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    MODULE 2
    GENDER AND IDENTITY
    Cross-Gender Expression

    "Sexual orientation and gender identification are important factors in healthcare, but are currently being neglected when public health funding is distributed by state and federal governments."
    [from a report issued by The Gay and Lesbian Medical Association (GLMA)]

    This module deals with a subset of individuals who are not 100% comfortable with the gender that was declared at their birth. The term we use for this group is 'transgendered.' There are other terms that people who fit this definition may prefer. Regardless of the language you use to define yourself, if you are a member of this group your service providers need to know about your specific health and human service needs. Transgender medicine is finally emerging as an area of study and it's challenging basic understandings of the dimorphic (male/female) gender system. So whether you identify as transgendered, transsexual, intersexed, or just as someone coping with cross-gender identity, the service provider must know about it so he or she can provide competent and compassionate care.

      The goal of this module is...
      ...to provide the transgendered with the information and strategies that will help in the process of making service providers aware of your specific health and human service needs.
            If you are not transgendered, our goal is to make you aware of the relationship between the transgendered and the lesbian, gay, and bisexual communities, as well as the ways you can help "trans" folk in there quest for equal treatment.

    PART ONE: The Assumption of Gender

    In many other cultures outside of the western medical tradition, a third gender is recognized which does not fit "male" or "female" medical definitions. Native American culture includes the Berdache, Indian culture recognizes the Hijra, and the Xanith recognize the Oman. In western culture, gender is assigned at birth based solely on external genitalia. The impact of this arbitrary gender assignment extends to every corner of our experience.

    Most of the time, gender assignment goes unquestioned, but for some, it causes extreme discomfort. We may be forced to express the gender we were assigned even if we don't identify with that gender. If this describes you, your medical and mental health provider needs to meet you "where you are," without any assumptions or forced roles. He or she should not identify you as belonging to either pole in the dimorphic gender system.

    Furthermore, the provider needs to know that there's some controversy regarding the Diagnostic and Statistical Manual of Mental Disorders (DSM's) diagnosis of Gender Identity Disorder (GID). Intersexed people are petitioning the medical establishment to stop surgically altering intersexed infants. If your caregiver wants to provide the most respectful, ethical care he or she needs to understand the newly emerging issues involved in treating gender variant people.

    If a provider interacts with you in an inappropriate or hurtful way, they need to be taught that choosing the most respectful language and ways of communicating are the proper alternatives. We need to make them aware that crossing gender lines as a means of expressing oneself is not something we take lightly; it takes a great deal of courage. We're confident, though, that once most professionals are aware of the challenges they will be better able to assess and assist us and our family members.

    The Role of Language
    Medical and mental health providers need a basic knowledge of the terminology describing sex, gender identity, gender roles, and sexual orientation in order to improve communication and understanding of transgender experience.

    We can begin educating our health care providers by explaining to them that gender is fluid. It is not fixed or rigidly defined, it is not always either male or female. This may be a totally new way of thinking for them. Giving them the definitions for sex, sexual identity, gender identity, gender role, sexual orientation, and intersexuality will help illustrate the fluidity of gender.

      Sex is not just physiology of the body; it is the complex relationship of genes, hormones, morphology, biology, chemistry and anatomy that determines the impact on that physiology and the sexual differentiation of the brain. It is usually referred to as biological or natal and usually thought of in a bipolar way, dividing the world into males and females.

      Sexual Identity refers to our sense of our own sexuality, including the complex relationship of sex and gender as components of identity. It includes the integration of biological sex, gender identity, gender role expression and sexual orientation. (The term is sometimes used in a more narrow sense to mean sexual orientation or preference, particularly for gay people who not only behave homosexually, but have pride or "identify" with that aspect of their self.)

      Gender Identity refers to a person's self concept of their gender (regardless of their biological sex). Gender is a social construct that divides people into assumed "natural" categories of "men" and "women" based on the physiology of the body. It is arbitrarily imposed at birth. Most people's gender identity is congruent with their assigned sex, but many people feel that their gender identity is not in agreement with it.

      Gender Role is the expression of one's masculinity and femininity, often referred to as "sex role." Gender roles are thought to be a reflection of one's gender identity and are socially dictated and reinforced. Gender roles are how gender is enacted or "performed" (consciously or unconsciously) and it may or may not be related to gender identity or natal sex.

      Sexual Orientation refers to the direction of one's sexual desire. It describes sexual preference as well as emotional attraction. Some people experience their sexual orientation as an unchanging essential part of their nature, and others experience it in a more fluid way. Sexual orientation can be directed towards members of the same sex (homosexual), the opposite sex (heterosexual), both sexes (bisexual) and neither (non-sexual). Sexual orientation is not merely "same-sex" attraction, but is experienced through the person's gender identity (regardless of their biology).

      Intersexuality refers to people who are not easily classified into the binary of male and female categories because they have ambiguous physical sex characteristics. They are not easily differentiated into established sex divisions. Intersexed people are assigned to either male or female categories at birth and many have been surgically altered at birth. Intersexuality and surgical alteration is often a secret, sometimes even to those who have been altered. Intersexed people can be heterosexual, gay, lesbian, bisexual, transgendered, or transsexual from the perspective of the sex and gender identity that they have been assigned. Approximately 2% of the population are intersexed.

    A common way to view sexuality is as a continuum from "feminine" to "masculine" with most people falling somewhere along a line between the two extremes. But a more accurate view uses overlapping concentric circles to show the interrelationship of these elements.

    Notice the distinctions between biological sex, core gender identity, gender role expression, sexual orientation, and the ways that they overlap and impact one another For newcomers to the field of gender identity and expression these can be very confusing. They involve complex issues. Many professionals have not dealt with these, so it may be incumbent upon you to provide them with the necessary information to 'educate' them.

      EXERCISE 3:
      Read Assumptions About Gender and Sex, then...
      ...select one of the four assumptions and identify a particular way this assumption plays out in your 'everyday' life. Post this explanation to the Discussion Board.

    PART TWO: Gender Identity Disorder Diagnosis and Transgender Emergence
    A criteria for Gender Identity Disorder (GID) is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [Fourth Edition, Text Revision (DSM-IV-TR]. This is the reference manual used by professional psychologists, clinicians, and others. We'll look at this definition and a developmental model for Transgender Emergence.

    One of the things therapists need to understand is that mental health concerns and gender identity concerns are often intertwined. For example, a Transsexual who is unable to get the proper care may become suicidal. If all the professional sees is the suicidal aspect the client is likely to be misdiagnosed and even mistreated. The DSM currently lists Gender Identity Disorders (GID) and identifies normal transgender emergence as pathological, without acknowledging how cultural contexts create the pathology. Here's the actual section of the DSM that defines GID. Read it over before continuing.

      EXERCISE 4:
      What's your Opinion in the Psychopathology Debate?
      Go to the Discussion Board and find the item with titled PSYCHOPATHOLOGY DEBATE. There are two groups; one favors keeping the definition you just read and the other is in favor of removing it. Among the arguments, those in favor believe if gender issues become civil rights issues rather than a mental health issue, gender variance will become normalized, consistent with other civil rights issues.
           Those opposed worry that necessary medical treatments will become cosmetic and unavailable for insurance coverage.
           Read what others have said and then post your own response. If you're comfortable doing so, explain whether or not you feel you "fit" within the DSM's description and why.

    Transgender Emergence involves a lot of personal development and interpersonal transactions. The process of developing a gender identity is a normal process that everyone experiences, but for gender variant people the process is complicated by cultural expectations. Because others see you differently than you see yourself, there's more that must be overcome. As an emerging transgender man or woman, most of us must come to terms with our gender variance and move from denial and self-hatred to self-respect and gender congruence. The steps for getting from "here" to "there" are also impacted by other identity issues. (Many transgender people negotiate these stages without professional assistance.) We've identified these stages not as a way to "label" people or define transgender maturity, but to give clinicians an idea of what to encounter when clients come to them for help with "gender dysphoria."

    Arlene Istar Lev's Developmental Model of Transgender Emergence identifies six stages in this process. Read them over now.

      EXERCISE 5:
      Reactions to Coming Out
      On a sheet of paper, write your answers to the following questions. If you feel a question does not apply to you now, but might have applied at an earlier point in your life, answer the question accordingly. (And if you are not transgendered, but reading to learn more, answer these as you think a 'trans' person might.)
      1. What were you most afraid of when coming out?
      2. Why might you want to come out to friends or relatives?
      3. How did you feel about coming out to people
      4. What did you feel after someone else came out to you?
      5. What do you want from the people you come out to?

      Now click here to read some possible answers. If yours aren't "in the ballpark" and you want to discuss them further, contact your coach.

    PART THREE: Intersex Issues
    "No longer should we be lied to, displayed, be injected with hormones for questionable purposes, and have our genitals cut to alleviate the anxieties of parents and doctors. Doctors' good intentions are not enough. Practices must now change.'
    [San Francisco Human Rights Commission]

    The biological differences between males and females develop at about 6 weeks into gestation. Before this stage male and female (XY and XX) appear the same, although genetic or chromosomal sexual differences were established at conception. The primitive duct systems are identical until the presence of male hormones triggers the development of male gonads, the differentiation of the duct systems, and the formation of external genitalia.

    The sex assigned to us at birth is based on an arbitrary definition of genital size. Approximately 2% of the population is born intersexed, or with ambiguous or intermediate genitals. In the past, doctors surgically altered babies to make their bodies conform to the common dimorphic (male or female) standards. These standards allow penises as short as 2.5 cm to mark maleness, and clitorises as large as 0.9 cm to mark femaleness. Infant genital appendages between 0.9 cm and 2.5 cm are unacceptable. This is the general guideline used by mainstream medical practitioners in "managing" infants and children born with unusual genitals. At many hospitals, surgeons will remove clitoral tissue from a child born with such in-between genitals. Surgeons have also transferred tissue from other body parts to build larger penises. But there have not been any follow-up studies on these genitally altered children to determine the effects on sexual function after genital surgery.

    In recent years, activists from the intersex community, anthropologists, and ethnographers have challenged these medical definitions and interventions. Outrage from activists and victims of the medical interventions have led professionals to question the practice of altering children's bodies at birth to force gender conformity. [The Intersex Society of North America (ISNA) provides a wealth of information on the current practices and need for reform.

      EXERCISE 6: Intersex Issues: A Case Study
      Erika Schinegger won the Olympic gold medal for Austria for women's downhill skiing in 1966. After the win she was given a sex test and declared unequivocally XY. When told of the test findings she immediately transitioned to living as Erik, a male. Erik said he never truly felt he was a typical girl. He had never been romantically interested in boys and was always more attracted to women. As Erika, however, she just thought that was her lot in life. None of the physicians she had been seen by previously wanted to tell her of the mistake for fear it would be too psychologically damaging. Switching sex never occurred to her until the condition and situation was revealed. Follow up showed that she was born in a small town, delivered by a midwife, and pronounced a girl due to a severe hypospadic condition. When she was made aware of the situation her transformation to male living was rapid. The hypospadic condition was repaired and her psychological adjustment to the change was appropriate. Erik is now a married ski instructor.

      In an e-mail to your coach, answer the following questions:

      1. What was your emotional response to the losses endured by these individuals?
      2. Why are intersexed people assigned a sex?
      3. Should babies be altered at birth to fit into the bipolar sex/gender system?
      4. What are the issues faced by intersexed people, as children, youth, and adults?
      5. What are some alternative ways to address intersex issues?
      6. What issues were raised that were new to you?

    PROCEED TO MODULE 3
    TRAUMA ISSUES
    Domestic Violence / Sexual Abuse
    Sexual Assault / Bias-Related Violence

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    The information provided by Rainbow Access Initiative, Inc. is for educational purposes only and is not intended to render medical advice or professional services. The information should not be used for diagnosing or treating a health problem or a disease and is not a substitute for professional care. If you have or suspect you may have a health problem, consult your healthcare provider.

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    These materials were produced through a grant from the New York State Department of Health.
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