About nancyquay

I am the director of the Gender Services Program at the University of Michigan Health System in Ann Arbor, Michigan, USA. We work with gender-variant people, helping them live authentically with or without full transition.

The Sound of One Hand Clapping

I am reminded of this ancient Zen koan when speaking to a person who doesn’t fit neatly into our binary ‘gender’ boxes.  And I try to keep it at the forefront of all that I do to serve the needs of gender variant people and their families.

As you’ll recall, the sound of one hand clapping is silence.  That is, the absence of sound.  Why the absence?  Because there is no resistance, no other hand to create a barrier against which the sound is created.

Gender variance is like this.

The ‘sound’ of feeling something other than ‘masculine’ or ‘feminine’ is only created because outsiders create a barrier.  That is, a child just feels how they feel.  We label it as appropriate, or not, depending upon how neatly the child’s feelings fit into our expectations, i.e. whether the child’s behaviors hit the ‘barrier’ of what we expect to see.

Confused yet?

Indulge me for a minute here, and consider a 3-year-old child.

The child feels feminine, loves activities we associate with little girls, colors we associate with female, the frilliness that Madison Avenue has taught us is ‘girly’.  This is one happy little kid, waking up each morning with energy and enthusiasm and readiness for whatever the day will bring—and for a 3-year-old, just being alive is a very exciting adventure.  Few 3-year-olds worry, or are anxious or depressed (thank goodness).

Enter Stage Right: Adult

The adult looks at this happy child, judges the child to be male or female (female, in this case), and treats the child accordingly.  Unless, of course, the adult is one who is intimately connected with the child, like a parent, or a doctor.  Then the adult might note the child’s physical body, and be concerned if there are body parts we associate with masculinity.

Once the dichotomy is noticed, it is usually not ‘unnoticed’ and the child begins to be treated differently.  In some families, the child continues to grow up happy and content and comfortable. In other families, the child is taken for evaluation to a doctor or psychotherapist to figure out what is ‘wrong’.

Incongruent Are Us

We might say the child is ‘gender incongruent’. Incongruence, as defined by Collins, is ‘the quality of being surprising because out-of-place; oddness’. But remember our story so far—the child isn’t surprised, nor feels odd.  The child just has feelings. Any incongruence is caused by adults who are uneasy with the mismatch between how the child feels and what expectations adults have for the child based upon the child’s body parts.

Wow, This Sounds Familiar

Who among us—having grown to a height out of range as ‘expected’ for our sex—hasn’t been asked many times “Do you play basketball?”  If I had collected spare change every time I’d been asked that growing up I might have been able to retire by now.

Remember the really bad old days, when your athletic ability was expected to correlate with your race? Or your cooking and cleaning ability was expected to correlate with your reproductive organs?  Sure, it sounds wrong and even silly now.  And may it ever be so.

What I’m suggesting is that the ‘wrongness’ of gender identity is external to an individual’s experience.  Any ‘wrongness’ is in our society, in our staunch determination to fit people into neat little boxes, and our unwillingness or discomfort when we can’t.

Here at the gender program, I’m watching the trends. Hang on to your hats, friends.  The world is changing, because we now know the truth.

It isn’t about them.  It’s about us.

And society needs to transition.  Right here.  Right now.


Great Expectations

Parents are often referred to as ‘expecting’ when a baby is on the way. Plenty of meaning in that phrase! So as we head into the season honoring those who raised us with their own expectations (Mother’s Day and Father’s Day) it makes me ponder what expectations are all about and how they influence us.

What do we expect of ourselves and others? What do we hope to accomplish as we move forward through life? And for transitioning people, what is expected before, during, and after transition?

Flower_reflectionMirror, Mirror

I am often told by a gender variant client that what they see in the mirror is not how they feel inside…or conversely, that what they see in the mirror is not what others see when they look at them.

Both viewpoints can be a double-edged sword. It can be very positive to see beyond an ‘imperfect’ self. On the other hand, the converse of this is what eating disorders and other body dysmorphic disorders are rooted in—an inability to see accurately what is reflected.

Reflections in the mirror are also based upon the belief that what we look like is who we are—appearance trumping all other characteristics. Given that we live in a society that judges people solely by physical attributes—skin color, height, weight, apparent age, physical abilities, etc.—I think that we’ve all fallen into the same trap to varying degrees, and it can be extremely limiting.

Boy ClothesDenimjeans

Is clothing gendered? Can you tell a boy sock from a girl sock just by looking? While we’re on the topic, why is it that girl’s and boy’s shirts button on opposite sides? Wouldn’t it make more sense to have left-handed clothing and right-handed clothing? And by the way, why don’t the clothing manufacturers ever ask my opinion?

Seriously, what does it mean to buy clothing of the ‘other’ gender? Given that gender is a social construct—academic-speak for ‘we make this stuff up’—how in the world have we come to infuse clothes with feminine or masculine meaning?

All those guys during the Renaissance period wearing tights and tunics—were they transgender? And what about the robes worn by many religious leaders today, not a trouser to be seen—are all those people transgender? What about women who wear jeans found in the men’s department because they fit better—are those women transgender? Or the new style of ‘skinny’ jeans worn by both men and women—are all those people transgender?

Perhaps clothing only takes on gender-meaning if we make it so…using external appearance to announce something about ourselves that has meaning for us, and therefore, everyone else too. Maybe we use clothing to judge others—to try to fit them into the neat categories we develop to make us less anxious about the real, true, ambiguous world.

My Point, and I Do Have One

Working with transitioning people means helping them manage their own expectations. ‘After’ transition (whatever that means for the individual) how will they look to others? How will they look to themselves? If they’ve spent years hiding their birth sex, will they now flaunt their destination sex? If so, will they look as different to those who love them as they think they look, or want to look? What if they don’t? How will they incorporate their destination gender into their real lives, because life doesn’t stop while one is transitioning?

Most importantly, will the life-long hatred of one’s birth sex and all the markers of it, lead to the same self-loathing, but just from the other side—such as, ‘I’m not girly enough’ or ‘I’m not manly enough’.

For all of us, it would be worthwhile to spend some time exploring just what it means to be girly, manly, or in-between…a more gender-fluid culture would expand options for everyone.

Agree? Disagree? Let me know what you think.

For Everything There is a Season

As a psychotherapist and program director assisting gender-variant people, I’m often urged to evaluate and recommend for hormone initiation quickly. Quickly, as in, ‘I can’t wait any longer; I’ve been waiting my whole life’.

Sometimes this pressure comes from other therapists working with clients, making it even more challenging—here I am, slowing down a process which involves two other people without having any first-hand knowledge of the situation myself.

It’s All Relative

Thinking of the various pros and cons of our program’s three-month evaluation period for new patients requesting hormone initiation, I developed the following timeline to illustrate some relative timing for crucial (or at least interesting) life events:

A baby learning to walk 12 months
Replacing 100% cells in human body 11 months
Gestating a human 9 months
One year of public education 7-8 months
Driver’s Education (Michigan) 6 months
One college semester 4 months
Evaluation for Hormones 3 months
Average annual television viewing 2 months
Average annual Internet usage 2 weeks
Slow-cooking a pot roast 8 hours
Watching a televised college game 4 hours


Faster Than a Semester in College, Slower Than a Pot Roast

For a gender-variant person, initiating hormones can be a significant event that demonstrates forward motion. It is similar to the experiences of coming out to family and friends, beginning to live as one’s destination gender, looking into legal name changes, and dealing with the inevitable questions. Starting hormones is a moment in time to be marked—it is technically the physical beginning of transition.

To rush the stage prior to hormones is to lose some important transition experiences. There is a unique quality to the social and emotional transition period which will never return once hormones are underway.

Similar to early childhood years, when life is fresh and new and exciting every single day, pre-medical transition is infused with the sweetness of ‘firsts’—the first time one is referred to by correct pronouns…the first time Mom uses one’s newly chosen name…the first trip outside dressed in the right clothes…the first time looking into the mirror and seeing the person one is meant to be.

Simply put, these experiences are not to be missed. They are an important part of one’s transition narrative, and to skip them in a rush to hormones is to lose something very, very precious.

That is why we recommend three months, and that is why I hope all transitioning people and their therapists will agree.

“The longer the waiting the sweeter the kiss”…it is a lovely tune, and an important message.

Informed Consent…and Thoughtful Consideration

NOTE: The opinions expressed here are only the writer’s, Nancy Quay, LMSW.  They are not meant to reflect any official statement from the University of Michigan Health System (UMHS) or the UMHS Comprehensive Gender Services Program (CGSP).

Informed Consent for Medical/Surgical Treatment

The Informed Consent model of care, growing in popularity and availability in the transgender health world, is based upon a common assumption that individuals can be—in fact, should be—responsible for their own healthcare decisions.  It is a medical model that grew throughout the 20th century, in part caused by legal action taken by patients against physicians.

An excellent article on informed consent was written by Hana Osman in 2001 and I encourage you to read it.  It is critical that we understand the history as we embrace change within the practice of transgender healthcare.

Informed consent for transgender patients is currently in practice in many places, and is being debated in others.  There are many arguments in favor of gender-variant people having access to the medical and surgical care that will bring them into congruence and enhance their lives.  The recent and appropriate shift from ‘Gender Identity Disorder’ (placing the problem within the patient) to ‘Gender Dysphoria’ (placing the problem within society) is an indication that the field of transgender healthcare is a rapidly evolving landscape.  Personally, I applaud many of the changes and also the larger conversation about the importance of serving the needs of our transgender citizens.

So where is my hesitation?

Addressing the Binary

The issue of binary genders is often brought up in discussions of gender variance.  Having only the choices of male/female, masculine/feminine, and boy/girl is restrictive, and robs many people of the freedom to live more fluidly.

But here’s what catches my attention—in the 16 years I’ve worked as a social worker and psychotherapist with transgender people, while many of my clients have commented on the restrictions of binary gender, those same people have moved from one end of the spectrum to the other.  That is, people assigned male at birth have become women; people assigned female at birth have become men.

See the problem?  It is still a binary designation, they’ve just moved from one side to the other, most usually with the help of medicine and/or surgery.

Do we live in a binary world?  Absolutely.  Gender is seen that way but there are other dichotomies as well—adult/child, teacher/student, therapist/client, doctor/patient, Republican/Democrat, and many more. 

The REAL Binary

However, I believe the real binary category is between SELF and OTHER…that these designations are the foundation of all other binary categories.  For example, the designation between ‘self’ and ‘other’ is the basis for many of the wars fought around the globe.

You are you.  I am me.  To you, I am the other.  To me, you are the other.

And therein is my personal issue with the model of informed consent for gender transitions.

There is No Vacuum

No one, NO ONE, transitions in a completely ‘other’ free environment, even transgender people who have no family, no close friends, no employer, etc.

We live in society.  We are surrounded by ‘others’ all the time.

All of us have ‘others’ in our lives.  It might be the person who walks his dog by our house and knows our dog, even if he doesn’t technically know us.  If we transition and change in looks or behavior, he will notice.  It might be the mail carrier, who notices our name change.  Perhaps it’s the grocery clerk who notes a change in our appearance and maybe even a change in what we buy to eat.

Does it matter?  Maybe, maybe not.

But the trouble with the informed consent model is that the question—does it matter? — is never asked.

What is asked?  Well, here are a few: are these medications safe for me?  Can I tolerate any side effects?  Do I understand the risks?  Am I prepared to take the medications on a regular basis?  Am I taking full responsibility for the effects of these medications on my body?

Too many people, daunted by the prospect of explaining their gender concerns to others, feel that medical and/or surgical transition will force acceptance.  That is, if one doesn’t want to hear dad’s disappointment, mom’s fear, or sister’s distress, just don’t tell them until after breasts develop, or voice deepens.  It will still be a battle, but the outcome will be pre-ordained, all of the good, but also all of the bad.

Informed consent allows this to happen.

Without a chance to talk to a professional—someone with no vested interest in one’s answers who has heard hundreds of stories from transitioning people—what about the other questions?

For instance: am I prepared emotionally for the change in my appearance? Am I prepared socially for how that might change my status in the world? Am I prepared for negative reactions to the changes, which may affect my job security, my social life, or my emotional and physical safety?

These are crucial questions.  A transitioning person who has limited or no opportunity to explore the full ramifications of their physical and emotional changes with a caring and supportive professional is at risk for negative outcomes.  And I don’t believe that is anyone’s goal.

Thoughtful Consideration

The informed consent model, with all of its strengths and weaknesses, is here already.  If it isn’t in your neighborhood, it will be soon, and in many, many ways transgender people will benefit from it if they are within the care of knowledgeable and compassionate medical providers.

But I encourage everyone—providers, patients, caring ‘others’—to thoughtfully consider all the ramifications of gender transition, not only for the person experiencing it but for society at large.

If we are to offer this service to our transgender citizens, we must also offer everyone else a chance to learn and grow about gender variance in a non-judgmental environment.

It won’t be achieved by forcing ‘others’ to accept the new ‘self’.   And it won’t be achieved by implying that gender transition is trivial, or doesn’t matter.

So What About Everybody Else?

In my work with gender-variant people, I often get the chance to talk to partners, spouses, parents, children, siblings, and sometimes even grandparents. Usually, I’m meeting with one of these people because they are struggling with a transgender family member’s disclosure.

These conversations are among my most satisfying. Why? Because the simple fact that we’re talking indicates that someone is truly trying to come to grips with this life-changing revelation.


Disclosing one’s gender identity is an important step in the process of transitioning. It is part of accepting and consolidating the new gender, making others aware of one’s (usually) new name, and new pronouns to be used.

But, it seems to me that disclosure to close family members is often done with some expectations on the part of the person disclosing. The expectation being that the recipient of this news will quickly accept the new gender identity, and embrace all the changes still to come.

Understandable, yes, that a person about to undergo such an enormous life change as transition would like to have close family members ‘on board’. But it is necessary? Is it even fair to expect?

It’s easy for transitioning people to forget how long they have spent pondering their gender identity, questioning how they want to pass through the world, investigating what it will take emotionally, financially and physically, and what it will mean to transition.

For family members who are learning of this for the first time, it is crucial for the transitioning person to allow them at least as much time to adjust to the idea and adjust accordingly as they have spent adjusting and accepting.

Must They Vote?

By Szczepan1990 13:39, 22 July 2006 (UTC) (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 http://creativecommons.org/licenses/by-sa/3.0/)%5D, via Wikimedia Commons
By Selena Wilke (Own work) [Public domain], via Wikimedia Commons

One point of contention I hear about most often is that family members hear about the upcoming transition and perhaps passively accept it, but that they don’t necessarily approve of it.

My opinion is that family members do not have to approve of someone’s transition, and in fact, the Transperson who insists that all agree is not ready to take such a crucial step forward.a

That is, if one is secure and steadfast in their gender identity, and is fully prepared to move forward and deal with all of the joys and challenges of this step, they won’t need to have 100% acceptance and participation. Because that’s real life, right? We do things we believe are right and hope that those close to us agree, but if they don’t, it’s okay. Our relationships are much more complex and interesting if there are points on which we do NOT agree…relationships that are always in complete harmony are actually a little dull.

Tasks and Responsibilities

What I do believe, is that it’s critical that families continue to love and have open hearts toward transitioning members, even while not fully understanding or being ready to embrace this change.

Every family has its own dynamics about members who are ‘different’ in some way. Some families make the necessary adjustments and discuss it thoroughly, some adjust but never discuss it, some resist any change, and some openly challenge the change. My experience is that families handle news about gender identity in exactly the same way they handle any big or unsettling news or announcement about any family member! We humans are pretty consistent.

Honesty and openness without expectation of immediate acceptance is the task of the transitioning person. Love and an open heart is the task of the family member.

Together, I believe a new ‘normal’ can be achieved, and I’ve seen it happen for others…it can happen for you, too.

Why Therapy Matters

I talk with a lot of people who call about services from our gender program, and many of them express annoyance that our program requires talking to a therapist before medically or surgically transitioning.

It is natural to question why programs like ours require this step. As the client, you ask yourself if the expenditure of time and money is worth it. What will time spent with a program psychotherapist provide for you that you don’t already have?

This is a serious question and deserves a serious response.

What Therapy Provides

Psychotherapy helps with many things, but one in particular is learning what is important
to you, and how to make decisions that follow and support your values. Could there be a more critical time than as you begin to transition to be making decisions based on values? I think not.

Who should you tell about your transition plans? Should you tell an employer before you take a job? Before or after a promotion? Should you tell extended family, children, neighbors?

How do you make those decisions if not from your values? For example, telling others of your transition…what is the impact on your partner or children? Jumping fully into living in your destination gender might sound like a great idea, but what will it do to your family? They are part of your life…do they deserve a vote on when and/or how you go about this process?

And what is your decision-making process? What kind of a communicator are you? Are you an extrovert (likely to think through decisions aloud with others) or an introvert (likely to consider possibilities quietly before involving others)? Are you someone who surrounds yourself with people who only agree with you, or do you welcome dissent? And if others disagree with your decisions, how do you go about resolving them?

Psychotherapy can help you to think through all of these questions.

The evaluation and assessment portion of our process helps you sort these things out…on-going work with your therapist will support you as you disclose to others and must deal with all of the consequences of those disclosures.

So yes, therapy matters in the process of transition. Therapy helps you know yourself. Therapy provides a place where you can consider all options with someone who supports you but is not vested in any particular outcome. Therapy is a safe, confidential, neutral time where you can explore your options before you make decisions.

And investing in you is always a good investment—not only for transition, but for life.

Labor Day…or Day-of-Labor?

I’m going to stretch the topic a bit. Instead of talking about the U.S. celebration of workers (see http://www.dol.gov/opa/aboutdol/laborday.htm for great information about this important holiday), I’m going to consider those days-of-labor that parents endure for the sake of adding a family member.

I’m going to further extend this to include all people who raise children. Because whether your ‘labor’ was to give birth to a biological child or your ‘labor’ was the emotional/logistical/financial effort to adopt a child, it all counts.

Once you’re a parent, you’re a parent, regardless of how that child arrived under your roof. Once that child is under your roof, you will always and forever be their parent, regardless of who they are and who they become. You are responsible for their development and growth as a human being. Which then raises the question–what does it mean to be a parent to a gender-variant or transgender child?

The UMHS Gender Services program holds a monthly support group for parents/guardians of these special children. Whether your gender-variant child is 3 or 33, there are particular issues which need to be addressed as you move through your lives together.

Here are the top three issues:


How did you find out your child is transgender?

This matters when it comes to acceptance. How did you discover this about your child? Were you blind-sided by an announcement or did you discover your child’s gender variance by accident? Had you noticed throughout your child’s lifespan that something was different about him/her, that she/he struggled with self-acceptance and/or the acceptance of peers?

When parents have a ‘heads-up’ of noticing gender variant behavior, the announcement comes as less of a shock and more of a confirmation, which is far less stressful overall.

So if you found out suddenly, by ‘accident’, or were otherwise taken by surprise, give yourself a break and some time to adjust. Remember, your child has been thinking about this (and dealing with it) for a long time. It’s okay if you don’t immediately jump on the bandwagon and become an advocate for transgender rights, it is more important that you take the time you need to learn and grow.


Now that you know, who do you tell? This is one of the top questions parents of gender-variant children face, and people deal with it in various ways.

What our kids don’t understand—and what is difficult to let go of as a parent—is that through their lives, we’ve watched them go through many, many ‘phases’. The reaction that gender variance is a ‘phase’ is exceedingly annoying to transgender children of any age (but the older the child, the more annoyed they tend to be).
The initial belief that the child’s transgender feelings are another phase can lead parents to hide, either consciously or subconsciously, the changes that are happening, both within the child and within the family.

This is a good time to employ the secrecy/privacy test: something which is ‘secret’ has the capacity to harm someone, either the person keeping the secret (by not telling it) or the person or people who don’t know the secret (by not hearing it). Something which is ‘private’ doesn’t hurt anyone…it is simply a fact about an individual that is their business and theirs alone.

Therefore, as an example, the test of information about your transgender child is this—sending your young child to school ‘stealth’ (that is, dressed contra-gender) without an adult at the school knowing is a dangerous secret. The child could be harmed by this, physically or emotionally, if discovered by other children, and it’s absolutely crucial to have an informed and compassionate adult on-site at school to help.

However, how ‘far’ your child has gone in transition (dressing? hormones? surgery?) is no one’s business but your child’s and yours. This is an example of private information. No one is harmed by keeping this information within good boundaries.


What do you do when your child tells you they feel gender-variant?

The answer depends on so many factors that there is not one right answer, but the first step is to learn all that you can.

If you’re a person who learns by reading other’s stories, Rachel Pepper edited a wonderful collection of essays by mothers of transgender and gender variant children. It’s called Transitions of the Heart and was published in 2012.

If you’re a person who learns by talking with others, consider joining a parent’s support group to have the opportunity to hear from parent ‘experts’ how they’ve dealt with their own transgender child.

Finally, you can talk to trusted others in your lives—friends, family, religious leaders, and medical practitioners. Many people will know nothing about this topic in particular—transgender health—but if they care about you and your child, it’s a place to start to regain your equilibrium and decide how to move forward.

In closing, let me share this: I often say to people that there are few emergencies in the gender variant world, and by that I mean, you have time to begin to deal with what your child has disclosed.

Love, support, an open mind and an open heart will lead you and your gender-variant child in the right direction, even if you have no idea where you’re really headed.

Best wishes on this Labor Day, and let the Gender Services program at University of Michigan know how we can help.