Kim P. is 14 years old. She wears light eyeshadow, a navel-baring top and embroidered jeans. She plays with strands of her long hair as she describes her dream of going to Paris one day to be a fashion designer. Her attic bedroom in her parents' house is a girl's paradise in pink, with the requisite fashion magazines, a makeup table, a sewing machine and even a clothes mannequin near the window.
She's had enough of psychiatrists who ask weird questions. She's had enough of doctors who reject her case because this fashion-conscious girl -- previously called "Tim" in her patient file -- unsettles them.
She was born as a boy. Her body, chromosomes and hormones were all undoubtedly masculine. But she felt otherwise. For Kim it was clear from the beginning that, as she says, "I wound up in the wrong body."
At the age of two, Tim tried on his older sister's clothes, played with Barbies and said, "I'm a girl." Her parents thought it was a phase, but at the age of four Tim was still bawling after every haircut. At last he ran into his room with a pair of scissors and hollered that he wanted to "cut off my thing!" -- and it was clear to his parents that the problem was serious. From then on, at home, Tim went by "Kim."
His parents found stories on the Internet about men and women who felt so unhappy in their own bodies as children that they came out as transsexuals and underwent sex-change operations as adults. They weren't all freaks -- there were engineers and lawyers, artists, programmers and teachers -- and it wasn't easy. A switched gender had to be maintained with a lifelong regime of hormones. Germany alone has 6,000 transsexuals under permanent medical treatment.
The P. family wanted a less complicated future for their Tim, but they've also found reasons for optimism. They've learned that transsexuality has nothing to do with homosexuality. It's not about feather boas and red-light districts so much as identity. Transsexuals aren't "queer birds" -- they want the perfectly normal life of the opposite sex. And some will submit to radical methods, from hormones to surgery, to conform their bodies to the "right" gender.
Well-adjusted in the wrong body
Maybe Kim's family could have tried to change her mind about feeling like a girl if they'd sent her to a psychiatrist early on. But would that have helped? By age eight there was nothing boyish about her hair; she wore it parted in the middle. She played typical girl games with other girls, went to their birthday parties and even dressed up for the ballet. In school she always wore trousers and never braids. Her teachers praised her exemplary social skills, and when she was teased in the schoolyard and called names like "tranny" or "queer," she simply walked away.
"We always saw Kim as a girl, but not as a problem," says the father. "In fact, our life was surprisingly normal."
Normal until Kim was twelve, and experienced the first signs of puberty. She was overcome by panic when her voice began to drop. She had no interest in becoming one of those brawny creatures with gigantic hands and deep voices who dressed like women but looked unfeminine. Only hormones could prevent Kim from turning into Tim again, and time was of the essence.
The family was at a loss when it came to seeking medical advice. "If your child has a heart defect you send him to a specialist," says Kim's mother, "but when your child is transsexual everyone seems to have an opinion."
"Hormone treatment! Gender adjustment! How could you possibly do this to the child?" the family's pediatrician barked at the father -- in Kim's presence. Then came the sessions at the state psychiatric hospital, where Kim would sit in green rooms with high ceilings, playing with experimental blocks, while her parents answered endless questionaires.
Sitting in the waiting room, Kim thought to herself: Does this mean I belong in an insane asylum?
The family's whole life up that point was suddenly in question. "Are boys unwelcome in your family?" they asked the mother. "Have you ever considered, instead of manipulating the child, sending him to be cared for by others for a while? Putting him in a closed children's psychiatric institution, for example?"
"What's wrong with being a real guy?" a doctor in a white coat would ask Kim. "Have you ever tried it? What do you think about your mother? Were you ever in love? With a boy or a girl? Do you like your penis?"
Kim answered their questions to best of her ability, but the whole thing felt humiliating. "All of a sudden I had the feeling that it was my fault, that there was something dirty going on."
Kim's is a classic case, according to Bernd Meyenburg. "Transsexual development is extremely rare, and very few youth psychiatrists have any experience with it. The families wander from one psychiatrist to the next" -- until they wind up in his office, or in the office one of his colleagues at the university hospitals in Hamburg and the southern city of Ulm. Germany has only a few experts on child transsexual development, and Meyenburg heads the Psychiatric Special Outpatient Clinic for Children and Adolescents with Identity Disorders at the University of Frankfurt Hospital.
Gender identity disorders are not rare among children, and they often appear as soon as a child starts to speak. The problem goes away in about a quarter of these children. Most of the remaining three-quarters become homosexual. In about two to 10 percent of the cases, though, early gender identity disorders lead to transsexualism.
"We face a real dilemma"
Prognosis is tricky, though: It's impossible to determine whether a person is transsexual by using standard diagnostic tools like hormone level testing or computer tomography (cross-section images of the body). Psychiatrists base their diagnoses on how long a person has been living as a member of the opposite sex and how convincing he or she is in that role. In adults, medical standards require years of psychotherapy and a trial run as a member of the opposite sex before hormone treatment can start. Children in puberty have little time to satisfy these requirements.
Should doctors second-guess nature because of a teenager's wishes? Can't puberty change everything? And what if it all turns out to have been the wrong decision? Meyenburg has mixed feelings about the fact that more and more -- and younger -- patients are coming to him for advice these days.
"From a purely medical standpoint we are dealing with the mutilation of a biologically healthy body," says Meyenburg. "We face a real dilemma. If we do something about it, it's irreversible. And if we allow nature to take its course, that too is irreversible."
But in Kim's case, says Meyenburg, "it would have been a crime to let her grow up as a man. There are very few people in whom it's so obvious." It takes a great deal of experience to be able to differentiate between a temporary gender identity disorder and "true" transsexuality. Meyenburg recently met a 15-year-old girl who didn't want to be a woman. It took a while, but he discovered that the girl had been brutally abused by her father when she was seven. The trauma of the experience had triggered a deep identity disorder, but not transsexual development. In the end, the girl chose not to undergo a sex change.
Based in part on such experiences, Meyenburg says "psychotherapy is always worth a try -- not because being a transsexual is such a bad thing, but because it is probably easier to go through life as an effeminate dance instructor than as someone who has had a sex change operation." Even if the process goes on to indicate a sex change, most adolescents also benefit from psychotherapy. "After all," says Meyenburg, "there are also parents who attempt to beat it out of their children."
Meyenburg has been studying transsexuality since the 1970s. In those days, orthodox psychiatry believed that adverse social circumstances -- namely the parents -- were to blame when someone felt out of place in his or her biological gender. The perpetrators were domineering mothers, absent fathers, parents with emotional problems who were unfit as role models, repressed parental fear of homosexuality. New York psychoanalyst Susan Coates believed that a little boy's first steps in his mother's high heels occurred when the mother was depressed and emotionally unavailable. In these cases, Coates theorized, the child, instead of "having Mommy," would "be Mommy" to fend off his separation anxiety.
Even Meyenburg was long convinced that severe emotional trauma in childhood caused transsexualism. "On the other hand," he says today, "depression isn't exactly rare in mothers. Wouldn't that mean there should be far more transsexuals?" Meyenburg points out another inconsistency: "There are cases in which you could poke around in the parents' relationship as long as you wish and still find nothing. They are often very pleasant, normal and likable people."
Treating the unknown
Gender development in human beings is a complex of bio-psychological processes, and when something goes wrong, not everyone understands. The medical community in particular tends to impose order, asking itself questions like: "Which gender is the correct one?" Developmental psychologists, for example, long believed that children were born emotionally neutral, and that a person's perceived gender affiliation was the result of social influence.
This approach led to drastic measures. Some children -- hermaphrodites -- are born with both male and female sex organs, and in the past they were operated on as quickly as possible. Psychiatrists thought the children as well as their parents should be spared the pain of growing up without a clear gender identity. But many of these kids later became unhappy with their surgically-determined genders. Some even committed suicide. Social influence -- from early childhood on -- failed to adjust their inner identities. The preferred approach nowadays is to wait.
Experts still think a lot of gender-specific behavior is learned, but they also believe some of it is pre-wired in the womb. The extent to which androgen or estrogen shapes the brain to be male or female is debatable; the age at which gender identity is established is unknown. But certain tendencies manifest early: At only a few weeks of age, female babies spend more time looking at faces, while male babies are drawn to abstract shapes. Three-year-olds handed anatomically correct dolls can tell which ones represent their own genders. This distinction becomes noticeably more difficult for children with gender-identity disorder.
Treating the problem with therapy is controversial: After decades of attempts, and despite some therapists' claims to the contrary, there is still no evidence that psychotherapy can change a transsexual adolescent's gender identity. Whether the development of an identity can be interrupted during early childhood isn't clear, but some experts think therapy is simply the wrong approach for transsexuals.
"Nowadays we believe that it's both," says Meyenburg -- "environment and biology."
But that doesn't clear up the puzzle. Researchers in laboratories are still looking for a sound explanation for the mismatch between body and soul in transsexuals. There are many theories: One holds that a specific gene disables the Y chromosome; another says unusual hormone levels in the womb cause specific areas of the brain in male-to-female transsexuals to acquire the size typical for females. (Certain medications taken by the mother may be to blame under that hypothesis.) A third theory holds that atypical hormone excretions are to blame. Lately some endocrinologists also wonder if a still-unknown disorder in the way genes are expressed in fetuses could impair the function of a child's sex hormones.
None of the theories are proven, though, and the upshot is: If we don't know what causes transsexuality, how can it be treated?
Early hormone treatment may work
Experts in the Netherlands are the most experienced in the field. A so-called "gender team" of somaticists, child psychiatrists, psychotherapists, endocrinologists and surgeons have spent the last few years monitoring more than 350 children and adolescents with divergent gender identity. It isn't rare for these experts to see the metamorphosis of puberty -- and the forced role-shift that comes with it -- transform young people who were emotionally stable into heavily traumatized adults. Many of these individuals also face personality disorders as adults: drug addiction, depression and thoughts of suicide.
To address these problems, in the late 1990s the Dutch cautiously started hormone treatment in a small number of transsexual youths -- similar to the treatment Kim later received in Germany. Asked later about the experience, none of this group regretted choosing the treatment. They were leading more satisfied, normal lives than others in the study who went on living as members of what they perceived as a false or hated gender.
"God made you a boy"
Two years ago, Tanja Pfeil says, she wept uncontrollably after a TV report about a girl like Kim. She mourned the girl she could have been, and the life she'd missed as a woman. The girl on TV looked perfectly female and showed no male characteristics at all, said Tanja. At that point, to the outside world, she was a businessman from northern Germany, in her mid-forties and named Michael. "I attribute it to my sunny personality that I didn't fall apart," she says now. "Being transsexual is something for people who are completely healthy."
As a 13-year-old, Tanja asked her grandmother where people came from. "They're made by our dear God in heaven," the old woman replied. "And when will I finally be a girl?" Tanja asked. "Never," her grandmother said, "God made you a boy." Her first thought at the time was that something had gone wrong in the cosmic factory: God had cobbled her together wrong.
But during Karneval, the German version of Mardi Gras, the young Michael wanted to dress up as Little Red Riding Hood or a princess. He liked playing games with the girl next door. By the age of 10, the family's first-born child -- their son and heir -- was envious of girls with developing breasts who were allowed to wear dresses and makeup. Whenever his mother left the house, he would secretly put on her clothes: lingerie, girdle, high heels and bras (stuffed with handkerchiefs).
He forced himself into the role of a man. He met a woman, fell in love, married and fathered a son. When the boy was born, Michael wished that he himself had given birth.
He held out until his 40th birthday, occasionally drowning his sorrows in red wine. Then he decided that he couldn't do it anymore. "My son Aron is a gift. He shouldn't find out during puberty," he told himself. When Michael was ready to make the change, about ten years later, his friends were deeply divided. But his family supported him and the expected upheaval in his village never materialized. Tanja Pfeil, previously Michael, didn't want to extinguish her old life. But after the first estrogen treatment she had the sensation that something fuzzy in her head had gone clear. "Michael dissolved and became Tanja," she said. "She is stronger than he was."
"I wish you had been like this when you were a man," Tanja's wife recently said. "I tried. I wanted to be a good husband," Tanja replied. But it was impossible. Now the couple plans to divorce and remain friends. "But I would have preferred sparing myself and everyone else my life as a man."
At least Tanja Pfeil was lucky when it came to her body. As a man, she was short and had delicate hands and feet. Now that the hormone treatments have rounded out her breasts and hips, her skirts fit better. "You look enchanting," an elderly woman and regular customer recently said.
"I just happen to be a girl"
To become a woman, Pfeil endured a nine-and-a-half hour operation and the torture of laser epilation to reduce facial hair growth. Other transsexual women have Adam's apple or cheekbone reduction surgery. They take voice lessons to make their voices sound higher-pitched. Some are unable to stop manipulating their bodies, constantly finding new aspects they believe need to be changed.
Kim will have none of these problems. Later in life, no one will be able to tell that she was born male, because her biological development into a girl started at the age of 12. She was the world's youngest patient to receive hormone injections to obstruct her male puberty. This gave her time before making a final decision on surgery.
Even with Kim, though, the decision to switch genders wasn't taken lightly. Before Bernd Meyenburg approved her sex-change process he took a detailed look at every aspect of her family life. Had there been any unusual incidents? Mental illnesses? What about her relationship with older siblings? Were there any day-to-day problems?
"From an emotional standpoint, Kim comes across as a healthy, happy and balanced child," Meyenburg wrote in his report. She had never behaved like a boy, not even for a short period of time. "There is no doubt that her wish is irreversible, because it has been evident since very early childhood."
In the past, Meyenburg was strictly opposed to hormone treatment before a child came of age. He began to question the wisdom of his own rules when one of his patients resisted his advice and ordered hormones over the Internet. She went abroad at 17 and had a sex change operation for a few thousand euros. Meyenburg was angry at the time. Today this woman, a law student, is one of his happiest patients.
Now Meyenburg allows his young patients to enter hormone treatment early, before puberty complicates a sex change. "They simply suffer less," he says.
Kim is already much closer to realizing her dream. The first letter of her name has been changed in her record, and her school now treats her as a girl. Thanks to the hormones, her breasts are developing, like those of other girls in her class. She's allowed to use the girls' locker room during gym class.
One thing hasn't completely changed for Kim, though -- heckling in the schoolyard. But now her best friend sticks up for her. Kim says she feels good about herself in spite of the taunts. "My girlfriends see me as a completely normal person," she says, and time seems to be on her side. The family is buoyed by signs of progress in public acceptance of transsexualism. In the United States, for example, some students have managed to convince universities to add a box -- "transsexual" -- next to "male" and "female" on their forms.
In New York and Spain, transsexuals are now permitted to change their gender on their personal ID cards without getting a sex change operation. Will such changes prompt some to dispense with surgery altogether?
"It's out of the question for me," says Kim, who still wants to get rid of the parts of her body that remind her that she was born as Tim. By law, in Germany, she'll have to wait until she's 18 to take the next step. Meanwhile, she resorts to wearing tight pants.
"I just happen to be a girl," says Kim. She keeps a piggybank in her bedroom filled with change she has been saving for the operation -- since the age of five. Once it's over, her new life will start. "In Paris," she says, "where no one knows me."
Translated from the German by Christopher Sultan