A recent court challenge to an Alberta law banning minors from medically changing their gender has put a spotlight on Canada’s approach to treating gender-diverse minors.
Egale Canada and Skipping Stone Scholarship Foundation, two advocacy groups involved in the challenge, warn the law “denies medically-necessary care” for youth. Alberta’s legislation came into force Dec. 5.
The province says it is in minors’ best interests to restrict them from making “potentially life altering decisions” before they are adults. But the Alberta Medical Association and Canadian Pediatric Society have both said they oppose the law.
We do not “believe the government has a role in the clinic — like the examination room — with the family, with the parents, with the child and with the physician,” said Dr. Sam Wong, a pediatrician and head of the Alberta Medical Association’s pediatrics section.
Gender affirming-care model
Alberta is the first province to implement legislation banning minors from receiving medical treatment to change their gender. But it is far from the only jurisdiction globally to take this approach.
Alberta is following a global trend in enacting stricter rules around medical gender transitions by minors, Dr. Roy Eappen, an endocrinologist at Montreal’s St. Mary’s Hospital, said in a statement on the Alberta government’s website.
“These policies provide essential guardrails,” said Eappen.
France, Sweden and the UK are a few of the countries that have limited minors’ ability to receive medical treatment for a gender transition.
But in Canada today, the primary treatment model for transgender youth is a gender affirming-care model.
This model can include several steps. Typically, the first step — which can occur at any age — is social transition, where an individual adopts a new name, pronouns and clothing. Later steps can include medical treatment, such as drugs or surgery.
Alberta’s new law bans individuals under 16 from being prescribed medications for gender transition, such as puberty blockers and cross-sex hormone therapy. Alberta’s Health Minister can override the law in exceptional cases, and minors aged 16 and 17 may medically transition if they have parental, physician and psychologist approval.
The law also prohibits physicians from performing gender reassignment surgery on youth under 18.
Wong, of the Alberta Medical Association, says medical transition for transgender children is safe.
“Puberty blockers do not have any irreversible effects,” he said. Puberty blockers give youth time to consider whether they will proceed with their gender transition, he says, whereas biological puberty causes irreversible changes.
Wong says puberty blockers “frees [young patients] up from a degree of anxiety and worry,” allowing them to postpone the development of sex-based characteristics.
And if a patient later chooses to stop transitioning, they can simply stop taking puberty blockers.
Alternatively, patients who choose to continue gender-transitioning are prescribed cross-sex hormones, Wong says. This therapy does cause some irreversible changes, including permanent infertility in males and females.
“That’s why one of the things [physicians] should do, and most physicians do, is talk about the effect on fertility,” said Wong. “If you’re a biological female, [physicians should ask], ‘Do you want to harvest eggs and set them aside for later on in case you want to have children?’”
Eappen, of Montreal’s St. Mary’s Hospital, says his concern is that minors often cannot appreciate at their age whether they may want children in the future.
“I see a lot of 20-year-olds [who] say, ‘I’m never gonna have a baby’ … and then 10 years later, they’re desperate to have a baby,” he told Canadian Affairs in an interview in June. “I don’t think we should do irreversible things without good evidence … I don’t think there is good evidence for the affirmative care model.”
‘Rubber stamp everyone’
Alberta expects the province’s professional regulatory colleges to enforce its new law through their disciplinary processes.
In Wong’s view, this approach is problematic, since physicians who prescribe medical treatment for transgender youth are following standard medical practice, at least in North America.
“How’s the regulatory body going to punish physicians who are practicing standard care?” he said.
But not all health-care professionals think the country’s gender-affirming care model is safe for youth.
Canada’s gender-affirming care model encourages children to medically transition without proper assessment, says Aaron Kimberly, a registered nurse and transgender man who medically transitioned at the age of 33. In 2018, Kimberly assessed youth at a Kelowna, B.C., clinic that offered gender-affirming care.
“This new model of care demands that I just rubber stamp everyone, that I just accept that anyone that says they’re trans, is trans,” said Kimberly, referring to how health-care professionals are currently taught to manage transgender patients.
“I’m supposed to somehow ignore my clinical judgment in those cases and not intervene and … not ever question that maybe they’re motivated to transition for the wrong reasons,” said Kimberly.
He says the gender-affirming care model is “very distorted in ways that are doing harm to these young people.” He says that when he expressed concerns at the clinic, he was removed from assessing transgender youth for gender-affirming care.
The Kelowna clinic told Canadian Affairs they could not share any information on current or former employees.
Numerous studies have found that many minors’ sense of gender dysphoria — the feeling of one’s physical body not matching one’s desired gender — subsides as they age, with the majority growing up to be homosexuals as adults.
The 2024 Cass Review, a nearly 400-page report released following a four-year review of the UK’s gender identity services, concluded that medical interventions should be discouraged for transgender youth. It recommended that puberty blockers not be routinely prescribed.
‘Very chilling’
Before the mid-2010s, the preferred approach to treating transgender youth in Canada was the “biopsychosocial developmental model.” This approach involved assessing a minor’s biology, psychology and social environment to understand their mental health and create a treatment plan appropriate for the individual.
This model was largely dropped after Kenneth Zucker, a prominent clinical psychologist who treated patients using this approach, was let go as head of the gender identity clinic for children and youth at Toronto’s Centre for Addiction and Mental Health.
Zucker was accused of practicing a form of “conversion therapy” on transgender youth. Transgender activists alleged Zucker’s approach forced children to live with gender dysphoria and not undergo immediate medical intervention.
“I spoke to clinicians across the world and, very much at the time, anybody who worked in gender identity, their feeling was, ‘If that could happen to Ken Zucker, I haven’t a chance,’” said Stella O’Malley, executive director at Genspect, an international advocacy organization critical of gender-affirming care.
“Ken Zucker was a professor, he was a director, and he had decades of experience in this field, so it was very chilling,” said O’Malley, who is also a psychotherapist. “It was very effective in silencing clinicians who had concerns that people … especially young people and children, were taking rushed, medicalized decisions without enough thought and consideration.”
The Alberta government consulted with Kimberly and O’Malley regarding its new law.
“I have been asked to defend the Smith government’s policies in court,” said Kimberly. “I will do that because I’m very much in support of the policies in Alberta.”
Suicidality
The advocacy groups and families bringing the legal challenge against Alberta allege the province’s law violates the Charter rights of gender-diverse youth.
“The actions of the Government of Alberta are unprecedented in this country. No government in Canada has ever enacted legislation prohibiting essential and life-saving gender affirming health care,” says a press release by Egale Canada, an LGBTQ+ advocacy organization.
Advocacy groups such as Egale say gender-affirming care is life-saving. They point to survey results, such as a 2017 survey on the mental health of Canadian transgender youth, that show transgender youth have higher rates of suicidality than non-transgender people.
Pediatricians who offer gender-affirming care often notice the mental health of their transgender patients improve after taking puberty blockers, says Wong.
“Whether that leads to decreased suicidality, some documents say, ‘Yes, it does,’ and other documents say it doesn’t lead [to decreased suicidality] as much as we think it does.”
A press release sent to Canadian Affairs by Egale Canada touted the results of a 2024 US survey that found transgender and non-binary youth self-reported more suicide attempts after states enacted laws imposing restrictions on transgender people.
However, O’Malley says international data suggest limits on gender transition do not affect suicide rates.
“Sweden, who were pioneers in bringing in pediatric gender transition … restricted [medical treatment for transgender youth]. There was no uptick in suicide. Finland did it. Denmark did it. The UK did it. Norway did it. No uptick, no uptick, no uptick, no uptick in suicide,” she said.
“So why do Canadians believe that they’re somehow different than all the other countries who, frankly, brought in pediatric transition before Canada did, and they’ve withdrawn from it before Canada has?”
Wong says a lot of controversy surrounds some of the studies on transgender youth, and the Cass Review has only heightened the debate.
“It’s polarized. There’s a lot of vitriol that goes on … And two sides can’t always see each other’s point of view,” he said.
“I try to look at the other side’s point of view and say, ‘Look, why I’m doing it is because I think it’s beneficial for the child, and really that’s what it comes down to. As a pediatrician, as a group of pediatricians, we’re trying to help the children do better’.”
I suspect that social media has been an accelerant in the transitioning movement. It does make sense that extreme discomfort with the reality of sexual attraction to same sex peers may have something to do with this. It doesn’t help that the right wing and the Christian right have exploited people’s fears about divergent types of sexuality and turned the issue into a political football. Since Alberta is going its own way on this issue, and a few other provinces may follow suit we may eventually be able to study the effects of these different provincial approaches and see where real harm is being done, if, in fact, it is the case. My sense is that medical professionals have been too quick to enable transitioning in adolescents, simply out of emotional pressure from teenagers who are too easily swayed by social media posts. Transitioning has always been around, but it also has always been a tiny minority of the population. The existence of a growing trend that coincides with the popularization of smart phones and social media is probably not a coincidence.