American Girl

Clinics are popping up across the country to help kids as young as 3 who might be transgender, but some say it's too much, too soon. While doctors argue, families like Nicole's don't have time to wait.

In October 2015, Nicole buckled in to her mom’s Prius, along with her older brother, mom, dad, and a bag full of her favorite dolls, for a three-hour drive to see a doctor about her new life.

Over the past 18 months, the 9-year-old had grown out her black curly hair from a crew cut to a flouncy bob just below her ears. She had traded in pants and overalls for pink and purple dresses covered in rhinestones. And she had changed her name, ditching the common boys name that now made her cringe to hear.

It had been a challenging time for Nicole’s parents, Kim and Andrew, whose conservative Christian circle of friends in Texas rejected the entire family after seeing the changes in this kid. Nicole was happier than she’d ever been, but the trip ahead still made her anxious. So, trying to calm her nerves, Kim switched on her daughter’s favorite book on tape, Hank the Cowdog, and stopped to get her kolaches, the Czech pastries that Central Texas is known for. Then she gave her an early birthday present: Next year, when she turned 10, they would get her a prized American Girl doll, just as they had for her older sister a decade earlier.

Puberty was just around the corner, and nobody knew exactly what it would bring for this sweet, lanky, and rapidly growing child who loved to sing. Which is why they were driving to Dallas, to a new clinic called Genecis, one of at least 16 centers in the US where psychologists, endocrinologists, and social workers help young kids who don’t fit in the tidy boxes of “boy” and “girl.”

Puberty was just around the corner, and nobody knew exactly what it would bring.

No clinics like Genecis existed in 2007, when 6-year-old Jazz Jennings became the youngest trans person to ever be interviewed on TV. Back then, Barbara Walters asked her what she would call herself. (“A girl,” she responded.) Back then, psychiatry’s official diagnosis for children like Jazz was “gender identity disorder.” Back then, though transgender teens and adults could see doctors for hormone treatments, the predominant way of treating small kids who were unhappy in the gender they were assigned at birth was to steer them toward accepting it.

Now, Jazz is just one of many trans kids visible in popular culture. This week, 8-year-old trans actor Jackson Millarker played a trans character on Modern Family, reportedly a first for network television. Before that was the TLC documentary Transgender Kids Camp, and the How to Be a Girl podcast. These kids' official diagnostic label has also changed, from “gender identity disorder” to the less stigmatizing — though still controversial — “gender dysphoria.”

Despite this broader understanding and acceptance, transgender teens — estimated to make up roughly 1.5% of all teenagers — are two to three times more likely than their peers to attempt suicide or experience serious depression.

The doctors who work at new “gender-affirming” clinics like Genecis say the best way to prevent these dire outcomes is to let young kids live out their gender identities however they wish — whether that’s as a boy, as a girl, or somewhere in between. They say that because gender identity is largely hardwired in the brain, kids as young as 3 can begin to articulate it, and that these kids end up happier, less anxious, and better adjusted socially the earlier we allow them to express the gender they feel themselves to be. For the small subset of kids who show a strong and consistent belief that they are a different gender, that means letting them “socially transition” to life as a full-time boy or girl.

But some doctors — as well as an unexpected mix of liberal academics, scientists, and religious conservatives — argue that we have no way of knowing with certainty which prepubescent kids who behave outside of gender norms will come to identify as trans, and which ones will not. Some worry that this approach could steer kids who are just going through a phase into a transgender “track” long before the kids know whether those feelings will really stick. Others say it reinforces outdated stereotypes — giving worried parents the false assurance that their girly boy is actually just a girl who was born in the wrong body. Conservative critics peg the increase in trans kids today to a dangerous new fad in parenting.

The most extreme members of each group have likened the other’s approach — whether pushing kids to identify as transgender or pushing them to repress their true gender identities — to “child abuse.” Unfortunately, there isn’t much hard data to help settle the debate: No study has looked at what happens later in life to kids who are allowed to socially transition before puberty.

Which leaves families like Nicole’s at a crossroads. While scientists carry out studies that will take many more years, a growing number of parents have to make decisions about their kids right now. Do they let their kids transition without knowing, for sure, that they’ll grow up to feel the same?

Nicole was born in 2006 in Austin. (“Nicole,” used in this story to protect her privacy, is her middle name.) Her biological mother had been a drug user, and her father was unknown. Child Protective Services took custody of the baby straight from the hospital.

Six months later, in a conservative suburb 20 miles away, Kim and Andrew were looking to adopt. They had used fertility drugs to conceive their oldest daughter, 12-year-old Olivia, and had later adopted a 6-year-old boy, WB. Kim had quit her job as a nurse to homeschool them and now wanted “just one more.”

Nicole had been placed with an adoptive Mexican family, but they sent her back after finding out that, although she was half Mexican, she was also half black. So the adoption agency asked Kim and Andrew if they could foster Nicole for the weekend before she was placed elsewhere.

“I said, ‘Yes, I’ll take the baby, but not for the weekend. If you want me to keep the baby, I want to keep the baby,’” Kim told me over root beers and Little Caesars pizza when I visited their home in July. “We knew who we were supposed to have.”

From the moment Nicole could move around on her own, she preferred girly things. “I hate to gender stuff, but we’d offer her trucks, superheroes,” Kim said. “She always wanted Barbies, pink things, sparkles.”

It’s OK, they thought — their new son didn’t need to like trucks any more than their daughter, who was bookish and always lost in her fantasy novels, needed to like makeup and high heels. Kim, who proudly does all the family’s sewing, cooking, and cleaning, disavows some gender norms herself: She lives in her cutoffs and Birkenstocks, and occasionally pulls out the combat boots left over from her military days.

Pediatricians told Kim and Andrew that Nicole’s interest in girl toys was just a phase and nothing to worry about. But some of their church friends and parents in their Christian homeschooling group were less sanguine, suggesting that the toddler should be steered toward more “appropriate” activities. They tried. “We were like, ‘Well, we know God gave you those parts for a reason. He’s got big things in store for you,’” Kim recalled.

For Nicole’s third, fourth, and fifth birthdays, her parents bought any boyish toys they could find — trains, cars, a Batman costume. But the cars were used to play house, with car moms and car dads, and Batman’s cape turned into a long-haired wig.

Although Kim and Andrew didn’t know it at the time, a similar debate was playing out among prestigious medical experts. In 2008, two of them spoke on NPR’s All Things Considered, in a 23-minute exchange that’s often cited by gender experts today. The segment focused on two young kids, raised as boys, who had for some time expressed strong preferences for stereotypically feminine toys and clothing, and had recently started acting out at home and school. From there, their paths diverged.

One mom took her child, 5-year-old Bradley, to see Kenneth Zucker, a psychologist who had founded one of the first gender identity clinics catering to adolescents, the Centre for Addiction and Mental Health in Toronto. Zucker was an early adopter of the so-called Dutch model, which recommends giving teenagers with gender dysphoria drugs to block puberty. These medications are reversible, so they essentially buy time: The adolescent can decide to stop taking them and go through puberty as the gender they were assigned at birth; or, after a couple of years, they can choose to continue their medical transition by starting estrogen or testosterone.

Although he was one of the most prolific scientists studying gender, Zucker had recently come under fire for his approach to younger kids, which steered them away from a new gender identity and instead attempted to make them feel comfortable in the genders they were assigned at birth. Some of his critics likened his methods to “conversion therapy,” the infamously discredited attempts to undo homosexuality.

Bradley’s mom told NPR that Zucker recommended he play more with boys rather than the mostly girl friends he had at the time. Zucker said they should try to swap his rainbow unicorns and Polly Pockets for more boyish toys, and discourage him from drawing princesses and fairies, or from playing girl characters during make-believe.

Two thousand miles away, in San Francisco, 5-year-old Jonah saw gender specialist Diane Ehrensaft, then a psychologist in Oakland who was touting a new and drastically different approach. Ehrensaft insisted that the label of “gender identity disorder” — or any therapy to treat it — was inappropriate for Jonah. Instead, she said, Jonah was acting out because of years of frustration over not being able to present as a girl. Ehrensaft recommended a full social transition, and Jonah started kindergarten as a girl named Jona.

In separate interviews with NPR reporter Alix Spiegel, Zucker and Ehrensaft openly denounced the other’s approach. Ehrensaft saw gender identity as strongly innate and believed that kids as young as 2 or 3 could begin to express it. “I think that our gender identity is not defined by what’s between our legs but by what’s between our ears — that it’s somewhere in the brain,” she said. “It’s pretty much hardwired.”

Zucker argued that this view was “astonishingly naive and simplistic” — a new form of gender essentialism disguised as progressivism. He instead saw a child’s gender identity as malleable, shaped largely by the family environment.

The crux of the argument came down to what happens to these kids when they grow up. In the interview, Zucker cited one of his studies of 25 girls diagnosed with gender identity disorder, which found that only 3, or about 12%, kept the diagnosis into adulthood, whereas the rest “desisted.” What’s more, Zucker found that 6 of the 25 grew up to be bisexual or homosexual. Several other studies of “behaviorally feminine” boys had gotten similar results. If these kids had followed Ehrensaft’s methods, Zucker said, they could have been wrongly sent down a track of hormone therapies and surgeries.

The crux of the argument came down to what happens to these kids when they grow up.

At the time of the interview, most doctors in the US agreed with Zucker. But in the eight years since, a huge shift has happened, says Ehrensaft, who now runs a gender-affirming clinic at the University of California, San Francisco. “You ask me now, and I say ours is absolutely the ascendant and increasingly predominant model for treating gender-nonconforming children, accepted throughout the world.”

(Zucker declined multiple requests for interviews from BuzzFeed News, instead sending five of his published papers on gender dysphoria in kids.)

Ehrensaft rejects the high desistance rates reported by Zucker and other researchers, cited repeatedly in arguments against social transitioning in kids. The biggest flaw in these studies, she says, was how they decided which kids to recruit. The children chosen showed a wide spectrum of gender-nonconforming behaviors that may have made parents uncomfortable at the time, but aren’t reliable markers of kids with lasting gender dysphoria. Those kids, Ehrensaft says, have the “insistent, consistent, and persistent” belief that they are another gender. What’s more, some of the studies assumed that teens who didn’t come back for follow-ups had desisted.

Since 2011, Ehrensaft’s clinic has seen about 100 children under 12. The kids are encouraged to choose from a huge array of gender labels, such as “gender hybrid,” “gender fluid,” “gender smoothie,” “gender Tesla,” and “gender Tootsie Roll pop.” Yet another category, “transgender” children, identify with the gender opposite what is marked on their birth certificates. Ehrensaft acknowledges that creating more labels might seem counterintuitive, but argues that they’re useful in making all kids — transgender or anything else — feel comfortable with the diversity of unique gender experiences out there. “Our clinical observation to date is that this is a very well-working model,” Ehrensaft said.

But she’s the first to admit that the approach hasn’t been tested in the long term. No study has yet looked at whether young kids who socially transition continue to thrive as transgender adults.

For the two kids in the radio segment, Zucker’s and Ehrensaft’s predictions seemed to play out as they each expected. Today, Bradley is a teenage boy who identifies as gay. (According to a recent interview with his mother, she said she appreciated Zucker’s “protective” approach.)

Jona, too, is doing well, according to Ehrensaft. “The most I can tell you about Jona without violating confidentiality is that she is doing beautifully eight years later.”

In 2013, a new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders changed the diagnosis of “gender identity disorder” to “gender dysphoria.”

Nicole was then 6, and still pressing her parents for dresses and Barbies. She would also insist on playing with the girls, and only the girls, in her Christian homeschooling group. Nicole would frequently tell her parents, “I’m a girl!” and was “ecstatic,” Kim said, anytime a stranger mistook her for one. “The littlest indication that she was a girl, she would just grab onto.”

Privately, Kim and Andrew wondered whether their child would grow up to be gay. So although they had started allowing Nicole to wear dress-up clothes at home more consistently, they’d also tell her that she was a boy, and that it was okay to be a boy who liked sometimes doing girly things.

It wasn’t working. Nicole would cry a lot more easily, get frustrated or angry over seemingly small things, and pick fights with her brother, WB. For Nicole, what was hardest was being told she couldn’t do something she felt like she couldn’t help but do.

“I usually felt like, I want to do this, but I can’t do this,” Nicole told me. She described how her dad didn’t let her play a girl character in her favorite video game, Toontown. “It made me feel very sad.”

Kim and Andrew suspected that Nicole’s issues with her brother were at the root of the problem, and took them both to a local child therapist, Kelly Nowotny. On her suggestion, they started to let Nicole wear a skirt or a dress — usually hand-me-downs from her 17-year-old sister, Olivia —when she went shopping with her mom. Nowotny also gave Kim a name for what Nicole might be going through: gender dysphoria. Before that, Kim said, her only reference point was confusing media coverage of Chaz Bono’s transition.

Around the same time, Olivia came to her mom with questions about sexuality. Her best friend had confessed that he was gay, and she didn’t know why her entire community pegged this as a sin. She was especially worried because she was also beginning to question whether she was straight.

That pushed Kim to action. “I was like, ‘OK, God, I have got to get off the fence.’”

Kim, who had been trained as a registered nurse and taught high school science for the homeschooling group, started reading everything she could about transgender people and kids with gender dysphoria — news stories, religious tracts, and scientific research papers, some of which were written by Zucker and critical of social transitioning.

There was no single moment when Nicole “became” their daughter.

Kim’s Bible is a sign of the inner battles she fought during that time, the margins littered with colored drawings depicting her personal interpretations. The pages containing the so-called Clobber Passages, the sections most commonly used to condemn LGBT people, are filled to the brim.

At first, she didn’t feel comfortable talking about what was going on with the other moms she knew, most of whom were in her Christian homeschooling group. So she joined private Facebook groups, such as Parents of Transgender Children, and Serendipitydodah, for Christian moms of LGBT kids. She’d often stay up late into the night talking and commiserating with these moms, her only outlet to a world beyond her conservative circles.

There was no single moment when Nicole “became” their daughter — it was a months-long process. But Andrew does remember the Saturday he realized that his resistance to what was going on might be harming her. Saturdays were his time to give Kim a break from watching all of the kids. He’d usually take Nicole to the Home Depot, which had sheds and playgrounds out front that kids played on.

“I wouldn’t let her play girl stuff. I wouldn’t take her to get her nails done or anything,” Andrew recalled, sitting at the dinner table. But that Saturday, she threw a fit, begging him not to make her go.

“I wasn’t necessarily forcing her to be a boy, but I wouldn’t let her be a girl,” Andrew said. And her reactions, he thought, were stunting her development: At the worst point, he said, “there was no bonding going on, no gender identity going on at all.”

As soon as they made the decision, when Nicole was 7, to let her present as a girl all the time, she was happier, more outgoing, and less anxious. He’d always thought of Nicole’s gender as a choice that he and Kim could influence, or something that would become clear when she hit puberty. But now, he realized, they couldn’t wait. “It’s a little like saying, ‘Let’s see about those arms when you get to be 12 or 13.’”

The first thing she would need was a new name. Her mom vetoed her top choices, borrowed from her favorite pop stars: Ariana (after Ariana Grande) and Selena (after Selena Gomez). They settled on a name that kept her first initial, pays tribute to her African ancestry, and could be used for a girl or boy. “Not that she’ll ever choose to go back, but it’s there for her,” Kim said. (“Nicole” was chosen as her middle name in tribute to Nicki Minaj.)

The change in Nicole’s personality, according to close family, was striking. Once shy and reticent in her theater class, she was now one of the most outgoing kids. Whereas she used to practice singing her favorite pop songs on the mic stand in her room, now she sang all the time in public. “She had all this fabulousness that couldn’t come out,” said Kim Carper, the drama teacher of her homeschool group at the time, “and it was being contained in this tiny little box.”

Carper, whose daughter had been Nicole’s best friend since they were 5, struggled initially with how her own kids would perceive the change. “When Kim first told me, I did have an instinctive fear, like, how do we tell the kids this without the kids wanting to change their sex or gender?” she said. “But my kids didn’t lose anything. They grew closer to the friend that they already had.”

But other family members, as well as many in their church community, thought Nicole’s new persona was a mistake. Many blamed Kim. “Oh, you can’t believe how Kimberly was hurt,” her mother, Gail, recalled. “The friends she thought were her friends turned their backs on her, and the church they had been attending for years more or less closed their door on them.”

After Kim told their Christian homeschooling group — a coalition of about 50 families who came together for some group classes and activities — about Nicole’s transition, the board called several parent meetings, excluding Kim and Andrew. Some families threatened to leave if Nicole was allowed to stay. So the family left on their own.

The head of another academy asked Kim “what kind of genitalia” Nicole had.

The rejection was just the first of many. The head of another academy asked Kim “what kind of genitalia” Nicole had. The pastor at their Baptist church said he couldn’t support “their choice” for Nicole. The head of another church suggested that, because she was adopted, Nicole might be suffering from “generational sin.” Kim blocked dozens of acquaintances on Facebook. Once at the center of a thriving community, the family was suddenly isolated.

In April of 2013, Kim went to a meetup of one of her Facebook support groups. Thirty mothers — who call themselves “Mama Bears” — drove to Dallas from as far as Oklahoma and Arkansas to pray and talk about navigating school systems and losing friends and family. Through the group, Kim discovered a local church that was LGBT-friendly.

Today Kim keeps her research papers in a hot-pink binder she calls a “safe folder,” along with letters from all of Nicole’s health care providers vouching for her gender dysphoria. Many moms from the Facebook groups cling to these documents. One told me: “They’re your final words, your desperate plea in case you’re stopped, your freedom papers.”

Kim takes hers whenever they go on trips, just in case. “When people say, ‘Well, the Bible says,’ I can pull this out and say, ‘Well, let’s look at what my Bible says,’” Kim said.

The baby-blue walls of their home are covered in crosses, Bible verses, and pictures of the three kids. The photos of Nicole show her as a tiny baby, or after her transition. She doesn’t like seeing pictures of what came in between.

By the beginning of 2015, 8-year-old Nicole had been living fully as a girl for about a year and was growing taller by the minute. With puberty on the not-too-distant horizon, Kim realized she was going to need some help from not only psychologists, but doctors who could advise them on what came next.

Genecis had just opened at the Children's Medical Center of Dallas two months earlier. Its admission process was long and arduous — an initial informational call, then a longer phone interview, an online interview, and a two-hour in-person interview in Dallas. The clinic required a “boatload of paperwork,” Kim recalls, including a letter from an outside therapist who had seen Nicole for at least six months. Because it’s the only clinic of its kind in the Southwest, families drove from as far as Oklahoma and Mexico.

After six months Kim finally got an appointment, and the family made the long drive up to Dallas. They first met with clinic founder Ximena Lopez, a pediatrician who specializes in hormones. Lopez told me she initially wanted the clinic to treat kids 8 and up, to avoid the controversy surrounding younger kids. But she lowered the age to 5, she explained, because “we saw a lot of families with younger kids that had nowhere to go.”

From Lopez, Nicole and her family finally got some assurance about the future. The doctor told them that if Nicole still felt like she was a girl around age 11, then she could take a drug called Lupron, which suppresses the ovaries or the testicles, essentially blocking puberty. That would save Nicole from the sweeping physical changes — developing an Adam’s apple, deepening her voice, growing facial hair — that might worsen her dysphoria, buying her several more years to decide whether to go through the more intensive estrogen therapy that would make her physically female. And years after that, she could decide whether to have surgery elsewhere to remove her male genitalia.

Lopez typically waits until kids are 16 to give them hormones — following the clinical standard set by the Dutch. But Kim, who staunchly believes that Nicole was born in the “wrong” body, wants to start the drugs earlier.

“I’m hoping 12, to tell you the truth,” Kim told me. “Girls who go through puberty at 13 or 14, they’re already feeling outcast. Thirteen would really be the latest I would want to go.”

Just as Lopez was supporting Nicole in her new gender identity, Zucker’s Toronto clinic was in jeopardy for taking the opposite approach. For years, clinicians and trans activists had skewered Zucker’s methods, writing op-eds, talking to hospital heads, and even getting the province of Ontario to pass a law banning “conversion therapies” meant to change someone’s gender identity. By February 2015, Zucker’s employer, the Centre for Addiction and Mental Health, called for an external review of his practices.

Nine months later, the hospital released a damning report. Zucker allegedly used controversial one-way mirrors (like those used in police interrogations) to interview and observe patients, intensely questioned young patients about their sexual orientation, and took pictures of patients without telling them why or how they would be used. According to the report, some patients reported feeling “poked and prodded.” Others described how the clinic had a “cisgender goal” which was “not right/shaming.” Zucker defended his approach with children by reiterating that “according to the current literature, [gender dysphoria] will diminish in 80% of cases.”

The investigators concluded that Zucker’s clinic was “not seen as a ‘safe space’ for gender questioning & transgender populations.” In December, the clinic was shut down. “We want to apologize for the fact that not all of the practices in our childhood gender identity clinic are in step with the latest thinking,” Kwame McKenzie, a medical director at the Centre, said in a statement at the time.

Some scientists and scholars have condemned the clinic’s shuttering, arguing that the decision was politically motivated and unscientific. Complicating matters, the report has since been taken down from the hospital’s website because it included an incorrect allegation against Zucker. He is now suing the Centre over the report.

A petition signed by more than 500 people argued that the hospital closed the clinic because of “activists for a fashionable cause” and “for some real or imagined local political gain.” It portrays Zucker as a hero for refusing to conform to a wave of political correctness in pediatric care when the future outcomes for these children are unknown.

"It was a lynching, pushed by activists."

“It was political. It was a lynching, pushed by activists,” Eric Vilain, a professor of human genetics and pediatrics at UCLA’s School of Medicine, who co-authored the petition, told me shortly after the clinic shut down. Vilain studies the genetics of sex development and is a strong critic of the gender affirming approach, which he believes is gaining traction too quickly. “There is far from any certainty that being gender affirming is in the best interest of the child,” he said. “You’re actually pushing the child in the direction of irreversible body transformations.”

Some sex researchers agree, arguing that the rise of the gender affirming approach is motivated by trans adults overcompensating for injustices they were forced to live through growing up. “Adult trans people look back and remember their situation and assume it’s true for every kid that looked like they did when they were little,” Alice Dreger, who wrote about the clinic shutdown, told me last year. She defended Zucker’s camp as “being pretty progressive, because they’re daring to slow kids down a little bit.”

But if you ask the doctors who are actually treating children at gender-affirming clinics, they say this is a dangerous oversimplification. It’s true that some kids who are confused about their gender identity will grow out of that phase (or will choose to identify outside of the gender binary entirely). But for those who are insistent in a trans identity over a long period of time, these doctors say, preventing them from socially transitioning could be psychologically damaging. They point to studies showing that LGBT teens whose families don’t support them are twice as likely to think about or attempt suicide. A second petition, signed by more than 1,300 people, supported the decision to close Zucker’s clinic.

Still other doctors fall somewhere in the middle, and are apprehensive about too strongly embracing the gender affirming approach. “I am concerned about some of the newer clinics,” said Walter Bockting, co-director of the Program for the Study of LGBT Health at Columbia University Medical Center. “We just don’t have the evidence to be confident about an approach like that, so I’m very concerned.”

That research is on its way. The first study of socially transitioned children in the US, called the TransYouth Project, was published last year by researchers at the University of Washington. The study takes as a starting point that kids across the country are transitioning, and it asks what happens to them afterwards.

“People talk a lot about their worries about social transition, but we don’t know which of those worries are going to be borne out,” said Kristina Olson, director of the project.

To date, Olson’s team has recruited over 300 kids and their families in 39 states. Of these, 250 have socially transitioned. Her first paper looked at how their mental health compared with their cisgender peers. Although previous studies had shown high rates of anxiety and depression among children diagnosed with gender identity disorder, Olson’s study found that socially transitioned kids have normal levels of depression and only slightly higher anxiety than their cisgender peers.

In the long term, the TransYouth Project will look at these kids over a period of 20 years. “We want to ask: Are parents figuring out which kids are trans, or not?” she said. But while everyone agrees that we need more research, some doctors worry about focusing too much on the future.

“We sometimes have to meet kids where they are,” Johanna Olson-Kennedy, medical director for the Center for Transyouth Health and Development at Children's Hospital Los Angeles, told me. Although the vast majority of Olson-Kennedy's patients are over the age of 15, she has seen about 100 under the age of 9. “If we spend so much time wondering what they’re going to end up looking like, we miss what they’re going through now.”

One sweltering afternoon in July, Nicole and her family drove to Dallas once again, so she could meet with her clinical psychologist at Genecis. This yearly check-in was part of the clinic’s own study on the psychological well-being of their growing client base.

Nicole DJ’d from the backseat — navigating expertly through the country hits of Carrie Underwood and Miranda Lambert, rapping to Desiigner’s “Panda,” and crooning dramatically to Ariana Grande’s “Dangerous Woman.” When she got bored, she pulled out her pink Nintendo DS to play her favorite game, Super Princess Peach.

At Genecis, the receptionist pulled up Nicole’s medical records and accidentally called her by her old name and gave her a wristband with the old name, too. Nicole, usually bubbly and loud, quietly played Pokémon Go until they called her in.

One of the program's mental health providers, Laura Kuper, met first with Kim in a nondescript medical office. She ran through a long laundry list: How was Nicole doing with friends? Did she still have an aversion to being identified as transgender, rather than just as a girl? How much was she focusing on her body, or asking questions about puberty? Was she beginning to express any interest in sexuality?

Kim said that her daughter’s biggest problem was anxiety, even though it had lessened considerably after her social transition. She still had some difficulty seeing people she knew “from before,” insisted on always staying in her mom’s sight, and wouldn’t go in the bathroom by herself. Kim updated Kuper on the status of her legal battle with the Texas judicial system, which wouldn’t allow Nicole to have an official gender and name change because she hadn’t yet started any hormone treatments.

When Kuper met with Nicole, they began by talking about the cherished American Girl books her sister had been reading out loud to her. They talked about the many friends she had in her neighborhood, and about the bullies who had recently upset her by calling a kid with Down syndrome an “it.”

She wanted long hair, “definitely no beard,” breasts, and a feminine body shape.

“When you think about yourself when you’re older, maybe Mom’s or Dad’s age, is there a way that you want to look?” Kuper asked.

“I didn’t really think about that before, wow,” Nicole said. They then ran through the physical traits that she imagined: She wanted long hair, “definitely no beard,” breasts, and a feminine body shape.

“So it’s sounding like the things you’re wanting are more of a girl body, so that would be kind of what the puberty blockers would help with, to stop the male changes,” Kuper said.

The psychologist explained how the Lupron would give her a chance to decide, later on in her teenage years, whether she was sure that she wanted those female changes to happen, then asked: “Anything about your body that makes you feel uncomfortable or you’re upset about right now?”

“Not that I can think of right away,” Nicole slowly answered. She paused, and then continued more quietly. “Maybe my private part.”

Kuper nodded. “So that’s something that makes you feel pretty upset or just a little bit upset?”

“A lot upset,” Nicole said.

At the end of the session, Kuper gave Nicole a pack of 24 colored pencils and asked her to draw herself. She carefully pulled each one out, laying them neatly in a line. She picked out a black pencil first, then played with the pink before putting it down. She looked at the pencils again, picked up the pink, and drew: some curly hair, a shirt, a long triangle-shaped skirt, and finally, a smiley face.

In September, Nicole got her 10th birthday present: a trip to New York City’s doll megastore, American Girl Place. Her parents, siblings, and grandmother had driven four days in one car to get there, and were planning to also visit family all over the East Coast, most of whom would be meeting the new Nicole for the first time. She could barely stand still for the two whole minutes it took to snap her photo in front of the store before bolting inside.

Hundreds of little girls ran around the three-story, pink-carpeted emporium, surrounded by a dizzying array of dolls and doll-related pampering: a doll hair salon, an ear piercing booth, a spa where dolls can get a soft scrub or a face mask, a mani-pedi station, and even a doll hospital.

“Oh my goodness, oh my goodness, the pink coat is so adorable!” Nicole squealed to her mom, her curls bouncing as she jumped up and down and pointed to a large display of one of the store’s most popular dolls, Samantha. “It’s my favorite,” she added more calmly, smiling and folding her hands in front of her pink and white flowered dress.

Kim and Andrew bought Nicole her Samantha doll, along with the smart pink peacoat, matching bag, hat, and carrying case. The family made their way to a bench, where Nicole impatiently pulled the doll out of its packaging, smoothed her shiny brown hair away from her pale face, and clutched her to her chest.

Ten days later, back in Texas, Kim tried one last time to get Nicole’s name and gender changed on her birth certificate. Kim, Andrew, Olivia, WB, and Kim's parents met with a judge, who first asked the family some questions, and then Nicole: How long had she identified as a girl? How long had she been going to Genecis? Why did she want the change to happen now?

Nicole told the judge about how she wanted to be on the girls dance and sports teams, without anyone questioning whether she belonged.

The judge signed the court order right in front of them. Nicole would get a new birth certificate, marked as “amended,” officially stating she is a girl. ●

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