The current gender-affirming care model in BC is unvalidated and outdated

As a psychiatrist, I have seen an explosion of gender-dysphoric youth and young adults in recent years. These vulnerable groups deserve compassionate, evidence-based care. I am concerned that the recent BCMJ content on gender dysphoria presents gender-affirming care as evidence-based[1] and as the only appropriate model of care. This premise forms the basis for the three articles that follow on the medicalized treatment of gender dysphoria.

The World Professional Association for Transgender Health (WPATH) Standards of Care Version 7 (SOC7) are not evidence-based. The WPATH website clearly states that SOC8 is the first version being developed using an evidence-based approach. In addition, a systematic review of its clinical practice guidelines states that SOC7 “contains no list of key recommendations or auditable quality standards.”[2] Furthermore, “many recommendations are flexible, disconnected from evidence and could not be used by individuals or services to benchmark practice.”[2]

Finland, Sweden, Norway, and the UK are re-evaluating care of gender-dysphoric youth due to concerns about medical harm and the uncertainty of benefit.[3]

I find it disconcerting that the validity of SOC7 and the gender-affirming model are wholeheartedly accepted and promoted by these articles. There is no balanced discourse of reported negative outcomes or alternative approaches.

Further, some high-profile members of WPATH have gone on record stating their concerns. Dr Marci Bowers, a trans woman surgeon, publicly disclosed her concerns about puberty blockers, particularly the age at which they are started.[4] Psychologists Drs Laura Edwards-Leeper and Erica Anderson (a trans woman), have raised questions about the significant rise of gender-dysphoric youth, particularly adolescent girls. They have advocated for thorough psychological assessment and questioned the potential harm of not providing exploratory therapy.[5]

While WPATH SOC8 may provide an opportunity for evidence-based guidelines, a review of the draft raises concerns. For example, the section on “eunuchs,” presented as a unique gender identity, was bewildering. I question the evidence for this category, and particularly the recommendation to “affirm” and refer for surgical castration lest they attempt self-castration.

For those hesitant to agree, I urge you to watch the Swedish Trans Train documentaries (part 1: Canadian physicians should not ignore the potential risks of the affirmation model when there is international evidence of harm to vulnerable youth. Distressed youth deserve diligent, nuanced care favoring psychological assessment and care over medical harm. Concerningly, Bill C-4 (banning conversion therapy) was recently passed by the Senate. Without a clear definition of what constitutes exploratory therapy versus conversion therapy, therapists risk being charged under this bill and may be dissuaded from treating people with gender dysphoria at all.

We are in a unique position to rethink the treatment model for gender dysphoria. I hope we can begin a dialogue, so that our youth can get the treatment they need and deserve. Gender affirmation is not a one-size-fits-all model. To allow ideology to prevail over sound medicine is negligent at best.
—Joanne Sinai, MD, MEd, FRCPC

This letter was submitted in response to “Guest editorial: Gender-affirming care in British Columbia, Part 1,” “Gender-affirming primary care,” “Endocrine treatment of transgender and gender-diverse people,” and “Gender-affirming surgical care in British Columbia.”


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1.    Knudson G. Gender-affirming care in British Columbia, Part 1. BCMJ 2022;64:18-19.

2.    Dahlen S, Connolly D, Arif I, et al. International clinical practice guidelines for gender minority/trans people: Systematic review and quality assessment. BMJ Open 2021;11:e048943.

3.    Society for Evidence-Based Gender Medicine. The signal—and the noise—in the field of gender medicine. 31 January 2022. Accessed 17 February 2022.

4.    Shrier A. Top trans doctors blow the whistle on “sloppy” care. Common Sense. 4 October 2021. Accessed 17 February 2022.

5.    Edwards-Leeper L, Anderson E. The mental health establishment is failing trans kids: Gender-exploratory therapy is a key step. Why aren’t therapists providing it? Washington Post. 24 November 2021. Accessed 17 February 2022.

Joanne Sinai, MD, MEd, FRCPC. The current gender-affirming care model in BC is unvalidated and outdated. BCMJ, Vol. 64, No. 3, April, 2022, Page(s) 106 - Letters.

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L. Regenstreif says: reply

Much rratitude to Dr. Sinai for her thoughtful and more scholarly approach to this topic than we are seeing these days. Gender-affirming care for young patients has indeed become a "standard" without adequate evidence, particularly given the precipitous rise in a new cohort of children and youth with unclear neuro-developmental and psychiatric presentations and a history of intense social media influences. The reversal of the sex-ratio and the emergence of a large cohort of young girls and women have all been well-documented internationally and should give us much more pause in our approach to young patients than we are seeing across Canada. Bravo to the BCMJ for opening up this topic for a more balanced dialogue. The safety and well-being of an entire generation will rest on the clinical directions taken.

Dr. Karen Palmer says: reply

Thank you for prompting this important dialogue. I agree that our youth deserve access to evidence based care that is flexible and responsive to their individual needs.

Laura Calhoun M... says: reply

Many aspects of this current social media driven frenzy of young people believing they are the wrong gender disturb me. Two in particular. We seem to have forgotten that identity formation needs years of trying different lenses, paradigms and mental models before settling into one’s skin. And the young age at which so many youth are being stripped of their ability to decide, or re-decide if they want to parent is tragic.
As an emergency psychiatrist I am seeing people who now regret the decision they made before their brain was fully developed. And they are stuck.
Young people deserve evidence based care. Kudos to Dr Sinai and others like her who want to ground this aspect of medicine in actual science.

Aaron Kimberly, RN says: reply

Thank-you for raising these important concerns. I'm a 48 year old transsexual FTM and a mental health nurse who has worked with youth. I'm very concerned about the current model of care for a number of reasons, many of which you've touched on. (1) the demographics have shifted to mostly girls, after decades of predictable cohorts of mostly boys and men, (2) the sudden spike in numbers starting around 2015, (3) the lack of high quality evidence for this model, (4) ignoring high quality evidence that does exist, including 11 studies showing that 60-90% of kids with GD desist by late adolescence in the watchful waiting model, (5) the lack of specialized training, oversight, and standards, (6) newer clinicians aren't being informed of what evidence exists for GD and the different developmental pathways to it. We're not all the same and we have different needs. There are treatment implications for each type of GD, and patients have the right to understand themselves.

When I first set out to transition 15 years ago, I wasn't harmed in any way by the assessment process. However, I also wasn't aware of how GD relates to sexual orientation. I wasn't aware of how common it is for gay kids to experience GD and gender non-conformity. When I learned this, it rang true to my experience and greatly reduced my GD. I'm not sure I would have needed to transition if I had that information up front. How many kids think they're "trans" when they're really just gay kids? How many just need correct information and support? I think activism has pushed clinical practices too far ahead of the evidence, and is confusing kids. I'm not opposed to medicalization when appropriate. I just don't think this model and the politics driving it, are safe for our often vulnerable patients.

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