(AP) — In the past year, Theo Gretz has hit major teenage milestones. His voice is getting deeper by the day. His facial hair is coming in spurts. He's been shaving, or at least trying to.
And three weeks ago, the 16-year-old had surgery to remove his breasts, marking a significant moment in his transition to male. The Claymont teenager has been taking testosterone since May 2017 and has felt more like himself since then. He says he's now more comfortable and relaxed.
When Gretz realized he was transgender at age 13, there were little to no resources for transgender youth looking to transition in Delaware. Many would have to travel to Philadelphia.
This past month, Nemours/A.I duPont Hospital for Children officially opened its Gender Wellness Clinic, in which a team of doctors — including a psychologist, endocrinologist and gynecologist — help patients, like Theo, who feel the sex they were assigned at birth does not match the gender they identify with.
The clinic represents a growing trend among pediatric hospitals: More and more are creating similar programs to help transgender or gender-nonconforming youth both medically and psychologically.
Nemours doctors say the treatment doesn't always consist of surgery or hormone therapy; sometimes it could be helping patients realize what name and pronouns make them feel like themselves.
A 2017 study by the UCLA School of Law found that about 150,000 young adults in the United States identify as transgender. In Delaware, there are about 400 teenagers between the ages 13 to 17, the study said.
Dr. Evan Graber, a Nemours endocrinologist and medical director of the clinic, saw his first transgender patient about three years ago — he now has about 50 patients who range from 10 to 21. And he isn't the only Nemours doctor to have a constant flow of patients.
"We're getting so many patients, it seemed like the best way to take care of these patients was as a group, not just individual practitioners that chat with each other in the hallway," he said.
Graber reached out to doctors at Children's Hospital of Philadelphia, which created one of the first gender clinics, for guidance. Despite being "so-called competition," Graber said the doctors were supportive of the Nemours clinic since they found their patients in southern Delaware struggled to make it to Philadelphia for appointments.
Like the CHOP program, the Nemours clinic has a social worker on its staff, in addition to a psychiatrist and pediatrician that help teens find adult care once they age out of Nemours.
Anthony Alioto, a Nemours psychologist and the program's clinical director, said there's often a misconception that every patient who comes into the clinic is looking for the "full gamut of interventions and surgeries."
Often times, the doctors are helping patients and their families learn about the options and help them understand what kind of services they are looking for, Alioto said. For some children, transitioning could just consist of changing their name and the way they dress.
"This is a family decision," Alioto said. "This isn't a random teenager walking in off of the street on a whim. And we say 'Sure, sounds great.' That's not how this works."
"This is somebody coming in with a condition for gender dysphoria that has really caused a lot of discomfort for them. And many times has a psychological impact for them."
Gender dysphoria is a condition in which a person feels discomfort because their gender identity doesn't match their biological sex, according to the American Psychiatric Association.
For Nemours patients who want to transition, the process typically begins with behavioral health, specifically, working with a psychologist.
Alioto said some children aren't entirely sure they want to transition to the opposite gender, at least right away. Gender is a spectrum, Alioto said, and some find themselves to be the most comfortable somewhere in the middle.
He prefers his patients to try transitioning incrementally before undergoing a medical procedure.
For those who feel they are ready for medical intervention, Graber often talks to his patients about undergoing hormone therapy, which consists of taking estrogen or testosterone.
His younger patients might receive puberty blockers, which allows them to "explore their gender identity without having to make those changes that can be very distressing," Graber said.
Insurance companies are increasingly covering these treatments, he said, though some still consider them to be cosmetic or experimental.
Graber estimates a handful of his patients — including Theo — have undergone top surgery, which consists of a mastectomy. He said a couple of patients have had "bottom surgery," or sex reassignment surgery, but only after they turn 18.
Few surgeons perform these procedures in the area, none of whom are at Nemours or CHOP, Graber said.
While there are guidelines from national medical societies, there are no "hard and fast rules" about when children can receive certain procedures, the doctors said. Graber has found most teenagers and families don't consider top surgery until around age 17 and bottom surgery at age 18.
These patients are also on hormone therapy for a period of time, he said.
The doctors said the decision to go forward on treatments is not taken lightly and often includes a lot discussion with the families and patients. Ultimately, the parents need to sign off on the procedures.
While there are parents who are supportive from the beginning, others aren't as accepting when they first meet the doctors. Some argue that teenagers' brains haven't matured enough to make these big decisions, Graber said.
But there's also a concern if families wait too long to have these procedures. Studies have found that transgender youth are more likely to experience mental illness, including depression, anxiety and suicidal thoughts and attempts, than their non-transgender peers.
"We know we're taking a calculated risk," Graber said. "But we also know not treating is taking a calculated risk that could have very detrimental effects."
Theo's mom, Carol Gretz, admits she had concerns, though she never thought Theo was too young to transition. Carol believes he began transitioning to male at age 3 when he preferred to wear boxer shorts.
She was more nervous about potential side effects Theo might experience when taking testosterone and undergoing major surgery. But after reading Theo's extensive research, and talking with the doctors, Carol came on board.
Her teenager no longer walks with his head down and curves his shoulders a certain way to hide his breasts. She can't remember a time when Theo was more confident or more social than he is now.
"He's happier," Carol said. "He walks with his head high and shoulders back."