The first clue came while Mela Singleton was giving her 2-year-old daughter Evie a bath.
“You’re such a pretty little girl,” she cooed.
Evie responded, “I a boy.”
Singleton didn’t think too much of it at the time, but over the next several years, her daughter’s protests got louder and more pointed. Evie insisted on standing up while urinating, rejected anything frilly or stereotypically girly and would dissolve into frustrated tears when people referred to her by the female pronoun, “she.”
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Then after Evie had an epic meltdown at about the age of 7, Singleton and her husband, Bryan, said they finally got it. Evie was born with a boy’s brain and girl parts. So, they changed their child’s name to Evan, cut his hair and bought a new wardrobe. That lasted about two years, until Evan started growing breasts.
Frantic, the Singletons ended up at the door of Dr. Ximena Lopez, a pediatric endocrinologist at Children’s Medical Center Dallas. Soon after, Evan became the first patient in what would become a new clinic for transgender children and teenagers.
The Genecis program — GENder Education and Care, Interdisciplinary Support — officially opened its doors in May, even though Lopez and other specialists have been treating young patients for three years. It’s the only pediatric clinic of its type in the Southwest.
“People have this idea that transgender people are just weird and awkward and troubled,” said Lopez, Genecis’s medical director and an assistant professor of pediatrics at UT Southwestern.
“That’s because historically people came out as transgendered adults when they’d … spent much of their lives depressed because they were not being themselves.”
But medical advances and increased public awareness of gender dysphoria — in the wake of the “I am Cait” announcement of Caitlyn Jenner, the former Bruce Jenner — suggest there may be a greater chance for social acceptance.
“These children have an opportunity to have a normal life,” Lopez said. “The new generation of transgender people we’ll see are completely different. They’ll look normal like you and me. And they’ll be happy.”
The treatment at Children’s works like this: When appropriate, doctors prescribe drugs to delay puberty, usually around the age of 12. About four years later, patients are administered cross-sex hormones that trigger a transition to adulthood in their identified gender.
Therapy is required at all stages, including a six-month assessment, before children are considered for medical intervention.
Dr. Meredith Chapman, a psychiatrist at Genecis, said she looks for several traits while screening patients.
They should identify as cross-gender consistently over time, and there should be a discrepancy about how they feel and how they’re perceived by the world. That conflict, she said, often stirs emotions and sets kids up for ridicule.
“As human beings, we live in a world that is gray,” said Chapman, an assistant professor of psychiatry at UT Southwestern. “But we strive for a world that is black and white, yes or no, with binary males and females.
“For a lot of people, it’s a very foreign concept to try to imagine someone who’s unbelievably distressed by this incongruence between their sex and gender.”
‘I never felt right’
Evan Singleton, the Genecis program’s first patient, is now a moon-faced 12-year-old with sculpted neck-length hair. He’s been living five years as a boy but remembers the pain of pretending.
“All the girls were doing Barbie dolls and nail polish, and I just wasn’t one of them,” he said. “All the boys were doing skateboards and helmets, and I wanted to do that stuff. I never felt right in that body.”
His mother said in the early years she nudged Evan toward an identity as a tomboy, but the label didn’t fit.
“You have two questions when this starts evolving,” she said. “The first one is, ‘How do I feel about it?’ and the second question is, ‘What do I do?’”
After research, Singleton said, she called at least 100 endocrinologists to ask whether they would consider administering puberty-blocking medicine for her son. All of them turned her away, except Lopez.
“She didn’t say, ‘Sure let’s just shoot this kid full of medication and figure it out later,’” said Singleton. “She said, ‘OK, let me look into this. Let me call some of my fellow (endocrinologists) who have experience with this.’”
Lopez said she was unprepared for her first transgender patient. The topic wasn’t covered in medical school.
But she remembered a day in 2007 while training at Massachusetts General Hospital in Boston, when Dr. Norman Spack, a pioneer in the treatment of transgender children, brought one of his patients over for a presentation.
“He was a Middle Eastern patient, and when he told me he was born a girl, I couldn’t believe it,” she said. “In every way, he looked like a male. He was an MIT student, and I thought, ‘This is the right thing to do.’”
The therapy used to treat transgender children is called “The Dutch Protocol” because it began more than a decade ago in the Netherlands. One study there of 70 patients — a small sample size — suggests children who’ve been treated with cross-sex hormones grow into emotionally stable adults.
A growing area
The first treatment for transgender youth began in 2007 at Boston Children’s Hospital. Last year, there were 24 clinics clustered mostly on the East Coast and California. Today there are 40.
“It’s growing really fast,” Lopez said. “And the main reason is parents are demanding it and bringing patients to the door of pediatric endocrinologists because they know this is available.”
For some people, gender reassignment surgery, commonly known as a “sex change operation,” is the last step in a years-long transformation.
Children’s does not perform the procedure because it is legal only for adults in the U.S. Also, many insurance companies will not pay for the operation because it is categorized as cosmetic. The out-of-pocket cost for vaginoplasty or phalloplasty often exceeds $20,000.
By some estimates, between 0.1 percent and 0.5 percent of people in the U.S. are transgender.
In the Genecis program, Lopez said, the goal is to intervene in early adolescence, before troubling psychological and physical changes are brought on by puberty. For example, it can be devastating for a transgender boy to grow breasts and start having a period. For transgender girls, physical changes such as hand size, height and shoulder width are permanent.
“Puberty blockers take all that away,” Lopez said. “Emotionally and socially, it lets them have a better transition to their identified gender, and it improves their psychological outcome.”
So far, Genecis has treated about 40 children and teenagers. Another 40 or so have been referred by therapists and parents.
Medicine to delay puberty can be stopped anytime without significant side effects, Lopez said, but cross-sex hormones trigger permanent changes in the body. So doctors are cautious.
“What we know from research is that some people change their minds and that’s more common in younger children,” Lopez said. “By adolescence, it’s more rare, but still possible.”
Once, she said, a young girl was brought into the clinic because her parents thought she was transgender. But during therapy, it became clear the girl didn’t want to be a boy, she wanted to be a mechanic like her dad.
Cases like that worry some politicians and clergy, who say it’s normal for children to experiment and role play across gender lines. But adolescents are too young, they say, to make decisions so big.
Doctors at Children’s disagree.
Without treatment, transgender teens are at grave risk for depression, anxiety and suicidal behavior.
“There’s good evidence to suggest the rates of depression and anxiety are two times higher than when children’s natal sex matches their gender,” said Chapman, the Genecis psychiatrist. “The risk of suicide is three times higher, and the risk of self-harm, like cutting, is four times higher.”
Without support at home, 80 percent of transgender teens attempt suicide, some studies suggest.
Doctors say children referred to the Genecis program are lucky in one regard — their parents are seeking treatment, and most have accepted their child’s identity.
Bullying at school
Even so, life can be hard, especially at school.
“They don’t bully me because I’m trans,” said Evan, a middle-school student. “They bully me because I’m weird, and I’m OK with that.”
But several times, mostly during schoolyard yelling matches, classmates have called him derogatory names. Later, he said, they usually apologize.
“People at school are getting, not more supportive, just less scared of me,” he said. “They’re not judging me as much.”
Despite increased public sensitivity after the recent blockbuster interview with Jenner, Mela Singleton plans to take her son out of public school next year and enroll him in a state-accredited online program. She said the issues — like requiring him to use a toilet in the nurse’s bathroom and the cumulative effect of bullying — are not worth the hassle.
“People always say, ‘Don’t you miss him when he was a girl?’” she said. “And I’m like, ‘No, he was kind of a jerk. He was an unhappy child, and he was going to make you pay for that.”
She paused briefly and glanced at her son.
“Now he has the opportunity to express himself wholly and fully,” Singleton said, a smile pulling at her lips. “And I like this kid a lot.”