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The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a miswiring of the brain or by genetic coding?

Has the Internet liberated teenagers like Kat from a narrow view of how they should live their life, or has it seduced them by offering them, for the first time, an answer to their self-searching, an answer they might later choose to reject?

Some experts argue that the earlier the decision is made, the more treacherous, because it is impossible to predict which children will grow up to be transgender and which will not.

Jack Drescher , a New York City psychiatrist and psychoanalyst who helped develop the latest diagnostic criteria for gender dysphoria.

On the other hand, Dr. As a child, she dressed in jeans and shirts, like all the other boys, and her best friend was a boy.

She liked to play with cars and slash bad guys in the Legend of Zelda video games. She still shuns dresses, preferring skinny jeans and band T-shirts.

But as a freshman in high school in Cazenovia, N. I was uncomfortable with my body, my voice, and I just felt like I was really a girl.

When she discovered the transgender world on the Internet, she had a flash of recognition. But inside, Gail Boone was terrified.

She had wondered if her son was gay, and that, she says, would have been easier to deal with than a child who wanted to be the opposite sex.

Gail Boone had a background in psychology, which helped her understand. Boone, an operations and project manager, had a harder time, but was brought around for the sake of his child.

At 16 and a half, after seeing a therapist, Kat began taking estrogen and a blood pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female.

In the fall of junior year, she showed up at school wanting to be called Katherine, or Kat, because she likes cats. She does not want anything to do with her birth name, Caden.

She also has discovered that she likes girls. It was the cutting that convinced them that if she could not live as a girl, Kat would kill herself.

She still has two angry scars on her left forearm. Boone said. Part of what brought her father around was the support network that has sprung up around transgender issues.

It is not easy to find. Visitors have to be buzzed in through an unmarked back door in a shabby neighborhood. But inside, it is homey, with a well-appointed library, a kitchen and a meeting room outfitted with beanbag chairs.

A meeting of teenagers in April began with each one declaring a name and pronoun of the day. Their choices were not always intuitively obvious.

But there were hints of the pain the children had to endure. One child was required to use a separate bathroom at school, and a hidden camera was later found there.

Kat told the group that she was looking forward to surgery in six days. They clapped. But the drive to treat children is relatively new.

One of the first and biggest hormone programs for young teenagers in the United States is led by a Harvard-affiliated pediatric endocrinologist, Dr.

Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.

The puberty-blocking protocol gained legitimacy in , when it was endorsed by the Endocrine Society, the leading association of hormone experts, on the recommendation of a task force including Dr.

The protocol calls for administering puberty-blocking drugs, generally Lupron, an injection, or histrelin, an implant, that are normally used to treat precocious puberty as well as prostate cancer and endometriosis, abnormal growth of uterine tissue.

The theory is that this drug-induced lull from about 12 to 16, sometimes younger, will help teenagers decide if they truly are transgender, without committing to irreversible physical changes.

Puberty blockers are reversible. If a psychological evaluation confirms gender dysphoria, teenagers are treated with cross-sex hormones estrogen for boys, testosterone for girls , so they will, in effect, go through opposite-sex puberty.

A consequence of going through the whole protocol is infertility. Spack said his clinic had treated about children since , and less than 20 percent had been covered by insurance.

Doctors say that if children are started on puberty blockers young enough, insurance is less likely to question it. While hormones for minors are sometimes covered by insurance, surgery almost never is.

But several doctors said they had performed surgery on minors. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.

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She lost weight from her already frail frame. She did not seem empowered; she seemed regressed. Emma is her black and white cat, at home outside Syracuse, N.

Her childlike reaction was, perhaps, not surprising. Kat, whose side-parted hair was dyed fire engine red, is just 18, and about to graduate from high school.

It is a transgender moment. They are characters in popular TV shows. By Anemona Hartocollis. In a cozy cottage decorated with butterflies to symbolize transformation, Katherine Boone was recovering in April from the operation that had changed her, in the most intimate part of her body, from a biological male into a female.

She retched for days afterward. She could hardly eat. Emma is her black and white cat, at her home outside Syracuse in central New York State, miles away.

Kat, whose side-parted hair was dyed a sassy red, is just 18, and about to graduate from high school. They are characters in popular television shows.

With growing tolerance, the question is no longer whether gender reassignment is an option but rather how young should it begin.

No law prohibits minors from receiving sex-change hormones or even surgery, but insurers, both private and public, have generally refused to extend coverage for these procedures to those under But the number of teenagers going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners.

Now advocates like Empire State Pride Agenda are fighting for coverage at an earlier age, beginning with hormone blockers at the onset of puberty, saying it is more seamless for a teenage boy to transition to becoming an adult woman, for example, if he does not first become a full-bodied man.

Irene Sills, an endocrinologist who just retired from a busy practice in the Syracuse area treating transgender children, including Kat.

Given that there are no proven biological markers for what is known as gender dysphoria , however, there is no consensus in the medical community on the central question: whether teenagers, habitually trying on new identities and not known for foresight, should be granted an irreversible physical fix for what is still considered a psychological condition.

The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a miswiring of the brain or by genetic coding? Has the Internet liberated teenagers like Kat from a narrow view of how they should live their life, or has it seduced them by offering them, for the first time, an answer to their self-searching, an answer they might later choose to reject?

Some experts argue that the earlier the decision is made, the more treacherous, because it is impossible to predict which children will grow up to be transgender and which will not.

Jack Drescher , a New York City psychiatrist and psychoanalyst who helped develop the latest diagnostic criteria for gender dysphoria.

On the other hand, Dr. As a child, she dressed in jeans and shirts, like all the other boys, and her best friend was a boy.

She liked to play with cars and slash bad guys in the Legend of Zelda video games. She still shuns dresses, preferring skinny jeans and band T-shirts.

But as a freshman in high school in Cazenovia, N. I was uncomfortable with my body, my voice, and I just felt like I was really a girl. When she discovered the transgender world on the Internet, she had a flash of recognition.

But inside, Gail Boone was terrified. She had wondered if her son was gay, and that, she says, would have been easier to deal with than a child who wanted to be the opposite sex.

Gail Boone had a background in psychology, which helped her understand. Boone, an operations and project manager, had a harder time, but was brought around for the sake of his child.

At 16 and a half, after seeing a therapist, Kat began taking estrogen and a blood pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female.

In the fall of junior year, she showed up at school wanting to be called Katherine, or Kat, because she likes cats. She does not want anything to do with her birth name, Caden.

She also has discovered that she likes girls. It was the cutting that convinced them that if she could not live as a girl, Kat would kill herself.

She still has two angry scars on her left forearm. Boone said. Part of what brought her father around was the support network that has sprung up around transgender issues.

It is not easy to find. Visitors have to be buzzed in through an unmarked back door in a shabby neighborhood.

But inside, it is homey, with a well-appointed library, a kitchen and a meeting room outfitted with beanbag chairs. A meeting of teenagers in April began with each one declaring a name and pronoun of the day.

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