For Mason Pekarovich, a 20-year-old Andover native, it was a lifetime of discomfort, culminating in the unshakable idea that being born a boy would have been better.
For Renee Manning, a 55-year-old Andover resident, it was a 1973 episode of the TV series “Medical Center,” in which Robert Reed portrayed a transgender doctor – a man becoming a woman.
For Zachary Kerr, a 21-year-old Wheelock College student from Methuen, it was the question, "What do you want to be when you grow up?" The answer was always "a boy."
Dr. Francie Mandel, director of mental health services at the Gender Management Services clinic at Boston Children's Hospital, said many of her patients have been crystal-clear as far back as they can remember that while they were born one gender, they're supposed to be the opposite.
Other people have more trouble pinpointing their gender identity issue until something helps them grasp it. It could be a handout in health class, a celebrity interview, or even a first encounter with the word “transgender.”
"Sometimes we have teens who say, 'I felt like something was wrong, but I didn’t know what,'" Mandel said. "'I knew that something was going on, but I didn’t have the words for it.'"
Recent widespread media coverage of Bruce Jenner's transformation into Caitlyn has drawn more young people and their families to the Boston clinic, Mandel said.
"We’re seeing people having a lot more permission to express what makes the most sense for them, rather than falling into definite, traditional (gender norms)," she explained.
The path to self-expression, however, is not always easy or clear.
The First Step
Until he began his transition from female to male, Pekarovich was depressed, at times suicidal, but blamed his turbulent home life.
At a young age, he had no way of understanding the concept of being transgender.
"Looking back at my childhood, I can see that I was trying to live as a female and that wasn't working," Pekarovich said.
Following his high school graduation, Pekarovich said he began to confront his feelings rather than shying away from them. With the support of his father and girlfriend, he began to speak to his therapist about transitioning from female to male.
Mandel has been with the GeMS clinic in Boston since it launched in 2007. She estimates she has met with about 900 children with gender identity issues and their families. Only about a third of them continued with the program after the initial consultation, she said.
Before a transgender child can begin medical treatment, Mandel's team conducts a long series of mental health evaluations. The child must meet with a specialized therapist for three to six months. Often, that goes hand-in-hand with a "social transition," in which a child may begin to dress differently and select a new name.
Most of the time, children must wait until they near the age of puberty to make permanent changes to their body.
Though the wait to receive treatments like hormone therapy is often frustrating for transgender youths, psychological testing is crucial to prepare for medical intervention, Mandel said.
Pekoravich saw a Tewksbury therapist for months before he was approved for hormone therapy with an endocrinologist. He began testosterone treatments about a year ago.
"(The endocrinologist) had to know that ... I understood the risks, that hormones create permanent changes in the body," he said. "Of course it was challenging because, say I came out (as transgender) on a Thursday — all I wanted was to wake up on Friday as a boy."
Kerr, who has been honored by Nickelodeon and Out Magazine for his work as an advocate for transgender youth, said waiting to find out whether his therapist had signed off on hormone treatments was the "scariest thing that I have ever experienced."
Born as one of a set of triplet girls, he felt like he had to convince his doctors that he was a boy, and would select masculine outfits weeks in advance of his appointments.
"I knew who I was ... and there was always that fear that someone would say, ‘No. that’s not who you are,'" he said.
Manning, who lived as a man until the age of 49, said she is glad transgender young people today can be prescribed puberty-blocking hormones, preventing them from developing as a gender they don't want to be.
"What was really tough when I first transitioned was you have this air of paranoia that you won't pass (as a woman)," Manning said. "You think everyone is looking at you."
Until she found a supportive community of parishioners at South Church in Andover, an open and affirming congregational church, Manning said she was afraid of entering new situations where she might be faced with explaining her story.
Even in familiar circles, transitioning was a struggle, she said. Her transition ended her first marriage, though she has since remarried. She was afraid of her parents' reaction, until an afternoon on Cape Cod when her mother saw Manning in women's clothes for the first time.
"She said, 'You're so pretty,'" Manning said. "I wasn't expecting that."
Manning said she admires Caitlyn Jenner for starting a widespread conversation about transgender people in a society where they are often overlooked. But Manning said Jenner's speedy transformation into a woman is not realistic for many transgender people. Dealing with insurance companies and finding ways to pay for treatments and procedures can be a huge burden, she said.
"To see this overwhelming acceptance (of Jenner) brought on a huge tinge of jealousy to see what you can do if you have a million dollars," Manning said.
Still, she said she "cried like a baby" watching Jenner's interview with Diane Sawyer on ABC's "20/20," because she related to Jenner's story in a way that she has related to little else on television.
As her confidence grows, Manning said she feels compelled to reach out to other transgender people, particularly those having a hard time transitioning. She said she has exchanged phone numbers and tearful stories with at least 30 people, reassuring them they are not alone.
Pekarovich returned to Andover High School this year to speak to health classes about his transition, hoping to educate students about the appropriate way to talk about transgender issues. Sometimes his peers ask offensive questions without even realizing they are being rude, Pekarovich said.
Through the Massachusetts Safe Schools Program, Kerr has done similar work on a larger scale, speaking at hundreds of schools. He hopes to pursue a career as a social worker.
All three of these people say the same thing: They feel they are meant to help others.
"I need to be a role model to trans youth and show them that they can be trans and they can have happy, healthy, functioning lives," Kerr said.
Tom Bourdon, president and executive director of Greater Boston Parents, Families and Friends of Lesbian, Gay, Bisexual and Transgender People, said LGBT youths who have support at home have the best chance of living such lives.
"School is critical, the workplace is critical, their neighborhood, all of that matters. But for there to be support in the home is really life-changing. It's often life-saving," Bourdon said.
PFLAG's mission is to educate and support the friends and families of LGBT individuals, helping them to create a safe, accepting environment. Six of the organization's 15 support groups cater to parents of transgender children.
The Merrimack Valley Alliance of LGBT Youth also holds weekly meetings for teens who are dealing with questions about sexuality and gender identity.
Bourdon said he has found that most families strive to be accepting.
A common emotion among parents of transgender children is grief, he said.
"For many trans people, hearing their old name or looking at old photos can be really uncomfortable, so different ways of supporting their child can lead to these feelings of loss," he said.
Many parents find the support groups to be a source of relief, and many of them stay on for years to offer support to new members, Bourdon said.
"When things go well, parents are able to see their children come out on the other side living their true, authentic lives," he said. "Seeing your child go from struggling to happy is such an incredible gift, but it can take a lot of work to get there."
In addition to facilitating support groups, PFLAG hosts educational and advocacy events. The demand for speaking programs featuring transgender people has grown exponentially, especially in schools, Bourdon said.
"I think there is the textbook-style education, and then there's personalizing it. One of Greater Boston PFLAG’s greatest strengths is to have people come out and tell their stories," he said. "By changing people's hearts, we can change their minds."