Nature, Nurture, Gender, and Identical Twins

The Children’s Hospital Gender Management Services Clinic can, using hormone therapies, halt puberty in transgender children, blocking the development of secondary sexual characteristics — a beard, say, or breasts — that can make the eventual transition to the other gender more difficult, painful, and costly.

Founded in 2007 by endocrinologist Norman Spack and urologist David Diamond, the clinic — known as GeMS and modeled on a Dutch program — is the first pediatric academic program in the Western Hemisphere that evaluates and treats pubescent transgenders. A handful of other pediatric centers in the United States are developing similar programs, some started by former staffers at GeMS.

This story is fascinating on multiple levels. Not only is it a compelling human interest story, but the fact that two people can have the same genes but different gender identities raises fascinating questions about where our sense of gender comes from.

Doctors will study Nicole (nee Wyatt) and her brother as they grow up. Their case may shed light on the effects of gender reassignment treatments. In any given person, you never know how they might have turned out if they hadn’t, say, taken hormones or hormone-blocking drugs. But if a patient has an identical twin who is develops according to the same genetic plan without hormonal intervention, that’s almost like a control group.

Nicole and Jonas are the first set of identical twins the program has seen, and they have provided critical comparative data, Spack says.

The effects of the blockers — an injection given monthly to prevent the gonads from releasing the unwanted hormones — are reversible; patients can stop taking them and go through puberty as their biological sex. This is critical, Spack says, because a ​“very significant number of children who exhibit cross-gender behavior’’ before puberty ​“do not end up being transgender.’’

Since the 1970s, the blockers have been used for the rare condition of precocious puberty, when children as young as 3 can hit puberty. They are kept on the blockers until they are of appropriate age. ​“The drugs have a great track record; we already know that these kids do fine,’’ says Spack. ​“There are no ill consequences.’’

It is the next big step — taking sex hormones of the opposite gender — that creates permanent changes, such as breasts and broadened hips, that cannot be hormonally reversed.

​“In puberty,’’’ Spack says, ​“when your body starts making a statement, you either have to accept it or reject it.’’

So far, the clinic has treated 95 children whose conditions range from ambiguous genitalia to failure of biological sex development.

Nicole and her family know they have a long road ahead. She will need surgery to achieve a typically female physique and she will have to take daily doses of hormones to maintain it.

Those burdens seem minor compared to the social stigmatization and legal discrimination that Nicole and other transgender people face.

As E.J. Graff writes in the Prospect, public bathrooms have become ground zero in the battle for transgender rights, ​“Imagine never knowing whether you will be able to pee without harassment, or being assigned just one unisex bathroom in a large complex.” Nicole and her family joined a successful lobbying campaign to defeat a 2009 bill in their state legislature that would have repealed protections for transgender people to use the public bathroom that suits their gender presentation.

It’s a small victory, but it’s a testament to the power of love, family, and community.