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MELISSA BLOCK, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.

MICHELE NORRIS, host:

And I'm Michele Norris.

We return now to a topic we explored yesterday: children who feel they are trapped in a body that's the wrong gender. Boys, who at two or three years old, began to insist they were girls. We told a story of two sets of parents faced with this problem who made different choices about what to do.

Today, NPR's Alix Spiegel reports on a controversial new medical treatment for preteens who wish to live as a member of the opposite sex. This is one family's story. To protect their privacy, we will not use their full names.

ALIX SPIEGEL: Like many 11-year-old girls, Violet have his favorite movie star, Bette Midler, and a favorite color, pink, and also a favorite video game. In her case, "Daphne Fights for Fashion."

(Soundbite of music)

VIOLET: That's Daphne. She gets her pink outfit stolen by these Hawaiian men, and then she fights them and to get back her outfit that sort of looks like this.

(Soundbite of music)

SPIEGEL: On a recent Tuesday afternoon, as "Daphne Fights for Fashion" plays on the family computer, Violet became totally absorbed by the action-adventure for girls. She commented on the outfit for each character, pointing out in particular a pair of tall pink boots.

VIOLET: Kim says these boots are made for kicking.

SPIEGEL: Does it show the dress?

VIOLET: I think it's on the fourth level, but no one has ever been through the fourth level. It's, like, impossible.

SPIEGEL: Like her videos heroin, Violet is engaged in a near impossible fight, in her case, against her own body. Within the next year, Violet will start a new medical treatment which will keep her from entering puberty. For the next three or four years, while she is on this medication, her body will grow bigger, but not mature sexually. The reason that Violet will take this medication is because while she feels she's a girl, she was born Armand - a boy.

SPIEGEL: Now, to understand why Violet's parents would take the radical step of allowing their child to change her name, live as a girl, and take a highly controversial medical treatment, it's helpful to know something about Violet's life.

Violet didn't want to be interviewed about this part of her story. She is shy about this topic. But Violet's mother Danielle says signs of gender confusion came early. She remembers that at the age of two, her toddler son put on a costume discarded by his little sister, a Minnie Mouse dress the family had gotten at Disneyland.

DANIELLE: And, she would not take it off. I mean, it was feet, you know, in a stance, strong stance and just standing there and just like, no. And then she pretty much from that point on slept in it, stayed in it all day. It was just really hard to get it off of her.

SPIEGEL: Violet's parents Danielle and Robert now refer to their child using the pronoun she. But they made this change only nine months ago. And it didn't come easily. To put in mildly, Danielle and Robert did not want their son to wear dress. They did not want him to play with Barbie dolls. Danielle and Robert tried to limit all of his behavior. But even when their son was small, whenever they did this, he would become enraged. And Robert says the older he got, the more explosive the behavior became.

ROBERT: Terrible twos became terrible threes and fours and horrible fives and intolerable sixes. She seemed on edge all the time.

SPIEGEL: There were two-hour tantrums, tornadoes of tears and screaming that left the family exhausted. Any comment could set Violet - then Armand off - and once triggered, there was no controlling him.

DANIELLE: It didn't matter what we did, if we took toys away, if we took the TV away, she would still as just as explosive and the behavior would just be out of control.

SPIEGEL: At that point, Robert says, he and Danielle had never heard of children who believed themselves to be the opposite sex. They didn't understand the depths of their child's female identification, and they were stunned by the intensity of his anger, even at the age of six.

ROBERT: One night, I remember it got so bad, where she was so out of control, I literally walked her throughout the front door and said you need to stay - and it was probably at 11 o'clock at night. And I walked her out the front door, closed the door, because I didn't know what to do.

SPIEGEL: Robert remembers standing with Danielle beside the door, listening to his son scream.

ROBERT: Pounding on the door, and us - my wife and I looking at each other, going what is happening? Why is this child so unhappy? What have we done?

SPIEGEL: Naturally, the family sought help from the counselors, from psychologists, psychiatrists, even forensic psychiatrists. Only their son seemed to understand what was going on. Danielle says that sometimes during quiet moments, like a ride from the school, Violet - then Armand - would confess to his mother what was causing so much trouble.

DANIELLE: A lot of times, she'd come out and say, you know, I'm a girl. No, at first it was, I want to be a girl. Then, it's like, no, I am a girl. And she'd ask if me if I think she was crazy, and I said, no, honey. You know, it's okay. And in the front, you know, I'm driving going…

(Soundbite of laughter)

DANIELLE: …and my face is like, oh, my gosh, what is this?

SPIEGEL: But Danielle and Robert could not, would not accept that their child was a girl trapped in a boy's body, not until early last summer, when it finally became clear just how desperate their 10-year-old son had become. Robert and Danielle's oldest child, 14-year-old Melina, tells the story.

MELINA: I just remember she came storming in the kitchen, and my mom and I were getting ready for dinner and everything. And she just took the knife from the counter. She was like, I'm going to kill myself. I'm going to kill myself. And then she was all cussing and stuff.

And she was pointing the knife towards herself, and I just remember running out of the room because I just didn't want to see that. And my mom just like, held my sister, and just like put the knife down and just like put the knife down and just like was holding him. I can't - what are you trying to do? And then it just like exploded into this huge, you know, I hate the world. I hate the world and everything. You know, it's really, it was really scary.

SPIEGEL: Danielle says the more desperate her child became, the easier it was to accept her son's identity as a girl.

DANIELLE: You know, to hear your child say, you know, I don't want to be on this earth anymore unless I can be who I am and you see the desperation in her face. It's not, okay, I'm throwing a tantrum or attention. You know, we have seen his desperation, and this child just, why can't I be this way? Why, you know, why can't you accept me? Why can't people see me for who I am? I mean, it was just became very real for us, how this child was screaming out and saying, hey, you know, listen to me. This is who I am. And I need to be me.

SPIEGEL: Finally, the family found a psychologist who had experience with gender issues. At the end of a two-month evaluation, he gave them a diagnosis, Gender Identity Disorder. That's what this kind of behavior pattern is called in the Diagnostic and Statistical Manual, the mental health diagnostic book used by psychologists and psychiatrists.

The doctor explained that their son would, in all likelihood, grow up to be transgender, someone who lives as a member of the opposite sex. Robert and Danielle said that at that point, the diagnosis was more of a relief than shock. They decided almost immediately to stop trying to force their son to live as a boy. But it also made the family think with some anxiety about the future.

ROBERT: We knew that puberty was around the corner. And we needed to start looking into, what do we do? How do we help this child, you know, develop in a way that is consistent with who she is?

SPIEGEL: Which is how they came to find out about the treatment that could postpone puberty. The treatment began in the U.S. around four years ago, and one of the earliest practitioners was an endocrinologist at Children's Hospital in Boston named Norman Spack.

Spack's doctors have actually been able to block sex hormones for decades. The technique has been used to treat everything from prostate cancer to fibroids. But it was only about 10 years ago that a medical group in the Netherlands decided to use it on kids like Violet.

Dr. NORMAN SPACK (Endocrinologist, Children's Hospital, Boston): They had the idea. They decided to see what would happen if they took such a child who is in such distress over their body, taking the form that they feared. Because remember, between the ages of about four or five, until puberty, kids are just a larger version of themselves everyday. And boys and girls, depending on how they wear their hair or dress, can look exactly the same. And with puberty, that all changes.

SPIEGEL: To put off puberty, children around 10, 11, 12, 13 are injected once a month with hormone blockers. Spack explains that the only thing the blockers affect are the gonads, the organs responsible for turning boys into men and girls into women.

Dr. SPACK: If you can block the gonads - that is the ovary or the testes - from making its sex steroids - that being estrogen or testosterone - then you can literally prevent almost all the physical differences between the genders.

SPIEGEL: Without testosterone, boys will not grow facial hair or body hair. Their voices will not deepen. There will be no Adams apple and less height. Without estrogen, girls will not develop breasts, fat at the hip, periods. And since most growth happens before puberty, if you block estrogen and therefore puberty, girls will grow taller, closer to a typical male height.

Spack opens a file of drawer and rifles through a folder. He brings out a picture of a teenager who's on the hormone blockers. Posed by the railing of a cruise ship in floor-length dress, her head is thrown back, the wind sweeps her hair, there is a huge smile on her face, and nothing to suggest that this 14-year-old girl was once known as he.

Dr. SPACK: This is a genetic male. She's coming to see me tomorrow, okay, and she's blossoming. All his anxiety spilled out the window.

SPIEGEL: So, that's the first stage of treatment, but there's another stage that children like Violet will have to make a decision about in a few years. Once children have postponed puberty for several years, at around the age 16, they can choose to begin maturing sexually into the opposite gender, the gender that they want to become. To do that, they begin taking the hormones of the opposite sex. For males, taking estrogen at this point will bring on breasts and hip growth and all of the attributes - physical and emotional - of females. The reverse will happen for girls who take testosterone.

Spack said this treatment can help make a transgender male almost indistinguishable from a biological male.

Dr. SPACK: We can make it possible that they can fit in, in the way they want to. It is quite amazing.

SPIEGEL: However, if puberty is not blocked, if it is allowed to happen naturally and sexual maturity takes place on time, fitting in as a transgender adult is harder. An adult man who chooses to become a woman by taking estrogen will still tower over other women - with larger hands and feet, a pronounced brow, facial and body hair they have to get rid off, things that can set them apart and make day-to-day life more difficult. This is the fate that Robert and Danielle say they hope to help Violet avoid. Violet will soon start the hormone blockers. And in the meantime, she's living as a girl.

DANIELLE: When we officially knew that, you know, that she was transgender, it was, like, what do you need? You tell us, you know, we weren't going to try to control, we've been doing that for years - so it was just like, what do you need? What do you want?

SPIEGEL: Violet was clear. She wanted to be Violet not Armand. She wanted to be known as their daughter, not their son. Robert and Danielle agreed. The first official day of Violet's new life was August 19th of last year. The first day of the family vacation, Violet was 10. Robert says that her emotional transformation that day was immediate and nothing short of astonishing.

ROBERT: It was the happiest kid I'd ever seen. Just lit up. Just funny and brilliant. And these things that we caught glimpses of that weren't always there. If you met her once when she was Armand and met her a day after that holiday, that vacation, you would think it was a different child.

DANIELLE: Just to see her skipping, you know, I've been at my sister's house and watching her skip out of the room. Just, she just looks freer, like a load was lifted off her shoulder.

SPIEGEL: Since the transition, there had been any real outbursts. Still, there have been challenges. Despite of his support for Violet, Robert somehow could not bring himself to tell his relatives that his son was now his daughter. Then in the fall, Robert's father died. A week later when Robert showed up at the funeral home holding his new daughter's hand, the first person he saw was the priest. He introduced Violet and they talked for a couple of minutes. Then the service started. From the pulpit, the priest spoke of how this death might affect family members. He mentioned, in particular, one grandchild, a little girl named Violet, who loved playing in her granddad's yard.

ROBERT: And I was in the front sitting next to my mother, and I could hear and sense the entire family behind me, looking around each other in a very confused manner going: Who's Violet? Who's Violet?

SPIEGEL: It was at the reception that Robert finally told his relatives.

ROBERT: All my aunts, seven of them, were sitting in a semi-circle and - I have one aunt who's kind of the matriarch, she's clearly in charge. And my aunt asked, she said, Bobby, I thought you had a boy? And I said, well, Tiya(ph), I did have a son, but I found out that I really never did have a son. What I have is two daughters. Armand is transgender, and what that means is that, even know that he has a male body, she's really a girl. And her name is Violet, and I want you meet her again. And I called Violet over and I said, honey, come here. And she come skipping over and I said do you remember all your tiyas(ph), you know, and I went through. And then she skipped off and I was ready for whatever was going to come. And there was a little bit of a silence. And they were all kind looking at my one aunt who was clearly in charge, and she looked at me and she said, you know, Bobby, I'm really proud of you. She said it couldn't have been easy. It couldn't have been easy to accept that. And I'm very proud of you.

SPIEGEL: Robert says that since the family event and violent transition, there's been a new level of peace in his household, a liberating clarity.

ROBERT: There's no doubt at this point in our lives that we have a transgender child. And there's no doubt in our mind that we're going to do what we can to help her.

SPIEGEL: But not everyone believes that it is possible to know with this level of certainty that a child is transgender. In fact, there are two views on this. Polly Carmichael is a British psychologist who works at a place called The Portman Clinic in London, which has the unit specifically dedicated to gender identity. She says the identity of most children this age is in constant flux.

Dr. POLLY CARMICHAEL (Psychologist, The Portman Clinic): You can have a child who's presenting with absolute certainty, and yet, it may be at a later stage, they decide that actually that's not what they want. And they find, perhaps, you know, another solution to their feelings so that feelings indeed change.

SPIEGEL: The Portman Clinic has treated 124 kids since 1989. They required children to leave as the gender they were born with. And looking at their patients, they have found that 80 percent of them, chose as adults, to keep their biological gender. The opposite outcome was seen by the researchers in the Netherlands who first developed the hormone-blocking treatment. They've treated a hundred patients, and all chose, as adults, to live as the opposite sex. So the verdict is still out about how many kids with gender identity disorder will choose sex reassignment as adults. And this makes deciding on treatment very difficult, because there is one very serious side effect to the second part of the treatment. Taking testosterone or estrogen after blocking puberty will make a teenage patient sterile.

Again, Norman Spack.

Dr. SPACK: This is, I personally believe, one of the most controversial aspects of this, and that is at what age can a young person fully understand the implications of doing something that will make fertility for them, by today's technology, virtually impossible.

SPIEGEL: Spack points out, though, that there is no risk of infertility from hormone blockers alone. So, he says hormone blockers, really, should be seen as a treatment that gives families more time to think about what to do.

Dr. SPACK: It's a lot different to be talking to a 14, 15, 16-year-old about the implications of this, than a 10 to 12-year-old. And so it buys you time, buys time without the tremendous fear of the body getting out of control.

SPIEGEL: Violet's father, Robert, remains absolutely certain that Violet is genuinely transgender. And he finds himself almost offended when people suggest that he and his family have been too quick to embrace a transgender diagnosis.

ROBERT: It puzzles me because we even have well intention parents who we care about and who know us, and care about us - say well, you know, she's too young to know. Well, when did you know you were a girl? When did I know I was a boy? I knew my whole life. I can't tell you exactly when, but it was like I was 10 I realized - oh, she must be a boy. What people fail to realize is they made that decision way earlier than that. It just happened that their gender identity and their anatomy matched.

SPIEGEL: In terms of how Violet herself thinks about hormone blockers, her dad, Robert says that she's made it very clear that she does not want to grow into a man. And her sister Melina says that the problem of puberty is very, very much on her mind.

MELINA: You know she's getting hair in some places and stuff, and you know, she just feels - every day she says that she feels a little bit more manly, which is really hard for her because just waking up, for her, that's a big shock. So, she said that she doesn't like taking the shower. She hates undressing. She hates going to the pool.

SPIEGEL: Melina says she sometimes thinks about what it would be like if she woke up every day to a body that was slowly turning male, growing in ways that felt alien and frightening.

MELINA: to go to the process of the gender that you're really not. I just think that's - that must be the most scariest, disgusting thing you - I don't know. It's just, I can't even imagine what that's like.

SPIEGEL: As for Spack, he says doing this work makes you think about gender and life really, in a completely different way.

Mr. SPACK: You start to realize what's really important in this world, you know. You start to realize what's really important. And I don't think there's anything as who you are, who you are.

SPIEGEL: Violet's fight for who she is will doubtless continue. Whether this treatment will simplify that quest or complicate it will become clear in time.

Alix Spiegel, NPR News, Washington.

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BLOCK: And in our Web site, you can read more from the doctors in this story about the benefits and risks of the puberty blocking treatment. That's in npr.org/health.

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