'They can see me'

Xan Smith pulls a fresh shot of espresso into their coffee mug one Thursday morning.

Their partner Randall gives them a quick kiss goodbye as he steps out the front door. The birds start chirping and light slowly shines through the home’s front windows. Xan picks up their mug and makes their way toward their office to get their medicine. It’s just about time for their weekly hormone injection.

From a nearby shelf, they grab a red and white striped paper bag. You can see the IU logo near its center. Inside are needles and small vials of clear liquid — testosterone. Xan takes a wrapped needle and one of the small vials.

Xan is a 31-year-old graduate student at IU. They are a Ph.D. candidate at the Media School, studying the application of gender in video game avatar creation. They’ve lived in Bloomington for nine years and got married to Randall in fall 2021.

Since the second grade, Xan has felt different from other kids. Relationships were hard for them. At the time, Xan was sure they were a girl. They just thought they had to express that identity differently. When they wore nails or dresses, it was upsetting and didn’t feel right. They used to like these things when they were little, but they didn’t like how nails and dresses made people perceive them. They weren’t sure why.

Xan enters the bathroom, sets their mug down on the vanity, unwraps the needle, pokes it into the vial and starts filling the syringe up with testosterone. They take a quick glance at themselves in the mirror. They’ve started to grow facial hair, and their voice is lower too. Their students use their correct pronouns, and they have a good support system. It took their whole life to get here.

About 0.5% of the population of Indiana identifies as transgender. That is around 25,800 people, according to data collected by the Williams Institute. For the trans community, coming to terms with your identity means interfacing with systems and people that feel owed an explanation. As a practice, gender-affirming care asks for no explanation. It builds acceptance. It saves lives. For four students at IU, gender-affirming care has helped them gain access to necessary therapies, surgeries, and support. But red tape, insurance issues, and unqualified professionals can make getting this care more difficult.

These students receive care at the IU Student Health Center through the Gender Affirming Care Team, but gender-affirming care is more than just doctor visits and medicine. It is a partner who supports and loves you unconditionally.

People spend their whole lives learning about and accepting who they are. The work of trans people is no different. It is the work of a lifetime, one day at a time.

Xan drops the needle in a bottle on the vanity. It is just another week.

•••

Dr. Laura Knudson leads IU’s Gender Affirming Care Team, which strives to influence the health center’s protocols and operations to be as gender affirming as possible.

“Gender-affirmative health care can include any single or combination of a number of social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity,” according to the World Health Organization.

For the health center, that care includes training nearly all of the center’s employees, including janitorial staff, in being gender affirming.

Knudson works closely with center’s transgender clients. Her office is full of visual cues to comfort her patients. On the walls are stickers representing different sexual orientations. She has a diagram mounted in a frame titled the “gender unicorn.” It delineates the differences between gender identity and gender expression. In another corner of the room hangs an art piece with flowers, captioned with the phrase “grow your own gender.”

Xan decided they wanted to start hormone replacement therapy at the health center in October 2021. From there, it took two weeks of blood tests and consultations until they could access the medication. Two weeks may not seem like a long time, but those two weeks were predicated upon over 10 years of work.

“Once you get in the mind of ‘I want to start this,’ then it's agonizing waiting,” Xan said.

Source: Dr. Laura Knudson

The health center has eliminated some of the boundaries other organizations and administrations fall into with gender-affirming care, Knudson said. Originally, hormone therapies were not based on informed consent, and instead required letters from mental health professionals to validate the care. These logistical trappings made it much harder to gain access to care, especially with low-income students. Now at the center, HRT is based on informed consent, so letters aren’t necessary. Trans people can also get informed consent HRT from Planned Parenthood.

Family therapist Deborah Pardue said gender-affirming care saves lives. A recent study shows about 40% of transgender individuals have attempted suicide. Pardue said that rate is even higher when factoring in those who succeed. That same study indicates 82% of trans people have thought about it at some point.

“Once they get gender-affirming care, rates of suicide, depression and anxiety go down because they're making progress to be who they are,” Pardue said. “It's really relieving for them.”

Indiana's trans health care is viewed positively compared with surrounding states

In a 2015 survey, trans Hoosiers reported fewer negative experiences with healthcare providers than respondents from surrounding states, but also reported high costs for gender-affirming care.

Source: 2015 U.S. Trans Survey

However, being gender affirming takes more than just providing medical care. Knudson takes time to design the environment she works in so it is welcoming to her patients. Gender-affirming care requires professionals to step out of the binary understanding of gender, she said.

“Those kinds of changes are really necessary in health care to make sure that everyone is being served,” she said.

•••

Gender-affirming care was not as widespread in fall 2008 when Xan was in high school. When they were 17, they didn’t know how to process how they felt inside. They said subconsciously they felt they were a feminine gay man.

“But I wasn't. I was in a female body. I didn't know why,” Xan said.

Growing up in that environment meant being outwardly trans didn’t feel like an option.

“The only other option was to fully deny it.”

Around that time, Xan developed a panic disorder. They still don’t fully know the reason why the disorder developed, but the attacks kept them up most nights. By senior year of high school, they said they felt like a husk.

They weren’t particularly enthused to go on their college search. Like every kid, they were overwhelmed by new places, new people, new everything. The last place they toured was Earlham College in Richmond, Indiana.

Xan said the tour was typical, but something about Earlham was different. Everything felt more accepting and less expectant.

That night on the dorm floor, Xan saw two girls asking students if they wanted their nails painted.

“I always admired people with fun nails,” they said. “But when I did it it felt like people were seeing me as a woman doing it.”

From very early on, Xan learned nails were a signifier, something that girls wore. Even though they loved nails, they couldn’t bring themselves to try them on. But at Earlham, gender norms were treated differently. There were masculine women and feminine men. Nails weren't weird or presumptive of one’s gender.

Much to their own surprise, Xan got their nails painted.

“I remember my head being like, that is the last thing I would ever want to do,” they said. “But then I just said yes.”

They don’t remember what color, but they know it was something dark — a black or purple perhaps. It didn’t matter. For the first time, they could express themselves free of judgment. Their instinct about Earlham was right.

As the night wrapped up, Xan wanted to sleep over, but that wasn’t the plan. At first, they didn’t want to stay because of their panic attacks. However, some instinct was telling them it was going to be okay, so they stayed.

Back in their house in Bloomington, Xan scours the house for one of their old journals, the one they knew they wrote on the day they left Earlham.

Randall sits back and watches from the living room couch, smiling the way one smiles toward someone they truly love. He wears an easy smile, one predicated upon years of experiences of hardships and good times.

“I appreciate hearing a lot of this because so many things just track really strongly for me, where I’m like ‘oh yeah, that's you,’” Randall said.

He says he can see how these moments helped form who Xan is now. But he knows these things aren’t so one-to-one.

Xan eventually found the journal. Written on the bottom of the page is a simple message.

Looking back, Xan said their time at Earlham through undergrad was healthy, but they say it also postponed their transition. They were still operating as though they were a woman.

The years between Earlham and now were tumultuous, filled with further denial and some of what Xan considers internalized transphobia. It wasn’t until after their wedding in 2021 when Xan started HRT.

•••

Once Xan decided they wanted hormones, they started within weeks. This was partly due to the insurance provided through IU for graduate students.

One of Knudson’s new patients did not qualify for that insurance, meaning they had to shop. They were not optimistic the center would accept their insurance.

Some states have protections requiring insurance companies to cover gender-affirming care, but Indiana is not one of those states. The 2015 U.S. Trans Survey shows 25% of trans people were denied coverage for hormone therapy in the U.S. While the health center tries to reduce these problems, the patient’s coverage was still denied due their insurance not being accepted.

Dr. Knudson recommended them to apply for a grant that would cover all medical visits, exempting the testosterone. Eventually, they could receive the care they needed.

The way institutional aid looks outside of the center is less clear-cut.

“Some of the stuff that has been good and supportive was because of the actions of individuals, and not necessarily because of institutional support,” IU graduate student Erin Ewart said.

When Erin began publicly identifying as a woman, she forgot about things like her graduate student photo online needing to be updated. It took the person in charge of the photos to realize that need rather than it being an expectation of the university to reach out.

“How can we make it to where we're not depending on the kindness and cooperation of the people who happen to be in these positions of power — minor or otherwise — to help to make this easy for trans people like me,” Ewart said. “How can we make sure that even if they were neutral or hostile, they would still be basically coerced by the institution into being trans supportive?”

•••

The 2015 U.S. Trans Survey reported 55% of trans people were denied coverage for gender-affirming surgeries.

“Surgeries are the hardest to get,” family therapist Pardue said. “You have all of the red tape that you have to jump through to get it.”

Pardue said these barriers can include requiring letters from medical professionals like herself as well as extensive wait times. She said there is also difficulty in finding a doctor who is adequately and competently trained to conduct gender-affirming surgery.

Xan knew they wanted top surgery before they were sure they wanted HRT. When it came time to look for places to get surgery, they were advised to look out of state. That led them and Randall to Dr. Haruko Okada, a plastic surgeon in Ohio who specializes in gender-affirming surgeries. Within a six-month period, Xan was admitted to surgery.

Xan spent the days leading up to their top surgery oscillating between confidence and extreme nervousness.

“My mornings: I'd wake up and be like, ‘I can do this.’ Evenings were like, ‘everyone's gonna think I'm insane,’” Xan said.

They were concerned people wouldn’t understand why they needed to change their body like this. They had similar struggles once they started on testosterone. Would people understand and respect their choice?

The surgery also fell right before their qualifying exams for their Ph.D. candidacy. This meant Xan studied up to the surgery, then spent their spring break recovering, before beginning exams. It made the whole process all the more stressful.

Although, many moments leading to the surgery were enjoyable for Xan. Days before they left for Ohio, they would often observe themselves amusedly — their breasts would soon be gone. At one point, they began to speculate with Randall about how heavy they would weigh. Their mom asked the same question. When the day finally came for Xan to pack for their trip, they realized they would only need one bra. And it could be their favorite bra.

From the car ride into the medical facility, Xan was tense.

They were waiting in the pre-surgery room, hooked up to an IV and sitting in a hospital gown. They sat in their curtained-off section, waiting with other patients. A nurse came in to talk to Xan before they were admitted. The nurse told them they were the fourth person that week to receive top surgery.

“It was the first time I felt like I wasn’t the only one doing this,” Xan said.

The surgery was successful. By the time they got to their hotel, Xan was loopy on post-op drugs and talking about how great it was that the nurse kept getting their pronouns right. Everything went perfectly.

“It was just so casual,” they said. “Just really casual.”

The experiences of transgender individuals

•••

Gender-affirming spaces do exist outside of the IU Student Health Center, albeit through less official means. IU freshman Elliot Wilson said his community at the Collins Living Learning Center has been very supportive. The center is known for being very queer friendly, Elliot said, and he knows a lot of trans people there.

Elliot isn’t focused on how he identifies. Right now, he’s just focused on feeling as good as he can. The same is true for Xan as they don’t have a concrete label.

“The most concrete is transmasculine nonbinary, but that's as concrete as I'm gonna get,” they said.

That is what they consider to be their gender identity. They say it allows them the flexibility to be who they are. They said they like to push back on cisgender people when they ask the label question. Cisgender people don’t have to answer those kinds of questions, so they don’t ask themselves those questions.

There is a tattoo on Xan’s right forearm. It is of the hanged man — a tarot card — and is representative of surrender. The card depicts a person, suspended by their ankle by a rope from a post. The sun illuminates from behind their head. Xan’s version is special. They have top surgery scars.

Sitting in the waiting room for their first testosterone injection appointment, that tarot card kept coming to mind. It always unnerved them. It displays someone allowing themself to die. But something about the card suddenly clicked in their mind. Surrendering to the unknowns of their experience — their past and their future, who they are and who they want to become — all of it is knotted into the figure attached to their arm.

Day by day, Xan finds themselves more comfortable in life. They get acknowledged as masculine in public. Guys fist bump them on the street. These small things make a big difference.

“I knew that this is what I had always wanted to do,” Xan said. “They can see me.”

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