About a Boy: Transgender teen’s quest for surgery (Part 2)
Seventeen million people tuned in the night Caitlyn Jenner came out on national TV as a transgender woman. Jay watched alone.
He hadn’t told many friends that he was transgender, too. His mom refused to watch.
“I have more important things to do than watch someone who’s rich and has their life figured out,” Nancy Munoz said. “My focus is on finding resources for you.”
It was 2015, and Jenner was 65. That meant six decades of secrets in a spectacular body that always felt wrong.
Jay was 15. He retreated to his bedroom, stepped over his PlayStation into bed. He leaned against a Bob Marley poster and watched the interview on his iPhone.
Diane Sawyer’s voice filled the room. For the past year, the reporter said, Jenner had lived “in a white-hot vortex of cameras, questions, speculation, jokes and ridicule.”
That was how most people thought of transgender people, Jay knew. Men in dresses. Ugly women.
“As we sit down,” Sawyer said, “the person whose face has changed so much over recent years is quiet, knowing the moment that carries you forward can also mean no way back.”
Jay bit his lip. After four months of testosterone, his voice cracked with the first hints of puberty. A few dark hairs shaded his chin.
“Are you ready?” Sawyer asked.
HOLDING HIS BREATH
Some days, Jay forgot he was transgender. For the first time in years, he volunteered to accompany his mom to WinCo for groceries. He no longer avoided mirrors. He gazed at himself before school. Had he grown taller? Had his face thinned?
The world saw him as he saw himself. He picked clothes that made him feel macho — gold chains and Timberland boots. Everyone called him “he.”
Then his depression crept back. He stood in front of his closet before school and worried his 2Pac T-shirt revealed too much. He walked to class, and his brain looped reminders.
My chest. My chest. My chest.
He bandaged his A-cup breasts so tight that he breathed in bursts. He slinked down hallways, terrified of contact. People rough-housed with guys, he had learned. They slapped his sternum to say hello.
“Girls will touch your chest, too,” his mom said. They lean in to cuddle. They rest a hand there as they kiss.
“If I wanted to date somebody now, or even in the future, how would I tell them?” Jay asked.
“Who’s going to date you?” Nancy asked. “Lesbians?”
“Straight girls,” Jay said.
“It’s kind of lying, though,” Nancy said. “What they see is a boy.”
“It’s not lying,” Jay said. “That’s who I am.”
It’d be easier to be open, Jay thought, if his body looked more like he wanted. He didn’t feel ready to consider genital surgery. Many transgender guys never did, he had read. But he couldn’t think about girls or school or anything else until the breasts were gone.
“I’ve been on testosterone a while,” Jay told his mom in April. “I’m thinking about top surgery.”
Nancy had struggled at first to accept that her oldest daughter was a boy. She still kept a few photos hanging on the wall that showed the kid Jay used to be. They captured him in scoop-neck T-shirts in fifth grade, with long hair in eighth.
He had been Jay for nearly a year. Nancy didn’t want to make him wait to live like a regular teenager.
“Let’s ask,” she said.
SOMETHING TO DISCUSS
Google Maps said the trip would take 34 minutes. But they had traveled the horseshoe route from one suburb to the other for an hour already, and Jay was sure they were lost again.
“It says turn right,” he told his mom.
Nancy cursed Portland, its city traffic and confusing interstates. Jay believed the winding path would end his depression, so Nancy kept driving, missing turns and backtracking until they found it, a nondescript Beaverton clinic for young transgender patients.
Inside the Legacy Medical Group waiting room, Jay grabbed a Teletubbies book and pretended to read. The walls were yellow, the art kid-friendly neon. He peered over the book as another patient floated by. She was tall and graceful, more at ease as a girl than Jay ever had been.
Some Oregon school districts estimate as many as 3 percent of students identify as transgender. At Jay’s school in Vancouver, Washington, the principal knew at least half a dozen kids whose gender identities and anatomies didn’t match. But Jay had never knowingly seen another transgender person in real life. His long lashes froze as the patient made her way to the parking lot.
“Jay?” a nurse called.
Inside, the nurse weighed and measured him. Not quite 5-foot-2, she wrote in his chart.
The doctor barreled in, a whirl of energy in coral pants and a floral shirt.
“What’s new?” Dr. Karin Selva asked.
Jay sat up straighter. “I actually have facial hair now.”
“Where is it? Where is it?” the doctor asked, inspecting his chin. He had three tiny hairs.
“Oh, yes,” his mom said. “He stinks a lot.”
Nancy cleared her throat.
“Jay has something he wants to discuss,” she said.
Jay tapped his black knock-off Vans nervously against the exam table. “Top surgery,” he said.
Selva sat down.
The pediatric endocrinologist had prescribed hormones for nearly 100 transgender adolescents. She traveled the country to share her experience with other doctors. She believed affirming a child’s gender identity could save their life.
But Selva had never recommended a 15-year-old for surgery. She wasn’t sure a surgeon would agree to do it.
The Endocrine Society’s guidelines suggested waiting until a patient was 18. Teenage brains are too malleable, some thought. But Selva and other doctors had started to think allowing teenagers to have chest surgery earlier was OK.
Jay had three more years of high school. Three years of homecoming dances and pool parties. With surgery, those might be bearable.
“Hmm,” Selva said, tapping her fingers on his chart. “Let me think about it.”
THE ROAD AHEAD
Jay spent the summer fine-tuning himself. He tried to make his handwriting sloppier like a guy’s. He and his best friend Maddie spent afternoons working out in the school weight room. And in August, eight months after his first dose of testosterone, he started injecting the shot himself.
He picked up the supplies at the Fred Meyer pharmacy, then laid them on the kitchen table. One syringe, two needles and a small vial of testosterone. His mother was at work, so he called his younger sisters to the living room to watch.
“If I start bleeding out, you guys are going to witness that,” he told 10-year-old Angie and 12-year-old Maria.
“Do you need a cotton ball?” Angie asked.
Jay shook his head no and studied the inch-long needle. He stuck it into the vial and drew out the hormone.
“OK,” he whispered.
His sisters moved to the couch and peered over the back. Neither spoke. Maria clutched a gallon-size freezer bag of bandages.
Jay shut his eyes tight. The needle stung. The hormone felt thick going in.
Later that week, Selva called. She and his counselor both believed Jay should have the surgery. The surgeon was willing to meet him to decide if she did, too.
Oregon is one of only three states that gives 15-year-olds the power to make their own medical decisions. As long as a doctor consented, Jay could have any surgery, including an abortion or a heart bypass, without his mom’s permission.
He was still a kid, though. State law prevented him from getting a tattoo or piercing his nipples. At doctors’ offices, his mom filled out his intake papers. The plastic surgeon, Jay knew, could meet him and decide he was too young.
Dr. Hema Thakar had spent much of her career helping women after breast cancer. By the fall of 2015, when she met Jay, transgender patients made up a third of her practice. She performed top surgery an average of three times a week, but only on adults.
“You are by far the youngest guy I have seen for this,” Thakar told Jay.
Thakar had some reservations. Jay’s body would grow and change for another few years. If Thakar removed Jay’s breasts at 15, she likely would have to perform a revision surgery later. Both procedures would be expensive, with long recovery times.
Because Jay’s breasts were so small, she said, Jay could consider a minimally invasive procedure called the keyhole. In that operation, Thakar would make small incisions in the nipples, then draw out most of the breast tissue.
“The incision gets hidden,” she explained. “The other thing is your nipple sensation has a better chance of being maintained. For a lot of people, that’s important.”
Jay laughed nervously.
“He’s young right now,” Nancy said. “He doesn’t care.”
“Jay,” Thakar said, her voice lowering.
“The last thing I’m going to say is – and it’s going to sound really serious because it is – removing the breast, that’s irreversible.”
“I really want you to talk about it with your mom,” Thakar said. “The major reason is you can’t breastfeed if your breasts are not there.”
“Yeah,” Jay said.
Nancy and Jay had discussed it. He wanted a family. They had talked about “the pregnant man,” a transgender guy in Bend, Oregon, who’d become famous when he stopped taking testosterone long enough to give birth. Jay figured he would adopt.
“Why don’t we meet in December one more time?” Thakar suggested. “I want all of your doctors to be involved and have a group of us agree. We all want the best for you.”
Jay had hoped he would have the surgery before school started. It was only four months, he told himself. One semester of his sophomore year.
He mustered a smile.
“Yeah,” Jay said. “I guess we could wait.”
“THAT WAS NEVER ME”
Jay had watched enough YouTube videos to know the transition wouldn’t be instant. His voice had deepened over time. Surgery, too, would be a process.
He went back to see Thakar in December 2015, and she suggested they wait another six months.
By early 2016, Jay was tired of waiting. That February, he slumped at the kitchen table while his sisters watched “Mulan.” When he was a kid, he had loved the Disney movie’s main character, a young girl who becomes a soldier by dressing as a boy.
Every day, it’s as if I play a part, Mulan sang. When will my reflection show who I am inside?
He looked down at the table, too bummed to watch. His school’s winter formal was that night. A friend had nominated Jay for the court, and he had scored enough votes to make it. A teacher passed out repurposed Burger King crowns for the princes to wear.
Jay tried to imagine himself swaying with a girl. If his date leaned in, Jay worried, her head might land on the soft curve of the breasts he worked so hard to hide.
Would a slow dance give his secret away?
He had almost talked himself into taking the risk, he told his sisters.
“Then the situation happened.”
That morning, a girl had brought Jay’s middle school yearbook to school. She cornered Jay and pointed to a picture. The hair was longer, and the name different, but there was definitely a resemblance. Jay played dumb, but the girl showed the yearbook around school.
Jay, she told people, used to be a girl.
He ran a finger over the black spray-painted crown. No, he realized, he couldn’t go to the dance.
Jay left the crown on the table and dragged himself to his bedroom. He fumbled through his closet until he found the yearbook. He flipped to the page the girl had shown around school and looked at the picture. Sixth grade. He had tried to curl his hair that day. Not good.
It felt like the girl at school was trying to trap him, like she wanted to prove the person in the photo was the real Jay. He’d told her to stop. What was her agenda?
He stared at the picture and didn’t recognize himself.
That was never me.
In the living room, the Disney characters were discovering Mulan was really a girl. Her chest gave her away. They dragged Mulan out of the tent and threw her into the snow.
BOY WITH BREASTS
When the letter came in May 2016, Jay’s mother tore it open. Nancy read it twice, then slammed the pages on the glass coffee table.
“This is so messed up,” she said.
The state of Washington required transgender patients to send three letters of recommendation for surgery. Public health officials accepted letters from Selva and Thakar, but the note from Jay’s counselor hadn’t been good enough. Medicaid wouldn’t pay for Jay’s surgery, the letter said, unless he saw a psychiatrist.
Nancy dialed the number at the bottom of the letter. When someone answered, Nancy unleashed years of frustration.
“If anybody can say no, it’s going to be me because I gave birth to him,” she told the woman who answered. “I carried him in my womb for nine months. I couldn’t even sleep at night — he was kicking me. I’m the one who has hopes for him. Every woman dreams of seeing their daughter marry in a church with a white dress. And a nice husband to the side and everybody crying. I’m the one who didn’t get the quinceanera. And I’m saying yeah, he should have surgery. And yet you’re saying no?”
Jay is a boy, Nancy told the insurance worker, just like any other. He was learning to drive. He loved his sisters and scary movies.
“Can you imagine?” Nancy asked the insurance worker. “What if you were a boy walking around with breasts?”
Nancy hung up. Jay sat quiet on the couch.
“We’ll fix this,” Nancy told him. “They just want to make sure. Minors change their minds sometimes.”
Everything seemed to go wrong that spring. A week later, Medicaid stopped paying for his puberty blockers – $8,000 a shot. No one could tell him why. He woke up every morning terrified that his period would return. At school, the yearbook staff posted a survey online for class favorites. Jay’s name was inadvertently listed on the girl’s side. He called the adviser and asked her to change it. She did, but Jay couldn’t help wondering if anyone had seen.
When Jay started transitioning, most people didn’t know a transgender person. State legislatures introduced more than 115 anti-LGBT bills the year Caitlyn Jenner came out. Parents packed school board meetings and begged officials across the country to keep boys like Jay out of locker rooms.
He slept away the afternoons and skipped dinner. He snapped at Nancy when she tried to help. He picked fights with his best friend, Maddie.
Eventually, Maddie confronted him. It seemed like Jay went out of his way to be rude to her, she said. If she accidentally stepped on his foot, he purposefully stepped on both of hers. When Maddie started dating a guy, they drifted further apart. They fought one afternoon over text, and that was it.
“It’s fine,” Jay told his mom. “She was being overdramatic. It wasn’t a big loss.”
But he felt deeply alone. Maddie was the one person who understood him. She was his only tie to a teenage life. Now she had a boyfriend and a life chugging forward. Jay worried he might stay stuck forever.
That spring, he rarely left his room. He gained weight, and his chest looked fuller, he thought. His mom suggested a trip to Klineline Pond, but he didn’t want to go anywhere near water.
“There are guys who have man boobs,” Nancy said.
Jay sighed and shook his head. He didn’t want to swim until his body was right.
He enrolled in driver’s ed but learned in the first class he needed a permit. His birth certificate still listed his old name and marked him as female. A permit would do the same.
Nancy hated watching him suffer. That spring, she wrote to the state of Washington. The old name and gender no longer fit, she wrote. Her child needed a new birth certificate.
In May, she signed Jay out of school for a doctor’s appointment. As they left the pediatrician’s office, Nancy told Jay he needed a haircut. It had been a few weeks. His hair sprang in unwieldy cowlicks.
A barber re-shaped Jay’s spikes, then Nancy told him it was time for school. They got in the car and she started the engine.
“Oh, wait,” Nancy said. “Can you hand me the paper in the glove box?”
Jay pulled out a folded piece of paper and handed it to his mom. Nancy told him to open it.
He unfolded the paper and read.
“Born at 9:21 a.m.,” he said. “Mom!”
He laughed and stared at the tiny miracle his mother had pulled off. She had changed his birth certificate. As of May 19, Jay was legally male.
Nancy suggested they go get his permit. They stopped for coffee, then strode into the licensing office all smiles. Nancy approached the front desk with a whisper. She needed to talk to someone who could be discreet, she explained. The receptionist looked confused.
Nancy leaned in.
“We’re dealing with transgender.”
The receptionist lowered her voice to a nearly inaudible level, then disappeared. Another worker eventually waved them over. Jay had a state identification card from childhood that listed him as a girl, she explained. He needed to apply for a gender change through the department’s headquarters.
“We’ve got the birth certificate,” Nancy said. “I scanned in his old ID, the application from the health department, the mental health professional’s letter.”
The worker was friendly but hamstrung by bureaucracy.
“Get this filled out.”
Jay’s face dropped. The woman handed them another stack of documents.
A BETTER NORMAL
A counselor, a doctor and a surgeon had all agreed he was ready. Why did he have to persuade someone else?
“You have to go to 100 different doctors and explain to them 100 different times in 100 different ways,” he complained. “‘This is who I am. Can you just help me please?'”
They went back to the T-Clinic in June. The office had expanded since Jay first visited two years before. Two doctors, two nurses, a psychiatrist and a psychiatric nurse practitioner worked together to decide when teenagers were ready to take irreversible steps. Together, they had treated more than 150 young people.
Selva suggested Jay discuss surgery with Valerie Tobin, the clinic’s psychiatric mental health nurse practitioner. Tobin had worked with transgender children for more than a decade.
Every case was different, Tobin knew. Some patients were ready at 16. Others had bigger issues that needed to be treated before surgery. Sometimes, a kid was so depressed that Tobin believed hormones or surgery were the only fix. Other times, she thought it was best to treat the depression first.
Jay was in many ways a great candidate. Nancy would be there to help him recover. His school had offered to send classwork home. But Tobin told them she couldn’t write the letter.
Jay hadn’t seen a counselor in a year. The therapist he had seen didn’t specialize in transgender kids.
Surgery would be emotional and painful in ways Jay couldn’t yet comprehend. Even anesthesia could induce a depressive episode, and Jay’s mental health history suggested he was more at risk.
Tobin thought Jay needed an ongoing relationship with a therapist who knew what to expect.
“And you need friends,” she said.
Making friends was a vital part of adolescent development. Teenagers needed to learn how to form relationships, mess up and apologize.
With Maddie out of the picture, Jay had no close friends. That could be a sign that he had trust issues or other problems he needed to explore.
Tobin recommended Jay follow up with a psychiatrist closer to his house. He went that August, but that psychiatrist agreed with Tobin – no surgery until Jay made friends.
“Does she know why we’re here?” Nancy complained after the appointment. “It’s because being trans is not easy. You can’t just say, ‘Hey, my name is Jay. I’m trans, can we be friends?’ You have to be very selective of who you are opening yourself to.”
“I told her I’m not very confident about my body,” Jay said. “If I want to make good, sustainable friends, it’d be better for me if I had the surgery because I’d feel more confident, and I’d feel OK with telling them more about it.”
He was quiet for a while. He pulled his Chihuahua into his lap
“If that’s what she really wants,” he said finally. “I can try. I can have a million friends.”
Jay’s town had meetup groups for young gay and transgender people. He couldn’t bring himself to go. He spent a week talking to one girl and imagined telling her. But he wasn’t ready.
He needed to start with someone who understood. Just before his junior year started, a friend of a friend messaged Jay on Facebook. Like Jay, he was 16 and transgender and living in Vancouver.
They met one Saturday afternoon at the mall. The guy was bigger and taller than Jay, with a style that skewed more emo-punk. His hair was shaved on one side. He wore gym shorts and a cartoon T-shirt.
They stopped first at a shop that sold ancient knives.
“This is so cool,” Jay said, browsing through glass.
His friend shrugged. He didn’t really like sharp things.
At an incense store, Jay bought sticks of musk. His friend preferred anime to scented oils. Eventually, their conversation turned to the one thing they had in common.
“What’s it like being on T?” Jay’s friend asked. His parents hadn’t let him start the hormones yet. He had tried beard oil to thicken his facial hair and took a daily dose of men’s vitamins. Neither helped.
Jay scanned the crowd as they walked, hoping no one could hear their conversation.
“It’s just going through another puberty,” Jay told him. It felt normal. A better normal.
“Expect your emotions to run crazy, but it settles down.”
They tried talking about music and dating, but those conversations fizzled, too. His friend liked bands, Jay liked rap. His friend was pansexual with plenty of boyfriends and girlfriends. Jay had no experience at all.
“The only thing we have in common is the fact that we’re trans,” Jay said.
Later, at home, Jay told his mom the trip had gone well. It was the first time he’d ever hung out with another transgender person. But Jay wanted a friend who liked the same things he did. Someone who listened to 2Pac and Odd Future.
Someone like Maddie.
They hadn’t talked in nine months, but he regretted how mean he had been to her. He missed life with his best friend. He had laughed more when she was around. When they went to the mall, they spent hours browsing. The conversation never lagged.
That Thanksgiving, he saw a picture Maddie’s mom posted on Facebook. The photo showed all of Maddie’s Christmas presents perfectly wrapped. He clicked like.
A few hours later, a text message came in.
Hey how was your summer, I hope you had a good Thanksgiving.
It was Maddie.
Did you ever have your surgery?
When the Medicaid letter arrived a week before Christmas, Jay texted Maddie first. His psychiatrist thought he was ready and had sent in the final recommendation Jay needed. Washington health officials had made a decision.
He held up the envelope. His fate was sealed inside.
— Casey Parks