Chapter 12

Two years later...

Glenn drove toward Clinton Middle school with Sierra in the passenger seat. “I feel bad taking Jackie out of school on her first day.” she said.

“It was Dr Langley’s only opening,” Glenn replied. He parked in the visitor’s lot. “I’ll go fetch her.”

After announcing himself via the intercom and being buzzed into the building he headed to the office. “I’m here to pick up Jackie Poole for a doctor’s appointment,” he said to the school secretary.

“May I see an ID?” He proffered his driver’s license. The secretary consulted a computer screen. “Just looking you up to see if you’re on the authorized list ... looks like you are.” She spoke into a microphone. “Jackie Poole, please report to the office for early dismissal.”

Shortly Jackie approached carrying a backpack. By now her hair was shoulder-length and she wore a knee-length navy skirt with black pumps for shoes and a light blue short-sleeved blouse. She followed Glenn to the car, tossed her backpack into the back seat and sat behind Sierra.

“It wasn’t like that when I was in school,” Glenn said. “The front door was unlocked and you didn’t need to present an ID to pick a kid up.”

“One of the schools in the district had an incident,” Sierra explained, “in which an estranged father picked a kid up and then ran off. Hence the enhanced security.” Sierra turned around toward Jackie. “How does it feel to be an eighth-grader?”

“You’ll never guess who I saw,” Jackie replied. “Tom Clarke.”

“He was one of the boys who assaulted you,” Sierra replied. “He was re-admitted?”

“Yes, and Art Rose and the third kid. They all repeated fifth grade. Dr Coyne wasn’t ready to re-admit them last year but thought they’d be ready for seventh grade. Since she considers Tom the ring-leader, he was admitted on the condition that he apologize to me. In writing.” She removed an envelope from her backpack. “This is what he wrote.” She opened the envelope and began reading.

“Dear Jackie. Please accept my sincere apology for assaulting you in the boys’ room. My actions were immature and totally inappropriate and I am very sorry for the distress, embarrassment and humiliation I caused you. I heard of the assembly Dr Coyne called and of you telling about your decision to transition to a girl and why. I admire your courage and although at the time I was too immature to understand, I do now. I hope some day you can forgive me, but if you can’t I’ll understand. I have grown in the past two years and believe me today I would never even contemplate such an act much less carry it out. I am so sorry for what I did. Sincerely, Tom Clarke.”

“That sounds sufficiently contrite,” Sierra said.

“It sounds like it was written by an attorney,” Glenn remarked, “or at least was vetted by one.”

“Do you forgive him?” Sierra asked.

“No. Not yet. He had a copy for me to sign that he had to return to Dr Coyne.”

“Did you sign it?”

“I wrote ‘apology noted but not accepted’ and signed it.

“Why not accept his apology?” Glenn asked.

“Because he didn’t apologize for all the names he called me. That’s what hurt the most. He had to deliver it to me, not for me to forgive him in order to be re-admitted. He did say he didn’t recognize me and he thought I was pretty. Then at lunch I pointed him out to Marcus. Marcus promised to keep an eye on him and take action if he tried anything. I said I doubt he would.”

“Marcus is taking care of you,” Sierra remarked.

“He’s sweet,” Jackie replied, “but he’s no match for Tom in a fight.”

Glenn parked in the lot of the medical building. They headed for Dr Langley’s office. Glenn checked in with the receptionist and proffered his medical insurance card. Then he joined the others in the waiting room.

A nurse called Jackie back. “Jackie is hoping we can convince Dr Langley to start hormone therapy,” Sierra whispered to Glenn.

“I sure think she’s ready for it. After two years, the histrelin has changed her. She looks more like a girl.”

“That’s due to her longer hair and wardrobe.”

“It’s more than that -- her legs are less angular and she’s developing hips and a butt. She even has the beginnings of breast buds.”

Sierra looked at him agape. “Have you been ogling her?”

“Of course not. I have no interest in underage girls in general and an underage girl who’s my daughter in particular. But, I’m a guy and it’s second nature for a guy to notice such things.”

Jackie appeared in the doorway leading to the examination rooms. “Dr Langley wants you to come back,” she said.

Glenn and Sierra followed her. “I think you’re right,” Sierra whispered to him. “Her legs and hips do look rounder.”

They stepped into an examination room and sat in hard metal-framed chairs with plastic seats. “Look at the look on her face,” Sierra remarked. “She looks like the cat that ate the canary.”

Dr Langley stepped into the room carrying a clipboard. “Good day, folks, good to see you again. It makes my day having Jackie visit -- she’s so bubbly. She tells me there have been some changes in the family.”

“Yes,” Glenn replied. “The paperwork is final and I have legally adopted Jackie. I’ve gone from stepdad-to-be to stepdad to dad.”

“Now I can call him Dad,” Jackie interjected.

“Are you happy for that?”

“Very happy.”

“We’re all very happy,” Sierra added.

Langley flipped through pages on his clipboard. “Jackie was asking about starting feminizing hormone therapy. I told her that I waited until a patient was in high school, and she reminded me that she’ll be fourteen soon.”

“In two weeks,” Jackie interjected.

“Then I remembered that since her birthday is just after the cut-off, it means she’s probably the oldest in her class ... not a bad thing, actually. Fourteen is my minimum age for starting hormone therapy. Since she’ll be fourteen in a couple of weeks, and is an excellent candidate, if it’s agreeable to you, we can start it right away.”

Jackie grinned and clapped her hands together.

“What’s involved?” Sierra asked.

“We discontinue the histrelin,” Langley replied, “and replace it with a two drug regimen. The good news is that these are old-school medications and consequently are significantly less expensive. The first one is estrogen, which will cause Jackie to go through puberty as a female. It’s available as an implant similar to histrelin but at a fraction of the cost. The second is an anti-androgen, to neutralize the testosterone she is producing.”

“Doesn’t that mean continuing with the histrelin?” Sierra asked.

“It’s a different mechanism. Ideally we’d like to use an androgen synthesis inhibitor. These stop the production of testosterone, but those drugs are either breathtakingly expensive or still in development. The one that’s approved is fifty thousand a year.”

“That’s worse than the histrelin,” Glenn replied.

“Exactly. Instead we start with an androgen antagonist. These block the action of the testosterone she produces, and are quite reasonably priced. Our first line is spironolactone. It’s a daily pill, available as a generic and costs only about twenty dollars a month.”

“That’s quite a bit more reasonable,” Glenn remarked. “If it’s generic, there’s no co-pay. The insurance will cover it all.”

“It’s well tolerated, however the drug’s primary use is to treat congestive heart failure or fluid buildup. Its anti-androgen properties are actually side-effects we exploit.”

“So, the drug’s primary purposes become side-effects,” Glenn remarked.

“I like to start patients like Jackie with a strong estrogen dosage, to jump-start her development.”

“How soon will I see results?” Jackie asked.

“If you start now, you’ll definitely see changes by the end of your first term. If all goes well, by the time you start high school, you’ll be caught up with the other girls in your class. You should expect to see an increase of body hair, but in a female pattern -- lower legs, under arms and pubic hair. You will not develop facial hair or other body hair. Your voice won’t deepen, you won’t grow an Adam’s apple and your features will become fuller and softer.”

“I think I see that already,” Jackie replied, “from the histrelin. I see it in my legs and here...” She cupped her hands under imaginary breasts.

“Those are side-effects,” Langley said. “If we discontinue the histrelin without starting the estrogen, those features will disappear. There are some risks with the estrogen dose I’m proposing. These are the usual risks associated with birth control pills and include hypertension and an increased risk of blood clots. Jackie -- you have a nurse at your school, don’t you?”

“Yes. Two in fact. My sixth grade homeroom teacher, Mrs Lipke, is one of the school nurses.”

“I’m sure if you ask she’ll be happy to take your blood pressure on a regular basis. I’d like to see it monthly for the first year or so.”

“I’ll ask,” Jackie replied.

“If she should start seeing complications,” Sierra asked, “what then?”

“We’ll adjust her prescription, or maybe add an alpha blocker.”

“What about surgery?” Jackie asked.

“I’m afraid reassignment surgery is out of the question at this point,” Langley replied. “It is major surgery done under general anesthesia and very expensive. It requires several days of hospitalization and recovery can take months. No reputable surgeon would perform this on a minor and most require an independent psychological examination plus several years’ track record on hormone therapy. It’s at least ten years down the road, Jackie. Many of my patients find they can live full and rewarding lives without it.”

“Carla hasn’t had it,” Glenn added.

“One surgical option you may wish to consider is orchiectomy -- removal of the testes. I recommend this for patients who wish to legally change their gender.”

“I remember Carla telling us about this,” Sierra remarked. “In order to change your gender you must be non-reproductive.”

“Correct,” Langley continued, “legally changing gender simplifies obtaining a driver’s license or a passport. A simple vasectomy would suffice, but if you’re not going to use them, why not lose them? We could stop the spironolactone and you’re down to only one drug. The procedure is simple, inexpensive and can be done under local anesthesia as an outpatient. Recovery is only a couple of weeks.”

“I wouldn’t want to wait until I’m eighteen to get a driver’s license,” Jackie said.

“This is something we can do on a minor,” Langley replied, “with parental permission.”

“Then let’s cut ‘em off now and get it over with,” Jackie replied.

“As a physician I took an oath and that oath requires that first, I do no harm. So far, your treatment is reversible. The next step, at least in the short term, also is reversible. Surgery is irreversible.”

“I’m not going back, Dr Langley. I’m living the life I want to live. I am not going back to being a boy.”

“We’ll cross that bridge when we get to it. In the meantime, we must hasten slowly. If there are no other questions I have a parental consent form to start hormone therapy. Sign this and we’ll get started.”

Glenn used a tape measure to size up the range in the apartment kitchen. Jackie entered wearing a mint green sleep tee of mid-thigh length. “Good morning,” he said.

“Mom downstairs already?”

“Yes. You know her drill.”

“What are you doing?” she asked.

“I’m thinking of surprising your mother with a new range.”

Jackie took a bowl from the cabinet, poured in some cereal and added some milk. “Dad?”

“What?”

“Are you going to OTB today?”

“Yeah...”

“Can I come, too?”

“Sure.”

“I need to get out of the house.”

“Say, your birthday is coming up. Anything in particular you’d like?”