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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 |
