Nicole clutches her phone, flops down on the couch next to her mother, and squeals, “Oh my God!” She’s just learned that a boy she met online is someone she might have known in preschool. Her mother Jenn looks skeptical. “How would he know it’s you?” she asks. Nicole tells a complicated tale involving a picture and shared acquaintances. Her excitement renders the story incomprehensible to all except perhaps other 13-year-olds. 

Jenn isn’t convinced. “But how would he know it’s you?” she repeats. Nicole loses interest in explaining herself and goes back to her phone without ever acknowledging what her mother is really asking. How would the boy have recognized Nicole, a pretty eighth grader with long, blond, fuchsia-streaked hair, as a former classmate? Back then, Nicole was a little boy named Nicolas. 

When he was two, Nicolas discovered his first Barbie at the house of his mother’s friend. Soon he was begging his parents for more dolls, and wrapping towels around his head and waist to mimic Barbie’s hair and dresses. By the following year his mother found herself constantly negotiating with the toddler about his toys, clothing, and more. He screamed and fought when she forced him to get his hair cut, so Jenn kept his hair mullet style, short on top but long in the back. He wanted pink and purple clothing; she tried to dress him in greens and yellows. The battles exhausted the stay-at-home mother and wore down her resolve.

“It was just so strong in her, and she would just cry so much,” Jenn told me the first time we met at a Starbucks near her home in southeast Houston. She’s a strong, solid woman with wavy brown hair who speaks with a twang that betrays a Texas City upbringing. “Eventually I thought, ‘What the hell? A little boy in a pink shirt. Who cares?’ My husband was shaking his head the whole time, saying this isn’t good, it’s not right, there’s something wrong here.” 

Jenn, who requested that we not give her family’s real names, uses female pronouns for Nicole, even when referring to incidents that happened before Nicole quietly made the social transition from male to female—meaning that she changed the way she presented herself in school and in public—in the summer before sixth grade. Only a few people outside the family know that Nicole’s gender identity and expression don’t match the reproductive organs with which she was born. Using a testosterone blocker to halt male puberty and synthetic estrogen to initiate female bodily development, her plan is to finish middle school by taking online classes at home, then attend high school as an openly trans female student. 

Until recently, children with gender dysphoria—the current psychiatric term for what used to be called gender identity disorder—had few options besides wearing the clothes and adopting the mannerisms of their preferred sex. But a shift in the medical consensus about the condition has now made it possible for children like Nicole to radically alter their physical appearance to match how they feel on the inside. 

Over the past 15 years, doctors have grown progressively more comfortable prescribing hormone blockers to transgender children, and transgender teenagers and their families aren’t waiting until adulthood for cross-sex hormones and sex reassignment surgery. They’re embarking on medically assisted transformations earlier. Much earlier. These days, such teens often learn about these procedures through a simple Google search, and the amount and availability of information out there is increasingly forcing parents like Nicole’s to make difficult decisions about whether to allow their children to undergo medical treatment, including life-altering hormones.  

Nicole was 11 when she decided she wanted hormone therapy to halt male puberty and promote the growth of feminine features. Her parents reluctantly agreed to support her decision, terrified by statistics showing that adolescents with gender dysphoria are at a higher risk for severe psychological distress, self-mutilation, and suicide. And so, for the past two years, Nicole has been taking pills twice a day—spironolactone, which blocks male hormones like testosterone, and estradiol, a synthetic form of estrogen often given as a hormone replacement to post-menopausal women, even though estradiol has been shown to increase the risk of breast cancer. 

It wasn’t an easy decision. “I was brought up in a religious family,” says Nicole’s father, Jim, a Houston native. “We were taught, ‘Live right, or you’re going to burn.’” That dogma, he said, crumbled under the task of raising Nicole. Nicolas wasn’t just a boy who liked to wear pink. By the time he was in preschool, he was lining up with girls, napping on his princess blanket, and carrying his lunch to school in a box stamped with Disney’s latest heroine. 

There is no medical consensus on the best course of treatment for gender-dysphoric prepubescent children, mainly because it’s almost impossible to tell which kids will continue to experience the condition as adolescents and adults. Citing informal studies, Drescher and Meyer estimate that only about 20 percent of prepubescent children who exhibit cross-gender behavior continue that behavior into adolescence. “You’re in unknown territory, where the experts disagree,” says Dr. Jack Drescher, a New York–based psychiatrist who, along with Dr. Kenneth J. Zucker of the University of Toronto’s Gender Identity Service, helped write the entry for gender dysphoria in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. “If most of these kids won’t grow up to be transgender,” says Drescher, “[socially transitioning] could be harmful,” never mind hormone therapy.

Jenn and Jim vividly remember the day the principal at Nicolas’s fundamentalist Christian preschool called them in for an emergency conference. Thrusting a copy of conservative psychologist James Dobson’s Bringing Up Boys at them, he instructed the couple to banish all of Nicolas’s girl stuff, including his beloved doll, Brenda, and stop the behavior before it progressed any further. Jim, an independent contractor who is happiest hammering nails, tried to interest Nicolas in baseball and skateboarding, but the only thing he ever wanted to do with his dad was play dolls. 

In the days and weeks that followed, Nicolas grew increasingly anxious as catastrophe seemed to strike his favorite things. His parents, who had taught him the alphabet by assigning a letter and corresponding name to each of his 26 dolls, took them all away. They told him that his favorite blanket had been shredded in the washing machine, that his Disney lunch box was accidentally run over by his mother’s pickup truck. One day Jim found himself screaming and threatening to hit his son for refusing to wear boys’ shoes.  

A window A/C unit rattles behind his head as Jim and I sit in the living room of his family’s Depression-era home, which despite being just minutes from downtown is tucked within an unexpectedly pastoral pocket of Houston. Although polite, he grows impatient when we sit down to talk, telling me that he’s “over the whole gender thing” and is more immediately concerned with Nicole’s total unwillingness to do chores. 

Unlike his wife, who has become active in the transgender community, organizing school assemblies and addressing local advocacy groups, Jim has hung back from the small, protective network that’s evolved for families with trans children. Yet, when he talks about his journey from denial to acceptance of Nicole’s identity, it’s clear that he’s undergone a profound transformation. The day he almost beat Nicole for not wanting to wear boys’ shoes was the day he started wondering who he was trying to help: his real child, or the child he wished he had.  

“That was the beginning of the awakening,” Jim says. “I realized that it wasn’t about me and how people viewed me and my son. It was about Nicole and my ability to allow Nicole to be who she really is.” 

In his office at the University of Texas Medical Branch in Galveston, Dr. Walter Meyer, a 72-year-old pediatric endocrinologist and psychiatrist, opens a drawer and pulls out what looks like a giant rosary with 25 wooden beads that grow progressively larger, from a jellybean to a large egg. It is an orchidometer, a tool used to measure testicular volume. “This is Tanner 2,” says the white-haired, bespectacled Meyer, holding the fourth bead between his thumb and forefinger. In 2009, the Endocrine Society, the field’s most prominent organization, issued new guidelines for care—drawn up by a committee that included Meyer—which recommended the use of hormone blockers for gender dysphoric adolescents, followed by cross-sex hormones if the dysphoria persists. 

According to the Endocrine Society’s guidelines, hormone blockers should ideally be administered when a child reaches Tanner 2, around age 12; cross-sex hormones, meanwhile, should not be given until age 16, and only if dysphoria persists and the patient elects to take them. The earlier in puberty the blockers are taken, the less progress children make toward the sex they don’t want to be, and the easier it is to begin transforming the teenager’s body with cross-sex hormones and, potentially, sex reassignment surgery. Furthermore, studies suggest that the physiological effects of blockers are ultimately benign—stop taking them, and puberty resumes.

Hormone blockers have been used for decades to treat the small percentage of children who experience too-early puberty (or precocious puberty, as it is known). But it was Dutch endocrinologists who, in the ’90s, began using the blockers for a different purpose—to alleviate the psychological distress that often accompanies puberty in adolescents with gender dysphoria. Following the Dutch protocol, Meyer began prescribing hormone blockers to children in 2000. (He is not treating Nicole.) “It’s a pause button,” he explains. “The blockers buy these kids more time.” 

Although the Dutch pioneered the treatment for adolescents—the Endocrine Society based its new standards on the apparent success of the Dutch physicians—Meyer had been using cross-sex hormones to treat transgender adults for decades. In fact, Meyer helped briefly turn Galveston into a national hub for such treatments in 1976, when he and Dr. Paul Walker, a fellow Johns Hopkins med school alum, created what was the state’s first clinic for transgender adults at UTMB. By the early ’80s, over a hundred transsexuals from around the country had made pilgrimages to the island to receive cross-sex hormones and sex reassignment surgery. UTMB hosted international symposia dedicated to transgender health issues, and its physicians began cranking out papers on the effects of female hormones on biological males.

Then it all came undone. In 1983, a new chairman of UTMB’s department of endocrinology was appointed, one who disapproved of the clinic’s activities. Dr. Walker moved his practice to San Francisco. Some of the doctors who trained under Meyer established the privately run Rosenberg Clinic down the street from UTMB. In discussing the closing, Dr. Meyer doesn’t display any anger, just disappointment at all the clinical research that was cut short. “We were way ahead of the Dutch,” he says with clear competitive pride. Still, UTMB never prevented him from treating transgender adults, which he resumed doing in 1991 after becoming board-certified in psychiatry (nor does the hospital prevent him from treating transgender adolescents now).  

Meyer says that over the last 14 years he has treated roughly 35 teenagers with hormone blockers. The youngest person to whom he has prescribed cross-sex hormones was 14, a female-to-male patient who would not leave the house, much less go to school, once she’d begun developing sexually. By the time of her arrival at Meyer’s office, she was using painful binders to hide her breasts, he says. Ultimately, he recommended that she be allowed to have her breasts surgically removed and begin receiving testosterone to develop male features. She had a double mastectomy later that year. “I know the most important thing for that 14-year-old is to go to school and live a normal life,” he tells me. “If they’re not in school, if they’re not a part of society, that’s a tragedy.” 

Meyer likes to steer his patients to Facebook, which earlier this year expanded its choice of genders to more than 50 options, including intersex, genderqueer, and pangender. “People have embraced the possibility that children might be a variety of different genders,” he says. “I refer them to Facebook to see what all the different choices are and how ambiguous the whole area really is.” 

Although the transgendered make up only an estimated 0.5 percent of the population, their visibility is on the rise thanks in part to TV shows like Amazon’s Transparent, about a father who comes out as a trans woman; openly trans actors like Laverne Cox of Orange Is the New Black; and a wave of new children’s books featuring transgender protagonists. In June, Time featured Cox on its cover next to the headline “The Transgender Tipping Point: America’s Next Civil Rights Frontier.”

To get a sense of how rapidly attitudes are changing, just talk to any trans person who grew up in an earlier era. James Gonzalez, a 30-year-old social worker who moved here from San Antonio seven years ago, is impressed by how accepting many families are today of their transgender children. “To have parents that are willing to go on that journey with them, and to see these kids being taken seriously, that’s the most amazing thing in the world,” he tells me. “They don’t have to experience the same things I did.”

In the days before the internet, Gonzalez says, people like him felt alone in their struggles. At one point, he came out as a lesbian but felt too ashamed of his body to be intimate with anyone; furthermore, he just didn’t feel like a woman. By his mid-20s, he was so depressed he withdrew almost entirely from his peers. It wasn’t until Gonzalez began taking testosterone and had his breasts surgically removed that he finally felt comfortable rejoining society. 

“I couldn’t imagine ever having a partner or kids. After I transitioned, I envisioned a life for myself. I could imagine getting older, getting married, having kids, getting short and bald and wanting a house with a barbecue pit. All those stupid things, I wanted them.” 

Gonzalez now works at a nonprofit and volunteers at Hatch Youth, a Houston center for gay and transgender children founded in 1987, where he leads a weekly support session. He also serves as a “big brother” to trans children in the Houston area, kids like Jacob, a 9-year-old Friendswood boy who was born Jessica. I spoke with Jacob’s mother Ann (not their real names).

She remembers praying for years for a child. “I would say to God, please bless me with a child. I have no expectations. I don’t care if it’s a boy or a girl, I want to be a mother and share the love I feel from you. Darned if God didn’t take me seriously.” After fertility treatments failed, Ann and her husband fostered and later adopted a baby through Child Protective Services.

Many young girls dream of becoming a princess. Jessica dreamed of becoming a boy. By the end of kindergarten, she was demanding to be called Jacob and requesting buzz haircuts, and when she tried to urinate standing up, Ann took her to see pediatric psychologist Marni Axelrad at the Texas Children’s Hospital. Ultimately, Ann decided to go along with her daughter’s image of herself rather than fight about appearances. “The two happiest days of my kid’s life [were] the day she got a boy’s haircut and the day she got boy’s underwear. She just blossomed into this boy.” 

When Jessica graduated from kindergarten, she wanted to dress up for the ceremony, so Ann took her to JC Penney, where her daughter picked out a navy blue suit and tie. “She was so proud and excited, she looked so sharp.” On the day of the ceremony, a man sitting near Ann commented, “What a handsome little boy,” pointing to the only child in a suit. She couldn’t help but chuckle to herself. “That’s my daughter!” she thought.  

As the ceremony began, the teacher began calling each child out by name to receive certificates. Neither Ann nor Jessica had anticipated this. Ann noticed Jessica backing off the stage. “Mom, they’re going to call me by my girl’s name,” Ann remembers her daughter saying. “I’m sorry, honey,” was all she could reply. The room was completely still as the handsome little boy named Jessica walked across the stage to claim her certificate. 

That summer, Jacob and his family moved to the Clear Lake area to be closer to his father’s job as a chemical engineer at the Houston Ship Channel. Ann met with officials at her son’s new school to explain that her first grader had been diagnosed gender dysphoric and wanted to be called Jacob. The school agreed to do so, although his secret was threatened every time a substitute teacher read from the class rolls. The boy quickly devised a work-around. If his birth name was called out during attendance, he would sit silently. Only later would he approach the new teacher, quietly telling her, “I’m Jessica, but I go by Jacob.” 

To try to forestall such embarrassments, Ann tapped into an underground railroad of sorts that has sprung up within the trans community. Both Jacob’s and Nicole’s parents hired the same local attorney, a long-time advocate for transgender rights, to secure legal name changes from a trans-friendly Texas judge. (Both families had to sign affidavits promising not to disclose information about the judge. In the past, the lawyer told them, judges have suffered political consequences for approving name changes for transgender people.)

Another child I spoke to for this story, whom I’ll call Angie, decided to make the social transition from male to female while a second-grader at her East End HISD school. When she needed to use the restroom there, she used the facilities in the nurse’s office, at least initially. But Angie really wanted to use the one the other girls used. Although the school had supported her through the transition—HISD passed an anti-discrimination ordinance encompassing gender identity and gender expression in 2011—the bathroom issue gave officials pause. The school’s legal department told Angie’s mother they would have to consult with the district’s Board of Education, which meant the case might become a matter of public record.

The 37-year-old mother of two says that for her part, she was prepared to battle the board and face a potential public backlash, but was worried about Angie’s privacy. Through calm persistence, she had previously worked out a compromise for her daughter at the family’s “very Mexican” Catholic church, persuading a priest there to allow Angie to receive her first communion in a dress, although the official certificate would bear Angie’s birth name. Ultimately, according to board member Anna Eastman, HISD lawyers advised the district that because Title IX protects students from gender-based discrimination, her daughter had the right to use the bathroom that most accorded with her gender identity. 

“It’s a very misunderstood circumstance,” Eastman tells me as we meet for coffee in the Heights, part of the district she represents. “I want families to know that in HISD we have their back. We want to create an environment where the child is comfortable and feels safe so that they’re ready and able to learn, and [so] everybody else who may not understand it doesn’t become the road block for that being possible for the kid and the family.” 

According to their parents, neither Jacob nor Angie has reported any major problems at their elementary schools. What most worries the children is what will happen to their bodies. Jacob has made it clear to his mother that he doesn’t want breasts. Angie, who is a year older, knows her voice will eventually change, making it increasingly difficult to pass as a girl. This terrifies her. 

Both children had consultations with UTMB’s Meyer earlier this year. Angie became distraught when she heard that as a 9-year-old she couldn’t yet get hormone blockers. Meyer showed her the fourth bead on his orchidometer—the Tanner 2—and explained that Angie could see him again when her testicles had become that size. Before she and her mother left his office, Meyer tried to reassure Angie he wouldn’t let anything happen to her body that she didn’t want.  

Because there is so little empirical research on the outcomes for prepubescent children who undergo a social transition, parents are left to sift through a jumble of often contradictory opinions on the best course of action. Some pursue treatment at Zucker’s University of Toronto clinic, where children are prohibited from cross-dressing and steered into more gender-neutral play. The clinic claims that its program reduces the likelihood of gender dysphoria persisting into adolescence. Other parents send their children to facilities like the gender clinic at the University of California–San Francisco, which guides patients through the transition from one sex to the other, with or without medical intervention. 

Both Meyer and Drescher say they are most comfortable with waiting until age 16 to administer cross-sex hormones, as the Endocrine Society recommends. “That feels like the most do-no-harm approach,” Drescher says. And while Meyer prefers to get “as close to 16 as possible” in his own practice, he believes that the guidelines will soon be revised downward. “I think it’s in the process of changing to an age which is more appropriate for normal puberty,” he says. Meyer also notes that he sees more and more young children these days who have made the social transition from one gender to another. “That makes me really uneasy, but I don’t ever say to people, ‘I’m not going to take care of you,’” he tells me. 

Skeptics say that however well-intentioned parents like Jenn and Ann may be, they are at best overreacting to childhood roleplaying, and at worst guilty of child abuse for allowing children to undergo medical treatments whose long-term effects are unknown. In August, conservative radio host Laura Ingraham worried that tomboys such as her younger self now run the risk of being pigeonholed as transgender and shuttled into a doctor’s office for hormone therapy. “Not everyone who shows these types of behaviors ends up feeling that way,” she told listeners, a view that research supports. 

Ultimately, the parents and medical professionals I spoke to said they were guided by the child’s insistence that something was not right. “It’s really driven by the child, and what the child says about themselves,” says Colt Keo-Meier, a PhD in psychology who specializes in LGBT health care. Even if cross-gender behavior ultimately ends up being a phase for children, believes Keo-Meier, who is himself transgender, allowing them to experiment with different identities does no harm. “If it’s a phase, then you’ve supported your child through this phase, and they know they can count on you for anything.” 

While acknowledging that the issue is controversial, UTMB’s Meyer also recommends that parents support their prepubescent children’s preferred gender expression, at least at home. “If a family has a child with cross-gender behavior, the safest thing is to allow that behavior to go on, don’t worry about it, continue to let the child go to school in the gender they were born in, and then, at some point in adolescence, before they get too far into puberty, evaluate that further. To put them in school in the new gender I think is not wise, because most school systems don’t understand ambiguity too well. You just invite teasing and everything else. This is a pretty serious change, so you want to do it at a time when you know it’s going to be permanent.” 

Although the overwhelming majority of children who display cross-gender behavior won’t grow up to be transgender, those whose gender dysphoria persists into adolescence are likely to be trans for life, according to a recent study conducted by the VU University Medical Center in Amsterdam and published in the journal Pediatrics. The researchers tracked 55 young adults who had  been diagnosed as gender dysphoric and placed on hormone blockers at around 14, before going on to take cross-sex hormones and, in many cases, undergo sex reassignment surgery. Seven years after beginning the hormone treatments, none of the study participants expressed regret about the gender transitions, and levels of emotional distress and body image concerns matched those of the general population. 

In his 14 years of giving hormone treatments to teenagers, Meyer has seen only a few patients change their minds. “I’ve had a few who stopped the blockers after a year and gone back [to their natal sex], and that’s been good for them,” he says. “I think that’s a success, actually. If you have a person on the blockers for a year, they consider all the options and they’re a year older, a little further along in their psychosexual development, they’re at a better position to make a decision.…And there doesn’t seem to be any lingering health effects.” 

When Nicole was 9 and her mother Jenn first took her to see Meyer for a consultation, they were told that Nicole was too young to begin treatment. They returned later, when it became clear that Nicole was starting puberty, only to discover that Meyer’s office didn’t accept CHIP, the Texas health plan for uninsured children. Jenn called endocrinologists all over the state before finding one in Luling who both accepted CHIP and agreed to prescribe hormone blockers. 

So that Nicole might go through puberty with other girls her age, the Luling doctor also recommended that the 11-year-old take a low dose of estradiol—five years earlier than the Endocrine Society recommends. When told about Nicole’s treatment, Meyer expressed concern. “I would not have done that,” he says. “I would have put her on blockers and then waited until the child was a little bit older to make the decision. You have to individualize it a little bit, but I think you have to be really careful.” 

For her part, Nicole couldn’t wait to start hormone treatment. By fifth grade, her angular contours were beginning to betray her masculinity, and she worried that she was starting to lag behind her girlfriends. She dreaded school every morning because her elementary school classmates, who watched her transition from boy to girl, ostracized her for being trans. But becoming a social pariah didn’t lead Nicole to question her decision. Instead, she became even more adamant. “I wanted breasts,” she tells me. “I had no doubts whatsoever. At that point I’d known for a long time I wanted to be a girl.” 

Acting like a boy to fit in was never an option, Nicole says. She didn’t know how to be one. At age 13, she is well aware that there are more options out there besides actually becoming a girl. She could be a boy who likes girl things, for instance, or a man who wears women’s clothing. But neither of those feels right. “Deep down I do feel that I am a girl,” she insists. “It’s not just all the things I like. I can’t really explain it. It’s like I’m living in a body that doesn’t represent me. You can’t really explain how you feel like a girl in my situation. It’s just, like, my nature. It’s how I feel.” 

Nicole’s father Jim admits to worrying about the pills Nicole takes. “It’s scary—I don’t like them,” says a man who claims not to even take aspirin. Ultimately, though, he believes that what’s most important is that Nicole feel whole. “It’s all about the reflection in the mirror. She’s got to like what she sees.” 

These days, Nicole mostly likes what she sees. She is tall and skinny, and has begun developing curvy thighs and hips, although she says her breasts are still too small. Her mother rolls her eyes at these words. If Nicole wanted to stop her sexual transition at this point and discontinue the drugs, presumably her natural testosterone would take over, and her development into an adult male would continue. In that event, however, she would still need surgery to remove her breasts. 

Nicole’s parents don’t spend much time dwelling on the possibility of their daughter going off the hormones. That issue, as far as they’re concerned, is settled. Rather, they’re consumed by the monumental task of shepherding a trans teen safely through the perils of middle school and beyond. They are terrified by the possibility of Nicole being the victim of a hate crime. According to a report issued in 2012 by the Anti-Violence Project, people who are transgender are almost twice as likely to be victims of sexual violence as people who aren’t. “She’s always in danger,” says Jenn. To drive the point home, in 2010 the family took Nicole to a candlelight vigil for Myra Ical, a 51-year-old trans woman who was beaten to death in Montrose. “She needs to know this is a possibility for anybody like her.” 

When Nicole begins going out on dates—soon, her mother believes—Jenn wants them to be with kids she meets at Hatch Youth, the center for gay and transgender teenagers. The need for a dating plan became clear two summers ago during a lakeside family vacation, when Nicole appeared to pair up with a local boy. At one point, Jenn recalls, the kids slipped out of view and her husband panicked. 

“Oh my God, he was freaking out,” she says. All the worst-case scenarios played out in his head. What if the boy discovered that Nicole was also a boy? What was to stop him from hitting her in the head and leaving her to drown? Nicole later confided to her mother that the boy did discover she was different and was okay with it. But now Jenn is worried that the experience left Nicole with a false sense of security as she ventures into the larger world. For her part, Nicole tells me that she knows people like her will always be at risk from “haters,” but thinks her dad overreacted.

When Nicole didn’t go back to her charter middle school this past September, opting to complete eighth grade at home, it wasn’t because anyone knew she was trans. Instead, Nicole says she had bristled against the school’s strict rules, and had had a hard time making friends. Her social life these days revolves around online manga and anime chat rooms, where she finds acceptance as an openly trans girl. The turquoise walls of the family’s living room are covered with Nicole’s anime-style self-portraits, in which she draws herself as she wants to be seen—as a young woman. In one of them, she’s wearing a Mickey Mouse sweater I recognize from our interview. 

A desk is piled high with art supplies, graphic novels, and Japanese language books; she’s working on her portfolio to get into a high school with a good arts program. With her parents doing all the worrying for her, Nicole feels free to socialize online and plot out her future. She wants to be an artist or a teacher when she grows up. She also wants to get married and have kids, though it makes her sad that she’ll never be able to carry a child like her own mother. 

“I know I’ll never be a 100 percent natural woman,” she tells me. “But I want to get as close as I possibly can.”