What would you most like people to know about transgender individuals?
I think the most important thing to know is that gender non-conformity is another form of diversity. And it’s not anything pathologic. That gender non-conforming people have the same needs, the same medical needs, the same emotional needs, as anyone else.
For the unfamiliar, how would you define transgender?
A transgender individual would be someone born in an assigned gender that does not match their gender identity. Perhaps born male, but feels female. Then they struggle with their gender expression — how to present in the world with a masculine body and a feminine interior.
Being transgender is not about genitals, it’s about how someone perceives themselves inside. Their sense of themselves in the world as a gendered person.
Is being transgender a choice?
I don’t think anyone chooses to be trans. That was a similar thing people would say, “Why would anyone want to be gay?” But, it’s not something people choose. It is something inherently part of someone’s make-up.
For those unfamiliar with the term, could you describe “gender dysphoria”?
Dysphoria is the incongruence someone feels between their perceived gender and their interior gender. It can be a very personal process, looking in the mirror and not liking what you see, not feeling that your body matches yourself, and, yes, it can be worsened by being out in society where people are marginalized, bullied, attacked, even killed. So, it’s a complicated process.
It appears there have been recent advancements for the transgender community.
The World Professional Organization for Transgendered Health revised their standards of care in 2011 and made a very clear statement that gender non-conformity is a matter of diversity, not pathology.
The new DSM-5 is coming out and there have been changes to that that depathologize the process. Now, the new language will say that gender diversity is not itself pathological, but it can produce gender dysphoria. Dysphoria is sadness, incongruence — that is something that causes enormous pain and can be treated. So, to identify the dysphoria as the problem, rather than the gender variance.
What would you like people to know about gender and gender identity?
People look at gender with four constructs. Their is a binary system where people think there are men and women. And then there is a more complicated way of looking at gender. The more complicated way has four precepts. The first would be your assigned gender, the gender that you are pronounced at birth based on your genitals, male or female. But, as you know, people sometimes fall in-between that spectrum and are born with intersex conditions. So, it’s not a binary, but a continuum from male to female. The next is gender identity and that is very much inside — what gender you feel inside yourself, who you are. And that is not necessarily linked to your assigned gender. It certainly can be. But you can be assigned male but feel inside that you are female. The next component of it is gender expression, that’s how you present yourself to the world — your haircut can be masculine, feminine, but just like the other two, there can be a continuum in between. Some people are very masculine looking. Some people dress more androgynously. Some people you look at and can’t really tell what gender they are. So, this precept, like the other two, is also a continuum. The last precept would be sexual orientation. Who are you attracted to? And this is also not linked to the other three and it can also be a continuum. You’re attracted to men, attracted to women, attracted to both. So, we look at gender as being made up of all those things.
Is it getting easier for people to come out as trans today?
In my practice I have people of all ages coming. I have a couple of nine year olds who are in that fluid stage and the parents are concerned as they seem very persistent in their cross sex behavior — we’re just watching them until they get to puberty. I have several people who started to transition in their 70’s. How people present in the different age groups is very different. The older individuals have lived in a society that was much more marginalizing to them. A lot more shame. A lot more feelings of regret. More sadness. I think truly it would have been very difficult for them to come out and transition in their younger days. So, it’s complicated for them. But still a very joyful process. I enjoy the older people very, very much.
The young ones who come in, 20’s, are often very straightforward. They don’t even, sometimes don’t have, much gender dysphoria at all. They haven’t been particularly distressed by their experience. They perceive themselves to be, for example, a female body person that perceives herself to be male, has come out to all of his friends, changed his name. A lot of social media stuff. And friends, family, not all of them, but many have had an experience of acceptance.
Can you talk about this issue as it relates to youth who think they might be trans?
Gender non-conformity before puberty is a very fluid process. So kids experiment and, if they are in a home where that is acceptable, kids will experiment in all kinds of ways. Trying on different roles — masculine roles, feminine roles, roles in between. Some kids become very fixed in gender expression as a tomboy. Some boys will present as a girl, play with girl toys, wear girls clothing. However, not very many of them persist into adulthood and are actually transgender individuals. The number I believe is, less than 17-percent persist into puberty. So, with little children before puberty we just encourage parents to let them explore in a nonjudgmental way. Once children hit puberty, there are stages of puberty called Tanner Stages. Once there has started to be the development of secondary sex characteristics, in general, children’s gender identity is fixed at that time. At that point, often the gender dysphoria becomes quite severe for transgender children. They’re suddenly having to deal with puberty in the assigned gender and it can be very painful to have periods, to suddenly grow masculine features can be very distressing.
If children meet certain criteria we can offer medication called pubertal blockers. It is a medication we have been using for years to treat precocious puberty — children who go into puberty too early. And what it does is it arrests puberty so the child and family have time to explore with a therapist just what is going on. Perhaps, they need a few more years to decide what their gender identity truly is. And it allows that to happen in a safe way.
What could be done in the medical field to help transgender individuals?
One of my hopes is that we can, over the next few years, train a whole new cadre of doctors, nurses, and providers in the basic skills required to care for this population.
Any final thoughts?
For me, watching someone come to terms with trying to find their authentic self has been a very beautiful, beautiful experience. Sometimes people compare it to being a midwife or being an obstetrician and going through a pregnancy and birth of a child. To watch someone go through a transition, struggle with all of the obstacles, mostly societal, but some physical come along with that, and then emerging on the other side a more authentic person.