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NotesonGenderRoleTransition
TheGenderVariantPhenomenonADevelopmentalReview
ByAnneVitalePh.D.
January27,2003
NOTE:Thisistaken,inpart,fromapaperIwrotein2001entitledImplicationsofBeingGenderDysphoric:ADevelopmental
Review.ItwaspeerreviewedandpublishedinGenderandPsychoanalysis,AnInterdisciplinaryJournal,Vol.6No.2,Spring
2001,pp121141.Ihaveupdateditandpostitheretomakeitavailableovertheinternet.
ABSTRACT
Livinginconflictwithoneofthebasictenetsofexistence(AmImaleoramIfemale?)isunderstandablyanxietyprovoking.This
factleadsmetosuggestthatGenderIdentityDisorderasthisconflictisdescribedintheDSMIV,isnotanappropriatedescriptor.
IsuggesthereasIhaveelsewhere(Vitale,1997,2001)thatinsteadtheconditionbetermedGenderExpressionDeprivation
AnxietyDisorder(GEDAD).Afterexplainingmythinkingongenderexpressiondeprivationanxiety,Iwilldescribehowthis
anxiety,ifleftuntreated,ismanifestedineachofthefivedevelopmentalstagesoflife:confusionandrebellioninchildhood,false
hopesanddisappointmentinadolescence,hesitantcomplianceinearlyadulthood,feelingsofselfinducedentrapmentinmiddle
age,andifstilluntreated,depressionandresignationinoldage.

ThereisagrowingbodyofevidencethatGenderIdentityDisorder(GID)asdescribedintheDiagnosticandStatisticalManualIV
(DSMIV)(1994)isatleastinpart,theresultofinsufficientorinappropriateandrogenizationofthebrainatacriticalstageof
embryonicdevelopment.Asaresult,theaffectedindividualmaybeleftwithsomewherebetweenapartialandafullsenseof
havingacrosssexedgenderidentity.Essentiallycreatinganotmale,notfemalebutotherwisepermanentgendervariant
condition.Eventhoughthereapparentlyaresomeindividualswhofallveryclosetoordeadcenteronthegenderidentity
spectrum,mostgendervariantpeoplecaneasilyidentifywithbeingclosertooneendofthespectrumthentheother.
Giventheprobablecause,itisreasonabletoassumetherearemanypermutationsofthewaygendervariantindividualsrelateto
theircondition.However,peoplewhopresentfortreatmentroutinelyfallintothreedistinctgroups:Twogroupsoffemale
identifiedmales(GroupOneandGroupThreeinthispaper)andonegroupofmaleidentifiedfemales(GroupTwo).
GroupOne(G1)isbestdescribedasthosenatalmaleswhohaveahighdegreeofcrosssexedgenderidentity.Intheseindividuals,
wecanhypothesizethattheprenatalandrogenizationprocessiftherewasanyatallwasminimal,leavingthedefaultfemale
identityintact.Furthermore,theexpressionoffemaleidentityofthoseindividualsappearsimpossibleorverydifficultforthemto
conceal.
GroupTwo(G2)iscomposedofnatalfemaleswhoalmostuniversallyreportalifelonghistoryofrejectingfemaledress
conventionsalongwith,girls'toysandactivities,andhaveastrongdistastefortheirfemalesecondarysexcharacteristics.These
individualstypicallytakefulladvantageofthesocialpermissivenessallowedwomeninmanysocietiestoweartheirhairshortand
dressinloose,genderneutralclothing.Theseindividualsrarelymarry,preferringinsteadtopartnerwithwomenwhomayormay
notidentifyaslesbian.GroupTwoisthemirrorimageofGroupOne.
GroupThree(G3)iscomposedofnatalmaleswhoidentifyasfemalebutwhoactandappearnormallymale.Wecanhypothesize
thatprenatalandrogenizationwassufficienttoallowtheseindividualstoappearandactnormallyasmalesbutinsufficientto
establishafirmmalegenderidentity.Forthesefemaleidentifiedmales,theresultisamorecomplicatedandinsidioussex/gender
discontinuity.Typically,fromearliestchildhoodtheseindividualssufferincreasinglypainfulandchronicgenderdysphoria.They
tendtolivesecretivelives,oftenmakingincreasinglystrongerattemptstoconvincethemselvesandothersthattheyaremale.
AsapsychotherapistIhavefoundfemaleidentifiedmales(G1)tobeclinicallysimilartomaleidentifiedfemales(G2).Thatis,
individualsinbothgroupshavelittleornocompunctionagainstopenlypresentingthemselvesastheothersex.Further,theymake
littleornoefforttoengageinwhattheyfeelforthemwouldbewronggenderedsocialpractices(i.e.,thegenderroleassignedat
birthasthebasisofauthority).AlthoughIhaveseensomenotableexceptions,especiallyinmaleidentifiedfemales,these
individualsatthetimeofpresentationfortreatmentarerarelymarriedorhavechildren,arerarelyinvolvedinthecorporateor
academiccultureandaretypicallyinvolvedintheserviceindustryatablueorpinkcollarlevel.Withlittleinvestmentintryingto

liveastheirassignedbirthsexandwithalotofpracticeinlivingascloselyaspossibletotheirdesiredsex,theseindividualsreport
relativelylowlevelsofanxietyabouttheirdilemma.Forthosewhodecidetransitionisintheirbestinterest,theyaccomplishthe
changewithrelativelylittledifficulty,particularlycomparedtoG3,femaleidentifiedmales.
ThestoryisverydifferentforGroupThree.Inthehopeofriddingthemselvesoftheirdysphoriatheytendtoinvestheavilyin
typicalmaleactivities.Beinglargelyheterosexual,theymarryandhavechildren,holdadvancededucationaldegreesandare
involvedathighlevelsofcorporateandacademiccultures.Thesearetheinvisibleorcloisteredgenderdysphorics.Theydevelop
anauraofdeepsecrecybasedonshameandriskofridiculeandtheirsecretdesiretobefemaleisprotectedatallcosts.Theriskof
beingfoundoutaddstothepsychologicalandphysiologicalpressurestheyexperience.Transitioningfromthisdeeplyentrenched
defensivepositionisverydifficult.Theironyhereisthatgenderdysphoricsymptomsappeartoworsenindirectproportiontotheir
selfenforcedentrenchmentinthemaleworld.Thefurtheranindividualgetsfrombelievinghecaneverliveasafemale,themore
acuteanddisruptivehisdysphoriabecomes.
Givengenderidentitypermanencyanditsobviousimportanceintheorderingofone'slife,itisreasonabletoconsidergender
identityasessentialexistentialknowledge,knowledgethatcannotbeunknownorseparatedoutfromthewholewithoutradically
redefiningthewhole.
Forallthreegroupsdescribedhere,Ibelieveitissafetosaythatgenderdysphoriaisthesinglemostdominatinginfluenceduring
developmentalstagesinallthreegroups.Inthispaper,Iwilltakeexamplesfrommycaseloadtoshowhowgenderdysphoria
effectsthesepeopleateachoftheclassicfivestagesoflife:childhood,adolescence,earlyadulthood,midlifeandoldage.
Livinginconflictwithoneofthebasictenetsofexistence(AmImaleoramIfemale?)iscertainlyanxietyprovoking.Thisfact
leadsmetosuggestthatGenderIdentityDisorderisnotanappropriatedescriptor.IsuggesthereasIhaveelsewhere(Vitale,1997,
2001)thatinsteadtheconditionbetermedGenderExpressionDeprivationAnxietyDisorder(GEDAD).Afterexplainingmy
thinkingongenderexpressiondeprivationanxiety,Iwilldescribehowthisanxiety,ifleftuntreated,ismanifestedineachofthe
fivedevelopmentalstagesoflife:confusionandrebellioninchildhood,falsehopesanddisappointmentinadolescence,hesitant
complianceinearlyadulthood,feelingsofselfinducedentrapmentinmiddleage,andifstilluntreated,depressionandresignation
inoldage.
UntreatedGEDADasitismanifestedacrossthefivestagesoflife:
Theperiodicneedtocrossdressorotherwiseexpresscrossgenderbehaviorisacommonelementingenderdysphoria.Costumeis
obviouslyaformofgenderexpression.Forpeoplewhoarenotgenderdysphoric,crossdressingonalarkorforsomeotherreason
maybefunbutinsomeonewhoisgenderdysphoric,itisanessentialaspectoftheirlife.Someindividualswithmildgender
dysphoriacometotermswiththeircrossdressing/crossgenderbehavioralneedsandmayevencelebratethemwithpublic
presentations.Othershaveafarmorenegativeviewoftheirneedtoexpresscrossgenderbehaviorandkeepthatpartoftheirlife
private.Eitherwaytheseindividualsstaylargelywithintheprimaryphysiologicalboundsoftheirassignedgender.Theproblems
theyencounterareprimarilysocialones,thetwomostimportantbeingfamilypressurestoconform,andthepotential
embarrassmentofdiscovery.
Forindividualswithamildtomoderateformofdysphoria,lifeistolerableandtheyrarelymakeanyovertattempttoliveoutside
prescribedsocialnorms.Forthosewithamoreextremedysphoria,mildpalliativessuchasperiodiccrossdressing,although
helpful,becomesinsufficient.Theseindividualsappeartoneedtoinhabitandliveoutthecrosssexedidentity.
TERMINOLOGY
IntheDSMIIIR(1987)peoplesufferingfromgenderdysphoriawerereferredtoas"Transsexuals."WhentheDSMwasupdated
in1994,theterm"Transsexual"wasreplacedwith"GenderIdentityDisorder."Thisisnotanimprovement.ThetermGender
IdentityDisorderimpliesthatone'sphysiologicalsexiscorrectandthatone'sinnersenseofgenderisdisorderedorwrong.Itis
clearthatthisisnothowgenderdysphoricindividualsperceivetheircondition.Thisisevidentbothinpsychologists'inabilityto
changeaperson'ssenseofgenderwiththerapyandthereadypreferenceofmanyoftheseindividualstoundergophysicalsex
reassignment.
DespitetheofficialdiagnostictitleofGenderIdentityDisorder,whatgenderspecialistsreallytreataredisassociation(Seil,1997),
depressionandanxiety(i.e.,dysphoria).Ofthesethreesymptoms,resultingofthedoubleburdenofbeinghormonallyandsocially
deprivedoftruegenderfulfillment,Ihavefoundanxietytobethemostacute.
Genderfulfillmentcanoccuronbothpsychologicalandphysiologicallevels.
Psychologicalpressurecomesfromsociety'sstrongexpectationsthatoneconformtoone'sassignedgenderrole.Thisanobvious
tenet.Physiologicalpressureislessobviousbutmostlikelyresultsfromtheinabilityoftheindividual'sbodytoproducesufficient
crosssexhormones.Thisbecomesevidentinthefactthatwithindaysorweeksofreceivingcrosssexhormones,dysphoric
individualsexhibitmarkedlyloweranxiety.Thisprocedureissoreliablethatitisthesecondstepinathetriadictreatmentplan

describedintheHarryBenjaminInternationalGenderDysphoriaAssociation's(HBIGDA)StandardsofCare.(W.Meyer,et
al.,2001).Hormonaltreatmentisconsideredbothaverifierofgenderdysphoriaandatreatment.Further,astreatmentcontinues,
theresultingcrosssexfeminizationormasculinizationtypicallyreducesandeventuallyeliminatestheanxietyentirely(W.Meyer,
etal.,2001).
TREATMENT
Althoughthereisstillsomedisagreementastohowgenderdysphoriabeginsandwhoshouldqualifyforhormonalandsurgical
intervention,thereisaremarkableamountofagreementinseveralimportantareas.Mostpsychologistsnowagreethatgender
dysphoriaqualifiesasasubjectofclinicalattentionseparatefromotherdisorders.Further,mostcliniciansagreethatthegender
identitybeliefsthesepeopleholdareprofound,deepseated,andnondelusional.Evenmoresignificantly,outcomestudiesnow
clearlyindicatethatwhenthreeconditionsaremet:aproperdifferentialdiagnosis,asignificantlylongtrialperiodoflivinginthe
genderofchoice,andasatisfactorysurgicalresult,thereisonlyasmallincidenceofpostoperativeregret.Indeed,inareviewof
theoutcomeliteraturePfafflin(1992)reportsthatlessthan1%ofthefemaletomaletranssexualswhohadundergonesex
reassignmenthadanyregrets.Formaletofemaletranssexualsthenumberwasslightlyhigheratlessthan2%.Laterstudies
supportingPfafflin'sreportincludeBodlundO.etal.,(1996)CohenKettenisP.T(1997)Exner,K.etal.,(1995)Rakic,Z.etal.,
(1996),andSmithY.L.etal.,(2001).Itshouldbenotedthatsatisfactionismeasuredbyselfreportofimprovementinthe
individual'spsychosocialwellbeing.
Sinceeveryone,evenanintersexedchild,israisedaseitheraboyoragirleveninthemostnonsexistenvironment(Stein,1984),a
chainofphysiologicalandsocietaleventsbeginsatbirththatpropeltheindividualintoapredeterminedsetofbehavioral
expectations.Inabicameralsexedculture,deviatingfromthoseexpectationsalmostinvariablyresultsinsocialconflict.The
individual'squalityoflife,hisorherrelationshipwithfamily,friends,career,legalgenderstatusandthenatureofhisorherbeing
intheuniverse,areallatstake.
Ifwekeepinmindthatgenderidentityisinrealityacontinuum,andifwhatonelookslikemaynotcorrespondtowhatonefeels
like,wecanexpectacorrespondingmildtosevererangeingenderrelatedanxiety.
WhatfollowsisasynopsisofwhatIhavelearnedfromtreatingandconductinginterviewswithapproximately350adults
presentingwithgenderissuesbetween1978and2000.Theagerangeisbetween17and71.MycommentsonhowGEDADis
experiencedinchildhoodaretakenfromselfreportofadultsinindividualandgroupsessions.Toaugmentmylimitedclinical
workwithchildrenIhavealsocitedtheworkofKennethZuckerandSusanBradley(1985).
InwhatfollowsIdescribefivedistinctdevelopmentalstages,thatmakeupthestandardperiodsofdevelopmentalpsychology:
childhood,adolescence,youngadult,middleage,andolderadult.
ChildhoodConfusionandrebellion
AdolescenceFalsehopesanddisappointment
EarlyadulthoodHesitantcompliance
MiddleageFeelingsofselfinducedentrapment
OlderadultDepressionandresignation
CHILDHOOD
Asearlyasagetwoandhalf,mostchildrenbeginshowingapreferenceforbehaviorsandactivitiesconsistentwiththeirassigned
sex.Byagethree,theyactuallyrefertothemselvesasaboyoragirl.Interviewswiththreeyearoldsrevealthattheyagreewith
statementssuchasgirlsliketoplaywithdolls,askforhelpandtalkmorethanboys,whileboysliketoplaywithcars,buildthings,
andhitotherchildren.
Eventhecasualobservercanseethatchildrenplaceahighpriorityongenderappropriatebehavioratanearlyage.Most
individualswithgenderexpressiondeprivationanxietyreportbecomingawarethatsomethingwasnotrightwiththeiroriginal
genderassignmentasearlyasagefour.Malesemphasizetheirexperiencethat,unlikeotherproblemsafouryearoldboymaybe
abletodiscusswithfriendsorparents,wantingtobeagirlwasdefinitelytobeavoided.
Eventhoughmyexamplebelowdatesbackfortyyears,Ithinkitisstillsafetosaythataboywhowantstobeagirlandiswilling
toadmitittodaycanexpecttobe"corrected,"ofteninaverysternandfirmwayorhisdesiresignoredas"somethinghewillgrow
outof."Forexample,Arlenewhoisnowinherfifties,reportedatraumaticincidentinschoolwhen,attheageofsix,she(then
he),wasmadetostandinfrontofhisfirstgradeclasswearingalargepinkribbonwhilehisclassmateswereencouragedtolaugh
athim.Hewasbeing"corrected"forhavingbeen"caught"playinghopscotchwiththegirlsduringrecess.Hereisanexampleofa
formofbehavioralmodificationmeanttoinsureimmediatecessationofeffeminatebehaviorinamale.

Ontheotherhandagirlwhowantstobeaboyandiswillingtoadmititcanexpectfarlessretributionforherbehavior.Girlswho
affectboyishbehavioraregenerallyperceivedascuteandthebehaviorisusuallytoleratedbyfriends,familyandschoolofficials
throughchildhood.Althoughtheyreportedmildsocialpressureto"dresspretty"andbemoregentle,noneofthemaleidentified
femaleclientsIhaveworkedwithhavesharedexperiencingbehavioralmodificationeffortsliketheoneenduredbythehopscotch
playingboy.
Undoubtedly,therearecaseswhereonlyguidanceandtimeareneededtocorrectagenderidentitymisunderstandinginachild.In
others,however,itappearsthatoncegenderidentityisestablished,noamountofredirectingcanchangethechild'sgender
identification.Someboysinparticularopenlyendurethetauntsoftheirpeersandcastigationsoftheirparentsinordertolive
accordingtotheircrossgenderunderstanding.TheChildandAdolescentGenderIdentityClinicofTorontotreatsmanysuch
childrenbroughtinbyparentswhoareconcernedoverwhattheybelieveisunacceptablecrossgenderbehavior.Zuckerand
Bradly,reportingontheclinic'soutcomes,reportahighrateofhelpingthesefamilies.Interestingly,KenZuckerandSusan
Bradley(1995,p32),reportareferralratioofmalechildrentofemalechildrenenteredfortreatmentsince1978(n=249)tobe6.3
to1.Sincethereisnoevidencethatcrossgenderbehavioroccursmoreofteninboysthanitdoesingirls,apossibleinterpretation
ofthisstatisticisthateffeminacyinboysmaybeconsideredbyparentstobemoreupsettingandinneedofcorrectionthan
tomboyishbehavioringirls.
Giventhenatureofthedisorderandtheabilityofsomechildrentoconcealit,Ibelievethatmostchildrenwithgenderdysphoria
areneverdiagnosedassuch.Thosechildrencopebystickingrigorouslytotheroleexpectedofthem.Privately,however,they
continuetogodeeperanddeeperintoahighlyguardedparallelworldofcrossgenderenvyandfantasy.Giventheirpropensityto
bestudious,detachedandselfabsorbed,Ihavecometothinkofthesechildrenaslivingcloisteredlives.Thesechildrengrowupto
formthecoreofGroupThree.
Littleisknownaboutgenderdysphoricboyswhoprivatelystruggletofitintotheirexpectedgenderrole.Withnoapparent
problem,(manyadultGIDclientsreportbeingexceptionallywellbehavedaschildren)theysimplygounobservedbyclinicians
studyingGID.Yetfrominterviewingadultswithgenderdysphoria,Icanreportthattheproblemwasasrealforthemthenasitis
now.Herearesomeoftheirchildhoodreflections.
Theunderlyingfeelingsmostoftenstatedwereofdetachmentandconfusion,asenseofnotreallyfittinginthoughfamilyand
teachersconsistentlyrewardedthemfortheirbehavior.Oneofthemostcommonareasofconfusionwasthesexassignment
processitself.Althoughweasadultsmaythinkitsimplistic,manychildrenarecompletelyperplexedastowhysomechildrenare
assignedasboysandothersasgirls.Givenatendencytowardprivacyandmodestyinoursociety,manychildren,especiallythose
withoutsiblings,oftenhavenowayofknowingthatthereisaphysicaldifferencebetweenthemselvesandthosedifferently
assigned.
Andrea,a35yearoldmaletofemale,postoperativetranssexualrecallsthatshewascompletelyperplexedoverherassignmentas
maleuntilwhenshewassevenhersisterwasborn.Whilefirstwatchinghermotherchangehersister'sdiaper,shelearnedforthe
firsttimethatherassignmentasaboywasbasedonarealphysicaldifference.Althoughitcleareduppartoftheconfusion,she
realized,evenatthatearlyage,thatheridentityconcernswerefarmorecomplicatedandseriousthenshehadfirstimagined.
AsAndreaabove,itiscommonforclientstoreportthinkinginchildhoodthatgenderassignmentwasbasedonparentalpreference
andthereforeopenforredress.Girlsareespeciallyaggressiveintheirinsistencethattheyarereallyboys.Indeedmanyareso
insistentthattheygoontoactforallintentsandpurposesasthoughtheyareboys,apatterntheycarryintoadulthood.
Forcloisteredgenderdysphoricboysitwasintheareaofpeersandactivities,especiallysports,thattheproblemwasmost
noticeable.Unableoruninterestedincompetinginorganizedboys'activitiesandhavingbeenshuffleddecidedlyawayfrom
playingwiththegirls,manybecamereclusive.Toaddtotheirconfusion,andcountertobehaviortypicallyreportedinopenly
genderdysphoricboys,manycloisteredboysactuallypreferredsoloplaywithboys'toysandhadlittleornointerestingirls'toys.
ForexampleIhaveheardmorethanonelongtimepostopmaletofemaletranssexualspeakfondlyofhavingspentcountless
hoursplayingwithanErectorSetoraLionelmodeltrainsetupthattheirfatherhadhelpedthembuild.Othersdescribedof
designingandmakingdetailedmodelairplanes,racecarsandsailingships.Themoreacademicofthisgroupreportlittleorno
interestinsportsandroughandtumbleplay.Toavoidcastigationfromtheirpeers,theyreportspendingalotoftimereadingand
studying.However,althoughthesechildrenappearedtobenormalboysdoingwhatmostpeoplewouldconsidersomenormalboy
activities,theymayverywellhavebeendoingsowhilesecretlywearingtheirmother'sorsister'sunderwear,fantasizingabout
beingagirlorbothiftheycouldmanageit.
Likemanychildrenfacedwithdifficultiestheyarepowerlesstochange,suchasfamilyangeranddivorce,genderdysphoric
childrenoftenseeksupernaturalhelpwiththeirspecialproblem.ThisisusuallyintheformofprayingtoGodandpracticing
specialreligiousindulgences.Thispracticehasaninherentopportunityforsecondarygain.Almostuniversallytheyreportthat
theybelievedthatifGodintercededforthembychangingtheirsex,theirparentsandtheworldwouldhavetoexoneratethem
fromwhattheytypicallyperceivetobeanegativeandshamefuldesire.

ADOLESCENCE
Iftherewasevergoingtobeachancefortheseindividualstoshowthattheyarenotreallythegendereveryoneelsebelievesthey
are,earlyadolescenceiscertainlyit.VirtuallyeveryindividualIhaveinterviewedreportedwantingdesperatelytohavehidden
internalsexorgansofthedesiredgenderfinallycometolifeduringadolescence,givingthemthedesiredsecondarysex
characteristics.
G1boys,whohaveastrongfemininecoreidentity,typicallydevelopasexualinterestinotherboysduringadolescenceandprefer
girlsaspeerfriends.Althoughtheystilldesiretobegirls,theyappeartohavesignificantlylessanxietyovernotbeingfemalethen
thatreportedbytheboysinG3.Ibelievethisisduetotherelativelyuninhibitedopenexpressionoftheirfemininity.Forexample
Monicawas19yearsoldwhenshereportedtomyofficeaccompaniedbyhermother.Sheworegenderneutralclothingbut
otherwisepresentedasfemaleinvoiceinflectionandmannerisms.Theproblem,ofcourse,wasthatMonicawasgeneticallymale.
Monica'smotherrelatedtomethatMonicahadbeenmorelikeagirlthenaboyallherlife.Herandherhusbandlovedherdearly
butthoughtofhermoreasadaughterthenason.OverthecourseoftreatingMonica,itbecameclearthatalthoughshewas
distressedoverhermalephysiology,shewasotherwiseemotionallystableandveryawareoftheseriousnessofhersituation.Once
itbecameclearthatshewasherownpersonandreadytoundergotransition,acourseofhormonereplacementtherapywas
introduced.Withtheexceptionofhavingtofacesomeextremereligiousissuesbroughtupbyhermucholderbrother,she
accomplishedanalmosteffortlesstransitionfrommaletofemale.Thepresenceoffamilysupportandlittleornoinvestmentbythe
familyorMonicainherbeingmalemadethistransitionstraightforward.
Assexualmaturityadvances,GroupThree,cloisteredgenderdysphoricboys,oftencombineexcessivemasturbation(one
individualreportedmasturbatingupto5andeven6timesaday)withanincreaseinsecretcrossdressingactivitytorelease
anxiety.InapostopgroupIfacilitated,Jenna(age43)spokefondlyofthedelightsheexperiencedasaboywhenshewouldfind
somethingofhermom'sinthedirtyclothes'hamperinthebathroom.Twoothersinthegrouplaughinglyagreedthattheytootook
manyatriptothebathroomforthesamereason.Atthesametime,intheirpubliclife,theseboysreportemployingovertly
stereotypicaleffortstodrawattentionfromtheirsecretdesirestobefemalebyaffectingappearancesofbeingnormallymale.This
includesdatinggirls,participatinginindividualsportsactivitiessuchasswimming,running,golf,tennis,andforsome,evenbody
building.
Cloistered(G3)genderdysphoricboysappeartoothersandeventothemselvestobeheterosexual.Althoughasagrouptheyare
notespeciallyactivedaters,theyclearlyprefertodategirlswhentheydodate.Significantly,unlikeotherboys,theirdating
motivesaremarkedlydifferent.Fortheseboys,beingonadatewithagirlisachancetospendtimewithagirlinawaynot
generallyallowedunderothercircumstances.Datingservestwopurposesfortheseboys.Thefirstissocial,asitgivesthemtheall
importantappearanceofbeingnormal.Thesecondistherapeutic.Beingclosetoagirl'ssoftness,andevenherfemalesmell,hasa
mitigatingeffectongenderexpressiondeprivationanxiety.Thefantasyisnottomakelovetoherbuttoactuallybeher.
Thesituationislesscomplexforgirls.Havingmoresocialfreedominboththeirdressandbehaviorcodesallowsatleasta
modicumofdysphoricrelief.Loose,genderneutralclothingistypicallyworntohidetheirfeminizingbodiesandthereislittleor
noattempttoappearoractfemale.Manyadultfemaletomaletranssexualsreporthavingadoptedadefiantattitudetowardthe
worldasacopingstrategy.Aswithallteenagers,genderdysphoricgirlsmustcontendwithemergingsexuality.Thesegirlsmaygo
outoftheirwaytodissuadeboysfromshowinginterestinthemwhilebeinginterestedinothergirlsinawaythatparallelsthatof
heterosexualteenageboys.
EARLYADULTHOOD
Asmoreinformationabouttransitiontoone'sfeltgenderidentitybecomesavailabletothegeneralpublic,weareseeinggenetic
maleswithstrongcorefemaleidentitiesandgeneticfemaleswithstrongcoremalegenderidentitiespresentintheirearlytwenties
withtheclearobjectivetobeingsexuallyreassigned.
Thecloistered,natalmales,ontheotherhandtypicallystarttorealizetheseriousnessoftheirdilemmaatthisage.Itiscommonto
hearreportsoftheseindividualsincreasingtheintensitywithwhichtheytrytoridthemselvesoftheeverincreasinggenderrelated
anxiety.Manyindividualsparadoxicallyadopthomophobic,transphobic,andovertlysexistattitudesinthehopethattheywill
overridetheirdesirestobefemale.
Thesituationcanbecomesoconvolutedthatsomegenderdysphoricmencometotherapywanting,almostdesperately,tobetold
thattheyarenottranssexual.Thatwouldbeunderstandableiftheyweresimplyconfusedandwantedtogettothebottomoftheir
problem.Unfortunately,theirstatedpreferencehereappearstobemoreaformofavoidanceofthefearandcomplexitiesinvolved
intransitioningthanitisanhonestdesiretoremainmen.Forexample,therearenatalmaleswhodesperatelywanttohavebreasts
butsaytheywouldbeterriblyembarrassedtohavethemshowinpublic.Thereareotherswhowinceatthethoughtofhavinga
femalenamelikeJaniceorMaryorLinda.Therearealsogenderdysphoricmaleswhothinkthatthesocialbehaviorsthatmost
differentiatewomenfrommenarefrivolousandunimportant.Goingsofarastobelievethatwomenare"lessthan"menand
beingembarrassedaboutwantingtobelikethem.Interestingly,thesepeoplehavenotroubleatallwithwearingfeminineapparel
aslongastheycandoitincompleteprivacy.

Perhapsthemostinsidiousformofsexismcanbeseeninthegenderdysphoricmalewhohasattainedarespectedpositionina
maledominatedprofession.Thesepeopleroutinelyassertthecommonsexistattitudethatalthoughwomenarenowalloweda
certainprofessionaltolerance,therealplayersarestillmen.Asmorepeopletransitionwhilecontinuingtoworkatthesame
position,thesetranssexualmalesseefirsthandhowpublicrespectbetweenmencanquicklyturnintoprivateridiculewhenamale
colleaguebecomesawoman.Furthermore,somegenderdysphoricindividualshaveconfessedtoparticipatinginsexistjokesasa
waytodiverteventheremotestsuspicionfromthemselves.Giventheseseeminglyunacceptableobstacles,manygenderdysphoric
malesunconsciouslyacceptcertainmaledrivennotionsaboutwomeninanefforttopurgetheneedtobefemaleoutoftheirmind.
Whentheseindividualsarequestionedfurther,itiscommontoseethattheyhaveadeepseated,love/haterelationshipwiththeir
inwardneedtobefemale.Whiletheyapparentlyneeddonothingtokeepthelovesideofthatdilemmaalive,thehatesideseems
toneedconstantcareandfeeding.Thedangerisobvious:Astheyseeit,iftheydon'tcontinuouslythinknegativelyaboutwomen,
theymighthavetofacetherealityofwantingtobeone.Inessence,thesexisminthisgroupservesasacover,providinga
convenient,andunfortunatelyasociallyacceptablewaytomaintaindenial.
Anothercommonattemptto"makeit"asamanbygenderdysphoricmalesinthisagerangeistomarryandhavechildren.Unlike
theirnondysphoricmalepeers,thesemen'sattractiontowardtheideaoffamilyisnotthestandardone.Someindividualsreport
tellingtheirpartnersabouttheirlifelongdesirestobefemalebeforegettingmarried,butthevastmajoritydonot,perhapsfrom
fearofridiculeorrejection,orbecausetheymaintainthefantasythatmarriagewillprovideacure.Manyclientsreportthatthey
weresurethatbeingahusbandwouldcementtheirmaleness.Thislogic,unfortunately,getsextendedtotheideaofhaving
children.Althoughgenderdysphoricmalesaregenerallynobetterorworseasfathersthenthenextman,theysooncometorealize
thatwhattheyhadhopedwouldbeananswerhasinsteadcomplicatedtheirgenderissuesenormously.
Indistinctcontrast,geneticfemaleswhodonotseeksexreassignmentmakelittleornoconcertedefforttoberidoftheirgender
dysphoria.Althoughtheymaybedeeplydisturbedbyhavingacquiredfemalesecondarysexcharacteristicsinpuberty,many
assumeanandrogynousappearanceandaffectoutrightmalemannerisms.Inlargercities,theymayfindrefugebytakingactive
rolesinthelesbiancommunityandbeinginvolvedintypicallymaleoccupations.
Meanwhile,genderdysphoricpeoplemustliveintherealworld,beingsubjecttothesamedevelopmentalpressuresastheirpeers.
Developmentalpsychologistsrefertotheagesbetween28and33asatimewhenindividualsreassesstheirdreamsandaspirations.
Mistakeninterests,familyobligationsandcareerdemandsstarttobecomeseriousconcerns.Forwomenwhoarereachingthelater
partoftheirchildbearingyears,theirchildrenarenowinschooloryettobeborn.Newdecisionshavetobemaderelativetothe
bulkoflifethatstillliesahead.Whensomeonecontendingwithagenderidentityissuereachesthispivotalperiod,thepressures
aremagnifiedfarbeyondwhatothersexperience.
Genderdysphoricindividualsrespondtothiscriticalperiodintwocharacteristicways.Agrowingnumberofpeople(thosewho
haveaccesstoinformationandotherresources)nowgodirectlytogivingseriousconsiderationtochangingtheirsex.Afteran
appropriateperiodofpsychotherapyandevaluationbyagenderspecialist,theseindividualsalmostroutinelygoontobe
physicallyandlegallyreassignedtothesexthatmorecloselyfitstheirinnersenseofself.Others,whomayalsobeawareofsex
reassignmentoptions,mayfindtheideatooimpracticalortoofrightening,decidinginsteadtoentrenchthemselvesdeeperintolife
asamemberoftheiroriginallyassignedsex.
MIDDLEAGE
Forthosewhocontinuetostruggleinwardlywiththeirgenderissuesintomidlife,newissuescometothefore.Asatimewhen
mostpeoplerealizethatabouthalfoflifehasbeenlivedandfeeltheneedtomakeanaccountingofwhotheyareandwhatthey
havedonewiththeirlives,thisperiodcanbeespeciallyanxietyprovokingforthegenderdysphoricindividual.Decadesoftrying
toovercomeanincreasinggenderexpressiondeprivationanxietybegintoweighheavilyontheindividual.Familyandcareerare
nowasdeeplyrootedastheywilleverbe.Theideaofstartingoverasamemberofadifferentsexhasbecomeseemingly
impossible.Thefactthattheneedtochangesexhasincreasedratherthandiminished,despiteHerculeanefforts,isnow
undeniable.
TheseindividualsoftenshowupintherapyofficeswithsymptomsmimickingDepressionorGeneralizedAnxietyDisorder.They
complainofpanicattacks,irritability,sleepingdisorder,inabilitytoconcentrate,andrecentweightloss.Iftheyaremarried,there
isoftenseriousmartialdiscordduetoselfimposeddisassociationfromthefamilyunit.Jobperformancemayalsobeaffected,itis
notuncommonthehearreportsofindividualsexperiencingnegativeperformancerevuesoroutrightthreatsofbeingfiredunless
theyseekhelpforwhateverisbotheringthem.Pressedeverdeeperintodespair,suicidalthoughtsbegintointrudeintodailylife.
Evenatthispointtheindividualmaybereluctanttodiscusstheirgenderissueslestthedoorbeopenedtoafearladenrealworld
explorationofgendertransition.Theyareconsumedbyfeelingsofbeinginexorablytrapped.
John,a50yearoldgeneticmale,medicalresearchscientist,married(23years),fatherofthreechildrenaged20,17and7,phoned
meafterexperiencingapanicattacksevereenoughtorequireemergencyattentionfromparamedicsattheairportonhiswayto
giveapresentationataconference.JohngavemeonlyhisfirstnameandinformedmethatIwasthefirsttobetoldwhathewas
abouttotellme.Hesaidhewas"genderdysphoric"andthathewas"desperate."Feelingsthatwereonce"controllablethrough

sheerforceofwill,"hadincreasedtowherehenowwashavingprotractedperiodswherehewouldclosehisofficedoor,lieonthe
floorandweepquietlywhilecurledupinthefetalposition,holdinghisgenitalsinpain.Otherthanintrusiveandrepeatedfantasies
ofbeingfemale,hehadrefusedtoallowhimselfanyovertformoffemalegenderexpression.Hereportedfeelingthatifhewasto
crossdressandbecaught,hewoulddishonorhiswifeandfamily.Havingattainedinternationalrecognitionforhiswork,hewas
alsoconcernedabouthisprofessionalreputation.Theonlyotherformoftemporaryreliefcamethroughmasturbating,oftenupto
fivetimesaday.
Ourworktogetheroverthelastthreeyearshasbeenslow.However,withthehelpofextensiveindividual,group,andfamily
psychotherapy,augmentedbyestrogenreplacementtherapy,withthefullpermissionofhisfamily,Johnhasrecentlytakenona
femalenameandislivingfulltimeinthefemalegenderrole.Sheisintheprocessofrenewingandredefiningherrelationshipwith
herfamily,andhassuccessfullyreturnedtoworkafteranextendedleaveofabsence.
OLDERADULT
Somegenderdysphoricindividualsproceedintotheirsenioryearswiththeirneedsanddesirestobefemalestillunresolved.Even
nowthenatalmale'sfeelingsaboutthemattermaybeasstrongasever.Therelativefreedomofgenderexpressionthatwomen
enjoythroughouttheirlivescontinues,andthereisevenlesspressureonG2femalestobeattractiveorfemininenowthanwhen
theywereyounger.Fornatalmales,thesituationisreversed.
Littleisknownabouttheseindividuals.Thattheyexist,however,isindisputable.Surgeonsreportperformingsexreassignment
surgeryonindividualsasoldas71.Ihavepersonallyworkedwithfournatalmalesintheirearlytomidsixties.Colleaguesinmy
peersupervisiongroupreportworkingwithothersintheirmidsixtiestoearlyseventies.
Theissuestheseindividualsfacearenowverydifferent.Concernsabouthowtobeafathertoyoungchildren,maintainacareer,
andestablishintimaterelationshipshavelessened.New,lessresolvableissuesemerge.Alongwithlowselfesteembroughton
fromyearsofselfdenial,theseindividualsmustnowcontendwithadeterioratingmalebody.
Alongwithbaldingandpaunchiness,therearemoreserioushealthissuestoconsiderifanolderpersonwishestotransitiontothe
othergenderrole.Cardiacdisorders,gastrointestinaldisorders,diabetesand,often,liverdysfunctionduetoalifetimeofalcohol
abusearesomeofthemostcommon.HereisastatementfromTom,a63yearoldnatalmalewhowasnotifyingmethathewas
leavinga"starter"groupIfacilitateafterattendingfortwomonths:
"IhaverecentlycompletedayearandahalfofinterferonandribovirontreatmentforHepetitusC.Thatmeansthatanythinglike
hormonescouldbedetrimentaltomyliverhealth.Nodoctorwouldapprovethat.ShortofthatIdon'tbelievethatthereisanyin
betweenformegivenmyhealth,age,appearance,marriageandfamily.IbelievenowthatIhavetolivemylifeasagentlemale
andthatismostcomfortableforme.Notidealbutmostcomfortable."
AmitigatingfactorforTomandotherseniors,ironically,isthatthenaturalagingprocessdecreasestheirserumtestosteronelevel
resultinginacorrespondingincreaseinestrogenlevel.Thefeminizingeffects,albeitmild,arewelcomedwholeheartedly.Asin
hormonereplacementtherapyforyoungermen,thenaturalhormonalchangesappeartoeasesomeofthepsychologicalaspectsof
thedysphoriainseniors.Yetwheninterviewed,thosewhochosetoremainmalespeakofaclearlongingforwhatmighthave
been.Seniorgenderdysphoricmalestypicallyreporttheyhavebeenwaiting,manysincechildhoodinthehopethattheirdesireto
befemalewouldsimply"goaway."Likethosewhoareyounger,theysayinresignationthatiftheyhadknownthedysphoriawas
goingtoremainsuchastrongforceintheirlives,theywouldhavebravedanythingtofacetheirdilemmadecadessooner.
Thereisoneotherproblemthispopulationfaces.Ininterviews,onegetstheimpressionthatthestruggletocontaintheirgender
expressiondeprivationanxietyinandofitselfhasbecomedeeplyingrainedintheirpsyche.Itisasifthegenderdysphoriahas
becomeacriticalcomponentofwhotheyhavebecome.Characteristicallythesepeoplecanbedescribedassad,depressedand
deeplyresentful.Intreatingtheseindividuals,thebestthatcanbedoneistohelpthemfeelbetteraboutcrossdressingand
encouragethemtohavecontactwithothercrossdresserstheirage.Successofsortscanbeassimpleashelpingsomeonefindthe
couragetoshaveoffamoustachebehindwhichhehasbeenhidinghisgenderissuesforfortyyears.
Conclusion
Clinically,genderdysphoriasharessymptomsoftenassociatedwithDissociativeDisorder,DepressionandGeneralizedAnxiety
Disorder.Differentialdiagnosismaybecomplicatedbytheclient'sreluctancetodisclosethesourceofthemorbidityforfearof
beingovercomebyrealorimaginedoutcomesofthedisclosure.
Genderidentityissuescanbealifelongconditionforthosewhofindittoodifficulttodealwithdirectly.Eachlifestagepresents
newdilemmasanddecisionsinrelationtothiscoreissue.Ingeneralitcanbesaidthatthemoretheindividualstrugglestorid
themselvesofgenderdysphoriabyincreasingsocialandphysicalinvestmentsintheirassignedsex,thegreaterthegeneralized
anxietyandtheharderitbecomestorestartlifesexuallyreassigned.Forthoseindividualswho,despiteallobstacles,cantransition

toanewgenderrole,ithasbeenshownthatgendertransitionthatincludespsychotherapy,hormonaltherapyandinmostcases
genderreassignmentsurgery,significantlyreduceandeventuallyeliminatestheanxietyentirely.
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