Dear Premier and Minister,

We, the below signatories, write as concerned members of the medical community about Premier Smith’s January 31, 2024 announcement regarding the UCP policy changes to youth trans health.

We resolutely oppose these policies. If enacted, these policies will cause significant harm to trans youth in Alberta by limiting access to medically necessary care. These policies and their announcement contribute to a false narrative about current practice in trans healthcare.

These changes were made without adequate consultation with medical experts in gender-affirming care and with trans youth. They do not reflect the values of evidence-informed practice or shared decision-making that are foundational to ethical, high-quality healthcare in Canada.

By failing to reflect current evidence and by limiting access to medically necessary care, these changes are contrary to the UCP’s stated goal of ensuring “Albertans have improved access to world-class health care when and where they need it” (Smith, 2023). In addition to the UCP’s commitment to accessibility, provinces are required under the Canada Health Act (2015) to ensure accessibility of medical services to receive federal funding for provincial healthcare services. Further, by failing to include trans youth in their own healthcare decisions, these policies constitute a violation of both medical ethics and human rights.

The fallacies and falsehoods in both the policies and Premiere Smith’s associated announcement must be addressed because they pose an immediate threat to the health and safety of trans youth. See below for a summary of responses in the hopes of providing clarity on this important issue:

CLAIM: Prematurely enabling children to alter their very biology…is something that I as premier am not comfortable with in this province.

FACT: This statement, made by Premier Smith, reflects a concerning lack of medical expertise informing UCP policy decisions. Medical professionals follow guidelines carefully developed by medical experts in trans health when making treatment decisions.

The UCP is right to consider the lasting implications of medical treatment on youth; however, they are categorically failing to recognize the equally important implication of withholding medical treatment. The World Professional Association for Transgender Health Standards of Care 8 (SOC-8), the internationally recognized guideline informed by scientific evidence, concludes that “allowing irreversible puberty to progress in adolescents who experience gender incongruence…may have immediate and lifelong harmful effects for the transgender young person” (Coleman et al., 2022). In other words, not allowing trans adolescents access to hormonal puberty blockers is known to cause harm. As medical professionals, we oppose in the strongest possible terms political leadership passing uninformed policies that have irreversible effects on trans youth.

POLICY CHANGE: Puberty blockers not allowed until age 16, and 16/17 year-olds need parental permission.

FACT: By preventing timely access to medically necessary healthcare as determined by the healthcare provider and informed by accepted standards of medical practice (American Medical Association, 2023), this policy contravenes the Canada Health Act. Further, by failing to include trans youth as decision-makers in the initiation of time-sensitive medical therapy with lifelong health implications, this policy is an overt violation of patients’ medical right to autonomy.

Hormonal suppression of puberty is reversible, and hormone production and associated effects return once suppression is stopped (de Vries et al., 2011). The benefit of using these medications is to provide youth with time and space to explore their gender identity without the pressure or distress of physical changes or gendered experiences associated with puberty. This approach is recommended by the SOC-8 (Coleman et al., 2022), and is endorsed by both the Endocrine Society (Hembree et al., 2017) and Pediatric Endocrine Society (Lopez et al., 2017).

Puberty in youth typically begins between the ages of 8-14. By delaying hormonal suppression until age 16-18 and allowing puberty to progress, this policy change is putting trans youth at increased risk of adverse mental health outcomes (van der Miesen et al., 2020, de Vries et al., 2011), increased risk of suicidal ideation (Turban et al., 2020), and more complicated medical and surgical transition in later life (Cohen-Kettenis & Klink, 2015; Coleman et al., 2022; Hembree et al., 2017; Rosenthal, 2014).

Detailed clinical practice guidelines have been developed including those from the Endocrine Society (Hembree et al., 2017) and the SOC-8 (Coleman et al., 2022). These guidelines are used in clinical practice to support healthcare providers in assessing the benefits and risks of medical interventions on a case-by-case basis, and to identify medically necessary interventions.

POLICY CHANGE: Hormone replacement therapy not allowed until age 16, and 16/17 year-olds need parental permission.

FACT: Gender-affirming hormone therapy (GAHT) can promote the development of physical features that are in alignment with the patient’s gender. When initiated appropriately, it has been associated with improved mental health outcomes (Allen et al., 2019; Kuper et al., 2019; Sequeira et al., 2017).

GAHT is considered partially reversible, and as such the Canadian Pediatric Association (Vandermorris & Metzger, 2023) recommends (1) it be provided only by those with specialized training; (2) under the guidance of evidence-informed guidelines such as those from the Endocrine Society (Hembree et al., 2017) and the SOC-8 (Coleman et al., 2022); and, (3) following careful assessment of the youth’s capacity to provide informed consent.

The process of determining capacity for informed decision-making is complex and depends on a wide variety of factors including patient age, maturity, and complexity of the medical intervention of interest. Given the complexity of informed medical consent in the adolescent population, this must occur on a case-by-case basis in collaboration with the patient and their circle of care, including their healthcare provider. For these reasons, Canada does not have a minimum legal age to consent for medical intervention. It is inappropriate for the UCP to define a set age of consent as it relates to trans healthcare.

POLICY CHANGE: Gender-affirming surgery not allowed until age 18.

FACT: Framing this statement as a new policy change is misleading as it has, for the most part, been in effect since before the UCP’s announcement. This again highlights a concerning lack of awareness of previous policy and practice regarding gender-affirming surgery for trans youth.

Bottom surgeries (e.g. phalloplasty, vaginoplasty, orchiectomy, etc.) were already restricted to patients over 18 years of age. In some rare cases, older youth have been able to access top surgery (e.g. bilateral mastectomy with chest contouring), but this required careful assessment by the patient’s care team including their primary healthcare provider, psychiatry, other specialists involved in their care (e.g. endocrinology) and plastic surgery. For nearly every surgical patient, gender-affirming surgery occurs after age 18.

Premier Smith’s proposed changes will negatively impact the health and well-being of Alberta youth. As per the Canadian Paediatric Society (Vandermorris & Metzger, 2023), trans youth “are at an elevated risk for many adverse health outcomes, including depression, anxiety, eating disorders, self-harm, and suicide.” The risk is mitigated by timely access to gender-affirming healthcare, and earlier presentation for gender-affirming care reduces the risk of poor mental health and psychosocial outcomes (Sorbara et al., 2020; Chen at al., 2021). By creating policy barriers that prevent timely access to medically affirming services, the recently announced policy changes will jeopardize the health and well-being of trans youth across the province.

IN CONCLUSION, we, as signatories to this letter, stand in solidarity with trans communities and supporters in opposing these harmful policies. We support gender-affirming care that follows evidence-based best practice as described in the SOC-8, and we recognize the importance of listening to our expert colleagues in the field of trans health. As such, we call upon the UCP to immediately revoke these policy changes and to leave medical care and decision making to qualified medical providers and our patients.

COPIED TO:

The Honourable Danielle Smith, M.L.A, Premier of the Province of Alberta

The Honourable Adriana LaGrange, Minister of Health

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