Waking up with a headache – kinda sucks.
Waking up with a flat chest – priceless.

Liam Kai, eighteen years old and just graduated from high school in a town near Ann Arbor, Michigan, tweeted these words on 18 June 2014. It was nine days after his breast surgery and the day after he had had the dressings and drains removed. On the same day he also posted a video on Instagram in which we watch the doctor unwrapping his bandages: Liam looks down over his newly boyish chest and whoops, ‘Dude!’ In a few weeks he will begin injecting the testosterone that will – finally – vault him out of the purgatory of an extended androgynous childhood into the manhood of body hair and a deep voice.

Liam was born female, adopted from China at six months and named Lucy by his American mothers. Always a tomboy, he had in fact been living as a boy since the age of thirteen, binding his growing breasts in constricting nylon vests. ‘I’m thanking whatever force out there that this is my last week having to bind,’ he tweeted before his surgery. ‘It’s painful, embarrassing, frustrating, and tiring.’

Shortly before Liam’s surgery, Time magazine had identified a moment in American culture by putting the glamorous transgender actress Laverne Cox, star of Orange Is the New Black, on its cover beneath the title ‘The Transgender Tipping Point’. President Barack Obama has made a point of including transgender children in his annual Easter Egg Roll, Barbara Walters has featured them on television, there are special summer camps for them and some authorities – most notably, New York City – have told schools to accept children in their ‘affirmed’ genders.

Until his eighteenth birthday, though, Liam could do nothing medically to assist his gender transition process. This is because his legal parents, a lesbian couple who had split when he was six, disagreed over the issue. After a somewhat rocky beginning his mother Beth, with whom he lives, has accepted Liam’s transgender identity: ‘I see the procedure as the plastic surgery my son needs to have rather than the double mastectomy my daughter needs to have,’ she told me just before Liam’s ‘top surgery’, as it is known in the trans lexicon. But the other parent, with whom Liam has broken entirely, vehemently policed his gender expression during his childhood: she insisted he wear dresses and grow his hair long, and that he would be much healthier and happier if he just accepted himself as female. Using court orders, she effectively withheld consent for any medical treatment while he was still a minor.

Beth has been with her current partner Andrea for more than twelve years and they have raised Liam together; he addresses them collectively as ‘moms’ (often with mock exasperation: Mo-oms!?!) and likes to call himself, on Facebook, ‘a mommas’ boy (get the plural?)’. There has been something redemptive, even victorious, for all of them in the moment of the surgery, not just in the way they believe it will make Liam’s life better, but in the physical, irrevocable marking of what they all believe to be true: he is a man.

Beth and Andrea agreed to pay for Liam’s first tattoo as a gift for his eighteenth birthday. Like muscles, tattoos are fetishes of masculinity, and Liam had been craving both for years. He had been particularly close to Beth’s father, a Midwestern farmer who died shortly after he transitioned and who, after a brief struggle with the fact that his granddaughter was now a grandson, had said, simply, to his daughter, ‘You have a very good son. He’s just good.’ Liam chose these words for his tattoo: ‘He’s just good’ is inked on the inside of his right upper arm.

‘Guys work out, they get those tattoos, they get those biceps,’ Liam said to me. ‘They have to work their asses off for those surgeries and hormones. They create the person that they always knew they were, and take pride in it.’ There was a phrase for this that Liam had found on the Internet, and liked: ‘self-made men’.

The United States is, after all, the place that defined and perfected reinvention, a place founded on the very notion of ‘transition’: across the Atlantic to a new world and (after many decades, in the case of slaves) a newly unfettered identity. America is a society that promises a transition across class if you work hard enough, and then another to happiness with the commodities you can subsequently buy, including cosmetic surgery – most of which is a form of gender enhancement anyway. It is also the society that pioneered identity politics and the idea that ‘the personal is the political’: the women’s movement, the gay rights movement and now the transgender movement, with its attendant social revolution in how to deal with gender-nonconforming children.

The term ‘self-made men’ was, in fact, appropriated to describe transgender men by the sociologist Henry Rubin, and he meant it to hold a double entrendre. Gender transition is not just an act of personal will and creativity, the phrase suggests, but also a conforming of your outer shell to your inner ‘true self ’. If you are ‘self-made’ you are made by your true ‘self’ rather than by your external characteristics. In most people, internal and external happily conform, but in some they do not, and for such people, gender transition brings them together, makes them whole.

The British travel writer Jan Morris began her 1974 book Conundrum, famously, with the line: ‘I was three or perhaps four years old when I realized that I had been born into the wrong body, and should really be a girl.’ The early age of her awareness was not unusual: in 2009, just over half of the adult transgender participants in an online survey in Britain said they knew they were ‘in the wrong body’ by the time they were six. Like almost all transgender people of her generation, Morris suffered a deeply anguished adolescence and early adulthood, and finally had sex-reassignment surgery in her forties. She was lucky to make it: the statistics show that transgender people are dramatically more vulnerable to depression, suicide, self-harm, HIV infection and physical violence than the rest of the population.

Today, medication that delays puberty means that boys who believe they are girls can be raised as girls, and vice versa, without having to endure adolescence. They can begin taking cross-sex hormones and transition straight into adulthood in their ‘affirmed’ genders, without, in the case of transgender men, having to submit to a mastectomy, because their breasts would not have grown in the first place.

The use of puberty blockers was pioneered a decade ago in the Netherlands; the ‘Dutch protocols’, as they are known, stipulate that minors should only be allowed to start cross-sex hormones later in adolescence. The initial idea behind the treatment is that it buys time, until children are older and able to make more mature decisions about their gender identity. According to the Dutch tracer research, not one of the initial patients who subsequently transitioned had any regret about doing so, and the cohort reflects the psychological health of the normative population.

Still, most Western European countries do not permit medical gender transition before adolescence, and some states use their nationalized health plans assiduously to regulate the body. The response to this, on the other side of the Atlantic, is increasingly: Why wait? ‘It would be cruel to deny him testosterone,’ one mother said to me of her thirteen-year-old transgender son. ‘I know he’s a boy. He knows he’s a boy. Why not let him have male puberty along with everyone else, rather than keeping him back, thereby adding to his already considerable social problems?’

Given both privatized health care and a culture of interventionist parenting in the United States, market forces prevail. What this means is that medical gender transition is, generally, out of reach for poorer people (the hormones are cheap, but the puberty blockers cost over 4500 a month, and are not covered by insurance). But if you have the resources and the will, you can now make it happen for your children. ‘The parents are driving this,’ Dr Herb Schreier, a psychiatrist at UCSF Benioff Children’s Hospital in Oakland, California, told me. ‘They’re way ahead of the medical profession. They’re challenging us.’

Previously, an approach drawn from psychoanalytic theory prevailed: girls, it was believed, might wish to become male because they saw their mothers as disempowered; more commonly, boys might wish to become female to draw detached mothers closer to them, or to meet these mothers’ narcissistic needs. The primary advocate of this approach, the psychologist Kenneth J. Zucker, insists that the idea of transgenderism as a natal condition is ‘simple-minded biological reductionism’, and there is certainly enough evidence to implicate family and social origins in some cases.

But there is a growing body of research that suggests that hormonal intrauterine imbalances may play a role too. And the resistance to the psychoanalytic approach comes not so much from its diagnostic theory as from its cure: an often severe form of reparative therapy that seems increasingly like a form of child abuse, given its denial of the child’s reality. The sea change among parents, says Herb Schreier, is the consequence of a refusal to pathologize families. ‘This idea of blaming mothers – in the way “refrigerator moms” were once blamed for autism – and then enforcing a draconian approach, it just isn’t going to wash any more. Parents have rebelled. They have said, “You’re not going to label my kid as disturbed. This is the natural form of things for my child.”’

Then again, asks the child psychologist Avgi Saketopoulou, ‘how are we to know when gender acts as proxy for psychopathology?’ She identifies a gap, in the current culture, between the old way – which pathologized transgender identities – and the new wave of political transgender activism, which ‘fails to inquire about gender’s psychic meanings’.

Professionals in the field use language such as ‘sea change’, or ‘explosion’, to describe the number of families presenting with transgender children. This is not only because of new medical treatments, such as puberty blockers, but also because of the dramatic new access to information that parents and children now have. Liam first thought about being transgender when he watched The L Word, the American TV series. He heard Max, the trans character, talk about ‘binders’, punched the word into Google, and he was off. Later, he researched surgery options by watching graphic videos on YouTube.

Diane Ehrensaft, based in the Bay Area, where she co-runs the UCSF Benioff Child and Adolescent Gender Center Clinic, has become the country’s pre-eminent child psychologist in the field. ‘One of our biggest challenges is putting the brakes on,’ she told me. ‘Parents are anxious, they can’t get their kids in focus. They come in and say, “If my child is transgender I’m OK with it, but how can I tell?”’ Ehrensaft often advises parents that they need to learn to live with the ambiguity for a while, until things become clearer. The evidence, she says, is that ‘most gender-nonconforming children are not transgender but either “proto-gay”, or simply exploring new options for “doing” their gender.’ She makes a careful distinction between two types of children: those who articulate their sense that they are the opposite gender from the moment they can talk, and those who are ‘gender-creative’ and might grow up to be gay or lesbian. ‘For our youngest transgender children, we usually can tell quite early, although not always in one moment in time. But when we do know, we should let them fly.’

When Ehrensaft was a student in the late 1960s – at the University of Michigan, in Ann Arbor – she found her own identity through the women’s movement. She became part of a generation that urged men and women to think beyond the blue blanket–pink blanket stereotypes. You could be a boy and play with dolls: this would teach you to grow up and be a nurturing father. You could be a girl and play with mechanical trains: this would prepare you to be a professional woman. ‘We challenged gender expression,’ Ehrensaft says, ‘but gender identity – who you are – remains unassailable, for all but the most open parents. Now parents are struggling with the possibility that their boy who plays with dolls might be a girl, or their tomboy daughter might be a boy.’

The newly revised American diagnostic manual requires at least six of the following symptoms to be met for a diagnosis of gender dysphoria in a child: a repeated insistence that he or she is the other sex; a preference for cross-dressing; persistent preferences for cross-sex roles in make-believe play; a strong rejection of toys or games stereotypically played by one’s sex; an intense desire to participate in the stereotypical games and pastimes of the other sex; a strong preference for playmates of the other sex; a strong dislike of one’s sexual anatomy; and a strong desire for the sexual anatomy of the other sex. The shift of name from ‘gender identity disorder’ to ‘gender dysphoria’ was part of a process of removing judgement from the diagnosis, but Schreier and Ehrensaft belong to a network of professionals working to de-pathologize the condition entirely. Nonetheless, they believe in the necessity and importance of early-transition protocols, and in applying diagnostic criteria, which they paraphrase as ‘Persistence, Consistency, Insistence’.

The decisions are not easy ones to make, says Joel Baum, who runs an educational and advocacy organization called Gender Spectrum. ‘But if you have these treatments available, and you have a desperate kid in front of you who is clearly in distress you have to remember your medical oath: “Do no harm.” In such instances, this means assisting them to transition, rather than standing by and watching them spiral into depression, self-harm or even suicidality.’

It is an approach that meets with significant resistance from professionals who feel that pre-adolescent children are too young to understand gender, and that adults have no right to make such decisions for them – particularly given that cross-sex hormones render their patients permanently infertile. But Baum has a different way of understanding children’s rights: ‘The idea that “children should be seen and not heard” doesn’t hold any more. So when we start asking children, “Who are you?”, they tell us. It is our responsibility to listen to them.’

Baum’s statement raises a question that is one of the biggest of the current transgender moment. Have there always been transgender people and, if so, has our society not, until now, had ears well tuned enough to hear them, brains big enough to understand them? Or has the confluence of medical technology and human rights discourse created a category that did not previously exist, but into which people who might previously have struggled with gender-nonconformity can now find their place?

I am a South African man who came out as gay in the early 1980s while an undergraduate at Yale. I was a direct beneficiary of American-style identity politics. As a child in my first year at primary school in Johannesburg, where the boys and girls were separated at break time, I struggled to compete physically with boys and usually found myself playing alone. On one particular day I must have been lingering around the runnel of sorts that formed the boundary between the two sides of the playground – my reverie might have even carried me across the boundary – when a teacher pounced, and gave me a firm lecture about where I belonged. I learned a valuable lesson: if I was going to fit in, I needed to appear to accept the boundaries set for me. Transgressions had to be underground or in the ether, beyond the patrol of adults.

But what if, as a little boy, I had been time-ported to the Bay Area in the 2010s, and had landed up in Diane Ehrensaft’s consulting room because of repeated runnel-transgression? Would I have been turned into a little girl because I harboured fantasies involving my mother’s wardrobe and didn’t like the rough play of boys? Or would I have been told it was OK to be ‘gender-creative’ and developed a whole new identity beyond the gender binary? What would I have become?

When I told Ehrensaft that such thoughts made me panicky, she nodded. ‘I think you’re relieved that you grew up in simpler times because you knew who you were. If, somewhere in your consciousness, you had been conflicted or ambivalent, you might feel differently now.’ Still, she said, ‘I have to ask, are we overwhelming the kids in any way with all these extended possibilities? It’s a lot easier to walk around in a box than to have no boundaries.’

I started to wonder about my own gender, and the paths not taken. To the extent that I had been somewhat effeminate as a boy, was it because I was attracted to other boys, and therefore thought I needed to be girlish to get their attention? Or did I become ‘gay’ – a tribal identity that has never seemed quite adequate – because I needed to belong somewhere, and heterosexual masculinity was not quite capacious enough? I never thought I was a girl, but there were certainly times – imagining myself in the arms of a pimpled Lothario rather than having to pass a ball to him – when I wished I were one. What if it had been OK to cross over that runnel, or even dwell in its ambiguity, turning that seemingly impenetrable border between the genders into a borderland that could hold me?