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Gender is complicated, and so is gender care. This talk will review the science of sexual development to demonstrate, objectively, that sex is more complicated than a simple binary and to look at the ways in which gender identity development appears to be affected by multiple biological processes. It will then examine how developing a transgender surgery center in a pediatric hospital has raised issues of access, autonomy, and policy making in health care and discuss some of the research that has been enabled by working with the adolescent transgender population.