Gender Identity
Dr Jonathan Haverkampf MD
Gender has meaning in the interaction with others. It is thus largely a concept that is generated from within communication with others, which is complementary to the communication one has with oneself. Unlike one’s sex, one’s gender is a description of psychological structures and dynamics within oneself, a result of internal and external communication patterns.
The benefits of shaping an own gender identity free from any external pressure are increasingly seen as important factors in maintaining mental health and raising the quality of life. This implies connecting with oneself, which also improves the relationships one has with others. An awareness for the own needs, values and aspirations is as important to achieve this as the freedom to identify them and reflect on them.
Keywords: gender identity, gender, psychology, psychiatry
Table of Contents
Introduction
Gender has meaning in the interaction with others. It is thus largely a concept that is generated from within communication with others, which is complementary to the communication one has with oneself. Unlike one’s sex, one’s gender is a description of psychological structures and dynamics within oneself, a result of internal and external communication patterns.
Gender is a communication construct, but it also typifies certain behavior and thought patterns one associates with a given gender. The concept of gender is formed in a society and as such predetermined for the individual. I can design my own gender, but it has to have a relation to the genders in society to be understood and to make it a gender. For an individual growing up and living on a deserted island, also excluding any animals, the concept of gender does not arise.
Society’s concept of gender on the other hand needs to link back to the physiological concepts of sex to justify the label ‘gender’. However, even this still leaves literally countless possibilities to combine certain attributes and aspects into gender. While most people equate gender with ‘male’ or ‘female’, in several cultures more than two genders exist, and two examples are given below.
Gender Identity
Gender identity is the personal sense of one’s own gender. This is probably the result of at least a partial observation of one’s internal communication about and in response to different events and situations. Gender identity can correlate with assigned sex at birth or can differ from it. All societies have a set of gender categories that can serve as the basis of the formation of a person’s social identity in relation to other members of society. Thus, gender helps in communicating with other members of a society. It is a construct that communicates certain attributes, including personality traits, needs, values and possibly even aspirations. It provides a whole timeline which can make communication easier, but also contains the risk that certain attributes are not open to further exploration, if a society is relatively rigid in its definition and understanding of gender. How a society communicates about gender thus reflects how it defines gender and the latitude it provides the individual in assembling a gender identity.
Age
Core gender identity is usually formed by age three. After age three, it is extremely difficult to change, and attempts to reassign it can result in gender dysphoria. Both biological and social factors have been suggested to influence its formation.
The Gender Binary
In most societies, there is a basic division between gender attributes assigned to males and females, a gender binary to which most people adhere, and which includes expectations of masculinity and femininity in all aspects of sex and gender: biological sex, gender identity, and gender expression. Some people do not identify with some, or all, of the aspects of gender assigned to their biological sex; some of those people are transgender, genderqueer or non-binary. There are some societies that have third gender categories. Some examples follow.
Khanith
The khanith form an accepted third gender in Oman. The khanith are male homosexual prostitutes whose dressing is male, featuring pastel colors (rather than white, worn by men), but their mannerisms female. Khanith can mingle with women, and they often do at weddings or other formal events. Khaniths have their own households, performing all tasks (both male and female). However, similarly to men in their society, khaniths can marry women, proving their masculinity by consummating the marriage. Should a divorce or death take place, these men can revert to their status as khaniths at the next wedding.
Two-Spirit
Many indigenous North American Nations had more than two gender roles. Those who belong to the additional gender categories, beyond cisgender man and woman, are now often collectively termed “two-spirit” or “two-spirited.” There are parts of the community that take “two-spirit” as a category over an identity itself, preferring to identify with culture or Nation-specific gender terms.
Society and Gender
Since all interactions are largely influenced by the society we live in, social norms and believes have an influence on what gender is and on gender identity. Our own identity arises in an interaction between our own sense of self and our relationships with other people. It is the result of an observation of internal and external communication processes. Our relationships with ourselves and others define our gender attributes. The gender attributes in term influence how we form and live relationships with other people, which in turn solidify and further define a gender identity. The result is an organic process in which identities arise.
Communication is the fundamental mechanism which leads to the creation of gender identities. Unfortunately, professionals in the health and mental health fields were not always as open to the nuances of communication and another person’s needs, values and aspirations as one would hope they are today. In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called “inverts”, and they were portrayed as having an interest in knowledge and learning, and a “dislike and sometimes incapacity for needlework”. During the mid 1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed. The aim of this therapy was to push children back to their “correct” gender roles and thereby limit the number of children who became transgender. The lasting and potentially multi-generational harm from such therapies needs no further explanation.
The Yogyakarta Principles
The Yogyakarta Principles is a document on the application of international human rights law.
The preamble contains a definition of gender identity as each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the person’s sense of the body and other experience of gender, including dress, speech and mannerism.
Principle 3 states that “Each person’s self-defined […] gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom. No one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity.”
Principle 18 states that “Notwithstanding any classifications to the contrary, a person’s sexual orientation and gender identity are not, in and of themselves, medical conditions and are not to be treated, cured or suppressed.”
Gender and Relationships
Gender identity issues can cause suffering when they influence relationships and self-perception. The objective then is not to change one’s true values and fundamental personality, the parts that determine what feels good an what does not, but to find out more about it. This awareness and insight, however, depends on one’s internal communication patterns, which are also linked to the external communication patterns. This is also the reason why gender identity and one’s relationships are linked via communication.
Disconnect
Suffering comes from being disconnected from oneself and others, if the internal and external communication patterns do not function optimally. How I truly feel about having a family and children or a need to be physically strong changes little over time. But if I do not act in accordance with what I deem important and worthy (my values) the consequences are likely lead to unhappiness. We are not born with gender, but we make it up from what we want and need in out interactions with our environment. ‘Gender’ is a construct, no more and no less. A decision to have a family does not determine my gender, but I subconsciously decide on one through interacting with and observing my environment. This process allows me to see myself as ‘male’, ‘female’ or some other construct that works for me in the long-term. The task of therapy is to clarify that I really decide my gender in a way that feels good by matching the construct to what I basically want and need, to my values, interests and aspirations. ‘Values’ in this instance simply means something I find worthy and valuable to have or to do.
Gender Identity
Identity arises in a communication system. Externally, it is the qualities, beliefs, personality, looks and other perceived attributes that make an individual or group distinct from others to themselves and to others. Internally, gender identity is how one sees oneself as a person in relation to oneself and other people. It is a construction from information that is available to the individual and others, and it requires the recognition of a system of attributes. For a socially determined gender system it requires practically a universal recognition of the attributes that are associated with a gender in the society. This does not mean that an individual cannot define and live a different gender identity.
We can only have an identity relative to some standard that is communicated. If I am an introvert, there needs to be someone who is not an introvert. Identity simplifies describing one’s behavior and how one sees oneself in relation to other people. If it helps me in my interactions with other people it can be of value, if I feel constrained by it or use it to discriminate against others then it has become too rigid. So, identity should always be seen as a flexible and fluid concept, while still being stable enough to be useful. There are many films that play on the tension between stability and fluidity of gender. One only has to think of films where men and women ‘switch’ bodies and the many embarrassing-humorous situations this simple narrative trick results in.
Gender identity is the identity about the relationship towards other people and towards oneself. Its explanatory power is often a major issue to patients. An identity here has the function to convey security and safety by offering a better explanation about the world, which is acceptable as long as it works for the individual. To resolve the tension between stability and tension when it comes to identity a closer look at one’s innermost values, needs, desires and aspiration is helpful. But this insight and a general sense of awareness about them may take some time to develop.
The terms gender identity and core gender identity were first used with their current meaning — one’s personal experience of one’s own gender — sometime in the 1960s. To this day they are usually used in that sense, though a few scholars additionally use the term to refer to the sexual orientation and sexual identity categories gay, lesbian and bisexual.
Gender Identity Formation
To assume a gender identity requires a couple of steps which follow from external and internal communication processes. The need to form an identity may be one of the heuristics humans use to make the information in the world easier to process. It speeds up decision making and communication with others. As such, there is probably a natural inclination to form various types of identity, among them a gender identity.
There are several theories about how and when gender identity forms, and studying the subject is difficult because children’s lack of language requires researchers to make assumptions from indirect evidence. John Money suggested children might have awareness of, and attach some significance to gender, as early as 18 months to two years; Lawrence Kohlberg argues that gender identity does not form until age three. It is widely agreed that core gender identity is firmly formed by age three. At this point, children can make firm statements about their gender and tend to choose activities and toys which are considered appropriate for their gender (such as dolls and painting for girls, and tools and rough-housing for boys), although they do not yet fully understand the implications of gender. After age three, core gender identity is extremely difficult to change, and attempts to reassign it can result in gender dysphoria. Gender identity refinement extends into the fourth to sixth years of age and continues into young adulthood.
Martin and Ruble conceptualize this process of development as three stages:
- as toddlers and preschoolers, children learn about defined characteristics, which are socialized aspects of gender;
- around the ages of 5–7 years, identity is consolidated and becomes rigid;
- after this “peak of rigidity,” fluidity returns and socially defined gender roles relax somewhat.
Nature versus Nurture
Although the formation of gender identity is not completely understood, many factors have been suggested as influencing its development. The extent to which it is determined by socialization (environmental factors) versus innate (biological) factors is an ongoing debate in psychology, known as “nature versus nurture”. Both factors are thought to play a role. Biological factors that influence gender identity include pre- and post-natal hormone levels. While genetic makeup also influences gender identity, it does not inflexibly determine it.
Nurture
In 1955, John Money proposed that gender identity was malleable and determined by whether a child was raised as male or female in early childhood. However, his theory has now been largely discredited. A well-known example which illustrates the link between gender identity and sex at birth is the case of David Reimer, otherwise known as “John/Joan”. As a baby, Reimer went through a faulty circumcision, losing his male genitalia. Psychologist John Money convinced Reimer’s parents to raise him as a girl. Reimer grew up as a girl for several years, was given female hormones and his testes were surgically removed. After he told his parents at age 13 that he would commit suicide if he had to have another session with Money, he was told that he had been born with male genitalia. He assumed a male first name and had surgery done which reversed the female sex characteristics into male ones to the extent this was possible. Unfortunately, he died by suicide at the age of 38 after suffering from depression when his marriage fell apart.
Theories suggesting that parental psychopathology might partly influence gender identity formation have received only minimal empirical evidence, with a 2004 article noting that “solid evidence for the importance of postnatal social factors is lacking.” A 2008 study found that the parents of gender-dysphoric children showed no signs of psychopathological issues aside from mild depression in the mothers.
Social Factors
Social factors which may influence gender identity include ideas regarding gender roles conveyed by family, authority figures, mass media, and other influential people in a child’s life. When children are raised by individuals who adhere to stringent gender roles, they are more likely to behave in the same way, matching their gender identity with the corresponding stereotypical gender patterns. Language also plays a role: children, while learning a language, learn to separate masculine and feminine characteristics and subconsciously adjust their own behavior to these predetermined roles. The social learning theory posits that children furthermore develop their gender identity through observing and imitating gender-linked behaviors, and then being rewarded or punished for behaving that way, thus being shaped by the people surrounding them through trying to imitate and follow them.
Biology
Several prenatal, biological factors, including genes and hormones, may affect gender identity. The biochemical theory of gender identity suggests that people acquire gender identities through such factors rather than socialization. However, since communication patterns have their roots in neuronal networks as well as in learning and socialization, the nature versus nurture debate actually lacks a correlate in the real world where biological systems are connected and change by communication, as do information networks in social systems. Since gender is a product of communication, the biology, including a person’s sex, plays a role in the formation of a gender identity, since it influences what information is communicated and in which ways.
Hormones
Sex-determining hormones are produced at an early stage of fetal development, and if prenatal hormone levels are altered, phenotype progression may be altered as well, and the natural predisposition of the brain toward one sex may not match the genetic make-up of the fetus or its external sexual organs. Since this can have an impact on a person’s internal communication and personality traits, it can also influence the formation of a specific gender identity.
Hormones may affect differences between males’ and females’ verbal and spatial abilities, memory, and aggression. Prenatal hormone exposure affects how the hypothalamus regulates hormone secretion later in life, with women’s sex hormones usually following a monthly cycle while men’s sex hormones do not follow the same patterns with the same intensity.
Parental Influence
Parents who do not support gender nonconformity are more likely to have children with firmer and stricter views on gender identity and gender roles. Recent literature suggests a trend towards less well-defined gender roles and identities, as studies of parental coding of toys as masculine, feminine, or neutral indicate that parents increasingly code kitchens and in some cases dolls as neutral rather than exclusively feminine. However, Emily Kane found that many parents still showed negative responses to items, activities, or attributes that were considered feminine, such as domestic skills, nurturance, and empathy.[60] Research has indicated that many parents attempt to define gender for their sons in a manner that distances the sons from femininity,[60] with Kane stating that “the parental boundary maintenance work evident for sons represents a crucial obstacle limiting boys options, separating boys from girls, devaluing activities marked as feminine for both boys and girls, and thus bolstering gender inequality and heteronormativity.”[60]
Many parents form gendered expectations for their child before it is even born, after determining the child’s sex through technology such as ultrasound. The child thus arrives to a gender-specific name, games, and even ambitions. Once the child’s sex is determined, most children are raised in accordance with it to be a man or a woman, fitting a male or female gender role defined partly by the parents.
When considering the parents’ social class, lower-class families typically hold traditional gender roles, where the father works and the mother, who may only work out of financial necessity, still takes care of the household. However, middle-class “professional” couples typically negotiate the division of labor and hold an egalitarian ideology. These different views on gender from a child’s parents can shape the child’s understanding of gender as well as the child’s development of gender.
Within a study conducted by Hillary Halpern it was hypothesized, and proven, that parent behaviors, rather than parent beliefs, regarding gender are better predictors for a child’s attitude on gender. It was concluded that a mother’s behavior was especially influential on a child’s assumptions of the child’s own gender. For example, mothers who practiced more traditional behaviors around their children resulted in the son displaying fewer stereotypes of male roles while the daughter displayed more stereotypes of female roles. No correlation was found between a father’s behavior and his children’s knowledge of stereotypes of their own gender. It was concluded, however, that fathers who held the belief of equality between the sexes had children, especially sons, who displayed fewer preconceptions of their opposite gender.
Gender Variance
Gender identity can lead to security issues among individuals that do not fit on a binary scale. In some cases, a person’s gender identity is inconsistent with their biological sex characteristics (genitals and secondary sex characteristics), resulting in individuals dressing and/or behaving in a way which is perceived by others as outside cultural gender norms. These gender expressions may be described as gender variant, transgender, or genderqueer (there is an emerging vocabulary for those who defy traditional gender identity), and people who have such expressions may experience gender dysphoria (traditionally called Gender Identity Disorder or GID). Transgender individuals are greatly affected by language and gender pronouns before, during, and after their transition.
In recent decades it has become possible to reassign sex surgically. Some people who experience gender dysphoria seek such medical intervention to have their physiological sex match their gender identity; others retain the genitalia they were born with (see transsexual for some of the possible reasons) but adopt a gender role that is consistent with their gender identity.
Psychoanalysis
In 1905, Sigmund Freud presented his theory of psychosexual development in Three Essays on the Theory of Sexuality, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the phallic stage, at which point gender identity became ascertainable. According to Freud, during this stage, children developed an Oedipus complex where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child’s power to appease sexual impulses. In 1913, Carl Jung proposed the Electra complex as he both believed that bisexuality did not lie at the origin of psychic life, and that Freud did not give adequate description to the female child (Freud rejected this suggestion).
Children Research
During the 1950s and ’60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homosexuality (which was viewed as a mental disorder at the time). In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersex and transsexual individuals. Psychoanalyst Robert Stoller generalized many of the findings of the project in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden in 1963. Behavioral psychologist John Money was also instrumental in the development of early theories of gender identity. His work at Johns Hopkins Medical School’s Gender Identity Clinic (established in 1965) popularized an interactionist theory of gender identity, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book Man and Woman, Boy and Girl (1972) became widely used as a college textbook, although many of Money’s ideas have since been challenged.
Gender Dysphoria
Gender dysphoria, which was previously called Gender Identity Disorder (GID), is the formal diagnosis of people who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex: “In gender identity disorder, there is discordance between the natal sex of one’s external genitalia and the brain coding of one’s gender as masculine or feminine.” The Diagnostic and Statistical Manual of Mental Disorders (302.85) has five criteria that must be met before a diagnosis of gender identity disorder can be made, and the disorder is further subdivided into specific diagnoses based on age.
Sex Reassignment Surgery
Transsexual self-identified people sometimes wish to undergo physical surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure, since many adults have regretted that these decisions were made for them at birth. Today, sex reassignment surgery is performed on people who choose to have this change so that their anatomical sex will match their gender identity.
Individual Freedoms
Medical practitioners, as well as an increasing number of parents, generally no longer support or believe in the idea of conversion therapy, which is now widely discredited as unethical and ineffective. In its place, the benefits of shaping an own gender identity free from any external pressure are increasingly seen as important factors in maintaining mental health and raising the quality of life. This implies connecting with oneself, which also improves the relationships one has with others. An awareness for the own needs, values and aspirations is as important to achieve this as the freedom to identify them and reflect on them. (Haverkampf, 2017a, 2017b, 2018b, 2018a, 2018c)
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
References
Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.
Haverkampf, C. J. (2018a). Building Meaning – Communication and Creativity (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2018c). Living Successfully.
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