A Pro Bono Transgender Primer

Transgender issues have been in the news with the recent announcement that Cher's daughter, Chaz Bono, is transitioning from female to male. This subject has been plagued by misunderstanding and fear of the unknown. Transgender children are often shamed, bullied, and made to feel totally alone. As adolescents and adults, they face denial of adequate medical coverage and other forms of discrimination -- and worse. Just two months ago, a Colorado man was found guilty of murdering an 18 year old transgender woman in what was judged to be a hate crime.

Chaz's decision to go public with his private struggle is extremely brave. His publicist said, "It is Chaz's hope that his choice to transition will open the hearts and minds of the public regarding this issue ..." Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. "Transgender man," "transmale," and "affirmed male" have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful.

What exactly does transitioning mean? It's the period during which somebody starts to live as his/her new gender. It can include changing a name or legal documents, taking hormones, and getting surgery. One misconception is that transitioning requires surgery. It doesn't. As Mara Keisling, the Executive Director for the National Center for Transgender Equality (NCTE) told me, "Most transsexuals don't get surgery. This is about gender identity, not about genitals."

There's a lot of controversy and confusion but experts agree on two crucial concepts:

1) Being transgender is not a choice.

2) Biological sex and gender identity are two different things.

There are people whose external appearance is female but who have felt they were male since they were toddlers -- and vice-versa. Norman P. Spack, M.D., an endocrinologist at Children's Hospital in Boston, Dept. of Pediatrics, Harvard Medical School, has been treating transgender patients since 1985 and significant numbers of teenagers since 1998. Most of his patients have told him "as far back as they can really remember that they were in the wrong body." Dr. Spack said, "there's a heavy skew to under 6 years."

Dr. Spack points out that because transgender has been labeled as a psychiatric illness ("Gender Identity Disorder") by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), patients are not adequately covered by health insurance. He says that the insurance industry will cover psychiatric costs but denies hormonal and surgical therapy, claiming they are non-covered cosmetic treatments. A step forward came in 2008 when the American Medical Association House of Delegates passed a resolution supporting "public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults" and opposing "categorical exclusions of coverage for treatment of gender identity disorder in adolescents and adults when prescribed by a physician." But for now, many transgender patients continue to receive inadequate medical coverage and therefore inadequate medical care.

Nobody knows how many transgender people exist. The very definition of transgender can differ from study to study. Some only count people undergoing hormonal/surgical treatment; others rely on self-identification. In the Netherlands and Belgium, estimates based on patients receiving surgery and/or hormones were about 1 in 12-13,000 for transfemales and 1 in 30-34,000 for transmales.

But Mara Keisling told me those estimates are way too low. "Our best estimate is that one quarter to three quarters of one percent of Americans are transsexuals." That's
2.5 to 7.5 in a thousand. Dr. Spack's estimate is about one in a thousand.

We are not close to understanding all the variables that go into determining why someone feels trapped in the body of the wrong sex. Parents often feel guilty, but the wide consensus is that parenting does not cause a child to be become transgender. Research in animals suggests that there are critical periods of development during fetal or neonatal life during which exposure to testosterone influences the sexual differentiation of the brain. But we're far from putting together any sort of unified theory of gender identity that weaves together genes, cell biology, hormones, brain wiring, and nurturing.

Experts stress that transgender is part of a wide continuum of gender identity. As Stephanie Brill and Rachel Pepper say in The Transgender Child: A Handbook for Families and Professionals, "Today, gender can no longer really be considered a two-option category." They emphasize the importance of patients and families understanding that they are not alone and that there are competent professionals who can help. They say they wrote the book, which I found to be very helpful, to "provide caring families with helpful tools they can use to raise their gender-nonconforming children so they may feel more comfortable both in their bodies and in the world." The authors quote Dr. Spack who, referring approvingly to the Dutch treatment of adolescents by delaying puberty and giving them hormones, said: "Suicide attempts, so frequent elsewhere, are almost unknown because parents and children know that they will be taken care of and will ultimately join a society known for its tolerance." Referring to his own patients, Dr. Spack told me, "They may be anxious, they may be depressed, but many, many no longer have psychiatric diagnoses after they are treated properly."

In today's video segment of CBS Doc Dot Com, I speak to Dr. Ward Carpenter of the Callen-Lorde Community Health Center in NYC, a facility that provides care to patients across the spectrum of gender identity and sexuality. In the segment that follows, Dr. Carpenter explains what surgery and hormones can entail. A warning: it's a graphic description. Its purpose is not to shock but to educate. Hopefully, better education will lead to less misunderstanding, less fear, and wider acceptance for people like Chaz Bono.

Sex Change Explained
Watch CBS Videos Online Coming Out As Transgender

Other Resources:

NCTE: Understanding Transgender

Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline

True Selves: Understanding Transsexualism by Mildred L. Brown and Chloe Ann Rounsley

Comments

[Rossa248]

Excellent article - though I do wish we could reach a consensus on the defintions of transgender as opposed to transsexual.
- Transgender has come to mean anyone who exhibits traits, mannerisms, or the appearance opposite of their birth sex.
- Transsexual is a person who has been medically diagnosed and is, or has, been treated with counseling, hormones, and surgerical reassignment.

If you'd like to get out of the theoretical and into reality - please watch this real, normal, woman describing her transsexual history - http://www.youtube.com/watch?v=ShS9kJ33RsM

[Genders]

Too bad we cannot accept feminine men and masculine women, so much so that surgery is easier. Go check out the article on leggings, as if women were the only ones who ever wore them, when it is men who first wore tights. Now straight men may not be: gentle, neat, stylish, long haired, slight, presentational, colorful, too happy, etc.... Straight men are Straight jacketed.

We have the bizarre case of homosexual rapists, claiming they are straight, because they do the penetrating, claiming that the raped man is gay because he was unwillingly penetrated, and scientist agreeing with this.

It seems obvious to me that there are women who behave in so called "masculine" ways and men who behave in so called "feminine" ways. Some of those people are homosexual, some hetero sexual, some bi, but we seek for force them into homosexuality.

If gender is innate, why do we apply so much hysterical reaction and deadly force to enforce conformity?

[rhondadavis28]

well as a straight lady - wellness educator- thought this was incredible.

nice job CBS

[btrim]

Before I commit to a sex change I would like to explore some women's bodies in order to see and feel what it might be like to inhabit a female bod. These procedures may well be lengthy. Try to bare with me, now....

[averygard]

Yet another example of how stupid the right wingers are when they call simply being GAY a "choice". Why would anyone willingly choose to go through such a struggle that goes along with coming out, much less all the flak you're going to get and problems you go through if you change gender. It must be very, very difficult.

[NWBrunette]

Thanks for helping to get the word out. The more people become aware of the vast diversity of human experience the better for everyone.

[TheBlackCat]

I am not convinced it is not a mental disorder, I speak from my experience as a former anorexic. Since the time i was a little girl, I always felt like I was fat and was obsessed with this fact. I always felt trapped in my body, I always felt like what I felt about myself was not what other people saw. I went through extreme lengths (starvation) to try and make my body look the way I thought I NEEDED it to look. When forced into treatment, I became suicidal at the thought of not being able to express what I TRULY felt I should be. It took over a decade of therapy, medications, and hospitalizations before I got better.

When hear transgendered people explain their feelings a lot of the time at being trapped in their own body, about being suicidal at the thought of not being able to change their bodies to reflect who they really are, and other such language, they sound EXACTLY like I did, and I know for a fact that I was severely mentally ill.

But at the end of the day, it's not like being transgendered has a huge chance of killing you the way anorexia can. So even if it IS a mental illness...if transitioning alleviates the person's suffering and prevents suicidal tendencies, who am I to judge? I just don't understand people who hate on transgendered, why do they even care? How does someone else's choices affect them?

[OkieIntellectual]

Actually, transsexuals have about a 50% suicide rate, so there IS a huge chance of it killing you.

[TheBlackCat]

What a great example of how to lie with statistics! .

50% of transgendered people at least ATTEMPT suicide...about 20-30% actually are successful, depending on what age/social group /sex you are talking about. But most importantly this statistic is for PRE sex change transgendered people- people who FEEL transgendered but do not actually transition into being the opposite sex.

Suicide rates for post sex change transgenders is only 1.9 percent (per a British Journal of Psychiatry article: http://bjp.rcpsych.org/cgi/reprint/152/4/550).

Granted, this is much higher than the national average, which is far less than one percent.

However, it is MUCH MUCH lower than the 20-30% suicide rate of transgendered people who DO NOT have a sex change. So I have a hard time condemning a practice which GREATLY reduces rates of suicide, especially as psychiatric treatment, whether through drugs or therapy, has not been successful in decreasing suicide rates among the non transitioned transgendered.

[Rebecca Booth - Huffpost Blogger]

Great blog Dr. LaPook!
This topic speaks to the higher spirituality of our identity that may literally transcend the physical vehicle. While many may decline the pain and risks to change their body, I'm sure the message is a comfort to those who have felt hopelessly trapped in a vehicle that does not match their true persona.

[DrLaPook]

Thanks Dr. Booth. It's been a long time since I learned so much doing a segment. And thanks to these fascinating comments, I'm continuing to learn.

[truthartbeauty]

I'm gay and I dont know if I have ever known a transgendered person or not. Probably we all have and have not known it. It is NOT the same thing as being gay but I dont care. We should try to love people and have compassion for them as fellow humans. Is that so hard to understand? Only a weak and unkind and misinformed person is threatened by somone different than them to the point of violence against them.

[grey32]

I'm gay and do have trans gender friends. I don't understand it but; yet in some ways I do. I jsut believe in live and let live. The human condition is a wonder. I to do have trouble with the he's and she's. It's not meant to be negative it's just hard to keep it all straight - no pun intended.

[mergina]

I disagree with you. We are indeed very close to understanding how and why someone is born with GENDER DYSPHORIA. . Imagine that every time you look in a mirror, what you see is wrong, and not only wrong but the complete opposite of what you perceive yourself to be. You see yourself as this, yet the world sees you as that. You are powerless to change what you feel within, what you know with your entire being to be the reality that is you, yet the world continues to see you as that which you are not.

It's a funny thing that gender dysphoria is still described as a mental disease, when all that needs to be changed are physical attributes in an attempt to make it all match, to make one complete.

One cannot change their gender, but they can change their sex to match what is within.

Of course, to those who will HATE and choose to commit VIOLENT ACTS against something or someone they choose not to understand, well that will never change. Men in general have a harder time coming to grips with anyone who has undergone a sex change, especially a male to female. Women embrace it much easier, probably because they are women and they themselves live their lives at times worrying about violent acts against them.

[Indra]

At this point in time I do not feel that operations in regard to sex change and or psychological counseling should be covered by insurance. Sex change operations are considered elective surgery for a reason. That reason is that the surgery does not provide relief from a physical malady or life threatening situation. Counseling for many behaviors and problems are not covered by insurance and it would be a stretch to think that this service should be available to people who want to explore the problems connected with their transgender feelings. There are too many people out there with real physical problems and real mental problems that need insurance. Why waste medical resources and personnel that are sorely needed in other areas to cater to this. I consider the whole field to be nothing more than a cosmetic surgery type of thing. A matter of vanity rather than need.

[Donkslayer]

Agreed. Whether we have private or public healthcare, considering the statistics, actual surgical operations for transsexuals must stay off the books as "necessary".

[massthreat]

Indra--do you know what the suicide rate is for trans people? It trumps the gay population's rate. That would suggest the condition is life threatening...

[truthartbeauty]

case in point for peple who do not understand

[MissLakshmi]

So gender dysphoria is not real?! Do you actually know any transgender people? Trust me, the mental problems associated with gender dysphoria are about as real as they get. If you rely on sensationalist freak shows like Jerry Springer to inform your worldview, you will continue to be steeped in ignorance. Try leaving the house or reading a book.

[Vickster]

I've known six people (all males) who had their genitals surgically altered. (As a young woman, I tended bar in a gay disco and ran with a gaggle of queens.) Two of those girlie-boys were identical twins. They became hyper-aggressive after the surgery. Eight months later, they picked a fight with the wrong man. He pulled out a gun and killed them.

Two other girlie-boys committed suicide within a year after their surgery. As for the fifth, the last time I saw him was six weeks after his surgery. I hope he's still alive and doing well.

Then there is the sixth, an old friend who's flirted with cross-dressing since he was a kid. When he decided to "live as a woman" and changed his name, I refused to play along for two reasons. First, my friend doesn't have a feminine bone in his body. What he does have are some serious anger issues. Not that my refusal changed his destiny. And so a year after he had the surgery, he slept on my couch until he could get into a psych ward because he was suicidal. Now he's a Krishna devotee who's gone back to using his male identity.

[OkieIntellectual]

"... I refused to play along for two reasons..."

So what you're saying is that you refused to respect your friend. If that's going to be your attitude, why even refer to this person as a friend, since clearly that's not the relationship.

[Vickster]

If I wasn't a friend, he wouldn't have parked his butt on my couch for two weeks because he was afraid to be alone, nor would I have taken care of his dog during the six weeks he was in a psych ward. As for respect, it seemed obvious to me (and to most of his friends... including those who humored him by playing along) that his actions were being driven by several underlying psychiatric disorders (including a bipolar disorder and a histrionic personality disorder), therefore "respecting" his decision to have himself castrated would have been akin to "respecting" someone's decision to cut off their nose to spite their face. And since he has now gone back to "living as a man" (minus a pound or two of flesh), it seems that my take on his mental condition was correct.

[OkieIntellectual]

I have to take issue with some of your terminology here, Doc. "Transgendered" is a non-clinical umbrella term that covers not only transsexuals like Chaz, but also transvestites, cross dressers, drag queens, androgynes, and any other lifestyle group that flaunts or crosses gender presentation boundaries. The important term there is "lifestyle."

Transsexuals, unlike every other group covered by the term "transgendered" are not living a "lifestyle", they are living their lives, plain and simple. Using the term "transgendered" is, in my opinion, a huge part of what is contributing to the confusion over the difference between transsexuals and all those "lifestyle" groups.

I realize that "transgendered" is the popular, politically correct social term, but that does not change the fact that is serves only to foster greater confusion over this entire issue. I've taught classes to 1st and 2nd year Psychology students on the subject of gender identity disorder and I've always opened the class with an explanation of the various groups covered by the term "transgendered", and how they are very different from transsexuals. I cannot count how many students thanked me for clearing up what is possibly the most confusing thing about the entire subject - defining the terms and differences between transsexuals and the "lifestyle" groups.

Personally I believe that transsexuals should be thought of as seperate from "transgenders", as a means to distinguish those who are living a life from those who are living a lifestyle.

[PhoebeH]

There are theoretical problems with trying to split transsexuals off from other transgender people -- namely that we don't really understand the science behind this well enough to that definitively.

But the practical problems of trying to do so are even larger. Because many (most?) transsexuals go through a stage -- sometimes a decades-long stage -- of trying *not* to be transsexual, and be a different kind of transgender. (Or, of course, not transgender at all.) Trying to build hard and fast lines between communities that are very fluid will never be successful, and ultimately isn't very helpful.

I've never understood what we're supposed to gain from this sort of separation -- the people who hate us certainly don't care.

[OkieIntellectual]

Ahh but we DO understand the science. The Netherlands Institute for Brain Research conducted two seperate studies, both of which found significant differences in neuronal density in the BTSc area of the hypothalamus, with females and male-to-female transsexuals showing a significantly smaller, less dense BTSc (including in MtF's who had never taken any hormones or other drugs or had surgery), and vice-versa for female-to-male transsexuals. This disparity was not observed in homosexual men. The conslusion is the the BTSc is the "seat" of gender identity. This structural detail is unique to transsexuals.

Additionally, it is the confusion over the diferences among the "transgendered" subgroups that compounds the problem. People think that transsexuals are men who get off on wearing womens lingere and just take it too far because they hear the term "transgendered" and do not distinguish the vast differnce between transvestites and transsexuals.

As a trans person myself (there, I came out & said it), I do not like the idea of being confused with one of the "lifestyle" groups.

[goodgravy]

i've had 3 transgendered friends in my life. one had transitioned with full surgery and two had not. i never really fully understood everything completely. regardless of gender, they were 3 very good and memorable friendships. we had a ton of good times together.