Gender affirming care (GAC), the suite of medical and surgical interventions used to facilitate a gender transition, was once considered the unquestioned standard of care for adolescents with gender incongruence. The provision of GAC to gender-distressed and/or trans-identifying adolescents had been endorsed by all Canadian major medical societies whose physicians are engaged in this care, and it was often portrayed as unequivocally life-improving, if not life-saving, with minimal risk of regret.

As a result, GAC was often provided on an as-requested basis in this population, so long as the adolescent, or their caregivers, expressed a desire for it and could provide informed consent about its purported effects, benefits, and harms. The move away from detailed and lengthy assessments also allowed young people to access these interventions more rapidly, ostensibly reducing the acute suffering associated with their dysphoria while preventing the progression of undesired and irreversible bodily changes brought on by natural puberty.

However, as the evidence behind GAC has been subjected to increased scrutiny over the last decade, and as more systematic approaches have been used to evaluate the evidence base, we have learned that assertions about its benefits have likely been overstated. Scientific reviews have revealed that we cannot say with confidence that the benefits of GAC consistently outweigh the risks, and have also noted the lack of tools to help clinicians determine which young people with gender incongruence may be most likely to benefit from GAC and who may be at higher risk of harm.

In response, many countries around the world have begun to curtail access to GAC, especially for minors, either through legislative or regulatory action; while some have sought to tighten the requirements to access GAC, other jurisdictions, particularly the UK and about 60% of US states, have essentially banned these interventions outright. Meanwhile, public opinion has been souring on GAC for adolescents and young people, at least partially as a result of a coordinated political campaign that has spent considerable resources seeking to delegitimize the practice in the public eye.

Until recently, Canada appeared relatively immune to these restrictions on the provision of GAC; Canada has a well-earned reputation for progressivism; its institutions are relatively depoliticized, and strong human rights protections, enforced by a liberal-leaning judiciary, have largely prevented political actors from imposing restrictions on care. This was the case until November 2025, when Danielle Smith, Alberta’s Conservative premier, invoked the notwithstanding clause to force through the first Canadian legislation explicitly prohibiting the prescription of puberty blockers or cross-sex hormones to anyone under sixteen to facilitate a gender transition.

Shortly thereafter, I wrote a widely circulated op-ed in Healthy Debate in which I provided a blunt warning to clinicians who provide, and continue to believe in, the project of GAC: do not assume this ban was merely a politically motivated aberration confined to Canada’s most socially conservative province, and that clinicians in the rest of Canada need not worry about government intrusion into their care. Rather, I suggested that what happened in Alberta may be a harbinger of what is to come elsewhere in Canada, even in jurisdictions with more liberal political cultures. I specifically called on adolescent GAC providers to communicate more directly to the public that they acknowledge the legitimacy of the concerns around GAC, and to be more transparent in demonstrating publicly and concretely how they are governing their own practices to minimize risks and mitigate potential harms. I also cautioned against adherence to the status quo of public reticence and reliance on the informed consent model, stating:

“If clinicians do not visibly set and enforce their own boundaries and demonstrate transparently that they can identify the young patients most likely to benefit from GAC, governments will increasingly feel empowered to do it for them, with the costs mostly being borne by those young people.”

Prior to my writing, several Canadian gender care specialists had privately shared my concerns and trepidations about how GAC was being administered in Canada; a handful more reached out in agreement in the days after publication. Yet publicly, physicians and care providers kept these concerns to themselves, reluctant to attract negative attention from trans advocates who strongly oppose any barriers to patient autonomy around accessing GAC, but equally unwilling to add fuel to an already volatile political debate. Also, many clinicians have an understandable fear of putting themselves in the crosshairs of a debate where many engage in highly violent and dehumanizing rhetoric in defense of their positions.

That was until today, when Dr. Karine Khatchadourian, a pediatrician specializing in adolescent GAC who until recently served as co-lead of the pediatric gender clinic at the Children’s Hospital of Eastern Ontario in Ottawa, came forward to speak with health reporter Sharon Kirkey in the National Post about her concerns with the current model of practice for GAC in adolescents. (Disclosure: I was also interviewed by Ms. Kirkey for this article, and was aware in advance of Dr. Khatchadourian’s decision to speak publicly.)

In this article, Khatchadourian shares her concerns as someone who had a direct line of sight to the management of more than 250 young people with gender incongruence over ten years. Over that time, she observed an increasing proportion of natally female patients, often with high levels of pre-existing mental health comorbidities and relatively short histories of consistently reported gender incongruence. Like other clinicians who have spoken publicly, she voices increasing doubt as to the extent to which the indiscriminate provision of GAC is benefiting these youth, especially in light of the irreversible nature of the hormonal and surgical interventions.

However, she is not someone looking to dismantle the ability to provide these interventions, stressing that she continues to “strongly believe in this care,” especially for those young people with more stable, long-term identification with their preferred gender, the types of adolescents more typical of those included in the original studies that demonstrated benefit. She further recommends adopting physician-led initiatives implemented in Sweden and Finland, two other socially progressive countries with strong protections for trans people that have nevertheless implemented a more restrictive model of care. In those countries, the management of gender-distressed youth focuses first on concomitant mental health issues and exploratory therapy, helping the young person better understand their motivations for seeking transition and how they intend to manage its consequences. GAC is then offered to those with a long-term, stable cross-gender identity who have the familial and community support, and the internal resilience required to manage the tribulations of a gender transition; or when it is deemed to be in the young person’s best interests following this extended assessment process.

While long-term data on the outcomes of a more deliberate, assessment-based approach to GAC are lacking, there is evidence from multiple studies suggesting that young people with good familial support and stable mental health tend to manage their transitions well. We also know that the majority of regretful detransitioners, people who received GAC and who over time came to view their decision to transition as a mistake, are more likely to be natally female with a high burden of coexisting psychiatric conditions, and thus bear a strong resemblance to the types of gender-distressed adolescents who would be screened more carefully under a gatekept model.

As I stated in my original essay, it is critical that people who had a direct line of sight in this field, and who still believe that GAC can be saved, come forward and speak out, even when it comes with a personal cost. Khatchadourian has already faced consequences for her deviation from the culture of silence around GAC: she is no longer leading the CHEO gender clinic, stating that it was determined she “would be better suited to focus on other clinical and academic responsibilities,” language that implies her transition out of that role was not entirely voluntary. It is likely that she will continue to face pressure and criticism from both advocates and opponents of adolescent GAC as this story captures the attention of the Canadian public and the various stakeholders in this contentious debate. I also fear that continued public rejection or abandonment by her clinical colleagues may eventually serve to push her into the arms of those groups who seek to ban care outright.

Although I have not yet spoken with her directly, but I broadly support her desire to reorient the goals of care away from how many transitions can be enacted or prevented, and toward understanding and individualizing the approaches that provide the best path to relief of gender dysphoria. I would be glad to lend my moral and material support to any initiative that takes a non-judgmental and treatment-agnostic approach to improving the lives of children with gender dysphoria. The Canadian data environment and its research community are especially well suited to address many of the key gaps in our knowledge, but they must be free to do so without undue influence from ideologues on either side of this debate.

More clinicians who share Khatchadourian’s concerns but who still believe in the promise of GAC must be willing to stand beside her publicly. Dr. Khatchadourian has taken the first difficult step that I believed, and still believe, is necessary to save access to GAC in Canada. Hopefully she won’t be alone for long.