What does gender-affirming health care for youth look like in Canada?
There has been a lot of fear-mongering from the far-right about protecting children from gender-affirming health care. Last month, the federal Conservatives even adopted a policy to limit health care for transgender youth in Canada.
The policy aims to stop life-altering medical or surgical interventions for young trans people in Canada. The language makes it seem as though life-altering surgeries are being performed on children.
That is not at all what is happening.
Most of us don’t know what types of health care services and procedures exist for trans youth in Canada. In this column, I will clarify what doctors can provide for trans youth. I will also explain why it is vital that youth continue to receive gender-affirming care. My hope is that when people have this information about the types of health care youth are able to receive, they will have the information needed to see through the rhetoric being used to try and block access to care for trans youth.
The information provided here is for informational purposes only and is not intended as medical advice. If you are a trans person needing information about your own transitioning, please see your family doctor or the gender clinic at Réseau Access Network. These are based on guidelines and best practices. It is possible there are occasional exceptions made in exceptional circumstances, but they would be quite rare and made by a team of health care professionals and even court systems.
What is gender-affirming care?
Gender-affirming care is anything that helps someone live as their gender. It often includes helping young people come out to family members, counselling services to cope with some of the difficulties around transitioning, accessing things like clothing and haircuts, helping with name changes on official documents, and some services considered more permanent, like hair removal, hormones and surgery.
But these services aren’t only accessed by trans people. Cisgender folks receive hormone blockers if they begin puberty too early or if their hormone levels are higher than expected. Cis women often get hormones during menopause, and cis men have increasingly been taking testosterone for depression or a low sex drive.
Bottom line: Many people benefit from gender-affirming care in some form.
A child comes out as transgender. Now what?
Some of the things I have heard said about trans medical care suggests many people believe a five-year-old can wake up one morning, declare they are transgender, and be in surgery by the following afternoon. This bears no resemblance to what is actually happening in the real world.
In reality, if a young child says they are trans, medical experts suggest you follow the child’s lead in terms of clothing, haircuts, and toys, as well as their chosen name and pronouns. These are things that can be very easily changed and reversed if the child does change their mind.
As the child nears puberty, they may get regular blood work for signs that puberty — and the many biological changes that it brings — is about to begin. At this time, there is an important decision for the child to make with help from their parents and doctors — provided they can even access medical care.
Puberty blockers and hormones
One of the only medications used in gender-affirming health care for youth are puberty blockers. This type of medication does not lead to any permanent changes; if the child stops taking them, puberty will commence within about three months, just as it would have before the medication. What these medications do is give the child and their families time to make important, and more permanent, medical decisions.
At the age of 16, the youth can decide to start hormone therapy to begin puberty. Feminizing hormone therapy consists of estrogen-based hormones taken orally or through injections, while masculinizing hormone therapy involves testosterone-based hormones taken through injections or as a gel that is absorbed through the skin.
These are the same hormones often taken by cis women during menopause. These are also the same hormones promoted to cis men by people like Joe Rogan.
But what about surgeries?
Accessing surgical gender-affirming care is a long and difficult process for anyone. This is not something that medicine takes lightly. The age requirement for surgeries is usually 18, but there are cases where 16-year-olds can access top surgery (the removal of breast tissue or the augmentation of breast tissue).
This surgery is never performed on children, which makes sense if you consider that children generally do not have breast tissue.
Top surgery consists of chest reconstruction for men by removing breast tissue and creating a masculine chest, or breast augmentation for trans women to create feminine breasts. Non-binary people sometimes access these surgeries as well, depending on their own experiences of gender. These surgeries are often not required when trans youth are able to access puberty blockers early enough, followed by a hormone regimen.
Bottom surgery, including phalloplasty and vaginoplasty, is accessed much less often and can be far more complex.The youngest person globally to have ever accessed this surgery was 16 years old, but the vast majority of countries, including Canada and the United States, require the patient to be at least 18.
I am not going to comment more about these procedures because the people involved are adults capable of giving informed consent to receive medical treatments.
Recent studies have shown that fewer than one per cent of trans people regret receiving gender-affirming surgical care, compared to 14 per cent for many other surgical procedures (and as high as 60 per cent for cosmetic surgery).
This regret is almost never related to gender, as in it is not people deciding to de-transition. It is usually because of surgical complications or pain, which is a risk anytime you have surgery.
Other procedures
There are other forms of gender-affirming health care procedures that may be more accessible to youth, but few people would consider them to be life-altering. These are things like hair removal, voice therapy, or exercise classes that focus on building long lean muscles for women or a broader chest and shoulders for men, all of which are considered to be minimally invasive.
Real world example
Let’s consider a child who was assigned male at birth then realizes they are a girl; they are a trans girl.
Without puberty blockers, they will go through puberty as a boy in their teenage years. This can cause them to grow taller than most women, develop a deep voice, broad shoulders, facial and body hair, an Adam's apple, and so many other changes that will make it harder for them to transition as an adult and be perceived as a woman by others.
The experience of going through the wrong puberty can also be devastating, not only on people’s mental and emotional health, but their social life as well.
If they are put on puberty blockers until they are 16 years old, then are able to switch to hormone therapy, medically transitioning to look like an average woman using hormones at this point is so much easier, as their body has not yet gone through the changes associated with puberty for men.
The hormone therapy will then kickstart female puberty, and although they will never menstruate, they will have many of the same changes that cis girls go through, albeit a few years afterwards because of the delayed start.
The use of puberty blockers is associated with fewer surgeries and other invasive and often expensive procedures. Without puberty blockers, the aforementioned trans girl could require laser hair removal or electrolysis, facial softening surgery, scraping the adam's apple, vocal cord softening, breast augmentation, and possibly more — all things that are rarely needed if puberty blockers are used.
Safety is also important to consider here. If you have two trans women, one who was able to receive puberty blockers and one who was not, which person do you think would be safer from experiencing transphobia as an adult? Gender-affirming care will make it easier for her to find housing, employment, and even walk down the street without experiencing transphobic harassment.
While all medical procedures and medications do come with some risk, the risk for the procedures described above are considered to be fairly minimal.
However, the risks of not getting gender-affirming treatment can be catastrophic. One study from Harvard found gender-affirming care was associated with a 42-per-cent decrease in mental distress and a 44-per-cent decrease in suicidal ideation.
Gender affirming care saves lives.
Dr. Laur O'Gorman (they/them) is the co-chair of Fierté Sudbury Pride, former professor of Women, Gender and Sexuality studies, parent, writer, and activist. They currently work in the field of mental health. Let Me Be Perfectly Queer is a monthly column about issues that impact 2SLGBTQ+ people in Sudbury as well as their friends, family, neighbours and co-workers; why queer issues matter to everybody. O’Gorman uses the word “queer” as an umbrella term that includes understandings of gender, sexuality, romance, and families outside of what is most common in our culture. If you have any questions relating to 2SLGBTQ+ issues, please send them to [email protected].
