Had Tucson pediatrician Dr. Andrew Cronyn been asked to help a child transition their gender with medical interventions a decade ago, his advice would have been to wait until the child turns 18.
Heโd never say that now.
โA lot of kids are still getting that advice,โ he said. โBut what we now know is waiting can put kids through agony in their teen years.โ
Since 2014, Cronyn and fellow El Rio Community Health Center pediatrician Dr. Tracey Kurtzman have gone from one young transgender patient to 75, ranging in age from 4 to 19.
The patients come to El Rio from not only Tucson, but from across Arizona, including Flagstaff, Safford and Phoenix.
Cronyn and Kurtzman are open to treating their patients with medication to inhibit puberty and with cross-gender hormones โ interventions that for certain kids are both positive and healthy, they say.
The Southern Arizona Gender Alliance estimates 1,000 to 1,500 transgender kids under age 18 live in the Tucson area. Transgender is an umbrella term for people whose gender doesnโt conform with the sex they were assigned at birth.
An estimated 0.7 of a percent of youths ages 13 to 17, or 150,000 youths, identify as transgender in the U.S., a 2017 study by the UCLA School of Law says.
First patient
Cronynโs first transgender patient was an 8-year-old trans boy whose doctor had insisted on calling him โshe.โ
The boy was anatomically a girl when born, but at a young age realized he was a boy. There wasnโt any question about it. To have a doctor call him โsheโ was beyond upsetting.
The impasse led the doctor to eventually โfireโ the boy from the practice. The boy and his family ended up in Cronynโs office at El Rio.
โThe doctor was telling the child, โYou have a vagina; you are a girl,โโ Cronyn said of that first trans patient. โIt was almost unbelievable. The child had chronic medical issues that werenโt being dealt with because the provider was so focused on the transgender part.โ
Word got out among kids and their families that Cronyn was supportive and open to giving kids hormone agonists that inhibit puberty, and to giving adolescents cross-gender hormones to bring on characteristics of the opposite sex. More trans kids began seeking care at El Rio.
Cronyn cared for the boy with three basic steps and now trains other medical providers to use them, too โ call the patient by their name (the one they want to be called); acknowledge the patientโs gender identity; and donโt look in their underwear unless itโs medically necessary.
โWhat do you like to be called?โ and โDo you prefer he, she or something else?โ are easy questions to ask, the doctors say. And they make a difference.
โIt is a new area of medicine in the U.S. that has really kind of exploded in the last decade,โ Kurtzman said.
For Pima Community College student Oliver Wagner, finding Kurtzman was a relief. Other health providers needed to be educated about โgender stuff,โ which could get both exhausting and annoying, said Oliver, 18, who prefers the gender-neutral pronoun โthey.โ
โI didnโt have to think about how to word things,โ Oliver said of Kurtzman. โI feel at ease with her.โ
Oliver, who was born anatomically female, was recently turned down by the familyโs private insurance company for โtop surgeryโ to remove breasts. Kurtzman is helping Oliverโs family appeal the decision, saying the surgery is a medical necessity.
Cronyn and Kurtzman regularly fight with insurers to pay for appropriate doses of puberty suppressors that prevent the development of secondary sex characteristics.
Puberty inhibitors have been declared safe by the international Endocrine Society but are expensive โ the cost can be up to $30,000 per year at a retail pharmacy if insurance wonโt pay.
Biological Betrayal
Researchers say thereโs a lot still to be learned about transgender kids. Gender is complicated, language thatโs used to talk about transgender issues is evolving, and while the data on trans youth are expanding, more long-term studies are needed.
What is known is that for certain kids who have persistent โgender dysphoriaโ โ distress over feeling oneโs gender does not match oneโs biology โ puberty can feel horrifying, like a betrayal of their body. Going on puberty blockers and cross-gender hormones may end up improving their mental health, Cronyn said.
โDelaying puberty does not hurt the child. It can keep the breasts from developing and the menses from happening, and give the child an opportunity to reach adulthood and then make the decision,โ said Erin Russ, director of programs for the Southern Arizona Gender Alliance.
For trans girls who were born male, puberty blockers can put off having the voice deepen and prevent the growth of facial hair and an Adamโs apple.
โItโs huge. Itโs tremendous for a trans boy not to have to go through puberty and have breasts grow,โ Russ said. โFor a trans girl to start having facial hair grow is demoralizing.โ
When Russ was a child, she used to imagine a set of stairs in her house was a starship for interstellar travel. Sheโd get on as a boy and get off as a girl.
โBut thatโs all I was able to do,โ said Russ, who transitioned from male to female as an adult. โI thought I was all alone in the world.โ
The El Rio doctors emphasize with families the different kinds of medical interventions by what is reversible, partially reversible and irreversible, and they have lengthy discussions with families about risks that are still unknown.
Puberty blockers, which pause puberty, are reversible. The child can stop the puberty blockers and go through natural puberty or else continue with cross-hormone treatments. Sometimes blockers give them a โtime outโ to explore what gender means, Cronyn said.
Fertility issues
One major issue to consider with medical interventions for kids is fertility.
If a child remains on puberty blockers, moves on to cross-gender hormones and never goes through their โnatal puberty,โ the child is unlikely to be able to have biological children , Cronyn said. Some kids choose to go through their natal puberty long enough to be able to harvest eggs or sperm to freeze, though that costs money.
โItโs one of the tough things we deal with in making decisions,โ Cronyn said. โItโs a big deal for families.โ
Cronyn has had patients choose not to go on puberty blockers because of a desire to have biological children. Heโs had patients choose the opposite, believing scientific advances could allow them to have their own children in a decade or two. Still others choose to go through their natal puberty long enough to produce eggs or sperm.
Cross-sex hormones are partially reversible โ breast growth and possibly sterility are not reversible, for example, nor are deepening of the voice and the growth of facial and body hair.
And sex-reassignment surgery, often called gender-affirmation surgery, is in the irreversible category.
If kids are on blockers for a long time without any hormones, there is a risk of bone-density problems, which is why the pediatricians ask their patients to take calcium and vitamin D supplements .
Some medical professionals say more data is needed to understand the long-term repercussions of the medical interventions.
A 2013 report by the American Academy of Pediatricsโ Committee on Adolescence noted that medical treatments for transgender youths are not standardized, nor are they approved by the U.S. Food and Drug Administration, โalthough they are increasingly supported by medical literature.โ
Kurtzman said about 80 percent of her transgender patients who are over the age of 11 are getting either puberty blockers or cross-gender hormones, or, in a couple of cases, both.
Oliver did not become a patient of Kurtzmanโs until age 15, so it was too late for puberty blockers. Oliver began receiving masculinizing, cross-gender hormones from Kurtzman at 16, which is the minimum age the Endocrine Society recommends starting them.
But Kurtzman, Cronyn and other U.S. health providers are now pushing that minimum lower, to about 14 years old in some kids.
Oliver said the wait for hormones seemed long, and itโs good that kids are able to get them at younger ages.
Treatment landscape
Cronyn and Kurtzman have become resources for families who have questions about issues like how trans boys can join Little League, where to get haircuts, where to buy clothes and how to get legal documentation that will match the childโs gender identity.
Families began asking about gender-affirming local therapists, for example, and Cronyn and Kurtzman initially began with a list of three. That list has significantly expanded, though finding child and adolescent psychiatrists for kids who arenโt covered by Medicaid remains a challenge since many either donโt take insurance or they have a waiting list, Kurtzman said.
โWeโve always had good physicians in town, but El Rio has really changed the landscape,โ Russ said.
Other doctors in Tucson are now offering medical interventions for transgender kids, but Cronyn and Kurtzman were the pioneers, Russ said.
โThey are the ones who cracked the code, worked with insurance and made this available on a broader scale,โ Russ said.
Russ can recall about 10 years ago when members of a local parent support group for families with transgender children began wanting to know about puberty blockers and cross-sex hormones. There wasnโt a lot of information. A few families ended up going to California โ either Los Angeles or San Francisco โ for treatment, she said.
โEl Rio made it possible for more families to get medical care for their kids,โ Russ said.
โKids now have the opportunity to develop the way they want to.โ
El Rio has been a longtime provider of health care to vulnerable populations. Anyone hired at El Rio must go through three hours of training in caring for marginalized populations and that includes the LGBTQIA+ community, Cronyn explained.
LGBTQIA+ is an umbrella term for a population of people united by having gender identities or sexual orientations that differ from the heterosexual and cisgender majority. Cisgender refers to people who identify exclusively with the sex they were assigned at birth.
In its 2018 Healthcare Equality Care Index, the Human Rights Campaign named El Rio as one of 418 health organizations leading the country in LGBTQ (lesbian, gay, bisexual, transgender and queer) health-care equality. El Rio was the only Arizona organization to earn the designation.
The growth in El Rioโs pediatric transgender population has fueled a more recent effort to identify unmet needs .
El Rio will hold a first-ever LGBTQIA+ youth and family day April 28 at the Donna R. Liggins Recreation Center, 2160 N. Sixth Ave. (See box on this page.)
โWho is not at the table? Who are we missing?โ Cronyn said. โWe want to know that, and we want to connect people.
โHealth disparities for trans people are horrible โ itโs like it is for undocumented people, people of color and low-income people. We know there is a cohort of patients who are not getting to us and we are not sure how to reach them.โ
Relief and euphoria
While 13 states and the District of Columbia prohibit insurance exclusions for transgender health care and provide transgender-inclusive health benefits for state employees, Arizona does not.
One of Cronynโs patients two years ago was successful in getting Arizonaโs Medicaid program to pay for puberty blockers. That paved the way for more transgender kids to get their blockers covered, though coverage is still on a case-by-case basis for both Medicaid and private insurance companies, he said. Medicaid is for low-income people and in Arizona the program is called the Arizona Health Care Cost Containment System, or AHCCCS.
AHCCCS does not pay for gender-reassignment surgery, agency spokeswoman Heidi Capriotti says.
Gender transition can be difficult for children and families, but the end result is usually positive, says a guide on supporting and caring for transgender children published in September 2016 by the American Academy of Pediatrics, along with the Human Rights Campaign and the American Academy of Osteopathic Pediatricians.
โWith their gender identity no longer in conflict, the child can focus on the important work of learning and growing alongside their peers,โ the guide says. โMany children feel relief, even euphoria, that the adults in their life have listened and understood them.โ
Karl and Jen Wagner, who are Oliverโs parents, were leery of hormone therapy . But then the family, which includes Oliverโs younger sister Julia, attended a local camp together โ Camp Born This Way, which is for transgender, gender-creative and gender non-conforming children and their families.
Some of the transgender volunteers at the camp told the families about their experiences with hormone therapy and how it improved their lives. The Wagners were moved by the stories and decided if Oliver really wanted hormones, Oliver had their support.
Kids at El Rio must read and sign a consent form and need the approval of their parents to get puberty inhibitors as well as cross-gender hormones. They also have extensive discussions with their doctors.
When kids are older, the El Rio doctors can refer them to surgeons who perform gender-confirmation surgery, sometimes called gender reassignment.
Such surgery is typically reserved for those 18 and older, but there are no local doctors who perform it, though some here will do elective hysterectomies, testes removal and mastectomies to remove breasts, Cronyn and Kurtzman said.
Catching up
Chris Lopez first heard about El Rio from other parents at a local support group for parents of transgender and gender-creative kids.
Lopezโs 10-year-old son, Gabe, has been one of Cronynโs patients since 2015. Gabe โsocially transitionedโ at the age of 8.
โDr. Cronyn understood what it meant for someone Gabeโs age to be transgender,โ Lopez said. โHe put in a prior authorization with insurance for a puberty blocker a year ago. He wanted it to be resolved by the time Gabe was ready.โ
Gabe, who is in the fifth grade, spoke extensively to Cronyn before deciding to take medication to prevent his body from going through puberty as a girl.
โGabeโs level of anxiety about it made it an easy decision,โ Lopez said. โBut we talked about it a lot. Dr. Cronyn was so patient and understanding. He made every effort to make sure this was right for Gabe.โ
Gabe, who is thinking about a career as a police officer, received his first puberty-blocking implant last month.
The El Rio pediatricians offer support to parents like Lopez who often need to catch up with their children. Lopez, for example, had always been an advocate for LGBT rights but had never considered that a child as young as Gabe could be transgender.
โA lot of trans kids are so savvy,โ Kurtzman said. โOur consent forms are six to seven pages, single-spaced. A lot of kids already know everything thatโs going to be on it.โ
For Lopezโs family, increased public awareness of transgender celebrities like Laverne Cox was also helpful. โI hadnโt considered that all transgender adults were once transgender children,โ Lopez said. โI also had never separated sexual orientation and gender.โ
As Gabe grew up wanting a boyโs haircut, wanting to dress like a boy and go to the bathroom like a boy, Lopez assumed he would be a lesbian when he was older.
โWe were wrong about so many things,โ she said. โFor eight years Gabe was trying to tell us something we didnโt understand.โ
What Lopez understands now is that gender is separate from someoneโs sexuality. Being transgender does not imply any specific sexual orientation. As many describe it, sex is about anatomy and gender is in the brain and the heart.
Nonbinary
The Human Rights Campaign defines gender identity as oneโs โinnermost concept of self as male, female, a blend of both or neither,โ as well as โhow individuals perceive themselves and what they call themselves.โ
Transgender kids who seek medical interventions represent a โsliverโ of the overall population of transgender youths, stressed Russell B. Toomey, an associate professor of family studies and human development at the University of Arizona.
Toomey said recent studies from the Human Rights Campaign suggest a large portion of transgender kids donโt see themselves as male or female, but rather a combination of the two or a third gender. Often those kids are known as โnonbinary.โ Cronyn and Kurtzman have transgender patients who are nonbinary. Some want medical interventions, others donโt. All need support.
The El Rio doctors see patients through situations where they have trouble with rejection and ostracism for being different, whether itโs from family members, friends or schools.
More often than not, the families come around.
โIโve seen so many examples of heartfelt parents who just love their children so much โ parents in the military, first responders, all different professions,โ Cronyn said. โYou are part of this team. It has changed the way I am with non-trans patients as well. I think it has changed my practice.โ
Kurtzman, a pediatrician for the past 18 years, says sheโs always loved her job. But working with young transgender patients has been the most fulfilling part of her career to date.
โItโs really touching,โ she said. โItโs wonderful to partner with these families. Itโs a privilege, and Iโm learning so much from the families and kids.โ
Before going on hormone therapy, Oliver Wagner attempted suicide. Oliver credits their family, Kurtzman, Camp Born This Way and hormone therapy for helping them move past that darkness. Oliver is now working part time for Tucson artist Josรฉ Trujillo, is hoping to be a volunteer at camp this year and is considering a career in video game design.
Oliver is also working on a school project about transgender health care and has anecdotally found that transgender kids often avoid going to the doctor.
The rate of suicide and suicide ideation for transgender kids between the ages of 11 and 18 is extremely high โ 45 to 50 percent, Toomey said. By comparison, itโs less than 10 percent for cisgender kids of the same age.
But such disparities are not inevitable, Toomey emphasized.
Research consistently indicates that when transgender youths have positive reinforcement, acceptance and proper guidance, their mental health and other outcomes are not much different than for non-trans peers, he said.
โItโs when there is no or little support that the disparities are alarming.โ
