How gender-affirming health care for kids works in Canada
Transgender youth and their health-care providers say the field is widely misunderstood
Robyn Hodgson says she's watched struggling young people heal, grow and ultimately thrive because of gender-affirming health care.
"It genuinely is profound," Hodgson, a registered nurse and co-ordinator for the transgender and non-binary program at the InterCommunity Health Centre in London, Ont., said.
"I'm in my 27th year, and I've worked in a lot of areas — and this has been the most rewarding area that I've ever worked in."
Gender-affirming health care — an approach that affirms a trans person's gender identity instead of trying to change it — is endorsed by medical associations in Canada and around the world, including the Canadian Psychological Association and the Canadian Pediatric Society.
But it's also a type of health care that's widely misunderstood, especially as it pertains to the treatment of young people, say the medical professionals who provide it and the patients who receive it.
"So many people make uninformed opinions," said Silas Cain, a 16-year-old transgender boy receiving gender-affirming care in Saskatoon. "They see a headline or they hear one person talking about it and they take it as fact, which is harmful in so many different contexts."
Here's what transgender youth, their caregivers and their health-care providers want you to know about what affirming care actually looks like for young people in Canada.
How does it work?
Affirming care ranges from social and psychological support, like using someone's chosen pronouns; to transition-related medical treatments, such as puberty blockers and hormones, or gender-affirming surgeries.
Hodgson likens it to how society accommodates people who are left-handed.
"We've tried changing handedness in the school system, and people were struck in the knuckles with rulers," she said. "Trying to force people to live in a shell that is absolutely foreign to their experience is equally difficult."
Forcing kids into genders they don't identify with can have negative impacts on their well-being, says Rhea Mossman Sims, a nurse practitioner at Trans Health Klinic in Winnipeg.
"They can have a significant decrease in their self-esteem and they can also have a significant decrease in their general mental health, and there is a potential for suicidality," she said.
Do kids get medical treatment before puberty?
Canadian health-care providers broadly follow the World Professional Association for Transgender Health (WPATH) standards of care, which has guidelines for patients at different stages of their development.
For kids who haven't hit puberty, affirming care means letting them explore their gender in a supportive environment. That can mean using different pronouns, trying out a new name, or letting them pick different clothes or try a new haircut.
"There is nothing medically that is done in a child [before signs of puberty]," Hodgson said.
For Cain, that started not at a health clinic, but at school when he found teachers who supported him as he explored different labels.
"Trying out different pronouns and different names was affirming care for me at that time," he said. "Having a space to experiment is so important and so vital."
Can minors get surgery?
Surgical options, Hodgson says, aren't considered until "very, very late in care" — and almost never for patients under 18.
"I can tell you, internationally, I do not know anybody that will perform any type of genital surgery on anyone under 18 years of age."
In some very rare cases, she says, older teenagers may be eligible for chest surgery — also known as top surgery — but only if they've already had "a significant duration of care," she said.
Are kids rushed into treatment?
Before puberty blockers or hormone therapy can be considered, WPATH guidelines recommend that all youth be assessed by a qualified health-care professional who has studied psycho-neurodevelopment in adolescence.
"I think that there is this assumption that people are rushing into medical care and there's no thoughtful contemplation or support," Hodgson said.
"It certainly hasn't been the experience of any of the providers that I know that are doing this care, nor of the trans population that's accessing care."
Since 17-year-old Seelie Romard of Sydney, N.S., first started seeking gender-affirming treatment in 2021, he says he's visited a pediatrician, a physician who specializes in gender care, and a psychologist — all before being put on a waitlist for testosterone.
"It took a really long time … just to make sure that I was, like, OK mentally, that I was in the right place, that I was informed," Seelie said.
What are the effects of puberty blockers?
Patients in the early stages of puberty may be prescribed puberty blockers, which slow the pituitary gland from stimulating secondary sex hormones, putting puberty on pause.
"One of the nice things about blockers is that they can give you some time to continue to explore, rather than having to go through the puberty changes that would happen otherwise," Dr. Tania Culham, a physician with Trans Care B.C., said.
Some countries have placed restrictions on puberty blockers until their long-term effects can be better studied. England has restricted their use to minors enrolled in clinical trials, and the Norwegian Healthcare Investigation Board has recommended they be considered "exploratory" and "experimental."
Culham says they are widely considered safe, noting they have been used for more than 40 years to treat precocious puberty — puberty that starts too early — and about 20 years for transition-related care.
Some research has linked them to decreased bone density over time, so providers may limit how long a patient takes them, Sims said. Doctors also supplement treatment with vitamins and dietary guidance for bone health, Hodgson and Culham said.
Patients can pull the plug any time, Culham said, and their regular puberty will resume.
"The whole point of the puberty blocker is that they are reversible," Culham said.
What are the effects of hormone therapy?
Adolescents further along in puberty may consider taking estrogen or testosterone to help develop sex characteristics that better align with their identities.
Cain started testosterone in July and says it's already having enormous benefits for his health and well-being.
"Pretty much everyone that I've talked to — my teachers, my therapist, doctors — they all say that I look so much happier now than I did before," he said. "And I definitely feel much happier than I was before."
Because hormones can have long-term effects on fertility, Sims says health-care providers don't prescribe them until a patient has shown a persistent desire to transition, been fully informed about the side effects and been offered a chance to have their sperm or eggs preserved for future use.
"These decisions, in general, are not taken very lightly," she said.
How involved are parents?
According to WPATH, parents should be involved in decisions to pursue medical treatments whenever possible. In fact, Culham says a "family-centred care" leads to better outcomes in all pediatric care.
"As hard as it is sometimes for people to come out to their parents or caregivers or have these conversations, I know a lot of youth take a lot of great care bringing their families, parents, caregivers along," she said.
But that's not always possible. In Canada, under the Convention on the Rights of the Child and Children's Participatory Rights, some people under 18 may be designated "mature minors," capable of making their own health-care decisions.
That's how Tristen Roscoe, 17, of Halifax was able to access testosterone.
"I did tell her about it, but my mom wasn't happy," he said. "She didn't have to, like, sign anything or give the OK, which was good because I don't think she would have."
Roberta Cain, mother to 16-year-old Silas, says helping her son navigate the health-care system has been a "a real balancing act" between respecting his privacy and making sure she has the information she needs to support him.
Ultimately, she says, it's worth it.
"My feeling is that the staff involved want the best for the kid," she said. "There's no other agenda than that."
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