Eve Gammill, 63, a retired coastal scientist from League City, Texas, was born and raised in Idaho Falls, Idaho. Local ranchers call the desert nearby "The Big Quiet." In keeping with the landscape, Gammill had her secrets.
Gammill was born and named Steven in the Sacred Heart Hospital run by the Church of Latter Day Saints and raised as a Methodist. "I was the third of five male children. At least, I was assigned male at birth," said Gammill.
Gammill says she always was a square peg. As a child, she always felt she should have been a girl and wanted to do stereotypical girly things like wearing dresses and playing with dolls. From her earliest memories as Steve, she wished her parents would make her a girl.
"I would identify more with the girls. I wanted to play with their toys. I wanted to play with them. I couldn't play sports. I always enjoyed the company of females more," she recalled. "I was always non-binary. I thought I was what they called a transvestite or cross-dresser way back before transgender was even a term. In truth, I didn't know who I was, but I lacked comfort with myself."
Steve joined the U.S. Navy right out of high school, turning 18 in boot camp. He (at that point Gammill used he/his pronouns) gritted his teeth and did the best he could to survive in a macho environment as a radio operator aboard the U.S.S. Nimitz, an aircraft carrier and one of the largest warships in the world. He was awarded the U.S. Navy Expeditionary Medal because the ill-fated mission to rescue American hostages held by revolutionary Iranian students was flown off the Nimitz. "That was the closest I got to warfare," she told me.
When Steve left the Navy, he had other battles to fight, which would lead him gradually to become Eve.
While earning a master's degree in marine biology, Steve married his first wife who knew he was "trans" before they got married. Eventually, they consensually parted. A few years down the line, he married his second and current wife, Jan, who also accepted Steve/Eve as he was. In 2002, he left a government job in Baton Rouge, moved to Texas, and bought a sailboat, which he captained for a living.
"I thought I could just get my jollies by imitating a woman some of the time," said Gammill. At that point, she hadn't seriously considered altering her male organs.
Ironically, cancer affecting her male organs -- an advanced prostate cancer -- finally led Eve to abandon Steve. In 2018, Gammill's prostate-specific antigen (PSA) level was rising. In a year, it had tripled from 4 to 12. That year, she was diagnosed with a Gleason 9 tumor and underwent prostatectomy.
Prostate Cancer in Transgender Women
"Transgender women present in different stages of transition," said Darryl Mitteldorf, LCSW, an oncology social worker who runs Malecare, a national support and advocacy organization for patients with prostate cancer. Malecare pioneered the field of LGBT psycho-oncology and founded the first prostate cancer support group for gay men in 1997 and the first transgender women with prostate cancer group in 2000.
Mitteldorf said some cis-gendered men presented their authentic female selves before moving forward with medical or surgical treatments. But most of the women who attended prostate cancer groups had completed top or bottom surgery and were on hormone therapy.
Being transgender can mean a lot of things. In the case of a transgender woman, the person may take on the identity of a woman without any medical or surgical treatments. Some take hormones and may have top surgery (breast enhancement), while others opt for gender reassignment surgery, which can involve a variety of operations.
"The key message is all of these ladies had prostates, and all wanted a safe place -- no matter which stage of transition they were in -- to talk about prostate cancer, as only they uniquely experience," Mitteldorf said.
Christi Butler, MD, a urinary system reconstructive surgeon in the transgender care program at the University of California San Francisco (UCSF), told me in a virtual ground rounds on transgender health in May, that the exact numbers of transgender individuals in the U.S. are not known.
Of 101 million American males age 18 and above, 0.6%, or 606,000, consider themselves transgender based on a Gallup survey reported in February.
"That probably is an understatement," Butler said, "Not everyone is comfortable saying or admitting that they are trans."
Transitioning to Eve
Steve had never considered altering his male organs until prostate cancer compelled him to make some changes. Because Gammill had advanced prostate cancer, he underwent a radical prostatectomy.
"I had given it a lot of thought. It's a little bit of a chicken-egg problem because I was already non-binary before I was diagnosed with prostate cancer. I was not convinced that transition [hormones and surgery] was the right thing for me until after surgery because the surgery emasculated me along with emasculating hormonal treatment. I was barely holding onto masculinity, within the context of I sort of enjoyed my penis once in a while, and when that went away with surgery, so did that feeling of masculinity. I thought there must be a new normal. I was devastated. I was upset. I had lots of problems. I was concerned that the end might be near."
Gammill said she had long been dysphoric and unhappy playing the male role -- often a reason for gender change. She had grown tired of being called, "'sir' while presenting feminine."
"I wanted to be more authentic. When you go in and you're trying to be more authentic and somebody misgenders you or calls you by the wrong name and does it repeatedly, it's a little stab," she said. "It felt like it really increased my gender dysphoria, made me upset and caused me stress."
Doctor's offices often were the site of these "little stabs" from staff members, and Gammill had more than her share of medical visits as she coped with her prostate cancer. She underwent medical treatment with estrogen and other hormones, which was feminizing as her testosterone was suppressed. She also underwent a total orchiectomy and breast reconstruction surgery. Prostate cancer got Gammill to fully embrace her feminine identity, and so far, her PSA remains zero.
"If I was still making testosterone, I would not have transitioned. If my penis still worked, I wouldn't have transitioned," she said.
Discrimination in the Healthcare System
Gammill said she has encountered some hassles from nurses and office staff, but generally, her physicians have been "wonderful."
"The doctors have been sensitive. They've been kind," she said. "The oncology team has been very good at using pronouns and treating me right." But she said she had to ask the office staff to change her name to Eve in the records of the U.S. Department of Veterans Affairs.
"Sometimes when I go to a desk, I get misgendered and I don't know what to do but gently correct them, look at my boobs or something. Say, 'excuse me,'" she said.
Transgender women can run the gauntlet in medical offices. Trans, gay, and bisexual patients can encounter a hostile environment in macho, locker-room-like urology offices. Transgender women are subject to embarrassment and harassment as medical office staff ask for their birth names or classify them as men rather than asking about their gender identification.
According to Geolani Dy, MD, assistant professor of urology at Oregon Health & Science University (OHSU) and OHSU's Department of Urology and Transgender Health Program in Portland, "Over 33% of transgender patients avoid seeking healthcare services due to possible mistreatment."
In a heterocentric culture, it is difficult for those who are non-heterosexual to be seen and heard. Doctors and medical staff need to learn to be sensitive to these differences and create a gender-affirming environment for patients.
Repeatedly in the prostate field, you hear about "men with prostate cancer." It's not inclusive. I , where I have come out in favor of using "people with prostate cancer" or "patients with prostate cancer" to include transgender women in the prostate spectrum. I got a fair amount of pushback for taking this stand from my generally supportive readers, though most supported changing the language.
Gammill doesn't see prostate cancer as a male/female issue. "It's just some cells in my body that mutated. I didn't have any decision or choice in it. They don't define me."
Gammill has won a victory in the semantic war. She was instrumental in changing the name of an Us TOO/ZERO support group. It had been called the Gay Men's Forum. Now it's the LGBTQIA Forum -- short for (lesbian, gay, bisexual, transgender, intersex, and asexual).
Butler displayed a slide at the end of her UCSF grand rounds showing two buttons: "Some women have penises. Get over it." And "Some men have vaginas. Get over it."
Isn't it time to get over it?
Howard Wolinsky (he/him/his) is a Chicago-based medical freelancer. He started covering transgender issues in the 1970s for Florida TODAY. Gay Chicago Magazine named him "a hero to the community" for his early coverage of the AIDS/HIV pandemic in the 1980s.