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OS ANGELES — Pediatrician Dr. Johanna Olson-Kennedy uses a stethoscope and otoscope, of course. But running a clinic for transgender youth means her pediatric medical supplies also include a selection of silicone penises and chest-flattening binders.

Thanks to the openness of Caitlyn Jenner and others, public awareness of transgenderism — and demand for trans-specific medical care like counseling, hormone treatments, and genital surgery — is exploding, even for the youngest of patients. At the 30-plus clinics for transgender youth across the US, doctors like Olson-Kennedy can barely keep up with the demand.

Chicago’s Lurie Children’s Hospital, for example, opened its trans clinic just four years ago but already has 500 patients — and a four-month waiting list. Seattle Children’s Hospital opened its clinic in October and immediately got scores of calls. Olson-Kennedy’s clinic, the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, is the country’s largest, treating 725 trans youth from across the western US. Five hundred of those patients are Olson-Kennedy’s.

Her youngest patient is 3.

What her patients share is the strong, almost certain, belief that they have been born into the wrong body. Their brains tell them they are one gender, their bodies another. Too often, Olson-Kennedy said, these kids have no one to help guide them or ease their pain or even offer routine medical care without disparaging them. “You sit in this room with these young people and see their distress so clearly,” said Olson, a 47-year-old California native. “It’s not OK to do nothing.”

So Olson-Kennedy battles. She fights with insurance companies, tangles with pediatric colleagues who think children are too young to transition, and persuades reluctant parents to help their distressed kids. She’s even taken on the authors of “What to Expect When You’re Expecting” for not including a section on transgender children. And now, just as her fledgling field is beginning to gain medical and mainstream acceptance, she’s got a new adversary: President-elect Donald Trump, who many fear will erode the recent gains of the transgender community and cut access to the health care they need to transition.

“It’s my number one concern right now,” Olson-Kennedy said. “I’m very worried.”

But there are also signs of hope. Olson-Kennedy is helping lead the first National Institutes of Health grant for research on transgender youth, now in its second year. And she and others hope that data will help win out over discrimination.

Dr. Johanna Olson
Olson-Kennedy treats 500 patients at the Center for Transyouth Health and Development at Children’s Hospital Los Angeles. Melissa Lyttle for STAT

Olson-Kennedy’s clinic sits on the fourth floor of a bank building on a busy stretch of Sunset Boulevard. In her office with a view of the iconic Hollywood sign, she counsels patients and their parents — a good many of whom have driven or flown from distant states to see her. She can spend hours getting to know a patient before beginning any medical treatment.

The youngest patients receive no medical interventions, just counseling. Olson-Kennedy describes one 18-month-old, born a girl, who understood her gender before her grammar. “I a boy,” she repeatedly told her parents. Many young children who experiment with gender roles end up reverting to their birth gender.

But when the gender discomfort persists into adolescence, said Olson-Kennedy, it’s usually there to stay. And puberty, when secondary sex characteristics develop, can be a dangerous trigger.

“I’ve had mothers call me who say their child tries to kill themselves every time they have their period,” Olson-Kennedy said. “Parents come in saying, ‘My kid tried to cut off his penis with dental floss.’”

Olson-Kennedy’s first line of treatment for adolescents is stopping puberty so children and their parents can buy time to sort out what they want to do. Puberty blockers, GnRh agonists like the injectable Lupron or the implant Supprelin, suppress puberty by modifying hormone release. Such drugs have been used off-label safely for more than 30 years to stop early puberty.

Trans doctors say it’s critical to stop puberty before the body morphs in ways that are difficult to change — the broadening of shoulders for men, for example, or the rounded hips of women. “Even 14 or 15 is too late,” said Dr. Norman Spack, an endocrinologist who founded the country’s first transgender youth clinic at Boston Children’s Hospital.

Once children are ready to make a permanent change, they can stop puberty blockers and use masculinizing or feminizing hormones. Some trans youth go on to have surgery to remove breast tissue or add breast contours or alter their genitals. Others forego surgery and use binders and packers to alter their body shape.

While some religious groups oppose the process of transitioning — and radio host Laura Ingraham, in the running to be Donald Trump’s press secretary, told her listeners to wear adult diapers rather than use public bathrooms with people who are trans — Olson-Kennedy and her colleagues mostly ignore the flack. They say the care they are providing is not only reducing emotional distress but saving lives. Without support and treatment, Olson-Kennedy said, trans kids are a risk for almost everything: depression, self harm, substance abuse, homelessness, HIV and suicide.

Athena Fenstermacher
Fenstermacher has routine blood work and labs before her surgery. Melissa Lyttle for STAT

Athena Fenstermacher was born male, but identified as a girl from her earliest days. “As soon as she could pick colors. As soon as she could talk,” said her mother, Jill. “There are pictures of me with a buzzcut and plastic heels and a Barbie,” Fenstermacher said. “I just knew I wasn’t born into the right body.”

Now 18, Fenstermacher is a petite and pretty blonde, demure, graceful and mature beyond her years. Living in nearby Long Beach, she found Olson-Kennedy at 15, after years of confusion and deciding she must be a gay male. “I didn’t even know transitioning existed until I was 14,” she said. “Everyone told me, ‘We don’t know what to do.’” Her treatment was further delayed by counselors who told her she had to undergo months of therapy before they would give her a referral to Olson-Kennedy. (While Olson-Kennedy said therapy is important, she said it should not be used as a roadblock to seeing a physician.)

Fenstermacher’s transition was excruciating. She attempted suicide, she said, after enduring extended bullying through high school and dealing with issues like trying to find a bathroom she could use comfortably. A 2015 study by the National Center for Transgender Equality found a majority of transgender Americans avoid using public bathrooms, even going so far as to limit their food and water intake when away from home. For 8 percent of people surveyed, this led to urinary tract or kidney infections.

It all took a toll: Fenstermacher went from an honors student with a stellar GPA to barely passing. She ended up earning her degree at home. Now, she fights constant loneliness and a sense she’s always being stared at and appraised. She hasn’t been swimming in seven years and says her slightly wider shoulders make her feel like a linebacker. She’s wistful when she describes watching her younger sister develop into the body she wishes she could have had. And she’s angry at her own genetics and a world that won’t accept her.

Fenstermacher is willing to discuss her experience and care because she’s so appreciative of Olson-Kennedy and because she wants people to understand the intense pain that comes with struggling with your birth gender. But she flinches every time her physician says the word “trans.” That word, Fenstermacher said, sets people to gawking, making judgements, and scrutinizing.

“I don’t feel like a trans woman.” Fenstermacher said. “I feel like a woman.” The word trans, she said, conjures up extremes: the flamboyant models of “Strut” or wealthy trans women like Caitlyn Jenner who order up any medical or cosmetic treatment they want. “The battle is a little different when you can just walk out the door and get facial feminization surgery,” said Fenstermacher, who dresses simply in jeans and T-shirts and, with her mother, has struggled to pay for therapy, treatment, hormones, and the surgery she recently underwent at a private clinic in San Francisco.

Athena’s mother fully supported the transition. “When you see their pain, you do what you have to do,” she said. Divorced and a waitress, Jill Fenstermacher literally had to scrape and borrow to get the money for Athena’s care, which was only partially covered by insurance. The costs of getting a legal name change, changing Athena’s driver’s license, it all adds up. “I told her, ‘I don’t care if I have to sleep in my car, I’m helping you do this.’” She’s battled so much: school districts, insurance companies, therapists, doctors. “I’m like the front line for her,” Jill Fenstermacher said. “I try to protect her, but there’s so much discrimination.”

Dr. Johanna Olson
Fenstermacher started seeing Olson-Kennedy at 15. Melissa Lyttle for STAT

Not all doctors agree with the approach of Olson-Kennedy and her colleagues. Some think young patients will grow out of their gender dysphoria, or that children should wait until they are 18 to make critical gender decisions. Many would simply like to see data on whether delaying puberty and allowing children to transition at younger ages is safe and healthy for them in the long run.

Olson-Kennedy is hoping to oblige. In 2015, she and three other leading trans youth doctors received the first NIH grant given to study transgender youth. The $5.7 million, five-year study will look at nearly 300 youth, some who received puberty-blocking hormones and others who took masculinizing or feminizing hormones after puberty. Teams at children’s hospitals in L.A., San Francisco, Boston, and Chicago have recruited patients and are now collecting data to evaluate the effect of treatment on mental health and determine how safe the treatments are.

The doctors think the study will prove that early treatment and puberty-blocking lead to far better long-term outcomes, making it easier for doctors and parents to accept that approach.

“It’s an imperfect field with regards to decisions we are asking these families to make,” acknowledged Dr. Robert Garofalo, who co-directs the Center for Gender, Sexuality and HIV Prevention at Chicago’s Lurie Children’s Hospital and is also working on the transgender youth study. Garofalo hopes the team will be able to study patients far beyond the current five-year term to address a host of questions that currently have no answers. Does hormone use in trans youth increase breast cancer risk? How well do adults who have transitioned as teens grapple with their loss of fertility? “These are things that are entirely unknown,” Garofalo said.

And the researchers are hopeful that more data will help to combat misconceptions, both publicly and within the medical profession itself.

Olson-Kennedy points to the stories she hears of pediatricians who say they don’t believe in providing trans care. “You don’t have people opting out of diabetes care because they don’t believe in treating diabetes,” she said.

Insurance companies also prove a roadblock for many of her patients. But with California law making it illegal to deny care for gender dysphoria and with her healthy appetite for a fight, Olson-Kennedy usually gets her way. “I have template letters for 100 different denials,” she said. “I just fax in a 100-page appeal and tell them if they deny me, I’m going to fax in 200 pages.”

The most counterintuitive end goal of such specialized transgender youth clinics may be to eventually not even need them.

“My goal is to make this absolutely mainstream,” said Dr. Cora Breuner, an orthopedist and pediatrician at Seattle Children’s Hospital who chairs the American Association of Pediatrics committee on adolescence. “People should not have to drive 17 hours for this care.” She thinks more kids would get the care they need if pediatricians — usually the first doctor parents seek out — were more comfortable with trans patients. Sensing urgency, the AAP is currently fast-tracking a statement on care for transgender kids, Breuner said.

Many physicians have a long way to go. The Twitter hashtag #transhealthfails chronicles a litany of frustrating experiences, from trans

Dr. Johanna Olson
A 4-year-old patient drew this picture for Dr. Olson-Kennedy, and her parents framed it. It now hangs proudly on the wall of the doctor’s office. Melissa Lyttle for STAT

women being forced to take pregnancy tests before X-rays despite their not having uterus, to a doctor saying he couldn’t put a cast on a broken arm because he wasn’t versed in trans health care.

Sixteen-year-old Shay Sullivan, a Montana resident, had a series of frustrating medical experiences before the family found Olson-Kennedy four years ago. For years, the Sullivan family had tried to find care closer to home and dealt with a palpably uncomfortable local pediatrician. All the while, Shay was becoming increasingly anxious. The clock was ticking as puberty approached.

After the family’s first meeting with Olson-Kennedy, Sullivan’s mom, Shelley, said, “We just looked at each other. We were so relieved. We finally found someone who was going to help us find our way.”

The family’s insurance covered all but $200 of the cost of Shay’s $17,000 hormone blocking implant and helped cover the gender confirmation surgery she had at 16. (Most doctors wait until patients are over 18 for such surgery, but Shay was considered exceptionally mature, her mother said.) The family paid for the travel to see Olson-Kennedy and for staying in Arizona for nearly two weeks for the surgery. “We’re fortunate,” said Shelley, a physical therapist. “We both have good jobs and are able to afford it.”

Today, Shay is a driven high school junior, earning an International Baccalaureate degree in high school as well as learning several languages and is planning to study abroad during college. She doesn’t travel as much to the Los Angeles clinic now because her pediatrician has agreed to work with Olson-Kennedy to provide her care. Shay volunteers to help other trans teens in Missoula and is having a “pretty good year socially,” she said. One low point: Since entering high school, she’s not allowed to play on girls’ sports teams.

 

 

Doctors on the front lines of transgender youth care say they are heartened that children are coming in at younger ages and that transgender youth clinics are opening in suburban areas. But they’ve also nervously got their eyes on what Trump may do.

“I don’t know if it will be any worse, but I don’t think things will get better,” said Boston Children’s Spack, 73. “I’m old enough to remember when homosexuality was considered a disease. Those ideas die hard.”

Garofalo, a self-described optimist, said he hopes medical care for trans kids won’t suffer greatly under the new administration. But he said, “I’d be naive not to be worried.” He said he is definitely “poised to fight,” if needed, to protect his patients and families.

Olson-Kennedy already has her sleeves rolled up. She’s worried about policy changes, like a dismantling of the Affordable Care Act, that might remove the insurance coverage trans youth need. But she’s also worried about an emerging ethos that may allow open discrimination and violence against transgender youth and adults.

“We’ve made such incredible strides,” she said. “We don’t want to see people going underground again.”

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  • if I read the numbers in this article correctly, there are maybe around 1300 transgendered in the country getting treatment—-out of population of 300M that is miniscule–and yet their stories are in the news all the time, like this one for instance. Is there some kind of powerful TG lobby pushing these stories to make it seem as if TG people is the worst kind of social problem in America?– a country full of poverty and poor health care, high infant mortality rates, drug epidemics, etc., etc., and we are being conned that these self-selected sex changers are so deserving of our sympathy. Let’s get our priorities straight, and stop making martyrs out of this very tiny minority of fake sufferers.

    • I’m alarmed such a Gothichorrific, transphobic comment was allowed to stand, but let me correct you: about 1% of people are transgender, which makes us as common as redheads and people on the autism spectrum. We deserve to live comfortably and with dignity, the same as anyone else.

  • 3? Did I read that right? Both the doctor and the parents should be ashamed of themselves. For that matter, the whole medical establishment should be ashamed of themselves, for convincing these troubled individuals that maiming themselves is the answer.

  • Sterilizing children is universally recognized as a human rights abuse. It’s not like they don’t know they are sterilizing perfectly healthy children. If the GnRH agonists are followed by cross gender hormones, these kids are rendered infertile. Some doctors are skipping the GnRH agonists and going to cross gender hormones at younger and younger ages. The use of GnRH agonists for what essentially amounts to a culturally defined diagnosis in children is an off label use for this particular class of drugs. This class of drugs is used to treat advanced prostate cancer and endometriosis. It’s also used to treat precocious puberty which is not the same as a psychological diagnosis in children. Olson knows that virtually all her patients on GnRH agonists end up on cross gender hormones. She knows she is sterilizing children. There is a reason why sterilizing children is viewed as a human rights abuse. Children lack the ability to give informed consent. The prefrontal cortex of the human brain isn’t fully developed until the early twenties. There is a reason we don’t let teenagers take out bank loans or buy alcohol. Why do we assume children possess the maturity and judgment to make rational decisions regarding their fertility?

    As to cross gender hormones, most hormones for “transitioning” adults is on an “Informed Consent” basis. That is, the patient is supposed to read and sign a long form that lists possible side effects. Maybe people should ask themselves this. If doctors were so sure about the possible side effects of decades of cross gender hormones, and if no one ever regrets “transitioning”, then why do they have patients sign these “Informed Consent” forms? The doctors are basically covering their ass if there are side effects, or someone regrets medically “transitioning”. Do children have the maturity and cognitive ability to fully understand everything in the “Informed Consent” form? For kids, I’m assuming that the parents sign for the children. This makes the assumption that children have the cognitive ability to give informed consent.

    For FTMs, this “Informed Consent” for testosterone lists a lot of possible side effects.

    I understand that there are brain structures which are affected by testosterone and estrogen, and that current medical science does not understand these adequately. I understand that taking a hormone may have long-term effects on the functioning of my brain which are impossible to predict. These effects may be beneficial, damaging, or both.

    I understand that the endometrium (the lining of my uterus)
    is able to turn testosterone into estrogen and so increase my risk of cancer of the
    endometrium. I have been informed that not having my period for prolonged times may increases this risk. In order to reduce this risk, another hormone may be recommended to induce a menstrual period (shed the endometrium) several times a year.

    I have been informed that testosterone puts a stress on the liver which may lead to liver inflammation. I will be monitored for liver problems before starting testosterone and periodically during therapy.

    I have been informed that if I take testosterone my good cholesterol (HDL) will probably go down and my bad cholesterol (LDL) will probably go
    up. This will likely increase my risk of a heart attack or stroke in the future.

    I understand that fatty tissue in my breasts is able to turn testosterone into estrogen, which may increase my risk of breast cancer in the future

    http://www.dimensionsclinic.org/docs/trans/testosterone_ftm.pdf

    • S – Thanks for the lesson on rocket science… slight problem the article is about dealing with a birth defect that these children discovered as they became aware of their sense of self. YOU – maybe I should call you GOD – know what these parents should do when faced with the direct evidence from THEIR child.

      WHEN did you know WHO YOU are? Did it take your mommy to tell you who you were? IF you knew who you are, how can you muddy the article with unnecessary facts. We ALL know that various medical forms must be signed before PROCEDURES are started but much of this about stopping the pain and allowing children to develop as the person THEY know they are. PARENTS are instilled with rights as the child’s parents. These doctors are dealing with numerous people and have trained in a specialty to give the best known current advice to the parents.

      Almost no doctor following the SoC will do anything before age 12 or the onset of puberty. Then its simple hormone blockers to delay puberty which apparently – per current evidence – can be reversed until THAT child is at least 16. Generally only hormone therapy is given until age 18 when the child is recognized as an adult. Breast tissue growth if needed to be removed is a fairly everyday procedure. One little thing is that ALL this time the child and often family are in counseling where there is another set of eyes with a different perspective on the child’s well being. The child’s mental growth and health. Who the child perceives that their are.

      The big goals are stopping this child from becoming a suicide or attempt which they do at 5X the rate of their peers. You don’t get to say I am sorry I should have got you help to a coffin. Its the parents challenge to get help and there is a lot of help through the internet these days. There are also semi private groups to discuss the relative issues and past experiences.

      Stop muddying the waters and do something positive — FROM someone WHO has been there and done that! When it was much harder…. I have no idea the total number of medical articles I had to find, print out and give to doctors and their staffs about dealing with a new issue to them. How various new changing physiology may interact with existing issues that they were dealing with. 20 years later it was worth every instant of effort it took to be me.

    • You have trouble producing children when you are dead from suicide as well… How about we just let these kids figure out who they are and love them for it.

  • doctors enabling the mentally ill need not only to lose their medical licenses, but to face stiff prison sentenced. would you be oohing and ahhing if doctors enabled bulemics and anorexics this way?

    • So you don’t believe in psychiatry either? That doctors shouldn’t treat mentally ill patients? That anorexics and bulimics shouldn’t be treated either?

      Yes, I understand what you were *trying* to say, but I’m doing my best to look beyond your bullying and transphobia.

      Where did you get your medical degree? I’m assuming that you must be a physician to be able to comment on the relationship that people have with their doctors in deciding on a course of treatment.

      Because it would be rather strange if you felt that only *some* people should receive medical care, perhaps based on your religious beliefs, or sense of personal morality. Because wouldn’t that be incredibly odd? That a complete stranger felt that they knew better than *you* and your physician on how to treat *you* to make or keep you healthy?

  • LGBT lifestyles are morally and physically wrong. This is why people go to therapy. They are trying to sweep under the carpet feelings of guilt that are normal when people do things wrong. God did not create a man to be a woman nor a woman to be a man, or for the purpose of same-sex intimate physical relationships. Some of these blogs need a dose of reality and wake up.

    • This comment is wrong on so many levels – you have no idea what it feels like to be transgender and nor should you. Fortunately you are CIS gender. Do you realise how strong you have to be to finally admit you are transgender? And one of the reasons for this is because there are people like you making comments like this in the world. You should be ashamed of yourself.
      Veronica

    • Which “god,” Joe? Your god? My god? A Hindu god or goddess? A Jain god? How about the Muslim god? Jewish god? Or is it just your flavor of Christian god?

      What if I think your bullying is morally and physically wrong? That your belief in naive, Bronze Age fairy tales should be a sign of mental illness?

      There is no guilt in being gay, trans, or middle of the road straight. There shouldn’t be any guilt in being human, and wanting to have the best, most authentic life for oneself–in the body that one was meant to have.

      I honestly find comments like yours to be so utterly bizarre; that a complete stranger feels comfortable not only belittling others, but then further claims that this shaming and bullying is caused by their belief in a god. That their religion has stringent rules about sexuality that everyone should follow–even (or especially!) non-believers.

      What deity would want one of its followers to spread hate? What deity would support the shaming of other humans? Such an odd mindset, anyway, that anyone other than you would ever care about your religious beliefs.

      No one “created” humanity, and our amazing evolution shows that time and time again–in the design of our eyes, in the color of our skin and shape of our eyes, in the varying heights of humanity–all the different shapes, sizes, and colors were evolutionary mutations linked to geography. So amazing!

      I find your parting statement to be brutally ironic, that you want “these blogs [to have] a dose of reality and wake up.” You could use some of that yourself.

      Thump your bible elsewhere, thanks.

    • Joe – YOU are a figging IDIOT. This is an article about who a person IS. It has NOTHING to do with who people are attracted to or fall in love with.

      Where you told who YOU are at age 3-5-7 or did YOU just know? That is gender self identification. T is about being the person only you know you are. Then medical help is enlisted to assist in correcting the problem just as a child with a cleft pallet or club foot would be instantly visible but a heart defect would not. So IF a heart problem or any other non visible issues arise in 2-3-5 years they should NOT be corrected per your comments.

      When did you decide what sex you were attracted to? Age? 8-10-12? Or did your mommy tell you what you had to love? Totally different issue than WHO you are as a person. Or is it OK for me to come up to you and tell you that you are not right and need to behave & dress in the opposite gender BECAUSE I THINK that is the way you should live?

    • Well MY God does not have an issue with it….which God were you referring to?

      And ANY God does not need your OPINION about how it…yes “it”…uses it’s powers…

  • This brings tears to my eyes. As a child I was beaten for being different. I wasn’t until at age 55 triggered by a serious cardiac incident that I could no longer keep up the lie that was the life I showed to others. 5 failed marriages (hiding the truth about myself was a cancer that slowly ate away the trust). Alienated from children I could not relate to and no friends I could really confide in…. I broke. Death looked so good but for some reason I didn’t die – why? What would happen – career, home, what relationships I did have? What if I lost everything?

    Early 2000s at 55 I stepped off the edge believing that anything had to be better than the lie I was living. Almost two decades later, I still find it hard to believe I could actually like the person in the mirror. I may be a freak to some but in my soul, I have finally been at peace for all these years.

    What would my life have been IF I had this support and understanding as a 5 year old. Would I still be a freak to some people? What would 50 years of liking your self be worth? 50 years of just being ME. — AND yes I am jealous of the lives these children should be able to enjoy just being who they really are inside.

    • Same here, I had my heart problems when I was 59 and once the stress of hiding a lie was removed my blood pressure went down and I no longer had stress related heart problems

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