The transition from youth to adolescence can be anxiety-inducing, navigating the physical changes and social pressures to fit in.
But for those who experience gender dysphoria -- the feeling that your gender doesn't match your biological sex -- adolescence can be especially traumatic. Support and care early on can make the difference between slipping between the cracks and thriving, as the stories of two transitioning youth show.
Abby Parmelee, who's 18, described gender dysphoria as "looking at your body and hating every inch of your body because it doesn't look like your brain imagines it to be."
I met Parmelee at Richwoods High School, in Peoria, Illinois. She was in the school theater's backstage dressing room, putting makeup on her friends who were about to take the stage. Parmelee towered over her peers in six-inch heels. She swiped a shimmery golden highlighter onto her friend McKenna Meyer's cheekbones.
"We're going to make you glow," Parmelee said to Meyers. The two snapped a selfie and hugged.
It was hard to imagine that only a few years ago, this poised and highly-social figure was friendless and suffered from debilitating depression.
Parmelee said she first remembered "feeling like a girl" as early as 5. By age 10, symptoms of gender dysphoria, like depression and anxiety, began to manifest. In eighth grade, the onset of male puberty exacerbated those psychological and emotional effects to an unbearable level.
"Listening to yourself talk and hearing your voice getting deeper, or looking at your face and noticing you have to shave because there's hair growing on your face," Parmelee said. "I just felt like I wasn't worthy of anybody, not even worthy of myself."
She developed an eating disorder, and even contemplated suicide.
"At the time, I couldn't be myself because I was going to a Catholic school," Parmelee said. "If I wouldn't have been able to seek treatment, I don't know if I'd be sitting here talking to you today."
During her freshman year of high school, Parmelee started seeing a counselor for the eating disorder. Behind closed doors, she said, her conversations with the therapist were all about being transgender and suffering alone. Those sessions ultimately helped her come out as female to her close friends and family.
By her junior year, in 2017, she donned a wig, stilettos and a pantsuit and came out to her entire high school, during an assembly in the gym. Her peers responded with a standing ovation.
"It was probably the best day of my life. I feel this overwhelming aura of acceptance around me," Parmelee said.
She said the depression subsided, and she has since become a leader in her high school community. Parmelee even started documenting her transition on a personal YouTube channel, with more than a thousand views on every post.
Parmelee's case reflects what the American Academy of Pediatrics accepts to be true -- affirming a person's preferred gender significantly reduces their risk of mental illness, and even likelihood of suicide.
Is affirming gender the answer?
The AAP released its guidelines "Supporting & Caring for Transgender Children" in 2017, stating that "in many cases, the remedy for dysphoria is gender transition: taking steps to affirm the gender that feels comfortable and authentic to the child. It is important to understand that, for children who have not reached puberty, gender transition involves no medical interventions at all: it consists of social changes like name, pronoun and gender expression."
While the AAP and other organizations, like the World Professional Association for Transgender Health, agree that affirming a child's preferred gender and supporting them can bring about profound psychological benefit, the field of medicine is still in the early stages of understanding the long-term effects of transitioning for youth who experience gender dysphoria.
Physicians in the U.S. largely rely on research from abroad, like from the Netherlands and Denmark.
That's about to change, as the National Science Foundation this year awarded $1 million to the Trans Youth Project. It's the first large-scale, national, longitudinal study of transgender children to date, covering about 300 children from 45 states over the course of 20 years. The long-term effects of certain medications, like hormones, on transgender youth will be among the topics investigated.
A young girl's story
Kay's experience is different from Parmalee's. She's making the transition to female in the small, conservative town of Washington, Illinois, about 20 minutes outside Peoria. The community of about 15,000 people is known for its mega churches and its charming town square.
I met Kay in 2016, when she was 8 and about to start third grade. Kay is her nickname, which we're using to protect her privacy. She and her family have received hateful comments, and they've been the subject of protests at school board meetings since Kay came out as a girl.
Kay was a little shy when we spoke, but she was direct about her identity. "Even if I have the wrong body parts, still, I mean to be a girl, not a boy," Kay said.
While Kay said she always knew she was a girl, she had to get those around her on the same page, including her parents. Her mother Amy -- we're also using just her first name -- said they initially brushed it off.
"'It's just a phase!'" Amy recalled. She remembered thinking, "'This will be alright, eventually, you know, when he grows up, this will all just go away.' Because in my mind, I really thought in binary terms of male and female. And didn't really think outside my box at all."
Kay first began insisting she was a girl around kindergarten. But her parents are both devout Catholics, and the notion of transgender didn't initially fit within their beliefs. Amy said they even tried to "force" boy toys on Kay. One Christmas morning turned into an emotional breakdown, when Santa delivered toy trucks instead of Barbie dolls.
Amy said it seemed the more they suppressed Kay's feminine tastes, the more depressed and anxious their child became. Even bedtime prayers seemed to escalate, Amy explained.
"As far as, 'God please let me die so I can have my right body. God please let grow up to be a mommy,'" Amy said. "The thing that finally got me: 'Mom, you told me that God doesn't make mistakes.' I said, 'God doesn't make mistakes. God is perfect.' 'Well he made a mistake with me. He gave me the wrong body.'"
Amy was crushed.
"I thought, what am I teaching my kid? Even now, it hurts to think about it. Because God doesn't make mistakes," she said.
That's when Amy and her husband decided to look for help. Amy said she poured over books about gender dysphoria and reached out to the local transgender community. Finally, the family packed up their minivan and drove three hours to Chicago to see a pediatrician at Lurie Children's Hospital.
"People are coming from hours away. That really makes things complicated," said Dr. Lisa Simons, one of the pediatricians at Lurie's Division of Adolescent Medicine.
Simons says when she sees kids and their parents for the first time, she's often just listening to her patients and validating their experiences.
"Some of the most important services that we offer here are not medical or mental-health related. Obviously some of those are. But the needs of every person is so unique and different," Simons said.
But there is a common struggle. Transgender youth are at a higher risk for mental health disorders, including depression and suicide, than their non-transgender peers. A 2015 study published in the Journal of Adolescent Health found transgender youth have a two to three times higher risk of mental health disorders, including depression, anxiety and suicide ideation, than the cisgender (non-transgender) control group.
That's why Simons said social support and gender-affirming care is like armor that keeps trans people from mental illness.
A family gets on the same page
That first appointment at Lurie's led Kay's parents to accept their daughter's behavior wasn't "just a phase." They enrolled her in school as a girl. They even found a church in Chicago that allowed her to wear a dress for her First Communion ceremony.
Kay, two years later, is now weeks away from starting fifth grade. Her room has changed accordingly. It's a soft lilac color, adorned with posters of Katy Perry and a boombox in the corner. Kay is growing up, and is more confident in herself.
She has advice for others who are afraid to explore their identity. "I would just want to tell them just don't be scared," Kay said. "Otherwise, nothing will happen. And nothing will change. You'll be sad, and you just won't be happy like you want to be."
There's another change ahead. Kay is about to go on a puberty blocker. It's a hormonal implant that blocks androgens, so she won't have to experience the effects of male puberty, like facial hair and a deeper voice. It essentially puts puberty on "pause," so if in the future Kay decides to go through female puberty, it will make for a much easier physical transition.
Abby Parmelee, the teenager from earlier in the story, is going through what many trans people refer to as "second puberty." She just started taking female hormones.
"I feel like something is changing," Parmelee said just a few weeks after starting on estrogen. "I feel very feminine. I feel I'm out to conquer the world, and I've never had those feelings before."
Parmelee turned 18 in March and got the prescription from Planned Parenthood. The clinic is the only health provider in Peoria that offers the treatment, called hormone replacement therapy, for transgender individuals. Some patients travel from other states, like Missouri, for the service. Transgender-specific care is still rare in areas like the Midwest and smaller communities. Even finding healthcare providers that use patients' preferred name and pronoun can be a challenge.
Parmelee wished her healthcare as a child and adolescent had been gender-affirming, like what Kay is experiencing. Access to a hormone blocker would have spared her, Parmelee said, the traumatic experience of going through male puberty. Still, she considers herself lucky.
"I haven't met a trans person who hasn't had suicidal thoughts," Parmelee said. "If we had better healthcare and people to talk to about it, we wouldn't hear as much about kids committing suicide because they would be able to empower themselves and work through it."
Hormone replacement therapy is just one part of the physical process of transitioning. Someday, when Parmelee can afford it, she wants to get gender reassignment surgery, so her biological sex will fully match her gender. But she doesn't like to think of that as her "end goal."
Parmelee said she's excited to see what happens in the year ahead, as she sets off for college. And she said, eventually, "I'd like to have a family, and I'd like to have a career."
Next month, Parmalee starts her freshman year at the University of Illinois-Chicago, where she plans on majoring in political science, while advocating for transgender rights.
This story was produced by Side Effects Public Media, a news collaborative covering public health.