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Boy/Girl interrupted
Source: http://www.sfweekly.com/2007-07-11/news/girl-boy-interrupted
A new treatment for transgender kids puts puberty on hold so that they won’t develop into their biological sex
By LAUREN SMILEY
Published: July 11, 2007The breast bud popped up about six months ago, and Marty knew something had to be done. It was the slightest of puckers, just on one side, so small you wouldn’t even notice it through a T-shirt. Still, boys don’t get breasts, and this had the unsettling potential to blow his cover big-time.
That’s because Marty was born, by conventional measures of modern science, a girl. Marty has two X sex chromosomes, like most females, and the hardware concurs. Yet ever since Marty’s parents flew back from China in 1998 with their 11-month-old adopted baby, their daughter seemed to be programmed male. She refused dresses by age two and half and mastered peeing while standing by three. She would identify herself as a girl only when grilled.
When Marty was about six, doctors said she was no tomboy. She seemed to fit the diagnosis of gender identity disorder (GID), and though dubbing it a disorder whips up a maelstrom of controversy, the basic sentiment is this: not only feeling an intense discomfort with one’s biological gender, but also feeling profoundly, compellingly, like the other.
Enrolled in a new school last year as a boy where only the staff knew otherwise, the nine-year-old passed without a hitch in his wardrobe of Nike trainers and T-shirts, paired with a crew cut, boyish build, and aggressive basketball moves at recess. (To keep his secret, the names of the boy and his parents have been changed.) But the days when the only outward markers of gender lie in haircuts, clothes, and personality only last so long. Deep inside Marty’s brain, a time bomb known as the hypothalamus waited to stage a hormone-armed mutiny. Breasts would sprout. Hips would widen. The uterus would shed blood on a monthly basis. Marty didn’t want any of it.
So when the bud appeared, his Bay Area parents hustled him to an appointment with an endocrinologist at Children’s Hospital and Research Center Oakland, who said the bud might progress no further and puberty could still be a few years off, his parents recall. They were temporarily relieved. Marty treated the bump as a boy would — poking at it at the dinner table, feeling it through his button-down shirts. Waiting.
Then, in May, Marty came to his mom frantically: “Mommy, feel this lump! You have to do something!”
The other breast had budded.
His parents called Children’s because now, due to the efforts of a small but growing number of doctors around the world, something actually could be done about emerging puberty. The endocrinologist agreed that Mother Nature was revving up, preparing to take Marty the way of trainer bras, Tampax, and, as his parents and doctors predicted, increasing distress as his body developed into a sex that to him seemed a cruel trick of birth. The changes would make living as a boy impossible in the present, and he’d potentially face scarring surgery to remove unwanted breasts down the road. What’s more, the upsurge in estrogen would slow and stop his growth, making it harder for him to ever pass as a male. Of course, that’s if Marty would end up living as a man. As boyish as Marty is, no one could know for sure.
But in the present, nature could be tricked. If they all agreed, Marty would never have to develop into a woman.
It was time to put puberty on hold.
The preferred drug for the controversial process is Lupron Depot. Slogan for the pediatric version: “Pause the child within.” It’s potent, yet reversible, and incredibly expensive, and for transgender kids backed by increasingly supportive parents, it’s ushering in a new era. Boys who’ve always known they were girls won’t get beards or deep voices. Girls who feel like boys will never have to grow breasts or tinker with a tampon.
Long prescribed to temporarily stave off puberty in kids who start developing too young, the drug blocks the brain’s release of the compound that triggers the chain of hormonal reactions, body mutations, and moody angst. Now an unknown number of doctors in the Bay Area, the country, and across the globe are following the lead of a fledgling treatment pioneered at a Dutch clinic that’s sparked debate in medical and ethical circles alike. The Dutch clinicians are suspending kids in physical childhood to buy them time to decide if they wish to begin the sexual reassignment process. If so, after a few years of continued psychological monitoring, they can start hormones to induce an “opposite-sex puberty.” If not, the teen can stop taking the periodic Lupron injections and appear to develop normally, as kids treated with the drug for early puberty have for years.
Although treating transgender kids is a non-FDA-approved or “off-label” use of the drug (which is legal, and is done frequently with other medications) the treatment is fast gaining legitimacy in the medical world. The world’s largest association of health professionals who specialize in transgender issues approved the procedure in its most recent treatment guidelines. A handful of doctors have touted the procedure at big-name medical conferences. More doctors are catching on.
“It’s time we have something going here in the Bay Area, because we should be at the forefront of this,” says Herb Schreier, a psychiatrist at Children’s Hospital Oakland.
Advocates say the treatment saves kids the anguish of continuing to develop into a gender they don’t identify with — reducing the risk of everything from depression to self-mutilation to suicide attempts — as well as later surgeries to undo what Mother Nature has done. By sitting out the irreversible changes of biological puberty, patients will pass more easily as the target sex, protecting them from potential discrimination and even violence. And transphobic violence is something that the Bay Area has been known for at least once, when partygoers beat and strangled 17-year-old Gwen Araujo of Newark to death in 2002 upon discovering she was a biological male living as a female. In March, the body of Ruby Ordenana, a transgender Nicaraguan immigrant, was found near a highway off-ramp in Potrero Hill.
“If you have someone who’s 6-3, with broad shoulders like a football player and a deep voice, there’s no amount of surgery or hormones in the world that’s going to allow that person to pass and be safe,” says Nick Gorton, a doctor who treats transgender patients at Lyon-Martin Women’s Health Services in San Francisco. “If you treat them [young] then maybe at 25 they won’t get raped, beaten, and killed.”
So far, none of the 60 or so teens choosing to delay puberty at the Dutch clinic have turned back. None have reportedly had regrets. Yet no matter how happy the patients seem, put “delay” and “puberty” in the same sentence, add in a little-understood condition like GID for which science still cannot pinpoint a cause, and, well, people start talking.
Some doctors say kids need to experience puberty to truly know if they’re misplaced in their bodies, and warn that the long-term side effects of diverting nature’s route are still unknown. A few doctors believe medicine should never intervene to change a person’s body to match gender identity, no matter the age — what one transwoman doctor dubbed the “you should be what God made you regardless of how miserable you are” camp. Paul McHugh, the psychiatrist who spearheaded the closure of the sexual reassignment clinic at Johns Hopkins Hospital in the 1970s, is an appointee to the President’s Council on Bioethics. He calls the Lupron treatment “a modern form of child abuse.”
“Some say you’re playing God,” says Stephanie Brill, the facilitator of a Bay Area support group for parents of gender-variant kids. “Our entire society is based on gender, and this hits right into the religious right and the whole Moral Majority idea, and doctors are worried of losing their funding and the backing of their hospitals if they do it.”
Indeed, some U.S. doctors don’t seem to be clamoring for attention. Norman Spack at Children’s Hospital Boston, who has supported the treatment in a medical article and on ABC’s 20/20, declined to comment for this story. A doctor at Kaiser Permanente identified by a Bay Area family as their son’s provider of the Lupron treatment also would not speak. But Schreier of Children’s Hospital Oakland says he’s not worried: “What we’re doing is based on data, not based on emotions or religious beliefs.”
All seem to agree on one issue: No matter how reversible Lupron may be, when studies indicate that the vast majority of kids with some gender-variant behavior in childhood will grow out of it, how do you block puberty in the right kids?
Marty’s parents say they are 99.8 percent sure that his identification as a boy is here to stay. Though they accept that now, it was certainly not their expectation, let alone their choice. Actually, checking “girl” on the adoption forms was a no-brainer for the middle-aged lesbian couple. As ardent feminists, the attorney and child psychologist felt equipped to raise an independent-minded girl, and Marty seemed to be right on track.
When she saw an astronaut, politician, or athlete on the TV, she said, “I want to do that!” “Of course you can!” the mothers would answer. She ignored dolls, but loved trucks. Somewhere around age two and a half, Marty refused to raise her arms when her mother tried to put a dress on her, the first time she’d ever rejected an outfit. One day out of the blue, she looked her mother in the eye and asked, “When is it my turn to be a boy?”
The mothers grew puzzled. Maybe she was just trying to set herself apart from her newly adopted little sister. They certainly didn’t want to overreact. If Marty would only wear drab clothes from Target’s boys department, why waste money on skirts? If she was proud she could pee like the boys at preschool, planting her feet together and arching her back to hit the pot, well, at least she was potty-trained. But they also didn’t want to fan the flames.
“I was aware to not pin him to a decision he made at the age of two,” says Margaret, the child-psychologist parent. “I didn’t want to build it in as a permanent part of his personality.”
Marty became increasingly self-conscious about being identified as a girl. With her bob haircut, she let kids at school assume she was a boy, and avoided the bathroom all day so she wouldn’t have to pick one. She refused to change her swimsuit in the girl’s locker room at the YMCA.
At age five, the discord between her identity and body seemed to take its emotional toll. At times she would play recklessly, and at other times, seem withdrawn and preoccupied. Marty’s parents took her in for a psychiatric evaluation, and she was prescribed antidepressants. She told Margaret that if she had to be a girl, she’d rather die.
But one topic seemed to cheer the kid up. One day, Janet, the attorney, told her that a friend’s daughter had started transitioning to manhood in her 20s. Marty lit up, pelting Janet with questions. How? It involved hormones and a surgery. Can I have it now? Can I get my penis? Janet said they would support her in whatever she decided, but that she would have to wait till she was older.
But the parents soon learned that interventions can start much earlier than that. Marty’s pediatrician pulled the mothers in after the child’s annual checkup: We all see what’s going on here, don’t we? Every year, the girl was presenting more and more like a boy. The doctor said the parents should find an endocrinologist who delays puberty for transgender kids. When puberty hit, the family didn’t want to be caught off-guard.
Janet was skeptical. Although she’d trumpeted lesbian causes for years, she knew little about transgender people. How permanent could this really be in a seven-year-old kid? She and Margaret started attending a support group for parents of gender-variant children, and discovered one couple was calling their son “she.” Janet thought it was a little odd.
“You would think of all people, I, who came out and went through all of this hullabaloo with my parents, would have the consciousness to understand people are who they are,” Janet says. “But for me, with Marty, it didn’t translate.”
But that would change after two years of the support group, a barrage of books, Internet searches, and an Oprah episode on transgender kids that Marty watched a dozen times. When Schreier, the support group’s psychiatrist, explained there was no way that parents could have made their kid this way, any last remnants of guilt dissolved.
“Look, we’re a lesbian couple,” Margaret says. “Even if we didn’t think we did, I know a lot of other people would think we influenced his gender identity.”
Finally last summer, at age eight, Marty said she wanted to be considered “he.” A boy. Their son.
“I finally got it,” Margaret says. “This is an identity.”
They were both sad to part with their idea of a daughter, but any final doubts faded after seeing how Marty seemed to glow in his new role, going to a new school as one of the boys.
But puberty?
The mothers had heard talk of “blockers” flung around in the support group, and had done some initial Googling on treatments. They attended a seminar this spring where Spack, the doctor from Children’s Hospital Boston, explained the treatment for delaying puberty. Having been prescribed Lupron herself for fibroids years before and ballooning 50 pounds in four months, Margaret wasn’t thrilled about the drug choice. (Indeed, women prescribed the drug for the approved uses for endometriosis or fibroids fill Internet message boards with complaints of hot flashes, mood swings, memory loss, and pain.) But the most common side effect in kids is irritation, sometimes including a sterile abscess, at the site of injection.
The idea of the injections was initially a relief to the parents. Something could be done, and with Janet’s salary as an attorney, they could afford the approximately $1,800 shot four times a year even without help from insurance, if need be. But the option also added pressure. With Marty too young to fully grasp the implications, the decision to start was going to fall on them. The mothers knew they had altered the course of Marty’s life the day they adopted him, changing his status from a Chinese orphan to an adopted Chinese-American child of gay parents. Now they faced taking the first step in what could become a transition to an identity even further from the mainstream: transman. All along, they had figured that decision would still be some years off.
But Marty turned nine and his breast buds demanded attention.
Give Marty a couple years without the shots and he might look something like the girl who sat before Dr. Henriette Delemarre-van de Waal at the Free University Medical Center in Amsterdam in 1986. Referred by a psychologist who diagnosed GID, the 12-year-old ace student was depressed about her growing breasts, which she had been binding to her chest to disguise. She wanted to be a boy.
The endocrinologist had never worked with a patient with GID, but a drug known as a GnRH blocker, the same compound as Lupron, had recently gone on the market and was being used to delay puberty for kids who developed too soon. The solution seemed obvious.
“She was crying for help, so I thought, let’s try,” Delemarre-van de Waal says. The treatment greatly alleviated the patient’s distress, according to the doctor. At 17, the patient began taking testosterone, and later underwent sexual reassignment surgery. He is now a veterinarian.
That positive outcome seemed to agree with follow-up studies of Dutch adolescents that indicated those who started hormone therapy between 16 and 18 were more satisfied with their sexual reassignment surgery and had fewer psychological problems than people who started transitioning in adulthood. Meanwhile, Dutch psychologist Dr. Peggy Cohen-Kettenis was seeing younger and younger patients with GID, many of whom were so distraught that they couldn’t start hormones until 16 that therapy couldn’t reach them.
So about seven years ago, the Amsterdam Gender Clinic became the first in the world to regularly block the early and still reversible stages of puberty, provided that the patients met strict requirements: Their GID had persisted since an early age, they were otherwise psychologically stable, and had a supportive family.
The clinic has treated around 60 adolescents between the ages of 12 and 16 so far with the GnRH blocker, about half of whom were referred early enough to start shortly after the onset of puberty. For those who had reached the middle stages of puberty, the drug could slightly reverse and stop any further development. All patients decided to start hormones of the target sex once they became eligible at age 16.
Ever since the first forays into treating humans with cross-sex hormones in the 1930s and ’40s, men taking estrogens and women testosterone has brought on expected changes. But by blocking puberty first, the changes can start on a blank canvas, resulting in a closer replication of the opposite sex’s development. With estrogens, biological boys grow breasts, and fat will collect on the hips and thighs to create an hourglass shape. By blocking the growth-spurt-inducing testosterone of male puberty, they’ll likely end up shorter — a plus if wanting to pass as a woman. The penis and testes will remain at a pre-puberty size, the voice will not drop, and no Adam’s apple will jut out. The face will not grow rugged ridges like that of a man’s, although the clinic will take pictures every three months to determine the exact effects on bone structure.
With testosterone, biological girls gain muscle in the shoulders and grow male-pattern body hair. Their voice will drop, an Adam’s apple pops out, and the clitoris lengthens a few centimeters. Since they’ve held off female puberty’s estrogen, which tapers off bone growth, they gain time to put on some inches. Height can be further enhanced by growth-stimulating hormones along with the GnRH blocker, and is given one final push by the testosterone-fueled growth spurt. The Dutch doctors say the interventions have been able to add or subtract up to five to seven inches from patients’ predicted heights.
With continued counseling, and after having lived for a period as the target gender, both sexes are eligible for surgery at age 18 to remove the testes or ovaries. After that, they stop the GnRH blocker.
Not all countries have such easy access. Hormonal intervention must be approved in court in some countries, and with Lupron costing roughly $500 to $700 a month in the United States, the treatment is out of reach for many families. Some doctors report getting payment from insurance by playing with the wording in the diagnosis — leaving the word “transgender” out — but many others have run into a brick wall with third-party payers, raising concerns in the transgender community that the treatment could create a class division between those who can and can’t access treatment.
Without the luxury of delaying puberty with Lupron, some doctors go straight to prescribing cross-sex hormones to kids as young as 12 or 13 to override their natural puberty and allow them to develop as the target sex at the same time as their peers. Cross-sex hormones can cost as little as $25 to $70 a month, a fraction of the cost of Lupron, but many of the changes are permanent.
“Most [adolescents] don’t want to just suppress. They want to move,” says Marvin Belzer, an adolescent medicine specialist who has started young teens on cross-sex hormones at Childrens Hospital Los Angeles. “In our society in America, starting early has far less bad consequences than starting late.”
But not all are convinced starting early is best. The team at the Gender Identity Development Service at the Tavistock Clinic in London will not intervene until puberty is nearly complete, saying the experience may help patients make a more informed decision about being misplaced in their body. Domenico Di Ceglie, the team’s child and adolescent psychiatrist, wrote in an e-mail that 20 percent of the adolescents treated in the clinic no longer wanted any intervention once they’d completed puberty.
He warns that the long-term effects of delaying puberty are unknown. He questions whether the puberty-blocking treatment itself could affect a patient’s gender identity, since adolescence is a key time for brain development and a possible time for a change in perceived gender.
Then there’s the question of bone density: The London team questions whether delaying puberty could cause a long-term deficiency, since bone accrues at a rapid rate with the hormonal flurry of adolescence. The Dutch say their patients’ bone density catches up to normal once they begin cross-hormones, but patients will be monitored until age 25 to see if there are any final differences.
The two teams plan to compare their outcomes in follow-up studies, but they agree on one principle: With studies showing anywhere from 75 to nearly 90 percent of children with gender-variant behavior will eventually be comfortable with their biological sex, tight screening is key.
The younger the patient, the more likely that the child will change his or her mind, says Ken Zucker, a psychologist who has treated 500 gender-variant children and serves as head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto.
“I just haven’t seen these kids where at age 10 I’m convinced that this is the way they’re going to be.” Zucker says. “Doing this type of endocrine treatment seems pretty cool, but it tends to ignore the possibility that psychological therapies can help kids resolve their gender identity confusion.”
So it comes down to an ethical dilemma of choosing the lesser evil: wrongly suppressing puberty in kids who will grow out of their gender variance or refusing treatment to all. Peter Lee, a professor of pediatrics at Penn State College of Medicine who has treated three young transgender teens with Lupron, knows on which side he’d rather err. Twenty years ago, a biological female who identified as male came to him in late adolescence with “so much pain and agony with her development in the wrong direction” that she later committed suicide.
“So you’re balancing that against the risk [of wrongly putting someone on Lupron],” Dr. Lee says, because with Lupron, “sooner or later in this realm, if you deal with enough individuals, you will make a mistake, and will have judged incorrectly.”
Few of the transgender adults interviewed for this story said they had the consciousness at such a young age to know what transgender was in the days before Internet communities and Oprah specials, let alone that they would assume this identity. While many concede that kids who receive this treatment will have an easier time in puberty and passing in the years beyond, some question how transitioning so early will change a community where having lived on both sides of the gender line is part of a collective identity.
After living 17 years as a male, followed by years of hormones to transition, Alexis Rivera of the Transgender Law Center says she decided to go off hormones and settle into a space somewhere between male and female, and now at 29, has proudly done so.
“If medical technology keeps advancing, are we going to eradicate transgenderism?” Rivera asks. “The younger the transition starts, the younger you start socializing a biological female as a boy, they’re not going to have that transgender identity. They’re not going to have to walk this earth as their genetic sex.”
Juan struts across the parking lot with the lumbering gait of a macho guy in training, with an eighth-grade graduation gown flung over his shoulder and a rhinestone glistening in one ear. He slaps five and curls fingers with a friend and then hugs a pretty classmate in heels who poses over Juan’s shoulder so his mom can snap a photo.
“She’s taller than you,” blurts out Juan’s seven-year-old niece.
Not what a 14-year-old guy wants to hear, but Juan doesn’t flinch. In this life, at this South Bay school, his identity is solid, his male status a commonly held truth. But just blocks and three years away sits Juan’s old elementary school, where the truth was different. There, kids knew him by another name. There, kids knew him as a girl.
Juan has been on Lupron for two and a half years, sometime after he took down the pictures in the house where he appeared as a girl, said goodbye to his fifth-grade classmates for good, and showed up for sixth grade with a new identity.
Without the monthly Lupron injections, Juan would have breasts by now. He would most likely be shaving his legs, whereas they still only have the slightest whisps of hair. Without the nightly shot of the growth-stimulating hormone, he would likely be shorter than he is, and he’s still only 5-2, just taller than his mom. But because of Lupron, he passes as 100 percent boy, and for now, everything rests on nobody knowing any differently. (His name has been changed for this story.)
Before Juan showed up at his new school three years ago, his mother worked out the ground rules with the school for the stealth experiment: The staff would know and Juan would use the nurse’s bathroom. During the first few days of school, Juan sometimes didn’t respond to his new name, his teacher recalls. She warned him that boys don’t dot their “i’s” with hearts, and his handwriting got less loopy. His seventh-grade teacher kept the attendance list where Juan was still marked “F” for female in her desk. When a kid noticed that Juan had an “F” by his name for his physical fitness test, the teacher made a fast save: Those state bureaucrats must have made a mistake, she joked. She remembers Juan looked a little sick, but they pulled it off.
Funny, outgoing, and, with his long lashes and delicate features, Juan is pretty cute. The ladies loved him, “and they were the very beautiful popular girls,” a teacher remembers. His sixth-grade teacher talked with him outside of class about his string of girlfriends: Was it really fair to the girls if they think they’re dating a boy? When in seventh grade Juan started dating a girl who had older brothers who would spell trouble if Juan were to be found out, the school staff got worried. Juan’s mom thought they were overreacting. After a chat with the Transgender Law Center, the staff decided they couldn’t ban him from having girlfriends. But the romance seemed to fizzle anyway, and Juan started a “girls are too much drama” line that many boys copied from him. But it didn’t last long, and soon, he was holding hands and slow dancing with girls again, his teachers recall.
He’s gotten good at cover-up strategies. While Juan’s mom recounted in the family’s living room how Juan cried when he had to wear skirts to elementary school, his niece, who, like the other young relatives, don’t know he was born a girl, grabbed his shoulders:
“You’re a girl?”
“No.”
“Why did you wear a skirt on the first day of kindergarten?”
“Why did you wear a skirt on the first day of kindergarten?” he shoots back.
“Because I’m a girl,” she answers, seems to lose interest, and bounces out of the room. Did that bother Juan? He nods, eyebrows knit.
On weekends or breaks, Juan flew to transgender conferences. He’d sit on panels of transgender kids. He’d read a poem he penned at Transgender Day of Remembrance. His mother said he’d then go back to school, the monthly Lupron shots at Kaiser Permanente Vallejo Medical Center sustaining his secret.
“He kind of has this double life,” his eighth-grade teacher says. “He’s so scared but so brave. I wish he would’ve [come out]. I’m just scared to death some mean person is going to find out and hurt him with it.”
Back at graduation, Juan accepts his diploma and walks out into a congested lobby. A high school hottie in bloom who hasn’t seen him for a year hugs him, pressing her body into his side and rocking back and forth. Juan looks a little overwhelmed by the ferocity of her ardor, but doesn’t pull away. She kisses him goodbye on the cheek. Out on the sidewalk, a petite bespectacled girl takes a running leap at him that knocks him off balance: “Juan! I gotta hug yoooooou!” A few last hugs and pictures, and Juan climbs into the car and shoots a backward peace sign to a classmate from the window. “I’m going to miss them all,” he says.
Done. He pulled it off for three years. Next stop: high school and a whole new set of people to convince. But by the time the first day rolls around, Juan might have a little help from his body to back him up. He got his first testosterone shot the week he turned 14 in May, and the facial hair and low voice are on the way.
Marty chases the Spalding basketball across the asphalt, past the girls on the swings, past his mom Margaret observing from a bench. “I’m trying to shoot from the three!” he yells, before dribbling back to the court, the long late-afternoon shadow of a boy in a baseball hat pattering alongside.
“Would you ever mistake him for a girl?” Margaret marvels. “He looks like a baseball player running out to take his post at second base or something.”
Both mothers say they’ve gotten used to Marty as a boy. They rarely slip on pronouns anymore, and admit that they’re sometimes caught off-guard when Marty strips for a bath and they realize he’s still a physical girl. When he budded breasts, Janet says she revisited the sadness of losing her daughter.
They acknowledge Marty has chosen a difficult path. Already, they are careful about with whom they share the truth. They sat out the Trans March on Pride weekend, partly because of the risk of getting put on the news, and they know life will only get more complicated as Marty gets older and birthday parties and day camps turn into locker rooms and school dances.
But mostly they worry about making a mistake. There’s no denying that Marty isn’t one for introspection, and he can’t much pontificate at length about the future. He still takes a “yuck” approach to anything romantic, and when his mothers have introduced him to transgender adults visiting the support group, they think much of the significance goes over his head. He stops batting his basketball against a wall long enough to reflect on puberty:
A period? “Sick.”
Breasts? “Floppy,” he says, juggling imaginary ones with his palms, adding “I don’t want bras!”
Back to wall ball.
His parents say they would be shocked if he were to turn back now.
“You don’t realize how serious this quest is until you follow the kid’s lead,” Janet says. “I’m convinced he feels like a boy inside.”
“I figure if you have a Beethoven,” Margaret adds, “you don’t take away the piano.”
So they will ensure Marty’s body doesn’t do any deciding for him, leaving the road open with Lupron until Marty can better navigate to points female, trans-male, or somewhere in between. It’s a decision, essentially, not to decide. But of course that’s still a decision.
So the Lupron has been ordered, and the family is waiting for the loaded syringe to arrive in the mail. Once it does, they’ll climb into the car and drive to Children’s Hospital Oakland, where Marty will steel himself and take the first shot.
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