Gender affirming care for youth is currently under political attack across the United States. Critics of affirming care often leverage a biological and fixed notion of gender as assigned at birth, which is at odds with how gender has been theorized academically for decades. Yet for some feminist clinicians, the popularized version of SOCIAL CONSTRUCTION present within rhetoric about the purpose of affirmative intervention also seems to undercut the legitimacy of care. In this article, I track how the difficult problems of the origins of gender itself, problems seemingly exposed by the invocation of the SOCIAL CONSTRUCTION of gender, are managed within the field of gender affirming care. I show how by drawing on the narrative power of very young gender expansive people, and by orienting clinical care away from identity towards DISTRESS, medical providers can align themselves both with feminist desires to change how gender ideology functions in the social world, and with the need to provide interventions that allow youth to embody the gender they desire.