what are little girls made of?

Fredd is 14. He was born a girl but 'knows' he's a boy. His mother agrees. His doctor is not so sure. Jenny Bryan on the plight of teenage transsexuals

fredd has always known that he is a boy; Lisa has always known she is a girl. But their bodies tell a different story. At 14, Fredd is watching his body develop into that of a young woman while, at nearly 18, Lisa is relying on the female hormone, oestrogen, to prevent her growing a beard.

Fredd and Lisa and an estimated 35,000-65,000 other people in the UK are transsexuals. They have a condition called gender dysphoria. For as long as they can remember they have been convinced that they were born in the wrong body. They never wanted to dress or play like others of their sex and they are deeply unhappy with their bodies. They don't want to cross-dress, like transvestites, and they are not gay.

Over 5,000 transsexuals have taken steps to put things right, undergoing prolonged hormone therapy, expensive cosmetic treatment and what many would regard as mutilating surgery. To convince the medical profession of their determination to change their body and qualify for treatment on the NHS, thousands more are risking abuse and ridicule by living and dressing in their chosen sex, without benefit of hormones or surgery, for up to two years.

Both Fredd and Lisa have been bullied at school, beaten up and verbally abused. Fredd refused to go back to junior school after a humiliating day on which a teacher took away the trousers he had worn to school and made him sit in class in a skirt. Only the determination of Fredd and his mother have ensured that he is now back at senior school developing his natural talents for both arts and science.

"Children can be born with all sorts of conditions," says Fredd's mother, Sue. "With Fredd it was gender dysphoria and I would search the planet for the best possible treatment for him. I just want a child that is happy and content and has the same rights as anyone else."

Lisa missed out on months of schooling and became so depressed that she contemplated suicide. She was so afraid that her parents would throw her out that she was 14 before she finally told them what was wrong.

"We were extremely relieved to find out what was wrong, but it was as though someone we loved was dying in front of us. We grieved for the death of our son but we knew that he just couldn't grow up to be happy as a man," Lisa's mother, Margaret, recalls. Today, Lisa travels 17 miles to work rather than get a job locally and face the taunts of people who knew her before she legally changed her name and began the long and difficult process of transforming her body from male to female.

Neither Fredd nor Lisa can understand why, in the UK, they are having to wait so long to change their unwanted bodies.

"I would like to start hormone treatment straight away so I don't have to grow up in the wrong body. I don't want to be the guinea pig who has to change the system. I just want to get on with my life," says Fredd, as he sits at the kitchen table in large collarless shirt, boy's trousers and the inevitable trainers.

All the NHS can offer him for the next few years is psychiatric therapy with no promise of when any other treatment can start. If he lived in Holland, he could soon be getting his wish, starting a course of reversible hormone treatment which would hold back puberty and prepare him for surgery at 18.

In 1987, clinical psychologist Professor Peggy Cohen-Kettenis started a gender clinic for children and adolescents at the University Hospital of Utrecht. After lengthy psychiatric assessment of children and their families, the clinic will prescribe reversible hormone treatment to 15-year-olds to put their puberty "on hold". To be eligible for this controversial treatment, the teenagers must have insisted that they are the wrong sex for their body from an early age,and must be experiencing obvious psychological problems.

"This is only partial hormone treatment and there is still a way back if the child decides not to go ahead with gender reassignment. The advantage of giving the children these hormones is that the boys don't grow beards and their voices don't drop any further and the girl don't grow heavy breasts," Professor Cohen-Kettenis explains.

If the children respond well to the reversible hormone treatment, are less depressed and are happy in their changed role, they are allowed to begin more advanced hormone therapy which will lead to irreversible changes in their body. That means oestrogen for the male to female transsexuals, testosterone for the female to male transsexuals.

"Some children progress to this stage in six months to a year, others prefer to wait until they have finished school. Then, by the time they are 18 or 19, and have continued the irreversible hormone treatment for some time, they can decide whether to have surgery," says Professor Cohen-Kettenis.

She has followed up the first 22 patients treated at the clinic, one or more years after surgery, and has data on 19 of them. Psychological tests show a big improvement in functioning. Most live independently and have jobs, some have relationships. Any residual difficulties, such as problems getting work, are not linked to the change of gender.

"Our approach is still at an experimental stage, but other doctors are showing interest. We have to be very cautious and I would not want to lower the general age for treatment any further until we have followed up more of the current group," she says. She has, however, treated one pre-pubertal girl, aged 12, at the unit, with the advantage that she did not require any breast surgery.

In contrast, Lisa gave up on the NHS last year and now sees a psychiatrist who practises privately. She was allowed to begin reversible hormone treatment when she was 16. By that time, her voice had already started to drop, but the hormone did prevent puberty from progressing any further.

She has now moved on to oestrogen therapy and passes easily as a woman. "I'm not tall or built like a bloke and the hormones stopped me getting a beard. I don't need to wear any make up to look like a woman." she explains. But she dreads waiting until she is 21 to get the surgery she needs to remove her male genitals on the NHS and hopes she will be able to borrow the money to have the operation done privately, earlier.

London psychiatrist, Dr Domenico Di Ceglie, who runs the only multidisciplinary unit in the country for adolescents with gender identity problems, sympathises with the predicament of teenagers like Fredd and Lisa but explains the need for prolonged therapy before embarking on physical treatment.

"We need to take account of the individual, the family and the wider social context in which the child is developing. It takes time to resolve the contradictions and conflicts," he says.

"Age is only one factor, psychological maturity is another. A child we have been working with for many years may be ready to start hormone treatment before a teenager who comes to us late and needs a lot of work," he adds. He refers to studies which show that the vast majority of children who dress or play inappropriately for their sex when young become homosexual rather than transsexual when older.

"It is very difficult to predict the outcome from early childhood, and it only becomes easier when children get to 14 or 15. The nearer they get to adulthood, the more precise the diagnosis," says Dr Di Ceglie.

A landmark case in the European Court of Justice in 1995 means that it is now illegal for employers to discriminate against people who are planning to change or have changed their gender. But pressure groups are continuing to campaign for British transsexuals to join those in most other European countries in being able to have their birth certificate changed after surgery to reflect their new status. For Fredd and Lisa, getting hormone treatment is only the first of many battles they will have to fight.

8 For more information, children with gender identity problems and their families can contact Mermaids, BM Mermaids, London WC1N 3XX

8 Fredd and Lisa's story is told on: 'The Wrong Body', Channel 4: February 6 and 13, at 9pm