Gender-affirming care for transgender youth is considered to be lifesaving healthcare, and advocates across B.C. are working tirelessly to increase accessibility to the multi-faceted and evidence-based care.
Each morning, transgender youth around the world wake up feeling at war with their changing bodies.
Without access to affirming care and the support of an adult in their life, transgender and gender-diverse youth experience disproportionately higher rates of mental illness when compared to their peers.
Feelings of gender dysphoria and not fitting in with North American society’s strict definitions of male and female contribute to the increased risk of mental illness experienced by transgender people, said Dr. Devon Mitchell, a UBC emergency medicine resident physician who is pursuing additional training in 2SLGBTQIA+ healthcare.
Biological sex is not binary
Mitchell says that transgender and gender-diverse youth are born into a body that does not match their gender identity, or fit in with North America’s definition of gender.
“Gender is a social construct, not a biological reality.”
He explained that all people are born on a spectrum of sex and gender identity and people can be born with differences in chromosomes, hormones and sexual development caused by a variety of factors.
“Biology is not an absolute,” said Mitchell.
For example, people can be born with XY chromosomes but develop completely as a female, some people have XX chromosomes but produce extra testosterone causing physical developmental differences, while other people are intersex without a clear sex based on their genitalia, or are born with both male and female sex organs. Approximately two to five percent of the population is considered to be gender-diverse.
“Biological sex is very complicated and it is certainly not binary.”
Mitchell said that being transgender or gender-diverse is not a radical, new wave thing.
“They’re just normal, diverse, people.”
Steps towards safety: the need for affirming care
The goal of affirming care is to alleviate gender dysphoria, which is the distress or discomfort an individual may experience due to a mismatch between their gender identity and their biological sex, said Meaghan Duckett, the founder of This Space Belongs to You, which is a mental health counselling resource in Kelowna. This Space provides a safe and supportive environment for queer and IBPOC youth with access to resources like affirming clothing and garments.
The distress and alienation that comes from not feeling at home in your own body leaves gender-diverse youth at increased risk of mental distress, including depression, anxiety and suicide when they are not provided with access to affirming care.
Tai August, 23, is a trans non-binary psychology student spoke about their experience growing up as a transgender person, and their work with Ecetera in Kelowna, where they provide youth with gender-affirming garments. August is intimately familiar with the darkness that can engulf a person’s life when denied affirming care, as well as the life changing impact that love and support can have on a gender-diverse young person.
“When I was young, gender-affirming care was pretty inaccessible.”
August grew up in a small town with little access to gender diverse education, affirming healthcare or garments, like breast binders. As a teen, they were told repeatedly that speaking about transgender people and gender-affirming care was not appropriate.
This sentiment was echoed through their community contributed to them feeling as though their body, and feelings of dysphoria were not appropriate.
For August, the gender dysphoria and distress that they experienced while developing breasts, and the society-driven gender divisions that coincided with puberty, manifested in self-harm.
“Maybe I would have found coping strategies other than hurting myself if I wasn’t treated differently because of my body.”
When they finally had the opportunity to access affirming care and use a binder, they felt it was “a very noticeable step towards safety for myself.”
For one of their closest friends, the gender dysphoria and lack of acceptance from their family resulted in months spent in the hospital after attempting suicide.
Something as simple as being able to wear clothes that feel comfortable and safe gives youth the opportunity to express themselves. For many transgender people, they live in fear of being mis-gendered or “outed” which can be dangerous, explained August.
Giving young people the resources to feel at home in their bodies and show up in the world in a way that feels safe and comfortable allows them the opportunity to focus on other parts of their life like education, hobbies and future careers, said August.
“I see a lot more confidence in the youth, I experienced it too… They’re not hiding themselves away.”
Robust clinical research and Mitchell’s personal experience as a healthcare provider shows that transgender adults who had access to evidence-based care as a youth have lower rates of mental illness and substance use disorders later in life when compared with people who were not able to access the care that they desired.
“From a mental health perspective, we see the impact for those who do not receive affirming care,” said Duckett.
“There remains higher suicidal ideation and attempts among those who do not receive gender-affirming care.”
Through her work at This Space Duckett has seen the positive impact that comes with affirming a youth’s identity, which includes lower rates of attempting suicide.
Carrie Broughton, the mother of a transgender child in the Okanagan, told Black Press Media she has seen firsthand the distress that going through puberty has on transgender youth, and the relief experienced with appropriate care.
“It is a high level of stress because their body is changing into something that they are not.”
Broughton explained that if a cis-gender man were to grow breasts, which can happen as a result of steroid use, obesity or genetics, they may be uncomfortable with the unwanted changes happening to their body and chose to have gender-affirming surgery to remove the breast tissue.
Dysphoria and the desire to access affirming care is not unique to transgender people, explained Mitchell. Treatment for erectile dysfunction and breast surgery help people to feel confident and at peace with their bodies within North American society’s definitions of male and female.
“Gender affirming care encompasses a range of social, psychological, behavioural and medical interventions that are designed to support and affirm a person’s gender identity,” said Duckett.
Gender-affirming care for youth - first steps
There are many paths and combinations of care that can be taken on a journey of affirming a person’s gender and not all of them involve medical intervention.
“I’ve seen people’s lives transformed by accessing affirming care,” said Mitchell.
Typically, people begin with a ‘social transition,’ which is when a person starts using preferred pronouns, changing their clothing and hairstyle and possibly using a new name.
Before reaching puberty, gender can be fluid and children may choose to experiment with different identities, which is perfectly normal.
Mitchell said that having the support of a trusted adult during this time is important for the child’s well-being, even if they are undergoing a temporary exploration into their gender identity.
The ability to access to diverse clothing and affirming garments can be an important step in a person’s journey of self-discovery, August said.
Some people may choose to only transition socially and will not pursue hormone treatments or surgery.
However, if a child displays consistent articulation that their gender identity is in-congruent with the sex they were assigned at birth and has maintained strong desire to transition over a period of time, medical interventions, like halting puberty, may be considered, said Mitchell.
Once a child begins puberty, they have the option of delaying its progression with medications called gonadotropin-releasing hormone agonists, also known as puberty or hormone blockers. The puberty-suppressing medication temporarily halts the body’s natural sexual development.
Broughton said that when her child was able to begin puberty blockers, which temporarily halts the physical changes associated with sexual development, like facial hair growth and breast enlargement, “it was as if a weight was lifted off their shoulders.”
Her child had been fighting the unwanted changes of puberty and dreaded each milestone of their sexual development. After pausing puberty, Broughton said that her child could focus on the day-to-day of being a kid, no longer consumed by the fear of turning into something that they were not.
Taking hormone blockers can give the child and their supporters time to pause and decide on a treatment plan and goals without fighting the biological clock of sexual development. The blockers can be stopped at any time.
Next, some people may chose to access hormone replacement therapy, which is taking hormones, like testosterone and estrogen, to simulate puberty and the changes associated with masculine and feminine sexual development.
Healthcare providers should also be having extensive conversations about all changes associated with sex hormone therapy since some aspects of the treatments, like breast development, a deepened voice and fertility, which may not be reversible, Mitchell said.
Surgical interventions are typically not considered until later in a youth’s gender-affirming journey. Each case is unique and a team of physicians and experts, along with the youth and their caregivers work together to decide on the safest steps for to the young adult. In some provinces certain surgeries are only offered to people over the age of 18.
Mitchell said that while the rate of regret of gender-affirming care like surgery or hormone therapy is low, at approximately one to two percent over a person’s lifetime, the permanence and potential risks should be discussed extensively, just like with any medical procedure.
Doing nothing is not neutral
Starting gender-affirming hormone treatment in adolescence is linked to better mental health when compared to those who wait until adulthood.
“The timing of starting these treatments actually does matter,”said Mitchell.
“Not offering evidence-based treatments that we know improves outcomes is not neutral… doing nothing is not neutral.”
During puberty, bodies undergo rapid and irreversible changes, like hair growth, vocal changes and breast development that could cause long-term dysphoria and distress if not prevented in transgender youth. In addition to the physical changes, when young people are forced to grow up in a body that does not feel safe, it has been shown to result in social isolation, self-harm and mental illness, that can have lasting impacts on a person’s well-being.
As a teen, August nearly lost their closest friend after they were denied affirming care.
August still remembers them saying, “if I can’t access this care, I don’t want to be alive.”
In cases where a youth’s guardians do not approve of their child’s desire to transition, the Infants Act can be used, which allows young people who are “mature minors” and have the capacity to make decisions the opportunity to consent to medical treatment on their own.
Employing the Infants Act is a not a decision that is taken lightly, Mitchell said, but can sometimes be necessary.
“Every effort is taken to include parents at every stage.”
Broughton, the founder of Trans Parent Okanagan, now works as advocate for youth and their families and is comfortable speaking candidly having a child access affirming care. However, she said that she was not always fully on board with the idea of her child transitioning.
“It’s OK and normal to have complex feelings.”
After accessing additional information and education on affirming care, Broughton was able to fully support her child. She now works to support other young people and their families and helps them access the resources they require.
All journeys are unique
People may choose to de-transition for a variety of reasons, but large clinical studies and Mitchell’s experience shows that external pressures are the number one reason that people chose to de-transition. He said that an inability to fit in and conform to gender-based societal norms and a lack of acceptance from loved ones is the primary driver behind the choice.
Additionally, some people are forced to de-transition due to legislation changes or an inability to access care, like hormones.
Broughton said that she cannot bear to imagine the horrible implications of forcing youth to stop their care.
“If our child was forced to de-transition, they would not be alive.”
In B.C., the Foundry offers free and confidential supports for diverse young people in need of physical and mental care.
Julie Zimmerman, provincial director of primary and virtual care at the Foundry said that when people experience marginalization and discrimination for not fitting in, “they experience a higher risk of mental health and physical challenges than the rest of the population.”
For her, gender-affirming care is simply healthcare that supports ones true self.
“It is not about changing people, it is about affirming a person’s identity.”
Zimmerman said that “anytime we endeavour to hold space and support youth, it is lifesaving… The opposite of it is not lifesaving.”
People looking for supports and additional resources are encouraged to contact the Foundry, Ecetera at the Bridge and the Okanagan Gender Identity Group.