The Riddle of Gender

by Deborah Rudacille

  Despite the serious health problems confronted by transgendered people, they remain a largely invisible and untreated population for a number of reasons. Some fear exposure, many lack health insurance, and more than a few have encountered hostility, ridicule, and rejection from health care providers when they have sought treatment. “Trans-gendered people commonly receive substandard or inadequate medical treatment due to discrimination, ignorance, confusion and loss of health insurance due to job loss,” the NTAC request for funding notes. To a certain extent, the difficulties that transgendered people encounter are shared by other members of the LGBT community. “Most physicians get no training at all” with respect to treating transgendered patients, says Dr. Ben Barres, but “this is related to an even bigger problem, because let’s face it, transgendered people are very rare, but homosexuals are very common, a couple percent of the population, and there’s no training in medical school about that. For example, most physicians are very insensitive to that issue when they do a history and physical. They’ll ask a person if they use birth control before they’ve even ascertained whether they are gay or not.”

  Speakers at the American Medical Students Association’s 2001 conference concluded that “LGBT patients face many barriers to adequate health care. These problems range from poor physician access to a lack of awareness in the medical community about the health concerns of LGBT patients, not to mention the failure to address these health issues in most medical school curricula.” The failure of medical schools to train future physicians to treat LGBT patients is yet another consequence of the lack of research on the specific health care needs of these populations. Research on LGBT issues typically begins and ends with AIDS research. AIDS remains a significant problem, to be sure— rates of HIV infection among male-to-female transsexuals in cities remain shockingly high. But the circumstances that drive those high rates of infection—needle-sharing among users of black-market hormones, sex work, substance abuse, and possibly depression—remain understudied, and therefore largely invisible. This lack of research has very large consequences for the transgender community, even beyond the basic but somewhat esoteric question of the etiology (cause) of gender variance.

  “In this culture, and in most of the civilized world today, research data is used to determine public policy, to determine legislation, making cases in court, is used in determining protocols in medicine and psychiatry. Virtually every place you touch, people are coming up against this system where research data would be helpful,” says Kit Rachlin, a psychotherapist with a doctorate in applied research who has worked with transgendered clients since 1990. “Everything from the quality of the medical care I get to whether I can get custody or adopt children, or have my license changed to reflect my gender—all of the services people want to be there for them, they don’t realize that for it to be there for them in a consistent way, in a supportive way, you need to have research data, and the data has to be of a certain quality. And it will have to come from outside the community, if the community hasn’t yet grown its own researchers.”

  In her plenary lecture at the 2001 True Spirit Conference, Rachlin focused on the mistrust many transpeople feel toward scientists and physicians, and the need to overcome that suspicion and participate in research studies. She noted that the two questions transgender people heard most often were “ ‘how many of you are there’ and ‘why would you do this?’” With regard to prevalence, Rachlin says, “we’re never going to get good numbers,” owing to the nature of the condition. Most cross-dressers, for example, remain deeply closeted. “So it’s the ‘why would you do this’ question that’s the most important.” If gender variance were proved to be “unchangeable and physical,” she says, it would have a very big impact, not only on public perceptions but also on the availability of insurance benefits for those who require surgical and hormonal intervention, and legal decisions regarding marriage, child custody, and discrimination on the basis of gender identity.

  “What you need when you go to court is persuasive data showing that this is a sane thing to do, it’s a necessary thing to do, there’s nothing antisocial about it, that it doesn’t make you an unstable person,” Rachlin says. “We saw recently with the Kanteras trial, all those accusations and how hard they are to refute. And then you need to be able—especially men—to justify physical choices, which Michael Kanteras had to do at the trial when they asked him, ‘Why didn’t you have genital surgery?’” Solid data would give Michael Kanteras and all the men like him the opportunity to say, “I am a man and I should be given all the rights and privileges of men no matter what my genital status is,” she says.

  Rachlin also sees a great need for outcome studies, particularly those comparing outcomes for people who do not follow the Standards of Care drafted by the Harry Benjamin International Gender Dyspho-ria Association, which are considered the gold standard. “I think that anyone who is doing anything medically should know the outcome,” Rachlin says. “The Standards evolved at a time when people were going from one gender to another. They were following a sequence, fairly structured; and using that system, they had incredibly low levels of regret. We don’t know why, because there are no controlled studies. All that we know is that using the SOC, people had low levels of regret. We don’t know whether the SOC contributed to that; we don’t know what the relationship is. Maybe the SOC didn’t have anything to do with it, maybe it was just a small piece of the SOC, maybe it was just that they got the medical care they needed. And someone else might say that the SOC had nothing to do with it, but my reply is that all the data was gathered from people who were treated using the SOC. What we need now is research that looks at people using medical and social interventions to suit their own unique gender identity or unique ways of expressing their gender identity, which shows that their way of using medical interventions produces just as good results as the traditional model.”

  Such research might help alleviate one of the major problems encountered by transgendered people, the lack of insurance coverage for medical and surgical interventions. Rachlin points out that the failure of most insurance companies to provide benefits covering SRS or hormone therapy is due to the lack of research establishing that this is a legitimate medical problem with treatments that have been proved effective. “If somebody approached an insurance company with a large current sample done well it should be taken seriously. But people think that insurance companies are discriminating against transgendered people because they are transgendered, and they get very angry about it. But we don’t have the same research that every other thing has that gets funded by insurance companies. We’re just not meeting the usual criteria.” As a consequence, some people buy hormones on the black market because they are cheaper, and they self-administer them, while those who can afford to do so see physicians and absorb the cost of all medical (and surgical) treatment themselves.

  Like many people I interviewed, Rachlin is not convinced that all transgendered people suffer from gender dysphoria. She makes a distinction between body dysmorphia—“discomfort with parts of your body or all of your body”—and gender dysphoria. “For me, gender identity and body dysphoria are related but not the same thing, and people have made an assumption that if you are transsexual or trans-gender, you are unhappy with parts of your body, and that’s not really the case all the time. And it’s certainly not true all of the time, with all of your body, and all of the parts of your body. Some men can live with the genitals that they have; they like them and relate well to them. Others can’t at all. And when you see enough men who are having these feelings you realize that it has nothing to do with gender identity. Body dysmorphia is something else, though it’s related.”

  These kinds of distinctions are confusing to those wedded to the classic paradigm of a transsexual as a “man trapped in a woman’s body” or vice versa. But the distinctions are borne out by a largely invisible population of gender-variant people who choose not to alter their bodies in any way, though they live
in the social role of the “opposite” gender. “As a therapist in private practice, I see people who refuse, for one reason or another, to meet other transsexuals or enter the community because they are so mainstream-identified, they are more likely to feel that they need a body that physically matches [their gender identity],” Rachlin says. “I also know people who think ‘maybe I’m not transsexual because I don’t mind my penis. It works and I like it. But I’m a woman and I’ve always thought I was a woman, so what’s the matter with me?’ I say that there’s nothing the matter with you and I think they are lucky if they can live with what they have and enjoy it. You have such an advantage over people who need the surgery.”

  The lack of research on gender variance makes it impossible to understand or predict why some people are comfortable with their anatomy even though it does not match their gender identity, and others attempt to remove the offending organs themselves if denied surgery. Why is this important, some might ask? If for no other reason than that increasing numbers of young people are identifying as gender-variant, and are transitioning at far younger ages. The True Spirit Conference, for example, is a very young meeting. Most participants appear to be in their twenties and have already begun hormone treatments and had (or are considering having) “top surgery” (mastectomy). A 1991 article published in the online journal Salon quoted staffers at the Callen-Lord Community Health Center, in New York City, who said that in the previous year, the number of transgender people under twenty-two in the gender-reassignment program had tripled. This increase in the number of trans-identified young people has been noted by members of the community as well. “I’m online a lot and I see these eighteen- and nineteen-year-old kids coming on and saying, I want to transition,’” says Brad. “And I think, ‘How can you do that?’ But then I think, ‘Wait a minute, when you were five, you knew.’”

  Like many older people in the trans community, Brad feels a certain degree of envy and resentment of these young people, who transition at eighteen or twenty or twenty-five, thus avoiding the lifelong misery and struggle that older transsexual men and women like him experienced. “There are a few of them that piss me off,” says Brad. “They come online and say stuff like ‘Oh, I’m twenty-three and I sure am glad to see some young guys here, instead of all these old guys.’ Fuck you, you little brat. If it wasn’t for us old guys, you wouldn’t be here. I thank all the guys who went before me—and the women that have gone before me to set the pace, that have paved the way.”

  However, as Kit Rachlin points out, there is no outcome research proving that these young people will not at some point regret their decision. Transitioning at forty-five, after a lifetime of pain, one can be reasonably sure that the individual has thoroughly considered the positive and negative effects of the decision. But what about someone who transitions at twenty or even younger? “A typical case would be somebody very young, queer-identified, going through top surgery, and the parents saying to me, ‘What does the research say? Is my fifteen-year-old capable of making this decision?’ “ says Kit Rachlin. “ Are people happy after doing this?’ And I have to say, I don’t know.’ There’s no good research data on queer-boy identified butch fifteen-year-olds making this decision. And so we need more therapists and doctors documenting what’s happening right now in terms of medical care.”

  The lack of data creates conflicts for health care providers working with trans youth. According to the Benjamin Standards of Care, kids under eighteen are not candidates for hormone treatment or surgery, despite the fact that puberty tends to be a nightmarish experience for some transgendered kids, whose bodies grow daily more estranged from the kids’ gender identities. Some find a way around the rules by taking hormones they purchase on the street, without medical supervision. Others may find a health care provider willing to prescribe hormone blockers, which don’t create permanent changes, but slow or postpone the morphological changes of puberty. Some providers who do adhere to the Benjamin Standards of Care will prescribe hormone treatment for adolescents if they seem emotionally and intellectually mature enough to make the decision. Medically and ethically, the decision is a tough call, as Maria Russo, author of the Salon article, discovered in her interviews with health care providers. “As more young transsexuals push to begin transitioning at a younger age, the social workers and medical providers who work with them are confronting a new frontier in gender ethics. What’s the best way to help kids who say they want to switch sexes? Should we make them wait as long as possible, to be sure their decisions are not simply adolescent rebellion? Or should we take them at their word and let them begin hormones during puberty?”

  As even this brief treatment of the issue shows, questions far outnumber answers in the realm of transgender health care and research. In no area is this more true than in the biggest and most controversial question of all—what causes gender variance and why do there seem to be so many more gender-variant people in the world today than there were fifty years ago?

  CONVERSATION WITH DANA BEYER, M.D.

  Dr. Beyer was trained as an ophthalmologic surgeon, though she no longer practices in that field. She currently serves as co-moderator of the DES Sons Network, founded by Scott Kerlin. I interviewed Dr. Beyer on two separate occasions; during our first meeting we addressed general issues and in the second, personal history. When I met Dr. Beyer early in the summer of 2002, she was still living as a man, though actively planning her transition. When we met for the second time, she had become markedly more feminine in her appearance, owing to estrogen therapy and electrolysis, and was preparing for facial feminiation surgery in January 2003 and genital surgery in June. At the time we spoke, Dr. Beyer was living with her second wife and two teenage sons. The couple later separated. What follows is a portion of the transcript of our second conversation.

  Q: So what has changed since the last time I saw you?

  I’m out with my wife and kids. I haven’t been doing anything differently since I last saw you, but she just finally came out of denial, even though I had transitioned and de-transitioned once before, nine years ago. But I didn’t have the strength to do it then. And it’s interesting now as I come out more and more, it’s such a relief. No matter how difficult this is, it is such a relief just to be myself. All of what you’ve been trying to project, express, what society demands of you, the role that you’re expected to play, the way you’re supposed to look and dress and behave. It’s complicated but it all comes down to denying your identity. And I would say that I’ve expended at least 50 percent of my life’s energy fighting this one way or another. All that energy needed to be a man in this society, when you’re not. You can’t imagine. I guess it’s like what it might have been like for some Jews to pretend to be Christian in order to survive. You’re constantly on guard, constantly aware that you are who you know you are but you can’t let it slip. Because when you are a child, if you let your feminine gestures slip, you’re spanked or slapped.

  Q: Can you give me some examples of what sort of feminine mannerisms or expression of femininity you would have to hide or repress?

  Many things. The trivial are usually the best example. I used to be pretty active with my hands, with hand gestures. Women do this all the time.

  Q: Maybe you just need to be Italian? Italian men are pretty expressive.

  Maybe, but I wasn’t. My family is Lithuanian and Ukrainian Jewish. We didn’t do that. And I remember my mother saying, “No no no, sit on your hands. Don’t do that.” It’s a trivial thing, really. What difference does it make? Now that I don’t care anymore, now that I’m coming out and I gesture naturally, it’s a relief. Or “don’t cry,” if you feel like crying. Or you have to go out for a sport, or “go out and play with the boys,” even if you don’t want to play with boys. “Go out and play with your friends.” Well, they’re not really your friends, and you know that they’re not your friends. And you know that they know that you’re different. And you keep trying to be more of what you know they expect you to be so
that you can fit in and have friends.

  Q: Some of the things that you’ve mentioned other XY individuals who feel comfortable being male might also wish to do or not to do—not playing sports, for example. So what’s the difference?

  There are some people—and since I do DES work, I’m involved with the intersex community, and you know that I consider transsexu-ality to be a form of intersex—there are some intersex activists who believe that if we could reform society and destroy the gender binary, there wouldn’t be any need for transsexes. There are some very reasonable, caring, loving, intersex people who feel that is the case— because they don’t fit into either category, they don’t want to be in either category. One thing that I’ve come to realize … my wife says, “What kind of woman do you think you’re going to be?” and I say, “I don’t know.” And my son says, “Okay, you’re doing this. Are you going to be sort of froufrou and frilly and have dinner on time every day?” and I’m thinking that this is interesting, that this is what he imagines that women do—and this is 2002?

  Q: And he has had a working mother?

  Several working mothers! His grandmother barely did that! And yet this is what he imagines. And I said, “No, I’m going to be me.” And it made me realize that I have male parts in me. I have a male history. I can’t forget that. I wasn’t “pinked,” as the feminists say, and of course the Janice Raymond crowd says, “If you haven’t been pinked, you can’t really be a woman.” But I am doing something they have never been asked to do. I am renouncing male privilege. It just hit me about a month ago, just how intense that is. I was lying in bed one night and I go, “You know, I really am giving this up.”