Tagged Transgender and Transsexuals

Being Transgender as a Fact of Nature

Photo

After surgical and hormonal treatment, George Jorgensen, a Bronx-born G.I., became Christine Jorgensen, a nightclub entertainer and advocate for transsexual rights.

After surgical and hormonal treatment, George Jorgensen, a Bronx-born G.I., became Christine Jorgensen, a nightclub entertainer and advocate for transsexual rights.Credit Fred Morgan/NY Daily News Archive, via Getty Images

In 1952, George Jorgensen, a Bronx-born G.I., underwent surgical and hormonal treatment in Denmark to become Christine Jorgensen, a nightclub entertainer and advocate for gender identity rights. Ever since, health professionals and lay people alike have debated the origins of gender identity, the wisdom of altering one’s biologically determined sex, and whether society should accept the transgender community as a fact of nature.

There is even disagreement over whether the Civil Rights Act of 1964, which bars discrimination because of sex, also protects gender identity, a person’s inner sense of being male or female. Many more transgender people, whose identity does not match their biological sex, have come forward in recent years. Some seek sex change treatment. The Olympic gold-medalist Bruce Jenner made a high-profile announcement last year of his transition to Caitlyn Jenner, including a cover story in Vanity Fair.

This year, the Public Theater in New York presented the musical “Southern Comfort,” adapted from an award-winning 2001 documentary film about transgender people living in rural Georgia who came together to support a dying friend who developed ovarian cancer years after transitioning from female to male.

Yet the controversy now raging over the rights of transgender students to use bathroom and locker room facilities that match their gender identity rather than their birth sex reflects the persistence of widespread prejudice and misinformation about the nature and behavior of people who identify as transgender.

Those who insist that people should use only the facilities that match the sex on their birth certificates may not realize that most states allow those who change their sexual assignment to change the sex on their birth certificates. Furthermore, a transgender individual using a facility matched to his or her gender identity is no more of a sexual threat to others than anyone else using that bathroom might be. Psychosocial distress or embarrassment can be avoided simply by providing closed-door toilet and changing areas in public bathrooms and locker rooms. After all, we should be used to mixed-gender bathrooms by now: We’ve had them in our homes for years.

I recently read a most illuminating article, “Care of Transsexual Persons,” that answered many of the questions and concerns that have been raised about transsexualism, which is now more commonly referred to as being transgender. Written by Dr. Louis J. Gooren, an endocrinologist at VU University Medical Center in Amsterdam and a leading expert in the field, it was published in 2011 in The New England Journal of Medicine.

Perhaps the most important point Dr. Gooren and others make is that a mismatch between gender identity and biological sex is not something people choose. The most common description given by transgendered individuals is a persistent, painfully distressing belief that they are females trapped in a male body, or vice versa.

Although being transgender is classified in the psychiatric literature as “gender identity disorder,” Dr. Gooren pointed out that “a substantial proportion of the transgender population does not have a clinically significant coexisting psychiatric condition” other than chronic suffering from feeling they are not what their bodies tell them they are.

No chromosomal or hormonal causes of being transgender have been identified. Also lacking is convincing evidence that it is caused by some aberration of family dynamics — how a child is treated or dressed by mom, dad or anyone else.

Being transgender simply happens, possibly during brain development in the womb. All brains start out female; if the fetus is male, testosterone normally programs both the genitalia and the brain to develop as male. But autopsies of a small number of male-to-female transgender people found that two important areas of the brain had a typical female pattern, suggesting an alteration in the brain’s sexual differentiation.

In individuals who transition from female to male, it is possible that excessive production of androgens during pregnancy could have programmed the brain to be male.

Among adults, male-to-female transitions are nearly three times more common than female-to-male ones. It has not been unusual for people born male to first acknowledge and express their female gender identity in midlife, often after having married and fathered children.

In young children, girls who are tomboys and boys who act more like girls are quite common and should not be assumed to be transgender. Such behavior often changes by adolescence.

However, when bodily changes at puberty differ from a child’s gender identity, they are typically a source of extreme distress. Still, experts warn that at any age, and especially in adolescence, great caution must be taken before irreversible treatments are provided to induce changes that conform to a person’s discordant gender identity.

“Persons with gender identity disorder may have unrealistic expectations about what being a member of the opposite sex entails,” Dr. Gooren wrote. Therefore, he and others say that before starting hormone treatments, the person should live for at least a year as the desired sex. Only then should hormone treatments be used to induce the secondary sex characteristics of the new sex and suppress those of the birth sex.

Surgical sex reassignment may then follow to remove and reconstruct the genitalia, breasts and internal sex organs to more closely resemble the desired sex. Some people, especially transgender males, also undergo facial reconstruction. Even after surgery, hormone treatments must continue indefinitely to maintain the desired gender characteristics.

It is especially important for transgender individuals seeking treatment to know the risks involved. Long-term studies of people who underwent sex reassignment surgery have been conducted in Sweden and Denmark, where excellent population-wide medical records are kept.

A Swedish team from the Karolinska Institute and the University of Gothenberg followed 324 people who underwent sex reassignment surgery and compared them with matched controls in the general population. After an average follow-up of 11.4 years, men and women who had sex reassignments had death rates three times higher from all causes. Suicide rates were especially high, suggesting “the need for continued psychiatric follow-up” among those undergoing sex change, the authors wrote. Cancer deaths were doubled in the surgical group, though the cancers appeared to be unrelated to hormone treatments.

The recent Danish study, by researchers in Copenhagen, investigated postoperative diseases and deaths among 104 men and women representing 98 percent of those who underwent sex reassignment surgery in Denmark from 1978 through 2010. One person in three had developed an ailment, most often cardiovascular disease, and one in 10 had died, with deaths occurring at an average age of 53.5.

The authors suggested that a host of societal factors, including social exclusion, harassment and negative experiences in school and at work, could largely contribute to the patients’ health problems. The findings underscore the importance of better postoperative support and closer attention to injurious lifestyle issues like smoking and alcohol abuse.

Related:

For more fitness, food and wellness news, follow us on Facebook and Twitter, or sign up for our newsletter.

The Other Bathroom Wars

Photo

Credit iStock

Jane Serge remembers her father pushing her wheelchair into a men’s room in the late 1970s. “Close your eyes,” he would say, as he quickly wheeled her toward the stalls.

Today, a father who took his disabled daughter into a men’s room in a public building in North Carolina technically would run afoul of the state’s so-called “bathroom bill,” which requires that people over the age of 7 use the bathroom that matches the sex on their birth certificates. While the law is aimed at transgender people, disability advocates worry that it also could affect people with disabilities who, because they need assistance from an opposite sex caregiver or parent, also use opposite sex bathrooms.

Parents like Jennifer Eldridge-Bird of Miami, whose sons, ages 11 and 15, have autism, say their children’s disabilities require that the parent and child stay together at all times.

“They’re not very high-functioning,” she said. “If I’m going in the ladies’ room, they’re going in the ladies’ room.”

Sharisse Tracy, a mother of four in West Point, N.Y., said sending her 8-year-old, who has autism, into a shared men’s room alone is out of the question. “I wouldn’t send him in anywhere alone, let alone a men’s room,” she said.

For Laura Rossi and her 13-year-old twins, using public bathrooms became more challenging as her children have gotten older. Her son, Matt, has Tourette syndrome, accompanied by significant impairment of fine motor and social skills.

“When the twins were little and cute, there were all these smiles and nodding heads,” said Ms. Rossi, a public relations professional who lives in Jamestown, R.I.

But as they got older, she began to hear criticism when she took them into the women’s room. “Matt’s needs are invisible, and he got tall very quickly,” she said. “If there’s not a family bathroom, we got a lot of looks and comments, you know, meant for you to hear but not really ‘to’ you — like ‘this is not the boys’ room.’”

With restroom access a topic of national debate, many people with disabilities and their families are hoping that conversation extends to expanding access to public facilities for every person.

For many of the nearly one in five Americans (and about 5 percent of school-age children) with some disability, lack of access to public toilet facilities challenges their ability to take part in ordinary daily life. For some, like Ms. Serge, 46, who was born with cerebral palsy, the challenges are primarily physical.

“The stalls aren’t wide enough,” she said, quickly ticking off a list of problems she faces regularly in public restrooms in Amherst, Mass., where she lives. “If the door swings in, not out, you can’t close it once you’re in there.” The rails or toilet seats are often loose; there’s not room for her and for someone to help her and she has hit her head on a badly positioned huge toilet paper roll more than once. “And by the time I’m done, the motion-activated flush has gone off, like, 14 times.”

For others — parents of teenage and adult children with physical disabilities, some of whom use diapers, or of older children and teenagers with autism or other cognitive and emotional difficulties — the challenges have to do with their ability to assist family members.

Family members of people with disabilities say large, multi-stall public restrooms present the biggest challenge. Some large retailers now offer family bathrooms, which are ideal because they are private but large enough to accommodate multiple family members as well as wheelchairs and strollers. Individual bathrooms also work better for everyone, but space and cost constraints mean that many public spaces don’t offer them.

Some people say that if there isn’t a bathroom that accommodates the needs of disabled family members, they just stay home.

“We plan all our trips around Michael,” said Jean Lucas, whose nonverbal 7-year-old son uses diapers and a wheelchair. “Sometimes I’m in the middle of the floor, changing him while people are washing their hands.” It’s a situation the South River, N.J., mother of four does her best to avoid. “People say, oh, he doesn’t know what’s going on, but he knows. He understands. He deserves privacy.”

Eric Lipp, executive director of the Chicago-based Open Doors Organization, which advocates for people with disabilities in the travel and tourism industries, says there is a slowly growing movement to offer facilities for changing a diaper on an adult or an older child — a large, stable surface, ideally with a lift, like those designed by the nonprofit Changing-places.org

“Family bathrooms have been a really big addition for people with disabilities,” he said.

Jennifer Kasten, a mother of two daughters, one of whom uses a wheelchair, and a lawyer and special education advocate in Scottsdale, Ariz., said that creating accessible bathrooms isn’t just an issue for people who are transgender or disabled, but something that may affect all people as they age or as their health circumstances change.

“Accessibility has unintended consequences that are good for everyone,” she said, “How we think about accessible bathrooms says a lot about how we think of people with disabilities in general.”

Interested in more Well Family? Sign up to get the latest news on parenting, child health and relationships with advice from our experts to help every family live well.

For Transgender Patients, Challenges at the Hospital

Photo

Beck Bailey has encountered some health care professionals who were unsure how to treat transgender patients.

Beck Bailey has encountered some health care professionals who were unsure how to treat transgender patients.Credit Kieran Kesner for The New York Times

After a skiing accident in January left him with a smashed knee, Beck Bailey, a transgender man in Greenfield, Mass., spent 15 days in a Vermont hospital undergoing a handful of surgeries. As part of his normal routine, Mr. Bailey gives himself regular shots of testosterone. But the endocrinologist on duty in Vermont told him that patients should not take testosterone post surgery.

Mr. Bailey explained that he couldn’t just stop his hormone treatment. But the doctors were so resistant that he finally had them call his primary care physician, who explained he should resume his usual protocol.

“I don’t expect every doctor in the world to become an expert in trans medicine, but I do think they should be knowledgeable enough to know what they don’t know and pick up the phone and call an expert,” said Mr. Bailey, 51, deputy director of employee engagement at the Human Rights Campaign, an advocacy group for gay, lesbian, bisexual and transgender people.

Mr. Bailey’s experience is echoed by many transgender patients, both those who have fully transitioned and those in the process. Research on nontransition-related medical needs is limited; most medical schools don’t prepare doctors for treating this community.

“What happens once you get past the immediate issues of transition, and you run into problems with diabetes, cancer, with the E.R.?” said Karl Surkan, 46, a professor of women’s studies at M.I.T. and Temple University.

Photo

Credit Mark Makela for The New York Times

Mr. Surkan, who is transitioning from female to male, has firsthand experience: He carries the BRCA1 gene and was given a diagnosis of breast cancer. When he inquired about whether testosterone would affect his cancer treatments, his oncologist told him, “It probably would, but we don’t have any data on whether testosterone would cause a recurrence of your cancer. We wish we could help you.”

Indeed, there are few longitudinal studies on hormone use in the trans community. Many doctors aren’t aware that some transgender men may still need pap smears, breast exams and mammograms, and that all transgender women should be screened for prostate problems.

“Many transgender men and women have not had genital affirmation surgery and retain reproductive organs they were born with,” said Dr. Harvey Makadon, the director of education and training programs at the Fenway Institute in Boston and a clinical professor of medicine at Harvard Medical School. “All transgender women still have a prostate gland, and a good clinician will need to learn about the current anatomy and provide appropriate preventive screening and care.”

In addition to medical concerns, many trans patients say they are discriminated against by doctors and other medical staff members who misuse pronouns, call them by incorrect names or house them with people of the wrong gender.

According to a 2010 report by Lambda Legal, 70 percent of transgender respondents had experienced serious discrimination in health care. And a 2011 study of more than 6,000 transgender people by the National Center for Transgender Equality and the National LGBTQ Task Force found that 19 percent said they had been denied health care because of their transgender or gender nonconforming status. Many of them avoided the doctor’s office altogether: 28 percent had postponed getting health care when they were ill or injured, and 33 percent had delayed or not sought preventive care because of their past experiences with doctors.

A 2014 report by the HRC Foundation found that out of 501 hospitals researched, 49 percent did not include both “sexual orientation” and “gender identity” in their patient nondiscrimination policies.

Hospitals, for their part, are often flummoxed. Where, for example, should they put a patient who identifies as female, but is anatomically still male or listed that way on their birth certificate?

Mr. Surkan said that he has been placed in hospital rooms with other women. “It doesn’t bother me as much as it bothers people who are housed with me,” he said. “I do have a friend who is much more masculine appearing who had a hysterectomy, and he was put in the ward with women. That was pretty awkward for everybody.” He has since co-founded the TransRecord, which, together with sites like RAD remedy, act as a kind of clearinghouse for trans people seeking medical care.

In July, a transwoman alleged sex discrimination at Brooklyn Hospital Center after being placed in a room with a male roommate. “We didn’t realize that the individual was transgender,” said Joan Clark, a hospital spokeswoman. The hospital now requires all employees to undergo sensitivity training. “I think it’s made us a better organization,” she said. “They don’t want different treatment, they just want equitable treatment.”

Wrene Robyn, 46, a transwoman in Somerville, Mass., began her transition in 1989, when she changed her name on her driver’s license and Social Security cards, and the gender on her driver’s license from male to female. While she integrates fairly well into mainstream society, she has avoided the doctor for years. “Most trans people don’t go to the hospital, because they’re terrified of the room situation,” she said. “They’re terrified of it all. They don’t want to be misgendered, and they don’t want to explain what they have or don’t have in their pants.”

In April, after a bout of pancreatitis, Ms. Robyn spent a week in Massachusetts General Hospital in Boston, where she was given a single room. “Nobody really asked me what my preference was,” said Ms. Robyn, who works as a software engineer at the hospital and also serves on a transgender care committee there. In addition to worrying about being discriminated against, “What goes through a lot of trans people’s minds is, is this going to cost more? Usually we can’t afford private rooms.” (It was covered by her insurance.)

Some hospitals are now overhauling — or implementing — policies on treating transgender patients. At Mass General, for example, transgender patients are now asked if they prefer a private room or double. “If they are going to be placed in a double room, we ask them how they identify themselves,” said Terri Ogan, a spokeswoman. “If the patient identifies as a woman, they will be placed in a room with a woman. If they identify as a man, they will be placed in a room with a man.”

Transgender patients at Mount Sinai Health System, which encompasses seven hospitals in New York City, have been housed according to their current gender identity, regardless of where they are in their physical transition, since 2013. They can also request a single room. Previously, the hospital always put them in private rooms, but that had drawbacks: Many patients felt as if they were being segregated, and worried that they would be charged extra (they weren’t). “Often the transperson would be delayed or in the E.R. waiting for a single room to open up,” said Barbara Warren, the director for L.G.B.T. programs and policies at Mount Sinai’s office for diversity and inclusion.

Terry Lynam, a spokesman for North Shore LIJ Health System, which has 21 hospitals in New York City, Long Island and Westchester, said that their transgender policy, which was approved in November of 2014, is to treat transgender patients like any other patient. “So, we wouldn’t necessarily give them a private room,” said Mr. Lynam. But, he acknowledged, the issue becomes a bit more complicated with patients who still look like the sex they were assigned at birth. In that instance, if a roommate objects, “We’ll try to accommodate them and move the person who complains,” he said.

Advocates see this as a long time coming. “I’ve been telling hospitals that they really need to think about this and adopt some policies proactively,” said Tari Hanneman, deputy director of the Health and Aging Program at the Human Rights Campaign. “The first time you think about where you are going to put a transgender patient should not be when they arrive.”

For more fitness, food and wellness news, follow us on Facebook and Twitter, or sign up for our newsletter.