Years ago, in a darkened parking lot in the middle of the night, Kathy Padilla would meet with fellow transgender people who sought support from one another in a society that treated them like outcasts.
How things have changed since then for transgender men and women in America, who have made great strides in recent years toward reaching their ultimate goal: to be treated like ordinary people. On Tuesday, they won another victory when a Massachusetts judge became the first to order prison officials to provide sex-reassignment surgery for a murder convict, saying it was the only way to treat her gender-identity disorder.
The ruling marked the latest milestone in the increasing visibility of a class of people once roundly derided as freaks or used as a punch line.
"Now there are transgender delegates at the Democratic National Convention," said Padilla, a 55-year-old transgender woman from Philadelphia who has been an advocate since 1984. "And a number of transgender people have been invited to the White House."
In recent years, more than a dozen states have revised anti-discrimination laws to include transgender people, giving them hate-crime protection and providing rights as basic as restroom access. Transgender officials have helped raise the movement's profile by winning elective office in city halls, landing coveted appointments in the White House and, yes, sending delegates to political conventions.
The Massachusetts court ruling, though, shines a light on what many advocates view as the worst form of discrimination still faced by transgender people: lack of access to medical care.
"Transgender people are still denied health care access all the time," said Mara Keisling, executive director of the National Center for Transgender Equality. "There's insufficient training, insufficient cultural competency, and insufficient humanity sometimes."
Transitioning from one sex to another can involve a variety of treatments, including hormone therapy, but the most expensive one is a sex-change operation, which can cost up to $20,000. Even though the American Medical Association and other medical experts recommend coverage of services for transgender people, a small but growing number of companies that actually provide it -- including Apple, Accenture and American Express -- are still the exception.
Federal health care that covers treatment for gender-identity disorders is virtually nonexistent, with no services for federal employees, veterans or Medicare recipients.
U.S. Sen. Scott Brown of Massachusetts, who as a state senator filed unsuccessful legislation in the late 2000s to ban the use of tax money to pay for the surgery for prison inmates, said surgery for the inmate at the center of Tuesday's ruling would be "an outrageous abuse of taxpayer dollars."
"We have many big challenges facing us as a nation, but nowhere among those issues would I include providing sex change surgery to convicted murderers," he said in a written statement. "I look forward to common sense prevailing and the ruling being overturned."
In July, Leon Rodriguez, director of the federal Department of Health and Human Services' office for civil rights, sent a letter to an advocate reaffirming that federal health care funding extends to medical needs of transgender people. But the agency also said insurers are not required to cover "transition related surgery."
The nation as a whole has not yet embraced the idea that a gender reassignment surgery is a medically necessary procedure that could have dramatic health benefits, advocates say.
"If somebody doesn't receive treatment, it can lead to very serious incidents of self-harm," said Jennifer Levi, a professor of law at the Center for Gender and Sexuality Studies at Western New England University in Springfield, Mass. "One of the things that the judge recognized is that there's a lot of public misunderstanding about the experience of transsexualism. And there's a lot of bias and prejudice."
In the Massachusetts case, the judge noted that inmate Michelle Kosilek's gender-identity disorder has caused her such anguish that she has tried to castrate herself and twice tried to commit suicide. Kosilek was named Robert when married to Cheryl Kosilek and convicted of murdering her in 1990.
While courts around the country have found that prisons must evaluate transgender inmates to determine their health care needs, most have ordered hormone treatments and psychotherapy. Wolf is the first judge to order sex-reassignment surgery as a remedy to gender-identity disorder.
"There are still people who believe that being a transgender person is a choice, or exotic or bad," Keisling said. "And you know, those people are becoming fewer and fewer all the time."
Turning the tide of public opinion has also been aided by famous transgender people like Keelin Godsey, a shot-putter who this summer fell just short of becoming the first transgender athlete to make the U.S. Olympic team. And there's Stu Rasmussen, of Silverton, Ore., who became the country's first openly transgender mayor in 2008 when he defeated the incumbent following a campaign that focused on policy -- not the fact that Rasmussen was wearing dresses and 3-inch heels.
Soon after Rasmussen's victory, President Barack Obama appointed three transgender people to posts in the Commerce Department, Labor Department and Presidential Advisory Council on HIV/AIDS. Obama later signed a landmark bill to expand the definition of hate crime violence, making it the first federal law to include legal protections for transgender people.
This year, the Equal Employment Opportunity Commission ruled that sex discrimination laws cover transgender people, and the Department of Housing and Urban Development ruled that transgender and gay people are protected from discrimination in federally funded housing, which includes Section 8 housing and homeless shelters.
"More and more people in the public are recognizing that transgender people are people," Keisling said. "And that being a transsexual or having gender identity is an actual, real, core component of a person's identity."