that a child born with a penis could grow up with the certain knowledge that she is a girl, or that a child born with a vagina could be equally convinced that he is a boy. Many people are unwilling to accept that “the hands of God” or Nature could have fashioned human beings whose sense of self is at war with their flesh, or whose gender identity falls somewhere in between the poles of male and female.
Because we live in a culture that expects science to settle questions based in the body, we look to science to tell us what it means to be male and female, how gender identity is formed, and why it is that the sex of the body sometimes seems to be at odds with the sex of the mind. But despite our sophisticated tests, science can still offer no definitive answer to this question, only tantalizing clues. When the governments of England and France attempted to solve the riddle of the Chevalier d’Eon’s sex, they called in two doctors to examine the chevalier’s body. From the evidence of their eyes (the chevalier appeared to have breasts), the doctors concluded that a woman stood before them. Only at death were the chevalier’s genitals examined, and they told a different story. Today our tools are vastly more powerful, yet they are no more accurate in predicting gender identity in certain cases than the eyeball test that established the Chevalier d’Eon’s or Herculine Barbin’s anatomical sex.
“Ordinarily, the purpose of scientific investigation is to bring more clarity, more light into fields of obscurity. Modern researchers, however, delving into ‘the riddle of sex,’ have actually produced—so far—more obscurity, more complexity. Instead of the two conventional sexes with their anatomical differences, there may be up to ten or more separate concepts and manifestations of sex and each could be of vital importance to the individual,” the pioneering sexologist Harry Benjamin wrote in 1966. “Here are some of the kinds of sex I have in mind: chromosomal, genetic, anatomical, legal, gonadal, germinal, endocrine (hormonal), psychological and also the social sex, usually based on the sex of rearing.”
Benjamin’s understanding of the multiplicity of factors that contribute to a person’s gender identity, and his ability to see that a lack of agreement among these components is a source of considerable anguish for some people, remains rare. Most people do not consider gender a riddle. Most do not make a distinction between anatomical sex and gender identity. Nor do they realize that it is possible for a person to have XY chromosomes yet female-body morphology and genitals as a result of androgen insensitivity syndrome (AIS), or XX chromosomes yet male-body morphology and genitals as a result of congenital adrenal hyperplasia (CAH). Those are only two of a number of genetic and endocrine conditions that can create anatomically inter-sexual people. Once these persons were called hermaphrodites, after the intersexual offspring of the gods Hermes and Aphrodite. As that myth indicates, in some cultures, intersexual and transgendered persons have been viewed with reverence and respect.
Our own culture has not been so kind. Intersexual people have been forced to undergo physically and psychologically traumatic surgeries to “normalize” their genitalia. The medicalization of intersex conditions has caused tremendous suffering. However, it has also granted intersexual people legitimacy in the eyes of the medical profession, lawmakers, and the public. No one accuses intersexual persons of being mentally ill. Their gender variance is inscribed on their bodies, in their gonads, genitals, or chromosomes—and so seems “real” because it is a material, measurable entity. The same is not true of trans-gendered and transsexual persons, who present a baffling enigma to their families, physicians, and themselves.
Take for example a genitally female, genetically XX girl who tells her mother at age three that she is a boy, and from her earliest childhood spurns girlish activities, clothing, and behavior. “My whole life I’m telling my mom, ‘I’m not a girl, I’m not a girl, I’m not a girl’ and thinking what the hell is going on here?” says Brad, one of the first employees of the city of San Francisco to take advantage of the new policy of insurance reimbursement for sex reassignment surgery for city employees. “When you are little, you’re kind of androgynous. Both little boys and little girls are running around, taking their shirts off, jumping in mud, throwing dirtballs. So if you are a little aggressive and gened as female, they say you’re just a tomboy. But once you get up to a certain age, like six or seven, it starts separating. And I was like, ‘You’re pushing me the wrong way. I’m supposed to be over there with the boys; why are you making me go over here with the girls?’ You look at your body and you are in the wrong body, and it’s a nightmare. You wake up in this nightmare every day and you have to deal with it. And you keep thinking, When am I gonna wake up?”
Brad’s description of his early life was echoed by many of the trans-gendered and transsexual people I interviewed for this book, who struggled for many years to understand their suffering and confusion without being able to put a name on what they were experiencing. Gender variance is not a widely discussed subject, even in medical schools, and as a consequence many physicians, like the general public, know very little about the subject other than what they are able to glean from sensationalist media accounts of cross-dressing and trans-sexuality. Gender variance still seems to be considered a more suitable topic for late-night talk show jokes than for journals of public health and public policy, even though a recent needs assessment survey in Washington, D.C., estimated that the median life expectancy of a transgendered person in the nation’s capital is only thirty-seven years. Poverty, substance abuse, HIV infection, violence, and inadequate health care are the factors behind this statistic. Of the 252 transgendered people surveyed in the district, 29 percent reported no source of income, and another 31 percent reported annual incomes of under ten thousand dollars per year. Half the participants did not have health insurance and 39 percent did not have a doctor, though 52 percent had taken sex hormones at some time in their lives and 3 6 percent were taking hormones at the time of the study. A number of the respondents were working, or had worked, as commercial sex workers—a consequence of the persistent employment discrimination experienced by many transgendered people.
Though many are far better off materially than the subjects of the Washington, D.C., study, transgendered and transsexual people of every social class and at every income level share many of the same vulnerabilities. Public prejudices make it difficult for visibly transgendered or transsexual people to gain an education, employment, housing, or health care, and acute gender dysphoria leaves people at high risk for drug abuse, depression, and suicide. “You do everything you can possibly do to check out, to get away,” says Brad, who at forty-six has been sober for sixteen years. When I asked if his drinking and drug abuse were tied to his confusion about his gender and related traumas, he replied, “Absolutely. Because I couldn’t be who I was after so many years of hiding from myself. At that point I didn’t really know who I was. It’s very much a catch-22, and you’re just like, ‘Fuck it. I’ll just take more drugs. I’ll just do more drinking. I’ll just do whatever because I can’t deal with this.’” Brad began his transition after nearly a decade of sobriety. “Without being clean and sober, I would never have gotten to this point,” he says. “I would have been dead.”
Though the first scientific study of gender variance was published in Germany nearly a century ago, scientific understanding of the causes of what are today classified as “gender identity disorders” remains sketchy. Did transvestites (people who wear the clothes and sometimes adopt the lifestyle of the other sex) exist before the German sexologist Magnus Hirschfeld introduced them into the clinical literature in 1910? Undoubtedly. But prior to Hirschfeld, transvestites were believed to be a kind of homosexual—a category that itself had been only recently created. (Hirschfeld was the first to note that transvestites were usually heterosexual.) Similarly, though Hirschfeld included case studies of people born male who clearly expressed female gender identities, he didn’t identify transsexuals as a separate diagnostic category. British sexologist Havelock Ellis, who had experience with both transvestites and transsexuals, wanted to call members of both groups “eonists,” after the Chevalier d’Eon, a nomenclature that never caught on. It remained for the American physician Harry Benjamin to clarify the distinction between transvestism (today called cross-dressing) and transsexuality in his 1966 book,
More recently, “gender identity disorder” has been created to replace “ transsexualism” as a diagnosis in the American Psychiatric Association’s
Statistics on transsexualism and transgenderism are notoriously unreliable; in the case of transgenderism (a broad and variously defined category) they are mere guesswork. However, it is possible to track the number of people requesting sex-reassignment surgery and to make some general estimates of prevalence (the number of cases of a given condition present in a given population during a given time) based on those figures.
According to the fourth edition of the DSM (DSM-IV), about 1 in 10,000 people seek sex-reassignment surgery (SRS) in the United States every year, and approximately 1 in 30,000 men and 1 in 100,000 women will undergo SRS at some point during their lives. This is believed to be a very conservative estimate, based on SRS statistics that are decades old. Professor Lynn Conway of the University of Michigan suggests that the DSM-IV
