Michele O'Mara

A Gender Primer

Filed By Michele O'Mara | November 19, 2008 5:00 PM | comments

Filed in: Marriage Equality, The Movement, Transgender & Intersex
Tags: ftm, gender, gender dysphoria, Harry Benjamin Syndrome, identity, MTF, sex reassignment, soc, therapy, transexual, transgender, transvestite

Editors' Note: With Transgender Day of Remembrance coming up, it seemed appropriate to re-post Michele O'Mara's great primer on gender from last year. She works with transgender clients in her private practice.

What is gender identity?
Gender identity occurs from the neck up. Biological sex is defined from the neck down. Our gender is the self-defined recognition of our selves as either male, female, or some combination of characteristics from both. Gender is a term which reflects our "social" self, rather than our biological self. Our gender does not, in fact, always match our biological markings as "male" or "female."

What is gender dysphoria?
Gender dysphoria, which is also known as 'gender identity disorder' or (GID), is a medical diagnosis that describes an experience of anxiety, confusion, and discomfort about the discrepancy between one's biological sex, and one's self-defined gender identity which does not match their biological sex.

The first three words that we often hear upon our entrance to this world are either, "It's a boy," or "It's a girl." When those words are spoken, an automatic series of expectations are set in motion about how we will think, look, dress and act as we grow-up. The gender dysphoric child, however, will soon discover that what is expected of him or her is not what feels good or right.

This begins the journey toward self-discovery. Unfortunately, this journey toward self-discovery is wrought with strong social influences, expectations, and misinformation. Much like being dropped in a thick dark forest without a guide, or any clear paths, the gender dysphoric child must safely navigate his or her way to his or her true gender, often alone.

Generally, early in life, a child who is born with mismatched sex and gender, will begin to feel as if they have been born into the wrong body. Though there is typically no language, or even understanding of what is happening, yet a dysphoric child will develop the sense early on that something is very different about them. The emphasis in our society on gender-appropriate behavior generally creates varying degrees of distress for a youngster with gender dysphoria. The boy who wants to wear pink, and is shamed for this; or the girl who doesn't want to wear a dress and is made to, may soon develop the belief that how he or she feels is "wrong," or "bad."

This feeling of shame often serves as the foundation on which the rest of one's gender then develops. Gender confusion, and conflict may ebb and flow over the years, with some periods of time being more difficult than others. Eventually, however, it will begin to permeate every aspect of life, causing increasing amounts of distress, confusion, and anxiety for the gender incongruent person.

The degree of dysphoria varies from mild to extreme. For some, dysphoria simply creates mild feelings of belonging to the opposite sex, and may cause people to dress as the opposite sex once in a while (called cross-dressing). For others, anxiety about being 'in the wrong body' can be the major driving force in their lives, leading them to seek gender reassignment, commonly known as a sex-change or (known as transsexualism). Others may simply question the rigidity of gender roles, and seek to establish a 'transgender' identity with out any particular motivation to alter their bodies.

For diagnostic purposes, the mental health community relies on a manual commonly referred to as the DSM-IV, to classify someone as having Gender Identity Disorder (or dysphoria) (GID). The primary criteria for this diagnosis is a strong and persistent cross-gender identification. This means the person wants to be, or is insistent they already belong to, the opposite sex. A person must be persistently uncomfortable in their current gender role, and feel that it's not congruent with their physical self. This diagnosis will not fit if a person is motivated to transition for the purposes of experiencing a cultural advantage of the other sex. Likewise, the diagnosis is not appropriate for someone with 'intersex' conditions. There has to be evidence of clinically significant distress, or damage to important aspects of the person's life to diagnose gender identity disorder. Gender dysphoria is an overwhelming and widely misunderstood condition that causes significant distress for those experiencing these conflicts. It is common for gender dysphoric men and women to develop anxiety and depression. The longer these issues go un-addressed, the more severe the conflicts can become.

Many people make choices to affirm their biological sex by over-compensating for their gender identification with the other sex. Men may go to extremes to prove their masculinity, including marriage and fatherhood, and biological women may also go to extremes to prove their femininity.

What is Transsexualism?
Transsexualism can be defined as an incongruence between the biological sexual differentiation and the gender identity. In a nutshell, a man or woman who experiences the feeling that they have the mind of one gender and the body of another. The intensity of conflict for a transsexual is such that relief can only be experienced by changing their body to match their mind.

Transitioning one's gender role typically involves a regimen of Hormone Replacement Therapy (HRT), which may or may not be followed by Sexual Reassignment Surgery (SRS) depending on how a person defines their own gender. Some men and women are able to find relief for their gender-incongruence by changing their physical self enough to be perceived by the world in the gender that is most true for them, regardless of the genitals they have. Others, despite the private nature of what one's genitals are, feel persistently uncomfortable until their entire physical self, genitals and all, match their gender identification.

How common is gender dysphoria?
There are no studies, currently, that reflect an accurate representation of the percentage of people who experience gender dysphoria. Because of the highly-stigmatized, often shame-based nature of this condition, it is common for those with gender issues to censor and conceal their feelings, thus compromising our ability to know how many people are experiencing this pain.

What are the causes?
The quick answer is, we just don't know. We do know that transsexuals have normal male (XY) or female (XX) chromosomes for their sex. There are no identifiable physical characteristics for gender dysphoria, and there is no 'test' for the condition. Hermaphrodites and others with ambiguous sexual characteristics at birth are not transsexuals, and don't necessarily experience gender dysphoria.One theory is that changes in the brain before birth cause certain parts of it to develop the opposite pattern to their sex. Significant proportions of male transsexuals have abnormally low levels of HY antigen. HY assists in the masculinising effect of the Y chromosome in men. Work done in the Netherlands also suggests that the problem arises in the hypothalamus in the brain. This is involved in the early development of sexual differences within the brain, and controls the production of sex hormones throughout life.

What do you look for when diagnosing Gender Identity Disorder (GID)?
There are two components of Gender Identity Disorder, both of which must be present to make the diagnosis.

  1. There must be evidence of a strong and persistent gross-gender identification, which is the desire to be, or the insistence that one is of the other sex (Criteria A). This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex.

  2. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex (Criteria B). The diagnosis is not made if the individual has a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) (Criteria C). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criteria D).

What is common to see from a person with GID throughout their development?

  • Childhood

    During childhood, boys will typically show an obvious interest in traditionally feminine activities. They may prefer dressing in girls' or women's clothes. A boy who openly admits wanting to be a girl is likely to be teased, redirected, or told that's not "right," and that he "shouldn't" want to be a girl. He is expected to grow out of it quickly. In boys, there is also often an assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.

    Traditionally, a young girl who wants to be a boy and expresses this is less likely to invite such criticism. She may be labeled as a tomboy, but is still expected to grow out of it. In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.Many children do grow out of gender dysphoria. Only a small number of children continue to feel the same way in later adolescence. Some families are better than others at accepting their children's behavior. Some children live openly in their chosen gender role, but have to endure the taunts of their peers as well as pressure from their parents. Others cope by hiding their feelings and learning to play the gender role assigned to them, meanwhile going deeper into a private world of cross-gender fantasy and desire.

  • Adolescence

    With puberty, hormones start to trigger body changes which often ignite greater stress for gender incongruent men not wanting to develop a deeper voice and greater muscle mass, or incongruent women not wanting to start their menstrual cycle or grow breasts.

  • Early adulthood

    In adulthood,, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

    Most people who have grown up with gender dysphoria show less openly cross-gender behavior as time goes on, because of their parent's interventions or pressure from their peers. By early adulthood, nearly 75 percent boys who had a childhood history of gender dysphoria may think of themselves as homosexual or bisexual. They no longer have feelings of belonging to the wrong gender.The remaining 25 percent or so, however, continue to experience gender dysphoria into adulthood. They may try to rid themselves of their ever-increasing gender anxiety in various ways. They may get married and have children, in the hope that this will help, or simply to hide their feelings from others. Some seek professional help, often to ask for gender reassignment.

  • Later adulthood

    Years of trying to overcome a deep-rooted desire and coping with anxiety can lead to depression. For some, the pressure is so great that they attempt suicide. Many re-assess their lifestyle when they come to later life. Some seek professional help; others start cross-dressing more frequently, in private.

How are gender and sexual orientation related?
Gender identity is the way in which a person defines their sense of self as male or female. Sexual orientation is unrelated, except that it is defined by the gender toward whom we find ourselves attracted both emotionally and physically. People with gender dysphoria can be homosexual, bisexual or heterosexual. Typically the direction of one's attractions toward males or females, remains consistent despite changes in ones gender role. So if a man is married to a woman (pre-transition), it is likely that after transition she will wish to remain married, or will likely remain attracted to women even if she now lives as one. Some men and women, however, who transition may uncover aspects of themselves, including an alternate sexual orientation, that were buried beneath the shame of their gender conflicts, or may choose to explore their sexuality from the perspective of their true gender.

What is a Transvestite?
A transvestite, or transvestic fetishist, will dress as a member of the opposite sex and will often get sexual excitement from it. Transvestism is quite different from transsexualism and other forms of gender dysphoria. Transvestites don't feel that they belong to the opposite sex or alienated from their own bodies or sexual organs.

What do you look for in diagnosing Transvestic Fetishism?
Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

What is gender reassignment?
Gender reassignment is a several year process that starts with an inner conflict that is unrelenting. Once the transgender person acknowledges this conflict and makes the decision to deal with it, he or she typically starts counseling. Typically within three months of counseling with a skilled gender therapist, a trans man or woman will initiate HRT (hormone replacement therapy) to begin reshaping their body and initiating a long-overdue ender-appropriate puberty. Eventually a real life test (RLT) will be initiated and this is an opportunity to live for an entire year in the preferred gender role.

For those seeking Sex Reassignment Surgery (SRS), this year of RLT is required prior to surgery. Some people reassign their genders without ever having surgery. It is difficult, however, to transfer your identity on legal documents such as birth certificates, drivers licenses, and social security cards if you do not have a letter from a surgeon stating your gender has been reassigned.

Although people's chromosomes and reproductive identity can't be altered, long-term hormone treatment and surgery should allow them the physical appearance and some of the sexual functions of the opposite sex. However, after surgery, they will lose the ability to have children.Gender reassignment is not the best solution for everyone. There are many steps to move a person closer to their authentic gender without requiring sugery. For others, though, it's essential to live peacefully.

What does male to female gender reassignment involve?
For a biological male wanting to affirm his female gender, it is necessary to first start a regimen of estrogen (hormone replacement therapy or HRT). This will move the affirmed female into something akin to puberty, whereby she will experience fat redistribution, softer skin, some mood changes with increased emotional sensitivity, breast development, and it will also cause the penis to atrophy and not perform as well, if at all, as usual.Following HRT, if surgery is desired, the candidate will have to live for one year in her new gender, prior to receiving a letter of referral from a gender specialist. It is common during this time to initiate hair removal (via laser or electrolysis), undergo facial feminization surgery, practice feminizing voice, experiment with feminine dress and make-up as well as hair styles and body language.

After carefully selecting a surgeon, receiving a letter of support from her therapist, the affirmed female can have surgery. Though there are different techniques for this surgery, the most common will form of surgery will remove the testicles and erectile tissue of the penis in order to create a vagina lined with the skin of the penis, where the nerves and blood vessels remain largely intact. Tissue from the scrotum is then used to create the labia, and the urethra is shortened and repositioned appropriately.

What does female to male gender reassignment involve?
For a biological woman wanting to affirm his male gender, it is necessary to first start a regimen of testosterone (hormone replacement therapy or HRT). This will move the affirmed male into something akin to puberty, whereby he will experience beard growth and muscle development, along with a deeper voice, changes in his body odor, skin (it's common to get acne), and even personality. Affirmed men often feel more aggressive on testosterone, than prior to taking it. On the whole, these changes can't be reversed later. It is also common for affirmed men to have a double mastectomy (breast removal) with chest reconstruction. This makes it much easier for the person to appear as a man in public.

After at least a year of hormone treatment, the ovaries and uterus are removed (although menstrual cycles tend to cease within the first couple of months on testosterone. For many female to male transsexuals, this is as far as they will go with surgery. Going further is more complex, very costly and the sugical techniques available are not as effective for affirmed males as they are for affirmed females. For those who do continue, phalloplasty (penis construction) and testicle implants are available. It's also possible to create a male urethra and to move the clitoris to the head of the penis.To research surgeons, click here.

Other Terms

Cross-dressing is simply the behavior of wearing clothes and styles that have been assigned by a culture or society for a person of the opposite gender. This behavior does not indicate that a person is transsexual or that he desires to live in the role of the other gender. Rather, it is a behavior that may be motivated by various reasons, including, but not limited to, transexualism. Cross-dressing behaviors that are not the same as Gender Identity Dysphoria include:

Drag is a special form of entertainment based on cross-dressing

Drag-Queen is a male-bodied person who performs as an exaggeratedly feminine character, in an elaborate costume. A drag queen will often imitate famous female film or pop-music stars. Drag king - is the counterpart of the drag queen -- a female-bodied person who adopts an exaggerated masculine persona in performance or who imitates a male film or pop-music star.

Androgyny This is a term derived from the combination of Greek words meaning man (andro) and woman (gyny), that can refer to two concepts regarding the mixing of both male and female genders or having a lack of gender identification.

Intersexuality This is a term used to describe a person whose sex chromosomes, genitalia and/or secondary sex characteristics are determined to be neither exclusively male nor female. A person with intersex may have biological characteristics of both the male and female sexes.

Genderqueer or (intergender) This is a gender identity of both, neither or some combination of "man" and/or "woman". In relation to the gender binary (the view that there are only two genders), genderqueer people generally identify as more "both/and" or "neither/nor," rather than "either/or." Some genderqueer people see their identity as one of many different genders outside of man and woman, some see it as a term encompassing all gender identities outside of the gender binary, some believe it encompasses binary genders among others, some may identify as a-gender and some see it as a third gender in addition to the traditional two. The commonality is that all genderqueer people reject the notion that there are only two genders in the world. The term genderqueer is also occasionally used more broadly as an adjective to refer to people who are in some way gender-transgressive, and could have any gender identity.

Pansexual Pansexuality means being attracted to or open to attraction to people of all different gender identities, and reflects a non-binary understanding of gender and its interplay with sexuality. Other associated terms include: Omnisexual Polysexual and Multisexual

Michele O'Mara, LCSW

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Wow - thanks Michele for a spectacular primer for those who don't understand the trans community!

Thanks for the explanations. I get frustrated when people interchangably use the terms transgendered and transexuals. I like the neck-up, neck-down example.

Excellent post, but I would caution you against referring to M-to-F transsexuals as "male transsexuals" (from the "What are the causes?" section). In general, transsexuals generally do not appreciate being referred to by their gender of birth.

This post makes several common mistakes....the first part talks about "degrees" of GID implying that sad old gender spectrum nonsense while later taking the position of the distinct differences in the definitions. While the exclusionary part about one part of the DSM regarding intersexed conditions is correct, it fails to note that there is another category called GID not otherwise specified that does include it, That is the part that will likely be expanded in the DSM revision that will address the state of science regarding physical causality of classic transsexuality.

For a discussion of the differences regarding the most importance diagnosistic difference see: http://radicalbitch.wordpress.com/2008/02/14/the-dysphoric-imperative

For a breakdown of the logical misrepresentation of the gender spectrum see:

Again, you take someone else's scientifically unfounded writings to justify your unfounded theories. Two wrongs don't make a right, just a "radical right."

While you mentioned that young girls may not receive the same pressure that young boys do to conform to their expected gender roles, you didn't really point out the other ways the system is focused on the two "default" genders differently. For example, you put the diagnosis criteria for Trasvestic Fetishism without bothering to highlight how it only appears to apply to men, and you didn't include Drag King in your definitions section at all.

I think it's really important to point out the way that the technical diagnostic tools that are currently available are woefully inadequate and do not actually reflect a lot of the reality as lived by trans people every day. In that vein, I'd love to see some discussion of the likely changes to the criteria for the DSM V that's been in the works for the past several years.

I agree. The explanation confuses gender roles with subconscious sex. Some of us are butch women born in men's bodies or femme men born in women's bodies. Some of us may seem androgynous, or even cisgender, in early childhood.

Okay, that was in reply to Cathryn's first comment, but I have to disagree with some of the statements in her link.

I have to add that being uncomfortable in one's assigned gender roles, or comfortable in the opposite gender roles, does not mean someone is transsexual. By the same token, being comfortable in one's assigned gender roles does not mean someone is cissexual. Body map, comfortable body image, comfortable hormone levels, etc. are at least as important as anything else.