Shifting Sands

Although it's over a year since its release, I came across this amazing publication, and I wanted to give it wider recognition.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is the medical college responsible for setting training standards for doctors specialising in the field of Obstetrics and Gynaecology in Australasia. So it's a very large, prestigious, academic organisation.

As most medical colleges do, it publishes a flagship academic journal; but also a more informal publication, O&G Magazine, which I admit I had never come across until I saw a pile of them lying in my hospital. The top one caught my eye, because it was colourful, and because it looked like Tetris (which is one of my favourite games). When I looked closer, I saw that the theme of this particular issue was "LGBTQIA", so I picked it up to have a read. I was immediately captivated. Best of all, the entire issue is available free online here.

Let's start with the editorial, from incoming RANZCOG President Dr Vijay Roach:

Roach: This issue of O&G Magazine addresses an important aspect of social, cultural and clinical life in Australia and New Zealand. Members of the LGBTI community have experienced a long history of marginalisation and discrimination, often to the detriment of their physical and mental healthcare. While the College acknowledges a diversity of opinion in the community and among our members on many issues, on one thing we are united: RANZCOG believes that every person, independent of their sexual orientation, has the right to high-quality medical care. 

In 2017, the RANZCOG Board issued a statement on same-sex marriage which read, in part '… the Board affirms its support for marriage equality and calls upon the Australian Parliament to ensure equal opportunity for lesbian, gay, bisexual, transgender and intersex (LGBTI) Australians in same-sex relationships and their families …' I was proud to be a member of that Board and grateful to then-President Prof Steve Robson for his leadership.

In this issue, the O&G Magazine editors have assembled a diverse series of articles relevant to the care of the LGBTI community. It is compelling reading and relevant to everyone’s practice.

The list of articles is impressive:

Fertility options for gender and sexually diverse people (Bronwyn Devine)
Rainbow IVF (Sarah van der Wal)
Gender dysphoria (Simone Buzwell)
Gender dysphoria: a paediatric perspective (Noel Friesen)
Fertility preservation in the transgender child and adolescent (Tamara Hunter)
Intersex: variations in sex characteristics (Jennifer Beale)
What do intersex people need from doctors? (Morgan Carpenter)
Hormonal treatment of the transgender adult (Rosemary Jones)
Surgery for transgender individuals (Charlotte Elder)
LGBTQIA gynaecological screening (Kimberley Ivory)
Takatāpui (Elizabeth Kerekere)
Tekwabi Giz National LGBTI Health Alliance (Rebecca Johnson)
Glass closets and the hidden curriculum of medical school (Amy Coopes)
Australia's queer history (Robert French)

I read these articles with two sets of eyes. The first were my medical eyes: was this the sort of thing that, as a doctor, would be helpful for me to read? The answer is clearly yes. The second were my transgender eyes: was this the sort of thing that, as a trans person myself, I would want doctors to read and know? The answer is also a clear yes. There is no doubt that transgender people are becoming more and more visible; their care has been, in the main, not that great; most doctors have very little training in care of transgender people, and reliable resources for doctors to draw upon are few.

The various authors all have special expertise and interest in their various fields, which is commendable. But it's the range of subjects which strikes me as particularly noteworthy. I've sometimes felt that the T is kind of tacked on to the end of LGB as an afterthought. But here we are, right in the middle, with articles dealing with not just hormones and surgery but issues like fertility and childhood and emotional wellbeing. Amazing.

I was pleased to note that the tone of all the articles was spot on, from the acceptance of the individuals, to recognition that care matters but is frequently lacking, to pragmatic information and guidance for practitioners.

There are several points which are very much worth making about a publication of this type.

(1) First, it's great that a major medical college is being so overtly inclusive. That alone is magnificent. RANZCOG is setting an example for others to follow. There has been lots of Twitter support for the issue.

(2) Second, most medical colleges publish guidelines for the care of patients with X condition. What strikes me about this one is a subtle but powerful shift in tone: not "this is what these patients are like" but "this is us, and that's OK". As Amy Coopes points out in her article, there is still great stigma in medicine if you are gay or non-binary. So a publication like this is extremely affirming. As a transgender person with a medical degree myself, I immediately wanted to reach out and make contact, so I wrote to RANZCOG and congratulated them on their magazine (and I’m not the only one: there is a very heartfelt response from a gay obstetrician in the following issue here).

(3) I wouldn't have necessarily expected O&G to be the specialty which would deal with the care of transwomen. Post-transition, care could potentially be complex, since O&G specialists are more used to the care of people with a uterus and vagina than a prostate gland. But this issue seems to be saying to its readers: don't panic, you can do it! It's started me discussing these issues with some of my colleagues much more openly than previously.

Whether you are medical or not, it's well worth having a browse through this magazine. If you're aware of any other medical organisations being explicitly rainbow-inclusive, please let me know.

Sex and Gender in Sports - Part One

It's just been Olympic time again, and that means we are overdue for a topic which I have been considering for a long time: how do you separate male and female athletes? This article was prompted by the Olympics, but has relevance to sporting competition in all spheres.

The modern Olympic games has been going for more than a century. Revived by Baron Pierre de Coubertin in 1896, the modern games started to allow women to compete in the 1900 games, held in Paris. But it took until 2012 (the London games) before every competing nation sent women athletes to the games, and the 2012 games were also the first to have women competing in every sport in the programme.

It turns out that men do better, in general, than women at sporting events. As just one example, the four-minute mile has been routinely broken by men, since it was first achieved by Roger Bannister in 1956, but no woman has ever achieved it; the fastest woman is still 12 seconds away. So it makes sense to segregate male and female athletes, so that the competition is fair.



Dora Ratjen

This throws up some problems. First, how do we actually decide who is a man and who is a woman? It hasn't ever been easy. Dora Ratjen was an intersex individual, born with ambiguous genitalia, assigned female at birth and raised as a girl. Ratjen competed for Germany in the women's High Jump in the 1936 Summer Olympic games, and finished fourth. In 1938, Ratjen competed in the European Athletics Championship, and won a gold medal in the high jump. The following year, Ratjen broke the World Record for the High Jump. After an official investigation (following a complaint from another athlete), Ratjen was, at that time, discovered to be working as a male waiter under the name Hermann. He was stripped of his title. Ultimately Ratjen chose the name Heinrich, and lived out the rest of his life as a man.

Wikipedia mentions two other athletes from this period, Zdenek Koubek, and Mary Weston, with similar biographies. These were intersex people with ambiguous genitalia, raised as girls, who competed as women. In common with Ratjen, Koubek and Weston each later transitioned to male.

US Olympic Committee president Avery Brundage called in 1936 for a system to be set up to examine female athletes to make sure they were actually female. Unfortunately, physical examination was the only way to do this. I do not doubt that those examinations were undignified, uncomfortable, and unreliable.

It took another 30 years for chromosome testing to be adopted, in 1968. Surely this would sort everything out, using hard science. Everyone knows that human males have the chromosome pattern 46XY, and females have the chromosome pattern 46XX. So there's your answer.

Maria Jose Martinez-Patino

Except that it isn't. Most individuals with androgen insensitivity syndrome have the chromosome pattern of a male, 46XY, and produce testosterone. However, their bodies are not sensitive to the testosterone, which means they develop as women. Such women are infertile, and lack a uterus, but are externally indistinguishable from 46XX women. Spanish athlete Maria Jose Martinez-Patino was disqualified from competition in the 1988 Summer Olympic games because she failed such a chromosome test, though she was reinstated for competition in the 1992 games. She has since become an academic, and has written about her experience here in the Lancet.

Likewise, some people have the chromosome pattern 47XXY (Klinefelter syndrome), or are mosaics (in other words, not all their cells have the same chromosome pattern).

So, once again, the testing lets us down. The problem is that, even at the chromosome level, the actual level of the DNA itself, humans don't fall neatly into male and female categories.

In 2011, the IAAF came up with yet another idea: that athletes should be separated according to how much testosterone they have. There is a good discussion of this ruling here. The focus on testosterone is because it's considered that a high level of testosterone is what provides men with their athletic advantage. The IAAF ruled (among other things):

Athletic competition will continue to be divided into men’s and women’s categories

A female with hyperandrogenism who is recognised as a female in law shall be eligible to compete in women’s competition in athletics provided that she has androgen levels below the male range (my italics)

The new testosterone limit was set at 10 nanomoles per litre of blood. This level was chosen because it's three times higher than the upper limit of normal for women, and it was reasoned that very few women would naturally have a testosterone level this high. It's at the very bottom of the normal range of testosterone for men under 50.

This does solve some problems. It does away with examining physical characteristics and chromosomes (though not the indignity of subjecting someone's identity to detailed scrutiny). It even allows for athletes to potentially change sex and still compete as their new sex, provided their hormonal profile fits.

Caster Semenya

But once again, there are different problems. Enter Caster Semenya. This South African athlete became the centre of another humiliating sex-testing furore in 2009 aged 18, when she won the 800m gold medal. She was cleared by the IAAF to compete as a woman in 2010, and has, most recently, won Olympic gold in Rio in the 800m event.

Details of Semenya's medical profile are somewhat sketchy, because she her test results have (rightly) been ruled confidential. The BBC reports that she has hyperandrogenism, which means her testosterone level is much higher than an ordinary woman, and even higher than many ordinary men. Indian athlete Dutee Chand has hyperandrogenism too.

The pressure on athletes to succeed at the top level, where the difference between success and failure can be measured in milliseconds or millimetres, is enormous. Therefore, it's understandable that athletes want to take every possible step to maximise their performance (and understandable--but not forgivable--when some resort to cheating to make this happen). And it's understandable that their opponents may be angered by what they perceive as an athlete with an unfair advantage being allowed to compete against them.

Because of the 2011 ruling, female athletes with hyperandrogenism were sometimes required to take medication to lower their testosterone to the "normal" female range. But it gets worse still. In 2016, the United Nations Special Rapporteur on health reported that "a number of athletes have undergone gonadectomy (removal of reproductive organs) and partial clitoridectomy (a form of female genital mutilation) in the absence of symptoms or health issues warranting those procedures". In other words, some athletes have been having surgery they don't need in order to ensure they don't fail a sex test. The UN is outspoken in its condemnation of this, and there are some more details here.

The testosterone restriction was removed for the 2016 Rio Olympics, allowing Semenya (and other hyperandrogenic women) to compete, free of testosterone suppression, because the Court of Arbitration for Sport (CAS) ruled that the limit should be abandoned for two years to study whether testosterone provides an unfair advantage to athletes. But the debate continues, and there is a powerful article here.

All of the athletes we have discussed have been competing as women. There seems to be no restriction on anyone who wants to compete as a man. The IOC released a statement in 2012 which said this:

IOC: In the event that the athlete has been declared ineligible to compete in the female category, the athlete may be eligible to compete as a male athlete, if the athlete qualifies for the male event of the sport.

Faster than Caster: Usain Bolt

The next point I want to make is that nobody here is cheating. Dora Ratjen was raised a girl through no fault of her own, and competed as a woman at a time when intersex conditions were poorly recognised or understood. Maria Jose Martinez-Patino has androgen-insensitivity syndrome. And Caster Semenya has hyperandrogenism. None of those people has deliberately done anything to improve their performance other than training. The notion that Semenya and other hyperandrogenic women should have their testosterone levels deliberately suppressed seems no more "fair" to me than the notion that Usain Bolt should have some of his thigh muscles removed, or his legs shortened, to make his performance "fairer". Intersex people have a long history of being "normalised" by medical treatments.

But Joanna Harper, herself a transgender athlete and medical physicist, argues differently. My quotes come from Sarah Barker's excellent article here:

Barker: ...success in sports is one of the greatest advancements in women’s lives. If we value women’s equality, it is imperative that we protect the ability of all women to succeed in sports. I believe that billions of potential female athletes deserve the right to compete with some semblance of a level playing field, and that requiring all women to compete within a given testosterone range is the best way we currently have to create such a playing field.

Is testosterone everything? Surely not; otherwise Caster Semenya would surely be able to run a four-minute mile. The exact role of testosterone remains unclear; there is even a 2014 paper which analyses testosterone levels in 693 elite athletes. It discovered that 16.5% of men (and remember, we are talking about elite athletes) had low testosterone levels, while 13.7% of women had high levels, overlapping with the men. The papers authors concluded:

Healy, et al: Hormone profiles from elite athletes differ from usual reference ranges. Individual results are dependent on a number of factors including age, gender and physique. Differences in profiles between sports suggest that an individual's profile may contribute to his/her proficiency in a particular sport. The IOC definition of a woman as one who has a ‘normal’ testosterone level is untenable.

So the debate clearly has a way to go. I think my bottom line is this. If you are going to separate men and women in athletic competition, you need to draw the line somewhere. This will--inevitably--provide advantage to some people and disadvantage to others. If you draw that line as the body you were born with, then hyperandrogenic women like Caster Semenya will surely come to dominate women's sports. If you draw it at an arbitrary level of testosterone, then you will force some athletes to take medications (and in extreme cases, to have surgery) in order to compete.

No easy answer. I had planned to include transgender athletes in this article, but, as usual, I have found too much material, so I will split this article into chapters. In the next section, I shall consider transgender (rather than intersex) athletes.

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If you enjoyed this article, you might be interested in my article about Female Bodybuilding.

A Tale of Two Boxes

Back in 2014 I wrote a post called Frightening the Horses, which largely discussed a 2002 article by American writer and psychotherapist Amy Bloom, entitled Conservative Men in Conservative Dresses, which was published in Atlantic Monthly.

The first line of the article is this one:

Bloom: Heterosexual cross-dressers bother almost everyone.

When I first read that line, I found myself agreeing with it. In fact, some of them even bother me, and I am one! If you missed Bloom's article, it's well worth a read in its entirety. I think it's also worth having a read of my post; it certainly generated a lot of discussion.

I've been thinking about why it is that crossdressing bothers us so much. As Bloom says, drag queens don't bother us. Nor do female impersonators (she cites several American examples; instead I point you to Danny la Rue, and Hinge and Bracket as popular British examples). She even points to those women in history who have had to adopt the male persona in order to succeed. And transsexuals don't bother us.

I don't speak his language

I cross-dress whenever I can, which is not as often as I would like. The rest of the time I live my life as if I were an ordinary man.

But my whole life I have been different from other boys and men. I am sensitive. I cry easily. I loathe many of the trappings of “traditional” masculinity (field sports, big rugged vehicles, hunting and fishing, weapons, coarse behaviour, macho posturing, or the objectification of women). I especially loathe it when other people (men or women) ascribe those things to me, or assume I must have some affinity with them, just because I was born a boy.

You might say that I should just learn to be a sensitive man and to find ways to explore and express my sensitive, caring, nurturing side in the world of men (and stick two fingers up to the knuckle-dragging bottom-feeders who would persecute me for it). But I don't: instead I choose to express those aspects of myself by attempting to experience the world of women. It's not just the clothes and the lipstick: those are merely the external manifestations of something which goes right down to my core identity as a human being. I feel much more comfortable in the company of women. I espouse feminist principles very openly. I suspect (but cannot, of course, be sure) that I have been imprinted (at a young age) to associate femininity with the aspects of my personality I cannot easily express as a man. In other words, it’s too late to change.

“Crossdressing makes you comfortable,” I am sometimes told. No. Slippers make me comfortable. Crossdressing (using that as a convenient shortcut for the whole package of stepping out of the male role and embracing the female one) is a necessity for my psychological wellbeing.

So it's a simplification (and a hurtful one) to say I just “like to dress up” or “it's all just a bit of fun”, or I am just “getting in touch with my feminine side”. It goes much deeper than that. I have powerful and irrepressible yearnings to dress, and when I do, it feels right on a level which is difficult to fully articulate. It isn't an act. It isn't a pretence. It doesn't feel like a sham.


Kept apart: male and female

I can see why some people need that feeling all the time. In other words, I think what separates me from them is not some huge gulf (“a cross dresser is only pretending to be a woman, while a trans woman is a woman”), but actually a considerable degree of overlap.

I have found that suggesting this makes some trans women uncomfortable: men who cross-dress in our society (and don't I know it!) are treated as figures of scorn or ridicule (or worse, sexual perversity), and I can completely see why trans women would want to distance themselves from that. But from my perspective, it is the truth.

As a male-to-female crossdresser, I do feel that some fully-transitioned people look down on me. They seem to be saying "We are nothing alike, since you are 'only' a crossdresser. Our motivations are not the same. Our behaviour is not the same. The reasons why we do what we do are not the same".

The difficulty I have is that none of these things is demonstrably true (and I admit I am a lumper, not a splitter). When I ask those people to explain their viewpoint (or occasionally challenge them) I get three basic responses:

1. Because I don't automatically accept their word, I must be transphobic, just like all those others.
2. I haven't done enough reading, and if only I would read this book or that blog it would all become clear; or
3. I can't possibly understand because I am "only" a crossdresser.

I stress that these people are the minority, and that most trans people I know are lovely, welcoming and inclusive.

The story we tell ourselves

But here is what I think: society has a story we tell ourselves. That story is that there are two genders, male and female. The most "acceptable" people are those who start off on one side and stay there. But most people are (I think) comfortable with people who start off on one side and go all the way across to the other, because that just about fits the story.

I think it’s easier for cisgendered people to accept a person who “was” once a man but “is” now a woman, and it’s harder for them to accept that, actually, there are a lot of us somewhere in the middle zone (perhaps the rainbow zone?) between those two boxes (including some people who might identify or “qualify” as cis-gendered). (Likewise, it's acceptable to be a drag queen, who is male in his normal life. Putting on a dress is only an act, right?)

But society is very uncomfortable with people in that middle zone, because they don't fit the story: it might be people who choose to be neither one nor the other gender, intersex people, or people (like me) who trespass across the middle zone from time to time. (I think that explains why there is tremendous pressure on intersex people to align themselves to one or other gender).

Which one do you think I am?

Of course, the story is wrong, at all levels from the cell, to the person, to society as a whole. But that is still the story we tell; even some trans people tell it. I think a lot of trans people overtly, or subconsciously, reinforce that gender binary. I think it helps them to feel more comfortable about themselves, and I think it helps cisgendered people to feel more comfortable about them.

I don’t identify as an ordinary man. I don’t identify as a woman either. I am not quite sure what I identify with! I sometimes describe myself on Quora as a "part-time woman". And I want to say to those people who think they are so different: we have more that unites us than divides us, and we should concentrate on our commonalities, not our differences.

As for the stereotypes of men and women, they are created by society. But I am a member of society. I cannot simply step aside from its conventions, nor ignore its rules (whether they please me or not). Even though there are many, many people who don't fit the stereotypes, the stereotypes persist. It does seem, though, that society is changing: it is becoming more acceptable to not fit the binary.

Come and join me in the middle zone. There are plenty of comfortable seats, and the wine has just been opened!

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Addendum 28th August 2016

My thanks to Patricia for sending me a link to this article by Rebecca Reilly-Cooper. It's articulate, forthright and powerful, and adds another perspective to the idea of the "spectrum of gender" You can read the full thing here.

Galileo's Middle Finger - Part Two

This is the second of my articles discussing the book Galileo's Middle Finger, by Alice Dreger. If you haven't already, it makes sense to start reading at Part One, which discusses intersex individuals.

Dreger: When people ask me how transgender is different from intersex, I usually start by saying that that intersex and transgender people have historically suffered from the opposite problems for the same reason. Whereas intersex people have historically been subjected to sex "normalizing" hormones and surgeries they have not wanted, transgender people have had a hard time getting the sex-change hormones and surgeries they have wanted. Both problems arise from a single cause: a heterosexist medical establishment determined to retain control over who gets to be what sex.

Manly: legs

Here she is, shortly into chapter 2, Rabbit Holes, and characteristically getting right down to the nub of the issue. (For my own, similar take on intersex vs transgender, I refer you to this post, though you might need to scroll down a bit).

Dreger: In the great majority of cases, medical scans won't detect any intersex feature in a transgendered person's body. Nevertheless, many people believe that transgender must be a special form of intersex involving the brain.

This fits with my comment that some transgender individuals look to the existence of intersex individuals to provide justification for their behaviour.

Dreger: Although there is very little science to support it, this has become the most popular explanation of transgender, probably in part because it is the easiest one for uptight heterosexuals to accept. (...) In practice, this story of transgender can function as a kind of get-out-of-male free card for men who seek to become women anatomically. When that card is played, the comforting narrative of "true selves" is preserved.

And there are scientific papers (such as this one) which seek to demonstrate anatomical differences in the brains of trans people. Though mostly their brains are very similar, some studies purport to demonstrate subtle differences in tiny regions of the brain (for example, some regions in MtF transsexuals are less like men and more like women). Most of these studies have small numbers of non-randomised participants, and even if these findings are robust (and I am nowhere near convinced that they are), correlation is not causation.

Science may indeed unlock some of these puzzles in time, but the only thing I am convinced of is that the science is pretty unconvincing so far.

Controversial: Bailey

It's at this point in the narrative that Dreger introduces Professor J. Michael Bailey, the author of the controversial work The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, published in 2003. Bailey drew on the work of Ray Blanchard, and is therefore supportive of the autogynephilia model, to which I subscribe, as you probably already know. See here for a fuller discussion of this model. In that link, I also discuss how the autogynephilia model makes me feel uncomfortable about myself, because it insists the root of my crossdressing is in sexual desire.

Dreger points out that the French translation of autogynephilia is amour de soi en femme (love of oneself as a woman) which is a much nicer expression.

But where I feel uncomfortable about the autogynephilia model, a lot of people felt a lot worse.

Dreger: Before Bailey, many trans advocates had spent a long time working to desexualize and depathologize their public representations in an effort to reduce stigma, improve access to care, and establish basic human rights for trans people. (...) This is similar to how gay rights advocates have desexualized homosexuality in the quest for marriage rights, portraying themselves in living rooms and kitchens instead of bedrooms, in order to calm fearful heterosexuals.

Indeed, a few retrograde clinicians, like Paul McHugh, a psychiatrist at the Johns Hopkins School of Medicine, still actively use the idea that male-to-female transgender is really about perverted sexuality and mental illness to argue against access to sex-transitional hormones and surgeries.

For Bailey or anyone else to call someone with amour de soi en femme an autogynephile or even a transgender woman-- rather than simply a woman-- is at some level to interfere with her core sexual desire. Such naming also risks questioning her core self-identity in a way that calling the average gay man homosexual simply can't. One really must understand this if one is going to understand why some trans women came after Bailey so hard for naming and describing autogynephilia. When they felt that Bailey was fundamentally threatening their selves and their social identities as women-- well, it's because he was. That's what talking openly about autogynephilia necessarily does.

Lynn Conway by Charles Rogers

It's worth digressing here to make a couple of remarks. Just because a scientific theory makes you uncomfortable, doesn't make it wrong. And just because you insist upon something, doesn't make it right. If you want to convince me, you need to do a lot better than insist. I respond to evidence, not vehemence. This has occasionally caused me to get into uncomfortable debates with other trans people when I dare to question them about their views and beliefs. Sometimes, when they are unable to explain themselves, they resort to some variant of: "Of course, you couldn't possibly understand. You're only a crossdresser, where I am a woman".

But back to the book. Dreger goes on to describe how a prominent transwoman called Lynn Conway, at the University of Michigan, started "what became a war" against Bailey, assisted by Andrea James and Deirdre McLoskey. Together they began to systematically ruin Bailey's reputation. They campaigned to have the book removed from consideration for the 2004 Lambda Literary Award. They cooked up stories about him practising psychology without a licence, doing research without appropriate ethical oversight, and even having sex with one of his research subjects. And Dreger digs deeply and thoroughly into all of this, interviewing as many of the original people involved as possible.

Dreger: As a result of all this, Bailey came across pretty clearly as an abuser, a trans-basher, and a sexual pervert.

After nearly a year of research, I could come to only one conclusion: the whole thing was a sham. Bailey's sworn enemies had used every clever trick in the book-- juxtaposing events in misleading ways, ignoring contrary evidence, working the rhetoric, and using anonymity whenever convenient, to make it look as though virtually every trans woman represented in Bailey's book had felt abused by him and had filed a charge.

But why did Conway, James and McLoskey feel they had to do all those things?

Dreger: "Narcissistic injury," the physician-researcher Anne Lawrence said to me, by way of explanation. "Followed by narcissistic rage." That, she told me, was the only real way to explain what happened to Bailey. The whole thing had been an attempt to kill the messenger bringing a message that Lawrence guessed wounded the accusers' sense of self.

Captivating: the book

By this point, we are barely a third of the way through the book. Several things stand out. First, the book is extremely readable, and the narrative is told in a personal, conversational style. Second, Dreger's scholarship is impeccable: many hundreds of hours of interviews and research have gone into this book (you should see the references), and Dreger seems uncompromising in her search for the truth. Third, it's clear that a great deal of her personal energy has been invested, not just in writing the book, but in sympathising with the people in it, befriending them and becoming part of their lives. Fourth, writing this book has taken considerable courage, and Dreger has herself come under fire, risking her own career and reputation (drawing parallels with Galileo, of course).

Overall, the book is a phenomenal read; gripping as a thriller, scholarly, yet incredibly human. There are so many points in the book where I thought: I can't believe I am actually reading this! I can't recommend it highly enough.

We part company with the book at this point, partly because this blog post is already way too long, and partly because the book leaves the subjects of gender and sex as Dreger finds other (compelling) subjects to sink her hungry scholastic teeth into.

I think the world of gender is changing more rapidly than it ever has before. The emergence of transgender celebrities like Laverne Cox and Caitlyn Jenner has caused mainstream society to become much more aware (and thankfully, accepting) of trans people and trans issues. Nonetheless, I am very uncomfortable about what happened to Bailey: vilified for his views, not because they were wrong, but because they made people uncomfortable. Dreger points out (and I don't know why I didn't think of this before) that as a result of Conway's attack on Bailey, "no one in sex research will touch male-to-female transsexualism with a ten foot pole any more. Which must have been just what Conway meant to do". That explains why there isn't good science: because scientists fear personal retribution if they publish results which are unpopular.

The way to enlightenment is not to silence people, even the ones who disagree with us, but to engage in open, civil, respectful debate; to seek out the best evidence, and incorporate it into the picture, recognising that the picture isn't complete and may yet change as new discoveries come to light.

Dreger's book has inspired me to be a little more upright, a little more outspoken in defence of the truth, a little more questioning of the "facts", than I was previously. And perhaps, therefore, a little more willing to extend my middle finger, just like Galileo.

Galileo's Middle Finger - Part One

My book this week is called Galileo’s Middle Finger, and it was recommended to me by my friend Patricia. You need to read this book, she told me. It took me a while to get around to it, but she was dead right.

Alice Dreger

Galileo’s Middle Finger is written by Alice Dreger, professor of clinical medical humanities and bioethics at the Feinberg School of Medicine in Chicago. I had not come across her work before. Her book is a personal account of her own involvement in a series of medical and ethical issues, over two decades of her life. For readers of this blog in particular, the first three chapters will be of greatest interest. The first discusses intersex people; the second and third transgender people. There is so much to talk about that I am going to split this article into two blog posts.

One of the themes of this blog (one I am always going on about) is that, when it comes to the study of sex and gender, hard scientific knowledge is pretty lacking. In its place is often entrenched dogma, coming from people (scientists themselves and their supporters) who insist on a particular paradigm or point of view; and the equally entrenched opposition of the activists and pressure groups, waving flags and making demands.

If someone comes up with a new idea, it can easily fall foul of one or even both of those groups, not because it is wrong, but because it challenges the way people think, and people (even scientists) can find themselves attacked and vilified, especially in this age of instant social media and viral messages.

Dreger is my kind of scholar: the one who is most interested in the truth above all, "a belief in evidence even when it challenges [her] political goals". In her book she describes how she has been on both sides of these debates; at times siding with the activists, pushing hard against dogma and accepted wisdom. At other times, she has sided with the scientists, defending them against unfair or personal attacks from critics.

Let’s cover some concrete examples. In the first chapter of her book, entitled Funny Looking, Dreger comes right to the point on the very first page.

Dreger: This was my stance: Children born with genitals that look funny but work fine should not be surgically altered just because their genital appearance upsets or worries some adult. Big clitorises shouldn't be shortened, and baby boys with very small penises shouldn't be sex-changed just because their phalluses induce Freudian crises of conscience in their caregivers.

Neither fish nor fowl: intersex

She is talking, of course, about intersex children, that 1 in 1000 or so babies who are born with genitalia which seem to be neither quite boy nor girl. In some (rarer) cases, intersex people can possess both testicular and ovarian tissue in an ovotestis. Cases of intersex people have been cropping up in the medical literature for centuries (I recall coming across them as a student) and are depicted in medical textbooks naked, in black-and-white, with a bar over their face to cover their "anonymity".

Originally, of course, medicine had nothing to offer those people. But over the last few decades, increasingly intersex children have been dealt with surgically. Big clitorises (and I'm sorry for wearing my geek hat long enough to point out that the official plural of clitoris is clitorides) were surgically shortened to look more normal (but often causing scarring and the inability to achieve orgasm). Small penises were sometimes completely amputated, and the child raised as a girl. Unfortunately surgery on children's genitals rarely turns out right.

I stress this was usually done with the very best of intentions by most doctors. I believe (and Dreger does too) that the doctors thought they were doing the right thing by these children. They believed that rigidly enforcing an anatomical binary would spare these children growing up different, and make them fit more comfortably. They believed if they did not provide the surgery, the children would commit suicide in puberty.

Dreger: Modern medicine now sought to reinforce the "optimum gender of rearing" by early management of children born with sex anomalies by means of "sex-normalising" surgeries, hormone treatments, delicate euphemisms, and sometimes lies.

This was also the system that led to a lot of really angry intersex adults who discovered that they had been harmed by the medical care meant to "save" them and who knew that the basic system was still being used on children who would likely grow up as hurt and angry as they were. In the early 1990's, a core group of these people formed the intersex rights movement I eventually joined. Some of these intersex adults had been physically harmed--left with damaged sexual sensation, incontinence or repetitive infections. Many had been psychologically harmed--left with a sense of having been too monstrous for their parents to accept as they came, of being sexually freakish, of being fountains of familial shame. All were left with a burning desire to try to save others from going through what they had.

Things were made worse by the actions of people like Dr. John Money. Money's most famous case was David Reimer, a healthy (non-intersex) boy whose penis was destroyed during a botched circumcision attempt. Money suggested that Reimer be raised as a girl, and he underwent removal of his testicles as a baby, together with hormone treatments intended to feminise him. Unfortunately, none of this worked: Reimer always identified as a boy (despite a rigid "girl" upbringing). Worse, Money continued to publish fraudulent reports (in what became known as the "John/Joan" case) that Reimer was doing well as a girl, and his reputation and prestige meant that other doctors followed his example of treatment. Money was a charlatan whose harms extended far beyond this one patient.

How do you measure up?

Together with intersex friend Bo Laurent, Alice Dreger formalised the Intersex Society of North America into a non-profit, tax-exempt organisation. Its purpose was to provide solidarity for intersex people, to realise they are not alone; to campaign to the medical profession for better, more understanding treatment of intersex individuals; and for more acceptance from society for intersex individuals.

Dreger: The problem in intersex care wasn't a problem of gender identity per se. The problem was that, in the service of strict gender norms, people were being cut up, lied to, and made to feel profoundly ashamed of themselves. Bo said it as plainly as she could: Intersex is not primarily about gender identity; it is about shame, secrecy and trauma.

Gradually, they began to gain some traction with doctors. One tool they used was the Phall-O-Meter (pictured), a ruler which is designed to measure the size of a newborn baby's genitals. Calibrated in inches, it was a way of showing how ridiculous it is, that one could use a ruler to categorise something as profound, as far-reaching, as a human being's sex. (This example misses out the humorous captions like "Phew! Just squeaks by!" for a barely acceptable penis).

Dreger: When I would ask treating physicians, "What is the goal of pediatric intersex treatment?" I was amazed at how often they could not articulate an answer. ... It would have been much easier if all these doctors had been evil. Instead they were good-- human, scared. They tried hard to write us off as evil, but when they met us, they realized that we were also good-- and human, and scared.

Giving the finger: Galileo

This is my second reason to love the book: that Dreger talks with compassion and a deeply-sensitive humanity. She adds more than a dash of her own personality to the book, so that, instead of reading like a dry academic treatise, it reads like a personal memoir, and is therefore approachable, funny and poignant. Alice, I would love to have dinner with you!

After some years involved in ISNA, Dreger decided to leave. It is here that the next chapter begins, the chapter involving transsexuals. But I wanted to finish this article by pointing out that the intersex community was very fortunate to find an ally in Alice Dreger: passionate, committed, articulate and seemingly fearless.

You might be wondering where the book's title comes from. It comes from the fact that one of Galileo's fingers (his middle one, of course) is preserved in a jar in the Museo Galileo in Florence. The museum insists that the finger is mounted pointing upward to the heavens which Galileo loved so much. But, because Galileo was fearless in speaking out against the Establishment of his time (getting himself in trouble with Pope Urban VIII over his views of celestial mechanics), Dreger impishly points out that an alternative interpretation is that Galileo is still sticking his middle finger up in the air against stubborn orthodoxy and entrenched dogma.

Join me for Part Two.

More About Children and Gender

In a previous blog post I discussed two particular parenting styles, which seem especially unusual concerning children and gender. The first was (what was probably) a fa'afafine, a boy raised as a girl in a culturally sanctioned third sex, a practice which occurs in several of the Pacific Islands. The second was about Kathy Witterick and David Stalker, who have refused to reveal the sex of their third child, Storm, with the intention of allowing Storm to discover his or her own gender identity, free of societal expectations.

Storm with brothers Jazz (left) and Kio (right)

As I write this, Storm is now three years old, and still of unrevealed sex. There is a more recent interview with the family here. It seems quite clear that Storm's parents love their three children very much. They seem able to stand aside from any expectation of what their children will be, and just watch what happens. As a parent myself, I find it extremely difficult not to project onto my children some sort of expectation about what sort of adults they will eventually become. In addition, gender-neutral parenting is extremely difficult to achieve, for even the most well-informed and well-intentioned parents.

Witterick and Stocker have (perhaps understandably) provoked a fair bit of outrage. While I admire the unconditional nature of their love, I ultimately think their idea is misguided. Children are not simply free to decide for themselves how the world works. I believe that responsible parents attempt to equip children with both cognitive and moral structures which help them to make sense of the world. (If they don’t, then sure as eggs someone else will: via the TV or the Internet or popular music; even their peers). Therefore, it is inevitable that some parental biases and ideas (and neuroses and hangups) will be communicated to their children. I believe it is an essential part of growing up to weigh those parental structures and decide to keep some and abandon others.

One might, for example, discover that one's child had a penchant for cruelty or mischief. I don't think a responsible parent would simply stand by and admire that ("Aww, bless, there's the kid setting fire to the cat again. Isn't it cute?") but would actually intervene.

Both of those situations are where the parents have decided how they are going to raise the children in a certain way. What happens when the child has other ideas from the parents?

In this powerful and thought-provoking article, Eric Adler of the Kansas City Star describes the situation of "A.J.". Born an apparently normal boy, A.J., now six years old, knows he is a girl.

Then around Christmas, A.J. said it. He took his mom's breath away. They were in a store, walking hand in hand.
"'Mom,'" she recalled him saying. "'Do you know that I'm a girl? I'm really a girl on the inside.'"
It was not a question. It was a statement.
"My child did not say, 'I want to be a girl.' He said, 'I am a girl. How can you not see it? Don't you know?'"
The room went out of focus. She tried to respond.
"I said, 'No. No. I didn't know. The doctors told us you were a boy, so that's what I thought.'"
"OK," her son replied. They kept walking. Her mind spun.
"You cannot be prepared for this as a parent," she said. "It's not in any of the What to Expect When You're Expecting books."
Back home, she phoned her husband. "We have big stuff going on here," she said.

A.J., has one older brother, who seems to be an "ordinary" boy, into trucks and sports and the like.

"We were just parents going to work, sending our kids to day care, and this happened to us," the mother said. "I had never even heard the term 'transgender.'"

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

A.J. in her bedroom

The article goes into considerable detail about the parents' reaction. For reasons of confidentiality, they are not named. As comparatively conservative people, they supported their child the best they could, and sought professional advice.

They called Children's Mercy [Hospital] and then Gibbs [Caroline Gibbs, gender counsellor]. They remained cautious and skeptical, wondering whether someone who ran a place called the Transgender Institute might be too apt to diagnose a child as transgender. They sat down with A.J., watching Gibbs for signs of leading questions. Gibbs, as A.J.'s mother recalled, began talking to A.J.
"Can you tell me something about yourself? Are you a boy or a girl?"
"I'm a girl," A.J. said.
"What makes you think you're a girl?"
"I just am," she said.
"Is it what you wear or what you play with?"
"No. I just am," she said.
"Your parents say 'my son' and 'him.' How does that make you feel?"
"I'm really a she," A.J. responded, "'cause I'm a girl. I'm a daughter."
"But they don't call you that."
"Yeah, I know," A.J. said.
Her mother could see her sadness.
The eventual diagnosis: gender dysphoria, which led to weekly counselling.

Both parents were supportive of A.J.'s change in gender and role, and both the school and the other schoolchildren were accepting. However, the parents of the other children were a different matter. Sadly, many of them turned their backs.

In the pickup line after school, parents stopped making eye contact. Invitations disappeared. Some parents said they would call, but they never did.

"It is not something that I expected," said A.J.'s father, "but as a parent you want to do what is in the best interest of your child. Your job is to shepherd them into the world. And if your own family can't be accepting of who they are, how is the rest of the world going to accept them, or how are they going to accept themselves?"

A.J.'s mother wrote a follow-up article, which you can read in full here. This article attempts to deflect potential criticism of her and her husband's approach to their transgender child. From my perspective, A.J.'s parents come across as sensible, concerned, loving and right-thinking people, and therefore this article does a great job. But doubtless other people may hold different views.

I absolutely admire A.J.'s parents for their standpoint. What they have done, in openly supporting their child in this difficult time, is both painful and courageous. It's quite clear this situation is not of their choosing; nonetheless they both seem determined to make the very best of it.

Adler's article goes into some discussion about what therapists do when faced with gender dysphoric children.

Treating and guiding young children identified as transgender remains a thorny issue. Some therapists discourage the transitions. Some remain neutral and allow free gender expression to see what evolves. And some actively support and guide children with their new identities.

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

The problem is that nobody knows how these children are going to turn out. Some children, known as "desisters" eventually change their minds and return to their birth gender. Again, nobody knows how common desisters are. The experts quoted in the article consider desisters to be few, but studies from other countries report that desisters are quite common. (Even adults occasionally detransition, as described in my blog post here).

Autism: getting commoner (US figures)

A generation ago, autism was very rare. Then suddenly it seems to be everywhere. Is that because we are facing an epidemic of autism? Maybe. On the other hand, maybe we are just getting better at recognising it. Autistic genius Daniel Tammet describes in his extraordinary autobiography, Born on a Blue Day, that his parents struggled to deal with his stereotyped behaviours and incessant wailing as a child, but labelled him "sensitive".

I wonder if something similar isn't happening with transgender children. A generation or more ago, most parents would just not have listened or sympathised (unless the child were a tomboy!). "It's just a phase, son. Here's a toy gun. Go and shoot something". I know that something akin to this happened in my own upbringing. My boyish behaviours were encouraged, and my non-boyish behaviours discouraged, and my family was educated, kind and enlightened. (And I believe, to a great extent, parenting of the kind I had is still very prevalent).

On the other hand, transgender children seem to be becoming more common. (Now you can even get picture books for children about it). The problem is, how common are they? Nobody knows for sure. There are no clear terms of reference, or agreed standards of diagnosis. In other words, we can't even be sure that the numbers they count in the Netherlands are directly comparable with the numbers in the US, or the UK, or anywhere else. I tend to think that, as with autism, the apparent rise in prevalence is not due to a sudden rise in actual numbers of gender-non-conforming children, but an increase in recognition and tolerance of them.

How should they be treated? Nobody knows for sure, and I can say this with absolute certainty. In scientific terms, it is an evidence-free zone. No amount of professional expertise (so-called "eminence-based medicine") can substitute for good scientific studies-- and there are none.

A generation ago, children with ambiguous genitalia were arbitrarily assigned their most likely sex at birth. This was done, with the very best of intention, by doctors, and supported by parents. It was believed at the time that surgical assignment of sex, together with hormonal and psychological treatment, would be all that was necessary to ensure the child would grow up happy and well-adjusted in their assigned sex. Unfortunately, this was often a disaster.

As they became adolescents and eventually adults, some of those people rebelled against the arbitrary assignment of sex at birth, and transitioned to the other sex. One particularly tragic case concerns David Reimer, born a normal male, whose penis was accidentally destroyed during circumcision. His parents were persuaded he should be raised as a girl, but despite orchidectomy and female hormone treatments, Reimer never accepted his assigned sex. He underwent surgical transition to a man, married a woman and became a stepfather to her children. He took his own life at the age of 38.

Reimer's case is pretty extreme, and the psychologist involved, John Money, seems in retrospect to have been profoundly misguided-- if not an unmitigated quack. Nonetheless, Money reported Reimer's habituation as a girl to have been successful, leading to this becoming the template for the care of many other children in similar circumstances.

Boy: dress

The warning signs are all there. Assuming Money was acting with good intentions (which is questionable), we have a case where a prestigious doctor decides on a course of treatment without doing any sort of studies first. Money brushed aside any evidence that went against his belief: that Reimer was doing fine as a girl. Unquestioning acceptance of Money's technique led to it becoming an accepted, standard treatment. I believe that most of the doctors who performed surgery on intersex children were doing it with the very best of intentions, believing they were doing the right thing. But we now know they were wrong.

Likewise I do not doubt that the clinicians caring for A.J. believe they are acting in her best interests, using the latest medical knowledge. Unfortunately, the latest medical knowledge just isn't up to much. All we have are case series; in effect, anecdote and eminence. There is absolutely no way to be sure that what we are doing now is not going to lead to further problems a generation hence.

What do we actually need? First, we need agreed definitions of what we are studying. Next we need numbers; as many as we can get. Next, we need randomisation into two arms: a treatment arm (say, hormones), and a non-treatment arm. Next we need double-blinding: the non-treatment group should receive placebo tablets instead of real hormones, and the researchers recording the results should be blinded as to which subjects have had which treatment. Next, we need clear, clinically-relevant endpoints. Finally we need time, lots and lots of time, since these outcomes can't be measured in six months or a year but over a decade or more.

There are plenty of good reasons why research like this is cumbersome, time-consuming, expensive, uncomfortable for the participants and difficult to conduct easily. Nonetheless, without it, clinicians treating transgender children are doing no better than informed guesswork. We do have the opportunity not to make the same mistakes as John Money, but do we have the will?

===

My thanks to Randy for drawing my attention to the Kansas City Star article. Thanks to Una for pointing out a factual error which I have now corrected.

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Addendum 13th April 2014

My thanks to Heather Colleen for drawing my attention to this interesting article in the New York Times written by the mother of a non-girly girl. What I hear in the article is the perplexity, the uncertainty, but also the love and acceptance, and the lack of hand-wringing or catastrophising. Well worth a look.

My thanks also to JJ Saphir for drawing my attention to this article from the New Zealand Herald, which strikes a very opposite view, and is highly critical of allowing children free gender expression. The author unfortunately trots out some fairly obsolete views in support of his very hardline position.

The Story So Far...

A couple of things prompted this blog post. First, it's the end of the year, which always makes me want to take stock of things which have happened over the last 12 months. Secondly, I came across another blog, Stop Crossdressing, quite recently, and having read quite a few of the more recent posts and discussion, I found myself wanting to repeat on there a lot of things which I've posted on other people's blogs. (Stop Crossdressing has been taken down since I wrote this post).


Vivienne



So I decided that a bit of summing up is in order. I've learned a tremendous amount about myself over the last 12 months, and I've profoundly re-evaluated my views about crossdressing. My plan is that, by putting this all together in the one place, I can crystallise my thoughts (always helpful, I have discovered), and also refer other people to here if they want to know my point of view. Regular readers won't find much that is new, but new visitors will hopefully find all my points here in one place.

For ease of reference, I have grouped everything into headings. Some of this stuff is overlapping, so please read to the bottom before you write in to complain about something!

We are all the same

First, we are all the same (provided we are talking here about men who wear women's clothing). Regardless of whether you call our behaviour crossdressing, transvestic fetishism, crossplaying, or whatever, just about everyone who comes to this site (and just about everyone mentioned on here) has the same inner motivations, which arose, at least in the first instance, for sexual arousal. (I am a "lumper", not a "splitter").

For some of us, those motivations are so strong that they overthrow us; for others, they are less strong and can be managed more easily. But all of us, all the time, feel the same desires and tendencies. For some of us, the fiery sexual component has mellowed into a gentler gratification which may not even involve arousal, but for some of us, it's still all about the sexual arousal.

For all of us, I feel sure, there is no other activity which provides the same relief and pleasure.

Alongside the assertion that we are all the same, but independent from it, is my deeply-held belief that no group is somehow more proper, more meritorious, more deserving of sympathy or recognition, than any other. I believe (and have repeatedly stated) that we have more that unites us than divides us, and that we ought to be generally respectful and courteous to one another at all times.

Crossdressing as an addiction

The concept of addiction is an attractive one for some commentators. Certainly crossdressing behaviour can have features resembling addiction, in that crossdressing desires are sometimes unrelenting and all-consuming. The person would rather be free of those desires, and they cause tremendous self-loathing. And the framework of addiction offers the prospect of rehabilitation, and eventually cure.

But for many common addictions (tobacco, alcohol, drugs, gambling) the initial activity is unpleasant. I still think smoking is loathsome, and I remember drinking my first beer, and hating it. I had to work at it to tolerate it, then enjoy it (which I now do). I have no desire whatever to take drugs, or to gamble (I don't even play the Lottery). On the other hand, I was drawn to crossdressing from my earliest memories, certainly before starting primary school, and the very first activities were pleasurable from the very outset. So I don't consider crossdressing to be an addiction in the same mould as those other things. However, it can certainly become one, if allowed to get out of control.

The morality of cross-dressing

The act of a man wearing women's clothing or cosmetics is morally neutral. I don't consider it intrinsically harmful in any way. In particular, I reject claims that there is somehow a biblical or Christian prohibition against crossdressing.

But crossdressing can be tremendously damaging and harmful. The reason is that many crossdressers seem to pursue crossdressing excessively, and it takes away time and money and other resources which could be better spent looking after a family, or a spouse, or a job. When crossdressing reaches the stage where it prevents someone being able to live a normal life, it's too much.

I frequently use the analogy of golf. Like crossdressing, golf is morally neutral. A couple of rounds a week is fine, but there are some guys who want to play golf all the time; they spend excessively on memberships and green fees, and on the latest clubs and equipment, and their wife might be called a  "golf widow". For those guys, golf is interfering with their ability to lead a normal life and has become excessive. But that doesn't make golf itself intrinsically immoral.

Who is in charge

Amour de moi en femme?

Without doubt, I wish I could be free of my crossdressing desires. They have caused me a considerable amount of personal unhappiness, self-loathing, and marital strife. I am not a "happy crossdresser". It seems I have two choices: either crossdressing is in charge of me, or I am in charge of crossdressing. It's clear for me which of us needs to be in charge.

Deciding that involves making an active choice about the priorities in my life. My marriage is more important to me than my crossdressing. My children are more important to me than my crossdressing. My career is more important to me than my crossdressing. On the other hand, setting aside crossdressing permanently costs too much in terms of mental and emotional effort: I become moody and tense all the time, and am no fun at all to be around. I know that my crossdressing feelings won't go away, no matter how long I desist.

So what I am seeking is a middle ground: to permit just enough crossdressing to assuage my yearnings, but not to pursue it to such an extent that it interferes with my normal life. You might well point out (and I would agree with you) that I am seeking to have my cake and eat it too; that such a balance won't be easily struck. But that's what I am aiming for.

Nobody can sum up my feelings better than old Polonius: This above all: to thine ownself be true.

Autogynephilia

Autogynephilia (or autogynaephilia if you speak British) is the word coined by the sexologist Ray Blanchard to describe "a man's paraphilic tendency to be sexually aroused by the thought or image of himself as a woman". Initially I resisted this description of myself, but after coming across Cloudy's blog On the Science of Changing Sex, I accept it as the only theory which fits all the facts and behaviour as I observe them, in myself and others.

The reason this troubles me is that I had considered that crossdressing was not a sexual thing for me; instead, it seems mostly to be about emotional expression and sensual pleasure these days. However, Blanchard's theory is that it has its roots in sexual arousal, and, though it makes me very uncomfortable to admit it, this is absolutely true for me. On the other hand, although the root of autogynephilia is sexual, sexual gratification isn't (by any means) the only reward which it provides, and emotional and sensual pleasures are comfortably within its purview.

Autogynephilia is also (I believe) the reason that late-transitioning transsexuals (like Caitlyn Jenner for example) desire to change sex, although in most cases by the time transitioning occurs the sexual aspect to it has mellowed into a sensation of comfort or belonging in the female role.

Addendum 22nd September 2015: I am extremely indebted to Alice Dreger's wonderful book, Galileo's Middle Finger, for providing the French translation of autogynephilia. In contrast to what I think is a very clunky and uncomfortable term, in French it is amour de soi en femme, (love of oneself as a woman) which sounds positively lovely.

Crossdressing is common

If you look at my post here, you can see fairly reliable figures from the UK's Office for National Statistics about the prevalence of homosexuality in the population. I had previously read a figure of about 1% of males being crossdressers. A more recent figure from Anne Lawrence says that "up to 3% of men in Western countries may experience autogynephilia". I suspect this might be a bit of an overestimate; one swallow does not a summer make, and I suspect that regular, frequent crossdressers are fewer. We are probably on a continuum of frequency or intensity of crossdressing expression, which makes drawing any line pretty arbitrary. (Are you autogynephilic if you dress once a week? Once a month? Once a year? Or are you autogynephilic if you don't dress at all, but are troubled by daily thoughts about it? How do you decide? I touch on these difficulties in my linked blog post).

What Anne Lawrence also says (and I am sure she is right) is that the number of people who change sex from male to female is rising sharply. Lawrence suggests that this increase is largely accounted for by late-onset transitioners, who previously would have been denied sex-reassignment surgery.

In any case, there are a lot of us out there.

Crossdressing is lifelong and incurable

I believe crossdressing is innate to me. Crossdressing desires have been present from my very earliest memories. Though they have faded from time to time, they have never completely gone away. I do not believe that they ever will. I do not believe that someone can be "cured" of crossdressing in any meaningful way; not any more than one can be "cured" of homosexuality.

One one occasion I met an older crossdresser, who told me that in his youth he had been subjected to electric aversion therapy as a means of attempting to cure his crossdressing. He pretended he was cured just long enough to escape the treatment, before returning to crossdressing, which he had pursued for the rest of his life. It had cost him his marriage, and he seemed deeply unhappy, even though he was dressed at a social gathering. And no amount of military discipline could permanently make a man out of Jan Hamilton.

There is a small amount of evidence that anti-androgens (such as spironolactone) can have some effect at suppressing crossdressing tendencies. However, since the hormonal balance of the human body is akin to an orchestra, to meddle with it carelessly is likely to cause far-reaching and potentially permanent side-effects. I therefore don't recommend anyone to take any hormonal medication without thorough discussion with their doctor first.

Crossdressing tends to be progressive as one gets older; a clear and detailed description of how crossdressing manifests in each decade of life is given in Helen Boyd's wonderful book (which I wholly recommend to everyone) My Husband Betty.

Putting crossdressing aside

Many of my correspondents, and some of the other bloggers I link to, are people who have chosen to set crossdressing aside from their lives. Their motivations vary, from religious or spiritual reasons, through to repugnance at crossdressing, through to a desire to retake control of their lives.

I want to be clear that I wish these individuals nothing but success. I think I have quite a lot in common with many of them (and you know who you are!), and the reason for this is that I share with them a determination that crossdressing will not overwhelm me, and a strong moral sense which keeps me away from the less savoury behaviour of some of my fellow crossdressers.

I don't think that crossdressing can be put aside permanently without considerable effort. It’s sort of like being on a diet. At first, it’s OK to go without chocolate and pizza and the other things you enjoy, but after a while you come to miss them more and more. No matter which way you dress your salad or your rice crackers, you can’t make them delicious or satisfying. And then you find that you are using up all your patience and your energy resisting the urge to have a slice of pizza, and you are moody and tense all the time. You may even accept that chocolate and pizza make you overweight, and all those vegetables are highly nutritious and doing wonders for your digestion (and all that is indisputably true). But still, nothing hits the spot like a fresh hot pizza dripping with melted cheese.

It can be done; some people can manage it for ever, but it costs. I believe people who say they have successfully given up crossdressing and no longer feel the urge to do it are lying to themselves and everyone else; just as I believe people who say they prefer salad instead of pizza are lying to themselves (and everyone else too). You can deliberately choose the salad for all sorts of reasons, and I wish you nothing but the very best of luck, but to insist you don’t like pizza any more makes me highly doubtful.

Intersex and transgender

Intersex isn’t the same as transgender because sex isn’t the same as gender. Sex is a biological distinction (chromosomes, hormones and physical characteristics). Gender is a social distinction (roles and behaviour). And to add a third term, sexuality is about who you want to go to bed with. Usually they coincide pretty neatly, but not always.

It’s absolutely true that sex is not black and white, and neither is gender nor sexuality. Intersex people cannot reliably be assigned to either female or male; some of them have unusual chromosome patterns (karyotypes, such as XXY), and some of them have other syndromes which cause them to develop features of both male and female anatomy. Almost all of them are assigned at birth in to one or other sex, and raised accordingly. I believe that's because parents want their kids to be spared the agony of growing up different. On the other hand, some intersex people, when they become adults, are very uncomfortable with the sex they were assigned to.

I think some transgendered people do probably identify with intersex people (without knowing the science well enough) and use the existence of intersex people to justify their views, beliefs, behaviour, whatever. I can also understand how transgendered people might be slightly envious of intersex people (you might wish you were a man with breasts or a woman with a penis) and why intersex people might be uncomfortable with that.

I think what makes some intersex people uncomfortable about themselves is not the same as what makes transgendered people uncomfortable about themselves. I think most members of both groups are uncomfortable about themselves; I know I am. However, I flatter myself that I do understand the science as well as just about anyone.

I imagine a transgendered person saying to an intersex person: “See, I am just like you: neither male nor female.” I imagine the intersex person replying “You’re nothing like me. You started off as one, and now you want to be the other. Whereas I started off somewhere in the middle.”

As a lumper, I say to both: I understand that you both have different feelings and different biology. But, seen from the outside, you are both people who don’t neatly fit into the categories of male and female. Therefore, perhaps you have quite a lot in common after all (rejection, loneliness, doubt), even if you got there by different routes.

Crossdressing and LGBT

And that brings me on to LGBT. The whole notion of LGBT is exactly this: an attempt to lump together people whose behaviour and predilections don’t quite fit with the "mainstream". Before I started this blog, I had joined a closed internet forum for LGBT academics. I had thought that I would have something in common with them. I was, at the time, desperate to open a dialogue with like-minded individuals, but found (almost) nobody like me there. Though I posted about my own thoughts and fears and concerns, all I seemed to get was a polite concern; nobody (and we are talking about gay and lesbian academics) seemed to feel I had much in common with them. I had hoped to strike a chord, but failed.

As it happens, this blog has done quite well, and I have all but given up visiting that forum. But in the months when I lurked, I realised indeed that I had little in common with the regular posters. I dutifully tried to pitch into some of the conversations, and was treated politely and with tolerance, but without ever developing a sensation of feeling I belonged. And I never felt like attending any of the social gatherings which were held quite regularly. It seemed to me that all I had in common with them was my sense of isolation and self-loathing.

I think, though, for the "general public" (if indeed there are any left when you subtract all the trannies and queers and gays and whatnot), crossdressers are considered to be lumped in with homosexuals. How often have you heard an accusation that because a man wants to wear a frock, he must be gay? And how often have you heard crossdressers insist and demand that they are not gay? Where men are concerned, I think most gay men are attracted to masculine men, not feminine men. So crossdressing isn't an especially effective way to find oneself a gay male partner; Jaye Davidson said something of this kind, and I guess he would know better than most.

Crossdressing isn't an expression of inner femininity

I've left this until the end because I think it is one of the most controversial, and counter-intuitive things which I have discovered. It bears repeating. Men don't crossdress because they are innately feminine. Crossdressers don't want to be like women; they want to be like men think women are. It's true that many crossdressers (and here I include myself) didn't behave like typical boys when younger, and were aware something about them made them different from others, but they didn't actually consider themselves to be girls.

Instead, crossdressers are attracted to women (remember: crossdressers are not gay). It's just, for crossdressers, the attraction to women extends to themselves as a woman (the technical term for this is an erotic target location error). In other words, crossdressing is an expression of heterosexual desire, turned inwards. Anne Lawrence puts it more prosaically, and I refer you to her whole article here:

Thinking about autogynephilic MtF... as men who “love women and want to become what they love” offers a more accurate and more richly informative model for clinicians.

In other words, autogynephilia isn't just a sexual fetish, and to dismiss it as such angers nearly everyone, who insist there is a lot more to it (I know I think so). But it can be conceptualised as a whole suite of romantic or attractive feelings, directed towards oneself as a woman, even though most of us are also capable of directing these feelings outward to a female partner. I suppose that makes me feel a little better about the label of autogynephilia applied to me: it isn't just about the sex thing.

I personally believe that the reason some male crossdressers seek out sex with other male crossdressers, is that the sex partner each is attracted to is not the other one, but themselves in the female role, doing things which they consider it erotic for women to do. Add to that the sexual overlay that many men consider it erotic for two "women" to have sex together, and you have a powerful mix indeed. And indeed, each participant will tell you he is quite sure he isn't doing it because he is gay. See here for Helen Boyd's comment.

I also believe that many crossdressers are more sexually attracted to the woman they see in the mirror than with the woman they may be married to, and Helen Boyd offers plenty in support of this assertion too.

My final piece of evidence in support of this assertion is mentioned above: if you want to suppress crossdressing desires, you don't take more androgens (which, you might think, would make you more "manly"). Instead you take anti-androgens, which suppress male sexual appetite and behaviour. Why does that work? Because crossdressing isn't driven by femininity, but by masculinity.

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Anyway, that's been a lot of useful discovery for just a little over a year. For regular visitors, please do keep coming, and posting your comments; I find them extremely stimulating and valuable. For new visitors, do please browse through; one of my personal favourite, but least-visited posts, is this one.

All the best for 2013,

Vivienne.