What If Your Child Says, 'I'm In The Wrong Body'?

Dr. Norman Spack at Boston's Children's Hospital has worked with 30 transgender youth and their families to get through the difficult phases of adolescence. One treatment includes a controversial medication that blocks puberty until he or she decides whether or not to transition to the other gender. Dr. Spack talks with guest host Allison Keyes.

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ALLISON KEYES, HOST:

This is TELL ME MORE from NPR News. I'm Allison Keyes. Michel Martin is away. Coming up, with economic troubles and natural disasters, this has been a tough year in many ways. But this week, NPR will highlight some people, trends, and ideas that have done pretty well in 2011. In a few minutes we'll hear the case for it being a good year for lesbian, gay, bisexual and transgender rights.

But first, we'll take a closer look at transgender youth. How would you respond if your child wanted to dress like the opposite gender? And what if that pattern continued for years and your child consistently told you that he or she was born with the wrong body? Since 2007, one clinic in Boston has treated about 30 transgender adolescents.

They offer a wide range of services, including a treatment that blocks puberty and the sexual characteristics that come with adolescence. Here to tell us about the treatment and the issues that some of these families face, is Dr. Norman Spack. He's one of the founders of the clinic at the Children's Hospital in Boston. Dr. Spack, welcome to the program.

And I should note that we'll be discussing sexual organs in a medical context, so this conversation might not be appropriate for all ears and some of you might be offended by it. Doctor, talk to us a bit about some of the risk that exists for children and teenagers who feel they were born with the wrong gender. I understand they face a higher rate of suicide if they don't get counseling and something like 90 percent face bullying. Right?

DR. NORMAN SPACK: Correct. You know, I came to do what I do partly from the top down. My first patients were post-college, my next patients were adults. It was a wasteland. Many of the male-to-females particularly had a very great difficulty in physically being accepted as a woman because of all of the male characteristics in size and hands and angular jaw and the things that we identify...

KEYES: Adam's apple.

SPACK: Adam's apple and voice. And had gone through a miserable time even if they didn't express how they felt about themselves because they suppressed it.

KEYES: So the argument here is that if you start this early the adolescent is going to be able to fit into their chosen gender better because it's physically different. You don't have, as you just said, the physical differences as you would for a man to a woman. So it doesn't make them stand out as much.

SPACK: Right. I mean, they may not stand out at all. I have patients who are male-to-female who are professional models. The defining moment of whether someone is truly transgender is how they react to the changes that are consistent with the genetic puberty that they were programmed for.

At that particular point if you feel like Pinocchio becoming a donkey and wish to rid yourself almost physically of those physical characteristics, the odds are then you are indeed a transgender. And one other characteristic about those kids is that they don't go back. They don't go back to their genetic sex.

KEYES: Let me jump in here for a moment, though, because I just need...

SPACK: Sure.

KEYES: ...our listeners to understand we're talking about medication that delays the onset of puberty.

SPACK: Right.

KEYES: So that's step one. This has...

SPACK: And step one is a diagnostic test.

KEYES: And then after they get to, say, age 11 to 13 when puberty is about to happen, then they could start this medication that delays puberty; which is not physically permanent, if we understand correctly.

SPACK: Exactly.

KEYES: Then there's a second step that is permanent, right, where they can take medication that actually means they can experience the puberty of the opposite sex, which is permanent, correct?

SPACK: Right. The changes that occur when they take the hormones of the opposite sex are as permanent as the changes as if they happened to them biologically.

KEYES: Doesn't that make them sterile?

SPACK: So that it - yes, probably. This is why we don't get involved with such things as permanent changes in 10- to 12-year-old girls or 12- to 14-year-old boys, and they have to be in counseling while on pubertal suppression for two to three or four years. And we regard how they react to that as very important diagnostic information.

KEYES: If you're just joining us, you're listening to TELL ME MORE from NPR News. I'm Allison Keyes and I'm speaking with Dr. Norman Spack, one of the founders of a special clinic at Boston's Children's Hospital that provides medical and emotional services for transgender youth. Doctor, there are a lot of phases that children go through and some experts have said that gender identity is kind of in flux when you're a child.

In fact, in 2008, NPR spoke with British psychologist Polly Carmichael, who studies the subject. Let's listen to what she said.

(SOUNDBITE OF ARCHIVED INTERVIEW)

DR. POLLY CARMICHAEL: You can have a child who's presenting with absolute certainty and yet it may be that a later stage they decide that actually that's not what they want and they find perhaps, you know, another solution to their feelings. Or their feelings indeed change.

KEYES: How do you trust that this is not just a phase that the child is going through?

SPACK: Well, Polly is really speaking about children, not about adolescents, and the reason I can say that is that her program is now beginning to do the same protocol that we are, for selected adolescents in a research way...

KEYES: When you say adolescent, what age are you talking about?

SPACK: We're talking about the beginning of pubertal changes in the biologic girl which could be between 10 to 12, and a boy between 12 to 14, on average. And she's absolutely right when she talks about it can be a phase and children can go back and forth and they may play with both kinds of toys. They may find psychological comfort in the role of the other gender.

KEYES: Let me make sure that I'm clear here. There is a number of children that are simply curious about being the other gender, but your criteria is if they are made uncomfortable by the thought or onset of puberty. This means medically and psychologically that you believe that they will move on to transitioning, say, from girl to boy or from boy to girl.

SPACK: If they pass the tests that we give them of gender identity. And they invariably do.

KEYES: Doctor, I wonder how you respond to those who say that this is too early for people to make such a decision; a 16-year-old can't possibly know if 10 years later they're going to want to do the same thing.

SPACK: Well, first of all, the satisfaction of these people with the affirmed gender and how it's been treated with both pubertal delay and later giving opposite sex steroids has been absolutely fantastic. You know, I have to turn around and ask you or everyone who questions how people know, well, I think they should look into themselves and say at what age did they think they knew they were a male or female. And I bet most people had a pretty good idea at a very early age.

KEYES: I wonder if you yourself have ever had a patient that decided this was not for them once they started the therapy.

SPACK: Yes. I did. And I think it turned out to be a blessing for this genetic female who was going through an incredible period of family strife, parental divorce, and a father who wouldn't see her while she was in any male attire. We had put her on a pubertal suppression and over the course of a year we saw her starting to dress a bit more feminine.

And, again, going through all counseling, we spoke to her counselor. I said, you know, she's no longer wearing a baseball hat every time she comes in. She's growing her hair a bit longer. Her counselor got back to us and says, you know, she was in a state of crisis. I too had feared for whether she was going to have to be psychiatrically hospitalized. She seems to have settled down.

On the other hand, she's claiming now that she thinks she can deal with being a girl. And this was about a year after we had started. So we stopped the medication and she eased back into female puberty and has done fine. And we were speaking to the mother about it, and because this was the first time we had ever seen this happen, some of us were wondering, well, did we do the wrong thing in what we did.

And she said, on the contrary. In her particular case by giving her another year to work things through without harming herself enabled her to sort out who she really felt she is.

KEYES: Some of the people who oppose this have actually accused doctors of playing God, basically. How do you respond?

SPACK: I think the people who say these things feel that they really are and will forever be in control of their children and I think they're going to be in for a shock. And the things we cannot control sometimes can lead to this group of people who are not supported by their parents and are not treated, have 45 percent incidence of suicidal attempt between age 18 and 25. And there is no group higher than that.

I go back to the text that guides me in this and that is Leviticus, that says if your neighbor is bleeding by the side of the road, you should not stand idly by. And that's a mandate to help and to treat and that's what we're doing and we are amazed at how well these kids are doing. But we have to continue to consider this a project which requires continued surveillance and research.

KEYES: Dr. Norman Spack is one of the founders of the Gender Management Services Clinic at Children's Hospital Boston. He joined us from member station WGBH in Boston, Mass. Thank you, Doctor, for a fascinating conversation.

SPACK: You're entirely welcome.

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