Category Archives: Guest blog

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First Do No Harm

 

Editor’s note: This article is written by a dear friend who was our North Star when we initially came to understand our child’s needs. I’m so happy that she was able to provide her personal and professional perspective. -Melissa

First do no harm

All persons should have the opportunity to live naturally

Intervene only as much as necessary to reduce the distress to manageable levels

Jesse is a 14 year-old smart, funny, precocious girl who would rather be with friends than do homework (or do anything actually). She won’t eat anything green, is a night owl, spends too much time on her phone, and loves, absolutely adores, Taylor Swift and Lorde. She cries copious tears when she is hurt; cares very deeply about people, animals, and the earth; and is fiercely protective of her self, her friends, her family, and her puppy. She is mostly vegan, and all the way vegetarian. Oh, and she is transgender.

By the time Jesse was two years old, two profoundly meaningful events occurred that would eventually become catalysts for a long journey into a great unknown. One was her first haircut in which she told me that she wanted me to do it like “Cinder-lella.” Shortly afterwards, Jesse got into a large bag full of hand me downs intended for her newborn sister. As one might imagine, the bag was full of things pink, pretty, and sparkly. Jesse beamed in what she thought was her new wardrobe. Our approach was to gently try to help her ‘organize’ and manage her preferences, interests, needs, and identity.

Over the next several years, and despite our very exceptional ‘organizing’ skills, Jesse’s female identity continued to strengthen. Every shooting star and every birthday candle held the same wish, “Please, please…let me wake up a girl.” One night when we came into her room to say goodnight, we caught her praying. Her hands were held in prayer and she was repeating the same old wish, “Please, please, let me wake up a girl.” So, finally, we stopped managing and organizing, and right smack in the middle of second grade, we helped her make a social transition to all things feminine. We came to understand that, for her, in order to not hurt her, we would simply have to let her be who she was. So we did. We said a few prayers of our own and allowed her to be her.

Then the phone calls started. As a Licensed Clinical Professional Counselor, I had been providing therapy for a number of years. Of course, I researched treatment options for transgender children and found that at the time, the ‘best’ advise out there was to remove all things girly from the ‘boys’ life and help him be comfortable with his body. I knew, not thought or suspected, but knew for sure that this was not always going to be possible, and was rarely going to be ideal. I also knew for sure that it was going to be harmful. Especially for our Jesse and likely others like her. So I developed a treatment approach with three main tenets: First, do no harm. Second, all persons should have the opportunity to act naturally. Third, intervene as minimally as possible to get the distress down to manageable levels.

Through word of mouth, anxious parents began calling me after hearing of this unique approach to working with transgender children. Families came to me from all over the Midwest for treatment, for consultation, for advise.

While my treatment strategy was not typical for the times, it really was not ground breaking. I was simply applying sound evidence based therapy to what we thought was a new population of children. There is no approach in psychotherapy that states that it is better to “hurt them a little now to protect a better outcome later” (these words were actually said to me by a psychologist and educator in justifying the corrective approach to counseling transgender children). This statement stimulated several questions for me. First, by “hurt” how much would be OK? How much hurt in early childhood would be commensurate with the better outcome that one might envision? Does this ‘better outcome’ include trauma? Or are we specifically measuring for transgender identity? What exactly is this better outcome? All of these questions led me to develop the first tenet of my approach: First, do no harm. This is the first law of medicine and provides the basic scaffolding surrounding healing and competent care. And this applies to all persons, young and old, regardless of race, sexual orientation, gender identity, or religion. First do no harm. As I said, not ground breaking. This has been the Hippocratic Oath for many decades. I simply applied it to a very vulnerable and marginalized group: gender diverse children.

The second tenet of my treatment approach is that all persons should have the opportunity to act naturally. Lets be clear, I am not talking about people who think they are cats or people who identify as a toaster. I am talking about a typically functioning individual whose gender identity is something other than what we, in binary America, think that it should be. There is much we do not know about the brain, about gender, and identity. Cross cultural research, as well as observational studies done in the animal kingdom, suggests that a binary code, while fine for computers, is overly simplistic for gender, and, in fact, humans. Social, personality, and sexual development are complex processes and 0’s and 1’s do not really explain us very well.

In this state of not knowing, it becomes critical to approach diversity issues with regard. Especially for children. I remember a time early in my process when I had a boy bodied child dressed as a princess and another boy bodied child dressed as batman. It is horrifying to me now to recall how one had to change into more appropriate attire to go to grandmas house and the other one didn’t. I can’t help but consider the impact of traumatic experiencing that this type of situation is likely to facilitate. At the very least, a child learns to develop a false self in the face of an unaccepting, critical, and dangerous world. This is one of the fundamental goals of psychotherapy for a great many number of clients: to help in the development of a true self with the goal of living an authentic and personally meaningful life. Therefore, I felt that all persons should be able to act naturally. All of our clients should be met with positive regard. It is just not up to us to tell them who they are. Who we think they are. Or aren’t. It is not up to us as therapists. For my family, it isn’t up to parents either. It is up to parents to teach values, to get the children to bed at a reasonable, to try to get them to eat something green. It is up to us to help the child develop and learn routines and structure. It is up to us to be a cook, chauffeur, tutor, manager, housekeeper, cheerleader…. It is not going to be our decision whether the child is going to have intrinsic interest in dolls, trucks, or games. Whether they will excel in gymnastics or debate team. Whether they will pursue a career in medicine or education. We can protect and guide. But for the vast majority of children, it is just not up to us to decide about orientation or identity.

Research has shown that a large percentage of gender dysphoric children may desist in their transgender identities. In a nutshell, this research concluded that many will grow out of it. These ‘outcomes’ caused significant anxiety in parents of gender diverse and transgender children. With medical technology exploding, and cross sex interventions becoming a viable option, parent’s questions and concerns regarding best practice were well founded. How do I know if my child will grow out of it? How do I support without encouraging? How do I help but not hurt? How much do I intervene? These are all valid concerns. To really capture parental and clinical panic regarding these outcomes and corresponding questions, research has also shown that suicidality for transgender youth was disproportionately high. In other words, gender diverse and transgender children, as a group, was not doing well.

However, the terms ‘gender diverse’ and ‘transgender’ are not necessarily the same and research had not yet empirically operationalized them. This research, while informative, had its limitations. So far, people weren’t yet talking about distress level as a diagnostic feature at that time. As a therapist, of course, this factor is critical in assessment and diagnosis for any mental health issue. Symptoms that do not cause marked impairment or distress isn’t diagnosed. And so this third tenet was to help parents navigate these very difficult questions and concerns. In a world where we simply don’t know, let your child’s overall wellness be your guide. Is their anxiety manageable? Are they learning to read? Or are they so distracted with gender incongruity that they can’t learn? Are they aggressive with others? How are they developing socially? This enable parents to map unchartered waters in a uniquely idiosyncratic way. Broad brush strokes simply aren’t going to be effective with this community. Nurture does have an impact. Community does have an impact. There are just too many variables. At the end of the day, we want healthy children who are well and whole. And the least harm approach to get there is to assist in the development of a true, natural, psychologically fit, and physically well self.

Back in 2010, when Jesse was right smack in the middle of second grade, we made some crucial decisions. First, we just weren’t going to knowingly hurt her. No way were we going to hurt any of our three children on purpose. Second, we were going to treat her, and of course all of our children, with positive regard, and allow them to be natural. Finally we were going to look at her overall distress/wellness as the primary guide for intervention. When we computed this fairly basic and humanistic algorithm, all of our anxiety decreased.

Today, we have three healthy children who are otherwise preoccupied with the natural emergencies of teenage life. Jesse is a remarkable, insightful, and charming 14 year-old transgirl. Our next problem? How do we get her to turn off her phone and get to bed on time. Maybe even eat something green. All things considered, these are good problems to have.

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Gender in the New Millennium: A conceptual proposal for LGBT identity and understanding

Editor’s note: This guest blog post is written by a friend of mine whom I have had the pleasure of sharing several excellent conversations with over cups of coffee. His books are fun reads and would be a great addition to your summer read-list. I remember the afternoon that we discussed the topic of this blog post. With my head spinning, I said, “Jeff, I need pictures!” And he has so kindly provided them. Thank you, Jeff. I hope this leads to a new thinking of how we classify gender. If you are hoping to download this article, it can be found at Gender Understanding in the New Millennium: A conceptual proposal for LGBT identity and understanding

Jeff Spence is a novelist and nonfiction writer (www.spencewriting.com) originally from Canada. He holds a B.Ed. (CUC), an M.A. (TWU), and an M.Sc. (Keller) as well as post graduate studies from the university of Oxford. He has traveled to more than thirty countries, studying and teaching, or just seeing the sights. Jeff is widely published in a variety of fields, including Religion, Psychology, English Literature, and has four novels published to date under the name “J. L. Spence.” He currently resides in Jupiter, Florida.

Background

Gender, in the modern world, is generally presented as consisting of two designations, at polar extremes from one another (fig. 1). “Male” and “Female” are widely used as if they are the only designations in existence and, although “LGBT” strives to be inclusive, inclusion of transgender people is still inhibited by a lack of an accurate understanding, and effective visual representation of the nature of a transgender person. This may be a result of the polar frame of mind to which we were all (or nearly all) exposed during our childhoods. Likewise, bisexual orientation is sometimes considered invalid even among gays and lesbians, as well as by other segments of society. What is needed, is the development of a conceptual framework into which all of the LGBT communities could be placed, as well as the heterosexual, non-transgender communities. There are some difficulties to be overcome.

Terms such as ‘the opposite sex’ are so familiar that few pause to reflect on the implications of such phrases. In this short article, I’ll take a brief and superficial tour through the development of the concept of gender, look at the more recent modern view of it (at least outside of the more right wing, or fundamentalist circles), and then present a new way of looking at it that goes beyond this and approaches, in my opinion, an effective representation of the reality of this complex aspect of human life.

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Figure 1: Bipolar concept of gender

One of the earliest, and perhaps most interesting concepts of gender comes from Plato’s Symposium, in which he cites Greek mythology (which would have been ancient history even in his time) as the source for a creative (and non-pejorative) explanation of homosexuality and heterosexuality. The idea is that people were once creatures with four arms, four legs, and two faces – basically, each creature was comprised of two persons. Some of these beings had male and female genitalia, others had two male, and others two female. They were considered very powerful, so much so in fact that Zeus, fearing their power, split them into two, condemning them to spend the rest of time searching for their lost halves. A male half that was originally created with a female half, would spend life seeking female companionship. A male half that had been created with another male half, would seek out companionship with another male. Likewise, a female half would seek either male or female companionship based on which genitalia their original form was coupled with (1).

Though fantastic and strange to the modern ear and mode of thinking, the knowledge of this extremely ancient proposition tells us two things. The first is that human kind has been struggling to understand gender and sexuality for a very long time, perhaps from the very beginning. Secondly, it implies that the ancients viewed homosexuality as an inborn trait, much as it is viewed outside of fundamentalist circles today.

Through to the late 19th century, the concept of “Homosexuality” in the Western world was understood differently than it is today — and “Transgender” had not even been coined, though “Transexual” was coined by Karl Ulrichs to describe an early, and rather confused, understanding of the phenomenon (2). From sometime after the writing of the Greek mythology mentioned above (and probably well before the time of Plato, based on his attitudes to male-with-male sexual relations), until perhaps the early nineteen hundreds, popular opinion held that, though a person could “commit” homosexual acts, there was no identification as “homosexual” as such — though the frequent or exclusive habit of homosexual relations could earn a person one or more of the various pejorative nicknames or titles associated with the practice in those times. It was considered a behavior rather than an attribute; a tendency rather than an identification.

In our own time, those who do not feel a religious compulsion or duty to categorize or understand LGBT along biblical lines (i.e. Romans 1:26), tend to see homosexuality as a trait with which a person is born — a part of who they are, before it is a part of what they do. Though transgenderism is much less understood by the general public, awareness is growing (in part thanks to groundbreaking programs like Transparent, which seems to avoid the easy caricatures so prevalent in early portrayals of homosexuality on mainstream television).

With that growth in awareness, the concept of gender as something other than a bipolar attribute has become mainstream as well. In this model, gender is seen as a continuum, with some at the extreme male end of the spectrum, and others at the extreme female end, but with far more individuals peopling the line somewhere between these two (fig. 2). This was a great leap forward in understanding gender as it broke the perception of gender identity as a black and white issue, a this-or-that designation.

pic2jeffFigure 2: Bipolar concept of gender

The shortfall of this representation is that it does not differentiate between physicality and self-identity (therefore it does not include transgender individuals). It also fails to represent sexual orientation, therefore (at best) implying that being nearer the center of the line indicates bisexuality. At worst it discounts the importance of this facet of human sexuality completely.

It is time, therefore, for a further step forward. Something must happen to our perception of gender in order to bring the “T” portion of “LGBT” onto the visual representation, and to represent sexuality as separate from male/ female self identity, just as it was separated from male/female physicality some time ago.

The Two Spectrum Model

The first step is to expand on the concept of the “spectrum.” I do not believe that a one dimensional spectrum is an accurate representation of gender (or sexuality) because it represents only one facet. It can refer to one’s genitalia, degree of body hair perhaps, musculature, size, pitch of voice, etc. — but then cannot simultaneously represent one’s feeling of masculinity or femininity. Likewise, a spectrum that represented masculinity and femininity would not represent anything regarding the physicality of the individual (I will leave out sexuality until the following section). What is needed, then, is an expansion into a second dimension; the model must be two-dimensional.

The Two Spectrum model looks like this (fig.3) and I have included an explanation below.

photo3jeffFigure 3: The Two Spectrum model

The Physicality (P) Spectrum

The P Spectrum measures the degree to which the individual represents exclusively male or female physicality. The more toward the left an individual is placed, the more “male” the body is. The center (horizontally) would indicate an androgynous or hermaphroditic physicality – the genitalia would be present as either not distinguishable as more male than female(or vice versa), or else both male and female genitalia would be present. Placement on the far right would indicate a very female physicality.

The Self-Identification (SI) Spectrum

The SI spectrum reflects self-identification with femininity or masculinity – the inward self concept of oneself as female, or male, regardless of the outward physical traits. Placement farther left would reflect feminine self concept – the inward self concept of oneself as female, regardless of outward physicality. Placement farther to the right would indicate a greater degree of self-identification as male. Placement near the center would indicate no strong self-identification with either male or female self-concept.

The Grid

Consider the following image, which combines the two spectrums in the form of a Grid.

photo4jeffFigure 4: The Grid model

Horizontally, there is the Physicality (P) spectrum, and vertically is the Self- Identification (SI) spectrum, tipped on end. By combining the two spectrums, we are able to represent an individual’s physicality and self- identification with one point on the graph. Let’s look at a few examples below:

photo5jeffFigure 5: Nine individuals on the Grid representation

Position 1
Very male in her physicality – a penis and testicles, (perhaps) male musculature and size, deep voice, etc – but would strongly identify as a female, perhaps also exhibiting very (so-called) effeminate mannerisms. If the same individual were represented on the two separate spectrums separately, the result would be something like this:

jeff6Figure 6: Position 1 on the Two Spectrum model

(The Grid model simply combines the these two spectrums into one.)

Position 2
Strongly identifies as a female, would perhaps exhibit mannerisms associated with femininity, but would have the physicality of a female – vagina, mammary glands, musculature, etc.

Position 3
The physicality of a male (just as in position 1), but would strongly identify as a male.

Position 4
The physicality of a female (as in position 2), but the strong self- identification as very male (as in position 3).

Position 5
Male, but would have some attributes more associated with female physicality. Penis and testicles would be present, but finer musculature, facial features, more pronounced breast tissue, or other attributes would shift to the right of extreme male physicality. This person would identify as female, but with a lesser degree of femininity, perhaps feeling a little closer to androgyny, but still identifying her inward self as a woman.

Position 6
Asexual or hermaphroditic physicality, the maleness indistinguishable from the femaleness. Inwardly though, this person would identify as a female, but toward the androgynous end of the femininity spectrum.

Position 7
Physically male (penis, testicles), but with some female-like traits (like position 5). The inner concept, however, would be androgynous, or asexual. This person does not identify internal identity as either male or female.

Position 8

In the physical middle ground, neither male nor female, or perhaps both; asexual or hermaphroditic. Likewise, the self identification is neither male nor female (or perhaps both).

Position 9
An individual with a physicality slightly more female than male, but with a very masculine self-identification.

It is my opinion that this kind of representation, though necessarily more complex than the simple spectrum, is a much more accurate reflection of the human condition. It is not, however, quite complete when we consider sexuality as an important part of our human experience and individual identity.

The Third Spectrum

As many already know, masculinity and femininity do not necessarily correspond to sexual orientation. An individual who is very male in physicality, but very feminine in self-identity, may yet be “hetero” in physical sexual preference. That is to say, a physical male who identifies as a woman, may yet be attracted to women. Such is the case for Martine Rothblatt (formerly Martin Rothblatt), the CEO of United Therapeutics, who is still with the woman she married prior to coming out as a transgender person (3). To better understand and represent the LGBT community as a whole, then, especially as a part of humanity as a whole, a third dimension must be added. I will call the two ends of this third spectrum male-yearning (MY) and female-yearning (FY) as an homage to the Greek mythology referred to by Plato, and briefly described above (1).

jeff7Figure 7: The Three Spectrum model

This representation still requires three points of reference, which is not prohibitive to understanding the complex reality of human sexuality, but which might imply a fragmented nature. Combining these three spectrums into a three-dimensional model, however, allows us to place a single point in three dimensional space in order to represent all three major aspects of an individual — as a coherent, unified identity.

The Cube

I will first explain the image (the “Cube”) without any numbers in it, as the placement of such numbers in a flat drawing can be unclear and confusing. In another medium, I will present the 3D digital model which includes them. For the purpose of this article, I think it is easiest for the reader to follow a brief explanation without them, at least to begin with. The Cube is a combination of three spectrums of human attributes: The Physicality (P) Spectrum and the Self-Identification (SI) Spectrum, both discussed above, and the Sexual Orientation (SO) Spectrum, included here.

A male with a position close to MY would be considered homosexual; but if he had a position closer to the FY, he would be considered heterosexual. A position in or near middle indicates no strong preference (either no desire for either: asexuality — or a desire for either one: bisexuality). Conversely, a female with a position close to the MY end would be considered heterosexual, or if more toward the FY end, homosexual. Likewise, if near the middle, asexuality or bisexuality is indicated. If we combine these three spectrums into the Cube, it looks like this:

cubejeffFigure 8: The Cube

An individual who has male physicality, but identifies strongly as a female (someone near Position 1 on the two-dimensional chart) would be in the same place on the Cube shown here. The only difference is that she would be placed on the blue spectrum, either farther toward the background (if her sexual orientation is toward females) or farther toward the foreground (if her sexual orientation is toward males). That same individual, as a bisexual, would fall somewhere near the middle ground, about half way from the front (or back) of the Cube. (Don’t worry, there are some practice examples below that will help make this clear.)

A female heterosexual might be represented by a point near number two on the 2D chart, and would be near the foreground in the Cube. This would indicate a female physicality, an identification as a female, and an orientation toward a male partner.

Thus, each individual’s attributes indicate placement at single a point within the Cube that would represent sexual physicality, gender, and orientation.

Your Turn

Want to give it a try? Have a look at this diagram and decipher each individual’s attributes before reading the explanations below. Each number represents a separate person.

cube2jeffFigure 9: Four individuals represented using the Cube

Consider position 1:
This individual is deeply in the male end of the P spectrum — obviously and easily identified as a physical male. She is, however, also quite high in the Cube, toward a female SI. As the smaller size of the number is meant to indicate (above), she is toward the background of the Cube, to the female-yearning (FY) end of the sexual orientation spectrum. Therefore she is a transgender female with a strong sexual preference for a female partner.

Consider Position 2:
This individual is also deeply in the male end of the P spectrum. She is also high up on the SI spectrum, so she self-identifies as female. She is, however, strongly toward the foreground on the SO spectrum, well into MY territory. She is therefore a physical male, self-identifying as a female, with a strong preference for a male partner.

Consider position 3:
This individual is androgynous or hermaphroditic, sitting right on the center of the P spectrum. Likewise, this individual is in the center of the SI spectrum, and so identifies with either both masculinity and femininity, or neither of them. This person is also at the center point of the SO spectrum, and so is either asexual, or bisexual. In either case, there is no preference for one sex over the other.

Consider position 4:
This individual is quite far into female physicality. He or she is obviously a physical female, with very few, if any male traits. He/she is about half way up the SI spectrum, so there is no strong identification with either a male or female self-identity. Slightly nearer to the foreground (the MY end of the SO spectrum), this individual would exhibit a stronger attraction toward males in general, but may feel attraction to some females as well.

An Alternative Notation, for Ease of Use

Finally, though this method of creating a visual representation of human sexuality as a point on a three dimensional graph — the Cube — should be helpful in understanding and explaining the stunning diversity and nuance in human kind, it is nonetheless a bit difficult to create or explain. As an alternative, one can represent the three spectrums with position letters, like this:

3smjeffFigure 10: The Three Spectrum model, with letters

Each individual then, can indicate his or her position using a simple set of capital letters. Thus, this representation for a female with a self-identity as a female, but toward the more masculine end of femininity, with a strong attraction to females:

11jeffFigure 11: An individual represented on the Three Spectrum model

This woman might be noted in this way: FCG    (P spectrum=F, SI spectrum=C, SO spectrum=G).
Likewise, the heterosexual male shown below would be: AGG:

aggjeffFigure 12: A heterosexual male represented on the Three Spectrum model

This may seem a bit cumbersome at first, but with some familiarity, it becomes very intuitive. A BAA, for example, is a physical male with very strong female self-identification and a strong attraction to females. A CGB would be a fairly androgynous male with a strong self-identification as male, and a fairly strong attraction to other males.

Conclusion

This method of classifying the complex attributes of human gender and sexuality is imperfect, as all such attempts will be. The Cube model allows an individual’s complexity to be represented by a unified single point, whereas the Three Spectrum model allows for greater ease of use and clearer representation in two-dimensional media, such as print. The use of this method is also inclusive, not only of transgender individuals, but of the full range of human sexuality, including heterosexuals. This provides a more unified and inclusive method, avoiding the creation of “us” and “them” thinking when discussing our variation as human beings.

It is my hope that it is a step in the direction of greater understanding (and subsequent tolerance and acceptance) of the LGBT communities and individuals by other segments of society, and that it might also lead to greater self understanding within LGBT communities themselves.

Note: By placing the various categorizations in the form of a Cube, I have attempted to avoid a sense of hierarchy or preference for any type of individual. Where it was necessary to place labels first, or higher, I have tried to do so with an even division of male- and female-associated labels as much as possible. In the 3D digital model, the Cube can be rolled around in three dimensional space and, while the numbers maintain their relative position in the Cube, and remain upright for easy reading, the labels and spectrum lined roll with the Cube, allowing the viewed to determine the placement of each label according to preference and ease of use.

Note: I would like to state an opinion that the placement of oneself on the representations above is not likely fixed. What I mean to say is that our position on the charts changes – probably not very much in most cases – but we should be open to the probably reality that, like nearly everything about us, there will be small shifts and migrations throughout our lives, as our biology and psyche are affected by age and experience. The tools above are not meant to be static, iron-clad designations, but rather a means by which everyone – LGBT community or not – might better understand both human gender and sexuality in relation to other individuals of our species.