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For Caitlyn, Coming Out Is Only the Beginning


Transgender people face discrimination and mental health risks, but society can ease their path.

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By Jeffrey Lieberman and Andrew Solomon

“My whole life has been getting me ready for this,” said Bruce Jenner in an exclusive televised interview with Diane Sawyer about his decision to live as a woman. The revelation by the Olympic athlete-turned-reality TV star that he is in the beginning stages of transitioning has elicited strong reactions from supporters and detractors alike. While hundreds of thousands of Americans are transgender, the emergence of a celebrity following this path continues to be the event around which a broader conversation crystallizes.

While many have remarked that this seems in part to be an orchestrated publicity stunt from someone addicted to the spotlight, it is also an opportunity to raise national consciousness about the subtleties of gender identity and to rein in the stigma that continues to blight the lives of members of the trans community. Ultimately, it may help to liberate into pride the many transgender people who have lived for decades in the shadows of guilt, shame and prejudice.

For a majority of the transgender population, daily discrimination is the painful reality, an unfortunate byproduct of the general population’s confusion about the very concept of variant gender identity. Trans people face widespread loss of employment, homelessness, expulsion from school, high rates of sexual harassment and physical assault, much of which goes unreported, and particularly among trans people of color, a shocking vulnerability to murder. Trans people are routinely denied medical care, housing rights, and police protection. Few trans lives escape such affronts.

Most alarmingly, the susceptibility to suicide attempts and to suicide itself among transgender individuals is frighteningly high. Between 38% and 65% of the transgender population experiences suicidal ideation, according to the National Alliance on Mental Illness (NAMI), and an estimated 41% will attempt suicide over their lifespan. Among transgender youth today, 50% or more will have attempted suicide at least once before their 20th birthday according to horrifying estimates from the Youth Suicide Prevention Program.

While many Americans have become increasingly accepting of variations in sexual orientation and supportive of civil rights for gay people, a deep disconnect remains in place for many between “sexual orientation” and “gender identity”. The best shorthand is that sexual orientation is whom you desire; gender identity is who you are. Attempts to pin down the rate of variants in either category remains troublingly imprecise.

Very little is known about the developmental and biological factors that determine sexuality or gender identity. But the lack of a biological or social model for people’s most deeply held knowledge about themselves should not be the basis for forcing such individuals to continue to live their lives in what they feel is an improper fit.

Over the past several years, trans issues have slowly been introduced into the mainstream. Films such as Transamerica and series such as Transparent and Orange is the New Black have given the trans community greater visibility, ushering in somewhat broader acceptance and understanding of transgender life experiences. Such visibility in popular entertainment can push a society toward tolerance, acceptance, and, perhaps, toward a human embrace of people who have been forced to live at the margins.

In another recently aired TV special, Jenner insisted “The only thing I want out of this is to help people.” While his choice to do so by way of a somewhat sensationalized, highly visible, exclusive interview, paired with a two-part special on a reality TV show — and now, a forthcoming 22-page feature in Vanity Fair through the lens of famed photographer Annie Liebovitz, where Bruce is introduced for the first time publicly as Caitlyn Jenner — may appear self-serving and overproduced, Jenner has nonetheless bravely and usefully shed light on an often stigmatized and too often agonized part of human experience.

Every kind of human variation contains inherent pain (authentic mental illness is painful even when stigma is removed) and socially determined pain (discrimination is what makes the lesbian, gay and bisexual lives painful). Most of what has made the trans experience so difficult is the mockery and violence it attracts.

There is still much work to be done to advance our understanding and embrace of the full spectrum of gender identity.

The medical profession must identify and address the needs of transgender individuals, from both medical and mental health perspectives. Further training, both clinical and academic, is required among medical students and psychiatry professionals as they begin their careers. This should be a part of every medical school curriculum, and training should be available for doctors who have already finished their medical education.

At the end of the day, families must practice patience and express love; employers must learn tolerance and commitment; insurers must adapt to diverse medical needs; politicians must enact new laws to protect civil liberties; and our society must learn to respect and celebrate members of the transgender community.

Dr. Jeffrey Lieberman is chairman of psychiatry at the Columbia University College of Physicians and Surgeons, where Andrew Solomon is professor of medical psychology.