Canada’s doctors advised to affirm transgender six-year-olds

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Newly published advice to Canada’s pediatricians continues to charge “full steam ahead” with the gender-affirming model of care in the face of increasing uncertainty about its safety, and suggests that parents who don’t unquestionably affirm their child’s expressed gender risk harming their child, concerned doctors say.

The advice, published in a brief paper in the Canadian Paediatric Society’s flagship journal, is silent on the Cass Review, a four-year long, independent British review that landed last spring that concluded the evidence base for gender-affirming care for minors is “remarkably weak” and that many unknowns remain about the impact of social transitioning, particularly on very young children.

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The paper advises pediatricians to offer parents of gender-questioning children advice on social transitions and the many benefits of an affirming environment, and to “support menstrual suppression” using medications such as hormone blockers for a gender dysphoric 12-year-old “if appropriate and desired by the patient.”

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The new paper is “essentially advocating for socially transitioning children,” said Calgary pediatrician Dr. Darrell Palmer.

The Canadian paper, “Gender-affirming practices for the general paediatrician,” has alarmed those calling for an urgent reappraisal of the gender-affirming model of care for minors amid new science questioning its safety and efficacy, a “meteoric rise” in kids presenting with gender distress and a dramatic shift in the sex ratio, from mostly natal boys to natal girls.

“Parents and young people deserve a balanced view of the care options ahead of them as they make these difficult decisions,” said Pam Buffone, founder of the parent group Canadian Gender Report.

“This short paper is extremely biased,” leaves out “inconvenient truths” and presents gender-affirming care as the only option, Buffone said.

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The new paper’s senior authors said, through their spokespeople at BC Children’s Hospital and Toronto’s Hospital for Sick Children, that they were unavailable for an interview.

In a statement, BC Children’s said that “research conducted over many decades supports the safety and accessibility of gender-affirming care in this province” and that the authors took the recent review led by Hilary Cass, a distinguished British pediatrician, under review.

My concern is that from the get-go it just assumes gender affirming care is the way to go

The paper presents gender identity in a very young child as a “fait accompli” and presents information on suicide in a misleading way, citing data from a 13-year-old study of 84 Ontario trans youth that reported strong parental support significantly reduces suicide attempts, several pediatricians said.

A recent Finnish study based on the health records of more than 2,000 young people who sought care at a gender service over a 20-year time span found that while gender dysphoric youth have higher rates of suicide than peers without gender dysphoria (0.5 per cent versus 0.3 per cent) the differences were not statistically significant after researchers took a history of psychiatric treatments into account. “Gender dysphoria, per se, does not seem to predict neither all-cause nor suicide mortality in gender-referred adolescents,” the Finnish team wrote.

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While stressing that it’s crucial to identify and treat mental disorders in youth experiencing gender dysphoria to prevent suicide, medical gender reassignment “does not have an impact on suicide risk,” the authors concluded.

The cited survey on suicide risk reported that 35 per cent of youth who described their parents as strongly supportive said they had considered suicide in the past year, compared to 60 per cent of youth whose parents weren’t described as strongly supportive. Among the latter 60 per cent, more than half (57 per cent) said they had attempted suicide, compared to four per cent with “strongly supportive” parents.

The data could be used to frighten parents, Palmer said. “At the end of the day, if you tell parents if they’re supportive it reduces suicide attempts from 57 per cent to four per cent, that’s just putting a tonne of pressure on parents with data that are likely to be highly inaccurate.” It also assumes that support for gender distressed children must take the form of unquestioning affirmation without exploring other variables that could be at play, he and others said.

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“Any consent process involves telling people about harms and benefits and what the evidence is,” added Dr. Ian Mitchell, a professor emeritus at the University of Calgary’s Cumming School of Medicine. “This is an enormous procedure, to change someone’s whole identity. This is not a little intervention.”

The authors of the advice wrote that trans and gender distressed children and youth continue to face many barriers to care, including discrimination, wait times for specialized care that can stretch a year or longer and lack of parental support.

They highlighted a one-time survey of Canadian pediatricians in February 2023 that found 77 per cent of respondents said they had provided medical care to transgender or gender diverse (TGD) children or youth in the last year. While most described feeling “comfortable or very comfortable” doing so, 16 per cent reported feeling uncomfortable, or very uncomfortable.

“Further research is required to understand the sources of discomfort and opportunities for this discomfort to be addressed,” they wrote.

“I don’t think that they are even contemplating that the source of discomfort could be that this 16 per cent knows that the evidence (supporting gender-affirming care) is poor, and they’re concerned,” said Dr. Joanne Sinai, a clinical associate professor and psychiatrist at the University of British Columbia.

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“This is clinical advice and my concern is that from the get-go it just assumes gender affirming care is the way to go,” she said.

Affirming means that “if the child declares their gender you accept it as is and you support them in the gender they want to be. There’s no questioning it at all,” Sinai said.

“There is no mention of the fact that there is any disagreement between professionals about this. It does not suggest the fact that gender dysphoria could be a symptom of many other psychological issues or psychiatric diagnoses, whether it’s trauma, whether it’s developmental issues, whether it’s the autism spectrum, whether it’s depression or anxiety.”

“It approaches (gender dysphoria) as a fait accompli that just needs to be affirmed by the parents, and if you are not actually supporting the children in a way that affirms them, then the suggestion is that you are a bad parent and a bad pediatrician,” Sinai said.

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“It’s just ‘full steam ahead. This is what we’re doing.’”

The paper builds on the Canadian Paediatric Society’s 2023 position statement on gender-affirming care, which said some children may recognize a degree of “mismatch” between their gender identity and assigned sex as early as age two or three. The goal is to “better support pediatricians in offering care to youth and their families, especially if they are waiting for a specialist,” the statement reads.

“Those things include making their clinic a supportive space, offering social supports, parental supports, exploring safe ways for them to express themselves and mitigating aspects that worsen dysphoria that can be managed by a pediatrician.”

The authors use two vignettes to offer advice, the first involving “Eva,” a six-year-old “who was assigned male at birth. She has asked to be called ‘Eva,’ uses she/her pronouns and has worn dresses for the past two years.”

Her parents are described as supportive and eager to support their child’s mental and physical health.

“You provide the family with appropriate resources to talk about gender, connect them to a local parent support group and describe the many benefits that an affirming social environment has on gender-diverse children and youth,” the paper reads.

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A second vignette describes “Jackson,” a 12-year-old who was “assigned female at birth but describes identifying as a boy, using he/him pronouns and engaging in stereotypically masculine activities since age nine.

“Jackson notes chest tissue development and recent monthly vaginal bleeding that are causing significant distress and gender dysphoria, impacting his mental health,” the paper says.

“Recognizing that the local wait time to access a specialized gender-care clinic is over six months, you explore options for menstrual suppression (including hormone blockers) and discuss other forms of care to support his mental and social transition (binding, packing, etc).”

The United Kingdom permanently banned the routine use of puberty blockers in minors under 16 in the wake of the Cass Review.

The Canadian authors also recommended pediatricians “provide advice on social transition: For many TGD (transgender and gender diverse) children and youth (e.g. case 1), there may only be an interest in/need to discuss social transition, which might include using an affirmed name and pronouns and exploring clothing and hairstyles that align with their experienced gender.”

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One study involving children who’d already made a complete social transition at enrolment found that about 94 per cent of those who socially transitioned between ages three and 12 continued to identity as trans after an average of about five years of follow-up. Of the remainder, 3.5 per cent identified as non-binary and 2.5 per cent identified with the sex they were born. About six per cent of those who socially transitioned before the age of six had re-transitioned, compared to 0.5 per cent who socially transitioned later. The results suggest re-transitions are infrequent, the authors wrote. “More commonly, transgender youth who socially transitioned at early ages continued to identify that way.”

The Cass review found no clear evidence that socially transitioning children has “positive or negative mental health outcomes.”

“The current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, although for a small number the incongruence will persist,” Cass reported.

Children who do socially transition at an early age are “more likely to proceed to a medical pathway,” she said.

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It’s just ‘full steam ahead. This is what we’re doing’

While it may not be thought of as a “treatment,” social transition is an active, and not neutral, intervention, Cass wrote, “because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes.”

Sex of rearing “seems to have some influence on eventual gender outcome,” Cass wrote, “and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence.

“For this reason, a more cautious approach needs to be taken for children than for adolescents.”

The original “Dutch Protocol” that set the early foundations for gender-affirming care recommended against children making a complete social transition before the very early stages of puberty “to prevent youths with non-persisting gender dysphoria from having to make a complex change back to the role of their natal sex.”

“One may wonder how difficult it would be for children living already for years in an environment where no one (except for the family) is aware of the child’s natal sex to make a change back,” the protocol reads.

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“When their whole world is supporting them, how are they going to say, ‘Actually, no, I’ve got some questions,’” Sinai said.

Gender variant behaviour shouldn’t be prohibited, the Dutch authors wrote. “By informing parents about the various psychosexual trajectories, we want them to succeed in finding a sensible middle of the road approach between an accepting and supportive attitude towards the child’s gender dysphoria, while at the same time protecting the child against any negative reactions from others and remaining realistic about the actual situation.”

Dr. J. Edward Les, a Calgary pediatrician and senior fellow with the Aristotle Foundation for Public Policy, said the latest advice for Canadian pediatricians is “blithely ignoring” the work of Cass and other investigations by “neutral doctors,” including two recent reviews led by McMaster University researchers.

“They’re exhaustive, systematic reviews and meta-analyses and yet they don’t even bear a mention,” Les said.

“In the end, I’d like to think that what we all want is what’s best for our kids. And I think that’s true of my colleagues who are involved in gender-affirming care as well,” he said.

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“I think it comes down to it being very difficult for physicians to admit when they get things wrong. And particularly when the implications of admitting that you got this wrong means that some children, or perhaps even many children were harmed by the model that you have engaged in implementing for years,” Les said.

“It can be very hard to pull back from that and raise your hand and say, ‘You know what? We need to take another careful look at this.’”

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