The Decibel - Fact-checking Alberta’s new gender-affirming care policies

Episode Date: February 7, 2024

Alberta Premier Danielle Smith unveiled a raft of new policies last week that have healthcare professionals warning of dire consequences for young transgender and non-binary people. The proposals will severely restrict when and what kind of gender-affirming care – ranging from medication to surgery – that young people and their families will have access to.Zosia Bielski, national news reporter specializing in gender, sexuality and sexual health for The Globe, explains what these policies are aiming to achieve and why experts are calling these rules the most restrictive in Canada on issues of gender and identity.Questions? Comments? Ideas? Email us at [e-mail]

prematurely encouraging or enabling children to alter their very biology or natural growth, no matter how well-intentioned and sincere, poses a risk to that child's future that I, as Premier, am not comfortable with permitting in our province. Last week, Alberta Premier Danielle Smith unveiled new policies that limit transgender rights and gender-affirming care. The proposals severely restrict when and what kind of medical care young people can access, and these rules would add up to the most restrictive policies in Canada when it comes to issues of gender and identity. So today, Zosia Bielski is on the show. She's a national news reporter for The Globe and often reports on gender and sexuality. Zosia Bielski is on the show. She's a national news reporter for The Globe and often reports on gender and sexuality. Zosia will explain what these policies are and why medical experts are warning against these restrictions.

I'm Maina Karaman-Wilms, and this is The Decibel from The Globe and Mail. Zosia, thank you for being here today. Thanks for having me on. Let's just start by defining, I guess, exactly what we're talking about. So gender affirming care really covers a lot of things. But what exactly does this term refer to? So gender affirming care can include sort of a wide variety of options. So it can be medical practitioners calling people by their preferred pronouns. It can be calling a patient by their preferred name. It can be therapy, counseling, and then it can also be medical interventions, including puberty blockers, hormone treatment. And on the sort of final end of things, it can also involve surgical procedures. So it's a wide

umbrella term that covers a lot of care, be it mental, physical, social support. Okay, yeah. So a lot of things then fall under that term. And how is this care established in Canada? Like how do doctors and healthcare professionals, I guess, know how to treat patients? So there are a number of tools that practitioners rely on. Chief among them is the Canadian Pediatric Society's position statement. So that society released a position statement recently that really lays out the standards of care. The practitioners also rely on endocrine societies. So those are societies that provide guidance on things like hormone treatment, for example. And then there's also a very long-winded guide, WPATH. So that's a global association that sets out standards of care for gender diverse people, transgender people.

And it's in its eighth revision, and the latest revision is a whopping 258 pages long. It goes into great detail and into research and established practices. So these are the tools that practitioners rely on. So needless to say, there are extensive guidelines here about how this is done. This has been documented and worked on over time. Precisely. There are real clear standards that practitioners rely on and guideposts that are commonly used. So let's now talk about what is being proposed in Alberta. So

the Premier, Danielle Smith, recently proposed new policies around gender-affirming care in the province. And this includes policies that are dealing with surgery and puberty blockers. So let's just break these down a little bit, Zosia. I think we should maybe start with surgery. What did Smith say about access to surgery? So Premier Daniel Smith announced restrictions on top and bottom surgery. So top surgery is the augmentation or removal of breast tissue, and bottom surgery includes phalloplasty and vaginoplasty. So respectively, those are the surgical creations

of a penis or a vagina. So what Premier Smith has said is that bottom surgery will no longer be permitted for those under 18. And ditto for top surgery. Okay. And so let's break this down, I guess, before this new proposal. How are the guidelines for when the surgery is performed decided in the province? So what was striking to critics and medical practitioners about these new restrictions was that they're putting age restrictions and prohibiting procedures in ways that sort of don't make sense because already in Canada, anyone under 18 is not eligible for bottom surgery. So if you're under 18, you cannot access bottom surgery.

And lots of health insurance policies also restrict this by age. So what Premier Smith has announced, the restrictions she has announced on bottom surgery, this simply does not happen in Canada. So she's kind of announced a restriction that's already in place, essentially. Exactly. As one of the doctors I spoke to put it, she's announced a policy solution for a policy and a problem that doesn't exist in the case of bottom surgery. As for top surgery, in Alberta, there is no specific billing code for anyone who would want to perform gender-affirming top surgery on anyone under 18. And on the point of the bottom surgery, even among adults,

we received figures from Alberta Health that reflected a paltry 89 people were approved for funding for bottom surgery, 18 and up, and only 36 of them were ages 18 to 25. So 89 people in a province the size of Alberta for bottom surgery, and most of them are over 25. Let's also touch on puberty blockers, because Smith also talked about access to those. This is medication that essentially delays puberty. Zosia, how is this usually used? So puberty blockers are typically used to pause puberty. And again, the medical guidance suggests you typically want to wait until the first onset of puberty, the first physical signs of puberty appear before you consider puberty blockers. And the idea, broadly speaking, is to give people some time to pause and think about their decision, whether they want to proceed or whether they've changed their mind.

And obviously, these kinds of discussions happen between physicians, patients and families. So the idea is to do this very soon after the onset of puberty, which aligns along the lower spectrum, like near 12. And what Alberta has decided is that puberty blockers will no longer be allowed for anyone sort of under 16. So this is their new proposal. This is a new shift. And the concerns we've heard from care providers is that basically you're through puberty at that point by the time you're 16. And the issue there for transgender and non-binary people is that, you know, once you've passed through puberty and you're experiencing dysphoria, that's when we really get into sort of the more invasive

surgeries. So it's sort of paradoxical. Premier Smith is expressing sort of real concern about how many people might be running off and getting surgery. But by denying people puberty blockers at the age they would be typically administered, you're running the risk of people sort of turning to more complicated, expensive, involved surgeries down the line after they've pushed through puberty. Yeah. Yeah. I guess kind of by definition, the puberty blocker makes sense kind of before puberty is fully happening. Yes. Okay. So that's the proposal is you won't be able to access puberty blockers if you're under 16. What about if you're over 16? In those cases, things will run the way they normally would. But obviously, they stress parental involvement,

which again, is the guidance in every single piece of literature. You know, you want parents or other guardians involved. And then that comes up up time and again in all of the medical guidelines that existed long before this announcement in Alberta. Yeah. Yeah, parental consent is definitely something that has come up a lot in these kinds of conversations. Generally here, Zosia, how does is stressed over and over and over again. That's already the case is what you're saying. Exactly. And there are a couple of reasons for that. But also parents are sort of in a unique position to know about their children's lives, obviously, their mental health, their physical health. They've got the window in on it. So it makes perfect sense that the guidelines would really stress parental involvement.

We'll be back in these spaces. What has been their reaction to this news, to these new proposals that Alberta has put out? Well, what I heard over and over was just how aghast they were and really how affronted they were. They really feel that this is a discussion that should happen between a patient, their physician, and their parents. And they were really affronted that the state has sort of stepped in and come up with these new rules. And for supportive parents, parents who are sort of with their children on this issue and with them through their care, they're getting a sense that those parents are affronted as well, because the state has sort of taken away their own right to consent as well, you know, when parents are supportive on this journey.

So, yeah, like you're talking about parental consent in a way, it kind of almost works backward here. If you have a supportive parent, you're still not able to access these things now. Exactly. So we have to sort of question parental rights, you know, for whom, right? UCP government kind of one of the tenets is less government in your life is kind of the idea behind the UCP and those kind of, you know, more right leaning movements. And in a way, this is the exact opposite. This is what these experts are saying is there's more government involvement in your medical decisions here. Absolutely. And again, we've seen this mirrored in the states with abortion and the state's encroachment on women's reproductive health. So, Zosia, Premier Smith also in these proposals, she talked about a continuum of care, kind

of drawing a line from pronoun changes at the start to surgery transitions as kind of an endpoint. But we think it's important that we set some guidelines so that those who are going through this journey know the decision points where they can commence hormone treatment and where they can commence surgery. What do doctors and people in the community say about that line of thinking? Right. So in speaking with reporters last week, Daniel Smith sort of described a trajectory of transition as she sees it. So she talked about kids changing the way they dress, then changing their names, changing their pronouns. Then we rapidly move into hormone

therapy, puberty blockers. And the end for each of these kids, based on sort of the way she described it, was surgical intervention. So as a parent listening to this, you would be rightly concerned, you know, especially if your child is somewhere along that continuum. But experts in a number of fields, medical fields, trans advocates, all stress, this is simply not the case. Like transition is not one thing. It's not one line. It's not the same for all kids. Because you've changed your pronouns doesn't mean you are gunning for a surgical avenue. So again, a real misrepresentation and a misunderstanding of what transition means to people. And ironically, as sort of the rest of the developed world becomes more understanding of gender diverse individuals and more accepting

of people on these spectrums, we're actually seeing less surgical intervention because people just feel more comfortable in their skin earlier in the process. So again, what Daniel Smith is sort of describing and characterizing this process as sort of runs counter to the way things are shifting today. So we've been talking about the medical side of these new proposals, but they also extend into sports and the education system, particularly around the topics of pronouns and sex education. So let me ask you about that, Zosia. What is the government proposing here? They have sort of followed New Brunswick and Saskatchewan's example in that you will now need parental consent if you seek to change your name or pronoun if you're under 16 in schools. And not only that, but if you're 16 or 17 and want to do the same, you still have to notify your parents or guardian. So that takes it further than the other two provinces.

So that's the pronoun side. And the concern there has long been, you know, outing to non-supportive parents, outing kids before they're ready to talk to supportive parents, a host of these concerns exist. So the other piece around education is, again, following a bit of Saskatchewan's example, Alberta is now tamping down on what you're going to learn in school in terms of sex ed. So they already had opt out opportunities for parents who were sort of uncomfortable with their kids going into sex ed. Now they've upped the ante. So you've got to opt in if you want to sit in on any class that touches on human sexuality, gender identity or sexual orientation. You can imagine what a headache this is going to be for teachers who have to send notes home every time any of this is mentioned.

So the clear fear there is that this is going to have sort of a chilling effect, that teachers are not going to want to touch this at all. So when you put that together with the medical restrictions, there's a real clear sense of erasure, you know, erasure of this population. You know, when you bundle it all together the way it's been bundled, this is the sense that advocates are getting loud and clear. So, Shusha, do we have a sense of how these proposals are going over in Alberta? Like, what has been the response to these? So, widespread condemnation on the political front. Obviously, Prime Minister Trudeau weighed in critically.

Mayors in Edmonton, Alberta, medical associations, doctors, nurses up in arms. But we also have everybody, many groups sort of involved in the educational sphere also raising concern. Social workers have raised alarm, principals associations, teachers associations. All of these individuals sort of involved in kids' lives on a day-to-day basis are gravely concerned this is going in the wrong direction here. Yeah, I mean, that sounds like a lot of opposition from people who are working with kids. Do we know, I guess, on the other side, do we know who's supporting these proposals? The governments that have passed these pieces of legislation, these policies, obviously it differs province to province, New Brunswick, Saskatchewan, Alberta.

These are conservative parties sort of kowtowing to fears that sort of have fomented in the states around parental rights, knowing what your children are doing at school. This is a pattern here that more and more conservative governments are trying on, clearly, to sort of placate their voters and their membership. So it sounds like there's a lot of people who are opposed to these proposals. Do we know if there's going to be a challenge to these from, you know, potentially civil liberty groups? So in Saskatchewan, it's, you know, they've sort of moved the fastest. The pronoun policy in Saskatchewan is now law as of October, because that government invoked the notwithstanding clause to sort of override sections of the charter and also

Saskatchewan's human rights code. So that is law. Of course, lots of opposition there. New Brunswick is essentially having trouble figuring out how the pronoun policy will be enforced in the school year. We have a number of school district councils that are considering suing the government over this. The Civil Liberties Association is also filing a lawsuit. So real uncertainty in terms of how that will play out. And again, experts caution that the goal here is this kind of uncertainty, not knowing what you can do in school and what you can teach. And all of that sort of uncertainty and that mess means teachers are going to be less likely to raise these issues in school or use a student's preferred pronouns because the consequences are unclear. The policies are unclear, the policies are unclear, enforcement is unclear. Yeah. It sounds like from what we're talking about,

especially when we're seeing this in three different provinces, there's political leanings that are kind of pushing this to the forefront. I wonder about the way that this was done in Alberta, because it sounds like many of the limits were already in place in the healthcare system. Like we're talking about the limits when you mentioned the limits for like bottom surgery, that was already the status quo, right? Like why would the government announce these things in a way that makes them sound like new proposed rules, even though they were already in place? Well, you have to sort of scratch your head and ask that very question because essentially what they're announcing already exists. And in a few cases, what they're

announcing sort of runs counter to all of the guidance, all of the medical guidance and the mental health care guidance for this population. So, and when you see the outcry that it's not just the medical practitioners, it's teachers, it's principals, social workers, everyone in youth sphere, you have to sort of ask yourself, you know, where exactly did this come from? And we're seeing time and again that these policies emerge with conservative governments. That's a pattern. Just lastly here, Zosia, I mean, ultimately, this is about the health of young people, right? And what it means for their lives. So from the experts that you've talked to,

what do experts say will be the impact of these proposed changes on them? I think there's grave concern. There's sort of clear documented evidence and research about just how vulnerable trans adolescents are. So they are five times more likely to have suicidal thoughts and nearly eight times more likely to have attempted suicide than their peers. So this is a very vulnerable cohort. And, you know, what's been made clear is that they need social support. They need counseling. They need therapy. They need the support of their families, most of all. That's clear in all the outcomes that supportive families really help get these kids through. And they need support at school.

So everything proposed here from, you know, the limitations on participation in sport to forbidding teachers to utter anything about sex ed or the existence of, you know, diverse gender identities, you know, without an opt-in note to restricting medical care. Really all of that flies in the face of sort of established guidance for this really vulnerable cohort that really does need support from the adults in their lives

and not this sort of erasure across a number of spheres in their lives. Zosia, thank you so much for being here today. Thank you for having me. That's it for today. I'm Maina Karaman-Wilms. Our producers are Madeline White, Cheryl Sutherland,

and Rachel Levy-McLaughlin. David Crosby edits the show. Adrienne Chung is our senior producer and Angela Pachenza is our executive editor. Thanks so much for listening and I'll talk to you tomorrow.