Dan Carmichael had barely taken his first breath when a doctor announced his gender: "It's a girl."
That's where gender identity begins for most. A pronouncement at birth, a quick glance at the genitals revealing a person to be either male or female.
If only it were that simple for Carmichael. He was raised a girl — then named Danielle Sosin — grew into a woman, served in the Iraq War, yet never quite felt comfortable.
"I felt like an impostor," said Carmichael, now 33 and living as a man, the gender he always identified with. "But who do you become when you're not really sure who you are?"
Carmichael is part of a once-hidden demographic that now feels freer than ever to show itself, even while faced with widespread discrimination and misunderstanding of what it means to be "transgender."
Unlike gays and lesbians, who in some substantive ways have been assimilated into modern American culture, transgender people remain on the fringe, often stereotyped as "trannies" and sensationalized in movies and television shows.
The recent appearance of Chaz Bono, a transgender man formerly known as Chastity Bono, on the television show "Dancing With the Stars" caused an uproar among some conservative groups like the American Family Association. And "Work It," a new ABC comedy that premieres Jan. 3, is being widely protested by transgender groups for its premise: Two men dress like women to get jobs.
Transgender activists have been on the front lines of the gay and lesbian civil rights movement since before the riots at New York City's Stonewall Inn in 1969, but only fairly recently has the transgender community felt empowered to speak up and demand recognition and rights of its own.
Across the country, legislative efforts are under way to make it easier for people to change the gender on their birth certificates and align identification documents — including driver's licenses and passports — with their gender identity. Many jails and prisons, including the Cook County Jail, have implemented rules to accommodate transgender inmates. And legal advocates agree that while gays and lesbians continue to fight for marriage and other rights, the next significant wave of legal action will involve transgender people.
On Dec. 6 in Georgia, the 11th U.S. Circuit Court of Appeals ruled in favor of a transgender woman who was fired from her state job in 2007 after telling her boss she planned to transition from male to female. In the court's ruling, Judge Rosemary Barkett wrote: "An individual cannot be punished because of his or her perceived gender non-conformity."
In October, the Illinois Department of Public Health, pressed by a lawsuit from the American Civil Liberties Union, said transgender Illinoisans could change the gender on their birth certificates without undergoing genital-reformation surgery.
Also this year, the 7th U.S. Circuit Court of Appeals in Wisconsin ruled it unconstitutional to deny transgender prison inmates hormone therapy and Connecticut and Massachusetts became the 15th and 16th states to protect transgender people from discrimination.
"I think it has been a good year," said M. Dru Levasseur, transgender rights attorney for the national lesbian, gay, bisexual and transgender legal rights group Lambda Legal. "I think the key thing — and it's very similar to the change that happened in the movement with gay and lesbian people — is that many people thought, 'Oh that's a choice, that's a lifestyle.' When people come to understand that this is who someone is, I think that's when they can really take it into their hearts."
Many religious faiths, however, strongly disagree with that belief, saying that uncertainty about gender identity is a distortion of God's design of humans as being male or female according to birth anatomy. The conservative Christian group Focus on the Family's position statement on transgender says, "Gender matters. In recent years, a revisionist transgender theology has been put forth in some theological circles that violates God's clearly articulated and intentional design for the sexes — thereby distorting His image and His plan for sexuality, marriage, family and the just and proper ordering of society."
And despite progress with civil rights, transgender activists say discrimination in public and in the workplace remains commonplace. The impact of that is crystallized in a national study released this year by the National Gay and Lesbian Task Force and the National Center for Transgender Equality.
The survey of more than 6,000 transgender and gender nonconforming people found that 41 percent of respondents had attempted suicide, compared with less than 2 percent in the general population.
One of the primary psychiatric terms linked to transgender people is "gender identity disorder," although it has been proposed that the term be changed to "gender dysphoria" in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association's listing of psychiatric conditions.
"People with severe gender dysphoria, there's a very high incidence of suicide if it's not addressed," said Randi Ettner, an Evanston-based psychologist who specializes in gender conditions and wrote the book "Gender Loving Care."
"Even people with lesser amounts of gender dysphoria can often have substance abuse problems. Men in prison with gender dysphoria will sometimes castrate themselves, because it's the only way they can feel right. This is not a lifestyle choice. It's a torturous road and nobody would choose to go through this."
Whether it's Joan of Arc — executed in part for routinely wearing male clothing — or the Native American "berdache" — gender-variant people revered in certain tribes as "twin spirits" — the world has a long history of gender roles being blurred.
Some cultures accept people whose gender identity doesn't match their anatomical sex. A tribe in Samoa, for example, has a third gender made up of men who perform tasks otherwise reserved for women. But in America and most parts of the world, the binary system of gender identification is not friendly to those who don't fit in.
"One thing that people feel they can hold on to is that if, on the day you're born, they look between your legs and say 'male' or 'female,' then it's expected you'll behave in a masculine or feminine way," said June LaTrobe, transgender liaison for the Center on Halsted an LGBT community center in Lakeview. "But if you say, 'Regardless of what my genitalia may look like, that's not how I feel about myself,' then it can get to be just confusing. It's just not part of what many people have in their database."
That's in large part because traditional gender roles are imparted on people at a young age.
"We teach gender roles mainly through shame," Ettner said. "Children learn quickly that there are certain feelings they can't express or they will be punished or shamed or ridiculed. But developmentally, gender variance is something that occurs very early in life."
Experts like Ettner agree that the term "transgender" means, in essence: people who want to spend all or part of the time presenting themselves in a gender other than the one they were assigned at birth. That said, sex researchers have found that there is tremendous diversity in the transgender community, so much so that many now view gender identity not simply as "male" or "female," but as points on a spectrum between masculine and feminine.
Some transgender people are transsexual, meaning they want to alter their primary and secondary sex characteristics, anything from taking hormones to having sexual-reassignment surgery. On the other end of the spectrum, a transgender person who is anatomically male might identify partially as a woman and need only to occasionally dress in women's clothing in order to feel complete.
People diagnosed with gender identity disorder have often gone for years battling depression and emotional stress, along with feelings of being disingenuous. Therapists have found that these people, in most cases, can find psychological relief only by living in the gender with which they identify.
"For an adult with real gender dysphoria, it's unlikely that they're going to be comfortable living in their physical sex," said Richard Carroll, associate professor of psychiatry and behavioral sciences at Northwestern University's Feinberg School of Medicine. "The crucial step is for the individual to take some time to examine the options in a thoughtful way."
For Carmichael, who was serving as a woman in the Army National Guard, the time to think about gender identity came during the Iraq War. When a close friend was badly injured, the thin line between living and dying prompted him to address the confusing feelings that had plagued him since childhood: "I had hard questions to ask myself. And I did it."
While still in Iraq, Carmichael began, in his head, referring to himself using male pronouns. It felt right. After the war, he returned to Chicago and spent time reading extensively about what it meant to be transgender. He considered his lifelong journey — being a young girl who felt awkward in traditionally feminine roles; coming out in high school as a lesbian, hoping the disconnect he felt was a matter of sexuality; then recognizing that the problem was actually one of gender identity.
When Carmichael decided to transition and began living his life fully as a man, he at last felt right.
"I'm very comfortable being a trans man," said Carmichael, who now does respite work for a family who has a child with autism. "I'm sort of reveling in the idea of finally being content."
Alice Dreger, professor of clinical medical humanities and bioethics at Northwestern, said this kind of outcome is common and demonstrates what it takes for a transgender person to find physical and psychological peace.
"People who are transgender do much better after they have the interventions they need," Dreger said. "The regret rate in sex-change procedures is very, very low."