It started with a pair of cowgirl boots – pink and blue with floral embroidery. Grandpa B. offered to take his grandchild Marty shopping for boots. At the store, which sells Texas-style western wear, 5-year-old Marty checked out the offerings and decided that the coolest by far was that special pair from the girls’ section. Assigned male at birth, Marty (a pseudonym) had already been experimenting with mixing “boy” and “girl” clothes, a point of tension between the generations in the family. Grandpa B. wasn’t about to buy girly pink boots for the kid he considered his grandson. He said no.
From there, tension grew steadily between Grandpa B. and Marty’s only living parent, whom we’ll call Leslie and who identifies as agender. The family lives in small-town central Texas, and although many of their neighbors identify as conservative, Leslie reports that most have gracefully accepted Marty’s choice of pronouns. One neighbor had assumed Marty used male pronouns but asked Leslie after seeing Marty in a dress. Leslie explained that Marty prefers “they/them.”
But Grandpa B. wasn’t so accepting. Even before the trip to get boots, he had begun questioning Marty’s fashion choices. “We’ve noticed him with nail polish, sparkling girls’ tights etc. We feel that this could be confusing him,” Grandpa B. wrote to Leslie in an email.
A few days after the cowgirl boots fiasco – on the same February day that Governor Greg Abbot released an order directing the Texas Department of Family and Protective Services (DFPS) to investigate families pursuing “abusive gender-transitioning procedures” – there was a development. Grandpa B. called the public school where Marty attended pre-K to falsely report that Marty was being bullied because of clothing. The vice principal declined to discuss the issue with Grandpa B. because he wasn’t on the approved contacts list and reported the call to Leslie. A month later, Leslie learned, Grandpa B. called the school again, reported more bullying, and threatened to call child protective services to report the family for abuse – a threat that never materialized.
Marty is even younger than the 30,000 13-to-17-year-old transgender youth who live in Texas, and the 300,000 who live across the country – about 1.4% of all youth, according to estimates by the Williams Institute at the UCLA School of Law. Fourteen bills in 10 states are currently under consideration that focus on transgender people – addressing medical care, sports participation and gender identity documentation. Five would restrict medical care for minors. According to data from UCLA’s William’s Institute, Texas has the third largest population of transgender people (behind California and New York).
Such care includes medical treatments like hormones or hormone blockers that suppress the development of physical characteristics that conflict with a person’s gender identity, as well as nonmedical procedures like voice training and hair removal. It may also include transition surgery, which is not recommended for those under 18 according to current guidelines published by the World Professional Association for Transgender Health.
Young people’s access to gender-affirming medical care has become a simmering culture-war debate; denying or delaying it appears to be a key factor in rising rates of suicide, depression and other mental health struggles among transgender people.
Off-the-charts suicide rates
A 2020 study in the Journal of Interpersonal Violence found that 82% of transgender people have considered killing themselves during their lifetime, and 40% have attempted suicide, with the highest rates among youth. Trans and nonbinary youth also have higher rates of self-harm and experience more bullying and depression.
Conversely, another recent study found that youth who got gender-affirming care – in this case puberty blockers or hormones – had 60% lower odds of depression and 73% lower odds of suicidality by the end of the year, compared with those who weren’t able to access such care. “Having an appropriate puberty is a huge part of what enables trans people to live a life that cis folks get to take for granted,” says the study’s co-author Arin Collin, a trans woman and medical resident at the University of Washington School of Medicine.
Marty was born to Leslie and their husband, who died in 2019. Even before Marty could talk, they would have outbursts and hit their genitals. At a later, verbal stage, Marty would ask Leslie when they would get a vagina or “boobs.” When Marty was 2-1/2, Leslie sought out help from a child psychiatrist because Marty was so distressed. The psychiatrist encouraged Leslie to let Marty choose what they wanted to wear, to express and identify themselves as they wished and to play with whatever “boy” or “girl” toys they wanted.
The approach seemed to work. After Leslie started parenting in a gender-neutral way, Marty stopped trying to harm their body. At a Christmas gathering last year, Leslie announced to the extended family that Marty identifies as gender-fluid. When Marty’s puzzled grandparents asked what that meant, Marty said, “Well, I feel boy but I also feel girl, and in between, and nothing.”
The only notable pushback at school came from a girl in Marty’s class who proclaimed that Marty is a boy and thus can’t play with girls. Leslie worked to help Marty prepare for such interactions, encouraging Marty to be friends with “whoever is friendly.” Still, when Marty wants to wear a particularly dramatic outfit, Leslie poses the question: “What will you say if someone says, ‘Boys can’t wear that?’” The answer they’ve settled on: “People get to choose what they wear.”
When Grandpa B. expressed concern over Marty’s fashion choices, Leslie offered explanations about gender expression, gender identity, sexuality, and biological sex – an approach that had worked with their own father, who’d been concerned about Marty wearing a dress for Halloween.
But it didn’t work with Grandpa B. “I don’t need to read an article to tell me that a kid with a penis is a boy,” he wrote Leslie in an email. Eventually, Leslie cut communications and blocked him online. At one point, Grandpa B. called the police, who came to Leslie’s door to do a wellness check. To Leslie, Grandpa B. had never supported gender-neutral parenting – and Abbott’s directive gave him ammunition to involve the authorities.
Abbott’s directive was based on an opinion from Texas Attorney General Ken Paxton that hormonal treatments for youth constitute child abuse under Texas law. The directive claims that treatments that “induce transient or permanent infertility” deprive children of their constitutional right to procreate. It later was blocked by a state-court judge as an unconstitutional overreach.
Path to better mental health
In the past decade, growing acceptance of transgender identities has allowed more transgender children to emerge and socially transition. In 2015, Kristina Olson, a professor at Princeton University, launched the first set of longitudinal studies of transgender children in the United States, following about 300 kids to study their development. Among her findings is that kids who socially transition before puberty and whose identities are supported in their families are as healthy mentally as their peers who are not transgender.
Kids who socially transition early and have family support may follow paths that are fundamentally different from transgender generations who came before them. If kids can access hormone blockers just prior to the onset of puberty, they can avoid going through the puberty of a gender they don’t identify with and ultimately avoid procedures and surgeries such as facial feminization surgery or electrolysis to remove unwanted facial hair.
Going through puberty of a sex they don’t identify with can be traumatic for trans youth who find their bodies taking forms that are antithetical to how they feel inside – a factor that may contribute to higher rates of depression, anxiety, self-harm, and even suicide.
Professional societies, including the American Psychological Association, oppose bans on gender-affirming care for youth, citing studies that affirm the psychological benefits of such care and the risk of stopping it mid-stream due to restrictive legislation.
Olivia is a 32-year-old transgender woman who wasn’t supported by her family as a child and didn’t have access to care. Her childhood memories revolve around the fear and isolation she felt about her identity, like when she was punished for wearing her mother’s shoes or demonstrating femme behaviors.
“I essentially had my childhood taken from me,” says Olivia, who asked to be identified by her first name only. Now she wants to tell her story, she adds, because “I don’t want kids to have to go through the amount of surgeries I’ve had to go through.” She’s had surgery on her face and body to align with her gender, but says “there are certain things I’ll never fix.” She still feels uncomfortable with how her hands and feet look. Height can also indicate gender and can’t be changed later in life.
Withholding medical care from transgender kids until they are 18 is cruel, she says, forcing someone transitioning from male to female to have their voices deepen, their muscles expand, and their height increase, setting them apart from other girls.
‘I am a boy’
Rabbi Daniel Bogard is determined that his son won’t have to go through such experiences. Bogard grew up and came of age at the Central Reform Congregation in St. Louis and four years ago, he and his wife, Rabbi Karen Kriger Bogard, became part of the congregation’s spiritual leadership. Together, they have an 8-year-old son, Alex (a pseudonym).
From an early age, Alex preferred his big brother’s clothes, including his “boy” underwear. At first the parents thought Alex just looked up to him, but one night, getting tucked in bed at the age of 4, Alex asked his father when God would “make me over again as a boy.” The rabbis let Alex cut his hair shorter and shorter, until finally, Alex had a full “boy” cut at age 5. Alex looked in the mirror and made a satisfied pronouncement: “I am a boy.”
Within his family, at school and in their religious community, Alex’s gender identity lies “somewhere between no big deal and a celebrated thing,” Bogard says. Looking back, he says, he and his wife were slow to adjust to Alex’s gender identity because it showed up so early. But the night Alex asked about God making him over, Bogard was up all night with anxieties, mostly about hormones and surgeries he figured would be a part of Alex’s future. As he came to terms with what he calls his internalized transphobia, he realized Alex’s care wouldn’t be all that different in scale from the care Alex’s sister requires for her ADHD.
What now fuels Bogard’s anxiety is to be raising a transgender child in a state where a flurry of restrictive legislation was proposed earlier this year. The night before he testified in the legislature in support of transgender youth, he had panic attacks and vomited.
Although the bills died without becoming law, Bogard is far from confident that Alex will have access to gender-affirming medical care in the future when he’s likely to need it. “The only bullies in my child’s life work for the Missouri government,” he says. If the state acts to limit those choices, Bogard – whose grandfather built the house his family lives in – might be faced with a decision: to stay or to leave.
Many states to the west, Gina Sequeira, a pediatrician who heads the gender clinic at Seattle Children’s Hospital, has been fielding calls from worried parents considering relocating from states that are debating restrictive legislation. Some expressed fear that their kids may be unable to continue the gender-affirming care they’re now receiving. Washington may also be attractive to some of them because health insurance companies there are required to cover the costs of puberty blockers, which can range from $8000 to $50,000 a year.
Matthew Goldenberg, a psychologist at the clinic, says there’s a history of transgender people needing to jump through hoops to get the care they need. He is transgender and remembers hearing from other transgender folks when he was coming of age about the requirements for transitioning.
“When I was coming up, everybody knew that you had to present as very mentally well,” he said. “If you were suicidal or depressed, you weren’t supposed to talk about it, because if you did, they wouldn’t give you hormones or they wouldn’t give you the surgery.”
Although some providers contend that completing a certain number of therapy sessions or psychological tests will help predict a young person’s gender trajectory, Goldenberg insists that no data supports that idea. So he tries to build from what psychologists do understand about family systems and effective parenting.
When families express concern that kids may later change their minds about undergoing a gender transition, Goldenberg offers this answer: Children who open up to a parent about wanting gender-affirming care are inviting them to connect, to really get to know them. If the young person later decides not to transition, “What they will know is that at that most vulnerable place, you loved them and affirmed them and supported them as a parent.”
Annette is the mother of Phoebe, a 14-year-old transgender girl in Seattle (their names have been changed). Phoebe, a “late bloomer,” was on puberty blockers for a year and has just begun a low dose of estrogen to trigger female puberty. She’s been vocal about her gender identity since she could speak, giving the family time to prepare.
Annette says her daughter’s puberty so far has been “so much more joyful and healthy” than hers or some of Phoebe’s peers. “We’re really grateful that she gets to have this body and that she actually took these very deliberate steps to get to have this body.”
The first night her daughter took estrogen, Annette says, one of Phoebe’s friends visited. The three of them made a little impromptu ceremony out of it, she says, cracking silly jokes about how Phoebe was growing boobs right before their eyes.
“If only people could know that this doesn’t have to be some dark and dreary path,” Annette says. “You hear all these scary stories that don’t show you how happy these kids are when they feel good in their own skin.”