Second Nature

In an exclusive preview from our March issue, meet a local family that is raising a little girl born in the wrong body.

March 2008

What determines whether a person is happy or identifies with his or her anatomical sex? It's a delicate alchemy of chromosomes and hormones, and the catalyst may all be in one's mind—specifically, in the hypothalamus, which is the brain's emotional control center. Really, though, no one knows. Thus far, scientific research has only produced very educated guesses. However, this much is certain: Being transgender is not a contemporary phenomenon. Among the ancient Greeks there were transsexual priestesses. The successor to the Roman emperor Macrinus was Elagabalus, whom historians suspect cross-dressed and talked of sexual-reassignment surgery. (Roman soldiers killed Elagabalus, along with his mother, when he was in his late teens.) The French explorers Louis Jolliet and Jacques Marquette were stunned in 1673 when they came upon Illini Indians who dressed and acted as women. The Illini called these men "Ikoneta." Rather than viewing transgender as an aberration, as the Romans saw Elagabalus, the American Indian elders regarded the Ikoneta as a bridge between the temporal and spirit worlds; they revered transgender people as "two spirits."

Regardless of science and history, transgender youth has proven a uniquely vexing reality for the modern world. Although there is much semantic hair-splitting in the prevailing views, essentially there are two schools of medical thought. Some experts, like Dr. Kenneth Zucker, believe that most transgender children are going through a "phase." Zucker is psychologist-in-chief and head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto, and during the past 30 years he has treated about 550 preadolescent gender-variant children. Based on his studies, Zucker says, 80 percent to 85 percent grow out of the phase, and only 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex. Zucker advocates counseling preteens with gender dysphoria to live according to their biological sex. "My approach," Zucker says, "has been to try to understand what might be the factors, of which I am sure there are many, that are causing a child to be so unhappy about their gender identity in relation to their birth sex, and then to make therapeutic attempts to help the child feel more comfortable in the gender identity that would make it more consistent with the biological sex, so as to avoid the path toward sex reassignment [surgery]." In other words, as Zucker sees it, more often than not a preadolescent's mood disorder causes the gender dysphoria—not the other way around, as Dr. Holden had diagnosed Luc. Zucker believes that if the mood disorders are adequately addressed then the gender dysphoria will go away.

Then there are the experts like Dr. Edgardo Menvielle who believe, simply put, that many transgender youth grow into transgender adults. Menvielle heads the Children's Gender and Sexuality Advocacy and Education Program at Children's National Medical Center in Washington, D.C., and oversees a support network comprised of some 300 families. "In some cases," he says, "children pretty much have to live according to their experienced gender [the gender opposite their birth sex], otherwise life is so miserable it's impossible. And if you don't act, if you deny the child's need to be who they need to be, you are subjecting them to a life that is very difficult for them and in the long run may be harming them."

Adolescence, and more specifically puberty, can be, as Menvielle says, "incredibly traumatic" for a transgender child. There are medical treatments that "block" the hormonal and physical changes of puberty; there is also hormone-replacement therapy (HRT), which triggers opposite-sex puberty. The blocking treatment is the more established option. This type of drug therapy is reversible; if a child-patient stops the treatment, puberty begins or resumes. HRT is more controversial because it has permanent effects. Once opposite-sex puberty is triggered, it cannot be undone. Neither form of treatment is FDA-approved, and there have been few tests to gauge their long-term efficacy and safety.

In February 2007, a clinic dedicated to gender-variant children opened at Children's Hospital Boston, where Dr. Norman Spack, a pediatric endocrinologist, oversees both puberty blocking and replacement therapies. Widely regarded as a pioneer in the medical treatment of transgender children, Spack is unwaveringly confident that the results of what he calls his "gender-management program" will persuade the many skeptics.

"You'll find," Spack says, "that many people want to wait until a child is about 16, after puberty, to do any kind of hormone therapy. But by 16, the average female has been menstruating for four years, and the average male is 90 percent of adult height, not to mention facial hair. All of these things are, by that point, irreversible changes. If we can give a transgender child time, if we can delay puberty for a child, for a child like Lucia, why don't we do that?"

In addition to the psychological cost of foregoing hormonal treatment, there is a high financial price to pay to make those physical changes as an adult. It costs a small fortune for the painful procedures and operations: The only way to address the male Adam's apple would be to have it surgically shaved. And an M2F person would likely spend approximately $120,000 over a lifetime on hair removal. The cost of a M2F genital reassignment surgery, compared to hair removal, is a relative bargain at about $25,000.

Zucker worries what effect hormone suppression may have on the kids who want to revert to their biologically assigned sex. Spack has heard the argument. "There is that possibility of a child with gender dysphoria growing into an adult who is content with their anatomical sex," he says, "but I haven't observed it in my patients." According to Spack, of the 50 children under age 21 whom he has seen thus far, none has changed his or her mind. Before he accepts a child-patient into the program, Spack says, each is psychologically evaluated, like Lucia. "Kids like Lucia aren't transitioning from one sex to another," Spack says. "They are affirming their sex." Hearing Lucia's case history, Spack bristles at the idea she's going through a phase. "I know her parents are doing the right thing. They are following the lead of their child, a child who has already exhibited not just displeasure at being forced to live in a male role, but has literally attempted to harm herself. These parents deserve a lot of respect. Sometimes they are second-guessed by society because there is a lack of knowledge and awareness of these issues. And those people that may criticize them, if they were in the same situation, they may do exactly the same things as this family."