What It Takes To Transition in the South

My step-brother, Atticus, hates when people ask if he is going to "get one." It's an innocent, albeit implicit, stab—the kind of reminder that he's not yet whole in their eyes. "You wouldn't normally walk up to somebody and be like, 'Hey, do you have a vagina? Are you gonna get a penis? Do you want a penis?'" he says, recounting recent interactions with his coworkers. "The way I like to describe it—and I don't know if it's politically correct at all—but it's like I was born with the most unusual birth defect I could have had." Atticus started his medical transition from female to male less than a year ago. And in truth, on the totem pole of challenges he has endured since that time, fielding questions about genitalia from strangers hovers somewhere near the bottom. Instead, he says, the harder part has been learning how to navigate his transition while living in the suburbs of Dallas, Texas. When Atticus wanted to start hormone replacement therapy (HRT), he discovered that the supply of clinics that offered the service for trans individuals wasn't matching local demand. He called around for hours, only to later discover that his insurance policy didn't cover the treatment anyway. Then, when Atticus decided to come out about his transition at work, he learned that Texas does not have a statewide law prohibiting workplace discrimination based on sexual orientation or gender identity. "If my management ever changed, they could decide to fire me for no reason," he says. Atticus's story is, no doubt, one of many. Because to be transgender in the South often means not only enduring social consequences, but living in a resource-limited environment stacked against transitioning. And, to make matters even more complicated, it varies state by state, so simple factors like where someone was born, where they currently live, and where they work can affect the process drastically. This creates a national clusterfuck of contradictory laws and rules directed at trans people.

Some of the legal prejudices levied against the trans community in the South are well-known. This past March, North Carolina passed House Bill 2 into law, which mandated that individuals use bathrooms corresponding to the sex on their birth certificate. Meanwhile, in Mississippi, Governor Phil Bryant signed a 'Religious Freedom' bill that would have granted individuals and businesses the right to openly discriminate against members of the LGBT community. A federal judge blocked the law from going into effect, but the sense of Southern hostility remained.

Now, in recent days, the reality of a Donald Trump presidency is shifting into focus. Whether Trump will destroy certain transgender protections codified by the Obama administration remains uncomfortably unclear. Although the president-elect stated back in April that trans people should be able to use whatever bathroom they want, Trump also released a plan saying he intends to "cancel every unconstitutional executive action, memorandum and order issued by President Obama" within his first 100 days in office.

"There is a sense of dread among many in the community. People fear that there will be efforts to roll back some of the legal and policy gains the trans community has made," says Demoya Gordon, an attorney for the civil rights organization Lambda Legal. "It's hard to predict what a Trump administration will do—given how little he has spoken about his policy plans during the presidential campaign—but we certainly plan to be vigilant and to hold the line against any efforts to roll back progress on various fronts."

If Trump moves forward with reversing orders put in place under Obama, trans people may find themselves gravely affected. Regulations that prohibit healthcare providers and insurers from discriminating against LGBT people could be repealed. Rights for transgender students at school and LGBT federal workers and contractors could also be compromised. And there is further cause for concern when factoring in a Trumpified Justice Department, a Vice President-elect who once proposed diverting HIV/AIDS funding to conversion therapy programs, and the appointment of a conservative US Supreme Court judge, perhaps even two or three, which could cripple transgender rights for years to come.

While these prospects remain hypothetical, the path thus far for trans people to transition in the US has been anything but easy—especially for those living in the south.

"I felt when I moved to Mississippi, I'd jumped back 100 years," Jensen Luke Matar, 29, a retail manager who lives in Jackson, says. "I had to essentially strategize my entire transition." Two years ago, Matar began his female-to-male transition the way countless trans people have: by seeking out a therapist who could write him a letter for hormone therapy. Ideally, Matar wanted to see someone who specialized in gender, though he knew that would be difficult to find in Jackson. He researched the area for local practitioners, and when none turned up, he opted for online therapy. The result: Matar paid $60 per session every two weeks for eight months before receiving the HRT letter that would ultimately allow him to start testosterone injections.

"I don't think I gained a single thing out of that experience," he says. "I was already dead set in my mind. I knew who I was. It was time to get the ball rolling, and I felt I was dragging it on by having these sessions."

Known as the "gatekeeper model," the requirement that therapists sign off on hormone treatment for a candidate is enforced intermittently across the US. For obvious reasons, it makes HRT a subjective process: While some trans individuals walk out of their first therapy session with a letter, others could spend months, and sometimes longer, waiting for approval. Proponents of this method say medical practitioners can help trans patients avoid uninformed decisions or irreversible physical side effects. But it becomes a problem in areas without sufficient numbers of mental health providers. That's sometimes why trans people choose to Skype counselors in bigger cities.

For Matar, the gatekeeping itself wasn't as staggering as the statewide lack of resources surrounding the practice. The Jackson-based Open Arms Healthcare Center, he says, is the only place in a city of 170,000 people that offers free sessions for trans individuals looking for an HRT letter in order to start treatment, as well as hormone therapy itself. The problem? The center is volunteer-based, and primarily devoted to helping minorities who are HIV-positive. That means the center is often understaffed, Matar says, and he still knows a host of individuals who are on a list waiting to be seen by a therapist so they can start their transitions.

"If you drive three hours north, you're in Memphis, and there's more resources there," he says. "Drive three hours south, you're in New Orleans. There are more resources there. But Jackson is where the need is. There is a surplus of [trans] people here, and a lot of them are quiet and underground."

Today, there are an estimated 1.4 million adults who identify as transgender in the US, according to a recent study by the Williams Institute. Yet even that number is debatable, considering the annual population count put out by the US Census Bureau still only asks about sex. There's an inherent issue here: Being transgender doesn't directly relate to someone's sex at birth, or even their sexual preference—it has to do with your gender identity; the gender you wholly feel you are inside, and who you were meant to be.

It's something Gina Duncan, 60, understands on a personal level. Before she transitioned ten years ago, Duncan was working as a regional manager for Wells Fargo in Florida, and living life as Greg—a husband and father of two. "My biggest casualty [of my transition] was with my spouse of 26 years," Duncan says. "We had these circular conversations over and over again, where I would tell her, 'I can't live this way any longer, but I love you and I don't want to lose you.'"

Today, Duncan serves as the director of transgender inclusion at Equality Florida, the state's largest LGBT advocacy organization. She dedicates a part of her efforts to traveling around the state in a push to educate people on what she refers to as transgender "cultural competency." The task can include anything from teaching the importance of using the right pronouns to explaining the concept of gender identity at its core. Recently, she trained the staffs at Planned Parenthood clinics before its 11 locations throughout Central Florida began offering hormone therapy services. "Florida is kind of the best of the worst in the South," she says. "There's a lot of research that shows we're really making progress for the transgender community."

Florida currently ranks sixth in the country in terms of the number of people (100,300) who identify as transgender. Duncan is proud of this, but knows her work is far from over. Affordable healthcare remains a serious problem for the trans community, given that an estimated 19 percent of patients seeking gender-affirming procedures have no health insurance. And when individuals are insured, it's an uphill battle to prove to insurance companies that HRT and surgical procedures are not "cosmetic" or "experimental," but rather, a necessity, linked to medical and mental well-being.

Studies show that the desire to transition can understandably impact the emotional state of trans people, often contributing to depression and anxiety if their needs are not met. Suicide rates in this population are equally staggering: One study showed that nearly 41 percent of trans or gender-nonconforming people have attempted suicide. Among trans people of color, statistics are disproportionately grave—African American, Latino, and indigenous trans people are unemployed, homeless, or uninsured at almost double the rate of white individuals. They also experience epidemic rates of violence and murder.

In response to some of these healthcare issues, Duncan has developed a guide of vetted therapists, primary care providers and endocrinologists for transgender individuals around Florida. But, she admits, there are some statewide policies that need to be fixed in tandem. The most glaring being the fact that the Sunshine State still lacks fully-inclusive anti-discrimination laws protecting workers or students based on their sexual orientation and gender identity; instead, protections vary based on county or municipality.

"I can leave where I live in Orange County and drive to Pensacola to do work with the ACLU," Duncan says. "When I get out of my car, I'll have less rights and protections than when I got in my car in Orlando, because they have no human rights ordinance."

In fact, there are few, if any, universal rights that apply to transgender people across all 50 states. Instead, there is what has been called a "patchwork" of protections laid throughout the country; an intricate web of policies that affect transgender lives regarding everything from employment, housing, healthcare, education, and family life to yes, even bathrooms.

Living in Tennessee, James Burrow, 23, has found himself lost in this legal gray zone many times throughout his transition. The first incident happened when Burrow went to change the name on his license and birth certificate at the county courthouse.

"They tried to tell me there was no paperwork for that. I talked to people and they'd say, 'Oh, we don't handle this here. You need to call the other department,'" Burrow says. He had known that no law in Tennessee prohibited a standard name change, so when he was initially asked why he was getting one, he openly identified as a trans man. "I was naive to the fact that I probably shouldn't [admit that] right off the bat."

Two months passed, and Burrow's female birth name remained on his paperwork. At the time, he didn't know of any transgender resources in the area, so Burrow saved money for months in order to a hire a lawyer. Unsurprisingly, with legal help, the process was resolved within a week—the paperwork that couldn't be found appeared within days.

Taking a closer look at state policies on birth certificates shows just how varied the laws can be. Ten states—New York, California, Connecticut, Hawaii, Maryland, Vermont, Oregon, Washington, Massachusetts, and Minnesota—alongside the District of Columbia and New York City, allow changes to the gender marker of the birth certificate, provided individuals have a notarized physician's note stating they have received appropriate treatment for the "purpose of gender transition." The terminology is vague—sometimes listing "surgical," "hormonal," or "other" in reference to treatment types—but the idea falls in line with what trans activists label the "modernized standard," where people may change their gender marker without undergoing costly surgery or hormone treatments.

As for 37 other states, requesting an altered birth certificate means trans individuals are required to provide medical proof they have undergone gender confirmation surgery (called "sex reassignment surgery" by law). Though Burrow was successful in changing his name, he knows there's nothing he can do when it comes to amending the gender marker on his birth certificate. In fact, Tennessee is the only state in the country that explicitly forbids altering the sex section of a birth certificate as a result of "sex change surgery."

To add insult to injury, Tennessee is also one of five states—alongside Alabama, Georgia, Kansas and Mississippi—that make it difficult for trans individuals to change gender markers on their government IDs. When coupled with the states' stricter voter ID laws, trans people can find themselves in a complicated bind when they head to polls.

Being told he can't do something in Tennessee isn't anything new for Burrow. After a few months on testosterone, Burrow began to notice bodily changes and decided it was time to tell his supervisor about his transition. The initial meeting went well, he says, but the next day he was called into a conference room with three of his district supervisors.

"They came after me. They told me that I could not come out to my co-workers," Burrow says.
"When I told them I was coming out [regardless], they tried to come up with terms by which I could. They then told me they would come out for me, and I wouldn't be able to say anything. They also said I couldn't ask my co-workers to use pronouns other than 'she,' 'her,' and 'hers,' because my driver's license says I am female. I think part of it was ignorance. I chalk a lot up to that, especially here in the South."

As it stands, Maryland and Delaware are the only southern states (if you can call them southern) that provide statewide protection against this type of LGBT discrimination. Other than that, the region is blatantly devoid of protections for transgender individuals.

It's one of the reasons Gretchen Wells, 45, knows she has to pick her work battles wisely. As a truck driver based out of Irving, Texas, she considers herself lucky to have the chance to openly transition on the job. Even if that means she gets misgendered often.

"Once I started wearing a bra at work, there were a few drivers that went in and complained to one of my supervisors, saying, 'Hey, what's with this? What is this person?,'" Wells says. "They put them in their place and said, 'Look, leave her alone.'"

Wells was surprised by the show of support, which is also why she doesn't want to push other issues too far. Even though her name and gender marker are legally changed, Wells was told she must use the male restroom until she undergoes sex-reassignment surgery.

It's unfortunate, but it pales in comparison to the familial rejection that has accompanied her throughout her transition. "My father is Southern Baptist and a deacon in his church," she says. "He hasn't spoken to me in ten years." Wells wrote a letter to her father about her transition, but never received a response. She began taking hormones for the first time around four years ago, though she recently took a six-month break due to the stress of her divorce—something, she says, was in part due to her decision to transition.

Wells is open about the fact that she has struggled with depression in the past, and that it's taken her years to get to this point. Yet what keeps her pushing to complete her transition is the knowledge that she'll soon be one step closer to becoming exactly who she was always meant to be. It's a realization that has given her a newfound confidence and pride in who she is today.

"Yeah, my situation is a little bit different, but I'm still human," she says. "You may not like it, but you damn well better respect it."

Image: Kitron Neuschatz