People protest Alberta Premier Danielle Smith's proposed youth transgender policies as she appears at an event in Ottawa, in February, 2024.PATRICK DOYLE/The Canadian Press
There are two fundamental principles when considering appropriate treatment for young people who believe they have a gender identity different than their biological sex.
The first is that the welfare of the young person must rise above all other concerns. The second, related, principle is that the decision about treatment for gender dysphoria must be based on the best medical advice available, not ideology.
It can be already an incredibly vulnerable moment for young Canadians struggling with their gender identity and for their parents who only want what is best for their child. Gender incongruence – seeing one’s true gender as different from their biological gender – can create severe distress, known as gender dysphoria, which can go so far as to put a young person at risk of suicide.
But what is the right answer for those youths who believe that they are transgender? For years in much of the Western world, the answer was straightforward: a treatment regime of hormones as close to the onset of adolescence as possible, in order to safeguard the mental wellbeing of a transgender youth and to minimize physical changes from puberty.
But that guidance has shifted in many countries. A growing number of countries now prohibit puberty blockers in all but the most extreme cases of youth gender dysphoria.
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In 2020, Finland changed course, urging caution in prescribing puberty blockers, pointing to questions about bone density and fertility. By 2024, various official bodies in Sweden, France, Norway, Denmark and the United Kingdom had made similar recommendations that puberty blockers be prescribed only in restricted circumstances.
Other reviews have pointed in the opposite direction, most recently in the Netherlands, where a report released in late June supports chemical intervention in some cases. The Dutch report acknowledges there may be negative effects from puberty blockers, but that the mental health risks mean such treatment should not be denied.
There has been no such re-examination in Canada. Meanwhile, Alberta has passed a law restricting the prescription of puberty blockers. That turns what should be a decision grounded in ethical and medical concerns into a legal matter.
That is the wrong approach: the course of treatment of gender dysphoria should be a discussion between a youth, their family, and their doctors. But that is not to say there cannot be a debate about best practices and about science. Unfortunately, Canada is not having that debate.
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The Canadian Paediatric Society issued a position paper on treatment for transgender youth, including the use of puberty blockers, in June, 2023. That document does acknowledge the potential risks to bone density and fertility, but its broad stance is a green light to the use of puberty blockers, a contrast to the more cautious approach emerging in Europe. It’s worth noting that the CPS paper is not clinical guidance (a point that the paper’s chief authors themselves make).
But there are growing questions in Canada that are leading some physicians to question that green-light approach, among them Dr. Karine Khatchadourian, a pediatric endocrinologist at the Children’s Hospital of Eastern Ontario and an assistant professor in the department of pediatrics at the University of Ottawa. Dr. Khatchadourian says she prescribed puberty blockers for more than 150 youths to treat gender dysphoria over a decade of practice.
But she stopped prescribing puberty blockers about a year ago, because of a lack of clarity on the long-term effects of the powerful drugs. “Evidence is gradually emerging that argues for us to be more cautious,” she says.
Dr. Khatchadourian says a more rigorous approach is needed, with puberty blockers prescribed through a central body, rather than individual physicians dispensing prescriptions, and with the collection of data. That would allow for long-term monitoring to see how many individuals stayed on medication, for side effects and complications and more broadly, quality of life.
There is a data vacuum in this country on the long-term effects of puberty blockers, one that deprives physicians, patients and their families of the best possible science in treating cases of possible gender incongruence and dysphoria.
So far, the medical establishment has not been willing to fill that vacuum. It’s past time for clinicians and researchers to do so: this country cannot shy away and hope to outsource this research to other countries.