Bill 17 - Gender Affirming Health Care Advisory Committee Act, 2021
Submitted November 25, 2021
In the past decade, throughout the West, two worrying trends have appeared in the world of gender medicine. The first is a dramatic increase in the number of minors being referred to gender clinics, and the second is a notable increase in the number of young people detransitioning after pursuing medical transition. Initial data indicate that natal females are greatly impacted by both these trends, and it is therefore on behalf of Ontario’s girls and young women that we submit this brief.
Our three main areas of concern are:
1. The emphasis on the gender-affirming model of care, which is coming under increased scrutiny throughout the world.
2. The intention to adopt the Informed Consent Model of care, which falls far short of current guidelines in jurisdictions which have recently reviewed and updated the practice.
3. The lack of diversity of opinion and experience in the proposed committee.
Is gender-affirming care beneficial?
There is an ongoing debate in the field of gender medicine regarding what is the best model of care for treating children and adolescents who suffer from gender dysphoria. In the past, therapists treating gender dysphoric children practiced watchful waiting – a therapeutic approach in which the child received on-going psychotherapeutic support while the causes of his or her gender dysphoria were investigated, with the aim of alleviating it without the need for medical intervention. This approach was highly successful – studies show desistance rates of up to 98%.[i] However, in recent years, watchful waiting has been replaced by the gender-affirming care approach, which requires that clinicians do not question the child’s transgender identity, but instead affirm them and support them in their desire to medically transition. Rather than focusing on psychotherapy to avert the need for medical transition, affirmative care prioritizes medical intervention in the form of puberty blockers and cross-sex hormones as the first line of treatment. We believe this approach is harmful for all children and adolescents, but particularly so for the cohort of teenage girls who may be experiencing a new, atypical form of late-onset gender dysphoria.
This new atypical late-onset gender dysphoria often begins suddenly at puberty in individuals who experienced no obvious discomfort with their natal sex throughout childhood. Little is yet known about its causes, but clinicians have observed that this new cohort is unlike those previously recorded in medical literature.[ii] The group appears to be made up of predominantly natal females, whereas in the past childhood gender dysphoria afflicted predominantly natal males.[iii] A Finnish study found that a majority of these girls have one or more psychiatric comorbidity, such as depression, anxiety, eating disorders, ADHD, or a history of self-harm[iv], and evidence for a link between this possible new developmental pathway to gender dysphoria and autism is also growing[v] [vi].
In sum, there is a group of individuals with very complex psychological needs who are presenting to gender clinics, and we know very little about their developmental course. We believe that the unconditional affirmation of this group without a thorough investigation into the patient’s history risks exposing these girls and young women to unnecessary and irreversible medical intervention.
International guidelines are evolving
In light of so many unknowns related to gender dysphoria in children, many countries are adopting a much more cautious approach to the treatment of children with gender dysphoria.
In 2020, Finland became the first country in the world to issue new guidelines for this group of patients after a review concluded that there is a lack of quality evidence to support the use of hormonal interventions in adolescents with gender dysphoria[vii]. The new guidance prioritizes psychological therapy over treatment with hormones or surgery and suggests different care plans for early-onset vs late-onset childhood gender dysphoria.
Earlier this year, Sweden also published a new guideline for the diagnosis of gender dysphoria in minors, now emphasizing the requirement for a thorough mental health evaluation. Since publication, five out of Sweden’s six paediatric gender clinics have halted the practice of prescribing puberty blockers and cross-sex hormones for minors under age 16[viii]. The Karolinska Hospital justified its decision by citing research which showed:
“a lack of evidence for both the long-term consequences of the treatments, and the reasons for the large influx of patients in recent years. These treatments are potentially fraught with extensive and irreversible adverse consequences such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.” [ix]
There is an independent review currently underway in the United Kingdom with regards to its gender identity services for children and teenagers.[x] Initial findings by the National Institute for Care and Excellence (NICE) found evidence for the use of puberty blockers and cross-sex hormones in adolescents to be of very “low quality”. [xi]
We therefore find it deeply concerning that as other countries are reverting back to a more cautious psychotherapeutic approach, this bill actively seeks to promote gender-affirming care, despite a lack of evidence of its effectiveness and increasing signs that it may be harmful to children and adolescents.
The Informed Consent Model
Our next concern regarding the bill is this entry on the list of proposed committee functions:
7. How to adopt the informed consent model of transgender care and how to reduce referral requirements for access to care
It is important to understand what the Informed Consent Model really is. Informed consent in the general medical setting means the process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. In the field of gender medicine, however, it means something very different. The Informed Consent Model in this respect is a form of gender-affirming care which removes the need for an official diagnosis of gender dysphoria by a mental health professional prior to starting medical transition. Proponents of this model of care argue that gender dysphoria is not a mental health issue, and that such a requirement is an unnecessary barrier to accessing care. We disagree. Gender dysphoria is a recognised mental health issue listed in the DSM-5, and a thorough psychological assessment prior to medical transition is a vital part of the treatment process, particularly for girls experiencing late-onset gender dysphoria, given the risk of coexisting mental health issues being present.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recently issued a position statement stressing the importance of psychological assessment in the initial stages of transgender care[xii]:
“Comprehensive assessment is crucial. Assessment and treatment should be evidence-informed, fully explore the patient’s gender identity, the context in which this has arisen, other features of mental illness and a thorough assessment of personal and family history.”
It went on to recognize that:
“Gender Dysphoria is an emerging field of research and, at present, there is a paucity of evidence. Better evidence in relation to outcomes, especially for children and adolescents is required.”
As gender dysphoria is an extremely complex mental health issue, it is nothing short of reckless to seek to remove mental health professionals from the initial diagnostic stage. Diligent screening is extremely important given the irreversible nature of medical transition.
Under the proposed Informed Consent Model, “informed consent” means nothing more than a healthcare provider explaining the effects and risks of puberty blockers or cross-sex hormones and the individual signing to say they have understood and accept them. This is concerning not only because it excludes the alternative treatment option of psychotherapy from the decision-making process, but also because there are serious questions about whether a child or young adult has the mental capacity to consent to medical transition. It is often claimed that puberty blockers are fully reversible, and that they are nothing more than a pause to allow the child time to decide if transition is right for them; therefore, consent can easily be given. New evidence shows this to be untrue. Aside from the detrimental effects on bone density[xiii], studies also show that approximately 99% of children who start on puberty blockers go on to take cross-sex hormones[xiv][xv], so it is more accurate to view the blockers as the first step on a medical pathway which leads to hormones and major surgeries – that affirmation and starting the child on puberty blockers prevents desistance and makes cross-sex hormones almost a foregone conclusion. Therefore, in order to give true informed consent to puberty blockers, a girl must also understand the irreversible effects of the testosterone that will almost inevitably follow. These include sterility[xvi], vaginal and uterine atrophy which can later lead to sexual dysfunction and the need for a hysterectomy