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Transgender children in America encounter new crossroads with medicine

Josie Romero, born a boy, believed she was born in the wrong body. By age 6, she was living as a girl.  Dateline NBC's Hoda Kotb reports.

By Tommy Nguyen
Dateline NBC 

It's unclear how many children around the world have felt trapped in their own bodies the way 11-year-old Josie Romero has struggled with hers. Born a boy but living socially as a girl since age 6, Josie -- the subject of a Dateline report airing Sunday, July 8th, at 7pm/6c -- is just one of 10,000 children who have significant gender identity problems, according to one popular estimate. Other experts say it's closer to one in 1,000, but nevertheless their relatively small population has generated much controversy and media attention recently.

The handful of American doctors who specialize in the care of transgender children have seen a marked increase in patients over the past few years. Children's Hospital in Boston, home to the largest clinic in the country for kids with gender identity problems, regularly saw in the past an average of less than 5 new patients a year; since 2007, the average is over 20. It's a result of more information being available to both parents and children, especially online. They're now able to identify the problems, if there are any, more readily. 

While the increase of children who may believe that they are transgender is newsworthy, the attention is pegged more to the medical issues associated with being transgender as opposed to what it is like simply being transgender. Indeed, the story of the transgender child has changed noticeably through the years. In the past, articles and television programs saw the very existence of transgender children as headlines. And if there were any in-depth reporting, it often focused on the social conflicts surrounding them - i.e., if this young boy is wearing a dress, how will he fit in with his family, on the playground, at church, or with the values of society?

But to more and more parents, doctors and mental health professionals these days, the problem of a boy wearing a dress -- and what other people think about that -- has become child's play by comparison. It's the internal conflicts raging in the heart, mind and body of transgender children and what their parents are willing to do medically to solve these problems that have become the more intriguing story of their already unique lives. The Dateline documentary report about 11-year-old Josie Romero and her mother, Venessia, which we began in the summer of 2010, is part of this new kind of reporting. 

Nine-year-old Josie Romero and her mother, Venessia, pay their first visit to Dr. Johanna Olson, a pediatrician who specializes in transgender children at Children's Hospital Los Angeles. 

Puberty is a traumatic experience for children with more significant gender identity problems. For young boys living as girls, the turmoil is caused by such things as growth spurts, bodily and facial hair, the deepening of their voice; for girls living as boys, breast development and menstruation are the major factors. There are "fairly significant psychological ramifications," says Dr. Norman Spack, an endocrinologist at Children's Hospital in Boston. "There is tremendous anxiety, often depression, sleep disorder and, potentially, self-harm and even suicidal behavior." According to his research, over 20% percent of his patients engaged in bodily harm and nearly 10% attempted suicide. Findings from other sources are even more striking:

  • Thirty-five percent of transgender adolescents have attempted suicide, 5.5 times higher than reports of all adolescents surveyed in the 2009 Youth Risk Behavior Surveillance (source: Children's Hospital Los Angeles).
  • Forty-five percent of transgender young people ages 15-21 had serious thoughts of killing themselves; 25% actually attempted suicide (The American Association of Suicidology).
  • The prevalence of attempted suicide among the 515 transgender people interviewed was 32% (Journal of Homosexuality, 2009).

Doctors sympathetic to the problems of transgender children are now trying to prevent these life-threatening moments from happening, made possible not so much by the breakthroughs in medicine, but by the opportune openings in it. Puberty-suppressing drugs, commonly called "blockers," have been around for decades for treating kids with dangerously early puberty; sex hormones (estrogen and testosterone) have also been available for other medical purposes. With the "off-label" use of blockers to treat transgender kids with severe anguish over their growing bodies, these drugs together now comprise the one-two punch of medical transitioning before the opportunity of sex reassignment surgery (18 is considered the youngest age before it can be performed). This medical process was almost unheard of for kids Josie's age just a decade ago, and it has dramatically changed the narrative of today's transgender children and their families.

Dr. Norman Spack, one of the first American doctors to treat transgender children with hormone "blockers," explains how these puberty-suppressing drugs 'buy time' for them. 

It's a richly complex narrative because the world of the transgender child is more time-sensitive than most. If the child truly wants to live as the opposite sex in adulthood -- with the most desired physical results possible -- then parents have to make medical decisions for their child at a time when many people would question a kid's ability to understand what he or she is asking for. But when people feel that the child may be old enough to make that kind of decision -- age 14? 16? 18? -- it may already be too late, and that's especially true for boys who want to be adult women. The child now has all the conspicuous physical attributes of the sex they don't want to be, and many of these features, such as height and voice, are irreversible without very costly and invasive surgery. Experts say that the mental health and overall happiness of transgender adults have a lot to do with their ability to pass visually for their desired sex. Not being able to pass could result in a lifetime of depression, or worse.  


But some medical experts feel that these transgender kids should go through some duration of puberty -- the very thing that's causing their anxiety -- in order for them to truly understand who they are. They believe that a lot happens to a child's mind and body during puberty that can't be predicted. If these new therapies are blocking the biological puberty of these transgender children, how will they ever really know for sure? And even though gender identity and sexual orientation (which usually gets articulated around adolescence) are completely different, there's a possibility that one might have the keys to unlock the secrets of the other.  Some research shows that many boys who express cross-gender behavior before adolescence grow out of it and go on to live as gay men. Even Dr. Spack relies on the research that concludes that as many as 80% of gender-variant boys do not become transgender adults. It's the other 20% that eventually make it to his clinic.

Related: More transgender kids seeking help, getting treatment

That's why blockers, which are completely reversible once a child stops taking them, have made waves in this community. It allows these kids and their parents to be right or wrong about their decisions, though doctors say it's rare that their young transgender patients change their minds once they start the medical process. And yet detractors say the drug's availability may invite over-diagnosis -- leading questioning kids down a medical path that they don't really need to be on, since society is already more open to different gender definitions. 

Josie Romero, an 11-year-old transgender child, reads a personal essay about her life today and what she sees in the future.