For Kyle Smith at age nine, the first two of GeMS clinic's three requirements to begin puberty blockers were easy: extensive psychological testing confirmed that he had a "strong and persistent" desire to be a boy, and ongoing mental-health counseling was also covered: he'd been going to therapists for years. But the third requirement — support of both parents?

"Fathers often do come around a little later," Aileen says of her husband. "Medical things are so hard. He was supportive, but he was saying, 'Let's see. This could be a phase. How do we know?' "

For Kyle at that first appointment in Spack's office, the stakes couldn't have been higher. "He walked up to his dad, and looked at him as if he was like a teenager, but he was only a little boy," Aileen recalls. "He must have been thinking, 'I didn't come this far to be told that I have to leave and not get help.' He said, 'Dad, I need help. You need to help me. You need to tell Dr. Spack. I need medical help.' He literally said those words: 'I need medical help.' " Aileen looks at Kyle now, who is fiddling with a rubber rainbow bracelet. "And Dad started crying."

"I really don't remember that," Kyle says. "I wish I did. I can't picture that at all. I've never seen my dad cry."

Aileen nodded. "Dad started crying and he looked at Dr. Spack, and he said, 'I understand. You need to help my son.' And that was the beginning."

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