Growing numbers of teenagers, convinced they have been born in the wrong  body, are switching gender. But young people change their minds about  lots of things. What if one of them is their gender?  

When she was 15, Max began to question her gender. A year later she told her parents she was a he. Max started taking testosterone, had a mastectomy and, by the age of 18, was passing as a man. Then Max began to have second thoughts.

  Max's honesty and openness about the potential issues such as changing  minds as children grow and reach maturity is remarkable. Her life  experience is a profound lesson that everyone needs to take heed from.   Some things in life are not black or white and therefore the exercise  of the virtue of patience by all involved in such situation may be one  of the key elements in such journeys.  I pray that Max's parents don't  beat themselves up or are not drowned in an ocean of guilt as often  parents tend to blame themselves about everything.  Complex indeed!  

 good reading

 

 Max Robinson’s house is full of junk. With her partner Kitty, she likes  to comb through the charity shops and yard sales of Klamath Falls, the  dusty city in southern Oregon where they live. Their spoils hang on  their living room walls: a painting of a white husky; a tired Lisa Frank  backpack decorated with cartoons of prancing pink ponies; a blown-up  photo of a Siamese cat mounted on imitation teak. 

 The only picture in their living room not from salvage is a close-up of  an Alaskan man smiling into the camera. Max, who is 21 years old, is an  in-home caregiver and the photo’s subject was one of her charges until  his recent death. It is the only image of friends or family that guests  can see. Pictures of Kitty and Max are also absent. This house is a  sanctuary – from the summer heat, the looks of strangers and, above all,  from the past. 

 Max grew up 300 miles south of Klamath Falls in Dixon, Cali­fornia, a  small city without a movie theatre or a mall. “You drive somewhere else  if you want to do something,” she tells me. Walmart dominated the  “popular hang-outs” page of her high-school yearbook. 

 Max’s childhood in the mid-noughties was not serene. She railed against  the expectation that she act “girly”. When she was in first grade, she  would go home from school in a huff because the girls’ bathroom pass was  decorated with pictures of bows, while the boys’ sported soccer balls.  “My teacher wouldn’t let me choose which pass I wanted. I played  soccer!” When she was in third grade, her mother “finally” bought her a  pair of boys’ shoes. She wore them constantly, until the fabric frayed  so much that the exposed plastic began cutting into her feet. “I didn’t  tell my parents. I thought I wouldn’t get another pair. They didn’t find  out until they saw the back of my ankles, torn and bleeding.” 

 This is Max’s first memory of hurting herself on purpose. Sometimes she  did so out of sheer tedium. In middle school, she began scratching off  her skin, and cutting it. “Sometimes I’d get so bored in class that I  would just go to the bathroom and cut myself because I was literally so  fucking bored. And miserable,” she says. For a while, she stopped eating  breakfast and lunch. “It was easier to focus if I was having pain from  being hungry.” Starving herself was also part of an effort to improve  her appearance – she wanted to be thin – but it did nothing to relieve  Max of her disgust for her body, an aversion that only intensified as  she began to attract the notice of boys. 

 She was never interested in them. When she was 12, she realised she  cared only for the attentions of women, and began dating girls her age.  The experience was bruising. Max describes a recurring scenario: her  advances would be reciprocated by a girl who assured Max she was  bisexual, even though she had only ever dated boys. But then the girl  would hook up with her next boyfriend, dump Max unceremoniously and deny  the relationship had ever existed. 

 Max decided that she would “try to be straight” and began dating an  older guy. “I wanted to please the guy, do what my friends were doing,”  she says. “I felt like that would fix something. At that point I was  still dressing pretty typical for my peer group” – push-up bras, low-cut  tops, flannel shirts, long hair caught up in a ponytail. Tweezing,  waxing, shaving. High heels on occasion. But none of it ever felt right.  Max longed to cut her hair short and wear boys’ clothes. When she was  14, she saw a friend get molested by a man. Max started to fantasise  about committing suicide. 

 One day she was thrown a lifeline. While surfing the web, she discovered  a new word: “transgender”. She began reading stories about women who  felt that their bodies didn’t match who they were inside. It had never  occurred to Max before that she might really be a boy trapped in a  girl’s body, but it was a compelling idea. It explained why she hated  that body and why she felt like she’d never belonged. It gave her a  ready-made group of friends. And it gave her hope: there was a cure for  feelings like hers. 

 “The longer I thought about it, the more sure I was that it was  true...It was just so comforting to think that I was born wrong. If my  body was the problem, it could be solved.” When she was 15, Max declared  that he was not female and never had been. He and all his new friends  agreed: “Being trans was very special...Before that, I had never felt  special, or that my pain mattered.” 

 The great majority of humans with XY chromosomes are men and those with  XX chromosomes women. But for a very small number of people, things  aren’t that simple. The members of this minority – the precise figures  are unknown, but conservative estimates suggest it ranges in size from  0.05% of Belgians to 1.2% of New Zealanders – might have ovaries but  know themselves to be male, or they might have testes but know  themselves to be female, even if they’re too young to know what ovaries  and testes are. 

 A growing number of children and adolescents are coming out as  transgender. Referrals to Britain’s Gender Identity Development Service (GIDS)  have increased from 94 to 1,986 over the past seven years. The picture  is similar in America. The country’s first gender-identity clinic for  children and adolescents opened in Boston in 2007; by 2015, there were  over 50 such clinics in North America. Their patients belong to the  first generation of children and teenagers who are altering their bodies  to fit their gender. 

 The science of gender-identity development is still in its infancy: the  causes of “gender dysphoria”, the clinical term for the distress caused  by the feeling that one’s body doesn’t match one’s gender, are still  unclear and evidence for the effectiveness of treatments is limited.  Randomised double-blind control trials, which afford the highest-quality  evidence, cannot be conducted for ethical reasons, and the first  long-term, large-scale studies have yet to be completed. “We are  building the data as we go,” says Dr Bernadette Wren, head of psychology  at the Tavistock and Portman, the GIDS clinic in London. 

 But children and teens with gender dysphoria often feel that they can’t  afford to wait for years while clinicians determine what constitutes  best practice. Many wish to begin transitioning in the earliest stages  of puberty, not just because prolonging the process would invite  unwelcome physical changes which are difficult to undo, but also because  it can be painful to watch one’s body blossom into the wrong shape. For  some, it is too much to bear. In December 2014, Leelah Alcorn, a  17-year-old transgender girl, stepped in front of oncoming traffic on a  highway in Cincinnati, Ohio. In her suicide note, she explained that her  Christian parents refused to give her permission to transition. 

 While clinical psychologists concur that the welfare of the child is  paramount, they disagree on what that means and how they might secure  it. Many think that medical and psychological treatment is often  necessary but views diverge when it comes to questions about which  children need it and when it should be dispensed. Clinicians are  influenced not just by the data (what little we have) but also by their  theoretical orientations and beliefs about the origin, meaning and  malleability of gender identity. 

 Just a few years ago, this debate was confined to the pages of sober  academic journals. But ever since Caitlyn Jenner starred on the cover of  Vanity Fair’s July 2015 issue and transitioning became a  subject of general discussion, the volume has been jacked up by  partisans of the culture wars. Massed on one side are trans activists  and their progressive allies, who champion the right of an oppressed  minority to self-determination. On the other side stand religious  ideologues, who deny the very idea that one’s gender can differ from  one’s God-given sex, and whose crusade to ban transgender people from  using the bathroom of their choice has become a campaigning issue in  American politics. Mustering uneasily nearby is a group of feminists,  some of whom do not think that men can ever truly become women. 

 Thanks in part to the full-throated support of progressives and trans  activists, one approach is gaining ground in America. It contends that  children know themselves best: if your three-year-old says he is a girl,  do not deny or question her but instead support her. When she is ready  to transition, assist her to do so – whether that means buying pink  dresses now or approving her use of cross-sex hormones later on. Parents  who affirm their kids’ desire to transition have been widely lauded for  their courage; doctors who question whether medical intervention is in a  child’s best interest have been accused of transphobia. 

 So contentious is this argument that parents I have spoken to fear  publicly raising issues that worry them. There is one, in particular,  that troubles many: what if my child changes her mind? 

 When Max came out to his parents six years ago, Caitlyn Jenner was still  Bruce. “Initially my parents were like, ‘What?’ They didn’t understand  or think that [transitioning] was a reasonable response to what I was  feeling.” Max demanded they take him to a gender therapist. The  therapist, a transgender man himself, diagnosed Max with depression,  anxiety and gender dysphoria, and explained to his parents that there  were steps he could take to alleviate the dysphoria. The first step was a  social transition, which involved changing his name, pronouns and  appearance to better fit the desired gender. Reassured, his parents  accepted that their daughter had become their son. After that  appointment, Max biked over to SuperCuts to get his long hair lopped  off. 

 Three months after Max’s first appointment with his therapist, he  started taking testosterone. Hormone therapy is often described as  “life-saving medical treatment” for those suffering from gender  dysphoria because it moulds the body into the desired shape. At first,  Max’s therapist urged him to address his anxiety and depression as  transitioning wouldn’t necessarily resolve them. But Max refused. “I  wanted testosterone and I wanted my surgery.” Eventually the therapist  relented, and wrote a letter to a local paediatric endocrinologist  recommending Max for hormone therapy. Max’s parents gave their consent:  in America, children under the age of 18 must secure the approval of  their parents, whereas in Britain, as in some European countries, the  law permits children aged 16 and over to make the decision themselves,  as well as children under the age of 16 provided they are deemed capable  of doing so – though clinicians at GIDS have yet to treat a patient who did not have the support of their parents. 

 Shortly before he turned 17, Max started taking “T”, as  it’s sometimes called. Over the next two years, he stopped menstruating,  lost some layers of fat, and gained more muscle mass and facial and  body hair. His voice deepened, his clitoris swelled in size and his  libido was invigorated. When transgender women take oestrogen, breast  tissue develops and body fat is redistributed to hips and thighs. 

 Hormones, however, can’t undo all of the effects of puberty. If breasts  have grown, testosterone can’t make them disappear. If an Adam’s apple  has already dropped, oestrogen can’t haul it back up. If follicles have  sprouted on the chin and upper lip, it can’t root them out. Prepubescent  transgender children are fortunate in this regard as they can take  puberty blockers. These drugs pause their natural development and are  viewed as a prudent, compassionate measure as they prevent changes they  might view as abhorrent. 

 Yet there are serious questions about these hormones’ medical and  psychological effects. Blockers are often described as “fully  reversible”, and it is true that if you stop taking them puberty will  eventually resume. But it is not known whether they alter the course of  adolescent brain development and possible side-effects include abnormal  bone growth. 

 Cross-sex hormones are even more problematic. Their long-term medical  and psychological effects are unknown, though it is clear that oestrogen  brings with it a clinically significant risk of deep vein thrombosis,  while testosterone increases the chance of developing ovarian cysts  later in life, which is why some transgender men have their ovaries  removed. In addition, some of the effects of cross-sex hormones are  irreversible. With testosterone, there is no return from the deepening  of the voice and the augmentation of the clitoris; with oestrogen  enlarged breasts will remain. 

 If children under the legal age of consent would like to start taking  hormones, they must secure the approval of their parents, and find a  doctor willing to administer them. They will have no luck with GIDS  in Britain, where doctors will not prescribe them to anyone under the  age of 16. Better to try Dr Diane Ehrensaft’s clinic in San Francisco.  Ehrensaft is the director of mental health at the gender clinic at  Benioff Children’s Hospital and one of the architects of the affirmative  model. She and her colleague, Dr Stephen Rosenthal, think that it is  more important to consider the stage of puberty at which children have  arrived, rather than their age. Rosenthal worries about the few British  children who, having begun puberty at age nine, will have to take the  blocker for seven years until they have reached the age of consent.  “That can be very risky to their bone health and perhaps even for their  emotional health, to be so far out of sync with their peers in terms of  pubertal development,” he says. At his clinic, he has administered  cross-sex hormones to patients aged 14, and sometimes  younger. 

 This approach makes Wren, of the Tavistock and Portman in London,  nervous, as children who begin taking blockers early on in puberty,  followed immediately by cross-sex hormones, will never produce mature  eggs or sperm of their own. “Can a 12-, 13-, 14-year-old imagine how  they might feel as a 35-year-old adult, that they have agreed to a  treatment that compromises their fertility or is likely to compromise  their fertility?” she wonders. The risks of hormone therapy are high,  but many young people and their families think that the price of caution  is greater. It’s hard for parents, says Wren. “They see their suffering  child, they want to remedy the suffering, and there’s a treatment out  there. Why wouldn’t you give it?”    

 Ever since his breasts began to develop, Max had been bothered. For  months, he had been binding his chest to make it look flatter, but the  binder was painful. The next step in his transition was a double  mastectomy, the most common form of surgery among transgender males.  (Other operations include hysterectomies and phalloplasties – neither of  which Max underwent – vaginoplasties for transgender females, as well  as vocal-cord surgery, Adam’s apple reductions and facial adjustments.)  In May of Max’s senior year at high school, his gender therapist wrote a  letter recommending him for “top surgery”. 

 Though Max insisted to his parents, therapist and doctors that he needed  hormones and surgery (“I was a very effective s   elf-advocate at the  time”), privately he had reservations. “As soon as I started thinking  about transition I had obsessive thoughts of doubt.” He wondered whether  he might come to regret making his body more masculine. During one  appointment with his therapist, he mentioned his fears. “I expressed  that I was scared of regretting it” and worried that internalised  misogyny might account for his desire to transition. But when the  therapist asked Max if he really believed that, he said no. After that  conversation, Max didn’t bring it up again. He didn’t want to give his  therapist any reason to doubt that surgery was right for him. 

 Max scheduled his mastectomy for July, even though he would still be 17  years old. In Britain, patients are eligible for surgery only if they  are aged 18 or over. American guidelines are more flexible. If minors,  with the backing of their parents, can find a surgeon who is willing to  operate, then they can proceed. Max had no trouble finding one. 

 Recovery was difficult. Lifting your arms is not recommended after a  mastectomy – it can disturb the stitches – but Max, who had little help  from friends and didn’t ask his family for assistance, washed his own  hair and emptied his own drains, the plastic tubes inserted into the  chest which collect the fluid that accumulates where the breast tissue  has been. “I have way worse stretch marks  than people who do the  recovery the way you’re told to do it.” 

 He spent the rest of the summer convalescing and writing zany slogans  for t-shirts he sold online (“Relentless do-gooder”; “You can call a lot  of different meals business lunches”; “If you’re looking for a sign,  this shirt is it”). That autumn, not long after he turned 18, Max moved  to Portland. He enrolled in community college, and made enough money  from his t-shirt business to live off. He started making friends in  Portland’s large transgender community and met someone called Kitty who  shared his mischievous sense of humour. 

 It was a happy time for Max. He felt like a man on the inside; now he  looked like one on the outside. Passing “was really cool”, he says in a  video he made for his blog. “I felt like I was becoming this new person  who could have an easier life.” He felt he was treated better because he  was now a man in a culture that privileges men. His anxiety and  depression faded into the background. In the video, he continues, “I  felt like I was re-creating myself. I felt like I was being seen.” Then  he pauses, and his smile fades. “And the longer it went, the less I felt  like that.” 

 When Max was 19, just over three years after he came out as transgender, she realised he’d made a mistake. 

 From her spot on the sofa, Max reads aloud from a heavy book. Reclining  to her right is Kitty, her girlfriend, resplendent in pink. To Max’s  left, nestled up against her thigh, is Chloe Elizabeth, one of their two  dogs. “It’s not a cure all,” reads Max. “If you go into it really  screwed up you’re going to come out of it really screwed up. Make sure  this is what you want to do. Make sure there is no other option because  this is truly the hardest thing I have ever done in my life. You put  everything that you are in jeopardy. Talk to as many people as you can  that are going through it. Be sure.” 

 Max is reading testimonies from transgender men compiled in the book “FTM: Female-to-Male Transsexuals in Society”. Not that that term applies to Max anymore. Now 21, Max would be better described as FTMTF, female to male to female. Max is a woman and has been one for two years. 

 Six months after he began successfully passing, he realised, deep down,  that he wasn’t sure. “I started being like, oh damn, this is for real.”  There were drawbacks to being seen as a man. Women he passed on the  street were “scared” of him. He couldn’t talk about his childhood  without lying or leaving things out. He found laddish banter  distasteful. And the possibility that someone would discover he was  transgender haunted him. “People don’t love to find out that you weren’t  born a man.” 

 At first, Max would only admit that he felt “kinda weird” about  transitioning. He told himself, “I’m not going to stop transitioning but  I acknowledge that transitioning isn’t always positive for everyone.”  Months passed. “Gradually, very slowly, the more I was honest about what  I was feeling, the more it became clear to me that I wasn’t having a  very good time with it.” In the summer of 2015, after four years of  identifying as a man and nearly two years of looking like one, Max  transitioned back to her old gender identity, and stopped injecting  herself with testosterone. Not long after, she convinced Kitty, who had  identified as a transman for a year and was days away from getting her  first shot of testosterone, to reconsider. 

 As the number of children – some under the age of 12 – being referred to  gender clinics increases, so does the relevance of a question which  troubles many clinicians and parents: what happens if a child changes  his mind? Studies show that a majority of pre­pubescent children with  gender dysphoria – between 73% and 88% – will not grow up to be  transgender adults (though some people dispute those figures). So  clinicians ask whether we can distinguish between those children who  will continue in their trans identity and those who won’t.  Ehrensaft  thinks we can. She looks for tell-tale signs: does the child  “insistently, persistently and consistently” identify as her chosen  gender? Does she say “I am a boy”, rather than “I wish I was a boy”? Is  she disgusted by her vagina? If she does and she is, then she may be  allowed and encouraged to transition. 

 But Dr Thomas Steensma, who belongs to an influential group of Dutch  clinicians, says that reliably distinguishing between those who will  carry on to be transgender adolescents and those who won’t is impossible  – a view supported by the American Psychiatric Association. This is why  the Dutch group counsels “watchful waiting” for prepubescent children –  a neutral, cautious approach which involves allowing their gender  identity to unfold naturally without encouraging them to commit to  either. Ideally, no decisions about transitioning are made until  adolescence. They worry that a child who changes his mind may find it  difficult to revert back to his original identity. 

 For the majority of those who transition physically, doing so is an  effective way of alleviating their dysphoria. But some eventually decide  to return to their original gender identity. The exact numbers are  unknown but probably amount to a very small proportion of the total. Out  of the hundreds of patients Ehrensaft has seen, only one has ever  regretted their medical transition. A 50-year study conducted in Sweden  found that only 2.2% of people who medically transitioned later felt  “regret” (in contrast, an estimated 16% of cosmetic-surgery patients are  unhappy with their nose jobs, according to the Aesthetic Surgery Journal). 

 But many who detransition never inform their doctors, Max says, so are  not reflected in the statistics. She acknowledges that people like her  are a “tiny subset” of the transgender population. Her network of  detransitioned people, which was formed a couple of years ago, numbers  just over a hundred. Kitty, who now identifies as a woman, thinks it  gains one to two new members each week. But it stands to reason that as  the number of people transitioning increases, so will the number of  people reversing the process. As Kitty says, “the argument that a group  is such a tiny minority that they shouldn’t be listened to is pretty  inappropriate.” Trans people are, after all, a small group themselves. 

 Transgender people detransition for a variety of reasons. Some people  find they are less comfortable in their new identity than their previous  one. Others cannot afford to keep paying for hormone therapy. Others  still suffer from surgery complications or have concerns about the  long-term effects of taking hormones. Sometimes it’s because life as a  transgender person is hard. Transphobia forces these people “back into  the closet”, Brynn Tannehill, a trans advocate, said in a recent article  for the Stranger, a newspaper in Seattle. 

 Max detransitioned for several reasons; the most significant one was  that she is not transgender. She was unhappy as a child not because she  was a boy trapped in a girl’s body but because she didn’t understand  that she could be the kind of girl who hated girly things but loved  other girls, without having to metamorphose into a man. 

 After she stopped taking testosterone, her body began to change again.  Over the next two years, body fat gradually migrated back to her hips  and thighs. She lost some muscle mass and began to menstruate again. Her  sex drive, which had been “ridiculous”, became “manageable”. She became  “more emotional”: “I cried a ton less on testosterone.” She watched the  hard edges of her face soften into roundness and her rough skin become  smooth. 

 Some of the changes wrought by transition cannot be reversed. Max’s  voice remains deep. Her beard is a permanent fixture, though the hair is  softer and finer than before. Her chest will remain flat. “Strangers  think I’m a man a lot of the time,” she says. This is a source of pain  and frustration, though she puts on a brave front. She firmly believes  that women should be able to look and behave however they want. But, in a  fundamental way, gender still informs how we interact with each other.  Confusion and hostility can ensue when a person’s gender is unclear. 

 When Max told her friends and family that she was detransitioning, she  “felt really fucking stupid”. Kitty strokes Max’s arm. “You really put  yourself out there when you say, ‘Hey everyone I’m a man now and you’ve  got to get on board with this’. So it does not feel especially dignified  to be like ‘Oops!’” 

 The question of whether a child can really know herself remains  unanswered. Max was sure, and she was wrong. Ever since she was 15, she  had attributed troubles such as anxiety and depression to  gender  dysphoria. It is often the case that such mental-health issues follow in  the wake of dysphoria; after all, being trans is hard. But Max and her  therapist overlooked, or discounted, the possibility that her mental  health problems, far from being symptomatic of gender dysphoria, could  actually be the cause of it. Max now believes that her dysphoria sprang  from the anxiety and depression, which in turn arose from her difficult  experiences as a young lesbian with bi-polar and attention deficit  disorders, with which she was diagnosed three years ago. 

 Ehrensaft agrees that “it absolutely is essential” to rule out the  possibility that gender dysphoria could be caused by “another life  problem”. That requires visiting a mental-health professional. But she  is also part of a movement encouraging the World Health Organisation to  declassify gender dysphoria as a mental illness, in much the same way  that homosexuality was removed from the “Diagnostic and Statistical  Manual of Mental Disorders” in 1973. Psychiatric diagnoses of gender  dysphoria stigmatise sufferers. Last January, Denmark became the first  country to take Ehrensaft’s advice. But removing the mental-health  element means it is less likely that people with gender dysphoria will  see a therapist before they are treated. In America, a growing number of  clinics will prescribe hormones to patients as long as they understand  the effects of the treatment – letters from therapists are not needed.  As Max’s story shows, seeing a therapist doesn’t guarantee that mistakes  won’t be made, but it may help people avoid them. 

 There is a growing view that transgender people, not their doctors,  should be in charge of their own bodies. Many argue that identity, not  health, is the fundamental issue. Though they know there may be  deleterious consequences, they want autonomy over their own treatment.  In this light, doctors – who are obliged to respect the right of  patients to do what they want to their bodies – should acquiesce. But  they are also required to do no harm. What if they suspect that a young  woman’s internalised misogyny and repressed lesbianism accounts for her  desire to turn herself into a man? Transitioning might temporarily  mitigate her dysphoria but therapy would be less drastic and more  effective, as would more informal kinds of support provided by LGBTQ groups. 

 Max believed that transition was right for her and she wasn’t going to  let a therapist tell her otherwise. Now, though, she wonders how anyone,  whether adult or child, can “provide meaningful consent to an  experience that’s pretty transformational…Kids are particularly  susceptible to pursuing things that later in life they might not believe  was the best possible thing for them to have been doing. Kids do all  kinds of stuff.” 

 Today, Max is much happier, she tells me, having returned to her true  identity as a woman. She is in a committed, loving relationship with  Kitty, and together they hope to run a refuge for troubled women. She  breaks off mid-sentence to look at her phone. She has received an email  from her grandmother containing an old photo she found of Max, aged  about ten, posing shyly in front of a tree with her two sisters. A smile  steals across her face. 

 Charlie McCann  is assistant editor  

 PHOTOGRAPHS CHLOE AFTEL 

source https://www.1843magazine.com/features/when-girls-wont-be-girls