The Gender Wellness Program at Nemours/A.I. duPont Hospital for Children in Wilmington has close to 100 patients./Photo by Joe del Tufo, Moonloop Photography.
When Charlie and Mary Masterson’s second daughter told them she didn’t want to live another day if she had to be a girl, the couple knew an adjustment was coming for their family. That adjustment continued when their third daughter expressed the same feelings.
“I can’t take another day of being called ‘she,’” the Mastersons heard.
Two children. Two struggles with gender identity.
For a family living in the Bible Belt, which isn’t exactly known for its progressive attitudes toward the transgender community, this added another layer of stress.
“We lived in a development where everybody knew everybody else,” Mary says. “We were involved in the church. Everybody went to the same school. We had meetings in our house to explain things to people for a year, trying to educate the community. Ninety-five percent of the people may not have understood, but they tried.”
Eventually, the Mastersons (the family’s names have been changed for this story) moved north, which brought them into the orbit of the Gender Wellness Program at Nemours/A.I. duPont Hospital for Children in Wilmington. The program’s clinical services assisted the family on its journey, and also helped the children, Bob and Landon, become more comfortable in their identities while facilitating treatment options that will allow them to move forward with their transitions on their own terms.
“They are fantastic,” Mary says about the Nemours staff. “I cannot say enough good things about them. Anybody I meet who has transgender kids, I send them to duPont. They embrace them for who they are and make them feel normal. It’s all so positive and professional. They have helped make life really easy knowing they are on our team. They have got our backs. They really understand it.”
Dr. Anthony Alioto and Dr. Evan Graber, a pediatric endochrinologist, work with patients at Nemours’ Gender Wellness Program to help ease gender transitions./Photo by Joe del Tufo, Moonloop Photography.
A new step for Nemours
It all started with a random request for treatment. Almost four years ago, a young patient had been visiting another medical center out of the area. Could Dr. Evan Graber take over the patient’s care at Nemours? A pediatric endocrinologist, Graber had no specific experience in gender transitioning, so he reached out to colleagues for advice, then accepted the patient. Soon other patients started “trickling in.”
Nemours hired Dr. Anthony Alioto as its director for pediatric psychology, and he began working with Graber’s patients and their families. A Nemours gynecologist, Dr. Beth Schwartz, had interest in providing treatment, and by last summer Nemours had opened its Gender Wellness Program to help children and their families handle the complicated process of transitioning. Dr. Zach Pranckun, a psychiatrist, and Dr. Amy Renwick, a pediatrician, are also part of the clinic’s team.
“We all decided we should have an interdisciplinary group, because patients need more than one treatment,” Graber says. “Since we opened, we have flourished. We now have close to 100 patients.”
This is a new enterprise for Nemours—and for the country at large. “Ten years ago, even five years ago, this was rare,” Alioto says. Because of that, information is difficult to find, and the medical community is still learning about the myriad shades on the gender dysphoria spectrum.
According to Dr. Jack Drescher, a Manhattan-based psychiatrist and psychoanalyst and a distinguished life fellow of the American Psychiatric Association, gender dysphoria is “a diagnosis in which an individual experiences incongruence with the gender that was assigned to him or her at birth and how he or she feels now.” A 2017 UCLA study found that about 0.7 percent of children between the ages of 13 and 17 are transgender. In 2018, a University of Minnesota survey of almost 81,000 teens in that state found that 2.7 percent identified that way.
Although the phenomenon was first described in the late 1800s by Austro-German psychiatrist Dr. Richard von Krafft-Ebing, it wasn’t until the 1970s that diagnoses started appearing in manuals, according to Drescher. What has become obvious over the ensuing decades is that there is no “standard” transgender diagnosis.
“Not everybody’s gender dysphoria is the same,” Drescher explains. “Some might go through the social transition and present publicly in clothes. Some want hormone treatments, because they desire certain physical aspects, and some people want surgery.”
Within that range is a collection of subtle differences and shades that make the work at Nemours delicate. Families encountering children’s wishes to transition must deal with a variety of circumstances, from basic questions about gender dysphoria to the biological components and issues facing the transgender community at large. The Mastersons have been fortunate that their sons’ experiences with schools and fellow students have been largely positive. That is not always the case. Because of the disparity in experiences, it’s impossible for the Nemours clinic to apply any templates to patients.
“Sometimes, patients are fluid,” Graber says. “They want ‘this change’ but not ‘this change.’ We tell our patients that treatment is personalized.”
At first, Mary and Charlie didn’t think very much of the fact that Landon was playing with toys typically associated with boys, or even the pixie haircut he asked for. When he was in preschool, he was “more and more adamant” about dressing and identifying as a boy. In kindergarten, that feeling grew. Landon’s mood lightened after getting the short haircut, and by the time he was in second grade, he identified as a boy, Mary says. “He said he was in the wrong body.”
A trip to a supportive therapist led the Mastersons to allow Landon to chart the course. When he finally declared that he couldn’t live as a girl another day, Mary and Charlie made a plan. After third grade, he transitioned. “From there on, everything clicked and made sense,” Mary says. “He could be who he was.”
Bob benefited from Landon’s experience, because his parents could understand the progression. By kindergarten, Bob was telling his parents he didn’t want to be a girl, and they brought him to a therapist, who confirmed that it wasn’t a “phase” or an attempt to parrot his older brother. Perhaps more importantly, Mary and Charlie learned that although the therapist wasn’t too familiar with the concept, it wasn’t unusual for a family to have a pair of transgender children.
“In support groups, we could see other parents of transgender siblings and could see it was fairly typical,” Mary says.
Landon transitioned as soon as his third-grade year ended, in May 2015, and the Mastersons moved north that August when Charlie accepted a new job. They weren’t fleeing an unfriendly environment, although Mary does admit that being in the Northeast has been easier in terms of people understanding the family’s situation. She and Charlie have only positive things to say about their new school district.
“Their approach has been terrific,” Charlie says. “They said, ‘You’re a boy. Use the boys’ room and play boys’ sports. It is what it is.’”
Graber’s consultations with patients in Nemours’ Gender Wellness
“It’s really refreshing,” Mary adds.
Bob transitioned in the middle of his first-grade year, after the move, and the Mastersons switched him to a private school that semester so he could enter as a boy. But the class sizes were too small for his liking, and he asked to go to the same school as Landon. Like his brother, Bob experienced no trouble with his classmates.
“They were fine with it,” Bob says. “Mostly other people are confused. They come up to me and say, ‘You were a girl in first grade. What happened?’ I say, ‘I transitioned.’”
On their own terms
When Landon was 11, he underwent blood tests to see whether puberty was imminent. Since it was, and because he and his family wanted to block it, the Nemours team inserted a small tube containing the drug histrelin into his upper arm to block the onset of a menstrual cycle and other bodily changes.
“That’s the only medical therapy so far (for Landon),” Mary says.
The next step for Landon, should he choose it, is a series of testosterone injections, which cannot begin until he is 14 at the earliest. If they are administered when he’s younger, they might inhibit his growth, so the Mastersons want to wait until Landon reaches “a good height” before beginning the shots.
“He may change his mind, but testosterone is the next step,” Mary says. “Then, we’ll see how he feels about bottom surgery”—when genitalia are surgically altered to reflect a new gender identity. “I think that’s what he will opt to do.”
Graber reports that the level of hormones used varies. Some patients are comfortable on a low dose, while others want to advance to the maximum possible amount. Other treatments, such as voice training, can also be part of the regimen.
Bottom surgery, as it’s known, alters the genitalia and not all transgender adolescents or adults choose this step. (The surgery is not offered at Nemours.) Adult women looking to transition to being men may want to have top surgery to remove fuller breasts, just as an older man transitioning to a woman could opt for breast implants in addition to taking estrogen to stimulate breast growth.
Bob is a couple of years behind his brother in his transition and has just started to undergo tests to gauge when his puberty will start. He also recently came out as gay. That won’t necessarily complicate his treatment, but it did make for some uncomfortable moments for him and his classmates, which thankfully was handled well by all involved.
“In the north, it’s easier,” Mary says. “The school is so supportive. They meet the kids where they are and work with it.”
Dr. Anthony Alioto is director of pediatric psychology at Nemours/Alfred I. duPont Hospital for Children, where he works in the Gender Wellness Program./Photo by Joe del Tufo, Moonloop Photography.
Creating a supportive environment
There are those out there who see a growth in the number of young people in the midst of gender transitions and blame the media and our culture for encouraging people to “choose” that approach. Alioto doesn’t see things that way at all. He says gender dysphoria is not a choice, and he emphasizes that the increased messaging and growing understanding of the condition has helped ease the confusion and pain of many who even a decade ago had no way to express how they felt.
“I think having more publicity and media attention allows people to be more open to talking about gender diversity,” he says. “Back in the day, adolescents didn’t know how to put into words how they were feeling. Now, we are more comfortable talking about it.”
Still, there remains plenty of confusion about gender diversity. Although most kids understand early on that their assigned gender doesn’t match how they feel, Alioto explains, it can sometimes be easier to effect the necessary changes than it can be to convince people around them—even their families—that this is something natural and not contrived.
“One of the external forces that I find most interesting is the internet,” Alioto says. “When I meet with parents, they often say, ‘None of this started until he looked at the internet.’ It’s like their child was influenced by that and thought it was a great idea.”
The reality is more complex, he says. “The child or teenager has already had experience with the feelings and [because of what they learn online] now is able to put into words how he or she is feeling.”
The work Nemours is doing to help children and their families through the transition process is necessary, and not only from a biological standpoint, clinicians say. The adolescent transgender community is at particularly high risk due to bullying and harassment, according to the Human Rights Campaign, America’s largest organization advocating for LGBTQ+ equality. Its 2018 LGBTQ Youth Report detailed many of the harrowing circumstances children and adolescents have experienced, along with lauding the significant perseverance the young people have shown while attempting to overcome challenges.
This pressure has manifested itself as a significant rate of attempted suicides. According to a 2018 study by the American Academy of Pediatrics, more than half of transgender male teens who participated reported having attempted suicide, while 29.9 percent of transgender female teens have tried.
That’s why the Nemours clinic does not look at a child’s transition as simply his or her experience. It is vital that the entire family participate, the better to produce a caring, supportive environment that can sustain a youth during a period that can be fraught with emotional distress and many trials. Often, parents are upset that the future they envisioned for their child will not occur, as if we can predict what will happen with anyone several years down the road. They worry children will make choices they regret later. That’s why the Nemours staff works to present options, rather than to suggest paths to be followed.
“We consider a successful outcome to be one in which the adolescent is feeling comfortable in his or her own skin,” Alioto says. “We want to help create a supportive environment where children experience as little negative feeling as possible toward themselves and so that they can lead authentic lives.”
—Dr. Anthony Alioto
‘They are her brothers’
The Mastersons move through their days like any busy family. They have two other children, the usual slew of extracurricular activities and typical daily issues—big and small—that arise and need attention. Landon and Bob fall in the middle of the four Masterson kids, and their two daughters have adjusted smoothly to their brothers’ transitions.
“Our oldest was entering sixth grade when Landon transitioned, and it has been four years,” Charlie says. “They are her brothers.”
Mary and Charlie are quite comfortable with their family dynamic. Although Mary was familiar with transgender children when Landon and Bob began their journeys, she admits to having read “50 million books” about the subject since. Her world has made far more sense because of the transition. Charlie admits that he wasn’t as familiar with the phenomenon as Mary was and needed some time to understand.
“I had to go through the process of education through my wife,” he says. “Life’s been a hell of a lot easier. We’re happy, and [Landon and Bob] are happy.”
Bob reports that his classmates are pretty supportive of his transgender identity, as well as his coming out as gay.
“To first come out, it took courage, and I was really, really worried,” he says. “After I first came out, it got easier to tell people. I didn’t care if people thought it was bad. Some people get confused, but I haven’t had any bullying.”
Landon reports a similar sense of calm about his life, even if kids in his school don’t know that he has transitioned. For him, life is far easier now that he is living as a boy.
“There was a good amount of stress before,” he says. “I kept asking myself, ‘Why don’t I feel right?’ and stuff like that.”
Mary and Charlie laud the Nemours clinic and the work Graber, Alioto and the rest of the staff have done with them. They have referred other parents with transgender children to the hospital—“They embrace them for who they are,” Mary says—and are happy the clinic is expanding its reach. And in their community, they feel that people are supportive and want to understand the Mastersons’ story.
As for the future, Mary and Charlie are making no predictions. They have already learned that trying to forecast what’s going to happen is futile. Their family is a perfect example of that.
“Some people say lightning doesn’t strike twice,” Mary says. “It does.”
Learn more about Nemours’ Gender Wellness Program at nemours.org/services/gender-wellness