A Boy’s Life

Diagnoses of gender-identity disorder among adults have tripled in Western countries since the 1960s; for men, the estimates now range from one in 7,400 to one in 42,000 (for women, the frequency of diagnosis is lower).

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Around the world, clinics that specialize in gender-identity disorder in children report an explosion in referrals over the past few years. Dr. Kenneth Zucker, who runs the most comprehensive gender-identity clinic for youth in Toronto, has seen his waiting list quadruple in the past four years, to about 80 kids—an increase he attributes to media coverage and the proliferation of new sites on the Internet. Dr. Peggy Cohen-Kettenis, who runs the main clinic in the Netherlands, has seen the average age of her patients plummet since 2002. “We used to get calls mostly from parents who were concerned about their children being gay,” says Catherine Tuerk, who since 1998 has run a support network for parents of children with gender-variant behavior, out of Children’s National Medical Center in Washington, D.C. “Now about 90 percent of our calls are from parents with some concern that their child may be transgender.”

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It took the gay-rights movement 30 years to shift from the Stonewall riots to gay marriage; now its transgender wing, long considered the most subversive, is striving for suburban normalcy too. The change is fuel‑ed mostly by a community of parents who, like many parents of this generation, are open to letting even preschool children define their own needs. Faced with skeptical neighbors and school officials, parents at the conference discussed how to use the kind of quasi-therapeutic language that, these days, inspires deference: tell the school the child has a “medical condition” or a “hormonal imbalance” that can be treated later, suggested a conference speaker, Kim Pearson; using terms like gender-­identity disorder or birth defect would be going too far, she advised. The point was to take the situation out of the realm of deep pathology or mental illness, while at the same time separating it from voluntary behavior, and to put it into the idiom of garden-variety “challenge.” As one father told me, “Between all the kids with language problems and learning disabilities and peanut allergies, the school doesn’t know who to worry about first.”

A recent medical innovation holds out the promise that this might be the first generation of transsexuals who can live inconspicuously. About three years ago, physicians in the U.S. started treating transgender children with puberty blockers, drugs originally intended to halt precocious puberty. The blockers put teens in a state of suspended development. They prevent boys from growing facial and body hair and an Adam’s apple, or developing a deep voice or any of the other physical characteristics that a male-to-female transsexual would later spend tens of thousands of dollars to reverse. They allow girls to grow taller, and prevent them from getting breasts or a period.

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In 1967, Dr. John Money launched an experiment that he thought might confirm some of the more radical ideas emerging in feminist thought. Throughout the ’60s, writers such as Betty Friedan were challenging the notion that women should be limited to their prescribed roles as wives, housekeepers, and mothers. But other feminists pushed further, arguing that the whole notion of gender was a social construction, and easy to manipulate. In a 1955 paper, Money had written: “Sexual behavior and orientation as male or female does not have an innate, instinctive basis.” We learn whether we are male or female “in the course of the various experiences of growing up.” By the ’60s, he was well-known for having established the first American clinic to perform voluntary sex-change operations, at the Johns Hopkins Hospital, in Baltimore.

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Today, the notion that gender is purely a social construction seems nearly as outmoded as bra-burning or free love. Feminist theory is pivoting with the rest of the culture, and is locating the key to identity in genetics and the workings of the brain. In the new conventional wisdom, we are all pre-wired for many things previously thought to be in the realm of upbringing, choice, or subjective experience: happiness, religious awakening, cheating, a love of chocolate. Behaviors are fundamental unless we are chemically altered. Louann Brizendine, in her 2006 best-selling book, The Female Brain, claims that everything from empathy to chattiness to poor spatial reasoning is “hardwired into the brains of women.” Dr. Milton Diamond, an expert on human sexuality at the University of Hawaii and long the intellectual nemesis of Money, encapsulated this view in an interview on the BBC in 1980, when it was becoming clear that Money’s experiment was failing: “Maybe we really have to think … that we don’t come to this world neutral; that we come to this world with some degree of maleness and femaleness which will transcend whatever the society wants to put into [us].”

Diamond now spends his time collecting case studies of transsexuals who have a twin, to see how often both twins have transitioned to the opposite sex. To him, these cases are a “confirmation” that “the biggest sex organ is not between the legs but between the ears.” For many gender biologists like Diamond, transgender children now serve the same allegorical purpose that David Reimer once did, but they support the opposite conclusion: they are seen as living proof that “gender identity is influenced by some innate or immutable factors,” writes Melissa Hines, the author of Brain Gender.

This is the strange place in which transsexuals have found themselves. For years, they’ve been at the extreme edges of transgressive sexual politics. But now children like Brandon are being used to paint a more conventional picture: before they have much time to be shaped by experience, before they know their sexual orientation, even in defiance of their bodies, children can know their gender, from the firings of neurons deep within their brains. What better rebuke to the Our Bodies, Ourselves era of feminism than the notion that even the body is dispensable, that the hard nugget of difference lies even deeper?

In most major institutes for gender-identity disorder in children worldwide, a psychologist is the central figure. In the United States, the person intending to found “the first major academic research center,” as he calls it, is Dr. Norman Spack, an endocrinologist who teaches at Harvard Medical School and is committed to a hormonal fix. Spack works out of a cramped office at Children’s Hospital in Boston.

Spack has treated young-adult transsexuals since the 1980s, and until recently he could never get past one problem: “They are never going to fail to draw attention to themselves.” Over the years, he’d seen patients rejected by families, friends, and employers after a sex-change operation. Four years ago, he heard about the innovative use of hormone blockers on transgender youths in the Netherlands; to him, the drugs seemed like the missing piece of the puzzle.

The problem with blockers is that parents have to begin making medical decisions for their children when the children are quite young. From the earliest signs of puberty, doctors have about 18 months to start the blockers for ideal results. For girls, that’s usually between ages 10 and 12; for boys, between 12 and 14. If the patients follow through with cross-sex hormones and sex-change surgery, they will be permanently sterile, something Spack always discusses with them. “When you’re talking to a 12-year-old, that’s a heavy-duty conversation,” he said in a recent interview. “Does a kid that age really think about fertility? But if you don’t start treatment, they will always have trouble fitting in.”

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Blockers are entirely reversible; should a child change his or her mind about becoming the other gender, a doctor can stop the drugs and normal puberty will begin. The Dutch clinic has given them to about 70 children since it started the treatment, in 2000; clinics in the United States and Canada have given them to dozens more. According to Dr. Peggy Cohen-Kettenis, the psychologist who heads the Dutch clinic, no case of a child stopping the blockers and changing course has yet been reported.

This suggests one of two things: either the screening is excellent, or once a child begins, he or she is set firmly on the path to medical intervention. “Adolescents may consider this step a guarantee of sex reassignment,” wrote Cohen-Kettenis, “and it could make them therefore less rather than more inclined to engage in introspection.” In the Netherlands, clinicians try to guard against this with an extensive diagnostic protocol, including testing and many sessions “to confirm that the desire for treatment is very persistent,” before starting the blockers.

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Spack’s own conception of the psychology involved is uncomplicated: “If a girl starts to experience breast budding and feels like cutting herself, then she’s probably transgendered. If she feels immediate relief on the [puberty-blocking] drugs, that confirms the diagnosis,” he told The Boston Globe. He thinks of the blockers not as an addendum to years of therapy but as “preventative” because they forestall the trauma that comes from social rejection. Clinically, men who become women are usually described as “male-to-female,” but Spack, using the parlance of activist parents, refers to them as “affirmed females”—“because how can you be a male-to-female if really you were always a female in your brain?”

For the transgender community, born in the wrong body is the catchphrase that best captures this moment. It implies that the anatomy deceives where the brain tells the truth; that gender destiny is set before a baby takes its first breath. But the empirical evidence does not fit this argument so neatly. Milton Diamond says his study of identical transgender twins shows the same genetic predisposition that has been found for homosexuality: if one twin has switched to the opposite sex, there is a 50 percent chance that the other will as well. But his survey has not yet been published, and no one else has found nearly that degree of correlation. Eric Vilain, a geneticist at UCLA who specializes in sexual development and sex differences in the brain, says the studies on twins are mixed and that, on the whole, “there is no evidence of a biological influence on transsexualism yet.”

In 1995, a study published in Nature looked at the brains of six adult male-to-female transsexuals and showed that certain regions of their brains were closer in size to those of women than of men. This study seemed to echo a famous 1991 study about gay men, published in Science by the neuroscientist Simon LeVay. LeVay had studied a portion of the hypothalamus that governs sexual behavior, and he discovered that in gay men, its size was much closer to women’s than to straight men’s; his findings helped legitimize the notion that homosexuality is hardwired. But in the transsexual study, the sample size was small, and the subjects had already received significant feminizing hormone treatments, which can affect brain structure.

Transsexualism is far less common than homo­sexuality, and the research is in its infancy. Scattered studies have looked at brain activity, finger size, familial recurrence, and birth order. One hypothesis involves hormonal imbalances during pregnancy. In 1988, researchers injected hormones into pregnant rhesus monkeys; the hormones seemed to masculinize the brains but not the bodies of their female babies. “Are we expecting to find some biological component [to gender identity]?” asks Vilain. “Certainly I am. But my hunch is, it’s going to be mild. My hunch is that sexual orientation is probably much more hardwired than gender identity. I’m not saying [gender identity is] entirely determined by the social environment. I’m just saying that it’s much more malleable.”

Vilain has spent his career working with intersex patients, who are born with the anatomy of both sexes. He says his hardest job is to persuade the parents to leave the genitals ambiguous and wait until the child has grown up, and can choose his or her own course. This experience has influenced his views on parents with young transgender kids. “I’m torn here. I’m very ambivalent. I know [the parents] are saying the children are born this way. But I’m still on the fence. I consider the child my patient, not the parents, and I don’t want to alleviate the anxiety of the parents by surgically fixing the child. We don’t know the long-term effects of making these decisions for the child. We’re playing God here, a little bit.”

Even some supporters of hormone blockers worry that the availability of the drugs will encourage parents to make definitive decisions about younger and younger kids. This is one reason why doctors at the clinic in the Netherlands ask parents not to let young children live as the other gender until they are about to go on blockers. “We discourage it because the chances are very high that your child will not be a transsexual,” says Cohen-Kettenis. The Dutch studies of their own patients show that among young children who have gender-identity disorder, only 20 to 25 percent still want to switch gender at adolescence; other studies show similar or even lower rates of persistence.

The most extensive study on transgender boys was published in 1987 as The “Sissy Boy Syndrome” and the Development of Homosexuality. For 15 years, Dr. Richard Green followed 44 boys who exhibited extreme feminine behaviors, and a control group of boys who did not. The boys in the feminine group all played with dolls, preferred the company of girls to boys, and avoided “rough-and-tumble play.” Reports from their parents sound very much like the testimonies one reads on the listservs today. “He started … cross-dressing when he was about 3,” reported one mother. “[He stood] in front of the mirror and he took his penis and he folded it under, and he said, ‘Look, Mommy, I’m a girl,’” said another.

Green expected most of the boys in the study to end up as transsexuals, but nothing like that happened. Three-fourths of the 44 boys turned out to be gay or bisexual (Green says a few more have since contacted him and told him they too were gay). Only one became a transsexual. “We can’t tell a pre-gay from a pre-transsexual at 8,” says Green, who recently retired from running the adult gender-identity clinic in England. “Are you helping or hurting a kid by allowing them to live as the other gender? If everyone is caught up in facilitating the thing, then there may be a hell of a lot of pressure to remain that way, regardless of how strongly the kid still feels gender-dysphoric. Who knows? That’s a study that hasn’t found its investigator yet.”

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Dr. Kenneth Zucker has been seeing children with gender-identity disorder in Toronto since the mid-’70s, and has published more on the subject than any other researcher. But lately he has become a pariah to the most-vocal activists in the American transgender community. In 2012, the Diagnostic and Statistical Manual of Mental Disorders—the bible for psychiatric professionals—will be updated. Many in the transgender community see this as their opportunity to remove gender-identity disorder from the book, much the same way homosexuality was delisted in 1973. Zucker is in charge of the committee that will make the recommendation. He seems unlikely to bless the condition as psychologically healthy, especially in young children.

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On one of his file cabinets, he’s tacked up a flyer from a British parents’ advocacy group that reads: “Gender dysphoria is increasingly understood … as having biological origins,” and describes “small parts of the brain” as “progressing along different pathways.” During the interview, he took it down to make a point: “In terms of empirical data, this is not true. It’s just dogma, and I’ve never liked dogma. Biology is not destiny.”

In his case studies and descriptions of patients, Zucker usually explains gender dysphoria in terms of what he calls “family noise”: neglectful parents who caused a boy to over­identify with his domineering older sisters; a mother who expected a daughter and delayed naming her newborn son for eight weeks. Zucker’s belief is that with enough therapy, such children can be made to feel comfortable in their birth sex. Zucker has compared young children who believe they are meant to live as the other sex to people who want to amputate healthy limbs, or who believe they are cats, or those with something called ethnic-identity disorder. “If a 5-year-old black kid came into the clinic and said he wanted to be white, would we endorse that?” he told me. “I don’t think so. What we would want to do is say, ‘What’s going on with this kid that’s making him feel that it would be better to be white?’”

Young children, he explains, have very concrete reasoning; they may believe that if they want to wear dresses, they are girls. But he sees it as his job—and the parents’—to help them think in more-flexible ways. “If a kid has massive separation anxiety and does not want to go to school, one solution would be to let them stay home. That would solve the problem at one level, but not at another. So it is with gender identity.” Allowing a child to switch genders, in other words, would probably not get to the root of the psychological problem, but only offer a superficial fix.

Zucker calls his approach “developmental,” which means that the most important factor is the age of the child. Younger children are more malleable, he believes, and can learn to “be comfortable in their own skin.” Zucker says that in 25 years, not one of the patients who started seeing him by age 6 has switched gender. Adolescents are more fixed in their identity. If a parent brings in, say, a 13-year-old who has never been treated and who has severe gender dysphoria, Zucker will generally recommend hormonal treatment. But he considers that a fraught choice. “One has to think about the long-term developmental path. This kid will go through lifelong hormonal treatment to approximate the phenotype of a male and may require some kind of surgery and then will have to deal with the fact that he doesn’t have a phallus; it’s a tough road, with a lot of pain involved.”

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Yet Zucker’s approach has its own disturbing elements. It’s easy to imagine that his methods—steering parents toward removing pink crayons from the box, extolling a patriarchy no one believes in—could instill in some children a sense of shame and a double life. A 2008 study of 25 girls who had been seen in Zucker’s clinic showed positive results; 22 were no longer gender-dysphoric, meaning they were comfortable living as girls. But that doesn’t mean they were happy. I spoke to the mother of one Zucker patient in her late 20s, who said her daughter was repulsed by the thought of a sex change but was still suffering—she’d become an alcoholic, and was cutting herself. “I’d be surprised if she outlived me,” her mother said.

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Many parents shared journals with me that were filled with anguish. If they had decided to let their child live as the other gender, that meant cutting off ties with family and friends who weren’t supportive, putting away baby pictures, mourning the loss of the child they thought they had. It meant sending their child out alone into a possibly hostile world. If they chose the other route, it meant denying their child the things he or she most wanted, day after day, in the uncertain hope that one day, it would all pay off. In either case, it meant choosing a course on the basis of hazy evidence, and resolving to believe in it.