goes on to state that within the large amount of naturally occurring variation in gender identity, there is also a tremendous amount of variation in the way that we feel about that identity and the meanings we attach to it, depending on our culture, our family background, our religious and ethnic identities, and our individual psychology. This is where it starts to get really complicated, and where the challenge to finding a way to fit comfortably into one’s own world begins.

People with gender identity issues come to me at different stages of self-awareness, self-acceptance, and experience living in the gender to which they were assigned.  Some are suspicious of my role as a “gatekeeper”, certain of their own identity and resentful that they would be required to demonstrate their fitness to make decisions about their own gender presentation.  I understand this completely, and explain quickly that I have no vested interest in dissuading or persuading them of anything, but want to offer my experience and knowledge to help them navigate the system as well as the potential obstacles in their social environment.

An example might be J, a young adult who identified as a gender queer female.  J was not interested in hormonal masculinization, but felt sure that she would be more comfortable in her physical body if she were to have top surgery.  She asked me to meet with her and her parents, a highly educated and liberal-leaning couple who understood the notion of transgender identity, but could not fathom why their daughter would want to have her breasts removed and remain female-identified.  Our opening of a dialogue on this subject may not have fully convinced the parents of the wisdom of her life choice, but it allowed for airing of feelings and opinions that had been considered off limits in the family up to this point.  Apart from facilitating dialogue, I was also able to offer observations about the transgender spectrum that put their daughter’s seemingly irrational choice into a more rational framework.

More often, clients come to therapy saying that “they know who they are” but for various reasons are unable or unwilling to move in a direction that would enable greater gender comfort or congruity.  They might have made choices into which they feel locked, such as marriage, parenthood, or careers that would not allow for the possibility of gender transition or increased cross-gender expression.  When I ask clients what they would do if there were no negative social, vocational, or financial consequences, a fair number of them say they would “transition in a heartbeat”.  In that case, I work with them to clarify what they assume the obstacles are, and offer my thoughts and experience about ways in which other people have dealt with these issues.  I neither sugar-coat nor overly catastrophize the challenges in balancing one’s gender path with the potential losses and hardships one might face. I also initiate with clients an examination of the pros and cons of the choices they have made to date, so they can begin to put their lives in a less guilty and shame-laden context.  This process can lead to a relatively quick discernment that will lead to a clear course of action, or it can set into motion a roller coaster ride of emotions accompanied by spiraling fits and starts over an extended period of time. I will try to provide examples of each outcome.

Jim, a 45 year old divorced father of two who was a well-respected high level executive of a major corporation, consulted me after having spent a year working with a therapist who was not trans-knowledgeable.  He had learned useful techniques for managing certain types of anxiety, but had not been successful in reframing his long history of cross-dressing as a “sexual addiction” that could be mastered, according to that therapist’s conceptualization.  His gender issues had led to the end of his marriage, and he still felt unfulfilled and lonely -   “part of me wants to know, can I be happy?  I want to know what the trade-offs are.”  Since his divorce, Jim had been going out more frequently as Julia, his femme persona, and enjoying that, although he still felt depressed and found that he had to keep busy all the time in order to stave off further depression.  After our first two or three sessions, Jim said that “Pandora’s Box had opened”, and he came to realize that he needed to pursue gender transition.  In the year since then, Julia has experienced many emotional highs and lows, but has remained steady in her conviction that she must transition, and has made great progress toward a successful one.

On the other hand, Dan, who, like Jim, first consulted me at age 45, continues after almost 9 years to struggle with the question of how to find peace with his gender dysphoria.  A highly competent chemist and conscientious married father of 3 teenagers, Dan was tormented by guilt after his wife accidentally discovered his secret.  They had come to an agreement that he would not take any drastic action until their children were out of the house, and his wife seemed to understand that the gender condition was not his fault.  Over the weeks and months that followed, Dan took some small steps to gain some relief from his gender dysphoria, including regular individual and group therapy sessions and some very low-dose female hormones. These moves helped Dan’s mood and outlook improve, but were met with unexpectedly fierce pushback and blaming from his wife. Predictably, Dan would begin to despair that he could never transition because of his size and appearance and his unforgiving employment setting (although I had never pushed transition).  This pattern would lead Dan down into a spiral of depression accompanied by a doubling back on his efforts to suppress the gender identity issue.  In the nine years since I first met him, Dan has dropped out of therapy with me for long periods of time and has also discontinued hormone support and severed contacts with his friends in the transgender community.  He re-contacted me a few months ago and stated that he was now in a better position to revisit his gender issue since his children were out of the home and he and his wife were planning to divorce.  However, even now, he has difficulty applying his good rational mind to a fair analysis of the costs and benefits of actions toward gender wholeness, and falls easily into patterns of guilt and self-reproach.  My current effort is to keep him from drastic and counterproductive choices that would spiral him into another depression.  We have a contract that he will call me and discuss any such impulses so that we can examine their wisdom together before he takes any external action to suppress his inner gender identity.

In next month’s column, I’ll continue with further case examples of individuals on the transgender spectrum who did not choose to transition as well as a young person whose emergent need to transition collided with family expectations.  Until then, enjoy the earth’s re-awakening, and, possibly, one of your own!

Category: Transgender Body & Soul