Determining if someone is transgender and then providing them with medical care is a complex, often lengthy and involved process that follows approved guidelines, state and national experts said.
Being transgender is an adjective, said Dr. Joshua Safer, a member of the national Endocrine Society and the executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York.
"It's somebody where their gender identification is not aligned with their body defined at birth," he said. "Knowing what sex you are is biologically coded in your brain, but the bad news is there is no scan or blood test to tell us if someone is transgender."
A person is transgender if their internal gender identification doesn't match their external appearance as judged by society, said Dr. Michele Hutchison, a pediatric endocrinologist and co-founder of one of Arkansas' two gender spectrum clinics.
"Society has a very binary gender structure: either male or female," she said. "For many individuals, their internal identification doesn't fit that very rigid binary structure. For example, they may be born male, but know on the inside that they're female. Or they may feel a gender where they don't identify with either gender. Or they may be fluid where they may feel more masculine on one day and more feminine on another day."
While there are no laboratory tests that can diagnose someone as transgender, there are very specific guidelines for diagnosing gender dysphoria in a transgender person based on their thoughts, feelings, and behaviors, said Dr. Luann Racher, director of the University of Arkansas for Medical Sciences Gender Clinic.
"An easy way to think of it is that the 'inside' doesn't match the 'outside,'" Racher said. "If your gender identity matches the gender you were assigned at birth then we call that cisgender. 'Trans' and 'cis' are Latin terms that mean 'opposite side of' or 'same side of.'"
Diagnosing a child under 18 as transgender runs the gamut of possibilities, Hutchison said.
If a 15-year-old clinic patient says he has known since he was 3 years old that he's a boy and that's been consistent with the parents' view as well, it's a clear diagnosis, she said.
"The ones that are less clear-cut for us -- and these are difficult for the family and difficult for us as well -- are the kids that come in and they're 15, 16, 17 years old and, maybe they had a recent trauma in their life, and they recently have come to the conclusion that they're transgender," Hutchison said. "Those are difficult for everyone."
The only thing to do in those cases is to give the child time.
"Lots of therapy, lots of talking, lots of discussion, more therapy and just lots of time," Hutchison said. "Everybody needs to feel confident that they're making that right decision."
There are no formal statistics on the number of transgender people in Arkansas, where the population is more than 3 million.
"Based on our best population estimates, there are at least 16,000 transgender Arkansans. You probably know someone who is transgender," Racher said. "They have the same wants, needs, hopes, and wishes as cisgender people. They are parents, teachers, doctors, nurses, bank tellers, grocers, postal workers, and police officers. They are just regular people."
Atticus Goswick, 16, began his medical transition to a transgender male last year when he began testosterone shots.
Sitting in a chair in his Centerton home surrounded by his parents Melissa and Allen Goswick, Atticus smiled wryly and pointed to his mother.
"She didn't take it too well," he said.
Laughter broke out.
Atticus came out when he was 13, "almost 14."
While his father and friends were accepting, his mother and extended family struggled.
He and his mother seemed to fight constantly, culminating in Atticus moving in with his grandmother.
"I just didn't understand like I do now," Melissa Goswick said.
Other family members accused him of transitioning to gain attention.
Racher said that many children do not disclose that they are questioning their gender because they are afraid of their family's and community's reaction.
"If your child comes to you and says they think they are trans, you can reduce their risk of anxiety, depression, drug use, and suicide by allowing them to explore and express their gender identity," Racher said. "This can be through clothing, makeup, hairstyles, using a preferred name, and using their correct pronouns. A child who is questioning their gender is not necessarily trans. But having that parental support at the time of disclosure can really impact their future."
Atticus, assigned female at birth, said he felt "gender neutral" as a child; neither female nor male. His mother put him in dresses and bought him dolls.
"If I wasn't forced more into a box, I would've figured it out sooner," Atticus said.
Melissa Goswick said she used the time apart from her son to delve into transgender research and to examine her emotions.
"I was losing my little girl. I was grieving," she said. "But I just decided that I wasn't going to lose him and I was going to have to change."
After the family members reunited, they sought out help from the Gender Spectrum Clinic at Arkansas Children's Hospital.
"There were a lot of hoops we had to jump through when we started," Allen Goswick said. "They explained to us from the first that it would require a year of counseling to make sure he was able to handle the change."
"Parental support is the biggest factor in trying to transition both mentally, socially, and medically," Atticus said in an email Friday. "It made me feel like I belonged and it helped me get on hormones to help me be me. As for the gender clinic support, their support was amazing. We were able to change my name, force the school to respect my identity, get me on hormones, and get me a therapist that helped me feel more secure in my body. Both of these things are absolutely vital for a trans teen to be able to transition at a young age."
While individual Arkansas physicians have always been able to offer transgender care, the first gender clinic -- which houses a multidisciplinary group of health care professionals, legal representatives and social workers all under one roof -- was the UAMS Gender Clinic that opened in 2009 to treat adult patients.
The Arkansas Children's Hospital Gender Spectrum Clinic -- which treats pediatric patients -- was founded in 2015.
Hutchison said the process to medical intervention for transgender care takes time.
"When a 15 year old comes to us and they've known they're trans for 12 years, they want to get their testosterone right away. They just want to leave with a bottle of testosterone," Hutchison said. "There are places where that can be done. That's not how we operate."
Time is the foundation of gender clinics that subscribe to a resource-intensive process.
It can take months, or even years, before a transgender child is prescribed hormone therapy.
"I need to be sure that I have it right and most of the time the parents want to be sure they have it right," Hutchison said. "We have to pump the brakes a little bit and that's why the patients feel like they're jumping through hoops. I understand that."
The Children's Hospital gender clinic, according to its website, begins with an initial telephone assessment by a social worker before an appointment is set. The initial appointment takes a minimum of three hours, during which the patient will meet with the members of the transgender-care team that includes doctors, nurses, social workers, attorneys, pastoral care and a psychologist.
The clinic provides hormone therapy, such as testosterone, but gender surgery is not an option. Nationwide, surgical intervention with children is nearly nonexistent, Safer said.
"Most medical organizations would have a hard time with genital reconstruction for someone under 18," Safer said. "It's very extreme."
Hutchison said genital surgery as a minor is too aggressive.
"Frankly, in this age group, it's not necessary," Hutchison said. "By affirming their gender and using hormonal therapy so that their insides feel the way they should, we've shown that we can reduce suicide rates, reduce anxiety, reduce depression scores and we can increase quality of life, and increase their satisfaction scores. We can do all of that without having to do anything as radical as genital surgery."
Some doctors in Arkansas do offer breast surgery for young transgender people.
BODY AND MIND AT WAR
From the time he was a toddler, Andrew Bostad, a Bauxite 15-year-old transgender boy, rejected everything typically affiliated with the female gender.
"He refused to wear dresses and always wanted his hair cut short. He rejected any facet of femininity," Brandi Evans, his mother, said. "It didn't strike us as odd."
Gender identity is formed at a very young age, Racher said.
"In fact, there are studies that demonstrate that a person's innate sense of gender identity forms around age 3-5 years old," she said. "This is also when children begin to pick up on societal clues from their family and community about gender expectations."
When puberty hit, Andrew fell into a deep depression, was angry all the time and had intense anxiety.
"His body and mind were at war with each other," Evans said.
Sitting across from his mother in their rural home, Andrew was dressed all in black -- black hoodie, black jeans, black shoes. His short hair was dyed half red and half black. A light sprinkling of facial hair extended from ear to ear. His voice was deep when he spoke.
"I wouldn't play with my Barbie dolls. I would cut all their hair off," Andrew said. "I would go fishing with my dad. No girly clothes for me."
He was 12 when he texted his mother from school, saying, "I think I'm a boy." It took two years at the Arkansas Children's gender clinic before he was prescribed testosterone.
"I give myself a shot every Sunday," Andrew said.
His mental health completely turned around once he started hormone therapy, Evans said.
Like Andrew, the hormones made all the difference in his mental health for Atticus as well.
Before treatment, Atticus said he was extremely depressed and skipped school a lot.
"I hated going out because I was afraid of how I was being perceived," he said. "Even in things I enjoyed, like theater, I was still constantly on guard and refusing to let anyone see me. Like I was getting changed in a whole different room away from the rest of the cast."
After hormones, he was happier with himself and the depression subsided.
"I started wearing shorts and just T-shirts, not a hoodie over it," Atticus said. "I felt happier. I went to school more and my grades went up. I was a completely different person but in a good way. I was me, so the emotional difference was a huge change."
Recent state legislation, though, has caused a spiral of anger and even thoughts of suicide, Atticus said.
House Bill 1570, now Act 626, bans gender-affirming care, including surgery and hormone treatment for minors. Gov. Asa Hutchinson vetoed the bill but the Legislature overrode the veto April 13. The law takes effect in July.
Other state legislation would block anyone who wasn't identified as a girl on their original birth certificate from playing girls' sports.
Another bill stating that Arkansas teachers wouldn't be required to address students by a name or pronoun inconsistent with their biological sex failed recently in the Senate Education Committee.
"I was a wreck. Very sad and mopey. I felt like I was useless because I couldn't do anything to stop it. I felt like I was causing an unnecessary burden," Atticus said. "I did consider suicide after awhile when moving seemed inevitable. I believed if I died, my family wouldn't have to worry about this. They could continue living here, finish school and wouldn't have to be uprooted again because of me. Overall this bill has made me more depressed and anxious as I don't know our futures anymore."
The legislation deeply traumatized the transgender teens it primarily targets and has led to at least four suicide attempts and an influx of teens in suicidal crisis, Hutchison said.
"Two of the suicide attempts were quite bad. One was really, tragically bad. Those were active suicide attempts that we were aware of. There may be many more that we're not aware of," she said.
The clinic has received numerous calls from parents saying their children are threatening to commit suicide over HB1570.
"We've had dozens of families call and ask, 'What state should we move to? Where should we go? I'm afraid my kid is going to kill himself if we have to stay here,'" Hutchison said. "It's tragic. It's bad."
Safer said transgender suicides and suicidal ideation likely will increase with the recent legislation.
"It's a huge mental-health stress. Already, when you look at transgender statistics, about 40% of them have considered suicide in their lives," Safer said. "Envision what's going on in the minds of these kids when they hear there's something wrong with them."
Hutchison said what she hears most from transgender teens is that the legislation makes them feel they are being erased.
"They are not being seen. It's terrifying and it's depressing and it's dehumanizing," she said. "Imagine if someone wanted to take the real you and just erase it and say, 'You don't exist.' That's what these children are living every single day."
For the parents of transgender young people, the legislation is taking the parents' rights away to have their child treated medically, Evans said.
"Outside of having a supportive family unit, having supportive medical staff absolutely goes that step further," she said.
"They are taking my right, my husband's right, my ex-husband's right, to parent that child in a way we see fit and to provide for him in a way we see fit," Evan said. "Just because they are afraid of it."
Taking away the medical care for transgender people can be devastating, Racher said.
"When someone experiences untreated gender dysphoria they have a higher risk of anxiety, depression, self harm behaviors (like cutting), being homeless, engaging in sex work, contracting HIV, and dying by suicide," she said. "When gender dysphoria is recognized and treated -- especially at an early age -- the risk of all those outcomes decreases."
Gender dysphoria is a clinical term that describes the severe psychological distress that arises from being transgender, Racher said.
"This can arise from internal stress -- meaning the feeling of being trapped in the wrong body and not being able to be your true self," she said. "And it can arise from external stress, when other people in society discriminate against, tear down, bully, and abuse transgender people."
Hutchison said she takes particular offense to House Bill 1570's use of the terminology "experimentation." The word is in the name of the law, the Arkansas Save Adolescents from Experimentation Act.
"Nobody is experimenting on these children. That's a horrible thought. We are following established guidelines that are accepted by every single medical organization in the country, " she said. "
"I wish there was a way to get the message out to people. We're not making this up. We're not medical cowboys out looking for adventure. We are focused on the health and well-being of these children and our primary, sole focus is keeping these children safe and happy. Why would we do anything other than what's best for the child?"
Numerous national organizations -- such as the Endocrine Society, the Human Rights Campaign, and the National Center for Transgender Equality -- came out against the legislation.
"Legislation should not interfere with physicians' efforts to provide their patients evidence-based medical care in line with the recommendations of the Endocrine Society and other respected international medical organizations," Safer said.
Atticus said friends from out of state are working to help bring testosterone into Arkansas after the law goes into effect in July, when doctors will be barred from prescribing it.
Andrew said he's channeling his anger at the anti-transgender legislation to advocate, protest, to rally and to support others in the same situation.
"I'm going to show people that there are actually, real lives behind this legislation that are facing these atrocities. I want to put a face to the cause so that people know that others care about them," he said. "When I say I say people, I mean the whole trans community, so that they know that they are not alone. We are still fighting and will continue to fight because we will not be erased. We will not be shoved back in the closet and forced to comply with what the government says."