Margie Fishman

The News Journal

It's a familiar refrain: The child knew from the beginning.

Yet for many older transgender individuals forced to live inauthentically for years or even decades, medical treatments weren't available to ease the transition. That was before an Olympic gold medalist introduced herself as Caitlyn, teen transgender activist Jazz Jennings dished on dating, and a smattering of television shows depicted positive transgender characters.

Third genders have been well-documented in other cultures, such as "fa'afafine" in Polynesia, "muxe" in Mexico and "two-spirit" in Native American societies.

Now, members of Generation Z, considered by many to be the first generation to fully express themselves and embrace gender fluidity, are demanding access to puberty blockers, cross-sex hormones and gender reassignment surgery.

"Younger people are proud of being trans and they hold on to that title," explained Brett Herb, a Newark gender therapist who has a waiting list of transgender teens.

"You see a dramatic difference in somebody's anxiety and depression and comfort with themselves when they go on hormones," he added. "They just blossom."

It's a new frontier for endocrinologists at gender identity clinics who see an increasing number of patients in preschool compared to pre-college. That's not due to a spike in the transgender birth rate, medical experts say. Rather, parents exposed to transgenderism in the media or through their peer group are less likely to dismiss a child who rejects his or her biological sex.

"Every parent wants their child to be happy, healthy and fulfilled," said Sarah McBride, a Wilmington native and national transgender advocate. "They're giving the child the space to find their truth, to live their truth."

Eight percent of LGBT youth identified as transgender in 2011, up from 3 percent a decade earlier, according to a survey by the Gay, Lesbian and Straight Education Network.

Gender typically solidifies at ages 3 to 6, when girls begin destroying their mother's lipsticks and boys plow toy trucks through the macaroni salad. Studies have found that 15 to 30 percent of children ages 3 to 8 who express gender nonconformity eventually become transgender.

While promising medical developments allow transgender children to begin transitioning at younger ages, doctors warn that it's still uncharted territory. Absent reliable, long-term data, patients need to be aware of the risks.

Puberty blockers

Pediatric endocrinologists have a wealth of data to support that puberty blockers are safe when given to children experiencing early-onset puberty. But their use in treating transgender children is relatively new. The Gender Management Service at Boston Children's Hospital first prescribed them in 2007. The Endocrine Society updated its guidelines two years later.

Medical experts say the benefits of blockers are that they stop hormone-induced biological changes, such as the deepening of the voice and the development of breast tissue, a process that can torment a transgender child. Blockers are typically initiated during a stage of development called Tanner stage 2, which is around 10 or 11 years old for girls and 11 or 12 years old for boys.

To date, the Food and Drug Administration hasn't approved stalling puberty for transgender youth. And some doctors worry about the long-term effects on brain function and bone development. Blocker injections can cost $9,000 a year, while implants (that last up to two years) cost $27,000, according to the Delaware Division of Medicaid and Medical Assistance.

Cross-sex hormones

Unlike puberty blockers, cross-sex hormones bring irreversible changes. The Endocrine Society suggests delaying them until age 16 for transgender youth, but it's not uncommon for teens to begin at ages 13 or 14 if their doctors, therapists and families all agree.

Hormones, which can cost as little as $4 a month, help the body and brain align, reducing the transgender patient's emotional distress.

Apart from typical side effects like acne and mood changes, hormone therapy can increase the risk of heart disease and diabetes later in life. Teens also must weigh whether they want to have biological children down the road.

"Prolonged exposure (to hormones) does have a negative effect on fertility, but we don't know the scope," said Diane Chen, a medical psychologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago. The hospital operates a highly regarded Gender and Sex Development Program, with about 600 active patients. Chen estimates that fewer than 30 are five and under.

When transgender youth are given the option for fertility preservation, very few agree to it, Chen noted in a recent study of 105 transgender adolescents. Among the concerns expressed were the invasiveness of the procedure and the teens not wanting to delay their transition, she said.

Gender reassignment surgery

The first American who came out as transgender was former G.I. Christine Jorgenson, who transformed into a striking blonde after traveling to Copenhagen for gender reassignment surgery in 1952.

In 1980, Philadelphia-area plastic surgeon Sherman Leis fashioned a penis from a desconstructed labia for a transgender male patient.

Since that time, he boasts that he's never had a penis fail.

"If a child of mine was transgender, I'd want to see them operated on as quickly as I could," said Leis, who is now booked a full year in advance.

When he started doing gender reassignment surgery in earnest 12 years ago, he was one of a handful of surgeons in the country. Today, with insurance companies increasingly reimbursing for the procedures, Leis is among more than 20 surgeons with specialized training. He's not familiar with any in Delaware.

There are no hard numbers on how many transgender people opt for surgery. In the community, such questions are frowned upon. Typically, a good candidate has been on hormones and living according to their expressed gender identity for at least a year, Leis said.

Male-to-female genital surgery is considered easier, less expensive, more successful, and, therefore, more popular than female to male surgery.

For transgender women, surgeons remove the testicles and most of the penis. Skin is reused to create a largely functional vagina, including a "neoclitoris" that feels sensations.

In female to male surgery, the breasts, uterus and ovaries are removed. A "neophallus" is constructed using tissue from the forearm or other parts of the body. The existing clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft.

The majority of Leis's clients report that they are able to experience orgasms, but can't urinate through the penis. Leis doesn't recommend testicular implants because they don't last.

National estimates for surgeries are a maximum of $75,000 for female to male and $50,000 for male to female. In 2014, Medicare began paying for such procedure.

Delaware's Division of Medicaid and Medical Assistance began covering gender reassignment surgery last year for teens who are at least 16 years old, though no one has applied yet, according to health department spokeswoman Jill Fredel. Medicaid beneficiaries who require surgery are provided access to an out-of-state provider if an in-state provider is not available, she said.

Some private insurers will also cover gender reassignment surgery. But facial feminization surgery, which involves shaping eyes, noses, brows, chins and hairlines are often considered "cosmetic" and excluded.

Contact Margie Fishman at (302) 324-2882, on Twitter @MargieTrende or mfishman@delawareonline.com.