Recent Articles The American Prospect - articles by author en The Great American Chain Gang <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"> <p><span class="dropcap">L</span>aurie Hazen has bad taste in men. “They’re my downfall,” the 41-year-old jokes in her Massachusetts accent. “I have to really stay single.” An ex-boyfriend first introduced her to prescription drugs, she says, a habit she maintained through the course of another relationship, with another addict, and through two stints in prison, most recently in 2012 for writing fake prescriptions.</p> <p>When she arrived at the Massachusetts Correctional Institution in Framingham, Hazen left behind a job as a records manager for a fiber-optics company. Her $14-an-hour salary had covered food, utilities, and rent on the modest apartment she shared with her boyfriend and her teenage son. She would have been putting some money away, too, if her paycheck hadn’t also been covering the couple’s drug habit. As it was, like many inmates, she went to prison with no savings and, because her boyfriend was locked up too, had no one on the outside to send her money. Her son went to live with his dad.</p> <p>After two weeks in prison, Hazen could apply for a job. Because her sentence was less than a year, she wasn’t eligible for the prison’s highest-paying job at $20 per week—stitching American flags for the state police—and she had to choose between washing dishes in the kitchen and cleaning bathrooms. Because portions in prison are notoriously small, Hazen took the kitchen job so she could eat a little extra before and after her shifts. She earned $2 a day collecting inmates’ dirty trays and loading them into the dishwasher during breakfast, lunch, and dinner. The cramped room where she worked had no windows and routinely filled with steam from the 200-degree dishwasher. There was one tiny fan. “It was pretty much slave labor,” she says, “but there was nothing I could do about that. I needed stamps to write to my child. I needed hygiene products.”</p> <p>About half of the 1.6 million Americans serving time in prison have full-time jobs like Hazen did. They aren’t counted in standard labor surveys, but prisoners make up a sizable workforce: with 870,000 working inmates, roughly the same number of workers as in the states of Vermont and Rhode Island combined. Despite decades’ worth of talk about reform—of giving prisoners the skills and resources they need to build a life after prison—the vast majority of these workers, almost 700,000, still do “institutional maintenance” work like Hazen’s. They mop cellblock floors, prepare and serve food in the dining hall, mow the lawns, file papers in the warden’s office, and launder millions of tons of uniforms and bed linens. Compensation varies from state to state and facility to facility, but the median wage in state and federal prisons is 20 and 31 cents an hour, respectively<span class="pullquote" style="display:none;">The median wage in state and federal prisons is 20 and 31 cents an hour, respectively.</span>.</p> <p><a href=""><em>CLICK HERE TO READ AN INTERVIEW WITH AUTHOR BETH SCHWARTZAPFEL BY THE SIDNEY HILLMAN FOUNDATION'S LINDSAY BEYERSTEIN</em></a></p> <p>Because inmate workers are not considered “employees” under the law, they have none of the protections that word implies. No disability or worker’s compensation in the event of an injury. No Social Security withholdings, sick time, or overtime pay. In three states—Texas, Georgia, and Arkansas—they work for free. In Texas, where inmates are required to work under threat of punishment, most do maintenance tasks like Hazen, but some are assigned to “field force” jobs designed to be particularly demeaning. “It wouldn’t be an ideal job,” says Jason Clark, Texas Department of Criminal Justice public information officer director. “Someone may have had disciplinary issues, so they end up in the field force, doing various things including clearing fence lines. They’re out under armed-guard supervision, using their labor.”</p> <p>If that scenario sounds familiar, it should. “Thousands of prisoners toil in the hot sun every day and make nothing,” says Judith Greene, a researcher and advocate with the nonprofit group Justice Strategies. “Prison guards on horseback, ten-gallon hats, prisoners in their uniforms. It looks like what it is: plantation labor all over again.”</p> <p>Critics trace the current system back to convict-leasing, which historian Douglas Blackmon calls “slavery by another name.” From the time of Reconstruction until the early to mid-20th century, prison inmates—almost all of them black, many convicted of fabricated crimes like “false pretense” or “selling cotton after sunset”—were routinely leased out to private companies to work on plantations and in coal mines and factories. There, they “were compelled to labor without compensation, were repeatedly bought and sold, and were forced to do the bidding of white masters through the regular application of extraordinary physical coercion,” as Blackmon writes.</p> <p>Conditions in most prison workplaces today are nowhere near as brutal, but the legacy is hard to ignore. Since prisoners are so far removed from the free market, and since their work is barely recognized as such by government agencies that regulate labor, they have little recourse and few protections. The Occupational Safety and Health Administration is one safeguard they do have—federal and some state inmates “working in conditions similar to those outside prisons” can file an OSHA complaint if their workplace is unsafe—but it’s toothless because, unlike in a free-world workplace, OSHA has to notify prisons in advance of inspections. A 2010 report by the government’s General Accountability Office (GAO) skewered the federal prison system for purposefully hiding from OSHA dangerous practices at an electronics-waste recycling plant where toxic dust sickened hundreds of inmate workers and officers.</p> <p>Despite the conditions and the pay, most inmates want to work. A job gives them a safe place to be for hours each day, provides a break from the monotony of prison life, and—in most states—puts a few dollars and cents in their commissary account. “I was happy to work,” Hazen says. “It made me feel like I wasn’t so much in prison. It gave me a minute by myself to get away from the craziness, time to think and reflect and figure out what I wanted to do with my life.” What the job didn’t provide was a wage sufficient to support her son and accumulate some savings for post-prison life, or job training that would help her pursue the goals she established in that dish room: to study psychology and one day open a domestic-violence shelter. After six months of work, Hazen left prison the way most people do: with a criminal record, no meaningful job experience beyond what she went in with, and not even enough savings to buy a suit for a job interview ($43).</p> <p>Study after study has found what common sense would suggest: Prisoners who gain professional skills while locked up, and those who earn a decent wage for their work, are far less likely to end up back behind bars. But if prisons in America, with the world’s highest incarceration rate, had to pay minimum wage—let alone the prevailing wage—they couldn’t keep operating. If inmates like Hazen weren’t washing dishes in Massachusetts prisons, the state’s corrections department would spend an average of $9.22 to hire someone else to do it (the mean hourly wage for a dishwasher, according to the Bureau of Labor Statistics). That’s 30 to 45 times what inmates make for performing the same service. As a result, prisons—and taxpayers—use prisoners to save hundreds of millions of dollars each year on labor costs, according to the GAO.</p> <p>“If our criminal-justice system had to pay a fair wage for labor that inmates provide, it would collapse,” says Alex Friedmann, managing editor of <em>Prison Legal News</em>, an independent magazine that promotes inmates’ rights. “We could not afford to run our justice system without exploiting inmates.”</p> <p> </p> <div class="right-margin" style="width:600px;margin-right:-400px;"> <div class="image image-large"> <div class="field-image"><img src="" alt="" title="" /></div> <div class="field field-name-field-credit field-type-text field-label-hidden"> <div class="field-items"> <div class="field-item even">AP Photo/The Daily News, Don Bryan</div> </div> </div> <div class="field field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item even"> <p>Sandra Amritt, a cook for the Onslow County Jail, prepares a tray for the days lunch Oct. 22, 2007, in Onslow County, Jacksonville, N.C. Amritt and fellow cook Vickie Futrell begin their day at about 6:30 a.m. and are responsible for feeding more than 150 male and female inmates three times a day. </p> </div> </div> </div> </div> </div> <p><span class="dropcap">I</span>f paying inmates pennies looks like savings to corrections officials, it translates to additional costs for everyone else. Consider, for starters, that more than 1.2 million prisoners have a minor child—2.7 million kids in all. About half of these parents were, like Laurie Hazen, their families’ primary breadwinners before they went to prison. Not surprisingly, their families often turn to social safety-net programs to compensate for the missing income. Families with an incarcerated parent are 50 percent more likely to use Medicaid and twice as likely to use food stamps.</p> <p>For most, the situation doesn’t improve upon release. Even as state and federal governments pour hundreds of millions of dollars into re-entry initiatives with the aim of easing the transition home and slowing the “revolving door” between prison and the community, they’re undermining successful re-entry by burying inmates in fees and fines while paying them next to nothing for their work. It costs money to be locked up in America—more and more of it all the time: court costs and fees when you’re tried, booking fees when you’re processed in jail and then prison, and supervision fees while you’re out on parole. Restitution costs, child-support arrears, and, in some states, “room and board costs” pile up during long prison terms. A state-sponsored study of the impact of legal fees in Washington found that the average inmate owes $2,540 per conviction in fees and fines.</p> <p>Once a prisoner is released, debt compounds another financial problem: a felony conviction makes job-hunting notoriously difficult. That’s especially true if you’re black, which almost 40 percent of prisoners are. In a seminal 2003 study, only 5 percent of black applicants to entry-level jobs got callbacks if they had a criminal record, one-third as many as black applicants without a record. (Whites <em>with </em>a criminal record were still more likely to be called back than blacks without one.)</p> <p>The combination of debt and poor job opportunities can lead recently released prisoners right back to prison—neither a cost-effective outcome for the state nor a desirable outcome for, well, anyone. Sometimes people land back behind bars because of their debts alone; the American Civil Liberties Union and New York University’s Brennan Center for Justice documented hundreds of cases in which people were reincarcerated as a result of their inability to pay criminal-justice debts. In one Ohio county, more than 20 percent of all jail bookings stem from a failure to pay fines—a Dickensian situation that critics liken to modern-day debtors’ prisons.</p> <p>Harvard sociologist Bruce Western is currently conducting a small study on re-entry, following 135 people in Boston’s urban neighborhoods during the first year after they’re released from Massachusetts prisons. More than half of the people in his sample have not worked a single day in the months since they’ve been released. They survive instead on $200 a month in food stamps. If they have no friends or family to stay with, they are homeless. “How do you live on zero income?” Western asks. “People appear to be doing that.”</p> <p>For many ex-felons, the only way to dig out of debt is to break the law. New Yorker Glenn Martin was 22 in 1995 when he was sentenced to six years for armed robbery of a jewelry store. In prison, he earned $10.50 for 30 hours of work a week as an administrator at the facility’s college program—approximately the same pay as Laurie Hazen earned washing dishes but with the benefit of providing real job experience. “I learned how to use computers. I kept spreadsheets, helped people register for classes,” he says.</p> <p>He was released in 2000 and took the bus back to Manhattan with just $230 in his pocket. Then he got a break: A nonprofit specializing in job placements for people with criminal records helped him land a job as a receptionist at a law firm. It paid $16,000 a year—a far cry from the thousands per day Martin says he used to make “ripping and running the street.” But, he says, “I was committed to turning my life around.”</p> <p>His meager pay plus the debts he’d racked up in prison made that practically impossible. When Martin had gone in, his son was six months old, and Martin was paying $50 a month in child support, an amount he naïvely thought would remain fixed during his bid, making paying it off “doable.” But later he learned that the judge had issued a default order, increasing his payments to $100 per week plus 9 percent interest. Now he owed $53,000 in arrears, plus the ongoing weekly payments, plus $5,000 in court fees and fines. “It’s insurmountable pressure,” he says. “Either I do something wrong to pay off the fines and fees, or I relegate myself to a debtors’ prison or a lifetime of poverty.”</p> <p>Locking Martin up for six years cost New York taxpayers approximately $360,000. The most cost-effective outcome would be for him to live a lawful life and not be incarcerated again. Yet Martin felt cornered. “I committed crimes,” he says matter-of-factly. “The statute of limitations are over, so I think I can say it out loud: I broke the law.” Martin says he brought in about $30,000 selling counterfeit designer handbags on eBay—enough to help pay off his debts as he continued to build what has become a successful career. Until recently, Martin oversaw a $1 million budget as public policy director of the Fortune Society, a service and advocacy group for former prisoners. (He left in March to found his own prison reform group, JustLeadershipUSA.)</p> <p><span class="pullquote">“The system creates this weird situation where it tells you to do the right thing and turn your life around,” Martin says, “and then actually incentivizes future violations of the law—even if you’re inspired to do the right thing.”</span></p> <p>Lately everyone from Attorney General Eric Holder to Senator Ted Cruz has called for reforms to just about every aspect of the system: how we target people for arrest, how we arrest them, how we try them, sentence them, incarcerate them, release them, and supervise and support them once they’re home. All are areas ripe for reimagining. But prison labor is not.</p> <p>In 1985, as “tough on crime” mania was sweeping the country, Supreme Court Chief Justice Warren Burger wrote presciently: “When our country is embarked upon a multibillion dollar prison construction program, it is fair to ask: Are we going to build more expensive human ‘warehouses,’ or should we change our thinking and move towards factories with fences around them, where inmates can acquire education and vocational training and then produce marketable goods?” History has answered Burger : warehouses. But it doesn’t have to be that way. What would happen if Americans decided to treat prison workers like, well, workers?</p> <p> </p> <div class="right-margin" style="width:600px;margin-right:-400px;"> <div class="image image-large"> <div class="field-image"><img src="" alt="" title="" /></div> <div class="field field-name-field-credit field-type-text field-label-hidden"> <div class="field-items"> <div class="field-item even">© chrisjo/iStockphoto</div> </div> </div> <div class="field field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item even"> <p>Prisoner working on an engine</p> </div> </div> </div> </div> </div> <p><span class="dropcap">I</span>t’s a noisy Wednesday at the Brown Creek metals plant in Polkton, North Carolina. The plant’s approximately 55 workers make fire rings for state parks, industrial sinks for school cafeterias, contraband lockers for the police. Some are experts in CAD, computer-aided design. Others are journeyman welders. A 44-year-old man named Joshua* built the plant’s plasma burn table from a pile of mail-order parts. Before he went to prison for sexual assault in 1999, Joshua made $15 an hour as a machinist making automobile cylinders; now he makes $15 a week operating the plasma cutter, designing and creating custom metal piecework. During his downtime at work, he uses leftover scrap metal to design and build grandfather clocks that keep remarkably accurate time. One sits next to his workstation, pendulum swinging, marking his time in custody: 15 years down, 8 to go.</p> <p>This plant and 31 others like it compose the North Carolina Correction Enterprises program, which puts inmates to work producing goods for sale to “tax-supported entities” like municipal or county governments. Every state, along with the Federal Bureau of Prisons, runs a similar program in which inmates learn skilled work that can ease their transition to the outside. Modern-day correctional industries date back to the 1930s, when Franklin Delano Roosevelt won the support of a reluctant American Federation of Labor to create Federal Prison Industries, with the dual aim of rehabilitating inmates and easing the burden on the taxpayer. “If we send men to prison, and don’t let them work, the taxpayer must foot the entire bill,” the Federal Prison Bureau director told <em>The New York Times</em>. FPI—now more commonly known as Unicor—sells products exclusively to the federal government, with the aim of minimizing competition with private-sector companies. State correctional industries follow similar rules.</p> <p>A hybrid between a for-profit business and a rehabilitation program, correctional industries are typically self-supporting: Program revenue, not taxpayers, pays for equipment, supplies, inmate wages, and staff salaries, and profit is rolled back into the program. But the idea is to train workers, not to compensate them; pay is only slightly higher than for prison-maintenance jobs. Still, even the savings Joshua has wrung from his $15 a week has made some difference, he says: “I send my kids money orders and buy them books. I’ve sent them several hundred dollars over the last couple years. I wish I could send them more.” But he has no complaints about the work: “I love making useful things. I do take pride in my work. I do like learning. I would wilt and die if forced to do some job such as folding sheets or slopping trays day in, day out for years.”</p> <p>The iconic prison job, making license plates, is typically a correctional industries job. Inmates also do telemarketing and data entry. They build office furniture, fill eyeglass prescriptions, manufacture cleaning supplies, and produce clothing—including, in North Carolina, their own uniforms and those of the correctional officers keeping watch over them. Prisoners gentle wild horses in Wyoming, raise water buffalo for mozzarella cheese in Colorado, and build motorcycles in Nevada. A men’s prison in Chino, California, runs a commercial dive school for inmates, training them to work as commercial divers, underwater welders, and heavy-construction riggers—highly specialized jobs that pay upward of $50,000 per year. Their recidivism rate is less than 7 percent, compared to 64 percent of the state’s general prison population.</p> <p>“When we can see a guy come in here with no marketable job skills—the only job he’s probably had is street pharmaceuticals—and he learns a skill and takes that skill out when he’s released, that’s the most rewarding part for me,” says Clayton Wright, the plant manager at Brown Creek. <span class="pullquote">The warm metal makes the shop smell like a toaster oven, and the din is so loud that Wright is shouting.</span> “I’ve been in my office and got phone calls from past inmates: ‘I got a job making 30 bucks an hour. I’m so happy.’ I’ve also gotten calls from employers, who ask, ‘Do you have any more like so-and-so? He’s one of my best.’ We’re so proud of that.”</p> <p>Programs like North Carolina’s are designed with a certain amount of intentional inefficiency, aiming to employ as many inmates as possible for as many hours as possible. During downtime at the factory, Wright encourages the men to experiment with the materials and equipment; that’s how Joshua came to make grandfather clocks.</p> <p>“What we want to do is, when they’re released, for them to feel unnatural not to be working,” says Mike Herron, who heads up correctional industries in Indiana. “For you and I, if we go a long period of not working, something’s wrong. But they have not lived their life that way. We’re trying to change that habit to where they need to work, mentally, just as much as you and I do.” Herron’s program stands out because almost every job—from cabinetmaker to electrician to housekeeper—comes with a Department of Labor apprenticeship, including one through the Library of Congress in which inmates produce Braille books for state-run schools for the blind. Apprentices leave prison with documented bona fides that help to counterbalance the difficulty they’ll face in job hunting. “These guys are felons, so paper helps them get in the door when they get outside,” Wright says.</p> <p>Research bears him out. One Washington state study found that working in correctional industries significantly reduces future crime rates and that the state saves $6 for every $1 it spends to launch the programs. In Tennessee, the state’s correctional industries program, TRICOR, estimates that taxpayers save $3.3 million each year by giving 1,500 inmate-employees a productive way to occupy their time. On the federal level, inmates who have worked in correctional industries are 35 percent less likely to land back in prison; a decade later, recidivism in this group was still substantially lower.</p> <p>But correctional industries, all told, employ only about 60,000 inmates—less than 4 percent of America’s prisoners. Why does a program with proven results remain so marginal? Largely because private-sector companies see inmates doing work that they do, at a fraction of the labor costs, and cry foul.</p> <p>The thicket of laws and regulations meant to alleviate that complaint—prohibiting most inmate-made goods from being sold across state lines or in the open market—limits correctional industries’ customers and hampers their growth, but it doesn’t address the root problem. “If the government would otherwise be buying its pencils from a private vendor,” the fact that they get them from prisoners still means that a private pencil vendor is out of a sale, notes Noah Zatz, a University of California, Los Angeles, law professor who studies nontraditional employment.</p> <p>American Apparel, an Alabama manufacturer of military uniforms (not affiliated with the retailer of the same name), says it had to lay off 225 workers in 2012 when it lost a contract to Unicor. “We pay employees $9 [per hour] on average,” American Apparel’s Kurt Wilson told <em>CNN Money</em>. “They get full medical insurance, 401(k) plans, and paid vacation. Yet we’re competing against a federal program that doesn’t pay any of that.” Last year Alpine Steel, a Las Vegas company, became the target of competitors’ ire when it paid Nevada inmates minimum wage for work that on the outside would pay $18 or $19 per hour. “Competing against prison labor reduces the number of jobs available in our industry and hampers our businesses from expanding,” read a petition from competitor XL Steel and a half-dozen other local steel companies.</p> <p>Alpine Steel was participating in the one prison work program that does pay competitive wages—at least in theory. The Prison Industry Enhancement Certification program (PIE) was created in 1979, over labor unions’ strong objections, after high-profile prison riots convinced politicians and the public that prisoners needed something useful to do. For the first time since convict-lease programs were outlawed, for-profit companies were permitted to set up factories inside prisons with inmates as employees. In 38 states, inmates do mostly factory-style work like packaging products, assembling clothing, and building circuit boards. Unlike correctional industries goods, these products can be sold on the open market. To avoid undercutting private-sector wages, companies must pay “prevailing wage” for their particular industry, although in practice this often means minimum wage; then the prison can deduct up to 80 percent of pay for “room and board,” victims’ compensation, and mandatory savings. Still, even with these enormous deductions, PIE jobs are the highest paid in prisons; the top of the pay scale is $16.95 per hour before deductions, according to the National Corrections Industries Association (NCIA), an industry group charged with auditing PIE programs.</p> <p>The PIE program accounts for fewer than 5,000 jobs—less than 1 percent of working inmates. Still, the direct link between corporate profit and prison labor—and, by extension, the potential for profit-driven exploitation—has made it a target for criticism.</p> <p>Proponents of prisoners’ and workers’ rights point to a push by the American Legislative Exchange Council, or ALEC, to ”improve and expand federal prison industries” in several states. Known for its “model laws” crafted in partnership between extreme right-wing legislators and powerful corporations, ALEC drafted the 1995 Texas Prison Industries Act, which expanded the program there and has since been replicated around the country.</p> <p>A loophole in the federal PIE legislation exempts companies from paying prevailing wage when the work is designated as a “service” rather than a “job,” and a recent exposé on the website Truthout identified at least one company exploiting that loophole to dangerous effect: An Arizona firm, <span class="pullquote">Martori Farms, which supplies produce to Wal-Mart, was paying inmates $2 an hour for involuntary agricultural work in the desert sun, with inadequate water or sunscreen.</span></p> <p>Labor unions would normally be an obvious advocate for exploited workers like these. But they have traditionally been either openly hostile or uncomfortably silent when it comes to prison labor, since inmate workers are seen as undercutting wages and competing for work with free-world union members. Neither the AFL-CIO nor the Service Employees International Union has an official position on prison labor.  While the AFL-CIO’s deputy policy director Kelly Ross says that “clearly we are in favor of raising standards for prison workers in terms of wages and working conditions,” neither union has organized on behalf of inmate workers. Union workers in trades and manufacturing, two of prison labor’s primary industries, are already struggling in post-industrial America. Many see prison workers along with sweatshops in China as a threat to their wages and their jobs.</p> <p>“Jobs are already under attack because of low-cost imports,” said Ann Hoffman of the textile workers’ union UNITE at a 1997 congressional hearing. “Our workers cannot afford to compete with the wages and the lack of benefits that exist in the prisons.”</p> <p>Unicor and proponents of state correctional industries argue, of course, that they’re not stealing jobs or suppressing wages. Lockdowns and other prison-related drags on productivity more than make up for the wage savings, NCIA officials say, and besides, they purposefully do a diverse array of work so as to limit their impact on any one industry. Before launching a new program, corrections programs collaborate with state and local agencies to make sure they’re not displacing existing jobs. “In times of high unemployment like we’ve had the last few years, Correctional Industries is even more careful than in good times of employment,” says Gina Honeycutt, executive director of the NCIA.</p> <p>And ‘round and ‘round the argument goes. When the <em>a priori</em> assumption is that inmates should not compete for free-world work, the argument is narrow: Opponents say that inmate labor displaces competitors on the outside, while supporters say it doesn’t.</p> <p>But the back-and-forth debate elides a larger question: So what if it does? We may all agree that by committing certain crimes, people forfeit their right to be free, at least for a time. Must that also mean they forfeit their right to fair pay for their work? Ultimately, does it serve justice—or benefit the economy—to have so many people released from prison with sizable debts, no job skills, and nowhere to turn but to crime or the government safety net?</p> <p> </p> <div class="right-margin" style="width:600px;margin-right:-400px;"> <div class="image image-large"> <div class="field-image"><img src="" alt="" title="" /></div> <div class="field field-name-field-credit field-type-text field-label-hidden"> <div class="field-items"> <div class="field-item even">AP Photo/The News Tribune, Peter Haley</div> </div> </div> <div class="field field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item even"> <p>Michelle Taimanglo sews 'surgi-sox' for pets to wear after surgery in a workshop in a Thursday, June 3, 2004 photo at the Washington Corrections Center for Women at Purdy run by the business, Inside Out.</p> </div> </div> </div> </div> </div> <p><span class="dropcap">T</span>hose who claim, as many do, that “every job a prisoner has is a job a person in the free world does not have” misunderstand how economies function, according to economists who have studied the issue. Think of these jobs not as a one-for-one swap—there’s only one position, and either I have it or you have it—but rather as a spiral. Economists call it a “multiplier effect”: Unemployment begets unemployment. Communities with high rates of incarceration don’t just lose the workers who go to prison. They lose the money those workers (and their families) spend at the local grocery, banks, restaurants, and shops. The impact is felt through generations; studies show that having a parent in prison hampers a child’s prospect of upward economic mobility. If the law required that inmates be paid wages comparable to peers doing similar work on the outside—what the PIE program is supposed to do—their jobs would have the opposite effect. When the inmate sent his income home, he’d help create additional jobs.</p> <p><span class="pullquote">Paying inmates a prevailing wage would eliminate the complaint by free-world competitors and labor unions that prison shops are undercutting wages</span>, since the wages would be the same on the inside and on the outside. It would help inmates make amends for their crimes, too, by allowing them to pay restitution to victims. And it would help them to accumulate some savings so they can rebuild their lives when they’re released.</p> <p>But prisons have no incentive to pay inmates better—to the contrary. Unlike workers in the free market, who (theoretically, anyway) can weigh factors like pay, working conditions, and other benefits when deciding where to work, inmates do not have a choice between employers. If they need the money, or the experience, they must take or leave what the prison is offering. “Prison is a deadening, horrific experience, and people line up for these jobs, whether they’re safe or unsafe, exploitative or not,” says Heather Ann Thompson, a Temple University historian who studies labor history and criminal justice.</p> <p>There is one way to change the system fundamentally: Bring prison jobs under the Federal Labor Standards Act (FLSA), which sets minimum standards for wages and working conditions.</p> <p>Don’t count on it happening anytime soon. Prison administrators say that paying real wages for real work would make them go bankrupt. Correctional industries administrators say the same thing: If inmates received the minimum wage, “we wouldn’t exist,” says Indiana’s Mike Herron. “Security costs and other costs are so high.” Even with the rising public and political recognition that America’s massive prison system is a costly, counterproductive mess, it’s inconceivable that lawmakers—who would be assailed by labor, business, <em>and </em>tough-on-crime holdouts—will take such a radical step any time in the near future.</p> <p>Genuine prison-labor reform would almost surely have to come through the courts. For decades, inmates have been asking the judiciary to step in and require that prisons treat their inmate employees like employees. <span class="pullquote">Countless judges, both state and federal, have held that inmate workers need not be offered the same rights or protections as free-world workers. But from one ruling to the next, they can’t agree on why, exactly.</span></p> <p>Some dismiss the claims on their face, concluding, as the 9th Circuit did in 2010, that “the Thirteenth Amendment does not prohibit involuntary servitude as part of imprisonment for a crime.” Other judges have grappled with the nature of the work, for instance whether the work is being done inside the prison or outside, as in work release programs. But as UCLA’s Zatz points out, “you can have a call center in a prison that’s competitive with other call centers. It’s sort of irrelevant, physically where it’s located.” Some judges zeroed in on who is buying the goods—the distinction between public and private customers that correctional industries officials are so careful to make. “Each of these is a kind of attempt to draw a boundary between the world of the prison and the world of the market,” Zatz says. “None of them really makes any sense. But you see courts constantly grasping for these kinds of explanations as a way to separate out inmates from regular workers.”</p> <p>Employment law is supposed to rely on a three-pronged test to determine whether two people are engaged in an employee-employer relationship: Are they producing something of value? Are they getting paid for their work? Do they have a supervisor telling them what to do? Prison jobs meet all three criteria. “The puzzle,” Zatz says, “is the way in which courts have a strong instinct: No, there’s something different here. And then they run around in circles trying to figure out what that something different is.”</p> <p>The something different is a moral judgment: Inmate workers are seen as less deserving of a decent job or a competitive wage. The courts, in this sense, are reflecting public sentiment. It’s why the idea that “law-abiding citizens … need jobs worse than inmates” (in the words of one recent Nevada editorial page) resonates the way it does. It’s the same reason people with felony convictions have such a hard time finding a job, why in so many states they’re barred from voting, why a criminal record can prevent you from living in public housing or securing student loans, and why political candidates have long won more votes with punitive rhetoric than with compassion or level-headed talk of prevention. In America, breaking the law has become more than just an occasion to be punished or even rehabilitated. It has become a permanent mark of who you are and what our country thinks you’re entitled to earn.</p> <p>For one brief moment, in 1992, prison-labor reform looked possible. Since the 1970s, a group of inmate workers in Arizona and their lawyer, Michael St. George, had pursued a case further and further up the courts, finally convincing the Ninth Circuit Court of Appeals, in <em>Hale v. Arizona</em>, that the Fair Labor Standards Act should apply to them. It appeared as though Arizona prisons would have to start paying inmates minimum wage. The ripple effect would have been enormous: Americans would have been forced not only to rethink their views of prisoners’ rights but to reconsider the prison system altogether. The country could not afford to incarcerate 1.6 million people if they all had workers’ rights.</p> <p>But it never came to that. The state appealed the decision, the Ninth Circuit reheard the case with 11 judges instead of the original 3-judge panel, and the court overturned its own ruling the following year. Why? When you ask St. George to explain the court’s logic, his voice carries decades’ worth of weariness: “The Ninth Circuit decided,” he says, “that the Fair Labor Standards Act didn’t apply to those inmates, because they were prisoners.”</p> <p> </p> <p><em>* “Joshua” is a pseudonym. The North Carolina Department of Corrections requested that inmates’ real names not be used in this story.</em></p> </div></div></div> Wed, 28 May 2014 12:55:17 +0000 220423 at Beth Schwartzapfel Born This Way? <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed"> <div class="image image-large"> <div class="field-image"><img src="" alt="" title="" /></div> <div class="field field-name-field-credit field-type-text field-label-hidden"><div class="field-items"><div class="field-item even">AP Photo/Jeff Roberson</div></div></div> <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"> <p>Dr. Rob Garofalo, left, a physician specializing in adolescent medicine at Children's Memorial Hospital in Chicago, listens in on a conversation at the Broadway Youth Center in Chicago. Garofalo helped create the youth center, which is one of the few places across the country services and support to transgender youth. </p> </div></div></div></div> </div><p><span class="dropcap">F</span>rom the time she could talk, Maggie* has told her parents that she is a boy. She doesn&rsquo;t say, &ldquo;I <em>want</em> to be a boy.&rdquo; She doesn&rsquo;t say, &ldquo;I </span><em>feel</em> like a boy.&rdquo; She says, &ldquo;I </span><em>am</em> a boy.&rdquo; She tells her classmates, too. Lately&mdash;she&rsquo;s in elementary school now&mdash;they&rsquo;ve been having debates about it. &ldquo;Maggie&rsquo;s a boy,&rdquo; one kid said recently, in a not-unfriendly, matter-of-fact sort of way.</span></p><p>&ldquo;No, you idiot,&rdquo; countered another. &ldquo;She&rsquo;s a girl. She&rsquo;s wearing pink shoes.&rdquo;</p><p>On a recent Tuesday morning, psychologist Kenneth Zucker tells this story at a weekly group supervision meeting, where he reviews cases with his dozen graduate students and postdocs. &ldquo;As if, &lsquo;duh&rsquo;&mdash;it&rsquo;s so obvious,&rdquo; he says, and the room chuckles along with him.</p><p>Head of the child and adolescent gender-identity clinic at Toronto&rsquo;s Centre for Addiction and Mental Health, Zucker is one of North America&rsquo;s most widely published experts in the field of transgender and gender-variant<sup class="sidenotenumber">1</sup><span class="sidenote"><span class="sidenotenumber">1.</span> <strong>Gender-variant</strong>: (adj) acting in a manner that varies from the stereotypical behavior associated with one’s gender. Because “vari- ant” may connote deviance, the term is being replaced by “gender nonconforming.”</span> children. Since it was established in the mid-1970s, his clinic has assessed more than 600 kids with gender-variant behavior and gender dysphoria&mdash;the distress that results from feeling that one&rsquo;s body does not match one&rsquo;s sense of self. He has treated more than 100 of those children.</p><p><span class="pullquote-right">Given how early dysphoria can emerge in kids like Maggie and how deeply it cuts to the core of who they are, a growing number of therapists, doctors, and parents are advocating an early gender transition: If Maggie says she&rsquo;s a boy, then it&rsquo;s our duty to believe him and treat him as such.</span> Given the very real risks to transgender people who remain in the closet&mdash;at one prominent clinic for transgender adolescents and young adults, 20 percent of patients have engaged in cutting or other self-mutilation, and almost 10 percent have attempted suicide&mdash;those in this camp say that to deny that Maggie is a boy is to set the child up for a lifetime of repression and pain.</p><p>Zucker, on the other hand, believes that girls who say they are boys are not expressing their true identity. Rather, they are confused. Their mismatched gender identity is likely the result of a childhood experience or trauma, or a manifestation of some underlying psychiatric or family problem. The situation will only be made worse, he argues, if parents and teachers encourage it. Zucker&rsquo;s aim, if a family comes in with a kid like Maggie, is to make her more comfortable in her own body: to make her understand that she is a girl.</p><p>&ldquo;We don&rsquo;t know why Maggie mislabeled herself as a boy when she was younger,&rdquo; Zucker says. &ldquo;Was it because she was in some home day-care thing where she was around a lot of boys?&rdquo;</p><p>One of Zucker&rsquo;s doctoral students has been working with Maggie in play therapy. The student, Julia Vinik, pulls out a drawing that she and Maggie made together. Four stick figures represent a girl who likes to play sports, a girl who likes to play with dolls, a boy who likes to play sports, and a boy who likes to play with dolls. Vinik had asked Maggie which one she was. &ldquo;She first went to circle the boy,&rdquo; Vinik recounts at the supervision meeting. &ldquo;And then stopped herself and said, &lsquo;Wait a minute. Can you make another one here called tomboy?&rsquo;</p><p>&ldquo;I asked her, &lsquo;What&rsquo;s a tomboy?&rsquo;</p><p>&ldquo;&lsquo;It&rsquo;s a girl who likes to do boy things.&rsquo;</p><p>&ldquo;I said, &lsquo;Do you think there&rsquo;s one already here like that?&rsquo;&rdquo;</p><p>Maggie pointed to the girl who likes sports. &ldquo;She said, &lsquo;Oh yeah, that&rsquo;s a tomboy,&rsquo;&rdquo; Vinik tells her colleagues.&nbsp; &ldquo;And she decided this one over here&rdquo;&mdash;Vinik points to the boy who likes dolls&mdash;&ldquo;would be called a tomgirl.&rdquo; Everyone chuckles. Vinik recounts how Maggie then pointed again to the tomboy. &ldquo;&lsquo;OK,&rsquo; she said, &lsquo;This is me.&rsquo;&rdquo;</p><p>&ldquo;That was very encouraging,&rdquo; Vinik says. &ldquo;She didn&rsquo;t see herself as a boy anymore.&rdquo;</p><p>This kind of therapy is precisely what worries Zucker&rsquo;s critics. &ldquo;That looks like psychodynamic free play, but it&rsquo;s really coercive,&rdquo; says Herb Schreier, a San Francisco Bay Area psychiatrist who has worked with children as young as kindergarteners to help facilitate gender transition. Schreier is part of a consortium of some 30 Bay Area psychiatrists, psychologists, and therapists who work with gender-variant children and their families. He&rsquo;s one in a large and growing chorus of voices that accuse Zucker of relying on regressive gender stereotypes and practicing a thinly veiled version of 1950s-style reparative therapy<sup class="sidenotenumber">2</sup><span class="sidenote"><span class="sidenotenumber">2.</span> <strong>Reparative therapy</strong>: (noun) any clinical practice that aims to change a gay person&rsquo;s sexual orientation to heterosexual. Also known as conversion therapy, it was widespread in the years homosexuality was considered a mental illness; it is now regarded as unethical since it is both ineffective&mdash;not a single peer-reviewed scientific study has demonstrated that orientation can be changed at will&mdash;and harmful, since it fosters shame and self-aversion. Still, according to the Southern Poverty Law Center, nearly 70 therapists in 20 states and D.C. currently advertise that they practice conversion therapy. Many are affiliated with fundamentalist Christian groups.</span>, which was used to &ldquo;cure&rdquo; homosexuality.</p><p>&ldquo;The therapy session starts with an incredible assumption: that these kids have a problem. &lsquo;We&rsquo;re trying to figure out what problem you&rsquo;re dealing with that gives you this particular way of being.&rsquo; It&rsquo;s not a neutral therapy if it starts with that premise,&rdquo; Schreier says. &ldquo;Any therapy that starts with that assumption is bound to be problematic. In essence, he&rsquo;s asking parents to deny who the kids say they are.&rdquo;</p><p>Schreier characterizes Zucker&rsquo;s approach as, &ldquo;I think we should change them, and this would be for their betterment.&rdquo; To Schreier and his colleagues, this sounds ominously paternalistic. &ldquo;We would strongly raise the point: Isn&rsquo;t there a downside to be had by denying a child&rsquo;s identity?&rdquo;</p><p>Zucker&rsquo;s peers have written detailed, impassioned critiques of his work and his theories in professional journals&mdash;to which he writes detailed rebuttals&mdash;and his lectures and panels at professional meetings are often peppered with hostile questions and comments. A quick Google search turns up scathing, profanity-laced takedowns of Zucker and his clinic, including one calling Toronto the &ldquo;global epicenter for oppression of sex and gender minorities.&rdquo;</p><p>&ldquo;The reason there is such dislike of and distrust for Dr. Zucker in the community is because he holds a position of immense power,&rdquo; says Madeline Deutsch, a Bay Area emergency-room physician specializing in transgender health care. Since he publishes so widely, and edits an influential journal in the field, Zucker&rsquo;s opinions matter. His opinions, she says, &ldquo;fail to incorporate the very real empiric findings and experiences of other experts in the field, experienced clinicians, and activists &hellip; and instead remain focused on attempting to prove his own theories.&rdquo;</p><p>Zucker does have a tone-deaf tendency to operate from the lofty perch of academia rather than engaging with communities on the ground. Despite a palpable empathy for his patients when he&rsquo;s with them, in conversation with his colleagues he slots patients into scientific categories and describes their lives in psych-speak. Zucker doesn&rsquo;t use the language or terminology that members of the trans community use to talk about themselves; instead, he refers to &ldquo;homosexual persisters&rdquo; and &ldquo;homosexual desisters,&rdquo; by which he means boys who grow up to be trans women and boys who grow up to be men. In meetings with his staff, he insists on referring to his patients&mdash;even those who have already begun to transition&mdash;by the pronouns of their birth sex. In an e-mail to me, he referred to a young patient by using that patient&rsquo;s preferred gender pronouns in scare quotes: &ldquo;&hellip; help us understand &lsquo;his&rsquo; insistence/belief that &lsquo;he&rsquo; &lsquo;is&rsquo; a boy.&rdquo;</p><p>The criticism of Zucker only became fiercer in 2008 when the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual, or DSM&mdash;psychiatrists&rsquo; bible of mental disorders&mdash;announced that for the manual&rsquo;s upcoming fifth edition, Zucker would chair the committee to revise the section on Sexual and Gender Identity Disorders. The National Gay and Lesbian Task Force issued a statement calling the appointment &ldquo;extremely disappointing and disturbing.&rdquo; In The Nation, Peter Rothberg called Zucker &ldquo;retrograde&rdquo; and encouraged readers to sign a petition opposing him. More than 9,000 people did. Circulated by the transgender community, the petition asked for Zucker&rsquo;s resignation or removal, declaring that &ldquo;in order to have any credibility in the field of gender identity, the DSM must not include discounted theories or junk science.&rdquo;</p><p>The DSM is the primary tool by which psychiatrists and other mental-health professionals standardize, diagnose&mdash;and, crucially, bill insurance companies for&mdash;the mental-health problems their patients suffer. As the authoritative psychiatric guide for the National Institute of Mental Health, pharmaceutical companies, and other national and international organizations, the book&rsquo;s practical and cultural significance is hard to overstate.</p><p>It&rsquo;s also a historically loaded book for the LGBT community. Until 1973, homosexuality was listed as a mental disorder, and it was under the guise of treating it as an illness that many psychiatrists offered reparative therapy. (The diagnosis also meant that gay psychiatrists, psychologists, and psychoanalysts were forced to remain closeted in order to practice.) It wasn&rsquo;t until a huge push by the gay community&mdash;and with fierce resistance by many association members&mdash;that the diagnosis was removed.</p><p>Transgender advocates and activists say that in a generation we will see the diagnosis of gender identity disorder as equally ridiculous. &ldquo;Being differently gendered is not a psychiatric problem,&rdquo; says Lisa Mottet, director of the Transgender Civil Rights Project at the National Gay and Lesbian Task Force. &ldquo;It&rsquo;s a human variation.&rdquo; Or, as the University of California, San Francisco, child psychologist Diane Ehrensaft writes in a recent journal article, &ldquo;As with left-handed children, who are also a small minority of the population, I believe these children who experience this discord [between their bodies and their sense of self] are not abnormal, they simply vary from the norm.&rdquo; Ehrensaft and Zucker have sparred publicly on this issue. Gender identity disorder in children, or GIDC, is &ldquo;a diagnosis and implied treatment that pathologizes perfectly healthy children who are simply expressing their authentic gender identity,&rdquo; Ehrensaft writes. &ldquo;The job of the clinician is not to ward off a transgender outcome, but to facilitate the child&rsquo;s authentic gender journey.&rdquo;</p><p>&nbsp;</p><p><span class="dropcap">A</span>t the heart of the debate between Zucker and his critics lie fundamental questions: Are transgender people &ldquo;born this way,&rdquo; as people who support early gender transition argue? Or is gender a set of learned behaviors, a mix of &ldquo;biological factors, psychosocial factors, social cognition,&rdquo; and other mechanisms, as Zucker argues?</p><p>For Zucker, these questions are partly matters of scientific and intellectual curiosity. But for gender-variant kids, the stakes are much higher: If being transgender is part of one&rsquo;s hard wiring, then to try to change kids like Maggie would be impossible at best, psychologically destructive at worst. Therapy that aims to change gay people&rsquo;s sexual orientation is condemned as harmful and unethical by a slew of major professional organizations, including the American Psychiatric Association. Gay people subjected to conversion therapy as children have higher rates than their counterparts of depression, anxiety, and self-harm, including suicide.</p><p>Critics say that Zucker&rsquo;s approach will have the same effect on trans kids: It will teach them from an early age that a fundamental part of their identity is wrong. What&rsquo;s more, if these kids aren&rsquo;t truly changed&mdash;if they simply learn to hide their identity until they are old enough to make autonomous decisions&mdash;then aside from the psychological harm caused by this hiding are issues of physical comfort and safety: Those who transition later in life have a harder time being perceived as the gender they identify with and require many more surgeries.</p><p>The argument about the origin of our gender identity has been simmering for decades, particularly among feminist theorists. On one side is the view called &ldquo;social constructionism&rdquo;: the idea that everything we know about what it means to be a man and a woman is something we learn, through subtle cues and explicit lessons, from our parents, TV, the world around us. The flip side is &ldquo;essentialism,&rdquo; a word radical feminists have used derisively, snubbing their noses at the idea that there might be something hardwired into women&rsquo;s brains to make them more inclined to like lipstick and less inclined to fix a leaky faucet.</p><p>It&rsquo;s not just the drag queens, social constructionists argue; we&rsquo;re all in drag, performing our gender as surely as RuPaul does. Gender is &ldquo;a kind of persistent impersonation that passes as the real,&rdquo; writes social constructionist Judith Butler in her seminal 1990 work, Gender Trouble. Or, as Simone de Beauvoir famously said, &ldquo;One is not born a woman, but, rather, becomes a woman.&rdquo;</p><p>To embrace social constructionism means that there is no &ldquo;born this way,&rdquo; no born any way, except with a body around which the world begins spinning meaning and symbolism even before we are born. (See: blue nurseries, &ldquo;it&rsquo;s a girl&rdquo; balloons, and, the latest, &ldquo;gender reveal parties.&rdquo;) So to hear the politically progressive, trans-positive community embrace essentialism, and then to hear Zucker, the man they accuse of being retrograde, embrace social constructionism is enough to make one&rsquo;s head spin. Until you remember the gay gene.</p><p>When, in the early 1990s, geneticists discovered a relationship between homosexuality and certain genetic markers, many members of the gay community embraced these findings, using them as the basis of a new push for acceptance. If we were born this way, the argument went, then you can&rsquo;t hold it against us; we can&rsquo;t help it. Indeed, the work of these geneticists was read from the floors of many a senate chamber, and the &ldquo;gay gene&rdquo; was part of what turned the tide of public opinion in favor of compassion and nondiscrimination.</p><p>But this emphasis on biological determinism is discomfiting. First of all, even if gay folks weren&rsquo;t born this way&mdash;even if they &ldquo;learn&rdquo; to be gay or develop the identity over time as a result of complex social processes&mdash;why would that make it any easier to change their identities? Second, there&rsquo;s something apologetic about the whole premise that the world should accept gay people because they can&rsquo;t help being gay. The unspoken part two of that argument is that if they could change, they surely would&mdash;or should.</p><p>It&rsquo;s now widely accepted that no amount of therapy can change a person&rsquo;s sexual orientation, and Zucker says he would not try to do so. But gender identity and sexual orientation are not the same thing. Sexual orientation is a matter of whom you are sexually attracted to. Gender identity is more elemental: It&rsquo;s who you feel in your bones that you are. Zucker&rsquo;s critics say that most transgender children know precisely who they are. &ldquo;These kids come out very early and say, &lsquo;Mommy, I&rsquo;m in the wrong body,&rsquo;&rdquo; Schreier says.</p><p>Sure, Zucker says, but that doesn&rsquo;t make it a fait accompli. <span class="pullquote">Children&rsquo;s gender identity is plastic and malleable, he says, shaped and formed by the world around them, by the feedback they receive, by the emotional resonance of the things they do, by their personal relationships, even by the clothes they wear.</span> If this is true, then it should be possible for these kids to change.</p><p>Zucker is quick to point out that his clinic has referred more than 60 kids for the medical interventions required to begin their transitions; a paper he wrote on the subject was, in fact, the first such study published in North America. By age 11 or 12, he concedes, trans kids are typically &ldquo;locked in&rdquo; to their gender identity, and for them, &ldquo;I very much support that pathway, because I think that is going to help them have a better quality of life.&rdquo; But it&rsquo;s different, he says, for younger kids. &ldquo;If a child can grow up and feel comfortable in his or her own skin that matches their birth sex,&rdquo; Zucker argues, &ldquo;then you avoid the complexity of fairly serious surgical treatments. Penectomy and castration are not the same thing as having mild and minor cosmetic surgery. Lifelong hormonal therapy. It&rsquo;s serious.&rdquo;</p><p>It&rsquo;s not just the medical interventions, he says. &ldquo;One could argue, like many things, that there&rsquo;s a strong value component to it. Holding everything else constant, at least at this point in time it&rsquo;s relatively easier to grow up with a gender identity that matches your birth sex.&rdquo;</p><p>&nbsp;</p><p>That may be true. But for how much longer? Society is changing. The alphabet soup of LGB&mdash;lesbian, gay, bisexual&mdash;has, bit by bit, broadened, first to include &ldquo;T&rdquo; for transgender, and, more recently, to become the unwieldy LGBTQQIAA, which includes people who identify as queer, questioning, intersex,<sup class="sidenotenumber">3</sup> <span class="sidenote"><span class="sidenotenumber">3.</span> <strong>Intersex</strong>: (noun or adj) someone whose genitals, chromosomes, hormonal systems&mdash;or some combination of these&mdash;don&rsquo;t fit the standard parameters for male or female. &ldquo;Intersex&rdquo; replaced the outdated and derogative term &ldquo;hermaphrodite&rdquo;; the more culturally neutral term is &ldquo;disorder of sex development,&rdquo; or DSD. As many as 1 in 100 people have a DSD like Turner Syndrome, androgen or estrogen insensitivity syndrome, and Klinefelter&rsquo;s (or XXY) Syndrome. <br><br><span class="sidenotenumber">4.</span> <strong>Genderqueer</strong>: (adj) used to describe someone whose gender identity or gender expression blurs the line between masculine and feminine or rejects the binary of male and female altogether. <br><br><span class="sidenotenumber">5.</span> <strong>Bi-gender</strong>: (adj) identifying or presenting as female at some times and male at other times. <br><br><span class="sidenotenumber">6.</span> <strong>Agender</strong>: (adj) identifying as having no gender, which is known as “neutrois.” Agender people often prefer the pronoun “they” to the singular “he” or “she.” <br><br><span class="sidenotenumber">7.</span> <strong>Two Spirit</strong>: (noun) a traditional American Indian term for people who occupy a third gender category. Also known as berdaches, Two Spirits were typically genetic/physical men who did women’s work, cross-dressed, and formed relationships with non-berdache men; some tribes had additional gender categories for women who hunted and acted as warriors. </span> asexual, and ally. &ldquo;Transgender,&rdquo; usually used broadly to encompass a range of gender-variant people (including transsexuals, the word traditionally used to describe people who make a full medical change to the &ldquo;opposite&rdquo; sex), is bursting at the seams as 21st-century gender identities proliferate. There are people who identify as genderqueer,<sup class="sidenotenumber">4</sup> bi-gender,<sup class="sidenotenumber">5</sup> agender,<sup class="sidenotenumber">6</sup> Two Spirit.<sup class="sidenotenumber">7</sup> There are trans people who choose surgery but no hormones, hormones but no surgery, or no medical interventions at all.</p><p>To the extent that Zucker builds upon this gender diversity by encouraging kids to widen their sense of what their gender can be&mdash;by helping kids feel comfortable as &ldquo;tomboys&rdquo; or &ldquo;tomgirls,&rdquo; or other gender inventions in between&mdash;he furthers the worthy cause of making the two traditional boxes bigger or helping to break them down, rather than stuffing kids inside them. At the same time, Zucker knows that the more society moves in this direction, the more his work becomes obsolete. &ldquo;One could argue that with the emergence of gender-transition subculture, Western culture in some ways now has a third gender category,&rdquo; Zucker says.</p><p>&ldquo;Gender-transition subculture&rdquo; is Zucker&rsquo;s mildly dismissive go-to term for the approach of people like Schreier and Ehrensaft who advocate allowing gender transition for very young children in certain cases. &ldquo;One could argue&rdquo; is also a favorite formulation&mdash;it&rsquo;s an easy way to distance himself from potentially controversial statements. He&rsquo;s not necessarily arguing this, it seems to imply&mdash;just that one could. &ldquo;It could be that in the next 10, 15 years, there will be more and more acceptance of extremely gender-variant kids, and the reaction will be, &lsquo;Oh, he&rsquo;s just a transgender.&rsquo; And we&rsquo;ll see. If there is this greater acceptance, the argument that [not being transgender] is an easier pathway may be harder to make.&rdquo;</p><p><span style="line-height: 1.538em;"><span class="dropcap">A</span>lex exemplifies the growing acceptance of gender diversity. Born with a girl&rsquo;s body six years ago, Alex is &ldquo;just a cool little kid, really,&rdquo; says his mom, Andie. At school, he is a boy: boy clothes, boy hair, boy pronouns. &ldquo;And at home, we respectfully&mdash;somewhat faking it, because I&rsquo;m not 100 percent there&mdash;we treat Alex as a boy.&rdquo;</span></p><p>Andie knew from the time Alex was a toddler that something was different. &ldquo;I noticed that Alex gravitated towards playing with the boys,&rdquo; Andie recalls. &ldquo;She* preferred to do the boy things.&rdquo; At three, Alex refused to put on a girl&rsquo;s bathing suit. She refused to wear dresses, then she refused to wear skirts, and then &ldquo;it got down to, if there was a little pleat that you wouldn&rsquo;t even notice on the shoulder,&rdquo; Alex would refuse to put it on. Still, Andie was herself a tomboy as a kid, so she mostly let Alex dress how she wanted and didn&rsquo;t think much of it.</p><p>About halfway through Alex&rsquo;s kindergarten year, Andie&rsquo;s usually easygoing, happy kid seemed anxious and irritable. She discovered that Alex was polling kids at school: &ldquo;Do you think I&rsquo;m a boy or a girl?&rdquo;</p><p>&ldquo;And I go,&rdquo; Andie says, &ldquo;&lsquo;Why are you doing that? You&rsquo;re obviously a tomboy.&rsquo;</p><p>&ldquo;&lsquo;Well, I want to be a boy.&rsquo;</p><p>&ldquo;I&rsquo;m like, &lsquo;Well, you&rsquo;re not a boy.&rsquo; I had no idea, really, about issues like that.&rdquo;</p><p>She went to talk to Alex&rsquo;s teacher, who had noticed a similar change in Alex&rsquo;s behavior. &ldquo;It&rsquo;s almost like she doesn&rsquo;t know who to play with or what to do,&rdquo; the teacher said. &ldquo;Have you heard of gender dysphoria?&rdquo;</p><p>Andie took a few weeks to think it over, do some research, and talk to her family. Then she called the principal. &ldquo;Listen,&rdquo; she said. &ldquo;Alex thinks she&rsquo;s a boy. So we need to somehow make Alex comfortable at school.&rdquo; The principal said, &ldquo;OK. I&rsquo;ll make some calls.&rdquo;</p><p>It was that easy. But it won&rsquo;t necessarily stay easy.</p><p>In five or six years, as boys his age find their voices deepening and their upper lips darkening, Alex will begin to develop breasts and hips. He will get his period. Unless, that is, he begins the long journey of medical interventions that will allow him to stay a boy.</p><p>First there are hormone blockers, medications that are used to suppress puberty in one&rsquo;s birth sex. These are fully reversible&mdash;an adolescent who stops taking them will begin puberty in their birth sex&mdash;and are meant to buy the child some time to mature enough before he or she makes irreversible choices.</p><p>For adolescents who continue their transition, hormone blockers also help to prevent later surgeries; a boy like Alex who never grows breasts in the first place need not have them removed. By around age 16, Alex could start on cross-sex hormones, which would deepen his voice, cause hair to grow on his face and his chest, and prompt the other hormonal changes of a typical teenage boy. Genital surgery&mdash;a much less common choice in transgender men since the surgical techniques are less advanced than they are for transgender women&mdash;can happen as early as age 18.</p><p>Andie admits that she would prefer Alex not go down this path. Not because she has a problem with him being transgender but because she hates giving her kids medication. &ldquo;I don&rsquo;t care what drug it is,&rdquo; she says. &ldquo;I don&rsquo;t like the thought of kids putting drugs in their body. But I also want a kid that&rsquo;s alive,&rdquo; rather than at high risk for suicide. &ldquo;My other little guy has epilepsy. So he has to take high levels of meds to keep his body safe. I&rsquo;m going to try to look at this the same way. If that&rsquo;s what Alex needs to feel secure, that&rsquo;s what Alex will have.&rdquo;</p><p>Andie brought Alex to Zucker&rsquo;s clinic after Alex had already made his gender transition at school. She Googled Zucker only once her family had gotten to know him and was shocked by the criticism she read; she says he has been supportive of her approach and has never encouraged her to treat Alex like a girl.</p><p>&nbsp;&ldquo;One starts, more or less, with where a family is at,&rdquo; Zucker says. &ldquo;I offered for us to see Alex in individual therapy to get a further and more in-depth understanding of Alex&rsquo;s internal, subjective world. I think that both Andie and I are watching to see if Alex will develop any alternative ways of how Alex currently experiences &lsquo;his&rsquo; gender.&rdquo; Zucker stops short of saying that fostering these alternative ways is his aim. &ldquo;It would have to be their aim,&rdquo; he says of Alex&rsquo;s family. &ldquo;It&rsquo;s not my job to impose it.&rdquo;</p><p>With encouragement from Zucker, Andie reminds Alex that he could grow up to be anything&mdash;a girl, a boy, or anything in between&mdash;and tries to encourage him in any case to love his body. &ldquo;My goal is for Alex,&rdquo; she says, &ldquo;to feel good about herself, and to have the tools she needs to be able to say, &lsquo;Hey, this is who I am.&rsquo; I have no right to tell somebody that they&rsquo;re something that they&rsquo;re not.&rdquo;</p><p>Alex plays on a local boys&rsquo; hockey team; his dad volunteered to coach so Alex would feel more comfortable playing. He goes snowboarding and dirt biking with his mom. In advance of Thanksgiving, Andie called her own mom&mdash;who is slowly coming around&mdash;to lay out the ground rules for their family dinner: &ldquo;&lsquo;Refer to Alex as he, or I&rsquo;m not OK with it.&rsquo;&rdquo; Andie&rsquo;s family complied.</p><p>Andie doesn&rsquo;t want Alex to talk to reporters, so I didn&rsquo;t get to meet him. But as Andie was gathering him to leave after his therapy session, I couldn&rsquo;t help but see his little snowboarder jacket and his mop of dark hair out of the corner of my eye. Zucker was bending down, hands on his knees, to look at the newly loose tooth Alex was excited to show off. &ldquo;Now what,&rdquo; Zucker said, with grandfatherly excitement, &ldquo;do we have here?&rdquo;</p><p>&nbsp;</p><p><span style="line-height: 1.538em;"><span class="dropcap">T</span>he industrial sign marking the bathroom in Zucker&rsquo;s clinic is all-inclusive, with a hybrid male-female symbol indicating a myriad of gender possibilities. Zucker&rsquo;s office door is papered with colorful marker drawings of smiling cartoon figures, trees, flowers, and houses. &ldquo;Thank you!&rdquo; several of them read, in rainbow letters. &ldquo;I enjoyed being with you!&rdquo; reads one. &ldquo;Thanks for helping me,&rdquo; reads another.</span></p><p>While countless individual therapists work with transgender kids on an individual basis, there are only about a dozen clinics for transgender kids and adolescents at major medical centers in the Western world. Most clinics take a &ldquo;watchful waiting&rdquo; approach. They advise against an early gender transition, instead counseling parents to find &ldquo;a sensible middle-of-the-road approach,&rdquo; as one clinic describes it&mdash;neither encouraging nor actively discouraging. A few, like Herb Schreier&rsquo;s Bay Area group, will&mdash;in extreme cases&mdash;help children make an early gender transition. But none attempt to actively prevent transsexuality as Zucker does.</p><p>With short silver hair and beard, mismatched belt and shoes, and a perpetual pen stain on his shirt pocket, Zucker looks, and has the demeanor of, the workaholic grandfather that he is. The first thing you notice, talking to him, is his voice: Its deep basso timbre rumbles in a blend of Canadian and Midwestern accents. He has a dry sense of humor and a penchant for deadpan teasing that at times catches even friends off guard. &ldquo;One of the things I told everybody that they really needed to think about today,&rdquo; Zucker said at the opening of his Tuesday-morning clinic-supervision meeting, &ldquo;was what to wear.&rdquo; He never even broke a smile, but he was (mostly) joking that everyone should try to impress the visiting journalist. &ldquo;I wore my best shirt and got here early and then&rdquo;&mdash;he pointed to that day&rsquo;s pen stain&mdash;&ldquo;put my blue pen in upside down.&rdquo;</p><p>Zucker grew up in suburban Skokie, Illinois, the older of two kids (his sister Barbara, he points out with an ironic smile, is nicknamed Barbie). His &ldquo;intellectual, left--winger&rdquo; Jewish parents were victims of McCarthy-era witch hunting&mdash;his dad lost several jobs, Zucker says, because he refused to &ldquo;rat on his Commie friends.&rdquo; In Zucker&rsquo;s telling, they ultimately decided that &ldquo;for the sake of their children, they needed to become conformist,&rdquo; and they moved to the suburbs to &ldquo;disappear from the scene&mdash;trapped in middle-class consumer subculture for the good of the cause.&rdquo;</p><p>Born in 1950, Zucker came of age at the dawn of a different kind of scene. During our time together, Zucker happened to mention, in passing, a cow that stuck its head into his VW van at Woodstock and a summer he spent in Cambridge, Massachusetts, driving &ldquo;the People&rsquo;s Bus,&rdquo; but when I pressed for more details, he would say only, &ldquo;We&rsquo;ll leave it at that.&rdquo; What he will say is that he emerged from those times with a distaste for dogmatism and a sense that &ldquo;maybe hiding in science is safer than fighting political, dogmatic battles.&rdquo;</p><p>He regards his detractors as dogmatists. &ldquo;I would say one thing that does bug me about some of the debates in this area is people&rsquo;s supreme confidence that gender is a complete social construction, or that gender is completely biologically determined, or that this can all be explained by specific psychodynamic mechanisms.&rdquo; Zucker calls himself a &ldquo;gender agnostic.&rdquo; He thinks that gender emerges as a mix of these elements, but he feels that the mechanisms are still far from clear.</p><p>His fascination with gender identities began while Zucker was a psychology graduate student and he read a book by UCLA psychiatrist Richard Green, whose pioneering work in the emerging field of sexology laid the groundwork for Zucker&rsquo;s practice today. Green&rsquo;s 1974 book Sexual Identity Conflict in Children and Adults was the first longitudinal, scientific description of a cohort of &ldquo;feminine boys&rdquo; and included transcripts of Green&rsquo;s sessions with these boys and their families. Zucker was intrigued. &ldquo;Identity is such a core part of what it means to be human,&rdquo; he says, &ldquo;and gender identity is such a core aspect of the self that it&rsquo;s inherently interesting.&rdquo;</p><p>When Green began his &ldquo;Feminine Boy Project,&rdquo; the research study on which his book (and The Sissy Boy Syndrome, a subsequent book) is based, his aim was to describe the &ldquo;natural history&rdquo; of transsexuals. He thought that by studying these boys early in life, he could watch their cross-gender identities unfold, like caterpillars in chrysalises. That&rsquo;s not what happened. Green&rsquo;s most striking finding was that only one of his 44 &ldquo;sissy boys&rdquo; turned out to be transsexual. Most of them&mdash;75 percent&mdash;grew up to be gay men. Subsequent studies led to similar findings: Gender-bending kids who grow up to be transsexual adults are the exception, not the rule.</p><p>This may be changing. <span class="pullquote-left">Given increasing visibility and acceptance (think Chaz Bono, Transamerica, RuPaul), more and more people who challenge traditional gender stereotypes (from butch women to &ldquo;sissy boys&rdquo; to those whose gender identity is more fluid) feel empowered to take on the mantle of genderqueer or transgender&mdash;and, in some cases, to seek medical attention.</span> Recent studies indicate that the number of people seeking treatment at gender clinics in the United Kingdom and Canada has risen sharply in the last five years.</p><p>Does this mean that Green&rsquo;s numbers are an under-estimate&mdash;that with greater parental and societal acceptance more of his &ldquo;sissy boys&rdquo; would have grown up to be transgender? New data might help to answer this question. During the time I was in Toronto, Zucker talked a lot about a scholarly paper currently under review by a group of well-respected Dutch clinicians and researchers. In their group, kids like Alex who underwent an early gender transition were more likely than other gender-variant kids to be &ldquo;persisters&rdquo;&mdash;that is, to continue to identify as the opposite sex into adolescence and early adulthood.</p><p>Because the Dutch data seem to support Zucker&rsquo;s theory&mdash;that the way parents respond to a child&rsquo;s early gender dysphoria has an impact on whether it persists&mdash;the paper feels, to him, like something of a vindication. Herb Schreier sees the same data and reaches the opposite conclusion: The kids who transition early, he says, are the ones who identified themselves vocally and from an early age&mdash;the ones who were clearly going to persist anyway.</p><p>In the vast majority of these kids, however, gender dysphoria resolves on its own. In light of that, I asked Zucker, how do you know your interventions are working? He was honest: &ldquo;I don&rsquo;t think we know.&rdquo;</p><p>&nbsp;</p><p><span style="line-height: 1.538em;"><span class="dropcap">A</span>s a child, Karl Bryant, now a sociologist at the State University of New York, New Paltz, &ldquo;desperately wanted to be a girl, and I expressed it often,&rdquo; he recalls. But this was the early 1960s&mdash;there was no early gender transition subculture&mdash;and Bryant was growing up in a small farming town about an hour from Los Angeles. So he became one of the earliest subjects of Richard Green&rsquo;s Feminine Boy Project. He was enrolled in the &ldquo;treatment&rdquo; arm and had sessions with Green every other week.</span></p><p>Bryant liked Green and remembers trying hard to please him. &ldquo;I knew at a certain point what the expectation was,&rdquo; he recalls. Bryant wrote his Ph.D. dissertation on the politics of gender identity disorder, and he recounts the story in the introduction. &ldquo;I remember occasionally trying to muster the kinds of masculine behaviors that I knew I was supposed to naturally express,&rdquo; he writes. &ldquo;Ultimately I learned to hide as best I could my feminine behaviors and identifications.&rdquo;</p><p>Bryant grew up to be a happy, successful gay man, and he refuses to speculate how, or whether, things would have been different if his parents had allowed him to follow his fervent childhood wish to be a girl. But his &ldquo;happy outcome,&rdquo; he says, is despite, not because of, Green&rsquo;s interventions. The study, he says, gave him the lasting impression that &ldquo;the people closest to me, and that I trusted the most, disapproved of me in some profound way.&rdquo; He says it&rsquo;s hard to overstate the harm that such knowledge can inflict: &ldquo;The study and the therapy that I received made me feel that I was wrong, that something about me at my core was bad, and instilled in me a sense of shame that stayed with me for a long time afterward.&rdquo;</p><p>Zucker acknowledges &ldquo;more similarities than differences&rdquo; between his treatment and Green&rsquo;s. &ldquo;The UCLA group, Richard&rsquo;s group, certainly had a big impact on me,&rdquo; Zucker says. That said, developmental and cognitive psychology are much more sophisticated now than they were then, and Zucker says that the theoretical underpinnings of his work rely on much of this new research. For example, he bases his approach in part on the concept of &ldquo;gender identity self-labeling.&rdquo; Zucker explains: &ldquo;You somehow, by the age of two or three, have recognized that gender is a social category. The world consists of males and females: mommies, daddies, men, women, boys.&rdquo; Children figure out how to label themselves as a boy or a girl (how they do this is the big question, and one that has not been satisfactorily answered) and then &ldquo;search out information in their environment: If I&rsquo;m a girl, how is a girl supposed to behave? You look to the social environment.&rdquo;</p><p>Take something as seemingly arbitrary as color preferences. In general, girls like pink and boys like blue. This is not just anecdotal, Zucker says; studies have confirmed &ldquo;sex-dimorphic<sup class="sidenotenumber">8</sup><span class="sidenote"><span class="sidenotenumber">8.</span><strong>Sex-dimorphic</strong>: (adj) used to describe a trait or characteristic that varies along gender lines&mdash;height, for instance, or the presence of facial hair.</span> color preferences.&rdquo; This isn&rsquo;t because girls are &ldquo;born&rdquo; to like pink, Zucker says, but rather because they say to themselves, &ldquo;&lsquo;I&rsquo;m a girl. OK, so what do girls do?&rsquo; You have your own self-label and then you actively try to behave in a way that matches the label.&rdquo; Zucker&rsquo;s aim, then, is to broaden the kids&rsquo; sense of what someone of their birth sex can be. &ldquo;Let&rsquo;s say a little boy with a strong desire to be a girl, in part, has come to this because temperamentally he has a lot of trouble with rough-and-tumble play,&rdquo; Zucker says. &ldquo;And so recognizing that some kids might think in binary terms&mdash;&lsquo;I&rsquo;m not like that, therefore, the only alternative is to be a girl.&rsquo; But if one can help kids realize there are different ways one can be a boy, maybe that lessens the wish to be a girl. Because one realizes, &lsquo;Oh, I don&rsquo;t have to be running around on a soccer field as the only way one can be a boy. I can do something else.&rsquo;&rdquo;</p><p>Zucker also relies on more traditional behavior--modification therapy, in which you reinforce or reward certain behaviors and ignore or discourage others. He encourages &ldquo;limit setting,&rdquo; like allowing your boy to wear a dress at home but not out of the house, for example, or only for a certain number of hours a day. But he stresses that each child&rsquo;s treatment plan is individualized: For a kid like Alex, encouraging him to be flexible in the way he thinks about gender is as far as he&rsquo;ll push. For a kid like Olivia, he felt comfortable going further. This is largely because Olivia&rsquo;s parents felt comfortable going further.</p><p>Olivia is nine now. But from the time she was two, &ldquo;She wouldn&rsquo;t wear things if there were a pleat or a bow or a sparkle,&rdquo; her mom, Erin, says. Olivia wouldn&rsquo;t drink from a pink cup or eat off a pink plate. She refused to go to school on her birthday, because the teacher gave girls a princess crown to wear on that day. &ldquo;And if there was a special day where I would tell her that a dress was required, there would quickly be juice dumped down the front of it.&rdquo; Erin laughs recalling it. &ldquo;Smart kid.&rdquo;</p><p>Erin also noticed that Olivia couldn&rsquo;t tolerate social situations. She got teased a lot at school, and at home, if Erin&rsquo;s friends came over with their kids, Olivia would either go up to her room and shut the door or sit and rock in the corner&mdash;&ldquo;almost like she was autistic,&rdquo; Erin says.</p><p>By the time Olivia was four or five, they would argue about her gender constantly. &ldquo;I would clarify&mdash;not understanding what the heck,&rdquo; Erin recalls. &ldquo;I would say, &lsquo;Olivia, you&rsquo;re a girl. You&rsquo;re a bit of a tomboy. You&rsquo;re a girl that likes boys&rsquo; things.&rsquo; Then it started into the whole dialogue of, &lsquo;When am I going to become one?&rsquo; That&rsquo;s when I realized that she needed help.&rdquo;</p><p>Erin was referred to Zucker by a therapist she was seeing, but having read some of the criticisms of him online, she was wary. &ldquo;My values are that you take people for who they are, and people can be whoever they want to be in life,&rdquo; Erin says. &ldquo;So if my daughter chooses to be a boy or chooses to be gay or whatever, so be it, and I&rsquo;ll love them and support them and do whatever I can to make them happy in their world.&rdquo;</p><p>But then Zucker asked her a question that stuck with her: &ldquo;If your daughter said to you that she wanted to stay up until two in the morning, would you let her?&rdquo; No, Erin told him. &ldquo;Well,&rdquo; Zucker continued, &ldquo;she&rsquo;s telling you that she&rsquo;s a boy and is going to change into one. And she&rsquo;s young enough that we think in this clinic that she&rsquo;s confused, and you can clarify that for her. What do you think about that?&rdquo;</p><p>Erin thought, &ldquo;OK, let&rsquo;s try this.&rdquo;</p><p>The first thing Zucker encouraged them to do was to go shopping for clothes. &ldquo;You&rsquo;ll have to try to make her clothes gender-neutral,&rdquo; Erin recalls Zucker saying to her. &ldquo;We&rsquo;re not telling you she&rsquo;ll ever wear a dress. But you need to try to get her to grow her hair, get it so she&rsquo;s not looking so much like a boy.&rdquo; He also told her to be clear with Olivia why they were coming to the center for ongoing therapy sessions and why they were going shopping. Erin was nervous about it, because she knew it would upset her daughter, but she recalls, &ldquo;I said, &lsquo;You&rsquo;re not going to be able to wear boys&rsquo; clothes anymore. So we&rsquo;re going to go to the store, and you&rsquo;re going to wear girls&rsquo; clothes because you&rsquo;re a girl.&rsquo;&rdquo;</p><p>Zucker is mindful that clothes and hair length&mdash;not to mention toys and games, indeed, just about every outward sign of gender that he targets&mdash;are superficial. &ldquo;Yet, if you look at normative studies of gender development, kids often use cues pertaining to hairstyle and clothing style to not only mark their own gender but to mark the gender of other kids,&rdquo; Zucker says. &ldquo;So those cues, or markers, are surface representations of a child&rsquo;s underlying gender identity. And I think, in young childhood, there can be a feedback effect.&rdquo;</p><p>If a young boy feels he is a girl, Zucker argues, then playing with Barbies is not as simple or as neutral as playing with blocks or puzzles. Part of the thrill of the Barbies for that boy is that they make him feel like a girl. Because he feels like a girl, he will continue to want to play with Barbies. And so on. &ldquo;There is a back-and-forth between gender identity and surface behavior,&rdquo; Zucker argues. &ldquo;I&rsquo;ve been trying little questions out lately, like: &lsquo;If you like to eat leaves off tall trees, would that make you a giraffe?&rsquo; Some little kids fit that kind of thinking. Kids conflate identity with appearance.&rdquo;</p><p>This was certainly true for Olivia. Finding gender--neutral girls&rsquo; clothes was a challenge, but she and her mom finally agreed on some collared shirts and cargo pants cut in a girl&rsquo;s style. &ldquo;What happened over time was, she stopped getting bullied at school because she stopped looking like a boy,&rdquo; Erin says. &ldquo;It would get her confidence going.&rdquo;</p><p>On days that Olivia came home from school and complained that &ldquo;so-and-so called me a boy,&rdquo; Erin would steel herself and reply, &ldquo;Well, you kinda look like one today, Liv. Your choice. I don&rsquo;t know what you&rsquo;re expecting.&rdquo; Ultimately, Olivia &ldquo;got to a point where she would get upset when people would get confused, calling her a boy. Even though originally that was what she wanted.&rdquo;</p><p>The final recommendation her parents followed was to help Olivia make more female friends. She&rsquo;d always had more boy friends than girl friends, but her parents enrolled her in girls&rsquo; soccer and hockey and were amazed at the difference it made. &ldquo;The girls are like her,&rdquo; Erin says. &ldquo;They&rsquo;re still more girly than her, but they&rsquo;re rough, and when they go to a tournament, they&rsquo;re just tearing around playing Hunger Games. They relate to her.&rdquo;</p><p>Social interactions still don&rsquo;t come easily for Olivia, but Erin feels the changes they made have helped give Olivia the confidence she needs to move through the world more peacefully. &ldquo;I think that if I hadn&rsquo;t gotten the help, I would have allowed her to continue to dress the way she was, and life would have been really tough,&rdquo; says Erin. &ldquo;I think she would have been very withdrawn and disturbed and had difficulty making friends, and been bullied.&rdquo; Erin knows the future is still uncertain: &ldquo;Who knows what she&rsquo;s going to decide? Is she going to be gay? Is she going to be transgender? I don&rsquo;t know. But I do know that she&rsquo;s going to be a confident person and be her own person and feel like she can make her own choices, and recognize how to fit in and how society works. I think this place has saved her.&rdquo;</p><p>&nbsp;</p><p><span style="line-height: 1.538em;"><span class="dropcap">T</span>here&rsquo;s a chance, of course, that Olivia might feel otherwise later in life. &ldquo;If your parents have brought you to Dr. Zucker to figure out your gender, and they are already perhaps less than supportive or [at] least nervous and confused, and then you sit in a play space with an authoritative doctor suggesting you play with a truck, what do you think the child would do?&rdquo; asks emergency-room physician Madeline Deutsch, who is transgender. &ldquo;I suspect that we will see a large number of Dr. Zucker&rsquo;s former patients in their thirties, forties, or fifties seeking gender reassignment, only to regret having not been able to do so decades earlier.&rdquo;</span></p><p>Traditional epidemiologic studies have assumed the prevalence of transgender people to be rare: somewhere in the neighborhood of 1 in 10,000. But recent studies show the numbers are much higher than previously thought (or are higher now than they used to be): 1 in 200, or even, in one recent sample of middle schoolers, 1 in 100. This means that only a tiny sliver of what may be a relatively large population of transgender people are showing up at clinics to make a medical transition. It speaks to the fact that in between living fully in one&rsquo;s birth gender or undergoing all of the cross-gender interventions that Western medicine has to offer is a whole range of options that Zucker&rsquo;s approach doesn&rsquo;t account for.</p><p>&ldquo;The proliferation of gender categories that represent people&rsquo;s desires and experiences and identifications, those are fairly new,&rdquo; Bryant says. So &ldquo;to look at kids today who are gender-nonconforming and try to make some prediction about what they&rsquo;re going to be when they grow up is really fraught. The things that they are going to be when they grow up don&rsquo;t exist right now.&rdquo;</p><p><span class="pullquote">Because of this proliferation, critics like Bryant say, Zucker is basing his work on an outdated conception of gender, suggesting parents radically change the way their children live&mdash;not let them play with the toys they choose, or wear the clothes that make them most comfortable, or play with the friends they most connect with&mdash;on the basis of a dubious guess that some tiny percentage of them will one day want to have sex-reassignment surgery.</span> Or, worse, on the basis of societal prejudice: because the world will not accept them for who they are. This seems as unsettling as Zucker&rsquo;s parents moving to the suburbs and conforming for the good of the cause. It&rsquo;s fair to ask: Whose cause, exactly?</p><p>Although the DSM is strictly a diagnostic manual&mdash;it does not make treatment recommendations&mdash;implicit in the very existence of a diagnosis is the suggestion that it warrants treatment. This is largely the concern that transgender activists and mental-health professionals had when they heard that Zucker would be chairing the DSM&rsquo;s Sexual and Gender Identity Disorders work group.</p><p>Zucker&rsquo;s approach &ldquo;has this default assumption that not identifying with the sex you were assigned at birth is in some way psychopathology,&rdquo; says Karl Bryant. &ldquo;It treats the gender of the child [as] a problem that merits some kind of correction.&rdquo;</p><p>But transgender advocates concede that the new diagnostic criteria represent an improvement over the old. In the previous DSM, for instance, the bar seemed lower for diagnosing boys than girls: To meet the criteria, boys need only have a &ldquo;preference for&rdquo; wearing girls&rsquo; clothes, whereas girls had to &ldquo;insist on&rdquo; wearing boys&rsquo; clothes. In the new DSM, the language is more analogous. The new DSM, which will be published in May, also recognizes the limitations of the gender binary, noting that a child could express either &ldquo;a strong desire to be of the other gender&rdquo; or &ldquo;some alternative gender different from one&rsquo;s assigned gender.&rdquo;</p><p>Still, whether the diagnosis should be in the DSM at all remains a contentious issue. Because hormone--replacement and sex-reassignment therapy cost tens of thousands of dollars, transgender people are in a bind: They need a diagnosis to get health-insurance coverage for their transition-related medical care. Zucker and his colleagues tried to address some of the community&rsquo;s concerns by renaming the diagnosis &ldquo;gender dysphoria.&rdquo; This means that it&rsquo;s not the identity that is a disorder but rather the distress that may result from that identity. A gender-variant kid&mdash;a boy who likes to wear dresses, for instance&mdash;wouldn&rsquo;t automatically meet the criteria, unless the behavior caused him &ldquo;clinically significant distress or impairment.&rdquo; In other words, unless he were suffering.</p><p>The name change alone was a big deal, says psychiatrist Dan Karasic of the University of California, San Francisco, because it implies that &ldquo;the distress of gender dysphoria is the pathology as opposed to gender identity.&rdquo;</p><p>Zucker likes to say that the DSM is &ldquo;agnostic&rdquo; with regard to the origins of one&rsquo;s suffering, but the question of where the distress originates is not a small one. Many kids in Zucker&rsquo;s clinic come in with psychiatric and psychosocial issues. A quarter of them have been involved with child protective services and a quarter have attempted suicide. Zucker concedes that &ldquo;experiences of ostracism, social rejection in the peer group, et cetera, does account for some&rdquo; of the distress. But, he says, &ldquo;I personally think that it&rsquo;s too simplistic to say that it&rsquo;s the peer ostracism or the stigma that explains it all. We see a lot of adolescents whose families are pretty supportive,&rdquo; he continues. &ldquo;They&rsquo;re not being rejected. Their friends are chill. But they&rsquo;re still very unhappy and very distressed and miserable. So even with external acceptance, the incongruence between somatic sex<sup class="sidenotenumber">9</sup><span class="sidenote"><span class="sidenotenumber">9.</span><strong>Somatic sex</strong>: (noun) the sex implied by one&rsquo;s physical body. People with gender dysphoria suffer a disconnect between their somatic sex&mdash;their physical sexual characteristics&mdash;and their gender identity.</span> and felt gender is still very painful.&rdquo;</p><p>For the most part, following his interpretation of the standards of care, Zucker will not recommend puberty suppressors or cross-gender hormone therapy for anyone whose psychiatric issues aren&rsquo;t addressed first. His critics say this misses the point: Transitioning is addressing their psychiatric issues. By offering hormone therapy and other medical interventions, &ldquo;you treat not only the medical hormonal deficiency and help them attain the body that they wish, but you are very likely to erase a whole bunch of psychopathology that&rsquo;s all secondary,&rdquo; says Norman Spack, an endocrinologist who runs the Gender Management Service at Boston Children&rsquo;s Hospital. Spack says he has seen major depression, anxiety&mdash;even mild Asperger&rsquo;s&mdash;resolve after kids are able to transition.</p><p>While I was in Toronto, a teenage patient of one of the other psychologists in the clinic came in for a follow-up visit. This person had the body of a female but covered his breasts in layers of binders and was so afraid to be read as a female that he wouldn&rsquo;t leave the house, even for school&mdash;he attended high school online and ventured out only for his appointments and, once a week, to the in-person component of his curriculum. He told his psychologist, one of Zucker&rsquo;s colleagues, that if she wouldn&rsquo;t refer him for hormone therapy, he would kill himself. The colleague stopped by Zucker&rsquo;s office to ask him what to do.</p><p>The standards of care say someone is ready for hormone therapy when he has lived successfully as his preferred gender for a period of time. Did this person qualify, if he never left the house? Is his extreme distress the result of his gender dysphoria? Or is the depression clouding the psychologists&rsquo; ability to get an accurate read on his gender identity? All these questions were theoretical, though. In the next room was a real patient who was suffering, and Zucker did what he thought was best: He referred him to the endocrinologist to begin hormone therapy.</p><p>&nbsp;</p><p><em>*The names of Zucker&rsquo;s patients and their family members have been changed to protect their privacy.</em></p></div></div></div> Thu, 14 Mar 2013 13:04:15 +0000 217021 at Beth Schwartzapfel Inconvenient Contraception <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"> <p>Last week, birth control for college students got cheaper. An "affordable birth control" provision in the 2009 appropriations bill, which President Barack Obama signed last Wednesday, restored an incentive for drug makers to offer college health clinics discounts on the pill (the longstanding incentive had been inadvertently eliminated in a 2005 deficit-reduction bill). Still, even when it's cheaper, birth control will continue to be two things: inconvenient and thoroughly tied up with the medical system.</p> <p>A trip to the doctor. Time off from work. A waiting room. A pap smear. A co-pay (assuming you're insured, of course). A trip to the pharmacy. Another co-pay. Then, finally, your birth control: 28 little pills, packaged in foil and plastic, standing between you and a pregnancy you don't want. </p> <p>If you are one of the 11.6 million women in this country who relies on the pill to prevent pregnancy, this scenario, or some variation on it, has played out in your life again and again. It may not have to be this way. </p> <p>"A pap smear is important. The pill is important. There's not really a connection between the two," says San Francisco gynecologist Dan Grossman. "It's a very paternalistic attitude to say, as a physician, we have to hold women's pills hostage -- you can't get your contraception until you get your pap smear." </p> <p>England's National Health Service recently announced that later this year it will launch a pilot program to allow young women in two London neighborhoods to buy birth control over the counter after a brief consultation with a pharmacist. The London program is modeled after a pilot program that was conducted in Washington state between 2003 and 2005, in which 26 pharmacists throughout Seattle safely provided hormonal contraception -- the pill, patch, or ring -- to almost 200 women without a prescription. A similar study is being planned for California. </p> <p>Now, a group of doctors, pharmacists, researchers, and advocates have received a grant from the Hewlett Foundation to fund a working group that studies the feasibility of making oral contraceptives available over the counter: as easy to purchase as aspirin. According to the reproductive-health think tank the Guttmacher Institute, nearly half of women will experience at least one unintended pregnancy by the time they're 45, and almost a third will have had an abortion. Part of the reason for this, those in the working group say, is that the barriers to birth control are simply too high. </p> <p>"It's harder and harder to access contraception care if you want it, here in the U.S.," says Grossman, who is a senior associate at the nonprofit research organization Ibis Reproductive Health, which coordinates the Working Group. "Non-use of contraception is going up among people who don't want to be pregnant, especially among vulnerable populations, like poor women and women of color." The group's hypothesis is simple: If birth control were easier to access -- fewer medical gatekeepers, less inconvenience, and lower cost -- more women would use it. If more women used it, there would be fewer unintended pregnancies. </p> <p>Fair enough. But is it safe? What effect would a switch to over-the-counter status have on poor women's access to the medication? And if women were no longer required to get birth control from their doctor, would they still go for their annual exams? </p> <p>The pill has been exhaustively researched, and most doctors agree that it poses almost no risk of serious side effects for the vast majority of healthy young women. But estrogen (one of two main ingredients in most forms of the pill) can slightly increase risk of heart attack or stroke among older women who smoke and women who have high blood pressure, diabetes, and a handful of other conditions -- so doctors prescribing birth control have long screened for these conditions. </p> <p>"I think the doctor's got to be a gatekeeper," says Michael Cackovic, an instructor of obstetrics and gynecology at the Yale School of Medicine. The doctor should "not necessarily decide who gets to be on the pill and who doesn't but [should] at least make sure patients understand the risk. I have prescribed [the pill] to patients that are smokers and over 40, but after we've had the conversation." </p> <p>Grossman instead argues that a clearly worded and easy-to-understand label is enough to let women screen themselves. "If you go through the list of all of the medical conditions that can make pill use dangerous, everything on that list except for [high blood pressure] is information that we get from a woman's history -- from what she tells us," he says. "You don't need a doctor to determine whether you have them." As for blood pressure, "educating women and making that service available," in places like self-screening kiosks in pharmacies, might be a better approach than requiring a doctor's visit as a prerequisite, he says. </p> <p>"I'm personally convinced that there are not safety issues in taking oral contraceptives over the counter," says Sharon Camp, president and CEO of the Guttmacher Institute and a member of the Working Group. "For most of the people in the reproductive-health field, the issue of safety is probably not the biggest one. It really is, will an over-the-counter product be affordable for women who now get low-cost or reimbursed drugs? That remains to be seen." Camp's concerns stem from an earlier fight for over-the-counter access to emergency contraception, also known as Plan B. </p> <p>Most insurance plans -- including most state Medicaid programs -- only cover prescription drugs. So when the Federal Drug Administration (FDA) finally approved the Plan B switch in 2006, millions of women suddenly found that the medication was no longer covered. At the same time, without insurance companies to bargain it down, the price of the medication jumped from roughly $27 to as high as $50. </p> <p>"If we don't address that, but [if] we make the pill available over the counter, we will have made it more accessible to women who already have good access to health care, and less accessible to women who don't," says Amy Allina, program director at the National Women's Health Network and a member of the Working Group. </p> <p>The Guttmacher Institute recently released a policy brief that said that at least 4.2 million women use visits to publicly funded family-planning clinics as their primary source of medical care. Clinics like Planned Parenthood become what the brief called "safety net providers." What would happen if they disappeared? "You don't want to say that you're requiring women to come in and get pills on prescription as a way of forcing them to get health-care services," Allina says. "But if women aren't coming into the clinics otherwise, and don't get those services, that's not good for them and eventually could lead to the loss of the clinics." </p> <p>Still, an application to the FDA to make the over-the-counter switch is more of a long-term goal than an immediate plan. Grossman is hoping for 10 years, and part of the goal of the Working Group is to identify all the outstanding questions and answer them with research. Before it would approve a switch, for instance, the FDA would require "labeling comprehension" studies, to make sure the average user would be able to understand the instructions on over-the-counter packaging. They would also perform "actual use studies" to see if women would follow the instructions in the real world. Some of the research is either ongoing or being planned. "One of the lessons that I feel like we learned from the long battles over emergency contraception at the FDA," Allina says, "[is] that, if we ask the kinds of questions that we may think are above and beyond what the FDA should require, but are the questions that people in the community are concerned about -- and we can answer them -- it makes it easier to get past the political opposition." </p> <p>But the precautions may not even be necessary. The Obama administration's proposed overhaul of the health-care system might make for an entirely new playing field by the time enough research has been conducted to actually move the process forward. Perhaps, in 10 years, poor women will have affordable and accessible access to health care, leaving Working Group members and other reproductive-health advocates to weigh the proposal on its merits alone. </p> </div></div></div> Mon, 16 Mar 2009 23:27:47 +0000 147839 at Beth Schwartzapfel Former Prisoners Reforming Prisons <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"> <p>Elizabeth Gaynes has worked with people involved in the criminal justice system for more than 30 years: as a young law student in the early 1970s, she was galvanized by the uprising at Attica, and helped to defend some of the incarcerated people who were involved. Later, she took the reins as executive director of the nonprofit Osborne Association, which provides services to incarcerated people and their communities.</p> <p>But until her daughter turned 16 and started speaking up about prison issues, Gaynes kept a rather relevant piece of personal information close to her chest: her kids' own father was incarcerated, and had been for a decade. "We really didn't volunteer that information very much in the world," she says. "Even people like me who worked in this business felt pretty restrained." </p> <p>All of that's changed now. Part of it, Gaynes says, was her daughter's outspokenness. Part of it, however, was a larger cultural shift that is now reaching a tipping point. People affected by incarceration are raising their voices and telling their stories in ever-larger numbers. And, for the first time, politicians, policymakers, correctional officials, and foundations are listening. </p> <p> "There are more formerly incarcerated people speaking up, organizing to fight for civil and human rights," says Dorsey Nunn of the San Francisco-based nonprofit organization Legal Services for Prisoners With Children. </p> <p>There is now more funding than ever before available for organizations doing work around issues of incarceration -- some $40 million in federal and foundation dollars, up from almost nothing in 1999. More organizations working in the field are employing people affected by incarceration, and graduating those employees to leadership positions. And politicians and correctional officials are recognizing that, in conversations about correctional policy, they must reserve a seat at the table for those who have lived it. </p> <p> "Especially in the last year and a half there's been a tremendous change in the attitudes of correction personnel," says Scott Washington, an attorney with the Dayton, Ohio-based nonprofit, Workplace Reconnections. Washington served some three years in prison and jails after spending his youth as a crack addict and member of the Crips gang. He later went on to college and then law school. "There's always going to be an ‘us against them' mentality," he says. "But the attitude of politicians is changing." </p> <p>The U.S. prison system is in the midst of a unique historical moment. Federal "Truth in Sentencing" laws and mandatory minimums have recently turned 20, and the stringent state laws which followed suit -- California's 1994 ‘three strikes' law, for instance -- are coming of age, such that the first generation of people who have served 10- and 20-year sentences under these laws are re-joining their communities in record numbers. They're arriving home at a time of increasing political consciousness about incarceration -- the term "prison-industrial complex" was coined only a decade ago, by activist and historian Mike Davis in a 1995 article in <i>The Nation</i> -- as well as a growing awareness on both sides of the political spectrum that the current system is not sustainable. More than 2 million people are incarcerated in U.S. jails and prisons. If you include people on probation and parole, that number jumps to over 7 million, or 1 in every 32 adults, according to the Bureau for Justice Statistics. At least 95 percent of them will come back home: 1700 people a day are released from state and federal prison. </p> <p>The staggering numbers of people being released are, at least in part, at the root of this new trend towards a larger role for formerly incarcerated people in the criminal justice policy discussion. In 1999, Jeremy Travis was director of the National Institute of Justice when then-Attorney General Janet Reno asked him what was happening to all the people coming out of prison. The answer was Travis's 2005 book, <i>But They All Come Back</i>, and a shift in the conversation from its previous focus, rehabilitation to the new buzz-word: re-entry. </p> <p> "Rehabilitation was seen as a pure left kind of issue," says Amy Solomon, senior research associate at the Urban Institute, who worked with Travis when he was a senior fellow there. "It was a discussion about helping offenders, coddling offenders." Re-framing the debate to be about re-entry, she explains, meant "rethinking how people are released into the community, [putting it in the context of] public safety, about doing things smarter so we prepare people for work and family when they get out. It really galvanized people on the right and the left." </p> <p>Further, the sheer number of those incarcerated, and the reach of the war on drugs, has meant that "we've now gotten to the point where there are very few people left who have not been personally touched," says Gaynes of the Osborne Association. "It's hard for it to keep being ‘them' all the time." Suddenly, politicians on both sides of the aisle could listen to those with a bent towards reform without being seen as soft on crime. </p> <p>In the past, says Glenn Martin, co-director of the H.I.R.E. Network, which seeks to increase job opportunities for those with criminal records, "we were caught in such a tough-on-crime era that people would stay away from taking advice from those directly affected because they were worried that their constituents would say, ‘what are you doing taking advice from these criminals?'" Now, says Martin, who served six years in New York state prison for armed robbery before being hired as a receptionist at the H.I.R.E. Network and working his way up to his current position, "I have to pinch myself. I'm sitting here with the head of criminal justice services, or I'm sitting here with the top Republican in a state somewhere." </p> <p>Susan Tucker, program director at the Open Society Institute's After Prison Initiative, one of the key funders in the field, says that six or seven years ago, meetings and panels about re-entry rarely included the perspectives of formerly incarcerated people. Now, she says, including formerly incarcerated people on the agenda is "pro-forma." </p> <p>State and federal funds are pouring into re-entry programs, which means there is more money than ever allocated for positions specifically for formerly incarcerated people. President Bush, in his 2004 State of the Union Address, proposed a $300 million prisoner re-entry initiative, citing Bureau of Justice Statistics data that some 600,000 inmates are released each year. "We know from long experience that if they can't find work, or a home, or help, they are much more likely to commit crime and return to prison," Bush said. </p> <p> The resulting $25 million Prisoner Re-entry Initiative was funded in fiscal year 2005 and now has 30 grantee organizations nationwide that work to transition formerly incarcerated people back into the workforce. State-financed programs have followed, and with them, more employment and advocacy opportunities for former inmates. </p> <p>Critics are quick to point out that re-entry work is, in the words of one person in the field, "tinkering around the edges." Which is to say, it doesn't address the real problem: the massive numbers of incarcerated people in the United States, and the socio-political structures which cause poor people and people of color to be locked up in numbers vastly disproportionate to their numbers in the country as a whole. </p> <p> "Out of the punishment industry comes a group of people who says, let's try something different," says a skeptical Nunn of Legal Services. "I don't know how different it is--they're just acknowledging that we're releasing a lot of people." In other words, politicians may be able to make changes to the way people are released without seeming soft on crime, but it would be a different story for a senator to propose changing the way we approach incarceration altogether. </p> <p>These types of proposals, more often than not, come from formerly incarcerated persons themselves. A 1998 conference was convened by formerly incarcerated people, including Nunn and Angela Davis, to examine ways of dismantling the prison-industrial complex. Nunn says the organizers were expecting some 500 attendees -- instead thousands flocked to New York City, and the weekend led to the birth of Critical Resistance, a national grassroots organization which seeks to "build an international movement to end the Prison Industrial Complex by challenging the belief that caging and controlling people makes us safe," according to its website. </p> <p>Organizations like Critical Resistance are still considered relatively fringe, but they have been successful in raising awareness and helping to politicize the issue. "We took an obscure term out of a Mike Davis [article]-- prison-industrial complex -- we turned that into common language," says Nunn. </p> <p>Nunn, who notes that after years of being the only one in his organization to be directly affected by incarceration, now up to 50 percent of his coworkers have done time, says that an increased political consciousness among people affected by incarceration has made the community speak out with a louder voice than before. </p> <p> "I used to run from being this particular thing. Now I'm not running anymore. That's absolutely new. Used to be a time we would internalize it," he says. He used to tell himself, "Maybe I'm not good enough for the apartment. Now, I say, I have a right to get an apartment. Maybe I don't deserve a job. No, I deserve a clean application." </p> <p>Foundation money has supported the push of the political envelope further to the left, allowing organizations to focus not just on re-entry, but on more systemic issues raised by incarceration, such as poverty and racism. "Most everybody agrees from right to left, people are coming out, they deserve a second chance, they need services, they need help," says the Open Society Institute's Tucker. "A more nuanced understanding is that incarceration itself is both a cause and an effect of political, economic, and social disenfranchisement." </p> <p>Since it was launched in 2000, the Institute's After Prison Initiative has distributed $16 million in grants to some 100 organizations doing work "to decrease U.S. over-reliance on mass incarceration and harsh punishment," according to its <a href="">website</a>. And this year the Funding Exchange, a national network of local community foundations, under its Criminal Justice Initiative, released its first request for proposals specifically targeting organizations with formerly incarcerated persons in leadership roles. </p> <p>Now that politicians and policy makers are listening, formerly incarcerated people have seen their stories go from being a source of shame to a force for change. Scott Washington of Workplace Reconnections, which helps people coming out of prison to lay the groundwork for successful re-entry, says, "I tell the guys that I work with, you're experts. If you transition fully back to community life, you have a commodity: your story." </p> <p> "I'm the storyteller in my organization," says Patty Katz, a program director at the Oregon-based nonprofit Partnership for Safety and Justice. "My claim to fame is I can make a legislator cry in two minutes." Katz, who served a cumulative total of some six years in prison and jail as a result of her 14-year drug and alcohol addiction, says, "you don't wish to shut the door on your past because your experience can benefit others. I had to believe that if I were brave enough to stand up out of my box of anonymity and publicly tell my story, I would be delivering hope to decision makers." </p> </div></div></div> Wed, 27 Jun 2007 22:49:15 +0000 146417 at Beth Schwartzapfel Barrier Methods <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"> <p>When Margaret Sanger was arrested in 1916 for "obscenity" (which is to say, advocating birth control), diaphragms were a revolutionary way for women to take control of their bodies. What do most women think of diaphragms today? Yawn. So quaint, so old-fashioned, so ... Margaret Sanger. The number of women using the diaphragm has fallen steeply since highly effective hormonal methods were introduced in the United States in the 1960s. What was once the country's most common contraceptive device is now used by less than 2 percent of couples nationwide, according to the Centers for Disease Control and Prevention.</p> <p>A small but growing number of researchers and advocates think that the oldest contraceptive on the market -- a latex or silicone cup with a firm, flexible rim and a shallow dome -- could be re-imagined for the 21st century. A Seattle-based international nonprofit organization, Program for Appropriate Technology in Health (PATH), is working on a diaphragm redesign, the first ever in the device's 120-year history. Not only could it offer American women yet another contraceptive option, but it could prove a powerful tool in reducing HIV infection rates both at home and abroad. In a large-scale clinical trial that's the first of its kind, researchers are currently testing the impact that diaphragm use has on HIV infection rates in Africa -- where methods of protection that women can initiate without requiring their partners' consent are badly needed.</p> <p>The new diaphragm, known as SILCS, tested well in early trials and is poised to enter the market before the end of the decade. Unlike the Ortho All-Flex, currently the most commonly prescribed diaphragm, which comes in nine sizes and requires a woman to undergo a specialized pelvic exam to be fitted with the correct size, SILCS is a "one size fits most" silicone device. "Providers look at [the Ortho All-Flex] as a hassle because of the fitting requirements," said Dan Grossman, a San Francisco-based gynecologist and senior associate at the nonprofit research and advocacy organization Ibis Reproductive Health. In a recent article in the <em>American Journal of Public Heath</em>, Grossman argued that there is no evidence for utility of the fitting requirement, and that a diaphragm in the most commonly-prescribed size may be just as effective as a fitted one. </p> <p>"Manufacturing processes have changed, materials have been updated, we know a lot more about vaginal anatomy now, so this is a good, simple technology that we could make significant improvements in," said PATH program officer Maggie Kilbourne-Brook. If all goes according to plan, SILCS will gain FDA approval and be available to American women by late 2009 or early 2010. The initial approval will likely require some sort of prescription, though once the product is on the market, PATH plans to submit a second round of applications to allow for over-the-counter access, according to Kilbourne-Brook.</p> <p>It remains to be seen whether even the most high-tech barrier method will become popular among a generation of American women who are far more comfortable using hormonal methods of contraception. The pill prevents pregnancy more effectively, and for many women it is more convenient. "Many women are likely to see the diaphragm as outdated, messy, unreliable, and generally inconvenient," wrote women's health researcher S. Marie Harvey in the journal <em>Perspectives on Sexual and Reproductive Health</em>.</p> <p>"The problem with the diaphragm was that it has to be 'in place' to work, and didn't work if it lay in its case in the drawer," said Dr. Diane Merritt, Professor of Obstetrics and Gynecology at Washington University in St. Louis and a member of the FDA's Advisory Committee on Reproductive Health Drugs. "It required planning, and as anyone will tell you, sex isn't always planned. Removing the act of contraception from the act of intercourse led to the popularity of the pill." </p> <p>Still, there's a reason the diaphragm has endured; when used correctly and consistently, it can prevent unintended pregnancy for upwards of 90 percent of users. (Researchers differentiate between "typical use" and "perfect use"; the diaphragm's typical use effectiveness is more like 85 percent, as opposed to 92 percent for hormonal birth-control pills). Unlike the pill and the vast array of other hormonal methods, including the patch, the Nuva-Ring, implantable rods, and Depo-Provera injections, a diaphragm is not systemic, has no side-effects, and can be immediately reversed by simply taking it out. It is a woman-controlled barrier method, meaning women can use it without the need for their partners' consent or approval.</p> <p>Perhaps most importantly, the newly redesigned diaphragm could prevent more than pregnancy. Scientists already know that the device provides some protection from gonorrhea, pelvic inflammatory disease, and abnormal cell growth. Why not HIV? Particularly among sex workers and other women in vulnerable situations, who may be unable to negotiate condom use given uneven power dynamics, the fact that diaphragms are woman-controlled and can be used without a partner's knowledge could make them a critical tool in the fight against AIDS. </p> <p>In 2002, PATH convened with virologists and immunologists to determine if cervical barrier methods, such as the diaphragm, might offer some protection against HIV. Inside and around the cervical os (the passage through the cervix into the uterus) is a single layer of delicate, easily ruptured, tissue. This area is packed with HIV receptor cells, and thus is thought to be particularly vulnerable to STIs. Conversely, the vaginal walls are lined with some 30 layers of tougher, more durable cells that are less susceptible to infection. </p> <p>But the vagina itself does contain HIV receptors, and lesions from other STIs, like herpes, can make even tough cells vulnerable to infection. Clearly a cervical barrier would only provide partial protection. However, in places like sub-Saharan Africa, where 2.4 million people are infected with HIV each year, even partial protection could potentially make a huge difference. </p> <p>PATH's research caught the attention of the Bill and Melinda Gates Foundation, which gave $28 million to the Women's Global Health Imperative program at the University of California, San Francisco medical school to further investigate whether diaphragms might be a part of the HIV prevention puzzle. The result is a large-scale randomized, controlled trial of 4,500 women in Zimbabwe and South Africa, examining whether diaphragm use may provide them with some protection against HIV. Preliminary results are expected this summer. </p> <p>"The world is waiting for the results," said Kilbourne-Brook. Unlike brand-new methods of HIV prevention which are still in the research and development phase, diaphragms are already widely available, cheap to manufacture, and relatively easy to distribute. "If it turns out that something as simple as a diaphragm, this old-fashioned technology, could actually offer some protection from HIV, that's something that could get into women's hands very easily."</p> <p><em>Beth Schwartzapfel is a freelance journalist and MFA student in creative nonfiction at the New School. She lives in Brooklyn, NY.</em></p> <p></p><center>* * *</center> <p>If you enjoyed this article, subscribe to <em>The American Prospect</em> <a href="">here</a>.</p> <p>Support independent media with a tax-deductible donation <a href="">here</a>.</p> </div></div></div> Wed, 21 Feb 2007 20:28:51 +0000 146070 at Beth Schwartzapfel