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
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
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
