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After Alberta Premier Danielle Smith announced a raft of proposals this week designed to restrict young people's access to gender-affirming health care - including puberty blockers, hormone therapy and surgery - medical providers in the field sharply criticized the measures, voicing concern they would harm vulnerable teens and adolescents.

The province's medical professionals rely on established standards of care and extensive guidelines set up by leading organizations, despite the Premier's characterization of the current landscape. These include guidance from the Canadian Paediatric Society and endocrine societies, and the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, a 258-page document viewed as a global gold standard by health care providers working with this population.

The Globe and Mail spoke with three experts about existing medical scrutiny on gender-affirming care in Alberta - and about what concerns them in the new restrictions.

At what age can young people obtain gender-affirming surgery in Alberta?

In her announcement on social media Wednesday, Ms. Smith said Alberta will not permit top and bottom gender-reassignment surgeries for people younger than 18 years old. Top surgery is the augmentation or removal of breast tissue; bottom surgery includes phalloplasty (the creation of a penis) and vaginoplasty (the creation of a vagina).

In reality, no bottom surgeries are performed on minors anywhere in Canada.

Funding requirements from Alberta Health already state that patients must be over the age of 18 to secure coverage for "final stage gender reassignment surgeries," including vaginoplasty and phalloplasty.

As for top surgery, a statement e-mailed from the Alberta Ministry of Health stated that the required age for masculinization of the torso surgery (mastectomy) is 16 years. Alberta has said that will change to 18.

Medical care providers argue it's a moot point: Very few of their younger patients seek out gender-affirming top surgery, for which no specific billing code exists in Alberta. "Top surgery for youth under 18 is already not funded by the province," said Simone Lebeuf, an adolescent medicine specialist in Edmonton.

What about access to puberty blockers?

The province said it will not permit anyone under 16 to access puberty blockers or hormone treatment for the purpose of gender affirmation, except for young people who've already begun these processes.

With hormone treatment, Dr. Lebeuf said practitioners already typically wait until a patient is 16; this is also the established guidance from endocrine societies.

But experts disagree with the government's move to delay puberty blockers - drugs that pause puberty - until age 16.

"We use puberty blockers to give people some time to think about their decision, to reinforce their ideas if that's what they want, or to change their mind," said Sam Wong, medical director for the Canadian Paediatric Society and a pediatrician in Alberta.

Medical guidelines recommend waiting until after adolescents exhibit the first physical signs of puberty to start blockers. Waiting until 16 to begin such treatment would be too late for many teens.

"The average child starts puberty between 10 and 12, and it takes two to five years to complete puberty," Dr. Lebeuf said. "So with this current proposal, puberty blockers would essentially be useless for the majority of patients."

Delaying access to puberty blockers may also mean that patients turn to more involved surgical avenues once they've developed masculine or feminine characteristics, providers caution.

"It makes it much more difficult and much more invasive later on when these patients want to go for gender-affirming surgery," Dr. Wong said.

Are age cut-offs the most important guidepost?

Alberta's medical restrictions focus on age, but most health care providers offering gender-affirming care question whether the numbers are arbitrary. Care providers prioritize patients' informed consent and their capacity for decision-making, alongside parental involvement.

Health care in general doesn't hinge on hard age limits, practitioners argue.

"That's another reason these policies are not only discriminatory, they're untenable. It's just simply not how the system operates," Kristopher Wells, Canada Research Chair for the Public Understanding of Sexual and Gender Minority Youth, said from Edmonton.

Are parents left out of the discussion?

Medical guidelines emphasize the involvement of parents and other guardians throughout adolescents' gender-affirming care.

"Parent and family support of transgender youth is a primary predictor of youth well-being and is protective of the mental health of transgender youth," read the latest standards of care from the World Professional Association for Transgender Health.

Instances where family members aren't involved are uncommon in Alberta, according to Dr. Lebeuf: "In rare cases where we don't involve parents, it's typically in the case of abuse; of parents who are no longer together and one parent is not involved at all in their child's life."

Is surgery the end goal for trans and non-binary teens?

Speaking to reporters Thursday, Ms. Smith portrayed transition as a singular, risk-loaded continuum, from youth altering how they dress, to changing their pronouns, to taking puberty blockers and hormones, to ultimately undergoing top and bottom surgery.

"We understand that beginning the process of transition is just one step, and there are other steps along the way that have serious consequences for kids," the Premier said.

This is a misrepresentation of transition, Dr. Wells said.

"It's a misnomer that every trans person requires or wants surgery. That's actually a minority of cases - and increasingly less as we have a greater understanding in society of sexual and gender diversity."....
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