Alberta has restricted access to gender based medical care for trans youth. Will the rest of Canada soon follow?

On Nov. 19, Alberta Premier Danielle Smith invoked the notwithstanding clause – a get-out-of-jail-free provision in Canada’s Charter of Rights and Freedoms that allows provinces to temporarily supersede many of its protections – to force the implementation of Bill 9.

The legislation prohibits Alberta clinicians from initiating puberty blockers or cross sex hormone therapy in anyone under 16 with gender incongruence and sharply limits access to gender-affirming surgery until adulthood. Alberta is now the first Canadian province to impose significant restrictions on the suite of interventions collectively known as pediatric gender-based medical care (PGBMC).

It is tempting to dismiss Alberta’s legislation as a purely political project. Smith leads the United Conservative Party and has long positioned herself as a champion of the policy preferences of the Canadian right. Restrictions on pediatric transition have been promoted for years by conservative opinion makers and policy influencers who oppose gender transition on ideological or religious grounds. In the United States – where the culture wars are most fiercely fought – such bans have been implemented almost exclusively in states where Republicans control the levers of government.

But it would be a mistake to view Smith’s actions merely as red meat for her base. Public support for access to PGBMC for minors has been in free fall, not only among conservative voters, but also among those who describe themselves as moderate or liberal. Jurisdictions with political cultures far more centrist or progressive than Alberta, including the United Kingdom, Sweden, Norway, Finland, the Netherlands, New Zealand and Australia’s state of Queensland, have already moved to restrict access to PGBMC. These decisions have largely followed non-ideological scientific reviews of the published literature, which have struggled to demonstrate benefits of a magnitude sufficient to broadly justify highly consequential and often irreversible interventions like PBGMC.

This raises an important question: will Canada’s more liberal provinces and territories follow Alberta’s lead in invoking the notwithstanding clause to restrict access to PGBMC? And if not, what would it take for advocates who continue to view PGBMC as medically necessary to persuade provincial leadership to resist that path?

The rationale for PGBMC has long rested on several core assumptions: that having a gender identity that differs from one’s birth sex is innate and immutable once established; that individuals who receive PGBMC rarely experience regret; and that intervening before puberty to  prevent distressing birth-sex-specific pubertal changes better enables adolescents to integrate socially in their preferred gender role as adults

These assumptions were largely derived from studies conducted in the 1990s and early 2000s, which examined a small and highly selected population of adolescents with long-standing and pronounced gender incongruence. These patients were closely monitored by expert multidisciplinary teams, and more marginal cases were typically not offered medical intervention.

Over the past two decades, however, there has been a dramatic increase in the number of young people seeking medical care for gender incongruence, accompanied by a shift away from a gatekeeping model widely criticized by trans activists to be judgmental and paternalistic toward more permissive prescribing practices. Demand for gender-based services has increasingly exceeded the capacity of specialty clinics to provide holistic care without prohibitive long wait lists, resulting in more care being delivered in community settings, where the emphasis may be more on prescribing and less on comprehensive, multidisciplinary assessment.

The contemporary population of young people seeking PGBMC also differs substantially from earlier cohorts. It is increasingly composed of natal girls, many of whom present with significant mental-health comorbidities, histories of adverse childhood experiences, neuroatypicality and relatively short or less clearly documented histories of gender incongruence. When studied more rigorously, the effectiveness of PGBMC in these populations has been far less clear-cut.

Perhaps most concerning, we are hearing with increasing frequency from individuals who received PGBMC as minors and who, as young adults, report regret and distress related to its irreversible effects. While the true incidence of severe decisional regret remains unknown, emerging evidence suggests that regret may be concentrated among individuals who share the same demographic characteristics as those driving the recent rise in trans identification: overwhelmingly natal females, with high rates of neuroatypicality, psychiatric comorbidity and later-onset gender identification.

When governments perceive that a profession has failed to police its own boundaries, even progressive governments may feel compelled to impose restrictions on practice.

Despite this, Canadian PGBMC providers and their allies have been publicly reticent to engage directly with these concerns, instead characterizing attempts to limit access to these interventions as being motivated purely by ideology or political animus. While it is undeniably true that substantial financial and political resources have been mobilized by groups opposed to PGBMC to amplify doubt about its effectiveness, safety and necessity, the failure of clinicians to explain how they are accounting for the changing patient population in their treatment models has made the medical community appear untrustworthy and out of touch. When governments perceive that a profession has failed to police its own boundaries, even progressive governments may feel compelled to impose restrictions on practice.

I have no doubt that Canadian PGBMC providers remain committed to this care because they genuinely believe it is overwhelmingly beneficial, and that the positive impacts they observe in their own practices are not being adequately reflected in the published literature. However, several providers have told me, off the record, that they already are becoming more circumspect, recognizing that they can no longer function as enablers of transition in all cases. At the same time, many have been understandably apprehensive about entering this contentious public sphere, fearing harassment or violence from highly motivated opponents, as well as backlash from trans activists who reject any form of medical gatekeeping.

Recent studies also suggest increases in suicidality among trans youth in jurisdictions where anti-trans legislation has been passed, and it stands to reason that absolute restrictions on access to PGBMC may have devastating mental-health consequences for some young people, particularly those who may lose access to interventions from which they are genuinely benefiting.

Risky as it may be, it is time for Canadian providers and their allies to show courage: not only by acknowledging the legitimacy of these concerns, but by demonstrating, publicly and concretely, how they are governing their own practice to prevent the types of adverse outcomes that have seeded doubt about the safety of PGBMC.

Patient care must be centred not on facilitating transition on demand, but on individualized, holistic assessment that matches intervention to need, with clear thresholds for treatment, robust monitoring and a willingness to change course when meaningful improvement does not occur. Just as importantly, gender-care clinics and professional bodies must commit to rigorous measurement and transparent reporting of outcomes, including adverse effects and regret, and be prepared to share these data openly.

If clinicians do not visibly set and enforce their own boundaries and demonstrate transparently that they can identify the young patients most likely to benefit from PGBMC, governments will increasingly feel empowered to do it for them, with the costs mostly being borne by those young people.