By Brenda Goodman, MAWebMD Health News

Reviewed by Hansa D. Bhargava, MD

April 22, 2015 — Sam was born Samantha.

When Samantha was 3, she drew a picture of a family. She explained that she was the daddy. By age 5, she’d told her mother, “My mind tells me I’m a boy.”

Mom made a note to ask her pediatrician about it.

By age 8, after a science class on chromosomes, Samantha came home to tell her parents that she finally knew what was wrong — her chromosomes were mixed up.

“I remember feeling my heart breaking. I called my husband at work and said, ‘We need to get this child help,'” says Sam’s mother Leslie Lagerstrom, who lives in Minneapolis. “This goes way deeper than we were hoping or believing this to be.”

Expert: More Kids Coming Forward

Specialty clinics in the U.S., Canada, and Europe say they’re seeing large increases in the numbers of children like Sam who are seeking help for gender dysphoria. That’s a feeling of extreme distress that happens when a person doesn’t identify with the body they’re born into. Gender dysphoria sometimes leads people to take steps to change their sex, or become transgender.

These kids can be quite young, sometimes as young as age 5. With the help of their parents and teachers, they’re entering school with new names, new clothes, and new gender identities. Later they may take drugs to delay the physical changes tied to puberty.

Experts are split about whether this is the right way to help them.

“There’s no question that people are seeing more kids than had ever been seen before,” says Norman Spack, MD, an endocrinologist at Boston Children’s Hospital. He has treated transgender people for 20 years.

At gender management clinic in San Diego, the number of new patients increased by 200% between 2012 and 2013, rising from eight patients to 26. A clinic in Toronto has seen a 600% increase in new adolescent patients since the year 2000. And the number of new patients seeking help for gender issues has quadrupled at a specialty clinic in the U.K. That clinic treated 77 new children last year, up from just 19 in 2009.

Nobody is sure how many kids have gender dysphoria. Definitive surveys are lacking for children. But the best available estimates of gender dysphoria in adults suggest that the condition is uncommon, affecting somewhere between 1 in 71 and 1 in 200 adults who are born male, and 1 in 333 to 1 in 500 adults who are born female, according to the handbook of psychiatry, the DSM-5.

Experts say it’s unlikely the disorder has suddenly become more prevalent. Instead, the increases are happening in part because more gender management clinics are offering to treat children. Before the medical help was available, experts say some young adults managed their own transitions.

“I have a patient who did her own transition buying medication online and checking on YouTube how to take it. This patient was 16 or 17 at the time. This was done with Mom’s help,” says Maja Marinkovic, MD, medical director of the gender management clinic at Rady Children’s Hospital in San Diego.

“These stories just break my heart. Kids really had nothing in this area,” she says.

Other experts attribute the increases to a societal shift that’s allowing more children to open up about their feelings.

“I think more kids are coming forward,” Spack says.

Knocking Down Stigmas

Spack and other experts say an important factor driving the trend is the growing visibility of transgendered lives in the public eye, including a highly anticipated interview with Bruce Jenner. The former Olympic gold medalist and reality TV star has lately been growing his hair, painting his nails, and altering his facial features in an apparent gender switch.

There’s also Kristin Beck, a transgender woman and former Navy SEAL who is running for Congress, and Aydian Dowling, a transgender man who’s currently leading a contest to be a cover model for Men’s Health magazine.

Add to those people the recent success of the Amazon TV series Transparent, and the advent of a transgendered actor, Laverne Cox, playing a transgendered character in the Netflix series Orange is the New Black. Observers say transgenderism is having a cultural moment, one that’s largely positive.

“Look at the media. Look at TV programs,” Spack says. “Basically, I look at article after article and they’re generally informative and understanding, and they add to the knowledge base. They appear to get it…” that being transgender isn’t a mental illness, he says, but a medical one that can lead to mental issues.

Leslie Lagerstrom, Sam’s mother, agrees. She writes a popular blog called TransParenthood about raising children who are questioning their gender.

“I think you’re seeing this more and more, and people are talking about it more and it’s all good. Because that’s how you bring down those stigmas,” she says.

“It’s going to help people like my son,” she says.

Early Treatment

By age 11, Sam was taking a powerful estrogen-blocking drug called leuprolide to delay puberty.

The thinking is that giving gender-dysphoric children puberty-blockers can help buy them a little more time to be sure about their feelings.

It can also help prevent the development of sex characteristics — breasts or a period in transgender boys, an Adam’s apple or voice change in transgender girls — that can be hard to undo with hormones or surgery.

But critics of this approach point out that most children who disavow their sex are going through a phase. There have always been girls who are tomboys and boys who prefer to play with dolls instead of dump trucks.

“We know that it’s normal for children to play in a different gender role on and off during childhood,” Spack says. Even for kids who spend almost all their time acting and living as the opposite gender, there’s a good chance they’ll grow out of it. They may eventually be gay.

“If you sum all those kids together, only about 20% will end up being transgender,” he says.

The problem is that there’s no way to tell which kids will continue to feel disoriented and distressed as they grow older, and which will some day make peace with their gender.

Puberty seems to be the tipping point. By delaying it, some experts worry that kids are being denied a chance to try to reconnect to their birth sex.

But puberty can also be devastating. “It’s one more reminder to these kids that their body is not matching their minds. It’s your body betraying you in yet another way,” Lagerstrom says.

At age 10, before he started the leuprolide, Sam went through one menstrual cycle.

“It was terrible. It was horrible,” Lagerstrom says. “You think, ‘One period, that’s no big deal.’ We misjudged what that would do to him. It put him over the edge. He was suicidal at age 10.”

Surveys show a staggering 50% of young transgender people will attempt suicide by their 20^th birthday.

Still, stories like Sam’s are the exception, not the rule. And there’s currently no way for doctors or parents to know who may be helped or harmed by early treatment.

“I can’t begin to tell you how phenomenally helpful it would be if we had some marker, whether it was measurable on an MRI or whatever, because if we knew which kids were truly going to be in the 20 percent, then I think everybody would say then those kids should be raised in the affirmed gender and the gender consistent with their brain wiring,” Spack says. “Then we would not torture these kids by making them live in the birth gender against their best interests.”

Discussion Over Strong Social Support

Dutch researchers are trying to find ways to distinguish kids who will go on to live as a different gender as adults from those who won’t. A study they did found some clues. Kids who become transgendered as adults tend to be more strongly gender dysphoric than those whose gender shift fades. They use words like ‘I am’ the opposite sex instead of ‘I wish I was.’ Girls were more likely to persist in a gender transition than boys.

The No. 1 predictor, at least for males who became female, was if their parents had socially transitioned them at an early age.

That is, kids who make the switch often have strong support from their parents, friends, and teachers to live that way.

Some therapists have interpreted that to mean that families who encourage a child’s initial choice may be inadvertently setting a gender identity that’s still fluid.

“They’re afraid to disappoint everybody, because everyone has been treating them as one gender and now they don’t feel that gender anymore,” says Jack Drescher, MD, a psychiatrist in New York City who helped revise the DSM-5 guidelines for gender dysphoria.

But others disagree. They think stronger social support may merely mean stronger gender dysphoria. In other words, kids who transition may have more support because their parents see and respond to their extreme distress.

“I could rephrase that statement to say that parental support enables a transgender child to express themselves, rather than suppress their feelings,” Spack says.

He says he’s had only one child change her mind after starting puberty-blocking drugs.

Lagerstrom has no doubt that she did the right thing for Sam, who began living as a boy at age 11 and is now thriving in his first year of college.

“You have to walk in these shoes and see how traumatic and how sad these kids are. Every day something is not right,” she says.

“I don’t think the fact that we did support him changed anything,” she says. “Had we not supported him, I don’t think he’d be alive right now.”

SOURCES: Leslie Lagerstrom, mother of a transgendered child; blogger, Minneapolis, Minn. Norman Spack, MD, endocrinologist, Boston Children’s Hospital, Gender Management Service, Boston. Marja Marinkovic, MD, medical director, Gender Management Clinic, University of California at San Diego, Rady Children’s Hospital, San Diego. Jack Drescher, MD, a psychologist in private practice, New York, N.Y. June 2013, Journal of the Academy of Child and Adolescent Psychiatry. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

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