Fourteen-year-old Grayson has a lot going on this summer — baseball games to attend, friends and prepping for his first year of high school.
His immediate focus, though, is learning how to inject himself with testosterone, the next step in a continuing medical process that's transforming him from a girl. It's a skill he needs to learn because he'll be giving himself these shots for the rest of his life.
"You can do it on the leg on the outside of the thigh," Becky Spee, a nurse at Mayo Clinic's Transgender Intersex Specialty Care Clinic, instructed on a recent visit. "You don't want to do it on the inside because that will hurt."
Grayson began his transition from female to male in 2016, first by dressing and living as a boy and then by legally changing his gender identification and his name from Grace to Grayson. MPR News is not using Grayson's last name to protect his privacy.
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He and Mayo, though, are at the front of a revolution in care for transgender people driven by the federal Affordable Care Act. The law effectively stopped insurers from refusing to cover hormone therapy and other interventions involved in the transition. Suddenly once-unaffordable medicines and procedures were within reach.
Mayo and other major hospitals across the country have responded with new clinics and consolidated mental and physical health services to meet the needs of trans people. But as they work to meet that rising demand, doctors are also navigating some difficult medical and ethical questions.
At Mayo Clinic, Grayson's experience reveals what's at stake.
'It's not a choice'
Grayson said that before his transition, he was depressed. He didn't like himself and hadn't for a long time.
"It's wanting to be something else, but you can't change yourself in the moment," he said. "It's a very horrible feeling."
Medical experts describe it as gender dysphoria. It's like being left-handed but being forced to use your right hand, said Mayo endocrinologist Dr. Todd Nippoldt.
"The one misconception is that trans patients are making a choice, that they choose to be of the other gender," he said. "It's not a choice, it's the way they are. Our goals are to relieve the distress that's associated with the incongruence between their gender identity and their physical body."
Mayo opened its trans clinic in 2015. Grayson is among its youngest patients. Most are older than 18. The clinic began as a half-day a week operation. It's now open four half-days a week with a full appointment schedule to meet the rising demand. It has seen more than 200 patients since it opened.
The need for such services has always existed but cost, distance to clinics and other obstacles kept people from using them, said Luc Rizzaro, policy counsel for the National Center for Transgender Equality
Rizzaro said a recent survey by the group found that one in four transgender people avoided going to the doctor for fear of discrimination, and one in three said they had experienced discrimination while seeing a doctor. The Affordable Care Act's protections were "really life-changing for trans people across the country."
Patients once had to seek mental health services, hormone therapy and surgery from an array of doctors at different institutions, but that's starting to change, too. Mayo Clinic's operation offers a view on how that's happening.
All of the clinic's services for trans people are under one roof and staff are trained to use the patient's preferred name and pronouns. These relatively small courtesies go a long way to reduce some of the challenges trans people face in accessing health care, Nippoldt said.
"It's a population that needs a lot of tender loving care," he said, "and one way to do that is to have a home base."
Part of that support is making sure patients and caregivers understand the risks involved and that some interventions are irreversible. If Grayson wants to surgically change his body, he'll need to wait until he's 18.
"We don't want anyone to have a regret," said plastic surgeon Dr. Oscar Manrique. "Because after we divide or cut, there's no step back."
'A happier child'
When Grayson first came to the clinic in 2016, he saw a mental health provider and pediatric endocrinologist. Together, they came up with a treatment plan to ensure Grayson was physically and mentally prepared for puberty blockers and then testosterone.
For starters, Grayson had to be mentally stable. And he had to live his daily life as a boy for an extended period of time.
Grayson also had to understand the short- and long-term aspects of hormone treatment. The hormone, for instance, could prevent Grayson from having children in the future, said Grayson's pediatric endocrinologist Dr. Aida Lteif.
Lteif requires consent from both parents to treat an adolescent. She also required Grayson to exercise and lose weight before starting hormones because testosterone can negatively affect cholesterol levels.
Grayson's transition has also brought changes for Grayson's family.
His mother Tami, a Mayo Clinic nurse, said she and her husband were not surprised when Grayson came out because they had long suspected he was struggling with his gender identity. She said they never considered rejecting Grayson's transition.
Still, Tami said she mourned the loss of her daughter.
"It was worry. It was panic. It was sadness. It was anger," she said.
But as soon as Grayson started living as a male, Tami said she and her husband saw a notable difference in Grayson's demeanor.
"Even that first week coming out, as hard as that was for him, he was a happier child," she said. "And we saw that every single day."
Editor's note: MPR News will follow Grayson as he starts his first year of high school and continues with his transition. We'll also be reporting on the medical and ethical questions surrounding transgender health care.