"Stealth" is a common term used to describe transgender people who have transitioned but choose to not publicly reveal their identity as a transgender person.
The term is going out of fashion due to the negative connotations of the word "stealth," which implies deception, said Joel Baum, Gender Spectrum's senior director of professional development and family services. He prefers the term "maintaining privacy," which "on the other hand places the child's experience on a very different plane. Most people understand that there are aspects of our lives that are public, and aspects that are private. There is dignity and a level of respect for the young person's experience that is implied by the phrase 'maintaining one's privacy.'"
"Scott," a Palo Alto high school student who transitioned from female to male this year, said he wishes he had more fully identified as transgender at a younger age so he could have transitioned earlier, perhaps in middle school, and then gone "stealth" in high school. Scott plans to maintain his privacy in college, one of the reasons that his parents and others did not want their names used in this story.
"Once you're out, you can't go back," said Emily, whose daughter, the first elementary-age student to openly transition in the district, is now at a new school, where she's able to keep her identity private.
"I think it's a testament to how even in a community like Palo Alto, which is very progressive and where you assume everyone would be supportive, there are still people who are not comfortable with transgender people," Emily said. "You cannot know how they will treat your child. You can't take back that information once it's out."
Rayden Marcum, a former Paly student who transitioned from female to male after transferring out of the high school, has since spoken openly about being transgender on panels and at other events. He said he feels "compelled to be a voice in order to allow those who don't want to or can't to not have to."
These parents and students have become familiar with this line between privacy and secrecy -- what is private information, and what is kept a "secret" or not.
"The thing is, it's not a secret that I'm trans," Scott said, "but what's private is when people at school ... will ask me, like, 'What type of genitalia do you have? What surgeries have you had? Are you on testosterone?' -- questions that you wouldn't ask a cis(gender) person (a non-transgender person), but apparently it's OK to ask a trans person.
Today, medical interventions are making it more possible for transgender children to transition earlier, and then maintain their privacy if and when they choose to.
A younger child who has yet to enter puberty might be a candidate for puberty blockers, a set of medications that are prescribed by an endocrinologist to suppress or inhibit the production of sex hormones. Though still controversial, opting for puberty blockers can change the course of a child's transition drastically. The treatment is fully reversible but can give "young people time to achieve greater self-awareness of their gender identification," according to the Child and Adolescent Gender Center at the University of California, San Francisco, which for close to a decade has provided comprehensive medical and psychological care, as well as advocacy and legal support, to transgender and gender non-conforming youth and adolescents.
A transgender teenager, on the other hand, who has already gone through puberty might opt for cross-sex hormone treatment, which can induce the physical and psychological characteristics of the sex that matches the patient's gender identity.
Patients must be evaluated by a mental health professional before receiving these treatments.
Doctors and mental health professionals look for clear signs that the child believes his or her gender does not match his or her gender at birth.
"A pervasive, consistent, persistent and insistent sense of being the other gender and some degree of gender dysphoria are unique characteristics of transgender children," reads an American Psychological Association report on transgender children.
Recognizing -- and accepting -- these markers earlier can also mean improved mental health outcomes for transgender youth, who are at high risk for depression, anxiety and suicide.
"People are noticing, also, that if these children get the treatment they need even from an earlier age and not wait so long, the depression and suicide and other comorbidities ... are improved," said Tandy Aye, a Stanford School of Medicine pediatric endocrinologist who began treating local transgender children and adolescents about six months ago. "Kids are happier."
Studies show that LGBTQQ youth experience high rates of bullying, harassment and discrimination. "Injustice at Every Turn: A Report of the National Transgender Discrimination Survey," conducted by the National Center for Transgender Equality, found that those who expressed a transgender identity or gender non-conformity while in grades K-12 reported "alarming" rates of harassment (78 percent), physical assault (35 percent) and sexual violence (12 percent). Fifteen percent of respondents, who were K-12 and higher education students, said the harassment was so severe that it caused them to leave a school.
An oft-referenced statistic within those working around transgender issues is that 41 percent of transgender people have attempted suicide, compared to 1.6 percent of the general population, according to the National Center for Transgender Equality. The center's discrimination survey found that the highest rates of suicide attempts were reported among those in the 18-24 age group (45 percent) and 25-44 age group (also 45 percent).
Transitioning during puberty can also mean "less corrective surgery down the road," Aye said.
Hormone treatments are expensive, and not always covered by insurance. Health professionals say the cost varies greatly depending on the treatment itself, method of delivery (puberty blockers can be given as monthly injections or more expensive surgical implants, for example) and even the institution providing the treatment. One local family pays $260 per month for puberty blockers; another, $3,500 a year. Both families' insurance providers don't cover the treatments. Other families said they pay close to $3,000 per month for a particular puberty blocker.
Emily paid out of pocket for her daughter's puberty-blocker implant, which cost about $20,000 and lasted almost two years. Their insurance provider originally considered the treatment "experimental" and "unnecessary" and would not pay for it but now covers this care, Emily said.
"In 10 years' time, my hope is that for a kid coming up in the next generation, being transgender will be accepted and supported: that not just specialists, but general doctors, will be educated, that insurance will cover trans care, that workplace protections will be in place," Emily said. "But right now we're still on the leading edge. It's better than it was 10 years ago; it's not as good as it will be in 10 years."
At Stanford, in addition to providing medical services, Aye is also working with mental health providers and social workers to guide and advise families throughout their child's transition. She said she saw an "increasing need" for such services and felt compelled to support local families.
Aye is currently seeing nine patients and receives several referrals per month. One family drove from as far away as six and a half hours because they couldn't access the services they needed where they live; another lives as close as Palo Alto, Aye said. Her patients are as young as 4 1/2 years old and as old as 15 years.
"We're assessing the need, but it seems like the need is there and growing," Aye said.
Last month, Stanford also made a momentous announcement for local transgender families: Within the next year, Stanford Children's Health will open a multidisciplinary clinic that would bring all of the subspecialties used by transgender children and adolescents -- pediatric endocrinology, adolescent medicine, psychiatry, psychology, social work, OBGYN and urology -- under one roof. This increases access for both patients and their providers, who can then more easily collaborate with each other, Aye said.
This is similar to the model at UCSF, where until this year Stanford would typically refer families seeking such care. The new clinic will fill a void on the Peninsula for families seeking care for transgender children and adolescents.
Stanford Children's Health plans to open the clinic somewhere in Santa Clara County in the next eight to 12 months.
Aye and Stanford child and adolescent psychiatrist David Hong are also in the midst of a pilot study that will follow both children with and without gender dysphoria for two to three years as they go through puberty.
The study aims to examine the physiological effects of puberty blockers and cross-sex hormones, an area Aye said has not been studied before in the United States.
This story was updated to correct in accurate information that stated 15 percent of transgender or gender non-conforming respondents in a survey, who were K-12 and higher education students, said they experienced harassment was so severe that it almost caused them to leave a school. Fifteen percent of respondents said it was so severe that they did leave a school.