"First, Do No Harm": There Is a Time and a Place to Come Out

Two arms reaching together with sun.
Two arms reaching together with sun.

Passover is the Jewish season of liberation and revitalization. Unfortunately, not only are Israeli Jews maintaining an occupation soon to become a half-century of deprivation of the rights of the Palestinian people, but also fifty years of denying the best of themselves, and particularly their youth, in maintaining that occupation. Each year we learn that the generation of Hebrews who lived as slaves in Egypt had to die off before their children were allowed into the land of Israel, because of their slave mentality. Today the oppressed and the oppressor are bound in a dehumanizing choke hold which drains the decency and hope from both.

The irony is the state of Israel is stronger than it's ever been, but that strength is damaging the weakest among them. Similarly, while the trans community is clearly winning the battle for acceptance in the United States, the most vulnerable among us still pay a high price. This is a difficult column for me to write, because I work so everyone will be able to live authentically. It needs to be said, however, that transition may not be the right answer for certain individuals in a particular place and time.

My primary motivation for my trans activism and advocacy, for the past twenty years, has been to create a world where trans children need not suffer the way I did as a child. My primary motivation for becoming a physician and surgeon was the same -- to prevent needless, unnecessary suffering in those who were completely misunderstood.

Today 35% of Americans know a trans person, and the growing acceptance is evident every day. Even Donald Trump, for God's sake, opposes North Carolina's HB2. Make no mistake -- while Hate Bill 2 is horrendous on many levels beyond writing transphobia into law, it is the trans bathroom language that has sparked the intense backlash in support of our community. A coalition of sexual assault and domestic violence groups called out the lie that anti-trans laws are meant to prevent male sexual predators from wreaking havoc. Even the NBA is directly getting into the fray. And the President commented for the first time today in London:

When it comes to respecting the equal rights of all people, regardless of sexual orientation, whether they're transgender or gay or lesbian -- although I respect their different viewpoints -- I think it's very important for us not to send signals that anybody is treated differently.

I've written about the dialectic of civil rights progress, and it's playing out before our eyes. That dialectic, however, is broadly historical, and not personal. Any one person's life is unique, and her place in her family and community will determine, along with her passion and determination, how she negotiates the changing climate. In other words, while this may be the best time ever to be trans in America, that doesn't apply to all racial, ethnic and socioeconomic subgroups equally, nor does it apply to all individuals in all such groups equally.

As an example from the news, trans persons in Raleigh, North Carolina, are being increasingly "triggered" by the conflict in their state. Obviously it's not easy being a target of your state government, and particularly a direct target, something that has never happened before. Sensitive persons are going to have a hard time. That's where the problem lies.

For decades trans persons have been subjected to the Standards of Care of the World Professional Association for Transgender Health. Originally developed to separate the "real" transgender persons from the false ones, (because you would never want to castrate a "real man," would you?) the SOC have evolved over the decades and today most therapy sought by the transitioner is to help navigate the very complex social and medical processes that are inherent in the transition process. The community has developed roadmaps to help, support groups exist in all major cities, and therapists have become much more supportive and affirming over the years. It really is getting better -- much better.

But therapists know, as do the physicians and surgeons who care for trans persons, that each person is a unique individual, and the transition care must be tailored to that individual. As visibility increases, more and more trans persons, from adolescents to the elderly, see an opening. As insurance coverage expands, more see an opening. As supportive parents of young children appear in multiple media forums, and even defend their children in state and local legislatures, more see an opening.

However, transition is NOT for everyone who is trans. Transition in any given place or time is NOT for everyone. There is no shame in delaying or deferring transition; I delayed for twenty years. What works for me may not work for you.

As a particular example, consider the activists who are willing to pursue legal action and deal with all the publicity over many years. It takes a special type of person who is tough enough to resist the hate while dealing with the emotional ups and downs of any legal case. I'm thinking of Diane Schroer, Vandy Beth Glenn, Mia Macy, Tamara Lusardi, and, now, Gavin Grimm.

We have learned, thanks to the superb work of Caitlin Ryan, founder of the Family Acceptance Project, that family support is the most critical factor in a successful transition. Given that, persons considering transition -- particularly older children and adolescents -- need assistance in determining whether or not it is safe to transition. One can wait until college or beyond if one's home life is potential dangerous. The apparent increase in suicides is indicative of too many young people transitioning without the support they need.

My friend, Brynn Tannehill, a fellow columnist at the Huffington Post, wrote last year that discrimination increases suicide risk. While we wish that everyone would be able to live authentically when they first feel the need, it may not be the best idea to do so in a community with no legal protections. Worse, to try to do so in a community that is actively hostile. Like North Carolina and Mississippi.

We had a simplistic test for being trans twenty years ago -- a trans woman would feel profound emotional relief on estrogen, a cisgender man would not. An equivalent simplistic test for transition today might be the willingness to use your gender-appropriate bathroom, regardless of state law or what you consider the level of hostility of those around you. You can't, and shouldn't "hold it in" all day. You need to be able to function normally in public to successfully transition. Otherwise, it's probably best to wait.

We all know that the only way to bring people to a place of acceptance is to come out, and that includes North Carolina and Mississippi. But it is still incumbent upon those who personally counsel those individuals to very carefully determine if their clients are able to transition in such a hostile climate. One cannot afford to be overly concerned with microaggressions when the world is filled with macro ones. It is a tragedy when we report another teen suicide, or worse, another homicide, as recently happened in my home county. "First, do no harm."

For any given individual, there is no harm in waiting for the right time, the right place. Be smart. Don't get carried away, either by the victories or by the defeats. Stay grounded and do what's best for you. You're the one living in your world, and you and those closest to you know that world best. While the world overall may be getting better, it is your personal world that matters to you. When you're ready, ensure you have all the support you need. Otherwise, just wait until you find it. You'll be happy you did.