 Hi everyone, good afternoon and good morning, depending on where you're watching from. Thank you for joining us for our second Health Law Seminar in the 2021 series. I'm Adelina Iftene, I'm the Associate Director of the Health Law Institute, and I'm talking to you from MiG-Mocchi, which is the ancestral and unceded MiG-Moc territory where the house university is located. Today, we are hosting Florence Ashley of University of Toronto. We are very, very thrilled to hear her talk about health law and conversion therapy. Now, before I introduce Florence, I would like to just make a few housekeeping points for the webinar today. First of all, the webinar is recorded. So that means that you are not going to appear as audience members on the recording. It's just going to be Florence and my introduction, but you will have access to it. You can re-watch it on the YouTube channel of Shulik School of Law or on the web page of the Health Law Institute. Secondly, we have closed captioning available. So if it doesn't appear automatically for you, you have an option at the bottom of the screen where you can turn your closed captioning on. And finally, after Florence's talk, which will be about 40 minutes, we will have time about 15 minutes for Q&A. You're going to see we do not have a chat box, and that's because it can get overwhelming if we have a lot of members in the audience, but we do have the Q&A function. So what I'll ask is that you type your question in the Q&A, whether it is during the talk or after the talk, and I will put the questions to Florence. And finally, this is our October event. So we will have two more events this year, which are in November. So I invite you to check out our event list. And if you're not already, perhaps write to the Health Law Institute to subscribe to our email list, follow the Health Law Institute on Twitter. Okay, so on to the speaker today, we are very pleased to have Florence Ashley. They are a jurist and a bioethicist currently completing doctoral studies at the University of Toronto Faculty of Law and Joint Center for Bioethics. In 2019-2020, they served as the first openly trans-feminine law clerk at the Supreme Court of Canada in the chambers of Justice Sheila Martin. Before clerking, they obtained a master's degree in law and bioethics as well as two law degrees from McGill University. They were awarded the Canadian Bar Association LGBT Hero Award for their leadership and contribution to trans-legal scholarship and have inspired the first special issue on trans law in Canadian history. They have published in a wide range of legal and bioethics journals, including the University of Toronto Law Journal, McGill Journal of Law and Health and Journal of Medical Ethics. Their work on conversion therapy has been cited by the UN independent experts report on the practices of so-called conversion therapy. And this is the topic of today's talk as well. We are very, very lucky to be able to welcome Florence, even at the house, even if just virtually. Florence, on to you. Hello everyone. First, I want to introduce my co-presenter today, Anora, who will be assisting me mostly emotionally through the talk. So today, I want to look at whether health law can help protect trans youth from trans conversion therapy. Now, when we're talking about conversion therapy, we're talking about a sustained effort to discourage behavior that's associated with the person's gender assigned to discourage behaviors associated with a gender other than the one that was assigned to the person at birth, as well as promote a gender identity that concords with the gender they were assigned at birth. In essence, their trans conversion therapy tries to turn the subject of the conversion therapy into a gender normative subject. And the goal is oftentimes not so much to entirely disallow being trans, but to minimize the likelihood that someone, especially in the case of youth, will grow up to be trans. And this has proved to be a difference that has allowed a lot of practitioners of conversion therapy to try to distinguish themselves from what has, in the imaginary, is gay conversion therapy, which completely disallows being gay. And they're saying, well, I'm not really doing conversion therapy because I'm not trying, I'm not completely disallowing people from being trans. Sometimes I let them like being trans. And instead, but instead, they're really trying to minimize and discourage people from being trans. And we see this in what was said by my friend and also a survivor of conversion therapy, Erica Muse before the Ontario legislature when they passed her law. And she said, the sessions were not therapeutic, but abusive. But eventually he relented and allowed me some care. But I think the only reason he did is that I proved to him that I couldn't be fixed. The scars of his abuse remain, and I've been suicidal and depressed due to his treatment of me. Also importantly, on top of trying to minimize the number of people who grow up or live openly as trans, when they do allow people to live as trans, it often has a very binary and a very normative span. So it's, you know, you're allowed to be trans, but only if you are have a binary gender identity. So you're only allowed to be a woman or a man. And that's it. And also, you know, you're not allowed to be gender nonconforming. And oftentimes it's looked down upon if in your live gender identity, you're gay or bisexual, as opposed to straight. Now, conversion therapy takes on many forms. Historically, it has been primarily behavioral. So they were trying to do conversion therapy a little bit like trans people were dogs. And they were doing token economies and like, oh, you're doing something we don't like, we're giving you, we're punishing you and you're doing something we like, we're giving you a reward. And oftentimes even instituted some sorts of token economies so that the parents would enforce this behavioral mechanism. To a certain extent, there was also some electroshock therapy and some hormonal therapy that was imposed nonconsensually on youth to try to make them into, you know, straight cisgender people. Nowadays, it has largely evolved in since the 90s, since the mid 90s, we have more to form that depends on place psychotherapy, psychoanalysis, parent counseling, and parental limit settings. So the idea is like, we're really, they're really trying to force the kid away from being trans in the everyday life. So the parent is told, don't let your kid wear, you know, if it's a kid that was assigned boy at birth, they're like, well, don't let your kid wear a dress. Don't let your kid play with the friends that they want. Don't let your kid, you know, essentially don't respect your kid's name and pronouns, essentially completely disregard their identity and try to reinforce that they're a boy or that they're a girl and things like that. And then in terms of the interaction between the practitioner and the person, the goal is often not so much to discourage in the immediate moment, but to really find a source to what they call their gender confusion. So why do they believe that they're trans? Because clearly in this mindset, being trans is pathological and not something you just get to be. Also, according to the UN independent expert report, which I mean, full disclosure citing me, it often includes unnecessarily delaying transition. So oftentimes they'll just always set up a new barrier to jump to prove that they're really trans and do this interminably often over years. And that's what Eric Amuse was speaking of is like, there's always this new barrier to prove that I'm really trans and thus really deserve to transition. And this can go on for, years if not decades before a conversion therapist eventually allow them to transition and just give up on conversion efforts, which can be immensely harmful. And it's really important to see the dynamic here is that by doing it, setting up barriers and delaying transition allows to set up this kind of carrot where they're like, well, I'll let you transition. That's what you want. I'll let you transition if you go through all of my trials. And if you come out sufficiently unscaded from there that you're still in the therapy because what happens oftentimes is that people go back into the closet or attempt suicide or give up on therapy altogether. So that's really harmful. Now, how often does this happen? Well, it happens a whole lot more than you probably think. So in Canada, a recent study with by Travis Salloway found that among trans men, 12.1% of them had experienced conversion therapy. That is immense versus around 44.1, blah, blah. Around 4.4% of cis gay men. So we're talking about three times as much as gay conversion therapy in Canada. In the US, we have a study from Jack Turbin that's based on a massive report of like 28,000 trans people that showed that 13.5% of trans adults had experienced conversion therapy. And that number was heightened to 19.6% if we're only including trans people who had spoken through a therapist at some point. So that means you have about 50 trans people who have ever talked to a therapist that were that were the therapist attempted to stop them from being trans. And well, what does this lead to? Well, this leads to a lot of shame. This leads to a lot of depression, a lot of anxiety, a lot of self-hatred, suicidality, and most likely a lot of CPTSD, although that element of it has been grossly understudied, which is, I think, a major limit of how we're approaching caring for people who have gone through conversion therapy, because, you know, therapies for CPTSD aren't exactly the same than therapies for depression and things like that. And we see these outcomes regardless of whether the child that was targeted for conversion therapy was actually trans, because one of the features of that approach is that it doesn't actually distinguish between kids who are who express themselves to be trans and kids who are just gender nonconforming. It kind of puts them all in the same basket and say gender nonconforming kids, we have to really prevent them from becoming trans. And a bunch of those kids aren't actually trans at all. They're like, they've never suggested they were trans and they're just included because they're, you know, they're gender nonconforming. So then we have people like called Bryant, who, you know, grew up to be a now professor of sociology and is a cis gay man and says, well, it made me feel that I was wrong and that something about me at my core was bad and instilled me a sense of shame that stayed with me for a long time afterwards. And that's regardless of whether it was actually trans because what you're shame, you're still shaming someone for the way they are in terms of, you know, their, their masculinity or their femininity, their identification with certain peers with certain, with certain activities. So, you know, regardless of gender identity, your, the entire pattern is to shame the kid into becoming a gender normative subject. And that's why I really emphasize this idea of, of pushing people into gender normativity, because what's important to see is how trans conversion therapy is in part also a way of removing gender nonconformity among gay men, which is also harmful to them on top of being so immensely harmful among trans people who are subjected to it. And in fact, so harmful that studies have revealed that trans people who have experienced conversion practices have, you know, 2.27 times the likelihood of lifetime suicide attempts. And we're talking about 4.15 times more if this was done before they were 10 years old. So when it's done really young, it has an even more devastating impact on them. And we see that also the phenomenon is even heightened, like the disparities even heighten if we're looking at the number of times people have attempted suicide and the likelihood that they recently attempted suicide. So there's this really long lasting effect that lasts well into adulthood that goes on with trans conversion therapy. So then the question becomes, well, what do we do with that? And one of my works is to move to trans law because, well, I'm trained in law. I did law degrees. I also did bioethics, but I did law degrees. So, you know, why not take the tools that I know? And well, my, you know, one of the things about why I turned to health law is, well, you know, the federal government has introduced the bill, bill C8 that prefers to ban conversion therapy, but it has a lot of flaws to the point where Eric Amuse has said that the bill as it currently exists would not ban the practices that she experienced, which is a huge problem. And then also it's disempowering because it is a criminal law. And I, like Eric Amuse and other people who are working around bill C8, recognize that it might be the best we can get and might be the only thing we can get because relying on provinces is extremely unreliable. Provinces has shown themselves to be extremely reluctant to legislate, unlike the federal government. But there are a lot of problems with criminal law. And a lot of us are actually fundamentally opposed to the expansion of the carceral state. We don't think that's how we solve problems. And in fact, this might end up just being retraumatizing for some of the trans people who go through the process as complainants, because as we've seen with sexual assault, the criminal law can be extremely retraumatizing. And I mean, I won't go into detail as to the parallels between sexual assault and conversion therapy, but the psychology of violation that goes around it and the CPTSD and all of those reactions tend to be very similar in both. So we can kind of look at the psychology and the socio-legal issues that arise in the criminalization of sexual assault to kind of have an informed guess as to what's going to happen when we criminalize conversion therapy. And this isn't to say that's not better than nothing. I do believe that it's better than nothing, but there's way better things to do that we could get. So that's where I moved to health law and start from this intuition that what one of the major purposes of health law is to protect patients. So if the goal of health law is to protect patients, well, trans people are patients. Conversion therapy is for trans people oftentimes practiced by licensed professionals. Yes, they're unregulated, faith-based professionals, but in trans conversion therapy, we haven't moved to that place where that's moving towards really faith-based and really kind of deregulated sphere because it's still a way too accepted among certain subsets of psychology that are still deeply pathologizing because there hasn't been enough negative attitudes towards those approaches and it's been lacking the support of people who have meditated against gay conversion therapy and haven't really put their weight behind notating against trans conversion therapy as well. So we have this intuition that, well, medical liability and codes of ethics may offer a way to seek redress, to punish, and to discourage conversion therapy. Now, when we look at how we might do this, I think where it's more helpful is to start by looking at codes of ethics because those codes of ethics tend to be more specific and are really helpful to start the stage for what kind of stuff we need to sue or get a license removed or get a sanction imposed on someone who does conversion therapy. So one thing that we see at first step is, well, law cares a whole lot about competence and about standards of care. The second thing is, well, what's the current stage, the current landscape in terms of scientific principles and evidence? And then the third question is, well, what about the dignity of the patient? Because a lot of codes of ethics care a lot about the dignity of the patient. Now, this is relevant even when we're looking at the medical liability sphere because a lot of norms that, you know, to use the language of moha versus ble, which is 1977 Supreme Court cases, they say, well, when you have norms in law that enshrine, that establish what they call elementary standards of care, which is oftentimes, you know, contrapose to kind of technical standards, like, you know, oh, an accountant has to stamp this by this date, like those things are not really elementary standards of care, they're really technical regulations that you kind of need to have to have a functioning profession, but they're not about, you know, protecting the patient. But when we have these elementary standards of care that are really about directly protecting people in this kind of, like, immediate and tangible manner, then these norms can be used to indicate an actionable fault. So if we're saying, well, this isn't, you know, respecting the current state of science, and that's a norm in the code of physicians of Quebec, then, you know, that may well be recognized in court directly as an actionable fault. In practice, oftentimes, we don't see disciplinary norms that are applied directly in ports or Quebec's equivalent, so, Delhi and quasi-Delhi. So we don't see them applied directly, but we do see them referenced in decisions as guidance. And, you know, it's even encouraged in Supreme Court jurisprudence, like in Simeon de Saint Laurent versus against Barrette, which is, you know, everyone who has studied law in Quebec, probably in other provinces too, but most, but especially Quebec will know as a 2008 decision that looks at these questions. So then we look, well, okay, well, what do the standards of care say? What do the science say? And what does the dignity of the patients say? Well, if we look at the standards of care, I've been doing a count and it's far from a complete count. It's kind of like I've just been keeping track of associations that oppose transconversion therapy. And so far my list, which is pretty much English and French, I have 56 professional organizations that say, don't do conversion therapy, it's bad. So the most telling one is, well, the document by the World Professional Association for Transgender Health, that is literally called standards of care, version seven. So those are the latest standards of care that are being revised right now. We are expecting the eighth version, probably somewhere in 2021, probably earlier than later. But honestly, we all know how these things go. It takes literally forever. But right now the current version says, treatments aimed at trying to change a person's gender identity and expression to become more congruent with sex-assigned at birth has been attempted in the past without success, particularly in the long term. Such treatment is no longer considered ethical. So this is a very, you know, clear statement in the document literally called standards of care that says, doesn't work and is unethical. Don't do it. That's a very clear statement. Now, want to look to Canada? Well, we're looking at Canada. So who is it opposed by? It's opposed by the Alberta College of Social Workers, Canadian Association for Social Work Education, Canadian Association for Social Workers, Canadian Professional Association for Transgender Health, Canadian Psychiatric Association, College of Alberta Psychologists, College of Registered Psychotherapists of Ontario, Manitoba College of Social Worker, or the Travelleurs sociaux et thérapeutes du Québec. Now, that is hella boring to listen to. But if I'm in court, I'm pulling a power move and just listening, saying, look at those. Can you tell me that like we have all of those associations saying it's deeply unethical and it's still standards of care? Clearly, it's not a competent approach to care. And one thing that is really telling, I think, is not only do they say it's bad, but especially in the documents emerging from social work places, which we can credit to Jake Pine, who is also a specialist in conversion therapy. And you're not a good friend of mine, but a lot of those documents emphasize how conversion therapy is not just unethical, but it is already against the codes of ethics of professionals. So they're just saying, well, we're just applying our codes of ethics to these documents and showing that it's already contrary to them, emphasizing things like how it's precisely not competent, not standards of care. So when we look at the standards of care, it's pretty obvious that conversion, that trans conversion therapy even can see broadly to include all of those practices that sometimes have difficulty being recognized as conversion therapy among professionals are indeed conversion therapy and are against current standards of competence and current standards of care. Then we looked at, well, what does the scientific principles and scientific evidence say? Well, we see that in 2012, 2013, 2013, the diagnostic statistic manual of mental disorders. So the DSM in its fifth edition had, in the previous edition, this thing called gender identity disorder. That's how we, that trans people were included. And the disorder was, well, the gender identity, the problem was the gender identity. But then it's shifted to gender dysphoria. And here what it's saying is, well, there's nothing wrong with being trans. And if there's any problem, it's really the distress that comes with having a body that doesn't match your kind of brain map of your gender body. And, well, that gives you distress. So to the extent that the problem is the body doesn't match your brain map, what do you do? Well, you allow people to transition. You let them change your body if they want. You let them change their clothing, because there's also social gender dysphoria, even though the DSM is primarily used to allow medical transition. So, yeah, you just let people transition. And then you have, well, the ICD-11, the international classification of diseases, which just, I want to say 2018, 2019. So it's really recent, but it's not yet enforced coming in fourth thing this year. They had the very outdated transsexualism diagnosis. And now they said, well, we're shifting the language. Now we're saying it's gender incongruence, which is, you know, a fancy way of saying this person is trans, but in a less pathologizing terminology. And then they took it out of mental health conditions and put it in conditions related to sexual health. Now, does it belong in conditions related to sexual health? I would generally tend to say no. And I know there was a lot of backroom politics that was involved in having it, in having to place it there instead of somewhere else. But the important message being sent here is it's not a mental illness. And therefore, from a diagnostic standpoint, you don't try to change the person's psychology. You don't try to make them not trans anymore. You offer them transition services, which isn't surprising because, well, all the evidence shows that transition and support for people's gender identity is overwhelmingly linked to positive mental health outcome. And in fact, among particularly young people, it's linked to mental health outcomes that are almost as good as kids who aren't trans. So despite, you know, the stigma and the bullying, they're still doing like pretty damn well. Now we have more limited evidence as to conversion therapy being harmful because it's extremely hard to study that because of, you know, a bunch of reasons. And we're stuck kind of doing like cross sectional retrospect, like looking back through a cross sectional study, which has, you know, a bunch of limitations for a bunch of reasons and means that, you know, we don't have that many studies. But the studies we do have and we're having more and more because, you know, the study I mentioned earlier about like being twice as much and four times as much as suicidality, that's a study came out like earlier this year. So we have more and more and those studies are framed expansively. So they're like, did someone, did a professional try to make you identify only with your sex assigned at birth? In other words, did they try to stop you from being trans? So this is an expensive definition that kind of covers the rebuttal of while they're talking about different practices, no, they're talking about you. And so we're getting more and more data and the data is showing that overwhelmingly trans conversion therapies are extremely harmful. And then we have the last question, which is, well, the dignity of patients. Well, when you have a practice that intimate that there's something wrong about the patient at their core, and that there's something wrong or undesirable about being trans, what does that say about dignity? Clearly, this is going against dignity. And we see it in what Carl Bryant had said, and which is, well, it made me feel that I was wrong, that something about me to my core was bad and instilled me a sense of shame that stayed with me for a long time afterwards. This shame comes from the impediment to dignity that comes with trans conversion therapy, an impediment that impacts not only the person experiencing the therapy, but also the broader social sphere because trans people have to live in a world where they know that their existence is judged undesirable by people who are actually being licensed and paid by the state and legitimated by it. Now I can hear you say, you're probably not thinking that, but let's pretend you're thinking again. But what about the respectable minority practice standard that was set out in Turn News and V-Corn in 1995 by the Supreme Court? Great question. Thanks for asking. So what about that? Because even if you show that something is against standards of care and against all of those things, if you're working in medical liability, now it's not quite the same in terms of licensure and disciplinary practices. But if you're working in court in medical liability, then you have this kind of exit strategy, which is, well, I just have to show that a respectable minority of practitioners would actually accept that practice, even if it's not kind of the leading practice, even if some people think it's not standards of care. And that's kind of a space that's made for new and emerging practices or for practices that are unpopular, but that reasonable, well-thinking individuals might use. And here, I think it's important to understand that, well, the respectable minority, it's really not a question of size. They're not saying, oh, you need to have 5% of practitioners who think it's fine. No, the respectable aspect is about whether the practices themselves and the practitioners themselves are respectable. And so there's a normative component to that. And that's where I'm made to think back to one of my favorite low snippets, my favorite obitur of all time in all of Canadian history in RV Tran, the 2010 case on provocation, which says it would not be appropriate to ascribe to the ordinary person the characteristic of being homophobic, if the accused were the recipient of a homosexual advance. What's saying, being hit on can't be ground provocation because the ordinary person isn't homophobic and therefore is fine with it. So where does that take us? Well, it seems to be another point about provocation law, but really think about it. If the ordinary person isn't allowed to be homophobic, what does that say about the reasonable person, the reasonable practitioner, so someone who's not even acting in their private life, but is actually acting in a professional capacity, where they have accepted a lot more obligations as a person in order to get the benefit of a license. And on top of that has to be reasonable, not just ordinary. Clearly this person would also not get to be homophobic. Okay, but where does that get us? Well, I want to propose a way of conceptualizing this aspect of respectability in the standard through a kind of principled approach that allows us to work with that. And here I kind of like circle back to the notion of dignity and human rights, right? And what I suggest we do is that we look at it through a kind of approach, an expressivist approach to the law, which is massively inspired by Paul Gowder's great book on the rule of law. So we have this kind of like two test analysis is like, well, is the expressive content of the practice from a fasche consistent with conceiving all members of the community as free and equal? So here in this question is, well, per fasche doesn't look like it says that trans people are free and equal. And here we're focusing especially on the equal part, but we're also insisting on the free part, especially when we're looking at youth who are being forced into that by parents, who themselves are often don't really know what's going on and are just following along with a professional with big degrees is telling them to do. So this is the first question. And how do we resolve this first question? Well, we asked, well, is there a legitimate clinical purpose to conversion therapy? And then is the practice consistent with community self understanding? Because if a practice is pathologizing and says that being trans is undesirable, but trans people themselves see it, you know, as something that's undesirable and to be and to be altered, then maybe that's fine. And the parallel I want to draw here is, well, what if someone has chronic pain? Well, most people who have chronic pain just want to be rid of it because they have this understanding of chronic pain as something that's negative in their life. The same thing is not true for, for instance, most physical disabilities where the people are saying, well, no, what is making me disabled is the society, not my body, there's nothing wrong with me. It's the society that's not well adapted to me. And by looking at those community self understandings, it actually tells us a whole lot about what the expressive content of a practice is. So first question, is there a legitimate clinical purpose? Well, the answer is no, because identifying their mental illness is not actually making trans people better. Pathologizing trans people and subjecting them to conversion therapy pretty much makes them worse. The only clinical purpose that's really, I would argue it's really following is reinscribing gender normativity. But doing that is not really a legitimate clinical purpose. And I put a little asterisk because in my work on that, I leave a tiny sliver of the world here, which I then should close later. But, but I'm like, okay, well, being like extremely, extremely, extremely charitable and like really taking the position of those practitioners, then maybe consensual conversion therapy by fully informed and not trans adults who don't have, you know, a lot of internalized transphobia and all of that. Like then maybe that would be legitimate, but like that is an extremely narrow opening. And then at the next stage, I couldn't close it because it's not consistent with community self understanding. It would be offensive to not just the patient, but you know, trans people in general to be like, it's a bad thing to be trans. And it's fine for individual trans people to believe that. But for someone who is licensed by the state and whose duties to respect the dignity of patients and, and carry those, those values of equality, that's not appropriate. So this is our first step. And then we end up at the, the, the realization, no, it's not consistent with this, with this expressive equality. Now the second step is, well, okay, but this is prima facie. Are there other concerns that would kind of outweigh this in order to make it perhaps not prima facie egalitarian, but once we really dig into it, then it comes to show that it's, you know, pro equality. So what would that look like? Well, if you were able to show that trans conversion practices are so beneficial for the patient compared to alternatives, you know, that it completely outweighs the prima facie inequality, then I mean, it would kind of suck. But we'd be like, okay, I kind of get it, you know, if trans conversion therapy made, made, you know, trans people into like super happy cis people who are like thriving in life and like so much happier than trans people who transition, then we'd be like, okay, like this, this hurts, but maybe I kind of understand it. And, you know, at the most extreme, you just be like, you know, if a practice is saving the entire world, then maybe, you know, a few casualties is not something we want, but maybe something we have to tolerate. Now the question is, well, how does it fare in those, in those, and here we have this shift in burden of proof, right? They don't have to just show that they're not harmful, which you can't even do, but they have to show that they are so much better than all the other approaches. And well, once we frame it that way with this kind of reversal in burden of proof, then becomes quite evident that no matter how many, how much of their wannabe evidence they'll throw at us, they'll never be able to show anything. They're never going to be able to meet that threshold because the evidence as it exists already rules it out beyond any, you know, reasonable doubt, beyond any, even of a figment of an imaginary doubt. So they, because, you know, at this point, they're struggling to show it's not harmful. And mostly they're not able to show it's not harmful. They only do that by kind of being like, oh, your studies are low quality, which is kind of a weird cop out because all studies are limited. But as far as studies go, they're really good studies. So here we're saying what I'm saying is that in some is that, well, if we're looking at the respectable minority standard, then this is clearly not meeting the threshold of what Catholic is respectable. It's not respectable to express a view that trans people are inferior on, on desirable in society in that we should kind of adopt some sort of eugenistic practices to, to make people not trans anymore. You might be thinking, okay, why didn't we use this approach in the first place? Like doesn't the, you know, doesn't the law care about that medical liability, you know, at the very first step of showing that it's wrong? And you'd be kind of right. I think that we can make a similar argument instead of going through, you know, all the standards of care and blah, blah, blah. We showed it's perma fascia wrong. And then we just showed that conversion therapy is not, is not good enough to warrant allowing. But honestly, I don't really do that for the very simple reason that I mean the standards of care are there. Like, like all the evidence, the standards of care and the scientific principles, they're all there. And it's already the language that courts are used to speaking. So I don't have to introduce that new language at all to get through that step. It's really easy. And then, you know, the, the under definition of respect, respectable minority makes it a little bit more necessary to dig into new tools to conceptualize, well, what the hell is it? Because honestly, the precedents like to turn news and is not all that altogether clear what the hell that means. And neither is cleveness wheel and which is one of the other leading precedents on this by the entire Court of Appeal. So here's our kind of like preliminary conclusion. Conversion therapy most plausibly is already against disciplinary codes of ethics and against medical liability. What do we do with that? Well, the first thing we do is we sue. But I want to go something somewhere that's a little bit more interesting and deeper. What does the fact that conversion therapy is most likely already illegal? Tell us about what the law can and cannot do. Because not only is conversion therapy for trans people plausibly already illegal, but all the arguments that I've made would also apply almost directly to gay conversion therapy. And despite the fact that it's been delisted from the SM in 1980, the law has not really gone after it. So what I think this tells us is first that courts may not be able to save us. And also that Bill C-8 might not be able to save us. Because it also relies on the same idea that by just legislating it away, we're going to be able to substantially decrease trans conversion therapy. And I'm not sure that that's true. And then we move to the question, well, why don't they work? Like why, if it's, you know, such a straightforward application of the law of medical liability as I've done, because I think I hope I've shown that it's a fairly straightforward thing. I'm just looking at like existing standards of care that I've existed for a while. Like it's all like black on white, it's on the paper. Well, there are multiple reasons why I think they don't work. So first we have continued funding of conversion practices, because well, no one is billing it as conversion practices. They're billing it as psychotherapy and stuff like that. So they're getting like state money for it. So it's relatively incentivized to do it for them, because they're getting money for it. They're getting that kind of support. If it was defunded, then you would have to pay between money and general affirmative approach that makes it a little bit more difficult to actually do conversion therapy, because you have to get, you know, paid more money by the patient and things like that. So we see this continued funding. Now, this is limited to the extent that funding for mental health services is already terrible. And a lot of people practicing it are psychologists not practicing in the, in, you know, hospitals and things, and the public system, a lot of them, you know, but they're also psychiatrists who do it. And those tend to be publicly funded. The second and kind of bigger issue is, well, it takes a long time for trans people to not only realize how they were harmed. And that's something we are also seeing in like, you know, child sexual assault. It's like, it takes a long time to actually realize the harm that was done to you, that it was wrong, how wrong it was. And then also gain the confidence that allows you to challenge it. And oftentimes by the time you get there, you have, you know, you've reached prescription of the claim. If you even get there, then there's a bunch of unregulated faith based practitioners, but I mentioned a lot of them are regulated. Then, well, once you sue someone, you need expertise. And a lot of people who do conversion therapy have great expertise on paper. And it's pretty hard to convince a court that this superstar of trans health is actually doing something that's completely evil and harmful. Because you only have one expert, one expert, and you're not really able to give the full portrait of the law. Then you have adjudicator reluctance as well, which kind of feeds into the same, in the same problem. But I think really, really the biggest and the biggest problem is this idea that, well, these laws all have fuzzy boundaries. It doesn't, it tells you, you know, when you sue, it tells you this person did conversion therapy, but it doesn't tell you what is the entire scope of conversion therapy, which allows for equivocation by practitioners, makes it really difficult for professionals to police one another. Because oftentimes they have very low knowledge in the area and a lack of confidence in challenging other professionals, especially in a clinical world that really has this attitude of all sciences valid kind of thing, and is really discouraging what they consider to be the incivilities of challenging other professionals on their practices. And research also shows that the malleability of legal and unethical norms helps unethical actors kind of preserve their morals of image by defining themselves away from conversion therapy. And the most obvious example of that is the Camage Clinic, gender identity clinic for children and youth in Toronto was closed in 2015 as the bill banning conversion therapy was coming in force. And it was, you know, done because their practices were out of tune with, out of line with, you know, current standards. And the members of the clinic in the report that was produced were said, oh, I don't think this law applies to me. I don't think I'm doing conversion therapy because it's different from conversion therapy in XYZ manner. And because the laws are relatively high abstraction, it lets people do that. Let's justify themselves to others and to themselves. So, well, how do we fix it? Well, I think the first thing is to have a clear and detailed definition of what conversion therapy includes. We really need an expansive definition. And that's why I wrote a model law and I'm working on a book on this. And the idea is that if we're being clear and detailed enough, then we can refer, well, what you're doing, this very precise thing, that's conversion therapy. Then we also need to involve professional associations much more directly because we need to reduce the reluctance of mutual enforcement. We need to really enhance this mutual accountability process because peer pressure is a fantastic way of changing professional practices. And then we also need to have education that allows the opposition to conversion practices to be entranced into professional self-concept as professionals, because that's the best way you get professional norms to develop in the culture is you make it a part of who they are as practitioners, as psychologists, as doctors, that they don't do conversion therapy. So that includes doing education, that includes doing policy statements, passing guidelines, and also really includes doing having structures and enforcement because studies have shown that education really means nothing if you don't have real accountability and enforcement structures. And that's where we get back to health law. Health law's role is to be one, the enforcement branch and also the supplementary branch because when we have disciplinary law, well, lawyers often get involved, but they're really there to help this enforcement mechanism that operates between professionals. And the disciplinary measures often take in people who judge them. A lot of them are professionals themselves. So we kind of have this wedding of law and medical professionals. And that's where the law comes in, is to not do its own thing on the side, but collaborate and reinforce what professional associations are supposed to be trying to do, and which unfortunately not all of them is doing right now. They really need to get more heavy into it. And then the second point is, well, medical liability gives redress. It gives compensation. It allows for things that disciplinary measures don't really give you space for. And that's something that's really important because, well, it hurts people and hurt people while they need therapy. They also need money to go to school because they've struggled to get education at the time they are expected to socially because they were traumatized. They need to have much more heavy support in terms of trying to heal from conversion therapy. And, well, being able to get money through medical liability, that can help. And if we have this well-known pathway towards compensation that is supported by codes of ethics, that is supported by the professional world, then people might start using it because right now they're not using it because they're going into the unknown. They're going into a sphere where they don't feel like they're supported neither by the law or by the professional associations against which they'll be fighting. And that's where the space of health law lies. So can health law protect trans youth from conversion therapy? Yes, but not in the way that it's trying to do so now. And that's why we need to take a different approach. One that's really geared towards law being a supplement to a pedagogical and cultural driven approach in professional associations, in society among parents of trans youth. And that's what we need. And that was my presentation. I will now take your questions. I'm sorry for going over time. Thank you so much, Florence. That was absolutely fabulous. It was such a depressing but fascinating topic. And it was really, really a very clear presentation. It was, I actually learned a lot from it and I took notes like crazy there. So thank you for that. I would like to open it now for questions. Okay, so we have a couple of questions coming in. I have a whole bunch of questions, too, but we'll see if we get to them. Otherwise, I'll send them in an email. So the first question from somebody says, you mentioned the link between face based therapies and conversion therapy. In terms of recommendations for changes to protect against conversion therapy, has there been any consideration of creating stricter or more specific norms and standards for when and how faith based therapies can be undertaken, meaning making a clearer scope for faith based therapies? Yeah, so there's, so there's on one side, you have, you know, faith based conversion therapy and you also have faith based therapies that are not all conversion therapy. Now, there has been relatively little talk about this because, well, a lot of that counts weird interstitial space between what is actually, could be considered as like an attempt at some sort of psychotherapy and other practices that are much more like just straightforward religious counseling. So there's a lot of reluctance to religious counseling. And to an extent, any attempt to bring them into the licensure of the law would run into the same problems of, well, they'll just take a step back outside of it. And they'll be like, well, no, I'm not doing that. I'm just being a priest who's giving religious counseling. So there is a lot of difficulty in trying to grab them. And I think that one of the advantages of a potentially medical liability is that, well, you're able to grab them not through medical liability, but to just straightforward towards law using some of what we learned from, from like medical liability. But I do think it's really problem is that faith based approaches that occur among people who are not licensed, because for those who are licensed, then all I've said applies. But for those who are licensed, then they already show certain resistance to disciplinary norms. And that's I know that's not a case in a lot of provinces, but in Quebec, for instance, you're not allowed to practice psychotherapy if you're not a psychotherapist. And that hasn't really changed anything, because a lot of them are already operating on in this kind of liminal space that's like already like not super legal. It's like it's in, it's in that's like weird space where you're just like, well, if it counts as more psychotherapy, then it's, then it's illegal, but if it like is sufficiently distant from psychotherapy, then it's legal, or at least they think so. But even in case, but in some of cases, we also see people just like blatantly ignoring the law. In fact, we have the law in Ontario, and people are still practicing conversion therapy in Ontario. They don't really know what we want. So I think that there's really a difficulty in addressing the faith-based side. And that's why my work focuses much more on licensed professionals for the two reasons that, well, you know, law deals with licensed professionals much more. But also there's actually a really large portion of conversion therapy that is actually being done by professionals that are licensed professionals and not actually by religious counselors. And that's something that often gets lost in the narratives and in the talks we have on conversion therapy, because so much of it is grounded in the idea of gay conversion therapy. And people assume that trans conversion therapy looks the same as gay conversion therapy, and it really doesn't. It's much more professionalized. Thank you for that. We have another question here. What do you think as healthcare providers can improve on what healthcare providers can improve in working with members of the LGBTQT plus community, especially with transgender members of our communities? So I think the first step is humility. So because I also do work on on bioethics and on like, you know, pure clinical ethics aspects. In fact, I have a paper coming out in the journal American Journal of Medicine. Yes, American Journal of Medicine on precisely that topic. So it's transgender healthcare doesn't stop at the doors of the clinic. And it's this idea that we need to practitioners to be really actively involved with their trans patients and really try to understand trans communities, but not as objects of study, but as agents in their own healthcare and learn from them, individual patients, but also learn from trans people outside the clinic and really engage with them as scholars, as activists, and as community knowers. And there's, I think a lot of that involves doing, you know, formal paid work, setting up formal paid work for trans people. So there are clinics that I know that hire, you know, trans social workers or community workers to help them with the more kind of like understanding what trans people need. Also providing help with the trans people who are going there for, you know, hormone therapy and things like that, but also need social support and don't necessarily know how to connect with the community organizations. And so we really need more of an integration between trans communities and professional associations. And I think that involves, so I mean, I'm talking about more in my master's and in my forthcoming book, but really the need to have, you know, working groups and things like that that develop, you know, very precise guidelines and also ways in which that, in which the profession can show inclusivity for trans people, but on their own terms, because one of the problem we often see is a very saviorist approach to engaging with trans communities that ends up oftentimes causing either more harm than good, or at least not doing the good that it wants to do. Because even though the intent is there, the humility and the centering of trans knowledge is not present. And that's what you really need, especially given the wide diversity of trans communities, which have an immense lot of expertise and who are despite the fact that have so much expertise are often relegated to a position of testimonies. You know, I can't even say often I'm being asked to just tell my story of transition and I'm like, yo, that's boring. Like I write papers, I do, you know, I have this huge expertise in the field, but I'm still being asked to just tell my story. And honestly, it's a boring ass story because I'm a white trans man who went to law school. Like, what is that? You were talking about the, we probably only have time for one more question, but you were talking about the limits of the federal bill that was criminalizing certain aspects of the conversion therapy. And I was wondering if you could describe a bit for our audience, you were quite clear and articulated in what the limitations are and why this and I, you know, I'm very sympathetic to your point that probably criminal further criminalizing behavior is not a solution. It's not in there. Sorry, I didn't I didn't hear that the later half of your right. No, I was saying I'm very sympathetic to your point that further criminalizing behavior, you know, it's not probably going to solve anything. And I also appreciate the point that it has other limitations, probably lacking the definition of conversion therapy and so forth. I was wondering if you could just describe a bit for our audience what the bill plans on doing, what's, you know, what's, what's its scope and what kind of behavior it criminalizes, whose behavior is criminalizing, and whether there has been any, any charges underneath really. Okay, so I, so I invite people to look at this document, the open letter titled Bill C8 exclude conversion therapy practices that target trans people. It's on the website of the Center for Gender and Sexual Health Equity. I was heavily involved in that, but it's also, so there, there's an open letter by Erica Muse, and then there's, but then the signatories include a lot of, a lot of like big names in, in the area, including, you know, my colleagues like Travis Selway, AJ Lowick, Faye Johnson, Hanakia, Kenan McKinnon, and things like that. And it explains, so it has the open letter, it has signatories, and then it also has an appendix that looks at, you know, the flaws and then propose changes. So one of the problems, so one thing that we've been wanting to push on is really having the federal government make it crystal clear that this is a kind of like blonde step that they're taking, but that they're really inviting and expecting provinces to continue their work towards criminalizing, towards making illegal trans conversion therapy at the non-criminal level, so in civil liability where, you know, it's a much more well-suited area of the law, and where they can also much more naturally go into details, because the problem I mentioned is a lot of the laws are insufficiently detailed, and thus create kinds of like huge interpretational gaps that are going to make it difficult for practitioners to know what they're doing, because, well, first of all, these laws have primarily an expressive and a pedagogical impact. Our goal is not to sue people who do conversion therapy after the fact, our goal is to prevent them from doing it in the first place, and so we need the laws to be sufficiently clear and detailed to be able to do that. So that includes working with the provinces, but it also includes doing things like adding the word gender expression so that it's covered in the law. It also means, you know, thinking much more deeply about what it means to use the language of change as opposed to, you know, change, repress, and discourage, because there's an entire, there's an entire philosophy of psychology that's built into word change that has assumptions about who are the targets of trans conversion therapy, what it means to be trans, and what it means to have a gender identity, and that doesn't necessarily capture what the actual practices look like on the ground, and it's precisely what I'm saying allows them to kind of self-define out of it, is by having focus on this word, the word change, but when a lot of the time what they're doing is discouraging and repressing. And then we also have things that, so that one of the things it says is like, it says, oh, well, you're allowed to do services that relate to a person's gender transition. Well, we get what they mean here, what they're saying is like allowing someone to transition is not conversion therapy. And is it important to add questionable honestly, but I guess better safe than sorry. But the problem is that it's worded super vague that you can see people doing conversion therapy say, well, it's really related to it, we're just doing an expensive diagnostic that takes, you know, five years. So there's a lot of weird wiggle room that's created by this by this that we want them to replace it with wording that's going to actually get to the bottom of this. Now, optimally, also, it doesn't apply to adults. And also, it's, and so basically, then it doesn't take into account the fact that there's a lot of social pressures, and a lot of coercion that's involved into into going there and knowing that we're that it's going to be difficult to get a change the age thing. I mean, I've been really saying they should just ban it altogether because something that's a harmful medical practice is a harmful medical practice at any age, like that doesn't matter. The point is they're professionals, they're not allowed to do harmful stuff, even if they're asked, that's different than if, you know, you're allowed to, you know, for instance, harm yourself, but you're not allowed to, you know, help others do a certain degree of harm to themselves, like there's a threshold where we just don't let people harm others. And so part of it is, well, if they're not going to change that, then we want them to have a stronger conception of consent. And that's where we're drawing for drawing from the provisions on consent in the context of sexual assault. And, you know, with regard to things like vulnerability to coercion, manipulation, maturity level level of internalized transphobia and things like that, so that we can so that we can really get to a point where at the very least, we're not able to to have a ban that covers, at least for adults, it's going to be banned for those who don't really consent, for those whose consent is not really free and enlightened, but is actually coerced or grounded in in some form of self-hatred and things like that. Excellent. Unfortunately, we're going to have to end here. Thank you so much again, Florence, for your amazing talk and for engaging with this question so insightfully and thoughtfully. And thank you, everyone, for attending. We're going to have our next seminar on November 6. So please have a look at that. And you can find a video from today's from today's talk on Shulik's YouTube channel. Thank you again.