How Alberta's proposed trans youth rules fit into a polarized international landscape

It's been a little more than a month since the Alberta government announced a planned fall rollout of legislation focused around top and bottom surgeries, puberty blockers, hormone therapies and other elements of what's referred to as gender-affirming care.

Canadian doctors, nurses and medical groups have pushed back against the move, while an open letter was released by 36 Alberta academics, predominantly from law schools, asking the province to reconsider the changes.

The measures in question — the strictest transgender youth rules in the country — are part of a fraught, polarized debate that has only recently entered Alberta's political landscape but have already been subjects of great controversy in Saskatchewan and New Brunswick.

They have long been the subject of battles fought by lawmakers and courts in the United States, where gender-affirming care for minors is endorsed by a number of major U.S. medical associations, including the American Medical Association and the American Academy of Pediatrics.

But though they have long held support from those U.S.-based medical organizations, in recent years, traditionally right-leaning states have taken a different view of the issue. More than 20 states have moved to ban gender-affirming care, according to tracking by the Kaiser Family Foundation, a non-partisan organization focused on health policy. Many of those bans are currently subject to lawsuits.

Lawmakers in those states have argued the U.S. should adopt some of Europe's more cautious and restrictive approach when it comes to gender-affirming care. In response to rapid growth in the number of youth seeking treatment, several countries in Europe have revised their approaches to gender-affirming care in recent years, most notably in the United Kingdom.

In response to the growing number of bans in the United States, the American Academy of Pediatrics commissioned a systematic review of evidence behind gender-affirming care in August 2023. The professional association of pediatricians, the largest of its kind in the U.S., acknowledged similar reviews in Europe had recommended a more cautious approach to treatment but said it had confidence its current policy was appropriate.

"At the same time, the board recognized that additional detail would be helpful here," Mark Del Monte, the chief executive of the AAP, was quoted by the New York Times as saying last August.

Closer to home, the Canadian Paediatric Society, Canadian Medical Association, Alberta Medical Association and Alberta Psychiatric Association all have stated their support of gender-affirming care. However, in discussing the possible upcoming changes in this province, Alberta Premier Danielle Smith has cast her eye past North America's shores and toward Europe's ongoing policy debate.

Tavistock clinic

The day after the measures were rolled out, the premier said the province had been tracking what was taking place internationally, including in Great Britain.

Much of the debate in the U.K. has revolved around the Tavistock clinic, the country's only centre dedicated to treat children with gender dysphoria, a formal diagnosis that refers to the distress that comes to a person when their experienced gender doesn't align with the sex they were assigned at birth.

In February 2022, an interim review of the clinic was published by Dr. Hilary Cass, the past president of the Royal College of Paediatrics and Child Health, the professional body for pediatricians in the U.K.

In her review of the clinic, Cass stated that Tavistock was overloaded by demand and had not seen data properly collected.

"We need to know more about the population being referred and outcomes. There has not been routine and consistent data collection, which means it is not possible to accurately track the outcomes and pathways that children and young people take through the service," the report states.

The review notes demographics have changed to include more young people with complex mental health needs as well as more who are neurodiverse and who are assigned female at birth. Ideas around gender are also shifting, the report said, with more youth perceiving gender as fluid rather than binary.

With that report in hand, England's publicly funded health service, the NHS, said that beyond exceptional cases, it would no longer offer puberty-blocking drugs to children and adolescents at gender identity clinics outside of a research setting.

While the Tavistock clinic is still open, it is scheduled to close later this year.

However, its closure doesn't equate to a ban of gender-affirming care in the country, as new regional clinics will soon take its place, and Cass has stated more services should be implemented.

And as a 2023 Politico review found, elsewhere across Europe, the rethink around access to gender affirming care ranges in approach. The debate centres around what the rules around access should be and, in some cases, involves a tightening of access to gender-affirming care — but doesn't equate to a move to ban the practice entirely.

You've likely been hearing a lot about these issues in Alberta since the proposed policies were announced, and more will follow over the coming months. Before that happens, there's a lot for the public to digest around what the provincial government says it's looking to change, and why.

Through it all, the policies will directly impact those families who are faced with making critical decisions around the health of vulnerable children in a complex field — treatment that doctors in Canada worry is growing increasingly politicized.

What's on the radar

CBC News spoke with six medical professionals, including one of the co-authors of the Canadian Paediatric Society's position statement on gender affirming care for youth in Canada, as well as a health policy expert, about what's changing in Alberta and how it fits into a global context.

First, a quick primer on the terms being used over the past month.

• Top surgery refers to a surgical procedure that adds or removes breast tissue. It is also sometimes referred to as masculinizing or feminizing chest surgery. Like bottom surgery, it's done as a part of gender-affirming health care. Pediatric youth also receive top surgery for other reasons, including for cancer or breast reduction due to pain.

• Bottom surgery, conversely, refers to the removal or surgical creation of a person's genitals.

• Hormone therapies are used to produce physical changes that are reflective of one's gender identity, such as receiving testosterone to produce facial hair. Hormone therapies are also used for a wide variety of other medical conditions.

Alberta has two hospital-based gender clinics for children and youth.

According to Alberta Health Services, 470 patients are currently registered at the Metta Clinic, part of the Alberta Children's Hospital in Calgary, with another 450 on the waitlist. The Stollery Children's Hospital in Edmonton has 209 active patients with another 200 waiting to be seen.

The Metta Clinic treats youth up to the age of 18, while in Edmonton, anyone over 16 is referred to the adult program.

It is unclear how many youth are being treated by physicians in the community.

Top and bottom surgeries in Alberta

In  revealing the new policies, the provincial government announced its intention to ban both top and bottom surgeries for minors under the age of 18.

"We want to make sure that kids know the consequences that it's going to have on their life, and that they're mature enough to be able to make those decisions and live with the consequences," Premier Smith told reporters Feb. 1.

This has become a point of confusion for many people.

Under the current system, Albertans under 18 are already not eligible for bottom surgery funding in the province. So that will not change moving forward.

Top surgeries, meanwhile, are extremely rare for youth. Under the current rules, a person must be 16 to be eligible for top surgery in Alberta.

"There may be a very few people whose gender identities have been stable for a very long time, have supportive families, good support network, are in therapy, that are able to get it under the age of 18," Dr. Jake Donaldson, a Calgary family physician who treats gender-diverse adults and youth, told Alberta@Noon.

"That is extremely rare. And those are for people for whom it is just abundantly clear that there's no concerns."

There were eight gender-affirming top surgeries for youth in Alberta that took place between January 2022 and February 2023, according to data provided by the province's health ministry.

Puberty blockers and hormone therapies in Alberta

Alberta's plan to restrict access to puberty blockers and hormone therapies represents a significant change from the status quo.

In a news conference in February, Smith said she wanted to protect teens from making irreversible decisions, adding the medications come with health problems, including a greater risk of osteoporosis and a higher incidence of heart problems.

"We want to make sure that as kids embark upon those life-changing decisions, that we're very clear about the appropriate level to be able to make those decisions," she said. "There has to be a certain level of maturity of understanding the consequences."

Puberty blockers

Under Smith's proposed policy, puberty blockers and hormone therapies for the purpose of gender affirmation will no longer be permitted for anyone under 16, except for those who have already commenced treatment.

It would be Canada's first ban on such medication.

But it's important to understand that hormone therapies and puberty blockers are different, and are used for different reasons.

Let's start with puberty blockers, which were first used with transgender youth in the 1990s, with a goal to give kids who feel distress in their body time to explore their gender under less pressure and to prevent developmental changes that would require surgery to alter later on.

Organizations such as the Endocrine Society, the World Professional Association for Transgender Health (WPATH) and the Canadian Paediatric Society recommend puberty blockers should not be started before the onset of puberty, which generally starts around the age of nine and 11 for girls, and nine and 13 for boys.

The proposed ban in Alberta on the medicine for those under 16 would render the medicines largely pointless, many doctors argue, as many youth have already gone through puberty at that age.

"To have these arbitrary age numbers inserted into the fold, it just defies all existing evidence that people working in this area actually follow," said Dr. Joe Raiche, a psychiatrist working at the Alberta Children's Hospital's Metta Clinic.

Under the government's new plan, mature teens aged 16 and 17 would be able to use puberty blockers and hormone therapies for gender affirmation reasons should they have parental, physician and psychologist approval.

Dr. Daniel Metzger, a pediatric endocrinologist, is one of the co-authors of the Canadian Paediatric Society's position statement on gender-affirming care for youth in Canada, released last June. He said puberty blockers have a long history of use.

"We know that the puberty blockers are completely reversible," Metzger said, referring to the medical understanding that once a youth goes off the drug, they'll proceed to go through puberty afterwards.

A number of high-profile medical organizations, including the Endocrine Society, the American Academy of Pediatrics and the World Professional Association for Transgender Health, assert that when puberty blockers are stopped, puberty resumes.

However, others — including jurisdictions that Smith has referred to — have said the medical effects and safety of puberty blockers are not fully understood and there may be long-term risks that are not yet known.

In her 2022 review for the NHS, Cass stated that due to "gaps in the evidence base," recommendations on puberty blockers could not yet be made. The important question to answer, according to Cass, is "whether the evidence for the use and safety of the medication is strong enough as judged by reasonable clinical standards."

According to Metzger, all medication comes with some risks, and physicians monitor children closely to minimize those concerns.

"So these are risks and benefits that we have to go over with families, just as you would with a child where you're going to start asthma medications, lipid medications, blood pressure medications, diabetes medications."

While he said puberty blockers are reversible, Metzger added they can also impact bone health by slowing calcium uptake into bones if used for long periods without hormonal supplementation.

When it comes to heart problems, a B.C. Children's Hospital information sheet states the use of puberty blockers with certain other medications, including those for mental health, may in rare cases increase the risk of a serious problems with heart rhythm.

The Cass review identifies concerns about the unknown impacts on brain development in youth if they don't experience the natural changes in the body and brain that are linked with hormone increases during puberty.

In its position statement, the Canadian Paediatric Society said concerns about potential permanent impacts on cognitive function when hormones are suppressed during adolescence "have not been substantiated to date."

But Metzger argues what would transpire for a transgender individual should the medicines not be used at all comes with serious risks.

"We can't make a child wait for four years, until they get to some sort of arbitrary age of 16. Firstly, that's torture for them. Secondly, by the time they're 16, their bodies will have changed quite appreciably in a direction that they're not happy with," he said.

In its position statement, the Canadian Paediatric Society states that transgender and gender-diverse youth who have sought and received hormonal suppression as a part of a multidisciplinary approach to care "report improved mental health and psychosocial functioning," and access to these medications has been associated with "lower odds of suicidal ideation" over their life.

The U.K.'s Cass interim review acknowledges the distress young people experiencing gender dysmorphia go through during puberty, including the risk of self-harm and suicide.

However, it states that "some clinicians do not feel that distress is actually alleviated until children and young people are able to start feminizing/masculizing hormones," adding its final review, due this year, will seek to gain a better understanding of this area.

Still, Metzger feels as though delaying treatment until 16 will lead to periods of significant distress for transgender youth given the physical changes they will experience.

"Then they're going to need surgery, top surgery for breast development, they're going to need electrolysis for the hair on their face and body. So you're increasing their burden upfront, and you're increasing their burden afterwards," Metzger said.

Hormone therapy

Let's look at hormone therapy.

When Smith announced the potential gender policy changes, she cited concerns about osteoporosis related to gender-affirming medication.

Metzger, the pediatric endocrinologist, said as soon as kids on puberty blockers start on the hormone that they identify with, calcium starts flooding back into the bones. What isn't entirely clear is whether they can completely recuperate the year or two that they've been on puberty blockers without hormones.

"That's where the research is right now, to see how we're doing with that, if we are able to prevent this. Osteoporosis doesn't happen when you're a kid, it happens when you're an old person. But pediatric endocrinologists are very mindful of that," Metzger said.

"It's our job for children to be putting calcium into their piggy bank. Not just trans kids. All kids."

Hormone therapy is described by doctors as "partially reversible."

Effects that cannot be reversed include breast development, facial hair growth and voice changes.

Some of the changes are reversible, according to Metzger, including testosterone-induced muscle development and changes to fat distribution (focusing around the hips, for example), triggered by estrogen.

According to the CPS's position statement, hormone therapy can permanently decrease fertility, but the extent of those changes is unclear. The document urges health-care providers to explore a young person's desire to have children, before starting the medication, and offer fertility preservation options.

All told, Metzger said it's important to continue to study the science.

"We don't know everything … but we don't know everything about asthma, either. Or diabetes. All of us are in a learning process," he said.

"We don't not treat [kids with diabetes] because we don't know everything. We have to treat them because they would die if we didn't. And I think the same is true of trans kids. They would have a very, very miserable mental health outcome if we just ignored them until they were 16."

According to Raiche, the psychiatrist who works in the gender clinic at Alberta Children's Hospital, there are no hard and fast rules governing the age at which puberty blockers and hormone therapy can start.

Each decision is made individually with youth and families alongside their health-care team and following international guidelines, he said. Puberty suppressing medication is often considered for gender dysphoric youth between the ages of 10 and 12 and hormone therapies may be considered starting around age 14, he added.

It appears unclear — even to the provincial health ministry — how many youths are actually seeking hormone therapy and puberty blockers.

When CBC News asked how many people under 18 are taking hormone therapy and puberty blockers in Alberta, the department said there were nearly 2,700 total claims for "non-surgical interventions" by minors in 2022-23.

However, the province says it's unknown how many of those claims are for gender dysphoria versus other medical conditions, such as cancer treatment, endocrine disorders, growth disorders, obesity and fatigue. It does estimate, however, that treatments for reasons other than gender dysphoria represent the majority of claims.

What's more, the government could not clarify how many people those 2,700 claims actually represent.

When Lorian Hardcastle, who teaches health law and policy at the University of Calgary, hears the government being unable to provide specifics around such data, she worries about the government passing significant policies that "have tremendous implications for the lives of certain people in a data vacuum."

"I think, from a policy perspective, there's a problem," she said.

The Canadian context

As Alberta positions itself as an outlier in Canada with its plans to dramatically restrict access to gender-affirming care for youth, vocal support from within the Canadian medical community appears in short supply.

While key medical organizations have called on the province to walk back its plans, CBC News spoke with a Canadian researcher who, while not endorsing the Alberta government's plan, does have questions about whether the race to treat the growing number of transgender youth on waitlists has outpaced the science, and sees value in a more cautious approach.

"I have a real hunger for more data right now, especially in the Canadian context," said Kinnon MacKinnon, an assistant professor in the school of social work at York University, who studies the experiences of people going through gender-affirming care as well as the detransition process, where a person stops treatment or reverses it.

MacKinnon, who is transgender, doesn't believe a ban on treatment is the answer and characterizes Alberta's move as politically opportunistic.

But he would like to see more government funding for research and assurances that international standards of care are followed as Canadian clinics work to keep up with demand.

"I certainly have people in my research studies who, at least in their perspective, feel like they received substandard care or were not provided with enough information to make decisions," he said.

"In Canada, we have very little understanding as to the proportion of those who have benefited from hormonal or surgical treatments, how they feel about these interventions five, 10, 15 years later.… In what ways have they benefited?"

Dr. Joey Bonifacio is also watching closely from Ontario. He's an assistant professor specializing in adolescent medicine at the University of Toronto who co-wrote a 2019 article for the Canadian Medical Association Journal on gender care provision in primary care.

"What we need is a very considered approach, and I would much prefer that than simply a ban," said Bonifacio, when asked what he thinks about Alberta's proposed plan to restrict puberty blockers to kids 16 and older.

He says ideas about gender have changed over time and he's seeing more young people who are gender-fluid and non-binary.

"Having this shift away from … starting medications as quickly as possible is one that I would advocate for," said Bonifacio, based on his experience providing gender-affirming care in Ontario.

He believes sorting through these complexities takes time and clinical practice needs to adapt.

"When it comes to hormone blockers, there's never a right time or a wrong time," he said.

"For many youth, hormone blockers, I would say, are definitely needed and should be provided at younger ages. I think, for some, perhaps waiting and being a little bit older would probably be in their best interest," he said.

For his part, Raiche, the Alberta Children's Hospital psychiatrist, says clinicians in this province already take a very cautious, individualized and holistic approach to providing gender-affirming care. And, he argues, any further pauses or restraints would be more harmful to the trans- and gender-diverse community.

Rather than restricting care, Raiche says more supports and resources are needed in Alberta.

According to Raiche, Canadian studies are being carried out and he believes any pushback in this country's medical community comes from a small minority of individuals.

When trying to contextualize this issue, he says it's important to consider where the medical consensus lies.

"We don't want to just dismiss them. But I think we need to weigh that against what are our regulatory bodies and what are our professional organizations, that actually set clinical care guidelines achieved through a quite vigorous standardization process … what are they saying," he said.

"[If] all of these organizations are saying the same thing — and reasonably forming a consensus — I think the average clinician is going to pay attention, rightfully, to that."

What's more, Raiche argues, the practice of medicine inherently requires a delicate, thoughtful and informed consideration of the benefits and risks for all kinds of medical treatments. That is not new.

"It's always about looking at taking a step back, looking at the bigger picture of doing something versus not doing something [and] balancing that risk with an individual's own goals and needs in the context of their psychosocial situation and support circles, and then together making a supported, informed decision," he said.

But in Alberta, Raiche argues, politicization is distorting a very nuanced discussion, and he worries vulnerable and marginalized children and teens will suffer as a result.

"It puts this extremely and unreasonably high bar [in place] that they're not implementing across the board," he said.

"The vast majority of countries that provide this kind of care are continuing to do so, unfettered by government."