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New York | The New Girl in School: Transgender Surgery at 18
The New Girl in School: Transgender Surgery at 18
It was not easy. For days afterward, she had dry heaves. She lost weight from her already frail frame. She did not seem empowered; she seemed regressed.

“I just want to hold Emma,” she said in her darkened room at the bed and breakfast in New Hope, Pa., run by the doctor who performed the surgery in a hospital nearby. Emma is her black and white cat, at home outside Syracuse, N.Y., 200 miles away.

Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed fire engine red, is just 18, and about to graduate from high school.

It is a transgender moment. President Obama was hailed just for saying the word “transgender” in his State of the Union speech this year, in a list of people who should not be discriminated against. They are characters in popular TV shows. Bruce Jenner’s transition from male sex symbol to a comely female named Caitlyn has elevated him back to his public profile as a gold-medal decathlete at the 1976 Summer Olympics.
In a cozy cottage decorated with butterflies to symbolize transformation, Katherine Boone was recovering in April from the operation that had changed her, in the most intimate part of her body, from a biological male into a female.
It was not easy. She retched for days afterward. She could hardly eat. She did not seem empowered; she seemed regressed.
“I just want to hold Emma,” she said in her darkened room at the bed-and-breakfast in New Hope, Pa., run by the doctor who performed the operation in a hospital nearby. Emma is her black and white cat, at her home outside Syracuse in central New York State, 250 miles away.
Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed a sassy red, is just 18, and about to graduate from high school.
It is a transgender moment. President Obama was hailed just for saying the word “transgender” in his State of the Union address this year, in a list of people who should not be discriminated against. They are characters in popular television shows. Bruce Jenner’s transition from male sex symbol to a comely female named Caitlyn has elevated her back to her public profile as a gold-medal decathlete at the 1976 Summer Olympics.
With growing tolerance, the question is no longer whether gender reassignment is an option but rather how young should it begin.
No law prohibits minors from receiving sex-change hormones or even surgery, but insurers, both private and public, have generally refused to extend coverage for these procedures to those under 18. In March, New York’s Medicaid drew a line at that age, and at 21 for some procedures.
But the number of teenagers going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners. Now advocates like Empire State Pride Agenda are fighting for coverage at an earlier age, beginning with hormone blockers at the onset of puberty, saying it is more seamless for a teenage boy to transition to becoming an adult woman, for example, if he does not first become a full-bodied man.
“Some of these women are passing, but barely, when they transition at 40 or 50,” said Dr. Irene Sills, an endocrinologist who just retired from a busy practice in the Syracuse area treating transgender children, including Kat. “At 16 or 17, you are going to have such an easier life with this.”
Given that there are no proven biological markers for what is known as gender dysphoria , however, there is no consensus in the medical community on the central question: whether teenagers, habitually trying on new identities and not known for foresight, should be granted an irreversible physical fix for what is still considered a psychological condition.
The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a miswiring of the brain or by genetic coding? How much does it stem from the pressure to fit into society’s boxes — pink and dolls for girls, blue and sports for boys? Has the Internet liberated teenagers like Kat from a narrow view of how they should live their life, or has it seduced them by offering them, for the first time, an answer to their self-searching, an answer they might later choose to reject?
Some experts argue that the earlier the decision is made, the more treacherous, because it is impossible to predict which children will grow up to be transgender and which will not.
“Basically you have clinics working by the seat of the pants, making these decisions, and depending on which clinic you go to, you get a different response,” said Dr. Jack Drescher , a New York City psychiatrist and psychoanalyst who helped develop the latest diagnostic criteria for gender dysphoria.
On the other hand, Dr. Drescher said, “Is it fair to make a child who’s never going to change wait till 16 or 18 to get treatment?”
Kat Boone did not fit the stereotype of a girl trapped in a boy’s body.
As a child, she dressed in jeans and shirts, like all the other boys, and her best friend was a boy. She liked to play with cars and slash bad guys in the Legend of Zelda video games. She still shuns dresses, preferring skinny jeans and band T-shirts.
But as a freshman in high school in Cazenovia, N.Y., she became depressed and withdrawn. “I knew that the changes going on with puberty were not me,” Kat said. “I started to really hate my life, myself. I was uncomfortable with my body, my voice, and I just felt like I was really a girl.”
When she discovered the transgender world on the Internet, she had a flash of recognition. “I was reading through some symptoms, not really symptoms, but some of the attributes of it did click,” she recalled.
It took a few months, but one night, she crept into her mother’s room and sat on the bed, crying. When she finally came out with what was bothering her, her mother’s first impulse was to comfort her, holding her hand and saying: “It’s O.K. It’s O.K.”
But inside, Gail Boone was terrified. She had wondered if her son was gay, and that, she says, would have been easier to deal with than a child who wanted to be the opposite sex.
“There’s this fear,” Ms. Boone said, “what is this going to do to my kid, what are people going to think, what are people going to think about me?”
Kat’s father, Andrew, had moved out when she was in fifth grade, and it took a few months for Kat and her mother to find the courage to tell him. Gail Boone had a background in psychology, which helped her understand. Mr. Boone, an operations and project manager, had a harder time, but was brought around for the sake of his child.
He read books about being transgender and raked his memory for clues in Kat’s early childhood, but could not find any. “Maybe she thinks this is the thing, and there’s something else going on,” he remembered thinking. “How do we know?” He wished there were something scientific like a blood test that would give him 100 percent certainty.
Mr. Boone recalls going into “a zombie trance,” a period of mourning for the child he thought he knew. “I was really eating myself up because I couldn’t help this overwhelming feeling as if my child had died,” he said. “But here was my child right in front of me.”
At 16 and a half, after seeing a therapist, Kat began taking estrogen and a blood pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female. In the fall of junior year, she showed up at school wanting to be called Katherine, or Kat, because she likes cats. She does not want anything to do with her birth name, Caden. She also has discovered that she likes girls. “I identify as a lesbian,” she said, though her attractions have not been reciprocated.
It was the cutting that convinced them that if she could not live as a girl, Kat would kill herself. She still has two angry scars on her left forearm. “It became clear to me that this wasn’t a passing phase or some choice or reaction,” Mr. Boone said. “This was truly the basis of what she was.”
Part of what brought her father around was the support network that has sprung up around transgender issues. In Syracuse, it is the Q (for queer or questioning) Center, run by the nonprofit ACR Health .
It is not easy to find. Visitors have to be buzzed in through an unmarked back door in a shabby neighborhood. But inside, it is homey, with a well-appointed library, a kitchen and a meeting room outfitted with beanbag chairs.
A meeting of teenagers in April began with each one declaring a name and pronoun of the day. Their choices were not always intuitively obvious. A young man with a scruffy beard and shaggy hair asked to be called Jackie and with the pronoun “she.”
“One of the nice things a trans person gets to do during transition is pick a new name,” said the facilitator, Mallory Livingston, a lawyer, “assigned male at birth,” now looking feminine in a tight pink camisole, black lace-up boots and miniskirt. “I went with the name of a character from my kids’ favorite movie, a strong female swordsperson.”
But there were hints of the pain the children had to endure. One child was required to use a separate bathroom at school, and a hidden camera was later found there.
Kat told the group that she was looking forward to surgery in six days. They clapped. “I’m scared,” she confessed.
The ability to alter a child’s gender physically has never been greater.
But the drive to treat children is relatively new. One of the first and biggest hormone programs for young teenagers in the United States is led by a Harvard-affiliated pediatric endocrinologist, Dr. Norman Spack , at Boston Children’s Hospital.
Dr. Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.
“I was salivating,” he recalled. “I said we had to do this.”
The puberty-blocking protocol gained legitimacy in 2009, when it was endorsed by the Endocrine Society, the leading association of hormone experts, on the recommendation of a task force including Dr. Spack.
The protocol calls for administering puberty-blocking drugs, generally Lupron, an injection, or histrelin, an implant, that are normally used to treat precocious puberty as well as prostate cancer and endometriosis, abnormal growth of uterine tissue.
The theory is that this drug-induced lull from about 12 to 16, sometimes younger, will help teenagers decide if they truly are transgender, without committing to irreversible physical changes. Puberty blockers are reversible. But in practice, some experts warn, once children have “socially transitioned” it is very difficult to go back.
If a psychological evaluation confirms gender dysphoria, teenagers are treated with cross-sex hormones (estrogen for boys, testosterone for girls), so they will, in effect, go through opposite-sex puberty. A consequence of going through the whole protocol is infertility.
The blockers cost thousands of dollars a year, and like all drugs used for transgender treatment, have not been approved by the Food and Drug Administration for that use, though they may be legally prescribed “off label.”
Dr. Spack said his clinic had treated about 200 children since 2007, and less than 20 percent had been covered by insurance. “That’s where
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https://www.nytimes.com/2015/06/17/nyregion/transgender-minors-gender-reassignment-surgery.html
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