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.

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