Land of the Fluid: Gender Identity and Gender Expression

What every therapist should know about gender identity and expression.

Posted Jul 26, 2019 | Reviewed by Abigail Fagan

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Gender identity and gender expression are complex terms that often confuse even the best therapists. At best, these are highly personal and often perplexing issues, with societal mores and understanding in constant flux. With that in mind, I have provided some basic definitions and discussion below, knowing full well that this material may not be entirely accurate tomorrow.

Gender Identity

The quick definition of gender identity is the degree to which a person self-identifies as male or female (or something in between). Gender identity can differ from a person’s biological gender at birth, though often it does not. The term for individuals whose birth gender and gender identity match is cisgender. The term for individuals whose birth gender and gender identity do not match is transgender. If you were born with male genitalia and self-identify as male, you are cisgender. If you were born with male genitalia and self-identify as female, you are transgender. The term for Individuals who do not identify as male or female, regardless of genitalia, is non-binary.

Gender identity shows up relatively early in life and is fundamentally fixed over the lifespan. Children as young as five will talk about gender identity issues, saying things like, “Everyone thinks I’m a boy, but I don’t feel like a boy.”

Consider Jack, a 14-year-old biological male with a loving and healthy family. He enters therapy because he hates his penis and wishes he didn’t have it. In his initial interview, Jack reveals that he has been wearing his mom’s dresses and shoes for as long as he can remember. He also states that his feelings of not wanting his penis started with puberty. He hates his body hair and deep voice, too.

At school, he wants to spend more time with girls than boys because he can be himself with the girls. He says he would like to have gender reassignment surgery to become female, but he feels romantically and sexually attracted to girls rather than boys. He says that when he physically becomes female, he will still be attracted to girls.

Gender Expression

The quick definition of gender expression is the degree to which society might identify a person as masculine or feminine (regardless of that person’s biological gender and gender identity). In many ways, gender expression is related to stereotypes about gender identity and gender roles. Typically, gender expression reflects a person’s gender identity, but not always. If a self-identified male is perceived as macho, his gender expression matches his gender identity. If he is more feminine, his gender expression might be described as gender non-conforming.

Some people express themselves via a mix of masculine and feminine traits; these individuals are referred to as androgynous, gender fluid, or undifferentiated. Often, it is assumed that feminine and androgynous men are gay and that tomboyish or androgynous women are lesbian. In actuality, gender expression and sexual orientation are unrelated. Gender expression is not always fixed over the lifespan. Some people choose to disguise the style of gender expression with which they are most comfortable to avoid stigma – effeminate men acting more masculine, masculine women acting more feminine.

Consider Alexander, a 42-year-old cisgender male with a successful interior design business. Alexander is very feminine in appearance and tone, speaking in a quiet manner about creative endeavors that fascinate him like fashion, theater, and the arts. He adores his wife Melissa, with whom he has two great kids. He has almost no physical attraction to males and strong physical attraction to females. In therapy, he says he feels misunderstood and wrongly labeled as gay or bisexual by people who assume that because he’s not overtly masculine he must be sexually attracted men. He wants to know if he should change how he behaves, or if it’s OK to be himself.

Treatment: Who Needs What?

When clients enter treatment with ego-dystonic (unwanted/undesired) gender identity or expression, our role as therapists is not to accept the presenting concern as being a problem. Rather, our job is to help these individuals explore what they feel and desire without judgment. Then we must work to help them understand and accept those thoughts and feelings as a healthy and normal part of who they are, no matter what their family, friends, religion, and society at large choose to say.

We must also help these individuals understand that gender identity is not automatically the same as gender expression, and neither gender identity nor gender expression is automatically indicative of sexual orientation. These are entirely separate facets of human experience. A person born as a biological female may self-identify as male (gender identity) and present to the world in masculine ways (gender expression). This individual might be sexually and romantically attracted to females, males, or both (sexual orientation). And this person may or may not be interested in gender reassignment surgery.

So, yeah, there can be a lot to learn and process in therapy. But such clients should never be told that what they are thinking, feeling, and desiring is wrong or pathological.

Whatever the issue – gender identity, gender expression, or even sexual orientation – therapists must understand that gender identity and gender expression (and sexual orientation) are relatively fixed. A person can choose to hide who he or she is, especially with gender expression, but that person cannot change his or her core sense of self. No amount of talk therapy, aversion therapy, prayer, or any other tactic will make a sensitive boy feel comfortable being butch, or a person who self-identifies as male feel comfortable as a female, or a gay man straight.


    Gender Expression Video on YouTube  What Not to Say Video on YouTube American Association of Sexuality Educators, Counselors, and Therapists (AASECT) LA Gender Center Society for the Advancement of Sexual Health (SASH) Society for the Scientific Study of Sexuality (SSSS) World Professional Association for Transgender Health (WPATH)