Two months after England released an expert report discouraging medical interventions for transgender youth, most Canadian provinces have signaled they do not plan to change the gender affirming-care treatment model that is popular here.
And yet, some experts say there is inadequate research on this treatment model, which supports medical interventions that affirm a person’s gender identity where it does not match their sex.
“The criticisms that have been evolving over the past number of years about the gender affirming perspective … the evidence that this is helpful is now being questioned,” said Dr. Kenneth Zucker, a clinical psychologist who runs a private practice focused on gender dysphoria in downtown Toronto.
Dr. Hilary Cass, a former president of the UK’s Royal College of Paediatrics and Child Health, was commissioned by the country’s public health-care system, NHS England, to independently review the country’s youth gender identity services. Her review, which took four years to complete and runs to nearly 400 pages, was released on April 20.
The Cass Review found poor evidence around medical transition for transgender minors, and recommended that puberty blockers not be routinely prescribed.
Dr. Sam Wong, a general pediatrician and head of the Alberta Medical Association’s pediatrics section, largely disagrees with the Cass Review’s findings. He is critical of its conclusion that medical intervention for transgender care is not based on robust medical evidence.
“To say that we don’t have data on puberty blockers … it’s a sleight of hand in some ways. We do have data, it’s just we’ve been using it [to treat early puberty], and some people have moved it over to gender clinic care,” he said.
Dominant model
In Canada today, the primary treatment model for transgender youth is the “gender affirming-care model.” It can include several steps.
Typically, the first step — which can occur at any age — is social transition, such as adopting a new name, pronouns or clothing.
“A healthcare provider is not needed for social transition but may help a youth access resources,” IWK Health, a children and women’s hospital in Halifax, said in an emailed statement. “Parents are most often the ones who make these decisions for young children or support their older child/youth to access resources to socially transition.”
Only after starting puberty is a patient eligible for medical treatment such as drugs or surgery. For example, a doctor may prescribe puberty blockers to stop the patient’s body from developing certain characteristics — such as breasts — and later prescribe sex hormones so the patient takes on characteristics of their new gender identity.
At this stage, a patient can also undergo some gender reassignment surgeries to change their appearance.
Wong says pediatricians will evaluate a patient’s medical, mental health and personal history to determine if they have gender dysphoria. Gender dysphoria is a mental health condition where an individual experiences psychological distress when their biological sex does not match their gender identity.
“If somebody comes in and they’re six years old, and they are playing with toys of the opposite gender, or they see themselves as the opposite gender … I’ll provide care for them until getting closer to puberty,” said Wong, who has had three or four transgender patients.
“[T]hen I’ll refer them to the transgender care clinic if they continue to have that continued gender diversity.”
‘Best way to help’
Gender-affirming care was not always the dominant approach to transgender treatment in Canada. This model only started to become popular in the mid-2000s, says Zucker, the clinical psychologist.
Previously, the preferred approach was the “biopsychosocial developmental model,” which involved assessing a minor’s biology, psychology and social environment to understand their mental health and create a treatment plan appropriate for the individual.
Social transition is not encouraged for every individual, says Zucker, who still uses the biopsychosocial developmental model in his own practice.
Rather, the goal is to help a patient feel more comfortable with their birth sex on the grounds that this enables them “to avoid the complexities of biomedical treatments such as hormones and gender reassignment surgeries,” said Zucker, who led the gender identity clinic for children and youth at Toronto’s Centre for Addiction and Mental Health for more than 30 years.
In 2015, Zucker was let go following accusations from patients, activists and clinicians that Zucker and the centre were practicing a form of “conversion therapy” — a practice that attempts to change a person’s gender identity to accord with their biological sex.
Zucker denied these accusations. In 2018, the centre reached a half-million dollar settlement with him and issued an apology for mistakes they’d made in their review.
In Zucker’s private practice today, youth are evaluated and may be encouraged to wait to see if their gender dysphoria can be resolved by treatments other than social and medical transition.
But Zucker says there is no “one-size-fits-all approach” to treatment.
“How I might approach things with a three-year-old is not going to be the same as with a 13-year-old or with a 20-year-old. So I think it’s very important to take into account developmental factors in thinking about what might be the best ways to help,” he said.
‘Different pathways’
A 2011 study co-authored by Zucker found that out of 139 male children who were diagnosed with gender dysphoria, 88 per cent had desisted as an adult. Other studies also show the vast majority of children do not persist in having gender dysphoria as adults.
But a 2022 study found that 94 per cent of 317 transgender youth who had socially transitioned maintained their new gender identity five years later. Zucker says these findings suggest social transition can influence a child’s gender identity.
“A social transition in childhood is not some kind of neutral act that occurs in vacuo,” he said. “It is a type of psychotherapeutic intervention that likely will be associated with a very different long-term outcome.”
This is why he suggests practitioners and patients spend time “exploring all options before reaching a conclusion that social transition is going to be the most helpful way in reducing gender dysphoria.”
Wong disagrees that a minor’s chosen gender should not be affirmed.
“I don’t understand how somebody who is a clinician is able to say, ‘No, you shouldn’t be social transitioning’,” he said. “I don’t need to write a prescription for them to do social transitioning. They’re doing it on their own, but I can support them with the social transitioning.”
In the past 20 years, there has been an increase in adolescents with gender dysphoria who had no history of gender diverse behaviour in childhood, Zucker says.
This “suggests that there are different pathways that lead to gender dysphoria, and it may imply that one should not use the same therapeutic approach for everybody,” said Zucker.
Some children who have socially transitioned under Zucker’s care have stayed transgender, but others have not.
“If you adhere to a kind of born-that-way philosophy, it sort of implies that a parent doesn’t think that there could be a host of factors that are contributing to why their child is feeling the way that they’re feeling,” he said.
Wong suggests social transitioning and early medical care can give youth time to explore their gender identity and reverse course if they so choose.
“Sometimes they just need time to figure out who they are,” said Wong.
No controlled trials
The Cass Review examined the gender-affirming care model and found a lack of studies on the safety and effectiveness of medical intervention for transgender youth.
There have been no randomized controlled trials — often called the “gold standard” for scientific study — to measure the effectiveness of the gender-affirming care model. The review evaluated other studies, but determined “many were very poorly conducted,” Cass said in an interview with The New York Times.
“I can’t think of any other situation where we give life-altering treatments and don’t have enough understanding about what’s happening to those young people in adulthood,” she said. “The critical issue is trying to work out how we can best predict who’s going to thrive and who’s not going to do well.”
Wong agrees that transgender patients and treatments need more research — but so does a great deal of pediatric care. Up to 80 per cent of pediatric medications in Canada are prescribed off label, meaning use differs from Health Canada-approved guidelines.
“Gender affirming care is just one of the areas where we lacked research,” he said. “Let’s be honest, there’s not a lot of money in pediatrics. So companies are not going to be doing a lot of research on pediatric patients. And that’s been the last 100 years.”
Wong also notes there is research showing puberty blockers are safe. “We’ve been using [it] for decades in precocious puberty,” he said, referring to early puberty.
Another common critique of gender-affirming care is that existing studies are fairly short in duration, so little is known about the long-term outcomes, says Zucker.
Dr. Roy Eappen, an adult endocrinologist who has been a vocal opponent of medical transitions for transgender minors, says some of his concerns lie in how youth may not be able to consent to some of the irreversible consequences of medical treatments.
“I see a lot of 20-year-olds say, ‘I’m never gonna have a baby.’… And then 10 years later, they’re desperate to have a baby. So, I don’t think we should do irreversible things without good evidence for them,” said Eappen.
Medical institutions that endorse and use the gender-affirming care model say the approach is crucial because transgender children are at greater risk of committing suicide if they are not provided with this care.
The medical “evidence is such to recommend that providing medical treatment including puberty-blocking medication and hormone therapy is helpful and often life-saving,” the World Professional Association for Transgender Health, a professional association devoted to transgender health, said in a published comment on the Cass Review.
But the Cass Review did not find evidence to support this risk.
“It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found did not support this conclusion,” the report says.
Health landscape
In March 2024, a month before the Cass Review was released, medical associations in every province and territory except Nunavut released a joint statement opposing government efforts to restrict access to medical care for transgender patients.
Both the Canadian Pediatric Society, a national association of pediatricians, and the World Professional Association for Transgender Health promote the gender affirming-care model. The latter has released a statement criticizing the Cass Review’s findings and recommendations.
The Cass Review made international headlines, yet it was barely reported on and addressed politically in Canada, says Dave Snow, associate professor in the department of political science at the University of Guelph.
One of the reasons it is difficult to see a report of this nature resulting in drastic changes in Canada is that, unlike in England, each province manages their own health-care systems.
Alberta, Saskatchewan and New Brunswick are the only provinces that have plans or policies to limit transgender minors’ social transition in schools or medical interventions. Alberta Premier Danielle Smith has cited the Cass Review as reason to restrict medical transition for those under 18.
“[The] Cass [Review] can provide some of the scientific impetus to say ‘There’s a lack of evidence in this area and that’s why we’re bringing in these regulations, these restrictions,’” said Snow. “Or it could provide a model to say, ‘Let’s study it first, before we do anything,’ or perhaps let’s ‘Let’s pause it and then study.”
A number of countries have limited medical intervention for transgender youth, including England, Finland, Sweden, Denmark and some US states. Others, such as the Netherlands, are conducting reviews on the evidence for medical transition.
Countries that support medical transition for transgender youth include Canada, Belgium, Germany, Austria and Switzerland.
Wong firmly disagrees that the gender-affirming care model should be restricted in any way.
“To have the government… pick on [transgender youth] for political reasons seems grossly unfair to me,” he said.
“We as pediatricians should be allowing them to come into our office and our clinic and say, ‘Here’s a safe space for you to be who you want to be who you think you are. And if you change your mind or something changes, and you decide not to move forward, that’s all right’.”
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