gender reassignment ontario

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Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

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Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

• be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
• have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
• have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

• one of the assessments must be from a doctor or nurse practitioner
• you have a diagnosis of persistent gender dysphoria
• have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
• you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

• have a diagnosis of persistent gender dysphoria
• have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

• find out about their ongoing project, Trans Health Connection
• consult their service directory
• find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

New gender-affirming surgery clinic now accepting patients

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Plastic Surgeon Dr. Nicholas Cormier has dedicated nearly his entire career to caring for trans and non-binary patients.

The Ottawa Hospital understands that trans and non-binary people often face barriers accessing gender-affirming care. Faced with long wait times or even lack of access in the communities where they live, they may struggle to achieve their gender-affirming goals.

We are very pleased to announce that The Ottawa Hospital’s new gender-affirming surgery clinic is here to help. Launched in September 2023, it is the only clinic in Ontario and the second in Canada to offer all three of the following gender-affirming procedures:

• Facial surgery to make facial features more masculine or feminine
• Top surgery to remove breast tissue for a more masculine appearance or enhance breast size for a more feminine appearance
• Bottom surgery to transform the genitalia

The clinic’s lead and co-founder, Plastic Surgeon Dr. Nicholas Cormier, has some more wonderful news to share: “We’re currently accepting patient referrals from physicians,” he announces with a smile. “We’re ready to service Ottawa and the surrounding communities.” 

A truly collaborative effort

Before our clinic, patients seeking gender-affirming surgery in Ottawa could only access top surgery but not bottom or facial. Previously, a clinic in Montreal was the only location in Canada offering all three procedures.

“There’s just a massive gap in our health-care system for the treatment of the transgender population and people seeking gender-affirming care,” says Dr. Cormier. “What’s so groundbreaking about this new clinic is that everyone is coming together to address this shortcoming in our system.”

These partners include different surgical divisions at the hospital—plastic surgery, urology, obstetrics and gynecology—as well as trans health programs out in the community, such as the Centretown Community Health Centre’s Trans Health Program , which provides patients with a referral to our clinic, and CHEO’s Gender Diversity Clinic , which provided Dr. Cormier and his team with advice on setting up the clinic and also refers patients who have reached the age of 18.

These community programs are also important for the overall health and wellbeing of Ottawa’s trans and non-binary population. “Accessing gender-affirming surgery is just one small component of gender-affirming care,” says Dr. Cormier. “That’s where these community partners really come into play.”

Years in the making

For Dr. Cormier, the clinic is the culmination of many years of caring for the gender-diverse community.

“In my residency, I was always interested in gender-affirming care, and that led me to seek out a fellowship in San Francisco, where I was able to train with world-renowned experts in gender-affirming care,” he recalls. “And I’m really excited about bringing that to my hometown of Ottawa.”

And Ottawa’s gender-diverse community is (literally) in good hands, says Dr. Daniel Peters, Division Head of Plastic Surgery at The Ottawa Hospital. “Dr. Cormier has dedicated nearly his entire career to caring for this often underserved patient population. He has learned from the best of the best in this field and has the compassion to match his expertise. He joined The Ottawa Hospital’s Division of Plastic Surgery not long ago, and yet he has already shown tremendous leadership by getting this clinic up and running. That’s really a testament to his passion for helping people on their gender-affirmation journeys.”

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Information on Sex Reassignment Surgery (SRS) and Trans Health Care in Ontario

This resource is currently only available in English. Visit our English resources for 2SLGBTQ health information in English.

Questions? Get in touch with us at [email protected]

Answers to Frequently Answered Questions about SRS and Trans Health Care in Ontario.

The document offers information on the current status of SRS in Ontario and related health care for trans patients under the Ontario’s Health Insurance Plan (OHIP) which has not been readily accessible. We have produced this Frequently Asked Questions document to address these issues.

If you are in an emergency, in crisis or need someone to talk to, there is help.

Gender Identity Clinic

The Gender Identity Clinic offers services to individuals and their primary care practitioners in regard to gender identity and expression.

Individuals over 17 who wish to explore issues related to their gender identity, which may include any degree of transgender expression.

Community professionals looking for support and consultation to help their clients reach their goals related to gender identity and expression.

Ask your health care provider to fill out the CAMH adult referral form. Here is a link to the online referral form . Forms should be faxed to Access CAMH at 416 979-6815. If you have any questions about the referral process, call Access CAMH at 416 535-8501 and press 2.

Types of Treatment and Services Offered

For individuals, consultation and support may include:

• diagnostic assessments in support of affirming a diagnosis of Gender Dysphoria in support of transition related surgeries. 
• individual support and treatment *Please note that our clinic does not offer long-term therapy
• surgical and hormone eligibility assessments *Please note that our clinic does not prescribe hormones
• group-based services

If you are interested in accessing LGBTQ2S affirmative psychotherapy, please check the service provider listing at Rainbow Health Ontario to find out options for psychotherapy in your region. 

For community professionals, consultations may include:

• completing a mental health assessment
• consultation with regard to completing a surgery referral assessment
• being a second assessor for surgery referrals

Program Overview

The Gender Identity Clinic at CAMH offers specialty services to both individuals and their primary care practitioners in Ontario with regard to issues related to gender identity and expression, including gender expansive, trans and non-binary identities. The program offers a comprehensive response to the variety of clinical issues experienced by clients. The clinical team is interdisciplinary and includes social work, psychiatry and psychology staff with specialized expertise in trauma-informed mental health and addiction care.

Our Services

For community professionals.

Primary care providers can diagnose for gender dysphoria, prescribe transition-related hormones, and refer for transition-related surgeries. If you are new to the field of trans care, Rainbow Health Ontario provides education, clinical support, and mentorship to primary care providers across Ontario. All courses provided by Rainbow Health Ontario are Mainpro+ certified. Please visit learn.rainbowhealthontario.ca for more information on courses offered at this time.

Rainbow Health Ontario also hosts a free bi-monthly Trans Health Mentorship Call to support clinicians in their practices. To register for this call, please visit learn.rainbowhealthontario.ca

IMPORTANT: Rainbow Health Ontario does not accept referrals or provide direct services of any kind.

Hormone Therapy

We would encourage referring physicians and/or nurse practitioners to consider prescribing hormone therapy (HT) for their trans clients.

If you are unsure about prescribing HRT:

• We recommend that you review the published Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients available through Sherbourne Health Centre , and review the WPATH Standards of Care
• If, after reading this document, you feel confident in your knowledge of HT, then you can prescribe in advance of the client’s initial assessment. If HT is your client’s sole gender goal, then there is no need to access the clinic once hormones have been prescribed. 
• If you are aware of complicating medical concerns and these medical concerns have prevented the initiation of hormone therapy, please consider making a referral to endocrinology on the client’s behalf.
• If you are interested in training to develop further competency in health care for trans clients, please contact Rainbow Health Ontario, which will take you to various training opportunities offered by that organization throughout the province of Ontario.

*If hormone replacement therapy is the primary reason for referral, we would ask that you consider these above-mentioned recommendations, as it will help to reduce unnecessary waiting for your client in terms of further medical transition.*

The clinic plays a significant role in training health professionals in culturally competent delivery of mental health assessment and treatment services to trans and gender expansive communities. We train and provide practicum and residency opportunities for social work students, psychologists and people from other health disciplines, including more than 10 PhD-level clinical psychologists over the past five years.

Consultation

Additionally, we provide support and consultations to primary care practitioners and other health care providers to help their clients reach their goals related to gender identity and expression. This may include consultations in regard to completing a mental health assessment, consultation in regard to completing a surgery readiness assessment, or being a second assessor for surgery readiness. The clinic will work collaboratively with you and your organization/practice to help you meet your client’s goals. Clinicians and organizations wanting consultation by the clinic for clients currently on our waitlist can contact our clinic at 416 535-8501 ext. 30985.

We have also launched an ECHO (Extension for Community Healthcare Outcomes) for trans and gender diverse health care . Please consider joining us for free CME-accredited training and consultation.

For Individuals

The clinic offers consultations and support to individuals over 17 years of age who wish to explore issues related to their gender identity, which may include any degree of transgender expression. Clients are seen for an assessment with one of our team members to determine the client’s transition goals, as well as to provide any diagnostic impressions regarding mental health and substance use. Recommendations about how to assist clients in meeting their transition goals are then made. This may include individual support and treatment, group-based support and treatment, as well as recommendations for surgery funding and referrals for clients seeking transition-related surgeries. The clinic follows the World Professional Association for Transgender Health Standards of Care (WPATH),V7 for transition-related surgery (TRS) .

Rainbow Health Ontario has an Ontario Service Provider Directory where you can search for a provider by region. Please go here to find a provider in your area.

If you cannot find anyone in your area after searching the provider directory, you can contact [email protected] . Please note that Rainbow Health Ontario cannot guarantee there will be a provider in your area to prescribe hormones or refer for surgeries.

Additionally, Rainbow Health Ontario’s Trans Health Knowledge Base can provide you with answers to general questions related to navigating the Ontario health care system. Go here for more information . 

For clients living outside the GTA

Given the context of the Covid-19 pandemic, our clinic provides virtual appointments via the Webex platform.

Given our referrals come from across the province, our clinic is equipped to see clients via telemedicine when possible. Typically, the first assessment in our clinic is in person in Toronto, and subsequent appointments for clients who live outside of the GTA may be made using telemedicine.

If you live in the north, you may be eligible for a Northern Travel Grant to cover basic travel costs to and from your appointments with CAMH. If you are an ODSP recipient, you may similarly be eligible to have basic travel costs reimbursed. Please ask your local provider for further details.

Transition-Related Surgery (TRS) - Frequently Asked Questions

T hese FAQ's are designed to provide a brief overview of the assessment and referral process in Ontario for persons considering gender-affirming surgeries funded by the Ministry of Health and Long-Term Care (MOHLTC). For more information on types of surgery, see the TRS Surgical Summary Sheets update .

For specific questions or more detailed information pertaining to gender-affirming surgeries, please don't hesitate to contact our office at 416 535-8501 ext. 30985.

Significant improvement in wait times for assessment

From 2008–2016 the Ministry of Health and Long Term Care (MOHLTC) regulation stipulated that CAMH was the sole assessment site for OHIP-funded transition-related surgery (TRS) (from 1998-2008 TRS was not funded by OHIP). In March 2016, the MOHLTC introduced a regulation change that improves and expands access to assessment for TRS for Ontarians, empowering primary care providers to provide surgery referrals and assessments. CAMH and its community partners championed this expansion of access to assessments for gender-affirming surgery. In anticipation of this important system change, CAMH partnered with Sherbourne Health Centre (including Rainbow Health Ontario) and Women’s College Hospital on a proposal to expand access to surgery-related care. Thanks to funding from the MOHLTC, the Trans Health Expansion (THEx) partnership is working on several key priorities including improving access to assessment, building capacity of primary care providers, and enhancing access to surgery and post-surgical recovery and support.

The funding helped our clinic to hire new staff members and in doing so, we were able to significantly decrease wait times for assessment. Prior to March 2016 the wait for assessment was over 30 months, and to date it is less than one-third of that. We continue to work to see more clients and reduce the current wait times.

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Ontario expands referrals for gender reassignment surgery

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The Ontario government will move to allow more health-care providers to provide patient referrals for sex-reassignment surgeries, a move Health Minister Eric Hoskins said will reduce long wait times currently faced by transgender people.

Hoskins made the announcement at a Friday news conference at the Sherbourne Health Centre in Toronto.

​Patients can currently only receive a referral for surgeries paid for by the province's health-care plan through the Gender Identity Clinic program at the Centre for Addiction and Mental Health (CAMH) in Toronto.

Hoskins said the province wants to allow all qualified health-care providers throughout the province to be able to refer patients for this surgery starting in 2016.

"Every Ontarian has the right to be who they are," said Hoskins. "Our health care system should reflect this vision, which is why we are improving access to sex-reassignment surgery."

He said more and more Ontarians are experiencing gender dysphoria, defined as the distress caused by a discrepancy between a person's gender identity and that person's sex assigned at birth. Patients who need surgery often face long wait times. 

2-year waitlist

"One of the most vulnerable times for trans people is when they are ready for surgery, but face a prolonged wait," said Hoskins. "This change would reduce wait times by allowing many trans clients to get surgical approvals from their own local primary care teams."

The wait list for gender reassignment surgery currently stands at more than 1,000 people. The referral wait time in Ontario is typically now more than two years, a wait that will be "dramatically" reduced as a result of the changes, said Hoskins.

Hoskins said the new referral process for gender reassignment surgery will still be based on existing criteria and internationally recognized standards of care. He also said the number of people in Ontario asking for gender identity services has been on the increase in recent years.

"We are moving from a single site [for referrals] to what could potentially be hundreds of sites," he said. 

The changes to allow local referrals will come in the form of amendments to the Health Insurance Act. Hoskins said the government will provide additional funds to CAMH while the transition to local referrals takes place. 

Patients will still head out of province for surgeries

Dr. Amy Bourns, whose practice includes a special interest in transgender health, said the announcement is "an amazing step forward." 

Hoskins was asked about the fact that gender-reassignment surgeries are currently not available in Ontario, even for patients who complete the long referral process. Many Ontario patients go to Quebec or other jurisdictions to have the surgery. 

"We need to look at the provision of the surgical services and we're looking at that," he said, pointing out the expanding referrals to health-care providers across Ontario as a "first step."

Dr. Amy Bourns at the announcement to expand referrals for gender reassignment surgery

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Toronto hospital first in Ontario to offer trans surgery

First Published:

A Toronto hospital has become the first in Ontario to offer gender-reassignment surgery.

Doctor Yonah Krakowsky, a urologist and medical lead of the Transition-Related Surgery program at Women’s College Hospital in Toronto says offering the surgery can be life saving.

Janet Macbeth, 40, was the first patient to receive a vaginoplasty – making this not only a milestone for her, but for Canada.

Previously, the trans community had to travel to Montreal or abroad to receive surgery.

Macbeth was approved to travel to Montreal, but chosse to wait until the Toronto program was in place. Once the program was in effect, Toronto’s Women’s College Hospital was officially the only public hospital in Canada to offer the surgery.

While the program is still in its early days, Krakowsky says the teaching hospital’s multidisciplinary approach will help establish a model that can be adopted by medical institutions across the country.

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Backgrounder – talking about gender identity and gender expression, page controls, page content, looking back….

Over the years, the Ontario Human Rights Commission (OHRC) has taken steps to address discrimination because of gender identity. In 1999, the OHRC released “Toward a Commission Policy on Gender Identity” for public comment. [1] In 2000, the OHRC released its first Policy on discrimination and harassment because of gender identity , taking the position that the ground of “sex” could be interpreted to include gender identity. Following the release of this policy, the OHRC continued to call for explicit recognition of gender identity as a protected ground in Ontario”s Human Rights Code .

The OHRC has also been actively litigating cases related to gender identity. For example, the OHRC was involved in XY v. Ontario (Government and Consumer Services) , [2] a case that dealt with requirements for transgender people to change the sex-designation on their birth certificates. The OHRC was also involved in Forrester v. Peel (Regional Municipality) Police Services Board et al , which dealt with how police services search transsexual detainees, [3] and in Hogan v. Ontario (Health and Long-Term Care) dealing with access to sex reassignment surgery services. [4]

Looking forward – towards a new policy

In 2012, Ontario added the grounds “gender identity” and “gender expression” to the Human Rights Code . The OHRC then moved to update its Policy on discrimination and harassment because of gender identity . In 2012-13, the OHRC did a literature review revealing a wealth of information on how gender identity and human rights is understood from a variety of perspectives. At the same time, human rights law in Canada and internationally has continued to advance understanding and protection of legal rights for trans people.

In 2013, the OHRC hosted an online public consultation survey on policy issues related to gender identity, including use of terminology, types of discrimination trans people experience, and how the OHRC can help organizations understand their Code responsibilities related to these grounds. We received more than 750 responses to the survey from members of the public as well as community services organizations, educators, unions and employers.

OHRC staff also conducted one-on-one interviews with a range of individuals and organizations to explore issues in depth and to identify individuals and groups who could take part in future outreach and education activity.

The survey – what we heard

The survey was not about statistics – it was about giving people an opportunity to share their experiences and their ideas, to give us a snapshot of some of the key issues relating to gender identity and expression in today’s world. The following sections outline the questions we asked and some of the responses we received.

1. Understanding the new grounds

The Code does not define the grounds of gender identity, gender expression or sex. Instead, the understanding of these and other related terms, and the implications for the Code and OHRC policies, is evolving from tribunal and court decisions, social science research as well as self-identity and common everyday use.

Like any other words describing individual characteristics, the language we use is deeply personal, and it changes over time. To guide us in the best choice of language for the policy, we asked survey participants to comment on a series of draft descriptions. We received a wide variety of suggestions and opinions, which reinforced our need to find a “middle ground” for today, and to be prepared to update the language in future. Here is a sample of the different comments we received for each term.

What we heard…

General comments.

• Need to explain concept of gender to understand gender identity
• Gender identity and gender expression vary depending on the cultural context
• Using the term “deeply felt” to describe gender identity is problematic – what legal test does this invite/imply? Is this a test of “bona fide” belief? A person shouldn’t have to prove this. This signals profound discomfort with the idea of self-identification for this group – should not be part of the definition
• Recognize gender fluidity, not just people who conform to binary vision of gender
• Some think both grounds apply to everyone, others think that gender expression applies to everyone (regardless of trans identity)
• Some trans people simply want to be recognized as the gender they identify with (e.g. man, woman or male/female) – they want to be recognized within the gender binary. Others have gender identities outside the binary – trans, gender non-conforming, etc.
• Important for descriptions to have a non-medicalized approach.

Gender Identity

• Gender identity doesn’t only affect trans people – cisgender people also have a gender identity – we should be clear in the policy that gender expression applies to everyone, while gender identity specifically applies to trans people
• Should be “may include” an individual’s personal sense of their body
• “Birth sex” should be replaced with “sex assigned at birth”
• Be clear gender is not only two categories – not a binary – a spectrum of identification
• Social norms of “male” and “female” not feminine and masculine
• Not everyone has a “deeply felt” “internal” sense of their gender. Also implicates a binary, and excludes people who are gender fluid
• Include deeply felt sense of having no gender or being gender fluid – “individual experience of gender, its fluidity, or lack of a strong experience of gender.” Also drop reference to “deeply felt” – it isn’t deeply felt by some
• Gender identity comes from within – however a person “self-identifies”
• A person's gender identity can be the same as, or different from, that which is typically associated with their assigned sex at birth
• Use of “correspond” reinforces cisnormativity. What does gender identity look like? Note that the most common pathway, of being cissexual, is not the only pathway
• “Social norms of male and female” reinforces heteronormativity – suggest using “socially constructed expectations” of male and female
• Gender identity is linked to an individual’s intrinsic sense of self and their sense of being male, female, a combination of both or neither regardless of the sex they were assigned at birth
• Suggest changing last sentence describing gender expression to say: “people may choose to modify their gender expression and/or their body appearance or function by medical, surgical or other means to better reflect their gender identity”
• After last sentence, add: “to align their physical appearance with their internal gender identity”
• A person’s gender identity may or may not correspond with social norms of “male and “female.” Reference to birth sex in a definition applicable to their core identity may be seen as inappropriate/offensive to trans people
• The definition should refer to social norms associated with being a “man” or “woman” in society – male and female are sexes (not norms)
• Gender identity is linked to an individual’s intrinsic sense of self and their sense of being female, male, a combination of both, or neither regardless of their biological sex
• A person’s gender identity may change over time.

Gender expression

• Not “external attributes” – but “expressive activities,” such as behaviour, appearance, dress, etc.
• Include: chosen names and preferred pronouns – two important ways to express one’s gender
• Include: gender expression doesn’t necessarily correspond with gender identity (e.g. identify as male, but express their male gender identity in ways perceived as “feminine” or of the female sex – e.g. makeup and nail polish)
• People can express a gender (or gendered attributes) that are different from their gender identity (e.g. identify as female, express “male” attributes/gender)
• People’s perception not important in a definition about how one chooses to express themselves. More concerns about expression being about how one chooses to express oneself, emphasis shouldn’t be on other people’s perceptions
• Other respondents liked including others’ perceptions – this description is accurate and reflects reality
• Communicate the idea of a gender continuum – not a binary or a list of abnormal states
• Dress, speech, mannerisms – include hairstyles and presentation
• The way a person expresses their gender identity
• Public expression of gender identity – performed to demonstrate one’s gender identity.

Other ideas on the grounds

• There is a continuum of identity which encompasses sex and gender and the expression of these aspects of identity
• Instead of “others” include gender non-conforming and gender neutral
• Discuss how the grounds are linked, discrimination often occurs on multiple grounds related to social norms about gender and sex – sometimes linked, but not always… discuss in the policy how they may be linked and not (e.g. a cisgender woman, who has masculine gender expression can face discrimination)
• Gender expression and gender identity may not “match” or correspond – e.g. born male, gender identity is female, and gender expression could be “male”
• Include that gender identity and gender expression may or may not be linked – e.g. a butch woman might identify as a woman but present a more masculine gender expression
• Concerns about linking sexual orientation – the need to make sure the policy clearly outlines that gender identity/expression are different and not related to sexual orientation
• Gender is about the cultural categories of “man” and “woman” rather than masculine and feminine (how we express our gender)
• “others” is dehumanizing – use another term, such as “any other form of expressing one’s gender”
• Concepts seem to overlap – this is confusing for some. Some would like the concepts to be clearly defined and separate/distinct
• Why do we need definitions? It seems limiting and we don’t want to exclude anyone
• Gender non-conforming/gender variant: people who do not follow stereotypes about how they should look or act based on the sex they were assigned at birth. For example, “feminine” boys, “masculine” girls and people who are androgynous
• Concerns about defining the grounds – will likely end up excluding some, even inadvertently.
• Should indicate the list of identities it refers to… and include “and many others”
• Is sexist and derogatory – reinforces the gender binary
• An umbrella term, like the term transgender, used to describe people who do not conform to societal expectations of “normal” gender behaviour. Includes all… including gender queer and gender non-conforming
• Trans definition should be same as for transgender
• An umbrella term referring to people who do not embrace traditional binary gender norms of masculine and feminine and/or whose gender identity does not fit with the one they were assigned at birth
• The emphasis on not conforming to the gender binary is oppressive.
• Intersex definition is outdated and doesn’t reflect current terminology
• Should include “medicalized definitions of male and female”
• An umbrella term used to describe people whose sex characteristics do not fit into traditional medicalized definitions of male and female
• Should include genetic and/or chromosome differences that may or may not be based on their physical characteristics at birth or after puberty
• General term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of male or female. Many do not identify as trans
• A person born with sex characteristics of more than one sex
• Intersex is a variety of differences defined as conditions in chromosomes, hormone levels and/or physical sex which sometimes make classification in “male” and “female” sex categories not immediately apparent
• A person who has male and female sex characteristics
• Includes hormones and chromosome characteristics
• An umbrella term used to describe people whose sex characteristics do not match traditional medicalized definitions of male and female
• A person who has male and female physical sex characteristics
• Take out reference to hermaphrodite.
• “Sex” should include intersex – is not a fixed category and sex can change over time through medical interventions
• “Biological classification” – legitimizes medical model. Maybe – the “label we are given at birth”
• An assigned classification – imposed by medical system at birth
• Not just biological – also legal – based on physical appearance of external anatomy
• Sex is assigned at birth by a doctor and is based on a visual assessment of external anatomy – include intersex as a third “sex”
• Add intersex – sex, like gender, is a spectrum
• Sex assigned at birth – includes internal reproductive structures, chromosomes, hormone levels and secondary sex characteristics
• Refers to sex assigned at birth, based on external genitalia but also internal reproductive systems, chromosomes, secondary sex characteristics (e.g. breasts, facial hair).
• Definition reinforces binary notion of gender – need to be legitimate space for gender expression beyond concepts of masculinity and femininity
• The social classification of men and women
• There are genders that do not fit in binary of “male” and “female”
• The social classification of people as men/women or someone who fits neither of those categories
• Gender norms are imposed on us by society
• Gender is also “assigned” – socially assigned based on social norms and expectations
• A mental realization of one’s personal niche in the sexual spectrum, usually defining itself before puberty
• Use “man” or “woman” – masculine and feminine is gender expression
• The social classification of a person as a “man” or “woman”. Gender socialization is often predicated on birth sex – a person is socialized into this identity/role
• Gender is about the cultural categories of “man” and “woman” rather than masculine/feminine – which is more how we express gender
• An aspect of personal/social identity usually ascribed at birth on basis of sex (assigned) – but the “natural” connection is an illusion. The idea that because there are two sexes there have to be two genders
• Should include masculine, feminine, androgynous and outside of these categories – not only binary folk have or express a gender.

Transgender

• Reinforces gender binary and cisnormativity
• “Disgender people” – people who reject “trans” as a term for their gender identity
• Many people who identify as transgender do not have an experience of existing in more than one gender (perhaps from childhood they always knew they were male, though they were classified as female)
• Transgender and transsexual should have same definitions
• Don’t use “internally felt” – makes it seem like it’s all in their head, and not as important as biology (i.e. they are “crazy”)
• Include the notion of “gender fluid, moving through either gender as desired”
• People who in some way do not identify with the gendered expectations of the sex they were assigned at birth
• Also a full spectrum term – like trans
• An umbrella term describing anyone who falls outside of traditional gender categories or norms. Literally means “across gender” and conveys the idea of transcending the boundaries of the gender binary system.

Transsexual

• Remove reference to “biological” – is offensive – puts assigned sex as objectively more valid than one’s gender identity
• Biological sex assigned at birth does not match their perception of their gender
• May or may not undergo medical treatments
• A person who undergoes a medical gender reassignment process to change their birth assigned sex
• Others: they may or may not undergo medical treatments.
• The term “may encompass spirituality, gender and culture
• Many different terms used in different First Nations cultures.

Cross dresser

• People may cross dress for emotional and psychological well-being or for “other personal reasons”
• Many do it for fun or as a hobby
• Maybe just say “for various reasons”
• A person who, as an expression of gender or simply as a matter of clothing choice, dresses in clothing not socially perceived as congruent or in keeping with the sex they identify as
• A person who dresses in clothing normally associated with a different gender than their own
• Some survey respondents prefer the term gender variant.

Transphobia

• Not just fear and hatred – also unexamined biases
• Irrational fear, hatred and intolerance
• Remove irrational – is subjective – many people noted this. Many people think that their fear and hatred is rational
• Mistrust or discomfort around trans people
• Some people disproportionately targeted – e.g. trans identified people who do sex work, people of colour, trans women.

Other comments

• Definitions (sex and gender) imply male/female and masculine/feminine are the norm and that trans and intersex people are deviants from the norm – othering
• Use “trans” – it is most inclusive (as opposed to transgender)
• Include other cultural terms that refer to other genders (bakla, kathoey, hijra)
• Include genderqueer – people who do not express their gender as male or female; people who may identify as both, neither, beyond or in-between genders
• Include agender
• Gender variant
• Gender fluid
• Transmisogyny
• Don’t put “spectrum” in quotation marks – delegitimizes anyone who is outside the binary
• Include cisgender: having a gender identity that is in keeping with one’s sex assigned at birth
• Include cisgender, cissexual and cissexism in glossary
• Cissexism: the institutional and systemic privileging of cisgender identities and experiences over trans identities and experiences
• Cisnormativity: assumption that it is normal for a person’s gender identity and expression to “match” the sex they were assigned at birth. This assumption overlooks the reality of sex and gender variance – trans people, intersex, and diverse gender expressions by cisgender people as well
• Gender variant/gender non-conforming – people who do not follow gender stereotypes based on the sex they were assigned at birth. For example, “feminine boys” or “masculine girls”
• Using terms like “match” and “align” for birth sex and gender identity reinforces cisnormativity and the gender binary.

2. Lived experience of transgender people

Many of the human rights issues discussed in the OHRC’s initial policy over 10 years ago remain relevant today. Research, media reports and human rights case law show that transgender people experience negative stereotypes, discrimination and harassment that have a pervasive and often traumatic impact on many aspects of their daily lives. For trans people, some of the fundamental things that many people take for granted, like jobs, housing and family life, are potentially at risk because they identify as trans or are seen to be trans.

We asked people to tell us their experiences of discrimination and harassment, and to offer ideas on what can be done about it.

a) In what ways do people experience discrimination and/or harassment based on gender identity and gender expression?

General experiences:.

• Being able to “pass” within the gender binary – to be recognized by others as a “man” or “woman” according to the gender binary and stereotypical gender norms influences what kind of discrimination a trans person might experience. MTF often face greater discrimination because they have more difficulty “passing” without medical treatments (that are expensive and/or hard to access/not readily available)
• Administrative barriers – gender classification system in documents – legal (birth certificates, passports, OHIP etc.) – ID of sex on official documents does not represent the diversity of gender identities and expressions that exist
• Identification of sex/gender on documents is narrow and doesn’t adequately reflect people’s gender identity or expression. There should be options on official records other than M/F
• Common themes: not being addressed by chosen name and pronoun, being asked overly invasive questions about body, being forced to use a private bathroom because of others’ discomfort (cissexism) (lack of respect)
• Intentional misgendering – being referred to by name/address that is not your gender identity – in some cases, being referred to as “it”
• Trans sex workers and trans women are at high risk for sexual assault – often victims are not taken seriously. They also may be HIV positive, and face stigma because of this, as well as HIV non-disclosure charges
• Discrimination contributes to poverty and lack of housing, then trans people often face further barriers and discrimination when trying to access services (e.g. at a shelter or hospital)
• Verbal harassment, being outed as “trans” against your will
• Trans people stigmatized as different – a “threat” – focus on proof of bodies – e.g. genitalia
• Idea that a trans person must always answer others’ overly intrusive questions about their body because others are uncomfortable with how they look (especially re: “passing”)
• People who are gender variant/gender queer can face a lot of harassment re: policing of gender norms – people demanding to know; are you a man or a woman?
• Street harassment – policing of gender norms
• Often perceived/assumed to be mentally unstable – “non-human” or “freaks” – or “perverts”
• Gender fluid – can also be the target of homophobic harassment – people assume you are gay, and harass you on that basis
• Bathrooms – often verbal or even physical harassment because you don’t “pass” as the gender you are presenting
• Cross-dressers – not feeling safe in bathrooms
• Hate directed towards trans people on the internet – social media, chat rooms
• Discrimination in employment and housing – can be hard to prove – very insidious –  social attitudes and exclusion
• In stores – service providers refusing to serve because of gender presentation/judgement
• Sports – sex segregation – creates a lot of issues and barriers for trans people
• Face discrimination in immigration and refugee system – they must prove they are “trans enough” or “count as trans” to qualify for refugee status. Often they may be deported back to countries that actively discriminate, and provide no protection from violence and hate crimes.

Police/security experiences:

• Trans women are often targeted by police – for frisks and stops, and their reports of harassment or sexual harassment are not taken seriously
• Ability to travel is severely affected – harassment by border officials, asked invasive personal questions about their gender and sex.

Youth experiences:

• Youth face harassment and bullying – may not have family support – social groups and support from school needed – washroom issues – and many school activities are gender segregated, perpetuating exclusion and harassment – lack of safe space
• Harassment and discrimination at school/public school – policing of gender norms; subtle cultural exclusion
• Children are forced into gender roles – gender binary – not valued for who they are regardless of what sex they were designated at birth.

Employment experiences:

• Employment – harassment and penalties (including firing) because of trans identity, although it may not always be obviously so (i.e., the employer doesn’t say “because you are trans”) – lack of understanding, knowledge and awareness; bullying and harassment
• Transition while at work is a very stressful time – harassment, abuse, lack of acceptance – it’s very easy for the employer to find a reason to fire the person at this time, and the person has little recourse to show objectively that they were fired because they were trans.

Social services experiences:

• Many social services are not equipped to deal with transphobia, and trans clients seeking services
• No gender neutral washrooms
• Shelters that have dedicated “trans” beds forces people to come out as trans against their will, can make them a target for harassment
• Homeless and women’s shelters – exclusion
• Gender segregated services are primary sites of harassment and exclusion: washrooms, jails, shelters, hospitals.

Housing experiences:

• Housing can be difficult to access – a lot of subtle discrimination. Landlords won’t rent to you but you don’t know why.

Health care experiences:

• Health care – medical model pathologizes trans as a “disorder” – can also be difficult to access transition surgeries and treatments (hormones, surgery etc.)
• Needing to prove you are trans to access services
• Access to health care is a big problem – rural areas (also for all services)
• Doctors refusing to provide treatment – lack of access to hormone treatment
• Access to mental health care that is sensitive and appropriate
• Stigmatized as having mental health issues – people who identify as trans are often pathologized, by the medical world and by others – told they are “confused”
• there is a lack of access (geography)
• their requirements are overly stringent and create barriers
• feelings of isolation and having to submit oneself to a process that is stigmatizing
• gate-keeping access to medical procedures to transition based on limited understandings of gender identity and expression.

b) What steps can be taken to prevent and address this discrimination and harassment?

Education/training:.

• Public education – campaigns – legal requirements and rights. Show trans people as positive, contributing members of society
• Education in public schools is important – teachers and administrators etc. – ways to make schools supportive and affirming for gender non-conforming youth
• Need to help teachers learn how to create an inclusive school environment around gender issues… gender neutral spaces, words, activities, addressing harassment
• Education for employers on rights and responsibilities
• Training of service providers and employers – from trans people and experts on trans competency and the Human Rights Code , respectful treatment by doctors, lawyers, police, teachers, social welfare, housing providers, media, school boards, government and students
• Increase knowledge and awareness in social services, health care system
• ensure sex reassignment surgery and hormone therapy available to all who want it, no cost
• access to top surgery – currently must go out of the province.

Community engagement:

• Engage with community leaders across the province on the issue
• Develop an OHRC stakeholder advisory committee on trans issues
• Have a champion of trans human rights – storytelling and positive stories – humanize the issue
• Bring clinical treatments in line with the Ontario Human Rights Code
• Resources need to be made available to support health care and social supports for trans people.

Justice/administration:

• Decriminalize sex work and HIV non-disclosure
• Eliminate requirements for a person to legally change their name to access services and be recognized in their lived gender identity
• Ensure complete ease in changing name and gender in all documents
• All official records, data collection and forms should use inclusive language.
• Services should have washroom policies to allow trans people to use the bathroom of their lived gender identity, as well as gender neutral washrooms for people in transition or other gender variant people who don’t feel comfortable using male or female washrooms
• Because of discrimination face serious issues – poverty and homelessness – need resources to support services to meet the needs of this population while challenging the social norms, etc. that lead to discrimination.

c) Are there other important human rights issues or concepts related to gender identity and gender expression that should be added or changed to improve the policy?

• Policing of gender norms for all people is negative… change the culture
• cissexism is closely linked to transphobia
• humanize trans people – avoid setting trans or intersex people, or gender fluid people up as “the exception” or “unnatural” – normalize the idea of being trans or transgender
• policing of gender norms affects cisgender people as well – e.g. being read as too masculine or feminine depending on if you are perceived as a “man” or “woman”
• Sex work and HIV related issues – trans people are over represented and very marginalized
• Sex work should  be decriminalized – protect them from violence and harassment – particularly for trans women
• Sex work and HIV are deeply linked in trans communities – discrimination against trans sex workers and people living with HIV particularly affects trans women
• Allow people to change their legal names on documents, don’t require people to identify as male or female – blank box
• Allow for gender neutral designation… people don’t want to identify as male or female
• make it easier to change names on legal documents – remove onerous requirements such as notes from medical doctors and fees
• difficulty changing name on identity documents – all at the same time, so that they all match up – can be very difficult
• for official documents, there should be a way to have undesignated gender; for gender fluid people and intersex people, a blank box to fill in
• Provide gender neutral washrooms everywhere – this is so very important for safety, well-being
• Provide access to health care services across the province
• We need access to services in rural areas, outside the GTA
• Provide access to health care services outside CAMH – more gender identity clinics
• Access and barriers to services – employment, housing, safe access to shelters
• Need to improve access to homeless shelters and women’s shelters – ensure no discrimination
• Social services in general need better training on how to respect trans people, support them etc. – social workers, EMS, hospital staff, police teachers, doctors – mandatory training
• Ensure better education in school system – about gender – need for better sex education in schools
• ensure universities have policies that address gender identity and gender expression
• Prisons… people should be treated according to their lived identity
• Employers, housing providers,  etc. need to be made aware that gender identity and gender expression are prohibited grounds
• Sports organizations should develop inclusive trans policies – need to address discrimination in sports.

3. Supporting people who are transitioning

• Explicit trans inclusion policy – workplace should have a formal policy with guidelines and processes in place before a person ever asks
• Provide guidelines to employees on how to respectfully interact, and make standards of non-harassment and discrimination clear (for example, respectful language, bathroom policies)
• this should be widely known, understood by management and staff – and communicated widely
• ensure policy is well understood and applied consistently – should not depend on any particular staff person or manager
• leadership – should be championed and communicated at highest levels
• Consult with the person transitioning – they know what they need
• Do not require people to disclose sex/gender and/or trans status – confidentiality
• Work with the person
• To change name on documents – make it simple, no requirements for surgery or for legal name change on other documents (e.g. birth certificate)
• Creating an easy way to change name, gender, etc. in all identifying documents – no hassles doing this – what changes will be made and when
• Managers’ support is crucial
• Key principles of respect, privacy, education
• Providing time off if needed – for medical treatments or other reasons
• Moving the person to another position or area if needed
• Creating a clear washroom policy, and communicating it to everyone
• Providing direction on how to inform clients or students about the transition
• Making the environment welcoming and accommodating
• Designing a communication plan
• Ensuring that health programs/benefits recognize gender reassignment surgery as medically necessary and providing coverage.
• Eliminate barriers to health program access, and recognizing WPATH standards of care as government health policy
• Keeping all medical and personal information confidential
• Referring to the person based on their chosen name – intentional misgendering or not referring to the person based on their chosen name is a form of harassment
• If a person does not identify as male or female, respecting and supporting their right to be referred to as “they.”
• Providing gender neutral washrooms
• Addressing the person as they self-identify – names, pronouns, etc.
• Providing health benefits
• Training for all staff – education for staff, management, unions, union representatives
• Ensuring people know how to file a complaint of harassment or discrimination
• Education about the Human Rights Code , and that the person is exercising their rights

4. Accommodation policies

• Explicit trans inclusion policies
• Communicate with the person, ask what they need, work collaboratively with them
• Recognize how a person self-identifies, pronouns and name, etc.
• Allow easy changing of documents for any official purposes – e.g., provide references, employment records, etc. under the person’s preferred name
• Provide gender neutral washrooms
• Educate managers and staff
• Treat people with respect, privacy and dignity
• Allow for time off for medical appointments
• Allow the person to move to another area, department or office if needed
• Provide medical coverage
• Apply the concept of “universal design” as per disability movement – to gender identity/gender norms
• Don’t ask invasive questions that you would not ask a cisgender person
• Respect, dignity, listen to their needs
• Proactively ensure a culture of respect
• Be sensitive and understanding, but do not overly emphasize their difference with respect to other employees, service users, etc.
• Needs to be a system in place to address any harassment or uncooperation from other employees re: preferred name, access to bathrooms, etc.

5. General suggestions for employers, service and housing providers

• Need to be educated about the new grounds, and their responsibilities
• Employers know about sexual harassment and their responsibilities, they don’t know about gender identity and their responsibilities
• Landlords shouldn’t ask about sex or gender – it doesn’t matter
• Need a discussion of what factors can be considered as part of an accommodation request
• Need clear information about responsibilities and obligations
• How will the shelter system that is sex segregated need to change? What about services that focus on women only? (eg. YWCA?)
• Best practices in accommodation would be helpful
• Sample policies for shelter staff and housing providers would be helpful, and language/terms to use when discussing the issue (for education purposes).

6. Miscellaneous comments

• Importance of broader public education – challenge heteronormative and cisnormative narratives
• Importance of changing media representations
• Need public and private sector leadership and role models
• Need for funding for trans-specific services, housing, employment, etc. and for trans youth.

[1] www.ohrc.on.ca/en/discussion-paper-toward-commission-policy-gender-identity

[2] XY v. Ontario (Government and Consumer Services ) 2012 HRTO 726 (CanLII).

[3] Forrester v. Peel (Regional Municipality) Police Services Board et al , 2006 HRTO 13 (CanLII).

[4] Hogan v. Ontario (Health and Long-Term Care), 2006 HRTO 32 (CanLII).

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Canada Finally Has Nation-Wide Funding For Gender-Affirming Surgeries

With last week’s announcement from the Government of Nunavut confirming that the territory will pay for mental health services and transition treatments for transgender and non-binary residents, Canada will now have nation-wide funding available for gender-affirming surgeries. Nunavut’s Health Department is partnering with GrS Montréal to provide the surgeries.

Health care in Canada is delivered by the provinces and territories and funding for gender-affirming surgeries varies depending on where a person lives. This patchwork of coverage has resulted in barriers to accessing care that have disproportionately affected people living in Canada’s territories in the North, which includes Yukon, Northwest Territories and Nunavut. While expansion of surgery funding in Canadian provinces has continually progressed over the last decade, comprehensive coverage has only been established in the territories over the past three years.

Nation-wide coverage is obviously a very positive development but advocacy is still needed to continue the work of dismantling barriers for Canadians to access surgical care. Current challenges include:

Getting coverage across the country for Facial Feminization , Breast Augmentation and Male Chest Contouring , procedures that are excluded from funding policies in some jurisdictions.

Surgeons who practice gender-affirming genital surgery are only located in Montreal, Toronto and Vancouver. This means that many transgender and non-binary Canadians need to travel great distances to access surgeons for primary surgeries, follow-ups and specialized care for complications, incurring significant expenses that aren’t universally covered or subsidized.

Wait times are a problem that is not unique to gender-affirming surgical care in Canada but with few experts performing these surgeries patients can wait up to three years just for a consultation with a surgeon.

With the Government of Nunavut’s funding commitment, the goal of nation-wide coverage for gender-affirming surgery in Canada has been achieved. Improvements to provincial and territorial funding policies are still needed but this is a milestone to be celebrated.

Review Funding Policies by Province and Territory:

• British Columbia
• New Brunswick
• Newfoundland and Labrador
• Nova Scotia
• Ontario – PDF
• Prince Edward Island
• Saskatchewan – PDF
• Northwest Territories – PDF
• Nunavut – News article: GN transgender, non-binary health services a positive step
• Yukon – News article: Yukon’s new gender-affirming care policy is most comprehensive in Canada

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Legislative Assembly of Ontario

Bill 77, affirming sexual orientation and gender identity act, 2015.

DiNovo, Cheri

• Acts affected

Bill 77 2015

An act to amend the health insurance act and the regulated health professions act, 1991 regarding efforts to change.

Her Majesty, by and with the advice and consent of the Legislative Assembly of the Province of Ontario, enacts as follows:

Health Insurance Act

   1.  Section 11.2 of the Health Insurance Act is amended by adding the following subsections:

Efforts to change or direct sexual orientation or gender iden tity

   (1.1)  Despite subsection (1), any services rendered that seek to change or direct the sexual orientation or gender identity of a patient, including efforts to change or direct the patient's behaviour or gender expression, are not i n sured services.

E fforts to change sexual orientation or gender identity

   (1.1)  Despite subsection (1) and subject to the regul a tions, if any, any services that seek to change the sexual orientation or gender identity of a person are not insured services.

   (1.2)  For greater certainty,

  (a)  the sexual orientation or gender identity of a patient is the patient's self-identified sexual orient a tion or gender identity; and

  (b)  the services mentioned in subsection (1.1) do not include services rendered to change the biological sex of a patient.

   (1.2)  The services mentioned in subsection (1.1) do not include,

  (a)  services that provide acceptance, support or unde rstanding of a person or the facilitation of a person's coping, social support or identity exploration or deve l opment; and

  (b)  sex-reassignment surgery or any services related to sex-reassignment surgery.

.     .     .     .     .

Regulations

   (6)  The Lieutenant Governor in Council may make regulations,

  (a)  clarifying the meaning of "services", "sexual orie n tation", "gender identity" or " seek to change " for the purposes of subsection (1.1);

  (b)   exempting services from the application of subse c tion (1.1).

Regulated Health Professions Act, 1991

   2.  The Regulated Health Professions Act, 1991 is amended by adding the following section:

Prohibition, patient under 18 years of age

   27.1   (1)  Despite any other provision of this Act, no person shall, in the course of providing health care se r vices, carry out any practice that seeks to change or direct the sexual orientation or gender identity of a patient under 18 years of age, inclu ding efforts to change or direct the patient's behaviour or gender expre s sion.

Sexual orientation and gender identity treatments

   27.1 2 9 .1   (1)  No person shall, in the course of provi ding health care services, provide any treatment that seeks to change the sexual orientation or gender ide n tity of a pe r son under 18 years of age.

   (2)  For greater certainty, the sexual orientation or gender identity of a patient is the patient's self-identified sexual orient a tion or gender identity.

   (2)  The treatments mentioned in subsection (1) do not include,

Person may consent

   (3)  Subsection (1) does not apply if the person is capable with respect to the treatment and consents to the pr o vision of the treatment.

Substitute decision-maker cannot consent

   (4)  Despite the Health Care Consent Act, 1996 , a su bstitute decision-maker may not give consent on a person's behalf to the provision of any treatment d e scribed in su b section (1).

   (5)  Subject to the approval of the Lieutenant Governor in Council, the Minister may make regulations,

  (a)  clarifying the meaning of "sexual orientation", "gender identity" or "seek to change" for the pu r poses of subsection (1);

  (b)  exempting any person or treatment from the appl i cation of subsection (1).

   3.  Subsection 40 (1) of the Act is amended by striking out "subsection 27 (1) or 30 (1)" in the portion b e fore clause (a) and substituting "subsection 27 (1), se c tion 27.1 or subsection 30 (1)" " subsection 27 (1), 29.1 (1) or 30 (1)" .

   4.  (1)  Subsection 51 (1) of Schedule 2 to the Act is amended by adding the following clause:

(b.0.2) the member has carried out any practice that seeks to change or direct the sexual orientation or gender identity of a patient under 18 years of age, i n cluding efforts to change or direct the patient's beha v iour or gender expression;

   (2)  Section 51 of Schedule 2 to the Act is amended by adding the following subsection:

   (1.1)  For greater certainty, the reference in clause (1) (b.0.2) to the sexual orientation or gender identity of a patient is the patient's self-identified sexual orient a tion or gender identity.

Commencement and Short Title

Commencement

   5.  This Act comes into force on the day it re ceives Royal Assent.

Short title

   6.  The short title of this Act is the Affirming Sexual Orientation and Gender Identity Act, 2015 .

This reprint of the Bill is marked to indicate the changes that were made in Committee.

The changes are indicated by underlines for new text and a strikethrough for deleted text.

______________

EXPLANATORY NOTE

The Bill amends the Health Insurance Act and the Regulated Health Professions Act, 1991 with respect to efforts to change or direct the services that seek to change the sexual orientation or the gender identity of p a tients.

The amendments to the Health Insurance Act prohibit such e f forts services from being insured services.

The amendments to the Regulated Health Professions Act, 1991 prohibit such efforts from being carried out as part of providing health care services to the prov i sion, in the course of providing health care services, of treatment that seeks to change the sexual orientation or the ge n der identity of patients under 18 years of age and make s it an offence to do so. The amendments also make the carrying out of such e fforts with respect to patients under 18 years of age an act of profe s sional misconduct.

An Act to amend the Health Insurance Act and the Regulated Health Professions Act, 1991 regarding efforts to change sexual orientation or gender identity

Efforts to change sexual orientation or gender identity

   (1.1)  Despite subsection (1) and subject to the regulations, if any, any services that seek to change the sexual orientation or gender identity of a person are not insured services.

  (a)  services that provide acceptance, support or understanding of a person or the facilitation of a person's coping, social support or identity exploration or development; and

  (a)  clarifying the meaning of "services", "sexual orientation", "gender identity" or "seek to change" for the purposes of subsection (1.1);

  (b)  exempting services from the application of subsection (1.1).

   29.1   (1)  No person shall, in the course of providing health care services, provide any treatment that seeks to change the sexual orientation or gender identity of a person under 18 years of age.

   (3)  Subsection (1) does not apply if the person is capable with respect to the treatment and consents to the provision of the treatment.

   (4)  Despite the Health Care Consent Act, 1996 , a substitute decision-maker may not give consent on a person's behalf to the provision of any treatment described in subsection (1).

  (a)  clarifying the meaning of "sexual orientation", "gender identity" or "seek to change" for the purposes of subsection (1);

  (b)  exempting any person or treatment from the application of subsection (1).

   3.  Subsection 40 (1) of the Act is amended by striking out "subsection 27 (1) or 30 (1)" in the portion before clause (a) and substituting "subsection 27 (1), 29.1 (1) or 30 (1)".

   4.  This Act comes into force on the day it receives Royal Assent.

   5.  The short title of this Act is the Affirming Sexual Orientation and Gender Identity Act, 2015 .

This Explanatory Note was written as a reader's aid to Bill 77 and does not form part of the law.  Bill 77 has been enacted as Chapter 18 of the Statutes of Ontario, 2015 .

The Bill amends the Health Insurance Act and the Regulated Health Professions Act, 1991 with respect to services that seek to change the sexual orientation or the gender identity of patients.

The amendments to the Health Insurance Act prohibit such services from being insured services.

The amendments to the Regulated Health Professions Act, 1991 prohibit the provision, in the course of providing health care services, of treatment that seeks to change the sexual orientation or the gender identity of patients under 18 years of age and make it an offence to do so.

An Act to amend the Health Insurance Act and the Regulated Health Professions Act, 1991 regarding efforts to change or direct sexual orientation or gender identity

Efforts to change or direct sexual orientation or gender identity

   (1.1)  Despite subsection (1), any services rendered that seek to change or direct the sexual orientation or gender identity of a patient, including efforts to change or direct the patient's behaviour or gender expression, are not insured services.

  (a)  the sexual orientation or gender identity of a patient is the patient's self-identified sexual orientation or gender identity; and

   27.1   (1)  Despite any other provision of this Act, no person shall, in the course of providing health care services, carry out any practice that seeks to change or direct the sexual orientation or gender identity of a patient under 18 years of age, including efforts to change or direct the patient's behaviour or gender expression.

   (2)  For greater certainty, the sexual orientation or gender identity of a patient is the patient's self-identified sexual orientation or gender identity.

   3.  Subsection 40 (1) of the Act is amended by striking out "subsection 27 (1) or 30 (1)" in the portion before clause (a) and substituting "subsection 27 (1), section 27.1 or subsection 30 (1)".

(b.0.2) the member has carried out any practice that seeks to change or direct the sexual orientation or gender identity of a patient under 18 years of age, including efforts to change or direct the patient's behaviour or gender expression;

   (1.1)  For greater certainty, the reference in clause (1) (b.0.2) to the sexual orientation or gender identity of a patient is the patient's self-identified sexual orientation or gender identity.

   5.  This Act comes into force on the day it receives Royal Assent.

The Bill amends the Health Insurance Act and the Regulated Health Professions Act, 1991 with respect to efforts to change or direct the sexual orientation or the gender identity of patients.

The amendments to the Health Insurance Act prohibit such efforts from being insured services.

The amendments to the Regulated Health Professions Act, 1991 prohibit such efforts from being carried out as part of providing health care services to patients under 18 years of age and makes it an offence to do so. The amendments also make the carrying out of such efforts with respect to patients under 18 years of age an act of professional misconduct.

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Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

Home » GET INFORMED » Talk Rights » Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

May 19, 2015

Like all content on this website, this document is not legal advice and is provided solely for the purpose of public information and education. If you are facing a legal issue or have a question about your specific situation, you should consider seeking independent legal advice. You can find a list of legal clinics and other resources to help you here.

The CCLA is a national organization that works to protect and promote fundamental human rights and civil liberties. To fulfill this mandate, the CCLA focuses on litigation, law reform, advocacy and public education. Our organization is not a legal clinic. As such, we are typically not in a position to provide members of the public with legal advice or direct legal representation. However, we do try to provide general legal information and appropriate referrals where possible. For questions about this document, email publicenquiries [at] ccla [dot] org.

How can Trans Persons Change the Sex Designation on their Birth Certificate?

This guide is focused on issues relating to how trans persons can change the sex designation on their birth certificates. For information on how trans persons can legally change the name used on their identification documents,  see this guide .

This page is intended to help trans persons with issues related to changing the sex designation on their birth certificates. As such, some of this information may not be helpful to those seeking to change their birth certificates for another reason.

Note: Every effort has been made to ensure comprehensiveness and accuracy (as of May 2015). However, this FAQ may not fully reflect the current state of the law.

We use the term “trans” to include anyone who does not identify with the sex designation they were assigned at birth.

Questions addressed in this FAQ:

Why might I want to change the sex designation on my birth certificate?

Should i have to have surgery in order to change the sex designation on my birth certificate, are sex designations on birth certificates even necessary, how can i change the sex designation on my birth certificate, where do i apply to change the sex designation on my birth certificate, what proof do i need to show in order to change the sex designation on my birth certificate do i need to show proof of surgery, can i apply if i am younger than 18 or 19, can i apply even if i was born outside of my current province/territory.

You can download a PDF of this document here:  CCLA Change of Sex Designation FAQ .

Many trans persons consider the sex they were assigned at birth to be inaccurate. If this is you, changing the sex designation on your birth certificate may be important for your well-being. It is also important for legal reasons as well.

In order to enjoy a greater degree of safety and freedom from discrimination, you may want to have identification documents that match the gender with which you identify and present yourself. The information on most identification documents is drawn from birth certificates, so changing your birth certificate is often a necessary first step. “Sex” is a category on most driver’s licenses, passports and health cards, and so you may find yourself being forced to discuss your gender identity – sometimes even your genitals – with a stranger. This is even worse when that stranger is empowered to make decisions that greatly affect you, such as whether to write you a traffic ticket, offer you a job, refer you for medical treatment, or let you enter the country.

Trans persons face widespread discrimination and high rates of violence. Of trans Ontarians  surveyed  by the Trans PULSE Project, 26% reported being hit or beaten up because they were trans, 73% reported being made fun of, and 39% reported being turned down for a job. In 2010, Trans PULSE  estimated  that 50% of trans Ontarians had seriously considered suicide at some point in their lives because of the discrimination they faced. Involuntary outing on a regular basis, such as by having an inaccurate gender specified on your identification documents, eliminates one of the few mechanisms you may have to protect yourself from transphobia.

In 2014, a judge in Alberta considered the constitutionality of the provincial law that regulated gender markers on birth certificates. The judge  struck down  that law, because it was contrary to the  Canadian Charter of Rights and Freedoms . In doing so, the judge cited a  prior decision  of the Ontario Human Rights Tribunal. That decision detailed some of the discrimination faced by trans persons (referred to here as “transgendered” [sic]):

“[T]ransgendered persons as a group tend to face very high rates of verbal harassment and physical assault and are sometimes even murdered because of their transgendered status. […] [I]t is very difficult for a transgendered person to find employment, […] there are very high rates of unemployment among transgendered people generally, and […] many transgendered people are fired once they are exposed in the workplace as being transgendered.”

These concerns also extend to young trans persons, who may be forced to endure bullying by their peers if the sex designation on school records does not match their gender identity.

Many trans persons want the benefits of official documents that correspond to their identity but may not want to undergo surgery. They may be content with the use of hormones or simply by presenting themselves consistently with their gender identity.

Gender reassignment surgery can be expensive, difficult to access, and carries the risks associated with any surgery. In addition, it has been reported to  typically cause sterility . Gabrielle Bouchard of the Montreal-based Centre for Gender Advocacy has said the surgical requirement in order for official documents to be changed  amounts to mandatory sterilization.  The surgery requirement also emphasizes biological sex characteristics rather than gender identity. Even after surgery has been performed, a second doctor must sometimes “confirm” the surgery. C.F., the plaintiff in the  Alberta  court case mentioned earlier,  told the  Edmonton Journal :

“What this legislation requires is that you not only submit to dangerous, risky surgery, but then actually attend for a humiliating genital inspection before two separate physicians, both of whom will make a value judgment about whether your genitals are sufficiently female[.] It’s like something from ages gone by. It’s very disturbing stuff.”

Due to these types of concerns, there have been and continue to be legal challenges to the various provincial legislation that require reassignment surgery in order to change sex designation. In the  Ontario  and  Alberta   decisions discussed earlier, the requirement for gender reassignment surgery was found to be discriminatory. As a result of these rulings, several provinces, including Alberta, British Columbia, Manitoba, Ontario, and Quebec, have taken steps to amend their laws to remove reassignment surgery from the requirements necessary in order for you to change your sex designation. Nova Scotia has also indicated that it plans to amend its legislation to remove the surgery requirement.

Some activists have argued for the removal of sex designations from identification documents altogether, on the basis that gender identity is not a binary classification. The binary does not accommodate people who do not identify with a binary gender classification.

Ongoing cases challenging legislation in  British Columbia ,  Saskatchewan  and  Quebec  are seeking the removal of sex designations from birth certificates. So far, although several provinces have removed the surgery requirement, no province has taken the step of removing sex designations altogether or providing for a third non-binary option.

In contrast, several countries, including  Australia and Germany , now allow persons to designate their sex on their passport with an “X”. However, some trans rights advocates argue that the “X” continues to out trans persons, and is used as an excuse for not eliminating the surgery requirement. An  Australian  court has ordered the government to register a third category of sex designations on birth certificates and name change certificates.

For more on the possibility of non-binary gender designations, see the BC Law Institute’s  report , where the Institute highlights the implications and consequences of different solutions to providing a non-binary sex designation in Canada.

All provinces and territories except Nunavut have procedures for changing sex designations when a person has undergone gender reassignment surgery.

The rules for changing the sex designation on a birth certificate vary from province to province. They are also changing rapidly. In all provinces except Quebec, where the  Civil Code  governs these issues, the law concerning birth registration is found in the provincial  Vital Statistics Act  and associated regulations. These laws and regulations can be consulted for free on  http://canlii.org . Note that a province may have policies that are not in the legislation. For more information about requirements, check with the government agency responsible for birth certificates in your province or territory (listed below), or with a trans advocacy organization, such as  Egale Canada .

Many provinces require letters from a mental health professional in order to change a person’s gender marker or name. Such a letter may also be required to access sex reassignment surgery.

Online government information is limited outside British Columbia, Manitoba and Ontario. Where specific information regarding change of sex designation is unavailable on a province’s website, the links below provide contact information for the appropriate agency.

Until recently, all provinces and territories required you to have gender reassignment surgery if you wanted to change the sex designation on your birth certificate. Ontario became the first province to drop this requirement in 2012 when, as mentioned previously, its human rights tribunal  ruled  the requirement was discriminatory. The Alberta Court of Queen’s Bench handed down a similar  ruling  in April 2014. Ontario has not officially amended their legislation, but are now registering changes without proof of surgery as a matter of policy. British Columbia, Alberta and Manitoba are the only provinces that have formally amended their legislation to eliminate the surgery requirement. In Alberta, the new requirements are set out in  regulations .

New Brunswick, Newfoundland and Labrador, PEI and Saskatchewan   all require applicants to document that they have undergone gender reassignment surgery, usually by having at least two physicians – the surgeon who performed the surgery and another who did not – certify that fact. Quebec and Nova Scotia also currently require proof of surgery, but changes to the law are on their way (see below). In Quebec, the second physician must practice medicine in Quebec. In New Brunswick and the Northwest Territories, the second physician must be licensed in any Canadian jurisdiction.

The law in this area is changing rapidly as legislation is amended and court challenges are brought regarding surgery requirements. Consulting the relevant statutes will not always give a full picture of the current requirements or upcoming amendments. For current information, contact a trans advocacy organization, such as  Egale Canada .

You must provide:

A declaration, which provides your date of birth, and states that you identify with and maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a licensed doctor or psychologist licensed in Alberta or another jurisdiction that the sex designation on your birth certificate does not correspond with your gender identityBritish ColumbiaNo proof of surgery required;

A declaration, which states you have assumed, identify with and intend to maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a doctor or psychologist licensed in BC or the province or territory where you live that the sex designation on your birth certificate does not correspond with your gender identityManitobaNo proof of surgery required;

A declaration, which states you identify with the requested sex designation, you are currently living full-time in a manner consistent with the requested sex designation and you intend to continue doing so; and

A supporting letter from a health care professional licensed in Canada or where you live that your gender identity corresponds with the requested sex designationNew BrunswickProof of surgery requiredNewfoundland and LabradorProof of surgery requiredNova ScotiaProof of surgery still required, but a bill to eliminate the requirement has received royal assent. Under the new law, which is not yet in force, you will written statements from themselves and a member of a profession to be prescribed in the regulations that confirm your gender identity.OntarioNo proof of surgery required;

A declaration, which states your gender identity); and

A note from a doctor or psychologist licensed to practice in Canada that confirms your gender identityPrince Edward IslandProof of surgery requiredQuebecProof of surgery required, but change is pending;

The requirements under the new law have not been set yet.SaskatchewanProof of surgery requiredNorthwest TerritoriesProof of surgery requiredYukonProof of surgery requiredNunavutThere is no provision in the  Vital Statistics Act  for changing sex designation, even with surgery

Sex reassignment surgery is generally not performed on those under the provincial age of majority, as all clinics in Canada that currently perform reassignment surgery conform to the recognized  Standards of Care . These Standards, which are regarding health care for trans persons, forbid irreversible interventions (such as surgery) on patients before they reach the age of majority. As a result, if you are a minor in Canada, you generally cannot change your sex designation in provinces or territories where proof of surgery is required.

In provinces that do not require surgery, the age requirements vary:

Note that legal challenges to the minimum age requirements are currently proceeding in several provinces, including  Quebec  and  Saskatchewan . Click  here  to listen to an interesting radio interview with a 10 year old who would like to change the sex designation on her birth certificate.

Under new law (not yet in force) : No age minimum, but if you are under 16, you must have parental/guardian permission or apply to the Supreme Court of Nova Scotia for an order dispensing with the requirement of parental consent.OntarioNo age minimum, but if you are under 16, you must have parental/guardian permissionPrince Edward IslandNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionQuebecAge minimum is 18.SaskatchewanNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionNorthwest TerritoriesNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permissionNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permission

British Columbia, Ontario and Northwest Territories will change sex designations only for births registered in their respective provinces. Some provinces will register a change of sex and then transmit it to the jurisdiction where the birth was registered.

Under new law (not yet in force) : Legislation requires that the applicant was born in Nova Scotia.OntarioLegislation requires that the applicant was born in OntarioPrince Edward IslandApplicants born outside of Prince Edward Island may apply, and the province will transmit their request to the jurisdiction where their birth was registered.SaskatchewanNo explicit requirement that the applicant was born in SaskatchewanQuebec Under the new law (not yet in force) : Legislation requires that the applicant was born in Canada and resides in Quebec, or that the applicant was born in Quebec and resides in a place where change of sex designation is unavailable or impossibleNorthwest TerritoriesLegislation requires that the applicant was born in Northwest TerritoriesNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonApplicants born outside of Yukon may apply, and the province will transmit their request to the jurisdiction where their birth was registered

For more information:

The Trans PULSE Project prepared a report for the Canadian Human Rights Commission on sex designation in federal and provincial IDs in 2012. The report was prepared for hearings on Bill C-279, a proposal to add gender identity and expression to the  Canadian Human Rights Act  and to hate crime provisions of the  Criminal Code . The report can be found  here .

In 2014, the British Columbia Law Institute prepared a report for the Uniform Law Conference of Canada on the state of the Canadian law regarding change of sex designation, and regarding options for reform in 2014. The report can be found  here .

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Support and Education for Trans Youth (SAEFTY) developed a short zine to support trans youth in better understanding their rights, healthcare needs and opportunities for self-advocacy.

Trans Care BC has created a self-advocacy tipsheet to support trans and gender diverse people to advocate for themselves within healthcare contexts.

Starting a conversation with your primary care provider about trans health can be difficult. RHO offers some quick and clear conversation starters that trans and gender diverse people can use to start this discussion.

The Champlain Regional Planning Table for Gender Diverse Health has developed a list of resources available for primary care providers that can help them build their knowledge, confidence, and competence in transition-related healthcare, most notably in regards to hormone replacement therapy.

Parents and families play an important role in supporting their trans and gender diverse children, youth and family members. The Families in Transition guide, created by Central Toronto Youth Services (CTYS) is a phenomenal resource for families and caregivers looking to learn more about trans people and how to support their trans loved ones.

It is important for trans, gender creative and gender diverse children and youth to see themselves reflected in the books they read, or that are read to them. It is equally important for all children and youth to understand diversity. Finally, it is important for parents, caregivers, and other caring adults to learn about trans and gender diverse communities. The RPT developed a list of picture books, chapter books/middle grade books, and youth and young adult books that touch upon issues relating to trans and gender diverse identities.

The Gender Spectrum website hosts a variety of resources, online groups, and programs for parents and families as well as their trans and gender diverse youth. Their resources for families can be used to further your understanding of gender and learn the value of parental and adult support.

Trans Care BC created an organizational assessment tool. Through this assessment, organizations can review their current capacity to serve and support trans communities, and identify viable next steps to improve trans inclusivity.

Trans Care BC created a service provider self-reflection tool to help service providers in exploring their knowledge and attitude towards gender diversity, along with their personal approach to supporting trans, non-binary, and gender diverse Two-Spirit individuals.

Wisdom2Action and the Canadian Public Health Association created a brief guide to support organizations in the development and implementation of trans inclusion within health and social services. The guide provides a flexible process that organizations can use to inform their approach to trans inclusion.

Creating inviting and trans inclusive clinic and care environments is an important way to model inclusivity and demonstrate your commitment to trans inclusion. Wisdom2Action and the Canadian Public Health Association created a guide on creating an inclusive care environment.

Trans Care BC has created an introductory guide to gender-inclusive language for service providers and primary care practitioners.

For a short review of terms best avoided, or to only be utilized in particular circumstances, Wisdom2Action and CPHA’s guide on harmful terminology can be accessed here.

Wisdom2Action and CPHA Developed a short guide to adopting gender-neutral language to help you avoid making assumptions and create safer spaces for trans and gender diverse communities.

Created by Trans Care BC, this resource provides a practical guide to how to address mistakes, such as the use of an incorrect name or pronoun.

Implementing inclusive intake forms is integral to creating a trans inclusive environment, while ensuring medically necessary information is collected accurately and appropriately. Wisdom2Action created a guide on trans inclusive intake forms, which you can access here.

The World Professional Association for Transgender Health promotes the highest standards of health care through the articulation of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. To access in-depth clinical guidance relating to assisting trans and gender diverse people, you can download the WPATH Standards of Care v.7.0 here.

The Endocrine Society developed this clinical practice guideline on endocrine treatment of gender dysphoric/gender incongruent persons. The essential points and summary of recommendations can be found here.

This Best Practice Guideline from the Registered Nurses’ Association of Ontario provides nurses and other members of the interprofessional team with evidence-based recommendations on foundational, inclusive, and affirming care practices for Two-Spirit, lesbian, gay, bisexual, trans, queer, and intersex people. To learn more and download the guideline, click here.

Intended for use by primary care providers, these summary sheets about transition-related surgeries (TRS) provide information to facilitate discussion of TRS between primary care providers and patients. (Please note that they are not exhaustive and do not replace the informed consent process between surgeon and patient.)

The Ministry of Health and Long-Term Care Request for Prior Approval for Funding of Sex-Reassignment Surgery form, must be completed by a primary care provider (nurse practitioner or physician) following Transition-Related Surgery planning visits.

Rainbow Health Ontario developed a resource for persons considering transition-related surgery in Ontario and the people supporting them. The resource discusses the frequently asked questions relating to transition-related surgery.

The Rainbow Health Ontario quick reference guide for gender-affirming primary care with trans and non-binary patients includes pertinent information for primary care providers on feminizing and masculinizing hormones, assessing hormone readiness and monitoring dosage.

The Rainbow Health Ontario Guidelines and Protocol for Hormone Therapy and Primary Health Care for Trans Clients provides detailed information about hormone replacement therapy. You can view the full Guidelines here.

The Rainbow Health Ontario Guide to Caring for Trans and Gender Diverse Patients offers a detailed walk through of key information and steps to beginning a client on hormone replacement therapy, you can access the guide here.

Patient-ready overview documents on the expected risks and benefits of feminizing or masculinizing hormone replacement therapy, created by Rainbow Health Ontario, can be accessed here.

This Rainbow Health Ontario Fact Sheet offers information about reproductive options for trans people interested in hormone therapy or surgeries. Knowing and discussing reproductive options is a necessary component of informed consent to transition-related care.

This 34 minute video, created by the Hamilton Trans Health Coalition, offers a guide for service providers to provide gender affirming PAPs. It reminds service providers the importance of trans-inclusive practice in cancer prevention services. Click here to watch the video.

This booklet, created by Rainbow Health Ontario, helps service providers understand the social determinants of health as relating to trans people and their risk of getting cancer as well as their ability to benefit from cancer prevention services. To download the booklet, click here.

This statement from the World Professional Association for Transgender Health Board of Directors to denounce ROGD as nothing more than an acronym created to describe a proposed clinical phenomenon. They argue for adolescents receiving gender-affirmative, evidence-based care. To read the full statement, click here.

Physicians, psychologists, and psychological associates can support their clients in changing the sex designation on their Ontario Birth Registration. Rainbow Health Ontario provides a template letter in support of an application for change of sex designation on an Ontario birth registration.

Physicians, psychologists, and psychological associate can support their clients in changing the sex designation on their Ontario driver’s license. Rainbow Health Ontario provides a template letter in support of an application for change of sex designation on an Ontario dricer’s license.

Physicians can support their clients in applying for a legal name change by acting as a guarantor. To learn more about the adult name change process, you can download a guide published by Positive Space Network and Pro Bono Students Canada here.

To download the most recent version of Ontario’s Application to Change an Adult’s Name, click here. Physicians acting as a guarantor will complete Form 8 of the application.

Primary care providers can submit support letters for trans and gender diverse patients applying for employment insurance through the just cause mechanism. Rainbow Health Ontario has developed this template to support you in writing this letter.

For patients covered by the Ontario Drug Benefit Program, injectable testosterone is covered with the submission of an Exceptional Access Program (EAP) form. Rainbow Health Ontario provides a sample request for the unlisted drug product, testosterone enanthate (Delatestryl) which you can access here. [It is recommended that if submitting this EAP form, physician should also submit a request for testosterone cypionate (Depo-Testosterone)]

For patients covered by the Ontario Drug Benefit Program, injectable testosterone is covered with the submission of an Exceptional Access Program (EAP) form. Rainbow Health Ontario provides a sample request for the unlisted drug product, testosterone cypionate (Depo-Testosterone) which you can access here. [It is recommended that if submitting this EAP form, primary care providers should also submit a request for testosterone enanthate (Delatestryl)]

Often trans and gender diverse clients need to travel in order to obtain their transition-related surgeries. If the person demonstrates financial need and the surgery is covered by OHIP+, they might be eligible for free air travel and/or accommodations through Hope Air. Primary care providers can submit a Hope Air request on their client’s behalf.

This handbook, developed by Fraser Health, will provide you with in-depth information on the best practices in providing care to Two-Spirit patients. You can download the handbook here.

This paper, developed by the National Collaborating Centre for Aboriginal Health provides an overview of the health of Two-Spirit people including an introduction to Two-Spirit roles and identities, the impact of colonization on aboriginal gender and sexuality, social determinants of health in the colonial context, the health status of Two-Spirit people, resilience and resurgence, as well as additional educational resources.

This peer support manual, developed by the Native Youth Sexual Health Network, is written by and for Indigiqueer, Two-Spirit, and LGBTQ+ Indigenous Youth. It provides some tips, strategies, and resources to manage mental health and wellness.

This resource from Fenway Health provides a step by step guide with visuals to giving yourself an intramuscular or subcutaneous hormone injection. To access this guide, click here.

This video from Veterans Health Administration, provides step by step instruction to give yourself an intramuscular injection. You can watch the video here.

Rainbow Health Ontario and their FAQs working group have gathered answers in response to questions they are commonly asked by trans and non-binary folks in Ontario. You can browse the trans knowledge base here.

The RHO Service Provider Directory is designed to help you find health and social service providers who have expressed a commitment to providing competent and welcoming care to LGBT2SQ people in Ontario. To visit the directory, click here.

SPECTRUM Waterloo partnered with Wisdom2Action to develop a Trans Mental Health, Wellness and Suicide Prevention Toolkit. This toolkit synthesizes pertinent knowledge and research on trans mental health and suicidality in Canada, alongside concrete tools and resources that trans people, friends and families of trans people, and service providers who work with trans communities can put to use.

This guide was developed by the Champlain Regional Planning Table for Trans, Two Spirit, Intersex, and Gender Diverse Health. It lists medical, mental health, and community-based services that are accessible to trans and gender diverse folks in Ottawa and throughout the Champlain region.

This guide builds on the Champlain Region Gender Diverse Health Resource Guide developed Champlain Regional Planning Table for Trans, Two Spirit, Intersex, and Gender Diverse Health. It lists medical, mental health, and community-based services as well as some additional resources that might be helpful for parents and families of trans and gender diverse youth in the Champlain region. To access the guide, click here.

This guide builds on the Champlain Region Gender Diverse Health Resource Guide created by the Champlain Regional Planning Table for Trans, Two Spirit, Intersex, and Gender Diverse Health. It lists medical, mental health, and community-based services that are accessible to trans and gender diverse youth throughout the Champlain region. To access the guide, click here.

This resource was developed to help trans and gender diverse people best advocate for themselves and their needs in health and social services. The resource includes information aimed at supporting trans and gender diverse people to prepare for a health or social service-related appointment, advocate for themselves during an appointment, and advocate for themselves after an appointment.

Positive Space Network collaborated with Pro Bono Students Canada to develop this Youth Name Change Guide for transgender, non-binary, and gender-nonconforming youth in Ontario looking to change their name. The guide provides you with document checklists, important tips, and additional information about the process of changing your name on a variety of different documents.

The 519 and CATIE worked together to develop this safer sex guide providing updated sexual health and safer sex information for trans women and their partners. Brazen 2.0 covers disclosure, negotiation and consent, sex work, safer sex, transition-related surgeries, and provides up-to-date information on advances in HIV prevention and treatment, the realities of online dating and internet culture, and access to trans-inclusive health care.

This resource, produced by Egale Human Rights Canada Trust, was designed to answer common questions that parents of intersex children often have, while empowering parents and their children to make informed decisions based on current research from intersex activism. The resource includes general guidelines for navigating the healthcare system, navigating conversations with your child, your family, and schools, a guide on the distinction between intersex and gender identity, and resources for further information.

This brochure was created by interACT Youth, a group of intersex advocates in their teens and twenties working to raise intersex awareness. The brochure was created to show their friends the best ways to support them on their intersex journeys

Prepared by interACT Youth’s Advocates for Intersex Youth, this brochure covers what intersex youth wished their doctors knew.

interACT Youth created this brochure as a way to prepare other families with intersex kids for the journey ahead of them.

This toolkit, developed by the City of Toronto Seniors Services and Long-Term Care features content and resources to aid in delivering respectful, inclusive and affirming care to 2SLGBTQI+ seniors. It includes resources on individual knowledge and skills (language, information about 2SLGBTQI+ seniors and their experiences, and how to practice allyship) as well as organizational capacity building (assessing capacity, working with stakeholders, updating policies/procedures, promoting training opportunities, and developing new and inclusive programming).

Les parents et les familles jouent un rôle important dans le soutien de leurs enfants, de leurs jeunes et des membres de leur famille qui sont trans ou de sexe différent. Le guide Families in Transition, créé par le Central Toronto Youth Services (CTYS), est une ressource phénoménale pour les familles et les aidants qui cherchent à en savoir plus sur les personnes trans et sur la façon de soutenir leurs proches trans.

Trans Care BC a créé un guide d'introduction au langage inclusif du genre pour les fournisseurs de services et les praticiens de soins primaires.

Ce guide pratique, créé par Trans Care BC, vise à offrir des solutions pour corriger certaines erreurs, comme l'utilisation d'un nom ou d'un pronom incorrect.

L'Association professionnelle mondiale pour la santé des transgenres promeut les normes les plus élevées en matière de soins de santé par l'élaboration de normes de soins pour la santé des personnes transsexuelles, transgenres et non conformes au genre.

Ces fiches récapitulatives sur les chirurgies de transition sont destinées aux prestataires de soins primaires et fournissent des renseignements pour faciliter la discussion sur ces chirurgies entre les prestataires de soins primaires et les patients. Veuillez noter qu'elles ne sont pas exhaustives et ne remplacent pas le processus de consentement éclairé entre le chirurgien et le patient.

Souvent, les clients trans et de genre divers doivent voyager pour obtenir leurs chirurgies liées à la transition. Si la personne démontre un besoin financier et que la chirurgie est couverte par OHIP+, elle pourrait être admissible au transport aérien et à l'hébergement gratuit par le biais de Hope Air. Les fournisseurs de soins primaires peuvent soumettre une demande à Hope Air au nom de leur client.

Ce document, élaboré par le Centre de collaboration nationale de la santé autochtone, donne un aperçu de la santé des personnes bispirituelles, y compris une introduction sur les rôles et les identités bispirituelles, l'impact de la colonisation sur le sexe et la sexualité des Autochtones, les déterminants sociaux de la santé dans le contexte colonial, l'état de santé des personnes bispirituelles, la résilience et la résurgence, ainsi que les ressources éducatives supplémentaires.

Le Répertoire de prestataires de services de SAO est conçu pour vous aider à trouver des prestataires de services sociaux et de santé qui ont exprimé leur engagement à fournir des soins compétents et accueillants aux personnes LGBTQ2S+ en Ontario.

Ce guide a été élaboré par la Table de planification régionale de Champlain pour la santé des personnes trans, bispirituelles, intersexes et non binaires. Il présente les services médicaux, de santé mentale et communautaires ainsi que d’autres ressources qui pourraient être utiles aux parents et aux proches de jeunes trans et de jeunes non binaires de la région de Champlain.

Wisdom2Action et l'Association canadienne de santé publique ont créé un court guide pour soutenir les organisations dans le développement et la mise en œuvre de l'inclusion des trans dans les services sociaux et de santé. Le guide fournit un processus flexible que les organisations peuvent utiliser pour guider l'inclusion des personnes trans dans leur approche.

La création d'environnements cliniques et de prestations de soins invitants et inclusifs pour les trans est un moyen important de donner l'exemple de l'inclusivité et de démontrer votre engagement envers l'inclusion des trans. Wisdom2Action et l'Association canadienne de santé publique ont créé un guide sur la création d'un environnement de soins inclusif.

Pour un bref examen des termes à éviter ou à n'utiliser que dans des circonstances particulières, le guide de Wisdom2Action et de l'ACSP sur la terminologie préjudiciable peut être consulté ici.

Wisdom2Action et l'ACSP ont élaboré un court guide sur l'adoption d'un langage neutre pour vous aider à éviter les suppositions et pour favoriser la création d'espaces plus sûrs pour les communautés trans et diversifiées.

La mise en œuvre de formulaires d'admission inclusifs fait partie intégrante de la création d'un environnement inclusif pour les trans, tout en veillant à ce que les informations médicalement nécessaires soient recueillies de manière précise et appropriée.

La Table de planification régionale de Champlain pour la santé de personnes de diverses identités de genre a dressé une liste de ressources disponibles pour les prestataires de soins primaires afin de les aider à renforcer leurs connaissances, leur confiance et leurs compétences en matière de soins de santé liés à la transition, notamment en ce qui concerne le traitement hormonal substitutif.

Ce guide s'appuie sur le Guide de ressources pour la pluralité des genres de la région de Champlain créé par la Table de planification régionale de Champlain pour la santé des personnes trans, bispirituelles, intersexes et de genre divers. Il liste des services médicaux, de santé mentale et communautaires offerts aux personnes trans et non binaires à Ottawa et dans la région de Champlain.

Cette ressource a été développée pour aider les personnes trans et de genre différent à mieux défendre leurs intérêts et leurs besoins dans les services sociaux et de santé. La ressource comprend des informations visant à aider les personnes trans et de diverses identités de genre à se préparer à un rendez-vous lié à la prestation de services de soins de santé ou de services sociaux, à défendre leurs intérêts pendant un rendez-vous et à défendre leurs intérêts après un rendez-vous.

This guide, developed by interACT Advocates for Intersex Youth and Lambda Legal provides a set of model hospital policies aimed at promoting best practices to ensure appropriate, ethical, and quality care is being provided to intersex patients, and to address bias and insensitivity toward intersex patients and their families.

Developed by interACT Advocates for Intersex Youth, this tool provides people-centered, educational definitions about a wide variety of intersex variations and how they can manifest in people’s bodies.

Developed by interACT Advocates for Intersex Youth, this brochure provides insight into what intersex people wish their therapists knew.

This resource, created by Intersex Campaign for Equality, explores the critical impact of language in creating safe and welcoming environments for intersex community members.

Developed by the National LGBTQIA+ Health Education Center, this is a community-informed clinical guide on primary care for intersex people. The guide provides an overview of intersex terms and concepts, the health concerns of intersex people, intersex-affirming practices, and resources for further learning.

In this AAFP accredited webinar, organized by the National LGBTQIA+ Health Education Center, Dr. Katie Dalke defines intersex terminology, discusses diverse sexual development, and presents an affirming approach to providing medical and behavioural health care for people with intersex traits. (Credits can be claimed through CFPC).

Hosted by the Human Rights and Social Justice Program at Icahn Mount Sinai, in partnership with the Intersex Justice Project and interACT: Advocates for Intersex Youth, this recorded lecture covers intersex basics, human rights violations within medicine, medical and surgical research, diverse personal narratives of navigating the medical system as an intersex person, current Congenital Adrenal Hyperplasia (CAH) medical treatments, problems with “nerve-sparing” clitoroplasties, affirming, and gender inclusive and trauma-informed alternatives to the current standard of care.

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Why the long wait for sex reassignment surgery isn’t about to get better

Written by Erica Lenti

Mar 10, 2016

As of March 1, the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery.

If bodies were Airbnbs, Marcel’s would be a one-star stay. The bed sheets would feel too staticky, the light in the bathroom unflattering, the carpet a little too rough. Like renting an uncomfortable room from a stranger, such is how Marcel describes his dysphoria. But while shoddy rooms for rent can be left, Marcel can’t escape this. A transgender man in the throes of transition: he can’t feel at home in his body.

Marcel, whose name has been changed to protect his identity, started his transition four years ago. The first step was hormone replacement therapy, a ritual of two-millimetre needles of testosterone that he will give himself every day for the rest of his life. For the first few months of the therapy, Marcel rode his bike from downtown Toronto to suburban Mississauga to receive his shots from a transgender-friendly doctor.

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By 2012, Marcel was ready for top surgery – a bilateral mastectomy. At Toronto’s Centre for Addiction and Mental Health, the only institution in the province at which reassignment surgeries are covered by health insurance, a queue had formed. Faced with a minimum wait of two years, he scrounged up as much money as he could—a loan from his sister, funds raised by friends, paycheques from a nine-to-five job—and had the surgery at a private clinic. The procedure set him back $6,000. Today, Marcel awaits one last surgical procedure: lower reassignment surgery.

Marcel is among a large group of transgender Canadians seeking this procedure to reconstruct the genitals. Not all people who identify as transgender seek to transition medically or physically, but prospects remain grim for those who do. Several years have passed, but Marcel still doesn’t have the body he says he needs.

Even in a country as accepting and progressive as Canada, Marcel’s transition from female to male has been difficult. The situation has improved only slightly: As of March 1 , the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery. The Ontario government has also set aside $2 million to reduce the backlog from CAMH. But while the province’s efforts are intended to relieve the referral wait, such a move also threatens to create an even larger bottleneck at the only institution near Ontario that offers the surgeries.

Since 2008, when provincial funding for the procedures began, transgender Ontarians have had to work through a seemingly interminable process to fulfill their surgical requirements for transition. Top and lower surgery can cost upwards of $8,000 and $100,000 respectively (though the costs fluctuate depending on the surgeon). Typically, OHIP will cover these fees, provided that the person transitioning passes psychological and psychiatric assessments and is referred to a surgeon by a designated doctor or clinic.

Each province has its own policies and procedures, but a pattern has emerged: the number of institutions at which transgender people can be assessed in each province is paltry, so there’s almost always a queue. Alberta boasts two qualified doctors. In B.C., there’s one. Prior to the province’s announcement, in Ontario the wait list for assessments at CAMH had swelled to more than 1,500.

“Certainly the demand has increased over the past five to 10 years, as people have found a word to describe their circumstances,” says Dr. Amy Bourns, a physician who specializes in transgender care at Toronto’s Sherbourne Health Centre.

Under new legislation, health-care providers who want to make assessments and referrals for transgender patients must undergo training that complies with standards set by the World Professional Association for Transgender Health, an Illinois-based organization. Currently, there is no word on whether this training will be mandatory.

Meanwhile, as the Globe and Mail has reported, doctors are urging transgender Ontarians to stay on the CAMH waitlist until “things get sorted out .”

On a Sunday in 2014 Marcel gave up waiting. No point in trying to get cozy in his body, he told himself. At that point, his wait for an appointment at CAMH could have taken as long as five years. He was just 26; he would be into his 30s before getting a referral. With no easy fix in sight, he says he hid under the covers and sobbed, his brain flooded with negative images. In his bedroom that night, he attempted suicide. His last thought before unconsciousness: I can’t believe I’m going to be another statistic.

Hours later, Marcel’s best friend found him passed out in bed. “I did not expect to wake up,” Marcel says. “That was hellish in its own right.” Even worse, he feared the idea of going to the hospital and being misgendered by doctors. His loved ones were able to convince him to visit his family doctor, who assessed the situation.

“The [prolonged] wait is something I couldn’t mentally last,” Marcel tells me a year and a half after his suicide attempt. While the long wait for assessment can perpetuate mental health issues in transgender Ontarians, acknowledging these issues can create setbacks for them; psychologists will often deem suicidal patients unfit for referral.

Even if assessments become more widely available, yet another bottleneck will occur: a queue for the actual surgeries. Just one clinic in the country performs lower surgery, and it’s in Montreal, headed by Dr. Pierre Brassard and Dr. Maud Bélanger; as a result, many are already choosing to have the surgery elsewhere, in the U.S. or Europe. The current wait list at Brassard and Bélanger’s clinic is six months.  According to Bourns, the two surgeons could increase their output, but not enough to prevent an even longer queue from forming.

Bourns says some surgeons have shown an interest in learning the ins and outs of reassignment surgery, but many aren’t committed to perfecting the craft. “There have been inquiries from surgeons who want to come for a week to train with Dr. Brassard, but it would require something more like a six-month residency for them to learn to do the surgery,” she says. In recent years, medical schools have begun to incorporate training specific to LGBTQ patients, with organizations such as Rainbow Health Ontario spearheading the cause. But only those with a specific interest in performing reassignment surgery are likely to learn about and train to execute the procedure.

As a result, patients are searching for alternatives. Marcel considered heading to Thailand for the procedure, but his doctor advised against it. (Many Canadians go anyway, because of the low cost. Vaginoplasty, for instance, starts at just $12,000, in comparison to about $50,000 in Canada.) Instead, he ponied up as much cash as he could and found a private gender therapist with the qualifications to assess and refer him to an OHIP-approved surgeon in San Francisco; so long as a transgender Ontarian has letters of assessment (from a CAMH therapist or a much more costly private therapist), OHIP will cover the cost of surgery out-of-province. Patients who go this route have to pay for their own travel and accommodations. After a half-year wait, Marcel has a consultation with the San Francisco surgeon this month, but what comes after that is still unknown.

Bourns suggests travelling for reassignment surgery could raise other issues. For one, she says, Canadian doctors could be unwilling to work with patients who experience complications from surgeries abroad. “That means they'll have to hop back on a flight to correct something like issues with urination,” she says. Until more surgeons practise in Canada, small corrections to these major surgeries could be incredibly costly.

“I realize I’m privileged,” Marcel says. He has a career, a modest but homey apartment, a puppy. These are not common comforts: Many transgender Ontarians live below the poverty line and private therapists are not an option.

Marcel says he thinks about time often. It is the barrier that keeps him from his true self. It’s what stops him from using public washrooms. There is no fast-forward button.

“I’ve always yearned for transition to end,” he says. “I feel stagnant right now. I don’t know where I’m moving.”  But, the way Marcel puts it, he does know where he’d like to be at: the sensation of coming home, of leaving a strange abode. Here, the sheets are crisp and the light natural. Here, there is comfort.

Erica Lenti is a Toronto-based freelance journalist who covers mental health, LGTBQ and women’s issues.

Erica Lenti

Erica Lenti is a Toronto-based writer and the deputy editor, features at Chatelaine. 

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Vatican says sex reassignment surgery, surrogacy and gender theory threaten human 'dignity'

The Vatican has declared gender confirmation operations and surrogacy as grave threats to human "dignity", putting them on par with abortion and euthanasia as practices that violate God's plan for human life.

The Vatican's doctrine office on Monday published a 20-page declaration titled Infinite Dignity that was in the works for the past five years.

It was approved for publication by Pope Francis on March 25 after substantial revision in recent months.

In its most eagerly anticipated section, the Vatican reiterated its rejection of "gender theory" or the idea that one's gender can be "a self-determination".

It said God created man and woman as biologically different, separate beings, and said they must not tinker with that plan or try to "make oneself God".

"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said.

It distinguished between transitioning surgeries, which it rejected, and "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health care professionals, it said.

The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close confidante of Pope Francis.

He had cast it as something of a nod to conservatives after he authored a more explosive document approving blessings for same-sex couples that sparked criticism from conservative bishops around the world, especially in Africa.

While the new document rejected gender theory, it took pointed aim at countries — including many in Africa — that criminalise homosexuality.

It echoed Pope Francis's assertion in a 2023 interview that "being homosexual is not a crime", making the assertion now part of the Vatican's doctrinal teaching.

It denounced "as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation".

The document restated well-known Catholic doctrine opposing abortion and euthanasia.

It also added to the list some of Pope Francis's main concerns as pope: the threats to human dignity posed by poverty, war, human trafficking and forced migration.

A child's right to 'a fully human origin'

In a newly articulated position, the declaration said surrogacy violated both the dignity of the surrogate mother and the child.

While much attention on surrogacy has focused on possible exploitation of poor women as surrogates, the Vatican document focuses more on the resulting child.

"The child has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver," the document said.

"Considering this, the legitimate desire to have a child cannot be transformed into a 'right to a child' that fails to respect the dignity of that child as the recipient of the gift of life."

The Vatican published its most articulated position on gender in 2019, when the Congregation for Catholic Education rejected the idea that people can choose or change their genders.

It insisted on the complementary nature of biologically male and female sex organs to create new life.

Gender fluidity was described as a symptom of the "confused concept of freedom" and "momentary desires" that characterise post-modern culture.

The new document from the more authoritative Dicastery for the Doctrine of the Faith quoted from that 2019 education document but tempered the tone.

Significantly, it did not repurpose the 1986 language of a previous doctrinal document saying that homosexual people deserve to be treated with dignity and respect but that homosexual actions are "intrinsically disordered".

Francis has made reaching out to LGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, describing it as an "ugly ideology" that threatens to cancel out God-given differences between man and woman.

"It needs to be emphasised that biological sex and the sociocultural role of sex (gender) can be distinguished but not separated," the new document said.

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Vatican Document Casts Gender Change and Fluidity as Threat to Human Dignity

The statement is likely to be embraced by conservatives and stir consternation among L.G.B.T.Q. advocates who fear it will be used as a cudgel against transgender people.

By Jason Horowitz and Elisabetta Povoledo

Reporting from Rome

The Vatican on Monday issued a new document approved by Pope Francis stating that the church believes that gender fluidity and transition surgery, as well as surrogacy, amount to affronts to human dignity.

The sex a person is assigned at birth, the document argued, was an “irrevocable gift” from God and “any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.” People who desire “a personal self-determination, as gender theory prescribes,” risk succumbing “to the age-old temptation to make oneself God.”

Regarding surrogacy, the document unequivocally stated the Roman Catholic Church’s opposition, whether the woman carrying a baby “is coerced into it or chooses to subject herself to it freely.” Surrogacy makes the child “a mere means subservient to the arbitrary gain or desire of others,” the Vatican said in the document, which also opposed in vitro fertilization.

The document was intended as a broad statement of the church’s view on human dignity, including the exploitation of the poor, migrants, women and vulnerable people. The Vatican acknowledged that it was touching on difficult issues, but said that in a time of great tumult, it was essential, and it hoped beneficial, for the church to restate its teachings on the centrality of human dignity.

Even if the church’s teachings on culture war issues that Francis has largely avoided are not necessarily new, their consolidation now was likely to be embraced by conservatives for their hard line against liberal ideas on gender and surrogacy.

The document, five years in the making, immediately generated deep consternation among advocates for L.G.B.T.Q. rights in the church, who fear it will be used against transgender people. That was so, they said, even as the document warned of “unjust discrimination” in countries where transgender people are imprisoned or face aggression, violence and sometimes death.

“The Vatican is again supporting and propagating ideas that lead to real physical harm to transgender, nonbinary and other L.G.B.T.Q.+ people,” said Francis DeBernardo, the executive director of New Ways Ministry, a Maryland-based group that advocates for gay Catholics, adding that the Vatican’s defense of human dignity excluded “the segment of the human population who are transgender, nonbinary or gender nonconforming.”

He said it presented an outdated theology based on physical appearance alone and was blind to “the growing reality that a person’s gender includes the psychological, social and spiritual aspects naturally present in their lives.”

The document, he said, showed a “stunning lack of awareness of the actual lives of transgender and nonbinary people.” Its authors ignored the transgender people who shared their experiences with the church, Mr. DeBernardo said, “cavalierly,” and incorrectly, dismissing them as a purely Western phenomenon.

Though the document is a clear setback for L.G.B.T.Q. people and their supporters, the Vatican took pains to strike a balance between protecting personal human dignity and clearly stating church teaching, a tightrope Francis has tried to walk in his more than 11 years as pope.

Francis has made it a hallmark of his papacy to meet with gay and transgender Catholics and has made it his mission to broadcast a message for a more open, and less judgmental, church. Just months ago, Francis upset more conservative corners of his church by explicitly allowing L.G.B.T.Q. Catholics to receive blessings from priests and by allowing transgender people to be baptized and act as godparents .

But he has refused to budge on the church rules and doctrine that many gay and transgender Catholics feel have alienated them, revealing the limits of his push for inclusivity.

“In terms of pastoral consequences,” Cardinal Víctor Manuel Fernández, who leads the Vatican’s office on doctrine, said in a news conference Monday, “the principle of welcoming all is clear in the words of Pope Francis.”

Francis, he said, has repeatedly said that “all, all, all” must be welcomed. “Even those who don’t agree with what the church teaches and who make different choices from those that the church says in its doctrine, must be welcomed,” he said, including “those who think differently on these themes of sexuality.”

But Francis’ words were one thing, and church doctrine another, Cardinal Fernández made clear, drawing a distinction between the document, which he said was of high doctrinal importance, as opposed to the recent statement allowing blessings for same-sex Catholics. The church teaches that “homosexual acts are intrinsically disordered.”

In an echo of the tension between the substance of church law and Francis’ style of a papal inclusivity, Cardinal Fernández said on Monday that perhaps the “intrinsically disordered” language should be modified to better reflect that the church’s message that homosexual acts could not produce life.

“It’s a very strong expression and it requires explanation,” he said. “Maybe we could find an expression that is even clearer to understand what we want to say.”

Though receptive to gay and transgender followers, the pope has also consistently expressed concern about what he calls “ideological colonization,” the notion that wealthy nations arrogantly impose views — whether on gender or surrogacy — on people and religious traditions that do not necessarily agree with them. The document said “gender theory plays a central role” in that vision and that its “scientific coherence is the subject of considerable debate among experts.”

Using “on the one hand” and “on the other hand,” language, the Vatican’s office on teaching and doctrine wrote that “it should be denounced as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation.”

“At the same time,” it continued, “the church highlights the definite critical issues present in gender theory.”

On Monday, Cardinal Fernández also struggled to reconcile the two seemingly dissonant views.

“I am shocked having read a text from some Catholics who said, ‘Bless this military government of our country that created these laws against homosexuals,’” Cardinal Fernández said on Monday. “I wanted to die reading that.”

But he went on to say that the Vatican document was itself not a call for decriminalization, but an affirmation of what the church believed. “We shall see the consequences,” he said, adding that the church would then see how to respond.

In his presentation, Cardinal Fernández described the long process of the drafting of a document on human dignity, “Infinite Dignity,” which began in March 2019, to take into account the “latest developments on the subject in academia and the ambivalent ways in which the concept is understood today.”

In 2023, Francis sent the document back with instructions to “highlight topics closely connected to the theme of dignity, such as poverty, the situation of migrants, violence against women, human trafficking, war, and other themes.” Francis signed off on the document on March 25.

The long road, Cardinal Fernández wrote, “reflects the gravity” of the process.

In the document, the Vatican embraced the “clear progress in understanding human dignity,” pointing to the “desire to eradicate racism, slavery, and the marginalization of women, children, the sick, and people with disabilities.”

But it said the church also sees “grave violations of that dignity,” including abortion, euthanasia, the death penalty, polygamy, torture, the exploitation of the poor and migrants, human trafficking and sex abuse, violence against women, capitalism’s inequality and terrorism.

The document expressed concern that eliminating sexual differences would undercut the family, and that a response “to what are at times understandable aspirations,” will become an absolute truth and ideology, and change how children are raised.

The document argued that changing sex put individualism before nature and that human dignity as a subject was often hijacked to “justify an arbitrary proliferation of new rights,” as if “the ability to express and realize every individual preference or subjective desire should be guaranteed.”

Cardinal Fernández on Monday said that a couple desperate to have a child should turn to adoption, rather than surrogacy or in vitro fertilization because those practices, he said, eroded human dignity writ large.

Individualistic thinking, the document argues, subjugates the universality of dignity to individual standards, concerned with “psycho-physical well-being” or “individual arbitrariness or social recognition.” By making dignity subjective, the Vatican argues, it becomes subject to “arbitrariness and power interests.”

Jason Horowitz is the Rome bureau chief for The Times, covering Italy, the Vatican, Greece and other parts of Southern Europe. More about Jason Horowitz

Elisabetta Povoledo is a reporter based in Rome, covering Italy, the Vatican and the culture of the region. She has been a journalist for 35 years. More about Elisabetta Povoledo

WA’s ‘cruel’ Gender Reassignment Board to be abolished

T he state government will abolish the controversial Gender Reassignment Board under a bill to overhaul the “cruel” legal process for gender recognition and bring Western Australia in line with the rest of the country.

Premier Roger Cook announced the bill would be introduced on Tuesday, which will see the board scrapped and the removal of the requirement to undergo surgical reassignment to legally register a change of sex.

Under the proposed administrative process, the Births, Deaths and Marriages registrar will be responsible for determining the gender recognition on a birth certificate, which will be done via an application.

The only evidence required to support an application will be a letter from a medical practitioner or psychologist confirming the person has undergone the appropriate clinical treatment.

The new process, which will allow West Australians to identify as non-binary, will not be accessible to children under the age of 18 without the consent of both parents.

For children under 12, the gender on their birth certificate cannot be changed without the approval of the Family Court.

Those relocating to Australia from overseas will also be able to obtain a gender recognition certificate.

The bill also contains a host of safeguards, which will prohibit certain classes of offenders or people on community service orders from applying to change their gender on their birth certificate.

Cook said the social reforms, which have been promised for two years, were consistent with the recommendations made by the Law Reform Commission in 2018 and brought WA into line with other states and territories.

“It’s important that these reforms are done properly… everyone deserves respect and dignity and to have their legal identity aligned with their lived identity,” he said.

“These reforms are about dignity, but most importantly, they’re about equality.”

Attorney General John Quigley said the bill was hardly earth-shattering, conceding the rest of the country had already implemented the changes, but would bring WA “out of the dark ages”.

TransFolk of WA spokesperson Dylan Green welcomed the changes, describing the previous process as “humiliating”, “inhumane” and “cruel”.

The move was also backed by former AFL star Danielle Laidley, who said she had been deterred from legally changing her gender in her home state because the process was “archaic” and allowed someone else to tell her who she was.

But Green said while the proposed legislation was welcomed, it was not in step with best practice employed in other jurisdictions, which have done away with the need for clinical evidence in favour of a self-determination model.

“The abolition of the gender reassignment board will allow trans and gender diverse West Australians an approved pathway to align their legal documentation more closely with their gender identity,” Green said.

“But we will be making further recommendations to the government regarding the bridging regulations for this proposed bill and advocating for further reform that we have seen interstate.”

The number of applications to the board has skyrocketed over the past 15 years, from five in 2008/09 to 80 in 2022/23.

And Green said many were deterred by the process because it was often lengthy and very costly.

The reforms are the first tranche of the state government’s pledge to improve the lives of those in the LGBTQIA+ community, the second of which will focus on developing a new Equal Opportunity Act and a ban on gay conversion therapies.

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The 10 Buzziest Releases Coming to Cannes in 2024—From a Selena Gomez Musical to Sebastian Stan’s Take on Donald Trump

By Radhika Seth

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The line-up at last year’s Cannes Film Festival —which included a staggering eight films that went on to be nominated for Oscars, among them best-picture contenders Anatomy of a Fall , The Zone of Interest , and Killers of the Flower Moon —was one of the strongest in years, cementing the festival’s reputation as the ultimate awards season launchpad. So, naturally, the illustrious French showcase has put together an even starrier shortlist for its 77th edition, due to run from May 14 to 25. Greta Gerwig will serve as jury president, George Lucas is due to receive the honorary Palme d’Or for lifetime achievement, and the releases on the roster range from mind-blowing action epics to surreal musical comedies and one particularly breathlessly anticipated (and expertly timed) political biopic. These are the 10 films you need to look out for.

Furiosa: A Mad Max Saga

Almost a decade after George Miller’s high-octane, nerve-jangling, running-on-fumes blockbuster Mad Max: Fury Road thundered into theaters, the visionary is back with an equally ambitious prequel, casting Anya Taylor-Joy as the titular road warrior previously embodied by a steely Charlize Theron. Snatched from the mythical “green place” as a child, she journeys across the wasteland to the citadel ruled by Immortan Joe, but once she comes of age, she vows to escape by any means necessary. Add Chris Hemsworth as a mustache-twirling warlord, Tom Burke as a warpaint-covered love interest, gasp-inducing stunts, eye-popping explosions, and an appropriately booming soundtrack, and you have a big-screen spectacle like no other.

Kinds of Kindness

Yorgos Lanthimos’s madcap follow-up to Poor Things zips us from a mind-bending Victorian London to the present—or, at least, a (characteristically bonkers) version of it—in which double Oscar winner Emma Stone dances with reckless abandon as cars are nearly crashed and bodies are dragged down hallways . A three-part sci-fi anthology which also stars Hunter Schafer, Joe Alwyn, Margaret Qualley, Hong Chau, Willem Dafoe, Jesse Plemons, and Mamoudou Athie, it looks set to be a surreal romp from an auteur who is, undeniably, at the peak of his powers.

The Apprentice

After making a splash at Cannes in 2018 with the Swedish fantasy Border , and then again in 2022 with the Persian-language thriller Holy Spider , Ali Abbasi returns to the Croisette with something far more conventional, though no less exciting: an account of Donald Trump’s rise in ’70s and ’80s New York, with Pam & Tommy ’s Sebastian Stan donning prosthetics and a blonde wig to play a younger iteration of the former president. Meanwhile, a still-very-much-Kendall-Roy-adjacent Jeremy Strong takes the role of Roy Cohn, the prosecutor and fixer who acted as Trump’s mentor, while Borat Subsequent Moviefilm ’s Maria Bakalova becomes the aspiring real estate tycoon’s first wife, Ivana, and Martin Donovan his father, businessman Fred Trump. With the next presidential election looming and the film’s real-life subject still neck and neck with Joe Biden in the polls , this examination of corruption and deceit couldn’t feel more timely.

Megalopolis

A passion project that’s been over two decades in the making, Francis Ford Coppola’s first big-screen release since 2011 is easily the festival’s most-talked-about Palme d’Or contender: a debauched and decadent cautionary tale about America’s future, with a star-packed cast featuring everyone from Adam Driver and Aubrey Plaza to Giancarlo Esposito, Chloe Fineman, and Nathalie Emmanuel. Early viewers’ responses have ranged from shock and bafflement to euphoria, though all agree that the 135-minute epic—which has, tellingly, still not secured a distribution deal—is an audacious piece of work. Cannes will be crucial to determining its fate: there’s a chance it could dazzle audiences and scoop the top prize (as another long-gestating and once seemingly cursed Coppola project, Apocalypse Now , did back in 1979), or it could be a major misfire. Either way, the entire industry will be watching with bated breath.

Emilia Perez

By Margaux Anbouba

By Hannah Coates

By Christian Allaire

Selena Gomez, Zoe Saldaña, Édgar Ramírez, and Karla Sofía Gascón lead this musical crime caper from Palme d’Or winner Jacques Audiard, which centers on a lawyer who receives an unexpected request: to aid a formidable Mexican cartel boss who wishes to retire from the business and undergo sex reassignment surgery—the latter, both to evade authorities and to finally affirm her gender. With original songs penned by French singer Camille, and Saint Laurent’s Anthony Vaccarello creating the costumes and serving as a co-producer, it’s guaranteed to be a wild and stylish ride.

A pitch-black political comedy helmed by Guy Maddin, Evan Johnson, and Galen Johnson, this satire follows the seven leaders of the world’s wealthiest liberal democracies at the annual G7 summit as they become lost in the woods and face ever-increasing peril while attempting to draft a provisional statement regarding a global crisis. Dressed in a pastel pink suit and wispy wig in the first released footage , its star, Cate Blanchett, looks like an amalgamation of Margaret Thatcher and Hillary Clinton, though Cannes’s festival director, Thierry Frémaux, has said that she’s something closer to the president of the European Commission, Ursula von der Leyen. Joining her are fellow power players Alicia Vikander and Charles Dance, with the cast rounded out by the likes of Persuasio n’s Nikki Amuka-Bird, Inglourious Basterds ’s Denis Ménochet, Giri/Haji ’s Takehiro Hira, and Triangle of Sadness ’s Zlatko Burić. Prepare for mayhem.

Paul Schrader—best known for penning Taxi Driver and Raging Bull , as well as directing American Gigolo and First Reformed —has secured a stellar ensemble for his latest portrait of male anguish, an adaptation of the searing Russell Banks novel Foregone : Uma Thurman, Michael Imperioli, Kristine Froseth, Richard Gere, and Jacob Elordi. The latter pair play older and younger incarnations of the protagonist, an enigmatic American documentarian who fled to Canada during the Vietnam War and now, decades later, finds himself on the brink of death. As he looks back on his youth, he’s forced to confront the foundational lies of his past and come to terms with his own mortality.

Horizon: An American Saga

Yellowstone fans, assemble: Kevin Costner is helming and starring in this sweeping new drama chronicling the true cost of the settlement of the American West, the first film in what the industry stalwart hopes will ultimately be a barnstorming four-part saga. Lending support in and amongst the gun fights and nocturnal ambushes are Sienna Miller, Jena Malone, Sam Worthington, Luke Wilson, Owen Crow Shoe, Tatanka Means, Danny Huston, Abbey Lee, Jamie Campbell Bower, Glynn Turman, and Giovanni Ribisi.

Barry Keoghan trades Oliver’s antlers and embroidered blazer in Saltburn for tattoos, gold jewelry, and a flat cap for Andrea Arnold’s first scripted film since 2016’s American Honey , another account of renegades living on the fringes of society. Opposite him is Passages ’s Franz Rogowski, as well as Top Boy ’s Jasmine Jobson, Industry ’s James Nelson-Joyce, and newcomer Nykiya Adams. Plot details are still shrouded in mystery, but given the director’s impressive track record (the BAFTA-winning Red Road and Fish Tank , the Oscar-winning short Wasp ), not to mention Keoghan’s habit of choosing challenging, provocative, and awards-worthy projects, expectations are sky-high.

The Substance

In this blood-soaked feminist body horror, Demi Moore, Margaret Qualley, and Dennis Quaid are under the direction of Coralie Fargeat, who proved her capacity to thrill (and her stomach for gore) with her breathless, candy-colored 2017 action movie Revenge . It promises to be a pulpy delight, with Thierry Frémaux likening it to Julia Ducournau’s recent Palme d’Or winner Titane —a good omen for its competition chances, if there ever was one.

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Trump says abortion should be left to states; Vatican takes stance on gender theory

Mansee Khurana

Today's top stories

Former President Donald Trump made a long-awaited announcement regarding his position on abortion policy. In a video released on Monday on Truth Social, Trump said that "you must follow your heart" on the issue of abortion, and that the issue of abortion should be left to the states. Since the overturn of Roe v. Wade In 2022, voters have repeatedly voted in favor of greater abortion rights in state-level ballot measures, even in red states like Kansas and Kentucky.

Former U.S. President Donald Trump is seen at the driving range during day three of the LIV Golf Invitational in April 2024. Megan Briggs/Getty Images hide caption

Former U.S. President Donald Trump is seen at the driving range during day three of the LIV Golf Invitational in April 2024.

• Trump's in a tough spot when it comes to abortion , NPR's Domenico Montanaro  explains on  Up First.  That's because Trump appointed three conservative justices during his presidency, which made it possible for  Roe v. Wade  to be overturned. Trump also knows that this ruling hurt Republicans in the elections that came after  Roe V. Wade  was overturned. "Trump is very much aware of the mobilizing effect of the Supreme Court actions, in favor of the Democrats," Lee Miringoff, director of the Marist College Institute for Public Opinion said. With this recent announcement, Trump is essentially abandoning the issue, Montanaro explains. But that doesn't mean voters will too. NPR's polling shows that college educated white women are shifting towards Biden this election.  

The Vatican released a new document calling abortion, surrogacy and gender theory "grave threats'' facing humanity today. The document argues that if a person is made in God's image, gender theory and gender reassignment surgery call into question why God would create a person with the wrong gender. The document also argues that the understanding of humanity as two sexes — male and female — is biblical and deeply meaningful, especially in terms of procreation.

• NPR's Jason DeRose explains that the Vatican does not see this as a move away from its existing teachings.  Just last year, Pope Francis allowed priests to bless people in same-sex marriages. This new document continues to allow priests to bless same-sex couples. But it makes a  clear distinction between  the issue of sexual orientation – whether a person is gay, lesbian or bisexual – and the issue of gender identity – whether a person's sex assigned at birth matches what that person understands his or her gender to be. DeRose explains that while the church may have more progressive views about sexual orientation, the language in this document is very similar to how conservatives often talk about being transgender as a choice, which is something major medical and psychological groups dispute. 

Missouri Governor Mike Parson has said that Brian Dorsey will be executed in Missouri tonight despite a coalition advocating against his execution. Dorsey pleaded guilty to killing his cousin and her husband in central Missouri in 2006. Advocates for Dorsey argue that he shouldn't be executed for two reasons: First, Dorsey's attorneys were paid a flat fee of $12,000 by the Missouri Public Defenders office, which his current lawyers say incentivized them to do as little work as possible and push Dorsey to plead guilty without trying to get the death penalty off the table. The second reason is whether Dorsey was in a drug induced psychosis when he committed the murders. If he was, then his attorneys argue that he wouldn't fit the confines of first-degree murder — and is therefore not eligible for the death penalty.

• Roughly 62% of Missourians support the death penalty  in the case of first-degree murder, according to a  SLU/YouGov poll. And both Republican and Democratic governors in Missouri have supported capital punishment. Death penalty opponents, like State Rep. Tony Lovasco, says that the only way to change that attitude is if  someone innocent is executed.  And though this is definitely not the case for Dorsey, his case does prompt some big questions about the legal system in the state. "I think it's important that we focus on the technical aspects of the case and the criminal justice system and really how this fits into public policy at large," Lovasco told NPR.

Katherine De Peña, left, a field organizer in charge of Make The Road Pennsylvania's voter registration program, and her colleague Mayra Del Toro wait to greet eligible voters in Spanish outside a CTown supermarket in Reading, Pa. Hansi Lo Wang /NPR hide caption

Katherine De Peña, left, a field organizer in charge of Make The Road Pennsylvania's voter registration program, and her colleague Mayra Del Toro wait to greet eligible voters in Spanish outside a CTown supermarket in Reading, Pa.

Asian Americans and Latinos are two of the fastest-growing U.S. voter groups, yet registration rates for both trail far behind those of white adults. While community organizers are trying to close the gap, some challenges will need dedicated investment to overcome.

• Many eligible voters are naturalized U.S. citizens who are too busy  navigating daily life in a new country – and working – to learn a complicated new political system. For some, taking a day off work to vote may not be an option.  
• Those who are interested in politics are often ignored by political campaigns.  Those casting ballots for the first time are often seen as "low-propensity" voters by campaigns and are less likely to be targeted. 
• Systemic barriers affecting people of color continue to persist,  even after the passage of landmark legislation like the Voting Rights Act of 1965. But organizers say change takes time, and as one of them put it, "We got this like within five, 10 years." 

Picture show

People watch in awe outside the Great Lakes Science Center in Cleveland as the totality of the solar eclipse occurs. Ryan Loew/Ideastream Public Media hide caption

People watch in awe outside the Great Lakes Science Center in Cleveland as the totality of the solar eclipse occurs.

Yesterday's total solar eclipse may have lasted only four minutes, but its impact on popular culture, media and the country has certainly lasted longer. Houlton, Maine, the final U.S. city in the eclipse's path, spent the last two years planning the city's festivities. One museum official in Muncie, Indiana, told NPR the city was expecting some 100,000 visitors — nearly doubling the population.

• From Indiana to Maine, NPR was there to document it all.  Check out the pictures that our network captured – from high resolution images of the moment of totality in the sky to the  reactions of people on the ground

Before you go

TOPSHOT - A mother humpback whale and calf are seen on the coast of Vitoria, Espirito Santo state, Brazil on August 22, 2023. CARL DE SOUZA/AFP via Getty Images hide caption

TOPSHOT - A mother humpback whale and calf are seen on the coast of Vitoria, Espirito Santo state, Brazil on August 22, 2023.

• Indigenous leaders in New Zealand have signed a treaty granting whales legal personhood  in an effort to pressure governments to do more to  protect the sea mammals , which are the sacred ancestors of indigenous Polynesians.
• A man was arrested for an alleged arson attack on Senator Bernie Sanders' office  in Vermont. The attack  damaged the building , but the occupants of the building were unharmed. 
• The University of Connecticut's men's basketball team won the NCAA championship Monday night.  The Huskies defeated Purdue University  by 15 points , becoming the first team in 17 years to win back-to-back championships. 

This newsletter was edited by Treye Green and Obed Manuel. Anandita Bhalerao contributed.