When girls won’t be girls

By Charlie McCann

Max Robinson’s house is full of junk. With her partner Kitty, she likes to comb through the charity shops and yard sales of the dusty city in southern Oregon where they live. Their spoils hang on their living room walls: a painting of a white husky; a tired Lisa Frank backpack decorated with cartoons of prancing pink ponies; a blown-up photo of a Siamese cat mounted on imitation teak.

The only picture in their living room not from salvage is a close-up of an Alaskan man smiling into the camera. Max, who is 21 years old, is an in-home caregiver and the photo’s subject was one of her charges until his recent death. It is the only image of friends or family that guests can see. Pictures of Kitty and Max are also absent. This house is a sanctuary – from the summer heat, the looks of strangers and, above all, from the past.

Max grew up in Dixon, Cali­fornia, a small city without a movie theatre or a mall. “You drive somewhere else if you want to do something,” she tells me. Walmart dominated the “popular hang-outs” page of her high-school yearbook.

Max’s childhood in the mid-noughties was not serene. She railed against the expectation that she act “girly”. When she was in first grade, she would go home from school in a huff because the girls’ bathroom pass was decorated with pictures of bows, while the boys’ sported soccer balls. “My teacher wouldn’t let me choose which pass I wanted. I played soccer!” When she was in third grade, her mother “finally” bought her a pair of boys’ shoes. She wore them constantly, until the fabric frayed so much that the exposed plastic began cutting into her feet. “I didn’t tell my parents. I thought I wouldn’t get another pair. They didn’t find out until they saw the back of my ankles, torn and bleeding.”

This is Max’s first memory of hurting herself on purpose. Sometimes she did so out of sheer tedium. In middle school, she began scratching off her skin, and cutting it. “Sometimes I’d get so bored in class that I would just go to the bathroom and cut myself because I was literally so fucking bored. And miserable,” she says. For a while, she stopped eating breakfast and lunch. “It was easier to focus if I was having pain from being hungry.” Starving herself was also part of an effort to improve her appearance – she wanted to be thin – but it did nothing to relieve Max of her disgust for her body, an aversion that only intensified as she began to attract the notice of boys.

She was never interested in them. When she was 12, she realised she cared only for the attentions of women, and began dating girls her age. The experience was bruising. Max describes a recurring scenario: her advances would be reciprocated by a girl who assured Max she was bisexual, even though she had only ever dated boys. But then the girl would hook up with her next boyfriend, dump Max unceremoniously and deny the relationship had ever existed.

Max decided that she would “try to be straight” and began dating an older guy. “I wanted to please the guy, do what my friends were doing,” she says. “I felt like that would fix something. At that point I was still dressing pretty typical for my peer group” – push-up bras, low-cut tops, flannel shirts, long hair caught up in a ponytail. Tweezing, waxing, shaving. High heels on occasion. But none of it ever felt right. Max longed to cut her hair short and wear boys’ clothes. When she was 14, she saw a friend get molested by a man. Max started to fantasise about committing suicide.

One day she was thrown a lifeline. While surfing the web, she discovered a new word: “transgender”. She began reading stories about women who felt that their bodies didn’t match who they were inside. It had never occurred to Max before that she might really be a boy trapped in a girl’s body, but it was a compelling idea. It explained why she hated that body and why she felt like she’d never belonged. It gave her a ready-made group of friends. And it gave her hope: there was a cure for feelings like hers.

“The longer I thought about it, the more sure I was that it was true...It was just so comforting to think that I was born wrong. If my body was the problem, it could be solved.” When she was 15, Max declared that he was not female and never had been. He and all his new friends agreed: “Being trans was very special...Before that, I had never felt special, or that my pain mattered.”

The great majority of humans with XY chromosomes are men and those with XX chromosomes women. But for a very small number of people, things aren’t that simple. The members of this minority – the precise figures are unknown, but conservative estimates suggest it ranges in size from 0.05% of Belgians to 1.2% of New Zealanders – might have ovaries but know themselves to be male, or they might have testes but know themselves to be female, even if they’re too young to know what ovaries and testes are.

A growing number of children and adolescents are coming out as transgender. Referrals to Britain’s Gender Identity Development Service (GIDS) have increased from 94 to 1,986 over the past seven years. The picture is similar in America. The country’s first gender-identity clinic for children and adolescents opened in Boston in 2007; by 2015, there were over 50 such clinics in North America. Their patients belong to the first generation of children and teenagers who are altering their bodies to fit their gender.

The science of gender-identity development is still in its infancy: the causes of “gender dysphoria”, the clinical term for the distress caused by the feeling that one’s body doesn’t match one’s gender, are still unclear and evidence for the effectiveness of treatments is limited. Randomised double-blind control trials, which afford the highest-quality evidence, cannot be conducted for ethical reasons, and the first long-term, large-scale studies have yet to be completed. “We are building the data as we go,” says Dr Bernadette Wren, head of psychology at the Tavistock and Portman, the GIDS clinic in London.

But children and teens with gender dysphoria often feel that they can’t afford to wait for years while clinicians determine what constitutes best practice. Many wish to begin transitioning in the earliest stages of puberty, not just because prolonging the process would invite unwelcome physical changes which are difficult to undo, but also because it can be painful to watch one’s body blossom into the wrong shape. For some, it is too much to bear. In December 2014, Leelah Alcorn, a 17-year-old transgender girl, stepped in front of oncoming traffic on a highway in Cincinnati, Ohio. In her suicide note, she explained that her Christian parents refused to give her permission to transition.

While clinical psychologists concur that the welfare of the child is paramount, they disagree on what that means and how they might secure it. Many think that medical and psychological treatment is often necessary but views diverge when it comes to questions about which children need it and when it should be dispensed. Clinicians are influenced not just by the data (what little we have) but also by their theoretical orientations and beliefs about the origin, meaning and malleability of gender identity.

Just a few years ago, this debate was confined to the pages of sober academic journals. But ever since Caitlyn Jenner starred on the cover of Vanity Fair’s July 2015 issue and transitioning became a subject of general discussion, the volume has been jacked up by partisans of the culture wars. Massed on one side are trans activists and their progressive allies, who champion the right of an oppressed minority to self-determination. On the other side stand religious ideologues, who deny the very idea that one’s gender can differ from one’s God-given sex, and whose crusade to ban transgender people from using the bathroom of their choice has become a campaigning issue in American politics. Mustering uneasily nearby is a group of feminists, some of whom do not think that men can ever truly become women.

Thanks in part to the full-throated support of progressives and trans activists, one approach is gaining ground in America. It contends that children know themselves best: if your three-year-old says he is a girl, do not deny or question her but instead support her. When she is ready to transition, assist her to do so – whether that means buying pink dresses now or approving her use of cross-sex hormones later on. Parents who affirm their kids’ desire to transition have been widely lauded for their courage; doctors who question whether medical intervention is in a child’s best interest have been accused of transphobia.

So contentious is this argument that parents I have spoken to fear publicly raising issues that worry them. There is one, in particular, that troubles many: what if my child changes her mind?

When Max came out to his parents six years ago, Caitlyn Jenner was still Bruce. “Initially my parents were like, ‘What?’ They didn’t understand or think that [transitioning] was a reasonable response to what I was feeling.” Max demanded they take him to a gender therapist. The therapist, a transgender man himself, diagnosed Max with depression, anxiety and gender dysphoria, and explained to his parents that there were steps he could take to alleviate the dysphoria. The first step was a social transition, which involved changing his name, pronouns and appearance to better fit the desired gender. Reassured, his parents accepted that their daughter had become their son. After that appointment, Max biked over to SuperCuts to get his long hair lopped off.

Three months after Max’s first appointment with his therapist, he started taking testosterone. Hormone therapy is often described as “life-saving medical treatment” for those suffering from gender dysphoria because it moulds the body into the desired shape. At first, Max’s therapist urged him to address his anxiety and depression as transitioning wouldn’t necessarily resolve them. But Max refused. “I wanted testosterone and I wanted my surgery.” Eventually the therapist relented, and wrote a letter to a local paediatric endocrinologist recommending Max for hormone therapy. Max’s parents gave their consent: in America, children under the age of 18 must secure the approval of their parents, whereas in Britain, as in some European countries, the law permits children aged 16 and over to make the decision themselves, as well as children under the age of 16 provided they are deemed capable of doing so – though clinicians at GIDS have yet to treat a patient who did not have the support of their parents.

Shortly before he turned 17, Max started taking “T”, as it’s sometimes called. Over the next two years, he stopped menstruating, lost some layers of fat, and gained more muscle mass and facial and body hair. His voice deepened, his clitoris swelled in size and his libido was invigorated. When transgender women take oestrogen, breast tissue develops and body fat is redistributed to hips and thighs.

Hormones, however, can’t undo all of the effects of puberty. If breasts have grown, testosterone can’t make them disappear. If an Adam’s apple has already dropped, oestrogen can’t haul it back up. If follicles have sprouted on the chin and upper lip, it can’t root them out. Prepubescent transgender children are fortunate in this regard as they can take puberty blockers. These drugs pause their natural development and are viewed as a prudent, compassionate measure as they prevent changes they might view as abhorrent.

Yet there are serious questions about these hormones’ medical and psychological effects. Blockers are often described as “fully reversible”, and it is true that if you stop taking them puberty will eventually resume. But it is not known whether they alter the course of adolescent brain development and possible side-effects include abnormal bone growth.

Cross-sex hormones are even more problematic. Their long-term medical and psychological effects are unknown, though it is clear that oestrogen brings with it a clinically significant risk of deep vein thrombosis, while testosterone increases the chance of developing ovarian cysts later in life, which is why some transgender men have their ovaries removed. In addition, some of the effects of cross-sex hormones are irreversible. With testosterone, there is no return from the deepening of the voice and the augmentation of the clitoris; with oestrogen enlarged breasts will remain.

If children under the legal age of consent would like to start taking hormones, they must secure the approval of their parents, and find a doctor willing to administer them. They will have no luck with GIDS in Britain, where doctors will not prescribe them to anyone under the age of 16. Better to try Dr Diane Ehrensaft’s clinic in San Francisco. Ehrensaft is the director of mental health at the gender clinic at Benioff Children’s Hospital and one of the architects of the affirmative model. She and her colleague, Dr Stephen Rosenthal, think that it is more important to consider the stage of puberty at which children have arrived, rather than their age. Rosenthal worries about the few British children who, having begun puberty at age nine, will have to take the blocker for seven years until they have reached the age of consent. “That can be very risky to their bone health and perhaps even for their emotional health, to be so far out of sync with their peers in terms of pubertal development,” he says. At his clinic, he has administered cross-sex hormones to patients aged 14, and sometimes younger.

This approach makes Wren, of the Tavistock and Portman in London, nervous, as children who begin taking blockers early on in puberty, followed immediately by cross-sex hormones, will never produce mature eggs or sperm of their own. “Can a 12-, 13-, 14-year-old imagine how they might feel as a 35-year-old adult, that they have agreed to a treatment that compromises their fertility or is likely to compromise their fertility?” she wonders. The risks of hormone therapy are high, but many young people and their families think that the price of caution is greater. It’s hard for parents, says Wren. “They see their suffering child, they want to remedy the suffering, and there’s a treatment out there. Why wouldn’t you give it?”

Ever since his breasts began to develop, Max had been bothered. For months, he had been binding his chest to make it look flatter, but the binder was painful. The next step in his transition was a double mastectomy, the most common form of surgery among transgender males. (Other operations include hysterectomies and phalloplasties – neither of which Max underwent – vaginoplasties for transgender females, as well as vocal-cord surgery, Adam’s apple reductions and facial adjustments.) In May of Max’s senior year at high school, his gender therapist wrote a letter recommending him for “top surgery”.

Though Max insisted to his parents, therapist and doctors that he needed hormones and surgery (“I was a very effective self-advocate at the time”), privately he had reservations. “As soon as I started thinking about transition I had obsessive thoughts of doubt.” He wondered whether he might come to regret making his body more masculine. During one appointment with his therapist, he mentioned his fears. “I expressed that I was scared of regretting it” and worried that internalised misogyny might account for his desire to transition. But when the therapist asked Max if he really believed that, he said no. After that conversation, Max didn’t bring it up again. He didn’t want to give his therapist any reason to doubt that surgery was right for him.

Max scheduled his mastectomy for July, even though he would still be 17 years old. In Britain, patients are eligible for surgery only if they are aged 18 or over. American guidelines are more flexible. If minors, with the backing of their parents, can find a surgeon who is willing to operate, then they can proceed. Max had no trouble finding one.

Recovery was difficult. Lifting your arms is not recommended after a mastectomy – it can disturb the stitches – but Max, who had little help from friends and didn’t ask his family for assistance, washed his own hair and emptied his own drains, the plastic tubes inserted into the chest which collect the fluid that accumulates where the breast tissue has been. “I have way worse stretch marks than people who do the recovery the way you’re told to do it.”

He spent the rest of the summer convalescing and writing zany slogans for t-shirts he sold online (“Relentless do-gooder”; “You can call a lot of different meals business lunches”; “If you’re looking for a sign, this shirt is it”). That autumn, not long after he turned 18, Max moved to Portland. He enrolled in community college, and made enough money from his t-shirt business to live off. He started making friends in Portland’s large transgender community and met someone called Kitty who shared his mischievous sense of humour.

It was a happy time for Max. He felt like a man on the inside; now he looked like one on the outside. Passing “was really cool”, he says in a video he made for his blog. “I felt like I was becoming this new person who could have an easier life.” He felt he was treated better because he was now a man in a culture that privileges men. His anxiety and depression faded into the background. In the video, he continues, “I felt like I was re-creating myself. I felt like I was being seen.” Then he pauses, and his smile fades. “And the longer it went, the less I felt like that.”

When Max was 19, just over three years after he came out as transgender, she realised he’d made a mistake.

From her spot on the sofa, Max reads aloud from a heavy book. Reclining to her right is Kitty, her girlfriend, resplendent in pink. To Max’s left, nestled up against her thigh, is Chloe Elizabeth, one of their two dogs. “It’s not a cure all,” reads Max. “If you go into it really screwed up you’re going to come out of it really screwed up. Make sure this is what you want to do. Make sure there is no other option because this is truly the hardest thing I have ever done in my life. You put everything that you are in jeopardy. Talk to as many people as you can that are going through it. Be sure.”

Max is reading testimonies from transgender men compiled in the book “FTM: Female-to-Male Transsexuals in Society”. Not that that term applies to Max anymore. Now 21, Max would be better described as FTMTF, female to male to female. Max is a woman and has been one for two years.

Six months after he began successfully passing, he realised, deep down, that he wasn’t sure. “I started being like, oh damn, this is for real.” There were drawbacks to being seen as a man. Women he passed on the street were “scared” of him. He couldn’t talk about his childhood without lying or leaving things out. He found laddish banter distasteful. And the possibility that someone would discover he was transgender haunted him. “People don’t love to find out that you weren’t born a man.”

At first, Max would only admit that he felt “kinda weird” about transitioning. He told himself, “I’m not going to stop transitioning but I acknowledge that transitioning isn’t always positive for everyone.” Months passed. “Gradually, very slowly, the more I was honest about what I was feeling, the more it became clear to me that I wasn’t having a very good time with it.” In the summer of 2015, after four years of identifying as a man and nearly two years of looking like one, Max transitioned back to her old gender identity, and stopped injecting herself with testosterone. Not long after, she convinced Kitty, who had identified as a transman for a year and was days away from getting her first shot of testosterone, to reconsider.

As the number of children – some under the age of 12 – being referred to gender clinics increases, so does the relevance of a question which troubles many clinicians and parents: what happens if a child changes his mind? Studies show that a majority of pre­pubescent children with gender dysphoria – between 73% and 88% – will not grow up to be transgender adults (though some people dispute those figures). So clinicians ask whether we can distinguish between those children who will continue in their trans identity and those who won’t. Ehrensaft thinks we can. She looks for tell-tale signs: does the child “insistently, persistently and consistently” identify as her chosen gender? Does she say “I am a boy”, rather than “I wish I was a boy”? Is she disgusted by her vagina? If she does and she is, then she may be allowed and encouraged to transition.

But Dr Thomas Steensma, who belongs to an influential group of Dutch clinicians, says that reliably distinguishing between those who will carry on to be transgender adolescents and those who won’t is impossible – a view supported by the American Psychiatric Association. This is why the Dutch group counsels “watchful waiting” for prepubescent children – a neutral, cautious approach which involves allowing their gender identity to unfold naturally without encouraging them to commit to either. Ideally, no decisions about transitioning are made until adolescence. They worry that a child who changes his mind may find it difficult to revert back to his original identity.

For the majority of those who transition physically, doing so is an effective way of alleviating their dysphoria. But some eventually decide to return to their original gender identity. The exact numbers are unknown but probably amount to a very small proportion of the total. Out of the hundreds of patients Ehrensaft has seen, only one has ever regretted their medical transition. A 50-year study conducted in Sweden found that only 2.2% of people who medically transitioned later felt “regret” (in contrast, an estimated 16% of cosmetic-surgery patients are unhappy with their nose jobs, according to the Aesthetic Surgery Journal).

But many who detransition never inform their doctors, Max says, so are not reflected in the statistics. She acknowledges that people like her are a “tiny subset” of the transgender population. Her network of detransitioned people, which was formed a couple of years ago, numbers just over a hundred. Kitty, who now identifies as a woman, thinks it gains one to two new members each week. But it stands to reason that as the number of people transitioning increases, so will the number of people reversing the process. As Kitty says, “the argument that a group is such a tiny minority that they shouldn’t be listened to is pretty inappropriate.” Trans people are, after all, a small group themselves.

Transgender people detransition for a variety of reasons. Some people find they are less comfortable in their new identity than their previous one. Others cannot afford to keep paying for hormone therapy. Others still suffer from surgery complications or have concerns about the long-term effects of taking hormones. Sometimes it’s because life as a transgender person is hard. Transphobia forces these people “back into the closet”, Brynn Tannehill, a trans advocate, said in a recent article for the Stranger, a newspaper in Seattle.

Max detransitioned for several reasons; the most significant one was that she is not transgender. She was unhappy as a child not because she was a boy trapped in a girl’s body but because she didn’t understand that she could be the kind of girl who hated girly things but loved other girls, without having to metamorphose into a man.

After she stopped taking testosterone, her body began to change again. Over the next two years, body fat gradually migrated back to her hips and thighs. She lost some muscle mass and began to menstruate again. Her sex drive, which had been “ridiculous”, became “manageable”. She became “more emotional”: “I cried a ton less on testosterone.” She watched the hard edges of her face soften into roundness and her rough skin become smooth.

Some of the changes wrought by transition cannot be reversed. Max’s voice remains deep. Her beard is a permanent fixture, though the hair is softer and finer than before. Her chest will remain flat. “Strangers think I’m a man a lot of the time,” she says. This is a source of pain and frustration, though she puts on a brave front. She firmly believes that women should be able to look and behave however they want. But, in a fundamental way, gender still informs how we interact with each other. Confusion and hostility can ensue when a person’s gender is unclear.

When Max told her friends and family that she was detransitioning, she “felt really fucking stupid”. Kitty strokes Max’s arm. “You really put yourself out there when you say, ‘Hey everyone I’m a man now and you’ve got to get on board with this’. So it does not feel especially dignified to be like ‘Oops!’”

The question of whether a child can really know herself remains unanswered. Max was sure, and she was wrong. Ever since she was 15, she had attributed troubles such as anxiety and depression to gender dysphoria. It is often the case that such mental-health issues follow in the wake of dysphoria; after all, being trans is hard. But Max and her therapist overlooked, or discounted, the possibility that her mental health problems, far from being symptomatic of gender dysphoria, could actually be the cause of it. Max now believes that her dysphoria sprang from the anxiety and depression, which in turn arose from her difficult experiences as a young lesbian with bi-polar and attention deficit disorders, with which she was diagnosed three years ago.

Ehrensaft agrees that “it absolutely is essential” to rule out the possibility that gender dysphoria could be caused by “another life problem”. That requires visiting a mental-health professional. But she is also part of a movement encouraging the World Health Organisation to declassify gender dysphoria as a mental illness, in much the same way that homosexuality was removed from the “Diagnostic and Statistical Manual of Mental Disorders” in 1973. Psychiatric diagnoses of gender dysphoria stigmatise sufferers. Last January, Denmark became the first country to take Ehrensaft’s advice. But removing the mental-health element means it is less likely that people with gender dysphoria will see a therapist before they are treated. In America, a growing number of clinics will prescribe hormones to patients as long as they understand the effects of the treatment – letters from therapists are not needed. As Max’s story shows, seeing a therapist doesn’t guarantee that mistakes won’t be made, but it may help people avoid them.

There is a growing view that transgender people, not their doctors, should be in charge of their own bodies. Many argue that identity, not health, is the fundamental issue. Though they know there may be deleterious consequences, they want autonomy over their own treatment. In this light, doctors – who are obliged to respect the right of patients to do what they want to their bodies – should acquiesce. But they are also required to do no harm. What if they suspect that a young woman’s internalised misogyny and repressed lesbianism accounts for her desire to turn herself into a man? Transitioning might temporarily mitigate her dysphoria but therapy would be less drastic and more effective, as would more informal kinds of support provided by LGBTQ groups.

Max believed that transition was right for her and she wasn’t going to let a therapist tell her otherwise. Now, though, she wonders how anyone, whether adult or child, can “provide meaningful consent to an experience that’s pretty transformational…Kids are particularly susceptible to pursuing things that later in life they might not believe was the best possible thing for them to have been doing. Kids do all kinds of stuff.”

Today, Max is much happier, she tells me, having returned to her true identity as a woman. She is in a committed, loving relationship with Kitty, and together they hope to run a refuge for troubled women. She breaks off mid-sentence to look at her phone. She has received an email from her grandmother containing an old photo she found of Max, aged about ten, posing shyly in front of a tree with her two sisters. A smile steals across her face.

PHOTOGRAPHS CHLOE AFTEL