Zucker claims that no patient who began seeing him by six has switched gender; he recently announced that a follow-up study of twenty-five girls he first saw in childhood showed only three with persistent gender dysphoria later in life. At the same time, because adolescents are less malleable than children, Zucker will sometimes recommend hormones and surgery for people who come to him later. He does so with regret. Many of Zucker’s patients have determined to live in their birth gender at the end of his therapy, but a recent article in the Atlantic Monthly quoted the mother of a Zucker-treated child who doubted her adult daughter, an alcoholic and self-mutilator, would outlive her. It seems overreaching to call this a success. Stephanie Brill said, “In my experience with many people who come to us after seeing Zucker, his work can alter gender expression, but it does not touch gender identity.”
The question is whether trans people, like most gay people, have a fixed identity that only a fool would try to alter—or whether a child born male who says he is really female is like, in Zucker’s simile, a child born black who insists he is white, and needs to be eased into accepting himself. Zucker points to the rigid way many trans children adopt the stereotypes of the opposite gender. “There is no joy in their play,” he said. “They’re struggling, experiencing social ostracism and difficulty establishing friendships with children of their own gender.” Zucker feels that the idea of GID as a natal condition not subject to repair is “simpleminded biological reductionism.” The therapists who support early transition are, in his words, “liberal essentialists.” He explained, “Liberals have always been critical of biological reductionism, but here they embrace it. I think that conceptual approach is astonishingly naïve and simplistic, and I think it’s wrong.”
Susan Coates, former head of the Childhood Gender Identity Project at Roosevelt Hospital in New York, agrees. She said, “I’ve seen about three hundred and fifty kids with gender issues. They are fundamentally creative, and part of the creativity allowed them to imagine solving their problems by switching gender. My experience is that no one becomes transgender who had treatment early. If you work on separation anxiety and aggression, the gender problem starts to fall away. Anxiety is what leads to gender dysphoria.” Zucker and Coates are accomplished academics who have personal integrity, but—like some of the activists who attack them—they seem to imply that universals exist in a field of highly varied stories.
You can damage someone who is trans by preventing him or her from living in his or her true gender; you can damage someone who has GID but will not be trans by trapping him or her in an ill-fitting cross-gender identity. The trans-friendly therapist Michele Angello said, “Parents tell me often, and it’s sort of PC, that they are following their child’s lead. If your child is seven, you probably don’t let them choose what they’re going to eat for dinner, let alone if they’re going to transition to a new gender. There is a very, very occasional phenomenon where the parents have their own mental health issues and their kid is not the most masculine male, so they’ve decided that their child is trans. The kid isn’t transgender and is being talked into it.” Stephanie Brill said, “It’s important not to overdiagnose transgender children. That’s a very small part of the gender variant population.”
• • •
When Dolores Martinez was fourteen and still a boy named Diego, living in Massachusetts, his mother caught him with his first boyfriend. “I was in a miniskirt doing the dirty,” Dolores said. “I put on my boy clothes again and went downstairs and she said, ‘Your father said to be out or he’s gonna kill you.’ I was on the streets for four years, and I was convicted of a major, violent crime and sent to prison. It saved my life. I spent almost four years in prison happier than ever before. When you’re in there, either you’re a man, or they’ll turn you into a woman. So I was a sister. That was my first experience at being myself one hundred percent.” After she was released, Dolores learned that her mother had lied. “She told my father I ran away. When he found out what she’d done, that was their divorce. When I told him about my transition, he said, ‘Oh, thank God.’” Dolores spent ten years in therapy before her first hormone shot. Eventually she met Gustaf Prell, a transman who was the love of her life, and they were legally married—under the law, however, she was a man and he was a woman.
When Tyler Holmes was a confused little girl named Serena, she “wished for boy parts,” but “didn’t really wish to be a boy.” She had a brief relationship with a sixteen-year-old, Freddie Johnson, and became pregnant. When their son, Louie, was born, Freddie expressed little interest. But when Louie was two, Freddie’s mother began complaining to the Department of Social Services about Serena. Louie’s guardian ad litem, assigned to look after the child’s interests, told Serena to sign something. “I didn’t know what it was, and I signed it, and it turned out it was for custody,” Tyler said. “I lost my child.” When Serena befriended Gustaf Prell and Dolores Martinez soon thereafter, she began to question her allegiance to her own gender. When she was hospitalized for endometriosis, her doctors said it could be treated with an estrogen-based medication, but Serena said that she’d prefer treatment with testosterone, that she really wanted facial hair and a lower voice. She began calling herself Tyler.
One Thursday in 2008, Gustaf, who had always been depressive, went to the emergency room of a local hospital seeking admission because he was suicidal; he was told that no beds were available to a transgender person. He hanged himself two days later, age twenty-seven. Dolores filed a complaint, but the Board of Mental Health found the hospital not at fault. Because transgender people are not a protected class, the ruling stated, the hospital had discretion to refuse them admission if their presence might disturb other patients.
After Gustaf was gone, it seemed natural for Tyler and Dolores to get together. I asked whether the fact that neither of them had made a surgical transition had any bearing on their attraction. Tyler said, “Love and relationships aren’t based on what you have underneath your clothes, what pronouns you go by, or the name you use. With Dolores, it’s based on the person she is and the way I feel about her, and the person I am and the way she feels about me. Dolores has expressed wanting some form of surgery at some point, but that’s her thing as far as when or what she wants.” Dolores said, “I see Tyler as a boy with benefits; he straps it on so I can select a size.”
In the five years since Tyler relinquished custody, Louie, now seven, has lived with his paternal grandmother. Tyler and Dolores are allowed to see Louie only once a week, for a supervised visit. Tyler said he didn’t think Louie had noticed his transition; I felt that Tyler’s full beard might have clued Louie in, not to mention Dolores’s habit of addressing him with male pronouns. Both Tyler and Dolores were interested in Louie’s gendered behavior. Dolores said, “Louie could be like my husband was, where he was a girl one day and a boy the next. He likes My Little Ponies, which we have to sneak in to him because he’s not allowed any girl toys. I’m not a doctor, but I think he’s genderqueer right now.” Tyler said, “He’s never said anything about being trans or wanting to be a girl, but I never said anything when I was little.” It seemed to me that absent any assertion from Louie that he wanted to be a girl, he was probably not trans. He did, however, do badly with male stereotypes. He inhabited a polarized world with either a terrifying genderlessness or an oppressive genderedness. “He might not know for sure that he’s a girl,” Tyler said. “He might not know for sure that he’s a boy. He might float back and forth from day to day, and that’s okay, too. I don’t want him to lose twenty-five years of his life like I did.”
Perhaps the immutable error of parenthood is that we give our children what we wanted, whether they want it or not. We heal our wounds with the love we wish we’d received, but are often blind to the wounds we inflict. Dolores said, “I want Louie to be comfortable with himself whether he’s a male, female, somewhere in the middle. I have a lot more years to fix than a youngster. My life is not what I want for him.” Child
ren should be able to be themselves; they also want rules and boundaries, and I feared that Dolores and Tyler’s infinitely permissive idea of love might be petrifying to a child. The longing of a child is to be seen, and once the child is seen, he or she wants to be loved for a true self. Dolores and Tyler were full of love unnuanced by seeing. “He’s the most beautiful boy that I’ve ever seen, and probably the most beautiful child on the planet for all I know,” Tyler said. “It’s cool, because it’s almost like I’m transitioning with my son. He has it a little bit better than most trans kids because he has two trans parents. We’re not going to let him do it by himself like our parents did. He has people who will go with him.” Dolores said, “His transition needs to move forward. I see him living in my yesterday. So hopefully he can learn from my tomorrow.”
• • •
The debate over gender identity was once framed as a nature-nurture divide; nowadays, it’s an intractable-tractable divide, which is equally hard to call. Clearly nature is involved, but the question is whether nurture enables it, whether it can and should disable it. The answers are frustratingly vague. Psychodynamics has proposed a range of contradictory explanations for cross-gender identification; as Amy Bloom wryly pointed out in her book Normal, it’s either absent fathers and overinvolved mothers, or dominant fathers and submissive mothers; it’s parents who encourage cross-gender identification and play, or who forbid and thereby mystify cross-gender identification and play. Some little boys may want to wear dresses because they have brutal fathers who scare them and loving mothers with whom they identify; others may have a condition determined by genetics, brain development, or the uterine environment.
Transitioning is still bound up with the medical and therapeutic communities. In the best cases, this means that responsible professionals can separate the fears and desires of the parents from those of their offspring and distinguish between an immutable imperative and a transient neurosis. That can, however, be daunting. Separating the psychiatric, the endocrine, and the neurocognitive seems almost poignantly old-fashioned. Modern psychiatry seeks the chemical pathways of emotional and thought disorders, but attempts to distinguish mind from brain are still primitive, and a condition as complex as GID must be described from multiple angles at once. Heino Meyer-Bahlburg, who serves on the DSM committee, acknowledged that the description of GID “cannot be achieved on a purely scientific basis.”
In his own practice, Meyer-Bahlburg believes that transition is best avoided if possible. “It’s terrible to mutilate a healthy body and make someone infertile,” he said. “Sexual functioning is not terrific even in the best cases and is horrific in the worst. There is some feeling that you’re enhancing a disorder rather than treating it.” He believes in a centrist treatment. “We try to introduce them to more of their same-sex peers,” he said, “and if their fathers have already turned into sissy-boy-hating, distant fathers, as happens in this homophobic country, we try to get them to reengage positively and to develop a relationship. Many of these children become more comfortable in their birth gender, and even if they don’t, they can have a broader circle of friends and experiences.” That said, he has also put children on puberty blockers as early as eleven. “Sometimes, I help patients make the change, and sometimes, in a noncoercive fashion, I try to stop them from doing so,” he said. “It’s only based on my own intuition; I have no algorithm.” Edgardo Menvielle said, “Most young children don’t come with a claim about their identity. They are brought because they are different in their gender expression. Whether they should transition or not? You’re never really sure you’re doing the right thing.”
Members of the trans community often fear therapists who steer children away from their true selves; parents are more likely to fear that their children will have surgery and come to regret it. It is impossible to know how many people who have transitioned socially but not physically have transitioned back. We do know, however, that as many as one in a hundred people who have had sex-reassignment surgery wish they had not done so.
Danielle Berry, born Dan Bunten, underwent sex-reassignment surgery in 1992 at forty-three in what she later described as a “midlife crisis.” She subsequently said, “I’m now concerned that much of what I took as a gender dysfunction might have been nothing more than a neurotic sexual obsession. I was a cross-dresser for all of my sexual life and had always fantasized going femme as an ultimate turn-on. I just wish I would have tried more options before I jumped off the precipice.”
The Iraqi-born Sam Hashimi underwent sex-reassignment surgery in England after his wife left him in 1997. “Trudi had never worked a day of her life,” he said. “She’d think nothing of spending a few thousand pounds on a dress. I always used to wonder what it would be like to have none of the responsibility I had, to have doors opened for me and all the privileges a woman seems to have.” So he became Samantha Kane. But Samantha found “being a woman rather shallow and limiting” and decided she’d made a terrible mistake. She underwent a painful and unsatisfactory “reversal” of her genital surgery and, after adopting the new name Charles, sued the psychiatrist who had supported the surgical transition.
Such stories are unfortunately used to discredit the trans movement as a whole. Cases of profound postsurgical regret make headlines, while much less space is given to people who would have been much happier with a full surgical transition but were never able to achieve one. Mistakes will be made in both directions, and lives can be ruined either way. Some children who are supported in conforming to a chosen gender identity may later feel trapped by it; their parents and doctors may make misguided decisions about hormone blockers, hormones, or surgery. Other children, not supported for transition, live and die in despair. It is terrible to perform unnecessary surgery on a healthy body, but it is also terrible to deny succor to a mind that knows itself.
Far more boys are referred for treatment for GID than girls. However, this does not mean that more natal boys have gender-atypical behavior than natal girls, only that they worry their parents more. Feminism won for women many rights formerly reserved for men. Girls who are aggressive and dominant are often admired; the very word tomboy has a measure of fondness built into it—though there is no shortage of insults for assertive women. In contrast, no movement seeks to legitimize stereotypically feminine traits in men. Girls can be masculine; boys are effeminate. Girls in jeans and T-shirts wear “unisex clothing,” but boys in skirts are “in drag.” Kim Pearson described asking that everyone in a parents group who had been a tomboy to raise her hand; hands went up all over the room. She then asked everyone who had been a sissy to raise his hand. No one stirred.
• • •
When Scott Earle was a tomboy named Anne-Marie, her parents regarded her toughness as a sign of strength. They were both pediatricians, living in liberal Vermont. “I loved the idea of having a woman unencumbered by limits,” Lynn Luginbuhl, Scott’s mother, said. Gender irregularities were plentiful in Scott’s early life. “As a little girl, Anne-Marie had this beautiful curly blonde hair,” Scott’s father, Morris, said. “One morning we got up and Anne-Marie, who was eighteen months old, was in her older brother Ben’s room, and Ben, maybe five, had cut off all her hair. Ben got in trouble, but later I wondered if Anne-Marie somehow asked for it.” Lynn said, “We had this pink, down snowsuit. My mother said to Anne-Marie, age four, ‘Oh, you’re a beautiful pink lady in that snowsuit.’ Anne-Marie refused to put it on. We finally dyed it black, and then she would wear it.”
In Anne-Marie’s first conversation with other trans people online, when she was fourteen, the name Scott emerged, and she realized that was what she wanted to be called. A few months later, her parents returned from a party to find a letter on their dresser: “Dear Mommy and Daddy, I have to be a guy. I’m trans.” Morris recalled, “I didn’t even know what that word meant. We walked downstairs to the basement where Scott was watching TV, and I said, ‘Is there anything that would make us not think you’re one of the greatest people
we ever met?’”
Lynn called some gay friends for advice, but they knew no more about being trans than she did. “I found a therapist who helped make people less inclined to transition physically,” she said. “Scott hated her. I had to come to an understanding that he really was going to live as a guy. We eventually found a therapist who had counseled seventy transgender people, and she felt Scott didn’t need to see her because he was so clear. I thought I was raising this strong woman, but most eight-year-old girls do not wear boys’ underwear.” For Morris, the challenge to accepting Scott’s new identity wasn’t a conservative belief in an unbreachable wall between maleness and femaleness, but a utopian belief that no natural disparity exists between genders—which made transition pointless. But he didn’t fight Scott’s wishes. “If there’s a snowstorm, you don’t spend time trying to get it to go away,” he said.
They called their local endocrinologist at the University of Vermont (UVM), where they were both referring physicians, and he said he didn’t deal with such cases. Lynn was shocked. “As pediatricians, when we take care of people, we need to leave our opinions at the door,” she said. “Our job is to meet people on their terms. This was no different.” She eventually found a trans health group in Philadelphia, drove Scott seven hours down, went to the appointment, and drove straight back. In testimony before the Vermont Senate on trans rights, years later, Lynn said, “I think what is hard is when you don’t know what to do, or when there is nothing you can do. It was very clear that there were lots of things to do. So we just did them.”
Scott, academically advanced, was boarding at St. Paul’s, a New England prep school. Lynn drove him back after Christmas break; they stopped at a gas station, and when Scott used the men’s room, his mother realized how far along he was. When he came out as trans at a school assembly shortly after his return, he was greeted with support from other students and much of the faculty, but not from the school administration, led by an ostensibly broad-minded Episcopal bishop. He told Lynn that her daughter needed to grow out of this and suggested that Scott might have a better time starting fresh in a new place. “I knew he was just trying to get rid of me,” Scott said, so he left.
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