Updated Dec. 7
Michael Alongi’s wardrobe usually involves a splash of rainbow: shoelaces, a bowtie, a pin. The 15-year-old’s cropped brown hair is even swirled with shades of blue.
He was born in a female body, but he says he didn’t feel like he was a girl. At the beginning of his freshman year, he started using “he” and “him” pronouns at his Sacramento high school, and also tried to deepen his voice. He isn’t shy about being gay and transgender.
“When I imagine myself when I’m 40, I imagine myself as male,” he said.
Like a growing number of transgender kids across California, Michael wants to start transitioning in a more permanent way. That can mean puberty blockers, hormone shots and even surgery.
Jeanne Alongi, Michael’s mother, said she was cautious when he started talking about making medical changes.
“I was concerned about things that aren’t reversible because he was 13 and 14, and that seems very young to make a decision that impacts the rest of your life,” she said. “But as we’ve gone through the last couple years, what I’ve really come to understand is Michael’s not confused about who he is.”
But even with full parental support, Michael’s had some trouble accessing care. The medical system hasn’t entirely figured out how to treat young transgender patients.
The American Academy of Pediatrics put out its first policy statement on transgender care this fall, recommending physicians and parents support a child’s gender choice and provide “comprehensive gender-affirming and developmentally appropriate health care.”
Adolescent gender clinics are helping to fill the gap; there are roughly 40 in the United States, including a handful in California.
But Dr. Katherine Gardner, a family medicine physician who works at Sacramento’s Gender Health Center, said there are few physicians who have experience treating transgender kids, and that they tend not to know how to proceed with these patients.
“Human beings don’t fit into the box the way medicine has created gender boxes,” she said.
Weighing The Risks
When Jeanne Alongi and Michael started looking for doctors to guide him through transitioning more than a year ago, they hit roadblocks right away. It took three months to find a gender specialist in their insurance network.
Experts say waiting that long for care can be unhealthy for kids with gender dysphoria. It’s an official medical condition, and patients must be diagnosed with it to be covered for treatment.
But the medical field isn’t fully in agreement about what pediatric transgender care looks like, and when it should start.
“There’s not consensus around the world on how to do this,” said Dr. Jack Drescher, a Columbia University professor who studies gender identity.
Michael’s dad, Sam Alongi, says it’s a worrisome position to be in as a parent.
“You don’t always know, with a treatment of any kind, what the long-term effects are going to be,” he said. “It’s always in the back of your mind as a concern.”
Right now, doctors tend to start treatment with puberty blockers. They delay the usual teenage changes and give doctors, parents and patients some time to figure out a child’s gender identity before major physical transformations begin.
After puberty blockers, some teens opt for hormone treatment — estrogen or testosterone shots. Protocol varies, but hormones are typically given at age 16 or later. Surgery generally isn’t available until after age 18.
There’s a push to change the guidelines and make this treatment available earlier. But some doctors feel even the current timeline is too risky. They worry kids will change their mind about transitioning as they get older.
The American College of Pediatricians, a Florida-based group of socially conservative doctors that the Southern Poverty Law Center classifies as an anti-LGBT hate group, put out a statement in November calling the treatment of gender dysphoria in children “mass experimentation on, and sterilization of, youth who are cognitively incapable of providing informed consent.”
Doctors who support pediatric transgender care say teenage patients are well aware of their gender identity, and that there are bigger consequences around denying treatment than providing it.
One study from the University of Arizona found that more than 40 percent of trans teens have contemplated suicide, compared to just 14 percent of gender-conforming teens.
“That risk is very real for trans and gender-nonconforming youth, and that risk goes down phenomenally with gender affirmation,” said Gardner. “What’s really important is that that youth is validated, and that what is important to them is respected and heard by the adults in their lives.”
Drescher said parents should be cautious. He cited controversial research showing that the majority of children who are concerned about their gender identity early on do eventually grow out of it.
“Problem is, nobody can tell the difference between the kids who will continue to have gender dysphoria and those who will not,” he said.
That’s why he’s in favor of the puberty blocker approach.
“If the child would grow out of the gender dysphoria, you’ve basically just delayed puberty,” he said. “But if the child doesn’t change their mind, what you’ve done is saved the child a lot of treatment as an adult because they don’t have to have their beards or breasts removed.”
Michael said his need for treatment became desperate when he started having periods. Every time it happens, his stress levels go way up.
“Having a menstrual cycle and having to deal with that every month … dysphoria on top of that was so hard to deal with,” he said.
Jeanne Alongi says she’s worried about Michael’s mental health. She still remembers getting calls from elementary school teachers reporting that he was having anxiety attacks on the playground.
And she’s frustrated that kids have to jump through hoops to get the care they need.
“Having to wait for the system to be comfortable seems like a lot to ask for a 14, 15, 16 year old, when he’s got to carry it all day every day,” she said.
The Waiting Game
Math isn’t Michael’s favorite subject. He’s more into literature, history and drama. But he’s had to do a lot of calculation since he started wearing a chest binder a few months ago: It’s essentially a tight wrap that goes around the torso to make someone’s chest look flat. It makes Michael feel more like he’s a boy, which staves off gender dysphoria. But it’s also extremely uncomfortable, and it can cause back problems.
He’s only supposed to wear it for eight to 10 hours a day, and he can’t exercise in it. He’s constantly doing what he calls “binder math” — a few hours before physical education, a few hours after. Sometimes, he takes it off for drama practice.
But he says there are days when his dysphoria is so bad that he can’t take off the binder, even if it means he’s clocking more hours than he should.
“It’s one thing to be concerned with physical health,” he said. “But mental health, that’s an issue for me.”
If Michael were to start taking testosterone, his chest would slowly become more muscular. He’d grow facial hair, and his voice would drop. His gender therapist recently gave him approval to start the shots, but it’s not a decision he takes lightly. He’s worried the mood swings and bodily changes will distract him from his school work.
“Because sophomore year is a lot in the program I’m in, and I don’t want to deal with all the stuff that comes along with [testosterone],” he said. “So, current plan is to start at the end of the year, but that might change.”
Michael’s parents say this is a typical Michael move. He’s a responsible, organized and goal-oriented kid. And they’re pretty sure he’ll stay that way, wherever he lands on the gender spectrum.
Clarification: This story was updated to reflect Dr. Jack Drescher’s past work, the typical ages at which transition treatment begins and the description of the American College of Pediatricians.