Exposure to “conversion therapy” — efforts by a secular or religious professional to change a transgender person’s gender identity — is associated with thoughts of and attempts at suicide, according to a study published Wednesday in the journal JAMA Psychiatry.
Dr. Jack Turban, the study’s lead author and a resident physician in psychiatry at Harvard Medical School, said it was the first study “to show that gender identity conversion efforts are associated with adverse mental health outcomes, including suicide attempts.”
Turban said that previous reports showing the negative effects of conversion therapy, also known as “ex-gay therapy” or “reparative therapy,” have focused on efforts to change a person’s sexual orientation.
But this was novel, he said, because of its large sample size — over 27,000 transgender people responded to the survey — and its broad approach to identifying past efforts to change participants’ gender identity.
Seventy-one percent of respondents recalled speaking to a religious adviser or secular therapist about their gender identity, and of those, roughly 20 percent said these interactions involved efforts to change their gender identity from transgender to cisgender.
“The rate of previous suicide attempts among transgender people in the United States is extremely high, with 41 percent reporting that they have had that experience,” said study co-author Dr. Alex Keuroghlian, director of the National LGBT Health Education Center at The Fenway Institute and the Massachusetts General Hospital Psychiatry Gender Identity Program.
“What this new study shows is that transgender people who are exposed to conversion efforts anytime in their lives have more than double the odds of attempting suicide compared with those who have never experienced efforts by professionals to convert their gender identity, he said.
Turban said one of the most alarming findings from the study was the even higher risk of psychological distress for those who reported exposure to conversion therapy during childhood. Those who were subjected to the practice before age 10 were four times more likely to report lifetime suicide attempts than the general transgender population, according to the findings.
“This is important because some experts continue to advocate for gender identity conversion efforts for young children,” Turban said in a statement. “We hope our findings contribute to ongoing legislative efforts to ban gender identity conversion efforts.”
Currently 18 states, along with the District of Columbia, ban the practice of conversion therapy on minors. And nearly every major health association — including the American Medical Association, the American Psychological Association and the American Academy of Pediatrics — has spoken out against the practice.
“The term ‘conversion therapy’ is a misnomer,” Keuroghlian noted. “It suggests that conversion efforts are a legitimate therapeutic practice, even though we are finding that this practice is associated with significantly increased risk of harm, including serious psychological distress and potentially fatal suicide attempts.”
The study found no difference in the outcome based on whether the effort to change a person’s gender identity was conducted by a religious adviser or secular professional. According to the findings, the vast majority of conversion therapy is conducted by secular professionals, like psychologists or counselors, with religious efforts accounting for roughly a third of all conversion therapy efforts reported by this cohort.
“Current training of mental health clinicians in the U.S. does not usually include gender-affirming care as standard curriculum,” Keuroghlian said. “We hope this study will inspire clinical training programs to revise their standard curricula.”
“All clinicians need to be trained in concepts and terminology related to gender identity, how stigma is related to mental health disparities and best practices for gender affirmation grounded in scientific evidence,” he added.
This latest study builds on previous work published last month by Turban, Keuroghlian and their colleagues that found nearly 200,000 transgender people in the United States have been exposed to conversion therapy at some point in their lives.
A black transgender woman was found dead in her burning car in South Florida in what is being investigated as a homicide, authorities said.
It is the 18th killing of a transgender person in the U.S. this year.
The body of Bee Love Slater, 23, was discovered in Clewiston on Sept. 4, according to the Palm Beach Post.
Hendry County Sheriff Susan Harrell told NBC News in a statement that authorities could not initially identify the body “due to the burns and lack of identification available.” A medical examiner later identified the body through dental records, Harrell said.
The body of transgender woman Bee Love Slater was found in a burned car in Clewiston, Florida.via WBBH
According to The Advocate, investigators said Slater’s death was one of the most brutal murders they had seen.
Authorities have not said if they think Slater’s gender identity played a role in her death, the Palm Beach Post reports. Investigators are not releasing how she died.
Her death is the 18th killing of a transgender person in the United States this year, according to the Human Rights Campaign, which tracks the deaths of transgender people. A majority of those killed have been black transgender women.
George Wallace, executive director of LGBT+ Center Orlando, told NBC News in a statement Thursday that transgender women of color “are killed at a higher rate than that of their peers.”
“I find it sad and upsetting that our trans brothers and sisters continue to be targets of hate and intolerance,” Wallace said. “I wish I had a solution, but we must continue advocating and educating.”
Slater’s friend, Jackson, who asked to be referred to by his last name, told the Palm Beach Post that Slater underwent surgery this year. But, he said, she was verbally harassed and bullied online and had expressed concerns about her safety.
“We have more questions than answers,” Jackson said of her death.
The American Medical Association in June announced it efforts to bring national attention to what it called “the epidemic of violence against the transgender community, especially the amplified physical dangers faced by transgender people of color.”
On Sept. 15, 2017, Olivia stepped into a full-body scanner at the Fort Lauderdale-Hollywood International Airport.
When she stepped out, a female Transportation Security Administration officer approached. On the scanner’s screen was an outline of a human body with the groin highlighted. The officer told Olivia that because of something the scanner had detected, a pat-down would be necessary.
As a transgender woman, Olivia, 36, had faced additional TSA scrutiny before. On those occasions, a manual search at the checkpoint had been enough to assure TSA officers that there wasn’t a weapon or explosive hidden in her undergarments.
This encounter with the TSA went very differently.
After patting down Olivia and testing her hands for explosive residue, the officer said that she still couldn’t clear Olivia to board her flight and that a further search would be required.
Olivia was led to a private room where, she said, the officer patted her down again, running her hands down Olivia’s legs and over her groin.
“I told her: ‘If the issue is what you are feeling, let me tell you what this is. It is my penis,’” said Olivia, who agreed to be interviewed only if she were identified by her middle name because she fears people will treat her differently if they know she is transgender.
Soon after, three other TSA officers, all of them women and at least one of them a supervisor, entered the room, Olivia said.
TSA rules require that passengers be searched by officers of the same gender as they present. But, according to Olivia, the TSA supervisor told her that she would have to be patted down by a male officer.
After Olivia refused to be searched by a man, the officers told her that because she was not consenting to a search, she could not board her flight and would be escorted out of the terminal.
Olivia said she started crying and pleaded with the officers. “Can I just show you?” she recalled asking them.
TSA officers aren’t supposed to allow passengers to remove undergarments. But Olivia said the officers in the room with her did not object when Olivia pulled her ruffled, black and white skirt and underwear down to her ankles.
Olivia was then cleared to continue to her gate.
A Flawed System
What happened that day traumatized Olivia, who is now fearful of airports, and what she experienced reflects the worst fears of many transgender travelers, who say the TSA is failing them.
Shortcomings in the technology used by the TSA and insufficient training of the agency’s staff have made transgender and gender nonconforming travelers particularly vulnerable to invasive searches at airport checkpoints, interviews and a review of documents and data shows.
The TSA says that it is committed to treating all travelers equally and respectfully. But while the agency has known about the problems for several years, it still struggles to ensure the fair treatment of transgender and gender nonconforming people.
To understand the extent of the problem, ProPublica reviewed publicly available complaint data from the TSA’s website and asked transgender travelers to provide accounts of their experiences at airport checkpoints.
The review, which covered civil rights complaints filed from January 2016 through April 2019, found that 5%, or 298 complaints, were related to screening of transgender people, even though they are estimated to make up slightly less than 1%of the population.
This may understate the proportion of complaints from transgender travelers. When Olivia contacted the TSA, her complaint was filed in a different category — a catchall classification called “sex/gender/gender identity – not transgender.” That category accounts for 15% of the civil rights complaints in the period examined by ProPublica, but the TSA said it did not have a more specific breakdown of these complaints and could not say how many were, like Olivia’s, related in some way to gender identity and screening. ProPublica filed a Freedom of Information Act request in April seeking information about each complaint in those categories, but the agency has not yet provided any response.
When ProPublica asked transgender and gender nonconforming people to tell us about their experiences, we received 174 responses, many of them recounting humiliating treatment after being flagged by full-body scanners for additional scrutiny. Of those people, only 14 said they filed a complaint with the TSA. Many of those who did not file complaints said they didn’t know how, were afraid of outing themselves or didn’t want to relive the experience.
Some of the travelers who responded to ProPublica said they were asked by TSA officers to lift clothing to show private parts of their bodies or were pressured to expose their genitals so that TSA officers would allow them to pass through the security checkpoint.
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“Transgender people have complained of profiling and other bad experiences of traveling while trans since TSA’s inception and have protested its invasive body scanners since they were first introduced in 2010,” said Harper Jean Tobin, director of policy at the National Center for Transgender Equality, or NCTE.
The TSA, which is part of the Department of Homeland Security, was created in an overhaul of transportation security after the 2001 terrorist attacks, with the mission to prevent similar tragedies. The agency, replacing a patchwork of private security providers, initially used metal detectors, which had been standard at checkpoints for years. But after a passenger attempted to blow up a plane in 2009 with plastic explosives hidden in his underwear, the agency began using full-body scanners.
The new scanners were designed to detect potential threats that are not necessarily metal. But TSA officers can’t tell by looking at the monitor whether the machine is detecting a weapon, or as in Olivia’s case, a body part that the scanner was not programmed to associate with a woman.
Since implementing the scanning technology, the agency has grappled with privacy and discrimination issues. Like the transgender and gender nonconforming communities, people with disabilities, people who wear religious head coverings and women of color, whose hairstyles trigger the body scanners to alarm more frequently, have raised concerns about profiling and invasive screening.
Jenny Burke, the TSA’s press secretary, said the screening is done “without regard to a person’s race, color, sex, gender identity, national origin, religion or disability.”
In February, the agency rolled out a new online transgender awareness training, mandatory for its 43,000 screeners, and is studying options for better technology, Burke said.
But advocates and some lawmakers said the improvements have taken too long for a federal agency that interacts with the public more than many others. On an average day, TSA officers screen more than 2 million people and manually search many of them.
“For many, TSA is not just the public face of government — but its hands, too. Its success as a security agency depends upon the trust and compliance of a diverse public,” Rep. Bennie Thompson, D-Miss., said during his opening statement at a Homeland Security Committee hearing in June.
Transgender people have faced growing uncertainty about whether their civil rights are protected by the federal government. In May, the Trump administration announced plans to roll back protections for transgender people under nondiscrimination laws. Earlier last year, the administration barred transgender people from serving in the military. As ProPublica reported last year, some states bar transgender people from obtaining a state-issued ID that matches their gender presentation unless they provide proof they’ve had surgery.
False Alarms
Most of the incidents ProPublica reviewed for this story started with a body scanner issuing an alarm.
Before a person steps into the full body scanner at an airport, a TSA officer must register the person’s gender, pressing a pink button for a female or a blue button for a male. Generally, the officers make the decision in seconds, based on a person’s appearance.
The body scanner is programmed to look for penises on passengers scanned as male and breasts on passengers scanned as female. If the officer selects the female button and the machine detects something in the passenger’s groin area — like in Olivia’s case — it could interpret a body part as a potential threat, issuing an alarm.
ProPublica also spoke to several cisgender women who said they were flagged for additional scrutiny after a TSA officer scanned them as male, causing their breasts to trigger the alarm. (“Cisgender” describes someone who identifies with the sex they were assigned at birth, meaning they are not transgender.) The women told ProPublica that they believed the officers scanned them as male because they had short hair or, in one case, because they were wearing baggy clothes.
Peter Neffenger, who served as TSA administrator for the last 18 months of the Obama administration, said he heard again and again about the anxiety brought on by the scanners.
“As many in the transgender community explained to me, it’s one of the most stressful parts of the screening process for them,” Neffenger said.
In September 2018, Terra Fox, a transgender woman, was at the airport in Albuquerque, New Mexico, on her way to a conference in Orlando, Florida. When she walked through the body scanner, the machine showed a yellow box over her groin.
Fox said she told the officers at the checkpoint that she is a transgender woman and that the machine was merely detecting her genitals.
Fox asked to be patted down by a woman, but the female officers near her refused to do it.
According to Fox, two male officers brought her to a private room and instructed her to pull down her leggings and show them her genitals. She complied, but the screening lasted so long that she missed her flight. She said the experience has taken a toll on her.
“Every time I travel, I have to cry and feel humiliated,” she said.
Fox has to travel for work frequently and said she doesn’t have the option of avoiding airports.
Terra Fox says she was instructed to pull down her leggings during a TSA search at the airport in Albuquerque, New Mexico. (Adria Malcolm, special to ProPublica)
Allister McGuire, a transgender man who lives on Long Island, N.Y., said he didn’t fly for five years after an experience in the St. Louis Lambert International Airport in 2014. McGuire was taken to a private room after the body scanner went off, displaying a yellow patch on his chest.
“I was very nervous,” McGuire said. “I did not feel safe.”
The two male officers in the room told McGuire to remove his chest binder, a cloth undershirt some trans men and gender nonconforming people use to flatten their chests, and then lifted each of his breasts with their hands, McGuire said. He was eventually allowed to leave, but he said he immediately had to take anxiety medication.
McGuire said he did not file a complaint.
In an interview with ProPublica, McGuire wondered: “If I was coming through as a woman, would [the officers] be touching me like that?”
Burke, the TSA press secretary, said that the agency does not conduct strip searches, but that travelers may be required to “adjust clothing” during the pat-downs. The agency didn’t respond to detailed questions about the allegations made by Fox and McGuire.
Neffenger said that during his time as TSA’s administrator, officers were not supposed to ask people to take off their clothes during a screening. But he acknowledged that it was difficult to keep such an enormous workforce consistently trained.
“It wouldn’t surprise me if you said you discovered that people have asked people to undress,” Neffenger told ProPublica. “It’s a big organization; it’s got a lot of turnover.”
The overall attrition rate for the TSA officers is 17%, which is roughly in line with the federal workforce, according to a report this year by the inspector general for DHS. But officers leave the TSA voluntarily at a higher rate than other federal employees, according to the report, which said “retention and training challenges are contributing factors to airport security weaknesses.”
Neffenger spent 33 years serving in the U.S. Coast Guard before being appointed in 2015 to lead the TSA. He arrived amid fallout from damning revelations about the agency. A leaked government report showed that TSA officers had failed to detect nearly all weapons and explosives smuggled through by DHS investigators during a secret test.
Neffenger said his immediate focus as administrator was to develop a nationwide training program. It was a challenging task, he said, because the intrusive nature of the screening process will inevitably make both passengers and officers uncomfortable.
“Pat-downs are, by definition, invasive,” Neffenger said. “What [TSA officers] are asked to do is stuff people don’t like to do.”
Public Comments
TSA officers would need to do fewer pat-downs if the agency had better technology.
The agency uses a machine called a millimeter wave scanner at nearly every airport in the U.S. The machines, manufactured by L3Harris Technologies, rely on an algorithm to analyze images of a passenger’s body and identify any threats concealed by the person’s clothes.
The TSA has spent about $110 million deploying the machines, which cost about $150,000 each, according to a government report.
Since the TSA began deploying body scanners at airports, LGBTQ advocates have expressed concern that the new screening procedures would disproportionately affect transgender travelers.
In a letter to then-TSA Administrator John Pistole in December 2010, NCTE, the Transgender Law Center and the National Center for Lesbian Rights described two incidents in which transgender men were interrogated by TSA officers because their bodies looked different in the scanners than what the officers expected. The organizations urged Pistole to take immediate action to stop discrimination against transgender people. In a written response, Pistole said the agency was “working hard to respond to the concerns of the traveling public.”
The full-body scanners at airports across the country frequently give false alarms for Afros, braids, twists and other hairstyles popular among black women.
In 2010, the Electronic Privacy Information Center, or EPIC, sued DHS in response to the TSA’s decision to make body scanners the primary screening system at airports. EPIC argued that the agency should have given the public an opportunity to comment on the technology before it was implemented. The District of Columbia Court of Appeals ruled in favor of EPIC in 2011, though the TSA didn’t begin accepting comments until 2013.
“They are now blaming the scanners when part of the rule-making process is to surface these kinds of issues,” said Jeramie Scott, director of EPIC’s Domestic Surveillance Project.
Burke said the agency procures equipment, such as body scanners, that can accommodate the largest demographic possible. Burke said the TSA does not develop its own technology and solicits private companies to develop scanners that meet the agency’s needs.
Neffenger said talking to transgender people and advocates helped him realize that the agency had to do better.
“You really have to design a system that is as close to 100% as possible,” he said.
The TSA and L3Harris Technologies did not respond to questions about how the scanner’s algorithm processes images to determine threats. (In June, L3 Technologies and Harris Corporation merged to form L3Harris, which has about 48,000 employees and is a key government contractor.)
In a written statement, Jennifer Barton, a spokeswoman for L3Harris, said details about the company’s research and development are confidential. She also said the company is working “with the TSA” on new technology and products that meet the agency’s “evolving requirements and the needs of all passengers.”
“We recognize the importance of ensuring that security scanning equipment accommodate all gender identities, and that is why (the company) is developing technology that moves away from the current male/female imagery and will safely screen passengers without the use of gender-specific images,” Barton wrote.
Barton didn’t respond to follow-up questions about when the technology would be ready for use at airports.
Beyond Technology
While Olivia was searched in the private room in Fort Lauderdale, her fiancee, Marguerite, was waiting on one of the benches near the security checkpoint. Olivia, a trial lawyer, and Marguerite, a school psychologist, had been dating for a year and were planning to marry that winter. The couple were on their way to New York for Marguerite’s brother’s wedding, and Marguerite was worried that they might miss their flight.
“I didn’t know if I could call the police,” Marguerite said. “I didn’t know what my rights were.”
Olivia said she is used to people questioning her appearance — and even her right to exist — because she is transgender. Showing her naked body to TSA officers, however, was a level of invasiveness she wasn’t prepared for.
“The whole weekend of the wedding I replayed the situation in my mind. It ruined the trip,” she said. “As a lawyer I am used to being in control of the situation, but that situation just completely went off the rails.”
Days after the incident, she filed a detailed complaint with the TSA. Her account describes actions, such as the directive that she submit to being searched by a man, that would violate TSA policy.
“As a lawyer I am used to being in control of the situation, but that situation just completely went off the rails,” Olivia said. (Annie Flanagan, special to ProPublica)
Burke, the TSA press secretary, said transgender people are supposed to be patted down by an officer of the same gender that they present.
A TSA officer, who has worked as a screener since 2016 and spoke on the condition of anonymity, said the officers should not have allowed Olivia to expose herself.
“The moment she [Olivia] said she was going to take her clothes off, they had to say: No, we can’t allow that. That is completely against SOP [standard operating procedure],” the TSA officer said.
Olivia said if she’d known she had the right to bring a witness into the private room, Marguerite would have been there with her.
Six weeks after she filed her complaint, on Oct. 31, 2017, Olivia received a letter from the TSA’s Office for Civil Rights and Liberties, Ombudsman and Traveler Engagement. The letter shared the conclusions of the agency’s investigation into the incident: “Our review to date does finds [sic] that the TSA officers and staff did follow Standard Operating Procedures (SOP) in the overall screening and the pat down procedures,” it said.
According to the letter, the agency’s investigation involved “a collection and review of eye-witness statements, close circuit television footage, and any other evidence tending to prove or disprove a traveler’s factual allegations.”
The two-page letter didn’t address Olivia’s claim that she had to expose her genitals to TSA officers.
“My complaint came back and it was not at all what I said had happened,” Olivia said.
Eventually, Olivia filed a Freedom of Information Act, or FOIA, request for the evidence the TSA said it reviewed to investigate her allegations. Her request was denied.
“Nobody called me, nobody did anything, they completely blocked my FOIA request,” she said.
ProPublica also submitted a FOIA request for documents related to the investigation into the incident, along with a privacy waiver signed by Olivia to allow ProPublica to access her records. The agency has yet to provide ProPublica with any of the requested records, citing a backlog in FOIA requests.
ProPublica reviewed the narrative that Olivia included in her original complaint to the TSA, as well as photos she took of the officers involved and an audio recording she made at the end of the incident, to corroborate her description of events.
The agency told ProPublica that it does not have cameras in private screening rooms and did not respond to questions about the incident or Olivia’s complaint.
ProPublica contacted one of the officers at her home in South Florida, but she declined to comment. We could not locate the other two officers.
Deficient Training
TSA officers and supervisors started taking a 30-minute online course titled “Transgender Awareness Training” in February. The course is supposed to teach employees how to interact with transgender people respectfully, according to a one-page summary of the training provided by the TSA.
Burke said that the agency would not provide a copy of the training materials because they are “sensitive security information.”
ProPublica reviewed hundreds of posts and comments from a private Facebook group for current and former TSA employees called “TSA Breakroom.” The conversations in the group, which has more than 18,000 members and is not administered by the TSA, shed some light on the content of the training.
In a series of discussions earlier this year, group members, some of them withholding their names, complained about the program. One of the anonymous posts said the course in the Online Learning Center, or OLC, instructed officers to introduce themselves to passengers by stating their name and the pronouns the officer uses.
A post in a private Facebook group for current and former TSA employees called “TSA Breakroom.”
This kind of introduction is common in the LGBTQ community, but dozens of group members wrote that they didn’t understand the instructions or would not be willing to introduce themselves that way.
Many group members wrote that they worried passengers would be upset if officers asked them about their gender identity.
“I shook my head through that whole dang course,” one member commented in April 2019. “Someone will throat punch me if I say that stupid shit.”
A comment from April 2019 about a transgender awareness training course, posted in a private Facebook group for current and former TSA employees.
Other group members wrote that the training didn’t address the fundamental problem that the scanners have only male and female options.
“I got a pink button and blue button. Which one you want?” one group member wrote.
The current TSA officer who spoke to ProPublica on the condition of anonymity said that she came up with her own ways to screen transgender passengers.
“I flip a coin in my head and hit a button, wait for the person to walk out of the scan, point at the screen and ask the person: Did I scan you right?” the officer said. “It is sort of a discreet way of asking.” If the passenger’s answer is no, the officer asks the passenger to walk through the scanner again and hits the other button.
Another TSA employee, who has worked for the agency for over a decade and spoke on the condition of anonymity, said that the gender buttons are stressful for both passengers and officers.
“A lot of the traveling public already hate us,” she said. “We don’t want to offend people by [scanning them] wrong.”
Some members of Congress have tried to address discrimination against transgender people at TSA checkpoints through legislation. In 2018, Rep. Kathleen Rice, D-N.Y., introduced the Screening With Dignity Act, which proposed funding for TSA training and education and a feasibility study for retrofitting or replacing the millimeter wave scanners. The bill died in the Homeland Security Committee and has not been reintroduced this year.
“It is clear that TSA needs to reassess its technological capabilities and improve its screening procedures to be more inclusive,” said Rice, who was the district attorney for Nassau County, on Long Island, before being elected to Congress. “No one should have to go through airport security scared that they might be humiliated, discriminated against or outed.”
In a 2015 survey of transgender Americans, NCTE found that of respondents who had gone through airport security in the last year, 43% had a problem at the checkpoint related to being transgender.
Many transgender people fear interacting with law enforcement in any setting. According to the NCTE survey, 57% of respondents said they would be afraid to ask the police for help.
Fox, the transgender woman who said she was asked to expose her genitals at the airport in Albuquerque, said her boyfriend encouraged her to file a complaint, but she decided against it.
“Dealing with the legal system is scary,” Fox said.
Lasting Trauma
When Olivia left the private room where she was searched at the Fort Lauderdale airport, she ran to Marguerite, who was waiting for her on the bench, and wept.
“Calm down, calm down, get your stuff together,” Marguerite can be heard telling Olivia in the audio recording Olivia took on her phone near the end of the incident.
Olivia and her wife, Marguerite. When they have to fly, Marguerite prints out the screening procedures from the TSA’s website in case Olivia is stopped again. (Annie Flanagan, special to ProPublica)
From the time Olivia stepped in the body scanner to the time she was allowed to head to her flight, the encounter spanned just 20 minutes. But it’s been impossible to forget.
Marguerite and Olivia, who married last year, have traveled a few times since the September 2017 trip. Marguerite prints the screening procedures from the TSA website and keeps a copy in her purse, in case she has to show it to a TSA officer.
Each time they travel, Olivia panics as she approaches an airport checkpoint.
“I feel my heart speed up. I start thinking: It is going to happen again, it is going to happen again, it is going to happen again,” she said.
This May, while flying back to Florida from North Carolina, a TSA officer asked Olivia to step aside. The airport body scanner issued an alarm in her groin area. The officer patted her over her jeans and allowed her to head to her flight.
When she left the checkpoint, Olivia ran to Marguerite, who held her as she cried.
In January of 2019, Japan’s Supreme Court upheld a law requiring trans people to be sterilized in order to legally change their gender. After the ruling, I remember seeing a tweet by the Economist sharing the article,“Should transgender people be sterilised before they are recognised?”. Posing this as a question legitimizes the idea that individual reproductive rights are up for debate. They are not.
I was infuriated, and deeply hurt. The right to reproduce is fundamental. To be told by the state that you must trade your right to have biological children to have your gender legally recognized is a chilling violation of human dignity.
It also got me thinking about how, reproductive rights violations aside, trans people’s fertility options are often overlooked, discounted or stigmatized. Oftentimes, conversations about fertility are glossed over by practitioners with trans clients seeking gender-affirming care. Maybe it’s difficult to think about having a biological child if you’re young, if you are just at the beginning of your medical transition or for any number of other reasons. But you should at least know about your fertility options.
To bring more awareness of fertility options for trans people, I recently organized a panel discussion with two reproductive health specialists who specialize in providing services to trans people: Evelyn Mok-Lin, MD, medical director of UCSF Center for Reproductive Health, and Pratima Gupta, MD, medical director of St. James Infirmary and board member of San Francisco AIDS Foundation. They answered questions about the effect of hormones on fertility, pregnancy options for trans people, and more. Here’s what we learned.
Do you get many trans clients who initiate conversations about their fertility?
Pratima Gupta, MD: It’s a very small percentage of my patients that ask. Anecdotally, I would say that this is just not something that’s on their radar. When people are initiating hormones, that is usually their priority. Fertility isn’t something that they are considering. They’re thinking about gender-affirming care, so it is important for us, as providers, to discuss it.
Why is it important for trans people to start conversations about their fertility with their health care provider?
Evelyn Mok-Lin, MD: The ideal right now is to try to conceive or try to preserve one’s fertility before starting hormone therapy. We know that people that have transitioned can still conceive. We also know that people who have not started hormones are more likely to conceive. So that’s why it’s important to have a discussion with your doctor about your future fertility plans and family plans before starting hormone therapy or having surgery.
Gupta: It’s really important for health care providers to have thorough discussions about options, planning and cost with their trans clients. It’s so much more than just ticking a box and asking trans clients if they want to get pregnant or get someone else pregnant. Although there are these recommendations for health care providers, it’s also good for people to advocate for themselves. It’s a good conversation to start, even if your provider doesn’t initiate it.
What are options for trans people to have a baby?
Mok-Lin: Of course adoption is always an option, but here I’ll discuss options for having a genetically related child. To have a genetically-related child, you need an egg, a sperm and a uterus. That’s the foundation of it. It depends on which of these you have, and which your partner (if you have one) has.
If between you and a partner, you have eggs, a uterus and sperm, spontaneous conception (getting pregnant “naturally”) may be an option.
Intrauterine insemination (IUI) may also be an option. This is when your sperm, a partner’s sperm, donor sperm or frozen sperm is put into the uterus.
In vitro fertilization (IVF) may also be an option. We can use frozen eggs from someone who may have frozen them prior to having ovaries removed or before starting hormone treatment. Or you can use donor eggs or a partner’s eggs and combine them with a partner’s sperm, donor sperm, or frozen sperm. If you have a uterus, the embryo could be transferred there, or it could be put into the uterus of a surrogate. There are a lot of ways to make it happen.
What are the costs associated with these procedures?
Mok-Lin: It depends on your insurance. We live in a unique place where a lot of people who work in Silicon Valley have coverage for fertility treatments. But not everyone does.
If you don’t have coverage, intrauterine insemination can cost about $1,000. That doesn’t include the cost of sperm. If the sperm comes from the couple, then there’s little to no cost. If you get donor sperm, the cost may be another $700. IVF can cost around $15,000 to $20,000 per cycle. If you use a surrogate, that can be on the order of $150,000.
There are a lot of options, but it can be extremely cost-prohibitive, unfortunately. Some people who need fertility coverage switch companies to get the right insurance coverage. They may move to another state (such as Massachusetts), or look for jobs that are local but at a company based in Massachusetts.
Gupta: I recently had a client who did that: She took a position at a company that was, job-wise, a bit of a demotion in terms of her career. But the company offered fertility coverage, and she did the math.
Can you get pregnant, or can you get a partner pregnant, if you’re taking hormones?
Mok-Lin: This is one of the things I always talk to teenagers about before they start testosterone. T (testosterone) is not a form of contraception! We know that people have gotten pregnant on testosterone. If you don’t want to get pregnant, and are having intercourse with someone who has sperm, you need another form of protection.
That said, there aren’t that many people who have gotten pregnant when on T, because T can prevent ovulation and the thickening of the uterus. When the lining of the uterus is thin, an egg—if one is released—isn’t able to implant properly.
There was one study by Alexis Light of trans men who had pregnancies. The group of men included those who had never taken T and those who had taken T and come off of it. This study concluded that men who had never taken T were three times more likely than those who took T to get pregnant. But the number of people in the study was so small, it’s hard to know for sure.
Gupta: The same is true for people on estrogen. Feminizing hormones, similarly, do not cease sperm production. You can’t rely on estrogen as contraception.
What about for trans people who do want to become pregnant or get someone else pregnant? What are the effects of hormones?
Mok-Lin: It’s more difficult to conceive naturally on hormones, but we know it’s not impossible. The recommendation now is to come off of hormones three to six months before trying to conceive. Time off of hormones allows the lining of the uterus to thicken, which allows the egg to implant properly. The life cycle of sperm is about 70 days so it takes between two and three months to resume spermatogenesis.
There is one study from our center comparing sperm samples from people who had never taken estrogen, who had taken estrogen but stopped and who were currently on estrogen.
The people who had never taken estrogen had the highest sperm counts. People who took hormones but stopped had relatively normal sperm counts, but had lower sperm counts than people who had never started hormones. The folks who stayed on hormones had really low sperm counts. This shows us that the decreased sperm count is reversible. That’s reassuring. Sperm seems relatively hardy.
Testosterone doesn’t make someone completely infertile. We know that people who have never taken testosterone are three times more likely to conceive naturally than people who have taken testosterone, even if the testosterone is stopped.
From the data we have on pregnancies that happened when people were on hormones, we know that there were no higher risk of birth defects or other issues.
How can the intersection of being trans and a person of color impact someone’s reproductive journey?
Gupta: I think it’s very complicated – this issue of being black or brown, being trans, and seeking pregnancy. We know that structural and institutional racism contribute to maternal mortality rates that are three to four times higher for African American women than white women. On top of that, you have challenges to health because you are trans. It’s not necessarily true that all providers are aware of and support trans health. There’s higher risk pregnancy and delivery. There’s postpartum depression. There may be complications. It’s something we need to be aware of and supportive of our trans brothers and sisters who are seeking pregnancy.
What are the options for trans people to breastfeed or chestfeed a baby?
Gupta: If a trans man who has had top surgery wants to breast or chest feed, it can be difficult. This is something to discuss before initiating gender-affirming care. If there isn’t any breast tissue left after a mastectomy, there aren’t any mammary glands to produce milk. That being said, there are options to use donor milk or formula.
For trans women, induction is an option. We can stimulate breast milk production—it’s similar to if a cis-woman adopts a baby and wants to breast feed. It does take a lot—it’s a lot of work.
What would you say to someone who says that trying to have a baby makes you less authentically trans?
Gupta: That’s horrible. And completely untrue! Everyone has their own journey. There’s no one way to be a trans person. Wanting to have a baby doesn’t make a person more or less trans.
Mok-Lin: Agree. Reproduction is a completely separate thing from gender identity. It’s like saying to a cis-woman who chooses not to have children that they are somehow less of a woman.
A woman in Idaho could be the first transgender inmate to receive gender-confirmation surgery through a court order.
A panel of judges ruled on August 23 that Adree Edmo’s gender-confirmation surgery should be provided by Idaho and Corizon, the state’s prison healthcare provider.
The surgery is estimated to cost between $20,000 and $30,000.
Edmo is serving 10 years for sexually abusing a 15-year-old boy when she was 22 and is scheduled for release in 2021. She is not eligible for parole.
The 9th circuit court of appeals ruling agreed with a December 2018 ruling from US District Judge B Lynn Winmill that was in Edmo’s favour and ordered the state to provde her with surgery.
The 9th circuit court of appeals judges wrote that Windmill’s findings were “logical and well-supported” and that “responsible prison officials were deliberately indifferent to Edmo’s gender dysphoria, in violation of the Eighth Amendment”, according to NPR.
Idaho has 90 days to appeal the ruling to the Supreme Court. In a statement, Idaho governor Brad Little said, “We cannot divert critical public dollars away from the higher priorities of keeping the public safe and rehabilitating offenders.”
“The hardworking taxpayers of Idaho should not be forced to pay for a convicted sex offender’s gender reassignment surgery when it is contrary to the medical opinions of the treating physician and multiple mental health professionals,” he said.
But the ruling consistently rejected the medical opinions of the prison’s healthcare providers.
“It is enough that [her doctor] knew of and disregarded an excessive risk to Edmo’s health by rejecting her request for [gender confirmation surgery] and then never re-evaluating his decision despite ongoing harm to Edmo,” the judges wrote.
“Prison authorities have not provided that treatment despite full knowledge of Edmo’s ongoing and extreme suffering and medical needs,” the judges wrote.
Edmo’s lawyer, Lori Rifkin, said news that Idaho would appeal was “reprehensible”.
“She suffers every single day while they have denied this treatment to her for years and there can be no reason justifying Idaho’s continued refusal to provide her care except bias,” Rifkin said.
Edmo has twice attempted self-castration while in prison.
The ruling doesn’t mean that all trans inmates in Idaho would be eligible for state-funded gender-confirmation surgery, but it would set a standard for providing the surgery to certain inmates with severe gender dysphoria like Edmo.
Police investigating the murder of Tracy Single, the 16th trans woman of colour killed in the US this year, have arrested a man she had been dating.
Joshua Dominic Bourgeois was arrested Friday, August 23, on suspicion of Single’s murder, according to ABC News.
The 25-year-old became a suspect after investigators learned he had been in a “dating relationship” with Single, also known as Tracy Williams.
Police said she was found dead with a puncture wound and several lacerations in a gas station parking lot in west Houston on July 30. She was 22 years old.
It took officials two weeks to identify her body with the help of local LGBT+ activists.
Tracy Single was ‘larger-than-life’.
Originally from New Orleans, Single had been living in a west Houston apartment after spending time at a shelter for homeless youth.
Friends told local paper the Houston Chronicle that she was a “larger-than-life” personality and who loved fashion, drag and performance.
After moving to west Houston, she would visit the a local centre for people “of all sexual orientations and gender identities” who were experiencing homelessness, where she would give peers and mentors dance lessons.
Her death was described as a “big loss for the community” by Courtney Sellers, executive director of the Montrose Grace Place centre.
16 trans women of colour killed so far in 2019.
Single’s death is the latest tragedy in an epidemic of violence against trans women of colour.
At least 15 other trans people of colour have been shot dead or violently killed so far this year, according to Human Rights Campaign.
Human Rights Campaign said that “it is clear that fatal violence disproportionately affects transgender women of colour, and that the intersections of racism, sexism, homophobia, biphobia and transphobia conspire to deprive them of employment, housing, healthcare and other necessities, barriers that make them vulnerable”.
When Maurice “Reese” Willoughby died by suicide last week, it came at the tail end of months of cyberbullying after a video emerged of him defending his girlfriend — a transgender woman named Faith — to a crowd of people who were hurling transphobic and homophobic comments.
“You f— what?” shouts the person holding the camera, in a video that racked up millions of views.
Willoughby was an aspiring rapper from the Philadelphia area, and initial reports stated that he took his own life because of the bullying seen in the viral video. However his girlfriend, Faith Palmer, said on social media that he struggled with drug addiction and intentionally overdosed.
“Oppressors will always find a label for you, so it’s better to have your own that’s a positive word that puts you in a positive light.”
PIPER DAWES
For transgender activists, however, the viral video was a rare opportunity to shine a light on the harassment and violence inflicted on the cisgender (non-transgender) people who openly love transgender people.
Kiara St. James, executive director of the New York Transgender Advocacy Group, said this moment is a time to teach people about the concept of “transamory,” which she defined as people who are attracted to and seek out relationships with transgender people.
“Transamory has had many names,” St. James told NBC News. “One of the original names, which was more stigmatizing, was ‘tranny chaser,’ which we don’t use any more. But for a lot of community members, there were a lot of gentlemen who dated a series of trans women. The term was used to kind of say that they had a fetish for trans women.”
“I think that as we have evolved, we have understood that there are people out there who are transamorous, who intentionally seek trans women or trans men for relationships and, it’s something that’s ongoing,” St. James continued.
For viewers of the hit FX drama “Pose,” this will be familiar: The show features several transamorous story lines, particularly with Angel, a sex worker and model, played by Indya Moore.
Indya Moore as Angel and Evan Peters as Stan in “Pose” on FX.JoJo Whilden / FX
In a tweet posted Tuesday, transgender author and “Pose” producer Janet Mock shared the video of Willoughby being bullied and condemned his harassers.
“These men screaming at him are beyond fragile, standing on a shaky altar of masculinity, too insecure to do what Reese did: Unapologetically love a woman who everyone says is unworthy of love,” she wrote.
Mock later shared an image from “Pose” of transgender woman Angel and cisgender man Lil’ Papi, whose romance blossomed in season 2.
St. James said she has been using her platform as executive director of a trans advocacy group to draw attention to transamory, because the violence that is faced by so many transgender women is the same violence faced by those who openly love them.
“Over the past couple of years, especially around Trans Day of Remembrance, we talk about the number of especially black trans women who have been murdered. Oftentimes, they were murdered by someone who they were intimate with over a period of time,” St. James said. “One of the reasons for those types of incidents is fear from the transamorous man of being outed.”
Ashlee Marie Preston, a trans activist based in Los Angeles, echoed this sentiment on Twitter: “When trans attracted men kill us; it’s out of fear that this will happen to them if they are outed.”
St. James said one of the ways to fight back against the violence that so many trans women face is to “create spaces where we see transamorous relationships as normal and healthy.”
“Transamorous does not necessarily mean men who are attracted to women, it can be men who are attracted to men who are of transgender experience; it can be women who are attracted to trans women; it can be women who are attracted to trans men — it’s not just a cis male-trans woman situation; it really runs the gamut of sexual orientation,” St. James said.
Piper Dawes, a trans woman living in northern England, was one of the first people to coin the term “transamory.” Her 2013 blog post used the term after wrestling with more stigmatizing and cumbersome terms like “gynandromorphophilia.”
“Oppressors will always find a label for you, so it’s better to have your own that’s a positive word that puts you in a positive light,” Dawes told NBC News.
Dawes said she realized that some people she dated really preferred transgender people. “It’s not fetishized, but it is a specific love for people like me,” Dawes said.
So, she created the term so that people could find a better way to express their attraction. “I don’t think, really, that it’s necessary to delve deeper than that, because it’s such a personal thing,” Dawes said.
St. James said that showcasing positive transamorous relationships also works to dismantle the stigma felt by trans people themselves.
“Too often, trans women are socialized to think that we cannot be in relationships, so the only way that we can really express ourselves is through sex work and things of that nature,” St. James said.
“I’m in a relationship, so I’m always sensitive of where we go,” St. James said of her and her boyfriend. “Even though he is very comfortable being seen with me, I still have that reservation of making sure we are in spaces where no harm will come to either him or me.”
“I think that’s something that a lot of transamorous couples think about if we go out in public,” she added.
If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 800-273-8255, text HOME to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.
The US district judge made the ruling in the case of four trans Wisconsin residents, who were challenging a 1997 provision that excluded coverage of “transsexual surgery” for Medicaid recipients.
Judge William Conley said on Friday, August 16, that the state’s Medicaid programme was discriminating against trans people by not covering trans healthcare.
The four trans people who filed the lawsuit argued that gender-affirming healthcare for trans people was medically necessary due to the medically recognised condition of gender dysphoria.
“There is now a consensus within the medical profession that gender dysphoria is a serious medical condition, which if left untreated or inadequately treated can cause adverse symptoms, such as anxiety, depression, serious mental distress, self-harm and suicidal ideation,” Conley wrote in his judgment, according to the Wisconsin State Journal.
In the 38-page ruling, Conley said that trans people in Wisconsin were being discriminated against on the basis of sex under the federal Affordable Care Act.
Conley’s ruling follows a temporary injunction against the provision that he issued last year.
Insurance companies that manage state Medicaid plans also “acknowledge that gender-confirming hormone and surgical treatments for gender dysphoria can be medically necessary”, Conley said.
Wisconsin is among nine US states that have explicit Medicaid exclusion for trans healthcare, according to the ruling, which also estimates the cost of gender-affirming treatments covered by Medicaid to be between $300,000 and $1.2 million per year.
Wisconsin spends $3.9 billion a year on its Medicaid programme.
Trump proposing nationwide rollback of trans healthcare.
On May 24, the Trump administration filed a 204-page proposed regulationthat would roll back healthcare protections for trans people.
The US Department of Health and Human Services (HHS) published the document proposing eliminating gender identity as one of the factors in healthcare and government policy.
The regulation would reverse changes made by the Obama administration and came as another knock to the transgender community.
The brief was submitted in a case concerning Aimee Stephens, a transgender woman who was fired from a Detroit funeral home after she informed her employer that she was beginning her gender transition. The case, R.G. & G.R. Harris Funeral Homes v. Equal Employment Opportunity Commission, et al., is one of three cases concerning LGBTQ workers’ rights that the Supreme Court is expected to hear this fall.
Aimee Stephens and her wife Donna, right.Courtesy ACLU
The brief, submitted by Solicitor General Noel J. Francisco and other Department of Justice attorneys, argues that Title VII of the Civil Rights Act of 1964, which prohibits employment discrimination based on race, color, religion, sex and national origin, “does not bar discrimination because of transgender status.”
“In 1964, the ordinary public meaning of ‘sex’ was biological sex. It did not encompass transgender status,” the brief states. “In the particular context of Title VII — legislation originally designed to eliminate employment discrimination against racial and other minorities — it was especially clear that the prohibition on discrimination because of ‘sex’ referred to unequal treatment of men and women in the workplace.”
If the Supreme Court sides with the Trump administration, it will be overturning a decision by the 6th U.S. Circuit Court of Appeals, which sided with Stephens in March 2018.
“Discrimination against employees, either because of their failure to conform to sex stereotypes or their transgender and transitioning status, is illegal under Title VII,” Judge Karen Nelson Moore wrote in the 6th Circuit’s decision. “The unrefuted facts show that the Funeral Home fired Stephens because she refused to abide by her employer’s stereotypical conception of her sex.”
Moore added that requiring the Christian business owner, Thomas Rost, “to comply with Title VII’s proscriptions on discrimination does not substantially burden his religious practice.”
Alliance Defending Freedom (ADF), the conservative legal group thathad petitioned the high court to hear the Stephens case, said the lower court overstepped its bounds by “redefin[ing]” the term “sex” in Title VII to “mean something other than what Congress clearly intended.” Just hours before the Trump administration submitted its brief, ADF submitted one of its own, arguing that “judicially rewriting sex discrimination in Title VII will spill over into other federal laws that prohibit sex discrimination.”
“It will deny women and girls fair opportunities to compete in sports, to ascend to the winner’s podium, and to receive critical scholarships,” the ADF brief states. “It will also require domestic-abuse shelters to allow men to sleep in the same room as female survivors of rape and violence. And it may dictate that doctors and hospitals provide transition services even in violation of their religious beliefs.”
In addition to Stephens’ case, the Supreme Court is set to hear two cases dealing with workplace discrimination on the basis of sexual orientation. Those cases — Zarda v. Altitude Express and Bostock v. Clayton County — will be consolidated.
The Trump administration has made its position clear on the scope of sex discrimination in Title VII, so Friday’s amicus brief did not come as a surprise to those following the cases. In July 2017, the Department of Justice submitted an amicus brief with the 2nd U.S. Circuit Court of Appeals in the Zarda case opposing the extension of Title VII discrimination protections on the basis of sexual orientation. And in October 2018 — prior to the Supreme Court decision to hear the Stephens case — the DOJ filed a brief with the high court siding with the funeral home. In the Stephens case, the federal government is pitted against itself, since the Equal Employment Opportunity Commission is a defendant in the case.
The Supreme Court will hear the cases next term, which begins in October.
Nearly 200,000 transgender people in the United States have been exposed to so-called conversion therapy at some point in their lives, according to a study published Thursday by The American Journal of Public Health.
“Conversion therapy” refers to efforts to change an LGBTQ person’s gender identity or sexual orientation and has been condemned by nearly every major health association, including the American Medical Association, the American Psychological Association and the American Academy of Pediatrics.
Using data from the National Center for Transgender Equality’s 2015 U.S. Transgender Survey and UCLA’s Williams Institute, researchers from Harvard and The Fenway Institute estimated that 187,923 trans people across all 50 states — or approximately 13.5 percent of the country’s estimated 1.4 million self-identified trans individuals — have been subjected to attempts to change their gender identity by a “professional,” such as a psychologist, counselor or religious adviser.
“Our research team was extremely concerned to find that this practice, which is widely discredited by major medical organizations, was so prevalent,” Dr. Jack Turban, a resident physician in psychiatry at Harvard Medical School and the study’s lead author, told NBC News in an email.
The researchers broke down the data in several ways, including by state. Respondents in Wyoming, South Dakota and Montana were the most likely to experience gender conversion therapy in their lifetime, with more than 20 percent of respondents in each state reporting they had experienced gender conversion therapy methods.
In addition to examining lifetime exposure of psychological attempts to change a person’s gender identity from transgender to cisgender (PACGI), researchers also examined exposure to such conversion efforts from 2010-15, “to capture the diagnostic change from ‘gender identity disorder’ to ‘gender dysphoria’” by the American Psychiatric Association.
Gender identity disorder was historically used by mental health professionals to diagnose trans individuals despite objections from advocates, who argued that the term further stigmatized trans people by assigning them a lifelong mental health diagnosis. Gender dysphoria, which is used to describe the emotional distress over “a marked incongruence between one’s experienced/expressed gender and assigned gender,” has been deemed the more accurate terminology by the APA since 2010.
Researchers found that 5 percent of trans people reported exposure to conversion therapy from 2010 to 2015. The number of individuals varied across states, but similar to the lifetime exposure results, respondents from South Dakota (16.3 percent) and Wyoming (9.1 percent) were the most likely to experience gender conversion therapy at some point during this five-year period.
Most major medical organizations, including the American Medical Association, have labeled gender identity conversion efforts as unethical and state that they can lead to adverse mental health outcomes.
Trans individuals suffer elevated risks of anxiety and depression compared with the general U.S. population, according to experts. In an earlier study, Turban looked at such mental health outcomes for transgender individuals and determined that exposure to conversion therapy is “associated with severe mental distress, suicide ideation and suicide attempts.”
Turban said he hopes his findings will highlight the magnitude of this controversial practice for state legislators who are considering legislation to ban the practice on minors.
“In the past, some state legislators have argued that such bans are not necessary because gender identity change efforts do not occur in their state,” Turban said.
He cited as an example former Maine Gov. Paul LePage, who vetoed a 2018 bill to ban conversion therapy in the state because he said there was “no evidence” that the practice was employed.
“Our findings show that this is false,” Turban said. “Transgender people in every U.S. state reported exposure to gender identity change efforts.”
In the last 30 months, 13 laws have been passed protecting minors against conversion therapy. Currently 18 states, along with the District of Columbia, ban the practice on minors.
