|
Clinical and research contact with male-identified genetic females,
including female to male transsexuals, transgenderists, Butch and
gender-blended women indicates that many of these individuals do not
receive comprehensive medical care because of gender issues, and that both
primary care physicians and their patients often lack the means to discuss
these gender perceptions [2]. Self-identifcation and the discussion of
gender issues is further clouded by the fact that language and (Western)
cultural assumptions commonly applied to erotic or partnered relationships
do not allow for couples for whom the psychological dynamics are
incongruent with the "genital" sexes. Therefore, individuals must search
for understandable ways of communicating about themselves and their
relationships. For example, Coleman et al report that "[b]efore sex
reassignment, a number of our [FTM] subjects had engaged in role playing
while having sex as a man with either a male or a female
partner...[regarding sex with women one person stated] 'I could not treat
them as women. They told me, "You treat me as a man in bed." I did not
appreciate their female attraction, their breasts, their genitals. I
suggested, "Let's behave as two men!" ' "[3] Grimm has stated that a man
can posses either a penis or a vagina, which can be used heterosexually or
homosexually.[5]
Several comprehensive systems have been developed for describing
interpersonal relationships between persons with non-traditional gender
identities. [4,5,6] These utilize either graphic representation, or
descriptors which reflect combinations of gender and sexual
self-perceptions. For example, Devor poses the question: "A female-to-male
transexual lives as a gay man. Are the people in these relationships gay
or heterosexual?" (In her taxonomy of gendered sexuality, this individual
can be understood as a "female-to-male transexual, female heterosexual,
gay man.") [6]. Gender variance across the life span can also be described
schematically, as in the system described by Jacobs and Cromwell. [7] In
their conceptualization, a female infant may be either a "girl," who will
mature into a heterosexual or lesbian woman, or a "female/ boy," who will
become a "tomboy," and subsequently a female-to-male transvestite or
transsexual. Uncertainty regarding future gender or gender qualities is
especially common during childhood and adolescence, yet may be followed by
stable adult identifications of either gender, or a blended
identification.
An
individually-based gender continuum
In 1948, Kinsey, Pomeroy, and Martin introduced the notion that sexual
orientation could be more clearly expressed as a continuous variable,
rather than as a heterosexual-homosexual dichotomy . [8] This concept was
illustrated with the seven-point "Kinsey scale," in which a value of zero
represented exclusive heterosexuality, a three indicated equal
responsiveness to women and men, and a six represented exclusive
homosexuality. Since that time, the Kinsey scale has been widely used in
clinical practice, and has provided a means for patient-physician
communication regarding sexual orientation.
One difficulty with the Kinsey schema is a lack of detail regarding the
concept of bisexuality. Individuals who self-identify as bisexual may be
attracted to male and female partners concurrently or at different points
during adult life, or may partner with members of both sexes, but with
vastly different relationship styles. Recent work in the field of
bisexuality has attempted to further refine discussion regarding this
sexual orientation. [9, 10]
Our gender schema is based on the premise
that, like sexual orientation, gender identity is also best understood as
a continuum. Furthermore, as with the phenomenon of bisexuality on the
Kinsey scale, individuals who consider themselves as being neither fully
male nor fully female may describe themselves with a variety of distinct
identifications. Observations at a recent FTM conference convinced us of
the need to include the other-gendered and ungendered options, and to
accommodate the "gender agnostic"; that is, the individual who either
regards gender as being a very fluid concept, or a notion which is
irrelevant to the freely-expressive person. This gender schema is
presented in Table 1 and described below.
Gender identification is scaled along a continuum with nine labeled
definitional points. The nine points are as follows:
- An individual of any genetic sex may self-identify as fully female,
having always considered herself to be a woman or girl, or as a female
with maleness, in which current identification is as a woman, but with
significant questioning regarding being more of a man (or boy) at least
some time in life, or as a gender-blended female person, in which the
individual perceives herself to be in some significant way both a woman
and a man, although more woman than man.
- An individual of any genetic sex may also regard him-herself as
neither a woman nor a man, but a member of some other gender, as is
common in non-Western cultures (and is becoming increasingly recognized
in the West as well), or as an ungendered person, who does not or will
not identify with any conventional gender. In addition, a person who
feels or acts as both a woman and a man may identify as bi-gendered.
- Finally, an individual of any genetic sex may self-identify along
the male end of the continuum, as either a genderblended male person,
perceiving himself to be in some significant way both a man and a woman,
although more man than a woman, a male with femaleness, in which current
identification is as a man, but with significant questioning regarding
being more of a woman (or girl) at least some time in life, or as fully
male.
- The utility of the individually-based gender continuum in clinical
practice can be illustrated with the following cases. One of these
individuals is a post-operative male-to-female transexual; the other two
self-identify as gender blended. Both are involved in long-term sexual
relationships, one with a woman and one with a man. The commonalities in
their stories of adolescence and young adulthood suggest a similar
process at work, but leading to different adult outcomes and subsequent
medical needs.
Adolescent
gender dissonance: three outcomes
These three participants reported a sense of conflict arising early in
life, resulting from varying degrees of gender dissonance. As girl
children who were to some extent male-identified, they then undertook a
lengthy process of social exploration, introspection, and accommodation to
gendered society, resulting in the construction of a workable personal
schema for gender and sexuality, and establishment of an adult identity as
either a female-to-male transexual (or transgenderist), a lesbian with
blended gender identity, or a publicly-identified heterosexual woman with
personal blended gender identity.
This process is represented graphically in Figure 1: Biological and
social influences both create and are influenced by a sense of gender
dissonance. This, in turn, interacts with the individual's personal gender
and sexuality schema, which includes perceptions regarding gender
polarity, desirability of gender role conformity, and sexual attractions.
Between late adolescence and early adulthood, a relatively stable
identification is formed, which may be either transexual (or strongly
transgendered) or a blended identification which contains transgendered
elements.
In this context, gender polarity refers to individual perception
regarding the degree of true, unalterable difference between women and
men, or between boys and girls.
Are the sexes perceived as being
fundamentally different? Or are they regarded as more similar than
dissimilar, with a range of behaviors being possible, and in fact
desirable, for each unique individual? Gender role conformity is defined
as the degree to which the individual desires or attempts to fulfill the
expectations of his or her birth-assigned gender. Adolescent and young
adult sexual attractions, as well as their perceived acceptability or
unacceptability, also probably influence the individual's sexuality/
gender schema.
Individual A self-identifies as a male with femaleness. He reports
having formed sexual relationships exclusively with women, beginning in
late adolescence. His family of origin was socially and religiously
conservative, strongly heterocentric and homonegative, and very much
oriented toward social compliance and "fitting in." This person's
knowledge that "she" was not in fact a Lesbian but a male was greatly
comforting. His pronounced perception of gender polarization and gender
role separation also facilitated the decision to solidify the male
identity and undergo sex reassignment surgery, which has resulted in much
improved adjustment and life satisfaction.
Individual B self-identifies as a female with maleness. By her
description, her sexual partners were initially "weak men," followed by
involvements exclusively with women beginning in the early 20s. Her family
of origin was paternalistic with an authoritarian father, leading to a
rejection of the "wife role" by the maturing daughter. Concurrently,
however, her father expressed an individualistic, "anti-establishment"
philosophy, including Plainist religious leanings, which promoted
self-actualization as a worthy life goal and left sexuality issues less
rigidly defined. This person's minimal
gender polarity and gender role
flexibility have enabled her to accommodate her fully-gendered self within
the Lesbian community.
Individual C self-identifies as gender-blended with female
predominating, or possibly as more fully bi-gendered. Sexual partners have
been gentle, feminine men. Her/his family of origin was politically and
religiously conservative, with overt goals of attaining moral
"righteousness" and worldly achievement. Family size was large, containing
both biological and adopted children. Heterosexuality was strongly
encouraged and homosexual feelings, thoughts, and actions strictly
forbidden. Gender polarization was substantial, yet messages with regard
to gender role differentiation were mixed and inconsistent, due to the
emphasis on academic, athletic and religious achievement during childhood
and adolescence. This person experienced considerable confusion regarding
gender during childhood, but was able to establish an adult personal
identity as genderblended, with a long-term relationship with a man who
also has many gender-opposite personality characteristics. Although
sometimes mistaken for a man on casual observation, she remains legally a
heterosexual, and in fact married, woman.
Primary
medical services and the gender continuum
When describing their needs for medical care, Individuals B and C felta
mild hyperlipidemia), validation of the male identity by physicians,
despite the absence of "natural" male genitalia, and protection of
confidentiality to the extent that this is possible. Pre-operative medical
contacts were oriented exclusively toward the attainment of hormonal and
surgical therapies, to the exclusion of recommended gynecologic care.
Management of transitional identity within the health care system was also
problematic.
Individuals B and C would like to receive greater acceptance and
support from their physicians with regard to gender opposite physical
characteristics, mannerisms, and modes of dress. Both would like to more
fully share their gender identities with treating physicians, but lack the
means to do so, and have serious concerns regarding confidentiality and
unnecessary psychiatric intervention. Although neither person currently
wishes hormonal or surgical intervention, Individual C considers
testosterone supplementation in the future, such as at the time of
menopause, a possibility, and Individual B would consider androgens if
medical circumstances, such as the development of breast cancer, made
oophorectomy necessary and estrogen replacement contraindicated. Both
participants also mentioned the need for dignified family care, with
physician acceptance of non-traditional family arrangements and
reproductive plans. Both felt that gender identity may possibly be
modified slightly over time, and would like to be able to discuss the
issue with their physicians if they were to reassess this in the
future.
Conclusion
Many genetic females who experience gender dissonance in childhood and
adolescence subsequently self-identify as genderblended adults. Their
experiences with the medical care system are different than those of
either female-to-male transexuals or fully female identifying women.
There is a need for family doctors, general practitioners, general
internists and pediatricians to become familiar with non-traditional
gender identities, and to discuss self-identification with their patients.
Our individually-based gender schema provides a practical method for doing
so. Further research which utilizes this clinical tool is presently in
progress.
"[W]hile the limits they face--and the solutions they choose--may be
extreme, transsexuals highlight the fact that all of us, to varying
degrees, must make an effort to manage self-expression in order to conform
to limitations, that is, in order to take our place in a
socially-constructed, gendered universe." --David Grimm [5]
" With regard to gender, we can each be in a category of one:
ourselves." --Carl Bushong [11]
TABLE I: AN INDIVIDUALLY-BASED GENDER
CONTINUUM
Female I have always considered myself to be a woman (or girl).
Female with I currently consider myself to be a woman, but at times I
maleness have thought of myself as really more of a man (or boy).
Genderblended, I consider myself gender-blended because I consider
myselffemale predom- (in some significant way) to be both a woman and a
man, but inant somehow more of a woman.
Othergendered I am neither a woman nor a man, but a member of some
other gender.
Ungendered I am neither a woman, a man, or a member of any other
gender.
Bigendered I consider myself bi-gendered because sometimes I feel
(oract) more like a woman and other times more like a man, or sometimes
like both a woman and a man.
Genderblended, I consider myself gender-blended because I consider
myself male predomi- (in some significant way) to be both a man and a
woman, but nant somehow more of a man.
Male with I currently consider myself to be a man, but at times I have
femaleness thought of myself as really more of a woman (or girl).
Male I have always considered myself to be a man (or boy).
References
Devor H. Gender Blending. University of Indiana
Press. 1989.
Eyler A, Wright C. unpublished data.
Coleman E, Bockting WO, Gooren L. Homosexual and
bisexual identity in sex-reassigned female-to-male transsexuals. Arch Sex
Behav 1993; 22: 37-50.
Coleman E. Assessment of sexual orientation. J
Homosex 1987; 14 (12): 9-24.
Grimm D. Toward a theory of gender. Am Behav Sci
1987; 31: 66-85.
Devor H. Toward a taxonomy of gendered sexuality. J
Psych Hum Sex 1993; 6: 23-55.
Jacobs S, Cromwell J. Visions and revisions of
reality: reflections on sex, sexuality, gender, and gender variance. J
Homosex 1992; 23: 43-69.
Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior
in the Human Male. 1948; Philadelphia, W.B. Saunders.
Berkey BR, Perelman-Hall T, Kurdek L. The
multidimensional scale of sexuality. J Homosex 1990; 19: 67-87.
Weinrich J. The periodic table model of the gender
transpositions: part II. Limerant and lusty sexual attractions and the
nature of bisexuality. J Sex Research 1988; 24: 113-29.
Bushong C. The multidimensionality of gender.
Tapestry J 1995; 71: 33-37.
Correspondence and requests for materials
to:
A. E. Eyler, M.D., M.P.H.
Director of Primary Care
Services
Comprehensive Gender Services Program
University of
Michigan Medical Center
1H223 University Hospital
1500 E. Medical
Center Dr.
Ann Arbor, MI 48109-0050
phone: (313) 936-6271
fax:
(313) 647-6892
email: aeyler@umich.edu |
