The Tempest Over Sex Identity*
By Lisa M. Hartley, ACSW-DCSW
( Lisa M. Hartley, ACSW-DCSW is a Master’s level Clinical Social Worker with over thirty years post Masters experience that includes clinical, supervisory, administrative and educational arenas. She began active transitioning from male to female in 1994, and completed her real life test in 1996-97. She underwent her confirmation surgery by Dr. Yvonne Menard in Montreal, Quebec, Canada on August 18, 1997. Several of her articles on the transgender experience have been published in books, magazines, newsletters, and the Internet. She has lectured to thousands of people about the transgender experience, including the sharing of her own story.)
Thomas N. Wise, MD., Professor of Psychiatry and Behavior Science, The Johns Hopkins School of Medicine wrote the following to The Dartmouth, the newspaper of Dartmouth College. It appeared as a letter to the editor in the online version, October 12, 2001 with the title “Transgender Truths.”
“I am concerned that there is ongoing confusion regarding sexual minorities. It is clear that homosexuality is not a psychiatric disorder. The official diagnostic stigmatization of homosexuality was abandoned after lack of data that could establish any pathology associated with being either gay or lesbian. Gender dysphoria, unhappiness with one’s biological sexual designation, is very different from same sex attraction and is a psychiatric disorder. Individuals who designate themselves as transgender, which is not a formal medical or psychiatric term, often are not homosexual but have significant problems of self identity. As director of research at the Sexual Behaviors Unit at Johns Hopkins, we have spent the past 25 years studying such conditions. Transgender individuals are not bad people but often have serious conflicts and issues that are not a result of society but due to internal psychological conflicts. They need treatment as well as acceptance. I recognize that this is not a popular stance but in the long run will save much suffering by these individuals.”
Well, I have serious concerns about Dr. Wise’s comments, which, at most could very well result in an injection of considerable suffering for transgendered people and, at least, continues the tired mythological and stigmatizing belief that transgender is just another way to say “we’re crazy.” Those who read his comments, made by a man of obvious standing and influence, may seize upon his “diagnostic” opinion about “gender dysphoria” and use it as another reason to fear transgendered people as potentially or completely unstable. This could worsen the already serious issues encountered by transgendered people in areas such as employment and housing, in receiving adequate medical care and health insurance coverage, or in numerous other areas that mainstream society enjoys.
Although Dr. Wise has worked for years studying individuals who have significant problems with “self identity,” the idea that transgender is a psychiatric disorder that exclusively involves “internal psychological conflicts” seems quite interesting to me. Dr Wise states that there is “lack of data” establishing homosexuality as a psychiatric disorder. Does this mean that there is data that transgender is a psychiatric disorder? After 25 years of study, there must be a vast body of information to support his assertion. If so, where is it?
There also seems to be little scientific curiosity or motivation to discover any physiological components associated with transgender. Yet studies that have been conducted over the years have often shown a physical component to emotional disorders, whether they are neurotic or psychotic in nature. As a result, most, if not all emotional disorders, are remediable to forms of medicine that are designed to relieve the symptoms presented, thus allowing the person to regain control and proceed with insight that leads to resolution of the problem(s). For example, if a patient is suffering from an anxiety disorder, a medicine can be administered, such as Valium, to relieve the physical symptoms while talk therapy continues.
Having no apparent motivation to understand the physiological components of transgender means that there are no medicines identified that would impact the specific “symptoms” of transgender. Anti-anxiety medicine will not work. Anti-depression medicines will not work. Anti-psychotic medicines will not work. Even electro-shock therapy will not work. In fact, there is no medicine to help a person relinquish the symptoms of a perceived “psychiatric disorder” defined by an unhappiness with a culturally designated sex identity, that is often accompanied by a “delusion” of wanting to be the other sex and gender.
However, counseling can be an important adjunct to help support the transgendered person in navigating the stormy seas of cultural ignorance. What seems interesting is that the counselor will, at the request of the “patient,” write a letter to the person’s physician approving the administration of opposite sex hormones. Upon receipt of the letter, the physician will do so. Later in time, another letter might be written to a qualified surgeon to confirm that the person is appropriate for “reassignment surgery.” Upon receipt of the letter, the surgeon will do the surgery. This would appear to be antithetical to the idea stated by Dr.Wise, that “gender dysphoria” is specifically an internal psychiatric disorder. Indeed, these actions might appear to be symptomatic of the counselor and the medical professionals being drawn into the “delusion” of the patient!
The dysphoria that Dr. Wise describes is, in all probability, not the result of “internal psychological conflicts” at all. It is most probably a product of an incongruity in physical structure that has been missed in the past due to a lack of understanding about the true origination of sex identity, which is located in the brain, and not the genitals. The mistake in sex identity designation at birth, followed by an intensive socialization in the wrong gender role, results in serious stress for the transgendered person—an external stress induced by the culture that will challenge the very core of the transgendered person, as will be explained later in this paper.
It is important to distinguish the terms we use. Transgender is not a sexual minority. It describes issues with sex identity. Sex identity is also distinguished from the sexual minorities in that identity describes, “Who am I?”(girl, boy, or whatever) and sexual minorities describe a sexual orientation toward another person, as in “who do I want to have a relationship with?” All too often, sex identity issues, as seen in transgender, have been included with the orientation groups, i.e. gay, lesbian, bisexual, and heterosexual. This is not only confusing but it is entirely incorrect.
Other terms that are often confused are “sex” and “gender.” Sex is the biological presentation of male, female, or other. The biological includes the brain, genetics, and hormones, along with the genitals. Gender is a culturally developed term that defines norms for the behavior of males and of females—a set of rules I call “cultural clothes.”
I do agree with Dr. Wise that transgendered people are not bad people. Actually, we are very good people. We are, in the main, above average in intelligence. We are mentally strong, creative, sensitive, reality based, and competent people. It is also important to understand that, like any other group of people, the transgender community includes a very diverse, broad continuum of personalities, lifestyles, sexual orientations, and gender expressions.
Schools of Thinking about Transgender
Much of the transgender journey is a private internal struggle. Thus, each transgendered person has his or her own unique way of explaining the ‘why’ of his or her situation. When they connect with other transgendered persons and share their explanations about “the journey,” there are often similarities and differences in their understanding of the process. Much is subjective and, for those who have researched, there are “factual” positions on the topic. Often there are heated discussions over who is more correct. Over time transgendered people gravitate to others who, like themselves, believe in the same transgender process, resulting in the development of several “schools” of thinking. Those professionals and allies who desire to assist the transgendered people have also developed their own views adding other “schools” of thought. All the “schools” have made contributions to our understanding of transgender, and all “schools” have their passionate devotees.
First, there is the school of thought that says a person has the right to express whatever gender, or claim whatever sex identity she or he desires, including androgyny. This is what I call the “naturalist school.” The generally held view expressed by this school is that there is no need to prove anything or to explain the “why” of transgender. It just is and that is sufficient, period. Transgendered persons have endured a multitude of negative experiences with the whole range of professionals and the systems in which they work. As a result, proponents of the “naturalist” school are suspicious of professionals in general. There is, then, a tendency to suspect professional people, often including transgendered professionals, and to dismiss professional views as arrogant, assumptive, trite, and unnecessary.
The “naturalist school” encompasses a significant number of transgendered people, including those who were our early “pioneers.” They are the true “sheroes” and “heroes” that continue to exert a powerful influence in the transgender community. There are also many advocates for social and legal justice who embrace this school of thought, as it espouses the human right of self-determination.
Secondly, there is an “anthropological-historical” school. This school, which is very supportive of the naturalist school, outlines the presence of transgender throughout history. The fact of historical presence further legitimizes the transgender community by revealing its roots.
Also in this school are those who document current trends and events that occur in the present time. Sobering is the website “Remembering Our Dead,” by Gwen Smith, who documents those of the transgender community who have been killed simply because they were transgendered.
Then, there is a “psychiatric school.” Proponents of this school believe that “gender dysphoria” is present in the so-called ‘transgendered’ persons. The “patient” reportedly suffers from an inner psychological unhappiness involving their biological sex identity designation, which, for some curious psychological reason, is unacceptable to that “patient.” The “dysphoric patient” is viewed as seriously neurotic, or perhaps even more seriously impaired, reflective of major diagnoses like, schizophrenia, dissociative personality disorder, bi-polar disorder, and so on. Also in this school are those who feel that the male to female “dysphoric patient” suffers from a condition described as “autogynephlia.” To me, that designation seems evidence of, “when psychoanalysis goes bad!” Others see transgender as a format of homosexuality, which is, of course, an obvious misunderstanding of the difference between identity issues and sexual orientation.
The psychiatric school sees the transgendered person as a patient, i.e. one who is disturbed (ill). Therefore, an appropriate “professional distance” from the “patient” must be maintained. This attitude, of course, inhibits meaningful collaboration between the naturalist and psychiatric “schools,” and provokes the flow of negative transference and counter-transference phenomena, so evident in the “naturalist” school toward the professional community and vice-versa.
Another “school” embraces the “hard science” of medicine. In medicine, the transgendered person is often viewed as a congenital anomaly, which occurs during the gestation process. After the proper clearance from the “patient’s” counselor, the physician develops baseline data collection, followed by careful administration of hormones, if the “patient” is desirous of taking them.
Unfortunately, there is nothing to compel a physician to spend much time understanding transgender. Information and training in “transgender medicine,” if there is such a thing, is not readily available, unless provided by the “patient.” To many physicians, treatment given to a transgendered person seems like sailing in uncharted waters. Many physicians refuse to provide care to transgendered people because of perceived risks. Others feel compassion and try to be helpful. Still others accept transgendered persons into their practice, yet seem unconcerned about the quality of care provided to them. Perhaps care is referred to the doctor’s Nurse or Physician’s Assistant, or ARNP, without much in the way of preparation. Some of these people turn out to be helpful, but the majority seems to view the transgendered patient as an ‘organism from outer space.’
When a physician does accept a transgendered person for treatment, there seems little, if any, sensitivity training provided to the office staff and nurses. All too often, the attitudes and behaviors of office staff and nurses destroy the “patient’s” motivation to trust the health care professionals or the process.
Another curious phenomenon that is evident, especially in the medical world, is an attitude of sophistication that is reflected in a calm exterior when a transgendered person appears for care. There seems an aura of, ‘we treat everyone the same and are completely objective.’ The use of an “objective professionalism” most likely will be perceived by the transgendered person as a defensive cover for a good deal of anxiety that lies within. All this foolishness is exposed when one looks at the quality of treatment, which all too often reveals a betrayal. It might be refreshing for the doctor to be open and honest when treating a transgendered patient. The doctor might see the transgendered patient as part of the care team—a valuable member indeed!
But with the increased volume of information, and the presence of transgendered people in the world today, many professionals feel less fearful and more interested in helping. I thankfully acknowledge the array of professionals from many different disciplines who are crucial to the emotional, legal, and physical health and welfare of transgendered people. As more and more transgendered persons identify themselves, the diverse bio-psycho-social needs of the transgender community will require more and more supportive professional resources to assist them.
Next, there is the important arena of the “Research School.” There are two different parts to this school. The first part is focused upon understanding the “why” of transgender through physical research. The prevalence of physical research on transgender is very limited at present, perhaps because there is little financial or cultural support for such work. Still, I believe that the physical research findings about the BSTc in the hypothalamus have been ground breaking and crucial to our development of a clearer understanding of the physical/biological etiology of sex identity.
The second part, social research, looks at the physical health, emotional well-being, and social issues that impact the transgendered community. Most of the work has been done by activists in specific cities and states, who use the data to show the need to protect transgendered persons by including ‘gender identity or expression’ in anti-discrimination laws.
As yet, there continues to be no definitive understanding of the incidence or prevalence of transgender. There are many guesses, but no one knows the numbers. In most census data collections, transgender is not mentioned, as if we do not exist. If we knew more about the incidence and prevalence of transgender, we could develop a clearer understanding of the issues, needs, and the many positive contributions made by the transgender community.
Finally, at least finally at this time, there is the “Legal/Political School.” Proponents of this “school” borrow heavily from the psychiatric and hard sciences schools in their work as legal advocates or policy makers. However, this school is vulnerable to the strong influences of social customs and deeply held values and ideals that often reflect entrenched mythical beliefs of culture. As we know, cultural traditions change very slowly, especially in the integration of new knowledge gained from research. This vulnerability can result in maintaining the status quo, which, for the transgendered population means serious delays in obtaining social justice. Another issue, which often influences decisions, is the practice of citing past court decisions, reflective of old myths and outdated “facts.” This only perpetuates the myths and misunderstandings about transgender.
Yet the “legal and political school” holds great promise. As lawyers and policy makers become educated about transgender, they are recognizing the urgent need to protect and defend transgendered persons’ civil rights, as well as to advocate for their acceptance in the mainstream of culture.
Even though the field of transgender study is relatively new, the “schools” have somehow maintained an independent status from one another that creates a sense of “turf” separateness. As they are not compelled to work together, any attempt to identify an “eclectic school”(my preference) or develop communication strategies that link the “schools,” would probably encounter significant barriers.
As a “resolved dysphoric” and a surgically “confirmed” female Master’s level clinical social worker with over thirty years experience, I learned long ago that each of us is a bio-psycho-social entity. I have become acquainted with the various “schools” of thought on transgender, and reviewed much of the vast amount of wonderful material associated with each school.
There are good things in each of the “schools.” I agree with the “naturalists,” who feel that there is an implicit human right to be oneself. After looking at the findings from physical research, and from understanding my own experience and the experiences of many in the transgender community, I do not agree with the “psychiatric school” position that transgender is a psychiatric problem. I do not believe that there is a “gender dysphoria” evident in transgender. I do believe that there are strong cultural components that complicate and exacerbate the transgendered person’s struggle to define their true sex identity as reflected in the brain. I believe that the response to transgender by so many in our culture reveals a cultural dysphoria. Culture is unhappy with, and cannot accept the reality of transgender. I agree with the “hard sciences school,” in that there must be a significant biological component that strongly contributes to the human motivation to express another gender role or sex identity, either on a part time or on a full time basis. Although I may be making premature assumptions from the studies done in Amsterdam and elsewhere, I believe that the ongoing work in the BSTc of the brain will eventually prove to be an important factor that defines the origin of everyone’s sex identity.
As I mentioned earlier, there are many good people doing a lot of good things to serve the transgender community. I do not believe that there is an evil plot against transgendered people. I do believe that we are wrongly perceived by many in our culture as a foolish, unwholesome, unstable, and worthless minority. These negative descriptors get further associated with all sorts of other negative images. In time, myths develop that pose a significant barrier to any legitimate effort at educating the public about the true etiology of transgender, or in obtaining social justice and equality for transgendered people.
Fortunately, tireless efforts by many including transgendered individuals, professionals from many disciplines, as well as advocates from human rights organizations, have made a significant impact in the education of everyone about the truth of transgender. Little by little facts are beginning to replace the fear and the many false and destructive myths about us. Yet I still continue to wonder why the archaic and mythological thinking about transgender is so amazingly persistent in professional circles, as well as in the general population, despite important research developments that have been reported. Perhaps it is very difficult to let go of long held belief systems, despite strong physical evidence to the contrary.
The situation with transgendered people is not so simple and easy to dismiss as Dr.Wise has stated, “not bad people who often have serious psychological issues.” With ongoing study, my own experience, and listening to many anecdotal accounts from those in the transgender community, I have developed an explanation that, I trust, reflects a more accurate picture of reality, and embraces elements of several of the schools of thought outlined above.
But, of course, that is not the case. It is a widely accepted belief among most in the professions that although there are physical elements in transgender, there is not, as yet, a precise understanding of the impact of these elements at this time. It is agreed, however, that it is absolutely crucial to provide transgendered people with competent assistance in issues of adjustment in the transitioning process, including supportive counseling, advocacy, resource referrals, and so on. Counseling almost always focuses on issues associated with being transgendered, not about the physical reality of transgender per se, which appears to be in-born and immutable.
There have been recent developments in research that provide important new and challenging insights concerning everyone, including transgendered individuals. Ground breaking research studies reported in journals and the popular press within the past decade include work done with the BSTc in the hypothalamus at the Institute for Brain Research in Amsterdam, Netherlands by Dr. Zhou et al, and also by Dr. Wilson Chung et al in the USA. Another study, involving intersexed persons, reported by Dr Reiner et al of Johns Hopkins Hospital, has added significantly to our understanding of the origin of sex identity. These studies have substantially challenged the traditional thinking about sex identity designation, and present the thesis that sex identity is an inborn physical reality that originates in the brain. The genitals, which have been the focus of “biological” sex identity designation for millennia, appear to be only incidental to sex identity, whether functional or not.
The genitals appear to have three important functions. First is the elimination of waste from the body. Second is the production of sex hormones that promote the physical characteristics of that particular hormone. And third, the genitals facilitate procreation. The sex identity designation, so often done by looking at the genitals, is a socially ascribed action, a mythical power given to the genitals that, as we now know, is a catastrophic error, especially in the instances of transgender or intersex infants.
We must challenge the current perception that the genitals define sex identity. We must also challenge the view that the transgendered person is psychiatrically disturbed. We must begin to understand and integrate the physical data from research. We must understand that transgender is an inborn physical incongruity where the origination of sex identity, located in the brain, is not matched by the genitals. This shifting of the paradigm is required of those in the counseling and medical professions, the insurance and allied industries, the systems of government and law, and everyone in the culture as well.