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Gender Identity and Diversity

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For many people, the sex we are born with (designated at birth) is a good match for how we see ourselves on the inside. But for others, the sex and gender identity don’t match at all. This could mean that:

  • A child who is born male at birth, feels like a girl on the inside
  • A child who is born female at birth, feels like a boy on the inside
  • A child or youth does not identify completely as either a boy or a girl


While some people see gender as ‘binary’ (either you’re male or female), others see it very differently. Another way to think about gender is as a continuum, a scale or a spectrum. A continuum can be helpful because it includes people whose gender identity doesn’t fall within the boundaries of either male or female.

Remember: sexual orientation (whom we’re attracted to) is not the same thing as gender. For example, some trans men are gay, and attracted to other men. Some trans women are lesbians, and are attracted to other women.

Someone’s gender identity can be at any point along the continuum…

image of arrow
Seeing yourself as neither male nor female Seeing yourself as a boy or man Seeing yourself as both male and female Seeing yourself as a girl or woman Seeing yourself as neither male nor female

Just to be clear, let’s go over a few terms…!

People who are transgender don’t all feel the same kinds of discomfort about their inner feelings and the sex they were born with. Some people feel a lot of conflict, while others feel less. Some people have more difficulty with other people’s reactions (social conflict) than with any conflict they feel inside. Others experience social as well as severe internal conflict.

Sex: (or designated sex) is about how we understand our bodies as male or female, including whether we’re born with a penis or a vulva.

Gender identity: is the personal feeling of being a man, a woman. Some people don’t identify as being either a man or a woman. They may feel that this ‘either/or’ system doesn’t offer a complete description of who they are. Gender identity and sex usually ‘match’, but not always.

"Sex is between the legs, while gender is between the ears."

Gender Non-conforming (or Gender Queer): describes a person who does not identify as a man or a woman.

Transgender/Trassexual: This describes people who don’t conform or identify with the gender expectations associated with their sex at birth. This can include people who live as the gender they feel inside, altering their bodies with hormone therapy and sometimes surgery so that their bodies match their gender identity. This also includes people who identify as transgender or transsexual. In this fact sheet, we’ll use ‘transgender’ or ‘TRANS’ as umbrella terms.

Two Spirit:visionaries, peacemakers and healers. This is a reclaimed concept from First Nations, Inuit and Métis people. It refers to Aboriginal people who are born one sex, and fulfill roles across sex and gender lines, including roles reserved for Two Spirit people. Some say they maintain balance by housing both the male and female spirit. Two Spirit people were considered to be a gift to the community. They were able to cross a range of genders, hold the balance and were respected and honoured as visionaries, peacemakers and healers.

Cross-Dresser (CD): is someone who wears the clothing assigned by society to the "opposite: sex. People who are CD may or may not be transgender.

How does gender identity develop?

Researchers have studied many possible ways gender identity develops, but there is no clear answer. The best answer we can give is that gender identity develops from many factors working together. You may be worried that the questions your child is having about gender is caused by something you did or didn’t do. This is not the case, there is no evidence to suggest that parenting or any other outside exposure contributes to children becoming transgender. Your child’s gender identity is unique, and he or she is just trying to express how they feel inside. We don’t choose our gender identity. Being transgendered or gender non-conforming is not a choice. But people’s life situations can determine how free they feel to express their true gender identity.

How Common is it for people to be transgender or transsexual?

Older studies reported that transgender identities were quite rare, but more recent studies show that they are more common. And studies assess different things, for example, some report on the number of people who have completed gender confirmation surgery, while other studies report on the number of people who have changed the gender on their passport. Telephone surveys in the US in 2010 indicated that 1 in 200 people were transgender. The numbers of transgender people appear to be increasing. It’s not clear if this is because people are more comfortable coming forward, or if the increase is due to something else. Unfortunately, people who are gender non-conforming, gender variant or transgendered can experience discrimination and rejection. Much pain could be avoided if all transgender people were treated with the acceptance and respect that every person deserves.

How do I know if my child or teen is transgender?  

Many boys and girls experiment with different gender behaviours as they are growing up. Many boys may try on girl’s clothing, and many girls may try on boy’s clothing. Children and youth who are questioning their gender identity may experience mild to severe discomfort with the sex they were born with. Below is a list of feelings and behaviours that transgender children and youth may experience, to one degree or another.

Boys who may be transgender may:

  • Express unhappiness at being a boy
  • Express the wish "to be" a girl, and say they will grow up to be a woman
  • Actively prefer dressing in girls clothes (like frilly underwear,or a girl’s bathing suit)
  • Avoid undressing in public change rooms
  • Avoid public washrooms
  • Play "stereotypical" games and hobbies of girls (for example, playing with dolls)
  • Be more comfortable in the company of other girls
  • Avoid "rough-and-tumble" play and competitive sports
  • Have little interest in cars and trucks
  • Insist on sitting to urinate
  • Pretend not to have a penis by pushing it in between their legs
  • Show confusion, or stress over their penis
  • Choose a female avatar for computer games or a feminine alias in email addresses

On the other hand, some transgender boys may work really hard to prove they are a boy. They may try to get involved in typically masculine activities, like rough sports.

Girls who may be transgender may:

  • Want to be "male"
  • Prefer boy’s clothing and short-hair, to the point where others may mistake the girl for a boy
  • Prefer to be with boys and to play "boy’s games"
  • Show less interest in feminine activities
  • Avoid undressing in public change rooms
  • Avoid public washrooms
  • Choose a male avatar for computer games, or a masculine alias in email addresses
  • May show confusion, or stress over her vulva or vagina (or breasts when they begin to develop)
  • May insist that one day she will grow up to be a manIt is possible that these behaviours in a very young boy or girl may not continue.

If youth begin to or still are questioning their gender identity in the teen years, it is more likely that they will maintain a trans gender identity or remain gender non-conforming. Some children and youth may not be able to express in words, or feel safe or comfortable describing their struggle. If youth do not feel supported by family, they may stop expressing their thoughts and feelings (‘closeting’ themselves).

What should we do if we think our child or teen is questioning gender identity or is transgender?  

Many transgender children and youth hide their questions and feelings about their gender identity from their family. They are afraid of being rejected, of losing their family’s love and support. Our society is not very understanding and accepting of transgender, and this can contribute to emotional difficulties like depression, anxiety, and feelings of isolation. Sometimes these feelings, or behaviours like skipping school or problems in school are the only signs that youth are struggling.

If you think your child is struggling with gender identity, listen with care. Your child or teen needs your love and support more than ever. If you’re finding this difficult, review the resources at the end of this fact sheet for more information and support. One helpful resource is: Families in TRANSition: A Resource Guide for Parents of Trans Youth. Central Toronto Youth Services

Why does 'Gender Identity Disorder" exist as a medical diagnosis?

Being transgender or gender non-conforming is not a mental illness. However, Gender Identity Disorder (GID) is the medical term that describes struggles or questions with gender identity. It’s officially ‘inthe books’ as a mental disorder. Gender Identity Disorder may also be referred to as Gender Dysphoria, Gender Incongruence, or Transgenderism. We know that people who are gender non-conforming or transgender can live happy, healthy and productive lives if they have the love and support everyone needs.  

Many people feel that having gender identity in the official manual of mental disorders implies that there is something wrong with being transgender. There is nothing wrong with being transgender or gender non-conforming. But right now, a diagnosis of GID allows access to medical treatments or surgery. At CHEO, we’re doing our best to provide respectful services within the limitations of this diagnosis requirement.

Treatment involves accepting a person’s gender identity in a way that makes sense to that person. It might mean supportive counseling to help a person navigate his or her unique gender identity, and to help families accept this as well. This process allows people to work through all the messages they’ve internalized about what it means to be transgender. It’s important to note that many of the struggles people have are the result of our society’s transphobia. Transphobia has a large and negative impact on mental health. Treatment might also mean medical therapies to help a person’s body match how they see themselves.

How do we help gender non-conforming or transgender children and youth?


If you have just recently learned that your child or teen is questioning gender identity, you might feel quite overwhelmed, upset, and not know what to do.

Remember that your child or teen may have been very worried about how you would react. Your child needs your love and reassurance more than ever. Children and youth need to hear that being transgender does not make you love them any less.

It’s important to use the name your child or teen prefers, as well as the preferred pronoun (he or she). This will mean a lot to your child or teen. You may need to get support for yourself, so you can be a strong support for your child or teen.


Children, youth and families can benefit from supportive counselling or psychotherapy. The goal of counselling is to support youth and their families as they adjust. Counselling can help guide youth and families along the journey of gender identity consolidation, and
support them as they face the challenges they are likely to encounter. Youth and families can also learn about the wide range of other treatment options so they can make well informed decisions.  

Hormone therapies

Pediatric endocrinologists who are experienced in treating transgender adolescents (up to age 18) may prescribe medications that suppress the physical changes of puberty (also known as hormone blockers). This treatment is only given to adolescents who:

  • Meet gender reassignment eligibility and readiness criteria;
  • Have started to show physical signs of puberty (confirmed by hormone blood tests).

Hormone blockers are safe, and have been well tested. The effects are temporary, so that if a youth stops taking them, physical changes of puberty begin again.

At age 16, cross-sex hormone therapy can begin. The timing can be important and depends on the teen’s readiness and support systems. Unnecessary delays or moving ahead too soon may increase the chance of psychological or social problems later on. Physical outcomes may be less favourable if cross sex hormone therapy is delayed until adulthood. A pediatric endocrinologist should initiate and monitor any hormone therapy in transgendered youth.

Surgeons do not perform gender confirmation surgeries on youth under 18. When youth reach adulthood, they can be referred to adult services.

For adults

Many transgender men and women live as the gender with which they identify. Some, but not all, have medical treatments to alter their bodies in order to appear more like the gender they identify with. Some might express an androgynous (neither male nor female) gender appearance all their lives. Some may not live full time as their gender, and only express their gender when it’s safe to do so.

Transgender adults can consider treatment options, like:

  • Supportive counseling
  • Hormone replacement therapy
  • Gender confirmation surgeries. These are procedures that change the body to better match a person’s gender identity.

What happens to transgender children and youth when they grow older?

Transgender children and youth are like any other children and youth. How they do in life depends on whether they are supported by family and friends, or whether they are rejected for who they are.

Transgender children and youth who are supported have the best chance of growing up to be happy, productive adults. People who are loved, supported and allowed to express their true selves, will do far better.

On the other hand, transgender people are much more likely to have future problems if they must stay "closeted" because of shame and fear of rejection. Transphobia can keep many people in the closet, and keep them from expressing their true selves. Sometimes this can lead to depression, substance abuse and even suicide. People who come out can still experience these struggles.

Gender Assignment in Canadian Law

Transgender people can change their name at any time. To change the sex designation on Ontario birth registration, people must:

  • Be 18 years of age;
  • Complete a declaration that they have assumed (or have always had) the gender identity that they would like on their birth registration;
  • Be living full-time in that gender identity and intend to continue doing so;
  • Provide a letter from a practicing physician or psychologist (or psychological associate), authorized to practice in Canada who can support the requested change. In some situations, other evidence may be accepted, and is outlined on the application form.

Visit Service Ontario for more information and application forms. 

Transgender people 16 years and older can also change the gender indicated on a passport, if they have completed sex reassignment surgery (SRS). If they are within 12 months of SRS, they can have a ‘limited validity’ passport (valid for 2 years) issued in their preferred gender. To do this, they need a doctor’s certificate stating they will have SRS within 12 months. For questions, send an email to Passport Canada by visiting the contact page of their website 

Support and advocacy groups


Before meeting any psychologist, social worker or counselor, make sure he or she has experience supporting children, youth and their families who are dealing with gender identity issues.

Publicly funded counseling services

  • Youth Services Bureau offers counseling/therapy for ages 12-20, 613-562-3004.  
  • Family Service Centre of Ottawa for counseling/therapy for all ages on a sliding fee scale. 
  • CHEO Adolescent Health Clinic 613-737-7600, extension 3664 
  • CHEO Diversity Clinic 613-737-7600, extension 3664. Our multidisciplinary team offers information, comprehensive assessment and treatment (which can include hormonal interventions) to children, youth and their families when there are questions regarding gender identity. We welcome referrals from community providers, schools, parents and the youth themselves.

Privately funded counselling services

  • To find a psychologist in Ottawa, you can contact the Ottawa Academy of Psychology referral service, P.O. Box 4251 Station B, Ottawa, (613) 235-2529. Note that the Ottawa Academy is a voluntary association that includes many, but not all Ottawa psychologists.  

To find a psychologist in Ontario:

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