Health Committee on June 18th, 2019

[Dr. Judith Bartlett, Retired professor, Faculty of Medicine, University of Manitoba, As an Individual]

Thank you for the invitation. I have lots of red marks on my paper because I realize I'm going to have to cut it down a lot.

I am going to talk about the Saskatoon Health Region lived experience of aboriginal women feeling coerced into tubal ligation. I and Dr. Yvonne Boyer were the co-studiers on that.

I won't go into the media reports. You've heard about those. We started this project—were asked to—in the fall of 2016. The Saskatoon Health Region had attempted before that to have a review, but they had an individual whom the community just wasn't going to trust, so no women came forward.

We proceeded with a community-based approach that involved pre-meetings with both the aboriginal and the health communities ahead of time, to get them to participate in the design of the study as well as to get their agreement to participate in the analysis of the data once we had it. It's a specific collective approach that I use in research.

We did literature searches, of course, looking at all the international tools, and reviewed all of the corporate documents and laws. At one point we realized we had to actually examine the child welfare law as well, because it did have an impact.

Eighteen aboriginal women called our confidential phone line. We interviewed seven of these—six in person and one by phone. Seven others made appointments, but for various reasons they were not able to attend. Some of them made a couple of tries, but they just weren't ready.

We did nine interviews with health care personnel and an interview with a couple of social workers, as well, from child welfare.

The interviews with the aboriginal women revealed that all clearly felt stressed and under much duress from being coerced, while they were in labour, into having a tubal ligation, and this added extra stress to the usual stress of childbirth. The review outlines the depth of the women's experience of being coerced. Themes arising reveal that aboriginal women were living, often, overwhelming and complex lives when this coercion was taking place. This complexity was intricately interwoven with the negative historical context of colonialism.

The overarching themes for the women were that aboriginal women felt invisible, profiled and powerless. They experienced the coercion. I don't have the time to talk about the details of that, but those are in the report. They talked about the impacts on their self-image, their relationships and their access to health care at a later time.

Such experiences as these keep aboriginal women from accessing health care. They're aware that the risk is higher to them, but they just cannot make themselves go, and that has implications for their children as well, and for the rest of their family.

Considering the distress they had and the angst they had about attending, the fact that they actually got there and told their stories to strangers was quite amazing.

The health providers were really concerned to hear that aboriginal women experienced coercion. Their overriding themes were in and around policy and team challenges. They realized there were negative attitudes toward aboriginal women and how this whole issue impacted internal and external care.

Data analysis revealed that health providers work in large, complex and ever-changing hospital systems and environments. Most felt that in recent years positive policy and practice had happened, but they did think that aboriginal women were still falling between the cracks. One thing they brought up, as did the women, was the issue of child and family services. On top of the coercion of having a tubal ligation, they were also often faced with their child being apprehended within a couple of days of birth. That was a major issue. They all came up with suggestions. You'll see them in the report and you'll see the details of the study in the report.

We came up with recommendations. In terms of the data, one thing we could not find was data on medical charts. We were able to get three medical charts, but the rest of them were destroyed at 10 years. That answers the question about litigation for some of these women. When their history goes back 20 years, there's no way to find that.

Saskatchewan, like all the provinces at that time, was in the midst of a lot of health care changes. We felt that their knee-jerk reaction to immediately stop tubal ligations post-delivery, unless you had a pre-discussion with a family doctor or an obstetrician, was going to be a real problem. The health providers and the women also thought that was going to be a real problem in the future. We suggested that the first thing they needed to do was to look at this policy. We also felt that they needed to utilize the resources they have. They have an aboriginal health council, they have a Métis and first nations health service, and they had, at the time, some sort of steering group that was working with changing their provincial policies. In these recommendations, we reminded them that there were requirements in Canadian law; that the implementation of an indigenous health engagement strategy, we felt, needed to be in place; and that there were requirements in Canadian law for consultation and accommodation.

Regarding cultural training, we recommended that they have mandatory cultural training looking at indigenous peoples and their cultures and at human rights cultures. There needs to be a clear addressing of the false stereotypes about aboriginal women being unable to look after their own children, where decisions are made for them.

In education, we recommended that there needed to be cultural competency in nursing, medical and all health professions. This is beyond cultural training. It means that there needs to be introspection by the learner to understand their own level of privilege in society. There are lots of papers on that. That can be learned.

They were talking about restructuring in Saskatchewan. We feel that the change has to be substantive, not simply an indigenization of health. That will not be enough. They need to begin extraordinary measures. It's been probably 20 or 25 years—I can't remember how long now—that we've had an Aboriginal Health and Wellness Centre in Winnipeg. Saskatoon has a large aboriginal population and they don't have that yet.

[The Chair, Liberal, Bill Casey]

I have to ask you to wind up, if you would. Thanks.

[Dr. Judith Bartlett]

Okay.

We thought they needed an advisory council to help the women who experienced this go through whatever process they selected to go through in order to go through a healing process. We expected that they needed to partner with expert groups—indigenous nursing, indigenous physicians and others—and that there be actual resources put on the table to ensure that those groups could participate.

Then, in terms of the issue of women who are at high risk, we recommended a reproductive centre of some type that would be supportive of women. One health provider stated that there were at least 30 high-risk pregnant women in her practice. There are examples. For instance, health providers talked about Sanctum House, which provides wraparound services for people living with or affected by HIV or AIDS, and Infinity House for mothers and children with transition—

[The Chair, Liberal, Bill Casey]

Dr. Bartlett, I'm sorry. We have to go to the DisAbled Women's Network of Canada now. Thank you.

[Sonia Alimi, Research Coordinator, DisAbled Women's Network of Canada]

Good afternoon.

Before we focus on the points we are discussing today, on behalf of the DisAbled Women's Network of Canada, we want to remind you that we are meeting on unceeded Algonquin territory and highlight the period of truth and reconciliation we are now going through. So let's take this opportunity to focus more specifically on the needs of our aboriginal sisters and on how we can repair the harm caused to improve the lives of current and future generations.

We thank the Standing Committee on Health for inviting our organization to testify and we recognize the other witnesses here today.

We will make our presentation in both official languages.

At the DisAbled Women's Network of Canada, we are committed to denouncing oppressions intersectionally. So we address oppressions stemming from ableism, a system that infringes on the rights and freedoms of people whose abilities do not meet the standards, as well as racism, colonialism, sexism and other systems of oppression.

When it comes to forced sterilizations, we think they are a direct consequence of an ableist society. In that sense, they have specific repercussions on girls and women with disabilities. Jihan Abbas will highlight that painful observation.

Let's not forget that forced sterilization is closely related to a eugenic vision to determine and hierarchize individuals and their possibilities of existence. It is based on the logic of ableist oppression, which has established notions of deviation, by targeting what is missing, what is against nature and what can be oppressed and limited. As a result, we consider that forced sterilization, being a concrete expression of the ableist system, opens the door to racist, colonialist and sexist practices, among other things.

We know that racism and ableism are tightly interwoven. It is very useful to remind you that the eugenics movement, both in the United States and in Canada, had to do with the white supremacist ideas focusing on the degeneration of the white race. An overwhelming number of black women have been subjected to and are still being subjected to non-consensual sterilizations.

Researcher Shatema Threadcarft, in her 2016 work on intimate justice and the bodies of black women in the United States, shows the prevalence of those practices.

Canada is no exception in that respect. Before the Standing Senate Committee on Human Rights, university professor Josephine Etowa revealed that, during a study on the health condition of black women in Nova Scotia, it was noted that hysterectomy was being practised in a worrisome proportion. Here is what Ms. Etowa said, and I quote:

They started telling us their personal stories of how women in their community, especially those with dark skin colour, every time they went to the doctor, even in their early twenties, hysterectomy was one of the answers to whatever problem they went to see the doctor for.

So we understand how racism and ableism are expressed, and we see that this is an important issue in the forced sterilization file.

It is also a problem experienced by trans and intersex individuals.

Alexandre Baril, assistant professor at the University of Ottawa, states in his 2013 thesis that the Canadian government requires trans individuals who want to acquire a marital status to undergo changes to their genital organs involving a suppression of the ability to reproduce “naturally”.

Canadian sociologist and anthropologist Morgan Holmes, who represents the Egale Canada group, also reports on the concrete effects of cisgenderism leading to the forced sterilization of intersex individuals, especially children. She also appeared before the Standing Committee on Human Rights, on May 15, 2019. During her presentation, she denounced the paradox of subsection 268(3) of the Criminal Code, which, while prohibiting female genital mutilation, authorizes surgical procedures on intersex children, whose reproductive capabilities are removed with impunity and without consent.

On another note, which still continues to shed light on the situation intersectionally, the issue of sterilization also affects women in prison in large numbers. A U.S. study from 2016 talks about the pressures on incarcerated women to undergo surgeries to remove their reproductive capabilities. That same study confirms that those injunctions always seek to respond to a eugenic and ableist system.

The facts I am sharing here with you are only the tip of the iceberg. It is important to know that many other women at the intersection of multiple oppressions are subjected to forced sterilization. That is why we feel it is important, in the context of our presentation, to insist on the intersectional dimension of this problem and to show that solutions cannot be found outside such an analysis.

I will now yield the floor to Ms. Abbas.

[Jihan Abbas, Researcher, DisAbled Women's Network of Canada]

In Canada, women with disabilities have historically been targeted for coercion and forced sterilization, and they remain vulnerable to these practices even today.

Canada was of course influenced by the eugenics movement throughout the 20th century. In fact, both Alberta and British Columbia had legislation enabling sterilization for anyone diagnosed as “mentally ill” or “deficient”. Data from the Alberta Eugenics Board case files indicate 1,154 women with disabilities were sterilized under these practices. Close to 40% of these were sterilized after 1955.

Sterilization laws in Alberta were not repealed until 1972. Unfortunately, in the case of British Columbia, records of these practices have been lost or destroyed. While other provinces may not have had official sterilization laws, countless women with disabilities were likely sterilized, as these procedures were often performed on young women with disabilities through parental consent. As well, sterilization practices in Canada have also been sexist, racist and imperialist and have disproportionately targeted indigenous women.

There are two examples of case law that show the vulnerability of women with disabilities to forced sterilization, as well as the possibility for legal protection. In 1995, Leilani Muir, a woman with an intellectual disability, successfully sued the Alberta government over the practice of forced sterilization. Muir, who had been admitted to the Provincial Training School for Mental Defectives in 1955, had been sterilized at age 14. Her advocacy led to an official apology from the Alberta government and compensation for hundreds of others.

There was also the 1986 Supreme Court of Canada decision known as the Eve decision. The case involved a 24-year-old woman with an intellectual disability. The mother had argued that, as her daughter's substitute decision-maker, she wanted to be authorized to have her daughter undergo tubal ligation. The Supreme Court ruled against the mother, saying that the procedure was “non-therapeutic”.

This landmark decision was a critical turning point in the struggle for recognition of the rights of persons with intellectual disabilities. It ended the long-standing practice of non-therapeutic sterilization of people with intellectual disabilities and other mental disabilities and affirmed that, regardless of cognitive ability, all persons have a fundamental right that cannot be overridden.

Despite these cases, parental influence continues to be a factor for young women with disabilities, as parents still wield power and control that can influence access to and decisions around reproductive health.

In our own research, the recently released “More Than a Footnote” report, we spoke to one woman who shared that her parents had made reproductive health choices on her behalf without her consent and against her will. Much of the existing research here deals with women with intellectual disabilities, as they appear particularly vulnerable to this. They have inadequate access to education and they're more likely to experience poor reproductive health outcomes.

We also want to note that in terms of reproductive coercion young women and girls with disabilities may be subject to problematic forms of power and control over their reproductive health because of the role of adult decision-makers in their lives. Of course, here is the intersection of paternalism and ableism.

One recent Canadian study framed these ongoing forms of coercion as violence enacted upon young women with disabilities and drew attention to some of the most prevalent forms. These include birth control sabotage, pregnancy coercion and controlling the outcomes of a pregnancy.

For young women with disabilities, there are unique dynamics that require our attention. On this note, the continued use of Depo-Provera as a contemporary practice is something to which we must pay attention. Depo-Provera remains controversial, and its side effects can be serious and are not well understood. There is evidence that this was prescribed to women with disabilities before it was approved in Canada as a contraception. As well, one Canadian study found that young women with intellectual disabilities were commonly prescribed this in response to family and caregiver concerns about pregnancy and menstrual hygiene.

One of the most disturbing things we've come across is the practice of applying invasive growth attenuation treatments, commonly referred to as the Ashley treatment, to children with complex disabilities and medical conditions. It's aimed at keeping them small, presumably to make it easier for their caregivers to provide care. Procedures can include things such as high doses of estrogen, hysterectomies and breast bud removal. While this practice seems more prevalent in the U.S., it has spread to other countries and it's difficult to gauge what is happening here in Canada. There is a need for a dedicated space to explore these things.

Finally, in DAWN Canada's research, it has also been illustrated how widespread reproductive coercion is for women with disabilities. Women with disabilities share that while they may not be the victims of forced sterilization, as they would have been historically, they continue to be actively pressured against motherhood. There are continued reminders from family, friends and medical professionals that shape their decision-making.

Of course, there are several factors that increase vulnerability among this group. These include limited contraception options and a lack of knowledge among health care providers about disability.

We have recommendations to reduce this vulnerability. These include supporting self-advocacy so women and girls with disabilities become partners in their own care, teaching health care providers about disability to avoid ignorance and ableism, and conducting more research and policy analysis to examine the many insidious ways in which women with disabilities and their bodies are controlled by caregivers, parents and support workers.

Finally, in terms of broader action, DAWN Canada points to the promise offered through the Nairobi principles, which seek to affirm sexual and reproductive rights through an intersectional lens that is inclusive of both a gender analysis and the very real impacts of ableism on the lived experiences of women and girls with disabilities. These principles move us collectively to a place that affirms both the need for access to safe abortion and the need to consider the ways ableism shapes autonomy and access to reproductive health.

Thank you.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we go to Dr. Richardson.

[Dr. Lisa Richardson, Chair, Indigenous Health Committee, Royal College of Physicians and Surgeons of Canada]

Thank you for having me here on behalf of the Royal College. I'm the chair of the indigenous health committee there and one of the few indigenous physicians at the University of Toronto. I practice general internal medicine. I'm very actively involved in indigenous medical education and I really want to focus my opening on the role of education and where we should go following these terrible and very upsetting activities. Particularly since I am a health practitioner and an indigenous woman, that intersection makes this topic area extremely personal and difficult to talk about, quite frankly.

I want to provide some context and background for how we think about the experiences of indigenous peoples overall in the health care system. We have ongoing evidence of the mistreatment of our peoples within health care. They experience racism and this most egregious manner of mistreatment in the form of forced sterilization. We have ample evidence around that: the Health Council of Canada reports, our health council report, and the “First Peoples, Second Class Treatment” report, as well as all of the anecdotal evidence that we experience every day as indigenous health advocates.

For example, I received a phone call from my colleague in emergency saying, “You need to come down and deal with this. I have a patient who's just had a large acute myocardial infarction and did not have any lifesaving treatment for six hours because there was a thought that this person was inebriated.” This is the reality of our peoples within the health care system.

Second, there is the intersection of this with being an indigenous woman. For these women who've experienced the forced and coerced sterilization this is, of course, another layer of intersection. I appreciate my colleague's approach to intersectionality, because we know that the vulnerability of an indigenous person in the health care system is extreme. Add to that the experience of being an indigenous woman and everything that we know from the MMIWG report and the embodiment of colonial violence is actually compounded when one enters the health care system. That is the context in which we need to consider how we move forward on this.

One of our major recommendations is that there be a large commitment to and investment in cultural safety education for our health care providers. This is what we are actively committed to at the Royal College. In fact, we passed a motion in our council in 2017 to make indigenous cultural safety and anti-racism education a mandatory component of every subspecialty training program across the country, as well as a part of accreditation. That needs to extend to people in practice. There needs to be an understanding not only of the specific needs and how to have important conversations in a culturally safe way with all practitioners but also of colonial and historical practices and how they continue to play out in that patient-provider interaction.

Working with a wonderful team at the Royal College, we're really trying to pull together information and push this out, but that leads to recommendation two, which is that we need to have accountability measures in place. We need data. I'm a physician. I'm a scientist. We need data, but I would argue that we need to think about what counts as data, because we don't need a randomized controlled trial to elucidate the fact that there is a problem here. We have stories from people coming forward. What we need to do is to facilitate that coming forward for those people, the women who've experienced this or who are concerned about an interaction, in a way that is safe and that lets them know that they will be listened to and that their experience as an indigenous person is actually recognized and valued.

What are some mechanisms through which one might do that? I want to draw upon what I think are different layers as to how one might think about this kind of work. I'm very familiar with some of the mechanisms in Ontario. One could leverage some of the quality metrics and quality standards that exist at the provincial and regional health authority level, such as the Excellent Care for All Act in Ontario, under which we're asked to have quality improvement plans, patient safety questionnaires, etc.

How can we build on these experiences of indigenous patients and indigenous women and, in particular, have an understanding of what policies and procedures exist around sterilization practices? How can that be embedded within existing structures?

At a larger level, how can PHAC, for example, build on the amazing work that's been done with the opioid crisis to collect, gather data, and then report on it? What I love about PHAC and the opioid response is that you can go on the website and actually see what the data is and what the numbers are. That level of transparency is very important when you're working with our communities.

The third piece I want to speak about is that in our practice at the Royal College we recognize that we are a colonial institution. We're working very hard to decolonize, but we recognize that tension. We have amazing indigenous practitioners who are working there, but our practice is always one of self-determination and allyship. Even though I'm an indigenous person working at the Royal College, I'm still working within a non-indigenous institution. We support our colleagues and national indigenous organizations in their calls around the criminalization of this behaviour and of this practice.

I actually believe, and in hearing the earlier testimony, that the current system is not working. How can we look at changing the Criminal Code in order to make sure that these cases are being appropriately investigated and followed? Thank you.

[The Chair, Liberal, Bill Casey]

Thank you.

Now we go to Dr. Blake.

[Dr. Jennifer Blake, Chief Executive Officer, Society of Obstetricians and Gynaecologists of Canada]

Thank you very much.

I'm the chief executive officer of the Society of Obstetricians and Gynaecologists of Canada, commonly known as SOGC. I am an obstetrician-gynecologist. I'm also adjunct professor of obstetrics and gynecology at both the University of Ottawa and the University of Toronto. In the past I've served as chief of obstetrics and gynecology and head of women's health at Sunnybrook Health Sciences Centre, chief of pediatric gynecology at the Hospital for Sick Children, and undergraduate dean of McMaster University's medical school. I'm bringing a lot of years with me.

Let me begin by saying that when I was first contacted about forced sterilization, I assumed we were talking about a deep historical practice. I was shocked to hear that we were talking about something that's current. It is my hope that, as of today, it is indeed history.

I also need to say that I'll be referring to women using “she”, “her” and “hers”. This is not because we are not mindful of the needs of all persons, but because the fundamental mission of the SOGC is the advancement of the health of women. As I think we've heard amply today, that work is not yet done.

The SOGC is a professional society that draws its membership from obstetricians, gynecologists, family doctors, nurses and midwives—many professionals. It advocates on behalf of women to receive quality care throughout their sexual and reproductive lives, including, always, the right to safe, respectful and culturally appropriate care. There are more than 380,000 childbirths in Canada each year. In each case, we believe that the caregivers are extraordinarily caring and professional and are mindful of the particular vulnerabilities we have when we are pregnant and when we are in labour; we can talk about what those are. We also guide women through a lifetime of intimate gynecologic needs. These needs must always be met with uncompromising professionalism and respect.

The SOGC advances health care through education, advocacy, leadership and collaboration. We have no examining, licensing or regulatory authority over any health care provider. We do provide clinical practice guidelines—10 to 17 each year—that are carefully researched and are interprofessional in their development. I would draw your attention to the 2013 guideline on cultural competence, which was developed by our indigenous women's health committee in consultation with many indigenous women's groups.

This is part of our significant educational role, providing professional development to licensed members, all based on a philosophy that respects sexual and reproductive health as a human right. These rights have been well described by the United Nations. The right to decide freely and responsibly the number, spacing and timing of an individual's children, and to have the means and information to do so, is a fundamental human right. We also seek to recognize and remedy the inequities of access and outcomes faced by indigenous women and vulnerable women in Canada and around the world. This is also in call to action 19 of the TRC report.

I'm here today to speak about the experiences of sterilization brought forward by indigenous women and described in the Boyer and Bartlett report. I need to say that coercion has no place in any surgical procedure. As physicians, we fully understand the ethical primacy of autonomy, and therefore, of freely given and fully informed consent, but consent is influenced by context. I need to address some of those contexts and considerations.

First, the bar for informed consent is much higher for vulnerable persons and for elective procedures than it is for life-threatening situations in an emergency room, for example, and particularly so for irreversible ones. For such an important choice as permanent sterilization, it is preferred to have these discussions long before delivery, for reasons that I can explain. It's always more challenging to obtain a fully informed consent when a person is in pain, or in crisis, or far away from her home and community. The process of obtaining consent is far more complex than just obtaining a signature. It's a thoughtful discussion of the procedure's risks and benefits but also the alternatives. For example, a hormonal IUD provides far better contraception than sterilization and is reversible, and a vasectomy carries much less surgical risk than a tubal sterilization.

There may be circumstances that lead to a late request. Dr. Bartlett alluded to the fact that a moratorium can also be harmful. However, we need to be aware that for some of these, such as a life-threatening complication that would arise in a subsequent pregnancy, you might not know it until the time of delivery, and therefore, that's the time when this discussion is happening. That is a problem, and you have to be extremely careful. It can result in a strong recommendation against subsequent pregnancies. Communication is critical, but it is always the woman's informed choice to make. It is her decision whether she wishes to have or to not have a sterilization, and to understand the risks that go along with either of those choices. There are risks, in that case, with either.

For no other procedure do we worry as much about the risk of regret as we do with tubal sterilization. We always have to worry about the woman not having reason for subsequent regret. The ability to bear a child is so fundamental. Tubal sterilization we always consider permanent and an irrevocable choice. There are different methods, and some of them are potentially reversible, but those reversals carry a risk of tubal pregnancy, which can be a life-threatening complication, especially if you live in a remote community.

Consent is fundamentally based on a therapeutic alliance between the patient and her health care provider. If that therapeutic relationship is not present, it's far more difficult to be sure that you do indeed have consent. Circumstances that erode trust are a perceived power imbalance and the experience of racism and isolation. All of these intersectional stresses that we've discussed can make it very difficult to be sure that consent has been freely given. The assent may be there, the signature may be there, but there is no true test of consent. That is one of the complexities.

As a physician, you are not aware of what's gone on before. You don't know whether conversations have gone on that might have influenced the decision. You don't know about prior traumas that may have led to an impaired consent. If a woman is incarcerated, does she have children in care? Has she been threatened with loss of her children? Are there other pressures at play that she might not disclose? Is she struggling with addictions? Is she a victim of human trafficking? All of these things make us vulnerable. The crucial context might not be disclosed due to fear or a sense of powerlessness or hopelessness. They can be difficult to determine in the best of circumstances, but when you're in a crisis or an acute situation, you really don't know.

Cultural safety and literacy are important competencies that we hope will lead to improved therapeutic relationships. We are well aware that how we communicate is culturally bound. It's not just about the language. A thousand other cultural influences bind our ability to communicate and to reach understanding with one another.

We support the recommendations of TRC calls to action 23 and 24. Those in fact were why we published our guideline in 2013. We believe this is crucial. We believe the currently available cultural safety training does not specifically or adequately deal with issues with respect to women's health. There are specific needs that this issue brings up that have to be brought forward. They are far more complex and just add layers of nuance to what needs to be taught.

Decisions with respect to fertility or sterilization are far more complex than a relatively simple technical procedure. I've seen women refuse cancer-curing treatments in order to not risk the potential that they might have a child, and they died knowing they'd made the right decision even though they had in fact never been able to conceive. Fertility is something that is deeply important to people.

While the cases that have come to light focus on indigenous women, we at the SOGC believe these considerations apply to all people, regardless of their identity. Trust, communication and understanding are paramount in any relationship. No physician wants to learn that a patient they treated in good faith gave their consent under coercion. We will work with all involved parties—we welcome this hearing—to ensure that a process is in place to protect the freedom of reproductive choice that all women should enjoy.

We support the recommendations of TRC calls to action 23 and 24 for cultural competency training, but we specifically call for additional modules dealing with the issues around women's health. We think all contraceptive options need to be fully available to all Canadians, free of barriers. We know that cost is a barrier for many. That ranges from education to cost-free access. We know that long-acting reversible contraception is the superior method of contraception, but we don't have implants yet in Canada that are easily inserted, easily removed and provide effective contraception. They are available in just about every other country. Not every woman wants an intrauterine device.

Finally, healthy pregnancy and childbirth lie at the heart of a healthy community. The most important thing that any of us has is our family. We know that a multitude of transgenerational harms can be transmitted in pregnancy and, conversely, can be mitigated by a healthy pregnancy, and there is so much evidence on this. That means good nutrition, clean air and water, and appropriate health care in a supportive and caring community. We ask the Government of Canada to really help ensure that every Canadian has the best start in life.

Thank you.

[The Chair, Liberal, Bill Casey]

I just have to say that you're all amazing. I think we're so lucky to have access to your experience, your knowledge and your thoughts.

As you did, Dr. Blake, I thought we were talking about something historical when this first came up.

[Dr. Jennifer Blake]

Yes.

[The Chair, Liberal, Bill Casey]

For a lot of us here, we're just scratching the surface in learning about this.

We will now go to questions. We're going to start with Dr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Chair.

Thank you all for coming.

Dr. Abbas, you hit the nail on the head. During the testimony, one of the words that came to mind from my medical training was the word “paternalism”. As a medical student, I would overhear these conversations at other tables among more senior practitioners: “This 23-year-old is on her eighth pregnancy. I'm going to do a caesarean.” “Why don't you just ask her if she wants a tubal when you do that?” More often than not they would be indigenous, but basically they would be people who were poor. Again, indigenous people are overrepresented among those in poverty.

I think I know the answer to this question, but if someone is in this situation and she's about to go in for a caesarean and the doctor says, “We're going in. Since I'm in there anyway, and you already have eight kids, do you want a tubal ligation?” would you call that being coerced?

Dr. Bartlett, I see you nodding your head.

[Dr. Judith Bartlett]

I would call that being coerced. That woman is in no condition emotionally to make that kind of decision. In fact, that happens—you're correct—more often than it should happen. Any time you're being asked to make a decision when you're not in a state of mind to weigh out the pros and cons, then it's coercion.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

Would we say there's general agreement to that around the table?

Go ahead, please.

[Dr. Jennifer Blake]

Can I just say that there is general agreement, but you don't know the circumstances. You've painted a picture in such a way that someone, in kind of a cavalier way, is saying, “While we're in there”, but you don't just “while we're in there” get to a caesarean section. Is this her eighth caesarean section, for example? Where does she live? I think in any case, you can talk about generalities—

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Absolutely.

[Dr. Jennifer Blake]

—but you have to really understand that there are specifics in each situation that need to be really thoughtfully considered.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

I agree. I meant if they were doing it, because as we know.... Again, I don't like to admit this on behalf of my profession, but there are those who do make cavalier decisions sometimes, and tragically enough they think their intentions are good even when you realize that ultimately there are very disastrous results.

[Dr. Jennifer Blake]

We can agree that cavalier decision-making is not good decision-making and is inappropriate.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Absolutely.

This is a question for all the people across the board here with medical backgrounds. If you find that a sterilization was performed and, in fact, the woman did not give consent, what sanctions or actions is a regulatory body like a licensing authority—for example, the provincial college of physicians and surgeons—able to take?

[Dr. Jennifer Blake]

Depending on the circumstances, you can lose your licence to practise. There are a range of issues, but if in fact there is coercion, which is operating without consent, that is actually something that would result in disciplinary action and there are a range of actions that the college can impose right through to permanently barring someone from practising.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

Dr. Richardson, you talked about the culturally relevant education. I agree. We had much of this in residency. I'm a rural college graduate from the EM program.

We find that for such fundamental issues this needs to be done more or less before residency. Has there been dialogue with the medical schools to get such culturally appropriate and culturally sensitive training at a very early stage, before people are heading out to the wards to actually see patients?

[Dr. Lisa Richardson]

Thank you for the question. It's actually great timing, because our major national organization, the Association of Faculties of Medicine of Canada, which is for undergraduate medical education, the Royal College and the College of Family Physicians of Canada are meeting next Sunday, because our deans have approved the creation of a national consortium in order to make sure that we are sharing and doing this work.

I'm going to speak as an educator. It's a spiral, so that you start before you enter medical school. We're now having conversations about having as a requirement for entry into medical school cultural safety education, so that once our students arrive, we're not having to teach what one of my elders calls “Indigenous 101”, but are actually able to delve into this. How does one practice trauma-informed care? How does one have these complex conversations where there's historical trauma?

We are all committed to that. It's happening. In fact, it's been happening in the medical schools for much longer, and now we're extending this into residency training.