Welcome to my column about LGBT, reproductive rights, and gender issues. Previous columns are here. If there's a topic you think I should cover, let me know!

In all the political and social battles over sex and gender, one thing is clear: Transgender kids have it rough. Over 80 percent of teens who think their gender doesn’t match up with their genitals contemplate suicide. But very few queer-friendly groups focus on transgender kids, in part because working with children is political controversial and can lead to the always-popular accusation of recruiting children. Portland-based TransActive is the only transgender youth nonprofit in the country with actual office space. I talked with TransActive Executive Director Jenn Burleton last week about how preventing transgender teen suicide means working with kids long before they hit puberty.

Before we get started, if you haven't read this heartwarming, tearjerking Boston Globe story about a transgender twin, break out the tissues and read it now.

MERCURY: At what age do people actually know they’re transgender?
JENN BURLETON: Parents have told us that as early as 18 months, when they would say things like, "Good girl," their kid would say, "Nooo, good boy." But the average age kids know their gender is about four and the modal age for kids to recognize that the way they're experiencing their gender identity is different than the way everyone else thinks they are is about seven. All kids have a pretty strong sense of whether they're a boy or a girl or some mix of the two. If the way you experience your gender identity matches your birth assigned gender, then there are no surprises for anybody and when you affirm that, no one says, “Whoa, whoa, whoa.” But trans kids, what they express at that same time gets a lot of cultural pushback. Especially transfeminine kids. Tomboy is not a dirty word in our culture. Sissy is.

But lots of kids play around with gender nonconformity—I have some great photos of male friends in princess dresses. How can parents be sure their kids are transgender?
There's a big difference between kids who are saying, “I like to do these things, I like to wear dresses or play with dolls” and kids who say, “No, I'm not a boy, I'm a girl.” To an adult, that might sound like the same thing. But it's important to listen and realize they're not just expressing their gender in a nonconforming way, they're experiencing it differently. This is not a whimsical thing for these kids at all. In an age group where kids are changing their minds about everything else, this is the thing that remains constant. While these kids are telling us that one day they want to be a ninja turtle and the next day they want to be a Power Ranger, what they're saying about gender isn't changing.

What steps can families take once they know their kid is trangender?
The cultural approach to trans care has always been reactive, rather than proactive. Now, the kids we work with have the chance to not go through puberty and develop the secondary sex characteristics of the gender that that doesn't match theirs. Little trans girls don't have to grow up and develop deep voices and facial hair and all these things that really limit their ability to be accepted by their culture. Trans kids can take puberty blockers, which are completely reversible and have been being used for years to treat the condition called Central Precocious Puberty. It's perfectly safe, and it puts puberty on hold for a couple years so they don't get the negative effects. When trans kids go through these changes that they know aren't reversible, their suicide and depression rates just shoot through the roof.

What are puberty blockers, exactly?
There are a couple different forms, they're mostly hormone injections or an implant. The major issue is that it's not covered by insurance—it costs $18,000 a year for the implant. The American Medical Association and American Academy of Pediatrics are all on board with this being the preferred course of treatment for kids who are trans.

[UPDATE! Burleton wanted to add this clarification about puberty blockers: "In both forms, they act in a way that prevents the pituitary system from beginning the process of secondary sex characteristic maturation… essentially blocking the pubertal body changes that cisgender youth experience. The kids stay on the puberty blockers until the decision is made, in conjunction with their physician and pediatric specialists to begin taking the cross-sex hormones that will allow their body to develop in a way that matches their gender identity; estrogen for trans-feminine youth and testosterone for trans-masculine youth."]

That sounds like a scary leap for families. How do parents decide this is the right choice for their kids?
Eighty three percent of transgender kids who don't get support and begin to go into puberty that doesn't match their gender ideate suicide. Forty one percent attempt suicide. Doing nothing is not the same as doing nothing. Doing nothing actually leaves these kids in trouble. Statistically speaking, based on prevalence estimates, there are about 3,200 trans kids in the Portland metro area alone. We're currently working with 70 families. So we're short by about 3,100 kids.

How do you count transgender kids?
Several different prevalence estimates have been done. One was in the San Francisco school district, where kids were given a choice of saying male, female, transgender, or other. One percent of the kids chose transgender [PDF here]. And Portland is a much more trans-friendly city than San Francisco. Portland has the largest population of any city in the US for trans people. It's a mecca for trans people. There are a lot of reasons for that—one is that the state has really progressive non-discrimination laws. They're not always enforced, but the laws are on the books. And Portland and Multnomah County both offer healthcare for trans people.

Talking about being proactive, what kind of concrete changes would you like to see in Oregon over the next 10 years?
The first thing that would be a major change in Oregon would be for more Oregon schools to adopt the policies required of them under the Oregon Safe Schools Act. That law was passed three years ago and says every kid is allowed to express their gender identity how they want. This isn't a warm, fuzzy anti-bullying suggestion, this is state law. The second would be to get medical coverage for puberty blockers. If you have a little girl who's terrified that she's going to grow up to look like daddy, she's probably going to become depressed and maybe even attempt suicide. That's a pretty damn scary option. What's standing between that and letting their daughter grow up to be a girl is $18,000 a year. If this was any other condition that had that kind of a drastic, alternate outcome, it would be a national emergency.