JesusA (imported) wrote: Fri Jul 13, 2007 7:10 am
Girl/Boy Interrupted
A new treatment for transgender kids puts puberty on hold so that they won't develop into their biological sex
By LAUREN SMILEY
Published: July 11, 2007
full
The breast bud popped up about six months ago, and Marty knew something had
to be done. It was the slightest of puckers, just on one side, so small you
wouldn't even notice it through a T-shirt. Still, boys don't get breasts,
and this had the unsettling potential to blow his cover big-time.
That's because Marty was born, by conventional measures of modern science, a
girl. Marty has two X sex chromosomes, like most females, and the hardware
concurs. Yet ever since Marty's parents flew back from China in 1998 with
their 11-month-old adopted baby, their daughter seemed to be programmed
male. She refused dresses by age two and half and mastered peeing while
standing by three. She would identify herself as a girl only when grilled.
When Marty was about six, doctors said she was no tomboy. She seemed to fit
the diagnosis of gender identity disorder (GID), and though dubbing it a
disorder whips up a maelstrom of controversy, the basic sentiment is this:
not only feeling an intense discomfort with one's biological gender, but
also feeling profoundly, compellingly, like the other.
Enrolled in a new school last year as a boy where only the staff knew
otherwise, the nine-year-old passed without a hitch in his wardrobe of Nike
trainers and T-shirts, paired with a crew cut, boyish build, and aggressive
basketball moves at recess. (To keep his secret, the names of the boy and
his parents have been changed.) But the days when the only outward markers
of gender lie in haircuts, clothes, and personality only last so long. Deep
inside Marty's brain, a time bomb known as the hypothalamus waited to stage
a hormone-armed mutiny. Breasts would sprout. Hips would widen. The uterus
would shed blood on a monthly basis. Marty didn't want any of it.
So when the bud appeared, his Bay Area parents hustled him to an appointment
with an endocrinologist at Children's Hospital and Research Center Oakland,
who said the bud might progress no further and puberty could still be a few
years off, his parents recall. They were temporarily relieved. Marty treated
the bump as a boy would poking at it at the dinner table, feeling it
through his button-down shirts. Waiting.
Then, in May, Marty came to his mom frantically: "Mommy, feel this lump! You
have to do something!"
The other breast had budded.
His parents called Children's because now, due to the efforts of a small but
growing number of doctors around the world, something actually could be done
about emerging puberty. The endocrinologist agreed that Mother Nature was
revving up, preparing to take Marty the way of trainer bras, Tampax, and, as
his parents and doctors predicted, increasing distress as his body developed
into a sex that to him seemed a cruel trick of birth. The changes would make
living as a boy impossible in the present, and he'd potentially face
scarring surgery to remove unwanted breasts down the road. What's more, the
upsurge in estrogen would slow and stop his growth, making it harder for him
to ever pass as a male. Of course, that's if Marty would end up living as a
man. As boyish as Marty is, no one could know for sure.
But in the present, nature could be tricked. If they all agreed, Marty would
never have to develop into a woman.
It was time to put puberty on hold.
The preferred drug for the controversial process is Lupron Depot. Slogan for
the pediatric version: "Pause the child within." It's potent, yet
reversible, and incredibly expensive, and for transgender kids backed by
increasingly supportive parents, it's ushering in a new era. Boys who've
always known they were girls won't get beards or deep voices. Girls who feel
like boys will never have to grow breasts or tinker with a tampon.
Long prescribed to temporarily stave off puberty in kids who start
developing too young, the drug blocks the brain's release of the compound
that triggers the chain of hormonal reactions, body mutations, and moody
angst. Now an unknown number of doctors in the Bay Area, the country, and
across the globe are following the lead of a fledgling treatment pioneered
at a Dutch clinic that's sparked debate in medical and ethical circles
alike. The Dutch clinicians are suspending kids in physical childhood to buy
them time to decide if they wish to begin the sexual reassignment process.
If so, after a few years of continued psychological monitoring, they can
start hormones to induce an "opposite-sex puberty." If not, the teen can
stop taking the periodic Lupron injections and appear to develop normally,
as kids treated with the drug for early puberty have for years.
Although treating transgender kids is a non-FDA-approved or "off-label" use
of the drug (which is legal, and is done frequently with other medications)
the treatment is fast gaining legitimacy in the medical world. The world's
largest association of health professionals who specialize in transgender
issues approved the procedure in its most recent treatment guidelines. A
handful of doctors have touted the procedure at big-name medical
conferences. More doctors are catching on.
"It's time we have something going here in the Bay Area, because we should
be at the forefront of this," says Herb Schreier, a psychiatrist at
Children's Hospital Oakland.
Advocates say the treatment saves kids the anguish of continuing to develop
into a gender they don't identify with reducing the risk of everything
from depression to self-mutilation to suicide attempts as well as later
surgeries to undo what Mother Nature has done. By sitting out the
irreversible changes of biological puberty, patients will pass more easily
as the target sex, protecting them from potential discrimination and even
violence. And transphobic violence is something that the Bay Area has been
known for at least once, when partygoers beat and strangled 17-year-old Gwen
Araujo of Newark to death in 2002 upon discovering she was a biological male
living as a female. In March, the body of Ruby Ordenana, a transgender
Nicaraguan immigrant, was found near a highway off-ramp in Potrero Hill.
"If you have someone who's 6-3, with broad shoulders like a football player
and a deep voice, there's no amount of surgery or hormones in the world
that's going to allow that person to pass and be safe," says Nick Gorton, a
doctor who treats transgender patients at Lyon-Martin Women's Health
Services in San Francisco. "If you treat them [young] then maybe at 25 they
won't get raped, beaten, and killed."
So far, none of the 60 or so teens choosing to delay puberty at the Dutch
clinic have turned back. None have reportedly had regrets. Yet no matter how
happy the patients seem, put "delay" and "puberty" in the same sentence, add
in a little-understood condition like GID for which science still cannot
pinpoint a cause, and, well, people start talking.
Some doctors say kids need to experience puberty to truly know if they're
misplaced in their bodies, and warn that the long-term side effects of
diverting nature's route are still unknown. A few doctors believe medicine
should never intervene to change a person's body to match gender identity,
no matter the age what one transwoman doctor dubbed the "you should be
what God made you regardless of how miserable you are" camp. Paul McHugh,
the psychiatrist who spearheaded the closure of the sexual reassignment
clinic at Johns Hopkins Hospital in the 1970s, is an appointee to the
President's Council on Bioethics. He calls the Lupron treatment "a modern
form of child abuse."
"Some say you're playing God," says Stephanie Brill, the facilitator of a
Bay Area support group for parents of gender-variant kids. "Our entire
society is based on gender, and this hits right into the religious right and
the whole Moral Majority idea, and doctors are worried of losing their
funding and the backing of their hospitals if they do it."
Indeed, some U.S. doctors don't seem to be clamoring for attention. Norman
Spack at Children's Hospital Boston, who has supported the treatment in a
medical article and on ABC's 20/20, declined to comment for this story. A
doctor at Kaiser Permanente identified by a Bay Area family as their son's
provider of the Lupron treatment also would not speak. But Schreier of
Children's Hospital Oakland says he's not worried: "What we're doing is
based on data, not based on emotions or religious beliefs."
All seem to agree on one issue: No matter how reversible Lupron may be, when
studies indicate that the vast majority of kids with some gender-variant
behavior in childhood will grow out of it, how do you block puberty in the
right kids?
Marty's parents say they are 99.8 percent sure that his identification as a
boy is here to stay. Though they accept that now, it was certainly not their
expectation, let alone their choice. Actually, checking "girl" on the
adoption forms was a no-brainer for the middle-aged lesbian couple. As
ardent feminists, the attorney and child psychologist felt equipped to raise
an independent-minded girl, and Marty seemed to be right on track.
When she saw an astronaut, politician, or athlete on the TV, she said, "I
want to do that!" "Of course you can!" the mothers would answer. She ignored
dolls, but loved trucks. Somewhere around age two and a half, Marty refused
to raise her arms when her mother tried to put a dress on her, the first
time she'd ever rejected an outfit. One day out of the blue, she looked her
mother in the eye and asked, "When is it my turn to be a boy?"
The mothers grew puzzled. Maybe she was just trying to set herself apart
from her newly adopted little sister. They certainly didn't want to
overreact. If Marty would only wear drab clothes from Target's boys
department, why waste money on skirts? If she was proud she could pee like
the boys at preschool, planting her feet together and arching her back to
hit the pot, well, at least she was potty-trained. But they also didn't want
to fan the flames.
"I was aware to not pin him to a decision he made at the age of two," says
Margaret, the child-psychologist parent. "I didn't want to build it in as a
permanent part of his personality."
Marty became increasingly self-conscious about being identified as a girl.
With her bob haircut, she let kids at school assume she was a boy, and
avoided the bathroom all day so she wouldn't have to pick one. She refused
to change her swimsuit in the girl's locker room at the YMCA.
At age five, the discord between her identity and body seemed to take its
emotional toll. At times she would play recklessly, and at other times, seem
withdrawn and preoccupied. Marty's parents took her in for a psychiatric
evaluation, and she was prescribed antidepressants. She told Margaret that
if she had to be a girl, she'd rather die.
But one topic seemed to cheer the kid up. One day, Janet, the attorney, told
her that a friend's daughter had started transitioning to manhood in her
20s. Marty lit up, pelting Janet with questions. How? It involved hormones
and a surgery. Can I have it now? Can I get my penis? Janet said they would
support her in whatever she decided, but that she would have to wait till
she was older.
But the parents soon learned that interventions can start much earlier than
that. Marty's pediatrician pulled the mothers in after the child's annual
checkup: We all see what's going on here, don't we? Every year, the girl was
presenting more and more like a boy. The doctor said the parents should find
an endocrinologist who delays puberty for transgender kids. When puberty
hit, the family didn't want to be caught off-guard.
Janet was skeptical. Although she'd trumpeted lesbian causes for years, she
knew little about transgender people. How permanent could this really be in
a seven-year-old kid? She and Margaret started attending a support group for
parents of gender-variant children, and discovered one couple was calling
their son "she." Janet thought it was a little odd.
"You would think of all people, I, who came out and went through all of this
hullabaloo with my parents, would have the consciousness to understand
people are who they are," Janet says. "But for me, with Marty, it didn't
translate."
But that would change after two years of the support group, a barrage of
books, Internet searches, and an Oprah episode on transgender kids that
Marty watched a dozen times. When Schreier, the support group's
psychiatrist, explained there was no way that parents could have made their
kid this way, any last remnants of guilt dissolved.
"Look, we're a lesbian couple," Margaret says. "Even if we didn't think we
did, I know a lot of other people would think we influenced his gender
identity."
Finally last summer, at age eight, Marty said she wanted to be considered
"he." A boy. Their son.
"I finally got it," Margaret says. "This is an identity."
They were both sad to part with their idea of a daughter, but any final
doubts faded after seeing how Marty seemed to glow in his new role, going to
a new school as one of the boys.
But puberty?
The mothers had heard talk of "blockers" flung around in the support group,
and had done some initial Googling on treatments. They attended a seminar
this spring where Spack, the doctor from Children's Hospital Boston,
explained the treatment for delaying puberty. Having been prescribed Lupron
herself for fibroids years before and ballooning 50 pounds in four months,
Margaret wasn't thrilled about the drug choice. (Indeed, women prescribed
the drug for the approved uses for endometriosis or fibroids fill Internet
message boards with complaints of hot flashes, mood swings, memory loss, and
pain.) But the most common side effect in kids is irritation, sometimes
including a sterile abscess, at the site of injection.
The idea of the injections was initially a relief to the parents. Something
could be done, and with Janet's salary as an attorney, they could afford the
approximately $1,800 shot four times a year even without help from
insurance, if need be. But the option also added pressure. With Marty too
young to fully grasp the implications, the decision to start was going to
fall on them. The mothers knew they had altered the course of Marty's life
the day they adopted him, changing his status from a Chinese orphan to an
adopted Chinese-American child of gay parents. Now they faced taking the
first step in what could become a transition to an identity even further
from the mainstream: transman. All along, they had figured that decision
would still be some years off.
But Marty turned nine and his breast buds demanded attention.
Give Marty a couple years without the shots and he might look something like
the girl who sat before Dr. Henriette Delemarre-van de Waal at the Free
University Medical Center in Amsterdam in 1986. Referred by a psychologist
who diagnosed GID, the 12-year-old ace student was depressed about her
growing breasts, which she had been binding to her chest to disguise. She
wanted to be a boy.
The endocrinologist had never worked with a patient with GID, but a drug
known as a GnRH blocker, the same compound as Lupron, had recently gone on
the market and was being used to delay puberty for kids who developed too
soon. The solution seemed obvious.
"She was crying for help, so I thought, let's try," Delemarre-van de Waal
says. The treatment greatly alleviated the patient's distress, according to
the doctor. At 17, the patient began taking testosterone, and later
underwent sexual reassignment surgery. He is now a veterinarian.