Michelle Zacchigna didn’t have an easy childhood. She had trouble making friends at school and was often bullied. These experiences led her to engage in self-harm at the age of eleven. After an attempted suicide, Michelle was treated for social anxiety and clinical depression, but these treatments didn’t improve her well-being. A year into therapy, an online community suggested that something else was causing her angst: that she was actually transgender. She was encouraged by that online community, then a support group community, and then a counsellor to medically transition. The counsellor even wrote a letter of recommendation for cross-sex hormone therapy that outlined an exaggerated medical history. Another therapist wrote a letter of recommendation despite a lack of any official diagnosis of gender dysphoria. A doctor at a Toronto health centre, ignoring her past mental health issues, prescribed cross-sex hormones after just three appointments and recommended a mastectomy and a partial hysterectomy a few years later. Michelle underwent both surgeries.
Eventually, Michelle realized that these procedures were not solving her underlying poor mental health, so she quit her hormone therapy, and detransitioned, presenting once again as a female. After a proper examination of her mental health, she finally received a full diagnosis of attention deficiency hyperactivity disorder, borderline personality, clinical depression, autism spectrum disorder, and traits of post-traumatic stress disorder, all of which were the true conditions underlying her distress. Nevertheless, Michelle still struggles “to come to terms with the permanent changes her hormone treatments and hysterectomy surgery have caused: a low voice, male-pattern balding, facial hair, an enlarged clitoris, a flat chest, and the inability to ever become pregnant. All of this has caused her to suffer from a worsening of her depression.” Michelle has also initiated the first lawsuit of its kind in Canada against the medical and health practitioners who helped her transition.[1] “If knowledge is power, then lack of knowledge is malpractice.”[2]
These are only some of the harms of medical gender transitioning, reassuringly but misleadingly called gender-affirming care. Hopefully, lawsuits such as this are one step towards finally pushing back against this unquestioned model of care.
Gender Identity and Gender Dysphoria
As we articulate in greater detail in our report on Sexual Orientation and Gender Identity,[3] every human being is born as one of two sexes: male or female. The word sex refers to the biological aspects of being male and female (e.g. the presence/absence of a Y chromosome, the capacity to produce sperms/eggs, and relative levels of testosterone/estrogen). Rooted in this biological reality is a person’s gender, the psychological, social, and cultural aspects of being male and female (e.g. different personality types, different gender roles, and different styles of clothing). Most people’s gender identity – their self-perception of being male or female, some combination of the two, or neither – aligns with their biological sex and associated gender. A small minority of people (0.33% of the population 15 years and older in Canada)[4] experience gender dysphoria, where their gender identity does not match their biological sex.[5]
While there is no single generally accepted cause for gender dysphoria,[6] there are discernible trends among children and adolescents with gender dysphoria. Among children who exhibit gender dysphoria prior to puberty, approximately 80% of these children will “desist” or out-grow this dysphoria by adulthood.[7] However, the number of post-pubescent adolescents – teenage girls in particular – with gender dysphoria has skyrocketed in Western countries like Canada, the United States, and the United Kingdom in recent years.[8] Researchers have called this phenomenon rapid-onset gender dysphoria and suggest that it is a social contagion.[9]
Current Approach of Gender-Affirming Care
The current approach to gender dysphoria is called gender-affirming care, a model described in the World Professional Association on Transgender Health (WPATH)’s Standards of Care.[10] Although various Western countries have guidance or laws that officially govern such gender-affirming care, Canadian provinces generally follow these WPATH standards, albeit with significant differences between provinces.[11] Under this approach, when a child, adolescent, or adult reaches out to a health practitioner about gender dysphoria, the practitioners unquestioningly affirm the patient’s self-perceived gender identity. Regulatory colleges and medical associations recommend this approach. However, in no other case in medicine or psychiatry do physicians unquestioningly agree and go along with a patient’s self-diagnosis. There should always be room for further questions and investigations to determine if a patient’s self-diagnosis actually aligns with objective reality. These patients may or may not have already proceeded with a social transition (e.g. adopting a new name, choosing new pronouns, dressing as the opposite sex, and using opposite sex facilities).
According to WPATH’s standards, medical practitioners should only proceed to gender-affirming medical and surgical treatment for children and adolescents if:
- Gender dysphoria is marked and sustained over time;
- The diagnostic criteria of gender dysphoria are met (as per ICD-11)[12];
- The patient demonstrates the emotional and cognitive maturity required to provide informed consent;
- Mental health concerns (if any) have been addressed;
- The patient has been informed of the effects of treatment on reproduction (these effects are profoundly negative and are described later in this ARPA report);
- The patient has reached Tanner stage 2 of puberty (the beginning of the physical stages of puberty) for puberty blockers and cross-sex hormones
- The patient has received at least 12 months of gender-affirming hormone therapy (before gender reassignment surgery can be performed)[13]
There are no age requirements specified in these standards; it is not uncommon for children to start taking puberty blockers at 9 or 10 years old and testosterone/estrogen at 14 or 15.
Problems with Gender-Affirming Care
The fundamental problem with gender-affirming care is that it misdiagnoses the problem. Gender dysphoria is not a problem of the body. While gender identity and gender expression can be changed intentionally or unintentionally, biological sex cannot change. Hormone injections and surgery can lead to the development of secondary sex characteristics (e.g. facial hair or an Adam’s apple). These procedures can even create replicas of reproductive organs (e.g. penis or breasts), although these organs do not function as native organs. However, they can’t change the fundamental sexual organization of the human body to either donate or receive genetic material; each cell remains marked with the XY chromosome as a male or an XX chromosome as female. In short, sex change is impossible.
Gender-affirming care assumes that the fundamental problem is that a person is born into the wrong body and so the solution to gender dysphoria is to radically reshape the body. But the problem does not lie with the objective body. It lies with the subjective mind. Those who experience gender dysphoria have the correct body, but they have difficulty subjectively identifying with that body. The solution then is not to reshape the body because there is nothing wrong with the body. The solution is to help a person reshape their understanding of their identity to align with reality.
In a review of Johns Hopkins University’s “sex change” clinic, former director Dr. Paul McHugh[14] states that “in a thousand subtle ways, the re-assignee has the bitter experience that he is not — and never will be — a real girl but is, at best, a convincing simulated female. Such an adjustment cannot compensate for the tragedy of having lost all chance to be male, and of having in the final analysis, no way to be really female.”[15] Dr. Sander Breiner[16] agrees, explaining that she and her colleagues at Michigan’s Wayne State University had to tell the surgeons that “the disturbed body image was not an organic [problem] at all, but was strictly a psychological problem. It could not be solved by organic manipulation (surgery, hormones).”[17]
This is a disorder of the mind, not a disorder of the body.
Toronto psychiatrist Dr. Joseph Berger[18] says that some transsexuals “have claimed that they are ‘a woman trapped in a man’s body’ or [vice versa]. Scientifically, there is no such thing.”[19]
But even if the problem behind gender dysphoria was the body, there is ample evidence that clinicians in Canada and around the world are not abiding even by their own standards of gender-affirming care. Jamie Reed, a queer woman married to a trans man and self-described as politically far left, worked as a case manager at the Washington University Transgender Center at St. Louis Children’s Hospital. After four years there, she resigned because she witnessed repeated cases where these standards were ignored and became convinced that, even when followed, the practice was “permanently harming vulnerable patients.” In her whistle-blowing article, Reed explains that the Transgender Center’s teenage patients could not understand the fertility repercussions of treatment and other side effects. She notes too that the Center failed to treat comorbid mental conditions and did not follow up with patients. Ms. Reed also decried the Center’s disturbing disrespect for the parents of minor patients. Patients and parents were not given the opportunity to express concerns about treatment options. Doctors at the Center, according to Reed, say they are “building the plane while we are flying it.” Reed concludes, “No one should be a passenger on that kind of aircraft.”[20]
Similar concerns were repeatedly raised in the disastrous Gender Identity Development Service at Tavistock in the United Kingdom. Many former clinicians describe the lack of proper procedure, standards of care, and the narrow range of treatment options as “madness.”[21] They describe the inability of clinicians to accurately distinguish between patients who will continue to identify as transgender as adults and those who will re-identify with their biological sex. In this context, referring patients for a medical transition was essentially a blind gamble.
The list of side effects and adverse reactions to gender-affirming care is significant. The risks from injections of cross-sex hormones alone include venous thromboembolism (blood clots), hyperkalemia (high potassium), hypertriglyceridemia (high level of fats in blood), polycythemia (high red blood cell count), hyperprolactinemia (high prolactin hormone levels), decreased HCL cholesterol and increased LDL cholesterol, hypertension (high blood pressure), cardiovascular disease, cerebrovascular disease, meningioma (brain tumor), polyuria (excessive urine production), dehydration, cholelithiasis (gallstones), type 2 diabetes, low bone mass, osteoporosis, weight gain, acne, sleep apnea, androgenic alopecia (hair loss), erectile dysfunction, and infertility.[22]
And this is just the list of possible effects of hormonal treatment. Surgical interventions can bring a host of new adverse effects.
While some studies document improved mental health outcomes for individuals experiencing gender dysphoria after hormonal or surgical interventions,[23] these studies only report on short-term outcomes. Much more valuable studies, known as longitudinal studies, track outcomes over long periods of time. One longitudinal study, headed by Swedish researcher Cecilia Dhejne, found that health outcomes deteriorate just one year after receiving a sex-change operation. By the fifth year, post-operative transsexuals had poorer outcomes in seven of eight measured categories: mental health, vitality, bodily pain, social function, emotional functioning, physical functioning, and general health.[24] And no studies compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention, primarily because of the unethical nature of randomly selecting some patients for medical transition and some patients for a wait and see approach.[25] In other words, there is no evidence that receiving remarkably invasive, risky, and irreversible gender-affirming care leads to better mental health outcomes than interventions that actively decrease cross-gender identification or watchfully wait for gender dysphoria to subside.[26] In fact, the opposite is true.
And while puberty blockers are often compared to hitting the pause button on puberty to allow time for a child to explore their gender identity, endocrinologist William Malone describes how, after a while, “the [endocrine] system ‘goes to sleep’ and at some point it may not wake up.”[27] Abigail Shrier notes, “we wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention – because it isn’t one… and yet the change in height brought on by growth hormones is arguably far less profound than that caused by puberty’s years-long flood of hormones, which transform our bodies into sexual adults.”[28]
Furthermore, medical transitioning sometimes fails to accomplish the desired outcome of relieving gender dysphoria. Some people, called detransitioners, choose to re-identify with their biological sex even after hormonal or surgical intervention. Just as the overall proportion of Canadians who experience gender dysphoria is low (0.33% of the Canadian population), the rate of detransition is also rare, but difficult to ascertain as most gender clinics do not follow up with patients following surgical transition and most detransitioners choose not to actively notify the clinic of their decision.[29]
Many detransitioners are uncomfortable sharing their story, either out of embarrassment that they made a massive mistake in life or out of fear of being labelled transphobic. As a result of these detransitioners, Dr. McHugh, who once led the gender identity clinic at Johns Hopkins Hospital, shut down the clinic because it was impossible to tell who might be genuinely helped by these treatments and who might be harmed.[30] In other words, the gamble was just too great.
Regardless of the number of detransitioners, the available stories and studies of detransitioners document that their mistreatment is real. Michelle Zacchigna, whose story opened this report, is not alone.[31]
Apotemnophilia: a comparison
Apotemnophilia is a psychological disorder characterized by an individual’s intense and long-standing desire for the amputation of a specific but healthy limb. It is a type of Body Integrity Identity Disorder (BIID). Some with this condition look for surgeons willing to perform an amputation and some apotemnophiles have purposefully injured limbs to force emergency medical amputation.[32] In 1997, Scottish doctor Robert Smith was performing these amputations before an outcry brought them to a halt.[33] Would the compassionate option be to accommodate the person’s self-perception by amputating healthy limbs as Dr. Smith did, or to treat the psychological condition itself?
The comparisons between gender dysphoria, apotemnophilia, anorexia, and other similar body identity disorders are clear. As Dr. McHugh says, “It is not obvious how this patient’s feeling that he is a woman trapped in a man’s body differs from the feeling of a patient with anorexia that she is obese despite her emaciated, gaunt state. We don’t do liposuction on anorexics. Why amputate the genitals of these poor men?”[34]
Informed Consent
While WPATH has dropped all age requirements for hormonal and surgical treatments for gender dysphoria,[35] age matters. Age matters because informed consent matters. In Canada, both Supreme Court jurisprudence, and in some cases provincial legislation, require physicians to obtain the informed consent of any patient before providing medical treatment – including treatment for minors.[36] The Supreme Court defines informed consent as anything a reasonable person in the patient’s position would want to know.[37] Lower courts have applied the Supreme Court’s guidance in slightly different ways, however, the central principle is clear – physicians have both an ethical and legal duty to “take reasonable steps, at minimum, to ensure patients understand the information provided to them.”[38]
Studies indicate that patients often do not understand the information that doctors present to them.[39] Furthermore, patients often have a difficult time identifying their own misunderstandings.[40] Doctors have an especially heavy burden to clearly convey information when there may be special or unusual risks that may arise from the procedure and when the procedure is elective, as hormonal and surgical treatments for gender dysphoria are.[41] A physician must go so far as to describe “infinitesimally small” risks.[42] A physician may not simply describe the probabilities of certain risks arising but must explain the full consequences to the patient should the risk materialize, along with the nature and severity of the potential injuries.[43] Hormonal and surgical treatments for gender dysphoria involve many and varied risks as detailed above.
If the social science evidence suggests that physicians are already struggling to provide adequate informed consent for far less complicated procedures, how can physicians provide properly informed disclosure in the far more complex cases of gender reassignment surgery?
Furthermore, with a lack of randomized controlled trials in this field to help inform the consent process, the ability to give fully informed consent to any medical transition treatment is dubious even for adults, much less for minors.
All across Canada, there are minimum ages (e.g. 18 or 19) for a variety of relatively trivial matters (e.g. to change your legal name, buy a lottery ticket, donate blood, watch an R-rated movie, buy cigarettes, consume alcohol, or adopt a pet from the SPCA) as well as more consequential matters (e.g. to marry or join the armed forces).[44] Governments restrict these activities because they realize certain risks and their ensuing obligations are only appropriate for certain ages.
But there currently are no age restrictions for receiving puberty blockers, cross-sex hormones, or gender reassignment surgery either in WPATH’s standards of care or Canadian provincial law or regulation. It is difficult to see how a lack of age requirements for hormonal and surgical treatments is acceptable when far less risky or consequential behaviour has age limitations. Gender clinics require children and adolescents to sign informed consent forms prior to treatment,[45] but do they really understand the consequences and risks associated with these procedures? If a girl starts puberty suppressants and testosterone beginning at age 14 and continuing for a few years, it will almost certainly make her sterile. If she continues down this road to receive surgical procedures such as removing her uterus and ovaries, pregnancy is out of the question. Does a 14-year-old girl understand the decision she is making here?
Although overturned upon appeal on a procedural matter, the trial judge in Bell v Tavistock in the United Kingdom concluded that it was “very doubtful” that 14- or 15-year-olds have such competence and “highly unlikely” that children aged 13 or under have competence for that decision.[46]
In almost every other circumstance in which a minor stands in need of medical care, their parents or guardians consent on behalf of the child. This reflects a common understanding that minors do not have the capacity to consent in the same manner as an adult. However, when it comes to treating gender dysphoria, there is a growing patterning of excluding parents from the entire treatment process if they object to a medical transition.[47]
Jurisdictional Scan
Many developed countries, after initially embracing the gender-affirming model of care unconditionally, have begun to realize the problems presented above and are moving to new models of care.
In 2020, the Finnish Health Authority broke with the prevailing gender-affirming model of care which rushes children and adolescents into medical and surgical treatments. Instead, psychiatric treatment and psychotherapy is now the first step prescribed to address gender dysphoria. Cross-sex hormones are generally available only to persons over the age of 18. Surgical treatments are not considered treatment methods for dysphoria in minors. The Finnish Health Authority also warns against general uncertainty of any irreversible gender-affirming interventions for those below the age of 25, due to a lack of neurological maturity.[48]
In 2021, Astrid Lindgren Children’s hospital in Sweden decided not to provide puberty blockers or cross-sex hormones to persons under the age of 16 and that these hormonal treatments would only be offered to patients between the ages of 16-18 within clinical trials.[49] In 2022, the Swedish National Board of Health and Welfare reformed the standards of care across the board, following Finland’s approach of making psychological and psychiatric care the first treatment option for all minors. As “the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases,” these treatments will allow cross-sex hormones only for people with early onset gender dysphoria and at a minimum age of 16.[50]
In 2022, the United Kingdom’s sole child gender identity clinic in Tavistock was closed in favour of a decentralized regional hub model following the release of the Cass Report, an interim report that studied the treatment of gender dysphoria in the United Kingdom. Although the report made no definitive recommendations, it did find that “an unquestioning affirmative approach is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters” and that greater safeguards, such as a formal diagnosis of gender dysphoria prior to hormonal treatment, was necessary.[51] In 2023, the National Health Service issued new interim guidance, reminding clinicians that “this may be a transient phase, particularly for pre-pubertal children,” that a “significant proportion of children and young people who are concerned about, or distressed by, issues of gender dysphoria experience coexisting mental health, neuro-developmental and/or personal, family or social complexities in their lives,” and that there are “risks of an inappropriate gender transition.” The primary intervention is now psychosocial and psychological support.[52]
In 2022, the National Academy of Medicine in France released a statement urging medical practitioners to use the “greatest caution” when prescribing puberty blockers or cross-sex hormones, given “the side-effects such as the impact on growth, bone weakening, risk of sterility, emotional and intellectual consequences and, for girls, menopause-like symptoms.”[53] However, the National Academy stopped short of issuing binding guidelines on treatment.
In 2023, the Norwegian Healthcare Investigation Board also found their national professional guidelines to be too loose and overly biased in favour of hormonal and surgical interventions. Like the United Kingdom in the Cass Report, Norway will be re-drafting its guidance on gender-affirming care.[54]
Finally, a growing number of American states have introduced, debated, or passed laws that establish legal guidance on the propriety of offering puberty blockers, cross-sex hormones, or gender reassignment surgery to minors.[55]
A growing refrain from these national reviews is that there is a lack of evidence to support these medical and surgical interventions, particularly in the long-term, and that these interventions are still experimental at best, with a growing body of evidence suggesting they do profound harm with no benefit to the patient.
| Finland | Sweden | UK | Canada | |
| First treatment option | Psychiatric treatment and psychotherapy | Psychiatric treatment and psychotherapy | Psychosocial and psychological support | Puberty blockers and cross-sex hormones |
| Eligibility for puberty blockers | Early onset gender dysphoria | Over 12 Early onset gender dysphoria Only in research settings | Tanner stage 2 of puberty | No domestic requirements Generally follow WPATH Standards of Care |
| Eligibility for cross-sex hormones | Over 18 unless severe and permanent gender dysphoria is present | Over 16 Early onset gender dysphoria Only in research settings | Approximately 16 and older | No domestic requirements Generally follow WPATH Standards of Care |
| Eligibility for gender reassignment surgery | Over 18 | Over 18 | Over 18 | No domestic requirements Generally follow WPATH Standards of Care |
The Compassionate Response
The current gender-affirming approach to gender dysphoria must be abandoned in favour of body-affirming care. If there is a perceived dysphoria between a person’s biological sex and their gender identity, health care practitioners should understand that trying to change biological sex is far more risky, difficult, and invasive than psychiatric treatment and psychotherapy that seek to change a self-perception. Fundamentally, biological sex cannot change but the self-perception of the psychological, social, and cultural aspects of being male and female can change. This is why psychiatric treatment and psychotherapy are becoming the first treatment method of choice for countries such as Finland and Sweden.
This approach and its underlying anthropology is the one best supported by science, but it also is consistent with a Christian worldview. The Bible describes each person as being made, male and female, in the image of God. Rather than each person choosing, feeling, or inventing their own identity, people receive various facets of their identity from other people and ultimately in God. Rather than trying to cast aside these received identities, each person should embrace the identity that they are given.[56]
Unfortunately, pursuing alternatives to gender-affirming care is very risky for anyone within or even outside of health care due to various federal and provincial bans on conversion therapy. For instance, the poorly written federal legislation bans “any practice, treatment or service designed to… change or repress a person’s gender identity to cisgender or… change, repress, or reduce a person’s gender expression so that it conforms to the sex assigned to the person at birth.”[57] This legislation effectively shuts the door to body-affirming care and leaves gender-affirming care as the only legally permissible option.
Beyond this, addressing gender dysphoria must be a holistic, multifaceted process. Gender dysphoria – the psychological distress caused by a perceived incongruence between one’s biological sex and their perceived gender – must be alleviated. Any comorbidities must be diagnosed and treated. The religious and cultural beliefs of the patient as well as their parents must be respected. The influence of peer groups on gender identity must be understood and countered, if required. The negative impacts of social media and web consumption must also be counteracted. Gender dysphoria is not something that is easily solved by hormones or surgery. It is far more complicated than that.[58]
Recommendations
- The federal government or provincial governments should establish an independent commission, similar to those in the United Kingdom, Finland, Norway, and Sweden, to review all of the existing evidence behind risks and benefits associated with medical interventions that aim to alleviate gender dysphoria.
- Provincial governments should prohibit the provision of puberty blockers, cross-sex hormones, and gender reassignment surgeries for minors.
- Provincial governments, either through medical colleges or through provincial regulation or legislation, must offer psychiatric treatment and psychotherapy as the first treatment option for gender dysphoria.
- Provincial governments, either through medical colleges or through provincial regulation or legislation, should require that if a child is being treated for gender dysphoria, they be thoroughly assessed for any comorbid conditions and that those conditions be addressed.[59]
- Given the current and developing evidence, federal and provincial governments must repeal or amend conversion therapy laws that make a body-affirming model of care legally risky.
- Parents should be fully informed and involved in the provision of psychiatric treatment and psychotherapy for their child’s gender dysphoria as well as the treatment for any other comorbid conditions.
Endnotes
[1] Adrian Humphreys, “Ontario Detransitioner Who Had Breasts and Womb Removed Sues Doctors,” National Post, February 23, 2023, https://nationalpost.com/news/canada/michelle-zacchigna-ontario-detransitioner-sues-doctors.
[2] J. Michael Bailey and Ray Blanchard, “Gender Dysphoria Is Not One Thing,” GD Alliance, September 10, 2022, https://www.genderdysphoriaalliance.com/post/gender-dysphoria-is-not-one-thing.
[3] To access this report on Sexual Orientation and Gender Identity, please visit arpacanada.ca/publications/?publication_category=policy-reports
[4] Statistics Canada, “Sex at Birth and Gender – 2021 Census Promotional Material,” 2022, https://www.statcan.gc.ca/en/census/census-engagement/community-supporter/sex-birth-gender.
[5] There is a variety of words that is used to describe this phenomenon. ARPA Canada prefers the term “gender dysphoria” that is found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V, but the International Classification of diseases uses “gender incongruence,” WPATH prefers the term “transgender and gender diverse people,” while the vernacular defaults to the descriptor “transgender.”
[6] Mark Yarhouse, Understanding Gender Dysphoria (Downers Grove, IL: InterVarsity Press, 2015); Hilary Cass, “Interim Report – Cass Review,” February 2022, https://cass.independent-review.uk/publications/interim-report/.
[7] Thomas D. Steensma and Peggy T. Cohen-Kettenis, “A Critical Commentary on ‘A Critical Commentary on Follow-up Studies and “Desistence” Theories about Transgender and Gender Non-Conforming Children,’” International Journal of Transgenderism 19, no. 2 (April 3, 2018): 225–30, https://doi.org/10.1080/15532739.2018.1468292; Thomas Steensma and Peggy Cohen-Kettenis, “Gender Transitioning before Puberty?,” Archives of Sexual Behavior 40 (March 1, 2011): 649–50, https://doi.org/10.1007/s10508-011-9752-2; Thomas D. Steensma et al., “Desisting and Persisting Gender Dysphoria after Childhood: A Qualitative Follow-up Study,” Clinical Child Psychology and Psychiatry 16, no. 4 (October 1, 2011): 499–516, https://doi.org/10.1177/1359104510378303; Kelley D. Drummond et al., “A Follow-up Study of Girls with Gender Identity Disorder,” Developmental Psychology 44 (2008): 34–45, https://doi.org/10.1037/0012-1649.44.1.34; Madeleine S. C. Wallien and Peggy T. Cohen-Kettenis, “Psychosexual Outcome of Gender-Dysphoric Children,” Journal of the American Academy of Child and Adolescent Psychiatry 47, no. 12 (December 2008): 1413–23, https://doi.org/10.1097/CHI.0b013e31818956b9; Susan J. Bradley and Kenneth J. Zucker, “Gender Identity Disorder and Psychosexual Problems in Children and Adolescents,” The Canadian Journal of Psychiatry 35, no. 6 (August 1, 1990): 477–86, https://doi.org/10.1177/070674379003500603; Jiska Ristori and Thomas D. Steensma, “Gender Dysphoria in Childhood,” International Review of Psychiatry 28, no. 1 (2016): 13–20, https://doi.org/10.3109/09540261.2015.1115754; Devita Singh, Susan J. Bradley, and Kenneth J. Zucker, “A Follow-Up Study of Boys With Gender Identity Disorder,” Frontiers in Psychiatry 12 (2021), https://www.frontiersin.org/articles/10.3389/fpsyt.2021.632784.
[8] Michael Smith, “Referrals to the Gender Identity Development Service (GIDS) Level off in 2018-19,” June 28, 2019, http://tavistockandportman.nhs.uk/about-us/news/stories/referrals-gender-identity-development-service-gids-level-2018-19/; Chad Terhune, Robin Respaut, and Michelle Conlin, “As Children Line up at Gender Clinics, Families Confront Many Unknowns,” Reuters, October 6, 2022, https://www.reuters.com/investigates/special-report/usa-transyouth-care/; Canadian Gender Report, “10x Growth in Referrals to Gender Clinics in Canada and Our ‘Consent’ Based Model,” Canadian Gender Report (blog), May 18, 2021, https://genderreport.ca/10x-growth-in-referrals-to-gender-clinics-in-canada-and-our-consent-based-model/.
[9] Lisa Littman, “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria,” PLOS ONE 13, no. 8 (August 16, 2018): e0202330, https://doi.org/10.1371/journal.pone.0202330; Abigail Shrier, Irreversible Damage (New Jersey: Regnery Publishing, 2020).
[10] Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8”; Canada has an analogous organization, the Canadian Professional Association for Transgender Health (CPATH), but it has been largely inactive in recent years; guidance is also available at individual gender clinics, such as Sherbourne Health Centre, “Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients” (Sherbourne Health Centre, April 2009). Appendix D
[11] Emily Mertz, “Gender-Affirming Health Coverage by Canadian Province, Territory,” Global News, June 23, 2022, https://globalnews.ca/news/8900413/gender-affirming-healthcare-province-territory-transgender/.
[12] The ICD-11 has two sets of diagnostic criteria dependant on age. “Gender incongruence of childhood is characterised by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children. It includes a strong desire to be a different gender than the assigned sex; a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex. The incongruence must have persisted for about two years. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.”
“Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior to the onset of puberty. Gender variant behaviour and
preferences alone are not a basis for assigning the diagnosis.”
[13] Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” 18.
[14] Dr. Paul McHugh is Distinguished Service Professor of Psychiatry at Johns Hopkins University. In 2004, Dr. McHugh published an article explaining the scientific reasons for rejecting sex change procedures. After describing the great deal of damage he witnessed from sex-reassignment, he concluded, “we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them… for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.” Paul R. McHugh, “Surgical Sex: Why We Stopped Doing Sex Change Operations” (Nov. 2004) First Things, available online: <http://www.firstthings.com/article/2004/11/surgical-sex>.
[15] Jon Meyer and John Hoopes, “The gender dysphoria syndromes: A position statement on so-called transsexualism,” Plastic and Reconstructive Surgery, (1974), p. 450.
[16] Dr. Breiner is a psychiatrist with clinical experience working with transsexuals at Michigan’s Wayne State University.
[17] Sander Breiner, M.D., “Transsexuality Explained,” National Association for Research and Therapy of Homosexuality, n.d., accessed March 26, 2015, http://www.narth.org/docs/transexpl.html. Dr. Breiner also explained that “[T]he significance of the psychological difficulty should not be minimized by a patient’s seeming success, socially and professionally, in other areas”.
[18] Dr. Joseph Berger, Consulting Psychiatrist, Fellow of the Royal College of Physicians and Surgeons of Canada and Diplomate of the American Board of Psychiatry and Neurology and Distinguished Life Fellow, American Psychiatric Association, Professor of Psychiatry, University of Toronto.
[19] Written testimony of Dr. Joseph Berger to the House of Commons Standing Committee on Justice and Human Rights, regarding Bill C-279, available online: <https://arpacanada.ca/attachments/article/1724/Testimony%20of%20Dr.%20Berger%20re%20c279.pdf>.
[20] Jamie Reed, “I Thought I Was Saving Trans Kids. Now I’m Blowing the Whistle.,” The Free Press, February 9, 2023, https://www.thefp.com/p/i-thought-i-was-saving-trans-kids.
[21] Hannah Barnes, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children (Great Britain: Swift Press, 2023), 354.
[22] Talal Alzahrani et al., “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population,” Circulation: Cardiovascular Quality and Outcomes 12, no. 4 (April 2019): e005597, https://doi.org/10.1161/CIRCOUTCOMES.119.005597; Michael S. Irwig, “Cardiovascular Health in Transgender People,” Reviews in Endocrine and Metabolic Disorders 19, no. 3 (September 1, 2018): 243–51, https://doi.org/10.1007/s11154-018-9454-3; Stephen M. Rosenthal, “Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View,” Nature Reviews Endocrinology 17, no. 10 (October 2021): 581–91, https://doi.org/10.1038/s41574-021-00535-9; Silvano Bertelloni et al., “Final Height, Gonadal Function and Bone Mineral Density of Adolescent Males with Central Precocious Puberty after Therapy with Gonadotropin-Releasing Hormone Analogues,” European Journal of Pediatrics 159, no. 5 (April 1, 2000): 369–74, https://doi.org/10.1007/s004310051289; Ana Antun et al., “Longitudinal Changes in Hematologic Parameters Among Transgender People Receiving Hormone Therapy,” Journal of the Endocrine Society 4, no. 11 (November 1, 2020): bvaa119, https://doi.org/10.1210/jendso/bvaa119; Hayley Braun et al., “Moderate-to-Severe Acne and Mental Health Symptoms in Transmasculine Persons Who Have Received Testosterone,” JAMA Dermatology 157, no. 3 (March 1, 2021): 344–46, https://doi.org/10.1001/jamadermatol.2020.5353; Mauro E. Kerckhof et al., “Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study,” The Journal of Sexual Medicine 16, no. 12 (December 1, 2019): 2018–29, https://doi.org/10.1016/j.jsxm.2019.09.003; Spyridoula Maraka et al., “Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis,” The Journal of Clinical Endocrinology & Metabolism 102, no. 11 (November 1, 2017): 3914–23, https://doi.org/10.1210/jc.2017-01643; M. Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy,” International Journal of Obesity 45, no. 12 (December 2021): 2562–69, https://doi.org/10.1038/s41366-021-00935-x; Sebastian E E Schagen et al., “Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones,” The Journal of Clinical Endocrinology & Metabolism 105, no. 12 (December 1, 2020): e4252–63, https://doi.org/10.1210/clinem/dgaa604; Daniel Klink et al., “Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria,” The Journal of Clinical Endocrinology & Metabolism 100, no. 2 (February 1, 2015): E270–75, https://doi.org/10.1210/jc.2014-2439; Magdalena Dobrolińska et al., “Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1469–77, https://doi.org/10.1016/j.jsxm.2019.06.006; Darios Getahun et al., “Cross-Sex Hormones and Acute Cardiovascular Events in Transgender Persons,” Annals of Internal Medicine 169, no. 4 (August 21, 2018): 205–13, https://doi.org/10.7326/M17-2785; Mariska C. Vlot et al., “Effect of Pubertal Suppression and Cross-Sex Hormone Therapy on Bone Turnover Markers and Bone Mineral Apparent Density (BMAD) in Transgender Adolescents,” Bone 95 (February 1, 2017): 11–19, https://doi.org/10.1016/j.bone.2016.11.008; Iris E. Stoffers, Martine C. de Vries, and Sabine E. Hannema, “Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1459–68, https://doi.org/10.1016/j.jsxm.2019.06.014; Michael Biggs, “Revisiting the Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria,” Journal of Pediatric Endocrinology and Metabolism 34, no. 7 (July 1, 2021): 937–39, https://doi.org/10.1515/jpem-2021-0180; Rafael Delgado-Ruiz, Patricia Swanson, and Georgios Romanos, “Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy,” Journal of Clinical Medicine 8, no. 6 (June 2019): 784, https://doi.org/10.3390/jcm8060784; Tobin Joseph, Joanna Ting, and Gary Butler, “The Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria: Findings from a Large National Cohort,” Journal of Pediatric Endocrinology and Metabolism 32, no. 10 (October 1, 2019): 1077–81, https://doi.org/10.1515/jpem-2019-0046; Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy”; Noreen Islam et al., “Is There a Link Between Hormone Use and Diabetes Incidence in Transgender People? Data From the STRONG Cohort,” The Journal of Clinical Endocrinology & Metabolism 107, no. 4 (April 1, 2022): e1549–57, https://doi.org/10.1210/clinem/dgab832.
[23] See Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” for a sample of studies
[24] Cecilia Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLOS ONE 6, no. 2 (February 22, 2011): e16885, https://doi.org/10.1371/journal.pone.0016885.
[25] See Michelle A Cretella, “Gender Dysphoria in Children and Suppression of Debate” 21, no. 2 (2016).
[26] See Yarhouse, Understanding Gender Dysphoria, 102–3. for a description of these approaches
[27] Shrier, Irreversible Damage, 165.
[28] Shrier, 164.
[29] Barnes, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children.
[30] Shrier, Irreversible Damage, 141.
[31] See, for example, Lisa Littman, “Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners,” Archives of Sexual Behavior 50, no. 8 (November 1, 2021): 3353–69, https://doi.org/10.1007/s10508-021-02163-w. See also Walt Heyer, Gender, Lies and Suicide: A Whistleblower Speaks Out, (2013, Make Waves Publishing), pg. 23, 26.
[32] Bensler, J. M.; Paauw, D. S. (2003). “Apotemnophilia masquerading as medical morbidity”. Southern Medical Journal 96 (7): 674–676; Berger, B. D.; Lehrmann, J. A.; Larson, G.; Alverno, L.; Tsao, C. I. (2005). “Nonpsychotic, nonparaphilic self-amputation and the internet”. Comprehensive Psychiatry 46 (5): 380–383.
[33] Tim Bayne & Neil Levy, “Amputees By Choice: Body Integrity Identity Disorder and the Ethics of Amputation.” (2005) Journal of Applied Philosophy, 22/1: 75-86. See also a book by the same Dr. Smith, co-authored by Gregg M. Furth, Apotemnophilia: Information, Questions, Answers, and Recommendations About Self-Demand Amputation, (2000).
[34] Paul R. McHugh, “Psychiatric Misadventures,” American Scholar 61, no. 4 (1992): 503.
[35] Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.”
[36] For a full overview of Canada’s informed consent legislation see, Gerald B Robertson & Ellen I Picard, Legal Liability of Doctors and Hospitals in Canada, 5th ed (Toronto: Thomson Reuters Canada, 2017) at 100-109; 154-204 [Legal Liability of Doctors].
[37] See, Reibl v Hughes, [1980] 2 SCR 880, 114 DLR (3d) 1, aff’m in Ciarlariello v Schacter, [1993] 2 SCR 119, 100 DLR (4th) 609.
[38] Sarah Birmingham, Christen Rachul & Timothy Caulfield, “Informed Consent and Patient Comprehension: The Law and Evidence” (2013) 7:1 McGill JL & Health 123 at para 5 [Informed Consent and Patient Comprehension].
[39] BM Stanley, DJ Walters & GJ Maddern, “Informed Consent: How Much is Enough?” (1998) 68 Australian & New Zealand Journal of Surgery 788; Jeff Whittle et al, “Understanding of the Benefits of Coronary Revascularization Procedures Among Patients Who are Offered Such Procedures” (2007) 154 American Heart Journal 662; Allison E Crepeau et al, “Prospective Evaluation of Patient Comprehension of Informed Consent” (2011) 93:19 Journal of Bone & Joint Surgery American Volume 114; Jü JW Wulsow, T Martin Feeley * Sean Tierney, “Beyond Consent: Improving Understanding in Surgical patients” (2012) 203:1 American Journal of Surgery 112; Sonu Pathak et al, “Consent for Gynaecological Procedure: What Do Women Understand and Remember?” (2013) 287 Archives of Gynecology & Obstetrics 59.
[40] Informed Consent and Patient Comprehension, supra note 35 at para 8.
[41] An elective procedure is one that is not medically necessary. See, Philion v Smith, [2008] OJ No 3412. Other examples of elective procedures include cosmetic surgery, sterilization, and even abortion. See Legal Liability of Doctors, supra note 33 at 180-81.
[42] Kitchen v McMullen, 100 NBR (2d) 91, 62 DLR (4th) 481 (NBCA), leave to appeal to SCC refused [1990] 1 SCR viii.
[43] Revell v Chow, 2010 ONCA 353 at para 43.
[44] Justice Education Society, “Youth Age-Based Legal Rights in BC,” accessed March 31, 2023, http://legalrightsforyouth.ca/age-based-legal-rights.
[45] See, for example, BC Children’s Hospital Gender Clinic, “Information Sheet: Testosterone for Assigned Females with Gender Dysphoria,” December 5, 2022, http://www.bcchildrens.ca/endocrinology-diabetes-site/documents/transtestosterone.pdf; BC Children’s Hospital Gender Clinic, “Information Consent Form: Minor Youth Testosterone for Assigned Females with Gender Dysphoria,” December 14, 2020, http://www.bcchildrens.ca/endocrinology-diabetes-site/documents/transconsentminor-t.pdf; Sick Kids, “Information Form: Testosterone Therapy for Individuals with Gender Dysphoria Assigned Female at Birth,” 2023.
[46] Bell v. Tavistock, [2020] EWHC 3274
[47] See, for example, the legal case of A.B. v. C.D. and E.F., 2020 BCCA 11
[48] Society for Evidence Based Gender Medicine, “One Year Since Finland Broke with WPATH Standards of Care,” July 2, 2021, https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors.
[49] Society for Evidence Based Gender Medicine, “Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies,” May 5, 2021, https://segm.org/Sweden_ends_use_of_Dutch_protocol.
[50] Society for Evidence Based Gender Medicine, “Summary of Key Recommendations from the Swedish National Board of Health and Welfare,” February 27, 2022, https://segm.org/segm-summary-sweden-prioritizes-therapy-curbs-hormones-for-gender-dysphoric-youth.
[51] Cass, “Interim Report – Cass Review.”
[52] NHS England, “Interim Specialist Service for Children and Young People with Gender Incongruence,” June 9, 2023, https://www.england.nhs.uk/wp-content/uploads/2023/06/Interim-service-specification-for-Specialist-Gender-Incongruence-Services-for-Children-and-Young-People.pdf.
[53] French National Academy of Medicine, “Medicine and Gender Transidentity in Children and Adolescents,” February 25, 2022, https://www.academie-medecine.fr/la-medecine-face-a-la-transidentite-de-genre-chez-les-enfants-et-les-adolescents/?lang=en.
[54] National Commission of Inquiry for the Health and Care Service, “Patient Safety for Children and Young People with Gender Incongruence,” Ukom, March 9, 2023, https://ukom.no/rapporter/pasientsikkerhet-for-barn-og-unge-med-kjonnsinkongruens/sammendrag.
[55] ABC News, “Map: Where Gender-Affirming Care Is Being Targeted in the US,” ABC News, March 27, 2023, https://abcnews.go.com/US/map-gender-affirming-care-targeted-us/story?id=97443087.
[56] For a more fulsome description of this Christian/biblical anthropology, please read the aforementioned Sexual Orientation and Gender Identity policy report.
[57] Section 320.101, Criminal Code of Canada.
[58] Bailey and Blanchard, “Gender Dysphoria Is Not One Thing.”
[59] See, as discussed above, Joost à Campo, et al., “Psychiatric Comorbidity of Gender Identity Disorders: A Survey Among Dutch Psychiatrists” The American Journal of Psychiatry (July 2003), which found that in 61% of cases of gender dysphoria, there were comorbid issues. See also U. Hepp, et al., “Psychiatric comorbidity in gender identity disorder” Journal of Psychosomatic Research, (March 2005) which found that lifetime psychiatric comorbidity in GID patients is high, and this fact should be taken into account in the assessment and treatment planning.