Young people exploring nonbinary gender roles
"I wouldn't mind having a mustache to twirl," says S.E. Smith, who likes to be referred to with the pronoun "ou" instead of she or he and her or him - and prefers seeing ou name in lowercase.
Smith was female-assigned at birth but doesn't like to be viewed as a woman. But "male" doesn't fit either. Smith identifies as "genderqueer," a word whose definition lacks consensus, but is broadly described as someone who "does not subscribe to conventional gender distinctions but identifies with neither, both or a combination of male and female genders."
What does genderqueer look like? To Smith, who is 29 and divides time between Fort Bragg and Berkeley, expressing ou gender can mean slicking ou hair back, binding ou chest and sliding into a suit. And it can mean "dressing up in floofy things and heels," as ou wrote for the website xoJane, where ou works as its social justice editor.
In that article, Smith wrote that ou "felt a growing sense of wrongness" starting in elementary school, when sent out to play with girls. "I wanted to be with the boys; I wanted to be a boy - but not exactly."
Smith's eureka moment struck in college when ou got in with a crowd of transgender people. "It's OK not to be a girl or a boy, there's a word for that. You're genderqueer," said a friend.
"It was like someone had opened a door in a previously unbroken wall," Smith said. "It had never occurred to me that gender might be a spectrum or that something beyond the binary might exist. It was a huge formative moment in my life - finally I had the tools to assert my own identity, rather than having to sandwich myself into definitions crafted by others."
For the doctors, social workers and therapists who work with transgender patients, Smith represents a small but increasingly visible minority that rejects the traditional binary gender model that forces a choice between being male or female. That minority first came to light for many people in November when Sasha Fleischman, a Berkeley high school senior who identifies as genderqueer or "agender," was set on fire for wearing a skirt. Fleischman's alleged 16-year-old attacker will be tried as an adult on hate-crime charges.
Approximately one-quarter of the 700 or so transgender patients who come each year to Lyon-Martin Health Services in San Francisco identify as nonbinary, an umbrella term that covers genderqueer and other gender variations, said Dr. Dawn Harbatkin, the executive director and medical director of the clinic, which was established to meet the needs of women, lesbians and transgender people. She believes that the emergence of this group is the result of "society's acceptance of fluidity in gender expression."
"These patients are more likely to be in their 20s and 30s. Older transgender patients are more likely to identify as male or female. When they were transitioning, nonbinary expression was not acknowledged as an option," said Harbatkin, an internist who has worked with transgender people since 1998.
"If you tell me you're transgender, binary or nonbinary, I'm going to accept it," she said. "My job is not to define your gender identity for you. It is paternalistic to assume I know better than you do when it comes to defining who you are."
Harbatkin said that Lyon-Martin does not view nonbinary patients as less likely to be suitable candidates for gender treatments, which may start with male or female hormone therapy, testosterone and estrogen, and may eventually lead to operations such as mastectomy, hysterectomy and genital reconstructive surgeries for which she will provide referrals.
She believes that patients, rather than their doctors, should have the ultimate say in aligning their bodies with how they see themselves on the gender spectrum. This might mean that a nonbinary female-assigned at birth patient requests testosterone because they want a deeper voice to make them appear less feminine. But that same patient may have no desire to undergo phalloplasty, because a penis doesn't fit in with their gender perception.
A doctor's role is to educate patients so that they can make the best choices for themselves, Harbatkin said.
Testosterone in particular can have undesirable side effects in some patients, such as "loss of emotionality and an inability to cry, irritability and increased sex drive," she said. Some of the masculinizing effects of testosterone cannot be reversed. Nor can some of the feminizing effects of estrogen. But it's rare for people to regret treatment, she said.
Micah, a 27-year-old San Francisco resident who prefers the pronoun "they" and uses the term "neutrois," which they define as "the absence of stereotypical characteristics of either gender" and a willingness to "embrace neutral characteristics, which belong to neither side," said they have no regrets about their own treatment. On their blog Neutrois Nonsense, they document a mastectomy, hysterectomy and low-dose testosterone taken intermittently, which they say has made them "more comfortable with certain aspects of maleness in my changing body."
"Yet I'm still put off by a lot of the side effects of testosterone, which accounts for my unstable regimen. My biggest discomfort is body hair, facial hair and an increasingly lowered voice. My goal was to lower it somewhat," Micah said.
Dr. Curtis Crane, a plastic surgeon and reconstructive urologist in San Francisco, said he is willing to work with both binary and nonbinary patients, because the same "high level of satisfaction" is found in both groups. Disappointment is rare, he said, pointing to his former partner, Dr. Michael Brownstein, a now-retired plastic surgeon who performed female-to-male chest surgeries and had only "two to four patients express regret" in his 35-year career.
Dr. Marci Bowers, a San Mateo obstetrician and gynecologist who is widely recognized as being the first transgender doctor to successfully perform gender-affirming surgeries, said she has relaxed a previous rule that stipulated operations can only take place after "demonstrable progress" has been made in "consolidating one's gender identity" - a welcoming nod to the 5 percent of her patients who are nonbinary.
While this group is small, Bowers believes that some binary transgender patients may eventually segue into a nonbinary identity, perhaps as a result of witnessing the openness of gender expression in the younger generation.
'Exploration ... is fun'
For Smith, mastectomy and hormone therapy are options ou might pursue one day, a move that would be supported by a rich circle of friends in Berkeley, accepted by ou father, but not by ou mother, from whom ou is estranged.
"I'm not currently interested in genital surgery. Testosterone would address some of the discomforts I have about my body - large hips and thighs. I'm not sure exactly what I do want to look like. I suspect that's something that would evolve as I move through transition."
Any treatment ou undertakes would not put a stop to the flaunting of frou-frou outfits from time to time. "It's fun to dress up, and that won't change, even if for me it feels like I'm in drag," ou says.
"Fun" in the context of gender is a word that appeals to Bowers, whose practice used to be based in Trinidad, Colo., and was the subject of Discovery Health's "Transgender M.D." in 2009 and We TV's "Sex Change Hospital" in 2008.
"The exploration of gender is fun. This generation of young adults is definitely questioning narrow definitions of gender role and expression, and I think that can only be a good thing for the future. It's not something to be feared. I feel that much of male violence in society has ties to uncomfortably narrow definitions for male gender role and expression. It is natural to be more fluid in expressing gender, and it is quite possibly a healthy thing that society is moving in this more blurred direction."
Suzanne Leigh is a freelance health writer in San Francisco. She blogs about the loss of her child at www.themourningafternatasha.wordpress.com.