As kids like Kyle become increasingly more accepted, and as access to care becomes easier, critics on both the left and the right of Spack's pragmatic, supportive approach fear that Spack and those like him are making it too easy for kids to transition.

"If you put a kid on blockers, in a way the clinician is giving either an implicit or explicit message that we don't really see that there are alternatives than to go down a sex-reassignment pathway. And we don't really see it as possible that there could be other outcomes that may be equally as good — maybe even better for some kids," says Dr. Kenneth Zucker, head of the child and adolescent gender identity clinic at Toronto's Centre for Addiction and Mental Health.

Accused by some of practicing "reparative therapy"— he encourages parents to stop their young gender-variant kids from experimenting with opposite-gender names, toys, and clothes — Zucker is something of a bête noir in many trans communities. But he feels strongly that "if a child can grow up and feel comfortable in his or her own skin that matches their birth sex, then you avoid the complexity of fairly serious surgical treatments. Penectomy and castration is not the same thing as having mild and minor cosmetic surgery. Lifelong hormonal therapy: it's serious."

On the left are critics who dislike the binary model that GeMS inevitably plays into. "Sometimes when I speak in a binary model, people are critical of that," says Spack. "They want more fluidity about gender." As an endocrinologist, Spack can only treat those trans kids who want to be either boys or girls: there can be no gray about it. His hormones and pubertal suppressors would be of no use to other kids — and the intervention is too serious for him to consider using with kids who might later change their minds. Still, he's not advocating that kids need to live in a binary if that's not right for them. "I would [defend] the right to be genderqueer just as much as I would defend the transgender person's right to be in the gender they affirm," he says. "So when people come up to me, I say, 'You know, you of all people should be sensitive to the fact that in my accepting you, you have to accept them.' "

Whether transsexualism is a medical or psychiatric issue — or an issue at all — is more than a rhetorical question. According to the American Psychiatric Association, Gender Identity Disorder (or GID, diagnostic code 302.6–302.85) is a mental disorder: it has been classified as such in the Diagnostic and Statistical Manual, or DSM — the bible of psychiatric illness — for 30 years now. A new volume, DSM-V, is currently being researched and written, prompting vociferous debate about whether trans people warrant a psychiatric diagnosis — and, if so, what to call it. (In the new edition, due out in May 2013, GID will likely be renamed "gender dysphoria." Over the protests of many trans activists, Zucker is chairing this committee.)

Hormones and surgery cost tens of thousands of dollars, and whether these are covered by insurance hinges, in part, on whether kids have a formal medical diagnosis. Spack sees families all the time whose insurance companies refuse to cover pubertal suppression because their gender dysphoria is classified as a psychiatric illness. But it seems clear to him that whatever mental distress these kids are suffering is the result of their medical problem. With treatment, he says, "You treat not only the medical hormonal deficiency, and help them attain the body that they wish, but you are very likely to erase a whole bunch of psychopathology that's all secondary."

He has seen this over and over again in patients like Kyle: once they are able to live comfortably in their affirmed gender, their anxiety and depression — even bipolar disorder — disappear. Spack says that even mild autism in trans kids (studies show that 10 times as many gender-variant kids than kids in the general population have autism-spectrum disorders) may be alleviated with treatment for gender dysphoria: "Perhaps the social awkwardness and lack of peer relationships common among GID-Asperger's patients is a result of a lifetime of feeling isolated and rejected," he wrote in a recent article in the Journal of Homosexuality; "and maybe the unusual behavior patterns are simply a coping method for dealing with the anxiety and depression created from living in an 'alien body,' as one patient described it."

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