By Seth Steinzor
Editor’s note: Steinzor lives in South Burlington and is a poet, woodworker and retired attorney. He worked for 32 years in the Vermont Attorney General’s Office.
The uproar over a trans student on the high school volleyball team in Randolph evokes memories for me of my own involvement in our society’s complicated, slow recognition that trans people are entitled to respect like everybody else.
Years ago, I was an attorney in a case testing the Vermont Medicaid program’s rules regarding eligibility for gender-affirming surgery. (Then called “gender reassignment.”) Representing the program, I was defending those rules. I wonder, if we had known then what we know now, how successfully I might have done so.
Medicaid programs around the country faced a dilemma. Gender-affirming surgery is a pretty drastic set of procedures. It consists of multiple phases, each with its own set of risks, and it isn’t particularly reversible. You have to be seriously in need of it, in order to justify the pain, risk, expense and permanent alteration.
But the feeling of being uncomfortable with one’s assigned gender may have multiple causes. How do you distinguish a person whose gender dysphoria may be treatable by nonsurgical means — for example psychotherapy — from someone whose alienation from their body can’t be alleviated that way? How do you tell whether a person’s suicidal ideation is rooted in a desperate need for gender reassignment, or something else? For that matter, how do you know whether claimed suicidality is a genuine expression of despair at misaligned gender identity, or mere manipulation for some other purpose?
In short, given that some people undoubtedly need the surgery, how do you know who they are, given that other people who don’t really need the surgery claim similar sorts of unhappiness?
There were no metrics for making this decision, no blood test, no objective, physical, diagnostic criteria. There still are not. The program could authorize payment for the surgery on the applicant’s word that they needed it, but that would have been irresponsible both to the applicant and to the program’s fiscal integrity. Or the program could refuse to cover the surgery altogether, but that would have been both cruel and illegal.
Vermont, like other states, decided to rely on expertise. At the time of my case, the rules required a psychiatrist to agree that the surgery was needed. The rules have loosened since then, but authorization still turns on getting an evaluation from a “qualified mental health professional.”
As it turns out, this approach may in fact have been mistaken. Transsexual gender dysphoria may not be purely a matter of psychological dislocation, of a person’s “mere belief” about themselves, the authentic roots of which can be identified only through the necessarily subjective judgment of a person skilled in diagnosing mental disorders.
Since I tried my case, scientific evidence has mounted fairly convincingly that trans identity may be a matter of neuroanatomy. Google “neuroanatomical correlates of gender dysphoria” and see for yourself.
Although research is far from complete and the mechanisms not understood, it appears that certain details of brain structure and neurochemistry are shared by trans people with persons of the gender with which they identify, instead of the gender they otherwise appear to have been born into.
A possible cause may be the neonatal hormonal environment in the womb. In short, a person may well be biologically trans from birth.
If so, the implications are vast and profound. They extend far beyond the possibility, as yet unrealized, of making an objective medical determination as to whether or not a person is trans. Fundamentally, the science indicates that being trans is neither a matter of mental health nor of choice. It resides at the bedrock level of a person’s being — just as trans people have been insisting all along.
A further implication that may be less welcome to some trans people is that there may be no such thing as “a man in a woman’s body” or “a woman in a man’s body.” The binary opposition “male” and “female” does not accurately express biological reality, which is far more complex and nuanced.
On this view, trans bodies (if we are to count the brain as part of the body) are wonderfully themselves. A trans person’s identification as either “male” or “female” may be a response more to socially constructed gender roles than an expression of that person’s true nature.
Perhaps these constructs, which demand that a trans person must sacrifice a part of themselves in order to live more comfortably in another part, are the ultimate cause of gender dysphoria. When trans people no longer need to seek acceptance for themselves as beautiful expressions of the spectrum of human sexuality, but are granted such acceptance merely for existing, will gender-affirming therapies be needed?
I don’t pretend to have answers. But the questions are increasingly posed by the facts at our command. Less and less can they be avoided.
