1. SECRETS UNEARTHED It never would have gone down this way if it hadn’t been for that stupid dance. Mikey’s girlfriend had dragged him out to the teen dance at the Brunton Community Hall, just outside Carleton Place, even though he hates dancing and loud noises. His girlfriend, who was in Grade 8, wouldn’t take no for answer, nor would she let Mikey take a pass when a slow song began cooing from the speakers. So there they were, awkwardly holding on to each other while people stopped and stared. No one threatened them or said anything mean, but that didn’t make Mikey feel any safer. Some older teens later cornered his girlfriend. “Are you lez? Are you lez?,” they demanded, slang for lesbian drenched in a sneer. Mikey wanted out of there. He called his mom and she hurried over to pick them up. He was angry, dropping f-bombs left and right. He was fed up with being misunderstood, being gawked at. Like so many, he turned to Facebook to vent. “I’m transgender,” he typed. “I’m done with people watching me kiss, hug, hold hands with my girlfriend ... This is me. I’m not going to change. If you don’t like it then don’t look at it.” The weight of the world — Mikey’s world, at least — was finally off those slight shoulders. His long-held secret had been unearthed for all to see. “I decided people need to stop picking on me and I need to do something about it,” he says a few months later, brushing wisps of auburn hair off his freckled face. “So I wrote that and the next morning I woke up and I had, like, 40 comments on it and 50 likes.” The comments were all encouraging and supportive. Overnight, Facebook’s ubiquitous thumbs-up symbol had been transformed into a chorus of people re-affirming who Mikey was — just as he is. More children today are speaking out about how the gender they were assigned at birth doesn’t line up with how they see themselves or what they feel inside. They are the ones often called sissies, tomboys and freaks on the playground — girls who want to be boys, boys who want to be girls, and others who place themselves somewhere in between on a spectrum that no longer has such rigid notions of what it is to be male or female. The Children’s Hospital of Eastern Ontario is on the leading edge of treating these gender independent children through a combination of puberty-blocking drugs, hormones and intensive talk therapy designed to steer children and their families through the complicated maze of gender transition and, hopefully, set them up for a positive long-term outcome. Estimates vary widely, but it is believed that somewhere between one in 200 and one in 500 people are born gender independent, meaning the child’s own gender identity clashes with what others expect of them based on their gender at birth. Some will come to identify as cisgender people (where the gender at birth matches their body and personal identity) who are lesbian, gay or bisexual, while others will identify as trans and seek to socially or medically transition to a new gender. Others still will view gender through a more fluid lens into adulthood.

What matters most though, say advocates and families alike, is how they are treated today. 2. LIGHT BULB MOMENTS Mikayla Lee Williams was born on April 6, 1999 in Pembroke, the second of two children to Matthew and Lesslie. (For consistency, the Citizen will use male pronouns whenever referring to Mikey, the name he’s used for most of his life). The family lived in Chalk River, not far from the Petawawa military base where Matthew worked as an armoured crewman, and later settled in Carleton Place. Matthew now works in Ottawa for the Department of National Defence; Lesslie operates a daycare out of the family home. When Mikey was five, his parents asked him what he wanted to be when he grew up and he replied, “A daddy.” They didn’t think much of the comment, nor of Mikey’s preference for hanging around with boys and keeping his fair-coloured hair cut short. They never made Mikey wear a dress, especially after he started throwing tantrums in stores whenever they tried to coax him over to the girls’ section. One time Mikey did wear a dress, at the special request of his great-great grandmother, everyone else in the family — dad, mom, older brother — wore a dress, too, so Mikey wouldn’t feel so awkward. He was five or six at the time, Lesslie recalls. “We just let him be who he was,” she says. Who he was was a confused young person. “I always felt out of place, like I didn’t belong in the body that I have now,” Mikey recalls. Looking in the mirror and taking showers depressed him; keeping his true self a secret gnawed at him. As Mikey got older and the feelings increased, he began to think he might be gay. But then he heard the phrase “sex change” and surreptitiously Googled it. He thinks he was 11. His searching continued after he came across the term “gender confused.” Somewhere along the way, a light bulb switched on. “I just realized that’s me,” he says. “Everything about that — that’s me!” Finding the words to describe what he had felt for years was a huge relief, but it took a couple more years before Mikey “got the guts” to tell his parents. That happened two summers ago when he and his mother were in the car heading home after an errand. His heart beating in his chest, Mikey blurted out that he was gender confused. Lesslie kept driving. “I’ll love you no matter what,” she told her son that afternoon. “Nothing’s going to change.” Matthew and Lesslie Williams had never met a trans person before the day they learned they were living with one. Mikey was probably gay, his parents had figured, but they hadn’t bargained for the trans twist. “It took a little time to understand what was happening,” Matthew admits. “I support my kids, no matter what, but yeah, it was shocking at first.” Lesslie nods in agreement. “I started reading right away and was, like, ‘Wow, this is Mikey,’” she says, recalling her own light bulb moment. She also started going to meetings in Carleton Place and Ottawa for parents and friends of lesbian, gay, bisexual and trans people (PFLAG).

One thing that soon began to make sense were Mikey’s frequent bouts of anxiety, especially when it came to school. He never wanted to go. Unbeknownst to his parents, Mikey had developed a deep fear of being teased for dressing like a boy and often missed up to three days a week when he was in Grade 5. He also didn’t feel like he belonged in the girl’s washroom but it wasn’t safe for him to use the boy’s washroom, either. Ask a trans person about public washrooms and you’ll likely hear that the significance of this issue cannot be overstated. Many are routinely subjected to harassment and have even had the police called on them. But when a child is unable to meet their basic bodily needs due to such rigid — and rigidly policed — gendered spaces, what are they to do? Mikey’s doctor put him on anti-anxiety medication and his parents sent him to school with notes so that he could come home at lunch. The notes were a lifesaver. “Before that, when I didn’t get notes, I would have to hold it and then at the end of the day, I’d have to rush home to go to the bathroom,” Mikey says. Several months after coming out, his parents took him to see a counsellor in Carleton Place, who referred the family to a doctor in Ottawa whose specialty was working with children like Mikey. 3. MAKING NEW MEMORIES Stephen Feder didn’t set out to work with trans teens. As CHEO’s head of adolescent health, Dr. Feder saw a lot of children with eating disorders, including one young patient who revealed that his motivation to lose weight was because he’d read on the Internet that if he lost enough pounds, he would block his body’s own hormone production. He wanted to starve the testosterone away. “This young person was desperate to reduce the influence of testosterone on his body because he identified as female,” the soft-spoken doctor recalls. “He felt he had no choice but to submit himself to a fairly devastating illness in order to accomplish that.” The revelation sounded an alarm for Feder, who soon learned his CHEO colleague, Dr. Margaret Lawson, a pediatric endocrinologist, was seeing children with similar issues. The pair saw four patients in 2011, but that number grew to two dozen the following year. Feder says he doesn’t think the prevalence of the issue is increasing, rather that there are simply more children and families facing it head on who may have previously struggled in silence. Until recently, some of these children were diagnosed with gender identity disorder. But in the American Psychiatry Association’s recently updated Diagnostic and Statistical Manual (known in medical circles as the DSM-5), that diagnosis has become gender dysphoria in children. Doctors don’t really know what causes it, Feder explains, other than to say it is generally accepted now that it’s biological and has nothing to do with how children are raised. What Feder and others are clear about is that it is not a mental illness, as the word “disorder” previously suggested.

“Somebody who identifies as the opposite gender is no more mentally ill than somebody who identifies as cisgender, there’s no doubt in my mind about that,” he says. The dysphoria occurs when a young trans person is forced to face society’s rigid gender realities and are intimately confronted with the clash between who they are and what their body is doing, such as when a person considered female at birth but who identifies as male begins to develop breasts or menstruate. While no one likes being labelled for who they are, the diagnosis is the key that unlocks the door to medical services and funding for medication and surgery. And it is applied only to those children whose gender identity is persistent, consistent and who are insistent on transition. Once a child is referred to CHEO, Feder begins by seeing them and their parents separately (with the child’s permission). This is quite deliberate. Parents play a crucial role in the outcome of the child’s transition, but they also often need an opportunity to unravel the biases and prejudices they hold, and to express grief and fear about the reaction of extended families or religious communities without the child having to hear it all. A parent who represses these thoughts will likely never get an opportunity to resolve their own issues, Feder says, and that will limit their ability to be completely supportive. Parents may also need some time to catch up. In many case, the child who has been struggling with and processing their reality for several years is suddenly juxtaposed with the parents who never anticipated or never allowed themselves to think this would happen. The toughest part so far for Mikey’s father was dealing with the sense of loss he felt for the father-daughter relationship he cherished. He won’t likely walk Mikey down the aisle on his wedding day, nor is it clear whether Mikey will ever have his own biological children. “The memories will always be there and we’ll make new memories,” he says. “That little person is still your child, nothing’s going to change that.” 4. ‘IT JUST DROVE ME NUTS’ After children have seen Dr. Feder — who conducts the baseline blood work and assessment — they meet Dr. Lawson, a pediatrician who specializes in the study of hormones. Her role is to talk to families about the medical treatment options and then prescribe drugs accordingly. The first step is Lupron, which is injected monthly at first and later every three months. Lupron is a synthetic form of a naturally-occurring hormone that has been used for decades to block the body’s production of either estrogen or testosterone in children who are prematurely entering puberty. In gender independent children, it gets rid of the hormone the children don’t think should be there. Females transitioning to male will, among other things, cease menstruating, while males transitioning to female will experience fewer and weaker erections. But Lawson says the best outcomes, physically and emotionally, actually occur when children begin taking the drug soon after puberty has begun, thus preventing irreversible physical changes such as deepening of the voice or development of a female pelvis, and making it easier for people to pass in their new gender.

Children can take Lupron for up to two years before starting cross-gender hormones, which is usually at age 16. The doctors at CHEO say prescribing the drug buys children and families some time to continue therapy and prepare to complete the social transition. Children taking Lupron often become less anxious or depressed because their bodies are no longer causing them as much distress, and their feelings and experiences have been validated. Lawson says she sees a marked difference between children who arrive at her clinic hunched over and avoiding eye contact and return later appearing much more comfortable in their skin: “It’s wonderful to see.” Lupron, which costs $475 per month, is often covered by a parent’s private insurance plan, but CHEO is usually able to offset the cost for families without third-party coverage. The effects of Lupron — that is, delaying puberty — are completely reversible, but any bodily changes caused by taking hormones, such as deepening of the voice or breast growth, are not. Surgery is not an option until the child is 18, and it’s something both Feder and Lawson say the wider public should quit fixating on. “We need to focus on the whole kid and not just what’s between their legs or isn’t between their legs,” Feder says. Lawson adds many patients are ambivalent about surgery. Top surgery, the far less clinical name for a double mastectomy, is often sought after by trans guys, but bottom surgery is expensive, invasive and not always successful in terms of the cosmetic and functional outcome. Mikey is eager to go on testosterone and is open to top surgery. He wants to walk around without a shirt on. But transitioning is a long process — mercilessly long for the teen in the middle of it — so there’s lots of time to think it over. Parents and clinicians, however, say that the elongated time frame, which is the recommended protocol internationally, helps confirm whether the treatment and transition is ultimately appropriate for the child. Mikey’s parents worried it might be a phase or that Mikey might change his mind down the road and then resent them for letting him pursue the transition. “If we get to the end of this road and it was wrong, then what? If we start this journey and it’s right, but we don’t go far enough ...” Mikey’s dad says, not completing the sentence. “It was total confusion and it just drove me nuts.” Doctors and other health-care providers share those concerns, and can appreciate why some people would question whether children who aren’t old enough to drive or vote are equipped to make such a life-altering decision. There also isn’t yet a vast amount of data taken over a long period of time to pore over and understand the outcomes, Lawson says. But what she can do is listen closely when a child recalls a moment from their life that clearly demonstrates they were not comfortable in their own skin; that reveals how their anatomy, biology and hormones were inconsistent with their own individual gender identity.

“It’s by hearing those stories over and over again that it becomes clear it’s the right thing to do,” Lawson says. “These youth know who they are. These youth are the experts on what matters most to them and what they’re living with.” 5. FAMILY MATTERS It should come as no surprise that a gender independent child with a supportive family has a far better shot at a positive long-term outcome than a child who does not. After facing Mikey’s situation as a family for several months, his parents slowly began sharing the news with their tight-knit group of friends, many of whom had known Mikey all his life, and later, with their extended families. Mikey’s mom even typed out a thoughtful two-page letter to her parents in which she explained what transgender means, outlined the difference between gender identity and sexual orientation, and offered to loan them some books and pamphlets so they could “inform yourselves about this adventure that we are about the embark on.” But she never actually got around to sending the letter because it just came up in conversation one day. Mikey’s grandmother would later be one of the commenters on his declarative Facebook coming-out post. “Nanny and Poppa are proud of you and love you like crazy,” she wrote. The importance of positive parental endorsement can’t be overemphasized for any child. But for trans youth in particular, says Dr. Feder, the denial of that endorsement and love can be devastating. For a parent to reject a young person, kick them out of the house or say they are no longer welcome in the family — at such a critical stage in the child’s development — undermines the child’s own sense of positive self-esteem and could set them up for a lifetime of seeking parental endorsement and validation in some other way. “Nobody needs their parents more than these kids,” he says frankly. There is data to prove it. Surveying the health impacts of parental support on trans youth between the ages of 16 and 24, the Trans PULSE Project — a community-based, mixed-methods research project aimed at understanding and improving the health of trans people in Ontario — found that 57 per cent of youth with unsupportive parents had attempted suicide in the past year, compared to just four per cent of those with supportive parents. And all of the youth with supportive parents reported having adequate housing, while less than half — 45 per cent — of those with unsupportive parents enjoyed the same. Trans youth are at a high risk of social isolation, and that leads some to unemployment and homelessness, not to mention harassment, violence and higher rates of suicide. Meanwhile, the desperation caused by feeling like a hostage in their own bodies forces some teens to purchase black market hormones or abuse other substances in order to numb their pain. Some turn to sex work to make ends meet. Access to appropriate medical care also plays a crucial role in the child’s outcome.