An Australian court has issued a landmark ruling to allow a 13-year-old child to begin sex-change procedures.
"Alex", is biologically a girl, but wishes to be considered and referred to as a male.
Brought up as a boy by his father, he opts to wear nappies to school rather than use female toilets.
It is the first time an Australian child has been given legal approval to begin hormone treatment based solely on a psychiatric assessment.
The decision has been both applauded and condemned by commentators.
The death of his father and estrangement from his mother had been formative experiences for the child, who legally can only be known as Alex, Australia's Family Court heard.
The court heard that Alex dressed in boys' clothes, and enjoyed activities and games mostly confined to boys.
He beat boys at arm wrestling and was attracted to girls.
Alex now lives as a boy with his aunt, though his legal guardian is the state welfare department - which lodged the application for treatment on his behalf.
He was assessed by a psychiatrist, who concluded he was a "bright, engaging, biologically normal 12-year-old girl who has a strong, persistent, longstanding belief and desire to live life as a male", reported the Sydney Morning Herald newspaper.
The psychiatrist reported that Alex "feels trapped in his body" and experiences depression and suicidal thoughts.
Step by step
In approving the application, the court stipulated that Alex's treatment be phased so that it does not become irreversible until he reaches 16.
The first stage of treatment will be a hormone course to suppress menstruation.
At 16, Alex will undergo irreversible testosterone treatment to develop muscle growth, a deep voice and body hair. Genital surgery will only take place at 18.
"In the present case, I have uncontroverted evidence not only that the proposed procedure is entirely consistent with Alex's wishes but also that the expert evidence as to the best interests of Alex accords with those wishes," Judge Alastair Nicholson said in his ruling.
PHASES OF TREATMENT
Age 13 to 16: Oestrogen and progesterone treatment to prevent menstruation and feminisation
13 to 16: Testosterone treatment for masculinisation
Judge Nicholson acknowledged that Alex could face ostracism and bullying, but said steps had been taken to anticipate such risks, and that Alex could resort to self-harm if treatment was denied.
The welfare department, as legal guardian, will pay for Alex's treatment.
Reaction to the ruling was sharply divided.
It was criticised by Nicholas Tonti-Filipini, a prominent ethicist at a Catholic institute.
"This medical treatment [is] completely unproven, even in adults," he was quoted as saying.
"To do it to a 13-year-old who is still in formation, whose body is still forming, whose sense of identity is still forming, it's just irresponsible."
But Louise Newman, a spokeswoman for the Royal Australian and New Zealand College of Psychiatrists, said it had been a sensible decision.
"Here the degree of stress is so great that going through the hormonal and bodily changes of puberty would actually be too distressing for the child to tolerate," she reportedly said.