Happy with the treatment he received from Spack, Mark referred his friends, and his friends referred their friends, and soon Spack had a busy practice of transgender teenagers and adults. Doing this work, he was often struck by "how difficult it was, particularly for male-to-females who were undergoing transition in their 30s and 40s," he recalls. For those who had completed puberty in their birth sex 20 and 30 years before, hormones and surgery could only do so much. So when, in the early 2000s, he heard about a new Dutch protocol which could prevent the onset of puberty in young trans people, he was intrigued.

He was a pediatrician, after all, and together with the administration at Boston Children's Hospital — where he was transitioning to a full-time position — Spack decided to transfer all of his adult patients to other providers in order to focus solely on kids. He personally trained many of these doctors who went on to care for his adult patients. One of them was Alex Gonzalez, medical director of Fenway Community Health Center.

The Fenway has 800 patients in its transgender health program and is considered one of the nation's premiere medical centers specializing in care of the LGBTQ community. Indeed, you might think they had a strong transgender health program from the start. But "of all the many different people we've had to come help us build our program here," says Gonzalez, "Dr. Spack stands out as one of the most instrumental." Spack's "Transgender Health 101" presentation some six years ago, and his ongoing support, has helped to quadruple the program's size. "Probably the most attention-getting aspect of Dr. Spack's approach is that it really isn't sensationalistic at all," says Gonzalez.

At the time, Spack had colleagues who wanted to start a program like GeMS, but they faced unsupportive department chairs reluctant to intervene medically "in a pediatric population deemed to have a primary psychiatric problem," as Spack describes it. "They said, 'You guys have got to be nuts, doing this in a pediatric hospital.' " But the administration at Children's was on board from the start. Joseph Majzoub, Chief of Endocrinology at Children's, who years earlier had helped arrange a special rider on Spack's malpractice insurance to allow him to see transgender adults, encouraged Spack to pursue puberty suppressants, the newest approach to treating transgender kids.

"The guiding principle should be what's best for the patients," Majzoub says. "Norm has been very crystal clear in his thinking about this and his commitment. He made it easy. I don't know what the biases might have been elsewhere, but when one takes one's cues from what the patients need, you're usually right."

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