Alex was born a female but identifies as a male.

The 16-year-old transgender male continues to face challenges — including criticism from people who believe a person’s gender identity, if different than the sex at birth, is wrong. He’s even received a death threat.

Alex struggles with anxiety, depression and suicidal thoughts caused by his gender dysphoria, a term used to describe the distress experienced when a person’s gender identity doesn’t match up with their genitals and chromosomes.

He says his depression comes from the feeling that something physical is missing from his body.

“I have mental breakdowns using the bathroom sometimes, knowing what should be there and it’s not,” said Alex, who attends an Akron-area high school.

But Alex thinks he’s one of the lucky ones.

His mother and grandparents have been a huge support. And though he has been bullied at school, he believes he has had it easier than other people in the transgender community.

“I have an accepting family. I haven’t been beaten up. There’s a bathroom labeled ‘men’s’ I can use. My friends are very accepting and most people know me as a guy,” said Alex, who has used bathrooms for both genders at school, but mostly tries to use a single-stall bathroom, to avoid problems.

“I’m lucky. It could be way worse.”

Alex is not alone. There’s a growing number of teens facing similar struggles, prompting Akron Children’s Hospital to launch a clinic this summer devoted to helping adolescents struggling with gender identity issues.

Alex and his family agreed to share their story to highlight the challenges of a transgender youth and the care that’s now available at Children’s Center for Gender Affirming Medicine.

Gender affirming medicine is an evolving field that involves consultation with medical and social work professionals to provide care for transgender patients seeking characteristics more aligned with their gender identity. It can include such services as puberty suppression, hormone treatment, mental health care coordination, well checks and preventative visits, education and supportive care for LGBTQ+ youth and their families.

The American Academy of Pediatrics urges doctors to provide support and care of the transgender community. But there are critics, including some in the medical community who are expressing concern that medical treatments for transgender patients are outpacing the science.

At Children’s Hospital, the new center, which is part of the hospital’s Adolescent Medicine division, offers care to transgender patients and LGBTQ+ youth. Patients see a multidisciplinary team that includes gender-affirming medical providers as well as a social worker, nurse coordinator, mental health therapist and endocrinologist. The center sees patients age 7 or older.

Sex-reassignment surgeries are not available at Children’s Hospital and the team waits to provide medication — such as hormonal treatments or puberty-suppressing medicines — until after the youth is fully evaluated, said adolescent medicine physician Dr. Crystal Cole, who is medical director of Children’s new clinic.

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Alex is a pseudonym. The Beacon Journal has agreed to withhold his name because he’s gotten a death threat from a fellow student, and some of his extended family is not accepting of him living as a male.

“I’ve gotten a death threat at school for using the guys’ bathroom. He said he would beat me to a pulp. My school is not very open. I don’t want them to track me,” he said.

Alex wants to have surgeries to change his sex in the future. He doesn’t want internet proof of his former life being born a female. (Experts say there is a difference between a person’s sex — or genitalia and chromosomes — and gender, which is how an individual or society identifies a person.)

Welcome relief

Alex has been a patient of Cole’s since the beginning of the year.

The hospital has been seeing transgender patients for some time, but recently formalized its team approach to care, expanded services and began running clinics on Thursdays. Children's Hospital previously referred patients seeking comprehensive gender-affirming medical care to other centers.

Having the team of experts at Children’s so close has been a welcome relief for Alex’s family, said his grandma, who, along with her husband, is helping Alex’s mother raise him.

Alex’s family doctor told the family he didn’t know enough to help care for the transgender teen.

“He said, ‘You’re on your own and whatever you find out, come back and let me know,’ ” Alex’s grandma recalled.

There are other gender-affirming clinics in Ohio; Cincinnati Children’s Hospital has had a transgender clinic since 2012. MetroHealth’s Pride Clinic in Cleveland also will see transgender patients, Cole said.

“A lot of times these families don’t have resources. They don’t know where to go. Their child comes out and identifies as trans and they may notice the child is having some issues with it, whether it’s bullying or difficulty with gender,” Cole said. “We’re that first stop for families.”

Cole said transgender patients have medical issues the team can help address, such as providing medications to suppress puberty or hormones, such as testosterone, to support desired gender characteristics for post-puberty patients.

“In the past, people would get testosterone and gender-affirming drugs off the street. We are providing them with things that are evidence-based,” Cole said.

The clinic also offers counselors to help patients know their rights when it comes to such things as using a bathroom that corresponds with their identified gender, getting schools to use their preferred name and participating in sports.

"If we need to intervene on their behalf, we can provide education to their schools,” she said

Transgender youths are at higher risk of suicide and homelessness, Cole said. Forty-one percent of transgender individuals have suicide attempts in their lifetime.

“The risk of homelessness is extremely high and resorting to sex work to pay for gender affirming medicines,” Cole said. “This is why we exist. We want them to be healthy, happy adults.”

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Alex has been dealing with suicidal thoughts since sixth grade, when he began having general depression.

Most recently, he’s been hating his body as he deals with constant breakthrough bleeding from periods despite being on birth control. The Children’s Hospital team is evaluating starting Alex on testosterone to stop the bleeding and help with some of the masculine traits Alex wants, Cole said.

He also has anxiety from looking at his skinny and lanky body, which isn’t overly feminine but not masculine.

“I had dreams I had a flat chest and would be a guy and have a beard,” Alex said.

Alex knew at a young age that he liked masculine things.

“I thought it was normal for a little girl to want to be a guy,” Alex recalled. “I didn’t really tell anyone. I would tell my Grandma, ‘I want guys’ clothes.’ ”

“I thought he was a tomboy,” his grandma recalled. “All his friends were guys and he played with superheroes and Beyblades. For his birthday parties, I would ask, ‘Do you have girls you want to invite?’ ”

Alex said he had one Barbie doll growing up.

“It was a Ken doll. I said, ‘I want that body and that hair.’ I was like 4 or 5,” he said.

Coming out

In seventh grade, Alex came out as bisexual.

“I like people regardless of how they identify. If I like them, I like them.”

His mom initially wasn’t too happy about Alex’s declaration.

In eighth grade, one of Alex’s friends said she had a crush on him.

“She said, ‘Maybe you’re just a guy.’ I said: ‘That makes so much sense. Oh, yeah!’ I started coming out to my friends that I’m a guy,” Alex said.

Alex’s grandma is the first person in his family he told about his gender identity — during a walk before ninth grade.

His grandma wasn’t surprised, but she was concerned.

“I can see the connection now. At the time, you make excuses; so he’s a tomboy. But I don’t think this is to get attention. It’s really there and it took time. It’s nothing you accept right away,” she said.

Alex said his teen cousins all kind of knew.

“One cousins said: ‘I called it. I knew you were a man.’ ”

His aunt said, “I just thought you were going to be a lesbian.”

Alex’s mom was in denial at first.

“It was a shock,” she said. “I thought, ‘That’s not going to be my child,’ but it is. Later after all this time, I’m getting more used to it and accepting.”

Alex’s grandma told her closest friends about her grandson and said they all understood.

“One said, ‘That’s how God made him,’ ” Alex said.

His grandma said she still struggles with accidentally referring to her grandson by the pronoun “she” instead of “he.” (Some gender-expansive people, who may identify as either male or female or neither, may prefer the pronoun “they/them.”)

Alex’s grandpa took a little bit of time to get used to the idea, but now is the one Alex turns to when ordering a “packer,” an insert he puts in his boxers to help with his dysphoria.

“Having something in my pants to give me completion makes me feels better,” he said.

Alex first started using rolled-up socks in his pants and when he wanted something more realistic, his grandma said, “Go talk to Grandpa.”

Alex intends on having what’s often referred to as “top surgery” after he turns 18 to take away the breast tissue in his chest to get a masculine chest. But it may not be covered by insurance and could cost up to $10,000. He will wait until later in his 20s for the “bottom surgery” because it's more invasive (a hysterectomy is needed and reconstructive surgery).

Alex is happy that Children’s clinic is available to help him through his teen years as a transgender.

It is good “having it close for minors so their family can come and understand things and so kids can get treated and not fall into depression and kill themselves,” said Alex, who wants to be a doctor, and perhaps a surgeon.

Still, his grandma knows he has a “rough row ahead of him.”

“We’re just starting this,” she said.

Betty Lin-Fisher can be reached at 330-996-3724 or blinfisher@thebeaconjournal.com. Follow her @blinfisherABJ on Twitter or www.facebook.com/BettyLinFisherABJ and see all her stories at www.ohio.com/topics/linfisher