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MICHELE NORRIS, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.

MELISSA BLOCK, host:

I'm Melissa Block.

Today, we meet two sets of parents who face difficult choices about what's best for their child. Both have 6-year-old sons who believe they were born into the wrong body - boys who say they are actually girls.

NORRIS: Now, this is nothing new - men who feel they're actually women and vice versa. What's less well known is that this conflict can also affect children.

NPR's Alix Spiegel has the story of two families making the opposite choice about the problem they have in common.

ALIX SPIEGEL: This is the story of two little boys. Both boys are now 6, both bright, both friendly, both born to parents of education and means. The first little boy is named Jonah. To protect his identity, the family asked us not to use his last name. Jonah lives on the West Coast with his parents, and his father, Joel, remembers noticing even at the age of 2, that his son didn't seem to be interested in traditional boy toys.

JOEL: Very early on, I recognized that Jonah was not a ball kid. Like I think there's ball kids and not ball kids, like kids who are good at throwing balls and catching balls, and, you know, interested in all that sort of - and she just never was.

SPIEGEL: Joel now calls his son a she. But that change only happened recently, and it didn't come easily. When Jonah was small, Joel, like every other dad, never considered the possibility that his son might feel that he was a girl. This realization dawned slowly, an accumulation of small observations - for example, that all of Jonah's stuffed animals were girls.

JOEL: Like I would always say, oh, what that guy's name? And the response was, oh, she's Bunny, she's, you know, this or that. And then, similarly, the characters and - that she identified with on TV, so she always liked the Kathy the Dinosaur and she liked Ducky, and it was always the female characters.

SPIEGEL: Three thousand miles away on the East Coast, another 2-year-old boy seemed to identify exclusively with female characters. We'll call him Bradley, because his parents asked us not to use his real name. Now, his mom,Carol, and his dad didn't see Bradley's identification with girls as a problem.

CAROL: We thought he was creative, lovely. Of course, why wouldn't you identify with the female characters? They're more colorful, and maybe he doesn't want to stab the other guy on the horse.

SPIEGEL: His mom, Carol, was also initially untroubled that Bradley played exclusively with Barbie dolls and princesses.

CAROL: It makes him smile, made him happy. It wasn't a loaded gun. It wasn't a lit cigarette. It wasn't, you know, anything harmful if we weren't thinking in terms of long-term emotional confusion, gender confusion. So it just never crossed my mind to say, I'd really rather you played with a truck.

SPIEGEL: It wasn't until one Halloween, when her 2-and-a-half-year-old son decided to dress as Dorothy from "The Wizard of Oz" that Carol really began to take note. To simulate Dorothy's hair, they covered Bradley's short blond hair with a brown tea towel. Bradley loved it. In fact, he became obsessed with his tea towel hair. For months afterwards, Bradley would wake up every morning and put the towel in his head. When Carol tried to remove it, he would protest.

CAROL: He seemed to feel uncomfortable and nervous sometimes when he didn't have this hair, this tea towel hair.

SPIEGEL: As both boys in this story grew older, they began to express more direct discomfort with being boys. On the West Coast, Jonah, at around the age of 3, started speaking out about these feelings. Jonah is beautiful. Truly. He looks like a very short version of Winona Ryder with his dark hair and dark eyes. So, casual acquaintances of his parents would frequently mistake him for a girl. And Joel says that his son hated it if his parents corrected anyone.

JOEL: What began to happen was Jonah got really, started to get upset about that, like, why do you have to say anything, you know? And I remember one distinct time when we were walking the dogs and this person came up and said, oh, is this your daughter? I said oh, no, this is Jonah. And Jonah just came running up and said, why do you have tell them? Why do you have to say anything?

SPIEGEL: Jonah felt that he was not a boy. Jonah felt that he was a girl, a girl to his core, a girl trapped in a boy's body. He was absolutely certain of it. A portion of kids with gender identity issues feel this way. They're at the more extreme end of the spectrum of behaviors and attitudes that indicate gender confusion. These kids are more than effeminate boys or masculine girls who may become gay as adults. They are children who genuinely believe themselves to be girls even though they have a male body, or boys even though they have a female body.

On the East Coast, Bradley, from a very early age, really would only play and talk to girls. He seemed positively uncomfortable around boys. This concerned his mom, Carol, but she wasn't frantic about it. For Carol, it was a single event when her son was around 5 that tipped her vague sense of worry into something more serious.

One day, her son came home from an outing at the local playground with his babysitter. He was covered in blood; a gash on his forehead ran deep into his hairline.

CAROL: What had happened was two 10-year-old boys had thrown him off some playground equipment across the pavement because he'd been playing with a Barbie doll, and they called him a girl. And so that sort of struck me that, you know, if he doesn't learn to socialize with both males and females, he was going to get hurt.

SPIEGEL: Carol decided to seek professional help. Bradley's school referred her to a psychologist, a gender specialist in Toronto named Dr. Ken Zucker, who is considered a world expert on gender identity issues, and who runs a clinic in Canada specifically devoted to these kids.

Dr. KEN ZUCKER (Psychologist, Gender Specialist): This is our humble family assessment room, where over the years we've met with hundreds of families.

SPIEGEL: Dr. Zucker has been treating kids with gender identity problems for close to 30 years. And for all of that time, his goal whenever he encounters a child under the age of 10 has been the same. He tries to make the children comfortable with the gender they were born with.

Now, there's a lot of debate about Zucker's approach. There's a group of mental health professionals who argue that trying to force children with these issues to accept the sex they were born with is akin to trying to force homosexuals to be straight, that it's unethical. But that's not how Zucker sees it. He offers this way of thinking about it.

Dr. ZUCKER: Suppose you were a clinician and a 4-year-old black kid came into your office and said he wanted to be white. Would you go with that? I don't think we would.

SPIEGEL: If a black kid walked into a therapist's office saying that he was really white, the goal of pretty much any therapist out there would be to try to make him feel more comfortable with being black. They would assume that his beliefs were the product of a dysfunctional environment - a family environment or a cultural environment, which is how Zucker sees gender disordered kids. He sees these behaviors primarily as the product of dysfunction. According to the official manual of psychiatry and psychology called "The Diagnostic and Statistical Manual," which he helped to write, these behaviors do constitute a pathology. It's called gender identity disorder.

Now, when Carol first went to Dr. Zucker, making Bradley feel comfortable with the gender he was born with was not necessarily her aim. She was just looking for general guidance. But something Zucker said in their first meeting really affected her.

CAROL: The one thing that Dr. Zucker said to us that stuck was that, you know, research shows or - that as he grows older, both peer groups may reject him. Males won't necessarily identify with him if he is, you know, more feminine and that kind of thing. And eventually, the girls like boys, and they like boys who are boys, and so he may have issues in that respect. And because, you know, he is a very sociable boy, that painted a very lonely picture.

SPIEGEL: To redirect her son, Zucker told Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls, no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker feels all of these activities are dangerous to a kid with gender identity disorder.

Dr. ZUCKER: The more you engage in a behavior, the more likely it's going to continue. If a little boy is only cross-dressing and only role-playing as a female, only playing with toys in the culture that we associate with girls, I think that that gets into a feedback loop that reinforces their identity or fantasy that they are a girl or that they're like a girl.

SPIEGEL: For Carol and her husband, though, these were huge changes. By the time Bradley started therapy, he was almost 6 years old, and Carol had a houseful of toys he enjoyed, a houseful of Barbie dolls and Polly Pockets. She now had to remove them. To cushion the blow, she didn't take the toys away all at once. She told Bradley that he could choose one or two toys a day.

CAROL: I mean, in the beginning, he didn't really care, because he picked stuff he didn't play with. And sometimes he'd pick his brother's stuff and say, give that away. Take that. I don't - you know? But then when it went really got down to the last few - and he would hide things.

SPIEGEL: Carol would find Snow White figures stashed between couch pillows, rainbow unicorns hidden in the back of her son's closet. Bradley seemed at a loss. They gave him male toys, but he chose not to play at all.

CAROL: He turned to coloring and drawing, and he just simply wouldn't play with anything. And he would color and draw for hours and hours. And that would be all he did in a day, because I think he was really lost, and the whole way that he knew and understood how to play was just sort of, you know, removed from his house.

SPIEGEL: And what did he draw?

CAROL: Girls, rainbows, butterflies, fairies.

SPIEGEL: They were all pink and lavender and pale yellow - colors that under Zucker's direction, Carol and her husband also tried to change.

CAROL: We would ask him, can you draw a boy for us? Can you draw a boy in that picture? And then he didn't really want us to see his drawings or watch him drawing because we would always say, can you draw a boy? And then finally, after - I don't know - a month or two, he just said, Momma, I don't know how. I don't know how to draw a boy.

SPIEGEL: Meanwhile, on the West Coast, Jonah was in the midst of his own change. Jonah's mom, Pam, says at around the age of 3, Jonah started taking her clothing. He would borrow a long T-shirt and belt and fashion it into a dress. This went on for months, with Jonah constantly adjusting his costume to make it better.

PAM: One day, she was just crying and crying, and just she couldn't get it right. She couldn't adjust it right. It just wasn't right. And she was just crying and so sad. You know, and I knew that she wanted a dress, and it was just - at that point, I just said, you know, you really want a dress to wear, don't you? And her face lit up and she's like, yes.

SPIEGEL: Pam says the drive to the store to choose Jonah's first dress was an experience she will never forget.

PAM: I thought she was going to hyperventilate and faint, because she was so incredibly happy. Like since before then, or since then, I don't think I have seen her so out-of-her-mind happy as that drive to Target that day to pick out her dress.

SPIEGEL: Pam allowed Jonah to get two dresses but says she felt incredibly conflicted about it. And even though Jonah asked, she wouldn't allow him to buy any more dresses for a year afterwards. And so Jonah wore those two dresses every day, nothing else, until Pam got sick of looking at them. After a year, when Jonah was around 4, she and Joel finally began to permit other small purchases. But Joel says every item provoked a crisis.

JOEL: We'd spend a few nights talking, do you think the shoes are like a line that we should cross? Or, you know, the girly hat, or the girly jacket with the frills? Or like what are we doing? Are we encouraging this? Are we doing something that we shouldn't be?

SPIEGEL: And so Joel and Pam also ended up in front of a gender specialist, a psychologist in Oakland named Diane Ehrensaft. Joel remembers an early session when Pam talked about her concerns.

JOEL: I remember her talking to the therapist and saying something to the effect of, like, you know, I'd be okay if Jonah just was gay. I just don't want him to be transgender. And the therapist just laughed. She said, you know, 15 years ago, I had people on this couch, saying I don't mind him being a little of effeminate, as long as he's not gay.

SPIEGEL: In fact, Diane Ehrensaft is a therapist who sees gender problems as akin to homosexuality. In her own words...

Dr. DIANE EHRENSAFT (Psychologist, Gender Specialist): I think we can learn from looking at what we had to unlearn and re-learn about homosexuality. You see, 35 years ago, homosexuality was considered a mental illness, a pathology so severe that it required aggressive therapeutic intervention. One common treatment was to try to condition homosexuals out of their sexual preference by attaching them to a electrical shock machines and shocking them every time they were aroused by homosexual pornography.

Today, the American Psychiatric Association's position is that therapies which try to turn homosexuals into heterosexuals are unethical. Homosexuality is now seen as a normal variant of human behavior.

SPIEGEL: Which is how Ehrensaft sees these kids. She doesn't use the label gender identity disorder. She calls this transgenderism. And for her, the lessons of the early therapeutic approaches to homosexuality are clear.

Dr. EHRENSAFT: If we allow people to unfold and give them the freedom to be who they really are, we engender health. And if we try and constrict it or bend the twig, we engender poor mental health.

SPIEGEL: This is why Ehrensaft didn't encourage Pam and Joel to place Jonah in therapy. Pam says that because Ehrensaft didn't see transgenderism itself as a dysfunction any more than she see homosexuality as a dysfunction, she didn't think it should be treated.

Dr. EHRENSAFT: She made it really clear that, you know, if Jonah's not depressed or anxious or having anything go on that she would need to really be in therapy for, then don't put a kid in therapy until they need it.

SPIEGEL: This is also why Dr. Ehrensaft did encourage Joel and Pam to allow Jonah to live as a little girl. Now, she doesn't always do that. If she thinks that a child is less certain about their gender identity or has mixed feelings, she'll ask parents to be cautious and not permit the child to live as the opposite sex. She describes one case.

Dr. EHRENSAFT: The mother is very supportive of allowing this child to transition from being a little boy to a little girl. The father is very opposed. And this child says to me, sometimes I'm a girl, sometimes I'm a boy, and if I can't be a young lady, I could be a boy. And that, to me, is a child who hasn't told us his whole story yet. And, in fact, what I advised to the mother is please slow down.

SPIEGEL: But Jonah on the West Coast had made it very clear to his parents that he wanted to wear girl clothes full time, that he wanted to be known as a girl, that he wanted his parents to call him their daughter. And Ehrensaft, who has treated dozens of transgendered kids, says that in her experience, allowing a kid like this to live as the opposite sex works out fine.

Dr. EHRENSAFT: I will see a child who at the beginning is anxious, sometimes frenetic, angry, transition. And there's a lifting of spirits. They're happier. They smile more, which isn't to say that they don't have a hard road ahead of them. But usually that's worry about the world, and how the world will receive them, rather than worry about who they are in themselves.

SPIEGEL: Joel says this has certainly been the case with Jonah. Last year, at age 5, Joel and Pam allowed Jonah to start kindergarten as a girl. They found a school that was supportive. And though they were initially nervous about it, it really went surprisingly well.

JOEL: They have these little conferences. And, you know, we are asking, like, well, how's Jonah doing? You know, does she have problem with other kids? And, you know, the teacher was like, God, I got to tell you, you know, Jonah is one of most popular kids. Kids love her. They want to play with her. She's fun, and it's because she's so comfortable with herself that she makes other people comfortable.

SPIEGEL: But for psychologist Ken Zucker, this approach is a terrible mistake.

Dr. ZUCKER: By declaring the child as transgendered, at say age 3 or age 4 or age 6, and then saying, in a sense, go with the flow, that will impact on how the kid's gender identity differentiates.

SPIEGEL: In other words, allowing the kid to transition that early will essentially track them into becoming a transgender adolescent and adult.

Dr. ZUCKER: That would be my prediction. Yes.

SPIEGEL: For Zucker, no child under the age of 10 or 11 can be definitively labeled transgendered. He says that kids' gender identities are flexible, and that even a child like Jonah - who appears absolutely consistent from the age of 1 or 2 - can change.

But Diane Ehrensaft says that this position is too absolute.

Dr. EHRENSAFT: I agree that children are flexible. I also think there is a subgroup of children, if we listen to them carefully, they will tell us, I know who I am.

SPIEGEL: And so, while Ehrensaft thinks it's important to be very, very careful about applying a transgender label to a young child, it is at least possible. And she is every bit as disapproving of Zucker's form of therapy as he is of hers. She says it's wrong to take away a child's toys, police the people he spends time with, the pictures he draws, even the colors he draws with.

Dr. EHRENSAFT: To me, this is coercive therapy, and I don't think we should be in the business of coercing people. And I understand we can say that development is malleable and we're simply helping children, so I understand that argument. But I would say all the kids I've worked with who have gone through that kind of treatment, they have not come out better. They've come out worse.

SPIEGEL: It does seem to be the case that at least in the short term, Carol's son Bradley is struggling in some ways with Ken Zucker's therapy. Carol says that it was particularly hard at the beginning.

CAROL: He was much more emotional. He could be very clingy. He didn't want to go to school anymore. He - just the smallest thing could, you know, send him into a major crying fit. And he seemed to feel really heavy and really emotional.

SPIEGEL: Her 6-year-old child has been in therapy now for eight months. And Carol says, still, on the rare occasions that she cannot avoid having him exposed to girl toys, like when they visit family, it doesn't go well.

CAROL: It's really hard for him. He'll disappear and close a door, and we'll find him playing with dolls and Polly Pockets and the stuff that he's drawn to.

SPIEGEL: In particular, there is one typically girl thing, now banned, that her son absolutely cannot resist.

CAROL: He really struggles with the color pink. He really struggles with the color pink. It's just - and he can't even really look at pink. He's like an addict. He's like, Mommy, don't take me there. Close my eyes. Cover my eyes. I can't see that stuff. It's all pink.

SPIEGEL: Still, Carol says her child has made some progress. Today, he is able to play with boys. He has a few male friends and has said that he now enjoys boy things. And there are other signs of change.

CAROL: I mean, he tells us now that he doesn't dream anymore that he's a girl. So, we're happy with that. He's still a bit defensive if we ask him, do you want to be a girl? He's like, no, no. I'm happy being a boy - I want to be - he gives us that sort of stock answer. I still think we're at the stage where he feels he's leading a double life.

I'm still quite certain that he is with the girls all the time at school, and so he knows to behave one way at school, and then when he comes home, there's a different set of expectations.

SPIEGEL: Zucker says despite these difficulties, it's important to at least attempt change because the burden of living as the opposite gender is great and should not be casually embraced.

Dr. ZUCKER: We're not talking about minor medical treatments. You're talking about lifelong hormonal treatment. You're talking about serious and substantive surgery.

SPIEGEL: In terms of which of these therapies is more prevalent in the U.S., Diane Ehrensaft says there's absolutely no doubt in her mind: Zucker's.

(Soundbite of laughter)

Dr. EHRENSAFT: Zucker's approach is much more prevalent, I would say.

SPIEGEL: Obviously, Ehrensaft hopes this will change, and she says that professional opinion on this subject is in incredible flux, that the treatment of transgendered children is becoming a kind of civil rights issue in the same way that the psychiatric treatment of homosexuals became a civil rights issue in the 1970s.

In the meantime, though, Zucker's approach continues to thrive. He says that at his clinic in Toronto, there are close to 80 children on his waiting list.

Alix Spiegel, NPR News, Washington.

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