Hannah Is a Girl. Doctors Finally Treat Her Like One.
NEW HAVEN — Hannah is a 14-year-old girl, clad in leggings and an oversize T-shirt, with long brown hair that she curls around a finger. She was also born a boy.
The government can’t seem to decide whether it should affirm children like Hannah. President Trump jumped from supporting workplace protections for transgender people to ending supportive policies for transgender students in public schools. The Supreme Court waffled on whether or not these kids can use the bathrooms of their identified genders, sending the question back to the Fourth Circuit. Last month, North Carolina repealed a law that forced transgender people to use the bathroom corresponding with the gender on their birth certificates, while strangely prohibiting schools from adopting policies that would let transgender students use the bathroom of their choice.
Politicians could learn something from the doctors who treat these patients. Over the past few years, it has become clear that if we support these children in their transgender identities instead of trying to change them, they thrive instead of struggling with anxiety and depression.
Hannah is using a puberty-blocking implant and getting ready to embark on the path of developing a female body by starting estrogen. Ten years ago most doctors would have called this malpractice. New data has now made it the protocol for thousands of American children.
Being transgender doesn’t affect Hannah much. She is a straight-A student and auditioning for her school’s production of “Annie.” She’s both embarrassed and excited to talk about the two boys who asked her out this year.
“I turned to him and said, ‘You know I’m transgender, right?’ ” she tells me. “He said that he knows I’m transgender and that he also knows I’m pretty and sweet.”
Taking her red cheeks as a sign to change the subject, we switch back to medicine. I feel around her bicep, where a hard rod just beneath her skin releases a drug that turns off the brain cells that would otherwise kick off puberty. The implant has been in place for two years, preventing the process that would have deepened her voice and given her an Adam’s apple. She has been happy with the blocker, but is ready to move on.
“I’m tired of being the only girl in my grade who looks like a little kid,” she says.
She has a point. A review of recent studies suggests we could start cross-sex hormones as early as 14, so that transgender kids don’t suffer the stigma of starting puberty years after their classmates.
As I talk to Hannah, I can’t help thinking how different things would have been just 10 years ago.
Back then, a doctor may have based her treatment on a 2002 manual for the treatment of “gender identity disorder in young boys.” The manual recommends a range of behavioral interventions to force-fit a child into traditional gender roles. They include keeping the child away from typically feminine activities like gymnastics, scheduling more play dates with boys and encouraging “letting go” of the boy by the mother. The hope was that early treatment would “diminish the risk of a continuation of gender identity disorder into adulthood” — in other words, make children stop being transgender. Transgender youth during this time suffered high rates of depression and anxiety. By young adulthood, nearly half had attempted suicide.
Fortunately, most doctors no longer think this way. In 2012, Dr. Diane Ehrensaft from the University of California, San Francisco, proposed “true gender self child therapy,” in which even the youngest children are allowed to explore their gender identity, with all outcomes (transgender or not) being treated as equally desirable.
That’s just what happened with Hannah. At 10, after a yearlong psychological evaluation, she underwent a nonmedical “social transition.” This meant changing her name from Jonah to Hannah, wearing girls’ clothes and using female pronouns. She went from the frustrated boy wearing a yarmulke to the bubbly child wearing a dress and joining the girls’ bunk at summer camp.
At this point, data on the benefits of early social transition is scarce. But this year researchers at the University of Washington published a study based on 63 transgender youth who were allowed to socially transition. They found that their levels of anxiety and depression were just about indistinguishable from their non-transgender peers.
Critics point to flawed studies that suggest that roughly 80 percent of prepubescent children ultimately change their minds about being transgender. Even if this were true, would it have been worth forcing Hannah to live as a boy, putting her at risk for depression and perhaps suicide? Though going back to a boy’s name and boys’ clothes would probably be hard, even a small risk of suicide is scarier.
Once transgender youth hit puberty, their gender identity is unlikely to change. At that point, doctors often consider medical interventions. The puberty blocker is the first step. In the unlikely event that a child were to change her mind about being transgender, we could remove the implant, and she would then go through male puberty. The implant has some mild side effects, most notably a decrease in bone density, but that quickly improves after the removal of the implant or the initiation of cross-sex hormones like estrogen or testosterone.
The effects of cross-sex hormones like estrogen are not easily reversible. The hormones can impair fertility, but transgender teens are offered fertility preservation options before that stage, like freezing sperm or eggs. Surgery, which often follows in young adulthood, is also, of course, essentially permanent.
In a Dutch study of 55 transgender people who were given puberty blockers during adolescence, however, none changed their minds and none regretted treatment. All went onto cross-sex hormones around age 16 and later gender-affirming surgery. Psychological functioning improved steadily over the treatment period, and by the end, metrics of happiness and quality of life were on a par with those of the general population. Larger studies are underway in the United States, and early clinical experience agrees with the Dutch results.