Q&A with Norman Spack

A doctor helps children change their gender

(Boston Globe / Erik Jacobs)
Email|Print|Single Page| Text size + By Pagan Kennedy
March 30, 2008

CHILDREN HAVE CUT themselves. In some cases, 9- or 10-year-old kids have staged suicide attempts. The little boys sob unless they're allowed to wear dresses. The girls want to be called Luke, Ted, or James.

Their parents, desperate to know what is wrong, go online and type "gender disorder."

And what they find is that, even now, decades after doctors performed the first sex changes in America, there's little help for transgender children.

Even the care of transgender adults remains a medical backwater in the United States; in fact, we do not even know how many people in this country have gone through sex changes, because doctors simply did not bother to keep track of patients. Until recently, children with cross-gender feelings rarely received modern medical care - and certainly not hormone shots. After all, who would allow a child to redesign his or her body?

But in the past few years, some doctors have come to believe that kids should be allowed to have some control over how they grow up. Dr. Norman Spack, 64, argues that transgender kids tend to be much happier - and less likely to harm themselves - when they're able to live in their preferred gender role.

Last year, the pediatric endocrinologist started a new clinic at Children's Hospital Boston; it is one of a few in the world to give children treatments that change their bodies. Working on a model borrowed from Dutch researchers, Spack uses drugs to delay the first stirrings of youngsters' puberty, granting them a few more years before they develop bodies that are decidedly male or female. The effects of these puberty-blocking drugs are reversible; that is, patients can later change their minds. Unfortunately, this is not the case with hormones. Therefore, Spack prescribes estrogen and testosterone to only a few teenagers - after months of consultation with the patient, his or her caregivers, and psychiatrists. When kids take this step, they are rewriting their own future: The hormones have a powerful, pervasive effect, changing their height, breast development, and the pitch of their voices.

IDEAS: When are children old enough to declare what gender they will be?

SPACK: All I know is that when I see preadolescents, they have been dressing in the underwear of the other sex for years. These kids are almost certainly transgendered. They're a unique population of patients. By the time a kid comes in to see me, both parents have agreed that the child is in danger and needs some form of intervention. And that has led to heavy-duty counseling for the child and parents. Therefore I see young people and families who have been evaluated by skilled professionals.

IDEAS: At what age do you give kids drugs to delay puberty?

SPACK: The puberty-blocking drugs work best at the beginning of the pubital process, typically age 10 to 12 for a girl and 12 to 14 for a boy. Stopping puberty is, in itself, a diagnostic test. If a girl starts to experience breast budding and feels like cutting herself, then she's probably transgendered. If she feels immediate relief on the [puberty-blocking] drugs, that confirms the diagnosis.

IDEAS: So the aim of your treatment is to protect children from harming themselves?

SPACK: Transgendered kids have a high level of suicide attempts. Of the patients who have fled England to see me, three out of the four have made very serious suicide attempts. And I've never seen any patient make [an attempt] after they've started hormonal treatment.

IDEAS: At what age should children be allowed to take hormones, like estrogen and testosterone, that will forever change the way their bodies develop?

SPACK: Well, the Dutch would say 16. But I think more flexible guidelines will be coming out. For some kids, 16 might be appropriate. For others {hellip} you lose opportunities if you wait. [One of my patients, a] transgendered girl from the UK, was destined to be a 6-foot-4 male. With treatment, she's going to end up 5-foot-10.

IDEAS: What are the most difficult ethical issues you face?

SPACK: The biggest challenge is the issue of fertility. When young people halt their puberty before their bodies have developed, and then take cross-hormones for a few years, they'll probably be infertile. You have to explain to the patients that if they go ahead, they may not be able to have children. When you're talking to a 12-year-old, that's a heavy-duty conversation. Does a kid that age really think about fertility? But if you don't start treatment, they will always have trouble fitting in. And my patients always remind me that what's most important to them is their identity.

IDEAS: Several years ago, you became an evangelist for transgender kids at Children's Hospital. How did you become so committed to this issue?

SPACK: Well, let's start with 1974: I'm working at Bridge Over Troubled Waters as a volunteer. I see lots of transgendered kids. They were runaways, in bad shape. Then years later, in 1985, I'm working in adolescent medicine. Someone sends me a transgendered Harvard graduate who presented himself as a male. He introduced me to his friends and support groups. And then I began working with transgendered people in their 20s. The people in their 20s were socially in good shape. But they were having trouble getting their physique to conform to their identity. I knew the twenty-somethings could have better chances of passing if they were treated earlier.

IDEAS: And how did you make the case for this specialized clinic at Children's Hospital?

SPACK: In the last five years, I've been getting more and more referrals, parents with gender-variant kids. The parents heard about me through Internet support groups. So, I began to bring my transgendered patients and their parents - kids as young as 9 - to a large number of clinical conferences in various departments at Children's Hospital. That way, my colleagues could learn about this population. My philosophy is, "Who am I to say what it's like to be transgendered when I have people who are living with it every day?" These kids won over the hospital, one department at a time.

IDEAS: You're involved with a number of Jewish philanthropic groups. How does your faith inform your work with gender-variant children?

SPACK: My own rabbi said it best: The transgendered are also created b'tzelem Elohim, in the image of God.

Pagan Kennedy is the author of nine books, most recently "The First Man-Made Man." She can be reached through her website,

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