The reversible portion of transition includes the adoption of preferred gender hairstyles, clothing, and play, perhaps adopting a new name, and suppression of puberty with gonadotropin-releasing hormone (GnRH) analogues. The portions of the reversible phase that do not involve suppression of puberty sometimes occur before the age of 10. Parents of younger children with GID may work with families, friends, teachers, and administrators to create a safe environment for children to present in their preferred gender. Allowing transition before the onset of puberty is controversial and should be determined by a close evaluation of the potential risks and benefits in a decision-making process among health care professionals, parents, and children. Before the onset of puberty, no hormonal intervention is necessary. The beginning signs of puberty in transgender children often bring increased body dysphoria and the potential development of a whole host of comorbidities including depression, anxiety, illicit substance use, high-risk sexual behaviors, and increased suicidality. The guidelines from The Endocrine Society call for the suppression of puberty at Tanner stage 2 for patients when GID is diagnosed.27 This suppression can be achieved by using GnRH analogues in a similar manner to the suppression of precocious puberty. To date, it has been difficult to get insurance plans to cover the cost of GnRH analogue therapy because the care for GID is frequently excluded from plans. Because patients are potentially starting GnRH analogue therapy early in the pubertal process, the common adverse effects of these agents are generally not expected. The most common concern with the administration of GnRH analogues is the effect on height and bone density. In a study26 of the Dutch protocol that calls for the administration of GnRH analogues starting at age 12 and moving to concomitant administration of cross-gender hormones at age 16, bone density was diminished at the time of GnRH analogue administration but was found to catch up when appropriate cross-gender hormone therapy was started. Height was increased for female to male patients by delaying biologic female puberty and was decreased in male to female patients with the administration of estrogen promoting closure of the growth plates. This effect is generally desirable to both populations. It is unlikely that GnRH analogue administration alone would affect fertility. However, initiating cross-gender hormones after the use of GnRH analogues is likely to prevent the maturation of the gonads. Early and effective treatment with cross-gender hormones clearly precludes the ability to bank sperm or ova. Parents, with input from their child, are generally capable of making an informed consent pertaining to these complex medical decisions.28 There are complicated logistical factors surrounding the initiation of GnRH analogues and cross-gender hormones. Ideally, adolescents should be treated early to facilitate psychotherapy by easing distress, “buy time” to avoid reactive depression, and prevent unwanted secondary sex characteristics, thereby reducing the need for future medical interventions.