When Danielle Sheridan got home from an appointment in April, the 7-year-old went straight to her bedroom and threw her boy clothes into garbage bags.

At the meeting with a gender specialist, her parents had allowed Danielle, who was born Daniel, to make a decision.

“We basically gave her a choice,” said Leah Sheridan, a Keswick, Ont., stay-at-home mom. “You can go home and live as Danielle, or you can go home and live as Daniel.”

For two years, Daniel had been dressing as a girl at home, wearing Leah’s clothes and playing dress-up, insisting she was a girl.

But Leah wasn’t convinced of the gravity of the role playing until one night while making dinner. Daniel said “if she has to keep living a lie as a boy ... she doesn’t want to live,” recalled Leah.

Vulnerable and helpless, Leah held her child tight in her arms, then she went in search of a specialist.

Leah was full of angst. She didn’t want to be one of those parents who ignored her child’s pleas only to end up with a kid who turns 16 and says, “ ‘OK, I’m done, I want to die,’ ” said Leah, “I don’t want that.”

Danielle, now 8, is hoping to be accepted as a patient at a new Transgender Youth Clinic set to open Oct. 11 at The Hospital for Sick Children.

The clinic is part of Ontario’s evolving response to gender dysphoria, the unusual condition when anatomical sex doesn’t match a person’s gender identity. It will focus on prescribing hormone blockers to youth who fit its criteria and want to take the medication to delay puberty. This would give them more time to decide their gender, and an increased ability to pass for the gender they choose as adults.

Right now, Danielle plans to take the hormone blockers in a few years and then have sex-reassignment surgery when she’s over 18, the age required for government-funded surgery. While her plans could change, what’s certain is that whatever Danielle decides it will be in a system that is increasingly better prepared to respond to transgender people than it has been in the past.

“In a way I’m kind of blessed that she was born when she was, because now there are specialists,” Leah said.

Sex reassignment surgery

There’s been a surge in adults requesting sex-reassignment surgeries since the provincial government reinstated funding five years ago.

Demand has gone up each year, according to data released to the Toronto Star by the Ministry of Health.

In the financial year beginning in 2008, 21 people were approved for surgery. In 2009, 24 were approved. In 2010, there were 70. In 2011, there were 95 and last year, 105 people were approved at a cost of more than $2.38 million, compared to $22,200 in 2008.

The cost is for four types of surgeries: mastectomy, vaginoplasty (male-to-female surgery that constructs a vagina), metoidioplasty (female-to-male surgery that constructs a penis using the clitoris) and phalloplasty (female-to-male surgery that constructs a penis by using donor tissue, likely from the patient’s arm or leg). Cosmetic surgery, including removing an Adam’s apple and electrolysis to get rid of facial hair, isn’t covered by the Ontario Health Insurance Plan (OHIP).

The adult Gender Identity Clinic at Toronto’s Centre for Addiction and Mental Health (CAMH) is the only facility in Ontario that can recommend a patient for surgery. It now has its longest wait-list ever, of 16 months, for a first appointment.

Dr. Chris McIntosh, the psychiatrist who has run the CAMH clinic since 2011, said funding isn’t the only reason for the surge in patients.

“The phenomenon of transgender identity is becoming more well known. As more people know about it, I believe more people are considering it as an option for them,” he said.

“It’s a distressing thing to seek help for a very distressing condition and have to be told you have to wait 16 months before you can be seen first.”

He has written an open letter to family doctors requesting they start prescribing hormone therapy so patients can begin the process without seeking specialty care.

CAMH’s recommendations are based on a psychiatric assessment, diagnosis of gender dysphoria and where people are at in their transition. Surgeons have separate health requirements, including not smoking or being overweight.

McIntosh’s clinic is moving beyond its past reputation of sending patients away to test their seriousness about gender reassignment. The clinic has lowered its requirement for patients to live in their new gender role before genital surgery from two years to one, bringing it in line with worldwide standards.

One of the most recent changes is the adoption this year of the term gender dysphoria to replace “gender identity disorder,” part of the depathologization of the condition, that emphasizes treating the stress, not the behaviour, McIntosh said.

There’s been a push to teach other doctors about gender dysphoria, since funding for surgery was reinstated in 2008 by the Liberal government, a decade after a Conservative government cancelled it. The cut prompted complaints to the Ontario Human Rights Commission, which ordered the government to compensate patients who had already begun the process.

In 2011, the Rainbow Health Ontario and Sherbourne Health Centre began training primary health-care providers to respond to transgender people, in both hormone prescription and mental health. It has since expanded across the province.

Program co-ordinator Jordan Zaitzow said his team has started working with the University of Toronto and Queen’s University medical schools, where transgender health hasn’t traditionally been taught.

Zaitzow wants to see more assessment sites besides the lone CAMH clinic. “The bottlenecking is prohibitive and distressing,” he said, noting 70 per cent of trans people in Ontario live outside of Toronto.

McIntosh cautions that getting the recommendation for surgery won’t change everything.

“The surgery doesn’t magically transform them into a biological person of the gender they wish to present themselves in,” he said.

Passing as a woman

Sometimes Elizabeth MacDougall, a Toronto Public Health inspector, hears snickering on the street. Or someone will repeatedly call her sir.

“Let’s face it. If you’re a male for 30 some odd years, you look male,” said MacDougall, who had sex-reassignment surgery in 1999, and is now 55. “I don’t look like a supermodel. I don’t even pass (as a woman) that well, right?”

However, with colleagues and most people she interacts with, her gender is a non-issue.

MacDougall was one of the last to qualify for gender-reassignment surgery before government funding was cut.

But hers was an arduous journey.

MacDougall grew up as Robert MacDougall in Woodstock, Ont. in the 1970s. As Robert, she “always knew something was wrong.”

She didn’t feel like a boy but “I didn’t have a word for it, I didn’t have a name for it,” MacDougall said.

In high school she heard about Renée Richards, the famous tennis player who was initially denied entry into the U.S. Open in 1976 because she’d had sex-reassignment surgery.

“The light bulb went on,” MacDougall said.

She wrote to Johns Hopkins University in Maryland, hoping experts there would help her understand her options. She got little help in response, but from that point on she knew she wanted surgery to make her body match her mind. Years later, she made her first visit to the CAMH clinic and after a battery of tests was told she wouldn’t benefit from treatment and to come back in five years.

She went back to feeling “beaten and driven into conformity.” She was petrified about how her small town would react to her secret and, in a last-ditch effort to live a “normal” life as a man, she married a woman in 1989.

But nothing changed. Still trapped, MacDougall had breakdowns and admitted herself to hospital.

“I couldn’t cope, I couldn’t function,” she said. MacDougall was honest with her wife, who was supportive and didn’t want a divorce initially, thinking they could make the marriage work.

“There was a point where I wanted to cut the damn thing off,” MacDougall said, referring to her penis.

Then in 1990, working as an ambulance attendant, MacDougall injured her back. While she recovered she had plenty of time to think and it became clear she had to do something.

“I’m married, I hate my life here. I’m getting a divorce, I’m moving to Toronto and I’m going to do something about this even if it kills me.”

This time she took matters into her own hands moving to Toronto and finding a hormone-therapy doctor before going back to CAMH and telling them she’d started transitioning by herself.

“I basically said, ‘Screw you, I’m going to do this,’” she said.

She attended weekly support groups, worked part-time in the office of a courier company and volunteered at a food bank. By the time she enrolled in Ryerson University’s public health program in 1997, she was living full-time as Liz. Two years later she was finally approved for her surgery.

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Along with the challenge of getting recommended for surgery MacDougall had to save up to pay to have her Adam’s apple removed and undergo other procedures to feminize her face. These procedures done first cost close to $17,000.

She also spent five years and about $15,000 on electrolysis to remove her facial hair. It was so painful, she said, that she paid a dentist to have her face frozen before hand.

MacDougall says the hormone therapy didn’t change her voice at all which is one of the benefits for youth now considering transitioning at a younger age.

Hormone blockers

Hormone blockers give youth more time to decide their gender, said Dr. Joey Bonifacio, the pediatrician and adolescent medicine specialist who will lead the Transgender Youth Clinic at SickKids when it opens later this month. The clinic will also refer patients to other resources if blockers aren’t right for their case, he said.

Use of blockers, an injection given about once a month, is limited in Toronto now because few people prescribe them, said Bonifacio, 34, who has been working on the clinic for more than a year. There are already similar facilities in Vancouver, Montreal and Ottawa.

He said part of what doctors look for is insistent, consistent and persistent gender identity.

“These medications are important because they’re quite timely. They need to be given to youth who are experiencing gender dysphoria or really don’t know what gender they are and just need a little bit more time to figure out what that particular gender is,” he said, adding blockers can be given when puberty starts, so many patients will be around 10 or older.

The blockers can stop development of a masculine voice or facial hair, for example, or breasts and a period starting. Those developments would be distressing to a child who doesn’t identify with their body, Bonifacio said.

Youth who start taking blockers but decide later they want to keep their biological gender, will have only delayed puberty, and can go off the medications to keep developing, said Bonifacio. For others who want to transition to the other gender, they could begin cross-sex hormone therapy later, and eventually have surgery if they chose to as adults.

“The hormone blockers allow the youth to pass better … and reduces the extent of surgeries possibly needed in the future,” said Bonifacio, Not being able to pass creates mental health concerns for many trans people.

Close to half of Ontario transgender youth, between 16 and 24, seriously considered suicide and 19 per cent actually attempted suicide, according to a TransPulse study in 2011.

The SickKids clinic — including a second adolescent medicine doctor, a pediatric endocrinologist, a nurse practitioner, a nurse and a social worker — will spread awareness as well, Bonifacio said. He’s already had several referrals each week since news of the clinic spread a few months ago.

Data from a Dutch surgical clinic, and highlighted by SickKids, suggests the prevalence of transgender persons is about 1 in 11,900 for male-to-female and 1 in 30,400 for female-to-males. But SickKids noted the numbers are likely an underestimate, and increased awareness and acceptance has resulted in more kids identifying as trans at an earlier age.

Barb Urman, a co-ordinator of LGBTTQ Services with York Region, is the social worker working with the Sheridan family. Danielle is one of about a dozen children she’s supported, helping parents and co-ordinating school response, and talking to classmates.

“I think in York Region, given that we’re just sort of into the beginning of serving this population, this is just the tip of the iceberg,” she said.

She said the best thing parents can do is support their kids, whether they identify as boys, girls or neither. “They’re not making the decision,” she said, “they’re simply taking the lead from the child.”

In the pink

The walls in Danielle Sheridan’s bedroom are pink and plastered with posters of Justin Bieber and a large rainbow flag. Sparkly and bright clothes line the closet. All are new additions since Danielle started living as a girl in April.

“I felt like I didn’t want to be living how I was. So I told mom when I was one that I wanted to be a girl,” said Danielle summing up her life so far.

Sitting on her bed, with a rainbow headband around her blonde hair, she flicks through a Bieber trivia magazine. She’s growing her hair longer and although her nails are bare on this day, they’re often painted pink.

“You were almost 3,” corrects Leah, who also has a 6-year-old son, Carter, who has become one of Danielle’s biggest supporters.

Despite Danielle’s insistence that she was a beautiful princess and was going to marry a handsome prince when she grew up, it took some time to really hear what she was saying, says Leah.

“We’ve always known there was something there. But what do you do until it’s so obvious and so apparent that you have to do something about it?”

She and Danielle’s father are now on board and working with a social worker to understand how best to handle Danielle’s transition. Most family members have been supportive, although there are some who don’t understand, Leah said.

She’s sharing the family’s story to try to help other kids and parents.

Danielle is adamant she doesn’t want to be a boy right now.

“It would ruin everything I’ve done being a girl,” Danielle said. “And I wouldn’t like it at all.”

Danielle has stayed close with most of her friends, still going to the park, listening to music and playing with Monster High dolls. She’s uses a gender-neutral bathroom in her small specialized class, which she’s in because of behavioural issues.

Going back to the main school in February will be more of a test of kids’ acceptance, Leah said, adding her understanding is that Danielle will be able to use the girls’ bathroom.

For now, Danielle seems happier, her mom said. She doesn’t have some of the anger problems she did before.

One of the toughest battles, initially, was keeping her shopping demands in check, Leah said. After throwing out her boy clothes, it was tough at first to find girls’ clothes she wanted to wear in the size 14-16 she needed. Then the family discovered her favourite store, Justice.

“Oh yeah. I’ll show you what Justice is like,” Danielle said, dashing out of her room and quickly reappearing, in a dress with a glittery green skirt and a grey bodice with the words, “Chase Your Dreams” splashed across the front.