Aidan Key, left, was born a girl named Bonnie.
When Aidan Key was a little girl, he didn't realize he had gender identity issues. He simply knew something was off.
"I didn't necessarily become aware that I was trapped in the wrong body," says the 49-year-old Bellingham, Wash., native who had gender reassignment surgery at the age of 33. "I became aware that people didn't perceive me as I felt myself to be. It was just odd to me to have to wear a dress the first day of kindergarten. It didn't make sense."
Today, Key might have received counseling -- and perhaps even puberty blocking drugs -- at one of a handful of U.S. clinics designed to help adolescents with what’s now called gender identity disorder or GID. The psychological diagnosis is used to describe a male or female who feels a strong identification with the opposite sex and experiences considerable distress because of their actual sex (the word "disorder" refers to the distress the person feels, not the fact that they identify with another gender).
According to reports published Monday in the medical journal Pediatrics, a small but growing number of teens and even younger children who think they were born the wrong sex are now getting support from parents and from doctors who give them treatments that could eventually help them change their sex.
Some estimates say about 1 in 10,000 children may have GID, Dr. Norman Spack, author of one of three reports published Monday and director of one of the nation's first gender identity medical clinics, at Children's Hospital Boston told the Associated Press. And that number does appear to be on the rise, experts say.
The number of people treated at Spack's Gender Management Service clinic, also known as GeMS, which was the focus of a study, increased fourfold between January 1998 and February 2010. The clinic now averages about 19 patients each year, compared with about four per year treated for gender issues at the hospital in the late 1990s.
While many children can take part in nonconforming gender activities without issue -- little boys playing princess, for instance -- those with GID can experience a host of psychological problems, especially with the onset of puberty.
"It's devastating to them," says Dr. Scott Leibowitz, a child and adolescent psychiatrist at GeMS clinic in Boston.
Those who don’t get support in the form of counseling or medical treatment can be at high risk for behavior and emotional problems, the study found. Of the 97 patients younger than 21 years old in the study who met the criteria for GID, 44.3 percent had a history of significant psychiatric problems, including 20.6 percent who reported self-mutilation and 9.3 percent who attempted suicide. The youngest in the study was age 4.
Laura Edwards-Leeper, a psychologist specializing in youth gender issues at Seattle's Children's Hospital and co-author of the Pediatrics study, says at her hospital, “more and more people are banging down the doors to get in. I'm guessing in part this is due to media attention and people becoming a bit more accepting about it. Parents are becoming more open to the possibility and willing to get help for their kids."
Unfortunately, some parents who seek help for their child through traditional channels - such as the family pediatrician - can come away feeling judged.
"I've heard many, many stories of adults and families being turned away with a stern lecture about their parenting or their choices," says Key, director of Gender Diversity, an education, support and training organization committed to increasing awareness about gender variations. "It can often be viewed as a moral issue."
Support from parents doesn't always exist either, says Key.
"The response varies so much," he says. "Some parents will tell the kids 'No, you're really a boy. No, those are girl toys. You don't want that.' They try to get the child not to engage in these activities because they know it's not accepted by society, they know the child will be teased. I try to think they have the best intentions."
Sometimes, the response of parents -- or others -- can be quite damaging. A related study of childhood abuse in the current issue of Pediatrics found gender nonconformity before age 11 was a risk indicator for physical, sexual, and psychological abuse in childhood as well as probable PTSD.
Key says there are many theories about why some people have GID but research seems to point to chromosomal variations, i.e., "intersex conditions," such as a female with XY chromosomes instead of XX chromosomes. Another theory has to do with the way a particular person's brain is mapped.
"A person may have a brain that is more oriented towards male and their body is female," he says. "There's been some preliminary research that supports that. But the verdict is still out. They need to do more research on it."
As for what parents should do if their child starts acting in a gender nonconforming way, Key advises ongoing communication and conversations.
"Ask them, 'Do you just want to wear dresses or do you feel like you're a girl?'" he says. "Sometimes a boy who just wants to wear dresses is just a boy who wants to wear dresses."
When little kids speak up and tell their parents "I have the body of a boy but the heart and mind of a girl," though, parents should take note and decide how they want to handle it, he says.
At the GeMS clinic in Boston, a team of psychiatrists, psychologists, endocrinologists, and pediatricians provide tools to help adolescents navigate the choppy social and psychological waters of gender identity.
"As non-transgender individuals, we take for granted how easy life is when our mind and our body are congruent with each other," says Leibowitz. "Clinicians and pediatricians need to understand what gender nonconformity and gender dysphoria mean for a specific individuals and to know there are options out there that will profoundly improve their quality of life."
But even kids who have emotional support can become extremely distressed when puberty hits and their body begins to change into that of a stranger, says Leibowitz.
Learning to fit in
Key says as a child, he had questions that grew sharper as he got older about where he fit in.
Courtesy of Aidan Key
Aidan Key, as a young girl named Bonnie, left, shown with his identical twin sister, Brenda.
"I remember once when I was 9 observing all the families in the lobby at church and realizing that I was supposed to grow up and get married and have a family," he says. "I remember thinking 'I don't mind getting married and having a family, but I don't want to be the wife. I want to be the husband.'"
Key says he received a lot of support from his mother, step-father and identical twin sister, Brenda.
"My family was very encouraging of nontraditional female activities," he says. "I was aware that society expected something different from me but since my family said 'We don't care about that,' I accepted that and said 'It's society's problem, not my problem.'"
Key says he had a couple of boyfriends in high school but by age 19, realized he was attracted to women and began to identify as a lesbian. Over the years, though, he came to realize that that wasn't quite right, either.
"It was challenging," he says. "I was getting all this support to be whatever type of woman I wanted to be, but no one asked what if being a woman wasn't the right part. That was a fixed situation. There was nothing to be done about it."
Today, at the GeMS clinic in Boston, young children and their families get psychological counseling and are monitored until the first signs of puberty emerge, usually around age 11 or 12. Then children are given puberty-blocking drugs, in monthly $1,000 injections or implants imbedded in the arm.
Being able to temporarily push the pause button on puberty (the drug's effect are completely reversible) is extremely helpful, says Edwards-Leeper. The idea is to give these children time to mature emotionally and make sure they want to proceed with a permanent sex change.
"By stopping puberty early on, a boy won't grow as tall, his facial hair won't come in, his Adam's apple won't develop," she says. "All the things that make it difficult for adult transgender people to pass are eliminated. The quality of life for transgender people who have been fortunate enough to receive puberty blocking medication is so much better."
Kids will more easily pass as the opposite gender, and require less drastic treatment later, if drug treatment starts early, Spack said. For example, boys switching to girls will develop breasts and girls transitioning to boys will be flat-chested if puberty is blocked and sex-hormones started soon enough, Spack said.
While many of the patients at the GeMS clinic included in the study were too old for puberty blocking medications, two-thirds did go on to receive cross-sex hormone therapy (i.e., testosterone for women and estrogen for men), which can be a precursor to sexual reassignment surgery. Only one of the 97 in the study opted out of permanent treatment, Spack says.
Not all adolescents with GID opt for the surgery when they reach the age of consent, though, says Leibowitz. "It's very individualized and it's really a private issue. It also isn't covered by insurance and can cost $20,000," he says. "For some people, that might not be a necessary thing."
Key, now married, says his surgery was not only necessary, but a "no brainer."
"Once I had a conscious acknowledgment that I was transgender, it was simply a matter of logistics," he says. "I started saving money. One of the most amazing feelings I ever had was being on a beach without my shirt on and being male and feeling like 'Finally, this is what I'm supposed to feel like.' Normal, natural and right. And about time."
The Associated Press contributed to this report.