Q:   Is being transgender a lifestyle "choice," or is there a genetic reason people are transgender?
A:   We don't know, but the expectation is that, yes, there is something different in people who are transgender. People tend to think of gender as binary: In most species, there are males and females. But the reality is that we know there are a lot of situations where that is not the case. Some people are born with a set of hormones that would make them male but have hormone insensitivity, so they live their lives as women. Some are chromosomally a male but have no penis and undescended testes, so their genitals appear to make them female. That is not what happens to transgender people, but the point is that gender is not as binary as most of us think of it as being. Our hunch is that transgender experiences are probably in part related to those kinds of differences. So, for instance, my brain might respond differently to female hormones than a transgender person's brain does, and we just haven't gotten our science fine-tuned enough to understand it. On the other hand, part of it is lifestyle. People can choose to live their lives as they feel — they may say "I'm too unhappy to live with the gender I was assigned, so I'm going to take the risks that are involved in living the way I feel." To that extent, it is a choice. But in terms of where the feelings come from, that is not something people choose without having some internal motivation. They have more opportunity for ridicule and harassment than almost anyone else in our society. The group that we are least accommodating of are people who cross gender boundaries — people lose jobs, their families, basically their entire support network. So it is not something anyone would take on lightly.

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Q:   What kind of medical help is there for people who are transgender?
A:   First, there are different levels of transition for people who choose to transition. Some people just choose to cross dress, while many people choose to do more than that — either by taking hormones to help make their body change somewhat toward the gender that they want or by choosing to have surgery. There is the expectation in many people's minds that everyone who is transgender chooses to have surgery. This is not true — first, because it is astronomically expensive, and secondly, because it is major surgery and there is the opportunity for something to go wrong. Even if surgery goes well, there may be problems, such as loss of sexual feeling or urinary incontinence. For those transitioning from female to male, you can fashion a penis, but to have one that functions with an erection is not possible at this point without some sort of implant. Likewise, you can't allow someone born with testicles to have a functioning uterus and ovaries or the ability to give birth. So there are severe limitations to surgery. More often people choose to live with some amount of medical intervention, but not as much intervention as is possible. The way it is set up right now, if they want medical intervention, they have to go through a counseling process and have to be assessed to make sure there are no major psychological problems, that they are of sound mind to make the decision and that this is what they want to do. So, often the help that we give them is not really help, it's more of a passing through particular barriers or jumping through hoops to be approved to go on for more medical care. The other thing that we can offer is support for dealing with the crises that can come up when they are going through the transition — telling your wife you want a divorce because you're becoming a woman, for example. These kinds of things are hard to do, as you can imagine. There are also support groups out there as well as the web, which has been wonderful because people can connect with others in similar situations. They can find support no matter where they live.

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