The night before his surgery, Rancho Bernardo's Sam Moehlig woke up several times. "Then I'd see it's 2 in the morning and go back to bed."
He rose at 4:30 for breakfast, his last meal before his 2 p.m. operation in a Thousand Oaks clinic. Going under the knife, the 14-year-old said later, "was kind of like a dream."
"It was just pure excitement," he said. "I was finally getting rid of something that had been bothering me for years."
Sam, who was born female, got rid of his breasts.
Gender reassignment operations are controversial, especially for minors.
Rady Children's Hospital San Diego will not recommend surgery for anyone younger than 16 because of the irreversibility of the procedure. Said Dr. Maja Marinkovic, medical director of Rady's gender management clinic: "Adolescents may not have the capacity to make informed decisions."
Sam's surgery came after years of anguish and depression. His suicidal thoughts eased when a psychiatrist suggested that Sam might be experiencing gender dysphoria, the intense sense that one's body and sexual identity are in conflict.
More counseling followed, as well as hormone blockers, testosterone shots and constant talks with his parents, Kathie and Ron, and his sister, Jacq. Sam's struggle has been a team effort.
Sam's double mastectomy was "the next step in our family as our family grows and gets closer," said Ron, 62, a service advisor for a local automobile dealership. "God has plans for everybody."
Samantha was born Oct. 20, 2000. The Moehligs adopted her from her homeless birth parents, tending the baby through fetal alcohol syndrome. Breathing was such a trial, her skin would turn blue. The infant needed nine medications and, from the age of 6 months until 3, feeding tubes.
Despite this fragile start, Samantha grew up to become a boisterous kid who loved sports and sci-fi movies. While she thought of herself as a boy, her body had other ideas. Her breasts began developing around the age of 9, plunging her into what Kathie calls "the deep dark."
Clinically depressed, Samantha spoke of suicide. Her parents sought counseling for her and searched for clues. All along, Kathie now believes, she was hunting for a word.
"I feel the guilt of knowing that your child is suffering for years," said Kathie, 54, "and then finding the term: transgender."
Counselors and physicians agreed: This was a case of gender dysphoria. On April 6, 2012, Samantha adopted a male persona and name.
Ever since, that has been Sam's "boy birthday."
His body, though, did not cooperate. At taekwondo, he wore a white T-shirt under his uniform to keep breasts from slipping out. After surfing lessons, he wrapped his torso in a towel while pulling off his wetsuit.
A hormone blocker was implanted in his left bicep to slow the growth of female characteristics. He bound his torso to minimize curves. Two years ago, testosterone shots were added to his routine. To all outward appearances, he became a typical boy.
But "it's hard to undo and unpack the discomfort that gender dysphoria causes," said Aydin Olson-Kennedy, 39, a transgender man who became Sam's counselor in 2014. "It is deep and it is very, very profound."
When Sam began his "social" transition, living as a boy, it wasn't a dramatic change — that's how he'd identified since at least kindergarten.
From his first "boy birthday," though, Sam became "he" in almost everyone's eyes. One set of grandparents has refused to accept their grandchild as a boy — or, as the rest of the family sees it, accept Sam as Sam. Still, his support group is large.
Jacq made her feelings clear at last summer's Pride Parade in Hillcrest. The 21-year-old held a sign: "My Brother Was My Sister. So What?"
As Sam changed, so did his family. "Parenting evolves," Kathie said, "and I've evolved as a part of this experience."
In June, she incorporated a nonprofit for families with transgender youth. Since October, her TransFamily Support Services has worked with 36 clients in a half-dozen states and one Canadian province. She's successfully advised seven families on how to have "top surgery" covered by insurance.
Ron marched with Sam in last year's Pride Parade. "I can't wait to march with him this year," he said.
Awkward moments have been rare, although there was one at the Presbyterian church the family had attended for 10 years.
Watching Sam, several worshipers who had been friendly with the Moehligs expressed misgivings. "When you and Ron die," one told Kathie, "you won't be with us in heaven."
The Moehligs left that church and eventually found a spiritual home at Agape International. One Sunday a month, they drive to Culver City to attend services with the nondenominational congregation.
As a youngster, Sam sometimes wondered: Had the Almighty goofed? Why would an all-wise, all-loving deity saddle a child with the wrong gender?
He no longer wonders. "I am grateful I was born the way I was," he said. "I look back on it and I don't think I would be the type of person I would be" without this experience.
"You can develop into who God intended you to be."
On the morning of July 23, the family piled into a van and drove to the Kryger Institute of Plastic Surgery in Thousand Oaks.
At the clinic, Sam was taken to a private room for photos of his chest. Then he returned to the waiting room for a family portrait. Finally, he was escorted into the operating room.
For the last four years, Drs. Gil and Zol Kryger have averaged 100 "top surgeries" a year, each costing $6,000 to $9,000. "Bottom surgery," constructing genitalia, is comparatively rare and far more expensive, running $75,000 to $100,000.
Sam is unsure he'll ever have bottom surgery. "You can get away with not having a part," Kathie said. "You can't get away with having parts that don't belong. This, the top surgery, is a necessity."
Still, is someone Sam's age too young to alter something as personal and intimate as gender?
"They've all known their entire life, from their earliest memory," that their bodies did not reflect their true gender, said Zol Kryger, 44. "It's just like you and I. We know. That's hard-wired into our brain."
Although the Kryger brothers are plastic surgeons, they reject the notion that these are "cosmetic" operations. "This," Zol Kryger said, "is surgery to restore someone to their natural state."
After two hours in the operating room, a still-sedated Sam was returned to his family.
"Everything," Gil Kryger told the Moehligs, "went exactly as planned."
The family drove to a nearby motel and tucked Sam into bed. Overcome by events, Ron shed a few tears. He was relieved the family would no longer have to battle insurance companies, pressing them to cover the operation.
"There was a lot of stress, not just for Sam but for the family," Ron said.
Now, he said, "the barriers are down. He can do whatever he wants to do, be whatever he wants to be and do it from his authentic self."
The day after his surgery, Sam woke up elated. "It was everything I ever wanted," he said.
Yet the immediate aftermath was a trial.
Sam had to miss team practices and competitions as his body healed. His parents waited until Aug. 29, a month after the surgery, before throwing a pool party for the boy and his friends.
Sam was thrilled: "I felt like that was my entire lifetime of wanting to take my shirt off at the pool."
Two weeks later, he resumed surfing lessons with one of his home-school teachers, Johnny Pontecorvo. At the beach outside Oceanside Harbor, Sam paddled a 9-foot Styrofoam board into the 4-foot swells.
He wiped out a few times and chased several waves in vain. Maybe 20 minutes into the session, Sam paddled down the face of a wave, rose to his knees, then popped onto his feet.
"He's excited to get back to his usual things," Ron said.
Few people have commented on Sam's new, flatter physique. But if friends had seen him on Christmas morning, they would have understood the power of this change.
Toting a twin-blade razor and a tube of shave butter, Sam prepared for his first shave.
Ron was at his side, coaching the boy, while Kathie took photos and Jacq watched. It was a family occasion — "a little weird, everyone jammed in there," Sam said — yet it was especially significant for the guys.
"The whole relationship of father and son rather than father and daughter has changed," Sam said. "We are able to relate a little closer."
A happy winter gave way to an eventful spring. An avid reader and creative writer, Sam worked hard in school. Flag football was a blast — "I was not worrying about my breasts bouncing all over the place" — and his balance in gymnastics improved.
"Gravity," he noted, "has the advantage. Surgery made it 10 times easier than before."
People see other changes in Sam. He stands straighter, speaks more confidently, smiles more easily.
"When I first met him, Sam was so shy," said Olson-Kennedy. "Now, he is just so much more available."
Available, even a bit outspoken.
Kathie and Sam's plans recently included a trip to Sacramento to lobby on behalf of LGBT youth. Once depressed and withdrawn, Sam was eager to testify.
"People need to hear it," he said. "Every person is different. That's who I am."
Rowe writes for the San Diego Union-Tribune.