A Duke University clinic helps transgender youth transition to new identities.
ATOM EDWARDS IS A HIGH-SCHOOL JUNIOR who carries himself with a confidence that not all his peers possess. The youngest of four siblings, he has a lanky frame and a hi-top fade that lightens at the tips like icing on a cupcake. He makes A’s and B’s; plays guitar, piano, and saxophone; and sits on the Teen Council at Duke’s Nasher Museum of Art. He counts his friends by the dozen.
Atom inhabits his seventeen-year-old body with grace, but it’s a hard-earned grace. Assigned female at birth, he rejected, early on, every marker of femininity. When he was five, his parents walked into the living room and found him with scissors in his hand and thick hair scattered at his feet. “He had a stoic look on his face,” says his father, Derlvyn, a mill worker. “It reminded me of that scene from X-Men when the little boy went in the bathroom and cut his wings off because they said he was a mutant, and there were feathers all over the floor.”
When he was younger, Atom clung to his older brother, favoring him over their sisters. He wanted to look like his brother, learn karate together, and play the same Dragon Ball Z video games. By seven, he refused to wear dresses. “No big deal,” recalls his mother, Delores, a state employee. “I didn’t wear dresses. I grew up as a tomboy, so I was cool with it.”
What did concern Delores was that her youngest child was a loner. “All the [other] kids had little friends that they would stay over and spend the night with,” she says. “Atom never had friends.” She knew he was different. But she didn’t know how.
“I think you were in denial,” Derlvyn tells Delores.
“I was in denial,” she agrees.
Atom, for his part, was muscling through big questions. “In sixth grade, I had a little sit-down chat with myself,” he says. “Am I gay? Am I straight? I was trying to understand myself better.” There was something about his identity he couldn’t quite discern, and it went beyond his penchant for thrift-store neckties: “Everyone else, it seemed, knew themselves.”
During his freshman year at Hillside High School in Durham, Atom figured it out: He was a boy. By then he was no longer solitary. He had joined theater and the marching band, and he was expressing himself through visual art and photography. Toward the end of that year, he began telling classmates he was transgender and asking them to use his new name and male pronouns. The reactions were uneven, he says: “It was a mixture of students who were really accepting and students who were very shunful, or students who didn’t know how to feel.”
The next step, Atom believed, was aligning his body with the new identity he was carving out. In March 2016, shortly after he turned fifteen, he and Delores met with their family physician, who gave them a referral. That’s how he found his way, a few months later, to the Duke Child and Adolescent Gender Care clinic and its pediatric endocrinologist, Deanna Adkins.
ADKINS, AT THE TIME, WAS STILL RELATIVELY NEW to transgender medicine. In 2014, while working at Duke, she had received a call from a fellow endocrinologist in New York. “I have this patient,” she recalls him saying. “They’re from Chapel Hill. They are coming to see me for potential hormonal transition. I would really like to refer them to someone closer to home. Do you think this is something you could do?”
Adkins had grown up surrounded by medical culture. Her single mother was the chief financial officer at a hospital, and young Deanna spent a lot of time at that workplace. “I kind of lived there,” she says. “We ate meals there. I got used to that environment.” Still, when she entered Georgia Tech, Adkins followed her friends into engineering instead.
As part of her studies, Adkins worked at a chemical plant—a disillusioning experience, she says. “Some of the women in the plant had bloodwork done every so often to look at their lead levels. They had to make sure they didn’t get pregnant. I was beginning to think, ‘I’m not sure this is the environment I want to spend the rest of my life in.’ ”
She shifted her focus to medicine, a return to her family roots. At the Medical College of Georgia, she realized that endocrinology suited her temperament. “The engineer in me was like, ‘Oh, look. You increase this hormone and that hormone goes up,’ ” she says. “It all fit together in little puzzle pieces.”
Adkins arrived at Duke in 2004 as a clinical instructor. She has worked with hormones ever since, treating children with a wide range of disorders. But when the New York doctor called, she had never used hormones to help patients conform their physical traits to their gender identities. (This is called gender-affirming therapy.) “I don’t really understand it,” she told her colleague. “I don’t know how to do it. They didn’t teach me that.” During medical school in the 1990s, Adkins had learned about gender dysphoria, the stress some people feel when their assigned gender conflicts with their experienced one. But treating transgender youth was a new arena in the United States, and she had not kept up with the literature.
The doctor assured Adkins that the work “is really not difficult” for someone with her skills, and he sent her some of his research. As she read more, she was encouraged by data showing that older trans teens suffered less depression and anxiety after starting hormone therapy.
She also realized the work was well within her wheelhouse. “I found it fascinating that what they were using to treat [transgender] people was exactly what I use in my clinic for people who don’t make their own hormones,” she says. “I was trained. I just didn’t realize I was trained to do the gender-affirming part.”
Adkins treated that first patient, a teenage girl: slowly rebalancing her hormones while taking care not to trigger any mood destabilization. Then more referrals arrived. “First it was one, and then it was two, and then all of a sudden it was seven,” she says. Working alone was not viable, she realized; someone needed to maintain contact with all her patients’ mental-health counselors. She tried to coordinate this by herself, but couldn’t. “It needed to be a team approach.”
Adkins approached Jonathan Routh, a Duke urologist who worked with a different set of children: those born with ambiguous genitalia. Their conditions are collectively known as “disorders of sex development” (DSD), though some advocates prefer the term “intersex.” Routh, in 2011, had tried to start a DSD clinic at Duke. “I failed miserably,” he recalls, in part because “I didn’t have great buy-in from our mental-health providers. In the face of that, I gave up on the whole idea.”
Routh recalls what came next: “Deanna called me and basically said, ‘I’m seeing more and more trans kids. I know you have an interest in the DSD side of things. Clearly these are two discreet populations, but there’s a lot of overlap.’ ” Both involve gender; both sometimes require endocrinologists and urologists; and intersex youth have a higher rate of gender dysphoria than the general population. Plus, “if we combine them as one functional clinic,” he says, “we gain some economy of scale.”
Routh and Adkins recruited Kristen Russell, a clinical social worker, and opened Duke Child and Adolescent Gender Care in July 2015. It was the first of its kind at a university hospital in North Carolina, and the idea was to tap into Duke’s vast resources to provide comprehensive services. The clinic began as a one-day-a-month operation—and as soon as it opened, there was a three-month wait for appointments. “We grossly underestimated the underlying need in our community,” Routh says.
THE IDEA THAT SOMEONE TOO YOUNG TO VOTE could be ready for a gender transition might not be intuitive for everyone. But doctors say there’s good reason to start early, and they warn that delays could take an emotional toll.
Underlying this consensus is a growing understanding that gender identity has a substantial biological component. “We have no clue what the biology is,” says Joshua Safer, medical director of the Center for Transgender Medicine and Surgery at Boston Medical Center. But even without understanding the mechanism, he says, researchers can point to four lines of evidence for a biological basis.
The first (and strongest) is what Safer calls “an accidental experiment”: the experiences of intersex children assigned the wrong gender. “We in the medical community, over many decades, were supremely confident that gender identity was malleable and not biological, and that we could therefore manipulate it,” he says. Genetic males were often assigned female because the surgery was easier, then raised as girls and given estrogen as adolescents. “Despite a very, very aggressive program, when those kids were queried, the majority say they have male gender identity,” Safer says. “We had a hypothesis, we tested it, and we were wrong.”
Second are twin studies that show identical—but not fraternal—twins of transgender people are dramatically more likely than the general population to be trans themselves. Third is the experience with genetic females exposed to an excess of male hormones in the womb; a substantial minority identifies as male. Fourth, and weakest, are brain studies that show some differences in structure correlating to gender identity.
Along with that research is this psychological reality: Gender dysphoria, left untreated in kids, can be devastating. One study out of Boston showed that trans youth suffer substantially more depression, suicidality, and self-harm than their non-trans peers.
“Depression and anxiety accelerate a lot when [children] start to go through puberty and it’s the wrong puberty,” says Duke’s Adkins. “It’s really the best to keep them safe just to address it early.”
In November 2017, the Endocrine Society published new guidelines for treating gender dysphoria. For kids, the society recommended a graduated series of steps. Early-stage adolescents can take a drug that delays puberty. This treatment, which is reversible, blocks the onset of menstruation and the development of breasts, adult genitals and bone structure, body hair, voice changes, and prominent Adam’s apples. These traits, once they develop, are hard to correct later, as any trans woman with broad shoulders and a square jaw could tell you.
One thirteen-year-old Duke clinic patient, who is taking a puberty blocker, says that he had dreaded growing breasts, wearing a chest binder, and having to deal with menstruation. As a result of the medication, he’ll avoid a mastectomy and will likely be less identifiable as transgender. “Being recognizable is not just an issue of discrimination,” says his mother, who asked that the family not be named. “It’s also, in some places, related to your personal safety.” More than two dozen transgender Americans were killed in 2017, according to the Human Rights Campaign, which works to ensure equal rights for LGBTQ Americans.
Next, for many, comes the sex hormones: testosterone for men, estrogen for women. These therapies are not fully reversible, so the Endocrine Society advises waiting until the teen is mature enough to make an informed choice. (Mental-health professionals are always involved.) This usually comes around sixteen, though in some cases it might be earlier or later.
Some, but not all, transgender people make surgical transitions, too. The Endocrine Society recommends waiting until eighteen before genital surgery. It allows for some trans men undergoing hormone therapy to receive mastectomies before their eighteenth birthdays.
Research indicates this early intervention works. A study from The Netherlands looked at fifty-five transgender adults who, on average, underwent puberty suppression at thirteen, hormonal treatment at sixteen, and surgery at twenty. Their psychological well-being, the authors wrote, was “similar to or better than” their peers in the general population.
ATOM EDWARDS IS FORTUNATE; HE COMES from a family that welcomes diversity and knows what ostracism feels like. Delores grew up with a lesbian mother and still remembers the whispers in their Durham public-housing community. “It was like a shame, like a shun on the family,” she says. Derlvyn says he was initially attracted to Delores, in part, because she embraced his disabled brother. “We took him to a Hillside football game,” he recalls. “I don’t know how we got the wheelchair in the stadium, but she wasn’t embarrassed by his presence.”
One of Atom’s sisters dated a transgender man, who spent a summer sleeping on their sofa when his own family rejected him. Both sisters belonged to their schools’ support groups for LGBTQ students and their allies. Older brother Devyn, surrounded by sisters, was happy to have a guy to hang out with.
“I was kind of outnumbered,” Devyn says.
“He always wanted [a] brother,” their father adds.
Still, when Atom announced he was male, his parents were caught up short on knowledge. “We had no idea there were so many young people going through the same thing,” Delores says. “In our old, old world, we thought we were the only people.”
AT THE DUKE CLINIC IN OCTOBER 2016, the family spent a couple of hours with Russell, the social worker. That included a one-on-one meeting with Atom. “Having someone ask questions and not be super- judgmental was very nice for me,” Atom says. “It was like: ‘I’m really happy that you’re feeling comfortable with yourself enough to tell others. This is what you need to know about name-changing. Do you want your name to be changed?’ It was information mixed with humanity.”
Atom impressed Russell with his certainty about transitioning, and with his school accomplishments and strong support network. “Even then, at that first visit, I was thinking this kid’s going to be a good candidate for hormones,” she says.
The family then met with Adkins, who noted Atom’s enthusiasm and clarity. “It was obvious he really understood where he was coming from,” the endocrinologist says.
What struck Delores was that so many professionals were invested in Atom’s care. No one pathologized him. “Remember back in the old days when you had people who were disabled and they put you in this special class?” That’s not what it was like, she says. “We were okay to be in the real hospital with other kids. They didn’t make it seem different than any of those other people, and that made it so easy for us.”
Atom wanted to start taking testosterone immediately. He learned that’s not how it worked. First, he’d need to go through counseling, outside the Duke system, to make sure he was truly experiencing gender dysphoria. His therapist also needed to ensure there were no psychiatric issues that would preclude a hormonal transition.
“They didn’t try to push this thing too fast, which was great,” Delores says.
“Great for you,” Atom interjects. “Terrible for me.” He was itching to get on with the process.
Six months later, in March 2017, Atom returned to the Duke clinic for his final education session. Shortly afterward, Russell, the social worker, says, Atom received his counselor’s blessing. “She sent me a letter saying she didn’t have any reservations or concerns of him moving forward with his transition,” Russell explains. “So we started.”
BY THE TIME ATOM ARRIVED AT DUKE, the gender clinic had already outgrown its original ambition. “It was incredibly overwhelming, the response we got,” says Adkins. She started with seven cases, “and by the end of the first year, we were over 100.” During that year, they scaled the clinic schedule from once a month to once a week. The case load, not including Routh’s intersex patients, now exceeds 200.
Part of the appeal of the Duke clinic is its relationships throughout the health system. Patients have access to experts from nutrition, adolescent medicine, ob-gyn, pastoral care, family medicine, psychology, and psychiatry. “We began building an infrastructure, so we have places to send these folks to, no matter what their needs might be,” says Russell. The ties, she notes, extend beyond the hospital: When staff members at two Duke law clinics offered their services, “we said, ‘Yes, we need some help with name changes and discrimination in school and bathrooms.’
For mental-health care, the clinic relies primarily on outside providers. That has proven tricky, say Adkins and Russell. Therapists are essential to help trans youth live in their new gender roles and navigate relationships with family, friends, and classmates. For patients like Atom, who lives in Durham, there are plenty of nearby counselors who understand gender identity. But many patients live in far-flung parts of North Carolina and beyond, including remote counties where therapists’ good intentions outpace their expertise.
“For those folks out in the rural areas, it really is tough,” says Russell. “It’s hard to find providers that have any knowledge related to trans health.”
Even identifying a sympathetic therapist can be hard. “I use a few websites to try to locate people who are at least interested,” Russell adds. “And I rely on the families to try to find somebody through word of mouth. I’ve had lots of conversations with providers who are supportive of their patient. They want to know more. They don’t know where to start. I send them articles [and] websites to start doing their homework, just as I had to do.”
The clinic’s other challenge is its own rapid growth. New patients wait five months for appointments. Adkins says she wants to build her clinic’s capacity and Duke’s to keep up with the demand. She is also looking outside the system— for example, helping colleagues at the University of North Carolina at Chapel Hill launch their own clinic. She says the uptick in patient load reflects shifting social attitudes toward transgender people.
“There’s a huge amount of acceptance and understanding,” says Adkins. “People are able to talk about it and not have as much stigma around it.” While transgender people still face discrimination, harassment, and violence, “the fact that it’s safer to come to medical care makes a huge difference.”
ATOM EDWARDS GIVES HIMSELF A SUBCUTANEOUS injection of testosterone every two weeks. When he started hormone therapy in April, he needed his mother’s help. “Now I can do it while I’m watching TV,” he says. “You just get used to it.”
Before he started taking testosterone, the clinic staff told him what to expect—plus, he says, “I researched like nobody’s business”—so when the hormone took effect, the changes already felt familiar. “Each week would be a different thing,” he says. “It was like my body was trying on a new suit.” For a while, it toggled between masculinity and femininity: “We’re going to make your voice drop, but then it’s going to go back, like ‘delete, delete, delete.’ ” Or his menstruation volume would taper off before growing heavy again.
Over time, the transition became less halting. The changes took firmer hold. “My voice is way lower,” he says. He has grown leg hair, and it’s become easier to put on muscle mass. His weight is redistributing to look more male, and his face carries a hint of peach fuzz. “And I’ve been more energetic. Testosterone has made me much more prone to working out or going for a run. I’m eating better— just feeling happier about myself.”
For the first time, Atom says, he can look in a mirror without recoiling. “Whenever we go to the store, and I have to change and try something on, I’m like, ‘Whoa, I look cool.’ I don’t try to point out certain things about myself that are terrible. I try to see the positive side.”
After his freshman year at Hillside, Atom wanted a fresh start. He transferred to Durham’s School for Creative Studies, a small public magnet school, where he has always been known as a boy. Atom has made a lot of friends there, including a favorite companion who’s also trans. “Having a friend like that—an equal relationship with give-and-take—makes such a difference,” he says.
This fall Atom served as a semi-public face for transgender youth, speaking on panels to first-year medical students at Duke. “He’s so comfortable in his skin now,” says his mother, Delores. “He’s jumping out. Not afraid anymore.”
One benefit of living as a male, Atom says, is that he can start planning for the future. He wants to go into music, possibly as a producer, “helping others be able to showcase their voice,” he says. “Being the helping hand is something that’s very important to me. I can see myself traveling around the world, trying to make music with other people.”
This is big for Atom: being able to look beyond everyday concerns like how his acquaintances view him and which pronouns they use. “I’m not entirely sure I would have had a future if I didn’t make my transition,” he says. “Or else I’d be very depressed, and not happy with anything I did. Now that I’ve gotten my identity out of the way, I can worry about more important things.”