The number of teens going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners.
In a cozy cottage decorated with butterflies to symbolize transformation, Katherine Boone was recovering in April from the operation that had changed her, in the most intimate part of her body, from a biological male into a female.
It was not easy. She retched for days afterward. She could hardly eat. She did not seem empowered; she seemed regressed.
“I just want to hold Emma,” she said in her darkened room at the bed-and-breakfast in New Hope, Pa., run by the doctor who performed the operation in a hospital nearby. Emma is her black and white cat, at her home outside Syracuse in central New York state, 250 miles away.
Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed a sassy red, is just 18, and about to graduate from high school.
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It is a transgender moment. President Obama was hailed just for saying the word “transgender” in his State of the Union speech this year, in a list of people who should not be discriminated against. They are characters in popular television shows. Bruce Jenner’s transition from male sex symbol to a comely female named Caitlyn has elevated her back to her public profile as a gold-medal decathlete at the 1976 Summer Olympics.
With growing tolerance, the question is no longer whether gender reassignment is an option, but rather, how young should it begin.
While no law prohibits minors from receiving sex-change hormones or even surgery, insurers, both private and public, have generally refused to extend coverage for these procedures to those under 18. In March, New York’s Medicaid, the nation’s largest, drew a line at that age, and at 21 for some procedures.
But the number of teenagers going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners.
“Some of these women are passing, but barely, when they transition at 40 or 50,” said Dr. Irene Sills, an endocrinologist who just retired from a busy practice in the Syracuse area treating transgender children, including Kat. “At 16 or 17, you are going to have such an easier life with this.”
Given that there are no proven biological markers for what is known as gender dysphoria, however, there is no consensus in the medical community on the central question: whether teenagers, habitually trying on new identities and not known for foresight, should be granted an irreversible physical fix for what is still considered a psychological condition.
The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a miswiring of the brain or by genetic coding? How much does it stem from the pressure to fit into society’s boxes — pink and dolls for girls, blue and sports for boys? Has the Internet liberated teenagers like Kat from a narrow view of how they should live their life, or has it seduced them by offering them, for the first time, an answer to their self-searching, an answer they might later choose to reject?
Some experts argue that the earlier the decision is made, the more treacherous, because it is impossible to predict which children will grow up to be transgender and which will not.
“Basically you have clinics working by the seat of the pants, making these decisions, and depending on which clinic you go to, you get a different response,” said Dr. Jack Drescher, a New York City psychiatrist and psychoanalyst who helped develop the latest diagnostic criteria for gender dysphoria.
On the other hand, Drescher said, “Is it fair to make a child who’s never going to change wait till 16 or 18 to get treatment?”
Kat Boone did not fit the stereotype of a girl trapped in a boy’s body.
As a child, she dressed in jeans and shirts, like all the other boys, and her best friend was a boy.
But as a freshman in high school in Cazenovia, N.Y., she became depressed and withdrawn. “I knew that the changes going on with puberty were not me,” Kat said. “I started to really hate my life, myself. I was uncomfortable with my body, my voice, and I just felt like I was really a girl.”
When she discovered the transgender world on the Internet, she had a flash of recognition. “I was reading through some symptoms, not really symptoms, but some of the attributes of it did click,” she recalled.
It took a few months, but one night, she crept into her mother’s room and sat on the bed, crying. When she finally came out with what was bothering her, her mother’s first impulse was to comfort her, holding her hand and saying: “It’s OK. It’s OK.”
But inside, Gail Boone was terrified. She had wondered if her son were gay, and that, she says, would have been easier to deal with than a child who wanted to be the opposite sex.
“There’s this fear,” Boone said, “what is this going to do to my kid, what are people going to think, what are people going to think about me?”
Kat’s father, Andrew Boone, had moved out when she was in fifth grade; it took a few months for Kat and her mother to find the courage to tell him about Kat being transgender. Gail Boone had a background in psychology, which helped her understand. Andrew Boone, an operations and project manager, had a harder time, but was brought around for the sake of his child.
He read books about being transgender and raked his memory for clues in Kat’s early childhood, but could not find any.
“Maybe she thinks this is the thing, and there’s something else going on,” he remembered thinking. “How do we know?” He wished there were something scientific like a blood test that would give him 100 percent certainty.
It was the self-cutting that convinced them that if she could not live as a girl, Kat would kill herself. She still has two angry scars on her left forearm.
At 16½, after seeing a therapist, Kat began taking estrogen and a blood-pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female. In the fall of junior year, she showed up at school wanting to be called Katherine, or Kat, because she likes cats. She does not want anything to do with her birth name, Caden.
She also has discovered that she likes girls. “I identify as a lesbian,” she said, though her attractions have not been reciprocated.
Part of what brought her father around was the support network that has sprung up around transgender issues. In Syracuse, it is the Q (for queer or questioning) Center, run by the nonprofit ACR Health.
At a meeting of teenagers in April, Kat told the group that she was looking forward to surgery in six days. They clapped. “I’m scared,” she confessed.
One of the first and biggest hormone programs for young teenagers in the United States is led by a Harvard-affiliated pediatric endocrinologist, Dr. Norman Spack, at Boston Children’s Hospital.
Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.
“I was salivating,” he recalled. “I said, we had to do this.”
If a psychological evaluation confirms gender dysphoria, teenagers are treated with cross-sex hormones (estrogen for boys, testosterone for girls), so they will, in effect, go through opposite-sex puberty. A consequence of going through the whole protocol is infertility.
The blockers cost thousands of dollars a year, and like all drugs used for transgender treatment, have not been approved by the Food and Drug Administration for that use, though they may be legally prescribed “off label.”
Spack said his clinic had treated about 200 children since 2007, and less than 20 percent had been covered by insurance.
While hormones for minors are sometimes covered by insurance, surgery almost never is. But several doctors said they had performed surgery on minors. Kat’s surgeon, Dr. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.
Advocates say that extending treatment to teenagers will alleviate depression and suicide. With that in mind, Oregon’s Medicaid began covering the gamut of treatment, regardless of age, in January. Patients as young as 15 do not need parental consent.
The evidence is mixed. A large-scale Swedish study at the Karolinska Institute found that starting about a decade after gender-reassignment surgery, transgenders are more than 19 times as likely to commit suicide as the general population.
Complicating matters, studies suggest that most young children with gender dysphoria eventually lose any desire to change sex, and may grow up to be gay, rather than transgender. Once they’re into adolescence, however, their dysphoria is more likely to stick.
Dr. Paul McHugh, a professor of psychiatry at Johns Hopkins University Medical School and its hospital’s former psychiatrist in chief, is skeptical of the use of surgery for a psychological condition, and even more so for children.
“Bruce Jenner — who cares?” said McHugh, who said he played a role in closing a transgender surgery program at Johns Hopkins about 35 years ago. “He’s a wonderfully successful person. He’s got all kinds of social networks. He’s got plenty of money. No one’s objecting to him if he wants to live as a woman. This is America, be my guest.
“But we’re talking about children with a future ahead of them.”
Kat went into the surgery on April 7 with high hopes.
McGinn was far from Cazenovia, in Lower Bucks Hospital in Pennsylvania. But Kat’s parents trusted her not only as a specialist, but also as a role model: She had been a dashing male doctor in the Navy, before becoming a beautiful female doctor in civilian life.
Kat had been accepted at Champlain College in Vermont, where she planned to use her artistic talent (she designed the rose tattoo on her shoulder) to study video-game design. Her goal was to start college as a woman.
Gail Boone’s insurance plan initially denied coverage for the operation. A customer-service agent told her genital reconstructive surgery was allowed only for conditions like birth defects.
“You got it,” Gail Boone retorted.
The operation involved deconstructing her male genitals and repurposing the nerves and skin as female anatomy.
Her father felt helpless as she refused food and lost about 20 pounds. McGinn said it was not unusual for patients to become depressed after surgery.
Kat was anxious about having enough privacy in college, since her new vagina needs constant care or it will close off like a wound.
Six weeks after the operation, she was still so weak that she had to take the elevator at school instead of the stairs.
At her two-month checkup, she had gained back half the weight she had lost, but still looked frail and self-conscious. She treated herself to a new hair color — strawberry blond — for graduation. She said she had “zero regrets.”