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As youngster transitions from girl to boy, family shifts between challenges, calm

Max is one of an estimated 1.5 million people in the United States who describe themselves as transgender, with a biological sex that does not match the gender with which the person identifies.

(MCT) ST. LOUIS — The first day of school can be a little nerve-wracking: new teachers, new classmates, new routine.

On his first day of third grade last year, Max stopped by the guidance counselor's office at his suburban St. Louis elementary school before the bell rang. He played with a "What Mood Are You In?" chart, picking out cartoon faces that matched his feelings.

He chose frightened, then anxious.

And finally — hopeful.

His mother walked him to his classroom. They stood outside the door while the teacher prepared her students for Max's arrival.

"You've known Max as a girl," she told a gaggle of fresh-faced, excited third-graders. "But Max is actually a boy."

Max's mom gave him a little pat as she guided him through the door. With that, his social transition was in full swing.

Max is one of an estimated 1.5 million people in the United States who describe themselves as transgender, with a biological sex that does not match the gender with which the person identifies. His parents agreed to be interviewed using a pseudonym for their son to protect his privacy.

And though Max, now 9, may seem young, the American Academy of Pediatrics says a person's awareness of being a boy or girl happens in the first year of life. By age 4, gender identity is stable; a child knows that if she is biologically a girl, she will always be a girl.

That knowledge can be a source of great distress for children whose gender identification differs from the gender assigned to them at birth.

In younger children, the distress can manifest as withdrawal, anger or acting out, said Patricia Berne, a psychologist based in Clayton, Mo., who works with children with gender-identity issues and their families.

Berne, who has been in practice for more than three decades, has seen an increase in the past five years in teens and children who identify as transgender.

She attributes the increase partly to the availability of information on the Internet and broader coverage of gender issues in the media.

"Before, when children would say things, it really wasn't heard," Berne said. "Many older people knew at a young age but couldn't express it."

There are four times when gender issues tend to emerge, Berne said: the preschool years, when gender identity is solidifying; in puberty, when bodies are changing; a few years later, when young adults head to college or begin living on their own; and finally, during midlife, when some people start questioning their life's path.

The medical, psychological and family support needed differ depending on when gender issues surface.

For Max's family, the buildup to his transition began when he was a toddler.

"He said some things — 'When will I be a boy?' — but we explained it away," Max's mom said. As he got older, his parents tried to give him space: He wore boxers, cut his hair short, tried out different names while on vacation.

Many people believe gender identity issues are a phase, said Max's mom, like wanting to be pirate or wishing you were a princess. But it was becoming more obvious that Max wasn't confused or playing make-believe. This wasn't a phase.

Occasionally, strangers took the rangy, tow-headed youngster as a boy. "Why do you keep correcting them?" Max would ask his parents. He was frustrated when his twin introduced him as "my sister."

By 2012, when Max was 7, he would no longer use a women's restroom.

"He is an extreme rule-follower," his dad said. And Max didn't think it was right for him, a boy, to be in the women's room. He would wait until he got home from school to go to the bathroom.

That summer, Max and his family attended a conference in California held by Gender Spectrum, an organization that provides education and support on issues surrounding gender identity and expression.

"I was struggling with what was going on with Max," said his dad.

"I knew we all needed to go the conference as a family." Being around others facing the same uncertainty and apprehension "was a big validation," he said.

"But it was scary, too," his mom added. "We had to get less scared."

FEAR AND MISUNDERSTANDING

Despite a greater awareness surrounding LGBT — lesbian, gay, bisexual and transgender — issues, the "T" is still largely misunderstood.

"It challenges our sense of orderliness," said Berne. "We can be fearful of anyone who is different."

Children who deviate from gender norms often face a tough road.

According to the National Center on Transgender Equality, 80 percent of transgender students say they have felt unsafe at school. More than a third reported being physically assaulted, and about 15 percent end up leaving school because of bullying.

Perhaps most alarming, the attempted suicide rate among people with gender-identity issues is 41 percent. Among the general population, it's 1.6 percent.

"There's a high incidence of individuals who feel helpless," said Berne. "They can feel trapped."

The best thing that families can do is make clear that they are there to help, she said. Negative behaviors often lessen when children are allowed to be who they think they are.

By second grade, Max was talking more about his life as a boy. He wrote in his journal about how others saw him. He went to the boys' side when P.E. class was divided.

Last summer, Max's parents knew they were at a critical point.

They started talking with family members and friends. "Max needs more room around gender," his mom would explain.

Max's twin sister took the changes in stride and "has been a champion for him," his mom said.

Finally, Max's parents emailed his school principal to explain his transition. Then the family left on vacation, a last hurrah before an anticipated maelstrom of questions, confusion, maybe even disapproval.

For the most part, though, "everyone was amazing," Max's mom said. "We pegged some people wrong. We didn't lose any friends, and we cemented many relationships.

"The year prior to the transition was harder than the year after. Our biggest concern was, 'What if he changes his mind?' But gender is not a choice; the transition was," she said. "In the year or two prior to the transition, I would flinch when people asked how the girls were.

"This is not a whim. This is about being authentic."

In his class, Max's gender faded into the background, replaced by the humdrum work of multiplication tables and spelling tests.

Still, there were hiccups.

After Max's principal relayed that she had received criticisms from a handful of parents, Max's mom told her she would prefer not to be told about any comments as long as Max was doing OK.

Once, in the boys' bathroom, a student from a different grade questioned why Max was there. "I am a boy," he said he responded.

PATCHWORK OF POLICIES

In Missouri, districts set their own policies on how to accommodate students, said Kelli Hopkins of the Missouri School Boards' Association. Bathrooms tend to be a touchy issue, particularly in middle and high schools. Some transgender students use the bathroom in the nurse's office or a restroom with a single stall. Others "buddy up" with a classmate, so that they won't be caught in the bathroom alone.

Hopkins said more districts have added gender identity to nondiscrimination policies since she started at the state board in 2001. Nationally, there is a patchwork of policies related to transgender discrimination.

The Department of Education's Office for Civil Rights in March clarified that the federal Title IX law prohibits discrimination against students based on gender identity or "failure to conform to stereotypical notions of masculinity or femininity."

More than a dozen states, including Illinois, have laws prohibiting gender-identity discrimination in public schools. Missouri does not.

Last year, California became the first state to extend its discrimination measure to include a mandate that transgender students have access to sex-segregated activities, sports and facilities — including locker rooms and bathrooms — that match their identified gender.

Sports often are contentious. Transgender girls — who are biologically male — are sometimes seen as having an advantage if they play on girls teams.

The Missouri State High School Activities Association allows high school students to play for the team that matches their identified gender if they are taking medicine to delay puberty or hormones to change their secondary sex characteristics. Transgender girls must be on hormone therapy for a year before they can participate on a girls team. Transgender boys do not have a waiting period.

Max, who has always loved sports, used to play on a girls soccer team in the Catholic Youth Council league. After he transitioned, he was not allowed to sign up for the boys team.

In an email, Gabe Jones, a spokesman for the Archdiocese of St. Louis, wrote that the newly formalized policy of the CYC maintains the church's fidelity to the teachings of Scripture and tradition. Teams are formed "based on the sexual identity of children as male and female rather than self-determined 'gender identity.'"

Other leagues, such as those sponsored by the YMCA of Greater St. Louis, handle such cases on a child-by-child basis. Community leagues also often deal with each situation individually. This summer, Max swam with the boys on his local swim team.

Other sex-segregated organizations are just beginning to address this situation.

The Girl Scouts of Eastern Missouri is creating a formal policy regarding transgender girls, said Kathryn Kiefer, a communication officer for the organization. A membership review committee would evaluate each case, taking into consideration how long ago the child transitioned and how others in the organization would be affected.

"The Girl Scouts is a very inclusive organization and has always been," Kiefer said.

The Boy Scouts of America uses "a child's classification at birth," spokeswoman Christine Dieckmann wrote in an email.

Max's dad, who was an Eagle Scout, has become involved with his son in the Baden-Powell Service Association, a scouting organization that is "intentionally inclusive," he said.

MEDICAL INTERVENTIONS

There will be bigger challenges than Scouts and soccer teams as Max gets older.

Dr. Abby Hollander, a pediatric endocrinologist with Washington University School of Medicine, typically begins working with transgender children as they are about to enter puberty.

When Hollander began her training in the early 1990s, she had no transgender patients. Now she sees about 20 children. The oldest — and the first one she treated — started college this year.

"Gender identity seems to be hard-wired," Hollander said. "But we tend to think about gender as Column 1 or Column 2, which doesn't work."

Gender identity is unrelated to sexual orientation, or to whom a person is attracted. Transgender people can be straight, gay or bisexual.

According to the clinical guidelines of the Endocrine Society, puberty should be medically suppressed in children who identify as transgender. "Once you've been through puberty, those changes are more or less in place," said Hollander, who works out of St. Louis Children's Hospital.

Hormone blockers delay puberty, preventing unwanted secondary sex characteristics — wider hips, breasts and menstruation in biological girls; and facial hair, broader shoulders and testicle growth in boys. Bones strengthen during puberty, so blockers can put children at risk for osteoporosis; patients undergo regular bone scans.

The treatment is reversible. Children who stop therapy will go through puberty. At 16, patients can begin cross-hormone therapy — shifting the transition from social to medical. Transgender girls receive estrogen and progesterone; transgender boys, testosterone.

The hormones build up over a couple of years, Hollander said. Girls develop breasts and wider hips. Boys get facial hair, deeper voices and broader shoulders.

Estrogen treatment puts transgender girls at a higher risk for breast cancer and blood clots. For transgender boys taking testosterone, there is a risk of liver inflammation, elevated red-blood cell counts and higher cholesterol.

Patients come in every three months for lab tests, Hollander said, to monitor those factors. Patients stay on hormones for the rest of their lives.

As adults, some transgender individuals will choose to have surgery to change their external anatomy; many do not.

'BEING HIMSELF'

For now, Max is content settling into fourth grade, learning about ecosystems and reading "Because of Winn-Dixie." He is still friends with the same crew of boys and girls from kindergarten.

At home, he likes playing with his twin sister, even when they bicker. He runs 5Ks with his dad and snuggles with his mom when they watch TV on the couch.

In most ways, his suburban, middle-class childhood is a typical one.

But his parents know that things are likely to become more difficult as he gets older.

"There's a loss of some 'normalcy.' Lots of stuff will be harder," Max's mom said. "What we've done now is create a base of security and love to weather those times. He feels safe and secure with our family.

"Max has taught us so much, just by being himself."

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©2014 St. Louis Post-Dispatch

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