Under the Microscope: Nova Scotia

Each of Canada’s ten provinces regulates gender medicine differently. This gives each province the ability to adapt to new evidence more quickly and respond to the demands of local citizens better than if health care were centralized with the federal government. But this also means that it is harder to understand all the nuances of each system and to collect data from across the country. Over the coming months, we will do our best to profile the data and policies on medical transitioning for minors in each province.

Policy

Nova Scotia is the only province other than Alberta to have clearly stated age restrictions for medical transitioning in its Gender Affirming Care Policy. Unfortunately, it only applies to surgery. The general rule is that a person must be 18+ to receive gender transition surgery, but 16- and 17-year-olds may request an exemption if they “demonstrate the emotional and cognitive maturity required to provide informed consent.” In other words, there are exceptions to this rule for mature minors.

However, Nova Scotia’s policy sets no hard age limits on hormonal therapies (puberty blockers and cross-sex hormones). Instead, following the World Professional Association for Transgender Health (WPATH) Standards of Care (SoC) 8, Nova Scotia requires that a gender dysphoric adolescent must have begun puberty (i.e. Tanner 2). The policy states that adolescents normally reach this stage of development between the ages of 8-14 years. 

Most forms of medical transitioning are publicly funded. Hormonal therapies are covered under the Nova Scotia Pharmacare Programs. “Top” and “bottom” surgeries are also publicly funded through the province’s Medical Services Insurance, though other surgeries (e.g. facial feminization, liposuction, tracheal shave and voice pitch surgery) are not covered.

Providers

The primary provider of pediatric gender medicine is IWK Health, formerly the Izaak Walton Killam Hospital for Children. According to their website, “IWK Health is a proud leader in gender-affirming care. We ensure youth in Nova Scotia access support and treatment based on evidence. Gender-affirming services at IWK Health include assessment for gender incongruence and assisting non-binary and transgender adolescents in understanding and meeting their embodiment and health goals.”

Nova Scotia Health advises that adolescents 17 and younger living within the Halifax Regional Municipality will be served by IWK Health’s Trans Health Team, while those outside the area will be connected with a “trans health clinician” in a local Community Health Centre. Specialized gender youth clinics recently opened in Kentville and Bridgewater, with more such clinics in the works. Eighteen-year-olds (who are still minors in Nova Scotia) can simply go to their family doctor or nurse practitioner or to a “WPATH SoC-trained clinician.”

As for surgeries, while some are performed in Nova Scotia, the province sends most people seeking surgeries to the Centre Métropolitain de Chirurgie-GrS Montréal in Quebec.

Prevalence

As we’ve mentioned before, it is challenging to find data on the number of minors who are medically transitioning. The ideal dataset would reveal the full number of minors currently prescribed puberty blockers or cross-sex hormones for the purpose of a gender transition, plus the number of “gender-affirming” surgeries performed on minors each year. But there are a couple of factors that make such data difficult to collect.

First, so many players are involved in gender medicine – children’s hospitals, gender clinics, and family doctors – that it is hard to collect all the relevant data. Not everyone involved in providing gender medicine reports all of the needed data. And so, the little data available makes up only a few pieces of the puzzle. Second, because all the medications or surgeries prescribed for gender transition are also used to treat other conditions (e.g. precocious puberty, breast or prostate cancer, menopause, or naturally low hormone levels), it is difficult to isolate prescriptions for “gender-affirming care.” For example, it is relatively straightforward to find the number of prescriptions of testosterone through a public drug plan. But that data isn’t very helpful when the reason for prescribing testosterone isn’t listed in the data.

In sum, the government doesn’t publish comprehensive data on medical transitioning anywhere. In most cases, that’s because the government doesn’t have the information. They simply let the system of medical transitioning carry on.

Some data on the number of minors who are medically transitioning in Nova Scotia have been uncovered by various Freedom of Information Requests, mostly filed by Melanie Bennet from Juno News. The FOIs revealed that 21 “top” surgeries (mastectomies) and 9 “bottom” surgeries were approved for minors in the fiscal year 2023-2024 in Nova Scotia and out of province. (In an attempt to maintain privacy, every number that is below 5 is redacted under the code 20(1). Hence, each cell obscured by 20(1) could be read as below 5 but at least 1.)

However, only a few of these surgeries were actually performed. No “bottom” surgeries and fewer than five “top” surgeries were performed on Nova Scotians younger than 19 from 2023-2024.

The reason for the difference between the number of surgeries approved and performed is not clear. It is possible that there was enough of a time delay between the approval of a gender surgery and the performance of a gender surgery that the person aged out of the data. For example, an 18-year-old could be approved for a mastectomy, but that mastectomy isn’t performed until she is 19. Alternatively, a young person may initially want surgery and receive approval but then decide they don’t want it.

Unlike most other provinces, Nova Scotia has released some data on the number of minors receiving puberty blockers and cross-sex hormones in recent years. Prescriptions for these hormonal interventions were relatively low from 2019-2023, with no more than 9 minors receiving puberty blockers and 37 receiving cross-sex hormones in a given year. But these numbers exploded in 2024 when 90 received puberty blockers and 195 received cross-sex hormones the following year. That is a 1000% and 696% increase, respectively, in a single year.

The reason for this spike is unclear. It may be the result of the opening of a new youth gender clinic in Kentville in February of 2024, allowing many minors who wanted hormones but previously couldn’t get them to access them. Or the number of minors actually seeking gender hormones went up drastically. Neither of these seems plausible to account for such a dramatic spike, however. It might simply be due to differences in data reporting, with the majority of minors receiving hormone therapy not being reported in previous years.

Conclusion

As in most other provinces, Nova Scotia liberally permits medical transitioning for minors. There are no hard and fast age restrictions to receive puberty blockers or cross-sex hormones. The province generally restricts “top” and “bottom” surgeries to those eighteen and older, but allows exceptions to this policy for 16- and 17-year-olds. Unlike most other provinces, Nova Scotia has some specific data on the number of minors who are medically transitioning. Ninety kids were prescribed puberty blockers and 285 were prescribed cross-sex hormones in 2024. Twenty-two were approved for “top” surgery and nine for “bottom” surgery in 2023-2024, though fewer than five actually received a mastectomy, and none received genital surgery.

Alberta has led the country in limiting medical transitioning for minors. And just last week, Alberta took another unprecedented step to protect the health and well-being of children: invoking the notwithstanding clause. 

Early in 2024, Premier Danielle Smith announced that Alberta would take steps to restrict these interventions, which until then had no legal age restrictions. Her government’s Bill 26, the Health Statutes Amendment Act, contained provisions to ban “puberty suppression,” “hormone replacement therapy,” and “sex reassignment surgery” to treat gender dysphoria or gender incongruence for any minor under the age of 18.  

Alberta took another unprecedented step to protect the health and well-being of children: invoking the notwithstanding clause. 

Despite the legislation’s passage in late 2024, only the ban on surgeries is in force right now. The government has not brought into force the provisions that ban “hormone therapies.” The rationale for this delay was the promise to craft an exception to allow “minors aged 16 and 17 with parental, physician and psychologist approval” and “minors who have already been prescribed hormone replacement therapies” to receive these pharmaceuticals. Such an exception has yet to be drafted, with no explanation for the year-long delay. The government could have brought the law into force, but, for whatever reason, has not chosen to do so. 

While the provincial government inexplicitly delayed, a new barrier arose that prevented the law from taking effect. This summer, Justice Allison G. Kuntz issued a preliminary injunction to prevent the ban on puberty blockers from coming into force, claiming that the law might infringe on Charter rights.  

The government is already in the process of appealing this injunction, paving the way for the full ban on medical transitioning for minors to go into effect. But that legal process could take years, years in which hundreds of children and adolescents could be prescribed a medical transition. 

And so, to bypass this potentially lengthy legal procedure, the government invoked the notwithstanding clause with Bill 9, the Protecting Alberta’s Children Statutes Amendment Act. The notwithstanding clause is a clause in the Canadian constitution that allows the elected parliament or legislature (rather than the courts) to be the final arbiter of whether a law violates certain sections of the Charter of Rights and Freedoms. With the ban on medical transitioning for minors shielded by the notwithstanding clause, the opinion of the courts remains just that: an opinion. Thus, a law could remain in effect despite a contrary opinion of the courts. 

Once considered the nuclear option to resolve differences between courts and legislatures, this provision is experiencing a renaissance (outside of Quebec, which has a long history of using the clause). Ontario used the notwithstanding clause to amend election spending rules. Saskatchewan invoked the section to pre-empt legal challenges to its legislation requiring parental consent for their children’s attempt to change their name or pronouns at school. The federal Conservatives have repeatedly promised to use it to ensure that criminals are appropriately punished. And just last month, the Alberta government relied upon the notwithstanding clause to end a teacher’s strike. 

The notwithstanding clause allows the elected parliament or legislature (rather than the courts) to be the final arbiter of whether a law violates certain sections of the Charter of Rights and Freedoms.

This is precisely what is needed to safeguard the health of young people and prevent these radical interventions. We know that over 1600 minors have visited Alberta’s two main pediatric gender clinics in the last five years. And we know that 36 minors have had gender surgeries over the past decade. Hundreds of children each year are being prescribed gender medicine. 

This even though over 80% of cases of pre-pubescent gender dysphoria among children resolve naturally after puberty. When clinicians cannot tell with any certainty whether a young person will persist or desist in their gender dysphoria, the responsible option is to wait and see, rather than turning to medical interventions that prevent development or surgically remove healthy organs. 

Rather than being cautious, clinicians in Canada are often far too quick to refer gender dysphoric children to the progression of medical transitioning. According to one study, over 62% of children and young adolescents referred to gender clinics in Canada were provided with hormones on the very first visit. Rather than providing kids time to think, taking puberty blockers sets children on the path of a further medical transition. As many as 98% of minors who take puberty blockers go on to take cross-sex hormones. 

And while pro-transition advocates claim that these interventions are “medically necessary” to protect the health, well-being, and even the life of “gender diverse” young people, the evidence to back that claim up is sparse at best. The United Kingdom’s Cass Review and the United States’ Health and Human Services Review find that there is little to no high-quality or long-term evidence to support the benefits of medical transitioning for minors. Earlier this year, two Canadian studies found the same thing. 

Alberta is taking the right step in invoking the notwithstanding clause to ensure that its restrictions on medical transitioning for minors go into effect.

For all of these reasons, Alberta is taking the right step in invoking the notwithstanding clause to ensure that its restrictions on medical transitioning for minors go into effect. Alberta is doing the hard part. But they need to do the easy part too. They need to proclaim the sections of the law that ban the provision of puberty blockers and cross-sex hormones. 

Without these actions, the law is just a façade. It looks impressive, but it isn’t functional. Alberta needs to finish the job of banning medical transitioning for minors. Invoking the notwithstanding clause is one step towards that goal, but more remains to be done. 

Dr. Gordon Guyatt is no lightweight. Inducted into the Canadian Medical Hall of Fame in 2016, Guyatt is one of Canada’s most cited researchers with over 1,200 publications, which have been cited by other scholars at least 100,000 times. 

Guyatt is most known for his contributions to evidence-based medicine. In fact, he coined that very term. Evidence-based medicine is “one of the great innovations in general medical practice over the last several decades.” As its name implies, the goal of evidence-based medicine is to make medical decisions based on scientific evidence. This might seem to be an obvious goal (e.g. what would medicine be based on if not evidence?). But the novelty of evidence-based medicine was to apply the most rigorous standards to assess existing evidence and then make medical recommendations.  

Guyatt was also an architect of one specific tool of evidence-based medicine: the Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE assesses the degree of certainty of academic studies and how various factors increase the certainty or uncertainty of the study’s findings. For example, GRADE will assess whether studies are biased towards certain findings. Evidence of bias reduces the certainty of a study’s findings.

“The goal of evidence-based medicine is to make medical decisions based on scientific evidence.”

Evidence-based medicine and GRADE have become the gold standard in science. In a world with so much information available, so many different study methodologies, and so much politicization in academics, evidence-based medicine helps medical practitioners to make the best medical decisions. 

Evidence-based medicine and medical gender transitions 

This GRADE methodology was briefly mentioned in the United Kingdom’s Cass Review and extensively used in the United States’ Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. Both of these seminal reviews strongly recommended against medical transitioning for minors. But relatively little work has been done in Canada.  

So, Guyatt and a team of researchers from McMaster University decided to apply evidence-based medicine and GRADE to assess the academic literature on medical gender transitions. The Canadian team of researchers wrote two papers, applying GRADE methodology to review studies on the effect of puberty blockers and cross-sex hormone therapy on youth under the age of 26.  

The results confirmed earlier reviews. They found that there was very low certainty about the effects of giving puberty blockers to children and adolescents with gender dysphoria on global function (i.e. overall well-being), depression, gender dysphoria, bone mineral density, and likelihood to progress to receive “gender-affirming hormone therapy.” The authors noted that all the studies suffered from methodological issues such as high risk of bias and imprecision. This study “is the first systematic review and meta-analysis to assess the effects of puberty blockers in children, adolescents and young adults with GD [gender dysphoria] using the highest methodological standards.”  

Guyatt’s team’s analysis of cross-sex hormones did not fare much better. The researchers had very low certainty about the effects of giving cross-sex hormones to children, adolescents, and young adults regarding their global function, depression, gender dysphoria, sexual dysfunction, and bone mineral density. The only finding that the researchers were highly certain of was that taking cross-sex hormones increased the risk of cardiovascular events (e.g. heart attacks or strokes) within 7-109 months. 

“Here we have two more studies that we can pile onto the growing list of academic papers that caution against medical transitioning for minors.”

Notably, the two studies used the age cut-off of 26. Most studies, medical systems, and legal codes focus on children and adolescents under the age of majority (usually 18 or 19). But the Finnish guidelines, commentary on the Swedish guidelines, and the Cass Review on medical transitioning for minors have noted that the human brain isn’t fully developed until age 25.  

Yet children, youth, and young adults are currently allowed to make irreversible decisions about their bodies before their brain is fully developed. Puberty blockers affect the development of their brain. Some of their impacts might not be fully apparent until brain development ends. Given these realities, it makes sense not only to assess the impact of a medical transition, not just on children and adolescents up to 18 or 19, but on young adults up to 26 as well. 

Here we have two more studies that we can pile onto the growing list of academic papers that caution against medical transitioning for minors. 

But that’s not the end of the story. 

Evidence meets ideology 

In the months after publishing these two studies, Dr. Guyatt was condemned by trans activists for publishing the study. They didn’t like an academic paper that failed to wholeheartedly support medical transitioning. Under pressure, Guyatt, his fellow researchers, and McMaster published a letter saying that “We are concerned our findings will be used to justify denying care such as puberty blockers and hormone replacement therapy to TGD individuals… it is unconscionable to forbid clinicians from delivering gender-affirming care… forbidding delivery of gender-affirming care and limiting medical management options on the basis of low certainty evidence is a clear violation of the principles of evidence-based shared decision-making and is unconscionable.” 

Well, it is only unconscionable if patient autonomy is far more important than evidence. The entire practice of “gender-affirming care” is predicated on the idea that puberty blockers, cross-sex hormones, and surgeries are beneficial treatments for gender dysphoria. Guyatt’s studies find that there is very low certainty that these benefits exist. If that is true, then medical transitioning can hardly be “medically necessary.” Actually, it can’t reasonably be called “health care” if there is very low certainty that it improves health. Trans advocates often speak about “embodiment goals,” using puberty blockers, cross-sex hormones, or surgeries to achieve a certain appearance. Interventions for these reasons certainly aren’t a form of health care. They are cosmetic interventions. 

“Guyatt’s studies find that there is very low certainty that these benefits exist.”

As part of their penance for their ideological sins, the researchers “personally made a donation to Egale Canada’s legal and justice work, noting their litigation efforts aimed at preventing the denial of medically necessary care for gender-diverse youth”. Egale Canada is a pro-trans group that, among other things, launched a legal challenge of Alberta’s restrictions on medical transitioning for minors. So the champions of a bias-detecting tool like GRADE made very public donations to an activist group. Not a great fit. 

To further complicate the story, Guyatt later said that he strongly disagreed with EGALE’s stated view that medical transitioning is “medically necessary care for gender-diverse youth.” Yet that statement was made in a letter that Guyatt signed. When asked about why he signed a letter he didn’t agree with, Guyatt responded that he must not have read the 507-word letter carefully enough before signing it.  

Dr. Guyatt may be a Medical-Hall-of-Famer, but that’s a rookie mistake. 

Evidence-based and ethical medicine 

Evidence can’t exist in a value-free vacuum. We are convinced that medical transitioning for minors isn’t a value-free activity either. The prevalence of harm, the question of consent, the rush to transition, and the immutability of sex all justify efforts by governments to curtail the practice. When studies find little certainty that medical transitioning improves the health and well-being of those suffering from gender dysphoria, greater caution over these interventions must be exercised. 

On Wednesday, October 8th, British Columbia became the second province to introduce a bill to ban medical transitioning for minors. However, while such a ban was proposed and then passed by the governing party in Alberta, the Protecting Minors From Gender Transition Act was introduced by a member of the fourth party in the BC Legislature, MLA Tara Armstrong of OneBC.

Here is how she introduced the bill:

Members, I stand before you today not only as a member at this Legislature but as a mother. British Columbia is sleepwalking through the greatest medical scandal in modern history, and it’s our kids who are at risk.

In B.C. today, doctors are causing irreversible harm to children with puberty blockers, cross-sex hormones and surgeries. These interventions rob children of the human right to grow up with their bodies intact and to one day have children of their own. B.C. schools add to this harm by socially transitioning children with new names and pronouns, often kept secret from parents. Gender clinics in B.C. are even performing double mastectomies on healthy young girls by the age of 14.

All because we fell for the lie — a lot of us did — that children can be born in the wrong body. It’s not true though. Every child is beautiful just as they are. No drugs or scalpels are needed.

Every jurisdiction in the world that has conducted a systematic review of the scientific literature has found no credible evidence to support this practice. So let’s all make it stop. This should not be a partisan issue. This bill will bring B.C. in line with the U.K. and other progressive European countries that have banned harmful and unscientific social and medical gender transition procedures for minors.

In our schools, it will stop them using the wrong pronouns, keep boys out of girls’ bathrooms and remove gender ideology from school libraries and curriculum. It will stop doctors from attempting to change the sex of minors. In short, it will end this unbelievable era of indoctrination and medical malpractice.

Please join me as we restore sanity to this province and provide the loving care that every child deserves.

It was a great speech. But sadly, the Protecting Minors From Gender Transition Act didn’t even make it past first reading in the legislature. MLAs voted 48-40 that the bill not pass first reading, meaning MLAs did not even have the opportunity to read the contents of bill before defeating it. This is very unusual but not unprecedented. Last year, the BC legislature did the same thing when BC Conservative leader John Rustad introduced a bill on segregating publicly funded sports by sex.

In both cases, the majority of MLAs were so captured by gender ideology that they refused to even read bills that question gender ideology, much less have a substantial discussion about it in the legislature.

More than just a ban on medical transitioning

MLA Armstrong’s bill would have gone further than any legislation in Canada in removing gender ideology from medicine and from education.

It would have defined “male,” “female,” and “sex” as based on biology rather than being arbitrarily assigned at birth or based on a person’s subjective belief. It defined gender as “the psychological, behavioural, social, and cultural aspects of being male or female.” In other words, the bill views gender as being the outworking of our biological differences.

The bill would have banned all forms of puberty blockers, cross-sex hormones, and gender surgeries aimed at addressing “the minor’s perception that his gender or sex is not male/female.” This would have gone further than Alberta’s recent legislation, in part because Alberta’s age of majority is a year earlier (18 in Alberta, 19 in BC). But Alberta’s legislation only prohibits puberty blockers and cross-sex hormones for ages 15 and under but permits 16- and 17-year-olds to access puberty blockers and cross-sex hormones with parental, physician, and psychologist approval. Alberta’s law has no restrictions past age 17.

The Protecting Minors From Gender Transition Act proposed heavy penalties for medical transitioning minors, including “suspension of the healthcare professional’s ability to administer healthcare or practice medicine for at least one year.” Furthermore, the bill would have made any medical professional who provided medical transitioning to a child liable for any physical, psychological and emotional harm to the child caused by the medical transition for the next 25 years. The bill also would have prevented professional liability insurance from covering this liability, shifting the risk entirely to health care providers and providing another deterrent.

Additionally, the bill would have prohibited the use of public funds, property, or time to pay for or promote medical transitioning for minors. This would exclude the provincial Medical Services Plan or BC PharmaCare Plan from covering the cost of these procedures or guidance on government websites on where minors could undergo medical transitioning in another province.

But the bill wasn’t just about medical transitioning. It also dealt with gender ideology and social transitioning in schools. The legislation would have required school employees to notify parents within three days if their child wishes to socially transition. School staff would have been forbidden to use pronouns that are inconsistent with a student’s sex, regardless of parental notification or consent. This goes a step further than Alberta’s and Saskatchewan’s laws that permit the use of pronouns based on gender identity with parental consent.

Further on the school front, the bill would have required schools to prohibit students from using an opposite-sex restroom, locker room, or changing facility. School staff would not be permitted to use any material or offer any program that encouraged or normalized a social transition or a medical transition. Whether this clause would entirely ban SOGI teaching resources, pride paraphernalia, or gay-straight alliance clubs is unclear.

Finally, the bill invoked the notwithstanding clause to shield it against the courts striking it down as a violation of The Charter of Rights and Freedoms. Opponents of Alberta’s ban on medical transitioning for minors have used the Charter to challenge Alberta’s law. While some of these legal cases are still underway, an Alberta judge did grant a preliminary injunction preventing the ban on puberty blockers from going into effect, as she opined that it might violate the Charter.

This is not the end

The introduction of this bill gives cause for hope in the cause of banning medical transitioning for minors, despite its quick demise. It shows how the desire to limit these harmful interventions isn’t just limited to Alberta but is present elsewhere in Canada. It shows that these objections aren’t just limited to private citizens or on social media but shared by politicians who are willing to raise this issue in the legislature. And it shows that, despite the defeat of the bill, many MLAs are willing to vote to ban the practice. The legislation failed in a relatively close vote, 48-40.

This legislation may be defeated in British Columbia for now, but the campaign to let kids be is only gaining momentum.

Image and audio source - The Legislative Assembly of British Columbia. (Oct 8, 2025). BC Legislature Livestream [Video]. YouTube. https://www.youtube.com/watch?v=n8KOX5oRWSo

Each of Canada’s ten provinces practices gender medicine differently, as provinces have primary jurisdiction over health care. This gives each province the ability to adapt to new evidence more quickly and respond to the demands of its local citizens better than if health care were centralized with the federal government. But this also means that it is harder to understand all the nuances of each system and to collect data from across the country. Over the coming months, we will do our best to profile the data and policies on medical transitioning for minors in each province. 

Our series is going to begin with Alberta.  

Policy 

Alberta is the lone province in the country that has taken the greatest steps to limit medical transitioning for minors. Prior to 2024, Alberta had no legal restrictions on the intervention, though “bottom” surgeries (e.g. penectomy, phalloplasty, vaginoplasty, orchiectomy) were rarely, if ever, performed on minors in practice. Pre-pubescent children received puberty blockers, and adolescents received cross-sex hormones and “top” surgeries without age restrictions.  

That changed in late 2024 when the Alberta legislature passed Bill 26, the Health Statutes Amendment Act. The new law bans “puberty suppression,” “hormone replacement therapy,” and “sex reassignment surgery” to treat gender dysphoria or gender incongruence for any minor under the age of 18. (Eighteen is the age of majority in Alberta.) However, the law permits the Minister of Health to create exceptions for puberty blockers and cross-sex hormones through regulation. The government intends to use this clause to allow “minors aged 16 and 17 with parental, physician and psychologist approval” and “minors who have already been prescribed hormone replacement therapies to treat gender dysphoria or gender incongruence” to receive these pharmaceuticals.  

Although the law passed the legislature, not all of these provisions banning medical transitioning are in force. In fact, only the ban on gender surgeries for those under 18 applies right now. The sections dealing with “hormone therapies” (i.e. puberty blockers and cross-sex hormones) will come into force upon Proclamation (when an order from Cabinet brings them into force). Ostensibly, the government is waiting to make this law legally binding until it has created the ministerial order that makes the exemption for 16- and 17-year-olds and minors already on puberty blockers or cross-sex hormones. 

Furthermore, one Alberta judge issued an injunction to further prevent the law from coming into force. The judge opined that the law would likely touch upon the Charter of Rights and Freedoms’ guarantees of “life, liberty, and the security of the person” and “equality rights.” These Charter issues must first be resolved before the law can go into effect. The government of Alberta is appealing this injunction. 

The bottom line? Alberta has banned surgical transitions for minors and set the stage to ban puberty blockers and cross-sex hormones for minors, but hasn’t implemented the full ban yet. Hormonal therapies for minors are still legal. 

Providers 

According to the Alberta Health Services’ hospital and facility directory, three main institutions in the province participate in pediatric gender medicine:  

But pediatric gender medicine is not just the purview of specialized gender clinics. It is increasingly being practiced by primary care providers, more commonly known as family doctors. Gender ideologues in medicine have taken up the slogan “gender-affirming care is primary care.” Another journal article opines that “because primary care providers often have in-depth understanding of their patients’ medical and mental health background and the greater context of their lives and support networks, they are well positioned to assess a patient’s readiness for gender-affirming hormone therapy and initiate treatment.” 

We have no idea precisely how many family doctors have begun to help children and adolescents medically transition, though the Trans Wellness Initiative has started an Alberta-centric directory of gender-affirming health care providers. 

Prevalence 

As we’ve mentioned before, it is challenging to find any data on the number of minors who are medically transitioning. The ideal dataset would list the entire number of minors currently prescribed puberty blockers or cross-sex hormones for the purpose of a gender transition, plus the number of “gender-affirming” top and bottom surgeries performed on minors. But there are several factors that make such data difficult to collect. First, so many players are involved in gender medicine – children’s hospitals, specialized gender clinics, and family doctors – that it is hard to collect all the data into one centralized spot. Every participant would have to report in order for the data to be complete. Second, because all of the medications prescribed for a gender transition are also used to treat other conditions (e.g. precocious puberty, breast or prostate cancer, menopause, or naturally low hormone levels), it is difficult to isolate just prescriptions for “gender-affirming care.” And finally, the involvement of both provincial drug programs and private insurance programs in funding “gender-affirming care” makes it difficult to track the money. Hence, governments don’t publish this data anywhere. In some cases, it doesn’t even seem like the government even has the information. They simply let the system of medical transitioning carry on.  

And so we made an FOI request for the number of patients seen at Alberta’s two main gender clinics at Alberta Children’s Hospital and Stollery Children’s Hospital between 2000-2025. The government released the following data. 

The first thing to note is that this data records the number of unique patients and total visits to these two gender clinics for whatever reason. Now, not all children struggling with their gender identity and visiting a gender clinic choose to medically transition. What this data does show is the number of children and adolescents struggling with gender dysphoria and considering – if not obtaining – a medical transition. 

And these numbers have been growing over the past few years. The number of visits reached 2,020 in 2023, while the number of unique patients peaked at 702 in 2024. 

And this isn’t even everyone. It accounts for those visiting Alberta’s two largest pediatric gender clinics, but it doesn’t include those visiting the Aberhart Centre’s Pediatric Endocrinology Clinic or lesser-known pediatric gender clinics, nor those who received puberty blockers and cross-sex hormones from family doctors. What we can say with some certainty is that at least 1,600 minors have sought to medically transition in the last five and a half years in Alberta.  

Thankfully, very few of them have received sex-denying surgeries. In another FOI, the government stated that “all lower or bottom surgeries are only available for people 18 years of age or older,” and so there were no recorded instances of a minor receiving these procedures. Thirty-six minors did receive “top surgeries” between 2013 and 2023, however, before the ban on such surgeries went into effect in 2024. And yet, at its height in 2018, one of every ten “gender-affirming” mastectomies was performed on minors.

Conclusion  

Alberta may have taken the furthest steps toward banning medical transitioning for minors, but it is still far from that goal. Surgical transitioning for minors is banned. The legislature has enacted a ban on puberty blockers and hormone therapies, but the ban has not fully come into effect, and a court injunction stands in its way. At least two major health care institutions – Alberta Children’s Hospital and Stollery Children’s Hospital – are providing puberty blockers and cross-sex hormones to minors. At least 1,600 minors have sought to medically transition at these two institutions alone in the last five and a half years in Alberta. 

If you live in Southern Ontario, you may have seen a billboard or bus ad like these in your local communities. Our goal with these billboards was to bring attention to the issue of medical transitioning for minors and garner support for the campaign to ban medical transitioning for minors.  

And they’ve certainly gotten attention! 

Everything started back in December when a local group collected money, negotiated a contract, and put up LetKidsBe.ca bus ads in the city of London. Those ads received a lot of attention from the media and from pro-transitioning groups. The London Free Press, CBC, and CTV covered the bus ads in some fashion, with a heavy bias against the ads and in favour of medical transitioning for minors.  

The London Transit Commission (LTC), having previously lost a court challenge to the Association for Reformed Political Action (ARPA) Canada (the creator of LetKidsBe.ca), kept the ads up despite pressure to remove them.  LTC Chair Stephanie Marentette said LTC could not reject the ad because doing so would violate freedom of expression. “Unless something is egregious or amounting to hate speech. that would trigger an exception. Unfortunately we don’t have the ability to arbitrate what types of ads go on the side of our buses. This is something we don’t have a lot of control over, the Supreme Court is the highest court in the country.”  

But this action inspired more action. 

A local group of Let Kids Be supporters in Hamilton wanted to see this message featured on a billboard on the Lincoln Alexander Parkway, a high-traffic expressway for commuters. Procuring such a prime location was an expensive endeavour, but they managed to raise the funds, and the electronic billboards in Hamilton went up on Monday, August 4th.  

That Friday, August 8th, the Hamilton Trans Health Coalition posted a warning on Facebook about the billboard, labelling it “disinformation,” “a harmful message,” and “an attempt at this [anti-trans] politicization.” Late that evening, Hamilton mayor Andrea Horwath, the former leader of the Ontario NDP, posted the following message on X:  

“This afternoon, my office was made aware of a transphobic ad on a billboard along the Linc.

While the billboard is not City-owned, it sits on City-leased space, and City advertising rules were not followed. We’ve directed Astral Media to remove it and put stronger safeguards in place.

Hate-related incidents are on the rise in Hamilton. In 2024, members of the 2SLGBTQIA+ community were among the most frequently targeted. But we are also a community that will not stand by when confronted by hate – I certainly will not.

Love will always be louder.”

Before the end of the day, Astral/Bell media took down the billboards.  

Undeterred by this event in Hamilton, a group of Let Kids Be supporters in Niagara pressed on. After some investigation, they found an advertising company that had billboards on private land. Since putting up billboards on city-leased space enabled the City of Hamilton to get them taken down, they thought that placing a billboard on private land would ensure that it would remain up. They contacted Vann Advertising to erect three billboards. Two of the billboards were digital, located back-to-back along the QEW in St. Catharines, another high-traffic expressway. The third billboard, this one printed on vinyl, was in downtown St. Catharines.  

The electronic billboards went up on Monday, August 25th, and the physical billboard was erected shortly thereafter.  

The reaction was swift. Within days, the physical billboard was vandalized.  

Pride Niagara called “on the City of St. Catharines to take urgent action against a transphobic billboard” and claimed that “this harmful and dehumanizing message spreads dangerous misinformation and creates an unsafe environment for trans and gender-diverse people in our community.” They encouraged people to reach out to Mayor Mat Siscoe and sent a letter to city hall themselves. Mayor Siscoe then called Vann Advertising, asking them to reconsider displaying the billboards. Furthermore, Vann Advertising received some aggressive messaging from LGBTQ activists. Worried about the viability of the company and its owners’ safety, Vann Advertising removed the billboards. 

But that is not the end. A private billboard owner in Hamilton was willing to sell us digital billboard space in downtown Hamilton. More groups around the county are considering putting up Let Kids Be billboards in their local communities, and we are pursuing legal action to ensure that local governments do not violate the Charter right to the freedom of expression. 

Ironically, the efforts of activists to censor these Let Kids Be ads have caused the call to stop medical transitioning for minors to reach far more people. Billboards are seen in passing only by those who happen to pass by them. But when they become the subject of a censorship battle which media reports on, their reach extends to many more people. People see the ad on their computers and phones, just a quick search away from the Let Kids Be website. And because our messaging is so clear, direct, and respectful, even media that are biased against us tend to report what the billboard said and often show the billboard itself. This respectful advocacy starkly contrasts with the disrespect shown by the other side when they vandalize a billboard. 

So take heart. More and more Canadians are hearing the message that we need to stop medical transitioning for minors. If you or your local group want to sponsor a local Let Kids Be billboard, the graphics are available for you to use. The more billboards that go up, the more the message gets out! 

But if you do participate in this endeavour, realize that erecting a billboard isn’t the end of the project. It is the beginning of a conversation. If a Let Kids Be billboard is up in your community, use that opportunity to encourage the billboard company to keep up the ad. Urge your local politicians to not interfere with private advertising. Petition your MPP/MLA and your MP to take action to ban medical transitioning for minors.  

Sex-based violence against women and girls – violence perpetrated against females solely because they are females – is a sad reality of our world. To combat this injustice, the United Nations established a Special Rapporteur on violence against women and girls in 1994. The mandate of the current Special Rapporteur, Reem Alsalem, is not only to identify common forms of violence against women and girls but also to investigate their causes and consequences. 

Late this spring, Alsalem released a report titled Sex-based violence against women and girls: new frontiers and emerging issues. The report is global in scope. It points out cases of gender-based violence in countries like Afghanistan, India, Myanmar, and Sudan that are egregious to Western sensibilities. But Alsalem doesn’t give Western countries a free pass. Sex-based violence happens here too. The most frequently mentioned Western countries in the report are Canada, the United Kingdom, and Israel.  

Alsalem touches on many forms of sex-based violence in her report. We will touch on two that relate to the Let Kids Be campaign: gender ideology and medical transitioning for minors. 

Gender ideology 

Alsalem devotes more space to discussing the abandonment of biological sex in favour of gender ideology than any other issue. Canada is one of the worst culprits. In the space of five short years, the federal government and almost every single province and territory incorporated gender ideology into their human rights statutes. Prior to 2012, these statutes forbade discrimination based on sex. But between 2012-2017, they added gender identity and gender expression as prohibited grounds for discrimination. This has allowed men to compete in women’s sports, men to enter women’s private spaces, teaching gender ideology to school children, and a surge in medical transitioning for minors. 

In response, Alsalem said this in a recent speech before the UN: “Let me be frank. I never imagined the day would come where my mandate would deem it necessary to prepare a report affirming that the words women and girls refer to distinct biological and legal categories.” 

“Let me be frank. I never imagined the day would come where my mandate would deem it necessary to prepare a report affirming that the words women and girls refer to distinct biological and legal categories.” 

– Special Rapporteur, Reem Alsalem

And thus, the report starts with a simple definition – or rather insisting – of terms: 

“Sex” is understood as a biological category and as a distinction between women and men, as well as between boys and girls. References to “sex” refer to the biological distinction between males and females, characterized by divergent evolved reproductive pathways through which, all else being equal, males develop bodies oriented around the production of small gametes and females develop bodies oriented around the production of large gametes. As evolutionary biologist Richard Dawkins notes: “Sex is a true binary.” 

The term “gender”, on the other hand, has been defined by the Committee on the Elimination of Discrimination against Women as the social meanings given to biological sex differences. It is supplementary to and built upon biological differences between women and men… In the last few decades, the term “gender” has wrongly been taken to be synonymous with the term “sex”, including in some international declarations and instruments. 

The report ends with a simple recommendation: governments must “ensure that the terms ‘women’ and ‘girls’ are only used to describe biological females and that such a meaning is recognized in law… Legislation and policies that expand the definition of sex to include ‘certified’ or ‘legal’ sex or conflate sex with gender identity or substitute one term for the other should be rescinded.” 

Medical Transitioning for Minors 

Perhaps the greatest effect of replacing sex-based identity with gender-based identity is the exponential growth of medical transitioning for minors in Canada and other Western countries. Alsalem condemns medically transitioning minors in the strongest terms:  

“The long-lasting and harmful consequences of social and medical transitioning of children, including girls, are being increasingly documented. They include: persistence or intensification of psychological distress; persistence of body dissatisfaction; infertility, early onset of the menopause and an increase in the risk of osteoporosis; sexual dysfunction; and loss of the ability to breastfeed in cases of breast mastectomy (to mention a few). That has rightly led several countries, such as Brazil, the Kingdom of the Netherlands and the United Kingdom to change course and restrict children’s access to puberty blockers, cross-sex hormones and surgery on sexual and reproductive organs. Allowing children access to such procedures not only violates their right to safety, security and freedom from violence, but also disregards their human right to the highest standards of health and goes against their best interests. Children are also not able to provide informed consent for such procedures. In situations in which such procedures have been found to have caused grave and lifelong harm, consent would be meaningless for both adults and children.” 

Alsalem recommends that governments: 

“Uphold the rights of children, including girls, to be free from all forms of physical and mental violence and to the highest attainable standard of physical and mental health, including through the prohibition of legal and social transitioning of children who claim to experience gender dysphoria, as well as their subjugation to experimental, irreversible medical interventions related to gender reassignment, while ensuring comprehensive, evidence-based assessments for them to address underlying neurodevelopmental, psychological or other conditions before any intervention. Moreover, States must establish legal and policy frameworks providing effective remedies, accountability mechanisms and robust support services for all harmed by such interventions, including those seeking to detransition.” 

Alsalem touches on several key issues around medical transitioning for minors: it is harmful, irreversible, has long-term effects, lacks meaningful informed consent, and is experimental. And notice the language that she uses. She doesn’t present this as a question of choice for children or even mature minors. Instead, she refers to children’s “subjugation” to these procedures. Who Alsalem has in mind as the subjugating party – medical professionals, governments, activists, or parents – isn’t clear. But what she does make clear is that this isn’t an issue of freedom, choice, or consent. This is an issue of harm, violence, and subjugation.  

This isn’t an issue of freedom, choice, or consent. This is an issue of harm, violence, and subjugation.  

Because of this harm, many people will choose to detransition. Rather than pretending that the desistence rate is low or ignoring detransitioners altogether, Alsalem insists that governments need to support detransitioners. Detransitioners will need health care, certainly. But they also deserve justice against those responsible for harming them and restitution for the bodily harm that they have suffered. Hence, the Rapporteur recommends that governments “establish legal and policy frameworks providing effective remedies, accountability mechanisms and robust support services for all harmed by such [medical transitioning] interventions, including those seeking to detransition.” 

The report also hints that government should do the opposite of medical transitioning. Governments must provide the “highest attainable standard of physical and mental health” and ensure “comprehensive, evidence-based assessments for [gender dysphoric children] to address underlying neurodevelopmental, psychological or other conditions.” In other words, governments should provide other interventions such as counselling to children with gender dysphoria.  

And finally, governments shouldn’t just stop at banning medical transitioning for minors. She recommends that government prohibit “legal and social transitioning” as well. This would include policies that prohibit adolescents from changing their sex designation on government-issued ID or to adopt a new name or pronouns at school. Instead, Alsalem recommends that governments begin education campaigns to reverse the growing acceptance of gender ideology. 

All of this is necessary if we are to let kids be. We’ve been pushing for action like this here in Canada. It is heartening that even the United Nations joining the cause. 

A couple of weeks ago, an Alberta judge issued an interim injunction stopping the Alberta ban on medical transitioning for minors from going into effect. This marks the first time that a court in Canada has weighed in on medical transitioning for minors. 

Alberta’s Bill 26, the Health Professions Act, passed last year, banned puberty blockers and cross-sex hormones for minors under 18 to treat gender dysphoria. Egale and the Skipping Stone Scholarship Foundation, described in the decision as “two leading 2SLGNTQI organizations,” as well as five children (aged 6 to 12) who claim to be transgender, and their parents challenged the legislation. They asked the court to strike down the law as violating the Charter rights to security of the person and equal protection under the law. 

The Alberta justice did not issue a final ruling on the constitutionality of the law. Rather, she found that there are serious constitutional issues to be resolved at trial, and that the prospect of harm to the applicants justified an interim injunction, preventing the law from taking effect before the case is fully resolved. 

The advocates in favour of medical transitioning argued that gender identity – a person’s internal sense of their own gender – is fundamental to their personal identity. And yet their personal identity cannot be entirely realized without puberty blockers. Specifically, withholding puberty blockers, the court ruled, 

Will have a serious and profound effect on the psychological integrity of transgender and gender diverse youth because it will: (a) take away medically necessary gender affirming care for gender incongruence and gender dysphoria; (b) take away a young person’s option to delay puberty (and the associated stress and fear) so that they can have more time to consider their gender identity and options; (c) subject them to the irreversible changes associated with puberty, which may result in more difficulty transitioning at a later date; (d) deny gender diverse young people autonomy over their own bodies; and (e) make it more likely that others will identify them as trans, increasing the risk of bullying, discrimination, violence, depression, suicidal ideation and self-harm. 

Since when does the “security of the person” include a right not to go through puberty? Will future cases find that Canadians have a right not to age in other ways too? Aging – or going through puberty – is not an experience that the government forces on people. They are natural, normal parts of the human lifecycle. 

If there is any violation of the security of the person at issue here, it is medical transitioning. The Alberta government pointed the court to the Cass Review, and the UK’s subsequent ban on medical transitioning for minors. Alberta also noted, in defense of its law, that: 

Egale and company dismiss or minimize these risks by claiming medical transitioning in Canada is done carefully and always follows international guidelines. But the claim that Canadian doctors are slow to prescribe puberty blockers or hormones seems unlikely given that 62% of children and young adolescents referred to gender clinics were provided with hormones on their very first visit. And yet, the justice opines that there is a serious threat to the security of the person in restricting access to medical transitioning.  

She also found that a ban on medical transitioning may violate the equality provisions of the Charter, a finding that diverges from that of a recent US Supreme Court decision/. The judge opined that gender identity is an immutable personal characteristic and that people who identify as gender diverse are “undeniably a marginalized group in Canadian society.” Both parties in the American case, however, admitted that gender identity is not immutable, but can change over time. Also, the US Supreme Court did not find a history of legal discrimination against people who claim to be transgender, and so they found that a ban on medical transitioning was not discriminatory. Although a powerful rhetorical and political argument, the existence of detransitioners demonstrates that gender identity is not immutable. 

But there is more to this case than just disputes over science and rights. A much broader clash of worldviews and ethics is involved too. One of the expert witnesses on the pro-medical transitioning side was Dr. Palmert, a co-founder of the Transgender Youth Clinic at the Hospital for Sicks Kids in Toronto. In his opinion, “efforts to change a youth’s gender identity are harmful and unethical and should not be undertaken.”  

Let Kids Be holds a different position: efforts to change a youth’s sexual identity (through medical transitioning) are harmful and unethical and should not be undertaken. A person’s sex (male or female) is immutable, even if his or her body can be medically manipulated to appear more masculine or feminine.  

At the end of the decision, the Alberta justice grants the injunction because it “is necessary to ensure that Albertans under the age of 18 who want medical treatment are not denied the protection of their constitutional rights while the case works its way through trial.” 

This case demonstrates just how deeply entrenched medical transitioning is among Canadian institutions and how much work is left for Let Kids Be to do. Although most Canadians want limits on medical transitioning for minors, most politicians, journalists, professional associations, and perhaps judges are firmly in favour of the practice. We need to keep up the work to advocate for society to let kids be. 

More good news for the movement to let kids be in the United States! The US Supreme Court just upheld a Tennessee ban on medical transitions for minors in United States v Skrmetti. 

In 2023, Tennessee prohibited prescribing, administering, and dispensing puberty blockers or cross-sex hormones for the purpose of medical transitioning for minors. The reasons for this ban are the same that every other jurisdiction has used to curtail medical transitioning for minors. As the official summary of the Court ruling explains: 

“Tennessee determined that administering puberty blockers or hormones to minors to treat gender dysphoria, gender identity disorder, or gender incongruence carries risks, including irreversible sterility, increased risk of disease and illness, and adverse psychological consequences. The legislature found that minors lack the maturity to fully understand these consequences, that many individuals have expressed regret for undergoing such treatments as minors, and that the full effects of such treatments may not yet be known. At the same time, the State noted evidence that discordance between sex and gender can be resolved through less invasive approaches.” 

This law was challenged based on the Equal Protection Clause of the fourteenth amendment to the American constitution, with the plaintiffs arguing that the law discriminated on the basis of sex and “transgender status.” 

Six out of nine justices upheld the ban, but for different reasons and with different emphases. 

The Legal Theory in the Majority Opinion  

The majority opinion largely side-stepped the substantive questions of the case and instead based its decision on the appropriate legal standard of review to judge the case.  

In U.S. constitutional law, not all classifications are treated equally. Some—such as race-based classifications—are considered suspect and receive “strict scrutiny” from the courts. This means the government must show a compelling interest and prove the law is narrowly tailored to achieve that interest. Other classifications—such as those based on age or medical use—are subject only to a “rational basis review,” where the law merely needs to be rationally related to a legitimate government objective. A third category, such as sex-based classifications, receives “intermediate scrutiny,” a middle ground between deference to lawmakers and judicial review. 

The plaintiffs argued that Tennessee’s law discriminated against them based on their sex and “transgender status.” Tennessee argued that any discrimination was based on age or medical use. So, the Court had to decide which characterization of the main issue was correct – and consequently which standard of review (rational basis or intermediate scrutiny) applied.  

The majority is quick to side with Tennessee, saying there is no discrimination based on sex or “transgender status.” The law doesn’t prohibit certain medical treatments for members of just one sex. For example, it didn’t only ban boys from taking puberty blockers or girls from receiving cross-sex hormones. So, there is no sex discrimination. The law also doesn’t ban people who claim to be transgender from accessing puberty blockers or cross-sex hormones for reasons other than to medically transition (e.g. to treat precocious puberty). That is, the law doesn’t target “transgender” persons per se. And so, there is no discrimination on the basis of “transgender status” either.  

Instead, the majority agreed that any discrimination in the ban on medical transitioning was based on age. The law only applied to minors (not adults), and it only banned puberty blockers and cross-sex hormones for the purpose of medical transitioning (but not other treatments). In these cases, the precedent was to apply only rational basis review to the case at hand. Using this standard, “where there exist ‘plausible reasons’ for the relevant government action, ‘our inquiry is at an end. SB1 [the ban on medical transitioning for minors] clearly meets this standard” (21).  

Noting that there is much scientific uncertainty and low-quality evidence in this area (the opinion cites Finland, England, Sweden, and Norway’s review of the evidence and changes to clinical care), the Court found it entirely appropriate for government to restrict a medical procedure in the name of safeguarding the health and safety of a segment of its population. 

In other words, the majority decided to defer to the elected branch of government on this one. 

But certain justices within the majority had more to say. 

The State’s Interest in Regulating Medical Transitioning – Justice Thomas’ Concurring Opinion 

Justice Thomas, who signed onto the majority opinion, wrote a concurring opinion that focuses on the practice of medical transitioning for minors rather than what standard of review to use. He discusses the harms of both puberty blockers, cross-sex hormones, and surgery; the inefficacy of these treatments in relieving gender dysphoria; the unethical nature of these treatments, particularly the inability for minors to give informed consent; the increasing number of detransitioners; and the activist nature of the World Professional Association on Transgender Health (WPATH). Given all of this, he opines the state has good reason to ban medical transitioning for minors. He concludes his opinion by saying, “[E]xperts and elites have been wrong before — and they may prove to be wrong again” (23). 

The Place of Gender Identity in Discrimination Law – Justice Barrett and Justice Alito’s Concurring Opinions 

Although the majority opinion and Justice Thomas’ concurring opinion definitively settle the legality of the bans on medical transitioning for minors – the primary issue for the Let Kids Be campaign – there is another issue at stake in this case that will impact a far wider set of cases: whether gender identity or “transgender status” should be added to the list of classes of people who receive greater protections against discrimination. Should a transgender identity more analogous to race or age, sex or disability?  

In the opinion of Justice Alito, this “important question has divided the Courts of Appeals, and if we do not confront it now, we will almost certainly be required to do so very soon.”  

Rather than waiting for another day, Justice Barrett and Justice Alito decide to tackle this broader issue in this case. 

Both justices agree that “transgender status does not qualify under our precedents as a suspect or ‘quasi-suspect’ class” (10). A “‘suspect class’ status is reserved for those groups whose members tend to ‘carry an obvious badge’ of their membership in the suspect class, which in part explains ‘the severity or pervasiveness of the historic legal and political discrimination against’ the group. Suspect class status is therefore generally inappropriate for ‘large, diverse, and amorphous’ groups that do not share ‘obvious, immutable, or distinguishing characteristics that define them as a discrete group’” (14).  

American courts have only considered race (along with its corollaries, ethnic and national origin) to be an inherently suspect classification. Even sex, disability, age, and poverty have been dismissed as suspect classes. For example, sex is an important and, in some contexts, a legally relevant and legitimate classification. Disability and poverty are too large, diverse, or amorphous to capture an inherently suspect classification.  

In the opinion of Justice Barrett, “transgender status” should not be considered a “suspect class” needing special protections against discrimination because persons who identify as transgender have not experienced discrimination de jure (in law). She concludes by saying 

Because the litigants assumed that evidence of private discrimination could suffice for the suspect-class inquiry, they did not thoroughly discuss whether transgender individuals have suffered a history of de jure discrimination as a class. And because the group of transgender individuals is an insufficiently discrete and insular minority, the question is largely academic. In future cases, however, I would not recognize a new suspect class absent a demonstrated history of de jure discrimination (10-11). 

In the last sentence, however, she leaves the door open to changing her mind in the future if new evidence came to light. 

Justice Alito comes down more firmly on this question. Although many citizens, activists, and judges compare every form of discrimination to racism, Alito states that he does “not think that transgender status is sufficiently similar to race, national origin, or sex to warrant a higher level of scrutiny” (19). Persons who identify as transgender have not suffered a long history of discrimination in law. They have not been excluded from participation in the political process. They do not necessarily carry an obvious badge for their transgender identity. They are too diverse and amorphous a group (given claims that there are possibly an infinite number of genders). And even the parties in the case admit that transgender status is not an immutable characteristic. 

And so, Justice Alito firmly contends that “transgender status” should not receive extraordinary legal protections. If adopted by the majority of the court, such a stand would have far reaching consequences far outside the issue of medical transitioning for minors. 

What All This Means 

First, Skrmetti signals to every American state that, if crafted the right way, the Supreme Court will uphold laws banning medical transitioning for minors.  

Second, while declining to give “transgender identity” special protections against discrimination, almost every justice used terms laden with gender ideology (e.g. “transgender boy”) in their reasoning, giving tacit endorsement to core tenets of gender ideology. While the American executive branch has explicitly stated that there are only two sexes and rejected gender ideology, the judicial branch hasn’t been willing to go so far yet. 

Third, while this decision is a victory in the battle to end medical transitioning for minors, the court didn’t squarely deal with whether there was discrimination against “transgender identity” or gender identity. Hopefully the Court will take a firmer stance on the issue in the future. 

Skrmetti, of course, doesn’t apply anywhere in Canada and Canadian courts rarely look to legal opinions outside our country for guidance. But the growing body of academic studies, legal cases, and democratic laws that support limiting medical transitioning for minors should encourage Canadian governments to follow suit. 

On January 20, 2025, the Trump administration issued an executive order titled Protecting Children from Chemical and Surgical Mutilation. This order required the United States Secretary of Health and Human Services (HHS) to “publish a review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion” within 90 days. 

That review has now been published. Although compiled much more quickly and with less emphasis on systematic reviews of the academic studies on the topic, this HHS Review is the United States’ version of the Cass Review. It reaffirms the Cass Review’s central findings that medical transitioning for minors is not supported by evidence. Instead, psychotherapy (or talk therapy) is a superior approach to treating gender dysphoria. 

Much of what is reported in this HHS report has already been presented elsewhere, but there are a few new matters we haven’t considered yet. Two overarching themes of the report are the need for evidence and the need for ethics in this field. 

The Need for Evidence 

HHS stresses the need to rely on evidence-based medicine rather than intuition, personal experience, or hoped-for results in “pediatric gender medicine” (the report’s preferred term for medical transitioning for minors). Evidence-based medicine makes use of systematic reviews – academic exercises that analyze all the studies available on a certain topic. Ordinary academic studies have differing methodologies, settings, researchers, and findings, but systematic reviews analyze the evidence of many studies. 

The HHS report analyzed 17 systematic reviews on the effects of social transition, puberty blockers, cross-sex hormones, surgery, and psychotherapy for minors. While there are many individual studies on these interventions, and many suggest that medical transitioning can have benefits, the systematic reviews expose major flaws in methodology. The review found a distinct lack of randomized controlled trials, small sample sizes, small effects, inconsistent study findings, and publication bias. 

HHS concluded that, in all these areas, the quality of evidence surrounding the benefits of these interventions is very low.

HHS concluded that, in all these areas, the quality of evidence surrounding the benefits of these interventions is very low. (The assessment tool they used grades the certainty of evidence as high, moderate, low, or very low certainty. Very low certainty means that we have no idea what the true effects of medical transitioning are.)  

There is very low certainty that puberty blockers lessen gender dysphoria or improve mental health. There is also very low certainty that cross-sex hormones reduce gender dysphoria or improve mental health. Likewise, there is very low certainty that surgeries (predominantly mastectomies among minors) ease gender dysphoria or enhance mental health, particularly when it comes to suicidality and depression. Little quality research has been done on the effects of psychotherapy either, leading to little certainty about whether talk therapy will achieve desired results either. 

The same is generally true of the harms of all these interventions. Because of the bias in the medical community and academia in favour of medical transitioning, researchers have tended not to evaluate various harms associated with pediatric gender medicine. While all sorts of harms – from lower bone density to reduced IQ to cardiovascular disease – have been documented, there is low certainty that medical transitioning causes these outcomes. 

Psychotherapy (talk therapy), however, has virtually no known risks or harms. And so, while there are both uncertain harms and benefits of medical transitioning, there are only uncertain benefits for talk therapy. The lack of the risk of harm in psychotherapy is one of the reasons why the review recommends this treatment for gender dysphoria. 

Another point in favour of psychotherapy is that the highest quality clinical practice guidelines – what health care professionals depend upon in their day-to-day care of patients – recommend this over medical transition. The guidelines issued by Sweden and Finland are ranked the highest quality standards of over a dozen standards around the world. Both recommend psychotherapy over medical transitioning for minors. 

Many of the guidelines that recommend medical transitioning are deeply flawed. For example, the HHS report devotes a whole chapter to critiquing the World Professional Association on Transgender Health (WPATH) and their Standards of Care 8. These standards carry great weight in the United States, Canada, and many other countries. However, in developing the latest standards, WPATH suppressed systematic reviews of the evidence because they didn’t yield the desired results.  

Every member of the guideline development group arguably had a conflict of interest, making them biased in favour of medical transitioning. In order to participate in the guideline drafting process, researchers were required to submit their “planned results and conclusions” to WPATH before even beginning to write their manuscript. The group replaced mentions of patients’ “wishes” with “needs” to frame them as “medically necessary” solely to qualify for insurance funding. And the group removed minimum age recommendations not because of evidence, but because of a stakeholder’s ultimatum that their support for the standards was conditional on leaving age restrictions out.  

In developing the latest standards, WPATH suppressed systematic reviews of the evidence because they didn’t yield the desired results.  

The Need for Ethics 

As focused as the report is on ensuring that treatment for gender dysphoria is based on evidence, the report also stresses the need for ethical judgement in this area.  

Advocates for “gender-affirming care” seem to apply few ethical considerations to their work. Does a minor want to medically transition? If yes, according to the model of gender-affirming care, then they are morally entitled to puberty blockers, cross-sex hormones, or surgery.  

But there are many more ethical considerations that the HHS report touches upon: 

An ethical practitioner of medicine must consider all of these questions before even considering recommending a medical transition. If even one of these ethical tests is failed, a medical transition is ethically wrong. 

If even one of these ethical tests is failed, a medical transition is ethically wrong. 

Additional Points 

It has been well documented for decades that over 80% of cases of pre-pubescent gender dysphoria resolve naturally after puberty. These studies were based on cases of gender dysphoria (largely in pre-pubescent boys) before transgenderism became mainstream and before rapid-onset gender dysphoria was a recognized phenomenon. Because of the novelty of this new presentation of gender dysphoria in a new group (largely in mid- or post-pubescent girls), there was little data on whether this new form of gender dysphoria would persist or also go away naturally. The HHS report cites a German study of insurance claims and found that “over 70% of adolescent females aged 15-19 no longer had the diagnosis five years later” (70). 

So, not only does gender dysphoria in young children tend to go away naturally, so too does gender dysphoria in adolescents. This is another blow to the claim that medical transitioning is an appropriate response to gender dysphoria. 

Another important point made in the report is that, “because contemporary gender medicine countenances a multiplicity of ‘genders,’ [there is a] newer emphasis on embodiment goals [that] moves beyond the ‘sex change’ framework of previous decades” (231). In other words, clinicians aren’t always trying to turn a “full female” into a “full male” by giving her give puberty blockers, cross-sex hormones, and every possible surgery. Many people who identity as non-binary or queer or agender might want various combinations of these interventions to achieve their desired appearance.  The greater the variation in the treatments and surgeries demanded, the harder it will be to collect and evaluate high quality evidence on the outcomes of various interventions. 

Conclusion 

This HHS report supports the growing consensus around the world that medical transitioning for minors needs to stop. Canada’s two largest English-speaking peers – the United Kingdom and the United States – have come out against the practice. And two countries that routinely rank as the happiest, most developed, and most progressive countries in the world – Sweden and Finland – have also curtailed the practice. It is time for all of Canada to follow suit.