Identity disorders – not just transgender

Russian version/Русская версия

Disclaimer 1: All conclusions are based on indirect evidence, intensive questioning of random individuals, and other hints and whispers on a corkboard with strings. I’ve done everything I could to account for all possible failure modes of drawing conclusions from anecdotal evidence, but of course, all of this could turn out to be simply untrue if I made a mistake somewhere along the way



Disclaimer 2: All quoted statements are taken either from publicly accessible spaces or with the authors’ permission. In cases where permission was not obtained, I refer to the case using generalized phrases like “there’s this guy”



Disclaimer 3: The text contains a lot of creepy shit, trigger warning and all that



With all this SJW-pronoun-twitter-culture-war around trans people, we are forgetting the biological and psychiatric basis of the phenomenon. However much you insist that it’s not a disorder, that gender is a social construct, that transgenderness is not defined by dysphoria, etc. – dysphoria exists, it has obvious psychiatric consequences, and there must be a reason for it. DSM-5, the closest thing we have to a medical consensus, keeps awkwardly denying that it’s a disorder before bringing up symptoms and treatments. The reason is clear – it needs to say that medical help is good, but stigmatization is bad. Commendable, but it complicates the discourse.



Well, I’ve never been afraid of being offensive and politically incorrect, and as a trans woman myself, I have the n-word pass, so let’s get to it.



Derealization and ‘henshin’



The core symptom of gender dysphoria is derealization, the rest is commentary. If you need a full description, go here, this page is true to my experience.



Some notable quotes:




A feeling of just going through the motions in everyday life, as if you’re always reading from a script. Everything always seemed like it was somehow less real than it ought to be. I didn’t feel like I was my own person — I had no sense of myself as someone who could make my own choices and decisions as I wished. I often lacked that internal initiative that wants things and seeks things for no reason other than the fact that you simply want them and that’s that. Since I didn’t want to do anything, I just did whatever was expected of me and said whatever was expected of me. That was all I ever did. I felt like an actor, being handed my lines by someone else, and I didn’t know how to be anything other than that.





Complete lack of motivation, very discouraged and bleak. Can’t care about anything. … Can’t summon the willpower to ‘be a person’ to people, feeling sort of like a wall that provides yes or no answers. Nothing seems important. A feeling of disconnect from myself, as if my mind and body are two separate entities. My day-to-day goals hold no weight in my decision making. … Nearly all the time I feel generally apathetic to things, my external reactions are more of a formality than what I actually feel about something. A faint feeling that I’m acting like a person as if it’s a social requirement?





In that state, I was a dispassionate observer of my own life. The person who went through the motions wasn’t the observer-me. Whenever the acting-me felt any emotions, the observer-me recognized the emotions but didn’t feel them herself. Furthermore, the observer-me had complete control over the acting-me in the sense that the observer-me could deliberately detach any part of the mind so that neither of the selves could access it.





I was never really present in my life. Everything was grey, foggy, and not really there. Nothing really got through to me. Eventually I ended up talking to myself a lot in my head and eventually felt like I was two seperate people.





It’s almost impossible to explain. But it’s so destructive. It’s the worst. It stops us dead: it’s the dysphoria that comes along and fucks everything, undoes the hard work, undermines our confidence, undermines our identities. It pulls the rug out from under our personal realities. It’s actual hell.




And here are some testimonies on post-transitioning:




It was possible to feel things in all their detail and depth and texture, rather than being limited to either numbness or emotional overload. The skin of separation was gone, and life was a breeze: I was just happy, all day, without constantly intrusive thoughts distracting me and separating me from the world. I can truly care about everything I choose to work towards, because it matters now. I’m the normal person I always wanted to be, and I can get on with simply living. Finally, I was a whole human being. Nothing was wrong and nothing was missing anymore. I found what I was looking for, and it gave me back the life that dysphoria had taken from me.





Last June 14th, I went under anesthesia for 6 hours and woke up with a vulva. It was 7 pm. On a Tuesday. The first text I sent was to my partner. Very simply, it read “I’m alive. I love you, and my brain is just … quiet”
I spent 23 years “in transition”. I spent a lot of that time convincing myself that I was okay. That I was okay with my body, okay with my penis, and okay with receiving the type of love I accepted because of those things. But when I woke up, my brain was quiet - and even 14 months later it’s hard to put into words, but it was like white noise that I somehow learned to ignore, but when it was gone was really the first time I realized that it had always been there. I just felt … different.
Everything is beautiful, and I have not thought about harming myself or have had a bad day since last June 14th. Bottom surgery not only changed my life. Bottom surgery saved my life.





I’ll be two years post-op in three months. I have never been happier. I knew I’d be happier after surgery, but it really took a look backwards afterward to realize how much dysphoria my natal genitals caused me. Now, that dysphoria is GONE. Now, I absolutely cherish who I am. Now, I can just not think about it. Let’s be clear: the first few hours awake after surgery were as much pain as I have ever known, but even that never occasioned a single instant of regret. Zero. Zip. Nada. Nihil. The first three months of recovery were memorable for the challenge and a bit of discomfort. Still: ZERO regrets. Given a chance to turn back the clock, I would make the same choice every time, the only difference being that had it been possible to do it sooner, I would have.




In my case, I got to savor the contrast between two conditions very clearly. Most of my life derealized, about 6 months in more-or-less-real, then back out. And I don’t call this “henshin” for nothing – it’s two different worlds, two different people, one weak and pathetic and unstable; the other powerful and tenacious and, dare I say, maybe even happy. It’s not just “I like this gender better” – those are real and strong psychiatric symptoms that you can’t miss, can’t ignore, and can’t fake. Where do they come from, how could such an ephemeral thing as gender affect a person to the extent many drugs couldn’t?



Most hypotheses focus on biological sex. They say that hormonal imbalance in the womb may make sex differentiation go different ways in the body and in the brain. They say some brains work better on testosterone and some work better on estrogens, and compare dysphoria to fueling a car with the wrong type of fuel. I, myself, linked somewhere a video of a biologist explaining structural differences in brain areas that can’t be changed hormonally or surgically, and pointing out that in trans people, they correspond to their chosen genders – a literal male brain in female body or vice versa.



Well, they’re all wrong, I Defy the Data. Sex differences are red herrings that have nothing to do with gender dysphoria.



It just doesn’t add up



While investigating my own ups and downs – what made me feel so much better only to later get so much worse? – I found plenty of inconsistencies in the narrative, none of which are a smoking gun, but when taken together make me notice I am confused.





The key to the answer



My tastes are… unusual, and they led me to unusual places where I found an unusual disorder – Body Integrity Identity Disorder. Those guys really want to be disabled. Here’s a story of a woman who always dreamed of being blind, successfully blinded herself, and then she was very happy and told everyone how awesome it is to be blind.



Over the last year, I made a lot of friends among them. They hide, fear stigma, routinely get banned from social media, and live in their own private spaces, where they share their suffering. And one thing that becomes very obvious very quickly – that it’s the same thing as transgenderness.



100% the same. Transgender people with BIID are very common, and they all say that their desire to be, say, a woman, and to be, say, a paraplegic, are the same desire that feels exactly the same. And cisgender people suffering from BIID describe their dysphoria in such a way that I can obviously see how their relationship with disability is the same as my relationship with gender.



Same derealization.
Same fits of dysphoria and euphoria.
Same envy upon seeing the desired traits in other people.
Same trek from denial to acceptance.
Same fantasy scenarios.
Same fixation not only on biology, but also on trappings like wheelchairs.
Same absolute enlightenment when they get what they want.
Same no-regret attitude despite sacrifices and hardships.



SAME. EXACT. SHIT.



So the question is – should transabled people be allowed to participate in the paralympic games? But first, let’s figure out the nature of the connection between transgenderness and BIID.



Same as with transgenderness, people offer organic and neurological explanations. They track it down to deficiencies in the somatosensory cortex, or point out the difference between galvanic skin response below and above the desired line of amputation. They often connect it to the “body map”, saying that phantom limbs are when there is no limb, but the brain expects it to be there, and BIID is the opposite.



When I interrogate those people more thoroughly, they admit that it only explains amputation disabilities and not, say, sensory disabilities. Same energy as “I don’t know how nonbinary brains work”. And while in case of gender there may be a common factor that explains all that away, with BIID there is no way that this disorder has a common organic cause. Because the range of desired disabilities is just too wide.



Amputation. Blindness. Deafness. Paraplegia. Quadriplegia. Mutism. Cerebral palsy. Locked-in syndrome. There are even people who want to stutter! The only thing missing is mental disabilities, but other than that, BIID covers disabilities with completely unrelated etiologies. If they want amputation, okay, reverse phantom limbs. If they want paralysis below waist, maybe there’s something with their leg nerves. Deafness? Maybe sensory sensitivities, makes sense with autism. Stuttering… eh… something something vocal cords. But inventing a new explanation for every new case can only get you so far, after a fifth coincidence you should notice a pattern. Something is going on with the phenomenon of disability regardless of the organic causes of the disability.



Interlude – a look into BIID





Some quotes:




Sometimes I feel like just killing myself instead of dealing with these thoughts. But then I figured I’d rather be deaf than dead. It’s such a weird train of thought





I see overcoming a spinal cord injury as kind of a coming of age or right of passage for me because its like my true life will begin when I become a quadriplegic. I feel like I will be complete living my true life then. I guess to me there’s kind of a mystique of living a completely different life in a way that is totally visible to everyone around me.
I love the ways people can use adaptive equipment. I want to be seen driving my wheelchair with a sip and puff controller. I want to learn how to use a computer with a mouth operated mouse or eye control or voice commands. I want to learn how manage and direct the day to day cares of life with quadriplegia like managing pressure relief and pain meds or incontinence management.
I like the idea that people in public will know I’m living a different lifestyle but also that I need these extra things. I want people to see me being hand fed and know that I need to be dressed and bathed by carers.
I also like the idea of the kind of non sexual intimacy that would be with those cares. I can’t explain why that’s so appealing to me but I dont like sexual touching and would permanently give up any chance at sexual pleasure to need that kind of attention.





For me my BIID feels like non stop suffering.
I would consider myself passively suicidal at worst, because there are often times where I feel no will to live, but don’t actively pursue taking my own life. I have no hope for living and sometimes wouldn’t be bothered if I just died. However I also am greatly afraid of death so that is also likely something else that stops me from doing so. At the same time I don’t want to die either, I just see no hope in living most of the time. I bring this up because of the emotional toll my BIID has on me
I mentioned that like what [name redacted] said above that my BIID is a constant and never ending thought that drills into my head that I am not in MY body, the one I should have been born in, that these limbs aren’t mine, they are foreign and shouldn’t be here <…> As well occasionally getting burning or numb feelings in the parts of my limbs that shouldn’t be there. That thought rings constantly in my mind, as if someone is playing something over the loudest PA system that constantly echoes to every corner of my brain. I also mentioned above that my brain seeing the physical body I am currently in, or just feeling it or the limbs that shouldn’t be here hits an intense panic button and sends my entire being into panic mode, like alarms constantly blaring because something is wrong. Of which my mind’s response to that is significantly and intensely heightening my anxiety.





I know exactly what I want, but it’s not painful to have my arms attached to me and I don’t feel like they don’t “belong” to me. Just an overwhelming desire to have them gone.




Back to our transes



There are a lot of trans people among BIID sufferers. At first I thought that it’s because trans people have an easier time to realize that they have BIID. After all, transgenderness is represented way better in the media, it’s easy to realize you’re trans, and once you identify your old feelings as dysphoria you’re five minutes away from also connecting it to disability. But no, it seems like there is an actual comorbidity. BIID sufferers who later realized they were trans are about as common. The math ain’t mathing.



And as you probably guessed, there are a lot of autistic people among BIID sufferers. Schizophrenics are less public about it, tend to speak unreliable gibberish when interrogated, and I strongly suspect that if I had schizophrenic tendencies and my new internet friend turned out to be doing research on me, that would be bad for my mental health in some way. So I leave schizophrenics to real psychiatrists and focus on the autism.



It certainly looks like autism drives a lot of the comorbidity. Which way the causality goes is unclear, but it’s a fact that autistic people often are trans and have BIID. The autistic brain is fixated on identity – and not on invisible biological factors like hormones, but on visible, functional, and social aspects. For gender, this may be pronouns and genital shape; for disability, this is needing assistance and using wheelchairs. And if this desire is not fulfilled, there is dysphoria – the patient doesn’t feel like reality is real and they are a person. As a just-so story, if you are confident that in the depths of your soul you are a girl with no limbs, but in reality you are a boy with a full set, you see the boy as a different person entirely, care less about his well-being, distance from him emotionally, and get derealized. And this has something to do with NMDA receptors.



I’ll get to receptors and hormones a bit later, now, I want to ask the next obvious question – what other identities can cause this? A quick Google shows that transracial is a thing – a person identifies as a different race. Is it the same kind of thing, do they experience dysphoria? Thankfully, Rachel Dolezal, a trans-black woman, wrote a book about her experience! Sadly, Rachel Dolezal, a trans-black woman, is an incredibly boring and basic writer who could take the life of Julius Ceasar and turn it into droning out minutiae. But after exhausting my country’s supply of coffee and reading it, I can say…



…yeah, looks like an identity disorder. It’s one data point provided by a frankly not very intelligent person, so it’s relatively weak evidence in favor. But if other transracial people lived the same kind of experience, then there can be no organic cause for dysphoria. Race as a social construct is way less consistently grounded in biology than gender or disability. The brain fixates on an identity and wants to play the role. Otherwise it doesn’t count.



Identity disorders? Where have I seen that before….



Dissociative identity disorder



Sometimes incorrectly known as split personality. A rare disorder, vulnerable to roleplayers and posers, overmythologised, where can I find this…



…jk jk. In my Malkavian Madness Network I found people with this disorder, and I don’t mean randoms on Discord servers, but personal friends in the meatspace who have no reason to lie to me. People on the plurality spectrum are more common than it seems, it’s just that it’s not always obvious and is often concealed. Normal people have connections in the government, police, or organized crime, and I have connections among the mentally ill. I didn’t choose this life.



I won’t go deep into plurality here, maybe I’ll write a separate post about what and how I learned. But I a) guarantee that this is not roleplaying but actually how this works b) farmed a lot of anecdata for this investigation.



Strong dissociation is horrible, and I genuinely pity the sufferers. My own complaints about derealization, isolation, “reverse solipsism”? Peanuts. On the far end of the spectrum, people basically live in “The Amazing Digital Circus” where everything is made up and nothing means anything. But I found what I looked for. Yes, different alters in one body can have different gender identities, and yes, it very well can be that one identity is dysphoric about the current gender presentation and the other is not. When people talk about how to deal with this disorder and hide it from normies, they often discuss what to do if different alters have different sources of dysphoria. The advice “just say you’re gender fluid” works less well than you would expect, and it seems like gender fluidity is on this spectrum, too – there are a lot of people whose way to discovering their plurality went like “I thought I was gender fluid, but it turned out to be way deeper than that”.



And yes, with strong enough dissociation, new personalities with new genders may appear. Those identities are very powerful phenomena – they can have different personalities, memories (dissociative amnesia), even different psychosomatic illnesses. Often those identities associate themselves with historical or fictional characters, and unlike the classic “guy who thinks he’s Napoleon”, those personalities do not harbor a delusion and understand perfectly clearly that they are just a psychological phenomenon.



What I learned is flatly incompatible with any organic causes. There are no pink and blue brains, any brain can work on either testosterone or estradiol, not having body parts in your schema is either not a thing or is downstream of identity. There is a thing called “identity”, which I will for now define ostensively as “the thing that people with multiple personality disorder have a multiple of”. Whatever those identities are made of, often they include specific social roles – “woman”, “black”, “blind” – and consider them to be fundamental parts of their self-image. If the identity doesn’t match reality, there is dysphoria. For most people, their identity either doesn’t care or matches reality, which makes it invisible. For some, their identity mismatches who they physically are, and that person is constantly derealized, doesn’t consider himself a person, and we call it “identity disorder” – either transgenderness if we’re talking about gender, or BIID if we’re talking about disability.



So what about NMDA?



Our perception works roughly by the Bayes Theorem – combining sensory data with prior hypotheses. Your sensory organs keep sending raw data to your brain (elongated green spot on the table), and your brain combines them with expectations (it’s more likely to be a cucumber than a snake). As long as expectations and data more-or-less match, you perceive their common denominator and see a cucumber. If there is mismatch, the brain alerts you about it, brings it up to your attention, and corrects the expectations (wait, it may be a snake after all). Here’s Scott Siskind’s explanation of this.



The prior expectations are relayed through the NMDA system. Hallucinations happen when NMDA receptors signal so hard that sensory data don’t matter – the brain wants to see the elephant, it sees the elephant, even if senses say there is none. Extend this logic to every function of the brain, and you get schizophrenia – the patient lives in his own isolated world by his own logic and ignores reality. In the reverse case, when sensory data matter a lot relative to expectations, the brain overfocuses on any new sensory data (my tea tastes a bit different than it used to, I expected something else, this is distracting and annoying). Extend this logic to every function of the brain, and you get autism – the patient is overloaded by all the small details in his environment and burns out.



So, this is a bit of an overview for why autism and schizophrenia are both associated with NMDA receptor disfunction. So, what does this have to do with dysphoria?



NMDA-antagonists cause derealization. Inconsistency between the expected and the actual identity causes derealization. NMDA receptors signal the expectations of sensory data. Hmmmmm…



My hypothesis: this “identity” that we’re talking about is exactly your set of low-level priors. The hypothesis about expected sensory data. Somehow your brain can maintain a few independent sets of priors and switch between them.





That’s my current hill.



(Added later:



One of my friends, who is an anesthesiologist, commented on NMDA receptor damage:
Her:




NMDA receptors are a complex and multifaceted thing
And the reduction in their activity is sometimes treated by blocking them
You block them in such a way that they stop reacting to every minor stressor all the time
And after this period of rest they go back to reacting normally to natural stimuli




Me:




I assume this is the way ketamine therapy works?




Her:




Yes, among other things. Sub-anesthetic doses.




)



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