Western society recognises male and female sex from physiological attributes, such as genitals and chromosomes. ‘Gender’ is the social and cultural expectation of how males and females should think, behave and how they should be treated by others (Diamond, 2002). Some children and adolescents experience distress, marginalization, and abuse associated with their gender identifications, preferences and behaviours, which are inconsistent with those expected of their biological sex. Often their families and society find gender non-conformity at best difficult, at worst offensive, distressing and intolerable. There is increasing focus on how mental health professionals work with difference in gender and sexual identity and recent publications highlight the shift from pathologizing transgender to a more ‘identity-based’ perspective, focussing more on the stigmatizing affects of the environment and the impact on the individual (Bockting, 2009). This article describes the challenges of binary gender discourse for young people and their wider contexts and considers how clinicians may more helpfully respond to avoid unhelpful binaries and so keep the young person in mind. The therapeutic aims of the UK Gender Identity Development Service (GIDS) for children and young people are considered and examples of our work provided.