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, where the walls are covered with diplomas and notes of gratitude scrawled in crayons or bright markers (“Thanks, Dr. Spack!!!”). Spack is bald, with a trim beard, and often wears his Harvard tie under his lab coat. He is not confrontational by nature, but he can hold his own with his critics: “To those who say I am interrupting God’s work, I point to Leviticus, which says, ‘Thou shalt not stand idly by the blood of your neighbor’”—an injunction, as he sees it, to prevent needless suffering.
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.”
When Beth was 11, she told her mother, Susanna, that she’d “rather be dead” than go to school anymore as a girl. (The names of all the children and parents used as case studies in this story are pseudonyms.) For a long time, she had refused to shower except in a bathing suit, and had skipped out of health class every Thursday, when the standard puberty videos were shown. In March 2006, when Beth, now Matt, was 12, they went to see Spack. He told Matt that if he went down this road, he would never biologically have children.
“I’ll adopt!” Matt said.
“What is most important to him is that he’s comfortable in who he is,” says Susanna. They left with a prescription—a “godsend,” she calls it.
Now, at 15 and on testosterone, Matt is tall, with a broad chest and hairy legs. Susanna figures he’s the first trans-man in America to go shirtless without having had any chest surgery. His mother describes him as “happy” and “totally at home in his masculine body.” Matt has a girlfriend; he met her at the amusement park where Susanna works. Susanna is pretty sure he’s said something to the girl about his situation, but knows he hasn’t talked to her parents.
Susanna imagines few limitations in Matt’s future. Only a minority of trans-men get what they call “bottom” surgery, because phalloplasty is still more cosmetic than functional, and the procedure is risky. But otherwise? Married? “Oh, yeah. And his career prospects will be good because he gets very good grades. We envision a kind of family life, maybe in the suburbs, with a good job.” They have “no fears” about the future, and “zero doubts” about the path they’ve chosen.
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.
Spack’s clinic isn’t so comprehensive. A part-time psychologist, Dr. Laura Edwards-Leeper, conducts four-hour family screenings by appointment. (When I visited during the summer, she was doing only one or two a month.) But often she has to field emergency cases directly with Spack, which sometimes means skipping the screening altogether. “We get these calls from parents who are just frantic,” she says. “They need to get in immediately, because their child is about to hit puberty and is having serious mental-health issues, and we really want to accommodate that. It’s like they’ve been waiting their whole lives for this and they are just desperate, and when they finally get in to see us … it’s like a rebirth.”
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?”