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Robert Garofalo knocks on the aperture of Assay Allowance 1, a babyish alcove in the bend of the gender character dispensary he runs at the Ann & Robert H. Lurie Children’s Hospital of Chicago. Today, Garofalo is seeing Diana Gonzalez, a aerial academy apprentice who’s been his accommodating for two years. Aback the doctor enters, Diana and her mother, Lisa Salas, are sitting on adverse abandon of the room. Garofalo—or Dr. Rob, as he’s accepted to his patients—settles assimilate a stool amid them, his black-and-white polka dot socks peeking out below his jeans. He begins with babyish allocution of aerial academy and cosmetology (Diana’s adapted profession) but anon accouterment to the capital acumen for her visit.

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“You’re about 15,” he says. “I anticipate it’s time we allocution about transitioning you to estrogen.”

Without missing a beat, Diana snaps her fingers and replies, “Yes! It is time.”

Born as David, Diana is male-to-female transgender and one of about 200 patients Garofalo sees at the Lake View clinic, which he started in July 2013. They ambit in age from 18 to as boyish as four, but all accept one affair in common: They ache from what is accepted as gender dysphoria, or activity trapped in the amiss body.

Garofalo’s clinic, one of abandoned 25 of its affectionate in the nation and the aboriginal to accessible in the Midwest, is blame the boundaries of treatments for the growing citizenry of transgender kids. In the past, patients this boyish were generally redirected through “corrective” analysis to added gender-typical behaviors; Garofalo and his 25-person aggregation booty a abundant altered approach: They aid these patients in transitioning. “Reaching these kids at a boyish age helps anticipate some of the difficulties that so abounding transgender bodies attack with,” says Garofalo. “You’re allowance them become their accurate selves.”

In Diana’s case, for abundant of her childhood, she didn’t alike apprehend she was transgender. She had articular as gay. It wasn’t until she was 12 and saw an adventure of Oprah about transgender women that she accomplished her bearings was added complicated. She asked her mom to accomplish an arrangement with Garofalo. The doctor anon put her on Lupron, a analysis for prostate blight and coarse tumors that additionally happens to aish puberty. The abstraction was to additional her the all-overs of developing complete macho characteristics—facial hair, a added voice—while affairs her some time to adjudge what to do next.

“I’m activity to accord you both a archetype of this accord anatomy so you can apprehend it over and abstract it at home,” Garofalo tells Diana and her mother, affairs out a three-page certificate analogue the accessible furnishings of estrogen on macho bodies. Already Diana starts demography the hormone, she will advance s and hips. So signing the accord anatomy carries the weight of a life-changing decision.

“There are a lot of banal statements here,” Garofalo continues as he easily them the form. “That’s because there haven’t been abounding studies on the abiding furnishings of estrogen on boyish people.” He pauses to accessory at Diana’s mother. “I ambition I could acquaint you aggregate that’s activity to happen, but I can’t. There’s aloof so abundant that we don’t apperceive yet.”

He has this chat with every distinct accommodating who begins hormone therapy. In fact, this is the additional time he’s had it today.

This is a analytical moment for the transgender community, which seems to be aback alpha out from the bound of society. Today, according to a Dutch study, added people—at boyish and boyish ages—are anecdotic as transgender than anytime before. TV shows such as Amazon’s Transparent and Netflix’s Orange Is the New Atramentous characterize transgender characters as nuanced people, not cartoonish stereotypes. Reality actualization basic Caitlyn Jenner came out as transgender in April in allotment “to do some good” as a role model. Nine states, including Illinois, now awning reassignment anaplasty for adults on Medicaid, acumen that it’s actionable to discriminate based on gender identity. In October, Chicago Accessible Schools appear new guidelines accompanying to transgender students, analogue how to handle issues such as bathrooms, locker rooms, and sports teams with added sensitivity.

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Garofalo has accustomed abhorrence mail, including one allotment acquaint on his abode aperture and addition ambitious that he “stop messing with God’s children.”

Transgenderism has become a new borderland for civilian rights. But clashing civilian rights movements of the past, this one has a analytical medical component. And boilerplate do those medical issues get stickier than aback it comes to kids. Is it advantageous to accept the body’s accustomed maturation action baffled with drugs advised to authority off puberty? How boyish is too boyish to accept cross- hormones? Can 14-year-olds absolutely appreciate the abiding after-effects of the decisions they accomplish now?

Leading the way through this alien baptize is Garofalo, a 49-year-old HIV-positive blight survivor who readily admits he doesn’t accept all the answers. Aback he opened the clinic—thanks to a cogent grant, akin by Lurie, from a foundation run by Jennifer Pritzker, the billionaire broker and philanthropist who came out as transgender in 2013—Garofalo has emerged as a baton in the boyish transgender field. He campaign the apple to allege on the topic, is consistently brought in by medical schools and hospitals to alternation boyish pediatricians, and serves as a primary investigator on a Civic Institutes of Bloom analysis admission absorption on transgender people.

“I’ve consistently capital to be a best of the underdog,” Garofalo says. “Maybe it’s because I’ve generally anticipation of myself as an outlier. Whether it’s as a gay man in bookish medicine, or accepting had cancer, or accepting to accord with HIV—all of those things accept fabricated me feel alienated. I like to do things that are out of the box.”

He has a angle in with the NIH to conduct the aboriginal American abstraction on the abiding furnishings of cross- hormones on boyish people. That affectionate of analysis is critical, aback protocols in the alpha acreage are still demography shape. For now, Garofalo’s treatments accept to be apparent as a aitionist anatomy of medical improvisation, and that scares some folks.

Over the accomplished two years, Garofalo has accustomed three pieces of abhorrence mail. One accepted that he “stop messing with God’s children.” Another—a abridgement about the clinic’s assignment with “No!” scribbled beyond it—was acquaint on the aperture of his Lake View condo. Added publicly, Laura Ingraham, a bourgeois radio auger from Connecticut, has alleged boyish hormone analysis “child abuse,” a angle that prompted Garofalo to pen a acknowledgment on the website Equality Matters: “Ms. Ingraham actual acutely has little abstraction what she is talking about.” Garofalo alike faced pushback from his own colleagues at the hospital aback he aboriginal campaigned to accessible a gender character clinic. “I got questions like, ‘Come on, how abounding kids could there be like that?’ ” he recalls.

“There are a lot of bodies who are compassionate, but in adjustment to do this assignment absolutely well, you additionally accept to be fearless,” says Johanna Olson, a doctor in boyish anesthetic who runs the gender character dispensary at Children’s Hospital Los Angeles and is an old acquaintance of Garofalo’s. “You accept to accept in your affection that the auto acquaintance is a animal acquaintance and that these bodies deserve to accept their needs met. Rob is one of those people.”

Like abounding transgender children, Diana has had a difficult time aback she was actual young. “I was absolutely lonely,” she says, blame her honey-blond-highlighted beard to one side. “I consistently acquainted different, but I didn’t apperceive absolutely why.” Diana, who lives with her mom and two brothers in a Portage Park accommodation (her parents are divorced), started transitioning socially in boilerplate school, alpha with renaming herself (“after Princess Diana”). She redecorated her allowance (more pink) and started bathrobe as a babe at school, including capacity her bra with C-cup silicone inserts she bought online for $60.

She was alienated at first. “Most bodies didn’t appetite to allocution to me,” she recalls. “Or they talked about me.” Transitioning at home wasn’t any easier. “My dad acquainted like he was accident a son,” she says quietly. Her mother, though, saw the bearings abundant differently: as an befalling to assuredly accept her child. “I met my babe at 10,” Lisa Salas says. “I ambition I had met her sooner.”

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For Salas, Garofalo’s dispensary offered advice in abyssal a apple that was a complete abstruseness to her. “I aloof didn’t apperceive area to start,” she says. “Raising a transgender kid is aloof . . . different.” Diana smiles aback asked about the Lurie staff. “They’re like my family,” she says. “Dr. Rob is like my cool uncle or something. I aloof feel absolutely adequate aback I’m there.”

Treating transgender kids agency authoritative abiding they get counseling. Garofalo has all his patients see a therapist (the dispensary has three on staff) and encourages ancestors associates to attend, too. Diana goes alert a month, accepting advice for all-overs and depression. She and her mother accept additionally been to a few of the annual boyhood nights that Lurie hosts to animate patients and parents to allotment their experiences.

In aerial school, Diana is accepted artlessly as a girl. She wears her beard continued and eyeliner blubbery and speaks quietly, usually in a falsetto. She loves to allocution about architecture and has a affection for delicate goth fashion. She hasn’t yet told any of her classmates that she’s transgender, and the anticipation of accomplishing so makes her uneasy. “I don’t appetite it to ascertain me,” she says, her articulation agreeable at the end of the sentence. “I’m afraid about added girls reacting weirdly and alleviative me different.” This prompts her to appraise an idea: “If I was built-in a girl, I would be actual different. I’d be, like, accepted and boys would like me and I’d accept a lot of friends. I assumption I’d aloof accept a acceptable personality.”

In this field, affinity is as important as science. And already you apperceive Garofalo’s backstory, what he has endured in his life, you activate to accept why he’s so acquisitive to advice these kids. In abounding ways, he’s a lot like them.

Raised in Parsippany, New Jersey, Garofalo was shaped, he says, by the Best Little Boy in the Apple syndrome. The phrase, coined by announcer Andrew Tobias in his 1973 autobiography, “refers to bodies who abound up closeted because they anticipate actuality gay is either base or adverse and atone by absolute in added ways,” explains Garofalo.

Garofalo accelerating fifth in his chic from Parsippany Aerial School, again went to Duke University, area he assuredly came to agreement with the actuality that he was gay. “It aloof array of happened,” he recalls. “It wasn’t article that I knew growing up. I consistently acquainted a little bit different, but I couldn’t accept said what that aberration meant.” He mostly kept his female clandestine throughout college, but by the time he got to medical school, at New York University, it was 1989, and the gay arena was exploding. “My aboriginal time at a gay bar was at this abode alleged Uncle Charlie’s—how tragically cliché—and I bethink activity in and attractive about and anon accepting nauseated. I ran alfresco and threw up.”

After commutual his abode at the Children’s Hospital of Philadelphia, he confused on to Harvard Medical School, area he accustomed a master’s amount in accessible bloom in 1999. At Harvard-affiliated Boston Children’s Hospital, area he was an accessory physician, he did a lot of beat to abandoned teens, abounding of whom were workers and at aerial accident of application HIV, teaching them about safe and how to administer the virus. Working at a abandoned clinic, he met his aboriginal transgender youth. “In walks this 15-year-old who wants me to accord her estrogen. And I was like, ‘Are you out of your mind?’ Nobody teaches you this bits in medical school.” He laughs. “I asked, ‘Who do you appetite to be aback you abound up? RuPaul?’ And she accomplished back, smacked me beyond the face, and said, ‘How cartel you. RuPaul is not transgender. He’s a annoyance queen. I appetite to be a nurse.’ And I was like, ‘Point consistently taken.’ ”

In 2001, Garofalo confused to Chicago (“for a man”) and landed positions at Lurie (then alleged Children’s Memorial Hospital) and Howard Brown, an LGBT nonprofit dispensary and bloom centermost based in Lake View. Hired as an accessory physician at Howard Brown, Garofalo was anon alleged administrator of adolescence services, again arch of analysis in 2006. (He larboard in 2011 afterwards a altercation with the CEO, but alternate aftermost year.) Then, aloof as his brilliant was ascent in the acreage of boyish medicine, his claimed activity fell apart.

Sitting on a charcoal-gray couch in his apartment, Garofalo leans adjoin a accumulation of pillows, his legs tucked below him. It was here, eight years ago, that he aggregate with a accumulation of accompany that he had renal corpuscle cancer. He affliction up accepting a allotment of one branch removed and is now in remission, but the bogeyman of the ache still hangs over him. “Every time article goes wrong, I affliction that the blight is back. That aloof doesn’t go away.”

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Neither does the agony of addition life-altering adventure that occurred two years afterwards the blight diagnosis. It was the bounce of 2009, and Garofalo was visiting Washington, D.C. Abounding of the specifics about what happened abide atramentous in his mind, but he believes he was benumbed and ually assaulted. That’s how he apprenticed HIV, he says.

He can’t accord an annual of the adventure afterwards breaking bottomward in tears. “My therapist consistently suggests aggravating to bethink the details. But I’m appealing blessed not remembering.” As he talks, he accouterment from ancillary to side, captivation his duke to his forehead like a affectation concealment his eyes from the light. “Anyone who sees me can acquaint that I accept been through some trauma. It’s obvious. Afterwards the blight and HIV diagnoses, I acquainted like one of those animation characters area a piano was activity to abatement from the sky and assimilate my head.”

For Garofalo, the healing is far from finished. “Sometimes I feel broken, and I’m not abiding I apperceive how to put those pieces aback together. I feel like all this [transgender work] is aggravating to ample gaps or adjustment wounds. But I’m not abiding they’re repairable.”

With that thought, Garofalo alcove for his dog, Fred, cradling him like a child. Best conversations with Garofalo eventually advance to Fred, whom he bought from a Missouri agriculturalist a year afterwards actuality diagnosed with HIV. In the contrarily minimalist apartment, a alternation of ample accurate portraits of buyer and pet boss the active room. “This fucking nine-pound Yorkie adored my life,” Garofalo says, abrading the dog’s stomach. “I could almost booty affliction of myself, let abandoned addition creature.” But that’s absolutely what Fred affected him to do. “I would deathwatch up every night agreeable from nightmares, and Fred would run beneath the bed in terror. I’d absorb hours aggravating to get him out. It didn’t amount how abundant bits I was activity through, I had to booty affliction of him—he bare me.”

In 2010, Garofalo got a alarm that afflicted the advance of his career. It was from a ambassador at The Dr. Oz Show. The amalgamated affairs was accomplishing a articulation on transgender youths and capital Garofalo on as a medical expert. He had aloof coauthored a study, adjourned by the Institute of Medicine, that had accustomed a lot of absorption for actuality one of the aboriginal across-the-board studies of the bloom of America’s LGBT community. “I anticipation I was activity on to allocution about transgender adolescents,” action Garofalo. “But I got there, and there were all these eight-year-olds active around. I had never been on civic television before, and kids that age were not my expertise!”

That hardly mattered. Anon afterwards his appearance, Garofalo was accepting calls from parents all over the United States who had apparent him on the actualization and capital a consultation. Admitting he had encountered transgender adolescence through his HIV work, he had no acquaintance allowance a boyish who capital to transition. “I was absolutely acquirements by the bench of my pants. I bethink accepting to go to textbooks to accomplish abiding I had assigned the adapted doses of medications.” The anamnesis makes him chuckle. “I had a mini agitation advance afterwards prescribing Lupron for the aboriginal time.”

But Garofalo did his appointment and over time got added adequate with the protocols for transgender youths. In the abatement of 2012, he went afore the Lurie administration aggregation to advance aperture a clinic. “If you accord me the blooming ablaze to do this now, we will consistently be leaders in the field,” he recalls saying. “And if you don’t, we’ll aloof be followers. And I’ve never been acceptable at actuality a follower.”

In the assay allowance at Lurie, Garofalo finishes walking Diana and her mother through the estrogen accord form. He speaks in a slow, abiding voice, pausing to ensure that both of them are processing what he says. Along with the accessible ancillary furnishings that Diana would welcome, including a higher-pitched articulation and tissue growth, appear those she wouldn’t: weight gain, affection swings, and an added accident of claret clots.

For Garofalo, though, the best important affair to abode is fertility. The estrogen will account Diana to stop breeding sperm, and no amount how abundant estrogen she takes, her anatomy will never aftermath eggs. “The bigger affair to anticipate about, which is a adamantine affair to do aback you’re a teenager,” he explains to mom and daughter, “is whether you appetite to accept a babyish someday.” Specifically, Diana has to adjudge now, afore her estrogen analysis starts, whether she wants to benumb her sperm.

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Diana doesn’t hesitate. “No,” she responds assertively.

But the weight of this accurate best hits her mother hard. “It makes me absolutely sad that she’s abandoned 15 and has to accomplish these decisions,” Salas says later. (Diana angry 15 in April, a ages afterwards her check-up with Garofalo.) “How do you decide? I don’t alike apperceive what to acquaint her. It’s angrily adamantine for me. Does she absolutely accept what the doctors are allurement her? It break my heart.”

In the United States, teenagers charge be 16 to drive, 18 to vote, and 21 to drink. Which raises the catechism of how able they are at 14 of barometer their approaching happiness. Both the Endocrine Association and the Apple Professional Association for Transgender Bloom acclaim cat-and-mouse until patients are 16 to activate them on cross- hormone treatment. But Garofalo and added doctors at the dispensary feel that is generally too backward and will alpha patients as boyish as 14 on hormones. Says Courtney Finlayson, an endocrinologist at Lurie who works with Garofalo’s patients: “Waiting until somebody is 16 to abet adolescence can be absolutely adamantine socially.”

And physically. Delaying adolescence too continued with Lupron can affect a teenager’s cartilage density. A child’s affairs of developing osteoporosis go up decidedly afterwards abundant testosterone or estrogen. And there’s addition reason, Garofalo argues, for transitioning kids early: “They can canyon better. That’s a big affair with bodies who alteration afterwards in life. Aboriginal interventions can advance to changes in the anatomy that are so acceptable that the achievement is these kids can be stealth in their identity.”

But is that abundant to absolve aboriginal medical intervention? “There are bodies aural the transgender association who are blame to do things alike added quickly. And patients are requesting irreversible treatments at boyish and boyish ages,” says Finlayson. “We’re walking this band in between. This is the beginning of medicine, and we can’t go too fast.”

That’s alike the case aback no medical treatments are involved. The Lurie dispensary uses comedy analysis to advice its youngest patients analyze new gender roles. But psychologists are disconnected about whether this is the adapted approach. One acumen is that studies accept apparent that in the case of accouchement boyish than 10 who analyze as transgender, 80 percent no best do so by the time they ability puberty. That’s why Kenneth Zucker, a Toronto-based boyish analyst and the arch of a admired gender character clinic, encourages parents to beacon kids that boyish against the analysis they were built-in with. Zucker’s adjustment has been alleged a “redirection approach,” the abstraction actuality that if you adviser a boyish to added gender-typical behavior, the animosity of affliction may blow over time.

Garofalo is analytical of that stance, arguing that preventing kids from advancing their gender inclinations can advance to added affliction for a accumulation whose suicide attack rate—41 percent for transgender bodies of all ages—is nine times the civic average. That doesn’t beggarly he has no doubts about his early-treatment approach, decidedly aback it comes to prescribing cross- hormones. “The pushback in my own apperception is my Hippocratic oath: ‘Do no harm.’ How can I apperceive that I’m accomplishing no abuse in the absence of accurate abstracts to abutment these interventions? I ambition we had ancestors of outcomes analysis to abatement aback on, but adapted now we don’t. We ask these families questions that they can’t absolutely apperceive the acknowledgment to. No one can.”

The actuality that addition is alike allurement them these questions is arresting accustomed that clinics like Garofalo’s did not abide 10 years ago. Low-income families, in particular, had bound options. Those kids ability end up self-­medicating with hormones bought off the atramentous market, out of ability of regulators. Transgender treatments aren’t cheap—Lupron, for example, costs $8,500 to $18,000 a year—but Garofalo works with his patients, including those on Medicaid, to advice get allowance companies to awning the medications. “Nearly every accommodating who comes through the aperture gets a abnegation initially from their insurance,” says Ginny Scheffler, the clinic’s nurse, who spends a acceptable bit of her time autograph appeals on account of patients. But alike those afterwards advantage can get analysis at Lurie acknowledgment to clandestine donations, including one from the Chicago transgender filmmaker Lana Wachowski of The Matrix fame.

The hashtag #translivesmatter afire beyond amusing media in February. The affect was a reaction, in part, to three incidents: the murders of two transgender women, Penny Proud in New Orleans and Bri Golec in Akron, Ohio, and the suicide of the Ohio boyhood Leelah Alcorn, whose parents banned to accede her transgender identity. In a agenda larboard on Tumblr anon afore she absolved in advanced of a affective truck, the 17-year-old abundant the affliction she had been feeling.

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Her death, in particular, apparitional Garofalo, and in March he wrote an op-ed about it for The Huffington Post: “Among all of this loss, it is the Leelah Alcorn case . . . that I cannot assume to agitate from my arch as a pediatrician. . . . Re-read some of her amusing media posts afore she took her life, ‘I can’t delay until I am 18 to activate transitioning,’ and ‘I can’t delay one added day.’ These posts point to her disability to admission adapted healthcare as a abeyant actual bottomward agency in her death. . . . For transgender youth, admission to bloom affliction casework saves lives.”

“Patients are requesting irreversible treatments at boyish and boyish ages,” says a doctor at the clinic. “This is the beginning of medicine, and we can’t go too fast.”

Those words arena accurate to Kyle Catrambone. Kyle, whose ancestors lives in Oak Park, started seeing Garofalo in 2013 aback he was 12. Kyle was built-in Isabella but never acquainted adequate as a girl. “I hated my hair, I hated my skin, and I absolutely hated cutting dresses,” he says. Now 14 and a apprentice at Oak Park and River Forest Aerial School, he has been on testosterone aback October. His articulation has deepened, and he has absent the adequateness in his hips, attempt up several inches, and started growing some facial beard about his chin. But it’s the transformation in his affecting bloom that has been best remarkable, says his mother.

“When Kyle was in fifth grade, he was suicidal,” Evaleen Catrambone says. “He was on the couch for three months straight, and the anticipation of academy put him into a ball. Dr. Rob helped us accept what was activity on with him. He was a godsend.”

The acquirements ambit for both Kyle and his mother has been steep. Catrambone rattles off a continued account of items that she’s gotten an apprenticeship on over the accomplished few years: a accessory that allows Kyle to pee while standing, which he uses to advice him alloy in; acutely bound nylon anchor that Kyle uses to abbreviate his s; and top surgery, a $6,000 bifold mastectomy that Kyle wants to get this summer. But award a surgeon who will accomplish that action on a 14-year-old has accepted difficult. Garofalo has had patients as boyish as 15 abide top surgery, but so far, none of the bounded surgeons Kyle has approached accept been accommodating to accomplish on him. “Being so young, I anticipate bodies are afraid that I’ll affliction it later,” he says.

Performing such a aitionist anaplasty on addition that age may assume extreme. But for Kyle, it’s artlessly the analytic aing step—and in his mind, the eventually he gets it, the better. “The affliction allotment of accepting dressed adapted now is attractive bottomward and seeing article that shouldn’t be there,” he says. “After surgery, I’ll assuredly be able to booty my shirt off and not accept to adumbrate in the bend of the locker room. I’ll go pond afterwards my shirt. I’ll be able to alive the activity I’ve consistently capital to live.”

Kyle’s conundrum—that he knows what he wants but hasn’t begin anyone who will accord it to him, at atomic not at his age—speaks to the inherent complexities of alleviative transgender kids. “I acclimated to antic that I accept bristles years in me,” says Garofalo. “This is backbreaking work. It’s complex, and it’s not easy. And sometimes I affliction that the science is backward abaft the field.”

Even already the absolute analysis has been conducted and the treatments perfected, the assignment of leading-edge doctors like Garofalo will abide abounding with questions that accept no simple answers.

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