2. Transgender patients
3. Clinical Skills
4. Abortions in Canada
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Although women's life expectancy exceeded that of men throughout the 20th century, the life expectancy gap narrowed from 7.1 years in 1981 to 4.3 years in 2011. Life expectancy at birth for Canadian girls was 83.6 years, compared to 79.3 for boys in 2011. The This change stems largely from changing patterns of mortality due to smoking-related respiratory cancers among women, a decline in cardiovascular deaths among men, and changing patterns of health behaviour.
Use of Health Care
Perhaps in part because women live longer than men, a higher percentage of women have chronic illnesses, and women use health care services more often. A 2007 Health Reports study found that women aged 18-64 were more likely to have visited a general practitioner, to have made multiple visits, and seen a specialist. These findings held even when adjusting for chronic conditions and self-perceived health; they also held when women who were pregnant or who had given birth in the previous year were excluded.
Risk and Protective Factors
There are gender differences in health behaviours:
- Women are more likely to use vitamins regularly, and to be an appropriate weight for their height.
- Men, on the other hand, are more likely to engage in vigorous physical activity in their leisure time.
- Men tend to drink and smoke more and are more likely than women to be overweight.
- Women are more likely than men to think of health when they select foods.
- Women report higher levels of stress at home and in the workplace, associated with the onset of chronic disease.
- Women's apparent resilience may relate to their greater tendency to build social support networks, which, in turn, help them cope with stress and deal with painful chronic conditions.
Such differences make it important to understand the role of gender in health, including the different perspectives of men and women toward their health. These differences go beyond the biological fact of being a woman or a man; many of the differences derive from social attitudes and roles.
A Note: Many of the terms for sexual identity below were historically created and imposed on people by doctors and researchers. While many LGBTQ+ individuals have reclaimed the terms, the language may still carry a traumatic legacy. As such, some patients or colleagues use alternate terms (for example, a patient may prefer “lesbian” or “queer” over homosexual). Let your patients and colleagues self-identify and follow their lead with their sexual identification.
Gender identity: one's deep-seated sense of being a man, a woman or a non-binary person (between male and female, fluid or outside the binary). Gender identity usually matches the person's sex assigned at birth (hence cisgender), but does not always match.
• See “Gender as an Identity” for more information.
Sexual orientation/sexual identity: refer to the category (or categories) of people to whom a person feels enduring physical and/or romantic attraction. Globally, three main components of sexual orientation are: desire, identity, and behaviour.
- For example, in some South American countries, you’re not considered gay unless you have been penetrated by a man (and the penetrating partner need not be gay)
- For others, it may be related to social roles (i.e. if you have a wife, kids, nice job and have sex on the side with a person of the same gender, you’re not gay)
- In Western culture, sexual orientation primarily focuses on desire and identity.
Heterosexual (Straight): Sexual preference for a partner of the opposite binary gender; i.e. men attracted to women or women attracted to men.
Homosexual: Attraction towards partners of the same gender.
Lesbian: Sexual identity for women attracted to women. Note that “women” here includes transgender women.
Gay: Sexual identity for men attracted to men. “Men” here includes all men, cisgender and transgender. Gay is also used as an alternate to homosexual, i.e. for anyone attracted to the same gender. For example, a female patient attracted only to other women may use the words “gay” or “lesbian” interchangeably.
There are times when gay is used to refer to all sexual minorities or even the whole LGBTQ+ community. If you are unsure what a patient or colleague means when they use "gay", it is okay to ask “What does that mean to you?”
Homophobia: refers to a range of antagonistic attitudes held against gay and lesbian people or those perceived to be gay or lesbian.
Bisexual: Historically, a term used to describe attraction to two sexes (male and female). Over the last decades, this has changed. Bisexuality is more often defined now as anyone attracted to men and women, and/or anyone attracted to two or more genders.
Biphobia refers to antagonistic attitudes specifically against bisexual individuals.
Queer: Non-categorized attraction that is neither heterosexual nor straight. May be used as a token of resistance to sexual labeling, or from personal preference, or because the person's gender identity conflicts with the use of a gender binary (for example, a non-binary person attracted only to women may choose to call themselves queer instead of heterosexual or lesbian).
Some people, especially younger ones, may also use queer as an alternative to LGBTQ+ (“the queer community”) and/or to emphasize a non-cisgender, non-heterosexual, non-heteronormative lifestyle. However, this is not universal and as some people may find it offensive, it is again best to wait until patients self-identify or use the word themselves.
Pansexual: Attraction to all genders (men, women, non-binary individuals, etc.) or attraction regardless of gender.
Asexual: Lack of sexual attraction to any gender. May or may not have a sexual libido. May or may not be interested in a committed relationship with a partner.
Heteronomativity and Heterosexism
Heteronormativity: The pervading social assumption that everyone is heterosexual. This is the basis of ‘coming out' - we assume everyone is straight / cisgender first, which is often misleading. This also leads to anxiety, stress and depression in sexual minorities.
A Discussion Point: A patient or colleague need not come out to you unless you incorrectly assumed that they were cisgender and straight to begin with. What role do your own assumptions play in making a safe place for a patient or colleague to discuss their gender or sexuality with you?
Heterosexism: The belief that heterosexuality is superior to, and/or more natural than, other sexual orientations and preferences. For example, most practice guidelines (e.g. for anal cancer management) assume individuals are only having PiV (penis in vagina) sex.
Sex work: Work/income earned from a spectrum of sexual activities and sexual labour.
Sex worker: Someone who does sex work. While a sex worker might use different terminology to refer to themselves, sex worker rights organizations have said it is best to stick to “sex worker” until told otherwise.
POWER (Prostitutes of Ottawa/Gatineau Work, Educate, Resist)
Gender roles: The particular economic, political and social roles and responsibilities that are considered appropriate for men and women in a culture.
Gender equality: The absence of discrimination on the basis of a person's gender in authority, opportunities, allocation of resources or benefits, and access to services.
Gender equity: The process of being fair to women and men. Sometimes this involves measures to redress historical disadvantages that have prevented men and women from having equal access to rights and privileges. Equity leads to equality. Gender equity also implies that health needs, which are specific to each gender, receive appropriate resources.
Gender awareness: understanding that there are socially determined differences between men and women, and that these influence access to and control of resources.
Gender sensitivity: the ability to perceive existing gender differences and issues, and to incorporate these into strategies and actions. Contrast with gender blindness – the failure to recognize that gender roles and constraints are imposed on people by their social context.
Gender analysis: identifies the inequalities that arise from the different roles of men and women, and analyzes the consequences of these inequalities for their lives, health and well-being.
The above terms consider the gender roles of men and women and the consequences of these roles; they do not distinguish whether the individuals are cisgender or transgender (and do not take into account other genders).
A gender perspective or gender analysis of a health problem asks, “How does gender affect this health issue?” or “How does this health issue affect men and women differently?” This quote comes from a 2007 WHO report on Gender Inequality in Health.
"Gender inequality damages the health of millions of girls and women across the globe. It can also be harmful to men's health despite the many tangible benefits it gives men through resources, power authority and control. These benefits to men do not come without a cost to their own emotional and psychological health, often translated into risky and unhealthy behaviours, and reduced longevity. Taking action to improve gender equity in health and to address women's rights to health is one of the most direct and potent ways to reduce health inequities overall and ensure effective use of health resources.
"Gender relations of power constitute the root causes of gender inequality and are among the most influential of the social determinants of health. They determine whether people's health needs are acknowledged, whether they have a voice or a modicum of control over their lives and health, whether they can realize their rights.
"Gender intersects with economic inequality, racial or ethnic hierarchy, caste domination, differences based on sexual orientation, and a number of other social markers. Only focusing on economic inequalities across households can seriously distort our understanding of how inequality actually works and who bears much of its burdens. Health gradients can be significantly different for men and for women; medical poverty may not trap women and men to the same extent or in the same way.
"This report has shown that gender relations of power exist within and outside the health sector, and exercise a pernicious influence on the health of people (. . .) in terms of differential exposures and vulnerabilities for women versus men, and also shows how health care systems and health research reproduce these inequalities and inequities instead of resolving them...”
Example: a Gendered Analysis of HIV
Plans for gender-appropriate HIV/AIDS programming might begin with an analysis of the inequalities between men and women that exist in the society, and how these inequalities interact with the spread and impact of HIV/AIDS.
In terms of etiology, women in a society with a high prevalence of HIV may have less education and lower access to information; they may have fewer rights, and less information about the rights that they do have. These will all affect a woman's ability to influence her partner to use condoms, and her ability to control her sex life. Because AIDS is a fatal disease, local inheritance rights become crucial when a husband dies, because they may offer the woman a source of economic independence to care for her family without reliance on a male partner. Or, if these rights are denied, she may become dependent on another male partner.
At a policy level, a gender analysis could show decision-makers how programs and policies may affect men and women differently. With this knowledge, programs that place demands on women (e.g., home care) or that ignore women’s vulnerability to infection, can be avoided. In their place, programs can be implemented that directly address the causes of women’s vulnerability and susceptibility to infection (e.g., programs to prevent violence against women). Programs could also be designed to take advantage of the different contributions that can be made by women and men in their roles in society in the fight against HIV and AIDS.
A Note on Language: The terms used by patients in referring to matters of sex or gender may differ from the language you find here or that you normally use. You may notice age differences in language, as well as geographic and educational differences. Clarify with patients the terms they prefer, and then use those. Patients may not identify with either male or female, so begin by asking the patient about how they prefer to be addressed.
Sex: The combination of chromosomes, external genitalia, internal gonadal organs and secondary sexual characteristics that make up the binary classifications of male and female.
Intersex: Persons born with ambiguous genitalia or other congenital lack of congruence between the typical anatomical, hormonal and chromosomal binary notions of male and female sex. Generally, intersex individuals prefer the term “intersex” over Variations in Sexual Development (VSD) or Disorders of Sexual Development.
• Aim to use words like "typical", "usual", or "most frequent" when discussing sexual development, rather than “normal”.
• Do not use the word “hermaphrodite” as it is inaccurate as well as stigmatizing (more information).
Gender: “…the characteristics, roles and responsibilities of women and men, boys and girls, which are socially constructed. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organized, not because of our biological differences.” (WHO)
Gender identity: One's deep-seated sense of being a man, a woman, or non-binary (between male and female, fluid or outside the binary). It usually matches the person's assigned sex, but does not always match.
Gender expression: The way a person acts, dresses, speaks and behaves in order to show their gender as feminine, masculine, both, or neither.
Gender Non-Conforming: People who express their gender differently than what is culturally expected of them regardless of their gender identity. Examples include a woman who dresses in a masculine style, a boy who likes to play with dolls, etc. A gender non-conforming person is not necessarily transgender.
Genderqueer: Used by some individuals who do not identify as male or female; or identify as both.
Cisgender: A match between the gender a person was assigned at birth and their current gender - i.e. when you were born your doctor said “It’s a boy!” and you still identify as a boy.
• Aim to use the word “cisgender” in discussions regarding gender instead of “normal”, to contrast “transgender” with “normal” is inaccurate and usually offensive
Transgender: Someone who does not identify with the gender or sex they were assigned at birth. Some people may also use transsexual. This is more likely among older patients but some younger patients may prefer it as well. If you are unsure what word to use, use transgender and then follow your patient’s lead.
The terms ‘transgender’ and ‘transsexual’ do not imply any difference in physical state or intentions to make a physical transition. Hormone or surgical therapy may or may not be used to align a person's sex or physical presentation with their gender identity. Not all transgender people want surgery or hormones and what medical therapies someone wants does not define “how trans” they are.
Transgender or trans is an adjective, not a noun or a verb. As such, one would not say that your patient is “a trans” or that the patient “was transgendered”.
Transgender (Trans) women: Women who were not assigned female gender at birth (i.e. usually assigned male at birth). Individuals may also use or self-identify the term male-to-female (MTF) transgender; best practice is to use “transgender women” unless your patient indicates they prefer otherwise.
Transgender (Trans) men: Men who were not assigned male gender at birth (i.e. usually assigned female at birth). Individuals may also use or self-identify the term female-to-male (FTM) transgender; best practice is to use “transgender man” unless your patient indicates they prefer otherwise.
Transition/Gender Affirmation Process: The process of coming to recognize, accept, and express one’s gender identity. Most often seen when a person makes social, legal, and/or medical changes, such as changing their clothing, name, sex designation and using medical interventions. Actions such as these help people affirm their gender identity by making outward changes.
Non-binary transgender people: People who do not identify with the gender they were assigned at birth and also do not identify solely as one of the binary genders of male or female. Non-binary people may have an androgynous (both masculine and feminine) gender identity, have an identity between male and female or have a neutral or non-existent gender identity.
Gender fluid: Refers to a gender identity that varies over time. A gender fluid person may at times identify as male, female, or another non-binary identity, or some combination of identities.
Two-spirit: A term that refers to sexual orientation and/ or gender identity within some Aboriginal cultures. The organization 2-Spirited People of the 1st Nations defines the term as follows: “Native people who are gay, lesbian, bisexual, transgender, other gendered, third/fourth gendered individuals that walk carefully between the worlds and between the genders”.
Preferred pronouns: The pronouns your patient prefers. Consider asking your patients “Which pronouns are you most comfortable with?” Individuals may respond with she/her, he/him, they/them (singular) or other pronoun choices.
Transphobia: Refers to a range of antagonistic attitudes held against transgender individuals or against people who do not conform to society's gender expectations.
Cissexism: Refers to the assumption that transgendered people are inferior and that to be cisgender is more natural than being trans; may also refer to the assumption that genitals = gender.
Gender dysphoria: As defined by the Diagnostic and Statistical Manual of Mental Disorders V, gender dysphoria is "a marked incongruence between one’s experienced / expressed gender and assigned gender associated with clinically significant distress or impairment in social, school, or other important areas of functioning. The incongruence may include a feeling of disconnect with one’s body, one's place in society or the terms people use to refer to you." This term is a revision of DSM-IV’s term 'gender identity disorder'.
One way to think of this is that while being transgender is not considered a medical condition, the diagnosable dysphoria that many transgender people feel can be treated by medical means (e.g. hormones, surgery). Choices regarding hormones, surgery and other methods of transition vary based on personal preference, funds and safety. The person may also address their dysphoria by making social changes – in clothing, changing in the way people address them, name changes. We may all work to foster a society that is more accepting and supportive of transgender people.
Due to stigma, discrimination, and marginalization, transgender patients are disproportionately burdened by an array of health issues. When caring for patients, it is important to keep these health and social issues in mind. Transgender people are at increased risk for:
- Mental health issues
- Physical abuse – in relationships and as a target of hate crimes in the community
- Social isolation
- Economic marginalization. Because of the stigma and discrimination faced by transgender people in the workplace, they are often unable to access work that is available to others or, if they already have employment, they are more likely to have pay docked or lose their job.
- Unique health care needs: hormones, gender-affirming surgery, mental health support.
Remember that many of these risks are the result of transphobia in the general public, in family settings, in relationships and in the medical community. Transgender people are often distrustful or scared of the medical system due to historical and ongoing abuse of transgender people by medical professionals (in the emergency room, in the family doctor’s room, etc). Do your part in reducing this distrust by creating a safe space for transgender patients wherever you are.
Intersex Society of North America
Canadian Centre for Gender and Sexual Diversity
CHEO Gender Diversity Clinic
A Canadian web site devoted to Gender and Health, with modules on CVD, depression, etc.
A 2009 WHO report "Women and Health”
Pan American Health Organization (PAHO) has a gender and health section
Due to stigma, discrimination, and marginalization, sexual minorities are disproportionately burdened by an array of health issues.
Clinicians must establish a safe place for their patients. A safe space is conveys humility and freedom from judgment; it is one that patients will wish to come back to. But beware: this is in the eye of the beholder – it is not for you to claim that your clinic is a safe space – that is for your patients to judge. You must be open to patient feedback and understand what the needs of the LGBTQ community are. You also need to become aware of your reaction when a trans person comes into the room; an attitude of color blindness will not work.
When caring for LGBT patients, keep in mind the following realities:
1. Mental Health - Negative mental health is associated with internalized homophobia / biphobia / heterosexism. Patients may internalize negative social norms towards themselves. They may also have mental health issues related to negative experiences they have endured because of their sexuality.
2. Sexual Health - (a) HIV burden is higher among sexual & gender minorities; 77% of new cases of HIV in Ottawa are in men who have sex with men (MSM). (b) Note that MSM is a epidemiological category and doesn’t describe sexuality – MSM can identify as gay, bisexual or other sexualities.
3. Health-Related Behaviours - Smoking, alcohol, drug use are higher among sexual minorities; lesbian women statistically have higher BMI.
Is Sexual Orientation Relevant to Health Care Provision?
Clinical interactions should not change. Sexual orientation should not be the focus of care, unless relevant (e.g. HIV seroconversion symptoms)
However, healthcare providers must challenge they own assumptions about sexuality and must address their own personal beliefs that promote heteronormativity and heterosexism. Healthcare providers must also be aware of group-specific health issues.
Canadian Centre for Gender and Sexual Diversity
Ottawa Sexual Health Centre or 613-234-4641
PFLAG Ottawa brings LGBTQ+ people and their families together in twice-monthly meetings
Gay Zone is a sexual health centre for gay men in Ottawa
Rainbow Health offers a range of educational documents
Rainbow Health Ontario
Is Gender Identity Relevant To Health Care Provision?
Clinical interactions should not change. Gender identity should not be the focus of care, unless relevant (e.g. patient discussing wish for hormones)
However, health care providers must challenge they own assumptions about gender and must address their own personal beliefs that promote cissexism and transphobia. Providers must also be aware of group-specific health issues.
Making Safe Spaces
Be confidential and make this explicit. Be aware of your own beliefs, attitudes and values. Allow your patient to have their own values and beliefs; avoid any sense of being judgmental. Be mindful of your language, tone and body language. Do not judge or moralize.
Make the person feel welcome. This can be done in a variety of ways. Consider putting a rainbow sticker in your office door, as well as trans-specific stickers, buttons or literature that indicates you are trans-friendly. Instead of “Male/Female” on your intake form, consider putting a blank option for Gender and consider having a place for individuals to out their “chosen name” in addition to a “legal name”.
Kind Space (previously Pink Triangle Services) or the Canadian Centre for Gender and Sexual Diversity can guide you to towards lesbian, gay, bisexual, and transgender persons (LGBTQ2) organizations near you.
In discussion, ask you patients their preferred pronouns and name. Use those pronouns and name for the patient (whenever safe), even when the patient is not present to hear. Do not disclose a person’s transgender status to anyone who does not explicitly need the information for care. If a patient’s genital status is unrelated to their care, it is not necessary to ask. Additionally, do not assume that your transgender patient consents to be a “training opportunity” for other health care providers.
“Many transgender people have had providers call in others to observe their bodies, often out of an impulse to train residents or interns. However, like in other situations where a patient has a rare or unusual finding, asking a patient’s permission is a necessary first step before inviting in a colleague or trainee. For transgender patients, in particular, it is often important to maintain control over who sees you unclothed. Therefore, when patients are observed without first asking their permission, it can quickly feel like an invasion of privacy and creates a barrier to respectful, competent health care”- Transgender Law Centre
All in all, be respectful to patients and stay educated so that you can provide appropriate care.
Some of this information was taken from the 10 Tips for Working with Transgender Patients by the Transgender Law Centre.
A simple place to start is to ask you patient “What do you need?” and begin there. Different transgender people will have different needs. Hormone or surgical therapy may be used to align a person's sex/physical presentation with their gender identity or may not. Choices regarding hormones, surgery and other methods of transition may vary based on personal preference, funds and safety. Do not assume that patient will or will not want to have certain medical procedures.
The term sex change is usually referring to medical therapy to change physical appearance and, in the context of trans people, usually refers to gender-affirming surgery (“sex reassignment surgery/SRS”). This often means genital surgery or chest surgery for breast augmentation or removal (“top surgery”). Hormones therapy also causes permanent body changes. It is best to use clear language with the patients and clarify what a term means for them.
- Supporting the health needs for transgender patients can be as simple as validation and affirmation of safety in the medical office. It is appropriate that both doctors and their staff are educated on how to support transgender patients’ safety (i.e. call preferred name in waiting room, refer by proper pronouns).
- MDs can also write supporting letters for patients looking to change their name & gender marker on their government ID. Note that as of 2016, there will be no gender markers on Ontario Health Cards and that the Ontario Driver’s License will have the gender options of M, F or X.
- If a patient asks for puberty blocking drugs, hormone blocking drugs or hormone supplements, it is the job of the MD to ensure that their patient is informed on the effects of the medication and that the appropriate criteria for each medication have been fulfilled before a prescription is given.
- A doctor may also support a patient who seeks gender-affirming surgery. While some patients may choose to pay for gender-affirming surgeries with personal funds, many others require provincial support (e.g. through OHIP). In many provinces, the Centre for Addiction and Mental Health in Toronto is the only clinic that can assess and refer individuals for transition-related surgery funding and hormone funding. In Ontario, Primary Health Care Physicians and Nurse Practitioners are now able to do so as well, if they have the training outlined in the most recent Word Professional Association for Transgender Health (WPAT) Standards of Care document (see below).
While these health care statements may seem vague, this is in part because there are provincial variations in the legal steps for many of these processes and also because the processes themselves are changing (such as with the referral process for gender-affirming surgery). It is recommended that you investigate the current standards of care in your region and that you periodically ensure that your current standards of care are appropriate.
The Word Professional Association for Transgender Health (WPAT) Standards of Care document, PDF) is an excellent resource.
Rainbow Health Care offers comprehensive CFPC Accredited training modules on general care and transition care for transgender patients. Rainbow Health also offers the Trans Health Connection phone services for practitioners with trans patients
Discussing matters of sexuality with patients can feel like walking through a minefield. Here are some general guidelines for communicating with patients about their sexuality.
SEX ASAP: An Approach to a Sexual History
It can sometimes be flustering or difficult the first time you walk through a patient’s sexual history. Here is one mnemonic, “SEXASAP” that can remind you on what to ask, in a comfortable order.
S: Situation → Do they have any current relationship(s) or sexual activity? You may want to get an idea of whether the relationship(s) is/are monogamous, the length of the relationship, and (especially for teenagers), the ages of the individuals involved.
In order to be inclusive of gay, lesbian, bisexual, pansexual and other sexual minority patients, it is better to not make assumptions in language during the initial part of the interview. Do not assume a man has a female partner and vice versa. Instead, chose questions like: “Do you engage in sexual behaviours with men, women, or both?' or, ‘Do you currently have a partner?’
Ex: Exes → Any previous partners? How were the relationships with the past partners and any issues at breakup?
A: Activities → What type of sexual activity are they doing? Vaginal, oral, anal, etc.
S: STIs → May want to inquire regarding previous history or symptoms of infection, treatment, last test for STIs and the history of STIs or testing.
A: Abuse → “Have you ever had an unpleasant sexual experience?”
P: Protection → Inquire after protection for unintended pregnancies as well as STIs. Watch for red flags like “My partner doesn’t like it” or “I don’t want to bother my partner about it”.
Communicating on Sexuality
Because of the unique role that sexual activity and identity have in our society and the stigma that may be associated with certain identities or activities, a patient may feel scared or hesitant to share elements of their sexual history.
Be confidential and make this explicit. Be aware of your own beliefs, attitudes and values. Allow your patient to have their own values and beliefs; avoid any sense of being judgmental. Be mindful of your language, tone and body language. Do not judge or moralize.
Make the person feel welcome. This can be done in a variety of ways. Use gender-neutral language: use "partner" or "spouse" until you learn the gender of that person. Do not assume that a person is monogamous or that they do not do sex work. Ask your patients about protection without assuming that they always use protection. Create a safe setting that encourages openness and dialogue. Consider putting a rainbow sticker in your office door or other pride flag stickers. Consider including some waiting-room literature that demonstrates inclusiveness: the usual fare of sports and women's magazines give the message that this place is for heterosexual or heteronormative people. Kind Space (previously Pink Triangle Services) or the Canadian Centre for Gender and Sexual Diversity can guide you to towards lesbian, gay, bisexual, and transgender persons (LGBT) organizations near you.
Click here to go to the “Caring for Sexual Minority Patients” page to learn more caring for LGBQ+ patients.
Half of adolescents (15-19) report having sex by the end of high school. The average age of first encounter is 16.5 years old. One-third of adolescents reported more than on partner in the last year.
School surveys suggest that many Canadian youth may have unprotected sexual intercourse. Figures vary, but somewhere between 30 and 40% of respondents report not using condoms.
In 2007, the pregnancy rate in Ontario for women aged 15-19 was 25.7 per 1,000. In 2014, 12,843 babies were born to mothers aged 15-19 in Canada. However, there has been a decline in this birth rate over the last 30 years. This is thought to be related to increased access to contraception and slightly delayed initiation of activity in adolescents. Older teenagers are more likely than their younger counterparts to be sexually active, which is reflected in much higher pregnancy rates.
Just over 50% of adolescent pregnancies end in an induced abortion; this percentage is higher than any other age group.
In Canada, the age of consent is 16 years for “nonexploitative sexual activity” – no prostitution or pornography; no relationship of trust, authority or dependency (e.g. coach, spiritual leader, teacher, principal, guidance counsellor, family member).
• Youth 12 or 13 years can consent with peers within 2 years of age difference
• Youth 14 or 15 years when age difference no more than 5 years
Children younger than 12 years can never consent to sexual activity with anyone.
Any health care professional must immediately report any suspicions that a child is or may be in need of protection to a Children's Aid Society (CAS). “In need of protection” includes any child who may be at risk of physical, sexual and emotional abuse, neglect, and risk of harm.
PDF by the Centres for Disease Control and Prevention with some examples of dialogue that can be used when interviewing a patient.
CDC treatment guidelines for STDs; this site also gives protocols for MSM and WSW
Providing culturally sensitive care under Special Patients
Canadian Centre for Gender and Sexual Diversity
Ottawa Sexual Health Centre or 613-234-4641
Note: The language in this section assumes that the individual who is pregnant identifies as a woman. This is not always the case; individuals of other genders may also have the ability to be pregnant and, as such, should also be considered in this discussion of reproductive rights. See “Caring for Transgender Patients” above for more information.
1869-1988: Before the Decriminalization of Abortion
In 1869, the Canadian Parliament criminalized both the provision and procurement of abortion in Canada. In 1892, contraception was also banned. These laws were maintained until 1969.
It is worth noting abortions were still being performed during this period; it is estimated that by the 1960s, 35,000 to 120,000 illegal abortions took place each year. These abortions were often unsafe for the patients as untrained physicians attempted them with unsafe or unsanitary working conditions.
In 1969, a woman was permitted to have a therapeutic abortion if a hospital Therapeutic Abortion Committee (TAC) agreed that continuing the pregnancy would risk a mother’s life or health. The women had no opportunity to meet the doctors of the TAC and there was no right to appeal if the committee turned her down. The process of working through the TAC took an average of eight weeks, which made it unfeasible for many women. As such, it is worth noting that while this committee process was legally available, it was not accessible to many women. In 1969, contraception was also legalized in Canada.
In the 1970s, Dr. Henry Morgentaler announced publically that he was performing abortions in his clinic. As these were done without approval by a hospital committee, they were illegal. Over the next ten years, this had a serious impact on the laws of abortion in Canada. Dr. Morgentaler was initially found not guilty, but then guilty by appeal court; he served time in prison and was finally acquitted.
In a retrospective interview in January 2008, Morgentaler said he confronted the choice between helping women obtain a safe abortion but risk going to jail, versus leaving the woman to the dangers of self-induced or non-professional abortion. He saw it as his duty to lead this crusade, as a medical doctor and a humanist. As a child, Morgentaler had been interned in concentration camps at Dachau and Auschwitz, which “gave me a heightened sense of injustice and I saw injustice being meted out to women who needed abortions ... I had a feeling I was fighting for fundamental justice.”
1988 to Today: R. v. Morgentaler, Bill C-43 and Private Clinics
In 1988, the Supreme Court decriminalized abortion in the case of R. v. Morgentaler.
“[The current abortion law] clearly interferes with a woman’s physical and bodily integrity. Forcing a woman, by threat of criminal sanction, to carry a foetus to term unless she meets certain priorities unrelated to her priorities and aspirations, is a profound interference with a woman’s body and thus an infringement of security of the person” - Chief Justice Dickson, 1988.
In 1990, Bill C-43 (a bill aimed at recriminalizing abortion) passed through the House of Commons but was defeated in the Senate. Following this, abortion was considered a legal medical procedure, subject to provincial and medical regulation. In 1995, it was ruled that abortions could also be performed in private abortion clinics. Since then there has been no federal abortion law in Canada, so it remains a right protected under the Charter, but is unregulated.
In November 1994, Dr. Garson Romalis was shot in his home in Vancouver. Two similar shootings followed in 1995 and 1997, in Ontario and Manitoba. All the shootings occurred around Nov. 11, Canada's Remembrance Day holiday for war veterans, a day that the pro-life movement has adopted to memorialize aborted fetuses.
Abortion Access in Canada
Before Bill C-43 was defeated in the Senate, many doctors stopped performing abortions for fear of possible criminal prosecution. Fewer than 20% of hospitals in Canada now perform abortions. Earlier, in 1995, these hospitals had performed 66% of all abortions, the remainder being performed in clinics. Now, a majority of abortions are performed in clinics.
As of 2016, there are 33 abortion clinics in Canada: 11 stand-alone clinics, 12 clinics located in a multi-tenant office or medical building, and 9 clinics associated with a hospital. The uneven distribution of these providers makes accessibility across Canada extremely variable.
One in 6 hospitals will also offer abortion services but access to these may be limited or affected by other factors (e.g., if it is a local hospital, privacy may be compromised).
As of 2016, Health PEI is on track to plan a new women’s health centre that will offer a number of services, including medical and surgical abortions. The province of PEI previously had no surgical abortion available in-province since 1982.
Abortion services are fully covered in Ontario, but wait times are long (up to 6 weeks in Ottawa). There is a looming shortage of doctors willing to provide the service; many are approaching retirement and younger MDs are not replacing them, some out of fear of harassment and others because they have not witnessed the dangers of unsafe abortions.
In sum, while abortion is decriminalized in Canada and therapeutic abortion may in theory be available, there is significant variation in funding and access for abortions inter- and intra-provincially.
ROE v. WADE
By 1970, five U.S. states had made abortion legal (NY; California; Washington; Alaska; Hawaii). In 1970, in Dallas, Texas, Norma McCorvey found herself pregnant for the third time. She was poor, uneducated, alcoholic and had a drug problem; she had given two children up for adoption and now she wanted an abortion. She failed to get one, but her case was taken up by liberals seeking to legalize abortion. Her name was changed to Jane Roe to disguise her identity, and the defendant was the Dallas County district attorney, Henry Wade. Norma McCorvey's baby was adopted long before the case came to trial.
Following various appeals, on January 22 1973 the U.S. Supreme Court ruled in Roe v. Wade to legalize abortion for the whole country, noting that “The detriment that the State would impose upon the pregnant woman by denying this choice altogether is apparent ... Maternity, or additional offspring, may force upon the woman a distressful life and future ... There is also the distress, for all concerned, associated with the unwanted child, and there is the problem of bringing a child into a family already unable, psychologically and otherwise, to care for it.”
• In 2006, the Canadian Contraception Study among sexually active women aged 15-49 found that 65% respondents who were sexually active and not trying to conceive reported always using contraception. 15% were using no contraception. The remaining 20% reported inconsistent use.
• Abortion rates are usually calculated as the number of abortions per 1000 women of reproductive age (usually 15 - 44). Figures vary (and are difficult to estimate accurately), but our overall abortion rate lies somewhere between 12 and 15 per 1000 women of child-bearing age per year; this is fairly low compared to other developed countries.
• In 2014, 81,897 abortions were reported to the Canadian Institute for Health Information; slightly more were performed in clinics than in hospital. However, as clinic reporting is not mandated and is voluntary, this information may be incomplete. Specifically, it is known for 2014 that the clinic data for New Brunswick are absent and data from British Columbia are incomplete.
• Over 90% of abortions in Canada are done in the first trimester; only 2-5% are done after 16 weeks, and no doctor performs abortions past 20 or 21 weeks unless there are compelling health or genetic reasons.
• The risk of maternal mortality is probably greater in carrying a pregnancy to term (7.06 per 100 000 live births) than the mortality risk associated with abortion (0.56 per 100 000 terminations) (Grimes D. Am J Obstet Gynecol 2006; 194: 92-94).
• A wide range of women undergo abortions. About 50% are under 25; 64% are single, and 45% have children.
The Catholic Health Ethics Guide forbids abortion and is applied in many private Catholic hospitals and clinics in Canada. It distinguishes between direct and indirect abortion: "A direct abortion is a procedure whose deliberate purpose is to terminate the life of an embryo or a fetus. An indirect abortion is a procedure necessary to save the life of the mother in which the death of the fetus is an inevitable result, e.g. the treatment of an ectopic pregnancy".
Doctors’ Rights Regarding Referral
The Canada Health Act guarantees all Canadians access to medically necessary physician and hospital services, free of financial or other barriers, within a system publicly administered on a non-profit basis. In other words, the Canada Health Act requires provincial governments to provide & insure (i.e. pay for) medically necessary services and ensures access.
The Health Act doesn’t define what is a medically necessary service; this is deferred to medical professionals. The Canadian Medical Association has deemed that abortion is a medically necessary procedure.
In 1988, the CMA drafted a policy on protecting doctors’ rights not to perform abortions. The policy also permits doctors to decline to refer patients to abortion providers, with the exception of an emergency situation. The National Abortion Federation argued that this policy impeded women’s access to abortion services, and so appealed to the CMA. The CMA only said “A physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician”, but there was no indication about whether the doctor must refer the patient themselves.
The College of Physicians and Surgeons of Ontario Policy 2-15
In March 2015, the College of Physicians and Surgeons of Ontario released the policy 2-15 “Professional Obligations and Human Rights” which outlines the physician’s requirement to make an "effective referral" and also outlines the physician’s duty to emergency care.
Effective referral: “Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health care provider must be provided to the patient. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician or other health-care professional, or agency. The referral must be made in a timely manner to allow patients to access care.”
Emergency care: “Physicians must provide care in an emergency, where it is necessary to prevent imminent harm, even where that care conflicts with their conscience or religious beliefs”
As a private citizen, one is free to actively solicit a change in Canada’s laws. However, as a physician, one is prohibited from impeding an individual’s right to access a legal medical service.
Policy 2-15 “Professional Obligations and Human Rights” from the College of Physicians and Surgeons of Ontario
CMA policy on induced abortion
The Abortion Rights Coalition (derived from the previous Canadian Abortion Rights Action League) has a small information web site.
Action Canada for Sexual Health & Rights
A major clinical challenge is to provide appropriate, patient-centered and sensitive support for a woman who experiences an unwanted pregnancy. It can be very difficult to balance an understanding of her preferences, which may be clouded by the stress she is currently experiencing, and your own perspectives. Not least, the time pressure works against making a fully balanced decision.
When counselling a patient with an unintended pregnancy, do not assume that this pregnancy is good or bad news: ask the patient how she feels about it. Do not assume that she did not use contraception, that she knows the date of her last menstrual period, that the couple knows what they are going to do or that you know the whole story. Keep in mind that probably 50% of all pregnancies are unintended.
Options for an Unintended Pregnancy
Initial counselling sessions need to be patient-centered, supportive and non-judgmental. The patient needs to choose whichever option is best for them. Three options for an unintended pregnancy include parenting, adoption and abortion.
When considering parenting, the patient may need to consider life plans, lifelong commitment, neo-natal support, birthing options and infant essentials, food services, financial resources and benefits, social assistance, housing services, creating a birth plan, solo-parenting as a possibility or the role of the partner in the pregnancy and child-rearing, support networks (partners, family, friends, community resources), young parent support programs, CAS for custody and childcare needs.
In this case, your role as a physician is to provide accurate and up to date information, explain levels of openness, explain private and public adoption, make community referrals to adoption workers and CAS, explain that adoptive parents must acquire training and help provide a social and medical history to have on file.
Private adoption: Administered by a Private Adoption Licensee or a Private Adoption Practitioner, in collaboration with a lawyer. No cost to birth parent, cost is to adoptive parent to cover legal and counselling fees of both parties.
Public adoption: No cost to either party. Arranged by caseworker, through the local Children’s Aid Society (CAS)
The adoption experience varies from person to person as does the “social” experience of being pregnant; some people may have negative experiences where they are perceived as failure, incapable of supporting a child, irresponsible.
Mifepristone/ misoprostol (gold standard of medication abortion worldwide) is often used; it is a synthetic progesterone receptor antagonist and can be used up to 9 weeks gestational age
• 92-98% success rate
• Less than 1% complication rate in large series; drastically reduced surgical abortion rate < 9 weeks
• Could be available in rural communities.
Another option is Methotrexate PO/IM and Misoprostol PO/PV; this can be used up to 7 weeks gestational age
• 88-95% effective, requires multiple follow up visits
• May take several weeks to abort; there are associated fetal anomalies if pregnancy continues. Surgical backup necessary, so may not be as useful in rural communities.
In the 1st Trimester, this is done with Analgesia by IV Fetanyl +/- Midazolam and paracervical block with lidocaine
• Outpatient same day procedure
• Very low complication rate.
2nd trimester abortions (12-28 weeks) account for <10% of all abortions. Reasons for delay in abortion services include late diagnosis of pregnancy, new diagnosis of fetal anomaly, difficulty making decision, barriers to access services.
• Increased numbers in teens, low SES, rural
• Requires a trained provider & cervical preparation with osmotic dilators (laminaria, Dilapan)
• Less available than 1st trimester abortion.
Spontaneous abortions (or miscarriages) refer to the loss of a fetus due to natural causes before 20 weeks of pregnancy (not due to human intervention).
Miscarriages are common, and are strongly related to the mother’s age:
Some medical settings may refer to an individuals’ pregnancy history as “GTPAL” or number of Gestations, Term deliveries, Preterm deliveries, Abortions, and Living offspring. While miscarriages are counted as “Abortions” in this setting, it is important to be sensitive of the language used with patients as they may have poignant feelings about the difference between miscarriages (spontaneous abortions) and induced abortions.
Planned Parenthood provides resources to help women choose between parenthood, adoption or abortion.
First Place Options similarly provides women with counseling; they use a decision aid to assist women in reaching a decision over an unplanned pregnancy.
The Medical students for choice site contains a wide variety of information, as does the Students for Life America
Action Canade for Sexual Health & Rights has some useful information, while the Life Canada site covers a wide range of pro-life topics, not just pregnancy, but also including palliative care.
The de Veber Institute for Bioethics and Social Research produces literature reviews concerning health problems associated with abortions.
Updated July 3, 2018