Robert Garofalo knocks on the door of Exam Room 1, a small chamber in the corner of the gender identity clinic he runs at the Ann & Robert H. Lurie Children’s Hospital of Chicago. Today, Garofalo is seeing Diana Gonzalez, a high school freshman who’s been his patient for two years. When the doctor enters, Diana and her mother, Lisa Salas, are sitting on opposite sides of the room. Garofalo—or Dr. Rob, as he’s known to his patients—settles onto a stool between them, his black-and-white polka dot socks peeking out beneath his jeans. He begins with small talk of high school and cosmetology (Diana’s desired profession) but soon shifts to the main reason for her visit.
“You’re almost 15,” he says. “I think it’s time we talk about transitioning you to estrogen.”
Without missing a beat, Diana snaps her fingers and replies, “Yes! It is time.”
Born as David, Diana is male-to-female transgender and one of about 200 patients Garofalo sees at the Lake View clinic, which he started in July 2013. They range in age from 18 to as young as four, but all have one thing in common: They suffer from what is known as gender dysphoria, or feeling trapped in the wrong body.
Garofalo’s clinic, one of only 25 of its kind in the nation and the first to open in the Midwest, is pushing the boundaries of treatments for the growing population of transgender kids. In the past, patients this young were often redirected through “corrective” therapy to more gender-typical behaviors; Garofalo and his 25-person team take a much different approach: They aid these patients in transitioning. “Reaching these kids at a younger age helps prevent some of the difficulties that so many transgender people struggle with,” says Garofalo. “You’re helping them become their authentic selves.”
In Diana’s case, for much of her childhood, she didn’t even realize she was transgender. She had identified as gay. It wasn’t until she was 12 and saw an episode of Oprah about transgender women that she realized her situation was more complicated. She asked her mom to make an appointment with Garofalo. The doctor immediately put her on Lupron, a treatment for prostate cancer and fibroid tumors that also happens to suppress puberty. The idea was to spare her the angst of developing mature male characteristics—facial hair, a deeper voice—while buying her some time to decide what to do next.
“I’m going to give you both a copy of this consent form so you can read it over and digest it at home,” Garofalo tells Diana and her mother, pulling out a three-page document outlining the possible effects of estrogen on male bodies. Once Diana starts taking the hormone, she will develop breasts and hips. So signing the consent form carries the weight of a life-changing decision.
“There are a lot of wishy-washy statements here,” Garofalo continues as he hands them the form. “That’s because there haven’t been many studies on the long-term effects of estrogen on young people.” He pauses to look at Diana’s mother. “I wish I could tell you everything that’s going to happen, but I can’t. There’s just so much that we don’t know yet.”
He has this conversation with every single patient who begins hormone therapy. In fact, this is the second time he’s had it today.
This is a critical moment for the transgender community, which seems to be suddenly bursting out from the fringes of society. Today, according to a Dutch study, more people—at younger and younger ages—are identifying as transgender than ever before. TV shows such as Amazon’s Transparent and Netflix’s Orange Is the New Black depict transgender characters as nuanced people, not cartoonish stereotypes. Reality show staple Caitlyn Jenner came out as transgender in April in part “to do some good” as a role model. Nine states, including Illinois, now cover sex reassignment surgery for adults on Medicaid, reasoning that it’s illegal to discriminate based on gender identity. In October, Chicago Public Schools released new guidelines related to transgender students, outlining how to handle issues such as bathrooms, locker rooms, and sports teams with more sensitivity.
Transgenderism has become a new frontier for civil rights. But unlike civil rights movements of the past, this one has a critical medical component. And nowhere do those medical issues get stickier than when it comes to kids. Is it healthy to have the body’s natural maturation process circumvented with drugs designed to hold off puberty? How young is too young to receive cross-sex hormones? Can 14-year-olds fully comprehend the long-term consequences of the decisions they make now?
Leading the way through this uncharted water is Garofalo, a 49-year-old HIV-positive cancer survivor who readily admits he doesn’t have all the answers. Since he opened the clinic—thanks to a significant grant, matched by Lurie, from a foundation run by Jennifer Pritzker, the billionaire investor and philanthropist who came out as transgender in 2013—Garofalo has emerged as a leader in the adolescent transgender field. He travels the world to speak on the topic, is regularly brought in by medical schools and hospitals to train young pediatricians, and serves as a primary investigator on a National Institutes of Health research grant focusing on transgender people.
“I’ve always wanted to be a champion of the underdog,” Garofalo says. “Maybe it’s because I’ve often thought of myself as an outlier. Whether it’s as a gay man in academic medicine, or having had cancer, or having to deal with HIV—all of those things have made me feel alienated. I like to do things that are out of the box.”
He has a proposal in with the NIH to conduct the first American study on the long-term effects of cross-sex hormones on young people. That kind of research is critical, since protocols in the nascent field are still taking shape. For now, Garofalo’s treatments have to be seen as a radical form of medical improvisation, and that scares some folks.
Over the past two years, Garofalo has received three pieces of hate mail. One demanded that he “stop messing with God’s children.” Another—a clipping about the clinic’s work with “No!” scribbled across it—was posted on the door of his Lake View condo. More publicly, Laura Ingraham, a conservative radio pundit from Connecticut, has called adolescent hormone therapy “child abuse,” a notion that prompted Garofalo to pen a response on the website Equality Matters: “Ms. Ingraham very clearly has little idea what she is talking about.” Garofalo even faced pushback from his own colleagues at the hospital when he first campaigned to open a gender identity clinic. “I got questions like, ‘Come on, how many kids could there be like that?’ ” he recalls.
“There are a lot of people who are compassionate, but in order to do this work really well, you also have to be fearless,” says Johanna Olson, a doctor in adolescent medicine who runs the gender identity clinic at Children’s Hospital Los Angeles and is an old friend of Garofalo’s. “You have to believe in your heart that the trans experience is a human experience and that these people deserve to have their needs met. Rob is one of those people.”
Like many transgender children, Diana has had a difficult time since she was very young. “I was really lonely,” she says, pushing her honey-blond-highlighted hair to one side. “I always felt different, but I didn’t know exactly why.” Diana, who lives with her mom and two brothers in a Portage Park apartment (her parents are divorced), started transitioning socially in middle school, beginning with renaming herself (“after Princess Diana”). She redecorated her room (more pink) and started dressing as a girl at school, including stuffing her bra with C-cup silicone inserts she bought online for $60.
She was alienated at first. “Most people didn’t want to talk to me,” she recalls. “Or they talked about me.” Transitioning at home wasn’t any easier. “My dad felt like he was losing a son,” she says quietly. Her mother, though, saw the situation much differently: as an opportunity to finally understand her child. “I met my daughter at 10,” Lisa Salas says. “I wish I had met her sooner.”
For Salas, Garofalo’s clinic offered guidance in navigating a world that was a complete mystery to her. “I just didn’t know where to start,” she says. “Raising a transgender kid is just . . . different.” Diana smiles when asked about the Lurie staff. “They’re like my family,” she says. “Dr. Rob is like my goofy uncle or something. I just feel really comfortable when I’m there.”
Treating transgender kids means making sure they get counseling. Garofalo has all his patients see a therapist (the clinic has three on staff) and encourages family members to attend, too. Diana goes twice a month, getting help for anxiety and depression. She and her mother have also been to a few of the monthly teen nights that Lurie hosts to encourage patients and parents to share their experiences.
In high school, Diana is known simply as a girl. She wears her hair long and eyeliner thick and speaks quietly, usually in a falsetto. She loves to talk about makeup and has a penchant for pastel goth fashion. She hasn’t yet told any of her classmates that she’s transgender, and the thought of doing so makes her uneasy. “I don’t want it to define me,” she says, her voice lilting at the end of the sentence. “I’m nervous about other girls reacting weirdly and treating me different.” This prompts her to ponder an idea: “If I was born a girl, I would be very different. I’d be, like, popular and boys would like me and I’d have a lot of friends. I guess I’d just have a good personality.”
In this field, empathy is as important as science. And once you know Garofalo’s backstory, what he has endured in his life, you begin to understand why he’s so eager to help these kids. In many ways, he’s a lot like them.
Raised in Parsippany, New Jersey, Garofalo was shaped, he says, by the Best Little Boy in the World syndrome. The phrase, coined by journalist Andrew Tobias in his 1973 autobiography, “refers to people who grow up closeted because they think being gay is either shameful or harmful and compensate by excelling in other ways,” explains Garofalo.
Garofalo graduated fifth in his class from Parsippany High School, then went to Duke University, where he finally came to terms with the fact that he was gay. “It just sort of happened,” he recalls. “It wasn’t something that I knew growing up. I always felt a little bit different, but I couldn’t have said what that difference meant.” He mostly kept his sexuality private throughout college, but by the time he got to medical school, at New York University, it was 1989, and the gay scene was exploding. “My first time at a gay bar was at this place called Uncle Charlie’s—how tragically cliché—and I remember going in and looking around and immediately getting nauseated. I ran outside and threw up.”
After completing his residency at the Children’s Hospital of Philadelphia, he moved on to Harvard Medical School, where he received a master’s degree in public health in 1999. At Harvard-affiliated Boston Children’s Hospital, where he was an attending physician, he did a lot of outreach to homeless teens, many of whom were sex workers and at high risk of contracting HIV, teaching them about safe sex and how to manage the virus. Working at a homeless clinic, he met his first transgender youth. “In walks this 15-year-old who wants me to give her estrogen. And I was like, ‘Are you out of your mind?’ Nobody teaches you this shit in medical school.” He laughs. “I asked, ‘Who do you want to be when you grow up? RuPaul?’ And she reached back, smacked me across the face, and said, ‘How dare you. RuPaul is not transgender. He’s a drag queen. I want to be a nurse.’ And I was like, ‘Point forever taken.’ ”
In 2001, Garofalo moved to Chicago (“for a man”) and landed positions at Lurie (then called Children’s Memorial Hospital) and Howard Brown, an LGBT nonprofit clinic and health center based in Lake View. Hired as an attending physician at Howard Brown, Garofalo was soon named director of youth services, then head of research in 2006. (He left in 2011 after a falling-out with the CEO, but returned last year.) Then, just as his star was rising in the field of adolescent medicine, his personal life fell apart.
Sitting on a charcoal-gray couch in his apartment, Garofalo leans against a pile of pillows, his legs tucked beneath him. It was here, eight years ago, that he shared with a group of friends that he had renal cell cancer. He wound up having a part of one kidney removed and is now in remission, but the specter of the disease still hangs over him. “Every time something goes wrong, I worry that the cancer is back. That just doesn’t go away.”
Neither does the trauma of another life-altering incident that occurred two years after the cancer diagnosis. It was the spring of 2009, and Garofalo was visiting Washington, D.C. Many of the specifics about what happened remain murky in his mind, but he believes he was drugged and sexually assaulted. That’s how he contracted HIV, he says.
He can’t give an account of the incident without breaking down in tears. “My therapist always suggests trying to remember the details. But I’m pretty happy not remembering.” As he talks, he shifts from side to side, holding his hand to his forehead like a visor shading his eyes from the light. “Anyone who sees me can tell that I have been through some trauma. It’s obvious. After the cancer and HIV diagnoses, I felt like one of those cartoon characters where a piano was going to fall from the sky and onto my head.”
For Garofalo, the healing is far from finished. “Sometimes I feel broken, and I’m not sure I know how to put those pieces back together. I feel like all this [transgender work] is trying to fill gaps or repair wounds. But I’m not sure they’re repairable.”
With that thought, Garofalo reaches for his dog, Fred, cradling him like a child. Most conversations with Garofalo eventually lead to Fred, whom he bought from a Missouri breeder a year after being diagnosed with HIV. In the otherwise minimalist apartment, a series of large photographic portraits of owner and pet dominate the living room. “This fucking nine-pound Yorkie saved my life,” Garofalo says, rubbing the dog’s stomach. “I could barely take care of myself, let alone another creature.” But that’s exactly what Fred forced him to do. “I would wake up every night screaming from nightmares, and Fred would run under the bed in terror. I’d spend hours trying to get him out. It didn’t matter how much shit I was going through, I had to take care of him—he needed me.”
In 2010, Garofalo got a call that changed the course of his career. It was from a producer at The Dr. Oz Show. The syndicated program was doing a segment on transgender youths and wanted Garofalo on as a medical expert. He had just coauthored a study, funded by the Institute of Medicine, that had received a lot of attention for being one of the first sweeping studies of the health of America’s LGBT community. “I thought I was going on to talk about transgender adolescents,” laughs Garofalo. “But I got there, and there were all these eight-year-olds running around. I had never been on national television before, and kids that age were not my expertise!”
That hardly mattered. Soon after his appearance, Garofalo was getting calls from parents all over the United States who had seen him on the show and wanted a consultation. Though he had encountered transgender teens through his HIV work, he had no experience helping a child who wanted to transition. “I was definitely learning by the seat of my pants. I remember having to go to textbooks to make sure I had prescribed the right doses of medications.” The memory makes him chuckle. “I had a mini panic attack after prescribing Lupron for the first time.”
But Garofalo did his homework and over time got more comfortable with the protocols for transgender youths. In the fall of 2012, he went before the Lurie leadership team to suggest opening a clinic. “If you give me the green light to do this now, we will forever be leaders in the field,” he recalls saying. “And if you don’t, we’ll just be followers. And I’ve never been good at being a follower.”
In the exam room at Lurie, Garofalo finishes walking Diana and her mother through the estrogen consent form. He speaks in a slow, steady voice, pausing to ensure that both of them are processing what he says. Along with the possible side effects that Diana would welcome, including a higher-pitched voice and breast tissue growth, come those she wouldn’t: weight gain, mood swings, and an increased risk of blood clots.
For Garofalo, though, the most important issue to address is fertility. The estrogen will cause Diana to stop generating sperm, and no matter how much estrogen she takes, her body will never produce eggs. “The biggest thing to think about, which is a hard thing to do when you’re a teenager,” he explains to mom and daughter, “is whether you want to have a baby someday.” Specifically, Diana has to decide now, before her estrogen therapy starts, whether she wants to freeze her sperm.
Diana doesn’t hesitate. “No,” she responds assertively.
But the weight of this particular choice hits her mother hard. “It makes me really sad that she’s only 15 and has to make these decisions,” Salas says later. (Diana turned 15 in April, a month after her check-up with Garofalo.) “How do you decide? I don’t even know what to tell her. It’s horribly hard for me. Does she really understand what the doctors are asking her? It breaks my heart.”
In the United States, teenagers must be 16 to drive, 18 to vote, and 21 to drink. Which raises the question of how capable they are at 14 of measuring their future happiness. Both the Endocrine Society and the World Professional Association for Transgender Health recommend waiting until patients are 16 to begin them on cross-sex hormone treatment. But Garofalo and other doctors at the clinic feel that is often too late and will start patients as young as 14 on hormones. Says Courtney Finlayson, an endocrinologist at Lurie who works with Garofalo’s patients: “Waiting until somebody is 16 to induce puberty can be really hard socially.”
And physically. Delaying puberty too long with Lupron can affect a teenager’s bone density. A child’s chances of developing osteoporosis go up significantly without enough testosterone or estrogen. And there’s another reason, Garofalo argues, for transitioning kids early: “They can pass better. That’s a big issue with people who transition later in life. Early interventions can lead to changes in the body that are so good that the hope is these kids can be stealth in their identity.”
But is that enough to justify early medical intervention? “There are people within the transgender community who are pushing to do things even more quickly. And patients are requesting irreversible treatments at younger and younger ages,” says Finlayson. “We’re walking this line in between. This is the forefront of medicine, and we can’t go too fast.”
That’s even the case when no medical treatments are involved. The Lurie clinic uses play therapy to help its youngest patients explore new gender roles. But psychologists are divided about whether this is the right approach. One reason is that studies have shown that in the case of children younger than 10 who identify as transgender, 80 percent no longer do so by the time they reach puberty. That’s why Kenneth Zucker, a Toronto-based child psychologist and the head of a respected gender identity clinic, encourages parents to steer kids that young toward the biology they were born with. Zucker’s method has been called a “redirection approach,” the idea being that if you guide a child to more gender-typical behavior, the feelings of dysphoria may dissipate over time.
Garofalo is critical of that stance, arguing that preventing kids from pursuing their gender inclinations can lead to more pain for a group whose suicide attempt rate—41 percent for transgender people of all ages—is nine times the national average. That doesn’t mean he has no doubts about his early-treatment approach, particularly when it comes to prescribing cross-sex hormones. “The pushback in my own mind is my Hippocratic oath: ‘Do no harm.’ How can I know that I’m doing no harm in the absence of scientific data to support these interventions? I wish we had generations of outcomes research to fall back on, but right now we don’t. We ask these families questions that they can’t really know the answer to. No one can.”
The fact that someone is even asking them these questions is remarkable given that clinics like Garofalo’s did not exist 10 years ago. Low-income families, in particular, had limited options. Those kids might end up self-medicating with hormones bought off the black market, out of reach of regulators. Transgender treatments aren’t cheap—Lupron, for example, costs $8,500 to $18,000 a year—but Garofalo works with his patients, including those on Medicaid, to help get insurance companies to cover the medications. “Nearly every patient who comes through the door gets a denial initially from their insurance,” says Ginny Scheffler, the clinic’s nurse, who spends a good bit of her time writing appeals on behalf of patients. But even those without coverage can get treatment at Lurie thanks to private donations, including one from the Chicago transgender filmmaker Lana Wachowski of The Matrix fame.
The hashtag #translivesmatter ignited across social media in February. The sentiment was a reaction, in part, to three incidents: the murders of two transgender women, Penny Proud in New Orleans and Bri Golec in Akron, Ohio, and the suicide of the Ohio teen Leelah Alcorn, whose parents refused to acknowledge her transgender identity. In a note left on Tumblr shortly before she walked in front of a moving truck, the 17-year-old detailed the anguish she had been feeling.
Her death, in particular, haunted Garofalo, and in March he wrote an op-ed about it for The Huffington Post: “Among all of this loss, it is the Leelah Alcorn case . . . that I cannot seem to shake from my head as a pediatrician. . . . Re-read some of her social media posts before she took her life, ‘I can’t wait until I am 18 to begin transitioning,’ and ‘I can’t wait one more day.’ These posts point to her inability to access appropriate healthcare as a potential immediate precipitating factor in her death. . . . For transgender youth, access to health care services saves lives.”
Those words ring true to Kyle Catrambone. Kyle, whose family lives in Oak Park, started seeing Garofalo in 2013 when he was 12. Kyle was born Isabella but never felt comfortable as a girl. “I hated my hair, I hated my skin, and I really hated wearing dresses,” he says. Now 14 and a freshman at Oak Park and River Forest High School, he has been on testosterone since October. His voice has deepened, and he has lost the roundness in his hips, shot up several inches, and started growing some facial hair around his chin. But it’s the transformation in his emotional health that has been most remarkable, says his mother.
“When Kyle was in fifth grade, he was suicidal,” Evaleen Catrambone says. “He was on the couch for three months straight, and the thought of school put him into a ball. Dr. Rob helped us understand what was going on with him. He was a godsend.”
The learning curve for both Kyle and his mother has been steep. Catrambone rattles off a long list of items that she’s gotten an education on over the past few years: a device that allows Kyle to pee while standing, which he uses to help him blend in; extremely tight nylon binders that Kyle uses to compress his breasts; and top surgery, a $6,000 double mastectomy that Kyle wants to get this summer. But finding a surgeon who will perform that procedure on a 14-year-old has proved difficult. Garofalo has had patients as young as 15 undergo top surgery, but so far, none of the local surgeons Kyle has approached have been willing to operate on him. “Being so young, I think people are worried that I’ll regret it later,” he says.
Performing such a radical surgery on someone that age may seem extreme. But for Kyle, it’s simply the logical next step—and in his mind, the sooner he gets it, the better. “The worst part of getting dressed right now is looking down and seeing something that shouldn’t be there,” he says. “After surgery, I’ll finally be able to take my shirt off and not have to hide in the corner of the locker room. I’ll go swimming without my shirt. I’ll be able to live the life I’ve always wanted to live.”
Kyle’s conundrum—that he knows what he wants but hasn’t found anyone who will give it to him, at least not at his age—speaks to the inherent complexities of treating transgender kids. “I used to joke that I have five years in me,” says Garofalo. “This is exhausting work. It’s complex, and it’s not easy. And sometimes I worry that the science is lagging behind the field.”
Even once the definitive research has been conducted and the treatments perfected, the work of leading-edge doctors like Garofalo will remain fraught with questions that have no simple answers.