Gender as a Continuum: Implications for Trauma Researchers and Clinicians
March 1, 2004
Gender is a societally based concept that perpetuates bio-deterministic ideas about sex. However, data demonstrate that sex is not dichotomous, and perceptions of gender should be adjusted accordingly (Fausto-Sterling, 1993). In particular, trauma specialists must be aware of gender issues due to high rates of trauma in the transgendered community.
Gender as a Continuum
Historically, sex has been defined as a biologically based construct that categorizes people as being either male or female. Although most societal conventions (i.e., legal, social) require that people are classified as either male or female, the reality is that such categories are not entirely accurate. The medical community has long recognized that sex is not a dichotomous variable; approximately 4 percent of individuals (Fausto-Sterling, 1993) are born intersexed (anatomical structures and/or external genitalia of both men and women). An umbrella term capturing the variety of human expression in sex and gender identity is transgenderism.
Heterogeneity in the Transgendered Community
The term transgendered covers a range of individuals. Cross-dressers (aka transvestites) who “cross-dress” part-time and do not typically identify as the opposite gender. Pre- and post-operative transsexuals are individuals for whom their gender self-identity is incongruent with their biological sex. Transsexuals often change their clothing and comportment and may seek hormone therapy and/or sex reassignment surgery (SRS). Intersexed individuals are discussed previously. Gender outlaws demonstrate characteristics of both genders openly and may not identify as either male or female—some consider themselves a third sex. Sexual orientation varies widely among transgendered people and is a distinct issue from gender identity (Bullough, 2000; Carroll, Gilroy, & Ryan, 2002; S. Kessler & McKenna, 2000).
Gender Variations as a Disorder
Classification of gender identity disorder (GID) is being debated in the field (e.g., Bower, 2001) due to concerns that it inappropriately pathologizes transgenderism. Similarly, homosexuality was a diagnostic category as recently as DSM-II (APA, 1968) but was removed from DSM-III (APA, 1980) following appropriate scientific exploration.
Estimates of the prevalence of transgenderism vary widely, in part due to definitional difficulties. Further, the stigmatization that accompanies transgendered status makes some individuals reluctant to be labeled and counted. It is estimated that as many as 3 percent of males and 1.5 percent of females have been diagnosed with GID (Green, 1995; Zucker, 1990). Although specific surgery is cost-prohibitive and not a goal for all transsexuals, it is estimated that 1:2,500 Americans have completed male-to-female (MtF) surgery (Conway, 2002) and 1:100,000 seek FtM SRS (APA, 1994).
Rates of trauma exposure in the transgendered community are high. In one study, transgendered outpatients reported more childhood abuse than psychiatric inpatients (Kersting et al., 2003). Further, transgendered individuals are at increased risk for hate crimes, as represented in a recent Newsweek article (Bailey, 2003). In studies of the lesbian, gay, bisexual and transgendered (LGBT) community, prevalence rates of hate crimes are as high as 17 percent to 25 percent (e.g., Herek, Gillis, & Cogan, 1999; Kuehnle & Sullivan, 2001), despite underreporting of these events (Levin, 1999). Transgendered individuals are more likely than LGBs to have experienced violent crimes requiring hospitalization or resulting in death (Kuehnle & Sullivan, 2001).
Relevance to Trauma Specialists
It is estimated that 19 percent of violent crime survivors will meet diagnostic criterion for acute stress disorder following assault, and 20 percent will develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999). Hate crime survivors are at elevated risk for problems including PTSD, anger and depression relative to other trauma survivors (Herek et al., 1999; McDevitt, Balboni, Garcia, & Gu, 2001; Rose & Mechanic, 2002; Ryan & Rivers, 2003). Following hate crimes, survivors also report more loneliness, higher rates of suicide attempts, lower self-esteem and poorer mental health (D’Augelli & Grossman, 2001). One hypothesized mechanism for higher rates of negative posttrauma sequelae is that hate crimes challenge assumptions about the worthiness of self, meaningfulness and benevolence of the world (Noelle, 2002).
For those interested in understanding trauma recovery, an appreciation for the transgender experience is vital. To be a gender-sensitive psychologist, it is important to recognize the effect of therapist bias on patients. In fact, the insensitivity of health care providers has been cited as the primary reason that transgendered individuals do not access services (Sanchez, 2002). The health care community must be willing to explore its own attitudes about gender and become culturally competent. For example, it is appropriate for providers to use pronouns that are consistent with the individual’s identified gender (e.g., Lombardi, 2001). Gender should be assessed with at least three options, including transgendered. As discussed by Carroll and Gilroy (2002), a culturally competent psychologist (see Sue, 2003) is one who is willing to adopt a “transpositive” approach. The negative effects of social stigma are well recognized (e.g., R. C. Kessler, Foster, Saunders, & Stang, 1995) and should not be perpetuated by a mental health system. Once individuals make the brave step toward accessing resources, they should be met with affirmation, regardless of their gender identity.
American Psychological Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, D.C.: American Psychological Association.
American Psychological Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author.
Bailey, H. (2003, September 8). Targeting transgenders. Newsweek, 53.
Boehmer, U. (2002). Twenty years of public health research: inclusion of lesbian, gay, bisexual and transgender populations. American Journal of Public Health, 92, 1125-1130.
Bower, H. (2001). The gender identity disorder in the DSM-IV classification: a critical evaluation. Australian and New Zealand Journal of Psychiatry, 35, 1-8.
Brewin, C.R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. The American Journal of Psychiatry, 156 (3), 360-366.
Bullough, V.L. (2000). Transgenderism and the concept of gender. International Journal of Transgenderism, 4, NP.
Carroll, L., & Gilroy, P.J. (2002). Transgender Issues in Counselor Preparation. Counselor Education and Supervision, 41, 233-242.
Carroll, L., Gilroy, P. J., & Ryan, J. (2002). Counseling transgendered, transsexual, and gender-variant clients. Journal of Counseling and Development, 80, 131-139.
Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research, 46, 315-333.
D'Augelli, A.R., & Grossman, A. (2001). Disclosure of sexual orientation, victimization, and mental health among lesbian, gay, and bisexual older adults. Journal of Interpersonal Violence, 16, 1008-1027.
Fausto-Sterling, A. (1993). The five sexes: Why male and female are not enough. The Sciences, March/April, 20-25.
Green, R. (1995). Gender identity disorder in children. In G.O.G. (Ed.) (Ed.), Treatments of psychiatric disorders (Vol.2). Washington: American Psychiatric Press.
Herek, G.M., Gillis, J. R., & Cogan, J.C. (1999). Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 67 (6), 945-951.
Kersting, A., Reutemann, M., Gast, U., Ohrmann, P., Suslow, T., Michael, N., et al. (2003). Dissociative disorders and traumatic childhood experiences in transsexuals. The Journal of Nervous and Mental Disease, 191, 182-189.
Kessler, R.C., Foster, C.L., Saunders, W.B., & Stang, P.E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. The American Journal of Psychiatry, 152 (7), 1026-1032.
Kessler, S., & McKenna, W. (2000). Who put the "trans" in transgender? International Journal of Transgenderism, 4, NP.
Kuehnle, K., & Sullivan, A. (2001). Patterns of anti-gay violence: an analysis of incident characteristics and victim reporting. Journal of Interpersonal Violence, 16, 928-943.
Levin, B. (1999). Hate Crimes. Journal of Contemporary Criminal Justice, 15, 6-21.
Lombardi, E. (2001). Enhancing transgender health care. American Journal of Public Health, 91, 869-872.
McDevitt, J., Balboni, J., Garcia, L., & Gu, J. (2001). Consequences for victims: A comparison of bias- and non- bias- motivated assaults. American Behavioral Scientist, 45 (4), 697-713.
Noelle, M. (2002). The ripple effect of the Matthew Shepard murder. American Behavioral Scientist, 46 (1), 27-50.
Rose, S.M., & Mechanic, M.B. (2002). Psychological distress, crime features, and help-seeking behaviors related to homophobic bias incidents. American Behavioral Scientist, 46 (1), 14-26.
Ryan, C., & Rivers, I. (2003). Lesbian, gay, bisexual and transgender youth: Victimization and its correlates in the USA and UK. Culture, Health & Sexuality, 5 (2), 103-119.
Sanchez, D. (2002). Giving healthcare to transgender patients. Boston, MA: JRI Health, Transhealth & Education Development.
Sue, S. (2003). In defense of cultural competency in psychotherapy and treatment. American Psychologist, 58 (1), 964-970.
Zucker, K.J. (1990). Psychosocial and erotic development in cross-gender-identified children. Canadian Journal of Psychiatry, 35, 487-495.
The authors thank the transgendered veterans from whom they have learned a great deal, and acknowledge the contributions of Shira Maguen and Lisa Welch in the preparation of this article.