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Friedemann Pfäfflin,
Ulm University, Germany

Walter O. Bockting,
University of Minnesota, USA

Eli Coleman,
University of Minnesota, USA

Richard Ekins,
University of Ulster at Coleraine, UK

Dave King,
University of Liverpool, UK

Managing Editor:
Noelle N Gray,
University of Minnesota, USA

Editorial Assistant:
Erin Pellett,
University of Minnesota, USA

Editorial Board


book Historic Papers


© Copyright

Published by
Symposion Publishing

ISSN 1434-4599

Volume 1, Number 1, July - September 1997

Gender Identification and Sexual Orientation Among Genetic Females with Gender -Blended Self-Perception in Childhood and Adolescence.

By A. E. Eyler, M.D., and K. Wright

Citation: Eyler A. E, Wright K (1997) Gender Identification and Sexual Orientation Among Genetic Females with Gender -Blended Self-Perception in Childhood and Adolescence. IJT 1,1, http://www.symposion.com/ijt/ijtc0102.htm

An individually-based gender continuum
Adolescent gender dissonance: three outcomes
Primary medical services and the gender continuum


This paper demonstrates a revised gender scale which we have designed for use in clinical medicine. Our gender schema identifies a continuum of gender identification, and is designed for representation of the self, rather than being primarily relational. In addition, it accommodates ungendered and "other gendered" identities, and permits evolution of the self-perception over time. It is intended to be used in a primary medical care setting, by providing patients with blended identities or other gender concerns with a mechanism with which to discuss these issues with their treating physicians. Its clinical application will be illustrated through the histories of three prototypic individuals, all of whom are genetically female, but only one of whom presented to a gender program. The commonalities in childhood and adolescence among these three people, and their differing adult gender identities, will also be discussed. Currently, one has undergone sex reassignment and is now a man. The other two consider themselves genderblended, and have incorporated this identity into their adult lives. Our goal in presenting this paper is to encourage discussion of gender identity in general medical practice and to improve the medical care of patients with non-traditional gender identities.


Research attention has to date been primarily focused on the transsexual or transgendered person who presents for clinical services during the course of his or her efforts toward gender reassignment or the acquisition of chromosomally-opposite gender characteristics. Much less is known regarding persons who experience gender identifications elsewhere on the theoretical continuum, such as those who exhibit a blended self-perception [1]. However, as the discovery of insulin led first to the treatment of patients with life-threatening diabetes mellitus, and only later to the discovery that many others exhibited a more mild glucose intolerance, so the acceptance of transsexuality makes possible discussion of gender- blending and other non-traditional gender identities. Currently, primary care physicians are encountering in clinical practice a significant population of people whose lives and experiences with medical care are affected by substantial gender issues, but who do not desire hormones or surgery, and who rarely present to gender programs.

Clinical and research contact with male-identified genetic females, including female to male transsexuals, transgenderists, Butch and gender-blended women indicates that many of these individuals do not receive comprehensive medical care because of gender issues, and that both primary care physicians and their patients often lack the means to discuss these gender perceptions [2]. Self-identifcation and the discussion of gender issues is further clouded by the fact that language and (Western) cultural assumptions commonly applied to erotic or partnered relationships do not allow for couples for whom the psychological dynamics are incongruent with the "genital" sexes. Therefore, individuals must search for understandable ways of communicating about themselves and their relationships. For example, Coleman et al report that "[b]efore sex reassignment, a number of our [FTM] subjects had engaged in role playing while having sex as a man with either a male or a female partner...[regarding sex with women one person stated] 'I could not treat them as women. They told me, "You treat me as a man in bed." I did not appreciate their female attraction, their breasts, their genitals. I suggested, "Let's behave as two men!" ' "[3] Grimm has stated that a man can posses either a penis or a vagina, which can be used heterosexually or homosexually.[5]

Several comprehensive systems have been developed for describing interpersonal relationships between persons with non-traditional gender identities. [4,5,6] These utilize either graphic representation, or descriptors which reflect combinations of gender and sexual self-perceptions. For example, Devor poses the question: "A female-to-male transexual lives as a gay man. Are the people in these relationships gay or heterosexual?" (In her taxonomy of gendered sexuality, this individual can be understood as a "female-to-male transexual, female heterosexual, gay man.") [6]. Gender variance across the life span can also be described schematically, as in the system described by Jacobs and Cromwell. [7] In their conceptualization, a female infant may be either a "girl," who will mature into a heterosexual or lesbian woman, or a "female/ boy," who will become a "tomboy," and subsequently a female-to-male transvestite or transsexual. Uncertainty regarding future gender or gender qualities is especially common during childhood and adolescence, yet may be followed by stable adult identifications of either gender, or a blended identification.

An individually-based gender continuum

In 1948, Kinsey, Pomeroy, and Martin introduced the notion that sexual orientation could be more clearly expressed as a continuous variable, rather than as a heterosexual-homosexual dichotomy . [8] This concept was illustrated with the seven-point "Kinsey scale," in which a value of zero represented exclusive heterosexuality, a three indicated equal responsiveness to women and men, and a six represented exclusive homosexuality. Since that time, the Kinsey scale has been widely used in clinical practice, and has provided a means for patient-physician communication regarding sexual orientation.

One difficulty with the Kinsey schema is a lack of detail regarding the concept of bisexuality. Individuals who self-identify as bisexual may be attracted to male and female partners concurrently or at different points during adult life, or may partner with members of both sexes, but with vastly different relationship styles. Recent work in the field of bisexuality has attempted to further refine discussion regarding this sexual orientation. [9, 10]
Our gender schema is based on the premise that, like sexual orientation, gender identity is also best understood as a continuum. Furthermore, as with the phenomenon of bisexuality on the Kinsey scale, individuals who consider themselves as being neither fully male nor fully female may describe themselves with a variety of distinct identifications. Observations at a recent FTM conference convinced us of the need to include the other-gendered and ungendered options, and to accommodate the "gender agnostic"; that is, the individual who either regards gender as being a very fluid concept, or a notion which is irrelevant to the freely-expressive person. This gender schema is presented in Table 1 and described below.

Gender identification is scaled along a continuum with nine labeled definitional points. The nine points are as follows:

  • An individual of any genetic sex may self-identify as fully female, having always considered herself to be a woman or girl, or as a female with maleness, in which current identification is as a woman, but with significant questioning regarding being more of a man (or boy) at least some time in life, or as a gender-blended female person, in which the individual perceives herself to be in some significant way both a woman and a man, although more woman than man.
  • An individual of any genetic sex may also regard him-herself as neither a woman nor a man, but a member of some other gender, as is common in non-Western cultures (and is becoming increasingly recognized in the West as well), or as an ungendered person, who does not or will not identify with any conventional gender. In addition, a person who feels or acts as both a woman and a man may identify as bi-gendered.
  • Finally, an individual of any genetic sex may self-identify along the male end of the continuum, as either a genderblended male person, perceiving himself to be in some significant way both a man and a woman, although more man than a woman, a male with femaleness, in which current identification is as a man, but with significant questioning regarding being more of a woman (or girl) at least some time in life, or as fully male.
  • The utility of the individually-based gender continuum in clinical practice can be illustrated with the following cases. One of these individuals is a post-operative male-to-female transexual; the other two self-identify as gender blended. Both are involved in long-term sexual relationships, one with a woman and one with a man. The commonalities in their stories of adolescence and young adulthood suggest a similar process at work, but leading to different adult outcomes and subsequent medical needs.

Adolescent gender dissonance: three outcomes

These three participants reported a sense of conflict arising early in life, resulting from varying degrees of gender dissonance. As girl children who were to some extent male-identified, they then undertook a lengthy process of social exploration, introspection, and accommodation to gendered society, resulting in the construction of a workable personal schema for gender and sexuality, and establishment of an adult identity as either a female-to-male transexual (or transgenderist), a lesbian with blended gender identity, or a publicly-identified heterosexual woman with personal blended gender identity.

This process is represented graphically in Figure 1: Biological and social influences both create and are influenced by a sense of gender dissonance. This, in turn, interacts with the individual's personal gender and sexuality schema, which includes perceptions regarding gender polarity, desirability of gender role conformity, and sexual attractions. Between late adolescence and early adulthood, a relatively stable identification is formed, which may be either transexual (or strongly transgendered) or a blended identification which contains transgendered elements.

In this context, gender polarity refers to individual perception regarding the degree of true, unalterable difference between women and men, or between boys and girls.
Are the sexes perceived as being fundamentally different? Or are they regarded as more similar than dissimilar, with a range of behaviors being possible, and in fact desirable, for each unique individual? Gender role conformity is defined as the degree to which the individual desires or attempts to fulfill the expectations of his or her birth-assigned gender. Adolescent and young adult sexual attractions, as well as their perceived acceptability or unacceptability, also probably influence the individual's sexuality/ gender schema.

Individual A self-identifies as a male with femaleness. He reports having formed sexual relationships exclusively with women, beginning in late adolescence. His family of origin was socially and religiously conservative, strongly heterocentric and homonegative, and very much oriented toward social compliance and "fitting in." This person's knowledge that "she" was not in fact a Lesbian but a male was greatly comforting. His pronounced perception of gender polarization and gender role separation also facilitated the decision to solidify the male identity and undergo sex reassignment surgery, which has resulted in much improved adjustment and life satisfaction.

Individual B self-identifies as a female with maleness. By her description, her sexual partners were initially "weak men," followed by involvements exclusively with women beginning in the early 20s. Her family of origin was paternalistic with an authoritarian father, leading to a rejection of the "wife role" by the maturing daughter. Concurrently, however, her father expressed an individualistic, "anti-establishment" philosophy, including Plainist religious leanings, which promoted self-actualization as a worthy life goal and left sexuality issues less rigidly defined. This person's minimal
gender polarity and gender role flexibility have enabled her to accommodate her fully-gendered self within the Lesbian community.

Individual C self-identifies as gender-blended with female predominating, or possibly as more fully bi-gendered. Sexual partners have been gentle, feminine men. Her/his family of origin was politically and religiously conservative, with overt goals of attaining moral "righteousness" and worldly achievement. Family size was large, containing both biological and adopted children. Heterosexuality was strongly encouraged and homosexual feelings, thoughts, and actions strictly forbidden. Gender polarization was substantial, yet messages with regard to gender role differentiation were mixed and inconsistent, due to the emphasis on academic, athletic and religious achievement during childhood and adolescence. This person experienced considerable confusion regarding gender during childhood, but was able to establish an adult personal identity as genderblended, with a long-term relationship with a man who also has many gender-opposite personality characteristics. Although sometimes mistaken for a man on casual observation, she remains legally a heterosexual, and in fact married, woman.

Primary medical services and the gender continuum

When describing their needs for medical care, Individuals B and C felta mild hyperlipidemia), validation of the male identity by physicians, despite the absence of "natural" male genitalia, and protection of confidentiality to the extent that this is possible. Pre-operative medical contacts were oriented exclusively toward the attainment of hormonal and surgical therapies, to the exclusion of recommended gynecologic care. Management of transitional identity within the health care system was also

Individuals B and C would like to receive greater acceptance and support from their physicians with regard to gender opposite physical characteristics, mannerisms, and modes of dress. Both would like to more fully share their gender identities with treating physicians, but lack the means to do so, and have serious concerns regarding confidentiality and unnecessary psychiatric intervention. Although neither person currently wishes hormonal or surgical intervention, Individual C considers testosterone supplementation in the future, such as at the time of menopause, a possibility, and Individual B would consider androgens if medical circumstances, such as the development of breast cancer, made oophorectomy necessary and estrogen replacement contraindicated. Both participants also mentioned the need for dignified family care, with physician acceptance of non-traditional family arrangements and reproductive plans. Both felt that gender identity may possibly be modified slightly over time, and would like to be able to discuss the issue with their physicians if they were to reassess this in the future.


Many genetic females who experience gender dissonance in childhood and adolescence subsequently self-identify as genderblended adults. Their experiences with the medical care system are different than those of either female-to-male transexuals or fully female identifying women.

There is a need for family doctors, general practitioners, general internists and pediatricians to become familiar with non-traditional gender identities, and to discuss self-identification with their patients. Our individually-based gender schema provides a practical method for doing so. Further research which utilizes this clinical tool is presently in progress.

"[W]hile the limits they face--and the solutions they choose--may be extreme, transsexuals highlight the fact that all of us, to varying degrees, must make an effort to manage self-expression in order to conform to limitations, that is, in order to take our place in a socially-constructed, gendered universe." --David Grimm [5]

" With regard to gender, we can each be in a category of one: ourselves." --Carl Bushong [11]

Female I have always considered myself to be a woman (or girl).

Female with I currently consider myself to be a woman, but at times I maleness have thought of myself as really more of a man (or boy).

Genderblended, I consider myself gender-blended because I consider myselffemale predom- (in some significant way) to be both a woman and a man, but inant somehow more of a woman.

Othergendered I am neither a woman nor a man, but a member of some other gender.

Ungendered I am neither a woman, a man, or a member of any other gender.

Bigendered I consider myself bi-gendered because sometimes I feel (oract) more like a woman and other times more like a man, or sometimes like both a woman and a man.

Genderblended, I consider myself gender-blended because I consider myself male predomi- (in some significant way) to be both a man and a woman, but nant somehow more of a man.

Male with I currently consider myself to be a man, but at times I have femaleness thought of myself as really more of a woman (or girl).

Male I have always considered myself to be a man (or boy).


Devor H. Gender Blending. University of Indiana Press. 1989.

Eyler A, Wright C. unpublished data.

Coleman E, Bockting WO, Gooren L. Homosexual and bisexual identity in sex-reassigned female-to-male transsexuals. Arch Sex Behav 1993; 22: 37-50.

Coleman E. Assessment of sexual orientation. J Homosex 1987; 14 (12): 9-24.

Grimm D. Toward a theory of gender. Am Behav Sci 1987; 31: 66-85.

Devor H. Toward a taxonomy of gendered sexuality. J Psych Hum Sex 1993; 6: 23-55.

Jacobs S, Cromwell J. Visions and revisions of reality: reflections on sex, sexuality, gender, and gender variance. J Homosex 1992; 23: 43-69.

Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male. 1948; Philadelphia, W.B. Saunders.

Berkey BR, Perelman-Hall T, Kurdek L. The multidimensional scale of sexuality. J Homosex 1990; 19: 67-87.

Weinrich J. The periodic table model of the gender transpositions: part II. Limerant and lusty sexual attractions and the nature of bisexuality. J Sex Research 1988; 24: 113-29.

Bushong C. The multidimensionality of gender. Tapestry J 1995; 71: 33-37.

Correspondence and requests for materials to:
A. E. Eyler, M.D., M.P.H.
Director of Primary Care Services
Comprehensive Gender Services Program
University of Michigan Medical Center
1H223 University Hospital
1500 E. Medical Center Dr.
Ann Arbor, MI 48109-0050
phone: (313) 936-6271
fax: (313) 647-6892
email: aeyler@umich.edu