Implications of Being Gender Dysphoric
By Anne Vitale Ph.D. Editor -- Mar 25, 2022
Notes on Gender Role Transition
Anne Vitale Ph.D. Editor
Implications of Being Gender Dysphoric
July 22, 1996
This piece has been updated and replaced by
The Gender Variant Phenomenon--A Developmental Review
January 27, 2003
Keywords: Transsexualism, cross-dressing, gender identity, gender dysphoria, gendermap, sex reassignment
Abstract: This essay outlines the difficulties experienced by individuals whose perceived gender identity differs from their genetic sex. The period covered is from early childhood through old age.
Most people never question the accuracy of the sex they were born into, while there are those who can't imagine a more important question. Some of this latter group don't raise the question until midlife, but most often those who feel they have been born the wrong sex are aware that there is something wrong as early as age four. Because of the importance sexual -- and by linguistic default, gender -- classification plays in a child's life, the notion of there being something wrong usually results in a feeling of being different from their peers and uncertain about their identity. Clearly a very shaky start for anyone's life.
For most, this feeling of being the wrong sex, known in the medical literature as either gender dysphoria or transsexualism (and now technically as Gender Identity Disorder (302.5), per the Diagnostic and Statistical Manual of Mental Disorders IV), comes and goes over the course of their lives. It can be gone for a few hours, a few days, or as long as a few months, but significantly, it always returns. It pervades all aspects of life.
People who can't express or are fearful of expressing their inner sense of maleness or femaleness develop an anxiety that builds over time, often leading to deep despair and chronic depression. Many think of suicide and attempts are common. Untreated, most live seriously disrupted lives.
The situation is made even more difficult because the condition, contrary to popular belief, is not necessarily apparent in ones behavior and generally is not recognized by society as a valid disorder. Furthermore, since everyone is raised as either a boy or a girl, without the individual doing a thing, a chain of physiological and societal events unfolds that entrench the individual into a predetermined set of behaviors and expectations. To insist on deviating from those expectations invariably results in social conflict. The quality of life of the individual, as well as his or her relationship to family, friends, career, legal status and the nature of his or her being in the universe, are all at stake. There may be no other psycho-physiological condition short of a severe mental disorder that has as far reaching an effect on the individual and the individual's family.
Even though the terms gender and sex are often used interchangeably there is now good reason to believe that we need be clearer on use of the terms. Behavior scientists are now routinely using the word sex to refer to the shape of the genitalia, while gender is a measure of the individual's imprint of being male, female, or somewhere in between. John Money calls this imprinting our gendermap. Money defines a gendermap as the entity, template, or schema within the mind and brain unity that codes masculinity and femininity and androgyny. The map is established very early in life through an interaction of nature and nurture.
If we accept the notion that gender is a continuum running from absolute male on one end to absolute female on the other, and that genital sexual physiology may not necessarily be congruent with gender identity, we can see the possibility of there being a corresponding mild-to-severe range in gender related anxiety.
Individuals who are generally satisfied with their assigned sex but experience a mild anxiety regarding their gender identity take two different views. The periodic need to cross-dress is a common element in both cases. Some individuals have come to terms with their cross-dressing needs and may even celebrate them with public presentations. Others have a far more negative view of their activities and keep their cross-dressing a private matter. Either way these individuals stay largely within the primary physical bounds of their assigned sex. The problems these people encounter are primarily social ones: family pressures to conform, and the potential embarrassment of discovery being the most important. As with more extreme cases, minimal to mild gender identity anxiety is known to affect individuals throughout their lives.
Interviews I have held over an eighteen-year period with approximately 200 adults presenting with Gender Identity Disorder reveal five distinct anxiety stages that, not surprisingly, parallel the standard periods of developmental anxiety: childhood, adolescence, young adult, middle age, and older adult. If untreated, individuals report a steady increase in both strength and frequency of gender related anxiety with age.
Childhood
Gender plays an extremely important role in the lives of all children. As early as age two and half, children begin showing a preference for behaviors and activities consistent with their gender. By the age of three, they actually refer to themselves as a boy or a girl. Interviews with three-year-olds reveal that they agree with each other that girls like to play with dolls, ask for help, and talk more than boys, while boys like to play with cars, build things, and hit other children. Children's perceptions of adult males and females tend to be simplistic and stereotypical.
If the social learning theory of gender acquisition is correct, it is little wonder that children place such a high priority on gender-appropriate behavior at an early age. Interestingly, most individuals with Gender Identity Disorder that I and others have spoken with report becoming aware that something was not right with their original gender assignment as early as age four. Males also report that, unlike other problems a four-year-old boy may have, discussing wanting to be a girl with one's parents was already out of the question.
A boy who wants to be a girl and is willing to admit it can expect to be "corrected", often in a very stern and no nonsense way. One individual reported a traumatic incident in school when, at the age of six, he was made to stand in front of his class wearing a large ribbon while his classmates were encouraged to ridicule him. He was being "corrected" for having been "caught" playing hopscotch with the girls. A girl who wants to be a boy and is willing to admit it can expect far less retribution for her behavior. Girls who affect boyish behavior are generally perceived as cute and the behavior is usually tolerated as tomboyish. They are also expected to outgrow it. Undoubtedly, there are cases where a little guidance and time are all that are necessary to correct a gender identity misunderstanding in a child. In others, however, it appears that once established, no amount of redirecting can change the child's gender identity. Some children openly endure the taunts of their peers and castigations of their parents in living life according to their gender understanding. Other children who decide to wait out their dysphoria (hoping and praying that it will just go away), cope by learning to play the role expected of them, all the while going deeper and deeper into a highly guarded parallel world of cross-gender envy and fantasy.
Another interesting constant is the search for supernatural help. This is usually in the form of repeated praying to God, or using birthday wishes to address the issue. The wish is always the same: boys pray that they be changed into girls while girls pray to become boys. Praying to God is usually based on the childhood logic that becoming the desired sex is surely an impossible dream, a miracle that only God could perform. Importantly, these individuals report believing that if God had changed their sex, their parents and the world would have to exonerate them from what is perceived to be a negative and shameful desire. It would also serve to force the world into accepting their new condition.
Adolescence
Adolescence is the next phase of life a person with sex/gender incongruity must negotiate. If there ever was going to be a second chance for these individuals, early adolescence is certainly it. Virtually every individual interviewed reported wanting desperately to discover hidden internal sex organs of the desired gender finally come to life, giving them the desired secondary sex characteristics. Although there are reported cases, most notably from New Guinea and the Dominican Republic, in which children raised as girls were found at puberty to be really males, individuals routinely develop the secondary sex characteristics expected: genetic boys develop into adult males and genetic girls develop into adult females.
At this stage, coping becomes far more complex. For boys, who must now contend with higher levels of testosterone, a two-pronged approach is typically reported. Boys often combine excessive masturbation with an increase in secret cross-dressing to release anxiety. At the same time, in their public life, they employ overtly stereotypical efforts to draw attention from their secret desires to be female by appearing to be normally male. This includes dating, sports activities, and for some, even tattoos and body building. The situation is less complex for girls. Having more social freedom in dress and behaviors allows at least a surface release of anxiety. Loose, gender-neutral clothing is typically worn to hide their feminized bodies and there is little or no attempt to appear or act normally female. Many adult female-to-male transsexuals report adopting a defiant attitude toward the world as a coping strategy.
Early Adulthood
The coping strategy of the gender dysphoric individual doesn't change fundamentally when the individual is in his or her twenties. What does change is the intensity with which the individual tries to rid his or her self of the ever increasing gender related anxiety. This is also the first period in which a small portion of these individuals search out professional help. Those that do seek help typically want help in changing their sex.
Males report making repeated efforts to purge themselves of accumulated female clothing only to reassemble yet another secret wardrobe. Involvement in stereotypical male activities increases, such as joining special hypermale divisions of the military or motorcycle clubs with outlaw reputations. Another common attempt is to get married and have children. To enhance this effort, many of these individuals paradoxically adopt homophobic, transphobic, and overtly sexist attitudes. This latter attitude is adopted in the hope that increasing a sexist, pro-male identity will override their desires to be female.
In distinct contrast, gender dysphoric females make very little attempt to rid themselves of their desire to be male. In fact, they continue uninterrupted by puberty in effecting an androgynous appearance and evoking androgynous-to-outright male mannerisms. In larger cities, refuge is often found by taking active roles in the lesbian community and involvement in typically male occupations. Homophobic and transphobic reactions are also not present.
Developmental psychologists refer to the age between 28 and 33 as a time when individuals reassess their dreams and aspirations. Mistaken interest, family obligations and career demands start to become serious concerns. For women who are reaching the later part of their childbearing years, the children are now in school or yet to be born. Either way, new decisions have to be made relative to the bulk of life that still lies ahead. When someone contenting with a gender identity issue reaches this pivotal period, the pressures are magnified far beyond what others experience.
People seem to respond to this critical period in two characteristic ways. A growing number of people (generally people who have access to information resources) give serious consideration to changing their sex, and seek professional help. If appropriate, these individuals often go on to be physically and legally reassigned to the sex that more closely fits their inner sense of self. Others, who may be as aware of the sex change options, may find the idea too impractical, deciding instead to entrench themselves deeper into life as a member of their originally assigned sex.
Mid Life
For those who have not undergone sex reassignment, the struggle continues into mid-life. This is the time when all people realize that about half of life has been lived. It is also a time when a full accounting of who we are and what we have done with our lives becomes a driving force in our plans. This can be a dangerous time for the gender dysphoric individual. Decades of trying to overcome an increasing anxiety begin to weigh heavily on the individual. Family and career are now as deeply rooted as they ever will be. The idea of starting over as a member of a different sex becomes a formidable obstacle. The fact that the need to change sex has increased rather than diminished, despite their efforts, is now undeniable. Pressed ever deeper into despair, they think even more about suicide.
Older Adults
Some gender dysphoric individuals manage to make it into their senior years with their dysphoria unresolved. Even now their need to be female may be as strong or stronger than ever. I say female because at this age, we are speaking almost entirely of genetic males. The relative freedom of gender expression that women enjoy throughout their lives continues, and there is even less pressure to be attractive on older women then ever before. This is not the case for males. Males often must contend with unfeminine balding and increased paunchiness. The individuals I have worked with in this age group range in age from their early fifties to early seventies. Issues such as young children, careers, and relationships are less of an issue at this point in their lives. It is their last two or three decades of life, and they feel an urgent need for what little time they have left to be spent as women.
In summation, although every individual is different, there are some common threads running through the lives of gender dysphoric people. Gender dysphoria usually starts to be a problem for the individual in early childhood. Those children who suffer their dysphoria openly face almost universal castigation from family, peers, and the larger society. In most cases, however, the dysphoria is suffered in silence through childhood and adolescence. Genetic males in their twenties and thirties often try to make the dysphoria go away by engaging in stereotypical male behavior, while secretly cross-dressing to relieve the dysphoria-based anxiety. Suicide ideation and aborted suicide attempts become sobering threats at this stage. Forced to recognize the seriousness of their dilemma, some individuals find the courage to seek professional help. Others go on with their private attempts to beat the ever present and often increasing need to change their sex. The final stage comes in the senior years. Those who are still contending with the disorder may finally search out help. Individuals who don't, sadly, take the dysphoria to their grave.
GENERAL REFERENCES
Berg, I. et al.,'Change of assigned sex at puberty', Lancet (7 December 1963, 1216-18.
Diagnostic and Statistical Manual of Mental Disorders IV. 4th ed. Washington, D.C. : American Psychiatric Association (1994)
Green, R., 'Sex-dimorphic behavioral development in the human: prenatal hormone administration and postnatal socialization'. Sex, Hormones and Behaviour, CIBA Foundation Symposium 62, Excerpta Medica, 59-80, Amsterdam (1979)
Kohlberg, L., 'A Cognitive-Developmental analysis of children's sex-role concepts and attitudes'. In E. E. Maccoby (ed.). The Development of Differences. Stanford, CA: Stanford University Press (1966)
Money, J., Gendermaps: Social Constructionism, Feminism, and Sexophical History. New York, The Continuum Publishing Company (1995).
Money, J. & Ehrhardt, A. A., Man and Woman, Boy and Girl: The differentiation and dimorphism of gender identity from concept to maturity. Baltimore: Johns Hopkins Press (1972)
Stein,S., Girls and Boys: The Limits of Non-Sexist Rearing, London, Chatto and Windus (1984)
Vitale, A., History and Resolution of Sex/Gender Integration Needs as Experienced In Four Male Transsexuals, Unpublished Dissertation, Professional School of Psychological Studies, San Diego, (1982)
