It is estimated that as many as 1% of American adolescents have a gender identity that is not congruent with their sex assigned at birth.1 Guidelines developed in the Netherlands and then adopted throughout the world allow clinicians to prevent physical changes of puberty with the use of gonadotropin-releasing hormone analogs (GnRHa) when the first signs of puberty have manifested, a point at which the patient’s dysphoria surrounding gender often intensifies. This may be followed with exogenous testosterone or estrogen therapy at ages as young as 14 years, but more typically at approximately 16 years of age, to more closely align the adolescent’s body with their inner sense of their gender.2,3