The Klebolds had letters from kids who idealized Dylan, and from girls who were in love with him. "He has his own groupies," Tom said with an ironic half smile. They were heartened by unanticipated kindnesses. At a conference about suicide some years later, a man came up to Sue, knelt in front of her, and said, "I just want to tell you how much I admire you. I can't believe the way you have been treated. Every day I picked up the paper, and I expected to read that people were coming up your driveway with pitchforks." Sue has had strangers hug her. But the prospect of a normal life remains elusive. She recounted a recent trip to the supermarket when the checkout clerk had verified her name on her driver's license. "And then she says, 'Klebold...Did you know him?' And I say, 'He was my son.' And then she started in with 'It was the work of Satan.' And I'm thinking, 'Please, let's bag the groceries here.' As I leave the store, she's yelling out after me about how she's praying for me. It wears you down."

Before I went to meet Tom and Sue the first time, a friend asked me whether I was afraid of the Klebolds, as if I might succumb to some contagious evil in their house. Ultimately, what proved difficult to reckon with was their underlying normality. One of Dylan's friends said that he used to call them Ward and June, after the sunny couple on on Leave It to Beaver, Leave It to Beaver, because their household seemed so pleasant and predictable. They showed me family photo albums and home videos. I was particularly struck by a video of Dylan on his way to his prom, three days before the massacre. He's a little churlish in the mode of adolescents, but also has a sweetness about him; he seems like a nice kid. It would never have occurred to me that he could be on the verge of wanton destruction. His long hair pulled back in a neat ponytail, he's adjusting his rented tuxedo and complaining that the arms are a little short, smiling while his date puts on his boutonniere. "Dad, why are you filming this?" he asks. Then he laughs and says, "Well, someday I'll watch it again, and I'll wonder what I was thinking." It was impressive dissembling, because he imparts the feeling of someone who will one day remember being dressed up, with a pretty girl, on the way to the biggest party of his life. Near the end of the video, he says, "I'll never have kids. Kids just mess up your life." The sudden angry moment comes out of nowhere and evaporates just as fast. because their household seemed so pleasant and predictable. They showed me family photo albums and home videos. I was particularly struck by a video of Dylan on his way to his prom, three days before the massacre. He's a little churlish in the mode of adolescents, but also has a sweetness about him; he seems like a nice kid. It would never have occurred to me that he could be on the verge of wanton destruction. His long hair pulled back in a neat ponytail, he's adjusting his rented tuxedo and complaining that the arms are a little short, smiling while his date puts on his boutonniere. "Dad, why are you filming this?" he asks. Then he laughs and says, "Well, someday I'll watch it again, and I'll wonder what I was thinking." It was impressive dissembling, because he imparts the feeling of someone who will one day remember being dressed up, with a pretty girl, on the way to the biggest party of his life. Near the end of the video, he says, "I'll never have kids. Kids just mess up your life." The sudden angry moment comes out of nowhere and evaporates just as fast.

From the day of the bloodbath, April 20, until the following October, the Klebolds knew few details about what had transpired, except that Dylan was at the shooting and supposedly committed suicide. "We kept clinging to the belief that he hadn't really killed anybody," Sue said. Then came the police report. "It just launched my grief all over again, because I didn't have denial anymore. They could talk about which people he'd killed. Here's the little map of the school, with all the little bodies on it." Then they saw the "basement tapes," which Dylan and Eric had deliberately left behind, which reveal a Dylan unrelated to the young man in the prom video, someone spewing hatred, full of self-aggrandizing rage. "Seeing those videos was as traumatic as the original event," Sue said. "All the protective beliefs that we'd held on to were shattered. There wasn't hate talk in our house. I'm part Jewish, and yet the anti-Semitic stuff was there; they were going through every derogatory word: a nigger; a kike. I saw the end product of my life's work: I had created a monster. Everything I had refused to believe was true. Dylan was a willing participant, and the massacre was not a spontaneous impulse. He had purchased and created weapons that were designed to end the lives of as many people as possible. He shot to kill. For the first time, I understood how Dylan appeared to others. When I saw his disdain for the world, I almost hated my son. I wanted to destroy the video that preserved him in that twisted and fierce mistake. From then on, no matter how lovingly he would be remembered by those who knew him, the tapes would provide a lasting contradiction to anything positive that could be said about his character. For me, it's a smothering emptiness." On these tapes, like the hope at the bottom of Pandora's box, is one moment of kindness: when Eric mentions their parents, Dylan says, "My parents have been good to me. I don't want to browse there." of Pandora's box, is one moment of kindness: when Eric mentions their parents, Dylan says, "My parents have been good to me. I don't want to browse there."

If you take Tom and Sue back to their prelapsarian memories, ease creeps into their voices. "Dylan was a marvel," Tom recalled of his son's early childhood. "Completely self-motivated. Curious." Every year on Dylan's birthday, Tom goes up to the place where the two used to hike and takes a Dr Pepper, because Dylan loved Dr Pepper, and the stuffed koala that was Dylan's childhood favorite. The Klebolds needed three years to clean out Dylan's room and to remake it into the pleasant guest room in which I slept on my visits. Sue said, "He was a wonderful, marvelous, pretty-close-to-perfect child. He made you feel like a great parent, because he did everything right. Dylan had this incredible sense of organization, and structure, and all this executive functioning." At three, he could already count to 110 and would use refrigerator magnets to make equations. He entered preschool a year early, earned top grades, and was accepted to the gifted-children program. "When he was very young, he would dump five or six puzzles into a pile, so he would have the thrill of working on them all at the same time. He liked mazes; he liked word searches. He played chess with Tom. He was just a delight." Sue looked at me sideways, then said quietly, "You can't imagine how long it's been since I had a chance to brag about my son." Later she said, "He was very malleable; you'd reason with him and say, 'This is why I think you should do something,' and you could almost always persuade him to change his mind. Which I used to see as a strength, from the perspective of a parent. But I see now that it might have been a terrible detriment."

Only one incident with Dylan, the year before the massacre, suggested something might be amiss. The spring of his junior year, Dylan had asked to spend the night at his friend Zack's place, and when Zack had to cancel, Dylan took advantage and went driving with Eric. On their way to set off fireworks on a canyon road, they stopped at a parking lot and noticed a van with video equipment in the front seat. They grabbed a rock, broke the window, stole the equipment, then turned on their interior lights to inspect their haul. When a policeman stopped to see what was going on, Dylan confessed to the theft almost immediately, and both boys were taken to be booked. "The phone rings," Sue said. "It was the sheriff's department-the darkest night of our lives to that point." They went down to the station to find Dylan and Eric in handcuffs. The police released the boys back to their parents' custody and put them in a diversion program, which aims to help juveniles avoid a criminal record by assigning them community service, educational directives, and restitution. With hindsight, Sue believes that this putative act of mercy was a mean trick of fate; had they gone to jail, the boys would have been separated and out of the school where they felt debased. directives, and restitution. With hindsight, Sue believes that this putative act of mercy was a mean trick of fate; had they gone to jail, the boys would have been separated and out of the school where they felt debased.

The family didn't get home until dawn, and Sue was so angry she couldn't speak to Dylan. When Tom went for a walk the next day with Dylan, he was startled by his son's fury about the arrest. "He felt so above it all, totally justified in what he'd done," Tom said. "The morality of the whole thing escaped him." Sue noticed a similar attitude, and the diversion record remarks that he didn't connect to the wrongness of what he did. "I said, 'Dylan, help me understand this,'" Sue said. "'How could you do something so morally wrong?' And he said, 'Well, I didn't do it to another human being; it was to a company. That's what they have insurance for.' And I said, 'Dylan! You're scaring me!' He said, 'Well, it scared me, too, because I don't know why I did it. Just, suddenly, we'd done it.' His mother chalked it up to teenage impulse and made him promise that he would never do anything of the sort again. "He said, 'I promise. But I'm scared, because I didn't know I was going to do it this time.' So I said, 'Well, now you know.'"

Sue asked the people in the diversion program whether Dylan needed counseling, and they administered standardized psychological tests and found no indication that he was suicidal, homicidal, or depressed. "If I could say something to a roomful of parents right now, I would say, 'Never trust what you see,'" Sue said. "Was he nice? Was he thoughtful? I was taking a walk not long before he died, and I'd asked him, 'Come and pick me up if it rains.' And he did. He was there for you, and he was the best listener I ever met. I realize now that that was because he didn't want to talk, and he was hiding. He and Eric worked together at the pizza parlor. A couple of weeks before Columbine, Eric's beloved dog was sick, and it looked like he wasn't going to make it, and so Dylan worked Eric's shift as well as his own so that Eric could have the time with his dog."

In the writing Dylan and Eric left behind, Eric comes off as homicidal; his anger is all directed outward. Dylan comes off as suicidal; his energy fuels self-abnegation and self-criticism. It's as though Dylan went along with the homicide for Eric's sake, and Eric with the suicide for Dylan's. Toward the end, Dylan was counting the hours he had left. "How could he keep it so secret," Sue wondered, "this pain he was in?"

When I asked the Klebolds what they would want to ask Dylan if he were in the room with us, Tom said, "I'd ask him what the hell he was thinking and what the hell he thought he was doing!" Sue looked down at the floor for a minute before saying quietly, "I would ask him to forgive me, for being his mother and never knowing what was going on inside his head, for not being able to help him, for not being the person that he could confide in." Later she said, "I've had to forgive me, for being his mother and never knowing what was going on inside his head, for not being able to help him, for not being the person that he could confide in." Later she said, "I've had thousands thousands of dreams about Dylan where I'm talking to him and trying to get him to tell me how he feels. I dreamed that I was getting him ready for bed, and I lifted up his shirt, and he was covered with cuts. And he was in all this pain, and I didn't see it; it was hidden." of dreams about Dylan where I'm talking to him and trying to get him to tell me how he feels. I dreamed that I was getting him ready for bed, and I lifted up his shirt, and he was covered with cuts. And he was in all this pain, and I didn't see it; it was hidden."

The Klebolds were caught in lawsuits brought by some victims' families. Four years after the tragedy, they were deposed-supposedly confidentially-in front of these parents. The next day, the Denver paper contended that the world had a right to know what they had said. "It was implying, after all that we'd been through, that they still believed we were at fault," Sue said. "It was, 'How could you not know? How could you not know?' And it's like, 'I can't answer that. I didn't know, I didn't know, I didn't know. How many times can you say that? Why would we have known and not gotten help, not told anyone?"

In the wake of so many enormous stresses, Sue was diagnosed with breast cancer. "I don't believe in chakras," she said. "But you think about all this heart pain, and failed nurturing, and losing a child. I finally had an opportunity to meet some women who had lost children to suicide. There were six women, and three of us have had breast cancer. I used to laugh and say it was my version of comic relief. Because after all we'd been through, the breast cancer seemed like sort of a nice, normal thing." For two years after the maelstrom of Columbine, she thought that she wanted to die, but now she was jarred into a new sense of purpose. "It was like, 'Wait a minute! I have something I have to do first. I have to explain who Dylan was and what he was like.' I met a woman recently who had lost one son to suicide and whose other son was in jail, and I said to her, 'You can't appreciate or believe this now, but if you plunge deep into this, it will lead you to enlightenment. It's not the path you would have chosen, but it will make you a better and stronger person.'"

After Columbine, Sue had a client who was blind, had only one hand, had just lost her job, and was facing trouble at home. "She said, 'I may have my problems, but I wouldn't trade places with you for anything in the world.' I laughed. All those years I have worked with people with disabilities and thought, 'Thank God I can see; thank God I can walk; thank God I can scratch my head and feed myself.' And I'm thinking how funny it is how we all use one another to feel better."

Sue spoke of herself as a lucky person. "I was fortunate that Dylan did not turn on us. The worst thing he did to us was he took himself away from us. After Columbine, I felt that Dylan killed God. No god could have had anything to do with this, so there must not be one. When everything in your world is gone, all your belief systems, and your self-concepts-your beliefs in yourself, your child, your family-there is a process of trying to establish, who am I? Is there a person there, at all? A woman at work asked me recently how my weekend was, and it happened to be the anniversary of the shootings. So I said that I wasn't doing so well and I told her why, and she said, 'I always forget that about you.' I gave her a hug and said, 'That's the nicest thing anyone has said to me in years.'" But Sue does not forget. "I sat next to someone on a train a while ago and we had a really wonderful conversation, and then I could feel the questions coming-'So, how many kids do you have?' I had to forestall it. I had to tell him who I was. And who I am forever now is Dylan's mother." could have had anything to do with this, so there must not be one. When everything in your world is gone, all your belief systems, and your self-concepts-your beliefs in yourself, your child, your family-there is a process of trying to establish, who am I? Is there a person there, at all? A woman at work asked me recently how my weekend was, and it happened to be the anniversary of the shootings. So I said that I wasn't doing so well and I told her why, and she said, 'I always forget that about you.' I gave her a hug and said, 'That's the nicest thing anyone has said to me in years.'" But Sue does not forget. "I sat next to someone on a train a while ago and we had a really wonderful conversation, and then I could feel the questions coming-'So, how many kids do you have?' I had to forestall it. I had to tell him who I was. And who I am forever now is Dylan's mother."

When I mentioned to the Klebolds that I thought they spoke with an extraordinary clarity about their situation, in contrast to some of the other people I had interviewed for this chapter, Tom said, "We are able to be open and honest about those things because our son is dead. His story is complete. We can't hope for him to do something else, something better. You can tell a story a whole lot better when you know its ending." A few years after we first met, Sue said to me, "Way back when, we almost got a house in California, and our offer was turned down, and this house in Littleton came up, we made a low offer, and we were so thrilled when it was accepted. At the time we said how lucky we were that the house in California hadn't worked out. But if it had, Columbine wouldn't have happened. When it first happened, I used to wish that I had never had children, that I had never married. If Tom and I hadn't crossed paths at Ohio State, Dylan wouldn't have existed and this terrible thing wouldn't have happened. But over time, I've come to feel that, for myself, I am glad I had kids and glad I had the kids I did, because the love for them-even at the price of this pain-has been the single greatest joy of my life. When I say that, I am speaking of my own pain, and not of the pain of other people. But I accept my own pain; life is full of suffering, and this is mine. I know it would have been better for the world if Dylan had never been born. But I believe it would not have been better for me."

XI

Transgender

Western culture likes binaries: life feels less frightening when we can separate good and evil into tidy heaps, when we split off the mind from the body, when men are masculine and women are feminine. Threats to gender are threats to the social order. If rules are not maintained, everything seems to be up for grabs, and Joan of Arc must go to the stake. If we countenance people who want to chop off their penises and breasts, then what chance do we have of preserving the integrity of our own bodies? As the noted psychoanalyst Richard C. Friedman once joked, "It might help if they all wore T-shirts that said, 'Don't worry-it won't happen to you.'" Gender itself is a slippery concept. The author Amy Bloom says, "Male is not gay or straight; it's male. Neither the object of desire nor the drinking of beer nor the clenching of fists makes maleness. We don't know what does, and neither do transsexual men, and neither do the people who treat them, psychologically and surgically." But though gender is hard to define, it is not hard to know. Jan Morris, who wrote bravely of her transition-the process of switching gender-in the 1970s, has said, "Transsexualism is not a sexual mode or preference. It is not an act of sex at all. It is a passionate, lifelong, ineradicable conviction, and no true transsexual has ever been disabused of it." She explained, "My inner uncertainty could be represented in swirls and clouds of color, a haze inside me. I did not know exactly where it was-in my head, in my heart, in my loins, in my blood."

The term transgender transgender is an encompassing term that includes anyone whose behavior departs significantly from the norms of the gender suggested by his or her anatomy at birth. The term is an encompassing term that includes anyone whose behavior departs significantly from the norms of the gender suggested by his or her anatomy at birth. The term transsexual transsexual usually refers to someone who has had surgery or hormones to align his or her body with a nonbirth gender. The term usually refers to someone who has had surgery or hormones to align his or her body with a nonbirth gender. The term transvestite transvestite refers to someone who enjoys wearing clothing usually reserved for the other gender. refers to someone who enjoys wearing clothing usually reserved for the other gender. Though the terms get used in a variety of ways, Though the terms get used in a variety of ways, transgender transgender and its abbreviation as and its abbreviation as trans trans are the most widely accepted in the trans community. A are the most widely accepted in the trans community. A transman transman was born female and became a man; a was born female and became a man; a transwoman transwoman was born male and became a woman. was born male and became a woman. Intersex Intersex describes people who are born with ambiguous genitalia or are in some other physical way both male and female from birth. describes people who are born with ambiguous genitalia or are in some other physical way both male and female from birth.

It is a poverty of our language that we use the word sex sex to refer both to gender and to carnal acts, and from that unfortunate conflation springs much of the disgust around the notion of transgender children. Being trans is taken to be a depravity, and depravities in children are anomalous and disturbing. But trans children are not manifesting sexuality; they are manifesting gender. The issue is not whom they wish to be with, but whom they wish to be. As Aiden Key, a trans activist, put it, "My gender is who I am; my sexuality is who I bounce it off of." This is an essential distinction. Yet teasing out the complexities of transgender identity reveals how often these things can be confused-in a child, by a parent, and across the larger community. to refer both to gender and to carnal acts, and from that unfortunate conflation springs much of the disgust around the notion of transgender children. Being trans is taken to be a depravity, and depravities in children are anomalous and disturbing. But trans children are not manifesting sexuality; they are manifesting gender. The issue is not whom they wish to be with, but whom they wish to be. As Aiden Key, a trans activist, put it, "My gender is who I am; my sexuality is who I bounce it off of." This is an essential distinction. Yet teasing out the complexities of transgender identity reveals how often these things can be confused-in a child, by a parent, and across the larger community. Gay Gay and and trans trans are separate categories, but a grayscale runs between them. Making the distinction is especially hard in childhood. A butch little girl or a feminine little boy may want to switch genders immediately; may develop that wish later; or may never develop it at all. One mother described being asked by a male friend whether her boyish daughter was gay and saying, "She's four-I don't think she's got sexual desires yet." But such children may be demonstrating qualities associated with subsequent patterns of attraction; they may, in effect, be pre-gay even if they haven't yet conceptualized the erotic. are separate categories, but a grayscale runs between them. Making the distinction is especially hard in childhood. A butch little girl or a feminine little boy may want to switch genders immediately; may develop that wish later; or may never develop it at all. One mother described being asked by a male friend whether her boyish daughter was gay and saying, "She's four-I don't think she's got sexual desires yet." But such children may be demonstrating qualities associated with subsequent patterns of attraction; they may, in effect, be pre-gay even if they haven't yet conceptualized the erotic.

In 1987, Richard Green published his influential The "Sissy Boy Syndrome" and the Development of Homosexuality, The "Sissy Boy Syndrome" and the Development of Homosexuality, in which he followed a cohort of forty-four feminine little boys for fifteen years. Only one transitioned; most turned out simply to be gay. Sexuality and gender are independent yet entwined variables. Because cross-gender expression is much more common among gay people than it is among straight people, prejudice against such expression is a gay issue. Despite Jan Morris's assertion, gay, too, is an identity-not something you do, but something you are. One can be gay despite never having had carnal relations with anyone of one's own gender; and one can be trans and have presented only in the gender one was assigned at birth. Those who are ignorant about homosexuality and transgender culture tend to confuse and conflate them with reason: homophobia has always targeted gender nonconformity. Immeasurable differences exist between the outre gay guy who likes fashion and decorating magazines, and the school football hero who happens to prefer sex with men. While the in which he followed a cohort of forty-four feminine little boys for fifteen years. Only one transitioned; most turned out simply to be gay. Sexuality and gender are independent yet entwined variables. Because cross-gender expression is much more common among gay people than it is among straight people, prejudice against such expression is a gay issue. Despite Jan Morris's assertion, gay, too, is an identity-not something you do, but something you are. One can be gay despite never having had carnal relations with anyone of one's own gender; and one can be trans and have presented only in the gender one was assigned at birth. Those who are ignorant about homosexuality and transgender culture tend to confuse and conflate them with reason: homophobia has always targeted gender nonconformity. Immeasurable differences exist between the outre gay guy who likes fashion and decorating magazines, and the school football hero who happens to prefer sex with men. While the footballer may encounter legal challenges if he tries to marry a man, and may hear slurs from his teammates if they find out, he will not encounter the same day-to-day abuse that will likely make his classmate's life a living hell. footballer may encounter legal challenges if he tries to marry a man, and may hear slurs from his teammates if they find out, he will not encounter the same day-to-day abuse that will likely make his classmate's life a living hell.

The political liberty of transgender people has been ingrained in the battle for gay and lesbian rights. There are far more gay people than trans people, and the trans movement needs numbers behind it, but the conflation of the two issues nonetheless causes confusion. Some gay people think their trans brothers and sisters are in the same situation as themselves only more so and become passionate advocates on their behalf; others find the trans community embarrassing and attempt to dissociate themselves, a pattern especially common among gay men who want to assert their masculinity credentials. The split echoes, in some ways, the split among early feminists about lesbians, with some viewing lesbianism as the ultimate expression of their identity, and others believing gay women would undermine their battle to ingratiate their ideals with the mainstream. The Employment Non-Discrimination Act (ENDA), intended to protect gay people from job discrimination, came before Congress in 2008 without any protection for gender expression. When the National Gay and Lesbian Task Force fought for a gender-expression clause that would have prevented people from being denied employment or fired solely because they did not conform to gender type, they were told by Representative Barney Frank, who had introduced the bill, that they were asking for too much.

Gender dissonance can manifest extremely early. By age three or four, sometimes even younger, children may notice an incongruity between who they are told they are and who they sense they are. That discrepancy has been called gender identity disorder, or GID. In early childhood, gender nonconformity is often tolerated, but by seven or so, children are pushed hard into gender stereotypes. Trans children may respond to such pressure by becoming anxious and depressed. Telling their parents is usually terrifying for them. "If you don't let them transition, their internal energy is fully occupied with gender identity, and this keeps them from reaching their developmental markers," said Stephanie Brill, founder of the counseling entity Gender Spectrum, and author, with Rachel Pepper, of The Transgender Child The Transgender Child. "Often with transition, children's learning disabilities and other diagnoses resolve themselves because the mind and heart are not so occupied with this central problem."

Even twenty years ago, most transsexuals sought to move completely from one gender to the other. Nowadays, the categories are blurred. Some live blurred. Some live stealth, stealth, meaning that everyone around them believes that they were born into the gender they inhabit. They feel they have failed when they are identified as their natal sex. Others live openly as transmen or transwomen. Many spend some time stealth and some openly trans. Some people are meaning that everyone around them believes that they were born into the gender they inhabit. They feel they have failed when they are identified as their natal sex. Others live openly as transmen or transwomen. Many spend some time stealth and some openly trans. Some people are genderqueer, genderqueer, identifying as neither male nor female. Others are identifying as neither male nor female. Others are gender fluid gender fluid: male some days, female other days, and sometimes neither, or both. Some suffer from gender dysphoria gender dysphoria-a deep misery about the body into which they were born-but others reject the darkness of that term. Some are exhibitionistic, and some, extremely private.

People in any of these categories may or may not have had surgery, be taking hormones, or have had a variety of other physical interventions; collectively, they form what one author has called a "gender chiaroscuro." The DSM DSM says that one in thirty thousand genetic males and one in a hundred thousand genetic females will undergo actual sex reassignment surgery in their lifetime, but such statistics would suggest that there are only fifteen hundred postsurgical transmen and five thousand postsurgical transwomen in the United States. The figures are based on antiquated surveys and reflect an extreme view of what constitutes reassignment surgery, not acknowledging, for example, that creating or removing breasts is a reassignment surgery even in the absence of genital procedures. Lynn Conway, a computer engineer who has analyzed more recent data, has estimated that there are between thirty-two thousand and forty thousand postoperative transwomen in the United States, but said that only one in five or ten people who experiences intense discomfort with birth gender pursues genital surgery. The National Center for Transgender Equality estimates that for up to three million Americans, in Barbara Walters's phrase, "what's between their legs doesn't match what's between their ears." says that one in thirty thousand genetic males and one in a hundred thousand genetic females will undergo actual sex reassignment surgery in their lifetime, but such statistics would suggest that there are only fifteen hundred postsurgical transmen and five thousand postsurgical transwomen in the United States. The figures are based on antiquated surveys and reflect an extreme view of what constitutes reassignment surgery, not acknowledging, for example, that creating or removing breasts is a reassignment surgery even in the absence of genital procedures. Lynn Conway, a computer engineer who has analyzed more recent data, has estimated that there are between thirty-two thousand and forty thousand postoperative transwomen in the United States, but said that only one in five or ten people who experiences intense discomfort with birth gender pursues genital surgery. The National Center for Transgender Equality estimates that for up to three million Americans, in Barbara Walters's phrase, "what's between their legs doesn't match what's between their ears."

Scientists, psychologists, clergy, and academics argue about whether bodies should be altered to accommodate minds, or minds to accommodate bodies. Some believe that all people who vary from gender norms can, with psychiatric treatment, live contentedly in their birth gender; they prescribe a broad range of reparative therapies to address the mind/body dissonance. Others presume that the role of medicine is to facilitate transition and believe in using hormones and surgery to do so. Parents are in a bind, familiar throughout this book, between cure and acceptance. Advocates for reparative therapy insist that people live better in unmutilated bodies and that medical corrections involving considerable pain, risk, and expense should be options of last resort. Opponents contend that strict gender rules are archaic and punitive, and that discouraging transgender people from inhabiting their real selves is a prescription for despair, often for suicide. Received wisdom is evolving at a breakneck pace. The social model of disability-that the problems trans people have are the result largely of the social attitudes they encounter-is argued here with particular ferocity. selves is a prescription for despair, often for suicide. Received wisdom is evolving at a breakneck pace. The social model of disability-that the problems trans people have are the result largely of the social attitudes they encounter-is argued here with particular ferocity.

Parents who support their child's transition-the shift away from a natal gender-must refer to that child by a new name; they must use new pronouns; and they must switch the words son son and and daughter. daughter. Linguistic chaos often ensues. "He's my daughter," one mother explained to me as she introduced her transgender son. Another said, "I use the word Linguistic chaos often ensues. "He's my daughter," one mother explained to me as she introduced her transgender son. Another said, "I use the word child child because I cannot wrap my mind around because I cannot wrap my mind around daughter, daughter, even though I am fine calling my child Elaine." Sociologist Holly Devor writes, "In those cases where persons were living as men at the time of their interviews but were talking about events lived as girls or women, I have used feminine pronouns. For example, 'He remembered that as a girl, she had been a tomboy.'" How we name something determines how we perceive it. even though I am fine calling my child Elaine." Sociologist Holly Devor writes, "In those cases where persons were living as men at the time of their interviews but were talking about events lived as girls or women, I have used feminine pronouns. For example, 'He remembered that as a girl, she had been a tomboy.'" How we name something determines how we perceive it.

Most of the trans people I met disliked MTF MTF (for male to female) and (for male to female) and FTM FTM (female to male), feeling that these terms demean the people to whom they are applied. Many activists speak of people having been "declared male" or "declared female" at birth and later becoming "affirmed females" or "affirmed males." Trans people often refer to the nontrans population as (female to male), feeling that these terms demean the people to whom they are applied. Many activists speak of people having been "declared male" or "declared female" at birth and later becoming "affirmed females" or "affirmed males." Trans people often refer to the nontrans population as cisgender, cisgender, borrowing the idea from the cis-trans distinction in chemistry; the Latin prefix borrowing the idea from the cis-trans distinction in chemistry; the Latin prefix cis cis means "on the same side." I have chosen to refer to people by natal gender prior to transition and by affirmed gender after transition, and to impose this on my interviews with families as much as possible. In cases where people prefer that their pretransition name be forgotten, I have consistently used the post-transition name. means "on the same side." I have chosen to refer to people by natal gender prior to transition and by affirmed gender after transition, and to impose this on my interviews with families as much as possible. In cases where people prefer that their pretransition name be forgotten, I have consistently used the post-transition name.

Twenty-seven weeks pregnant as a single mother, Venessia Romero was rushed to a Denver hospital, where she gave birth to a girl and a boy. The girl looked fairly strong, but the boy was less than a pound and a half and covered with fuzz, his organs visible through his unformed skin. Premature babies are given pulmonary surfactants, which help them to breathe. Because the girl was stronger, they treated her first; she had an adverse reaction and died within minutes. The boy survived.

Within a year, Venessia met and married Joseph Romero, an air force sergeant. The baby's father had never even seen him; Joseph adopted him and changed his name to Joseph Romero II, called Joey. When the baby was twenty months old, the family was posted to the US Air Force base in Okinawa. "The baby would cry all the time," Joseph recalled. "But not 'I want food,' 'I want to be changed.' It wasn't a physical need, and we had no way to console him. The temper tantrums were so bad that we couldn't take him out in public." and we had no way to console him. The temper tantrums were so bad that we couldn't take him out in public."

Over the next four years, Joey was diagnosed with ADHD, depression, anxiety, attachment disorder, and asthma. At three, he was on fourteen different medications. "We had a child who never smiled," Venessia said. "All the time we were cooing, 'Oh, you're such a good boy, such a beautiful boy.' Boy, boy, boy. Every time I put shoes on him, they were little boy's shoes. A little boy's jacket." Joey was already interested in wearing girlish outfits; Venessia thought he was probably gay and worried about how that would go with her military husband.

The Romeros had access only to military doctors, who were cautious of a diagnosis that the military does not welcome, but one finally told Venessia, when Joey was five, to look up GID online. "It was making him squirm just to say that, like his rank was going to fall off," Venessia said. "I had never even heard the word transgender. transgender. I was hugely relieved. Other people go through this?" The Internet introduces trans people and their families into instant networks that can provide information and support; it likewise offers misinformation. Online spaces created to shield and help trans children can easily become the locus of predators with disturbing erotic fantasies, or of transphobic people with murderous intentions. In this instance, however, Kim Pearson-herself the mother of a transgender child and one of the founders of TransYouth Family Allies (TYFA), a group that supports families addressing gender variance-found Venessia online. "She carried me to a forum with other parents," Venessia said. "I cried with gratitude." I was hugely relieved. Other people go through this?" The Internet introduces trans people and their families into instant networks that can provide information and support; it likewise offers misinformation. Online spaces created to shield and help trans children can easily become the locus of predators with disturbing erotic fantasies, or of transphobic people with murderous intentions. In this instance, however, Kim Pearson-herself the mother of a transgender child and one of the founders of TransYouth Family Allies (TYFA), a group that supports families addressing gender variance-found Venessia online. "She carried me to a forum with other parents," Venessia said. "I cried with gratitude."

The revelation threw Joseph into an abrupt and severe depression. Venessia started to call their child Josie. "Josie wouldn't go outside unless she could go in her girl clothes. I had to decide then, was I willing to leave my marriage to protect Josie? Well, to make Josie be a boy is asking her to commit suicide. I'm not that kind of parent." By this time, Venessia and Joseph had adopted a younger daughter, Jade, from China. "I'm willing to give Joseph up, and I'm willing to walk away from Jade, which was incredibly hard. But Josie was five and had already paid enough penance for ten lives." While Venessia was making these calculations, her husband gradually came around. "She had that sparkle," he said. "I just decided, Josie is here to stay."

When I first met Josie, she was eight, and she said, "I'm a girl and I have a penis. They thought I was a boy until I was six. I dressed like a girl. I said, 'I'm a girl.' They didn't understand for the longest time." Josie was increasingly assertive about her need to be a girl all the time, so one day Joseph agreed to take her to school on the base in a denim skirt with a pink rabbit on it, and pink leggings underneath. The kids were mostly accepting, but their parents were another story. "The next day, there was a screaming crowd outside Josie's classroom door," Venessia said. "I was terrified." In Josie's own yard, someone snatched her bicycle from her and tossed it into the jungle. "People were throwing things at our house, calling us child molesters," Venessia said. "Little girls screaming, 'You're a fucking faggot.'" The wife of the judge advocate general on base started a petition to remove Josie from school. "It was awful when everyone found out I was a girl," Josie remembered. "My neighbor Isabelle said she was going to call the police and put me in jail. It made me sad. I thought she was my friend." The kids were mostly accepting, but their parents were another story. "The next day, there was a screaming crowd outside Josie's classroom door," Venessia said. "I was terrified." In Josie's own yard, someone snatched her bicycle from her and tossed it into the jungle. "People were throwing things at our house, calling us child molesters," Venessia said. "Little girls screaming, 'You're a fucking faggot.'" The wife of the judge advocate general on base started a petition to remove Josie from school. "It was awful when everyone found out I was a girl," Josie remembered. "My neighbor Isabelle said she was going to call the police and put me in jail. It made me sad. I thought she was my friend."

Venessia allowed Josie to choose her clothes, and every day she shunned the boy clothes. "She wouldn't go outside without a skirt on," Venessia said. "But she's got the biggest smile on her face. Well, I'm going to smile, too. So I did. I was holding her hand tighter than usual, but she just kept on marching." Before long, Venessia and Joseph had taken her off all her medications. Her asthma, depression, anxiety, and attachment disorder were all gone. But the military told the family to get out of Okinawa, claiming they could not protect Josie; they were reassigned to a base in the Arizona desert.

Venessia didn't want Josie at another military school. She located a public school in Tucson with a liberal-leaning principal and enrolled both daughters. But Josie's teacher refused to call her by a female name and told Josie that Venessia was a "mean mommy" who was forcing her to live as a girl when everyone could see she was a boy. "She was an awful, rude teacher, who didn't want me at her school," Josie said. "I got so angry and frustrated." Venessia said, "Josie's self-esteem was crushed. She was back to being gloomy." Josie complained of stomachaches and headaches and fought every day against going to the school, which began sending truancy notices.

The Romeros moved to another town. Fearing for Josie's safety, they installed alarm wiring on the windows and doors and bought a Great Dane to intimidate attackers. Venessia sent an e-mail to the principal of the local public school that began, "I'm the proud mother of an eight-year-old transgender daughter." His head of human resources said, "We follow state laws, and there are no antidiscrimination protections for your child here." In November, Venessia placed her daughters at a Waldorf school, but, at $20,000 per year, it was impossible on an air force salary. The only option left was homeschooling. Josie said, "I miss going out." Joseph said, "The isolation is the price we pay to shield her from a world that could harm her."

Isolation is not the only difficulty. "I always have the penis problem," Josie said. "I want to get rid of it. But I think it will hurt. They said I have to be a certain age to take my penis off, when I'm more like fifteen." Venessia said, "Eighteen. But you'll be able to take estrogen and grow boobs sooner than that." Josie explained, "When I'm a mommy, I'll adopt my babies, but I'll have boobies to feed them and I will wear a bra, dresses, skirts, and high-heeled shoes." She seemed equally definite when she told me that she wanted to marry someone with rainbow-colored hair who was beautiful on the inside and the outside. "We'll get a baby here in Arizona, and then go live in whatever state Jade is in so we can be next-door neighbors," Josie said. "We'll live in a tree house. I'll grow my hair all the way to California." have to be a certain age to take my penis off, when I'm more like fifteen." Venessia said, "Eighteen. But you'll be able to take estrogen and grow boobs sooner than that." Josie explained, "When I'm a mommy, I'll adopt my babies, but I'll have boobies to feed them and I will wear a bra, dresses, skirts, and high-heeled shoes." She seemed equally definite when she told me that she wanted to marry someone with rainbow-colored hair who was beautiful on the inside and the outside. "We'll get a baby here in Arizona, and then go live in whatever state Jade is in so we can be next-door neighbors," Josie said. "We'll live in a tree house. I'll grow my hair all the way to California."

Later, Venessia said to me, "I wouldn't put Josie through surgery until she was emotionally ready for the physical pain, but if she were, I would absolutely do it right now." Venessia plans to give Josie puberty blockers, which stop the production of testosterone and estrogen. "She won't have testosterone ravaging her body," Venessia said. "So she'll never get an Adam's apple or facial hair. She'll never look like a man in a dress." Venessia found a doctor in Tucson who was willing to work on this protocol. Joseph persuaded the department of records to issue a new birth certificate for Josie, with her correct name and gender. But Venessia also deliberately kept toys for boys around the house, saying, "I don't want her to feel like she's proving she's a girl by playing with Barbies all the time."

Most trans children I encountered were living stealth. I was struck that many of these kids had gone from one discrepancy-living in an anatomical gender that was anathema to them-to another-living in a gender that did not match their body. Josie's openness had come at high cost, but she struck me as more truly free than many other trans children. Josie has become an activist. It's a hard role to imagine for someone who is eight and still thinks she may live in a tree house, but this strange jumble of hypermaturities and childishness was her core. When I met her, she had just been filmed by National Geographic for her second documentary; she has met with members of Congress and the governor of Arizona. I wondered to what degree Joseph and Venessia shared-or, indeed, manufactured-this activist bent, but Venessia, who had considered the wisdom of having her daughter stealth at least in some contexts, asked rhetorically, "What's the first thing Josie says? 'Hi, my name is Josie. I'm eight. I'm transgender. Who are you?'"

In 2009, Kim Pearson, by then a friend of the family, was chosen for a community service award but was unable to attend the ceremony; she asked Josie to accept the award on her behalf. Seven hundred people were in the audience. "She turns to me on the podium," Venessia remembered. "She whispered, 'Mommy, I have really big stage frightfulness right now.' But she whispered right into the microphone. Everyone laughed, and that relaxed her." Josie ad-libbed her speech and got a standing ovation. "Josie's very fragile, very emotional," Venessia said. "But Josie wants to change the world." right now.' But she whispered right into the microphone. Everyone laughed, and that relaxed her." Josie ad-libbed her speech and got a standing ovation. "Josie's very fragile, very emotional," Venessia said. "But Josie wants to change the world."

Venessia noted, "Little boys don't go around saying they're little girls without good reason. They're trusting you to listen, and we didn't know how. The other day she said, 'Mommy, why did you want me to be a boy?' That killed me. I told her, 'I didn't understand and I'm really sorry.' She said, 'It's okay, Mommy. I love you, and everything's so good now.'"

Gender is among the first elements of self-knowledge. This knowledge encompasses an internal sense of self, and, often, a preference for external behaviors, such as dress and type of play. Gender identity's etiology, however-posited to lie in genetics, in uterine androgen levels, in early social influences-remains obscure. Heino Meyer-Bahlburg, a professor of psychology at Columbia University who specializes in gender variance, has described numerous possible biological mechanisms, and said that as many as four hundred rare genes and epigenetic phenomena may be involved, genes associated not with hormone regulation, but with personality formation. "The view we have of the brain now is like those wonderful pictures of earth that the first astronauts took from the moon," said Norman Spack, associate professor of pediatrics at Harvard University and a leading endocrinologist in the field. "You can see the continents, the oceans, the weather systems. When you can read the license plates, we'll know what causes gender nonconformity." Like autism, gender nonconformity seems far more prevalent than ever before; as with autism, whether the condition is actually more frequent or simply more recognized is unclear.

The nongenetic biological arguments are confusing. The synthetic estrogen diethylstilbestrol (DES), developed in 1938 and used until the early 1970s to prevent miscarriage, has had many adverse effects on both males and females exposed to it in utero. A 2002 survey of members of the DES Sons Network found an extraordinary 50 percent rate of transgenderism; this supports the hypothesis that gestational hormone levels can trigger cross-gender identity. Scientists have also expressed concern about endocrine disruptors (EDCs), a class of chemicals found in everything from food to floor polish to packing materials. EDCs are known to be responsible for an increasing incidence of deformities in amphibian reproductive systems; researchers have speculated that they might be responsible for the increasing incidence of genital abnormalities and atypical gender identity in human beings. of genital abnormalities and atypical gender identity in human beings.

In 1991, Georges Canguilhem, a historian of science who worked on the concept of mutation, wrote, "Diversity is not disease; the anomalous anomalous is not the pathological." Being trans is without question anomalous; the relentlessly debated question is whether it is also pathological. Gender identity disorder was introduced as a medical category in 1980. The is not the pathological." Being trans is without question anomalous; the relentlessly debated question is whether it is also pathological. Gender identity disorder was introduced as a medical category in 1980. The DSM-IV DSM-IV requires that four of the following five symptoms be present for a diagnosis in children: strong and persistent cross-gender identification, defined as the desire to be, or the insistence that one is, of the other sex; persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex, often manifested in cross-dressing of some kind; an inclination toward cross-sex roles in make-believe play, with fantasies of being the other sex; a constant wish to participate in the stereotypical games and pastimes of the other sex; a preference for playmates of the other sex. Boys diagnosed with GID commonly prefer feminine clothing and hairstyles, often are mothers when they play house, avoid rough-and-tumble play and athletics, and are interested in female fantasy figures such as Snow White. Girls diagnosed with GID often have intensely negative responses to being asked to wear dresses, prefer short hair, are often mistaken for boys, seek out rough-and-tumble play, enjoy sports, and choose fantasy figures such as Batman. In an age when women can work in construction and men can marry other men, the notion of a medically enshrined, "Batman vs. Snow White" typology of gender identity seems reductive, yet it still has considerable currency in the medical literature. The diagnosis is specified as inapplicable to anyone with an intersex condition. requires that four of the following five symptoms be present for a diagnosis in children: strong and persistent cross-gender identification, defined as the desire to be, or the insistence that one is, of the other sex; persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex, often manifested in cross-dressing of some kind; an inclination toward cross-sex roles in make-believe play, with fantasies of being the other sex; a constant wish to participate in the stereotypical games and pastimes of the other sex; a preference for playmates of the other sex. Boys diagnosed with GID commonly prefer feminine clothing and hairstyles, often are mothers when they play house, avoid rough-and-tumble play and athletics, and are interested in female fantasy figures such as Snow White. Girls diagnosed with GID often have intensely negative responses to being asked to wear dresses, prefer short hair, are often mistaken for boys, seek out rough-and-tumble play, enjoy sports, and choose fantasy figures such as Batman. In an age when women can work in construction and men can marry other men, the notion of a medically enshrined, "Batman vs. Snow White" typology of gender identity seems reductive, yet it still has considerable currency in the medical literature. The diagnosis is specified as inapplicable to anyone with an intersex condition.

Whereas most children will play at an early age with toys suitable to either gender, trans kids often refuse the toys associated with their natal sex. Meyer-Bahlburg describes these children as "pervasively gender atypical from birth." A scale of gendered behavior ranks people as very masculine at one end and very feminine at the other. Typical boys are 3.5 to 5 standard deviations in the direction of masculinity, and the girls are the same number of deviations toward femininity. But trans kids will tend to be 7 to 12 deviations from the norm in the direction away from their birth gender. In other words, natal males become more female than most females, while natal females become more male than most males. "It's almost like their play is a political statement," Spack said. Adults with GID show clinically significant distress or impairment in social and occupational functioning. Some children who have gone undiagnosed will manifest the syndrome during puberty or afterward; conversely, only a quarter of children given a GID diagnosis will show full cross-gender identification in adolescence. In other words, sometimes their play means nothing about their future identity and sometimes it means everything. This is why decisions about how to raise them are so fraught. show full cross-gender identification in adolescence. In other words, sometimes their play means nothing about their future identity and sometimes it means everything. This is why decisions about how to raise them are so fraught.

Many professionals who work with trans children believe that the society at large is failing them. Kelly Winters, founder of GID Reform Advocates, has written, "Behaviors that would be ordinary or even exemplary for gender conforming boys and girls are presented as symptomatic of mental disorder for gender nonconforming children," meaning that what is deemed healthy in a girl is considered a symptom of psychiatric illness in a boy. Activists have spoken of the GID diagnosis being used not only to prevent natal boys from identifying as girls and natal girls from identifying as boys, but also to stigmatize or prevent effeminate homosexuality and butch lesbianism. Stephanie Brill added, "A male child who says, 'I must be a girl because only girls want to do these things,' is not showing evidence of being transgender; he's showing evidence of sexism." Gerald Mallon and Teresa DeCrescenzo, social workers with experience in this community, complain that natal boys are given "the sports corrective," and natal girls, "the etiquette corrective." At the 2009 meeting of the American Psychiatric Association, protestors gathered at a "Reform GID Now!" demonstration. Diane Ehrensaft, of the Child and Adolescent Gender Center in Berkeley, California, where she specializes in children with gender identity issues, said, "The mental health profession has been consistently doing harm to children who are not 'gender normal,' and they need to retrain."

Other activists, however, rail against the possibility of losing the diagnostic category. In The Riddle of Gender, The Riddle of Gender, Deborah Rudacille writes, "The diagnosis legitimizes the range of hormonal and surgical interventions that have provided relief to thousands of transsexual and transgendered people. Activists who argue that the 'medical model' of gender variance 'pathologizes human diversity' tend to miss this point. Without some sort of diagnosis, sex reassignment becomes nothing more than a kind of extreme cosmetic surgery/body enhancement, or in the view of critics, a fad, a fashion, a 'craze.'" GID's presence in the Deborah Rudacille writes, "The diagnosis legitimizes the range of hormonal and surgical interventions that have provided relief to thousands of transsexual and transgendered people. Activists who argue that the 'medical model' of gender variance 'pathologizes human diversity' tend to miss this point. Without some sort of diagnosis, sex reassignment becomes nothing more than a kind of extreme cosmetic surgery/body enhancement, or in the view of critics, a fad, a fashion, a 'craze.'" GID's presence in the DSM DSM facilitates insurance coverage for the psychological support transgender people may require; William Narrow, the research director for the facilitates insurance coverage for the psychological support transgender people may require; William Narrow, the research director for the DSM-5, DSM-5, has said, "The harm of retention is stigma, and the harm of removal is potential loss of access to care." The task at hand, he continued, is "to create a situation where access can be not only available but increased, and discrimination can be reduced." This quandary echoes the experience of deaf people and dwarfs, who may has said, "The harm of retention is stigma, and the harm of removal is potential loss of access to care." The task at hand, he continued, is "to create a situation where access can be not only available but increased, and discrimination can be reduced." This quandary echoes the experience of deaf people and dwarfs, who may not care for the disability label yet need it to secure accommodations and services. not care for the disability label yet need it to secure accommodations and services.

Surgical and endocrine interventions for transgender people, however, are seldom eligible for reimbursement and tax deductibility. Many transgender people would like to see their condition classified as a physical condition, which would resolve that problem. Michele Angello, a PhD therapist specializing in gender identity issues, has pointed out that if something can be fixed with a physical transformation, it shouldn't be categorized as a mental health condition. Some activists maintain that trans, like pregnancy, is a medical condition but not a disease. The AMA has issued a resolution that they "support health insurance coverage for treatment of gender identity disorder as recommended by a physician," which leaves the door open for bodily or psychological interventions. Reclassification as an endocrine or neurocognitive condition could be achieved by developing a new listing in the ICD ICD (the (the International Statistical Classification of Diseases International Statistical Classification of Diseases) of the World Health Organization.

As long as GID is classed as a mental illness, professionals will try to cure it, and parents will refuse to accept it. It is time to focus on the child rather than on the label. Edgardo Menvielle, a psychiatrist at Children's National Medical Center, said, "The goal is for the child to be well adjusted, healthy, and have good self-esteem. What's not important is molding their gender." It seems right to prioritize each child's mental health over a system that makes universal predictions about what should constitute happiness or what values are healthy. Menvielle does not see trans children as being automatically disordered; he does see them as being at risk. Peggy Cohen-Kettenis, a professor of gender development who works in Amsterdam, has likewise attempted "to diagnose and treat functional problems (such as separation anxiety, disorganized parenting, and depression), so regardless of which gender the child ultimately exhibits, the family is well." In other words, gender identity should not obscure underlying problems, and such problems should not interfere with addressing gender identity.

Most Deaf people don't take exception to being called deaf deaf; most people with intellectual disabilities raise no objection to the term Down syndrome Down syndrome; yet gender identity disorder gender identity disorder infuriates the people it ostensibly describes, to a degree and extent that transcends semantics. Most conditions in this book entail a positive model of identity and a negative model of disorder. While no one wants to be put in a stigmatized diagnostic category, most people fight the stigma rather than the category. Those who think of deafness or autism as identities can do so even if others call them disorders. infuriates the people it ostensibly describes, to a degree and extent that transcends semantics. Most conditions in this book entail a positive model of identity and a negative model of disorder. While no one wants to be put in a stigmatized diagnostic category, most people fight the stigma rather than the category. Those who think of deafness or autism as identities can do so even if others call them disorders. GID GID suggests not simply that trans people suggests not simply that trans people have a disorder, but that their identity itself have a disorder, but that their identity itself is is the disorder. This is a dangerous standpoint. We all have multiple identities, and most of us regret some of them, but identity is who we are. The law of identity is among the first precepts of philosophy; it states that everything is the same as itself. Aristotle explained that "the single cause" as to "why the man is man or the musician musical" is simply "because each thing is inseparable from itself." Locke declares that our most fundamental knowledge is "a man is a man." Undermining anyone's personal tautology by suggesting that he should not, in fact, be himself sabotages whatever he might become. The GID designation bespeaks an agenda of terminating identity. You can seek better ways to manifest identity, but you can't ask any class of people to discard their identity itself. The twentieth century reached its nadir with attempts to free the world of Jewish identity, Tutsi identity, or the many identities that communism suppressed. The practice of obliterating identities does not work at this macro level; it does not work well at the micro level, either. the disorder. This is a dangerous standpoint. We all have multiple identities, and most of us regret some of them, but identity is who we are. The law of identity is among the first precepts of philosophy; it states that everything is the same as itself. Aristotle explained that "the single cause" as to "why the man is man or the musician musical" is simply "because each thing is inseparable from itself." Locke declares that our most fundamental knowledge is "a man is a man." Undermining anyone's personal tautology by suggesting that he should not, in fact, be himself sabotages whatever he might become. The GID designation bespeaks an agenda of terminating identity. You can seek better ways to manifest identity, but you can't ask any class of people to discard their identity itself. The twentieth century reached its nadir with attempts to free the world of Jewish identity, Tutsi identity, or the many identities that communism suppressed. The practice of obliterating identities does not work at this macro level; it does not work well at the micro level, either.

Bettina and Greg Verdi both come from traditional Italian Catholic families in the Northeast. Greg works as an airline ground mechanic and Bettina as a preschool teacher. When Greg was hired by Lockheed Martin, they moved south of Atlanta. Their second child, Paul, preferred pink toys at three months; at two, he would drape a shirt over his head to mimic long hair and wear one of Bettina's tank tops as a gown. When he was two and a half, Bettina agreed to get him a yellow, flowered dress at a garage sale. "I figured at home at playtime, what's the harm?" Bettina said. Greg was not entirely comfortable with the dress, but like Bettina, he assumed it was a phase. When their older son, Eric, was four, his preschool had a visiting day for siblings, and Bettina took Paul. "Families were coming in with girls in frilly dresses, and Paul gasps, 'Mom, I want that dress,'" Bettina recalled. "All the moms were giggling." Bettina told her pediatrician that Paul headed for the girls' section at every toy store. The doctor said, "Well, then, say no." Greg said, "Paul would say, 'If I can't have the girl toys, then let's get out of the toy store.'"

At five, Paul said to Bettina, "Mom, I want to go to school as a girl, dress like a girl, have a girl name, have girl toys. I want to be a girl." Bettina was terrified. They went back to their pediatrician and asked what he thought about GID; he told them "those children" mostly committed suicide, so they should go to the Christian bookstore, read up on it, and pray. Bettina found a therapist in Atlanta and made an appointment to go in with Greg. "I was prepared to make this happen without Greg," Bettina said. But on the drive home, Greg said to Bettina, "Okay, let's do it." Bettina called a good friend whose kids were the same age as hers and suggested a playdate. "I told her, 'We want you to call her Paula.' She said, 'Oh, Bettina, I don't know. The kids are going to make fun of him.' I said, 'Can we try it?'" So they went. The older son said to Eric, "Uh, how come your brother is dressed like a girl?" Eric said, "It's called transgender. It means when a boy wants to be a girl or a girl wants to be a boy. I don't really want to talk about it." The boy said, "Okay, let's go play." The younger one never even noticed, probably because Paul had always acted like a girl. Bettina, "Okay, let's do it." Bettina called a good friend whose kids were the same age as hers and suggested a playdate. "I told her, 'We want you to call her Paula.' She said, 'Oh, Bettina, I don't know. The kids are going to make fun of him.' I said, 'Can we try it?'" So they went. The older son said to Eric, "Uh, how come your brother is dressed like a girl?" Eric said, "It's called transgender. It means when a boy wants to be a girl or a girl wants to be a boy. I don't really want to talk about it." The boy said, "Okay, let's go play." The younger one never even noticed, probably because Paul had always acted like a girl.

Bettina went to see the religious education director at her Catholic church. "I was so emotional about it. She was like, 'Okay, do you want her to attend as Paula? We'll just change the paperwork.' So we transitioned at church." Next, Bettina told the school, and the principal said, "We provide a safe, friendly environment for all our children, and yours is no different." Paula would have to use the nurse's bathroom, but otherwise, she would just be Paula. Bettina's family was supportive from the start. Greg's parents, already in their eighties, accepted it the first time they saw Paula.

But Greg and Bettina did not reckon with their community. "Suddenly, we're in the Bible Belt," Greg said. Bettina notified the neighbors. "I had gone to the bus stop with this one guy every morning for two years, and I felt like he was my friend," she said. "The first week of school he would meet me at the end of his driveway with papers he downloaded about how evil this was." One brother and sister put their hands on Paula's head on the school bus and prayed to turn her back into a boy. Paula came home and said, "I didn't really mind, but does this mean they're not going to be my friends?" Bettina went to see the mother of the praying kids. "She's telling me, 'God doesn't make mistakes.' I'm telling her, 'Look, if God doesn't make mistakes, then your son doesn't have a vision problem and doesn't need glasses.' 'Well, that's not the same thing.' 'Why is it not the same thing? It's a body part. What's the difference?' I just said, 'Look, you're a really good mom, and I know in my heart of hearts, if you were in my shoes, you would do the same thing. You would listen to your child and make your child happy.'"

Bettina works at the preschool where her children were enrolled, and she informed everybody there about the situation. She warned her boss that there would be a backlash. A month later, her boss told her, "A parent questioned your ability to teach. I said, 'You cannot find a better teacher. What she does in her home life doesn't affect what she does at work. Your child is lucky to be in her class. Bettina would be willing to sit down with you and answer any questions. So I'm going to hang up. Why don't you write down your concerns and call me back?'" The parent never called back, and the parent's daughter remained enrolled. up. Why don't you write down your concerns and call me back?'" The parent never called back, and the parent's daughter remained enrolled.

I first met Greg and Bettina at a trans conference in Philadelphia. Soon, a beautiful little girl came over with Greg's courtly parents, who presented the deceptive air of having attended trans conferences for decades. Paula shook my hand, a little somberly, then skipped down the hallway, her grandparents in pursuit. Bettina said, "This conference is more for us than for her. She knows what she's doing. We're clueless." I asked whether they thought Paula's identity would, over time, be trans or simply female. Bettina said, "Greg doesn't see her as transgender anymore, but that's partly because he doesn't give her a bath every day."

Bettina and Greg showed me the "safe folder" they take with them at all times. Many parents of trans kids keep one: paperwork to be shown in the event of trouble, as law enforcement and the medical system can be unfamiliar with or hostile to gender variance. A folder may include letters from the child's pediatrician and a psychotherapist confirming the child's gender identity; letters from at least three friends or family members and, if possible, a pastor or minister or other prelate that testify to the parents' sound parenting skills; videos or snapshots of the child displaying atypical gender behaviors throughout life; copies of birth certificates, passports, and Social Security cards that reflect a change of gender or name; a home study documenting family stability, if available; and a Bureau of Criminal Information report that shows that the parents are not child abusers.

I asked whether Bettina's advocacy perspective made it easier for her than for Greg, or the other way around. Greg began crying. "I just struggled," he sobbed. "Because it was my little boy. I want my child to be happy. But I found the pictures of us as a family before all this, and I miss that little boy. Just once in a while, it still hurts." I asked Bettina whether she ever felt that way. "No," she said, after a minute's thought. "What I regret is that time with Paula that I didn't have. I missed my daughter's infancy, spending all my energy on someone else who never existed."

Many parents of trans kids described to me grieving for the child they had lost, even as they gained another. The mother of one transman observed, "The same-sex parent experiences a certain kind of rejection-a rejection by one's child of membership in a tribe-that the opposite-sex parent doesn't." I met one father at a trans conference who said, "I accept it intellectually, but I still have emotional prejudice against my son-and even saying son son sticks in my throat." He had an autistic daughter and a deaf wife. "Autistic and deaf were easy. No one sticks in my throat." He had an autistic daughter and a deaf wife. "Autistic and deaf were easy. No one blamed me. But this-people laugh at me. Why can't he just come to terms with his handicap privately? We all have handicaps and disabilities, and we learn how to live with them." This father's son said to me, "I knew from the time I was an infant that I had something to hide, and for a long time I didn't even know what it was. But I immediately knew who I was not-and then who I am is what was left." blamed me. But this-people laugh at me. Why can't he just come to terms with his handicap privately? We all have handicaps and disabilities, and we learn how to live with them." This father's son said to me, "I knew from the time I was an infant that I had something to hide, and for a long time I didn't even know what it was. But I immediately knew who I was not-and then who I am is what was left."

One father fought against using feminine pronouns for his trans daughter and ended up in counseling. "Finally our therapist asked-is it making him happy for you to insist on calling him a boy? Of course the answer was no. But when he asked me if it would make my son happy if I called him she she-the answer was a clear yes. He then asked what was more important to me than my child's happiness. I started to cry. My fear of ridicule coupled with my fear of the ridicule he would suffer was causing me to deny him true happiness."

The Bettelheim-like notion that the child's gender-inappropriate behavior is symptomatic of the parents' gender transgressions determined treatment for most of the twentieth century. In the 1940s and '50s, the psychologist John Money posited that gender is a learned set of behaviors and attitudes. He believed that health required strong gender identification and favored giving girls every encouragement to be girlish, and boys every inducement to masculinity. Money's theory was explicitly tested on David Reimer, one of identical twins whose penis was burned off during a circumcision. Money proposed to Reimer's parents that they raise him as a girl, oversaw infant sex-reassignment surgery, and instructed them to give him only girlish clothes and toys. The parents were told that they must never tell David what had happened. For years, Money published fraudulent articles about the great success of this experiment, thereby encouraging others to attempt similar therapies, which damaged thousands of people. Only in the late 1990s did David Reimer give an interview to Rolling Stone, Rolling Stone, which eventually grew into the book which eventually grew into the book As Nature Made Him: As Nature Made Him: The Boy Who Was Raised as a Girl The Boy Who Was Raised as a Girl. Reimer's childhood was the antithesis of the one Money had portrayed, filled with rage and misery: he insisted on urinating standing up and despised Money and the dolls and frilly dresses that were forced on him. His behavior at school became so violent that his parents finally broke down and told him the real story when he was fourteen. Reimer had penile reconstruction and lived as a man in later life, but the damage done was enormous, and he committed suicide at thirty-eight.

Recent science suggests that successfully raising genetically programmed boys as girls is almost impossible. A study from Johns Hopkins looked at children born with cloacal exstrophy-a condition in which they have XY (male) chromosomes and testes, but no penis-who were castrated and assigned female gender at birth. Many chose to live as boys or men as they grew up, and all had "moderate-to-marked interests and attitudes that were considered typical of males." William G. Reiner, who authored the study, said, "These children demonstrate that normal male gender identity can develop not only in the absence of the penis, but even after the removal of testicles or castration at birth, and unequivocal rearing as female. Their identity and gender role seem to have developed despite a total environment telling them they were female." which they have XY (male) chromosomes and testes, but no penis-who were castrated and assigned female gender at birth. Many chose to live as boys or men as they grew up, and all had "moderate-to-marked interests and attitudes that were considered typical of males." William G. Reiner, who authored the study, said, "These children demonstrate that normal male gender identity can develop not only in the absence of the penis, but even after the removal of testicles or castration at birth, and unequivocal rearing as female. Their identity and gender role seem to have developed despite a total environment telling them they were female."

Kirk Murphy was treated for childhood effeminacy at UCLA in the 1970s under the auspices of O. Ivar Lovaas, the theoretician who developed the reward-and-punishment behavioral treatments for autism to which some autistic people have vigorously objected. Kirk's mother was coached through a one-way mirror to reward him for masculine behavior and to ignore feminine behavior. Though he became so upset during these sessions that he would scream, his mother was reassured that she was doing the right thing. At home, a token system much like that used with autistic children was put into play. He was given blue chips for masculine behaviors; a certain number of these meant he got a treat. He received red chips for feminine behaviors and was beaten by his father with a belt when he had too many of them. The effeminate behavior eventually ceased, and for years the work was written up as a success.

The experimenters changed Kirk's name to Kraig for their publications and made him an avatar for the pliability of behavior. George Rekers, the therapist who had worked directly with Kirk, became a founding member of the Family Research Council, a religious organization that lobbies against gay rights; he was ultimately revealed to be gay himself. Kirk joined the air force and lived as a masculine man-until he hanged himself in 2003 at thirty-eight. His mother and siblings went public in 2011 to talk about how the therapy had destroyed him. His sister said, "The research has a postscript that needs to be added. Kirk Andrew Murphy was Kraig and he was gay, and he committed suicide. I want people to remember that this was a little boy who deserved protection, respect, and unconditional love. I don't want him to be remembered as a science experiment." Phyllis Burke's Gender Shock, Gender Shock, published in 1996, documented with considerable horror that many of the techniques that destroyed Kirk Murphy were still in use-and still receiving government funding. Indeed, some are in use even as I write. published in 1996, documented with considerable horror that many of the techniques that destroyed Kirk Murphy were still in use-and still receiving government funding. Indeed, some are in use even as I write.

Tony Ferraiolo showed such pronounced masculinities all his life that doctors who examined him when he was still called Anne thought he must be intersex. When I met him, Tony was in his forties. His father had not spoken to him in five years; his mother saw him occasionally and continued to call him Anne. "They're missing out on a really cool guy," Tony said to me.

At five, Anne and her twin, Michelle, were playing football with their brothers, Frank and Felix, and Anne took her shirt off. Her mother said, "Girls don't take their shirts off." Anne began to cry and said she was a boy. "She never played with dolls," Tony's mother, big Anne, remembered. "She never wore a dress. She wouldn't carry a pocketbook. I surmised she was going to be a lesbian." Three early behaviors are often taken as indicators of fixed identity: what underwear the child selects; what swimsuits the child prefers; and how the child urinates. "I remember trying to stand up and pee as a little kid," Tony said. "I never wore girl underwear or bathing suits. I didn't even know that people had intercourse, but I knew that my gender was male." When Anne was in fifth grade in a New Haven elementary school, the teacher asked what each pupil wanted to be when he or she grew up, and Anne said she wanted to be a boy. The class erupted in laughter. By eleven, she was self-injurious. "You've got a little kid that's outside for recess, taking a piece of glass, cutting themselves," Tony said. "I'd gouge and gouge, then take dirt and try to get an infection, to hurt myself as much as I could. My parents knew it. No one did anything." Anne's sister, Michelle, identified as a lesbian early on, but she was a jock, as popular as Anne was marginalized.

Anne's father, Anthony, was abusive, and big Anne, addicted to Valium, was passive in the face of that. Adolescence is a trauma for most trans people, and for Anne, doubly so, as she had organic surges of both male and female hormones, despite showing no anatomical or genetic markers for intersex. "My facial hair and boobs are growing at the same time. What the hell's going on here?" By the time Anne was thirteen, she was shaving every day. "I took up drugs and drinking; I was suspended more than I was in school." From age thirteen, Anne was being sexually abused by a neighbor who was a good friend of her father's. The neighbor would call and ask Anne to help him with something. "If I didn't go, I got punished. If I went, I got raped." She finally told a neighbor what was happening, and the neighbor told her parents. "Two days later, my father had the guy over for a beer. From that day on, I didn't trust anybody," Tony said. Her father often refused to speak to her; when she was sixteen, he threw her out of the house. She walked fifteen miles into New Haven and moved in with a girlfriend; when that arrangement failed, she was homeless for a month. "Then I called my mother and asked to go back home," Tony recalled, hanging his head. "I went back into the bullshit." when that arrangement failed, she was homeless for a month. "Then I called my mother and asked to go back home," Tony recalled, hanging his head. "I went back into the bullshit."

Through her twenties and thirties, Anne was a club promoter and threw huge parties for hundreds of lesbians; she started a band called Vertical Smile. But she never felt like a lesbian. She started using Tony, Tony, spelled spelled Toni Toni in a concession to the family. "I used to pray to God that I was a butch lesbian," Tony said. "But a butch lesbian wants breasts and a va-jay-jay. A transgender person wants a penis." In his mid-thirties, Tony was in a car accident and received an insurance settlement. His family suggested he buy a house. He spent the funds on a double mastectomy. in a concession to the family. "I used to pray to God that I was a butch lesbian," Tony said. "But a butch lesbian wants breasts and a va-jay-jay. A transgender person wants a penis." In his mid-thirties, Tony was in a car accident and received an insurance settlement. His family suggested he buy a house. He spent the funds on a double mastectomy.

Tony was not interested in bottom surgery. "That part of my body isn't public, so it was never an issue. The boobs were public. When the doctor unbandaged me, my knees just buckled. When I took my girlfriend, Kirsten, to the beach, I said, 'I'm experiencing everything for the first time.' I haven't shaved since. I fuckin' love my goatee. When I look in the mirror, I see the person that was always supposed to be there. I used to take sleeping pills so I wouldn't have to live much of my life. Now all I want is to stay awake." When I saw Tony, he'd lost more than sixty pounds. "You can't love your body if you hate your body. Now, I eat healthy. I work out." Tony credits his therapist, Jim Collins, for much of his psychic transformation. "I was an angry lesbian," he said. "I didn't want to be an angry man."

Tony's younger brother, Felix, said, "My sister's my brother now, and I've never seen him happier in my life." Felix's kids switched naturally from "Aunt Toni" to "Uncle Tony." Tony's father and his brother Frank were not supportive. Big Anne was distraught, and they did not meet for a full year after the surgery. "Then she just said, 'Well, I'll come over,'" Tony said. "I thought, is she going to open the door and pass out? So, she came in and she was like, 'Oh, my God, you look just like my dentist.'" After Tony's surgery, Michelle began calling herself Nick. "At first, I was pissed," Tony said. "The first thing I do alone as a twin, he's got to stand on my fuckin' coattails. But I can see his sadness that he's not who I am yet. He still has breasts. He doesn't pass. People were like, 'You're sure he's not doing it because you did it?' I said, 'I need to support him no matter why he's doing it.'"

When I asked big Anne if she could see that Anne had become Tony, she said, "Once in a while, I say 'Tony,' but mostly it just comes out 'Anne.' Really down deep, it's my daughter. When I look at 'him,' I still see her." She turned to Tony. "You always had that angry something that was bothering you inside. But I didn't know anything about this back then. I was stupid, in a way." Tony put a hand on her arm. "I don't think you were stupid," he said. Big Anne said, "I watched things on television about it. I started understanding more. It's not that you wanted to be this way." She turned to me. "Her being unnatural, I was upset by it at first. But I understood more how they felt inside. Now she does all this activism. That's very good." Big Anne turned back and forth. "You're still my child," she said to Tony. "I still love her," she said to me. "You know what I mean. Him?" I asked Tony whether he minded being called "Anne" and "she." He said, "Andrew, she thinks I'm a straight girl going through a phase. But I had to realize that my mother's my mother. My mother can call me 'them,' and it wouldn't bother me. What bothers me is that I still see her just four or five times a year." this back then. I was stupid, in a way." Tony put a hand on her arm. "I don't think you were stupid," he said. Big Anne said, "I watched things on television about it. I started understanding more. It's not that you wanted to be this way." She turned to me. "Her being unnatural, I was upset by it at first. But I understood more how they felt inside. Now she does all this activism. That's very good." Big Anne turned back and forth. "You're still my child," she said to Tony. "I still love her," she said to me. "You know what I mean. Him?" I asked Tony whether he minded being called "Anne" and "she." He said, "Andrew, she thinks I'm a straight girl going through a phase. But I had to realize that my mother's my mother. My mother can call me 'them,' and it wouldn't bother me. What bothers me is that I still see her just four or five times a year."

Big Anne's quiet acceptance of and palpable love for her child are in her mind subsidiary to the splintering of her family following Tony's transition. She responded to most of the questions I asked her about herself with information about her husband; her effacement of Tony echoed her self-effacement. When I asked how she had felt about Anne's being gay, she said, "My husband accepted her being a lesbian." She turned to Tony. "He knows that you should have been a boy, but he still says, 'Why couldn't she just stay a lesbian like everybody else?'" Tony said to his mother, "You have risen to the occasion. You come and see me. We talk." Big Anne sighed and turned to me. "My husband went to his mother's sister, who's ninety, and she started crying, 'She's still your child. You go see her. You'll get used to it.' Then the priest said, 'Go see him. He's your son. Tell him that it bothers you, but talk to him.' But he never did. When holidays come around, I'd like to have all my children with me, but he won't allow it. He worries that people will think he gave in." I was surprised that big Anne had agreed to talk to me. Tony had told her to watch an Oprah Oprah special about trans kids; she called him and said, "I'll meet with Andrew, if you like. That was you. I'm sorry. I didn't know." Tony explained, "Nobody fuckin' knew in the seventies. My mother's a nice lady. She has a good heart. But this is big. Her only two daughters weren't daughters." I asked big Anne what her husband would say when she arrived home. "He'll ask how she is," she said. "He misses her." special about trans kids; she called him and said, "I'll meet with Andrew, if you like. That was you. I'm sorry. I didn't know." Tony explained, "Nobody fuckin' knew in the seventies. My mother's a nice lady. She has a good heart. But this is big. Her only two daughters weren't daughters." I asked big Anne what her husband would say when she arrived home. "He'll ask how she is," she said. "He misses her."

Tony's natural hormonal balance-whatever caused him to grow facial hair-has been sufficient, and he does not take testosterone. Like all trans people, Tony is often asked about his genitalia; he takes it as a question about his strap-ons. "A lot of people ask, 'Do you have a penis?' My answer is 'I have five.' I just go to the next question. 'Does your girlfriend know you're trans?' I'm like, 'Love is honesty. I'm not ashamed of who I am.'" Tony described being at a Stop & Shop and seeing a woman he used to work with. "She was, 'Oh, my God! Annie?' I said, 'Actually, it's Tony now.' She grabs my hand and says, 'It is not God's fault that you're a freak.' I just said, 'I've never been happier in my life.' I knew that if I lost it, it would have been, 'Oh, look at the transguy, what an asshole.' If you have a positive interaction with me as a trans person, you're going to think twice about jeering at a transwoman, or doing a hate crime. There's a purpose to everybody's life. That's mine. I want to start a nonprofit to give two guys a year chest surgery. Screw Starbucks gift cards. You want to give somebody a present? Give them a chest, give them a penis." ashamed of who I am.'" Tony described being at a Stop & Shop and seeing a woman he used to work with. "She was, 'Oh, my God! Annie?' I said, 'Actually, it's Tony now.' She grabs my hand and says, 'It is not God's fault that you're a freak.' I just said, 'I've never been happier in my life.' I knew that if I lost it, it would have been, 'Oh, look at the transguy, what an asshole.' If you have a positive interaction with me as a trans person, you're going to think twice about jeering at a transwoman, or doing a hate crime. There's a purpose to everybody's life. That's mine. I want to start a nonprofit to give two guys a year chest surgery. Screw Starbucks gift cards. You want to give somebody a present? Give them a chest, give them a penis."

A few months later, Tony started a foundation to do exactly that, and he named it after his beloved therapist, Jim Collins, who had died a few months earlier. "He inspired me to be an activist, as I hope to inspire people behind me to be activists, and hopefully the people behind them won't have to be activists, 'cause it won't be a fucking issue," Tony said. When big Anne had confessed, during our conversation with Tony, that she still worried everything was her fault, her son had responded, "It's nobody's fault. But I have to tell you that if it was your fault, I would thank you. Because my transition is the best thing that ever happened to me." Then Tony laughed. He said, "Life isn't about finding yourself; life is about creating yourself."

Natal males who become females are often unconvincing as women when clothed because of their height and the thickness of their bones; however, their postoperative genitalia, sexual response, and urination patterns can be almost identical to those of genetic females. Natal females who transition can usually pass in public once they develop facial and body hair, deep voices, and, in many instances, male-pattern baldness, but their sex organs are noticeably different from the genuine article; most cannot urinate while standing up, and none can achieve a male orgasm. One preoperative transwoman I met said, "These body parts are nice but they're not mine, and it makes me feel better to know that I don't have to keep them going forever." A transman to whom I repeated this replied, "I'm like one of those IKEA sets of furniture that looks great until you realize you're missing a few parts."

It takes little injected testosterone to overwhelm a genetic female's estrogen-about the same amount that would be administered to a male whose body was not producing the hormone. To overwhelm a genetic male's testosterone is a bigger project. A female whose body is not producing estrogen requires one to two milligrams of estradiol per week to remain premenopausal. A genetic male requires twenty-eight to fifty-six milligrams of estradiol per week to feminize the body. Many endocrinologists recommend that genetic males undergo gonadectomy as early as possible, because such high levels of estradiol create health risks. After gonadectomy, estradiol is effective in much smaller doses. to fifty-six milligrams of estradiol per week to feminize the body. Many endocrinologists recommend that genetic males undergo gonadectomy as early as possible, because such high levels of estradiol create health risks. After gonadectomy, estradiol is effective in much smaller doses.

Most professionals working with trans people follow the Harry Benjamin Standards, which require that the patient live in his or her preferred gender for at least a year and complete a full year of psychotherapy prior to surgery or hormone treatment, and that two clinicians, one a doctor, recommend medical procedures. These safeguards are intended to weed out people at risk of postoperative regret, though many complain that they eat up time when a despairing person could be achieving happiness through a speedy transition. They also protect health-care providers from liability.

For natal males being affirmed as female, procedures may include not only castration and vaginoplasty, but also electrolysis, which can take up to five thousand hours and cost over $100,000; feminizing facial surgeries to reduce the forehead, chin, and jaw; a nose job; a tracheal shave to reduce the Adam's apple; breast augmentation; hair transplants to conceal baldness; and tightening of the vocal cords. The construction of a vagina is most often achieved through penile inversion. After a space is cleared between the rectum and the urethra, the inverted skin of the penis is used to line the vagina, sometimes supplemented by skin grafted from the stomach, buttocks, or thigh. A second method, rectal sigmoid transfer, uses a segment of the large intestine to create a vaginal lining, which provides natural lubrication and unlimited vaginal depth. The procedure is more invasive, more costly, and can lead to mucus leaking into the vagina. In both methods, the scrotal skin is used to create the labia, and part of the glans, to create a clitoris.

Natal women being affirmed as male may remove breasts (double mastectomy), uterus (hysterectomy), ovaries (oophorectomy), fallopian tubes (salpingectomy), and vagina (vaginectomy), because regular gynecological exams are anathema to most transmen. Surgically constructed penises are expensive and often unsatisfactory, so many transmen opt not to have them, but for those who do, there are two primary methods. In a genitoplasty, the surgeon wraps skin around the hormonally enlarged clitoris to form a penis about the size of a thumb. It maintains orgasmic capability but is not generally large enough for intercourse. In a phalloplasty, a tube of skin is raised up out of the groin or mid-abdomen and attached to the pubis; it looks a bit like a suitcase handle. Secondary procedures augment the blood supply to this flap, and it is cut free after two to four months and sculpted to resemble a phallus. It lacks sexual feeling, but implanted silicone rods or a manual pump can allow an erection. In the most complicated procedure-running at least $100,000-flesh from the forearm, with the blood vessels and nerves that supply it, is fashioned into the shape of a penis, and then, using microsurgery, the blood vessels and nerves are attached to those in the pubis. Such a penis appears most natural and has sensation. In any procedure, a scrotum is constructed by sewing the labia majora together. Urethroplasty-urethral extension to the end of the newly made glans-is a further surgical undertaking. "Think what a complicated organ it is," Norman Spack said. "It's amazing it works at all, and the human species depends on it." pump can allow an erection. In the most complicated procedure-running at least $100,000-flesh from the forearm, with the blood vessels and nerves that supply it, is fashioned into the shape of a penis, and then, using microsurgery, the blood vessels and nerves are attached to those in the pubis. Such a penis appears most natural and has sensation. In any procedure, a scrotum is constructed by sewing the labia majora together. Urethroplasty-urethral extension to the end of the newly made glans-is a further surgical undertaking. "Think what a complicated organ it is," Norman Spack said. "It's amazing it works at all, and the human species depends on it."

Prepubescent transgender children with supportive families may avoid some physical difficulties of transition through the use of hormone blockers, which suppress puberty. This therapy may start as early as age ten for girls and twelve for boys. Lupron, the most common of these GnRH inhibitors, was developed thirty years ago as an alternative to surgical castration in the treatment of androgen-dependent tumors; because it is associated with decreases in bone mineral density and compromised memory, it requires careful monitoring. The treatment effectively buys families time; if the child is indeed transgender, puberty blockers can save him or her from going through the "wrong puberty" and may obviate many surgeries in later life. Girls administered Lupron do not develop breasts, widened hips, female fat distribution, or active ovaries. The estrogen surge that limits female height does not occur for them, so they grow tall. Boys administered Lupron do not develop facial or body hair; their voice does not deepen and their Adam's apple doesn't grow; bones do not thicken, shoulders broaden, or hands and feet enlarge. Estrogen supplementation, which closes the growth plates, can be timed to limit their height.

The essential androgyny of childhood can be prolonged. If someone goes off Lupron without starting cross-sex hormones, the deferred puberty of his or her natal sex will begin within a few months and will follow its natural course. Cross-sex hormones will initiate the puberty of the person's affirmed gender. None of the children in the original, Dutch protocol to study this practice has chosen to revert to natal gender, and most have stayed on GnRH inhibitors until they obtain gender reassignment surgery between eighteen and twenty-one. Lupron delays certain events, but it is also an event itself, heralding a profound transformation. There is concern that starting children on blockers will cause some who are just going through a phase to make it permanent; they may be too embarrassed, scared, or confused to revert if they think that they've made a mistake.

In Britain, where reassignment surgery is covered by the National Health Service, particularly conservative policies on hormone blockers prevail. The Gender Identity Development Service at the Tavistock Clinic requires patients to progress through most of their natural puberty before allowing them to transition. Domenico Di Ceglie, the team's child and adolescent psychiatrist, reports that 20 percent of adolescents treated at his clinic choose to forgo medical intervention after completion of puberty. The underlying modernist fallacy here is that doing nothing is not doing something-that slowing transition is cautious, and accelerating it is rash. Rushing a child into a transition in which he will psychically or medically be trapped for the rest of his life would be a terrible mistake; however, forcing a child who is firm about his own identity to develop a body that will never match who he knows himself to be, even after multiple, expensive, traumatic surgeries, is equally troubling. The Tavistock model of prudence contains marked cruelty. Health Service, particularly conservative policies on hormone blockers prevail. The Gender Identity Development Service at the Tavistock Clinic requires patients to progress through most of their natural puberty before allowing them to transition. Domenico Di Ceglie, the team's child and adolescent psychiatrist, reports that 20 percent of adolescents treated at his clinic choose to forgo medical intervention after completion of puberty. The underlying modernist fallacy here is that doing nothing is not doing something-that slowing transition is cautious, and accelerating it is rash. Rushing a child into a transition in which he will psychically or medically be trapped for the rest of his life would be a terrible mistake; however, forcing a child who is firm about his own identity to develop a body that will never match who he knows himself to be, even after multiple, expensive, traumatic surgeries, is equally troubling. The Tavistock model of prudence contains marked cruelty.

In the United States, these are family problems rather than national policy. "Parents say, 'I'm not ready to deal with this yet,'" Stephanie Brill said. "But they are dealing with it. Badly." Spack said, "Those who oppose puberty blockers complain of the young age at which we make this 'intervention.' I would argue that puberty itself is the most noxious intervention possible." Use of Lupron for gender dysphoria is seldom covered by American insurance plans, and its prohibitive cost creates a class divide between transgender youth whose parents are willing and can afford it, and all others. Likewise, there is a generation gap. At trans conferences I attended, older people would weep openly when they met children who would never have to "walk this earth as their genetic sex," as one put it. Shannon Minter-civil rights attorney, legal director for the National Center for Lesbian Rights, and himself a transman who did not have the benefit of Lupron-spoke of these young people as "a kind of superclass."

What did transgender people experience in the past, when they could not alter their bodies to harmonize with their identity? What will transgender people experience in the future, when surgery becomes more refined? These questions are both technical and teleological. Minter acknowledged, "The idea that in order for a child to express his or her authentic identity there has to be a dramatic physiological intervention challenges our most foundational ideas about authenticity and self-identity. It can feel like a technological madness." One has to wonder whether it is more of a technological madness than the cochlear implant. Many people outside these horizontal identities class that intervention as a way to normalize an abnormality, and this as a way to indulge one. It is instructive to note, however, that whereas the protest the protest against against cochlear implants comes from the marginal identity group, the demand cochlear implants comes from the marginal identity group, the demand for for trans surgeries comes from the marginal identity group. trans surgeries comes from the marginal identity group.

Jennifer Finney Boylan has written two books that deal with her gender switch and has held forth about gender identity on All My Children All My Children and and Oprah Oprah. When I asked whether she hoped to be perceived as female or as transgender, she said, "On a national stage in front of twenty million people, I'm happy to be trans. On a day-to-day basis, when I go into a store, restaurant, or gas station, I want to be read as a woman. I refer to myself as female, knowing that female female includes Britney Spears and Barbara Bush. Look at Julia Child! I'm certainly as feminine as Julia Child." includes Britney Spears and Barbara Bush. Look at Julia Child! I'm certainly as feminine as Julia Child."

I visited Jenny, then forty-nine, in her mother's house on the Philadelphia Main Line. Her old room looked like a boy's room-banged-up furnishings, rock-and-roll posters on the walls. She showed me an adjoining storage room. "Back in the day, there were girls' clothes in here, my mother's, my sister's," Jenny said. "I could grab whatever was on the back of that door." Jim Boylan always knew that he was female, but he also knew that his transition would be painful for others. "So, I thought, if I can make the guy thing work, let's go for that," Jenny said. "It took until I was almost forty before I saw that I'd gone as far as I could, forty-four before I had surgery. Rather than wishing I'd gone through transition earlier-if it's about wishing-I wish that I'd been born female. Here I am, a grown woman, but I have a boyhood. If I ever feel lost or melancholy, it's because I can't see my life as a whole, I can't figure out how I got here from there."

Becoming Jenny entailed a truckload of surgeries: vaginoplasty; a procedure in which her face was peeled down so her skull at the brow level could be shaved to give her a more plausibly female look; a reduction of her Adam's apple. "The surgery turns out to be easy," she said. "Nothing is cut off. The neo-vagina looks like it's supposed to and does what it's supposed to; the plumbing works and so does the electricity. I've been to doctors who didn't know and couldn't tell."

Jim Boylan was married, and his wife, Dede, chose to stay in the marriage, though she once said to Jenny, "Every success you have as a woman is a failure for me." They have two children together, fathered when Jenny was still a man. "Dede is a straight woman who's the center of my life, and yet she's not attracted to me," Jenny said. "Everyone always says Dede is this great saint. Does it betray a complete lack of humility to say that she's lucky to be married to me because I'm a nice person and I love her and I'm a good parent to our children? All kinds of things happen to families. Children get cancer. Parents have car accidents. Families have to move to Texas. This has involved some heartbreak, but life does that anyway." At six and eight, Jenny's two sons decided that they couldn't really call her kinds of things happen to families. Children get cancer. Parents have car accidents. Families have to move to Texas. This has involved some heartbreak, but life does that anyway." At six and eight, Jenny's two sons decided that they couldn't really call her Daddy Daddy anymore. They already had a anymore. They already had a Mommy Mommy. So they announced that they were going to call her Maddy Maddy. When Jenny last did Oprah, Oprah, her older son wrote a letter that was read on the show. It said in part, "Sometimes it's true that I wish I had a regular father. Most of the time, though, I feel like I am the luckiest kid on earth. I cannot think of a way in which life could be better." her older son wrote a letter that was read on the show. It said in part, "Sometimes it's true that I wish I had a regular father. Most of the time, though, I feel like I am the luckiest kid on earth. I cannot think of a way in which life could be better."