Victor Lopez, 17, pictured in Miami Beach, Florida, on October 17, 2015. Ryan Stone for Al Jazeera America

Ask Victor Lopez, a 17-year-old transgender male, what it was like when he got his period at the age of 8, and he’ll tell you a wrenching story about locking himself in his room for hours, crying and hiding from his family. Just getting out of bed for school was a struggle. The onset of menarche made him feel disgusting and terrified, as though his body had dragged him through someone else’s puberty, he says, and there was nothing he could do to stop it. “Preteen and adolescence were some of my most messed-up years,” says Lopez, who adds that he has always felt like a boy. “I went through so much more with puberty than any normal kid would go through by trying to understand myself and who I was. It’s not anything someone should have to face. It was scary.” For the transgender female-to-male youth population of the United States, markers of puberty such as menstruation and developing breasts are even scarier prospects than usual. Confronting a biological reality at odds with gender identity can distress — even traumatize — trans youth. And while hormone-based therapy can delay puberty, very few people even know it exists, or if they do, can afford to pay out of pocket for the treatment, which is expensive and typically isn’t covered by insurance. In Houston, even if a gender nonconforming child is able to delay puberty, the city’s transgender community will not be protected by the Houston Equal Rights Ordinance (HERO). HERO was an effort to prohibit discrimination in city employment and services, city contracts, public accommodations, private employment and housing on the basis of certain characteristics, including sexual orientation and gender identity, and was similar to anti-discrimination measures passed in 200 other cities. It was adopted by the City Council in May but was not implemented. On Tuesday, it was rejected by 61 percent of voters. The vote against the legislation is a win for conservatives who argued that men should not be allowed in women’s restrooms or boys in girls’ locker rooms. Supporters such as Annise D. Parker, the openly lesbian mayor of Houston, countered that the ordinance was about broad anti-bias measures and didn’t specifically discuss access to bathrooms.

‘Unfortunately, many gender non-conforming and transgender youth will make the decision not to use restroom facilities at all during the day, which will leave them at risk for urinary tract infections, and other medical consequences.’ Dr. Johanna Olson-Kennedy Center for Transyouth Health and Development

But opponents of HERO aren’t considering how gendered bathrooms might affect children and teens facing gender dysphoria, says Dr. Johanna Olson-Kennedy, the medical director at the Center for Transyouth Health and Development at Children’s Hospital in Los Angeles. Gender dysphoria is a condition of experiencing an emotional and psychological identity that is the opposite of one’s gender assigned at birth. “For trans folks of any age in Texas, using public restrooms will continue to be a traumatic experience,” Olson-Kennedy says. “Unfortunately, many gender nonconforming and transgender youth will make the decision not to use restroom facilities at all during the day, which will leave them at risk for urinary tract infections and other medical consequences.” When he went through puberty, Lopez kept his brown hair short and shaggy and shopped in the boys’ section of department stores. Even during Florida’s sweltering summers, he wore oversized hoodies to hide his developing breasts. His rejection of training bras resulted in a family intervention and a talking-to from a female cousin.

‘I had an emotional breakdown and started cutting myself. It was a painful time.’ Victor Lopez Transgender teen who developed gender dysphoria

“I was sobbing for two days straight because they made me wear this bra,” Lopez says. “It didn’t feel right.” In the fifth grade, he says, he developed severe depression from gender dysphoria. His grandmother, who played a big role in raising him, also died from cancer that year. “I had an emotional breakdown and started cutting myself,” Lopez says. “It was a painful time. I thought I wanted to die.” According to a new study published by the Journal of Adolescent Health, transgender youth face a higher risk of being diagnosed with a mental illness or related problems compared with nontransgender teens. Olson-Kennedy says depression and anxiety stem from how parents, peers and society respond to a child’s need to be in a different body. “Most people think genitalia equals gender, but it doesn’t,” Olson-Kennedy explains. “If you’re going through puberty, which is already a difficult time for any teen, but the wrong puberty on top of that — it can cause a lot of internal trauma.” According to the World Professional Association for Transgender Health, children going through gender dysphoria should be treated with puberty blockers, which pause physical changes such as breast development and menstruation. This treatment is fully reversible. While proponents say the benefits outweigh potential risks, they remain uncertain about how puberty suppression can affect a child’s neurocognitive and bone development. Trans youth specialists stress the importance of thoroughly explaining the pros and cons of pausing puberty to patients and parents before proceeding. In 2007, Dr. Norman Spack, an endocrinologist who co-founded the Gender Management Service clinic at Boston Children’s Hospital, was one of the first in the country to offer puberty blockers to children experiencing gender dysphoria. He says that they have been used to treat children undergoing precocious puberty for more than 30 years; that’s how trans youth medical specialists know that the medication is safe and reversible, Spack explains. To halt the process, transgender male children who show signs of breast development are injected with hormone blockers every three months. Another option is to implant a tiny hormonal device under the skin of a child’s upper arm, which is replaced annually. The implant can last longer than a year and a blood test will detect its effectiveness. Spack says the medication gives children time to better understand their identity. But children cannot stay on hormone blockers forever; they will need to experience the puberty that best matches their gender identity by undergoing cross-hormone therapy later on if they choose to transition.

‘It is a complete denial of human rights for insurance companies to have exclusion clauses for gender-related care — and many of them do.’ Olson-Kennedy

Insurance coverage for youth gender-transition care varies from one provider to the next, though most health care plans don’t cover puberty blockers. The injections can cost about $1,200 per month, according to the trans education and support nonprofit TransYouth Family Allies, and arm implants can range from $4,500 to $15,000, not including expenses for blood work, X-rays or office visits. “It is a complete denial of human rights for insurance companies to have exclusion clauses for gender-related care — and many of them do,” Olson-Kennedy says. Despite the financial burden, available research shows, puberty blockers are proving to be effective. In fact, a recent Dutch study that assessed 55 young trans adults suggests that people who were treated with puberty blockers during adolescence were happy with the outcomes and none reported any regrets with their choice to delay puberty. “We’ve seen this treatment having huge benefits for these children,” says Olson-Kennedy, referring to hormone blockers. For many, this treatment is a matter of life and death. “Proper care early on can save these kids’ lives.” Trans youth health care is a highly specialized field, meaning resources in the United States can be hard to come by, Olson-Kennedy explains, particularly if a teenager lives in a rural area. But with or without medical treatment, counseling, along with parental and community support, is vital for transgender children, she adds. In sixth grade, Lopez tried to kill himself. A therapist then suggested he visit the Yes Institute, a Miami-based gender and sexual orientation youth advocacy group. For the first time, he met others who also felt they were living in a body that wasn’t home.

Victor Lopez and Jack Jordan, 20, met at Miami's Yes Institute, a gender and sexual orientation youth advocacy group. Ryan Stone for Al Jazeera America

At a Yes Institute workshop for parents and kids, Lopez met 15-year-old Jack Jordan, another transgender male. Jordan, who refers to himself in the plural “they,” is from Miami Gardens, Florida — a short drive away from Lopez’s town. The two teenagers became friends, Jordan says, and started dating earlier this year. Like Lopez, identifying as male came early for Jordan. Jordan’s mother, Maritza Jordan, recalls her 6-year-old crying inconsolably when dressed in girls’ clothes. When Jordan came out to their mother as transgender, Maritza was initially ambivalent, but gradually came to accept it, especially when they transitioned at 17 with testosterone therapy. “The real person finally came out,” says Maritza. “I never mourned a loss of a daughter — I had gained a confident son.” She says she has encountered skeptical people who believe teens like Jordan are seeking attention or just going through a phase. She asks them why anyone would seek out “what society puts any gay, lesbian or transgender person through.” For gender-nonconforming young people like her son, she says, it’s terrifying to hear about suicide rates, bigotry and murders of transgender people. Lopez and Jordan both have friends who have attempted suicide. In 2011, the National Center for Transgender Equality and the National Gay and Lesbian Task Force conducted a survey that estimated that 41 percent of transgender people attempt suicide in their lifetime, a rate nearly 10 times the average among nontransgender people. Fortunately, with medical insurance, cross-hormone therapy treatment is relatively affordable in the United States. For Jordan, who has coverage with their father’s insurance plan, testosterone costs about $20 per month. (They weren’t “out” as transgender while going through puberty, so taking hormone blockers wasn’t an option.) For teens like Jordan who come out as transgender later on, testosterone therapy can be an option, says Spack. He explains that unlike hormone blockers, cross-hormone therapy changes a person’s physical appearance.

‘Now, I finally feel like I have control over my life to be what I want to be. It feels wonderful.’ Alexander Campbell who is undergoing testosterone therapy