In recent years, there has been a surge of attention to transgender children and youth. In medicine, this has meant the establishment of specialized pediatric gender identity clinics, which provide hormones and other medical interventions as well as social support for young people who choose to transition. This dissertation seeks to understand the ways that childhood gender is changing in the United States today from the perspective of transgender children who are receiving gender-affirming care. I draw from ethnographic research with patients, families, and practitioners at the Gender and Sexuality Development Clinic at the Children’s Hospital of Philadelphia, a specialized pediatric gender identity clinic. I show how gender identity is understood through a logic of recognition, which shifts the focus from diagnostic practices to child-centric ones that I refer to as “following the child’s lead.” I also describe the way that success in gender-affirming care is linked to experiences of normalcy and ordinariness, and show how this shapes race- and class-based inequalities in access to care. I argue that the care I observed was rooted in particular historical practices, especially those of HIV medicine. I show how this orientation to care forces clinicians to contend with the tension between individual trajectories and collective futures. I use the term “utopian care” to refer to these efforts to produce social transformation through clinical intervention, and I suggest that this conceptual framework illuminates an important dimension of contemporary biomedicine as it engages with identity in new ways.