Big Anne’s quiet acceptance of and palpable love for her child are in her mind subsidiary to the splintering of her family following Tony’s transition. She responded to most of the questions I asked her about herself with information about her husband; her effacement of Tony echoed her self-effacement. When I asked how she had felt about Anne’s being gay, she said, “My husband accepted her being a lesbian.” She turned to Tony. “He knows that you should have been a boy, but he still says, ‘Why couldn’t she just stay a lesbian like everybody else?’” Tony said to his mother, “You have risen to the occasion. You come and see me. We talk.” Big Anne sighed and turned to me. “My husband went to his mother’s sister, who’s ninety, and she started crying, ‘She’s still your child. You go see her. You’ll get used to it.’ Then the priest said, ‘Go see him. He’s your son. Tell him that it bothers you, but talk to him.’ But he never did. When holidays come around, I’d like to have all my children with me, but he won’t allow it. He worries that people will think he gave in.” I was surprised that big Anne had agreed to talk to me. Tony had told her to watch an Oprah special about trans kids; she called him and said, “I’ll meet with Andrew, if you like. That was you. I’m sorry. I didn’t know.” Tony explained, “Nobody fuckin’ knew in the seventies. My mother’s a nice lady. She has a good heart. But this is big. Her only two daughters weren’t daughters.” I asked big Anne what her husband would say when she arrived home. “He’ll ask how she is,” she said. “He misses her.”
Tony’s natural hormonal balance—whatever caused him to grow facial hair—has been sufficient, and he does not take testosterone. Like all trans people, Tony is often asked about his genitalia; he takes it as a question about his strap-ons. “A lot of people ask, ‘Do you have a penis?’ My answer is ‘I have five.’ I just go to the next question. ‘Does your girlfriend know you’re trans?’ I’m like, ‘Love is honesty. I’m not ashamed of who I am.’” Tony described being at a Stop & Shop and seeing a woman he used to work with. “She was, ‘Oh, my God! Annie?’ I said, ‘Actually, it’s Tony now.’ She grabs my hand and says, ‘It is not God’s fault that you’re a freak.’ I just said, ‘I’ve never been happier in my life.’ I knew that if I lost it, it would have been, ‘Oh, look at the transguy, what an asshole.’ If you have a positive interaction with me as a trans person, you’re going to think twice about jeering at a transwoman, or doing a hate crime. There’s a purpose to everybody’s life. That’s mine. I want to start a nonprofit to give two guys a year chest surgery. Screw Starbucks gift cards. You want to give somebody a present? Give them a chest, give them a penis.”
A few months later, Tony started a foundation to do exactly that, and he named it after his beloved therapist, Jim Collins, who had died a few months earlier. “He inspired me to be an activist, as I hope to inspire people behind me to be activists, and hopefully the people behind them won’t have to be activists, ’cause it won’t be a fucking issue,” Tony said. When big Anne had confessed, during our conversation with Tony, that she still worried everything was her fault, her son had responded, “It’s nobody’s fault. But I have to tell you that if it was your fault, I would thank you. Because my transition is the best thing that ever happened to me.” Then Tony laughed. He said, “Life isn’t about finding yourself; life is about creating yourself.”
• • •
Natal males who become females are often unconvincing as women when clothed because of their height and the thickness of their bones; however, their postoperative genitalia, sexual response, and urination patterns can be almost identical to those of genetic females. Natal females who transition can usually pass in public once they develop facial and body hair, deep voices, and, in many instances, male-pattern baldness, but their sex organs are noticeably different from the genuine article; most cannot urinate while standing up, and none can achieve a male orgasm. One preoperative transwoman I met said, “These body parts are nice but they’re not mine, and it makes me feel better to know that I don’t have to keep them going forever.” A transman to whom I repeated this replied, “I’m like one of those IKEA sets of furniture that looks great until you realize you’re missing a few parts.”
It takes little injected testosterone to overwhelm a genetic female’s estrogen—about the same amount that would be administered to a male whose body was not producing the hormone. To overwhelm a genetic male’s testosterone is a bigger project. A female whose body is not producing estrogen requires one to two milligrams of estradiol per week to remain premenopausal. A genetic male requires twenty-eight to fifty-six milligrams of estradiol per week to feminize the body. Many endocrinologists recommend that genetic males undergo gonadectomy as early as possible, because such high levels of estradiol create health risks. After gonadectomy, estradiol is effective in much smaller doses.
Most professionals working with trans people follow the Harry Benjamin Standards, which require that the patient live in his or her preferred gender for at least a year and complete a full year of psychotherapy prior to surgery or hormone treatment, and that two clinicians, one a doctor, recommend medical procedures. These safeguards are intended to weed out people at risk of postoperative regret, though many complain that they eat up time when a despairing person could be achieving happiness through a speedy transition. They also protect health-care providers from liability.
For natal males being affirmed as female, procedures may include not only castration and vaginoplasty, but also electrolysis, which can take up to five thousand hours and cost over $100,000; feminizing facial surgeries to reduce the forehead, chin, and jaw; a nose job; a tracheal shave to reduce the Adam’s apple; breast augmentation; hair transplants to conceal baldness; and tightening of the vocal cords. The construction of a vagina is most often achieved through penile inversion. After a space is cleared between the rectum and the urethra, the inverted skin of the penis is used to line the vagina, sometimes supplemented by skin grafted from the stomach, buttocks, or thigh. A second method, rectal sigmoid transfer, uses a segment of the large intestine to create a vaginal lining, which provides natural lubrication and unlimited vaginal depth. The procedure is more invasive, more costly, and can lead to mucus leaking into the vagina. In both methods, the scrotal skin is used to create the labia, and part of the glans, to create a clitoris.
Natal women being affirmed as male may remove breasts (double mastectomy), uterus (hysterectomy), ovaries (oophorectomy), fallopian tubes (salpingectomy), and vagina (vaginectomy), because regular gynecological exams are anathema to most transmen. Surgically constructed penises are expensive and often unsatisfactory, so many transmen opt not to have them, but for those who do, there are two primary methods. In a genitoplasty, the surgeon wraps skin around the hormonally enlarged clitoris to form a penis about the size of a thumb. It maintains orgasmic capability but is not generally large enough for intercourse. In a phalloplasty, a tube of skin is raised up out of the groin or mid-abdomen and attached to the pubis; it looks a bit like a suitcase handle. Secondary procedures augment the blood supply to this flap, and it is cut free after two to four months and sculpted to resemble a phallus. It lacks sexual feeling, but implanted silicone rods or a manual pump can allow an erection. In the most complicated procedure—running at least $100,000—flesh from the forearm, with the blood vessels and nerves that supply it, is fashioned into the shape of a penis, and then, using microsurgery, the blood vessels and nerves are attached to those in the pubis. Such a penis appears most natural and has sensation. In any procedure, a scrotum is constructed by sewing the labia majora together. Urethroplasty—urethral extension to the end of the newly made glans—is a further surgical undertaking. “Think what a complicated organ it is,” Norman Spack said. “It’s amazing it works at all, and the human species depends on it.”
Prepubescent transgender children with supportive families may avoid some physical difficulties of transition through the use of hormone blockers, which suppress puberty. This therapy may start as early as age ten for gi
rls and twelve for boys. Lupron, the most common of these GnRH inhibitors, was developed thirty years ago as an alternative to surgical castration in the treatment of androgen-dependent tumors; because it is associated with decreases in bone mineral density and compromised memory, it requires careful monitoring. The treatment effectively buys families time; if the child is indeed transgender, puberty blockers can save him or her from going through the “wrong puberty” and may obviate many surgeries in later life. Girls administered Lupron do not develop breasts, widened hips, female fat distribution, or active ovaries. The estrogen surge that limits female height does not occur for them, so they grow tall. Boys administered Lupron do not develop facial or body hair; their voice does not deepen and their Adam’s apple doesn’t grow; bones do not thicken, shoulders broaden, or hands and feet enlarge. Estrogen supplementation, which closes the growth plates, can be timed to limit their height.
The essential androgyny of childhood can be prolonged. If someone goes off Lupron without starting cross-sex hormones, the deferred puberty of his or her natal sex will begin within a few months and will follow its natural course. Cross-sex hormones will initiate the puberty of the person’s affirmed gender. None of the children in the original, Dutch protocol to study this practice has chosen to revert to natal gender, and most have stayed on GnRH inhibitors until they obtain gender reassignment surgery between eighteen and twenty-one. Lupron delays certain events, but it is also an event itself, heralding a profound transformation. There is concern that starting children on blockers will cause some who are just going through a phase to make it permanent; they may be too embarrassed, scared, or confused to revert if they think that they’ve made a mistake.
In Britain, where reassignment surgery is covered by the National Health Service, particularly conservative policies on hormone blockers prevail. The Gender Identity Development Service at the Tavistock Clinic requires patients to progress through most of their natural puberty before allowing them to transition. Domenico Di Ceglie, the team’s child and adolescent psychiatrist, reports that 20 percent of adolescents treated at his clinic choose to forgo medical intervention after completion of puberty. The underlying modernist fallacy here is that doing nothing is not doing something—that slowing transition is cautious, and accelerating it is rash. Rushing a child into a transition in which he will psychically or medically be trapped for the rest of his life would be a terrible mistake; however, forcing a child who is firm about his own identity to develop a body that will never match who he knows himself to be, even after multiple, expensive, traumatic surgeries, is equally troubling. The Tavistock model of prudence contains marked cruelty.
In the United States, these are family problems rather than national policy. “Parents say, ‘I’m not ready to deal with this yet,’” Stephanie Brill said. “But they are dealing with it. Badly.” Spack said, “Those who oppose puberty blockers complain of the young age at which we make this ‘intervention.’ I would argue that puberty itself is the most noxious intervention possible.” Use of Lupron for gender dysphoria is seldom covered by American insurance plans, and its prohibitive cost creates a class divide between transgender youth whose parents are willing and can afford it, and all others. Likewise, there is a generation gap. At trans conferences I attended, older people would weep openly when they met children who would never have to “walk this earth as their genetic sex,” as one put it. Shannon Minter—civil rights attorney, legal director for the National Center for Lesbian Rights, and himself a transman who did not have the benefit of Lupron—spoke of these young people as “a kind of superclass.”
What did transgender people experience in the past, when they could not alter their bodies to harmonize with their identity? What will transgender people experience in the future, when surgery becomes more refined? These questions are both technical and teleological. Minter acknowledged, “The idea that in order for a child to express his or her authentic identity there has to be a dramatic physiological intervention challenges our most foundational ideas about authenticity and self-identity. It can feel like a technological madness.” One has to wonder whether it is more of a technological madness than the cochlear implant. Many people outside these horizontal identities class that intervention as a way to normalize an abnormality, and this as a way to indulge one. It is instructive to note, however, that whereas the protest against cochlear implants comes from the marginal identity group, the demand for trans surgeries comes from the marginal identity group.
• • •
Jennifer Finney Boylan has written two books that deal with her gender switch and has held forth about gender identity on All My Children and Oprah. When I asked whether she hoped to be perceived as female or as transgender, she said, “On a national stage in front of twenty million people, I’m happy to be trans. On a day-to-day basis, when I go into a store, restaurant, or gas station, I want to be read as a woman. I refer to myself as female, knowing that female includes Britney Spears and Barbara Bush. Look at Julia Child! I’m certainly as feminine as Julia Child.”
I visited Jenny, then forty-nine, in her mother’s house on the Philadelphia Main Line. Her old room looked like a boy’s room—banged-up furnishings, rock-and-roll posters on the walls. She showed me an adjoining storage room. “Back in the day, there were girls’ clothes in here, my mother’s, my sister’s,” Jenny said. “I could grab whatever was on the back of that door.” Jim Boylan always knew that he was female, but he also knew that his transition would be painful for others. “So, I thought, if I can make the guy thing work, let’s go for that,” Jenny said. “It took until I was almost forty before I saw that I’d gone as far as I could, forty-four before I had surgery. Rather than wishing I’d gone through transition earlier—if it’s about wishing—I wish that I’d been born female. Here I am, a grown woman, but I have a boyhood. If I ever feel lost or melancholy, it’s because I can’t see my life as a whole, I can’t figure out how I got here from there.”
Becoming Jenny entailed a truckload of surgeries: vaginoplasty; a procedure in which her face was peeled down so her skull at the brow level could be shaved to give her a more plausibly female look; a reduction of her Adam’s apple. “The surgery turns out to be easy,” she said. “Nothing is cut off. The neo-vagina looks like it’s supposed to and does what it’s supposed to; the plumbing works and so does the electricity. I’ve been to doctors who didn’t know and couldn’t tell.”
Jim Boylan was married, and his wife, Dede, chose to stay in the marriage, though she once said to Jenny, “Every success you have as a woman is a failure for me.” They have two children together, fathered when Jenny was still a man. “Dede is a straight woman who’s the center of my life, and yet she’s not attracted to me,” Jenny said. “Everyone always says Dede is this great saint. Does it betray a complete lack of humility to say that she’s lucky to be married to me because I’m a nice person and I love her and I’m a good parent to our children? All kinds of things happen to families. Children get cancer. Parents have car accidents. Families have to move to Texas. This has involved some heartbreak, but life does that anyway.” At six and eight, Jenny’s two sons decided that they couldn’t really call her Daddy anymore. They already had a Mommy. So they announced that they were going to call her Maddy. When Jenny last did Oprah, her older son wrote a letter that was read on the show. It said in part, “Sometimes it’s true that I wish I had a regular father. Most of the time, though, I feel like I am the luckiest kid on earth. I cannot think of a way in which life could be better.”
Transition is a change of identity for the person who goes through it, and also for all the people who surround that person. “I’m glad for my story to be a public narrative where things worked out,” Jenny said. “You know, boy meets girl, boy is girl, girl meets girl, girl stays with girl. That age-old tale. The biggest change for me is not going from male to female: it’s going from someone who has a secret to someone who doesn’t really have secrets anymore. It’s unimaginably difficult to kno
w that other people consider your fondest of dreams and greatest of sorrows (a) incomprehensible and (b) hilarious. A double life is exhausting and ultimately tragic, because you can’t ever be loved if you can never be known.” People often question a trans person’s authenticity in his or her affirmed gender. “I call myself a gender immigrant,” Jenny said. “I’m a citizen of this land of women. But it is true that I was born somewhere else. I came here, and I got naturalized.” Jenny laughed slyly. “Or unnaturalized, as the case may be.”
In the summer of 2000, Jenny decided to tell her mother, who was then eighty-four years old. “I thought Mom was going to be resilient,” Jenny said. “But resilient means that someone snaps back after a blow, and I was aware that it was going to be a blow. She was bewildered, so I started to explain it, and I began to cry.” I met Hildegarde Boylan when she was ninety-one, and as we all sat together, she said to Jenny, “You waited until five o’clock when we were having a gin and tonic. Then you just said, ‘I always wanted to be a girl, and I didn’t know how to tell you, because I didn’t think you’d love me anymore.’ Then I broke down and said, ‘I’ll always love you.’” Hildegarde experienced considerable difficulty at the beginning. “He’d led a perfectly normal life,” she assured me. Jenny protested, “I was never perfectly normal.” Hildegarde laughed. “I was a Cub Scout leader and he was a Cub Scout.” It took Hildegarde some time to be ready to tell her friends, but about a year after that conversation she had a party to introduce her daughter. She turned to Jenny. “You were surprised when all of your close friends accepted it so readily. So I thought it worth trying my friends. I hadn’t even heard the word transgender so I just went with Jenny. It’s impossible to hate anyone whose story you know.” Hildegarde leaned forward as if to tell me a great confidence and said the only thing she could never accept was Jenny’s shoulder-length blonde hair. Turning to Jenny, she said, “If I tell you this, you’ll cut your hair tonight when you go to bed: Ann Coulter has your hair.” Jenny said indignantly, “So does Laura Dern, and she’s a movie star!”
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