KANSAS CITY, Mo. — She is only 6 years old. Already the child who sits, legs tucked, on a canopied bed near a closet filled with princess dresses has lost her best friends. Kids who used to ask A.J. to birthday parties stopped calling. Parents back in preschool avoided making eye contact. Once, at a ballet open house, A.J. and her mom ran into a family with whom they had always been close. "They looked at us," the Kansas City, Mo., mother recalls, "crossed the sidewalk and didn't say anything."
"For a while it made me hate humanity," she conceded. "'You just proved yourselves to be the lowest human beings on the planet. You know my kid. You know my child is a happy, kind, sweet, considerate kid and nothing has changed, except ...'"
Except that A.J., born and known to all as a boy, had been determined to be transgender. The rough-and-tumble kid who once sported buzz cuts and dressed for his birthday as a pirate was growing her chestnut hair below her shoulders.
A.J. was now a girl.
"There is huge judgment in society," said her father. "Not only on her, but on us."
Today some 2,500 young people are gathered for the final day of the annual Midwest Bisexual Lesbian Gay Transgender Ally College Conference, held this year at the Kansas City Convention Center and hosted by LGBT groups at the University of Missouri-Kansas City.
In the 21 years since the conference began, no one denies the advances that gay, lesbian and bisexual people have made in winning broader acceptance and civil rights, as evidenced by the open policy toward gays in the military and the growing legalization of same-sex marriage.
Yet when it comes to public understanding of the T's in the LGBT community, many agree that transgender people have largely been left behind.
"They're lagging - maybe a decade or more," said Jill Jacobson, an endocrinologist at Children's Mercy Hospital.
Jacobson saw her first transgender patient several years ago - an 8-year-old girl who at age 3 had asked her mother, "If I died and went to heaven, would I come back in the right body?"
Now Jacobson is using hormones or hormone blockers to treat 28 children from grade school to high school who are making the transition from one gender to the other. Nearly all began treatment in the last year and a half.
"It is certainly true that America's acceptance of gay people is ahead of trans people," said Mara Keisling, executive director of the National Center for Transgender Equality, a Washington-based social justice group formed in 2003. "I think we are getting to the point where every reasonable person in America understands that gay people really exist, that it's not a choice, that some people are just gay. We are not nearly at that point yet for transgender people."
Advocates insist that because of the diversity battles fought by others - women, minorities, gay people - the arc of history is moving quickly toward both greater tolerance and acceptance. They point to a spate of events:
Barneys New York, a high-end fashion store, last month unveiled a national ad campaign in magazines, online and in its own catalog featuring 20 transgender models.
The U.S. Senate in November voted 64-32 to approve the Employment Non-Discrimination Act, a bill that has been introduced since 1994. It would protect workers based not only on sexual orientation, but also on gender identity. It now awaits a vote in the House.
A Colorado civil rights panel ruled in June that a 6-year-old transgender girl, born as a boy, suffered discrimination when she was not allowed to use the girls' bathroom at her grade school.
Last month, the Kansas State High School Activities Association, which administers interscholastic activities in Kansas public high schools, adopted a policy allowing transgender students to participate in activities "consistent with their gender identity." Missouri high schools and the National Collegiate Athletic Association already had similar policies.
Also in January, a federal appeals court ruled that the Massachusetts Department of Corrections' refusal of sex reassignment surgery for a transgender inmate was unconstitutional, a form of cruel and unusual punishment.
Michelle Kosilek, 64, who was born a male and since 1992 has been serving a life sentence for murder, had been taking female hormones for decades. The court ruled that Kosilek had received a legitimate diagnosis of "gender identity disorder" - defined as "a psychological condition involving a strong identification with the other gender."
The corrections department needs to offer the medical care, the court said. The department has said it will appeal the decision.
In Johnson County, Kan., two students - Michael Galvin, 17, and Isaac Barnett, 18, who have been friends since grade school - felt comfortable enough with the atmosphere at their Blue Valley district high school to agree to be the focus of a video played last year for the student body. For years, the two students had been known as girls and called by different names.
In the video, they revealed that they are transgender, explained what it meant and said they preferred to be called by their male names. The reaction, the boys said, has been almost all positive. Some of that may be chalked up to student ennui, but experts also give credit to schools' efforts to combat bullying and embrace diversity.
"Some people have said, 'I don't approve of what you're doing, but I'm still going to be your friend,'" Isaac said. "Or 'I think what you're doing is really brave and you have a lot of courage.'"
But none of that speaks to how difficult it is not only for individuals to come to terms with being transgender, but also for their friends, families and outsiders. When it comes to children, it can be even harder. Misconceptions abound.
A.J.'s parents understand.
"We were just parents going to work, sending our kids to day care, and this happened to us," the mother said. "I had never even heard the term 'transgender.'"
It is a sad reality of life now, she said, that they felt compelled to request that neither A.J.'s full name nor an identifiable picture be used for this story.
If they had a son or daughter who was gay or lesbian or bisexual, they are convinced that people would view it as no major matter, no reason for anonymity. But they have come to realize many in the public still don't accept transgender people, considering them inscrutable oddities.
A.J.'s parents said that choosing not to be identified was not an easy choice. They support their child.
"She's a blessing to us," her father said.
But their daughter has lost enough friends. Some new pals don't yet know that A.J. is transgender, and her parents don't want to take the chance of her losing more. Moreover, they think A.J.'s gender identity is ultimately her business.
"I'm trying to protect her," her dad said, "but I'm also trying to allow her to put this out to the world when she wants to."
Their hope is to dispel misconceptions.
No, they are not liberal activists trying to push a gay or transgender agenda. A.J.'s mom grew up in the South, a Republican raised Southern Baptist by a conservative, Christian family.
"I was my high school chaplain and on the student council," she said. "I actually read a devotional over the PA system every day."
Yes, there was plenty of male influence in the house. A.J.'s dad is a sports medicine expert who helps train competitive athletes.
No, the couple didn't secretly want a girl and thus "turned" one of their sons. In fact, it's the opposite.
"I wanted boys," said A.J.'s mom, who concedes to having been a sports-minded tomboy.
"The idea of having a little girl whose hair I would have to put up in braids, and later deal with teenage hormones, was scary."
A.J.'s parents had two boys. One, now 8, and A.J., now 6. Their behavior was the same. They wrestled. They played with trucks and footballs. She and her husband had no clue that A.J. was anything other than "all boy" for the first few years. It's only looking back now that they see it.
They had gone shopping together.
"I think he was 3," his mom said. "He asked if we could turn down the girls' aisle and pointed to a princess dress and said, 'Mom, can I have that?' I thought, 'Huh.' Our rule is not to entertain (purchases) at first. But if, after a month or two, they are still interested in it, we will get it for them."
A few days later at day care, A.J. brought his mom over to some dresses. "Look, Mom," she recalled him saying, "this is the one I wanted."
Curious, she talked to the teachers. They assured her that at that age, boys play with girls' stuff and girls play with boys' stuff and A.J. played with both. It was no big deal.
"We thought, if that's normal, whatever," A.J.'s mom said. "We're not going to freak out about something like that. Girls play with footballs. If he wanted to wear a dress for a little while, whatever."
But it wasn't a little while. A few months passed and A.J. still hounded his parents to buy a dress. They relented. Why not? He was just a little boy.
"We thought he'd move on, no biggie," his mom said. But it became more than a phase.
At home, the dress was all he wanted to wear. Soon he asked for a nightgown. Then "the disturbing thing" happened, she recalled.
"I say disturbing because it got our attention," she said. A.J. was about to turn 4. "He started pushing down on his genitals a lot. Pressing down, squeezing his legs together" as if he didn't have male genitalia.
His parents checked for rashes, itches.
"He said, 'No, I don't like them,'" his mother recalled "They're in the way.' ... This is a 4-year-old!"
It was time to seek advice.
Psychologists and other researchers concede they know very little about what creates transgender. A few studies of transgender adults have found differences in the brain's white matter and in hormones.
Males who transition to female, known in the trans-gender community as MTFs, for males-to-females, have been shown to have some neurons and hormone levels more consistent with females. Females who transition to males, FTMs, have shown some of the opposite.
A key to understanding transgender, experts said, is first to understand the difference between "gender identity" and sexual orientation.
Sexual orientation is about which sex one is attracted to. Individuals attracted to men are either straight or gay. Attracted to women - straight or lesbian. Bisexuals are attracted to both.
"Who you're attracted to has nothing to do with your gender identity," said Laura Edwards-Leeper, a psychologist at Oregon's Pacific University who works with transgender kids.
Gender identity is the deep-seated, believed to be hard-wired, inner knowledge that one is either male or female. Why an individual who is biologically one gender, with all the organs and chromosomes of that gender, would be absolutely sure they are the opposite gender is far from clear.
What is known is that gender is not as binary as is often thought. Beyond singular males and females, biology allows for various "inter-sex" individuals who are born with mixed genitalia or even the chromosomes of the opposite sex.
In transgender individuals, experts said, the brain appears to say they are one sex while their body is the opposite.
"We are talking about a subset of kids who are saying, 'I am born in the wrong body. My body doesn't match my brain. God made a mistake,'" Edwards-Leeper said.
Just as homosexuality was once considered a mental disorder, the American Psychiatric Association had for years used "gender identity disorder" to explain and diagnose transgender individuals. The diagnosis has been a mixed blessing.
It allowed people to receive medical treatment such as counseling, hormones and even surgery and increasingly have it covered by insurance. But it also suggested that transgender people suffered a stigmatizing mental illness.
As a consequence, the association changed the name in the new edition of its Diagnostic and Statistical Manual of Mental Disorders to "gender dysphoria," an unhappiness with one's biological gender.
"Replacing 'disorder' with 'dysphoria' ... removes the connotation that the patient is 'disordered,'" the association said.
A.J.'s parents certainly knew their child was not mentally ill. He was happy, healthy, athletic.
Wearing sparkly princess dresses was one thing. They wondered if perhaps their son was gay. If so, fine. But it is a different matter to contemplate him being trans-gender.
They talked to their day care providers, their pediatrician and a psychologist. A.J. asked for more princess dresses and more nightgowns.
"We asked all the experts. Everyone said it was probably not a big deal," A.J.'s mother said. "We were trying to be good parents and ask the right questions."
A.J. began asking for girls' toys, girls' shoes. His parents tried to steer him toward boys' things. When his fourth birthday party arrived, he agreed to a pirate theme with swords.
"We are figuring we have a boy who likes girl things," his mom said.
Soon he was asking for girls' underwear. His parents said no.
When they went out for ice cream one night, he wanted to wear a fairy dress with wings. It was the first time he insisted on wearing girls' clothes in public. He was wary.
"I don't want people to make fun of me," he said.
They took him out. A few people gawked.
"I gave them the death stare," his mom said.
Then around Christmas, A.J. said it. He took his mom's breath away. They were in a store, walking hand in hand.
"'Mom,'" she recalled him saying. "'Do you know that I'm a girl? I'm really a girl on the inside.'"
It was not a question. It was a statement.
"My child did not say, 'I want to be a girl.' He said, 'I am a girl. How can you not see it? Don't you know?'"
The room went out of focus. She tried to respond.
"I said, 'No. No. I didn't know. The doctors told us you were a boy, so that's what I thought.'"
"OK," her son replied. They kept walking. Her mind spun.
"You cannot be prepared for this as a parent," she said. "It's not in any of the 'What to Expect When You're Expecting' books."
Back home, she phoned her husband. "We have big stuff going on here," she said.
Caroline Gibbs, a Kansas City psychologist who sees more than 100 clients at the Transgender Institute, said many transgender people "come out," publicly revealing their gender identity, at puberty.
Others reveal after high school, from age 19 to the mid-20s.
"Some people bury this, they are so afraid. My oldest client is 73, male to female," Gibbs said.
But many realize their gender, she said, when they are as young as 3, 4 or 5.
"I knew I wasn't a girl. I kind of always knew," said Michael Galvin, one of the Blue Valley FTM seniors. "I have been talking about it with my mom since about elementary school."
Janet Galvin, Michael's mother, said some signs arose as early as first grade when she threw a Harry Potter party and her child wanted to dress as a boy.
Isaac Barnett, the other FTM senior, said, "I've known since I was 8."
"What makes me a boy is that, I don't know, I don't feel comfortable in my (female) body," he said. "... It's not that God made a mistake or I'm blaming anybody. It's that I was born in the wrong body and I need to fix that."
As late as his junior year, Isaac was still known to all but a few classmates as a girl. He had even grown his hair long.
"Still, looking in the mirror and stuff, I still saw a boy," he said. "I will look at my old pictures and stuff when I was a girl and I'll think, 'That's not me. Who is that person?'"
Isaac was adopted from China in 1997 as a 17-month-old girl by his mother, Lynn Barnett, and her partner, now separated.
Lynn Barnett remembers that when Isaac was 8, "he didn't like dressing in girls' clothes. ... He really didn't get into playing with other little girls in the same way they played."
But, she said, "I wasn't sure he was transgender until last fall, his junior year, when he said he was trans-gender."
Feelings now: "He is so happy and feels so much better about himself, I have to be OK with it. I am so glad to see that he is feeling comfortable in his body. I'm pleased that he's happy."
A.J.'s parents kept looking for answers.
"I had no idea what to do with a kid like this because no parent had ever said, 'Yes, my kid has done this too,' " A.J.'s mother said. "You feel completely isolated and question everything. ... What did I eat? What chemicals? Is this a genetic thing? Is it a medical thing?"
They called Children's Mercy and then Gibbs. They remained cautious and skeptical, wondering whether someone who ran a place called the Transgender Institute might be too apt to diagnose a child as transgender. They sat down with A.J., watching Gibbs for signs of leading questions. Gibbs, as A.J.'s mother recalled, began talking to A.J.
"Can you tell me something about yourself? Are you a boy or a girl?"
"I'm a girl," A.J. said.
"What makes you think you're a girl?"
"I just am," she said.
"Is it what you wear or what you play with?"
"No. I just am," she said.
"Your parents say 'my son' and 'him.' How does that make you feel?"
"I'm really a she," A.J. responded, "'cause I'm a girl. I'm a daughter."
"But they don't call you that."
"Yeah, I know," A.J. said.
Her mother could see her sadness.
The eventual diagnosis: gender dysphoria, which led to weekly counseling.
Treating and guiding young children identified as transgender remains a thorny issue.
Some therapists discourage the transitions. Some remain neutral and allow free gender expression to see what evolves. And some actively support and guide children with their new identities.
Part of the contention centers on a few studies out of Toronto, the Netherlands and elsewhere suggesting that without treatment, as many as 80 percent of children who identify as trans-gender early, before puberty, may actually become "desisters."
Desisters are kids who, upon follow-up, are found to no longer consider themselves transgender but instead identify again with their birth gender. Only a handful of published studies have shown this effect and the sample sizes in each tend to be extremely small, often only a couple of dozen children.
Jacobson at Children's Mercy said flatly, "I have never seen a desister."
At Boston Children's Hospital, which operates one of the leading programs for transgender children, physician Norman Spack said he has treated more than 250 transgender children. Desisters?
"One," he said.
But because therapists currently have no way of knowing which children will be "desisters" as opposed to "persisters" - and because early hormone therapy can have negative side effects on the developing body - they roundly agree that young kids should not be subject to any permanent medical intervention until later in puberty.
In puberty's earliest stages, children can be given hormone blockers, which have reversible effects. When given to young FTMs, the blockers help prevent menstruation and the development of breast tissue, which can be psychologically jarring for individuals who identify as male, Jacobson said.
In MTFs, blockers help prevent the deepening voice, facial hair and other changes that accompany male puberty.
Hormone therapy comes later. And one must be at least age 18 before undergoing the "top" or "bottom" surgeries to add or remove breast tissue or augment or remove lower genitalia. The surgeries are not required or necessary and a great many transgender men and women never have them.
Still conflicted about what to do or how to react, A.J.'s parents gradually allowed her to wear the sparkly clothes and have the girls' toys she wanted.
What her mom called "the watershed moments" came near and after Christmas. A.J. was invited to a birthday party with all the 4- and 5-year-old boys and girls from day care.
To that point, A.J. had worn girls' clothes only at home and on weekends. Now she wanted to wear them to the party. Her mom had no idea what would happen. Parents would be there too.
"She had a long-sleeved pink shirt with sequins and pink hearts and pink leggings and a tutu skirt and out the door we went," A.J.'s mother said. "We show up at the party and the moms are all OK with it. ... The other kids are like, 'Cool. Let's go skate.'"
Then one day in January, A.J. showed up at school dressed as a girl. "We'll work it in," the teachers said. They calmly talked about diversity and accepting differences. A.J.'s mom was thrilled - but only briefly.
"The kids were OK all day long and then they got home and talked to their parents," she conjectured, "and then they came back and said (to A.J.), 'You're weird.'"
A.J.'s mom wrote an email to the parents explaining what A.J. was going through.
"If you're confused, just imagine how confused we are," she wrote. "But we are trying to do what is going to make our child the most happy and confident kid possible."
In the pickup line after school, parents stopped making eye contact. Invitations disappeared. Some parents said they would call, but they never did.
When A.J.'s mom looks back on the most significant moments, she recalls a time around the day care Christmas party when A.J. was still dressing as a boy. Around her buddies, she was urging her mother to check out the boys' toys.
Then the boys left. A.J. whispered to his mom.
"'Come here. I want to show you something else,'" she recalled her child saying. " 'We got these new Barbie dresses over here, and this thing turns into a shower.' He's showing me all these things in hushed tones.
"That's when everything changed for me. You think it would be the moment when he said, 'I'm really a girl.' But I saw my 4 1/2-year-old living two lives. What 4 1/2-year-old has to play that game?"
She now home-schools both A.J. and her older brother, who, his mom said, was a bit confused by his sibling's transformation but quickly adapted.
"He had one week when he was kind of upset," the mom said of the older brother. "He said, 'She's a girl and she's not going to play ninjas with me anymore.' "
The mom assured him A.J. would, and he was happy.
The family is not sure what lies ahead except that now, A.J. is growing up as a girl.
Her pink and purple room, her clothes, her dolls, her toothbrush, everything. New friends only know her as such.
Currently she is receiving no medical intervention.
Eighteen months after A.J.'s gender identity changed, she is as happy as she has ever been, her parents say. They're grateful.
Historically, rates of depression, self-mutilation, drug use and suicide attempts have been high among transgender individuals - which many believe is as much a consequence of poor societal or family acceptance as anything else.
A.J.'s mom concedes that her own conservative parents are not as accepting.
"We still have discord happening," she said, but they are making headway.
A.J.'s parents know the future may not be easy when it comes to their daughter's friendships, dating, marriage, children. Positive experiences like Isaac's and Michael's bring hope. Recently Isaac shopped for a suit for a date for an upcoming dance.
"Honestly, I don't know about other people," Michael said. "I haven't had anyone who was mean to me about it. I've never been bullied or anything."
There are still some problems, the boys said. At school they are not allowed to use the boys' restrooms but must go to a nurse's bathroom, which is hardly convenient for their schedules.
They maintain that greater acceptance comes from understanding.
"Family is everything," said Gibbs of the Transgender Institute. "It is everything. ... You can handle anything if you have a loving mother and loving dad, or at least one."
A.J. has two.
"It is not something that I expected," said A.J.'s father, "but as a parent you want to do what is in the best interest of your child. Your job is to shepherd them into the world. And if your own family can't be accepting of who they are, how is the rest of the world going to accept them, or how are they going to accept themselves?"
How many people are transgender?
It's difficult to know for many reasons, including that many people never come forward as transgender, said Seth T. Pardo, a San Francisco psychologist who is scheduled to present a paper on transgender demographics this month at the World Professional Association of Transgender Health in Bangkok, Thailand.
Different studies offer different numbers:
Data from the Netherlands cite a rate of 1 in 11,000 (0.009 percent) of biological males who identify as women, and 1 in 30,400 (.0033 percent) of biological females who identify as men.
Various parental reports from 1997 to 2009 indicate as many as 0.5 percent to 1.4 percent of biological males and 0.6 percent to 2 percent of biological females express a "wish" to be the opposite gender.
International reports of college students from 2010 and 2011 report 0.7 percent to 0.9 percent of biological males and 2.2 percent to 2.9 percent of biological females expressing a similar wish.