The Tempest Over Sex Identity*
(revised 9/03)
By Lisa M. Hartley, ACSW-DCSW
A Formulation Concerning Transgender:
First of all, “transgender” is an inclusive, umbrella term under which a continuum of behavior is revealed. At one end of the continuum are the most secretive (“closeted”) transgendered persons. As one moves toward the center of the continuum line, behaviors include progressively more and more open expressions of opposite gender or gender-neutral behavior. Moving along the continuum toward the other end are transgenderists, who live in the opposite gender role. And finally, at the other end of the continuum are the transsexuals, many of who obtain corrective genital surgical procedures to confirm their true sex identity. Most transgendered persons fall near the center of the continuum line.
I think that what we see in transgender is related in some way to the intersex community. But in the instance of transgender, the person is born with completely formed genitals. Because the new and important research has not been incorporated by the medical community to date, an archaic protocol continues to be used, in which the designation of a “biological” sex identity is made by looking at the external genitals of the infant. Although the genitals should reflect the brain sex identity, in transgender there is no match. Thus, a catastrophic error in sex identity designation occurs in the case of a transgendered baby. This error starts a chain of events that are outside the control of the child. Events like naming the child, completing legal papers that include the error in sex identity designation, primary socialization, and the continual reinforcement of wrong gender role expectations is carried out by a culture that is unaware of the primordial error.
Equally devastating is when the genitals are ambiguous, as is often seen in an intersexed infant. Surgery is all too often the solution to a perceived medical or social “emergency.” In these cases, a transgendered person is all too often surgically created! Yet the practice of surgical assignment of sex identity upon intersex infants continues to be done by rigid, unsophisticated professionals. Surgery on helpless infants seems to me to be a serious violation of their rights. In my opinion, it constitutes a criminal surgical assault upon the helpless infant.
In addition to the work with the hypothalamus, which continues in Amsterdam and elsewhere, a study done at Johns Hopkins Hospital by Dr. Reiner et al on intersexed infants with incomplete external genitals, has demonstrated that the brain is the primary site in determining a person’s true sex identity. As Dr. Reiner stated:
“The sense of who one is (boy or girl) is a crucial existential aspect of humanity. It is powerful and inborn….. The most important sex organ is the brain.” (Johns Hopkins Hospital Magazine, September 2000).
This finding strongly reinforced the conclusions by many in the scientific community concerning the famous “twin study,” where one of the infants, David Reimer, was injured in a botched circumcision. Clearly, Dr Milton Diamond did science a great service by discovering that John Money, PhD was in error in his assumptions that genital manipulation could be done without the child ever knowing the difference. Despite all the surgical technology used to impose a female sex identity upon David Reimer’s genital region, all the hormones administered, and all the psychosocial strategy with the family designed to reinforce the surgical sex identity assignment, he refused live as a girl. His true sex identity as a male, originating in his brain, would not be denied.
Overview of Culturally Induced Stress (Internal and External)*
When the transgender community is viewed as a whole, a pattern of stages emerge that reflect an intense struggle which every transgendered person must navigate in order to “be.” As the person moves from one developmental stage to another, the awareness of a need to express the “other” sex identity intensifies. While trying to “be” what culture assigned him/her to be, the transgendered person must also privately address the relentless inner struggle to understand their true sex identity as reflected in their brain. This struggle often results in outward signs of a culturally induced stress that can take the form of mild to moderate depression, isolation, anxiety, low self-esteem, and other stress related behaviors.
The inner struggle to understand their brain sex identity, versus the culture’s designation of a sex identity via the genitals, will never cease until the transgendered person resolves the struggle by getting information, finding and joining supportive groups, going into counseling, or by a courageous exploration on their own. Once the true sex identity is understood and accepted, a “coming out” process begins.
The external struggle to achieve acceptance by the culture is a scary one indeed. Ideally, the culture should recognize the error made in the sex identity designation, and then assist the transgendered person in the transition process to confirm their true sex identity as expressed in the brain. But the rigidity of socialization is enforced by many persons of influence in the culture, such as those in positions of power and authority, like physicians, psychologists, law makers, the courts, law enforcement, the church, employers, and others, who continue to insist on forcing the transgendered person to live with the sex identity designation mistake that was made at birth, regardless of the human suffering it induces.
Even the media participates in this rigidity, referring to transgendered persons with the wrong pronoun or using the person’s former name. After speaking in Nyack, NY, a newspaper reported me as a “former man!” There are countless other examples, including the use of the birth given name in referring to transgendered persons. For example, Eddie “Gwen”Araujo instead of just Gwen Araujo.
The stress phenomena experienced by the transgendered person is what I call “Culturally Induced Stress”(CIS)*. There is an “internal CIS” component, and an “external CIS” component.
Internal CIS:
The “ CIS” component involves the transgendered person’s dealing with the struggle that exists between the constantly reinforced culturally designated, genitally based “sex identity,” versus the opposite and true biological sex identity that is physically present and expressed in the brain.
The inner struggle may be more clearly understood by referring to the process of homeostasis (physical balance) as described by Walter B. Cannon, MD, ScD, in his book entitled The Wisdom of the Body, (Second Edition, WW Norton, New York, 1939).
Simply explained, homeostasis can be understood by the following example. If you had a headache, you would be experiencing an imbalance, a lack of homeostasis. The pain you feel would be a signal for you to do something to eliminate the discomfort. Perhaps you would take an aspirin or enjoy a brief rest, or do whatever you do to find relief. Soon the pain is gone and you feel like yourself again—you have achieved a physical balance called homeostasis.
Most people are born with genitals that match the brain sex identity. But in the instance of transgender, an incongruity is present. The genitals do not match the brain sex identity. But to be in physical balance, to achieve homeostasis, the incongruity must be resolved.
The process of homeostasis, then, includes the person’s internal struggle to understand and accept that the culture’s designated sex identity that was imposed upon him or her at birth was an error, and then recognize and accept that the true biological sex identity located in the brain is what defines his or her true sex identity. This process, in the final analysis, is truly “mind over culture.”
The process of working through the internal component of CIS to achieve homeostasis, is exceedingly difficult. After all, there are observable, “normal” genitalia. Everyone says she is a girl, or, he is a boy. Yet, there is the continuous feeling that something is wrong-- that things are slightly out of focus. For most transgendered persons, the awareness of the incongruity of their sex identity begins in early childhood as a preconscious awareness, which is usually not fully understood or articulated by the child.
The ever-present internal struggle to understand their true sex identity is continuously frustrated by the relentless external efforts to reinforce the primary cultural socialization. There is a strong prohibition (“taboo”) on any conversation that questions the sex identity designation made by the doctor, let alone the “preposterous” idea of “changing” one’s sex. These rigid external pressures constitute a culturally induced stress that inhibits the transgendered person’s freedom to outwardly explore and understand his or her true sex identity. Transgendered persons, like everyone else, have learned that there is retribution for openly embracing and expressing their true sex identity, which is at odds with the initial designation made by the culture.
It should not be surprising that the transgendered person will most often choose to struggle with their sex identity incongruity alone. It is much safer, and avoids the likelihood of punishments from others who would not understand. Like the ‘skeleton in the closet,’ the struggle is almost always regarded as a private and carefully guarded “secret”—a “secret” that carries with it much suppressed fear, guilt, shame, loneliness, and feelings of futility--that there is no way to resolve the problem.
Most transgendered people make an attempt at conforming to the culturally designated sex identity as a way to survive. But this approach is rarely satisfactory or successful, even with culture’s positive reinforcement. As the years go by, the transgendered person becomes more and more aware of the need to resolve his or her sex identity incongruity. In Wilson Chung’s study reported in 2002, we learned that the BSTc matures in adulthood. Thus, like turning up the volume on a radio, the need to understand and achieve homeostasis increasingly intensifies through the years, forcing the person to pay more and more attention to the issue of their sex identity incongruity. Indeed, the internal CIS struggle will never end until homeostasis, is somehow achieved.
The details of the internal struggle are individualized for each person, their environment, experiences, perceptions, and so on. But there are many common guideposts in the journey. These common points are presented in the “The Process of Becoming—A General Overview of the Transgender Journey” section at the end of this paper. The range of coping strategies can go from emotional ups and downs, to acting out, to substance abuse, to just about anything else, including an outwardly “normal” adjustment.
The relentless internal struggle will eventually lead the person to information, counseling, support groups, private or public cross-dressing or cross-living, or a combination of these resources and activities. Tragically, many transgendered persons fall into lives of despair in the margins of culture, often experiencing physical abuse, emotional abuse, and exploitation. For some who can no longer go on--- there is suicide.
For the survivors who overcame their fears of retribution, the achievement of homeostasis in such a basic, cornerstone reality of sex identity is very empowering. The relief in resolving the intensive and painful internal struggle brings an emotionally moving fulfillment that is described in many ways, such as: ‘for the first time in my life I felt a peaceful feeling inside,’ or ‘I felt a reduction of tension,’ or ‘at last I felt a comfortable feeling inside myself,’ or ‘at last I am me,’ and so on. There is a sense of euphoria, as occurs whenever anyone achieves an incredibly difficult goal. Indeed, the transgendered person has achieved an incredibly difficult goal in rising above culture’s error in sex identity designation and courageously proclaiming his or her own true sex identity!
In the study by Dr. Reiner et al with intersexed infants described earlier, a discussion of Kayla, age seven, who had been born without a penis and was subsequently surgically made into a female, is a powerful example:
[After thorough evaluation, Dr. Reiner met with the parents. When he met with Kayla to tell him that “she” was in reality a boy], “his eyes opened as wide as eyes could open,” recalls Dr. Reiner. “He climbed into my lap and wrapped his arms around me and stayed like that.” As Dr. Reiner cradled the child in his arms, he felt as though an enormous weight had been lifted, and he himself was overcome with emotion. The child remained in his arms without moving for half an hour.” (Johns Hopkins Hospital Magazine, September 2000).
Those who were born with a congruent sex identity, where the brain sex identity and genitals match, have a difficult time understanding what it is like to realize, at last, what one’s true sex identity really is. To them, all this activity seems foolish and absurd. After all, they have always known their sex identity without having to put forth any effort whatsoever. Yet it is important to understand that for the transgendered person, there is an incredibly complex struggle to overcome strong cultural forces to reach “square one.”
External CIS:
Once homeostasis is achieved and the internal CIS is overcome, the outward expression of that resolution takes a multitude of formats, as seen in a continuum of gender manifestations and behaviors that can include cross-dressing, cross-living, a plethora of other creative expressions, or complete transitioning that surgically confirms the person’s true sex identity. It is incorrect to view genital surgery as a “sex change,” or “sex reassignment,” or “gender reassignment.” These terms reflect the dysphoria of culture. In truth, the genital surgery confirms the true sex identity of the person. It is confirmation surgery (CS).
Unfortunately, the transgendered person’s joy-filled proclamation in resolving his or her true sex identity struggle, is all to often met by a world that most likely will doubt it, and will probably label the transgendered person as psychiatrically disturbed. This is as catastrophic as the wrong sex identity designated at birth, and initiates what I call the “external” component of Culturally Induced Stress”(external CIS).
Initially, there are various and seemingly relentless activities carried out by family, friends, and the culture in general, which seem to be a “warning” designed to force the transgendered person to conform to the genitally based sex identity designation. Implicit in these “warnings” is the threat of retribution-- that the culture will use punishment, including emotional and physical abuse, neglect, exploitation, or the outright rejection of family and friends. Should the behavior reflective of one’s true sex identity continue, more serious punishments may be undertaken. Cultural marginalization, and economic impoverishment are extreme forms of rejection experienced by many transgendered persons.
The punishments that are designed to force conformity to cultural expectations, act as a self-fulfilling prophecy. Poverty, brought about by the removal of economic opportunities from the transgendered person, all too often results in a lifestyle of high risk behaviors that place the transgendered person in situations where many serious problems will develop, including stress related problems and health issues. These unfortunate outcomes are then weaved into false cultural myths that look at the status of transgendered persons and judge them as unworthy, even though it was the dysphoric culture that trashed the transgendered persons in the first place!
All too often, the punishments are so blatant and cruel that many transgendered people cave in, succumb to depression, and commit suicide. Uncorroborated estimates are as high as 25% of the transgendered population, who successfully kill themselves.
There also seems to be a shockingly perverse and implicit “approval” in the culture that a few mindless people interpret as a permission to do whatever they wish to do to the transgendered person. Perhaps they believe that severe punishments will serve as an example of what would happen to others who would dare to cross the culture’s rigid binary, genitally focused, sex identity designation lines. Hate crimes are all too frequent. According to statistics compiled by National Transgender Advocacy Coalition and Gwen Smith, there has been a hate filled murder of a transgendered person every single month since 1990.
Those that survive the social wounding inherent in external CIS must face continuous instances of discrimination, public humiliation, and attempts at cultural marginalization. This relentless level of culturally dysphoric behavior sends a message to the transgendered person that he or she is not fit to be in the cultural mainstream. For many, the only alternative becomes a marginal lifestyle that is very different from the world that the transgendered person knew before he or she “came out.”
The Role of Counseling:
The internal stress experienced from having to deal with the sex identity incongruity is indeed monumental. That, combined with the constant external cultural pressures to conform to a sex identity and gender role expectations that are genitally focused, accompanied by the guilt and a fear of retribution by others, and there will ultimately be various stress related symptoms exhibited by the transgendered person,
ranging from acting out, to withdrawal, and everything in between. These symptoms, along with various expressions of unhappiness, anxiety, or other stress related symptoms (CIS), will often be expressed at intake. Sex identity issues may be verbalized, but due to fears of retribution, the transgendered person will need time to feel safe with the therapist in order to feel comfortable enough to “come out.”
It is crucial that the counselor understands the physical origins of transgender and be comfortable in working with a transgendered person. It is not a psychiatric problem. It is a physical issue that has placed the transgendered person at the mercy of a culture that not only refuses to understand, but one that ostracizes and punishes the transgendered person relentlessly. Individual supportive approaches and later adding group sessions with other transgendered persons, appear to be the state of the art in counseling, and generally work well.
Many counselors follow the Harry Benjamin International Gender Dysphoria Association’s Standards of Care. The standards are helpful but must never be used as a rigid procedure or used to prolong counseling to satisfy the counselor’s need for power as a gatekeeper, or to the benefit of the counselor’s income. The Standards of Care have always been accepted as guidelines for working with transgendered persons. Rigid adherence to these standards usually reflects a counselor who is not competent in working with transgendered persons.
In some instances there may be other diagnostic conditions concurrent with, but separate from, the presence of transgender related CIS, which can make the treatment process more complex.
But whatever the presenting problem(s) described, the appropriate tasks for the counselor in these cases include: 1. defining the problems, including the history of these problems; 2. taking a detailed history of the person; 3. the understanding and exploration of the current bio-psycho-social issues experienced by the person; 4. assisting in the management of stress related issues; and, if applicable, 5. the exploration and confirmation of the true sex identity as reflected in the brain. Basic counseling skills are necessary, as always. A good counselor knows that he or she must develop rapport that earns the right to respectfully discuss the information shared by the person.
Along with the ongoing assessment, diagnostic, and intervention work, there are a number of other important roles that the counselor will need to assume in working with transgendered persons. These include, but are not limited to: family counselor, civil rights advocate, and resource mentor.
The fact of transgender is not an issue for employing so called “reparative therapy” strategies that attempt to force the person to accept the gender roles of the “culturally induced” sex identity designation made at birth. If attempted, “reparative strategies” will succeed only briefly, most likely as a way for the person to show compliance with the counselor. But over time, the relentless sex identity incongruity struggle will reassert itself. The person will then become aware that he or she has been seriously wounded by the process of “reparative therapy,” and will undoubtedly feel betrayed by the counselor. Confidence in the counselor, as well as the process of helping and support will be seriously compromised, if not destroyed. Tragically, this cruel abuse of trust by the counselor quite often results in the person stopping counseling altogether. Many conclude that the process is useless, thus rejecting a crucial support system that can assist them in the successful working through of the many issues related to the transgender journey.
The primacy of the brain in determining sex identity cannot be overridden or ignored. It must be respected as the true sex identity of the person.
