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But Selva had never recommended a 15-year-old for surgery. The Endocrine Society's guidelines suggested waiting until a patient was 18. But Selva and other doctors had started to think allowing teenagers to have chest surgery earlier was OK. He tried to make his handwriting sloppier like a guy's. She believed affirming a child's gender identity could save their life. "Let me think about it." Jay spent the summer fine-tuning himself.When someone answered, Nancy unleashed years of frustration. " Jay is a boy, Nancy told the insurance worker, just like any other. Parents packed school board meetings and begged officials across the country to keep boys like Jay out of locker rooms. They fought one afternoon over text, and that was it. "If anybody can say no, it's going to be me because I gave birth to him," she told the woman who answered. I couldn't even sleep at night -- he was kicking me. Every woman dreams of seeing their daughter marry in a church with a white dress. He stood in front of his closet before school and worried his 2Pac T-shirt revealed too much. At Jay's school in Vancouver, Washington, the principal knew at least half a dozen kids whose gender identities and anatomies didn't match. She performed top surgery an average of three times a week, but only on adults. He went that August, but that psychiatrist agreed with Tobin - no surgery until Jay made friends.

Seventeen million people tuned in the night Caitlyn Jenner came out on national TV as a transgender woman. He hadn't told many friends that he was transgender, too. "I have more important things to do than watch someone who's rich and has their life figured out," Nancy Munoz said. For the first time in years, he volunteered to accompany his mom to Win Co for groceries. He bandaged his A-cup breasts so tight that he breathed in bursts. His long lashes froze as the patient made her way to the parking lot. If Thakar removed Jay's breasts at 15, she likely would have to perform a revision surgery later. A friend had nominated Jay for the court, and he had scored enough votes to make it. As they left the pediatrician's office, Nancy told Jay he needed a haircut.

"I'm thinking about top surgery." Nancy had struggled at first to accept that her oldest daughter was a boy. One syringe, two needles and a small vial of testosterone. The surgeon was willing to meet him to decide if she did, too. They stopped for coffee, then strode into the licensing office all smiles. She needed to talk to someone who could be discreet, she explained. He needed to apply for a gender change through the department's headquarters. "I scanned in his old ID, the application from the health department, the mental health professional's letter." The worker was friendly but hamstrung by bureaucracy. Selva suggested Jay discuss surgery with Valerie Tobin, the clinic's psychiatric mental health nurse practitioner. Others had bigger issues that needed to be treated before surgery. Even anesthesia could induce a depressive episode, and Jay's mental health history suggested he was more at risk. "It's just going through another puberty," Jay told him. Later, at home, Jay told his mom the trip had gone well. When they went to the mall, they spent hours browsing. That Thanksgiving, he saw a picture Maddie's mom posted on Facebook. When the Medicaid letter arrived a week before Christmas, Jay texted Maddie first.

"That's who I am." It'd be easier to be open, Jay thought, if his body looked more like he wanted. "I've been on testosterone a while," Jay told his mom in April. He picked up the supplies at the Fred Meyer pharmacy, then laid them on the kitchen table. She and his counselor both believed Jay should have the surgery. "We're dealing with transgender." The receptionist lowered her voice to a nearly inaudible level, then disappeared. Jay had a state identification card from childhood that listed him as a girl, she explained. A counselor, a doctor and a surgeon had all agreed he was ready. "You have to go to 100 different doctors and explain to them 100 different times in 100 different ways," he complained. Together, they had treated more than 150 young people. Surgery would be emotional and painful in ways Jay couldn't yet comprehend. He had tried beard oil to thicken his facial hair and took a daily dose of men's vitamins. Jay scanned the crowd as they walked, hoping no one could hear their conversation. "Expect your emotions to run crazy, but it settles down." They tried talking about music and dating, but those conversations fizzled, too. His friend was pansexual with plenty of boyfriends and girlfriends. "The only thing we have in common is the fact that we're trans," Jay said.

They captured him in scoop-neck T-shirts in fifth grade, with long hair in eighth. Nancy didn't want to make him wait to live like a regular teenager. Jay believed the winding path would end his depression, so Nancy kept driving, missing turns and backtracking until they found it, a nondescript Beaverton clinic for young transgender patients. "If I start bleeding out, you guys are going to witness that," he told 10-year-old Angie and 12-year-old Maria. He stuck it into the vial and drew out the hormone. His sisters moved to the couch and peered over the back. Maria clutched a gallon-size freezer bag of bandages. As long as a doctor consented, Jay could have any surgery, including an abortion or a heart bypass, without his mom's permission. State law prevented him from getting a tattoo or piercing his nipples. " He laughed and stared at the tiny miracle his mother had pulled off. Other times, she thought it was best to treat the depression first. Teenagers needed to learn how to form relationships, mess up and apologize. ' You have to be very selective of who you are opening yourself to." "I told her I'm not very confident about my body," Jay said. But Jay wanted a friend who liked the same things he did.

She still kept a few photos hanging on the wall that showed the kid Jay used to be. But they had traveled the horseshoe route from one suburb to the other for an hour already, and Jay was sure they were lost again. Nancy cursed Portland, its city traffic and confusing interstates. His mother was at work, so he called his younger sisters to the living room to watch. Jay shook his head no and studied the inch-long needle. Oregon is one of only three states that gives 15-year-olds the power to make their own medical decisions. Tobin had worked with transgender children for more than a decade. Sometimes, a kid was so depressed that Tobin believed hormones or surgery were the only fix. Tobin thought Jay needed an ongoing relationship with a therapist who knew what to expect. Making friends was a vital part of adolescent development. Eventually, their conversation turned to the one thing they had in common. It was the first time he'd ever hung out with another transgender person. They hadn't talked in nine months, but he regretted how mean he had been to her. The photo showed all of Maddie's Christmas presents perfectly wrapped. His psychiatrist thought he was ready and had sent in the final recommendation Jay needed.

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