Medical sex reassignment for minors: Is Quebec moving too quickly?

Stunned parents

“We like talking about the Scandinavian model in Quebec. Well, the Scandinavian model, perhaps we should also be interested in it in terms of gender transitions. »

— A quote from Antoine*, father of Amélie*

Antoine* saw his daughter Amélie*, a creative and cheeky child, turn into a suicidal teenager after early puberty. At thirteen, she had the body of a grown woman, but she was still a child in her head, he remembers. Her figure made her uncomfortable, you could clearly hear that. Especially his chest.

Amélie begins to control the amount of food she eats. Over time, she lost weight and it became more apparent that she actually had an eating disorder, her father recalled.

His vital functions are compromised and his parents have no choice but to hospitalize him. She will spend two months in the eating disorders unit at Sainte-Justine Hospital. When my daughter goes to the hospital, she has nothing to do with gender dysphoria. Nutrition is particularly problematic, emphasizes Antoine.

Sainte-Justine Hospital.Sainte-Justine Hospital (archive photo) Photo: Radio-Canada

However, he was offered puberty blockers a few times, including once in the emergency room the day after his arrival. Parents attended the meetings and confirmed that Amélie's gender dysphoria had not been formally assessed. Besides, his puberty has long since passed.

But her daughter is 15, so she has the right to take the medication without her consent. Her father is adamant that she is too sick to make this decision and tells the doctors so. My daughter has difficulty eating. I have to encourage him to shower because it causes him distress. […] There is extreme anxiety and depression. For me, she was completely incapable of agreeing to an operation at the time, that was clear, he explains to us.

Hormone blockers slow hormone production during puberty and give the adolescent time to think about their gender. One of the most commonly prescribed medications is Lupron Dépôt, whose long-term effects are still poorly understood. Sainte-Justine Gender Diversity Clinic co-founder Nicolas Chadi recognized this at a conference on February 23rd. Currently the studies are not rigorous, there are only very small samples […] And it remains something that is under-researched, he says, mentioning in particular the effects of blockers on brain development and intellectual abilities.

Prescriptions of blockers to adolescent girls have increased sixfold since 2010, according to RAMQ data.

Amélie ultimately won't receive a Lupron shot, but after several suicide attempts and the emergence of features of borderline personality disorder (BPD), she announces to her parents what she really wants: to have her breasts removed. .

My daughter admitted to me that she had read online that in order to have a mastectomy she would have to be trans and define herself as trans, her father recalls. So she started doing everything she could to get the surgery she wanted.

A few months later, Amélie gets an appointment at the gender clinic at Sainte-Justine Hospital to discuss a mastectomy. Antoine takes part accompanied by his ex-wife. Given the lack of a diagnosis of dysphoria and his other mental health issues, his parents expect their child to be redirected elsewhere. That didn't happen.

The doctors before us knew absolutely nothing about my daughter's history. The pediatrician was not aware that my daughter had been in the hospital several times [à Sainte-Justine]. At that time there was a suicide attempt, eating disorders, and the person in front of me is not aware of it.

The parents are stunned.

The doctor still takes the time to explain to the family that no decision will be made that day and that the decision will ultimately be left to the surgical team.

That was really the trigger, remembers Antoine. When I got home I started crying. I was confident that it was done and that we were on our way to my daughter's surgery. At four in the morning I made myself comfortable and began writing a letter to the hospital.

He sends it to the Ste-Justine Complaints Commissioner.

Antoine*, Amélie's father.Antoine*, Amélie*'s father. Photo: Radio-Canada

I was shocked at the rush to initiate medical treatment without truly verifying the presence of gender dysphoria or knowing my daughter's history. […] The principle of caution and protection of the child should prevail […] I know Amélie's suffering is real, but I deeply disagree […] with the proposed treatment. She doesn't have the maturity to make such a decision.

Sainte-Justine's answer came four months later. The contents pleasantly surprise Antoine.

In addition to acknowledging that there is room for improvement in its practices, the hospital claims to have already taken steps to correct the situation.

Your comments, as well as several other interventions from patients and their families, have raised questions among all members of the clinic, assure Josée Brady, complaint officer, and Dr. Marie-Josée Clermont, forensic pathologist. Your daughter's journey took her through a changing clinic. Since then, numerous improvements have taken place and profound changes have been made to the arrangements for the reception of young people and their families. Stakeholders are better equipped, assessment practices and detection […] It is argued that the signs of mental health problems have become much clearer.

“I was obviously expecting a somewhat laconic answer,” Antoine admits. But on the contrary, I felt that internal evaluation work was actually being done; even introspection.

Her daughter's case is now closed. Amélie just turned 18. She stopped demanding a mastectomy and identifying as transgender. Anorexia is no longer a problem, but her mental health issues continue to be treated.

“I am convinced that there are people who suffer and for whom gender reassignment is the solution,” believes Antoine. But I feel like we're skipping steps.

Clara, in the whirlwind of transition

“I think respecting children's rights means respecting that they don't necessarily have the maturity to make decisions that impact their entire lives. »

— A quote from Clara

Clara, 24, in front of her mirror.Clara, 24, in front of her mirror. Photo: Radio-Canada

These are not their real first names, but François, Suzie and their only daughter Clara agreed to testify openly despite their fears. “I was afraid of being judged or that the world would think I brought this on myself,” explains the 24-year-old student.

10 years ago, Clara was a teenager with fragile mental health who spent her time on Tumblr. Her curiosity leads her to several blogs by young people for whom gender is primarily a feeling, a feeling. Her words challenge him. I didn't feel like I was specifically a woman because the portrayals of women I saw felt like it was a standard I would never reach.

She believes she has found the label that best describes her: agender. Today we would probably say non-binary.

I said: That's it, she's agender! remembers his mother Suzie. So I'll accompany him on that.

Suzie finds a psychologist who specializes in gender identity, one of the few at the time. I want to help my daughter navigate herself and decide what is mental health and what is identity.

But that's exactly what doesn't happen in the psychologist's office.

From the first meeting, it was important to immediately pretend that she was a boy. […] To take steps with the school to start hormone therapy as soon as possible because the suicide rate was very, very, very high in the first year, she assured. As for me, I definitely want to save my daughter, I want to keep her alive.

After some consultations, Clara announces to her mother that she is no longer agender, but a trans boy. She told me, “I'd rather be a effeminate boy than a butch woman,” Suzie recalls with emotion.

François, in turn, doubts the psychologist's diagnosis of gender dysphoria, partly because his daughter has significant psychological problems. A psychiatrist had already diagnosed them with symptoms of borderline personality disorder (BPD), also known as borderline. He calls the psychologist. Her answer surprises him.

I asked: Why shouldn't it be borderline personality disorder? I wanted to see his reaction and I still remember the reaction clearly. She told me that there was no such thing as BPD and borderline personality disorder. BPD-Borderline Personality Disorders are transgender people.

A confirmation that the psychologist will repeat to the mother at another consultation.

A paper published in 2019 by the American Psychiatric Association said: Every LGBTQ person would need further observations over time before a diagnosis such as borderline personality disorder could be made.

Françoise Susset, considered an expert on gender issues, remembers this in the training she offers to her sisters and brothers from the Order of Psychologists of Quebec.

We're going to talk about borderline personality disorder. For what? Because it is the diagnosis most often confused with gender dysphoria. And it's a diagnosis that's really over-applied to trans and non-binary people.

Therefore, at the age of 15, Clara began injecting puberty blockers and then testosterone. She chooses the minimum dose because, like other trans men, she is afraid of losing her hair.

In 2013, ten girls ages 14 to 17 received testosterone prescriptions. In 2023 there were 97.

Testosterone satisfied Clara's need for physical transformation, but probably not her psychological need. My psychologist […] constantly said that everything would get better. […] But I didn't like what I saw any more than before. In fact, my condition worsened.

“I didn’t see any benefit to his health,” his father added. It was just painful. We always think in the back of our minds that… she might commit suicide.

François and Suzie, Clara's parents.François and Suzie, Clara's parents, meet with Enquête. Photo: Radio-Canada

Clara is dying in October 2015. She is hospitalized in Rivière-des-Prairies. The team stops the testosterone injections and questions the psychologist's diagnosis. His desire to change gender is an ineffective solution to his fears… his medical records say. Therapy is recommended for Clara.

But when she leaves the hospital, she starts the injections again and returns to see her psychologist. Suzie learns from her daughter that most of the sessions focus on Clara's rights as a trans person. The next session will be the last: I said: That's enough! I'm not paying you to advise her on legal matters or tell her how to campaign. I wanted her to see you so you could help her. Apparently she wasn't helping him.

Clara is still moving forward and continuing her transition. In December 2017, she underwent a double mastectomy at the GRS Clinic in Montreal. She was 17 years old at the time and had been taking testosterone for two and a half years. I told myself that maybe it couldn't be undone. I had no chance of becoming a woman again, so I thought I had no choice.

His mother accompanies him to the operation. “The next day or two I saw that she had made a mistake,” says Suzie. I felt it in his energy.

A few months later, she noticed that Clara was no longer getting her testosterone from the pharmacy and at one point she started crying. I said: Can you tell me what's going on? She wasn't capable, she cried too much. I said: Could it be that you want to end the transition? She said yes.

Then the long path back to the feminine begins. Clara gets a wig, clothes and eventually breast implants. The rest came… with time. It happened naturally through spending time with other girls. I had to redesign my socialization. But it is certain that I was behind and had not passed through the important stages of a woman's adolescence.

Clara, 24, in the family living room.Clara, 24, in the family living room. Photo: Radio-Canada

And his parents are still there.

“You find another girl because the girl you had is lost,” concludes François. “I had a boy that I loved just as much, and then I found another girl that I loved just as much.”

“Clara mourns the loss of the girl she could have been, the woman she could have been without having hormones,” Suzie adds.

Children's transition should not be taken lightly.