Gender Variations and Self-esteem in a Critical Society.

A Counsellor's Perspective

Alice Purnell BSc, RGN, PGDC

Transgender 2003 University of East Anglia, Norwich, Norfolk.


Issue 24
Winter, 2003


Perhaps it is stating the obvious; people find challenges to a fixed, black and white view of sex, gender, or sexuality uncomfortable, incomprehensible or even amusing. Few understand, some find it fascinating, but society is not ready yet to accept differences of these sorts without considerable resistance. Some of this reaction is intellectual, even scientific, some prurient, others prejudiced and downright hostile.

This makes the gender challenger face a choice of either accepting the status quo, or becoming a gender warrior, who has to fight for respect in a critical and uncomprehending society. The self-esteem of many is deeply challenged by the need to conform; the very human need for acceptance, even for respect and love.

Most gender dysphoric people have to fight a personal battle to understand themselves, to accept or reject the "real persona", let alone to gain the acceptance of others. They feel they need to express this need, to conform their image, especially body image, to their actual gender, against the reality of their bodily configuration and lifestyle. They first face the internal gender challenges and conflict before however nervously or unwillingly taking on the rest of society.

In an ideal world gender might be irrelevant, fluid, or treated as a rainbow of colours of gender. Masculine, feminine or neuter are the only three available options offered in most European societies or languages.

Gender differences are very important even to the smallest child; a baby boy in blue, a girl in pink, a forename which says what sex you are, what sort of person you are destined to be, how others will behave towards you, how you "should" interact with others. It dictates how to be throughout your life, not just in sex, but even in Sainsburys!

There have been many debates about the causation, the etiology of gender dysphoria, why a person should dress as the "opposite sex"

(There is no opposite sex. Sex, like gender, is a spectrum, a continuum).

There is considerable debate as to why "they" want to take hormones, to as some might say "go against nature", to seek invasive surgery, to adopt the lifestyle and body they feel comfortable with, even though there is little understanding or compassion for those who are gender dysphoric.

To get help with this sort of problem is a long painful journey for many, but few think it was not worthwhile. However many go through life after surgery as a sort of second-class woman or man.

We all notice difference. This is inbuilt. How we react to it is taught.

UK Law still discriminates against this group of people, although on July 11th this year the legal minefield of "Trans rights" started to be addressed in the Draft Gender Recognition Bill, which may be passed by autumn 2004. Stopping hunting with dogs was more pressing than correcting the legal inequalities of this group of people. Society and religious extremists add to the problems that the transperson has to face.

We live in a society where plastic surgery solutions and so much money are spent on self-image are almost de rigeur. There are some that might say this is increasingly, even unnaturally, important. We have heard a lot about plastic surgery junkies, the cult of perpetual youth and anti-ageing procedures. Discussion continues about plastic surgery for those distressed by self image, with large noses who want rhinoplasty, or by faces which are "not beautiful enough." There are others who are deeply affected by their appearance, who go to great lengths to get them put right. Those with birth disfigurements like cleft lip, protruding ears or others whose appearance is damaged by accident have more sympathy. If a disfiguration was caused by trauma in fires, car, plane or train crashes, or as a result of war, there is no stigma attached. Few would deny a deformed child or with an accidental mutilation deserves help, respect or understanding, including all that medical science can do to alleviate these problems.

There is generally great public sympathy for the disfigured person, with perhaps also a horrified sense of fear, or even revulsion perhaps, but no ridicule, save by the totally ignorant or insensitive.

As a nurse in casualty or the operating theatre you see a lot of horrid things which the general public manage to avoid. You also see what can or cannot be done to help these people in trauma and burns units.

Rationing often means people's needs are not met by the NHS, which is swamped by "more pressing" problems presented by the sick. I remember a woman of seventy who was in my care (I worked as a nursing sister as well as a counsellor) who had taken a shine to an elderly gentleman and wanted to be able to smile for him. The NHS hospital dental team told her, that her gums had receded so they would not fit her with new false teeth. I wondered if ageism as well as practicality had crept into this decision, because at her age (70) they thought she could not have a libido or a need to feel good about herself, rationing applied as she was old.

If a person is damaged by their body image is there a difference in the distress this causes, between what is considered reconstructive after accidents or trauma, or what is considered cosmetic or elective surgery? Obviously there are some things that we all think do need medical or surgical intervention to treat and improve, for good health reasons as well as any aesthetic reasons. It is true to say we live in a world dominated by the media, where stereotypical models of the "ideal female" or "male idea of beauty" are rammed down our throats.

For the T-person "looking right" seems to be a vital preoccupation, not solely out of a narcissistic drive, but for reasons of a survival strategy in a hypercritical society. All T-people have been denied loving parents saying to them as children, "my beautiful girl" or "my darling boy", what they actually heard was a challenge, not a reinforcement of who they actually felt themselves to be. They would hear boy and not girl, or the opposite. Usually they could not tell anyone, especially not their Mother or Father. That is where the guilt trip starts.

"Not good enough" and "guilty" become texts. The internal critical parent takes over so they learn to cover up their "guilty secret".

Even among the general (ordinary) population (I won't say normal) we all have it drummed into us that boys are tall and strong, girls are the weaker more delicate sex, should not be too big boned or tall. We are all told fat is ugly as well as unhealthy, old is ugly, that sort of thing.

We live in a youth culture, which I believe, is driven and dominated by media people, designers, photographers and advertising agencies. Often the creative side of the media is made up of a group of men who must surely be ageists and misogynists and blind if they believe real women are supposed to look like never ageing stick-insect models. These anorexic, teenage, flat-chested, boyish, bimbos should not be our physical or role models.

This ethos has exacerbated problems like anorexia and bulimia, and also makes those who are quite naturally ageing, or overweight, or not a standard height, (or, worse women who look like men, or men who look like women), feel bad about themselves. Those who are too short, tall, fat, ugly, or are not within this impossible idealised stereotypical image concentrate to an unhealthy extent on what is "wrong with them".

The "gender police" reinforce this. There is too much emphasis on the image or appearance and often too little on the mess inside their own heads.

This media-fed brainwashing and exploitation of youth-culture has reinforced the tyranny of needing to conform to an impossible physical standard stereotype.

A text, which most people suffer from at some stage in life, is. "I am not good enough because I do not look right". This develops feeding personal self-disgust and paranoia.

In opposition to this genuinely damaging, unhealthy psychological situation there are others who feel tremendously strong urges not to conform, to as they put it, to be themselves, to be out-and-proud, but they need to be very strong to stand against the mainstream.

Last year television documentaries looked at physically nonconformist people, including female heavyweight body builders (who admittedly do often look more like men) and those men who have a wish to remain men, but wish to be eunuchs (often it seems associated with sadomasochistic fantasy). Television examined both these extremes in separate programmes. This sort of anthropological approach is often more for the impact of the story than to support these "different" people. However, portraits of T-people are not now all in the Jerry Springer mould of prurient voyeurism, some do seem to seek truth and understanding.

To be obviously different and to survive one needs to be brave. At the Gendys Conference in 1998 we met Christie Elan Cane, who is ungendered and challenges the two- sex system by an ungendered name, appearance and lifestyle.

This causes some real linguistic challenges. "Sh/he, hir", what do you say?

There is almost always the question "male or female?" on any documentation: passport, licences, insurance, banking and so on - no option not to belong to one of two camps. Humanity is divided not joined by this mentality.

However most of us know transsexuals, transgenderists and transvestites, even some intersexed people who do NOT want to be seen as different. They wish to be themselves but to conform. To look like, or to live and be, the sex or gender they feel strongly that they are, to be invisible as such, is a real goal. Yet many face challenges from "society", from louts, rabid so-called-feminists, religious extremists, insensitive journalists, sexist members of the public, who openly criticise them for not having the "right" history, or not looking "right". Even the existing legal system discriminates against them, although anti-discrimination legislation has made some progress. But abuse and intolerance still exists.

Some of my clients have suffered discrimination from other T-people.

Even among the "Trans-community" there are boring stereotypicists. They seem to feel it is all right say "Your hands are too big", or "You are too short/tall to pass", "Your voice is too deep" and a plethora of personal remarks which are not helpful in reinforcing the well-being of the recipient of this unwanted "advice". Just as closet gays persecuted their peers, some Trans-people set out to hurt others. This cruelty often comes from someone on a power trip. They themselves often do not pass as a woman, and seem to want to score points by being bitchy.

I realise am being unkind here myself, but if a life is spent scoring points to cover a personal vulnerability at the expense of others it is helpful to neither. There are those who do not pass who do really embarrass other Trans-people as well as the general public, but even they have a right to be themselves, but not to be unkind or judgmental of other T people.

In a sense we all adhere to values and judgements of others and of self, which are based on aesthetic or conventional values; in expressing these we can do considerable damage to those with low self-esteem.

In the States and to a lesser extent here, there are groups formed for those who intend to shock and provoke by being outrageous, bizarre, in your face, supercamp, alternative, or offensive.

It seems that to challenge gender or sexual stereotypes often stimulates others, who should know better, to feel they can make personal remarks and attacks or ask amazingly personal questions of the "trans-person", the one who fails to conform, as to how they "should" be or look or present. This enables some people to feel free to express a curiosity which can be very intrusive as to what "they" do in bed, like the "who does what to whom" asked of many a lesbian. This demonstrates a total lack of respect for that person, whose self- esteem is often almost nil, unless they are out-and-proud.

If someone asks advice as to why they get a lot of stick or "read" by many people, there is nothing wrong with asking that person what they themselves think will help them to be less visible as "different". But it is insane to suggest that a person needs to be smaller, taller, have a different skeletal frame. They can do nothing about that.

A counsellor's task is to help the person come to terms with her or his reality. Help her or him to do away with regrets or fantasy self-images, to be genuinely cognitive and to learn to value themselves.

What may also help is to suggest that she or he look at real people as they move around their world. They will see a great range of ordinary people, some small men and tall women, no Rambos, few bimbos or size 8 women. (They will also see very few of them done up to the nines in a cocktail dress in the Co-op).

People come in all shapes and sizes and ages. Most of us simply get on with life, working, leisure activities, doing the shopping etc., with "being" rather than trying to look like a dog's dinner. There are certain dress codes in this country as to what is or is not appropriate to wear in a particular place or time, so as to avoid standing out.

If do you wish to stand out it is actually getting harder, as there are exhibitionists around. There are quite a lot of people who enjoy challenges to "society", gender-bending and shocking (tattoos, piercings, green hair, kinky clothes, shaved female heads, males in makeup or nail varnish) - but they tend to belong to style types or uniforms. (For example new-romantics, hippies, punks, pop groupies).

The type of person you are or seek to be is defined by what you wear. What you wear, how you present, says a lot about you to others - little old ladies usually look like little old ladies, there are power-dressers, county types, joggers, students, sportsmen and women, each has a fashion a uniform for a particular lifestyle. Dress codes are more relaxed these days, but there still subtle codes of acceptability and conformity- there is even a sort of conformity among the non-conforming, a sort of fashion or uniform is a way of displaying. You have to have the right trainers, the four-wheel drive, the right mobile phone, and even the latest computer as a personal accessory.

There are short men and also women with big feet who want to spend their money on what fits or suits them. Big can be beautiful, especially if that person feels good about herself. The grey pound, the pink pound and the purchasing power of marginalised groups means some enlightened manufacturers and outlets are beginning to meet their needs. Small men do not have to shop in children's departments now, although kids dress more like adults these days, so they might save some tax if they do! So far, nobody is a clone. Variation exists in shapes and sizes. People vary. Sizes and shapes and sounds of women and men do overlap.

There is physical reality portrayed, even in the media. There are TV soaps with people who are not beautiful, young, or stylish, - characters that seem to be almost real one might say. Even advertising is including people who do not fit the "ideal stereotypes". I don't just mean men in frocks selling cleaning products or sweets.

People do age. It is pathetic to emulate King Canute and rail against that tide as it comes in. It is important to age naturally, even if disgracefully. To conform to oneself, not to an advertiser's view of how we "should be" is vital for a healthy self-image. It is OK to be a wrinkly. Incidentally, Anita Rodick recently announced that anti-ageing creams are a waste of money, moisturising is all that actually helps a healthy look. At least with a depleted Ozone layer people have generally stopped wrecking their skin by over exposure to solar radiation.

There are a host of people anxious to take your money, so you can try to halt ageing, to diet, to look conventional, to look "good". It is a seductive marketing ploy.

If a person looks good, and feels good about her or himself, they are actually treated better; if not, that is another story. "Looking good" is often interpreted as opposed to bad or evil, so that if he "looks bad" he must be bad, or at least is a natural for abuse and victimisation. So even in these days of celebrating diversity, people are beaten up or ridiculed, particularly if they are "T people". They are seen as asking for it, as perverts or somehow subhuman. Even if you look old, fat, foreign, or unconventional, packs of louts do often see this as an excuse for a laugh at that person's expense.

Respect is lacking. There is something wrong with the way many children are educated if they know they can victimise those who are "different". To be different is to be a potential victim.

In Counselling I have heard many accounts from clients, especially from inner city areas, who have been hounded from their homes by abusive kids. Even one from Leeds who committed suicide because of this. Housing policies are failing to address this problem.

How can counsellor help a person whose self-esteem is already low, who is constantly harassed, who is too poor to move, and whose local council only offer similar housing in bad areas, to feel good about herself? It seems that if you have financial security it definitely helps to avoid this sort of trap. For the person who may not look conventional who is on benefits, there is nowhere safe to go. This should be a practical consideration for someone seeking surgery or a lifestyle change. They do need to be emotionally strong not to feel crushed by this sort of dreadful harassment.

To work towards reasonable self-esteem the appropriate thing we all need to do is to be the best version of oneself one can be, to feel comfortable with oneself.

It is a shame to have to say this; you need to keep away from harm. But to be out- and-proud, though dangerous, is preferable to being frightened and guilty, but to be suicidal or trapped indoors, is no way to live.

I suggest that as humans are complex beings, naturally there are combinations of reasons for gender diversity, but to conform with oneself is desperately important, rather than to wear the straight-jacket of conforming to other's stereotypes.

Individuals are, or can be, existential. We need not suffer the restraints or need the approval of others to accept us. This does not give others the right to hurt another, but we all do have the right to be ourselves.

The idea of personal freedom with responsibility is moving as a significant feature of life in our society in this new Millennium. But as science progresses, great ethical issues are being raised. Some time ago there was the debate, with profoundly divergent points of view. Some were ethical and others pragmatic, some religious and others practical about conjoined twins. Lawyers and doctors versus the parents' right to decide whether to operate and save one twin, or leave them alone, in which case both would probably die. Nobody was able to ask them (these children) what they would choose. The clock is often against a wait-and-see policy. Tragically, this year the Iranian Bijani girls paid with their lives for their hoped for surgical separation.

Medicine is in a position to help in some extremely difficult cases. With gene therapy, use of embryos or foetuses, use of placenta material, i.v.f., use of the eggs of dead foetuses, and designer babies and terminations, we seem to have entered a minefield of ethical dilemmas. Judgements are becoming more complex, even Solomon would probably be at a loss what to do.

Whatever we do decide is acceptable, babies are not able to speak for themselves. Surgery without consent of a baby (obviously they cannot give consent) is often performed to help the parents deal with the situation of having a baby with incomplete or ambiguous genitals. Intervention is ethically sound if to help save the life of the child if, for example, she cannot micturate, in which case there is no choice.

How though can we assess the gender identity of a baby? There are many interventions simply to make a baby conform to anatomical normality which sometimes results in an intersexed or physically sexually ambiguous baby being wrongly assigned, or denied a sex-life or the possibility later in life of having children.

Gender is more "in the head" than in the genitals, as demonstrated by Prof. John Money's unsuccessful experiment in reassigning a boy as a girl, after an appalling accident in which the child severed his genitals. But once she could speak for herself the "girl", in spite of all the nurture effects "she" had been subjected to, insisted this should be reversed and Prof. Money was discredited.

It seems nature is more powerful than nurture in terms of gender identity.

A sense of gender identity seems to be inherent, if it were not the case there simply would not be any Trans-people.

Doing the "best thing" is not always doing the right thing, when a person's right to self determination is to be challenged. Sometimes the right thing to do is nothing, rather than dashing in with a scalpel or a psychiatric theory.

Identical nurturing does not bring out identical people. Nature seems to hold the key to identity. Siblings, even twins are different people, have separate views of themselves and the world, though they usually have shared a life.

Even conjoined twins who are craniophagus (joined at the head and sharing much of the frontal lobes of their brains) actually also seem to have very different personalities. In the case of the Chapella girls, two American conjoined twins, one is a Country singer; the other is not interested in that. They share affection for a disabled dog, but do contemplate separate loving relationships with different men. When one dies the other will also probably die because of shared bloodstream, as did the original "Siamese twins". But they did not want to be separated. Who can estimate the traumatic psychological effect of separation to each? They seem to have individual personalities and tastes, though perforce they have identical experiences and to some extent personal neurological reactions and some shared emotions; hurt one and you hurt both. Theirs seems to be an impossible situation. Are they to be freaks to be probed by medical science or in a freakshow, open to gratuitous stares of the so-called "normals"?

There seems to be a general view that what is considered "normal" is good rather than it is merely average, whilst abnormal is bad, weird, a curiosity, so we "have to" intervene.

The right to being respected is put on hold by so many of us, including well wishers, who seem to crave "normality", like a drug. A situation, which has some reverberations in the world of TG for those who, do not quite fit, who are not invisible.

What I wonder is the body map like for Siamese twins? Do they see themselves as having all the body parts we expect to have? How far does the body map of a post-op woman or man, who started life as an ordinary child, or as an intersexed baby, drive his or her wish to bring his or her body to conform as much as possible with that in his or her brain?

Amputees often feel pain from the removed limb for some time after surgery. After a new-man's breasts are removed or a new -woman's vagina has been reconstructed, there is a period of getting used to the new plumbing or weight distribution. But these women have no phantom willie, or in the men's cases phantom boobs, according to many I have asked about this, so the body map probably was appropriate to the "brain sex" or gender identity.

How much does a perception of how things "should be" affect one's body map? How much is this a factor in gender identity?

If craniophagus twins have different personalities and sometimes twins even have different sexual preferences, is it not reasonable for other less acute variations from the "norm" like gender dysphoria to have several explanations and a range of other variables?

The feel-good-factor has plenty of challenges for many Transpeople, but in Counselling we see mainly those with problems. The ego has to be strong not to be crushed by all this; there is often a crisis when these problems come to a head.

Depression, exhaustion, low self-esteem are common, suicide is not rare.

Some happy few sail through with family support, understanding supportive loved ones and employers, but this is rare.

Generally there is a catalogue of hurdles to cross.

Some of these problems are predictable.

Even the young Trans woman or man has to cope with the agony of a series of very compelling problems and questions:

  • Recognising their condition,
  • Self acceptance,
  • Convincing the Gender Identity Clinic,
  • Telling others. Who to tell? How to tell? And risking all in doing so. You cannot go back once it is said.
  • Staying put or relocating
  • Passing in public
  • Voice
  • Finding money for treatments. Electrolysis or laser treatment
  • Finding a style of dress that suits the person, shape, age and size.
  • Learning all that a teenage girl will have learnt from peer groups
  • (or boy in the case of the ftm person)
  • Loneliness
  • Questions of sexuality, like:
    "I believe I am a woman but I have never been attracted to men"
  • Realising that they will be infertile
  • Fears about loss of libido
  • Change of employment
  • Creating a lifestory that fits the actual gender for their c.v.
  • Getting references
  • Changing documentation.
  • Knowing they will not be able to bear a child or father one after surgery.

The older T person usually has these and other problems.

Many have "lived a lie", trying to cope in the "wrong body" or gender identity, sometimes quite successfully. Along the way some have married (even several times in some cases). Often a wife or partner and the T person have split up.

Divorce leaves guilt and resentment and self-hate, with its emotional problems related to parting from a loved one, the effect on children, and the financial implications.

"You should never have married me" is a cry from many spouses.

"I have lost my dad" another from a child of an mtf transsexual person.

"You still look and sound like a man" or "You look like a freak, from others in the family.

There is often disruption of employment, with a lowering of income and problems, with some employers and workmates in spite of Employment Legislation, particularly during the real life test period. Being an "in-betweenie" is not easy.. There is a strange preoccupation with which loo she or he should use. They are often also casualties of all this mess.

Constant challenges to self by others, and self-examination, with an emphasis on physical appearance becomes a way of life. This can be quite destructive, and a hard almost ruthless shell is often adopted as a defence.

Some use drink or drugs as a release, others do try to get appropriate help. The NHS does not generally provide this support, unlike the Netherlands and Canada.

Trans people are as diverse as any segment of society, with individuals having differing strengths and vulnerabilities, and ability to be invisible in society.

Because of a history of abuse, verbal or actual from the crueller members of society, some become paranoid, reclusive, or alternately some develop a very tough skin, but inside they often bleed.

It is important to recognise the difference between dismorphophobia and a wish for a body that is compatible with a person's core gender identity.

A hatred of inappropriate genitals and secondary sexual characteristics often grows from the conviction of suffering from acute gender dysphoria, but hating your hands; feet or height is a fruitless obsession. There is no evidence a skeleton can be adapted, any more than ageing can be reversed.

Totally unrealistic aspirations to be somehow, magically, totally changed into some ideal woman or man are just not practical. For some the quest becomes lifelong, this cannot be healthy.

A pragmatic view of one's body seems to be what most women men accept, otherwise too much time and energy can be ascribed to physical image, and too little to the inner self. There is no evidence that being beautiful or handsome always means a happy life. Think of Marylin Monroe.

But feeling monstrous, like some sort of freak is very damaging.

In spite of these and so many other problems only 4% of post 'op people said they have regrets about their surgery or switch of lifestyle.

Most people are not challenged as to what they are, but we are all challenged as to whom, and what sort of person we are. That is an important message.

So what are my recommendations?

1. Apply a just, confidential equal recognition and protection of gender people. The law should not reinforce marginality or discrimination and is in a position to take a lead in changing the often-hateful attitudes of society.

2. The NHS should make funds available so that the G.I.C.'s provide thorough independent gender counselling before, during and after surgery, rather than concentrating simply or acting as gatekeepers.

3. The privately funded client group needs to include gender counselling in their own care plan.

4. Trans people need to face reality and look cognitively at all the options before proceeding with surgery.

5. Support needs to be provided for loved ones, including education, practical advice and counselling.

6. Those who are post-op should commit to helping others on their quest for understanding by committing to assist with research, by offering support individually or in support groups.

7. Trans people will be more accepting of themselves if they aspire to and accept a realistic body image, realistic goals, realising that we cannot all be young and beautiful, or tall and strong.

8. Celebration of the gift of having lived both sides of the gender divide can be a reality and need not be a handicap if society grows up.

9. The distractions of gender dysphoria take up vast amounts of time, energy, pain and money. It is important to keep the other dimensions and interests of life alive, and not to wallow in self-pity, of what is lost or cannot be, but at what opportunities there are for a quality life in spite of this.

10. Stereotypes and diagnoses are important short cuts, but it is vital to remember that no two people are identical.

11. An individual person-centred approach by gender professionals is needed.

12. Nobody is a "hip replacement". Equally nobody is simply a transsexual. They need to be helped holistically and respected as individuals.

13. Trans-gender states are part of natural variation. Nobody is to blame. Guilt is inappropriate.

14. Sensitivity and damage limitation is important for all involved.

15. Self-acceptance and comfort with self is possible once these issues are resolved. There need not be a guilty secret once public awareness and education has moved on. This should mean Trans people will be less stigmatised by others

16. Society, especially the law, needs to provide equality and equal protection for this group of people as is in situ for racial minority groups, disabled people and all the rest of our population. 17. The mythologies of sex, gender, sexuality, stereotyping, Bible-bashing condemnation, need to be eradicated through education, and acceptance of human variation as a part of the wonderful gift of being human.

Web page copyright GENDYS Network. Text copyright of the author. Last amended 16.08.06