Michaela was born a biological male 13 years ago. Her dad Joe says when she was eight, the family moved to Portland so she could grow out her hair, wear dresses and attend school as a girl.

“As a dad, I was just immediately fearful just of the unknown situations that could be coming up and having to get into a fight …. I didn’t give the world enough credit. The world has responded with a lot of love.”

Michaela is 13 now. With her long, blonde hair and a dress, nobody questions her gender identity.

Michaela is 13 now. With her long, blonde hair and a dress, nobody questions her gender identity.

Kristian Foden-Vencil/OPB

So far Michaela, is passing - nobody questions her gender identity. Her family wants to keep it that way, which is why OPB is not using real names for this story. 

A few states now cover medical treatment for transgender people. But Oregon is the only state in the nation that will pay for children to undergo puberty suppression - if they’re on the Oregon Health Plan.

What are the medical pros and cons of the therapy?

About a year ago, Michaela began to exhibit the first signs of puberty.

“As soon as puberty hits, that’s when the body pretty much turns on someone who is transgender,” says Karin Selva, Michaela’s doctor and  pediatric endocrinologist at Randall Children’s Hospital. “With male puberty,” says Dr. Selva, “you get the changes in the genitalia that happen, you get an Adams apple. You get facial hair that we can’t get rid of. You have a body structure that’s male, that doesn’t easily turn female, even though you give it estrogen later. It’s hard to reverse those processes that happen. And same thing for a female.”

So Michaela says she gets an injection to suppress puberty once every three months and, “it hurts really bad.” 

Michaela is not on the Oregon Health Plan, which is the state’s version of Medicaid. She has private insurance. But the medication she gets— that the health plan now covers— is Lupron. It’s been used for years on children with precocious puberty - that is children who start puberty too early. It’s also used to treat prostate cancer and fibroid tumors.

Dr. Karin Selva

Dr. Karin Selva

 Courtesy of Dr. Selva

Dr. Selva says in cases such as Michaela’s, administering Lupron gives a child more time to come to a decision about their gender identity. Once they’ve decided, they can start taking the hormones for the gender they’d like to be - or they can stop taking the medication and allow their body to develop unhindered.

But what about side effects?

Dr. Megan Bird is with Legacy Medical Group. She’s supportive of puberty suppression, but says there are risks. “So the biggest risk that we talk about is bone deposition.” Dr. Bird says there’s no evidence puberty suppression treatments put teens at higher risk of osteoporosis later in life. But she adds, there isn’t much research available either.

There are, Dr. Bird explains, other concerns: “Kids who first start Lupron get head aches and hot flushes sometimes, but those are usually only for a few weeks, and then they go away. Estrogen and testosterone are involved in the process of limiting our growth … so these kids tend to be a little bit taller, which is a plus or minus depending on how you look at it. Other issues is that they’re out of synch with their peers. So if you delay a kid at 12, and their peers are developing breasts and they’re a late bloomer in that sense, that can be disruptive to their life as well.”

Dr. Megan Bird

Dr. Megan Bird

 Courtesy of Dr. Bird

There’s also the issue of sterility. But Dr. Bird says it is possible to allow a child to experience a temporary puberty - just long enough to harvest sperm or an egg  - which can then be frozen for later use.  

Dr. Ariel Smits is the medical director of the commission that prioritizes treatments for the Oregon Health Plan. She says the commission’s final vote to include a range of treatments for transgender people - including puberty suppression - was not unanimous. But she was swayed by the medical literature.

“People with gender dysphoria that did not receive treatment had a much higher rate of hospitalizations or ER visits or doctors visits for depression and anxiety, and they had a pretty significantly high suicide rate. Some studies found about 30 percent,” Dr. Smits says.

When people have options, and they’re treated, she says, the rates of suicide, depression and anxiety are much closer to those of the general population.