"Are you a man or a woman?"

It seems like a simple question, with an obvious and clear-cut answer.

But for psychotherapists Moonhawk River Stone, of Schenectady, and Arlene Istar Lev, of Albany, complicated responses are at the core of their private practices in transgender care.

The way a person answers the question, ranging from certitude to confusion, holds the key to treatment options.

Both therapists view gender with a wider lens than a binary classification of either male or female. Rather than dealing with black and white distinctions, they work with clients who express themselves in many shades of gray when it comes to gender.

In addition, as part of a newly emerging trend, the therapists are seeing youths at ever-younger ages who have a disconnect between their biological sex and the gender they feel compelled to express.

"It's not a matter of 'I want' to be that gender, but 'I am' that gender," said Stone, who prefers the terms 'gender variant' or 'gender non-conforming' in place of transgender.

Ongoing research suggests that there is a biological component to the transgender experience and scans have shown that the brains of transgender people bear structural differences.

"We don't understand how people get that way, but in my practice I've seen that it tends to run in families and that there is probably some genetic component," said Stone, who has seen more than 300 transgender clients from ages 4 to 75 in the past 20 years. "Gender variance is a very complex issue grounded in physiology and genetics."

Stone speaks from both professional and personal experience. He had been a woman who identified herself as a lesbian before beginning hormone therapy and a transgender transition that included surgery in the late-1990s.

"My story is boringly ordinary," said Stone, who declined to share more of his personal narrative due to professional concerns. "There are some people who say I shouldn't be treating anybody because I'm 'one of them.' People know I have transitioned, but my medical situation is, like everyone else's, a private matter."

Lev has been treating transgender clients locally since 1986. She teaches courses on sexual identity at the University at Albany and Empire College. She's the author of "Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families."

Stone and Lev have been on the forefront of working to change the way transgender people are viewed by the medical establishment. Lev has worked with the World Professional Association of Transgender Health to develop new standards for transgender care. Currently, their clients are diagnosed with a "gender identity disorder" by the American Psychiatric Association's fourth edition Diagnostic and Statistical Manual of Mental Disorders, or DSM, the standard text for the profession.

The DSM's definition includes: "Long-standing and strong identification with another gender" and "long-standing disquiet about the sex assigned or a sense of incongruity in the gender-assigned role of that sex." Stone and Lev are among advocates of reform urging a change to "gender dysphoria" for the fifth edition of the DSM. Words matter greatly to the therapists and both express optimism when it comes to progress on societal attitudes toward transgender issues in the past decade.

"The problem is that even a majority of social workers and therapists know nothing about this issue," Lev said. "We're just beginning to see more therapists seeking out specialized training, which is still hard to find."

There are no solid statistics on how many transgender people live in Capital Region, but their practices suggest there are probably several hundred. Many remain closeted or have not sought care because they do not have health insurance or cannot afford treatment. Nationally, surveys and analysis suggests there are as many as 700,000 transgender individuals who identify themselves as gender variant or have taken active steps to transition to a different gender.

Lev works with transgender clients of all ages, including a number of teenagers. She also runs support groups for parents of young gender non-conforming children. "I work with a lot of middle-aged clients who come in and say they've never told anyone, not even their wife," Lev said. "They are clear they are not gay and have been gender dysphoric their entire lives. They are confused and in pain. But it's much harder for people in their 50s and 60s than it is for people in their teens and 20s to come out as transgender."

Although a substantial majority of transgender patients traditionally go from male to female, Lev is seeing a growing number of female to male clients. "They were born female, they were allowed to be tomboys, they cut their hair short and were pegged as lesbians," she said. "Now, they're finding other available options and they're living as men."

Both Lev and Stone work with parents with young children who are gender dysphoric, such as boys who like to play with Barbie dolls and dress up in girls' clothes.

No longer is the social norm one in which these non-traditional children are kicked out or run away from their parents' house. "Children do better with their parents' support and I do everything I can to keep the family intact," she said. "We want to help these gender dysphoric children have the most healthy adolescence possible."

The therapists' work extends beyond the family to helping school administrators and teachers find ways to make accommodations for gender non-conforming students. They encourage the creation of school environments that are supportive of all children, with less focus on gender differences at school. "It can be something as simple as asking the teachers not to line up boys on one side and girls on the other side and dividing them by last names, A to L and M to Z."

Lev is encouraged by the attitude of school administrators. "I never thought I'd see suburban schools allowing a child to go to school in their affirmed gender," Lev said. "The world is changing in major ways. I never thought I'd see marriage equality in my lifetime!"

Treatment is customized with each of their clients, who range from occasional cross-dressers to fully transitioned transgender people who have undergone gender reassignment surgery.

"I'll use psychodymanic, cognitive behavioral therapy or whichever tool is needed at that moment," Stone said.

Both hormone therapy and psychological counseling has been shown to be more effective the earlier it is started. "The younger the folks start, generally the less complications," Stone said. "Older folks have gathered more troubles and traumas. It's also easier for younger people to disclose their gender variance to family and friends. Teaching disclosing skills to clients is an important part of my work."

Stone's practice currently numbers about 50 clients, who range in age from the oldest at 75 to the youngest at 5. Those seeking treatment include auto mechanics, entrepreneurs, engineers, teachers, attorneys, retail workers and state employees.

"The narrative is similar across all the ages and professions," Stone said. "We are ordinary people with a very big difference."

A distressingly common thread in the narrative is a high level of psychological distress. Among more than 300 clients that Stone has treated, about 40 percent have contemplated or attempted suicide, a forty fold increase over the general population.

"People are told horrible things about themselves, they become despondent, they have no access to care and the situation becomes a crisis," Stone said.

In his career, Stone has had three transgender clients who committed suicide. They were middle-aged and did not come out until late in their lives.

"When people are so despondent, you never know what they're capable of," Stone said. "Suicide takes you totally by surprise. It's a terrible shock for everyone."

Lev and Stone are both quick to offer a more upbeat counterpoint by describing transgender clients who have completed transitions to a different gender and are living happy, well-adjusted lives.

"There are no shortage of trans success stories," she said.

Reach Paul Grondahl at 454-5623 or pgrondahl@timesunion.com.