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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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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History of GCS in Ontario

Coverage for gender confirmation surgery (GCS) has a long a complicated history in the province of Ontario. These procedures, previously and incorrectly referred to as sex reassignment surgery (SRS), became delisted under the provincial healthcare plan in 1998 in the early days of the new Conservative government. It was only through the fervent work of transgender activists throughout the province that coverage was eventually reinstated in 2008. 

Martine tells the story of coverage for GCS in Ontario before the 1998 delisting. During this period, individuals had to complete a rigorous program at the Gender Identity Clinic of the Clarke Institute of Psychiatry (later CAMH), as well as other requirements from government agencies such as OHIP. In particular, Martine shares how one of the hurdles imposed by the health care system in Ontario at the time was requiring individuals to publicly live in their genders for a period of two years before accessing GCS. This included changing their names and designations where possible, a process that she recalls as extremely challenging given that there was an 18-month backlog just to change the name on a birth certificate. In addition, the Gender Identity Clinic would subject patients to a number of physical and psychological tests that individuals often found uncomfortable, offensive, and inappropriate. After completing the extensive program at the Clinic, individuals would then be referred for GCS, which at the time did not cover breast operations in transgender women. 

However, the newly-elected Conservative government under Mike Harris suddenly delisted coverage for these procedures in 1998. Martine recalls going through newspapers at the Toronto Reference Library and finding out that the governmental push to delist coverage for GCS started in 1992. At the time, the New Democratic Party in charge considered delisting coverage for the procedures as part of its austerity package at the time, deciding to retain it at the last minute as it was considered an essential service. This decision was criticized by the Conservative party, who argued that such funding should not persist while other cuts are being made. This reaction started a chain of events where coverage for GCS was used as a minor but present partisan issue throughout the 1990s, as Martine discovered that in 1995 the Conservative party once more denounced to the NDP government that coverage should be removed. Indeed, Martine recalls Jim Wilson, the Minister of Health of the newly-elected Conservative government, publicly expressing that "sex changes have gotta go" as one of his first statements while announcing a set of OHIP rollbacks in 1996. Interestingly, Wilson retained coverage for GCS as he ultimately deemed it a necessary service, angering the Conservative party and resulting in his eventual replacement with Elizabeth Witmer. Witmer eventually followed through with the Conservative goal to delist coverage for GCS, which became official on October 1st, 1998. As of this date, no patients who hadn't already been approved by the Gender Identity Clinic for GCS could receive provincial funding for the procedure.

This decision caused immediate uproar in the transgender community. A number of influential transgender activists, such as Susan Gapka, Martine Stonehouse, and Ki Namaste pressured government officials, community members, and academic researchers in order to raise awareness of the precarious state of transgender health and wellbeing in the province. Narrators describe the Harris years as challenging and demoralizing for the queer and transgender liberation movement. Nick Mule, for example, recalls how this administration completely ignored the results of Project Affirmation which looked at the state of LGBTQ2+ health in the provice. While some of these challenges endured during the subsequent Liberal government in 2003, many narrators agreed that they were able to push forward with their demands during this period. George Smitherman served as Minister of Health for this administration, and as an out gay man, many LGBTQ2+ rights activists took advantage of this connection to pressure the government for better access to health care. During this time, Martine together with other three transgender people had a case against the province at the Ontario Human Rights Commission, which started as a result of the delisting of GCS in 1998. Although the pressure surmounted for the Liberals to relist coverage it would still be a few years until they did so. 

During this decade, activists worked nonstop in their push for queer and transgender liberation. Rainbow Health Network emerged as a group of volunteers who met at Sherbourne Health Centre to discuss the state of LGBTQ2+ health and wellness in the province. RHN, together with SHC, were successful in drafting the proposal for what would eventually become Rainbow Health Ontario, a province-wide LGBTQ2+ health framework. As well, the Trans Lobby Group formed as an offshoot of the RHN, as it wanted to centre transgender lives and narratives away from the largely theoretical focus on gay and lesbian rights employed by the latter. This group, partly composed by Susan Gapka, Rupert Raj, and Martine Stonehouse, had a long history of lobbying and engaging politicians on the matter of transgender rights and health care, often crashing political events to push forth their liberationist agenda. 

On June 3rd, 2008, after nearly an entire decade on relentless activism from the transgender community, the Liberal government quietly reinstated coverage for GCS under OHIP, to the surprise of many in the community. Worryingly, the guidelines employed by CAMH and used until 1998 would be used after the relisting, which alerted many activists. Susan Gapka, in particular, was instrumental in communicating to the government how harmful and damaging these policies were, as they asked individuals to live in their genders for two years before being considered for GCS. These policies required transgender patientd to be approved by a number of specialists and boards before receiving recommendation for their surgery, placing an unjust restriction on their right to access publicly-covered medical procedures. These guidelines were eventually ammended through the work of transgender activists as well as Rainbow Health Ontario, which emphasized the role of local, primary health centres in providing transgender healthcare away from relying on the centralized power of CAMH. This model proved successful in allowing transgender patients to access most of their mental and physical health needs through their primary providers, although some narrators lament how many surgical procedures can only be provided by a handful of centres, particularly the GCS clinic in Montreal. 

Despite the hurdles and challenges associated with the delisting and relisting of GCS, most narrators agree that this fight helped solidify the transgender liberation movement in Ontario, breaching some of the divides and ruptures existing within the community. As well, many argued that this fight eventually led to the passage of Toby's Law, otherwise known as Bill 33, which added gender identity and gender expression to the Ontario Human Rights Code. This decision was the result of a triparty agreement and at the time was the most comprehensive of such laws in North America, extending to area such as housing and education. However, some narrators like Cheri DiNovo argue that it is not enough to add protections for transgender people under human rights law, but rather, this has to extend to every extent of social law and public programs as well.

The fight for transgender rights in Ontario has existed for as long as transgender people have resisted and organized against their marginalization, disenfranchisement, and exclusion from the legal system and mainstream society. The activism around the delisting and relisting of GCS represents only a fraction of the hard work that many transgender people have contributed to demand rights, freedom, and justice. Nonetheless, it symbolizes the undying spirit of many who fight this cause, and the large amount of work that remains to be done in order to ensure that Ontario is a welcoming space for all transgender people. Moving forward, the trans rights movement in the province needs to centre those who are the most excluded from our present social, political, and economic systems. By engage with decolonial, anti-racist practices that centre the voices of First Nations and Black individuals in the fight for trans liberation, this movement can adequately fight the systems of oppression that continue to marginalize transgender people across the world.

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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

The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan Gwun D, Snow B, Potter E, Walker RL, Millman AL, Krakowsky Y, Lorello GR, Du Mont J, Barker LC, Lezard P, Sivagurunathan M, Urbach DR, Armstrong K. BMC Health Serv Res. 2024 Aug 10;24(1):916.

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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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Feminizing Hormone Therapy

The goal of hormone therapy in transfeminine patients is to reduce the endogenous effects of testosterone such as a coarse body hair and facial hair; and to induce feminine secondary sex characteristics such as breast and hip development, in keeping with the patient’s individual goals. Physiologically, this requires a suppression of endogenous androgens and the addition of estrogen.

Quick reference guide for feminizing hormone therapy:

Quick reference guide for primary care providers (english version), aide-mémoire pour professionnels de la santé de première ligne (french version), topics in this section:, hormonal agents, expected effects, risk mitigation.

• Monitoring strategies

Long-term preventive care

Anti-androgens.

• The anti-androgens typically used at Sherbourne Health are spironolactone and cyproterone, with the former historically chosen preferentially as it was believed to have a superior safety profile. This practice has changed somewhat over time, as adequate anti-androgen effects and testosterone suppression into the female range have been shown to be attainable at lower doses of cyproterone (i.e. 12.5 – 25 mg daily) at which adverse effects are less likely. Thus the choice of anti-androgen should be made individually for each patient based on their medical history and preference regarding risk and side effect profiles.
• If contraindications or intolerances exist for both spironolactone and cyproterone, GnRH analogs (leuprolide or “Lupron”) may be considered. Finasteride is a less effective anti-androgen and is generally not recommended, but may be considered for those who desire very mild anti-androgenic effects (dose range 1-5 mg daily).
• Following orchiectomy (+/- vaginoplasty ), most transfeminine patients will not require androgen suppression. The androgen-blocker can be stopped immediately after surgery or tapered over the course of 4-6 weeks or more depending on risk factors (e.g. in patients with hypertension or renal dysfunction on spironolactone consider monitored taper).

For help deciding which anti-androgen may be best for an individual patient, please refer to the following table comparing effects, side effects, and contraindications of spironolactone and cyproterone.

Effects, side effects, and contraindications of spironolactone and cyproterone.

• Estrogen acts directly on estrogen receptors to initiate feminization. Several forms and routes of estrogen have been used for feminization. At Sherbourne Health, the most common form used is oral 17-β estradiol (Estrace), which is now covered by the ODB program without an EAP request. While conjugated estrogens (e.g. Premarin) have historically been used due to their accessibility/affordability, they are no longer recommended. 1
• There is a lack of consensus on the preferred timing of the initiation of estrogens in relation to an anti-androgen. Common approaches have included both the initiation of an anti-androgen (usually 1-3 months) prior to the addition of estrogen, or alternatively, the simultaneous introduction and subsequent titration of both components. The starting dose of estrogen can be maintained for 1-2 months, after which a dose increase can be considered barring any concerning effects. In patients over 50 years old who have been on estrogen for several years, doses may be reduced to those administered to post-menopausal cis women (e.g. starting/low dose topical formulations, i.e. 0.025 – 0.05 mg patch).
• 1. 4th edition: Sherbourne'sGuidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients.
• With the exception of cyproterone, the use of progestins in transfeminine patients continues to be controversial 2 . There have been anecdotal reports of improved breast and/or areolar development, mood, sleep, and libido with the use of progestins 3,4 ; however a clear impact has yet to be demonstrated. Common side effects include weight gain, edema and depression. Given the lack of clear benefit, and potential risks, progestins are not routinely recommended as part of a feminizing hormone regimen. However, should patients request progestins, a trial may be considered following a frank discussion of expectations and risks. Further information can be found in the full Guidelines , and in the Checklist for Patient Review - Initiation of Progestin Therapy.
• 2. Hembree WC, Cohen-Kettenis P, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism 2017
• 3. Wierckx K, Gooren L, T'Sjoen G. Clinical Review: Breast Development in transfeminine patients Receiving Cross‐Sex Hormones. The Journal of Sexual Medicine 2014;11(5):1240-1247.
• 4. Orentreich N, Durr NP. MAMMOGENESIS IN TRANSSEXUALS. J Invest Dermatol 1974;63(1):142-146.

Keep in mind

What to expect from a regimen consisting of an anti-androgen and estrogen.

The degree and rate of physical effects are largely dependent on patient-specific factors such as age, genetics, body habitus and lifestyle, and to some extent the dose and route used (selected in accordance with a patient’s specific goals and risk profile). Physical changes related to androgen blockade and estrogen may take months to appear and are generally considered to be complete after 2-3 years on hormone therapy. Breast growth is an aspect of feminization to which many transfeminine patients assign great importance. The degree of breast development is dependent on many factors, but most transfeminine patients experience modest breast development (average cup size 12 ) In early studies, neither type nor dosage of estrogen was shown to affect final breast size, and no relationship between serum estradiol levels and breast development was found. 12, 13

Feminizing therapy does not affect the pitch of the voice in transfeminine patients. Some patients may obtain benefit from voice therapy with a qualified and supportive speech and language therapist who can work with the patient to modify their vocal characteristics. There are also a variety of surgical techniques (not covered by OHIP) that have been utilized to feminize the voice through alteration of the vocal cords.

• 12 Wierckx K, Gooren L, T'Sjoen G. Clinical Review: Breast Development in transfeminine patients Receiving Cross‐Sex Hormones. The Journal of Sexual Medicine 2014;11(5):1240-1247
• 13 de Blok C, Klaver M, Wiepjes CM, Nota NM, Heijboer AC, Fisher AD, et al. Breast Development in Transwomen After 1 Year of Cross-Sex Hormone Therapy: Results of a Prospective Multicenter Study. JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM 2018;103(2):532-538.

Effects and expected time course

Click to view individual expected effects

Hover over the coloured regions to view expected information on the reversibility, onset a and maximum effects a of physical changes

Skin changes

Skin becomes softer and less oily. Acne may decrease

Thinned/slowed growth of body/facial hair

Complete removal of facial and body hair requires electrolysis, laser treatment, or both.

Scalp hair loss (loss stops, no regrowth)

Breast growth.

The reversibility of the following effects are variable. Decreased sperm production (infertility) as well as reduced erectile function may also occur.

Decreased testicular volume

Decreased libido, decreased spontaneous erections, decreased muscle mass/strength.

Significantly dependent on amount of exercise

Body fat redistribution

Fat redistributes from abdomen and mid-section regions to the buttocks, hips and thighs.

• Adapted from Hembree et al., The Endocrine Treatment of Gender-Dysphoric/Gender Incongruent Persons: An Endocrine Society Guideline
• Toorians AWFT, Thomassen MCLGD, Zweegman S, Magdeleyns EJP, Tans G, Gooren LJG, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab. 2003 Dec;88(12):5723–9.
• Asscheman H, Gooren LJ, Assies J, Smits JP, de Slegte R. Prolactin levels and pituitary enlargement in hormone-treated male-to-female transsexuals. Clin Endocrinol (Oxf). 1988 Jun;28(6):583–8.
• Gooren LJ, Harmsen-Louman W, van Kessel H. Followup of prolactin levels in long-term oestrogen-treated male-to-female transsexuals with regard to prolactinoma induction. Clin Endocrinol (Oxf). 1985 Feb;22(2):201–7.
• b) Significantly dependent on amount of exercise
• c) Complete removal of facial hair requires electrolysis, laser treatment, or both
• Visual reference: Tetzlaff K. Patient’s guide to transgender, trans, & gender diverse health. 2015.

Contraindications

• Unstable ischemic cardiovascular disease
• Estrogen-dependent cancer
• End stage chronic liver disease
• Psychiatric conditions which limit the ability to provide informed consent
• Hypersensitivity to one of the components of the formulation

Precautions and risk mitigation

Pre-existing medical conditions and risk factors may impart increased risks with estrogen administration and should be considered in order to enable individualized discussions with patients regarding their unique risks and benefits of treatment. Available measures to reduce associated risks should be considered and discussed with patients and, if possible, undertaken prior to or concurrently with the initiation of hormone therapy.

Precautions in red impart moderate to high risk of an adverse outcome without risk mitigation Feldman J and Safer J. 2009. Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of the Standards of Care , Intl J of Transgenderism. 2009; 11(3)146-182, DOI: 10.1080/15532730903383757

Select area of concern below

More information on seizure disorders and anticonvulsant therapy is in the full Guidelines

More information on metabolic risk factors and hyperprolactinemia/prolactinoma in the full Guidelines

Cardiovascular

More information on cardiovascular disease and related metabolic risk factors in the full Guidelines

More information on liver/gallbladder effects in the full Guidelines

More information on breast cancer in the full Guidelines

Hematologic

More information on venous thromboembolism in the Guidelines

Respiratory

Immunologic

More information on HIV in the Guidelines

Legend for short forms:

• ACE/ARB: angiotensin converting enzyme inhibitors/angiotensin-receptor blockers; ASA: acetylsalicylic acid; BP: blood pressure; NAFLD: non-alcoholic fatty liver disease; DVT: deep vein thrombosis; PE: pulmonary embolus; NRT: nicotine replacement therapy; RA: Rheumatoid arthritis; MS: multiple sclerosis; IBD: inflammatory bowel disease; HIV: Human Immunodeficiency Virus

Monitoring and dose titration strategies

Standard monitoring of a feminizing regimen should be employed at baseline, and at 3, 6, and 12 months following initiation (creatinine and electrolytes should be checked 4-6 weeks after initiation or dose increase of spironolactone). Some providers prefer to see patients monthly until an effective dose is established. Follow up visits should include a functional inquiry, targeted physical exam, bloodwork, and health promotion/disease prevention counselling as indicated.

Dose titration of anti-androgen and estrogen may be performed over the course of 3-6 months or more and will depend on patient goals, physical response, measured serum hormone levels, and other lab results.

A common titration might look like:

Starting dose, titrating up.

In the vast majority of cases, the measurement of total testosterone is adequate to assess the degree of androgen suppression. Measurements and calculated estimates of free testosterone are imprecise and generally don’t add value.

Serum estradiol levels should also be monitored. Anecdotally, we have found that most patients reach considerable feminization at estradiol levels between 200-500 pmol/L.

• Clinical effects are the goal of therapy, not specific lab values.
• For lab results, reference ranges will refer to the sex assigned at birth if the sex marker associated with the patient’s health card has not been changed. Reference ranges vary between laboratories - refer to reference ranges from the specific laboratory (often available online or by request from the lab).

APPENDIX J: Reference Ranges (Lifelabs)

Click here to view monitoring parameters specifically for spironolactone or cyproterone without estrogen, monitoring parameters for spironolactone or cyproterone without estrogen.

Hormone Monitoring Summary

See tables below for a summary of recommended monitoring for transfeminine Patients at baseline, 3, 6, and 12 months after starting therapy

Note: Some providers prefer to see patients monthly until an effective dose is established.

Summary for recommended labs

Note: In this table, lighter grey checkmarks indicate parameters that are measured under particular circumstances.

Additional notes and references

• a) Baseline for all and regularly with cyproterone, otherwise repeat once at 6-12 months then as needed. For Hb/Hct use female reference for lower limit of normal and male reference for upper limit of normal.
• b) Baseline for all and regularly with cyproterone, otherwise repeat once at 6-12 months then as needed
• c) Cr/lytes should be monitored at each visit with spironolactone (including 4-6 weeks after starting and after any dose changes), but is only required at baseline and then once between 6-12 months with cyproterone unless risk factors or concerns re: renal disease are present; use male reference range for upper limit of normal for Cr

• d) Prolactin should be monitored at least yearly with the use of cyproterone, and more frequently if elevation noted
• e) During first year of treatment only

Mental health

Suggested elements for review by collaborative md and nursing team.

• Screen for depressive symptoms (including suicidality), anxiety disorders, and other mental health concerns
• Inquire re: current experience of gender dysphoria and body image
• Screen for disordered eating
• Assess patient interest in surgical treatments if not previously undergone
• Inquire re: libido/changes in libido

Education / Lifestyle counselling

• Review healthy eating and general nutrition
• Adequate calcium intake – ensure a minimum intake of 1200 mg of calcium daily (total: diet + supplements)
• Adequate Vitamin D – ensure 1000 IU of vitamin D daily
• Hormone adherence – missing doses of estrogen may impact bone health if post-orchiectomy, while extra doses may lead to supratherapeutic serum levels
• Regular, moderate physical activity – encourage weight-bearing exercise for osteoporosis prevention as well as aerobic exercise
• Alcohol and other substances – inquire re: problematic use of substances including non-prescribed hormones; estrogen affects the metabolism of alcohol by the liver thus we suggest using the same safe-drinking guidelines for transfeminine individuals as for cis women (see Canada’s Low-risk Alcohol Drinking guidelines)
• Smoking – cessation, stages of readiness, etc.
• Review the signs and symptoms of deep vein thrombosis (DVT) and pulmonary Embolism (PE), particularly if risk factors present
• STI prevention – transfeminine patients may be at high risk of STIs depending on behavioural factors; safer sex counselling is recommended, consider indications for HIV PrEP (for patient-centred handout materials, see Brazen 2.0: a Trans women’s Safer Sex Guide )

Psychosocial

• An effort should be made to assess the impact of transition/trans identity on employment, housing, family, relationships, and economic wellbeing
• Social Supports – specific attention should be given to assessing the extent of a patient’s social supports, creating an opportunity to suggest additional resources if needed
• Name change/identification – assess patient need/desire to change name and/or gender marker on identification and offer support for this process (see template letters and RHO fact sheets in the resource section )

Health maintenance

• Immunization history
• STI screening, HIV risk assessment and screening as indicated, frequent screening (i.e. every 3 months) for those at high risk, consider indications for HIV PrEP
• TB skin test as indicated

Transfeminine patients maintained on feminizing hormone therapy have unique preventive care needs and recommendations.

Long-term care of transfeminine patients on feminizing hormone therapy should involve (at least) annual preventive care visits. A Preventive Care Checklist with accompanying explanations for trans-specific recommendations can be accessed below.

Preventive care checklist for transfeminine patients

Accompaniment to the preventive care checklist for transfeminine patients, ensuring patient comfort in clinical encounters.

Physical examinations that involve intimate body parts are discomforting to anyone. However, it is important to consider how trans patients may need a slightly different approach in some areas of primary care practice: tasks like disease prevention and screening, which may also require us to think differently.

It is important to reflect on approaches to clinical encounters with trans patients to provide a more comfortable and gender-affirming experience.

When interacting with trans patients, asking what’s most comfortable for them is fundamental—what one patient prefers is not always transferable to the next.

Provide care based on organs present

It is best to base routine screening on the presence or absence of body parts. Refrain from calling body parts ‘male’ or ‘female’. Instead use non-gendered terms or ask the patient what they prefer to call their body parts. Organs present should receive routine preventive care.

Click on one of the tabs to learn about routine care and screening suggestions.

Osteoporosis and bone mineral density screening

Indications for bmd screening.

• All patients over 65 years old.
• Patients 50-64 years old at higher risk for osteoporosis (e.g. smoking history, HIV+, high alcohol intake, body weight under 60 kg).
• Certain high-risk conditions such as hyperparathyroidism or malabsorption syndrome.
• Patients who have undergone orchiectomy and have been on low-dose or no hormones for any significant length of time (>2 years).
• Patients who have been on anti-androgens or a GnRH analogue for a significant length of time (>2 years) without co-administration of exogenous estrogen.
• All transfeminine patients should ensure a daily intake of 1000 IU Vitamin D and 1200mg of Calcium (total of diet + supplements).
• Weight-bearing exercise should also be encouraged (this could include walking and low-impact aerobic exercise).

Keep in mind:

• There are no studies to guide the interpretation of BMD results and fracture risk in trans people, and whether to use sex assigned at birth or affirmed gender. One option is be to interpret results in comparison to both cis men and cis women.
• Frequency of BMD screening will depend on the results of the initial scan.

Breast/Chest health

• Longer duration of feminizing hormone exposure (i.e. number of years taking estrogen), family history of breast cancer, obesity (BMI >35), and the use of progestins likely increase the level of risk of breast cancer. 1
• Transfeminine patients should receive counselling around breast self-awareness as is recommended for cis women.
• Annual clinical breast examination as part of routine breast cancer screening is of questionable utility, but may be useful in transfeminine patients to assess the degree of breast development or to assess for implant complications if the patient has undergone breast augmentation.
• 1 Feldman J, Safer J. Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of the Standards of Care. International Journal of Transgenderism 2009;11(3):146.

In Ontario, transfeminine patients who have changed their OHIP sex marker to “female” can be screened as part of the organized Ontario Breast Screening Program.

Breast Cancer Screening

Use the diagram below to find out whether your patient needs breast cancer screening. Note: This applies only to those at average risk of breast cancer (not those that have an increased risk based on genetic factors, whom should be screened earlier and more frequently).

Does my patient need breast cancer screening?

Implant Rupture Screening

Use the diagram below to find out whether your client needs screening for implant rupture.

Does my patient need screening for implant rupture?

Colon cancer screening.

Screening guidelines for transfeminine patients are no different than for cis populations. Please follow your local screening guidelines (e.g. Cancer Care Ontario for Ontario guidelines).

Cervical cancer screening

Use the diagram below to find out what type of cervical cancer screening is recommended.

Does my patient need cervical cancer screening?

Prostate exam

The risk of prostate cancer is not increased by estrogen use; in fact it is reasonable to assume that the risk is significantly decreased by the associated androgen deprivation. Although rare, there have been cases of prostate cancer reported in transfeminine patients, generally occurring in those who started hormone therapy after the age of 50. 1, 2 It is important to note that estrogen will lower PSA values even in the presence of prostate cancer, thus impacting its utility in this population. A reduction in the upper limit of normal for PSA to 1 ng/L can be considered in transfeminine patients with low testosterone. 3 Routine PSA screening is not recommended in transfeminine patients in the absence of significant risk factors. There is little evidence to support a role for annual DRE in prostate cancer screening; however, it may be considered according to a provider’s routine practice with cis men. In patients who have undergone vaginoplasty, the prostate remains in situ and may be palpated anteriorly via digital vaginal exam in a gender affirming lithotomy position.

• Gooren LJ, Giltay EJ, Bunck MC. Long term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab. 2008; 93(1):19-25.
• Mueller A, Gooren L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2008; 159(3):197-202.
• Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s persective. Acta Obstet Gynecol Scand 2015; 94(6):563-567

Hormone Planning Period

Masculinizing hormone therapy.

Resource Library

• Self Advocacy
• Community Members
• Families & Caregivers
• Service Providers
• Organizational Trans Inclusion
• Inclusive Language
• Clinical Resources
• Transition-Related Surgery
• Hormone Replacement Therapy
• Reproductive Options
• Sexual Health
• Legal Name and Gender Marker Changes
• Financial Support
• Harm Reduction

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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How gender-affirming health care for kids works in Canada

Transgender youth and their health-care providers say the field is widely misunderstood.

Social Sharing

Robyn Hodgson says she's watched struggling young people heal, grow and ultimately thrive because of gender-affirming health care. 

"It genuinely is profound," Hodgson, a registered nurse and co-ordinator for the transgender and non-binary program at the InterCommunity Health Centre in London, Ont., said. 

"I'm in my 27th year, and I've worked in a lot of areas — and this has been the most rewarding area that I've ever worked in."

Gender-affirming health care — an approach that affirms a trans person's gender identity instead of trying to change it — is endorsed by medical associations in Canada and around the world, including the Canadian Psychological Association and the Canadian Pediatric Society.

But it's also a type of health care that's widely misunderstood, especially as it pertains to the treatment of young people, say the medical professionals who provide it and the patients who receive it. 

• CBC Kids News Explaining gender-affirming care to kids

"So many people make uninformed opinions," said Silas Cain, a 16-year-old transgender boy receiving gender-affirming care in Saskatoon. "They see a headline or they hear one person talking about it and they take it as fact, which is harmful in so many different contexts."

Here's what transgender youth, their caregivers and their health-care providers want you to know about what affirming care actually looks like for young people in Canada. 

How does it work?

Affirming care ranges from social and psychological support, like using someone's chosen pronouns; to transition-related medical treatments, such as puberty blockers and hormones, or gender-affirming surgeries.

Hodgson likens it to how society accommodates people who are left-handed.

"We've tried changing handedness in the school system, and people were struck in the knuckles with rulers," she said. "Trying to force people to live in a shell that is absolutely foreign to their experience is equally difficult."

What it’s like to fight for health care as a trans teen

Forcing kids into genders they don't identify with can have negative impacts on their well-being, says Rhea Mossman Sims, a nurse practitioner at Trans Health Klinic in Winnipeg.

"They can have a significant decrease in their self-esteem and they can also have a significant decrease in their general mental health, and there is a potential for suicidality," she said.

Do kids get medical treatment before puberty?

Canadian health-care providers broadly follow the World Professional Association for Transgender Health (WPATH) standards of care, which has guidelines for patients at different stages of their development.

For kids who haven't hit puberty, affirming care means letting them explore their gender in a supportive environment. That can mean using different pronouns, trying out a new name, or letting them pick different clothes or try a new haircut. 

"There is nothing medically that is done in a child [before signs of puberty]," Hodgson said.

For Cain, that started not at a health clinic, but at school when he found teachers who supported him as he explored different labels. 

"Trying out different pronouns and different names was affirming care for me at that time," he said. "Having a space to experiment is so important and so vital."

Can minors get surgery?

Surgical options, Hodgson says, aren't considered until "very, very late in care" — and almost never for patients under 18. 

"I can tell you, internationally, I do not know anybody that will perform any type of genital surgery on anyone under 18 years of age."

In some very rare cases, she says, older teenagers may be eligible for chest surgery — also known as top surgery — but only if they've already had "a significant duration of care," she said.

Are kids rushed into treatment?

Before puberty blockers or hormone therapy can be considered, WPATH guidelines recommend that all youth be assessed by a qualified health-care professional who has studied psycho-neurodevelopment in adolescence.

"I think that there is this assumption that people are rushing into medical care and there's no thoughtful contemplation or support," Hodgson said.

"It certainly hasn't been the experience of any of the providers that I know that are doing this care, nor of the trans population that's accessing care."

• Trans teens and youth say gender-affirming care is 'life-changing.' So why is it so hard to find in Canada?

Since 17-year-old Seelie Romard of Sydney, N.S., first started seeking gender-affirming treatment in 2021, he says he's visited a pediatrician, a physician who specializes in gender care, and a psychologist — all before being put on a waitlist for testosterone. 

"It took a really long time … just to make sure that I was, like, OK mentally, that I was in the right place, that I was informed," Seelie said. 

What are the effects of puberty blockers?

Patients in the early stages of puberty may be prescribed puberty blockers, which slow the pituitary gland from stimulating secondary sex hormones, putting puberty on pause.

"One of the nice things about blockers is that they can give you some time to continue to explore, rather than having to go through the puberty changes that would happen otherwise," Dr. Tania Culham, a physician with Trans Care B.C., said. 

Some countries have placed restrictions on puberty blockers until their long-term effects can be better studied.  England has restricted their use to minors enrolled in clinical trials , and the Norwegian Healthcare Investigation Board has recommended they be considered "exploratory" and "experimental."

Culham says they are widely considered safe, noting they have been used for more than 40 years to treat precocious puberty — puberty that starts too early — and about 20 years for transition-related care.

Some research has linked them to decreased bone density over time , so providers may limit how long a patient takes them, Sims said. Doctors also supplement treatment with vitamins and dietary guidance for bone health, Hodgson and Culham said.

Patients can pull the plug any time, Culham said, and their regular puberty will resume.

"The whole point of the puberty blocker is that they are reversible," Culham said.

What are the effects of hormone therapy?

Adolescents further along in puberty may consider taking estrogen or testosterone to help develop sex characteristics that better align with their identities. 

Cain started testosterone in July and says it's already having enormous benefits for his health and well-being. 

"Pretty much everyone that I've talked to — my teachers, my therapist, doctors — they all say that I look so much happier now than I did before," he said. "And I definitely feel much happier than I was before."

Because hormones can have long-term effects on fertility , Sims says health-care providers don't prescribe them until a patient has shown a persistent desire to transition, been fully informed about the side effects and been offered a chance to have their sperm or eggs preserved for future use.

"These decisions, in general, are not taken very lightly," she said.

How involved are parents?

According to WPATH, parents should be involved in decisions to pursue medical treatments whenever possible. In fact, Culham says a "family-centred care" leads to better outcomes in all pediatric care.

"As hard as it is sometimes for people to come out to their parents or caregivers or have these conversations, I know a lot of youth take a lot of great care bringing their families, parents, caregivers along," she said.

But that's not always possible. In Canada, under the Convention on the Rights of the Child and Children's Participatory Rights , some people under 18 may be designated "mature minors," capable of making their own health-care decisions.

That's how Tristen Roscoe, 17, of Halifax was able to access testosterone.

"I did tell her about it, but my mom wasn't happy," he said. "She didn't have to, like, sign anything or give the OK, which was good because I don't think she would have."

Roberta Cain, mother to 16-year-old Silas, says helping her son navigate the health-care system has been a "a real balancing act" between respecting his privacy and making sure she has the information she needs to support him. 

Ultimately, she says, it's worth it.

"My feeling is that the staff involved want the best for the kid," she said. "There's no other agenda than that."

ABOUT THE AUTHOR

Sheena Goodyear is a web journalist with CBC Radio's As It Happens in Toronto. She is equally comfortable tackling complex and emotionally difficult stories that hold truth to power, or spinning quirky yarns about the weird and wonderful things people get up to all over the world. She has a particular passion for highlighting stories from LGBTQ communities. Originally from Newfoundland and Labrador, her work has appeared on CBC News, Sun Media, the Globe & Mail, the Toronto Star, VICE News and more. You can reach her at [email protected]

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Gender Care Program

UPDATE: As a result of staffing changes and a recent increase in client numbers, prospective clients may experience a short wait period before being contacted by the Health Centre. Please be patient as we work through our client waitlist. As always, please ensure your referral form is accurately completed including by your physician. If you are self-referring, you may not be rostered to a family physician in Ontario. As of May 1st, 2024, the estimated wait time is 5-6 months.

PLEASE NOTE: As of April 1st, 2024, regretfully, we are unable to receive referrals for individuals under 16 years of age. Anyone under 16 years of age should be referred to the Gender Pathways Program at London Health Sciences Children’s Hospital.

Welcome to our Gender Care Program

Welcome to the Trans Health Program at the Health Centre. The Trans Health Team specializes in trans and non-binary related health care with wraparound support including physicians, a dedicated program nurse, social workers and other supports as well as referrals to affirming specialists.

Our funding and care model ensures that we can provide care for clients who reside in London, Ontario. If you require care but do not live in London, you can consult your local community health centre or contact Rainbow Health Ontario.

Prospective clients need a referral from their primary care provider (family physician). Those prospective clients that do not have a family doctor are able to self refer. In either case, you or your physician need to complete the Gender Care Referral Form  after reviewing the Information for Primary Care Providers (downloadable version).

The wait time form referral to your first visit is generally around two-weeks.

Informed Consent and the Patient-Centred Approach

The current prevailing model used by clinicians to inform health care provision to transgender patients is the World Professional Association of Transgender Health Standards of Care.  WPATH is a non-profit health professional body that advocates for “high quality care for transsexual, transgender, and gender non-conforming individuals internationally”.  WPATH publishes clinical guidelines for assessing and referring trans people for hormones and transition-related surgeries. The WPATH-SOC is intended to provide clinical guidance, and it is designed to be flexibly interpreted across clinical specialties. Here, the Path to Patient-Centred Care resource provides WPATH-SOC instruction through an informed consent and patient-centred care model.

The Informed Consent Model (ICM) offers a more collaborative and patient-centred approach that addresses debates surrounding exactly how and when trans people should access these gender-affirming medical treatments   that persist amongst clinicians and researchers.

Using ICM in gender-affirming medicine allows for trans people to access hormones and transition-related surgeries with self-determination and autonomy, without the need for: a gender dysphoria diagnosis, mandatory pre-transition psychosocial readiness assessments, and unwanted mental health treatments. Visit the Path to Patient-Centred Care to learn more about this approach.

The Trans Health Care team is available by:

Phone at 519-660-0874 ext. 1279

Email at [email protected]

Fax at 519-642-1532

Trans Health Care Services

Our Health Centre services include:

– Hormone Replacement Therapy, initiation and dosage titration*

– Blood (serum) monitoring for the therapeutic effect of hormones, and associated known possible common or usual eventualities at prescribed intervals

– Referral for Trans Related Surgery through MOHLTC and surgical services

– Collaboration with Trans affirming surgeons and post Trans related surgical assessment and support

– Mental Health support regarding Transition

– Pubertal suppression (as per Rainbow Health Ontario Guidelines)

– Counseling and support to children/prepubescent adolescents

– Clinical mentoring support to regional partners and services

– Referral to endocrinology – gynecology or other specialties when indicated

– Identification – identity remediation support

*following Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients, produced by Rainbow Health Ontario in collaboration with Sherbourne Health.

Primary Care Collaboration: You, the Team & Your Family Doctor

The London Intercommunity Health Centre’s Trans Health Program operates in collaboration with clients’ own personal medical providers (doctors/nurse practitioners), and as such, only manages aspects of Transgender care.

In 2016, the province deregulated Trans care from the only centralized option at the Centre for Addiction and Mental Health in Toronto, and placed it where it rightly belongs, in the purview of primary care providers across the province, in an individual’s home communities.

Trans care starts with your primary care provider. To assist you in preparing for this important conversation, we recommend “ How Can I Start a Conversation… ” published by Rainbow Health Ontario.

If you do not have a family doctor, you can self refer but having an affirming primary care physician is an important part of Trans Health. Health Care Connect assists Ontarians find family physicians and can support you with your search.

Gender Journeys

Gender Journeys is an in-person program, offered in collaboration with London InterCommunity Health Centre, provides a safe space to explore questions of gender identity and belonging.

This group is primarily for individuals age 16+ in the beginning stages of transition, which includes those just thinking about transition and those who may have already taken early steps towards their transition, as well as those who are gender-questioning.

Visit Thames Valley Family Health Centre for more information or visit us online at: https://lihc.on.ca/gender-journeys/ 

A Guide to Trans & Non Binary Health

An affirming approach to caring for transgender and gender-diverse youth (Canadian Paediatric Society, June 20, 2023)

Promotion of Gender Diversity and Expression and Prevention of Gender-Related Hate and Harm (Canadian Psychological Association, April 19, 2023)

Gender Affirming Care Saves Lives, Study (Boston Globe, April 18, 2023)

A Timeline of Transgender Milestones (Queerevents.ca, March 31 2023)

Health Centre Celebrates Transgender Day of Visibility (March 31, 2023)

Two-spirit, trans, non-binary, gender diverse people face ‘exceptional barriers to overcome’: Manitoba artist (CBC, March 31, 2023)

The crisis of Trans Health Care in Canada (Canadian Dimension, March 6, 2023)

New study highlights increasing prevalence of muscle dysmorphia among Canadian boys, young men (CTV News, February 5, 2023)

Testosterone Shortage Affecting Trans Men in Canada, Worldwide (LGBTQ Nation, January 17, 2023)

Testosterone Shortage Puts Trans Men at Risk (The Advocate, January 13, 2023)

Day of Pink: Robyn Hodgson, a specialist in transgender health at the Health Centre, and Tamara Lopez, Co-Director of Halton PFLAG, sharing their stories, and how to create more inclusive and diverse spaces (May 10, 2022)

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London InterCommunity Health Centre

DUNDAS SITE             659 Dundas St. London, ON, N5W 2Z1 P: (519) 660-0874 F: (519) 642-1532

HURON SITE             Unit 7 – 1355 Huron St London, ON, N5V 1R9 P: (519) 659-6399 F: (519) 659-9930

ARGYLE SITE Unit 1 – 1700 Dundas St. London, ON, N5W 3C9 P: (519) 660-5853 F: (519) 642-1532

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Ontario Human Rights Commission

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Under the Ontario Human Rights Code , discrimination and harassment because of gender identity or gender expression is against the law. Everyone should  be able to have the same opportunities and benefits, and be treated with equal dignity and respect including transgender, transsexual and intersex persons, cross-dressers, and other people whose gender identity or expression is, or is seen to be, different from their birth sex.

In 2012 “gender identity” and “gender expression” were added as grounds of discrimination in the Ontario Human Rights Code . To fully address the new Code grounds, as well as the significant legal decisions, policy changes and other developments since its first policy, the OHRC released a new Policy on preventing discrimination based on gender identity and gender expression in April 2014.

To learn more about the OHRC’s work on gender identity and expression, and the public consultation it undertook to develop the new policy, see Talking about gender identity and gender expression .

Relevant Policies:

• Policy on preventing discrimination based on gender identity and gender expression  (2014)
• Policy on preventing sexual and gender-based harassment  (2013)

Policy on preventing sexual and gender-based harassment - Summary (fact sheet)

In the Ontario Human Rights Code (the Code), sexual harassment is “engaging in a course of vexatious comment or conduct that is known or ought to be known to be unwelcome.” In some cases, one incident could be serious enough to be sexual harassment. Gender-based harassment is one type of sexual harassment.

Sexual harassment and your education (fact sheet)

As a student, you have the right to an education where you are not sexually harassed. This includes primary, secondary and post-secondary education, and school activities such as sports, arts and cultural activities, field trips and tutoring.

Sexual harassment in housing (fact sheet)

The Ontario Human Rights Code says everyone has the right to be free from sexual harassment by their landlord, someone working for their landlord, or someone who lives in the same building. Because landlords are in a position of authority, and have access to apartments and often hold personal information, tenants can feel very threatened when they are sexually harassed. This may be especially true for low-income, racialized, gay and lesbian people, people with disabilities and other people identified by the Code who are sometimes targeted for sexual harassment.

Gender identity and gender expression (brochure)

April 2014 - People who are transgender, or gender non-conforming, come from all walks of life. Yet they are one of the most disadvantaged groups in society. Trans people routinely experience discrimination, harassment and even violence because their gender identity or gender expression is different from their birth-assigned sex. Under the Ontario Human Rights Code (the Code) people are protected from discrimination and harassment because of gender identity and gender expression in employment, housing, facilities and services, contracts, and membership in unions, trade or professional associations.

OHRC seeks input on new Code grounds gender identity and gender expression

Toronto – A new survey launched today by the Ontario Human Rights Commission (OHRC) asks for public input on definitions for the new grounds of “gender identity” and “gender expression” that were added in June 2012 as grounds of discrimination under the Code.

Consultation survey: Revised Policy on discrimination and harassment because of gender identity and gender expression

Introduction.

In 2000, the Ontario Human Rights Commission (OHRC) released a policy on gender identity and human rights, taking the position that the ground of sex could be used to protect transgender people from discrimination and harassment. The OHRC also called for an amendment to the Ontario Human Rights Code (the Code ) to add “gender identity” as a prohibited ground of discrimination and harassment.

Policy on preventing sexual and gender-based harassment

May 2013 - Sexual harassment is a form of discrimination based on sex. The Ontario Human Rights Code (the Code) prohibits all forms of discrimination based on sex, and includes provisions that focus on sexual harassment. The principles set out in this policy will, depending on the circumstances, apply to instances of sexual harassment in any of the social areas covered by the Code. However, to reflect the most important recent developments in the law and in social science research, this policy will focus on the areas of employment, housing and education.

Letter to the Editor – The Toronto Star: Trans myths based on intolerance

Recent references to a transgender person in a column and in letters to the editor are of concern to the Ontario Human Rights Commission, because they advance some common misinformation that has caused serious harm to the transgender community.

Policy on preventing discrimination because of gender identity and gender expression

Backgrounder – talking about gender identity and gender expression.

April 2014 ­­­­- 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. 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.

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Biden ‘Gender-Reassignment’ Surgery Mandate Blocked

The ruling expands an earlier court decision that blocked the mandate for hospitals in Texas and Montana to all hospitals.

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender-reassignment” surgeries or face a range of penalties, including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” said Paxton.

The Biden administration will likely appeal the ruling to the 5th Circuit Appellate Court.

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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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Ontario school hid girl's transition, called CAS on parents questioning trans identity

Their daughter eventually detransitioned. Now, her family is raising the alarm about the power schools have to keep parents in the dark

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Julie’s life turned upside down after COVID hit. Barely ten, and physically isolated from much of the world, in early 2021 she installed TikTok and began spending hours online, falling down social media rabbit holes. She eventually “discovered the LGBTQ+ community” and started questioning her identity.

Ontario school hid girl's transition, called CAS on parents questioning trans identity Back to video

“At first, it was only my sexuality: pansexual, lesbian, maybe bi?” she later wrote in a personal essay. Eventually, videos asking viewers whether they were “anxious and uncomfortable” in their own bodies triggered her to question her gender identity.

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“Transgender activists were actively posting videos about ‘safe’ breast binding and how euphoric testosterone makes you feel and how it makes all your problems suddenly disappear. The more I was brainwashed by these videos, the more I started to resonate with them,” she wrote.

Julie began identifying privately as non-binary in 2021, at the start of Grade 5. She came out to her class at the beginning of 2022.

With the help of a teacher in York Catholic District School Board (YCDSB), her parents were kept in the dark about her use of “they/them” pronouns and a new masculinized name in the classroom. Only in June 2022 did her parents learn what was quietly going on in school. When they objected and asked school leaders to include them in conversations about their daughter, the school called the Children’s Aid Society (CAS), which investigated the family.

In December 2023, Julie detransitioned after realizing she’d been swept up in a social fad that overlooked her underlying mental health issues. Now, her family is raising the alarm about the power schools have to keep parents in the dark.

It was a horrible time for me as a parent because so much was happening behind my back Christina

“It was a horrible time for me as a parent because so much was happening behind my back. I didn’t know for a long while about many things that were happening. I suspected that something was really wrong,” Julie’s mother, Christina, said.

National Post is not naming the school or using the real names for Julie or her mother, in order to protect the identity of a minor.

“I was a bit of a tomboy,” Julie wrote in an essay, shared with the Post, reflecting on her childhood and this confusing period in her life. “I loved sports and I had friends who were boys, but I never experienced gender dysphoria. I loved dresses and I felt comfortable being a girl.”

Julie said she started to go through puberty when she was 10 years old, earlier than her peers, and she felt like an outcast.

“I didn’t have many friends at the time, and I was being bullied by people in my class so, of course, I wanted to be part of a community that loves me,” Julie told National Post in an interview. Her bodily discomfort coincided with several classmates identifying across the gender identity spectrum. “I think, unfortunately, that started it,” Julie said.

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Christina said at the time she was unaware that her daughter’s school board permitted children to socially transition without the consent or knowledge of their guardians.

Ontario’s education minister refused to comment on this case, but a spokesperson said schools should not have policies that keep things secret from parents.

“We have been made aware that Children’s Aid Society has been involved in this case, and it would be inappropriate to comment on this individual situation,” Isha Chaudhuri, a spokesperson for the ministry, told the Post in a statement. “However, I can reaffirm the government’s clear expectation that parents be fully involved and engaged by school boards in the life of their children. We expect transparency between all parties to ensure the safety and success of every child.”

The Ontario Association of Children’s Aid Societies, a group which represents the majority of children’s aid societies in the province, said in a statement that while they could not discuss the specifics of Julie’s case, in general, the body has observed an uptick in gender identity-related calls in recent years.

“Anecdotally, we are hearing from our member agencies that they are increasingly being contacted by community members about issues related to gender identity,” spokesperson Brynne Clarke wrote in an email. “When assessing a concern raised about the well-being of a child or youth, child welfare agencies must ensure they are adhering to Katelynn’s Principle, which puts children and youth’s voices and identities at the centre of all decision-making.”

Christina learned of her daughter’s social transition for the first time after Julie began cutting her hair and confided that she no longer felt “like a girl anymore,” she told National Post.

The revelation was disconcerting to Christina and her husband. The parents felt the teacher’s failure to inform them undermined Julie’s well-being.

They eventually requested a meeting with school leaders, after which, according to Christina, school administrators agreed to stop using they/them pronouns and only refer to her by her legal name. However, Christina said the school failed to uphold their promise.

Julie’s physical discomfort with her body worsened over the summer break. Within weeks of starting Grade 6, in September 2022, Julie began identifying as a trans boy for the first time. She used a male name and became interested in beginning testosterone treatments and undergoing a double mastectomy.

Christina and her husband were alarmed by Julie’s change in gender identity and how much she knew about surgical options and hormonal therapy. “I was shocked how much a child knows and where this information is coming from,” she told the Post.

Julie began wearing a chest binder constantly, which led to a heated fight with her parents. Her skin was bruising because of it and Christina feared that it would have long-term health implications. Then, Julie ran away in mid-September. She was hospitalized after running away with the intent to self-harm.

Julie’s interactions with medical professionals throughout this time were overshadowed by gender-affirming advice, she said.

When she was just 11, Julie wrote, her family doctor assured her that “binding is perfectly healthy,” and asked if she was interested in learning about puberty blockers. A psychiatrist warned her parents that if they did not affirm her trans identity, she could kill herself, Julie said.

“At that age, I can’t make a conscious decision about medical interventions with an extremely high risk of life-threatening side effects that could make me unable to ever conceive a child,” she wrote in her essay. “All accepted that I’m a boy and never tried to dig up any underlying problems that might be causing these suicidal ideations.”

When Julie ran away, her principal called CAS, relaying Christina’s opposition to Julie’s transgender identity as a potential “culprit of conflict,” states a report from the Children’s Aid Society that Christina obtained from the agency and shared with the Post.

This was the first of several calls the school placed to CAS over the coming months, resulting in at least five home visits, Christina said. The school pinned Julie’s struggles on Christina’s failure to affirm her new trans identity. Christina said she believes these calls “for sure” resulted in subsequent CAS home visits and follow-ups. Official documents show the school referrals were acknowledged by CAS during these periods.

In October 2022, CAS “received a subsequent referral from school” after Christina and her husband requested the school revert to calling Julie by her legal name. Julie attempted to run away again. The family eventually reached a compromise, contracting a therapist and reluctantly accepting that classmates would call Julie by whichever pronoun and name she preferred in school. However, the parents asked educators to continue to use Julie’s legal name.

By January 2023, Christina was still seeking assurances from the school to ensure Julie’s legal name was being used by teachers and administrators. According to an email exchange shared with the Post, the principal responded by telling her that such demands were causing Julie “trauma” and that her “role as an administrator is to support the students in my care.”

Within days of the exchange, the principal placed a third call to CAS in five months, sharing her concerns about Christina’s parenting style. “Caller said ‘she knows that the family loves their child and want the best for the child but they are doing a lot of damage emotionally at this time,’” the heavily redacted CAS report says.

A subsequent home visit proceeded much like the previous ones, with the parents discussing Julie’s mental health, self-harm and concerns the school was interceding in a private matter.

At one point, the CAS employee asked Christina’s consent before using they/them pronouns when speaking about Julie.

“Mom cried and said no one ever asks them and thanked worker for asking. Mom said it was fine for worker to call child they/them,” the report says.

In an email following the unexpected visit, Christina asked why the principal had contacted the agency. “Julie doesn’t recall any specific concern for you to be worried on that date or around that date,” she wrote in an email viewed by the Post. The principal cited the “Duty to Report” educators have under section 125 of the Child, Youth and Family Services Act.

“When CAS reached out to you regarding the report they would have explained the nature of the concern,” the administrator said in yellow-highlighted text above a greeting wishing Christina “a lovely Valentine’s Day.”

Parents across the country have experienced similar reactions from schools when they express caution or hesitancy about their child identifying as a different sex Marty Moore

Marty Moore, a lawyer with Charter Advocates Canada, a group which advocates for the protection of constitutional rights, said “this is not a unique situation,” in an email to the Post. “Parents across the country have experienced similar reactions from schools when they express caution or hesitancy about their child identifying as a different sex.” The lawyer said he fears that the “broad statutory language leaves significant room for school officials, and CAS personnel, to be guided by their own subjective views concerning a child’s emotional harm.”

Earlier this year, Alberta joined Saskatchewan and New Brunswick in announcing a new disclosure policy requiring parental consent for children transitioning at school. In Alberta, any child under sixteen who wishes to transition at school needs permission. Parents of students over sixteen will be notified, but their consent is not needed.

Moore foresees that such initiatives will inspire pushback from LGBTQ groups, but that provincial ministries of education and local school boards will need to be guided by legislation.

“Such legislation will likely need to invoke the notwithstanding clause of the Charter in order to avoid being stayed by courts and embroiled in years of fraught litigation,” he added.

Throughout Grade 6, Julie’s pattern of running away, periodic self-harm, and hospitalizations continued. Julie said that the lack of support her parents initially showed was distressing. However, she said that the decision by school administrators to exclude her parents from the beginning greatly exacerbated her issues.

“Because the school was hiding a lot of stuff from my parents, I was just trying my best not to accidentally tell my parents about that stuff,” Julie told the Post. “My principal, she talked to me a few times, and she said that she understands that I’m in a very bad position; that my parents are not doing what they should be, they’re harming me. And that, if I ever need to talk to a children’s aid worker, she can always call them for me.”

The school board declined to comment on the matter “out of respect for privacy rights,” spokesman Mark Brosens told the Post in an email. “The YCDSB believes the partnership of home, school and parish provides the best educational experience. Our Board supports the Catholic Church’s teachings and our community members’ human rights. The YCDSB has many supports available to assist the mental health and well-being of all of our students and staff.”

Christina looks back on Julie’s time in Grade 6 as when “the real hell for us started.” Caring for her daughter, while navigating the legal and educational worlds, visiting hospitals and dealing with surprise CAS visits, became all-encompassing. The stress began taking a physical and mental toll on her, too. “I had to quit my job to be involved because I kept writing letters to the teacher. The teacher and the principal never responded,” Christina said.

Julie continued to struggle with her gender identity and mental health into the early months of Grade 7. After moving to a neighbouring middle school, Christina discovered that the principal voluntarily offered to let Julie use the boy’s washrooms and change rooms without their daughter first proposing the idea.

Julie wrote in her essay that she didn’t feel comfortable using the male washroom (she used a gender neutral one instead) but she did use the male changeroom as it had individual stalls. Neither Christina nor the parents of the boys using the changeroom were notified, Julie wrote.

Julie’s life turned a corner in November 2023, when her father brought home a copy of Irreversible Damage by Abigail Shrier. The book argues that many young girls experienced rapid onset gender dysphoria (ROGD) as a result of social contagion. Julie’s father bought the book for himself and warned Julie that she wouldn’t understand it and would be “triggered by it,” she wrote. Although Julie thought the book was “transphobic,” she decided to read it out of curiosity.

“After reading about detransitioners and how they came to identify as transgender, I understood I was heading in the wrong direction and needed to turn around before I hurt my loved ones or myself,” she wrote.

Soon after, Julie ditched her chest binder and began reverting to her female identity. However, the stream of applause and support she’d received after initially identifying as non-binary, and then as trans, was nowhere to be seen after desisting, she said.

“When we announced that she wants to go back to female pronouns, everyone kept asking: ‘Are you sure? Are you sure you want to transition?’” Christina told the Post, before Julie cut in. “‘Are you sure your parents are not pushing this on you?’”

Despite assuring her friends and teachers that detransitioning was a voluntary choice, Julie feels it has impacted her social life. “I did not really lose any friends, but my closest friends seem to be, pushing away from me. Like, they’re not talking to me as much, and they’re part of the LGBTQ” community.

As the tide of her transgender identity receded, Julie was left to grapple with the underlying mental health issues that had been overlooked since 2022. She self-harmed after detransitioning, but this time, the mental health counsellor evaluated her with traits of borderline personality disorder, bulimia, and anxiety stemming from body image issues. Christina now feels that her daughter is doing “much better than throughout Grade 6” and is finally addressing her mental health problems.

Julie’s journey dealing with mental health issues, having educators actively hiding what was going on, and finally getting a diagnosis addressing her underlying issues, highlighted the shortcomings of Ontario’s school policies to Christina.

“I was an enemy to my child in their face. If I didn’t support her, don’t call her ‘he,’” she said. “They were giving me a hint that I am, you know, transphobic, homophobic.”

Julie said that suicidal thoughts continued into the middle of April this year, but that her outlook has improved considerably since the summer break.

She attributed part of her ongoing mental health struggles to classmates unwilling to call her by her birth name.

This week, she’s starting Grade 8 at a new school where she hopes to make new friends “who don’t know my past.”

Over the summer, Julie got an open water scuba diving certificate, restocked her wardrobe with girls’ clothing and made friends at a Christian overnight camp.

“I really enjoyed it,” she said, “and finally felt truly at peace with my identity.”

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