MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Caitlyn Jenner is bringing star status to transgender issues. Her highly public transition from a former male Olympic athlete to a glamorous woman is prompting new questions about social recognition and civil rights for transgender people. Here to speak about transgender life and challenges, Sharon Beckett of Gender Rights Maryland, Nicole Joseph, a clinical psychologist in private practice.

MS. DIANE REHMBy phone, from Los Angeles, Nick Adams of GLADD and by phone from Philadelphia, Harper Jean Tobin of the National Center for Transgender Equality. I invite you to join us. Call us on 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or Twitter. Thank you all for being with us.

DR. NICOLE JOSEPHHi, Diane. Thanks for having us.

MS. SHARON BRACKETTHi, Diane. Thank you very much.

MR. NICK ADAMSHi, Diane. Thank you.

REHMGood to have you all with us. Nick Adams, I'd like to start with you. Talk about the reaction to Caitlyn Jenner's very high profile debut as a transgender woman.

ADAMSYes. So over the past 60 years, there have been many transgender people who've told their stories in the media, but the amount of interest in Caitlyn Jenner's story and the generally positive reaction she's received does seem new and, frankly, is quite a pleasant surprise.

REHMWhen you say a pleasant surprise, what do you mean?

ADAMSWell, when I -- I have worked at GLADD for 17 years and have worked on transgender issues that entire time and I was involved with the media when Chaz Bono came out and did a media tour just a few years ago. And even then, it was much -- seemed to me, much harder to get the media and the public to understand what being transgender meant and to use the new name and pronoun for Chaz Bono.

ADAMSAnd yet, what I see today is that in most of the media coverage that has happened as a result of Caitlyn telling her story, people have been anxious to want to start using the new name, want to start using the new pronoun and seem to understand much more clearly what it means to be transgender.

REHMSo what do you think the reaction tells us about perhaps society's changing attitudes toward transgender issues?

ADAMSWell, we know from a recent Pew poll that nine out of ten Americans say that they personally know someone who's lesbian, gay or bisexual and we also know that when someone personally knows someone in their life, they're much more open to understanding what that means and to be supportive of equality for a lesbian, gay or bisexual person.

ADAMSNow, studies show that many fewer people personally know someone who's transgender so the way that people are learning about who transgender people are is through the media and transgender people, like Laverne Cox and Janet Mock and Caitlyn Jenner, telling their stories. And so I'm very hopeful that as transgender people tell their stories and media does a better job of reporting those stories, more Americans are gonna feel like, oh, I know someone who's transgender.

ADAMSEven if it's not in my family or school or workplace yet, I feel like I know Caitlyn Jenner and I want to learn more about the issues that transgender people face.

REHMUm-hum. And to you, Sharon Brackett, as a representative board chair of Gender Rights Maryland, not everybody is Caitlyn Jenner. What are some of the biggest challenges that transgender men and women face who are not celebrities?

BRACKETTWell, part of the issue for -- I'm very happy for Caitlyn Jenner first. I'm glad she's realizing her self and expressing herself in a manner that makes her feel good and that's fantastic. But in some respects, she's the exception rather than the rule with respect to trans people. Many trans people do not have the means or access to the sorts of resources that Caitlyn has had.

BRACKETTMany of them don't have as desirable an outcome in their transitions. It's hard. It's a long road. It's a hard journey. And in particular, we had this sort of balkanized perspective on civil rights in our country where, depending on where you live, you may or may not have protections under the law with respect to maintaining your job, keeping your housing, being discriminated in a public place of accommodation and this seems to be variable depending on what city or town you happen to live in or what state you may live in.

REHMAnd to you, Harper Jean Tobin, as director of policy at the National Center for Transgender Equality, give us a sense of the transgender community in this country. What are the trends in regard to the numbers of person who identify themselves as a transgender person? Harper Jean, are you there?

MS. HARPER JEAN TOBINThank you, Diane. And thank you for having me on the show. It's actually difficult to say exactly how many people are transgender in America and there's a simple reason for that, that the major national surveys that we rely on for a great deal of demographic and economic and health data still don't ask about being transgender, don't allow us to count transgender people as a group.

MS. HARPER JEAN TOBINStill, we do have a pretty good idea from state surveys and other research. The Williams Institute at UCLA estimates that about 700,000 adults in the U.S. are transgender. Now, it's somewhere between the populations of D.C. and Alaska, although, of course, we live in every part of the country. And that's only the number of people over 18 who would self-identify in a telephone survey. It doesn't include teens or children of which there must be many thousands more and it doesn't include people who are at a point of exploring and understanding their identity where they might not yet self-identify in a survey as transgender.

MS. HARPER JEAN TOBINSo we're talking about certainly a small part of the population statistically, smaller than the number of people who are gay or lesbian or bisexual, but still a significant part of the population. And we don't think the number of people who are trans is growing because there is a lot of evidence that gender identity may be something that's largely hardwired very early on in life and it may just be part of the human diversity of nature.

MS. HARPER JEAN TOBINBut certainly, transgender people are more visible in society and more people feel able to come out and live their lives in accordance with their identity, even though there are still those barriers that Sharon was just talking about.

REHMAnd to Dr. Nicole Joseph, as a clinical psychologist in private practice, your practice includes transgender adults, children and their families. What are the generalizations you can make about transgender people?

JOSEPHWell, I think it's difficult to make generalizations exactly. They're all individuals so I don't quite see the same person. I'm not sure I can generalize exactly, but what I can tell you is that oftentimes I'll have people come in who may or may not have had experiences where they were questioning gender from the time that they were very young.

JOSEPHAnd then, there are, of course, varying family reactions to that, even among my adults and young adults who I see.

REHMWell, you know, I was going to ask you about that because, of course, Bruce Jenner is 65.

JOSEPHExactly.

REHMHow unusual is that?

JOSEPHWell, you know, not as unusual as you would think. I think -- I have said in the past that coming out as transgender in this day and age is kind of like what it was like to come out as gay in the 1980s. So it's becoming more and more, with media exposure such as Caitlyn Jenner, it's becoming more and more common and more and more understood. And so I think people of various generations who may have felt like this their entire lives are just now starting to embrace some of these thoughts and feelings that they've had.

JOSEPHSo I, in fact, do have patients who come in who are in their 40s and 50s. It's not terribly uncommon. And, of course, the fear is -- and, you know, we can talk about Caitlyn Jenner in terms of how much work she's had down and how successful she has been with her transition, but the fear, especially among older folks, is gosh, I really, if I'm going to make this transition, if I'm going to do this, I really want to make sure I pass. It's very important to them.

REHMInteresting. What sort of help do you try to give family members who are watching this kind of transition? They may need help themselves.

JOSEPHRight. Oftentimes in treatment it is a two-pronged approach. It's not just assessment and providing a supportive environment for patients who are struggling or, you know, questioning their gender identity. It's actually very much so working with families. And oftentimes even very supportive family units will have a grief and loss process that they'll go through, a mourning process.

JOSEPHYou know, even from pregnancy, we conceive of our child as being one gender or another, a very binary concept of gender, if you will. So when, you know, your son comes to you and says, you know what, actually I would like to be your daughter, there can be some feelings of loss there. And I think parents are very much concerned about discrimination in their child's future. They're very much concerned about whether or not their life will be harder in the future.

JOSEPHAnd unfortunately, there is research data to suggest to that there is discrimination and life can be more difficult, including for bullying for children and employment issues for transgender folks as well.

REHMI wonder. We're going to have to take a short break here. When we come back, we'll talk about the experience of moving from one gender to another.

REHMAnd welcome back. We started this program by talking about the transition that Caitlyn Jenner has now made from male to female. She is on the cover of this month's Vanity Fair, looking very attractive and having had facial work, I'm sure being accepted by many. And yet there must have been some great difficulties along the way. I wonder, Sharon Brackett, you began life as a boy. You were a family man, a married man, with two children, two boys, who I'm sure are totally accepting of your transition. Tell us what it was like for you to recognize the difficulty within yourself and how late in life you came to the conclusion that you were a woman.

BRACKETTSo the notion of being a woman for most trans people -- or for trans women registers fairly early in life at some point in time. I know some folks where they were, you know, six or five years old and some in their early teens. And it varies a little bit. But usually what you -- what your sense is, is that something's off. Something's wrong. I don't fit in quite right. Something's unusual about me. And it sometimes takes a little while to sort that out in your own mind. So it's not an instantaneous revelation necessarily. For some people it is but not for everybody.

BRACKETTSo in the back of my mind, from being very young, I had this notion, something's off a little bit here. And then it sort of dawned on me, like, I think, when I was 12, I said, wait a second. I'm not hanging out with the girls. What's going on? And so you go through life and sort of shovel that into the closet because, certainly in those days, to put that sort of knowledge out there, you would have been ridiculed. You possibly could have been put into a mental institution or any number of other things that might have happened.

REHMMm-hmm. Hmm.

BRACKETTAnd so you kind of zip it up and you silence it. And you may walk through life looking for challenges to sort of man-up. Some go into military. Some go into risky professions and try to prove their masculinity. And if I take Caitlyn Jenner as a perfect example of this, Caitlyn went ahead and achieved the height...

REHMWhoa, I should say. Yeah.

BRACKETT...of masculine perfection, as the, you know, gold medalist in the decathlon. And you try to do that in order to sort of create cover, a way to hide. And so many of us do that. We go through life. We marry. We often have children. We're hoping, at any instant in time, that this will go away and it never does. At least this has been my experience and with people that I know. And at some point, you reach some sort of breaking point.

REHMMm-hmm.

BRACKETTThere's either some change in the dynamics of your marriage or your workplace or your life. Or some folks look and just say, wow, the show is half over. I need to do something about this.

REHMHow long were your married?

BRACKETTOver 20 years.

REHMOver 20 years.

BRACKETTYes. Yes.

REHMAnd, at first, how did your family react when you became more honest with them?

BRACKETTWell, prior to being married, I had expressed to my ex that I had an issue. But of course, this was the '80s. There's no Internet. There's no knowledge.

REHMMm-hmm.

BRACKETTI had no support structure. I had just thought it was an impossibility. But I did share it before we were married. So this was -- should not have been great news. But it had sort of put itself in the back room. When I came up to my children, they were -- both of them were immediately accepting and immediately supportive.

REHMHmm.

BRACKETTI would have to say that they've been my biggest supporters. My oldest son, who's now 21 and a senior, College Park, lives with me and has lived with me since his senior year in high school -- lives with me exclusively, very supportive. My younger son absolutely floored me by saying, you know, I don't care who you are, what you are, your gender, your race or whatever.

REHMHmm.

JOSEPHWonderful (unintelligible)

REHMLovely.

BRACKETTYou're still you and I love you.

REHMThat's lovely. Nick Adams, what about you? You moved from being a female to a male. You underwent, I'm sure, a lot of psychological help along the way. Tell us your story.

ADAMSYeah, so when I was born, the doctor did take a look at me and say, it's a girl, and write that down on the birth certificate. But, you know, nobody asked me at the time, how -- what I thought about it. So when I got older, I knew that I did not feel like a girl in any way. I was very uncomfortable. And, you know, I was fortunate because there's a little bit more room in society for girls to be gender nonconforming. So I was a tomboy, right? And that's very cute when you're a tomboy, until you get to a certain age, around junior high or high school, and then it's no longer considered cute and you're supposed to start acting like a girl.

ADAMSSo that was a real struggle for me. And, like Sharon, I was trying to figure all this out before the Internet. And the Internet has really made a huge difference for transgender people...

REHMHuh.

ADAMS...because prior to that, it was extremely difficult to see anything about transgender people either on TV or in films or -- it was hard to find books. It was just like the Dark Ages, literally, of information. So, you know, I was trying to find a word for who I was. And it was actually sort of when the Internet started to get more expansive and easier to use and I could find out information, and that's when I realized, oh, that's -- it's possible...

REHMHmm. Hmm.

ADAMS...for me to actually be the man that I see myself as.

REHMMm-hmm.

ADAMSAnd I think that stories like me and Sharon, we're older -- sorry, Sharon...

BRACKETTThat's quite all right. I'm not offended.

ADAMS...are going to become less common as time goes on. Because now that there is so much more information available, younger and younger people are able to articulate what their identity is and, honestly, are also more likely to find family acceptance. And so, you know, I think the story of trans people transitioning in their 40s and 50s is going to become less and less prominent. And stories of people transitioning in their teenage years or in college is going to become more and more common.

REHMThere's one thing that I'd like to have clarified here, Dr. Joseph, and that is to explain the difference, if you would, between gender identity and sexual orientation.

JOSEPHRight. And I think this is sometimes very much confused among popular society. I think people see individuals who might, quote, unquote, "cross dress," which, again, is kind of a different concept. But they make assumptions about them. Oh, they must be gay or they must be, you know, whatever label, you know, insert whatever label there is. So, yes. So gender identity is very different than sexual orientation. So, in fact, if you are a transgender male to female, let's take Caitlyn Jenner for example, Caitlyn now, she was attracted to, I guess, females. She was married previous -- previously to a female. I guess I don't want to make that assumption. But let's assume that that's the case.

JOSEPHAnd so her sexual orientation may be that she is a lesbian and that she is now a transgender female. It's possible. So within the transgender scope, you can also be heterosexual or homosexual, if that makes sense.

BRACKETTOr asexual.

JOSEPHOr asexual. Exactly. Yes, that's exactly true. Yeah.

REHMAnd tell us what gender dysphoria is.

JOSEPHWell, if I may, let me step back, too, just to talk about sex and gender. So sex is a biological concept. It's the anatomical features that we're born with. Gender is both a social construct as well as an individual identity and a personal identity, right? So when you think about gender dysphoria -- gender dysphoria is the diagnosis that now clinicians, such as myself, use to diagnose individuals who come in for therapy, who might be struggling with the conflict between their born gender and their gender identity.

REHMNick Adams, I know you want to say something.

ADAMSOh, no, actually. Well, I can actually contributed to that a little bit. I'll use myself as an example. So I am a transgender man who transitioned several years ago. And I am attracted to men and have been in a relationship with my partner for the last 14 years. So I am also a gay man. So sometimes it's oversimplified to say that sexual orientation is who you want to fall in love with and go to bed with and gender identity is who you want to go to bed as.

JOSEPHMm-hmm.

ADAMSThat kind of -- if that helps clarify things a little bit.

REHMHarper Jean, do you want to jump in here?

TOBINWell, yes, thank you, Diane. I was thinking about what Sharon and Nick were saying a little bit ago about the sort of generational difference of this. And I think, my own experience, I guess, reflects that. I was a child of the '80s. And I was in college at, I guess we're saying now, the turn of the century. Boy, that feels weird.

TOBINAnd I, you know, at that time, even though things are now where we are now, there was a -- I think, a lot more visibility. I was able to meet other people on my small college campus who were transgender…

REHMHmm.

TOBIN...and was able to maybe not go through some of the as severe or long-standing sense of hiding or of dysphoria as maybe some other people have experienced. You know, I got to a point, in my late adolescence, where I -- I could understand what it meant to be transgender and I could say, oh, yes. Okay. That's me. I definitely, this sense that I've had of being different is that I am a transgender woman and I may be feeling that I'm not -- that I am doing okay in college and in my personal relationships now. But I know that if I don't make this change in my life, to be able to live more authentically, that I can know -- I know that the direction I'm going is of more dysphoria and loneliness and depression.

TOBINAnd I largely was able to avoid that by being able to transition in college in what was, for me, a supportive environment and really start out my adult life and my professional life as a transgender woman. And I, you know, can look now and see younger people at, you know, even back at my own high school or my own hometown in Louisville, Ky., and see, you know, people coming to that point and being able to live authentically at a younger age. And that's really very encouraging.

REHMBut I gather, Harper Jean, even with some psychological support, even with friends around you who are supportive, depression that may even lead to suicide can be part of what you go through.

TOBINWell, that's certainly true. And of course the causes of suicide are complex. It's risky to talk about kind of any one thing, you know, for a group of people or for a particular person, that causes suicide. But we do know that transgender people report much higher rates of having attempted suicide at some point in life -- 41 percent in a national survey that we conducted a few years ago. And, again, the causes are complex. But we know that it's not because transgender people are inherently unhappy or unhealthy and that social stigma and rejection and discrimination and even violence all play a role.

TOBINAnd having those supportive families, supportive schools, supportive communities and access to supportive health care can all help to reduce that risk. But because -- but those high levels of discrimination and stigma...

REHMHmm.

TOBIN...and the rejection that many people still experience probably do play a role in that much higher level of people reporting that they've attempted suicide at some point. And that's something that I think we would hope to see change as society changes. Although, again, the causes in any individual case are very complicated.

REHMAnd you're listening to "The Diane Rehm Show." And speaking on that very plane, Sharon Brackett, what kind of progress have we made in regard to transgender civil rights?

BRACKETTSo there's been actually a fairly decent amount of progress but, as I mentioned before, it's kind of spotty. There are a number of states now that have protections for trans people, both in employment, housing, some states education, some states credit, and of course public accommodation. And I want to stress public accommodation for just a moment because a lot of people think that's your ability to get served in a restaurant or something like that. And it's really much broader than that. It's fair treatment when you get on the bus, when you go to a hospital for medical treatment, when the EMTs show up to take care of you -- all these things fit the category of public accommodation and everyone should be treated fairly and equally.

BRACKETTOne of the good-news points is that there are over 200 municipalities in the United States that have protections like this and that's great. And then, in terms of recent developments -- and I'm sure Harper Jean can speak to this even more -- the EEOC has basically taken the position that discrimination against trans persons in employment is sex discrimination under the Civil Rights Act, Title 7. And there have been a number of cases that have gone before the EEOC and we're winning some of those cases. I think there's still a long way to go with respect to that. But arguably, within the United States, you can make a case that you can't be dismissed in employment for being trans.

REHMBut, Dr. Joseph, what about the status of access to health care?

JOSEPHAnd I think this is a continuing, very difficult issue. Oftentimes, transgender folks are questioning folks who'd like to, perhaps, transition in the future. They do need -- there are guidelines and they need certain things from, for example, therapists or multiple therapists. So oftentimes, individuals are forced to or compelled to go seek therapy and which sometimes they can't afford it. Sometimes insurance won't cover therapy, especially for that type of diagnosis. So it can be very difficult. So access to health care is a continuing issue. And so, I mean, imagine being told, you have to go through these steps to become the person you feel you are and yet you can't afford that.

JOSEPHAnd not to mention the cost of surgery or hormone replacement or other things of that nature, which has also continued to not be covered by insurance.

REHMI gather, though, Medicare does cover surgeries to alter gender since 2014. Well, is that actually the case, Sharon?

BRACKETTSo the -- and, again, I'll defer to Harper Jean on the specifics on this. I know that, I believe, Medicare and Medicaid have been addressing this to some degree. The problem is, is that that sort of knowledge hasn't trickled down into the universe.

JOSEPHMm-hmm.

BRACKETTAnd the other thing to be aware of is, is that most insurances do not cover any trans care whatsoever. There are a number of states that have mandated this. I would be happy to see every state mandate private carrier coverage. In Maryland, we do not have such coverage presently. It is covered if you are a state employee, which was recently the result of some good work from FreeState Legal.

REHMAnd we should say that Medicaid does cover transgender medical care in Oregon, California, Massachusetts, Vermont and the District of Columbia. We'll take a short break here. When we come back, it's time to open the phones for your calls, comments. Stay with us.

REHMAnd as we talk about issues regarding transgender individuals, let's go to Alisha in Fort Lauderdale, Florida. You're on the air.

ALISHAYes. Good morning.

REHMHi.

ALISHAI'm just a little nervous. I'm afraid of my voice being recognized. I've been listening to all the issues. I'm familiar with Harper Jean Tobin. She and I have exchanged emails in the past. The issues that you've been discussing that I've been listening to, I could comment on any one of them.

REHMBut let's hear what you wanted to say. I gather it's in regard to acceptance and work.

ALISHAYes. There's a lot of us who live what we call a stealth life. We would rather be recognized as women rather than as transgender individuals. So, we typically don't talk about it, don't divulge to anybody.

REHMWhat do you think would happen if the people at work, if your bosses, knew you were trans?

ALISHAThey couldn't fire me outright, but they could make life awfully miserable for me, to the point where it would be impossible to work. And I could be forced to resign.

REHMSo, for some people, it's, as Caitlyn Jenner has found, acceptance for others, it may be far more difficult.

JOSEPHAbsolutely. And Alisha's story's not uncommon from what I also hear from clients at my practice, which is coming out at work or the process of transitioning at work is extremely anxiety provoking. And to the point where some people want to avoid it for years and years, even though they feel so much not themselves in their workplace. And I think it's very true. I hear often that the term double life, I'm leading a double life. I'm only male at work now. Or, I'm only female at work now.

JOSEPHAnd you hear this over and over again. So, it's a very common fear and very, very prevalent, unfortunately, still among the trans community.

REHMGo ahead, Sharon.

BRACKETTSo, there's one thing about this that I want to make clear for everybody in their minds. You know, this is a personal choice people make. Some choose not to divulge their being trans or not. But I think it's wise of trans people, today, to take a play, a page out of the playbook from our gay and lesbian peers. Which is, if you're not out and people don't know, and once you're out and people do know, it becomes the new normal. This is a phrase I've used for some time, and in fact, I just recently heard Caitlyn Jenner use the exact same phrase.

BRACKETTIn a promo for her show. So, if you know a trans person, it becomes personal. It becomes not stigmatic. And most of us today can say, I know a gay or lesbian person, personally. So, if you're out there hiding in stealth, you can't make that impression and you can't move the ball forward.

REHMHere is an email from Paul, who says this is a remarkable program today. 20 years ago, this discussion would not be taking place with references to such well known and courageous individuals. The question, actually, has two parts. The legal rights of transgender individuals and how to manage a form of social acceptance. As an openly gay man since my early 20s, he is now 61, I've seen momentous changes in civil rights afforded the LGBT community, but there is still a struggle for the social acceptance of those individuals, which is very different. How do you see that moving, Dr. Joseph?

JOSEPHI definitely see that moving, and I think that the internet and cases like Caitlyn Jenner are definitely helpful. I think in terms of social progress, you know, it's just becoming more and more common. And again, with the dawning of these types of stories, I think it's very helpful for the community. Although, I'll tell you, and I don't, you know, pretend to speak for the transgender community, but my patients really do view high profile media appearances or comings out online, such as Caitlyn Jenner, with really a mixed bag.

JOSEPHThey view it as, you know, very highly positive and yes, wonderful to publicize this and get the word out to other people. And yet, on the other side, they feel a lot of pressure. It's really difficult for everyone to use Caitlyn Jenner as, sort of...

REHMA role model.

JOSEPH...a role model. Right, because, you know, she, her, the resources she had, and I think that Sharon had talked about this previously, the resources she had and the ability for her to do this sort of, you know, butterfly transition where she sort of went into a bit of a seclusion for a while and she was able to transition a little bit more privately. That's not something that many of us have the availability to do.

REHMOf course. Here's an email from Zane in Cleveland Heights, Ohio. And Nick Adams, I'm going to address this to you. Zane says, I think your panelists are being way optimistic that this is the beginning of a new social acceptance. Sure, the more liberal media outlets and celebrities are being supportive, but if you read the online reader comments, on stories connected to Caitlyn's transition, you see many mean spirited and hateful outpourings. Nick Adams.

ADAMSWell, do have a long way to go, in terms of the cultural acceptance of transgender people. I think we are just at the starting point for that. And it's somewhat frustrating, because as I said, I mean, Christine Jorgensen was one of the first transgender women in the United States to become very famous, and that was in 1953. And then, in the 70s, you had Renee Richards about the same time that Caitlyn Jenner was winning the gold medal in the Olympics, Renee Richards was a transgender woman who was fighting for the right to play women's tennis, which she won.

ADAMSAnd in the subsequent years, there have been many, many transgender people who have told their stories. People like Jenny Boylan, people like Chaz Bono. And in the last few years, particularly, we've had incredible, wonderful women like Laverne Cox and Janet Mock who have really stepped up and talked about their experiences as transgender women and particularly transgender women of color. Because all of these social issues that we have talked about today are compounded and amplified if you are a transgender person of color.

ADAMSYou are more likely to live in poverty, more likely to experience discrimination from the police, more likely to experience violence. There have been eight transgender women murdered in the United States since January 17, 2015. And almost all -- all but one of those women was a transgender woman of color. So yes, we absolutely have a long way to go in terms of the general public accepting transgender people and seeing us as full human beings.

ADAMSThat being said, you know, as someone who transitioned nearly 20 years ago, I can definitely see the difference between then and today. We have come a certain way forward. But we definitely still have a long way to go.

REHMHarper Jean, today in the New York Times, there exists the largest editorial I think I've ever seen. And this on transgender individuals within the military. Secretary of Defense, Ashton Carter, when asked about transgender people in the military, which thus far has had a mixed bag. Some military officers accepting it, others blowing the whistle and making sure these individuals are pushed out of the military. Secretary of Defense, Ashton Carter, said, the question is, are they going to be excellent service members? Well, haven't they already? Harper Jean?

TOBINYes. This is one of those issues where there is, I think, a disjuncture between policy and between real life. Because officially in the military, you are not supposed to be able to serve in the military if you're a transgender person. The reality is that we estimate that there's probably over 15,000 people serving currently who are transgender people, many of them serving with distinction. But most of them serving in silence. An increasing number, I think, are coming out and transitioning.

TOBINAnd I think commanders understanding that they are excellent service members, that there's no real, no reason to discard the value that they add to their units, are trying to keep them in. But the official policy is to push them out, and that's something that I expect just has to change. Because it's, you know, it's at odds with what we see going on in the civilian work force, where, as Sharon pointed out earlier, people are increasingly protected.

REHMAll right. Let's go to Louisville, Kentucky. Hi there, Cynthia. You're on the air.

CYNTHIAHello. My question is kind of a two parter. One is, is there any chromosomal testing that's ever appropriate for children that might reveal gender issues that could prevent pain or anguish growing up. Certainly, if someone like that was revealed for my son, I would say, let's be who you are. Let's do it. And I also was curious if anybody worked with their parents to choose their new name, because I would feel sad if my son decided he was my daughter or has been my daughter all along and I didn't know.

REHMAll right. What about those chromosomal tests, Sharon?

BRACKETTWell, one thing. First off, let me preface this. I am not a medical professional, so I'm not offering any advice or consideration here, but I have some good friends who are. And the notion that somehow there's a test for trans. You know, presently, we don't have such a test. It's not available. Whether there is some indicator in chromosomes or not of this is an unknown presently. I don't know that we will or won't have someday, but the fact that an individual believes that there is something about themselves that they're not able to express is usually sufficient.

BRACKETTYou don't need proof, basically. What you need to do is convince others of this fact and support you.

REHMCan you add to that, Dr. Joseph?

JOSEPHWell, I'm also not a medical professional, but as a psychological professional, my understanding is that the causes or the ideology of transgender, you know, is, are largely unknown. So, I think this is still very much under review. I think there is some research and some studies that talk about, you know, genetic and environmental influences, as well as potentially questions about hormone exposure during pregnancy and in vitro as well.

REHMInteresting. Nick, what about the name factor? Did anyone in your family have a problem?

ADAMSNo, I was old enough that I -- when I transitioned, that I could choose my own name, and I don't think my parents had an issue with that. But it is sometimes an issue with youth. I work in Los Angeles with a large support group for families with trans and gender non-conforming kids. And that is something that comes up sometimes, especially when the child is younger, that the parents would like to have a say. And the child, you know, would like to pick their own. So...

REHMAnd you're listening to The Diane Rehm Show. Did you want to add to that, Dr. Joseph?

JOSEPHJust to say that anecdotally, the patients or the clients who I've had generally like to pick their own name, but they will sort of ask parents, you know, call me this, please. And then also, multiple reminders, and we all struggle with this from time to time, about pronouns as well.

REHMYes. And pronouns are something that we've got to get used to. Harper Lee, there's also a battle over use of the bathrooms. Talk about that, if you would.

TOBINSure. Using the bathroom, obviously, is something that we all have to do every day. And most of us just want to do our business in peace and quiet. But this is one of those things, because we still often have separate restrooms for men and women, that people just naturally have questions about, particularly if they don't personally know someone who is trans. And the reality is that everywhere in the country, every day, trans people are doing what everyone else does.

TOBINUsing the restroom that best fits our identity and where we think we'll be able to just do our business and be left alone. The problem today is that many trans people live with a lot of fear around it. Am I going to be harassed? Am I going to be interrogated by somebody? Am I even going to be victimized by someone who thinks we're not where we're supposed to be? And that does happen. Where Sharon and I live in Maryland, a young woman was beaten on video by two people at a McDonald's, a couple of years ago. Just walking out of the woman's restroom.

REHMWow.

BRACKETTAnd we also have research showing that many trans people simply try to avoid public restrooms, just hold it until they get home, to avoid those kinds of fears. And then you can really have medical issues because of it. Unfortunately, we also have politicians in some states trying to exploit whatever uncertainty or questions people may have about trans people, about a group of people that's unfamiliar, and generate fear and hostility in the form of bills that would make it a crime for trans people to use the restroom that fits who they are.

BRACKETTOr open trans people or businesses welcome them up to lawsuits. Now, those bills have failed, because they're not really consistent with our values and because they would violate the constitution and the federal civil rights laws. Which, as we've talked about, you know, protect people from discrimination in employment and in schools. And that would include, as the EEOC and others have said, not being able to use the restroom that fits who you are, which can really make just being able to work or go to school untenable.

REHMI understand that the White House now offers a gender neutral bathroom in the old executive building. I also understand some people have problems getting a drivers' license in West Virginia. There's a battle with some officials refusing transgendered women licenses until they stop representing themselves as women. And finally, Dr. Joseph, what about birth certificates?

JOSEPHWell, I'm not sure that I'm a legal expert on birth certificates, but I'll say that it's very much a challenge for my patients and certainly the birth certificate issue is, in some ways, can be linked to the DMB issue, as well. And it's very much a big step and very important to my clients to have their gender markers changed on things like driver's license and their birth certificates.

REHMI understand.

JOSEPHSo, there are organizations that I refer patients to, free organizations, in some cases, when they're available.

REHMTo get help.

JOSEPHThat can have attorneys who work pro bono, to help patients get that. But it can be quite a struggle.

REHMAll right. We'll have to leave it there. Many, many issues still to be talked about. Nicole Joseph, Nick Adams, Harper Jean Tobin, Sharon Brackett. Thank you all, so much, for helping us begin to understand a very complex issue.

JOSEPHThank you.

TOBINThank you, Diane.

REHMAnd thanks all for listening. I'm Diane Rehm.