Behind America's seismic shifts on transgenderism, loving parents

Some of the most important changes involving transgender issues are happening at home. More and more, experts say, today’s parents are making different choices about how to handle the identity issues of their children.

Sixteen-year-old Heather was born a boy. Her family supports her.

Jonathan Smith, a fast-pitch softball coach in a quiet riverside town in the Illinois Valley, was “thrown for a loop” when his 12-year-old son, Chance, said that deep down, he felt he was a girl.

“Well, that seems a little far-fetched, I thought at first,” Mr. Smith says of his attitude more than three years ago. “My original reaction was like, is he – ‘he’ at the time, that is – experiencing stress with the other sex, and he might think, ‘Man, it’d just be a lot easier if I were a girl?’ ”

Like many, Smith had given little thought to the concept of “transgender” people, other than having a vague sense that it referred to those who choose to get sex-change operations. He and his wife, Monica, a health-care compliance attorney, had mostly applauded the seismic shifts in attitudes toward lesbian and gay people over the years. But this, this was more difficult to wrap their minds around, they say.

“My biggest concern, though, was, she must be in a lot of pain,” Smith says of his youngest – now 16 and known as Heather. “So something is causing this. What is it?” (The family asked that their surname be changed to protect their identity.)

The same question is now being asked by many Americans as transgender people become more visible across the country. From the screens of pop culture to the rubrics of public policy, the United States is beginning to alter its views of those who express their gender in ways outside expected social norms.

Over the past year, award-winning TV shows such as Netflix’s “Orange Is the New Black” and Amazon’s “Transparent” have featured transgender characters prominently – prompting many to compare them to the NBC sitcom “Will & Grace,” which 15 years ago was credited with helping transform American attitudes toward homosexuality. And millions watched as 1976 Olympic decathlon gold medalist Bruce Jenner, once dubbed the best athlete in the world, came out as transgender – and Republican – in April.

At the same time, state and federal government agencies, as well as businesses and schools, have been ushering in more-inclusive policies toward those who do not easily fit into cultural expectations of gender. Last year, the Obama administration ended the 33-year-old ban on Medicare coverage for transition-related care and sex-reassignment surgery, and at least nine state insurance commissions have told private insurers to pay for transition procedures now deemed “medically necessary.”

The private sector has mirrored this trend: One third of Fortune 500 companies have moved to cover transgender-related health care, including sex-reassignment surgeries – up from zero in 2002, according to a Human Rights Campaign report released last fall. And 2 out of 3 of the nation’s largest companies now offer explicit nondiscrimination protections for transgender people.

“Many of these events were unthinkable even five years ago,” says Kristina Olson, director of the TransYouth Project at the University of Washington in Seattle, which is conducting the first large-scale study of development in transgender and gender-nonconforming youth. “Maybe because of these events – as well as some of the tragic stories we hear – a subset of parents with transgender children are starting to make different decisions than parents a few decades ago did, or could.”

“I believe this is where life for transgender people is changing the most,” Dr. Olson continues. “Twenty years ago there were almost no transgender kids who were going to school or playing at the park or even leaving the house presenting to others as their gender identity. That happens now. It’s hard not to see that as some serious cultural change.”

The increasing visibility of transgender people may present an even deeper challenge to visible societal norms than sexual orientation did a decade ago. A male or female identity, even within a broad array of cultural expressions, is still rooted in basic biological facts, many say. Whatever the reasons a person may have for not feeling born with the “right body,” how can you argue with biology?

Fears of bullying and violence, as well as the journey that lies ahead as Heather transitions to a young woman, have led the Smiths to enroll her in a home-schooling program for now.

“I usually worry a lot about my future,” Heather says, describing how she’d have panic attacks in public situations. “I always worry about school, and what am I going to do? I kind of delve into, like, how people think about me, and whatever, so I always worry about that, especially in a conversation with someone.... I wonder how they would react if I told them I was trans, and then I would, um, just panic.”

In school and beyond, social life for those who express a transgender identity or exhibit “gender nonconforming” behavior can be a daily ordeal. Nearly 4 out of 5 say they have been harassed, more than 1 out of 3 say they have been physically assaulted, and nearly 1 out of 9 has experienced sexual violence, according to the 2012 National Transgender Discrimination Survey. More than 40 percent of transgender people at some point attempt suicide – compared with 1.6 percent of the general population.

“We are stigmatizable people; we are others; we are ‘those’ people,” says Mara Keisling, executive director of the National Center for Transgender Equality in Washington, which commissioned the study. “It’s still true that every day, all around America, there are tragedies still happening.”

Like gays and lesbians a generation ago, transgender people today are often rejected by their families, have high rates of homelessness, and experience overt discrimination in the workplace, the survey found. They are also the most likely of any group today to face overt hostility and discrimination.

A few years ago, there would have been few places for families like the Smiths to turn to. Hospitals and research institutions from Seattle to Boston have begun to focus more attention on causes and treatments for what is known clinically as “gender dysphoria,” or “gender identity disorder.”

Even these clinical terms have become controversial among researchers. Many believe the “disorder” or “dysphoria” describes the inner malaise and pain that transgender people experience when they confront social settings where they simply don’t fit in.

Whatever the developmental causes, simply being transgender is not a dysfunction or psychological “problem” per se, many say.

“There’s a growing understanding that being transgender is just another normal variation of human diversity,” says Marco Hidalgo, staff psychologist in the multidisciplinary gender and sex development program at Ann & Robert H. Lurie Children’s Hospital of Chicago, where Heather goes for treatment.

“And there’s no one way to be transgender,” Dr. Hidalgo continues. Not all transgender people decide to have surgery or take hormones to transition to the opposite sex. In fact, the majority cannot afford to.

Much remains to be learned about the transgender phenomenon that occurs in less than 1 percent of humans, researchers say. At Lurie Children’s Hospital, 180 families, including the Smiths, are being helped through sometimes difficult decisions by a team of endocrinologists, psychologists, pediatricians, and medical ethicists, as well as a surgical team.

“Gender-nonconforming play, like wanting long hair or to play with dolls if you’re a boy, or play with trucks or guns if you’re a girl, there’s nothing abnormal about that,” says Robert Garofalo, the pediatrician who oversees the gender development program at Lurie Children’s Hospital. “But there are young children even at age 3 or 4 who can begin to voice, ‘I’m not a boy, I don’t feel like a boy, I was born with the wrong body parts,’ and although that seems counterintuitive for some of us, that’s the reality for some of these families.”

More and more, parents are allowing their children to express their gender in a way that feels most natural – including “socially transitioning” to another gender in terms of clothing or appearance.

“I never knew that I wasn’t a boy,” says Jae Bates, a freshman at the University of Puget Sound in Tacoma, Wash. “I had to like figure out that people saw me as a girl first, because I always saw myself as a boy as a little kid. I didn’t understand the gendered way that the world was, and I kind of realized that when I was about 8, and I was playing baseball, and I got bullied off the baseball team.”

Mr. Bates says his parents let him be a “tomboy” through junior high. At that time, when it came to formalwear for weddings or school dances, they pressured him to wear a dress rather than the suits and ties he preferred.

“So I kind of tried to force myself to act more feminine, dress more feminine, present more femininely,” Bates said. “I did that, and when I got home I had these panic attacks, crazy anxiety – I became really, really depressed.”

His parents decided to allow him to dress the way he wanted to, and it made an enormous difference for his happiness, Bates says. By the end of high school last spring, he began to medically transition to become a young man, with the support of his parents.

The support that Bates and Heather are getting from their parents makes all the difference when it comes to the overall well-being of transgender children, experts say. According to a study by the Trans PULSE Project in Ontario, Canada, parental support is the most significant factor in stemming the social and emotional malaise most transgender people endure.

While 75 percent of transgender young people without parental support said they were depressed, only 15 percent of those who had parental support reported symptoms of depression. More than half without support reported problems with finding a place to live – many are still kicked out of their homes – while no one who had parental support said they had a hard time finding housing. Most significantly, the suicide rate drops to 4 percent – a fraction of that found among those without familial support.

Because of data like this, there has been a dramatic shift in how the nation sees transgender people and their medical needs. The country’s medical guilds, including the American Medical Association and American Psychiatric Association, have supported transition-related medical care such as hormone therapy and sex reassignment surgeries as “medical necessities.”

As a result, procedures that long had been denied coverage and thought to be more akin to cosmetic changes are now considered basic health care. In 2012, Oregon’s insurance commission became the first to include transition-related care for transgender people. Those in California, Colorado, and Vermont, as well as the District of Columbia and five other states, followed.

In 2013, the Veterans Health Administration approved all “medically necessary care” for intersex and transgender veterans – though not for surgery. And this February, the Defense Department for the first time approved sex-transition treatments for Chelsea Manning, the transgender soldier convicted of espionage in 2013 after sending classified government documents to WikiLeaks.

For many people of faith, gender distinctions, rooted in human biology, are part of the divinely created order. “God has placed man and woman at the summit of creation and has entrusted them with the earth,” said Pope Francis in a statement critical of what he called “gender theory.” “The design of the Creator is written in nature.”

Last year, the Southern Baptist Convention, the nation’s largest Protestant denomination, affirmed the creation of “two distinct and complementary sexes” and “God’s good design that gender identity is determined by biological sex and not by one’s self-perception.” The denomination also rejected hormone therapies and surgeries as treatment for transgender people, though it denounced “acts of abuse or bullying committed against them.”

Some secular psychiatrists also maintain that self-perceptions of being “trapped in the wrong body” are by definition delusions.

“The proper treatment of emotional unhappiness is not surgery,” Joseph Berger, fellow of the Royal College of Physicians and Surgeons of Canada, testified before a panel considering including transgender people in its human rights laws in 2013.

“Cosmetic surgery will not change the chromosomes of a human being,” said Dr. Berger, who also has supported reparative therapies for homosexuals.

But even among liberal groups, the issue can raise heated debates. Many self-described “radical feminists” from the 1970s and ’80s see transgenderism as simply based on cultural stereotypes of gender.

“Transgenderism depends for its very existence on the idea that there is an ‘essence’ of gender, a psychology and pattern of behaviour, which is suited to persons with particular bodies and identities,” writes Sheila Jeffreys, in “Gender Hurts: A Feminist Analysis of the Politics of Transgenderism.”

Ms. Jeffreys points out the number of “detransitioners” – an estimated 1 to 2 percent of those who have come to regret their hormone treatments or surgeries – as evidence that being transgender is not immutable. 

Such views have become a minority among medical and social thinkers over the past decade, but in the US, from high schools to workplaces, many Americans remain deeply uncomfortable with, if not downright hostile to, the presence of transgender people in their midst.

In recent months, questions about their use of bathrooms or locker rooms, their participation in gender-segregated athletics, or how they choose to dress in a classroom or workspace, have roiled many communities.

This year, in Minnesota and Kentucky, Republican lawmakers proposed laws that would require high school students to use the public restrooms designated for the sex they were born with. In Florida and Texas, Republicans sponsored bills to restrict all public facilities to the gender listed on a person’s birth certificate. By contrast, the Obama administration in April established a transgender restroom in the White House.

This is why, advocates say, one of the biggest battles outside health care is making it easier for transgender people to change their identification, including their birth certificates. In the past, a full surgical transition – which was not covered by insurance and which few could afford – was required to officially change a person’s “M” or “F” marker.

In 2010, however, the Obama administration removed the proof-of-surgery requirement to update passports. About half of US states have also eased back requirements to change a person’s name and gender markers on driver’s licenses and state IDs.

“One of the most exciting things about the social movement happening now, is that I see transgender people for the first time in a long time being viewed in a much broader lens,” Dr. Garofalo says.

“Hopefully, with added visibility comes a hope of a kind of normalization,” he adds. “I hate to use the word ‘normal,’ but I mean there’s the hope that there can be an acculturation into a society that begins to look at them as people, just like any other people in our society, as opposed to being othered.”

But the biggest changes may have begun with the parents who are choosing to handle the gender issues of their children in a new way, and finding the support to prevent the very difficult lives transgender people have faced in the past, Olson says.

“It was almost like the clouds cleared, and the sunshine came out,” says Monica Smith. “Finally somebody understood what Heather was going through and was willing to go the extra mile to find out what we needed to do, because she was so young at that time.

“And she was so convinced that this was what she wanted – a full transition.”

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