Four in 10 transgender teens in the United States attempt suicide. Leelah Alcorn's death was a clarion call for the transgender community. This is Zay Crawford's story.
On the drive to Cincinnati one morning last fall, Jason Crawford peeked in the rear-view mirror to the back seat, at his child. No doubt about it, Zay was growing up. But months of heart-to-heart talks about that unavoidable fact had left Zay in a panic, in tears.
Jason and Chasilee Crawford chose to live in Yellow Springs because the college town's progressive vibe matched their own. Yet parenting Zay had challenged them. They often argued with their child even as they advocated for Zay to the outside world. And as Zay stepped toward adulthood, the Crawfords' options were disappearing.
Now, driving his family for their first visit to Cincinnati Children's Hospital Medical Center, Crawford glanced back at that young face, so like his own, and read excitement, even joy.
A path had appeared.
"What's going on here?": When Isaiah wanted to play the little girl
Jason is a pilot, Chasilee a nurse. In 2002, they had a second child, a boy they called Isaiah, to join older brother Jeffrey. A relative nicknamed the baby Zay, and it stuck. Life went on.
One day when Zay was about 2, the Crawfords watched a movie made from the Dr. Seuss classic "The Cat in The Hat." Not long after, Jason and Chasilee overheard the kids playing scenes from the movie in which Jeffrey was the little boy . . . and Zay was the little girl.
"I remember thinking, 'What's going on here?' " Jason said. "That was something that was different to us. I didn't know what to think about it. Then, I don't know how, but Zay got a princess dress. It was blue. Zay wore holes in it."
Every time the family went to Toys R Us, Jeffrey aimed for the Legos, Zay for the dolls. Jeffrey said, "There was a lot of stuff like: 'I'm not like Dad. I'm like Mom.' "
The war over clothing started early. Zay's preschool had boxes of dress-up clothes. Chasilee dropped off Zay at school in pants and shirt, "then the boy clothes came off and the girl clothes came on." Zay wore the Hawaiian grass skirts as if they were long hair.
Jason wondered aloud to Chasilee: This has to be a phase. Chasilee said she considered the clothing a form of play. But parents have to pick their battles: At Halloween in first grade, Jason and Chasilee told Zay's teachers at the public school that Zay would dress as Dorothy from "The Wizard of Oz."
The clothes battle: Zay kept pushing
Yet, "Zay kept pushing us more and more," Chasilee said. The rule became girl clothes OK inside the house, not OK outside or at school. Then it was skirts on special occasions. Jason and Chasilee did Internet research, but what they found about transgender children did little then to dispel the confusion. Chasilee did not want anyone labeling Zay. Jason feared girl clothes would leave Zay vulnerable.
The arguments exhausted everyone. Over and over, Zay demanded an explanation for the wardrobe restrictions. Jason kept stating the obvious: You're a boy. Every time, Zay shouted back: No, I'm not!
Jason didn't want Zay to hate him. He could see that Zay radiated joy in girl clothes, misery in boy clothes. Finally, Jason relented, fine, all the time. He and Chasilee informed Zay's school of the choice at the beginning of third grade. Zay collected a circle of gal pals, joined Girl Scouts. But other complications arose.
Zay wouldn't use the boys' bathroom and couldn't use the girls'. So Zay waited until after school and made a dash for the bathroom at home. When Jason learned about that, he went to the school to negotiate, and a bathroom was set aside for Zay.
As Jason feared, the bullying at school escalated, mostly as verbal abuse. Sometimes, Zay got pushed or shoved. But what hurt more were the mean questions: "Why are you so gay?"
Teachers summoned Chasilee to talk about Zay's sinking performance. Jason and Chasilee discussed getting Zay some counseling. Then Zay confided having thoughts of suicide, which galvanized the Crawfords to find a therapist for Zay. The school environment did not improve in fifth grade, so in the middle of the year, the Crawfords moved Zay to the private Antioch School.
A boy who likes girl things: "It hit me: this is not a phase"
One searing moment snapped Jason out of his just-a-phase explanation. Zay needed to go to an urgent-care office for treatment of an ear infection. Jason filled out paperwork for his boy Isaiah, and they waited in an exam room. The doctor came in. He looked at the clipboard, at the child in a dress, at the clipboard, at the child. Perhaps the paperwork is wrong, said the doctor. Jason replied, no, Zay is just a boy who likes girl things.
On the ride home, Jason, weary of always having to explain Zay, wondered how to spare his child such embarrassment again. He chose his words carefully: Isaiah, when we go do things like this, where there are going to be forms, do you think it would be easier to just throw on a ball cap and a pair of shorts? Would that be easier?
Without hesitation, Zay said, "Wouldn't be easier for me."
The words struck Jason like a knife. Zay wasn't the one who was embarrassed about Zay.
"Right then it hit me: OK, this is not a phase," Jason said.
"There was a very short period, where I felt like I had lost a son. Chas is a nurse, and she was further along than I was. She pointed out that we weren't losing anything. Zay's always been Zay."
Zay grew out long ponytails, took up violin, experimented with recipes for gourmet cupcakes, begged for trips to Jo-Ann Fabrics. Once in a while, Zay broached the idea of going by the name Amber, after one of the backyard chickens that had disappeared. Chasilee and Jason, who figured the chicken had been snatched by a hawk, always voted no. "Amber" would only remind them that the world contained predators.
Big brother Jeffrey stood guard over Zay. When Zay wondered why things were so hard, Jeffrey recalled a line from one of his favorite movies, "The Iron Giant:" You are who you choose to be.
The Crawfords knew Zay wouldn't be little forever. That thought only instilled terror in them all.
"Zay had been coming up to me, coming up to Chas, asking about puberty, and it would usually end in tears," Jason said. "We thought, we've got a couple more years where this kid can pass, and then it's going to get really, really hard."
Then last spring, a friend who knew about Zay tipped Chasilee to a TED talk online by a pediatric endocrinologist. One summer night, Jason and Chasilee powered up a computer to watch Dr. Norman Spack of Boston Children's Hospital describe his groundbreaking work to help transgender youth through puberty.
"I don't think we said a word through the whole thing," Jason said. "Then we just looked at each other, and I saw exactly the same thing in Chas's face that she did in mine: There's something we can do . . . "
"There's hope," Chasilee said.
A few days later, Jason wrote to Spack with an email subject line: My son Isaiah who wants to be Amber. He asked for guidance, never expecting an answer. Two days later, Spack responded: Good news. There's a clinic in Cincinnati.
Intervention: Stopping puberty in its tracks
The free-thinking Dutch, who have long advanced medical care for transgender people, pioneered the technique of puberty suppression more than three decades ago. As the Crawfords learned in Spack's TED talk, the treatment means giving young teens early in puberty a course of hormones that halts sexual development. Bones and muscles still grow.
But with puberty-suppressing hormones, a boy would not get the body hair and the deep voice and may not have erections; a girl would not develop breasts or begin menstruating. The treatment is reversible: If the child decides to remain as the birth gender, the suppressing hormones are removed, and the child goes through a normal puberty. If the child remains certain of the transgender identity, the suppressing hormones are slowly substituted with sex hormones. A male-to-female transgender teen receives estrogen, and the body becomes womanly; a female-to-male gets testosterone, growing facial hair, an Adam's apple.
In 2008, Spack opened the first U.S. clinic at Boston Children's Hospital to adopt the Dutch protocol. Today, there are 38 clinics around the country that treat transgender youth with puberty suppression.
The transgender clinic at Cincinnati Children's Hospital opened in July 2013, led by Dr. Lee Ann Conard, recruited from Pittsburgh where she treated transgender youth, and social worker Sarah Painer.
While rare, the transgender human has always been present in the species, Conard said. "It's a normal developmental variant. In some societies, it's actually embraced. It's revered. In some Native American societies, you're two-spirited, and you're special."
Gender identity appears to be established in the brain at age 2 or 3. When Painer talks with patients, "They'll say things like, 'I've just always known I was different.' Or, 'I felt I was different, and something wasn't quite right, but I didn't know what it was.' "
At first, the Children's clinic operated one day a month. But as word of mouth spread, the clinic expanded to six days a month. Today, the clinic has more than 120 patients, "and they keep coming," Painer said. They range in age from 5 to 24 and come as far away as Lexington and northern Ohio.
"Patients tend to know what's going on and what they want," Painer said, "and their parents are like, we don't understand, help us out." For parents, Conard said, "it can be reassuring to hear that there is something medically going on, that this can be a part of normal development, that there's nothing wrong with their child."
Counseling: "We're doing something to keep them alive"
Treatment at the clinic takes months of preparation. A transgender youth must be in therapy to prepare for the physical and social transition. Experts assist with navigating school or other environments and handling gender changes to birth certificates or other official documents. Conard counsels patients about the effects of sex hormones – for example, testosterone, among other things, worsens acne.
Two drugs can be used for puberty suppression. Leuprolide acetate is an injection given monthly or quarterly. Histrelin is an implant that lasts 12 to 18 months. The choice, Conard said, depends on how, or if, insurance will pay for the treatment.
In puberty suppression, the child does not develop functioning sperm or eggs. If the child wants to have biological children, then the child must progress through a normal puberty to get mature sperm or eggs for preservation and then go on the suppressing hormones.
When an older transgender adolescent has already gone through puberty, the clinic offers the possibility of sperm or egg preservation before starting the gender transition with hormones. "But that's hard for a 15- or 16-year-old to think about," Conard said. "Rarely do people take me up on the idea."
Once hormones are started, return to fertility by reducing the use of sex hormones is not guaranteed. An ethicist consults on the reproduction issues "because it's not like chemotherapy where we're taking away somebody's ability to have a baby to keep them alive," Conard said. "But I would say that because these kids have a high rate of suicide, we're kind of doing something to keep them alive."
Jason Crawford, too, understood the risk of suicide. Online, he found research that conservatively pegged the rate of suicide attempts by transgender youths at 41 percent. Now that he understood the journey Zay was taking, he wanted to give his child the best start possible.
What I was thinking about when I wrote that email to the doctor in Boston was: If Zay is going to present as a female at 35, would it be better if she has to start off looking like me, because we look a lot alike, and deal with being female that way? Or to help her now? I worry about how Zay will be treated in high school and college, when I'm not around for protection. I know the statistics about homelessness and suicide. I worry about that for Zay."
The Crawfords made a September appointment at the Cincinnati Children's transgender clinic. Then they told Zay that they might have found a way through puberty. For the first time, Zay cried tears of happiness.
Early on that September day, Jason Crawford drove Chasilee and Zay south from Yellow Springs. In the rear-view mirror, he sneaked that glance at his child, who was smiling. They parked the car at Cincinnati Children's Hospital. Then Jason and Chasilee took Zay's hands, and they walked into the clinic together.
Gender identity: Changing names, changing pronouns
Jason filled out the paperwork for Isaiah Crawford. But the receptionist asked the child for a name and pronouns. Zay said, "I'm a she."
Jason felt the force of that word. She. Yes, he knew it now.
A nurse took Zay's vital signs; the Crawfords met Painer and Conard, "all these people who had answers," Chasilee said, "who knew the way things worked, not just about the hormones but just, hey, here's how you handle paperwork."
When they got home, older brother Jeffrey was waiting – how did it go? "Dad said, well, we have a Team Zay now," Jeffrey said. "My first thought was like it was a transgender support pit crew."
Jason's insurance covered the drugs and the clinic visits. "We're lucky that we can do this," he said. "Not everyone can."
Jason and Chasilee watched dread lift from Zay as she grew vivacious and happy. They went to the Antioch School and told administrators that going forward, their child would officially be known as Zay, not Isaiah –as she, not he.
"I tell myself that I didn't give birth to a boy," Chasilee said. "I gave birth to a girl, who just happens to have boy parts."
Zay is precocious and sensitive. For a December music concert, Zay was to play a lead violin part. Zay practiced, but at the event played badly. At home, Zay ran upstairs, dived amid a pile of stuffed animals and sobbed. Chasilee said a friend told her later, "You definitely know she's a girl because a boy would never go to his room and cry for 45 minutes about messing up."
The big day was Dec. 19. Zay put on a black skirt with white polka dots, her I Heart DC T-shirt and a pink sweater. Jason, Chasilee and Jeffrey went with Zay to the clinic. They squeezed into a small examination room. Zay took off the sweater and lay down, raising her left arm over her head. Chasilee stroked Zay's hair, Jason held Zay's hand. Jeffrey asked goofy questions to ease Zay's nerves.
The anesthetic hurt the most. Then a clinic doctor made a small incision on the inside of Zay's upper left arm about three inches above the elbow. The implant was installed, the wound quickly bandaged, and it was done.
That night at home, Zay directed the family to the living room couch to hear a speech of thanks. "I love you all. I am on a bumpy road, and you are my pit crew."
There were tears all around, then Jason laughed with pleasure. "It's always nice to hear your kid express appreciation."
Front and center: Zay steps up, speaks out
Two weeks later, at Zay's request, the Crawfords drove on a rainy Saturday night from Yellow Springs to Kings High School in Warren County. A vigil had been organized in memory of Leelah Alcorn, the transgender teenager who committed suicide Dec. 28, leaving an anguished note of despair and rejection.
The Crawfords walked around the school grounds, marveling at the 300 people who had gathered in the rain. Zay wandered away from Jason and Chasilee. Speakers took turns at a microphone, then an emcee invited others to address the group.
A moment later, the Crawfords heard Zay's voice, amplified. They moved quickly to stand close as Zay uttered the words, "I'm trans, and I'm proud." The crowd cheered.
Beaming through the rain, Zay walked from the microphone into her father's arms, and Jason Crawford hugged his daughter for a long time.