The Spectrum of Being

It's very often the first thing we ask about someone. "A baby! How wonderful -- is it a boy or a girl?" Or when we meet someone: "She's a nice-looking girl," or "He's a handsome guy." Gender identification is a core classification that everyone makes, automatically, without consciously thinking about it. Until you are confronted with just how limited that way of thinking is. I have been  fortunate to attend the past few Transgender Lives: Intersection of Health and Law conferences in Farmington CT, and from those conferences, I brought home a single, yet far-reaching fact.

Although we think of the expression of gender as binary, either boy or girl, feminine or masculine, gender is actually a spectrum of human expression in which the elements of masculine and feminine mix and combine over the entire range.

None of us are fully masculine or fully feminine. We are all a combination of gender traits to varying degrees. This mixture of yin (feminine) and yang (masculine) are what the ancient chinese philosophers had in mind in the development of the taijitu:


That small dot of the opposite color within each side represents the simultaneous, mutual existence of opposites within each other. While the taijitu is the reflection of larger universal truths, the characterization of yin and yang as feminine and masculine principles makes the meaning unmistakeable with regard to gender.

The individual intermixture of gender is also embodied in the work of the psychologist Carl Jung, who developed the concept of anima and animus, representing the female aspect within the male psyche and the male aspect within the female.

The idea that we, psychologically, embody both genders has long been accepted. But that the blending of gender would be reflected physiologically and neurologically is a concept that has fought an uphill battle to, first of all, be recognized, and secondly, to be regarded not as a psychological or moral pathology but as a normal variant.

Transgenderism is the umbrella term for the expression of gender identity that differs from the strict male/female dichotomy recognized as normal by society. Transgender people range from those who enjoy dressing as, and behaving as, a person of different gender than their birth gender; to transsexual people who, with the assistance of hormones and surgery, change their entire appearance to live their lives as a different gender; to people who are born with the physiology of both genders and choose not to identify as strictly male or female.

Because it is so basic to our patterns of classification, gender expression outside of the norm can be quite disturbing to many people. Transgender characteristics are usually lumped together with sexuality, although sexual orientation is entirely different and unrelated to gender expression.  Transgender people, like everyone else, may be straight, gay, both, or uninterested. Unfortunately, transgender people are considered by some to be morally corrupt, or predators disguising themselves to gain intimate access to the opposite gender (this is the laughable -- and indefensible -- argument used by some in Connecticut to restrict restroom access by transsexual people).

And, though once thought of as a psychological disorder, research is making it evident that transsexual people do not suffer from some sort of behavioral aberration. More and more it becomes obvious that transsexualism is the result of neurological and hormonal activity and development in the womb. Studies of the brains of male-to-female transsexuals show that their brains are much more similar to the gender they identify with (female) than the gender they were born as (male).

Unfortunately, that research goes unrecognized at many doctors' offices, where both doctor and staff have little understanding of this segment of their patient population, and transgender people may be subjected to anything from embarassment at the hands of thoughtless and poorly-trained staff to outright discrimination because of their gender preferences.

Like most doctors, I received absolutely no education on the requirements of treating transgender people, either from a clinical standpoint or from a practical standpoint. But once I became aware of my ignorance, I undertook to rectify it. From talking to people, to reading, to attending the Transgender Lives conferences, I learned.

Much of it boils down to simple things that I already know and try to practice. Things like respecting my patients. Accepting what they bring to me as people and understanding their needs and goals for their care. Recognizing people's boundaries, and not transgressing them without permission and without good reason.

That last sentence bears a little more explanation. For obvious reasons, both personal and social, a patient may not be comfortable revealing to me their gender history, though clues may be evident in the general health history with which they provide me. But the more important question is whether gender is pertinent to the problem at hand.

And, frequently, it is not. For example, most musculoskeletal issues are gender-neutral, and whether or not my  patient is a transgender person is simply not important. Why make someone uncomfortable by delving into aspects of their life that they would rather not reveal? Being a doctor gives me great latitude to explore another person's privacy in the search for clues to the nature of their problem, but that license must be used with discretion.

Much of being a transgender-friendly practice also boils down to attending to simple things that are easily overlooked. For example, the patient whose legal name on their insurance card is Jennifer Smith would rather be addressed as David. Or that gender isn't as simple as circling the M or the F on the intake form.

So I don't use M or F on the form anymore. Instead there is a blank line for the patient to provide the gender information which most suits them.  And in addition to the Last Name and First Name entries, I have a Preferred Name entry, so that we know that Jennifer should be addressed as David, the name he prefers.

These and other alterations are subtle changes, unlikely to even be noticed except by those to whom they are directed. But for that very reason they are important.

I hope that other doctors, particularly those who provide alternative medicine services, take it upon themselves to enhance their practices in this manner. It is not difficult and the rewards can be significant.

I will unfortunately not be able to attend the Transgender Lives conference this year. It will be the first time in several years that I will miss it. But I am grateful for what the conference, and my patients, have taught me.