Critics say Canada is too quick to treat gender dysphoria in minors with hormones and surgery

Other countries have taken a step back and the critics’ concerns are unexpectedly being shared by some leading figures in the transgender medical world itself

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Mary’s troubled daughter had talked about her changing sexual identity before, but when she announced at age 16 that she was a transgender boy, it seemed to come out of the blue.

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Even so, a doctor later wrote her a prescription for testosterone after a pair of 15-minute appointments, the mother says. Within months, the teenager had also had a double mastectomy. She was now a trans male.

But Mary says her child’s long-standing depression and anxiety only worsened. And last year the young woman made a stunning admission to her mother: even as she was being wheeled into the operating room to have her breasts removed, she was having doubts about her decision.

Now the 21-year-old is “detransitioning,” reverting to her original female identity. And Mary is part of a nascent movement calling for breaks to be placed on a health-care system geared to affirming a young person’s transgender feelings with drugs and surgery, allegedly in some instances after little assessment of other psychological issues.

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That movement has picked up steam just in the last year. Countries from Finland to Australia have stepped back somewhat from the affirmative approach, while the critics’ concerns are unexpectedly being shared by some of the leading figures in the transgender medical world itself.

But in Canada the thrust is if anything in the other direction, which proponents say is a positive thing.

Alarms are being sounded all over the world, and Canada seems completely deaf to it

A bill now before the Ontario legislature emphasizes speeding up access to medical transition, reducing the need for practitioners’ referrals to get such treatment and defining services like double mastectomies as life-saving.

And on Wednesday the House of Commons passed legislation that would ban the widely condemned practice of conversion therapy, despite concerns that it could also make it a crime to provide any therapy to gender-identity patients that explored broader psychological issues.

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“Alarms are being sounded all over the world,” says Aaron Kimberly, a B.C.-based transgender man and registered nurse with qualms about the current approach. “And Canada seems completely deaf to it.”

Parents, detransitioners and other critics say they support improving access to medical transition for those who need it and decry transphobic bigotry and violence. They do not oppose gender-neutral bathrooms or public funding for transition treatment.

But they argue the pendulum has swung too far from the days when people with gender dysphoria – a sense that their birth sex does not match their gender identity – often met resistance and prejudice in the health care system.

“For years and years, people have been homophobic, transphobic,” said Mary, who asked that her full name not be published to safeguard her daughter’s privacy. “We’re now trying to correct that but by doing that we’re putting others at risk. And those others we’re putting at risk are children.”

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The Toronto resident said she and her daughter even considered suing the health professionals responsible for her transition. Mary cites the case of Keira Bell, the British woman who won a court ruling that restricted prescription of puberty-blocker drugs to minors, a decision that was overturned on appeal recently.

Prime Minister Justin Trudeau, with Justice Minister David Lametti, left, Tourism Minister Randy Boissonnault and Government House Leader Mark Holland cross the floor of the House of Commons to shake hands with Conservative leader Erin O’Toole and other MPs after the unanimous adoption of legislation banning conversion therapy, December 1, 2021.
Prime Minister Justin Trudeau, with Justice Minister David Lametti, left, Tourism Minister Randy Boissonnault and Government House Leader Mark Holland cross the floor of the House of Commons to shake hands with Conservative leader Erin O’Toole and other MPs after the unanimous adoption of legislation banning conversion therapy, December 1, 2021. Photo by Adrian Wyld/The Canadian Press

But the NDP MPP who introduced Ontario’s Bill-17 says its main goal is to address a much louder alarm she’s hearing from doctors and constituents. Far from the pendulum having swung too far, Suze Morrison says, backlogs for gender reassignment surgery are so long, it’s driving patients to suicide.

“People are dying on wait lists so there is clearly a gap in care and a gap in quality of care that needs to be addressed,” said Morrison. “At the end of the day, I don’t think a five-year wait list is acceptable for any form of health care in Ontario.”

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A prominent expert in the gender-treatment world here agrees, saying that concerns about a rush to transition simply do not apply to Canada, where hospital-based clinics, at least, are exhaustive in their assessment of young patients.

“No one makes these decisions lightly,” said Dr. Margaret Lawson, medical director of the gender-diversity clinic at the Children’s Hospital of Eastern Ontario. “They are made very slowly, very cautiously, after long discussions with these youth and their parents.”

Regardless, she said the question of patients like Mary’s daughter with psychological issues separate from gender dysphoria is a relatively minor one. Barely one in 10 patients her clinic sees have such conditions, said Lawson.

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But some gender treatment now occurs outside of hospitals, and the tentative questioning of the current status quo has come in parallel with a boom in demand and changing patient demographics. Critics see both as red flags.

While those presenting with gender dysphoria were once predominately young boys or middle-aged men, gender-identity clinics are now seeing mostly teenagers who were born girls. The number of pediatric patients at 10 hospital clinics across Canada jumped from almost none in 2004 to more than 1,000 in 2016. About 80% were natal girls, most under 16 when they first came to the clinics, says the Trans Youth Can! research project .

A major, ongoing U.S. college health study found the percentage of students identifying as transgender or gender non-conforming soared from about .05 per cent between 2008 and 2015 to three to four per cent recently.

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A 2018 U.S. study of parents skeptical about gender treatment hypothesized that there was a new “rapid-onset gender dysphoria” phenomenon involving young girls who were sometimes swayed by online influencers and social contagion .

But gender-medicine professionals say the explosion simply reflects a growing acceptance of transgenderism after years of stigma and hatred – and may actually underestimate the number of youth in need.

A study published this year by Trans Youth Can! – which generally promotes the current treatment approach – rejected the ROGD hypothesis, finding no evidence  teenagers who had recently come out as transgender were swayed by psychological distress, gender-supportive friends or online influences.

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Even so, critics complain that rather than explore the often-complex mental-health issues of young people who present as trans, health-care practitioners are too readily putting children on “puberty blockers” – drugs that “pause” the development of puberty – and then cross-sex hormones, followed often by reassignment surgery.

“We feel the health-care system has been completely taken over by a political agenda at the expense of the actual evidence,” argues Kimberly, who runs the group Gender Dysphoria Alliance .

Another Trans Youth Can! survey found that five of 10 clinics do not have psychologists or psychiatrists assess patients before prescribing puberty blockers or hormones.

But Lawson said those five still have social workers or other professionals do mental-health screening. At CHEO, such assessments are followed by two or more doctor appointments and then a two-hour session with an endocrinologist like her, she said.

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Yet the concerns have led to change in some countries in recent months. Finland last year encouraged psychotherapy before transition treatment, while the Australia-New Zealand psychiatry regulator said it was essential. Clinics in Sweden this year stopped prescribing puberty-blocking drugs and cross-sex hormones to patients under 18.

And more strikingly, three top figures in the field have echoed such worries lately.

They include Dr. Marci Bowers, a trans woman and widely-respected gender-reassignment surgeon who is to become president next year of the World Professional Association for Transgender Health (WPATH). She suggested in an interview that children are sometimes being put on puberty blockers too soon, leading to complications in reassignment surgery that can potentially deprive them of sexual pleasure for life.

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Dr. Margaret Lawson says “it would be incredibly worrisome” if Canada adopted the same measures taken by places like Finland and Sweden to take a more cautious approach toward gender transitions.
Dr. Margaret Lawson says “it would be incredibly worrisome” if Canada adopted the same measures taken by places like Finland and Sweden to take a more cautious approach toward gender transitions. Photo by ERROL MCGIHON/Postmedia/File

In a Washington Post op-ed article this month, psychologists Erica Anderson , a transgender woman, and Laura Edwards-Leeper, both senior officers with WPATH, complained about sloppy and dangerous assessment of young people presenting as transgender, with overly hasty prescribing of medical interventions. They also call into question the assumption that delays in getting such treatment – as opposed to general mental distress – increases the risk of suicide.

But critics worry the federal government’s conversion-therapy Bill C-4 , passed by the Commons with unanimous consent Wednesday, could inadvertently outlaw more careful assessment before transition — or at least discourage therapists from providing it.

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The legislation has been hailed as a triumph for LGBTQ rights, criminalizing treatment that tries to change someone’s orientation to heterosexual or gender identity to that of their birth sex.

Opponents worry the bill is vaguely enough worded that it could also call into question the legality of therapy that explores other mental-health issues or reasons for gender dysphoria before a decision to medically transition.

The Ontario bill — which passed second reading without opposition from the Conservative government — also reflects none of the other nations’ or WPATH experts’ cautions.

It would set up an advisory committee consisting predominately of LGBTQ people to advise on how to speed up access to transition treatment and implement an “informed-consent” model with less need for referrals from health professionals, making it easier for patients to get hormones and surgery based on their transgender feelings.

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Morrison says constituents tell her the process is too cumbersome now, one person describing it as being like a Catch-22.

“She said … “I have to prove I’m both mentally well enough to have surgery, and that I’m mentally unwell enough that I need surgery.”

Michellle Zacchigna says she was among the first people in Ontario to be treated under the sort of model encouraged by the bill, and now has deep regrets.

We feel the health-care system has been completely taken over by a political agenda at the expense of the actual evidence

At the third of three perfunctory appointments with a doctor at age 21 and armed with a short letter from a therapist, she was prescribed testosterone, and later had a double-mastectomy and partial hysterectomy.

But her mental-health issues only got worse and Zacchigna was eventually diagnosed with autism, anxiety, ADHD and depression – problems she says were largely overlooked by professionals before she transitioned medically. Then last year the 33-year-old detransitioned, though she will never be able to get pregnant.

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“In trans health care, patients diagnose themselves and prescribe their own treatment,” she charged in a submission on Bill-17. “Medical professionals are encouraged to accept a person’s belief without question under the assumption that it will never change.”

Lawson said Zacchigna’s critique runs counter to her experience in the field and argues that the measures taken by places like Finland and Sweden would only create more damaging delays here.

“It would be incredibly worrisome,” said the University of Ottawa professor. “It would harm so many kids. I would hate to think what would happen to them.”

As for Mary’s daughter, she’s still suffering psychologically as she adapts to her new/old gender identity. But there’s hope, says her mother: the young woman no longer wishes she were dead.

“When I talk to her about how she’s doing … she says ‘I want to live. I’m still alive, I want to live.’ ”

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