Her Changing Body, and Politics, Sent a Transgender Preteen on a Quest

The Washington Post

12:01 JST, December 27, 2024

ROME – She sat at the gate at the airport, self-consciously probing her upper lip. She had recently started waxing to hide the stubble. Nothing about puberty bothered her more than the hair.

A year earlier, she had “killed” her male birth name and entered her Rome middle school as a baggy-clothes-wearing, basketball-loving girl. But then she shot up three inches. Her voice notched down a pitch. Only a few friends at school knew her birth sex, but soon, she feared, it would be too obvious to hide. The thought of it kept her up at night, gave her stomachaches.

The distress had led 11-year-old Maria and her mother to this flight – her first out of the country. They were headed to Spain, on a quest for a puberty-blocking drug they had tried and failed to obtain in Italy.

“I’ll relax when it’s over – when I have it,” Maria said from her seat at the gate, pumping her legs with nervous energy and clinging to her mother’s arm.

There was no ban on puberty blockers in Italy. But amid a politically charged outcry, a committee appointed by the right-wing government had begun reviewing treatment guidelines for transgender youth. The primary clinic providing the drugs had come under scrutiny, resulting in what appeared to be a de facto freeze on new prescriptions.

In countries across the West, the geography of access to puberty blockers and hormones for transgender youth has been in flux, as doctors and politicians engage in debates about science and ideology. That’s left children such as Maria in limbo, while the passage of time constrains their options.

In the United States, the American Academy of Pediatrics maintains that puberty blockers are safe, “generally reversible” and effective, tending to reduce depression and anxiety until an informed decision can be made about a more permanent transition. But the treatments have been banned or restricted in two dozen states, and the Supreme Court appears inclined to let such restrictions stand.

President-elect Donald Trump has said he plans “to stop the chemical, physical, and emotional mutilation of our youth” with new federal action. Among those who have his ear is billionaire Elon Musk, who, when talking about his own transgender daughter, has said, “The woke mind virus killed my son.”

In Western Europe, too, the pendulum has been swinging against puberty blockers for children – though in many countries the debate is less politicized than in the United States. Britain has banned the treatments outside clinical trials, saying more research is needed on the potential benefits and harms. Denmark, France, Finland, Norway and Sweden have issued more-restrictive guidance. That’s led to reluctance by some doctors and clinics to write prescriptions – and long waiting times for appointments at places that are more willing.

Maria’s mother had tried to prepare her for the possibility that she wouldn’t get the blockers in Italy. To that, Maria replied, “I’ll kill myself.”

As the wait for access stretched from weeks to months, the family made a radical choice: They would join what doctors, researchers and advocates say are hundreds of others who have been crossing national borders in search of gender-affirming care for trans daughters and sons.

“I know what’s best for my daughter, not the government,” said her mother, Chiara, protectively stroking Maria’s shoulder-length hair before the boarding call.

– – –

An appointment in Florence

From the moment she could speak – late, at nearly 3 years old – Maria had referred to herself as a girl. She rejected clothes designed for boys, clinging to her older sister’s glittery My Little Pony T-shirts. She would correct her parents when they spoke of her in the masculine form of Italian. She developed a fanciful story of her birth: She had been born female at some hospital in Paris. But when her parents picked her up, her father had wanted a boy – so the doctors attached a penis that wasn’t hers.

At age 6, she began seeing a psychologist who noted her “gender incongruence.” Through primary school, she kept her birth name, played judo, took drama classes and had friends of both sexes. She sometimes insisted she was “in between” a boy and a girl. She kept seeking clarity. “Do some women have a penis?” she had once asked her mother. By age 8, she sometimes wore dresses – in the house and outside. Her parents reassured her it was okay to like feminine things and still be a boy.

Her paternal grandparents, though, criticized the way she dressed and insisted she cut her long hair. Maria broke off contact. “They don’t accept me,” she said. “I don’t accept them.”

She was near the end of primary school when she told her parents it was time to “kill” her birth name. (The Washington Post agreed to refer to her by her middle name and her mother by her first name, to protect the privacy of a minor and shield the family from attacks.)

There was an announcement in class. One bully, a boy, especially teased her, but it was nothing she couldn’t handle.

The battle against her body was different. She had thought she would grow up svelte and androgynous. But her shoulders and legs were filling out. And then there was the hair. She couldn’t even bring herself to say the word – miming it instead by brushing a hand over her chin.

It was another psychologist, at a center for gender-affirming care in Lazio, Italy, who first presented the idea of puberty blockers – drugs that temporarily stop the production of sex hormones but allow puberty to proceed if a patient decides to discontinue use. Maria’s endocrinologist pointed her to Florence’s Careggi University Hospital, which had been prescribing the drugs through the national health service since 2019.

And so, Chiara and Maria drove from their family’s three-bedroom apartment in Rome to Florence, city of the Renaissance and the center of gender-affirming care for minors in Italy.

Chiara, a multilingual civil servant, had jitters. She had followed the bitter debates across the West, pitting allegations of transphobia by advocates against cries of child abuse by opponents. She knew that Italian Prime Minister Giorgia Meloni opposed LGBTQ+ rights and that the far-right party in power – its motto “God, fatherland and family” – had issued an edict directing cities and towns to cease registering parents of the same sex on birth certificates.

“They define family differently than we do,” Chiara said.

But during that first consultation, in September 2023, the staff neuropsychiatrist and other doctors at Careggi were receptive.

“They had a very positive approach; they told us from Day 1 that our case should be very smooth,” Chiara said. “There weren’t any doubts about my daughter’s story. We took the report from her therapist in Rome. They told us to come back in March, that everything seemed okay.”

– – –

The Florence clinic under pressure

But by March, everything had changed. The Careggi clinic’s care of trans youth had become the subject of newspaper stories, government debates, a Health Ministry audit and a criminal probe. When Maria and her mother returned to Florence for the planned follow-up, they learned their appointment had been canceled. The clinic didn’t give a reason, saying simply the endocrinologist “could not see” Maria.

The heightened scrutiny started with reporting from the conservative-leaning Corriere della Sera newspaper. One story quoted Careggi medical staffers saying that candidates for the puberty blocker triptorelin shouldn’t have to undergo psychotherapy or be evaluated by a child neuropsychiatrist – requirements under national guidelines. “Cisgender people are not asked for psychotherapy to define their gender identity. This also applies to trans people,” Jiska Ristori, a senior medical official at the clinic, told Corriere.

Careggi officials declined requests for comment from The Washington Post.

Conservative politician Maurizio Gasparri denounced the clinic on the floor of the Italian Senate, calling for a probe. Meloni’s Health Ministry obliged. The ministry declined requests for comment for this article. But a copy of its investigative report obtained by The Post shows that authorities found weak data-reporting and lax application of psychiatric assistance, in part based on a faulty interpretation of poorly written national guidelines. In some cases, the report stated, children were being prescribed triptorelin without ever being assessed by a national health service neuropsychiatrist.

“I did it out of concern for the health of children,” Gasparri said. “Science must tell us whether these drugs are useful.”

Yet the science is newly unsettled.

Early intervention with puberty blockers was a standard of care that originated in the Netherlands. The idea was that the temporary treatment would allow patients some relief from their distress while giving them time to consider more-permanent interventions such as hormone treatment or surgery later on. Parents and doctors backing puberty blockers for trans youth call the treatment essential for psychological well-being and suicide prevention.

But the research, often based on small samples, has faced challenges. None was more prominent than the Cass Review, which this year prompted Britain’s National Health Service to confine puberty-blocker prescriptions to a medical trial. The final version of the Cass report found “weak evidence” that blockers have positive impacts on gender dysphoria, and cited their risks to cognitive, psychosexual and bone-density development. Many children resolve gender dysphoria during puberty, the report argued, suggesting that blocking it could work against that goal.

Maria and her mother remained determined. After they received notice of the canceled appointment, Chiara emailed the endocrinologist directly and got back on the schedule. She said they were reassured in that session that Maria’s X-rays, blood tests and bone-density scans fit the requirements for blockers. Soon, they were told, a final decision would be made.

What followed were weeks, then months, of postponements.

In July, the Italian government appointed an expert commission to devise new guidance on treatment for trans youth. Some of its members did not recognize adolescent gender dysphoria as a real condition – seeing it as a by-product of depression or other disorders. One member, Sarantis Thanopulos, head of the Italian Psychoanalytic Society, had written two open letters to Meloni expressing alarm over the use of blockers. In an interview with The Post, he said Italy should follow Britain and put care under a closely monitored clinical trial.

“The fact is most of the children who declare themselves gender-incongruous will no long feel incongruous by the end of puberty,” he said. “This gender dysmorphia will not be anything but temporary.”

Francesco Lombardo, president of the Italian Society for Gender Identity and Health and a minority voice on the panel, argued that a clinical trial would be of limited use. Only about 100 trans children in Italy are receiving blockers. That’s about double the number five or 10 years ago, he said. But in a country of 59 million, cases remain rare, and sample sizes would be extremely small. Placebos wouldn’t work for comparison, he argued. “Either you block puberty, or you don’t.”

He conceded a lack of strong research on outcomes. “But if you can only give a drug when you have strong, absolutely certain evidence, then you’d have to renounce a lot of drugs,” he said.

An appointment in Barcelona

“Buenos días,” the Barcelona taxi driver said on a July morning as Chiara and Maria, wearing a loose Chicago Bulls T-shirt, clambered into the back seat. On the drive from the airport, Maria started counting pharmacies. “Uno … due … tre,” she said in Italian, reassuring herself of their abundance.

They had given up on Careggi after a consultation with its new neuropsychologist. Previous reassurances had disappeared – in their place came assertions that Maria had never been promised puberty blockers.

So Chiara launched herself into internet research and identified Spain, with some of the strongest transgender rights protections in Europe, as a promising destination for those struggling to find trans care.

Walking through Barcelona, Maria marveled at its liberal street life. She passed same-sex couples strolling hand-in-hand. She saw daringly dressed women and what appeared to be a young boy, perhaps 4 or 5, walking in a dress while holding his mother’s hand. Such scenes were far less common back home in more conservative Rome.

“I’m moving here,” a beaming Maria said to her mother.

Inside a central Barcelona medical clinic, Maria held her mother’s hand as the doctor spoke. He had already reviewed her records, done an online consultation. He saw the case as straightforward and said so in English – a language Maria didn’t speak but her mother did.

“Everything is okay to start,” the young doctor said, smiling at them both.

“Translation, Mom?” Maria anxiously asked. She got one. Then the doctor handed over prescriptions for three months’ worth of injectable triptorelin.

“You know, you saved our lives,” Chiara told the doctor.

“I know,” the doctor said. “It’s very time-sensitive.”

Maria relaxed in her chair.

“Today is my new birthday,” she said.

A real birthday celebration

“Let’s eat!” Maria declared as she and a gaggle of friends tucked into a platter of rectangular pizza slices. It was three months later, her 12th-birthday slumber party. The girls giggled, gossiping about kids in school. The one lone boy – a friend from before Maria’s social transition – sat quietly on the other side of the table. He wasn’t spending the night – he had said he was uncomfortable doing that with four girls.

Later, Maria unwrapped her gifts. “Yes!” she cried as she unwrapped a plastic doll of her favorite character from Japanese manga – a young girl who had undergone a frightening transformation. Maria had begun to sleep better at night. At school, her grades were improving.

Out of earshot, by the dining room table, her mother and her father, Domenico, mused over her future.

Might she take hormones when she is older and later seek gender-affirming surgery?

“I would be surprised if she didn’t,” Chiara said.

“I wouldn’t,” Domenico said. “Not because I don’t want her to. But it wouldn’t be easy for her in Italy, with all this machismo.”

“She’s already talking about surgery in Thailand,” Chiara noted.

“What’s important is that she’s happy,” Domenico said. They both agreed on that – and the idea that puberty blockers would buy her time.

They had taken one more stab at getting the drugs in Italy, after receiving a surprise call from Careggi – more than a year after their first visit. They returned to Florence for an appointment on Halloween and were told that a prescription for a six-month dose of blockers had been approved, but with a big caveat.

“They couldn’t promise we would get it again,” Chiara said. It could depend on what the new commission decides.

This month, a separate National Bioethics Committee issued a nonbinding recommendation that puberty blockers be limited to controlled trials, with children allowed to enter only if they have been involved in psychiatric therapy, as well.

Maria and her family have decided to continue treatment in Barcelona.

“I won’t take a risk with my daughter’s care,” Chiara said. “I sometimes think it would be better for her to go somewhere else, to another country, a place where she is better accepted. I don’t see that in Italy. Not anymore.”