This paper attempts to enhance understanding and communication about different sexual issues. It starts by offering definitions to common terms like sex, gender, gender identity, and sexual identity. Alternate ways to discuss one's sexual attractions are also presented. Terms are defined or redefined and examples given of their preferred use in different clinical situations including those associated with children. Adherence to the usage advocated here is proposed as helpful in theory formulation and discussion as well as in clinical practice. When reference is made to individuals of various sexual-minority groups such as transsexual or intersexual persons, the distinctions offered are particularly advocated.
Sexual identity, gender identity, sexual orientation, transsexuality, intersexuality, transvestite, transgender, ambiguous genitalia
For the last several decades the term gender has come into common usage particularly as a synonym for sex. The term has proved useful in many ways although distinctions between the two words, sex and gender, when one might be more appropriate than the other, has not been firmly established. In most instances, particularly in casual conversation, the words gender and sex are used interchangeably and it seems to make little difference. If there is room for doubt the context generally makes the meaning clear. However, in scientific, medical, legal or political and even religious discourse the discrepant use of the terms can lead to confusion and a lack of understanding.
Here is a quote from a recent report (Schmidt 2001): "the findings [of a second gene related to sex determination] offer new hope for parents whose babies are born with this [ambiguous genital] condition - as well as valuable information to help physicians more accurately and quickly diagnose the newborn's gender." Knowing the genetics of a child's sex in cases with ambiguous genitalia is not always helpful in knowing what a child's genitals would look like and certainly rarely helpful in predicting a child's gender. The term sex is related to anatomical structure, the term gender is related to an imposed or adopted social and psychological condition. Explaining the difference to anguished parents and confused physicians occupies a good part of my time. Both parents and many professionals assume that knowing sex infers gender but this is not always the case.
Maintenance of clear conceptual distinctions between the two words sex and gender and associated concepts is particularly helpful for the psychological understanding of identity. This paper attempts to show that, in certain contexts --particularly those involving transsexuality and intersexuality but in other instances as well-- it is most useful to recognize and encourage the distinction.
The term sex, since classical times, has been used to designate matters related to biology and medicine when male, female or bisexual were in context. Thus animals, including humans, are categorized dependent upon whether they either produce gametes as, or similar to, spermatozoa (males) or ova (females), or have parts of the reproductive system appropriate to the development of and delivery or reception of such gametes. Among non-human animals bisexuality covers those cases where both male and female reproductive components are present.1 Among animals the term bisexuality, unless specifically so-stated, usually refers to anatomy and not to sexual behavior. Classically, for humans, those individuals that had both male and female characteristics were called hermaphrodites. Presently the term intersex is preferred (Kessler 1998).2
The term gender has generally been used in social or cultural contexts, in distinction from biological ones. This was particularly associated with language. The first known use of the word gender was listed as 1387 CE when T. Usk wrote "No mo genders been there but masculine and femynyne, all the remnaunte been no genders but of grace, in faculte of grammar (Simpson and Weiner 1989)."3 This context for gender has been expanded so that since the 1960s or 1970s the word is often used as a euphemism for the sex of a human being but the intended emphasis remains on the social and cultural, as opposed to the biological. United States Supreme Court Justice Anthony Scalia, in an attempt to clarify usage of the terms has written (J.E.B. 1994) "The word gender has acquired the new and useful connotation of cultural or attitudinal characteristics (as opposed to physical characteristics) distinctive to the sexes. That is to say, gender is to sex as feminine is to female and masculine is to male," According to U.S. Supreme Court Justice Ruth Bader Ginsburg, however, the words are interchangeable. She relates that she used them in composing her legal briefs about sex/gender related matters so the word sex would not appear on every page. Supposedly her secretary encouraged this saying: "Don't you know those nine men [on the Supreme Court, when] they hear that word their first association is not the way you want them to be thinking (Case 1995)."
With these distinctions in mind, contemporary use of the terms often maintains these discriminations but frequently does not. Much seems to depend upon the proximity of the speaker/writer to a background or reference related to biology or medicine or to philosophical, social or anthropological studies. For most of those persons, who are biologically or medically attuned, sex appears fixed. The gonads determine sex or it is diagnosed by the gametes that the individual possesses or would be expected to possess on the basis of some other biological feature such as chromosomes.4 Human males and females, as biological entities, are also categorized as male or female or intersexed (having biological features of both a typical male and female). As social entities, however, men and women, by virtue of the multitude of different roles they play in diversified societies, and by virtue of the many individual decisions they make in their own lives, are not so easily distinguished. Males can certainly live, work, or play, as girls or woman appropriate or not to their society, and females can equally live, work, or play, as boys or men. This mutable aspect of their lives is their gender.5
Roles and Identity
Most usually the roles that one enacts are sex-linked. The term role is used to indicate that the behavior patterns exhibited are learned or acted as if according to some sort of social script (Gagnon and Simon 1973). Men and men's roles are typically associated with strength and dangerous occupations while woman and women's roles are more often associated with child rearing and nurturing pursuits. But even so, these distinctions are increasingly being blurred. What was seen as a man's job at one time came to be seen as a woman's job and now anyone's job today (e.g., telephone operator). Since these aspects of life are seen to vary in different cultures and to be changing at different rates the society and learning-bound nature of culture is acknowledged.
Many of the cultural and social differences in behavior patterns associated with the two genders, man and woman, have came to be accepted and recognized as societal constructs -notions or abstractions which carry with them certain expectations and classifications. Man in a technological Western society means different things than does man in a non-technological African society. Woman in both types of societies also brings to mind different things. It is particularly this cultural flexibility that is central to the arguments of writers like Michel Foucault (Foucault 1980). To Foucault gender, unlike sex, should be recognized and accepted as a fluid variable that shifts and changes in different contexts and times.6
For transsexuals and intersexuals the distinction between sex and gender, as presented here, can become central to their being. The values each group or individual transsexual or intersexual person assigns to sex and gender, however, might be quite different. It is also suggested that to psychologists, philosophers and others it is also of benefit to clarify the differences between the two concepts. To best understand these distinctions one other set of definitions should first be made clear. These terms are related to the concept of identity.
Identity is a term that has usage in psychology but is also a term used in everyday conversation. Commonly, people 'identify" themselves as homosexual or see their 'identity" as heterosexual. Individuals may identify, recognize themselves, as transsexual or intersexed without being specific as to what the term means. This usage of the terms is in an affiliative sense. It is as if one might identify as a Conservative, a Unitarian or a mechanic.
The following terms are defined as some others and I use them. While they might be considered somewhat idiosyncratic, I find them useful (e.g., Diamond 1976; 1979; 1994; 1995) and so have others.
Sexual identity7 speaks to the way one views him or her self as a male or female. This inner conviction of identification usually mirrors one's outward physical appearance and the typically sex-linked role one develops and prefers or society attempts to impose. Gender identity is recognition of the perceived social gender attributed to a person. Typically a male is perceived as a boy or a man where boy and man are social terms with associated cultural expectations attached. Similarly, a female is perceived as a girl or woman. The distinctions made between boy and girl and man and woman are of age and usually again represent differences in societal expectations that go along with increases in maturity.
Gender and gender role refers to society's idea of how boys or girls or men and women are expected to behave and should be treated. A display of gender, as with a gender role, represents a public manifestation of gender identity. It can be said that one is a sex and one does gender; that sex typically, but not always, represents what is between one's legs while gender represents what is between one's ears. A sex role usually involves the acting out of one's biological predisposition. In young males this is associated typically with their greater aggressive, combative, and competitive nature than is usual with young females. In young females their sex roles are usually manifest by nurturing and compromising behavior, less frequently seen in boys. These might actually better be called sex-typical (male-typical; female-typical) behaviors. Gender roles are those behaviors imposed overtly or covertly by society. As described by Gagnon and Simon (Gagnon and Simon 1973) gender roles are behaviors that can be considered "scripted" by society. Examples of this is how girls learn to keep their knees together or adjust their dresses and apply cosmetics while boys actively memorize the rules of sports and games. Gender has everything to do with the society, in which one lives and may or may not have much to do with biology (Gagnon and Simon 1973).
This usage and terminology presented is somewhat different from that used by John Money and Anke Ehrhardt (1972). These investigators do not use the term sexual identity and have generally conflated the meanings above under the terms gender identity/role and offer, in addition, their own definitions: "Gender identity is the private experience of gender role; and gender role is the public manifestation of gender identity . . .'gender identity' can be read to mean 'gender identity/role. (Page 146)." But here again the terminology has not been consistent with that used by others. Stoller (1968), for example, called this inner realization of self-identity as a male or female "core gender identity."8
Let us see how these terms and concepts might involve a developing child.9 A mother of an 8-year-old chromosomal XY male with ambiguous genitalia said to me:
"My child has questions on her gender. Oddly enough, we have raised her as a complete female child, to date...she does not know of her condition. We thought best to wait, as a young child would never understand. ...Increasingly over the years she has said things like ' I'm not a girl...I'm a boy'...clothing desired is neutral...teachers' complaints (they are unaware) is that she is very tomboyish.... all her friends are boys. At home it is her brothers she hangs out with. And her strength...wow!"
The mother, at the child's birth, had been advised by her physician to raise the child as a girl due to its lack of a penis. This was a standard recommendation until just several years ago (Diamond and Sigmundson 1997a; b; Diamond 1998; Kipnis and Diamond 1998; Diamond 1999). The child's sex is male but it had an imposed gender of girl. It had been raised since birth as a girl. Obviously here is a case where sex and gender are not in agreement.
The child knows it is being raised as a girl and encouraged by its parents and physicians to live as one. The child recognizes it is being seen and reacted to as a social girl. It is, thus, aware of its (social) gender identity. Yet, although raised as a girl, the child manifests gender roles more typical of a boy. Further, despite its rearing and ignorance of its biology, the child has developed the (inner) sexual identity of a boy; i.e. the child feels at his core that he is a boy or should be a boy. This realization comes about by comparing his feelings, interests, attitudes and preferences with those of male and female peers and judging that his living as a boy is a better "fit" with the reality he sees and comes to know (Diamond, 1999).
The child has male chromosomes (is an intersexed male pseudohermaphrodite) with the imposed gender of a girl. When the child matures and becomes more aware of his history I predict he will likely come to live as a man or in as close to a neuter gender as possible. He will come to recognize that he is intersexed and might or might not openly identify as such.
The mother asked if I thought it would be better to allow the child to switch to live as a boy or proceed with the prepubertal feminizing hormone administration advised by her physicians. My advice was to allow the child to live as a boy and foster typical male development. Despite the genital ambiguity such management would allow gender and sex to be better matched than is presently so. Genital reconstruction can occur later if desired.
In communicating about or describing transsexuals the distinctions in definitions are also helpful. In the real world, the potential transsexual, no different from others, is reared in accordance with custom, boy or girl, as society views his or her genitals. Unlike many intersexed individuals, there is no way to identify those who will develop as a transsexual.
The term transsexual is best reserved for those adult individuals who manifest the diagnostic criteria for gender dysphoria or Gender Identity Disorder (GID) and not used for children. In the DSM-IV there are separate criteria for GID of children (302.6) and GID of adolescents and adults (302.85) (Frances, 1994). A child or adolescent with GID is generally not considered a transsexual until he or she is an adult. In some circles distinctions are made between preoperative transsexuals and postoperative transsexuals.
Some clinicians such as Issay (1997) and Menvielle (1998) have argued that childhood GID should not be in the DSM because it appears to be a symptom of homosexual orientation. Cohen-Kettenis ( 2001) and Zucker (2001) find of value its consideration as a distinct entity so its treatment may be appropriately managed.
A child might have a gender identity conflict but such conflicts, more often than not, have been reported by Green, (1987), Zucker and Bradley (1995), and Zucker, (2001) to resolve themselves to a homosexual or typical condition. Cohen-Kettenis (2001) finds this also, however, she finds a large percentage of those children who manifest GID as children (17 of 74), as adolescents continue to exhibit gender dysphoric behaviors and have requested sex reassignment surgery).10
If a designation of transsexualism is to obtain, as the individual matures, the self-image (sexual identity) he or she has of himself or herself solidifies as that of the sex opposite to their anatomical sex. The mirror image is in conflict with the mind's image (Benjamin 1966; Green and Money 1969; Bolin 1987; Docter 1990). The developing male, for instance, knows he is being raised as a boy but thinks it more appropriate that rearing and treatment ought to be that accorded to a girl. The transsexual male thinks he is actually a female or should be a female or aspires to be a female. Gender identity conflict can start quite young and is illustrated by the following portion of a recorded dialogue between a therapist (Interviewer =I) and a 4 year old boy (Zucker, Bradley et al. 1992):Interview with child:
I: Are you a girl?
I: When you grow up, will you be a Mommy or a Daddy?
I: Could you grow up to be a daddy?
I: Are there any good things about being a boy?
I: Are there things that you don't like about being a boy?
I: Tell me some of the things that you don't like about being a boy?
C: Because I hate it. 'cause we get to do stupid, sitting down.
I: Do you think it is better to be a boy or a girl?
C: Because it's fun - they sit around and talk.
I: In your mind, do you ever think that you would like to be a girl?
This child is aware of being raised as a boy but thinks of himself as a girl. This awareness of how he is living and is expected to live in society is his gender identity. The child's core view of self is "her" sexual identity. This gender identity and sexual identity disparity diagnosed as gender identity disorder, may or may not persist into adulthood. If it does persist this child can then be diagnosed as a transsexual. If he is typical, he will then eventually attempt to arrange endocrine therapy and or surgery or both to have his features changed sufficient that he be seen as a woman. Changing his anatomy to that resembling a woman's will facilitate social acceptance and life as a woman. His gender identity and sexual identity will thus be brought into concert.11
The processes through which the transsexual passes in getting to his or her physical transformation might be tortuous and conflict laden. It can involve a prolonged process of introspection, and often psychotherapy and counseling. Not a few undergo an extensive set of self-tests in attempts to prove to themselves if they are male or female, should they live as man or woman (Diamond 1996). For others, however, the inner processes are fairly straightforward with the individual harboring little doubt of the correctness of the decision to switch gender. In general, however, the transsexual's final mantra becomes "change my body, not my mind." Socially he becomes she and she becomes he. The transsexual's sexual identity is immutable.
An intersexed individual is one born with physical characteristics that are both male and female. For instance an individual can be XX in chromosomal configuration but have a male-like phallus; another individual might be XY in chromosomal make-up and not have a penis but have a vagina instead. The intersex person might have genitals that are ambiguous in character or they might appear typical.
Intersexed men and women might identify as female, male or intersexed and they might live ostensibly as women or men or in some sort of neuter manner (Diamond, 1999). Intersexed children, while not aware of their condition, might nevertheless manifest this neuter status in choice of dress, hairstyle and comportment.
The variety of intersex conditions is so large that only broad generalizations can be made as to how any single individual's sexual identity and gender identity might compare. While some intersexed individuals can easily meld their biological incongruities with the way they are raised and with the life they lead, others find great difficulty in reconciling the disparities they see and feel with the social input that is thrust upon them. Even within a single category of intersex there is a great variation. It is for this reason that I believe it best that the child itself, particularly after puberty, have the final say in how he or she is allowed to live (Diamond and Sigmundson 1997b).
Before leaving this topic let me emphasize that at issue here is not whether a person, male for example, thinks he is masculine looking "enough" or macho behaving "enough" to satisfy his ego or some social stereotype. Most men wish that they could increase some aspect of their male selves. And the same can be said similarly for females. Most women would relish the ability to enhance some aspect of their feminine looks and modify some aspect of their behavior. But for the typical person there is little doubt of his or her basic male or female self and sexual identity despite any lack in wished for socially preferred gender feature.
One's sexual identity, gender identity, and gender roles are aspects of life tangentially related to a person's sexual orientation. Sexual orientation refers to the sex of the erotic/love/affectionate partner a person prefers. Does the individual seek a mate who is male or female; does the desired person live as a woman or man? Most often, to describe orientation, the term's heterosexual, homosexual, and bisexual are used. Scientifically it would be better if these terms were used as adjectives, not nouns and better applied to behaviors not people. In lay usage, however, one often speaks of a person as a homosexual or heterosexual. Indeed, people often refer to themselves the same way. Unfortunately such causal usage often links together those whose regular sexual partners are of the same sex with those whose same-sex encounters are only occasional in comparison with heterosexual contacts. The term homosexual is best reserved for those whose sexual activities are exclusively or almost exclusively with members of the same sex, the term heterosexual for those whose erotic companions are always or almost always with the opposite sex, and the term bisexual for those with more or less regular sexual activities with members of either sex (Diamond 1993). Lately it is advocated that the terms androphilic, gynecophilic, and ambiphilic are used to describe the sexual/erotic partners one prefers (andro = male; gyneco = female; ambi = both; philic = to love) (Diamond 1997). The use of such terms obviates the need to define specifically the sex or gender of the person referred to and focuses solely on the sex of the desired partner. Again, this clarity of usage is particularly advantageous when discussing transsexuals or intersexed individuals. For instance, what would be homosexual or heterosexual for an intersexed person? And there is often confusion when discussing transsexuals as to whether a designation of homosexual refers to a pre or post surgery situation. These latter terms also do not carry the social weight or taboos of the former ones.12
Before leaving this topic it should be mentioned that individuals that engage in same-sex behaviors do not necessarily exhibit any particular concomitant sexual identity or gender identity. Males that engage in homosexual behaviors, for instance, can be comfortable in their male bodies and have no gender atypical behavior patterns. The same for lesbians; they can be quite pleased with their sex and gender roles.
For most people their identity, orientation and gender are in concert. The typical male sees himself as such, acts in a masculine manner-a combination of biologically and socially determined gender behavior patterns-is treated as a male by society, and prefers to have sexual interactions with females. The typical female sees herself as such, acts in a feminine manner-also a combination of biologically and socially determined behaviors-is treated as a female by society, and prefers to have sexual interactions with males. For the usual person there is no conflict between sexual and gender identity and it makes no difference that the terms involved refer to different things.
Now consider the atypical person. When variations occur, such as when individuals want to live in the gender opposite to the one in which they were reared, for any of several reasons, the distinct meanings of the terms, and their usefulness, becomes clear. So too do the separate terms offer clarity for cases when an individual chooses to be atypically flexible in manifestation of gender.
It is useful to note that our discussion has covered three of five central aspects of life I use to register a sexual profile for an individual. In addition to the three mentioned already, gender role Patterns, sexual Identity, and sexual Orientation, I find it advantageous to specify aspects of sexual Mechanisms and Reproduction. Mechanisms refer to those processes usually associated with sexual activities. They include, for example, erection, nocturnal emission and ejaculation for men and lubrication, pregnancy, and lactation for women. Reproductive history, functioning and attitudes are also significant. Regarding reproduction we are interested in pregnancies, live births, miscarriages, abortions, fertility or infertility, if they did or didn't occur and one's attitudes toward these processes. Used together I find these five parameters offer a rather broad yet full picture. The acronym PRIMO serves as a mnemonic to keep these five features in mind (Diamond 1995). (A diagrammatic representation of Sexual Development utilizing the PRIMO components is seen in Figure 1).
The following examples will present some instances of how the terms might be appropriately applied. The quotes are relatively typical and, with minimal modification, taken from relevant testimonies. In actual life, the intensity of the feelings of identity might vary among individuals and along one's life course. There may be periods of doubt and conflict or never any hint of them.
Typical female or male:
"My parents wanted to be up-to-date in the way they raised my siblings and myself and sort of let us do what we wanted. I was very much a tomboy. Regardless of all that room in which to express myself I never had any doubt as to what I was nor how I preferred to live."
The average woman or man, while perhaps questioning his or her degree of masculinity or femininity, never or rarely questions if he or she is male or female. Sexual identity conforms to sexual anatomy and gender identity follows along the same lines. 13
Transsexual (male to female):
"My dad very much wanted me to grow up and paddle and fish with him, and follow in his footsteps. But that was not me. Since I was about six or seven, or maybe even earlier, I wanted to grow my hair long, paint my fingernails, wear pretty clothes and hang out with the queens downtown."
Here the individual is obviously aware of his sex as a male but yearns to live as a woman. Although he is aware he is a male, his sexual identity is female. And he knows his gender identity, as male, the way he had been perceived by others in his community, was not in keeping with the person he imagined himself to be. His present condition at this time, before transsexual surgery, is as a woman. After male-to-female surgery his gender identity and sexual identity will match. By altering his body, in his mind and to the world, he will become she.
Transsexual (female to male):
"When we were having sex things never seemed right. I had always felt masculine but in erotic situations in particular, I thought I should have a penis instead of what I had. While I had felt that way for many years, I always saw myself as a man even more strongly in these situations. And even though, for several years I had considered myself a butch lesbian that was very masculine, I came to realize that was not sufficient for me. That life didn't feel right. After sex reassignment surgery things felt right. Being a man solved those problems."
This female has a male sexual identity. She knows, however, that the world was recognizing her as a woman and she uncomfortably recognized herself in that role. Her gynecophilia was not a major factor in the desire to transition although it did seem to make things easier. Her societal gender identity was that of a woman yet she saw herself as a male. Her sex reassignment surgery brought her gender identity into agreement with her sexual identity; her body was reshaped to conform to her mind's image.
Before leaving this topic of transsexualism it is illuminating to consider what one highly educated male-to-female transsexual said to me when she heard how I was trying to understand the motive or drive for sex change. It illustrates that these are questions of the investigator and clinician and may have nothing to do with the interest of the transsexual. "If there is anything I want to shout from the rooftops, it is that some of us want to change our bodies for reasons that have little or nothing to do with facilitating our acceptance as social women. We want to change our bodies because we want to change them. Sometimes we decide to change them even though we know we won't be accepted as women, and wouldn't want to be accepted anyway." An intersexed person who wants to change his or her life for reasons that are personal and not necessarily available or amenable for investigation can say the same.
Intersexual (content with rearing):
"When I was first confronted with the diagnosis I was freaked out and almost had a break down. Now I have accepted it and move on with life. I have always felt to be a female and a feminist and I feel comfortable living as a woman."
This person, having XY chromosomes and testes, until the diagnosis, had no doubts as to her sexual identity as a woman. She had always considered herself to be a female and accepts living as a woman. She accepts her gender identity as a woman and, despite concerns with infertility and other features common to her intersex condition, confidentially presents herself to the world.14
Intersexual (not content with rearing):
"I had been living with doubts as to who and what I was ever since I was small. I had always felt myself to be a female rather than as the male I was being raised." When I found out that I had both male and female chromosomes, with XXY, I figured I could and should and would more comfortably live as the woman I felt myself to be."
This woman, while quite young, as many individuals who will eventually switch their gender, had developed a sexual identity other than in accordance with how she was being raised. Thus, despite her upbringing as a male and her having a penis, she envisioned herself growing up to be a woman. As a woman in society her gender identity conforms to her sexual identity. She had genital surgery and breast implants to satisfy her needs.
Lately, along with greater freedom in many social areas, in the West it is becoming more common for intersexed individuals to accept their condition and identify as intersexed persons rather than considering themselves either male or female. While this might solve some psychic considerations, this stance is not without its social cost and legal repercussions. Difficulties can occur with driver's license identification, marriage license or passport acquisition, and birth certificate verification. Intersex identification can make it difficult for family and potential partners.
Male, Sex Reassigned due to genital trauma:
"Even though I was being brought up as a girl, I suspected I was a boy since the second grade. At about the age of 14 I decided I had to either live as a boy or I would kill myself."
This statement clearly shows an individual with the sexual identity of a male strongly expressing his move to live as one. He saw the overwhelming need for his gender identity to match his sexual identity. Once making the shift, he was accepted well in his new social role.
"This is the way I see myself. I love parading [in woman's clothing and heels] as I do. Sure, I get a lot of grief from the straights around the neighborhood, but I have no doubt as to who and what I am."
This male accepts that he is confronting strong social conventions against his behavior. He maintains a male sexual identity and does not want to lose his penis. He does not see its presence as incongruent with a woman's gender identity or gender role. To the Western world in which he lives, his gender is that of a woman while his sex is male. He is willing to accept the incongruity for perceived real and potential gains. Except for the exceptional stage cross-dresser, drag queens are androphilic.15
As many of the terms presented, this noun has a long and varied history. First coined by Magnus Hirschfeld (1910/1991) this word referred to individuals, usually men that sought and received erotic pleasure by wearing the clothes of the opposite sex. While Hirschfeld used the term for individuals who might engage in heterosexual as well as homosexual or bisexual behaviors, he also described individuals who cross-dressed solely for autoerotic pleasure. Presently, many that cross-dress dismiss the allegation that it is related to autoeroticism and contend it is basically to satisfy a feature of their personality not otherwise expressed. In the general press or everyday speech the term might be applied to any one who cross-dresses. Among the majority of sexologists, however, the term transvestite usually refers to men who are gynecophilic in orientation. "The Society for the Second Self" (SSS)16 is basically an organization founded for heterosexual men and their wives and, in the United States, is the largest organization of its kind.
To our lexicon a relatively new term has come into use, transgender. An individual exhibiting transgender behavior is one that sees gender as being either constructed or inborn but nevertheless open in manifestation. The term has taken on a very fluid meaning adopted by individuals and for individuals who might otherwise be identified as transsexual, intersexed or even homosexual or bisexual; anyone who simultaneously exhibits traits or characteristics of both men and women. Actually the word transgender has been, in a continuous state of flux since its having been coined by Virginia Prince in the late 1960s (Denny 2000). Prince, considered by many the first modern public transvestite, found the term transgender useful to describe individuals like herself that had no difficulty accepting that they were male but who wanted to live as women, at least partially or part time. She also saw the term extending to females that manifest male characteristics. In her use of the term transgender, it excluded transsexuals.
Individuals that exhibit transgender behaviors don't necessarily want to change their sex but do want to change aspects of their gender (Bullough, Bullough et al. 1997).17 Many such persons eschew any strict dichotomy in male and female gender roles. In their own lives, they mix characteristics that are most often considered both male and female.
Lately the word transgender has become quite inclusive to cover transsexuals, transvestites, drag queens and others that bend society's usual gender boundaries. Some welcome the term transgender due to its inclusiveness and others abhor it for the same reason. The individual exhibiting transgender behaviors does not attempt to pass as anything he or she is not. Transgender individuals feel they are expressing aspects of themselves that can not be manifest any other way. As Anne Bolin has written (Bolin 1997): "The formation of a transgender community denotes a newfound kinship which supplants the dichotomy of transsexual and transvestite with a concept of continuity. "18
Earlier I remarked that the terms heterosexual, homosexual and bisexual might better be used as adjectives rather than nouns since the terms too often label individuals as if that is the total aspect of their character rather than just representing one facet of their personality and life. I think that caveat might also be extended to all the other terms often used as labels for people. One is not simply a lesbian, or transvestite or transsexual any more than one is simply a teenager, a Jew, a political Green or plumber. Life and character are complicated and it is clinically and socially better and wiser to acknowledge this diversity. Clients, children as well as adults, will appreciate this recognition. Similarly, when labels such as victim or perpetrator are used, the persons referred to are denied recognition for other, and probably better characteristics. The danger is that individuals so labeled might, themselves, come to see only that facet of self and limit or deprive their life of other aspects of meaningful expression. Or they might think they then have to conform to some model of group stereotyped behavior. Particularly for children and adolescents, allowing, recognizing and supporting multiple aspects of an individual's personality is usually a welcome clinical practice.
This paper has attempted to enhance clarity in understanding and communicating with different terms. In particular, emphasis was placed on the terms: sex, gender, sexual identity, and gender identity. The value in doing so is particularly seen when reference is made to individuals of various minority groups such as transsexuals, intersexuals or others. Standardization of these widely used terms, it is hoped, will help in theory formulation and discussion. It also allows for a more precise way to document an individual's clinical ontogenetic path especially if he or she exhibits an atypical life. A warning is also given not to use these terms as all encompassing labels.
For support of this work thanks are due to the Eugene Garfield Foundation of Philadelphia, Pennsylvania and the Sabra Stiehl Foundation of Atlanta, Georgia.