Alberta has a new collection of proposed policies seeking to govern the age trans and gender-diverse people can receive gender-affirming care, whether they can use their preferred name and pronoun in school, and their ability to participate in sports.
Premier Danielle Smith made the announcement on Wednesday with several questionable assertions made about trans people and transitioning genders.
Smith’s argument suggests that a youth who, by virtue of hormonal changes in puberty, might turn to transitioning gender and might have some irreparable damage done because of surgery or other medical procedure before they reach legal adulthood.
“We want to make sure that children do not prematurely make decisions that are going to be irreversible and affect their ability to have sex and affect their ability to have children until they’re of an age where they’re fully responsible for those decisions,” the premier said at a press conference on Thursday.
At an unrelated press conference in Ottawa on Monday, Smith said “when a child moves down this pathway, it moves very, very quickly.”
But the reality of a gender transition – and a later possibility of surgery on sexual organs – is marked with cautious moves forward and multiple alternatives to going under the knife.
The difference between puberty and gender transition
In the video recording posted to social media on Wednesday and in comments during a press conference on Thursday, Smith appeared to be conflating puberty with gender transition.
“Children and teenagers are in a constant state of biological, social, emotional, and sexual development and change. They’re constantly learning about themselves, trying new things, dealing with biological changes, and trying to understand a wide range of new thoughts and feelings,” Smith said Wednesday.
But puberty – the process of sexual maturation via the natural release of hormones – is not the same as transitioning genders.
And sex – a biological difference that is expressed in chromosomes and sex organs – is not the same as gender – how a person expresses their identity and role in society in line with societal norms and expectations.
Is there any real connection between going through puberty and deciding to undergo gender transition?
“No,” said Dr. Tehseen Ladha, pediatrician and assistant professor at the University of Alberta.
“The only similarity is that they can occur at the same time. The ideal time for some of the medical treatments to be implemented, namely hormones or hormonal blockade, would be at the initiation of puberty.
“There are a lot of misconceptions that, during puberty, adolescents somehow frivolously decide to transition to the opposite gender or are inappropriately influenced by friends or medical professionals to transition to another gender – those are false.”
Ladha said her trans patients have identified as the opposite gender early in life, often during preschool years.
Anna Murphy, a trans woman and community organizer, is one such case of identifying as a gender other than the one assigned at birth when she was “very young.”
“High school was when I began to affirm who I knew to be my most true and authentic self. However, at a very young age, I knew that something was wrong,” Murphy said at an Alberta NDP press conference. “By five years old, I was desperate to just be like any other girl.”
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The decision to transition gender is not made lightly and usually begins with changing names, pronouns and how the person dresses.
“These decisions are not made quickly and they’re not made without a lot of external consultation,” Ladha said. “Some of these decisions, such as what pronouns they’d like to use, are certainly their choice. But other things like hormones, or hormone-blocking agents, those are done in consultation with the adolescent if they’re a mature minor, in consultation with the child and their family if they’re not a mature minor, and always involve specialists like pediatric hormone specialists or endocrinologists and mental health therapists or psychiatrists.”
The Alberta Medical Association’s section of child and adolescent psychiatry issued a statement on Monday saying sometimes no interventions are necessary. Sometimes, only social transitioning via a change in dress and pronouns are sufficient.
“It may involve being part of a broader team offering puberty-blocking agents to temporarily slow development to give youth time to explore and consider,” the AMA statement said.
Why block puberty blockers?
The announced policies would restrict access to puberty blockers and hormone therapies to children aged 15 and under.
Puberty blockers are used to pause the development of secondary sex characteristics that aren’t present at birth, like breasts on women and Adam’s apples on men.
Smith suggested the entire suite of gender-affirming therapies, including puberty blockers, are “permanent and irreversible.”
The Alberta Medical Association’s pediatrics section said that idea is false.
“The effects of puberty-blocking agents are not irreversible; and once treatment stops, puberty goes forward,” the AMA said in a statement on Thursday. “Treatment allows the patient time to determine their options without permanent effects.
“Puberty blocking actually has benefits for gender-divergent patients by preventing development of mature secondary sex characteristics so that, later in life, the most invasive gender-affirming surgery may not be necessary if the patient moves forward with gender-affirming care.”
Ladha noted that puberty blockers are used in scenarios outside gender transition, too.
Dr. Jillian Demontigny, a family doctor in Lethbridge, said the idea of prohibiting the use of puberty blockers and hormone therapies for trans people until they’re into late adolescence runs contrary to all of the best practices and scientific consensus.
“The physical changes that happen much earlier than the ages she’s mentioning – 15, 16, 17 – are ones that cause permanent voice change, permanent hair growth, permanent breast development. And things that can’t be reversed if a person decides they need to for their gender affirmation. And if they can be reversed, it requires things like surgeries and medications,” Demontigny said.
“And so she’s basically dooming gender diverse kids who don’t wish to undergo their first puberty, to be forced to do that before they can never access the care that might just let them pause any permanent changes from happening, to give them time to explore and get to learn what are their options and decide on their goals.”
Earlier access to puberty blockers avoids unnecessary and more invasive surgeries, which increase better healing outcomes and save public health dollars, both Demontigny and Ladha said.
Travers, a Simon Fraser University sociology professor who goes by the single name, said many of the dozens of trans kids they’ve spoken with sometimes halt the use of puberty blockers and hormone treatments.
“For kids who are experiencing really severe gender dysphoria and who find the development of secondary sex characteristics to be deeply distressing, hormone blockers are a short-term solution that have no permanent impact in the sense that you could be on hormone blockers for a couple of years and go, ‘You know what? I think that I’m going to try to make it work in the body that I have,’ and they go off hormone blockers, and what would have happened a few years earlier happens then,” Travers said.
The new policies would render the use of puberty blockers largely moot, one doctor said.
“If a patient is too old, there’s no use for puberty blockers,” Calgary physician Dr. Ted Jablonski said. “There would be no place for them medically. So essentially, that decision or that proposal would limit our ability to use them at all.”
The new policies also said teens aged 16 and 17 would only be able to take puberty blockers and hormone therapies for gender reassignment and affirmation with the approval of parents, a physician and a psychologist.
Demontigny said those ages don’t make sense in light of the biological realities present in transitioning.
“It was confusing to me, the suggestion that the best thing to do is to basically just delay all care until it’s too late to make as much of a difference,” Demontigny said.
Travers said there are no doctors, medical professionals, or trans-supporting organizations who are encouraging access to gender-affirming health care unless it is in response to that child’s expression of distress with their gender assigned at birth.
“For kids who do get gender-affirming health care, the screening is extensive: psychological assessments, multiple appointments,” they said. “Most trans kids that I talked to, it was like at least a year before they accessed any kind of treatment beyond talk (therapy).”
“Denying them access to hormone blockers is incredibly dangerous because it is forcing them to undergo a puberty that they are going to find intensely traumatic,” Travers said. “It means that, as adults, they will be more vulnerable to discrimination and violence.”
They said interviews of trans kids and parents over the past decade revealed a “significant number of those kids would be dead if they had not gotten access to hormone blockers.”
Demontigny questioned the medical ethics of having the government’s presence, vis a vis a restrictive policy, in the room with the family and doctor.
“Whenever the government starts to try to wade into the exam room with the patient and their guardians and myself, but that’s when I get the most concerned,” the Lethbridge doctor said.
'Not a recipe book'
Smith said the new policies would prohibit gender-affirming surgeries for minors under 17 – procedures known as top and bottom surgeries.
Addressing the media on Thursday, Smith said bottom surgery “has implications for sex and for fertility.”
“They’re adult decisions, so we want to make sure that certain decisions are made as adults,” Smith said.
Those decisions are already made by adults, for adults.
According to the Canadian Pediatric Society, bottom or “lower” surgeries pursued by some trans and gender-diverse people are already restricted to people over 18.
Smith also recognized that, historically, bottom surgery was already restricted to people aged 18 or older.
Smith also said the province would try to attract experts to the province to avoid trans people from having to go to Quebec to get assistance, which is the current practice in Alberta.
A private clinic in Montreal has, for years, been the only facility performing certain gender-affirming genital surgeries, but in the last few years, Ontario and B.C. started offering them at public hospitals.
According to the premier, in 2020-2021, 104 surgeries were approved and 119 were approved the following year. Roughly 25 per cent of those surgeries were for trans people aged 18 to 25.
The 2021 census showed Alberta’s trans population amounted to less than one-quarter of one per cent of the entire province, and non-binary persons were another 0.15 per cent.
Amelia Newbert, managing director and co-founder of Skipping Stones Foundation, said her trans-supporting organization is seeing “very little, if any access to those surgeries right now.”
“And so the idea that this is endemic is fundamentally not true,” Newbert said.
Newbert said top surgeries are sought by youth as a “really important” part of their gender affirmation process.
“When we’re seeing youth accessing gender-affirming surgeries, we’re only seeing top surgeries with the immensely rare exception. And we’re seeing that those surgeries are being supported by a huge health care team as well as the family,” she said.
Ladha said that some surgeries have an element of reversibility, like how breast cancer patients can have breast reconstruction.
“Generally some of the surgeries would be considered somewhat reversible, but they would likely be quite involved,” the U of A professor said. “When we think of surgery there are risks to surgery, of course, and I think having multiple surgeries would be difficult on a person and could lead to complications.
“That’s why there’s that due diligence in ensuring that an individual does want to go forward with that part of gender-affirming care.”
Demontigny said each trans person’s journey through transitioning genders is unique to that individual.
“We have different aspects of transition that are available, but what our patient goals are is what’s going to drive their gender-affirming care,” she said. “So it’s not like you’re following a recipe book.”
–with files from Emily Mertz, Global News
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