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"Kim, the doctor is ready to see you now." I stood up, smoothed down my skirt, and adjusted my still-too-short hair. I arranged my schoolbooks in my backpack, and then followed the receptionist into the hallway and down the carpeted corridor lined with offices and examining rooms. I had lost track of how many times I had been to Highland Park clinic over the past year. Of course, I could figure it out from my diary. When I got out of the hospital I was encouraged to keep a journal and track both my medical progress and my emotional state. I bought a blank book suitable for a typical girl's diary, but the entries have not been fairy-tale pretty. Highland Clinic is a modern place, located in an office park near the hospital, and contains specialties ranging from anatomy to zoology. Well, not really, but both the reconstructive surgery and adolescent psychology departments are here on different floors. Despite trying to be calm, I could still feel tension as we walked. My care team had brought in an outside consultant, and I was sure this was related to the controversy about treatment plans. Everyone agreed how to repair my battered body, but my mental and emotional state challenged the doctors. Was this shrink going to be like Dr. Glenwood? He was smart, but always aloof and impersonal, helpful but unsympathetic. Glenwood seemed to be my biggest obstacle. He occasionally remarked that what I needed was a big dose of testosterone, nothing more. That never sounded very professional to me. The receptionist directed me into a small, sparsely furnished office, nodded toward the doctor, and closed the door as she left. "Good morning. I am Dr. Charlene Olsen from San Francisco. I will be reviewing your history, diagnosis, and treatment plan with you today. Please, be seated." Dr. Olsen was a tall, solidly built woman. Heavier than average, but definitely not fat. She wore a crisp, white blouse, tan slacks, and practical low-heel shoes. She looked more like a Phys Ed teacher than like a psychologist. I noticed she had put a few personal touches onto the desk. There was a picture of her with a crowd of friends hiking up a steep mountain trail. I wonder what message that was supposed to carry? I nervously eased myself down into the chair. I knew the drill. First a few minutes of casual conversation to lower barriers, then 50 minutes of increasingly focused and emotionally charged questions, followed by a summary quickly typed into the computer to end within the scheduled hour appointment. Each doctor was different, but all showed genuine concern and seemed to love their work. Maybe I could eventually major in psychology myself. I think I would be good at it after all the time I have spent being questioned by docs. "I see in your chart several forms of your name, may I call you Kim?" "That's what I use mostly," I replied with a bit of nervousness. To make a proper impression I needed to keep myself under control, not break down crying, and get my message across. "Are you comfortable? There is a glass of water on the table if you need it." "Yes"... "OK." ... "No sudden change." ... "Yes, school is going well." Dr. Olsen was going through all the standard opening chit-chat, and I was answering on autopilot. Darn! That is how they catch you off guard. Need to pay attention and be careful with my answers. I wanted to show her I was mature enough to make my choices. I knew what I needed. I had told the doctors time and again, but always had to revisit the same questions. "According to the chart your full name is Kimball Leroy Smith." "Was - those names were from ancestors on my father's side. My last name has now been officially changed to my mother's maiden name, Young." I tried to answer in a calm, matter-of-fact voice, but mentioning my father immediately brought in bad memories. "As you likely were told, I have been brought in as an external consultant. Your caregiver team felt they needed an independent psychological review. You are twelve, almost thirteen. That is a difficult and confusing time of life for anyone. It is especially difficult for someone with your situation. What has been discussed is a big step and is rarely taken with someone as young as you. However, given your extreme circumstances there has been strong support for your expressed wishes. Since I am a specialist in cases like yours, the Highland Clinic doctors convinced your insurance company to fly me in to do a comprehensive review and evaluation. I have had time to read your entire chart." Entire chart? I wonder how long it is? All the interviews, counseling sessions, questionnaires from the psychologists; I wonder if she looked at the medical and surgical parts too? No, concentrate on what she is saying. Don't daydream. "I have read all the psychological clinic's documentation, and have also looked at the charts from the surgeons, the radiologists, and the physical therapists. The social worker and police reports have also been provided." Gosh, she really has been learning about me. What is she going to be looking for during this appointment? "Today, I want to review some key areas with you. I will evaluate your emotional responses to the past events, and your understanding of your future options. Everyone at Highland clinic wants to be sure that any decision is based on your own free choice with full understanding. We need to be sure that your often-repeated request is not based on bad motives or unrealistic expectations, or because you are being pressured by anyone." Wow. This is the first time any of the mental health staff had talked to me in such a grown-up way, She even told me up front what the questioning would be about. Usually I have had to guess after the fact, and maybe do some web searching once I got home. "There has been a concern that you may be overly influenced by your mother. For this reason we requested that she drop you off at the clinic two hours before your appointment and not return until noon. This allowed you to sit in the green room and have some quiet time to think. I assure you that you are safe here. You can tell me anything. If your mother or anyone else is inappropriately trying to influence you or force you to do something against your will I will immediately call the Child Welfare office and request you be placed back under protection. Do you understand you are free to speak your mind?" "I understand. I have said before, being a girl is what I want." Keep calm. Answer sincerely, but with a reasoned tone. "I know what I am, and should be." Now I know what the time in the fish bowl was about today. I had been stuck in that room before, and had figured out that the plastic domes on the ceiling were video cameras. Today, since I knew I was being watched, I sat down gracefully on the couch smoothing out my skirt beneath me, then spent a little time thumbing through the table magazines like Seventeen and Cosmo Girl before starting my homework. I had learned on the web that this type of room is widely used to evaluate patients' actions when they don't think they are being watched (or are not smart enough to figure out the psychologists' games). There must be some ethics issues involved with this kind of sneaky observation. Stop, focus on what she is saying. Dr. Olsen leaned forward and looked right at me. "To carry out my professional duties I unfortunately have to evaluate how you feel now about the events that sent your father to prison and brought you here to Highland Clinic. Tell me about your relationship with your father, and why you think you were so severely beaten?" Here it goes again I thought as a chill went up my spine. Doctors and police investigators were endlessly trying to talk me through his attack and my recovery. When these interviews first started I would break down into tears as soon as I started talking. Drugs saved me when I first arrived at the hospital. Narcotics softened the physical pain and tranquilizers controlled the anxiety and fears. Body and mind healed gradually, and I was able to play a more active role in the recovery process. The therapists helped me deal with the events, and think about them from a distance. The therapy also helped me come to grips with my inner self and use precise clinical terms to describe my condition. Today, I just need to calmly and rationally state the facts and my future goals, and convince this new doctor that what I had been telling all the others has been true. "A year ago I wouldn't have given this answer, but now I think my father may have been emotionally unstable, not evil. He never knew how to deal with me. Ever since I can remember I considered myself a girl. I wanted to wear girl clothes, play with girl toys, and have other girls as friends. Father kept pushing me to act like a tough boy, and screamed when I did not. We had arguments before about my girl interests, and they usually ended with him shouting things like 'sissy' and 'queer,' so loud that the neighbors could hear. Often he slapped me or pulled my hair. But, on the day he beat me he must have completely lost control of himself." "Please tell me about previous times your father responded violently to your acting like a girl. I need to understand your feelings about your earlier years - do you feel hostility, guilt, confusion? Specifically tell me about the doll incident, here in your chart, that took place when you were in first grade." "Leslie had been my best friend since kindergarten. She knew about my interests, and gave me one of her old dolls. I would play with it after school, but Mom always insisted I hide it before Father came home. One day I was playing later than usual. I was playing 'mommy' to my baby. I had unbuttoned my shirt part way, and was holding my doll against my breast, like I was nursing. You know, the other doctors always seem to find this story important, somehow. "Anyway, my father came home and saw me. He grabbed the doll, slammed it into the floor, then he started slapping me. Mother screamed at him to stop before he hurt me. He kept shouting 'I never want to see you pretending to be a girl in this house again.' I never forgot those words." "Did your mother seek help after this incident? "We scheduled a family conference with Bishop Rulon Grant. Bishop is what congregation leaders are called in the Mormon Church. I remember him as an overweight but dignified gentleman who was uncomfortable with his church calling. While we talked he just stared at the ceiling. Eventually he opened the black leather-bound books on his desk and started quoting. 'The Lord has commanded Honor thy FATHER and thy mother. Genesis 1:27 says MALE and female He created them. Deuteronomy 22:5 tells us, a man should not put on things pertaining to woman for it is an ABOMINATION.' On and on he went, and I became more confused. Finally he asked us to pray together that Heavenly Father would free me from my bizarre affliction. That's what he called it. The only thing he said to my father was a reminder to heed the word of wisdom and refrain from alcohol. Nothing about hitting me. "It was a terrible day, and for years after I was angry, depressed and afraid that I was a hopeless sinner." "How do you feel now about what the ... the bishop told you." "In the last year Mom and I have been going to a new church, a totally different kind of church. They call themselves a 'welcoming congregation.' That means that they accept everyone no matter what their gender identity or sexual orientation. It says so right in their new members' pamphlet! Everyone at South Church goes out of their way to make me feel comfortable about who I am. Mom and I have had long talks with our minister, Reverend Dennis Parker. He tells me that churches read scripture in different ways. Some give black and white answers based on words written long ago, but to find truth we have to use our gift of reason. Reverend Parker keeps saying that everyone needs to find spiritual answers that are right for them self, and that I am a good person whether I am a boy or a girl. So, I no longer feel I am a sinner - God made me who I am. Reverend Parker has given me a lot of books to read, my favorite is called 'The LGBT Teenagers' Guide to Accepting Yourself.' Dr. Olsen, I am no longer confused, and I do not let anyone make me feel guilty about being what I am." "You seem to have found a source of spiritual comfort and reconciliation. The unhelpful answers your bishop gave are a common problem in denominations that chose clergy based on religious fervor, but do not require training in family counseling. Do you want to know why I specifically brought up the incident of your play-nursing a baby?" "Yes, if it will help." She claims to have read my chart so she has a lot to choose from. Why this incident? I better figure out what she is thinking. "You understand that even with the best modern medicine you can never get pregnant and become a real mother?" "Yes, but girls like me can adopt or help raise our partner's children." "True." "And Dr. Siegel, the endocrinologist, told me that under the right circumstances it is possible to induce lactation with hormones. So, maybe I really can nurse someday." "You seem to know a lot of big words for your age." "I read a lot, talk to adults a lot, and listen carefully. I get top grades in English and science too." "Yes, I have noted your exceptional academic record. Let's get back to the events that have caused you so much pain." "OK, but I rather talk about my future." "I need to be sure you are at peace with your past. What you are asking for is a life-changing procedure. Do you understand?" "I guess... yes, of course." I was right about this visit. Dr. Olsen was going to have a big say in what gender therapy I would be allowed before I turned eighteen. Need to keep focusing on the questions and answer carefully. No more indecisive 'I guess so' answers. "After talking with Bishop Grant, did you continue to dress up and pretend to be a girl?" "For a year or so I while I tried to be a boy, but it didn't feel right. I kept dreaming of how wonderful it would be if I could live as a girl. I often visited Ms. Stewart next door. She was like a grandmother to all the kids in the neighborhood, and she always listened to me. At first it seemed awkward talking to her about right and wrong because she did not belong to our church. Bit by bit she pried out my story, and to my amazement she was not upset. She was understanding and supportive. She even she started to invite Mom over to talk about me without Father being around. She told us about the Unitarian church and said Reverend Dennis Parker would be a good source of advice. At the time Mom did't want to talk about it with anyone but Bishop Burton." "What happened then?" "I kept talking about wanting to spend time as a girl, and Ms. Stewart suggested a solution. I would dress up, but only at her house. She offered to provide a place where I could store my girl clothes and other stuff. She even arranged odd jobs for me so I could earn some money to pay for my favorite things." "Wasn't that disobeying your father? How did you deal with that issue then, and what do you think about your actions now?" "What he said was 'I never want to see you pretending to be a girl in THIS house again' and I was strictly following those orders. I was dressing as a girl, but in another house." "Kim, have you ever heard the term 'Jesuitical reasoning' or something similar?" That question got me. What did the term mean, and how did it apply to me? This was one time I would have to admit uncertainty. "No, I don't think so." Quick, say something more. "Does it have anything to do with trying to justify your actions?" "Yes, that is part of it. The Jesuits are a Roman Catholic religious order renowned for their intellect and their intense faith. Most Jesuits are extremely well educated. But they have often been unpopular, and they have their critics. The word "Jesuitical" has come to mean a form of argument designed not to seek the truth, but to make a case for a predetermined conclusion. Jesuitical reasoning can be aggressive and clever, and at times their arguments are cunningly equivocal. They would argue that it is not a lie to say something so ambiguous that the listener is certain to misinterpret the words." I could see where she was leading. "Reverend Parker calls himself a humanist and says similar things. I think both Jesuits and humanists would agree that choosing the lesser evil is an acceptable way out of a moral dilemma, and that is what I did by dressing up only at Ms. Stewart's." Dr. Olsen sat back looking surprised. "You have an amazing understanding of ethics, Kim." The surprised attitude was replaced by a well-practiced 'concerned doctor' manner. "We need to continue exploring your thoughts about what your father did. Please describe the events on the day you were beaten, and how you now feel about about those events." "It was early evening. Mom and I expected Father to be gone on a work trip until late the next day. He often traveled for his construction business. I had left a note in the kitchen telling Mom that I was over at Ms. Stewart's until dinnertime. I was sitting in her living room playing the piano. I was wearing one of my favorite dresses, open toed sandals, and a little makeup. This was one of my girl outfits that stayed at her house. That evening, I imagined was a beautiful girl giving a recital for her friends. Yes it was deception, but deep inside it seemed right to me at the time. Since then I have talked about my behavior with my social workers and therapists and with Reverend Parker. To answer your question, no, I do not feel guilty. I was being myself in a way that did not hurt others. I have been told that what I was expressing is, ... is called transgender behavior." "That is a very clinical word. We can talk more about transgender later. For now, keep telling me what happened." Don't seem impatient I reminded myself. Tell her the truth, and be convincing. "Anyway, I was playing, harming no one, and feeling really self confidant. Suddenly Father burst through the door. His fancy sports car had broken down on the highway; he had waited hours for a tow truck; missed his business flight; and finally had to get a work buddy to give him a ride. Since the trip was ruined anyway he had persuaded his buddy to stop for a few drinks on the way home. I understand now that he was upset about the events of the day. I know he was drunk when he got home and saw my note in the kitchen. I also know that none of his actions were my fault. "When he looked thorough the front window and saw me dressed as a girl at the piano he started screaming. He burst into the living room, grabbed my sheet music and tore it in half, then he grabbed me by the hair. He dragged me out of Ms. Stewarts's house and into our garage. He picked me up and tossed me into the covered shell on the back his work pickup truck and locked me in. I was lying on top of his construction equipment crying as he screeched out of the driveway and headed to his shop at the edge of town. I had never seen him act so violent. "When he got to the shop he jerked open the tailgate and ... and dragged out. He tore at my dress as he ... shoved me into the shop." I was unable to keep my voice calm. Keep control; just tell the truth to the doctor. "Please, go on. I know this is hard, but it is important for you to be able to talk about it. You fully recover mentally only after you are able to see your trauma from a distance, and this is what I must assess." "He pulled off his belt, the one with a big brass buckle, and started to beat me. He kept shouting obscenities and hitting. The buckle caught my face and tore a deep gash. The blood made him angrier and he slammed me down onto the floor and started kicking. "From what I have heard during the court sessions I must have lost consciousness from the blows to my head. When I came to he was gone. I knew he had tried to kill me, and I needed help. I bandaged my face with some shop rags, then headed along a back alley toward a gas station a few blocks away. "As I stumbled out of the darkness the store clerk gasped at my appearance. 'Help,' I screamed, 'Please, call the police.' I hid myself in the womens' restroom, locking the door. "After what seemed a long while I heard a siren followed by a knock and an authoritative voice. ' Deputy Frank, Sheriff's Department. Please come out. You are safe now.' Finally, I knew I was going to live." Tears started filling my eyes, and I had to stop. "That's all right. Let yourself cry, it is OK to be upset." Doctor Olsen handed me a box of tissue and let me regain my composure. "What happened is traumatic, and even an adult would have trouble recalling those events without being flooded with emotions. For this to happen to a child is even worse. You have shown great maturity in what you have told me. Take some water, and I will wait until you are ready before we go on. I pulled myself together. "May we continue now? We don't need to talk anymore about that terrible day. You are ready to move on. Tell me about your recovery afterward." "When the ambulance arrived the medics focused on my physical injuries and rushed me to the hospital. I was taken to surgery, and given some drugs that put me to sleep. The next afternoon a social worker came in and started talking calmly and compassionately. She told me that I had been placed in State custody until a judge could hold a hearing. I asked about Mom, and was told she knew where I was, but I could not see her right then. I really needed her. I spent the rest of the day sleeping under the effect of the pills the nurses kept giving me. "The next day the social worker returned with a wonderful surprise, Mom was following her. A huge bruise covered her face, but neither of us cared. We were back together. The judge had determined that she was also a victim of my father's violence, and had given her custody of me, subject to court oversight. Mom told me Father was in jail and could not hurt me. "During the week I was in the hospital everyone was professional and concerned. They focused on what was best for me, and were totally understanding. Looking back, I now realize that no one said anything about my being a boy who arrived in a torn dress and panties. They even gave me choice of what style hospital gown I wanted. The bright yellow one with flowers and butterflies made me feel better. "Since I got out of the hospital I have been treated mainly here at Highland Clinic. My primary care doctor, the plastic surgeons, and the psychologists are all here. Everyone has been wonderful to me. The worst is past, but now I need to heal completely," "Heal completely?" "I need more reconstructive surgery on my face. I need more counseling to control the nightmares that keep coming back." Mustering all my sincerity I continued. "And, I need medical help to grow up to be the girl I was meant to be." "I know that is what you most want to talk about. But first, let me ask about the situation with your father now." "Mother got a permanent restraining order keeping him away from us. Since then she divorced him, and he is now in state prison. He pleaded guilt to one charge of felony child abuse. I don't think this plea was based on remorse, because he knew the prosecutor was getting ready to charge him with attempted murder." "Do you ever want to see him again?" "He is the only father I will ever have, but I would not want to see him unless he accepts me for what I hope to become. Even then I would want a guard present." "That is reasonable. Do you forgive him?" "Reverend Parker talks to me a lot about forgiveness. I don't hate my father, and I can accept that there is a fine line between mental illness and criminal intent. On the other hand, he made the choice to become drunk that day, and has responsibility for what happened as a result. I do feel sorry for him, though. If I ever become totally sure that he was mentally ill when he beat me, then I would say yes, I forgive him. Something bad must be in his mind. How could any parent act like he did?' "Again, you have achived mature acceptance, and this will help you move on. Is there anything else you want to tell me?" I glanced at the wall clock. We were already past the normal appointment duration and she was still asking questions. "We still have not talked about Dr. Siegel and my other treatments." "I have looked over all the material in you chart. I think the conclusions are obvious." What does that mean? My heart was racing. What was 'obvious' to Doctor Glenwood would be a disaster for me. So far, Doctor Olsen had given no hints of her intended recommendations. I knew that whatever was said next would seal my fate, at least as long as I was being treated at Highland. She was again typing furiously into the computer. I told you my story, so now please help me, I repeated to myself as I waited. Finally, she looked up. "Let me give you a summary. I believe that you are sufficiently mature and rational to make a major decision about your future. Although the physical and mental trauma are still healing, your desires are based on sincere feelings that predate your father's violence. Your motivations are not a result of a desire for vengence or a result of external influence. I fully concur with the psychological and medical team here at Highland Clinic ..." Please, get to the point. Why do you keep talking around the real issue, I thought impatiently. " ... and specifically concur with the diagnosis code 302.6 Gender Identity Disorder in Children. You have shown since early childhood a persistent and intense distress about being male and a desire to be female. I concur with the recommendation of endocrinologist Dr. Siegel and of the Highland Clinic psychologists that you begin hormone treatment immediately..." Finally! Keep focused and listen. "... A combination of puberty blockers and a low dose of female hormones will keep your body from entering male puberty as it would otherwise. After a year or so Dr. Siegel will adjust your doses and allow you to develop more completely into female puberty. As you know, the surgery generally has to wait until eighteen, but there can be exceptions. "I am so confident of your eventual outcome that I am recommending a minor exception right now." "What kind of exception?" "Since you will being undergoing surgery soon to reshape the facial bones damaged in the attack and to remove the scars left after your initial emergency treatment, I think the surgeons should take advantage of the opportunity. You have barely started to develop masculine facial features, but transgendered girls need all the help they can get. I am recommending that facial feminization, nose, chin, and forehead reshaping, be considered a medically appropriate treatment for you, and should be included as part of your post-injury facial reconstruction. Seeing a pretty, feminine face in the mirror each day will boost your self-confidence, although you hardly need that. More importantly, presenting a female face will help your socialization while you are awaiting gender affirmation surgery. Affirmation is the term I prefer - the goal is to affirm what your really are, not to reassign you to something else." Dr. Olsen began arranging the papers on her desk. I started to get up, but she indicated that I should wait. "The appointment is officially over, but since I am a visiting consultant I do not have to rush to my next patient. We can talk off the record for a few minutes, then I will take you out to the reception room. Your mother should be there by now, but she can wait. There are some important things I want to share with you. "First, let's talk about all the tests in your chart. I strongly disapprove of my collegues who force tests on their patients then withold the results. Unethical in my mind! So, I will share with you. Your intelligence tests show unusual understanding, and personality profiles show maturity several years beyond normal for your age. The psychological tests you have been given assess many aspects of both mental health and personality. Here are your MMPI-A test scores..." I was amazed. This was the first time any doctor was so open with me about what all the different medical, psychological, and personality tests showed. Some doctors, especially certain pediatricians, assume everyone they treat is a baby, and talk accordingly. I moved around so I could see the computer screen. She seemed OK with my looking. "...the adolescent test version of the widely used Minnesota Multiphasic Personality Inventory. Scale 5 measures masculinity/femininity, and your score was solidly in the feminine range. The MMPI also assesses clinical pathologies like hypochondria, depression, and paranoia. You have shown marvelous recovery, and despite what happened to you, all these scores are tending into the normal-healthy range. You also scored very feminine on the California Psychological Inventory, and you have favorable scores on CPI factors like self-acceptance and empathy. Of course, I am skeptical of all these gender self-image tests. They are based stereotypical gender roles, and the tests were developed long before our current understanding of transgenderism or the social changes brought about by the feminist movement." Her voice hushed as she turned toward me. "You are mature enough to know about the controversy here at Highland. One doctor, unnamed - but you can guess - is philosophically opposed to gender reassignment under any circumstances, and nothing will ever convince him. This led to an impasse, and the doctors agreed to bring in an outside consultant. When he heard I had been selected, this obstructionist signed himself off of your case. That way he will never have to agree. But, since his expertise is crime victim therapy, and because he has admitted to having no training in gender issues, he very professionally agreed not to be a roadblock." What a relief. My tormentor, Dr. Glenwood, is finally gone. "Now, let's look to your future. I see in your chart that you have considered social work or psychology as a career. You have excellent science grades and if you keep up the hard schoolwork for another dozen years, yes I know that sounds like forever at your age, you could get through a doctoral-level program. Please think about a career in psychology. My profession needs clinicians with real-life experience that will help them relate to their patients. "Too much of current gender care has been based on old white men talking to each other at medical conferences. Abstractions and quantitative outcome assessments are important, but so is first-hand knowledge. You have exceptional maturity and would be an excellent therapist for both transgender children and crime victims. Think about it. "Let me also tell you about myself. I told you my name is Charlene. Would you believe my high school year book shows Charles Olsen?" Awesome. Another transgender person! I had been so involved in presenting my own case that I never though much about this doctor herself. "See the picture on my desk? After becoming a woman I continued my interests in active outdoor sports. The physical activity is good for mind and body. Have you heard that before? Of course you have. Continue with any sports or physical activities you enjoy. If it was something that Kimball was good at, then Kimberly will be good at it too. If a coach or teammate thinks you have an unfair advantage because you still have boy stuff between your legs - I don't have to use medical terms once the appointment is over - just send me an email. I will send them back a professional statement on office letterhead with a clear, supportive message. Here is my card. Girls like you have a right to participate in sports. "Many psychologists see them selves as gatekeepers. I disagree. I went though years of anguish; and this was at a time when attitudes were not nearly as progressive as now. I know the kind of frustration you have been through, including today. Being asked the same questions again and again is not enjoyable for you, or really necessary. I apologize, but I had to do my job. However, I believe that once the diagnosis is clear those on the care team need to become facilitators, not obstructionists. "You have a marvelous future ahead of you. Good luck, young lady." I related the wonderful news to Mom the moment we were in the privacy of her car. I knew better than to shout out a diagnosis in the reception area. Patient privacy is important, even when it is your own. As we headed home I daydreamed about a bronze nameplate on my office desk, "Dr. Kimberly Young, Clinical Psychologist." Trying out for the girls' bicycle racing team seemed like a good idea too.