Reimagining the Future

Riley* began preschool at three years old. After school, she’d ask her mom to paint her nails. She also liked to play dress up, and she requested Barbie dolls and mermaids as presents. 

“I remember even before she could really get the sentence together, she would take her blankie and hand it to me and say, ‘Make a dress,’” her mom, Jessica*, recalls. “She wanted me to wrap her blanket around her shoulders and tie it, so it looked like she was wearing a dress. We didn’t have any dresses for her age because I had two boys.”

And when the movie “Frozen” captured the attention of almost every child in America, Riley, like many little girls, loved pretending she was Elsa. She would take a curtain tie and hold it behind her head so that she could have a ponytail like Elsa. Eventually, Riley got her very own Elsa dress and wig. 

“Every day, she would come home from pre-K and put on her Elsa dress and her Elsa wig and she often stayed that way for the rest of the day,” Jessica remembers.

Sometimes, Riley would play soccer with her older brother and the other neighborhood boys. Sometimes, she’d play in her dress. While her brother was only 18 months older, he was “gigantic” for his size, and his mom describes his friends as “a rough and tumble crew of kids.” But Riley, who was small and skinny, didn’t mind or even seem intimidated – she played with them anyway, and she loved that dress.

“One day, they were outside playing soccer, and Riley said, ‘hold on a minute,’” her mom recalls. “She ran inside and put on her entire outfit – the gown and everything. Then she went back outside and played soccer like a badass. And here’s the thing – she’s never known any other way. But the other boys asked her, ‘Why are you wearing a dress?’ And she simply responded, ‘I’m a boy who likes dresses.’ They’d all say ‘okay,’ and then they continued playing soccer.”

Riley, who is now 10 years old and lives in Bedford, is transgender. Assigned male at birth, she asked to wear dresses and play with dolls before she ever understood the difference between boys and girls. In preschool, Riley had a “school life” where her “old-school Italian teachers” told her the girl’s toys weren’t for her and she couldn’t wear dresses, and she had her “home life” where she wore her favorite Elsa dress daily, played with dolls and also played soccer with the boys. Her mother assumed she was either gay or transgender, but she didn’t push the issue. 

“If she asked me for something, I gave it to her,” Jessica explains. “But I never asked, ‘Why do you want a dress? Do you feel like a girl?’ I just let her lead.”  

Consistent, resistant and insistent

Dr. David Rosenthal, the medical director of Northwell Health Physician Partners’ LGBTQ Transgender Program at New Hyde Park, says that gender identity is how a person perceives their gender in their head. 

“It’s not what sexual organs they have, how they appear or how they dress,” he explains. “Gender identity is their self-perceived understanding of their own gender. And that’s different than their sexual orientation, which is who they are romantically attracted to.”

While the science surrounding mental health and sexual health has come a long way over the past several decades, the science regarding transgender is still in its infancy.  Scientists don’t know when or how the brain is wired so an individual perceives their gender as different than their sexual organs, but scientists do believe that some people’s gender identity appears to be “fixed at birth” while other people’s gender identity appears to be a developmental process. Since it’s impossible to determine what factors contributed to a person’s gender identity, medical professionals rely on “a complex set of information” to determine if a child, especially a very young child, is really transgender.

“Studies have shown that when a child is consistent in identifying as a different gender, resistant to change about identifying as a different gender and insistent in their identification as a different gender, that’s a very good set of criteria.”

Consistent, resistant and insistent are key. Riley, Jessica says, met all three. 

“Riley never changed character,” she explains. “It was every single day. She loved all those things.”

About halfway through Riley’s last year of preschool, the school burned down. They didn’t reopen in another location, so Riley ended preschool about half a year early, and she seized the moment to make a change.

“She went to my husband and said, ‘Daddy, I want dresses all the time,’” Jessica remembers. “She understood that she was supposed to be and act a certain way at that school, and even with all our support at home, it didn’t matter. She was only four years old, and she knew what she wanted. So, my husband, a very tall Italian man who works as a police officer, turned to me and said, ‘Honey, sounds like I’m taking our son to get dresses tomorrow.’”

Her dad took her dress shopping the next day. Then, he took her to the diner he’d taken his kids to since they were babies. It was a monumental moment in their lives, and Riley never looked back. 

But while Riley still identified as “a girl when I’m dressed this way,” she didn’t always identify as a girl.

“I spoke to experts, and they told me that she wasn’t old enough to truly grasp pronouns,” says Jessica. “They say that happens around four and a half or five years old. So, I didn’t push it. I didn’t say anything. But she was wearing dresses everywhere and kids were asking her questions. She didn’t care; she answered everybody. But I was ready – I just wanted her to say it.”

Two months later, it finally happened. 

“I heard her and my son fighting in the other room,” Jessica remembers. “And my son said, ‘You’re the most annoying little brother in the world!’ Riley immediately responded, defiantly saying, ‘I’m a sister!’ So my son responded, ‘Well, then you’re the most annoying little sister!’ It was hysterical, and I realized that was my cue. So, I walked in and said, ‘I couldn’t help but overhear…’ Riley responded, ‘Yes. I am a dah-der.’ She couldn’t even say it right, but I knew she said, ‘I am a daughter.’ She hit that milestone, and that was it.”

Riley wanted her room redone to look more like a girl’s room, and her parents obliged.

“We literally did it overnight,” Jessica remembers.

Luckily, because Riley was given a gender-neutral name at birth, there was no name change. And when it came time for kindergarten, Riley told her mom she wanted to be referred to as a girl.

Age doesn’t matter

Not every transgender person can or does transition from one gender to the other at Riley’s age. According to Dr. Robbins Gottlock, the medical director of Ambulatory Primary Care & Medical Specialty Services and a family physician at Phelps Hospital, a lot of current adults didn’t transition when they were younger for many reasons, including because they knew they’d be bullied or kicked out of their homes, which, Gottlock says, could put them in a very dangerous situation.

“Transgender patients come to me in their teens or 20s, 30s, 40s, 50s, 60s and 70s,” says Gottlock, who is known as a transgender-friendly doctor and sees patients from adolescence through late adulthood. “Sometimes, at their first visit, they tell me they just began accepting and recognizing this about themselves. It’s so interesting because it is generational. Twenty years ago, there weren’t a lot of kids who were in a place where they could come out as gender diverse and be accepted. There wasn’t a framework in society to support them and accept them and help them on their journey. Instead, they probably felt shame and confusion, and they had no framework to conceptualize who they were. Even though who they are is really inherent and they could see through the cultural construct, it didn’t feel comfortable to be different.”

Gottlock says that when many of his adult patients transition, they are forced to switch jobs, which can be a painful loss if they were successful and enjoyed their careers. Many also lose their spouse or romantic partner, and some even lose children or other family members. 

“Everybody’s journey is very different, but many of my older trans patients express sadness for what could have been if they could have come out earlier,” Gottlock says. “It would have allowed them the opportunity to be their true self earlier in life, and who doesn’t want that? But there are also disadvantages to coming out and transitioning sooner. Mainly, our society is still very hostile towards trans persons. And depending on the environment, it could be very hard on them.”

Kids these days

Even as it becomes more dangerous to be transgender in some states, there are teenagers in our towns who wake up in the morning and state that today, they are male, even though they identified as female yesterday. There are others who use the pronouns “they, them” to describe themselves. Some declare that they are gender nonconforming, genderqueer or X gender.

What does all this mean? 

“It’s called exploring,” says Rosenthal. “And that’s what kids do all the time; it’s part of normal development. Sometimes, they want to wear a dress. Sometimes, they want to wear jeans. Sometimes, they want to wear goth clothes. And sometimes, they want to have their hair done in a certain way and look like a punk rocker. All these things are different expressions of identity that children experience during normal childhood development. And it’s really important that we let kids be kids and allow them to explore and figure out what is right for them.”

“What becomes dangerous is when a family or society is pushing a child one way or another,” Rosenthal continues. “Instead, what we really need to do is listen to our kids – we need to hear what they’re saying. And we need to make sure that we’re giving them the space to explore and make the decisions that will help create their identity as a person.”

This exploration doesn’t mean that a child who changes their pronouns daily is transgender. However, recent studies indicate that up to 2.7 percent of high school students say they experience some level of gender diversity (a general term that describes anyone who identifies their gender as something other than the binary “male” or “female”), and up to 1.2 percent of high schoolers identify as transgender. So, unless they’re “consistent in identifying as a different gender, resistant to change about identifying as a different gender and insistent in their identification as a different gender,” they’re simply exploring who they are. 

Why? According to Gottlock, today’s children have a better understanding of gender and its constructs.

“My perception is that kids nowadays can see these constructs of gender better than any other generation,” he explains. “They recognize that these constructs are somewhat ridiculous when you start breaking it down. Kids nowadays are realizing that if you take out the sex organs, their friend who was assigned female at birth has many of the same characteristics as their friend who was assigned male at birth. And maybe, none of their friends follow the societal norms about males being aggressive or women being quiet. Maybe these constructs don’t work. Therefore, they’re not going to be beholden to this construct of male or female. They’re playing with constructs; they’re not necessarily playing with their innate identity as a trans person, but they may be more gender fluid or gender nonbinary.”

“But then you have people like Riley, who isn’t gender nonbinary,” Gottlock continues. “Riley has really accepted these gender constructs and said, ‘Well, if I have to choose, if it is binary, then I’m a girl.’ And, maybe when Riley is older, she will be more nonbinary and say, ‘Well, I tried feminine, but I actually don’t consider myself to be a girl.’ So, who knows what the future is going to bring for her as well.”

Comfortable and confident

Among transgender people, Riley is in the minority. According to reports from transgender clinics, teens assigned females at birth initiate gender-affirming care 2.5 to 7.1 times more frequently than those who were assigned males at birth.

Jessica says that Riley has always been “very, very bold, very unapologetic” about being transgender and identifying as a girl. For example, a few weeks after she started kindergarten, a girl on the bus repeatedly said Riley was a boy. Riley responded by saying, “I’m sorry, but we can’t be friends unless you change your act.” 

Before Riley began second grade, her family moved to a new house, which meant a new elementary school. Jessica met with the principal in advance and recommend she send a letter home before school began. Riley, Jessica explained, is the type of child who puts it out there immediately – she wants people to know who she is, and she wants to know where they stand. 

The principal thought it would be best to let Riley settle in first. She suggested that, at the end of the first month, she’d host a principal coffee about gender identity and Jessica could be the speaker. But Riley had other plans.

“On day two, Riley got off the bus and said, ‘Mommy, I asked my teacher if I could use her microphone to tell my friends because telling everyone one-by-one just takes too long,’” Jessica remembers. “They didn’t give her the microphone because they wanted to create a plan. Shortly after, the principal called me hysterically laughing. She said, ‘Okay, so you know your daughter very well.’ She told me that Riley had told two girls that day, and their parents called the school to confirm because kids at that age say all kinds of things. So, they had the whole class sit in a circle, and the principal read a book I recommended. Then, everyone said something special about themselves. When it was Riley’s turn, she said it, and then she asked her classmates if they had any questions for her. A lot of kids raised their hands, but it wasn’t really an issue. They just wanted to say things like, ‘I speak French.’ But the school had psychologists there to facilitate. It was brilliantly done. And that was that.”

“Now, it’s been so long, and she looks just like a little girl, that she recently told me she thinks some of her friends have even forgotten,” she continues. “It’s just so normal.”

She’s not “woke,” she’s a child 

We’re not a political magazine, and we don’t plan to become one. But we cannot write a story about transgender children or people without mentioning the politics. As of deadline, several states have banned access to transgender care for young people, but other states, like Minnesota, are passing laws to safeguard anyone who comes to their state for gender-affirming care. New York Attorney General Letitia James is co-leading a coalition of 18 attorneys general to support a West Virginia transgender girl who is fighting a law that bans her from competing on her middle school’s cross country and track teams. The Biden administration has proposed a new federal rule for transgender athletes, and the U.S. House of Representatives passed a bill restricting transgender athletes. 

And while, overall, Riley’s community has fully embraced her and her family, there are a select few who have expressed negative views.  One person, Jessica says, even posted something about “trans woke ideology” on the school district’s Facebook page. 

“I went back – hard,” she remembers. “And they removed their post. They didn’t respond to me, but they removed their post. My approach is always to take the politics out of it by just talking to people, mom to mom. So, I ask them to tell me how I can be a better parent to my child. Every day, my child says, ‘I’m a girl.’ So, I could put pants on her, but she’ll still say, ‘I’m a girl.’ She’ll just be a sadder little girl. But right now, she’s a girl.”

“And she’s just a child,” Jessica continues. “That’s all she is. She’s a child. She has nothing to do with your politics, or any politics. She doesn’t understand that this is considered woke. So please don’t allow your politics to make her the victim of something she has no say in. She is not a danger to anybody.”

But Jessica also recognizes that the day will come when Riley won’t be a child. She’ll enter puberty soon, and she’ll require medical intervention to continue down this path. 

Medical interventions 

Gender-affirming medical interventions are not experimental – they’re based on decades of clinical experience and research, and they’re proven to be safe and effective. But it’s still not easy for teens to receive gender-affirming medical care. 

To receive treatment, they must first undergo a complex assessment that looks at, among other things, how long the child has identified as transgender – has it been consistent, resistant and insistent over an extended period? There are mental health assessments for the child, discussions with the parents, assessments of medical conditions and family history, and appointments to explain (to the child and parents) the various medications and how they may interact with the current medications a child is taking (when applicable), etc. Depending on a variety of factors, it could take a year or more before treatment begins. 

“We look at how well they identify, how well they can express their needs, how much gender dysphoria they’re experiencing – which is a medical diagnosis, and how they perceive themselves,” Rosenthal explains. “Then, if they qualify, we’re able to start with something called puberty blockers, which prevents the onset of puberty.”

“But I want to make it clear that we’re not making any permanent, lifelong decisions at this age,” Rosenthal explains. “We’re not doing irreversible surgeries, or surgeries of any kind, on children. What we are offering is the ability to allow children to identify as the gender they view themselves as and to not be forced to go through puberty as another gender.”

The first medical intervention is what’s commonly called a “puberty blocker” – it was originally (and still is) prescribed to children who experience something called “precocious puberty,” which occurs when females begin puberty before age eight and males before age nine. This medication is entirely reversible – children with precocious puberty fully develop once they stop taking the medication. 

For transgender children, medical guidance states they should not start puberty blockers until they reach the early stages of puberty. And although current research indicates a 98 percent likelihood that transgender people will continue their gender-affirming medical care, if a transgender person decides, at any point, to live with the gender they were assigned at birth, they will begin puberty naturally once they stop taking the medication. 

“It doesn’t have any effect on the onset of puberty,” says Rosenthal. “We’ve used puberty blockers since the 1970s for precocious puberty, and now those initial individuals are adults who had children of their own, so we know there are no long-term effects on fertility, overall cardiovascular health, or things like that. We don’t have 100 years of data, but 50 years of data show puberty blockers are safe. The only thing we’ve noticed is that while a person is on puberty blockers, there’s a little bit of a decrease in bone density, so we make sure they receive an adequate supply of vitamin D and calcium so they can build strong and healthy bones.”

Research has shown that when teens receive gender-affirming care, it improves their overall health, well-being, self-esteem and quality of life. But when teens don’t receive this care, it can impact their mental health and put them at a greater risk for substance use and suicide.

“We know that, in some cases, forcing puberty can cause significant mental health problems, including suicide, suicidality, mental health, anguish, bullying and other sociological and psychological problems,” says Rosenthal.

A 2020 study found that teens who sought gender-affirming medical care at the age of 15 or older experienced more depression, had self-harmed, had considered suicide and had attempted suicide, compared to those who sought care before the age of 15.

Eventually, transgender people will need to take estrogen supplements to develop female characteristics or testosterone to develop male characteristics. Research has shown this may cause a reduction in sperm count (and therefore infertility) in people who were assigned male at birth. For people assigned female at birth, they may regain their fertility once testosterone therapy is discontinued. 

And although, according to a report from the American Society of Plastic Surgeons, over 3,200 teenagers received breast augmentation surgery in 2020, both Rosenthal and Gottlock say surgical procedures to remove breast tissue are very rarely performed on transgender children.

What the future holds

Right now, Riley is a confident, outgoing, friendly little girl with a lot of friends and a great attitude. 

“She is a force,” says Jessica. “She’s gonna change the world, one way or the other. She’s very self-confident. In the morning, she’ll come to me and say, ‘Good morning, bestie. Slay all day.’”

But Riley has become more sensitive about the topic over the past several months. And she begins middle school in the fall, which means a new school and a whole new set of situations. Jessica plans to speak with the principal in advance to stress the importance of everyone learning about her daughter.

“I want the entire staff to know, that’s always been our approach,” she explains. “Because if, God forbid, something happened, like an incident in the hallway or a bathroom, everybody’s aware, and everybody knows what to say and can do something right away.”

And Jessica also recognizes that although it’s not “a big, earth-shattering secret that Riley is transgender,” there will come a time when she and her peers will start dating. 

“All the parents at the elementary school are so supportive,” she says. “But I’ve said to them, ‘Let’s dig deep. I’m going to make you all uncomfortable and go into our unconscious bias. Right now, you’re all telling me that you support her so much. And, frankly, she looks like a little girl. It feels very comfortable, right? But what happens, though, when she’s 15, and your son wants to date her? Where are we then?’”

“These are very normal, natural biases that we all have,” Jessica continues. “And unless we really dig deep, they will remain. Right now, she looks like a cute little Shirley Temple, and she’s not a threat to anybody. But I suspect that she’ll be a stunning young lady at some point, and then what? So, I did that very purposefully because I want to plant that seed in their heads. For the next 10 years, I want them to think about it, because it is a small community, and it’s bound to happen.”

Not everyone has a supportive family and community like Riley. Transgender people’s lived experiences vary, depending on the societal and cultural norms where they live, their race and their economic status, among other things. It takes many people years to come out as transgender, even to their families because they fear rejection. 

“The saddest situations are when I see a transgender kid living in a homeless shelter because their parents told them they could no longer live in their house,” says Rosenthal. “That’s the most tragic situation because the child is just trying to be themselves, and pushing them out of their home does not help them in any way whatsoever. In many ways, it does considerable harm.”

Whether it’s in our small communities or the larger country, advocates and medical professionals encourage people to consider the person, not the politics. 

“It’s very important to follow the science and not the hysteria,” Gottlock encourages. “Remember, we’re talking about real human beings with real feelings. And they’re really being harmed when their body doesn’t correspond to the gender they know themselves to be. We must recognize the pain and discomfort they go through. If people really get to know transgender people, they will learn that they’re honest, legitimate people who are really searching for comfort and just want to be themselves.”

*Riley’s and Jessica’s names have been changed.

This article was published in the May/June 2023 print edition of Katonah Connect.