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Opinion

RUTH BONNEVILLE / WINNIPEG FREE PRESS For Frances, living as a man was taking a toll on her health. 'It's like acting 24 hours a day.'

They'd been best friends for nearly 33 years and did everything together, including raise two children.

In hindsight, Sue says, she should've known something was up when her bearded, fashion-indifferent husband suddenly started dressing better and watching his weight.

Sue's suspicions that her spouse was living a secret life were confirmed the day he drove her to his psychologist's office instead of to work and, once inside, confessed.

"I never dreamt that he was the other woman," says the 65-year-old retired Winnipeg secretary.

Eight years later, not much has changed. Yet everything has.

Sue and Frances -- who had gender re-assignment surgery four years ago -- are still married. They're still best friends and they still have their kids over for Sunday dinner. Their son took a lot longer to come around than their daughter. (They asked that their surname be withheld to respect their children's privacy.) Their social circle, never large to begin with, shrunk by half a dozen people.

Sue, who had never even heard the term "transgender" until that day in the therapist's office, admits it's been a long and "incredibly hard" journey to reach this place of peace and acceptance. She had to grieve the loss of her husband, almost as if he'd died, she says, before she could open her heart to the woman he became.

"It's not possible for me to love Frances the way I loved the man I married," Sue admits. "It's a platonic relationship, but we still have laughs, we still talk, and we still share meal preparation and dishwashing and laundry. I couldn't imagine not being with Frances now."

Frances, meanwhile, had intended to take her secret to the grave.

She'd known since childhood that "something wasn't kosher," but she also remembers being repeatedly reminded of the protocol for being a boy in the 1950s and working very hard not to break it.

Growing up in a tiny house in rural Manitoba with six other family members didn't afford much privacy, so any compulsion to see how the other half lives -- not that cross-dressing was a viable option, for several reasons -- went underground.

MIKE DEAL / WINNIPEG FREE PRESS Shandi Strong wept tears of joy when the bandages came off following male-to-female surgery last February.

"Eventually I sort of buried it. And then it came screaming back to life," says Frances, 66, who transitioned shortly before retiring as a facilities manager for the provincial government. She used her retirement savings to pay for the surgery.

She had no choice. Living a lie was taking its toll on her health, and her blood pressure was off the charts. "It takes a tremendous amount of energy to maintain that identity," she says. "It's like acting 24 hours a day." Taking hormones had an immediate calming effect.

What many people fail to understand is that gender identity has nothing to do with sexuality, says Frances, who currently identifies as asexual. "If people realized the very first thing that happens to us is we get castrated, they'd probably have a better understanding that it's not about sex."

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That there are people out there who are leading seemingly normal lives but feel as if they were born into the wrong body - their insides don't match their outsides, as it's been put -- may be unfathomable for those of us who have never questioned the gender binary.

You're either born with a penis or a vagina, XY or XX chromosomes, male or female. Simple, right?

Except that pink and blue doesn't cut it in many cases, says Jule Henderson, a Winnipeg clinical psychologist who has been working with the transgender community for more than 25 years.

"Both sexual orientation and gender identity are variables that are on a continuum," Henderson explains. And they're independent variables, so people can be gay or straight in any combination of male-identified or female-identified. They can be very masculine or very feminine, regardless of the gender they were assigned at birth.

Aaron Devor, a B.C.-based international expert in gender and sexuality, puts it this way: "Sex is between the legs and gender is between the ears."

And when those two things are at odds, life can become a life-or-death struggle for identify and acceptance -- internally and externally.

"If I had to summarize it, it'd be the incredible anguish that comes with living so inauthentically," says Henderson, who does the psychological assessments required prior to hormone therapy or sex reassignment surgery. (Her services are not covered by Medicare.)

During the third biennial Canadian Professional Association for Transgender Health (CPATH) conference, which was held in Winnipeg in September, an epidemiologist from the University of Western Ontario delivered some shocking statistics to put that anguish into context.

MIKE DEAL / WINNIPEG FREE PRESS Daniel's journey has been fraught with anguish. His chest is covered in a web of scars, inflicted with the pain of knowing he has a long road ahead.

"Considering suicide at some point is pretty much the norm," Greta Bauer told a session titled Transition, Transphobia and Suicidality Among Trans People in Ontario. Half of her research subjects-- the Trans PULSE Project collected information from 433 trans people (ages 16 plus) across Ontario from April 2009 to May 2010 -- had seriously considered suicide and related it to being trans, while 43 per cent had actually made an attempt on their life, 10 per cent within the last year.

Trans youth, ages 16 to 24, are most at risk, Bauer said, while the period of greatest vulnerability is when a trans person is planning but has not yet begun the medical stage (hormones and surgery) of the gender transition process.

Sitting at the back of a West End eatery, Daniel, 33, opens the top buttons of his shirt to reveal a web of scars across his chest. "They were all inflicted with the deep pain of knowing I have a long road, if any road, ahead of me," says the third-year sociology major, who came out as a trans man five years ago - to family and close friends, anyway.

He's not out at school. Few people know he takes testosterone and wears a chest binder, and that he leaves the gym without changing or showering because he has a hard enough time getting up the nerve to use the men's washroom. Or that he's too scared to change the gender on his Manitoba Health Care card because he's worried what might happen if he ever ends up in the emergency room.

"I'm really afraid of being seen as a freak," says Daniel, whose stocky build, dark faux-hawk hairstyle and beard and deep voice help him easily pass as male.

He gave a poster presentation at the recent CPATH conference about the challenges and discrimination he's faced as a single, transgender father of three -- his kids are 16, 12 and eight and live with him full-time -- but asked that his real name not be published to protect their identities.

His children have been the easiest part of the transition, says Daniel, who is on waiting lists for top and bottom surgery. Four years ago, when he asked them to stop calling him mom -- after doing so elicited an unpleasant reaction from a pair of strangers in a supermarket -- his youngest dubbed him Fred. The nickname stuck.

His kids' school, however, insists on moving his name over to the "mother" box on the registration form every year, he says, even though he keeps identifying himself as their father.

Daniel also recalls going to see a counsellor because he was depressed and suicidal, only to walk out of the session feeling moreso. Rather than address his emotional state, the therapist launched right into theories -- some of them outdated, he says -- about why he is the way he is. He ended up having to educate her about transgenderism.

"A lot of people believe it's a mental illness," says Daniel, "that you're so screwed up that you need to mutilate your body."

The diagnostic term psychologists and physicians use to describe people who feel their biology and gender identity are mismatched is Gender Identity Disorder (GID), also known as transsexualism.

The condition is still recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), put out by the American Psychiatric Association. However, the newest edition (DSM-V), to be published in May of 2013, is expected to replace the term with "gender dysphoria." The diagnosis will apply to people who display "a marked incongruence between one's experienced/expressed gender and assigned gender."

WAYNE GLOWACKI/WINNIPEG FREE PRESS Rikki Dubois was 45 and suicidal when she realized she was transsexual.

The cause of gender dysphoria is not fully known but research suggests genetic abnormalities, hormone imbalances during fetal and childhood development, and social and environmental factors (such as parenting) may be involved.

Daniel, who could pass for male before he started taking hormones -- an endocrinologist accused him of taking testosterone "under the table," because his levels were so high -- can trace his "wrong body" feelings back to age seven or eight. That his fraternal twin sister was more feminine and outgoing didn't help, and he recalls being reprimanded for behaving in ways considered unacceptable for girls.

"I did things like put a sock in my underwear, and I peed backwards on the toilet," says Daniel, who grew up in rural Manitoba. "I got in trouble once when I kissed a girl at a birthday party and told her 'This is what kissing a boy feels like.' The other kids called me a dyke after that."

As a compromise, Daniel's mother let him cut his long hair in a short, boyish style. He recalls how a feeling of elation welled up in his chest every time his parents' friends would refer to him as their son. It was usually short-lived, though.

"My dad would say, 'No, that's my daughter,' and the hope would just flicker away."

Puberty was a mess. Daniel developed early -- first period at 11 -- and says it was around this time that he developed "a permanent ability to hunch my shoulders," as a kind of contraction around a core of deep shame.

His parents rejected him for awhile, he says, but have come around and now make an effort to call him by his chosen name and to use the correct pronoun. His sisters are very supportive and advocate on his behalf.

Still, Daniel admits he stole old photos of himself from his parents' home because he can't bear the thought of them ending up on the walls. Rather than burn them though, he's saving the photos for his kids to have when he's no longer around.

"I may be different now, but they still had me as a mother for a while and I don't want to deny them that," Daniel says.

The articulate and well-spoken, full-time student -- he started university as a mature student, having dropped out of school in Grade 9 -- and father says he feels guilty for not doing more to advocate for the transgender community.

But on his bad days, the isolation, alienation and shame get the best of him. Cutting helps numb the pain, but he still feels suicidal at times.

"I cry a lot," Daniel says. "Not all of me is convinced I'm OK. In my deepest, darkest place, I'm ashamed. But I couldn't not transition or I would've killed myself."

BORIS MINKEVICH / WINNIPEG FREE PRESS Dr. Ian Whetter of the Klinic Community Health Centre says the clinic is seeing about three-quarters of the city's trans people, but he's concerned that a segment of the population is being missed.

One thing he knows for certain -- and it's a statement echoed by every transgender person interviewed for this article: "Every step you take toward that mind-body congruence, the better you feel," says Daniel, who is on waiting lists for both top and bottom surgery.

Shandi Strong, 51, who had male-to-female surgery in Montreal last February, wept tears of joy when the bandages came off for the first time. "I saw that something was gone and that something proper was there," she recalls, "even if it was all purple and swollen."

As many trans women will attest, the need to express one's femininity can be a strong drive. Cross-dressing, albeit often done in secret and burdened with guilt and shame, can offer a glimpse at and connection with an authentic self who's trying to come forward.

"Cross-dressing allowed me to gradually come into my own," says Strong, adding that it also allowed her two teenage daughters to adjust to the transition.

Strong secretly cross-dressed throughout her early teens, until one day her mother noticed a stash of her own clothes between the mattress and box spring of her son's bed. That discovery led to Strong's first visit to a psychologist, who dismissed it as little more than youthful experimentation.

Rikki Dubois, 50, can remember being nine and finding a pair of old pantyhose in her dad's shoeshine kit and pulling them over her hands. "It made me feel pretty," recalls Dubois, who had a sex-change operation in June of 2011. "It was a feeling of peace."

Shame kept her from exploring further, but in her 30s she began "hard-core" cross-dressing, even setting up a camera and tripod to photograph the fashion show. "That was the first time I liked a picture of myself," she recalls. "I fell in love with myself."

Then one day Dubois's wife came downstairs and found her all dressed up. While initially accepting -- she though it was a fetish and only asked that Dubois not cross-dress in the house -- it was the beginning of the end for their 20-year marriage. They have two teenage children.

The more Dubois tried to fight the urges, the stronger they got, as did a case of chronic depression. She was 45, and suicidal, by the time she realized she was transsexual.

Patrick McNorgan loved the military and he loved airplanes -- being around them, fixing them as an aviation technician for the Royal Canadian Air Force, painting pictures of them and later educating people about them as the heritage and history officer at 402 squadron.

But as the tall, dark-haired, moustachioed sergeant and one-time disc jockey began building a career in a male-dominated field, and starting a family with a woman who would be his wife for 30 years, he had to work increasingly harder at denying his deepest truth.

He cross-dressed a bit in his 30s, but suppressed the urge for the next two decades. Then one day in his late 50s when he was grocery shopping, he rolled past a rack of pantyhose and found himself throwing a pair into his cart.

WAYNE GLOWACKI/WINNIPEG FREE PRESS Trish McNorgan was in her late 50s when she stopped denying a deeper truth -- her life as Patrick (below), a sergeant and aviation technician with the Royal Canadian Air Force, was over.

"You can only hold the beach ball under the water for so long and then it's going to come to the surface," says McNorgan, 62, who had sex reassigment surgery in 2009 and became Trish.

"Pat was a persona that Trish used to get by," says the striking redhead, who stands 6-foot-3 and bears a resemblance to Susan Sarandon. She has also had facial feminization surgery and voice surgery, which had minimal results. (While female-to-male transsexuals can thicken their vocal cords with hormones, trans women typically have to undertake voice training as part of their transition process.

McNorgan, who is divorced and has two adult children, retired from the military in 2010. She lives alone and has an amicable relationship with her ex. She and her daughter are in contact, but her son is estranged.

Her trans experience runs the gamut from "happiness to total despair," she says, and is a constant weighing of what she lost and what she gained.

"I lost my son. I lost my mother, who's 87. She said 'I'll just remember you as the son I had.' We had a loving relationship. It hurts," says McNorgan, tearing up. "I've gained a lot of sanity. I've also gained a peacefulness and happiness. And I gained a vagina."

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Gender dysphoria is relatively rare. Approximately one in 11,000 men (0.009%) and one in 30,000 women (0.003%) seek treatment for it at specialized clinics, according to the Canadian Psychological Association.

However, experts admit these numbers are likely significant underestimations since many people with the condition don't seek treatment. This is likely due, at least in part, to the ignorance and the stigma associated with any gender variation.

Two years ago, Strong, who is divorced with two adult children, was fired from her 15-year job as manager at a local photo shop after coming out as a trans woman, despite having sent her employer a letter of explanation, in which she offered to take a position in the lab or otherwise remove herself from the front lines. She filed a human rights complaint.

"I got a few extra thousand dollars (severance) out of it, and a letter of apology saying 'We handled the situation poorly,'" says Strong, who is now happily employed at a competing photo shop.

The theme of this year's annual Canadian Professional Association for Transgender Health (CPATH) conference, which drew about 200 care providers from across the country to Winnipeg in September, was Shifting Paradigms: Breaking With Pathology, Affirming Gender Diversity.

It signifies a pivotal time in the history of the transgender person, says Frances, an advocate who facilitates a transgender support group at the Rainbow Resource Centre.

Canada's transgender community, long plagued by discrimination and bureaucratic obstacles, is celebrating a series of small but significant victories.

This spring, Manitoba's Human Rights Code was changed to extend protection against discrimination to gender identity.

Around the same time, Montreal's Concordia University became only the second university in the country to allow transgender students to use their chosen name in class and on their ID.

And just this week, Ontario became the first jurisdiction in Canada to allow transgender people to change the gender on their birth certificates without sex-reassignment surgery.

Another victory celebrated at the CPATH conference is the revised Standards of Care (SOC) issued by the World Professional Association for Transgender Health (WPATH). It's the first revision since 2001 for these non-binding but internationally recognized protocols, which are used by health-care professionals to guide their work with transgender people

The new standards acknowledge gender dysphoria may be classified as a mental disorder in order to facilitate access to health care, however "transgender, transsexual, and gender non-conforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available."

"Up until now, we were considered mentally ill for the rest of our lives," says Frances. "For the transgender community, this is the same kind of pivotal point as the homosexuals reached in 1973 when homosexuality was delisted as a mental disorder."

A major distinction, however, is that the gay-lesbian movement has never had to solicit the health-care system to the extent that trans people have to, says clinical psychologist and CPATH president Francoise Susset.

"This isn't just a fight for rights and respect and an end to violence and discrimination, it's also a fight for access to the services that are absolutely essential in the lives of trans folks," says the Montreal-based therapist, who has worked with Quebec's transsexual community for 20 years.

During her address, Susset told the conference Manitoba could be a model for trans care in Canada, and that the rest of the country is "a little envious."

In British Columbia, for example, only one transgender clinic serves the province's entire population of 4.6 million.

There was nothing in Manitoba catering specifically to transgender health until 2010, when the Trans Health Klinic opened in Winnipeg in the Klinic Community Health Centre on Portage Avenue. It has an annual budget of $125,000 and a waiting list of about six months. About 150 clients have been processed through intake since the doors opened.

"We're probably seeing about three-quarters of the trans people in Winnipeg," says Dr. Ian Whetter, one of three family physicians at the clinic. There is a doctor available Fridays only.

"I think there's a whole segment of the population that we're missing, partly because of our location." First nations trans women, including sex workers, living mostly in the North End are likely among that group, he says.

"Then there's probably a population of people who either haven't figured out where they are on the trans spectrum yet or who don't even know that we exist."

(Winnipeg clinical psychologist Jule Henderson, who does the mandatory assessments required for hormone therapy or sex-change surgery, has seen a dozen people with gender-identity issues in the past two months.)

The Trans Health Klinic's waiting list, currently at around 20 names, has been as long as 50, says executive director Lori Johnson. She points out that the scope of the province's trans population was not known when the clinic was first established.

Now that it is, the clinic's $125,000 annual budget would have to at least triple, she says, in order for it to fully meet its needs.

"The primary pressure is access," Johnson, a long-time nurse, says. "Our job at Klinic at this point in time is to provide health services to people in their process of transitioning. Something we are very concerned about is the fact that we are not able to provide full primary care services to members of this community -- primary care being all the other things anyone goes to a doctor for, that are really unrelated to being trans."

Johnson acknowledges a part of the problem is a lack of "culturally sensitive, competent" family physicians across the province.

Manitoba isn't alone in that.

"We have provinces where we have zero physicians identified," says Susset.

Most care providers aren't connected to the trans community, she says, so they don't know that the year preceding access to hormones or any kind of physical transformative care is the period when trans people are most at risk of suicide.

"We're talking an almost 50 per cent suicide ideation rate and people are on waiting lists to see a doctor for a hormone prescription," Susset says.

Whetter, 35, who started working with the trans community because he had friends who transitioned when he was living in Montreal, says there's nothing in the basic medical training about dealing with transsexual issues and so many doctors are leery of using hormones in that context.

But it's no excuse, he says, because the care provision is "remarkably straightforward" and there are all sorts of protocols that make it easy to start a person on hormone therapy.

"Managing diabetes is probably more complicated than offering people trans health care," Whetter says. "This treatment is not cosmetic. It's life-affirming and in some cases, life-saving."

-- with file from Canadian Press

carolin.vesely@freepress.mb.ca