Question Period Note: Access to Sexual and Reproductive Health Care Information and Services

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• People who are 2SLGBTQI+, Indigenous, racialized, living with disabilities, or women and youth from underserved communities face the highest sexual and reproductive health risks and the greatest barriers to accessing support, information, and services. Often, they do not receive quality care.
KEY MESSAGES
• All Canadians should have access to sexual and reproductive health resources and services, no matter where they live.
• Budget 2023 committed $36 million over three years, starting in 2024-25, to Health Canada to renew the Sexual and Reproductive Health Fund.
• This fund supports community-based organizations that help make access to abortion, as well as other sexual and reproductive health care information and services, more accessible for vulnerable populations.
• Mifegymiso, the abortion pill used in Canada, is safe, legal and remains accessible.
IF PRESSED ON DATA…
• The Government is also investing $7.6 million over five years for Statistics Canada to collect data that will fill existing information gaps and help us target appropriate sexual and reproductive health supports for Canadians.
IF PRESSED ON ABORTION SERVICES – GENERAL…
• This Government is committed to upholding the fundamental right to choose and believes that no one should be forced to carry an unwanted pregnancy.
• Of the $45 million committed in Budget 2021, the Government has allocated $38.9 million. Of that, $8.0 million to date has been invested in four projects focused on access to abortion. Through these projects, new resources and supports are being developed for health care professionals, access to accurate information about abortion is being improved, and financial and logistical support for travel for abortion care is being provided.
If PRESSED ON ABORTION SERVICES – COMPLIANCE UNDER THE CANADA HEALTH ACT…
• While abortion services are insured in all provinces and territories there is still work to be done to improve access in many areas of the country.
• Health Canada continues to engage with Ontario as they work to implement their action plan to eliminate patient charges for access to abortion services.
• New Brunswick will continue to be subject to Canada Health Transfer deductions as long as the province refuses to cover insured surgical abortion services provided at private clinics, resulting in patient charges.
IF PRESSED ON WHETHER THE GOVERNMENT WILL PROVIDE FUNDING TO ORGANIZATIONS OFFERING ALTERNATIVES TO ABORTION (I.E. CONTINUING THE PREGNANCY) …
• This fund is specifically designed to help women access abortion and it will not support initiatives that discourage or are opposed to freedom of choice or attempt to override the individual’s right to make decisions about their own body.
IF PRESSED ON THE LEGAL STATUS OF MEDICATION ABORTION IN THE UNITED STATES AND THE AVAILABILITY OF MIFEGYMISO IN CANADA…
• Health Canada is aware of the decision issued by the U.S. Supreme Court, allowing continued access to mifepristone, a drug used to safely induce abortions.
• Mifespristone is not marketed in Canada.
• Mifegymiso is the only abortion pill authorized in Canada and is not available in the U.S. It includes Mifespristone and Misoprostol. Mifegymiso is publicly covered by all provinces and territories.
• Health Canada is closely monitoring the supply of Mifegymiso in Canada. There are currently no supply issues.
IF PRESSED ON MISINFORMATION AND DISINFORMATION REGARDING THE CARE OF TRANS AND NON-BINARY CHILDREN AND YOUTH …
• This government believes that trans and non-binary young people, and their families, should have access to gender affirming, evidence based, and high-quality health care.
• Gender identity is an inherent characteristic that cannot be changed.
• This government is protecting trans and non-binary young people through strategic funding, as well as through outlawing conversion therapy. The government is monitoring with concern the rise in both misinformation and disinformation regarding trans and non-binary young people, as well as harassment, intimidation, and threats against health care providers.
IF PRESSED ON CONCERNS ABOUT DESISTANCE OR TRANSITION REGRET …
• While stories of “desistance” or “transition regret” can receive significant media attention and are used as part of misinformation and disinformation campaigns, in fact it is rare that youth stop their gender transition and return to living as their gender assigned at birth. Evidence shows that a number of young people who do stop their transition report it was because they did not have enough support or were experiencing discrimination due to being trans; some of these youth go on to transition later in life

The Government of Canada has made strong commitments to gender equality, using a feminist lens, and realizing and protecting sexual and reproductive health rights.

Key barriers and challenges related to inequitable and variable access to sexual and reproductive health services remain. Members of 2SLGBTQI+ communities, racialized Canadians, Indigenous peoples, and women and youth from underserved communities face the highest sexual and reproductive health risks and the greatest barriers to accessing support, information, and services.

An initial targeted call for proposals inviting select organizations to submit applications for funding was launched on July 29, 2021 and closed October 4, 2021. Nine projects were funded through that call. A second targeted call for proposals was launched on July 12, 2022, and closed on September 16, 2022. Thirteen additional projects were funded through the second call for proposals call. One unsolicited project was also funded.

Of the $45M committed through Budget 2021, to date, over $38.9 million has been allocated. Twenty-three projects, valued at $29.2 million, have been funded. Of these projects, four address access to abortion, seven address 2SLGBTQI+ communities, and four focus on Indigenous communities, including Indigenous youth and Two Spirit people. Two projects focus racialized people or newcomers, two more address youth from a range of populations, and four more address additional priorities. In addition, as the projects above are national in scope or focus on provinces and territories other than Québec, per capita funding of $9.7M has been allocated to the Province of Québec to support community-based organizations located in Québec.

Canada’s current national-level data on sexual and reproductive health is limited to a narrow range of indicators. There is insufficient data available to support understanding and evidence-based decision-making to address a full range of key indicators of sexual and reproductive health, including prevalence of sexually transmitted infections, contraception use, pregnancy intention, and sexual knowledge and behaviours.

Legal Landscape in Canada
Abortion became legal in Canada through the Criminal Law Amendment Act, passed in 1969. This allowed abortions to take place in hospitals, provided that the pregnancy posed a danger to the health of the woman, as determined by a three-doctor therapeutic abortion committee. In 1988, the Supreme Court of Canada held that the Criminal Code provisions restricting abortion were unconstitutional and struck them down.

Those unenforceable provisions were repealed in 2019 by An Act to amend the Criminal Code, the Youth Criminal Justice Act and other Acts and to make consequential amendments to other Acts (former Bill C-75); other abortion-related provisions had been repealed in 2018 by An Act to amend the Criminal Code and the Department of Justice Act and to make consequential amendments to another Act (former Bill C-51).

Patient charges for abortion services
Although access to abortion services in Canada has been improved by the approval and roll-out of Mifegymiso for medical abortion, the availability of surgical abortion varies both between provinces and territories and nationally. Health Canada is aware of coverage issues resulting in patient charges for surgical abortion services in a limited number of private clinics in both New Brunswick (1) and Ontario (5). Patient charges for abortion services received in private clinics are considered user charges under the Canada Health Act.

Access to Abortion in New Brunswick
In New Brunswick (NB), Regulation 84-20 of the Medical Services Payment Act limits coverage of surgical abortion services to approved hospitals (three NB hospitals currently offer the service – two in Moncton and one in Bathurst). This means that individuals who receive these services at the private clinic in Fredericton are required to pay out-of-pocket. New Brunswick is the only province with a private abortion clinic (Clinic 554) where the province does not provide coverage for services. In December 2022, the government of NB passed legislation allowing for some insured surgeries to occur in private clinics (including cataracts) as a means of reducing surgical waitlists. However, this new legislation did not extend to surgical abortion services in private clinics.

Patient charges for abortion services received in private clinics are considered user charges under the Canada Health Act and raise concerns under the accessibility and comprehensiveness criteria of the Act. Since March 2020, deductions totaling $334,766 have been levied against the NB’s Canada Health Transfer (CHT) payments in respect of patient charges for surgical abortion services. The lack of coverage for abortions performed in private clinics has been discussed bilaterally with NB since 1995, without resolution. Currently, Clinic 554 appears to be operating one day per week, offering only surgical abortion services for a fee of $700.

Access to Abortion in Ontario
In summer 2019, media stories in Ontario revealed fees charged to individuals to access surgical abortion services in some private clinics. Health Canada followed up on these reports by analyzing clinic websites, and by making phone or email inquiries to clinics of concern. While the Ontario Health Insurance Plan provides coverage for physicians' fees related to abortion services in all private clinics, the province only covers facility fees in the four private abortion clinics licensed as Independent Health Facilities (IHF). Evidence gathered confirmed that some private non-IHF abortion clinics charged fees for uninsured services, while not consistently informing patients these fees were optional, with respect to accessing insured surgical abortion services.

When the Ontario Health Ministry conducted further investigations the patient charges discovered were reported to Health Canada. These charges formed the basis of Ontario’s March 2021, 2022, and 2023 deductions (totaling $53,265). In December 2021, Ontario submitted a Reimbursement Action Plan to Health Canada, and has committed to revisit the current framework for the funding of insured surgical abortion services in the province. Health Canada continues to engage with Ontario as they work to implement their action plan to eliminate patient charges for access to abortion services.

U.S. Abortion Landscape
Dobbs v Jackson Women’s Health Organization in the United States
The U.S. Supreme Court, in rendering their decision in the case Dobbs v. Jackson Women’s Health Organization, held that the Constitution of the United States does not confer any right to abortion, overruling the decisions in Roe v. Wade (1973) and Planned Parenthood v. Casey (1993) that prohibit U.S. states from passing legislation criminalizing abortion. This decision makes it possible for states to criminalize abortion at their discretion.

Because of differences between the American and Canadian legislative and judicial systems, the Canadian legal context for abortion is distinct. In Canada, following the Supreme Court of Canada’s decision in R. v. Morgentaler (1988), abortion was decriminalized in Canada. There is therefore no regulation at the federal level regarding abortion. As with other health care, abortion service delivery is managed at the provincial or territorial level. Similar to other health care services, Americans coming to Canada would be able to obtain safe abortion care in Canada, but would have to pay for the service out-of-pocket.

US court decisions on mifepristone.
In response to conflicting rulings by two federal district courts, both of which were released on April 7, 2023, the US 5th Circuit Court of Appeals blocked U.S. District Judge Matthew Kacsmaryk’s order that suspended the Food and Drug Administration’s 2000 approval of mifepristone. However, the ruling also rolled back major changes the FDA has implemented over the years that have made mifepristone easier to use and obtain. The judges blocked mail delivery of the pill, reimposed doctor visits and shortened the length of time mifepristone can be used during pregnancy. In response to the rulings, several U.S. states are indicating an intention to stockpile mifepristone, as well as the other medication used to cause abortions, misoprostol.
On Friday April 14, the U.S. Supreme Court issued a five-day hold. This was extended until Friday, April 21. On April 21, the U.S. Supreme Court stayed the decision that would have undermined the FDA’s approval of Mifepristone; however, appeals have already been filed. The 5th U.S. Circuit Court of Appeals heard oral arguments on May 17, 2023. The ruling has not been released but it is anticipated that the case will continue to the U.S. Supreme Court on appeal from the losing party.

Mifepristone is not available in Canada; the only abortion pill available in Canada is Mifegymiso. Mifegymiso, marketed by Linepharma, is a combination drug that includes mifespristone and misoprostol, and is the only drug authorized in Canada for the medical termination of pregnancy. Mifegymiso is not available for sale in the U.S. Health Canada is in close communication with Linepharma to monitor the supply situation for Mifegymiso in Canada. At this time, there are no supply issues with the drug in Canada.

Misoprostol, manufactured by AA Pharma Inc, is indicated for the treatment and prevention of NSAID-induced gastroduodenal ulcers and for the treatment of duodenal ulcers caused by Peptic Ulcer Disease. It is used off-label for the treatment of miscarriages and medical termination of pregnancy. Health Canada has been in close communication with AA Pharma Inc. to monitor the supply situation.

While AA Pharma Inc. is currently reporting shortages of misoprostol due to issues with the availability of the active pharmaceutical ingredient; there is sufficient supply and the shortage is not expected to impact patients. The company is closely monitoring and in regular communication with Health Canada. AA Pharma Inc. does not market misoprostol in the U.S.

Barriers to care for trans and non-binary children and youth
Misinformation, disinformation and hate is emerging as a key barrier to care for transgender and non-binary young people. Misinformation and disinformation campaigns are active across Canada, these campaigns, in concert with high-profile legal cases and negative press, are impacting trans and non-binary young people, their families, and their health care providers.

The focus of misinformation campaigns tends to be on pubertal suppression, hormone therapies, and gender-affirming surgeries. These campaigns are designed to create fear about young peoples’ capacity to know their gender, consent to care as well as raise mistrust about established clinical practices. Some materials urge healthcare providers and parents/caregivers to question the validity of young people’s gender health needs and delay or deny access to necessary healthcare, placing trans and nonbinary youth at increased risk of harm. Stories of occurrences of ‘transition regret’ and ‘detransition’ are rare. They have prompted challenges to evidence-based healthcare practices and resulted in harassment, intimidation, and threats against healthcare providers working with trans and non-binary children and youth. Evidence, including Canadian research, indicates that in the rare instances where young people stop or reverse a transition, it is often due to lack of support from family and due to experiences of discrimination. Some of these young people restart their transition later. Others who have stopped transition do not express regret in relation to steps they took in transitioning, but instead considered these steps as a necessary part of their development of their gender identity.

• People in Canada, especially those from underserved populations (including people who are 2SLGBTQI+, Indigenous, racialized, living with disabilities, women, and youth), continue to face barriers in accessing abortion services. Barriers include lack of availability, lack of financial and logistical resources required to travel to abortion care, and lack of culturally safe, stigma-free sexual and reproductive health services. Health Canada’s Sexual and Reproductive Health Fund was created to advance mandate commitments relating to sexual and reproductive health and to strengthen the healthcare system and public health supports for vulnerable members of our communities, and those who have faced discrimination in Canada.