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The Gendered Self

Back In 1965, John Money of John Hopkins thought that gender self identification was largely a matter of socialization and he counselled David Reimer’s parents to raise their child as a girl following a botched circumcision where the majority of his penis was accidentally severed. As I have written previously in this blog, David Reimer (raised as Brenda) eventually resumed living as a male once he understood his origins but tragically committed suicide in his thirties.

A New England Journal of Medicine article dating back to 2004 chronicled the genital reassignment surgeries performed on patients suffering from Cloacal exstrophy which is a severe birth defect that occurs in approximately 1 in 400,000 live births. One of the most pronounced characteristics is severe phallic inadequacy, or the complete absence of a penis in genetic males. Historically, doctors have treated cloacal exstrophy by surgically altering, or "reassigning" these babies as female.

John Gearhart, M.D., director of pediatric urology at Johns Hopkins Children's Center and an expert on exstrophy complexes, and colleagues challenged this standard treatment by studying 16 genetic males from 5 to 16 years of age, 14 of whom underwent surgical conversion to female sex. They found that more than half of them identified themselves as male; six individuals were so unhappy with their female sex of rearing as to pursue gender reassignment back to male. All 16 had interests and attitudes that were considered typical of males.

So there is strong evidence that our brains are to some extent gendered at birth and that what follows is a process of socialization that then tempers and adapts our biological predispositions. What we do not know is to what degree our socialization can alter our perception of our own gender and whether it can sway the biology to skew some individuals towards the opposite gender.

In some cases the cross-gender feelings resolve themselves and the child turns out to be gay or lesbian but in others there is a strong and unwavering insistence that they can no longer pretend to be the gender they were born as. Today we call these children “trans kids” and many end up successfully transitioning under the watchful eye of specialists trained in their field and loving parents who want them to grow up with a positive self image.

From the 1940’s through the 1960’s the endocrinologist Harry Benjamin believed that this phenomenon had a biological explanation and saw a great many patients over his career whom he graded according to the degree which they felt estranged from their birth sex. His scale had 6 classifications - the sixth being the strongest and most severe and the one that most often led to gender reassignment surgery. He chronicled his findings in his landmark 1966 book titled “The Transsexual Phenomenon”. After a lifetime of dealing with gender dysphoric patients, Benjamin died in 1986.

By 1989, the Clarke Institute’s head of psychiatry Ray Blanchard proposed a psychological origin for his patient’s distress in the form of a sexually fuelled mental disorder but failed to find universality by conveniently ignoring female to male transsexuals whom his theories could not adequately fit; if he could not explain their transitions he would simply disregard them. For his male to female patients he proposed they were either in love with their own image as women or in love with increasing their selection of partners depending on their sexual orientation. Kurt Freund, who had a background in testing homosexuals and sex offenders with a penile plethysmograph (which measured sexual arousal in men), was replaced at Toronto’s Clarke institute by Blanchard and their collaboration helped hatch the pseudo scientific idea of Autogynephilia (or AGP for short). Therefore it’s not hard to see how the focal point could be rerouted towards the idea of gender variance as sexual deviance.

Blanchard’s legacy left us with one dubious theory for male to female gynephilic transsexuals, a tenuous explanation for androphilic transsexuals and none for female to male transsexuals.

AGP did not explain why someone transitions because there are people who we used to call transvestites and now term cross dressers also experience arousal but they do not necessarily need or desire to modify their body. Why then were some people advancing beyond a limit and others happy to stay where they were?

In 2003, Anne Vitale (a PhD in psychology who dealt with gender variant individuals) wrote an essay called “The Gender Variant Phenomenon – A Developmental Review”. Vitale, like Benjamin believed that there was a biological explanation for her patient’s gender confusion and proposed that it was due to, at least in part, the insufficient or inappropriate androgenization of the brain at a critical stage of embryonic development. In her essay she described the 3 types of gender variant individuals (a sample of 350 people between 1978 and 2000) which she saw in her practice:

Group One (G1) consisted of natal males with a high degree of cross-sexed gender identity. In these individuals, she hypothesized that the prenatal androgenization process--if there was any at all--was minimal, leaving the default female identity intact.

Group Two (G2) consisted of natal females who almost universally reported a life- long history of rejecting female dress conventions along with, girls' toys and activities, and with a strong distaste for their female secondary sex characteristics. These individuals rarely married, preferring instead to partner with women who may or may not identify as lesbian. Group Two was the mirror image of Group One.

Group Three (G3) was composed of natal males who identified as female but who acted and appeared normally male. We can hypothesize that prenatal androgenization was sufficient to allow these individuals to appear and act normally as males but insufficient to establish a firm male gender identity. For these female-identified males, the result was a more complicated and insidious sex/gender discontinuity. Typically, from earliest childhood these individuals suffered increasingly painful and chronic gender dysphoria. They tended to live secretive lives, often making increasingly stronger attempts to convince themselves and others that they were male.

She came up with the term Gender Expression Deprivation Anxiety to describe the struggle that her patients felt and concluded that their gender dysphoria shared symptoms often associated with Dissociative Disorder, Depression and Generalized Anxiety Disorder.

According to Vitale, gender identity issues could become a life-long condition for those who found it too difficult to deal with directly. Each life stage presented new dilemmas and decisions in relation to this core issue and the more the individual struggled to rid themselves of gender dysphoria by increasing social and physical investments in their assigned sex, the greater the generalized anxiety and the harder it became to restart life sexually reassigned. For those individuals who, despite all obstacles, could transition to a new gender role, it has been shown that gender transition that includes psychotherapy, hormonal therapy and--in most cases--gender reassignment surgery, significantly reduce and eventually eliminates the anxiety entirely.

I have found that Vitale’s work complements the findings of Harry Benjamin and shows the same level of empathy and understanding but most importantly, it removes the focus from a sexually driven motive to one, at least partly, rooted in biology.

In 2010, after having worked with over 500 patients, she wrote the book “The Gendered Self” which, besides Harry Benjamin’s “The Transsexual Phenomenon” is one of the best books on the subject that I have ever read. Her invention and use of the term gender expression deprivation anxiety (which she uses in lieu of gender dysphoria) is a spot on descriptor for what often ails the transgender person before self acceptance.

WPATH recognizes that not all gender variant individuals need to transition. The idea is to find the right amount of gender expression that will ease their anxiety and, after many years of depriving themselves due to religious beliefs, family rejection or guilt and shame issues, some individuals can be happy by simply crossdressing on a regular basis. Of course for the more intense cases, only gender reassignment can resolve the anxiety.

In the end, the litmus test of whether the individual has done the right thing will be their level of contentment and freedom from a problem that has always plagued them. Once they get a taste of life without the societal and self-imposed road blocks, they realize that they proceeded correctly.

The key is to enter into a truly honest reflection free from fear, guilt and shame and only then will they have their answer.

To quote from the conclusion of Anne Vitale’s “The Gendered Self”:

“The goal for therapists working with gender dysphoric individuals should not be limited to helping clients to transition, it should instead be to relieve the client of the chronic gender expression deprivation anxiety associated with gender dysphoria. That opens up a whole realm of possibilities, ranging from encouraging responsible cross-dressing/cross-living to referring the client to a physician for exploratory doses of cross-sex hormones, and helping the client undergo full gender-role transition, with or without surgery. No one has the right to determine what gender role anyone else should live their life in.

The therapist’s goal should simply be to help their client to live a happy and productive life rather than make gender-role decisions for them. We know with certainty that taking cross-sex hormones can be a very effective psychotropic medication in certain cases. Combine this with sex reassignment surgery and we reach the upper limit of what is physically possible. From there on forward, success in the new gender role depends on the individual’s attitude, support network and willingness to accept life as it is and not as one would have wished”


  1. This was an amazing post and you did a good job of building to a position and then concluding that we are all different and that while study is a good thing it may not be possible to find a single cause, treatment or classificantion for the many manifestations of gender discomfort.
    I like your conclusion and support your quote from the conclusions reached by Anne Vitale.


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