Sex, Gender, and Personal Identity: What to Know as a Mental Health Practitioner

Sex and gender aren’t synonyms, though they’re often treated as such on medical documents, legal forms, and in casual conversation. Therapists who intend to work with intersex and gender diverse people must understand how independent sex and gender are, in order to comprehend how they intersect.

Consider the nuanced social issues facing a male (sex) man (gender) who acts masculine (gender expression), versus a male (sex) man (gender) who acts feminine (gender expression). Now consider how these categories blur together, and how it’s rarely so easy to pick them apart.

Pragmatic thought exercises like this are a useful way to introduce diversity, but they are limited. There are many divergent and conflicting views of sex and gender, even within the trans community. For example, some may view their self-actualization journey as a transition of sex, and so resonate with the term transsexual. Others may view their self-actualization journey as a validation of gender, and so resonate with the term transgender. Others may be nonbinary, or agender, or belong to an indigenous third gender culture completely outside of these contemporary Western paradigms. For this reason, mental health therapists are urged to learn and respect the language and pronouns used by each respective client.

Even the delineation between sex and gender can inadvertently come across as offensive when handled in a clumsy way. To call a trans-man “female-bodied,” for example, invalidates his gender while also limiting the very definition of sex itself.

Once again, while dissecting, sex, gender, and gender expression into neat categories may be a useful way to frame a case study, it can feel incredibly reductionist to have one’s identity packaged as a female (sex) man (gender) who acts masculine (gender expression). There are some trans-men who feel the term FtM (female to male) is incredibly accurate, and others who feel it is incredibly inaccurate— especially if they never saw themselves as female to begin with.

Any conversation about sex and gender is limited by our use of language, and our tendency to create false inferences, false dichotomies, and false hierarchies. For this reason, mental health practitioners must learn to recognize and challenge their own assumptions, definitions, and biases pertaining to sex and gender, in order to hold ample room for the client’s exploration.

Intersex Considerations in Therapy

Biologically, sex can be categorized as male, female, and intersex depending on genital, chromosomal, or phenotypic anatomy. However, medical terms like “mutation” and “deformity” can stigmatize intersex people, adversely impacting psychological wellbeing. For the purpose of discussing anatomic diversity, terms like “difference” and “variations” are far less charged. Even within the medical community, physicians have begun using the term “Differences of Sex Development” or “DSD” for short.

Because of the diversity of sex development, a variety of issues may emerge in therapy, including age of awareness, family response, and degree of self-identification. Some individuals may be aware of their DSD their whole lives, yet others may have no idea until later, perhaps because their DSD was not apparent at birth, or perhaps because their parents elected for a medical procedure.

Bioethics professor and former President of the Intersex Society of North America, Alice Dreger, PhD, observed the split between the Concealment Centered Model and the Patient Center Model of care. As it sounds, the Concealment Model emphasizes corrective surgery, presuming that intersex genitalia will lead to depression and maladjustment. Proponents of the Concealment Model point to longitudinal studies demonstrating the positive mental health outcomes of children who received genital surgery and therapeutic care at an early age. However, a growing number of outspoken intersex individuals and their parents, alongside intersex advocacy groups like InterACT, challenge this interpretation.

In 2017, three former US Surgeon Generals called on physicians to rethink their approach, stating that “while there is little evidence that cosmetic infant genitoplasty is necessary to reduce psychological damage, evidence does show that the surgery itself can cause severe and irreversible physical harm and emotional distress.”

Empowering the individual, the Patient Center Model respects body autonomy, de-pathologizes what it means to be intersex, and provides psychological support to the whole family.

In therapy, intersex individuals may explore their level of identification with their sex and gender, and come to different conclusions. Regardless of how a person was medically classified at birth, only the individual in question can determine how relevant their anatomy is to their identity.

Consider three chromosomally XY individuals, who each have genital differences impacting their testosterone levels:

  • The first rejects intersex terminology, identifying as male because of how he sees himself, citing his XY chromosomes as evidence. When asked, he says he’s cisgender, describing himself as “a man.”
  • The second individual incorporates being intersex into his identity. When asked, he says he’s “an intersex man.” 
  • Likewise, the third individual also identifies as intersex, yet describes themselves as “an intersex nonbinary person.”

No assumptions can be made. For some, their DSD may be a source of shame or pride. For others, it may be a minimal aspect of their lived experience. Today, online organizations like Interconnect and the Interface Project strive to network intersex individuals, providing guidance and insight while elevating their voices.

Gender Variant Considerations in Therapy

Postmodernists view gender as a social construct. Anthropologically, gender norms differ between cultures, just as they evolve and change throughout history. Before delving into the full diversity of gender variance, it’s important to challenge the idea that cisgender identities are a monolith. What is a man, and how do we define masculinity? What is a woman, and how do we define femininity?

Each construct is encoded with meaning, idealizing what men and women are “supposed to be.” Each construct draws up a series of rules and expectations that we may or may not agree with, may or may not aspire to, or may or may not be aware of. These associations are what queer philosopher Judith Butler called a performative act, as these scripts shape our social behavior, and even how we treat ourselves. And these scripts are culturally informed.

Consider the differences and similarities between men and women in a traditional Japanese household, a South African household, and a Californian household? Then zoom in, and explore how the rules and expectations defining men and women are influenced by race, ethnicity, religion, sexuality, and even socioeconomic class. Gender is a multifaceted aspect of a person’s intersectional identity, nuanced even within allegedly binary cultures. That said, there is a multitude of gender identities beyond the cultural definition of men and women, which is why so many LGBTQ+ advocates attest that gender is a spectrum.

The term gender variance is useful here for two key reasons. Firstly, not everyone beyond the binary identifies as transgender, which may be viewed as a culturally Western construct. As an example, the Bugis are an ethnic group in Indonesia that have five genders, which do not neatly translate to cisgender or transgender, which is in itself a binary. For more on this, read Sharyn Graham Davies’ Gender Diversity in Indonesia: Sexuality, Islam and queer selves. Consequently, indigenous cultures frequently wrestle with issues of interpretation, especially when their spiritual and ethnic identities are lumped in with Western LGBTQ+ politics they may or may not connect with. 

Secondly, all the labels and terms pertaining to gender identity create the illusion of categorical division—the idea that there is an easily identifiable line between what is, or is not, cisgender, transgender, or nonbinary. Cisgender people can be gender nonconforming, and transgender people can be incredibly binary, and vice versa, and all things in between.

Quite literally everyone in society contends with gender, and all its messy implications, complications, pleasures, and problems. Even agender people, who actively reject gender paradigms, may struggle with constant misgendering as they explore what it means to be a non-gendered person.

Out here, beyond the normative bell curve, trail-blazers rely on self-definition, which is why there are so many labels, and why not everyone agrees on the terminology. This can be confusing for those unfamiliar with the ever-evolving LGBTQ+ micro-groups and social scenes. Some may, for example, draw distinctions between being genderqueer, genderfluid, and genderflux, whereas others may not.

In my text, ACT for Gender Identity: The Comprehensive Guide, I note how, under all the labels, gender can be conceptualized as an intrapersonal experience.

“For some:

Gender may remain fixed.

Gender may transition from one identity to another.

Gender may incorporate the experience of transition into identity.

Gender may downplay the experience of transition altogether.

Gender may blur masculine and feminine to create blended androgyny.

Gender may combine masculine and feminine to create dichotomized androgyny.

Gender may alternate between two or more gender identities contextually or over time.

Gender may be neutralized, negating gender, or the prioritization of gender, as a part of identity.

And for some:

Gender may be a nebulous experience they can’t put into words.”

What labels people use to describe said experiences differ not only geographically but also generationally. In turn, the politicization of transgender and nonbinary people also impacts the etiquette of contemporary conversation. Just as describing a transgender person as “female-bodied” or “male-bodied” can be offensive, so too are modifying phrases. It’s one thing, for example, to say “I identify as nonbinary,” as I am the one identifying myself. Yet it’s potentially offensive to say “they identify as nonbinary” instead of “they are nonbinary,” because of the longstanding history of erasure. Those with cisgender privilege, by contrast, never have to say “I identify as____” since they’re permitted to exist without question.

Unfortunately, many of the predominant issues facing gender variant people emerge from being misgendered, misunderstood, traumatically oppressed, and capped by occupational and socio-economic glass ceilings. Extensive surveys from UCLA’s Williams Institute and the National Center for Transgender Equality also demonstrate how the risk of violence, unemployment, and homelessness multiplies exponentially for gender variant people of color, as does discrimination in both legal and medical settings.

Often, the extent of psychological distress gender variant people face correlates with how rigid or flexible the gender norms of their social, communal, or familial groups are. Rigid gender norms often drop terrible consequences on anyone who doesn’t adhere to “normal behavior.”

Many gender variant people must wrestle with the constant threat of violence, bullying, public shaming, and exile. The internalization of this threat can contribute to closeted behavior, low self-worth, substance abuse, self-harm, and suicidal ideation. Even within relatively healthy households, the gravity of gender norms can feel incredibly claustrophobic, especially for young people who have yet to self-actualize. It is not uncommon for some to break away from their family of origin in order to find themselves. In any case, feelings of estrangement, alienation, and isolation may arise, which is why it’s so important to connect gender variant people to accepting communities who embrace them as they are.

As always, mental health therapists working with sex and gender minorities should follow the standards of care outlined by the World Professional Association of Transgender Health (WPATH), the ACA’s Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE), and the APA’s professional practice guidelines.

That said, there are many complex layers to sex and gender as they develop over the lifespan, far more than can be listed here. Because self-actualization is so contextually dynamic, Affirmative therapy is often recommended for those exploring their own gender identity. Having developed from the humanistic branch of psychology, Affirmative therapy validates the unique experience of the individual, while also providing skills and psychoeducation to meet a client’s self-identified needs.

In this way, Affirmative therapy can be augmented with cognitive behavioral therapy, person-centered therapy, acceptance and commitment therapy, dialectical behavior therapy, and expressive art therapy, to name a few complementary modalities.

Alex Stitt, LMHC

Alex Stitt, LMHC

Writer & Contributing Expert

Alex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.