For Kyle's part, now that he has less to prove with regards to his masculinity — he has been on testosterone for more than a year and lives fully as a boy — he has chosen to express his boy-ness in a less "binary" way. "I'm not exactly the most masculine of masculine," Kyle says. He feels freer to express what he calls his "feminine side," sewing, knitting, and shedding the emphatically masculine clothes he used to wear in favor of more gender-neutral or feminine attire, like wrists full of beaded bracelets. He has become deeply involved in the Trans Youth Equality Foundation, a national organization that provides support and education for families and communities of trans kids. He recently came out as gay. And he has stopped being "stealth" at school and started telling friends about his experience.

As for GeMS, since its founding, it has grown into a multidisciplinary clinic, with a team that includes a psychiatrist, a psychologist, a urologist, a gynecologic surgeon, a specialist in genomics, and a social worker. They have developed a careful algorithm: families do a preliminary intake with an administrator first, then a more thorough intake with a social worker, followed by exhaustive testing by a psychologist, before they ever set foot in Spack's office. That's how it's designed to work, anyway, and it's largely set up to save Spack time and trouble; patients who are too young, or are not totally sure they want to transition, are referred for further therapy or counseling. But as often as not, Spack thinks of kids like Kyle, and is so eager to end their suffering that he just picks up the phone himself.

Victor Samuels, father of Spack's patient Justine, e-mailed Spack when his daughter was 11. The reply came the next day, Samuels recalls.

" 'I have a six-month waiting list,' " Spack told him, " 'but I'll see if I can get you in earlier.' Ten o'clock that night I get a phone call at home. It's Dr. Spack. He says, 'I have a cancellation tomorrow at 10. Would you and your wife like to come in to see me?' "

Justine is now 13, and "sometimes I actually have to remind her," says Justine's mom. "If you look at so many other transgender individuals who have had to figure out how to take back certain things: how to become more feminine, how to become more masculine. And she's been able to stop time. And stop this puberty. We're sometimes like: 'You don't know how lucky you are.' "

On the day I met her parents, Justine was at cheerleading tryouts. "At my chagrin," her mom said, laughing. "But she's there."

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