THE STANDING SENATE COMMITTEE ON HUMAN RIGHTS

EVIDENCE


OTTAWA, Monday, April 25, 2022

The Standing Senate Committee on Human Rights met with videoconference this day at 5:04 p.m. [ET] to examine such issues as may arise from time to time relating to human rights generally.

Senator Wanda Thomas Bernard (Deputy Chair) in the chair.

[English]

The Deputy Chair: Honourable senators, I am Senator Wanda Thomas Bernard from Nova Scotia, deputy chair of this committee. I join you today from my home community of East Preston, which is in Mi’kma’ki, the ancestral and unceded territory of the Mi’kmaq people.

I would like to introduce the members of the committee who are participating in this hybrid meeting. In the room is Senator Audette from Quebec, and online, we have Senator Boyer, Ontario; Senator Gerba, Quebec; Senator Hartling, New Brunswick; Senator Omidvar, Ontario; and Senator Wells, Newfoundland and Labrador. Also, welcome to all who are viewing these proceedings across the country.

Today, we are continuing a study that began in 2019 on the forced and coerced sterilization of persons in Canada. The committee tabled an interim report on this topic in June 2021. We will continue this review with three meetings, and we will then table a final report.

I would now like to introduce our first panel of witnesses. From Indigenous Services Canada, we have Dr. Evan Adams, Deputy Chief Medical Officer of Public Health, and Aimie Hillier, Acting Director, Healthy Children, Youth and Families Division, First Nations and Inuit Health Branch. From the Public Health Agency of Canada, we have Tasha Stefanis, Associate Vice President.

Dr. Adams is a former Chief Medical Officer of the First Nations Health Authority, and Ms. Stefanis was, until recently, with Health Canada and worked on this issue.

I invite Dr. Adams to make his opening remarks. Afterward, we will have questions from senators for Dr. Adams, Ms. Hillier and Ms. Stefanis.

Dr. Evan Adams, Deputy Chief Medical Officer of Public Health, Indigenous Services Canada: Thank you very much. I am calling in today from my home territory of Tla’amin First Nation, which is about 150 kilometres from Vancouver.

We’re all here because we are disturbed by ongoing reports of the forced and coerced sterilization of Indigenous women in Canada. Sterilization of women without their informed consent is a form of gender-based violence. It constitutes an assault and is a criminal offence. It is inconsistent with basic human rights and medical standards, and it is unacceptable that this could happen and continues to happen in Canada’s health care system.

For Indigenous women in particular, forced and coerced sterilization is an act of sexism, racism and cultural genocide, rooted in colonization and paternalism, which disrupt continuity of care and future generations.

My remarks are rooted in my experience, and I am here as both the Deputy Chief Medical Officer of Public Health for Indigenous Services Canada and also as an Indigenous physician.

I clearly recall through medical school and residency being asked by obstetricians many times: “What are you going to do about Indigenous birth rates and teen pregnancies?” The judgment and sense of entitlement that I remember illustrate the arrogance, racism and sexism that can be so pervasive across a profession that is in such a position of power over women. In my first five years working in Aboriginal family practice, I was often in Vancouver’s Downtown Eastside, where there are many Indigenous people. In that area, an entire industry has developed, with some men highly invested in the exploitation, subjugation and degradation of women, many of them Indigenous women and many of them challenged by mental health and/or substance misuse issues.

The issue of forced and coerced sterilization, in many ways, links those two experiences. Violence is normalized, as are paternalistic and racist approaches to clinical care for women.

All Indigenous women must receive culturally safe health services, no matter where they live or who provides services to them. Both the TRC Calls to Action and the Calls for Justice from the National Inquiry into Missing and Murdered Indigenous Women and Girls call upon us all to ensure Indigenous women receive culturally safe services, including health care.

In May 2019, my colleague Dr. Tom Wong spoke to you and referenced the British Columbia First Nations Health Authority’s declaration on cultural safety and humility. I am pleased that Dr. Malhotra from the First Nations Health Authority is here to speak to you as well. Cultural safety and humility differ from cultural competence as they are first and foremost about actual safety. This is principles-based, patient-centric care where health practitioners understand their role as supportive and are committed to providing safe environments. This is the model that Indigenous Services Canada hopes to see replicated across other jurisdictions in Canada.

Since Dr. Wong last appeared before you, and stemming from a recommendation made by the Inter-American Commission on Human Rights, Indigenous Services Canada provided funding to Indigenous women’s organizations to develop information products on women’s reproductive rights and to begin to understand the scope of forced and coerced sterilization.

Further, the Advisory Committee on Indigenous Women’s Well-Being, established in 2019, in response to the issue of forced and coerced sterilization, provides the department with distinctions-based advice, guidance and direction on issues affecting the health and wellness of Inuit, Métis and First Nations women. The committee, led by Indigenous partners, has evolved to become an important avenue to mobilize Indigenous partners, federal departments and professional organizations to take collaborative actions on women’s well-being. Culturally safe reproductive health care has been identified as the committee’s champion priority.

Indigenous Services Canada is well aware of the need for collective action across governments and professions to address forced and coerced sterilization. Collaboration with Indigenous partners is paramount, and opportunities for the voices and lived experience of Indigenous women must continue to drive our response. To this end, the department’s supported a 2020 national forum on informed choice and consent in First Nations, Inuit and Métis women’s health services bringing together over 100 stakeholders from across Canada to examine current realities and future directions for informed choice and consent in Indigenous women’s health services.

Themes arising from this forum echo in the Indigenous women’s advisory committee priorities. They work towards addressing the following issues: promotion of Indigenous-led midwifery and Indigenous patient advocates, accountability, improved data collection, the role of child welfare, changes to the Criminal Code and mandatory anti-racism training for health care providers.

Following the racist mistreatment and tragic death of Joyce Echaquan, the Government of Canada also convened three national dialogues in October 2020 and January and June 2021, which brought together Indigenous organizations, provincial and territorial governments, health system partners and people with lived experience to discuss and present plans for concrete actions to eliminate anti-Indigenous racism in health systems. These conversations are ongoing.

The federal response to the national dialogues consists of initiatives and activities that will improve access to high-quality and culturally safe health services, including those for Indigenous women, 2SLGBTQQIA+ people, people with disabilities and other marginalized groups who are disproportionately impacted by anti-Indigenous racism.

Budget 2021 provided $33.3 million to expand support for Indigenous midwifery and doula initiatives as recommended by the Indigenous women’s advisory committee. Midwifery recognizes informed choice as a central tenet and is considered a protective factor against anti-Indigenous racism across health and social systems. This investment also strengthens funding for national Indigenous women’s organizations, youth sexual health and regional and grassroots organizations.

We are committed to continued work needed with partners to address forced and coerced sterilization as part of a broader imperative to eliminate systemic racism, improve cultural safety, support the transformation of health service delivery and reduce the barriers that Indigenous people, and particularly Indigenous women, face when accessing health services.

I would be very pleased to take your questions. Thank you.

The Deputy Chair: Thank you, Dr. Adams.

Now we’ll go to questions from senators. We’re going to start with Senator Hartling, followed by Senator Boyer.

As it was our previous practice, I would like to remind each senator that you have five minutes for your question, and that includes the answer. For those on Zoom, please use the “raised hand” function if you have a question. For those in the committee room, please advise the clerk. When asking your question, please indicate if you are requesting an answer from a specific individual or from each member of the panel. We’ll now go to questions, starting with Senator Hartling.

Senator Hartling: Thank you, Dr. Adams. It was a very interesting presentation. It’s hard to believe, and it is shocking that this still happens in Canada, but we know it does. In our last study, it was revealed the number of people this has happened to. I’m wondering about health care professionals. Are they aware of the consequences and the damages this is doing? What should happen to people who continue to do this? Are there some good regulations we could suggest that would help for prevention and attitudinal changes, education, things like that? What could you tell me about that?

Dr. Adams: In my opinion, it’s very clear in the midst of our medical training to do no harm and that we must work within the scope of which we are trained. Deciding for a person the course of their treatment without proper consultation or informed consent is absolutely verboten. It doesn’t mean, though, that certain health care professionals and definitely certain individuals don’t have a kind of gaze or a kind of positioning about how women should conduct their pregnancies, how often they should be pregnant, the age of their pregnancy, what they should eat, what reproductive services they should access or not access or what services they should have access to.

I think the solution in those situations is to have very clear policy about how these situations are to be conducted and to have very clearly stated policy around what happens when patients are harmed or when the rights of patients are transgressed. I think it is the responsibility of every health institution to be clear on those policies and for individuals in their employ, i.e. obstetricians and other doctors who might be performing these services, to be completely and fully aware of these policies as a condition of their employment.

I already mentioned some of the other issues that need to be addressed. It’s not just having the policy but having data as well around when those policies are transgressed, when harm happens and the resulting repercussion. There should not be violence, racism, sexism in the health care system without repercussion. That’s definitely not punitive. There could be some kind of restitution. But, definitely, these kinds of actions should not be occurring without some kind of balance and obligation on the part of the caregiver to address their own actions. Thanks.

Senator Hartling: Thank you very much.

Senator Boyer: Thank you, Dr. Adams, for your very interesting presentation, although sad. I know that you’ve worked with both feet: one foot in the community and one foot at the highest level of civil service. I am wondering about how many survivors were actually involved in the over 100 people, professionals and others, who attended the anti-racism forums? How important is it to actually hear from the voices of the people who have been sterilized, particularly when looking at solutions to some of these problems?

Dr. Adams: Thank you. I unfortunately don’t know the breakdown of the attendance of those three different national forums. I do think that the majority of those presenting on anti-Indigenous racism in the health care system were health care professionals and not patients. I agree; I think it’s very important to hear directly from consumers, patients, clients and people who have been affected by the system, because often it has been the system that hurts them. People who have feet in both camps, like Indigenous health care workers, are not representative of Indigenous patients, clients, who are being served and often harmed in a different way.

For instance, when I’m in the health care system, I am a very privileged and high-status patient, unlike many other Indigenous patients. So we must never mistake Indigenous caregivers for the voice of Indigenous clients. I do hope that we will have more and more occasions to hear from women and people who have been affected by these kinds of actions. It’s almost unfathomable to others, but I definitely made a point today of talking about my everyday realities as a medical student so that you can see clearly how mundane and frequent people’s disdain for Indigenous women is — how often there is disdain for their reproduction, their families and the choices that they make in life, how often they’re being judged and how often they’re getting kind of a weaponized repartee with the health care system.

Senator Wells: Thank you, Dr. Evans, for your presentation. I look forward to further presentations. Although we studied this in a previous Parliament at Human Rights Committee, it seems like we only scratched the surface.

First, I want to recognize the work of Senator Boyer on this topic. It was something I was unaware of until those earlier human rights committee meetings. Thank you, Senator Boyer, for your work then and for your continuing advocacy for this.

In the UN Committee Against Torture’s report, Canada’s response noted there were sections of our Criminal Code whereby forced sterilization would be considered an offence, namely, sections 265, 267 and 268. I’m assuming there’ve been no prosecutions under these sections of the Criminal Code. Why wouldn’t there be? From your lofty perch as Deputy Chief Medical Officer, is there something more specific required to address this?

Dr. Adams: I think you will hear more from Dr. Malhotra, who will follow me, about the issue of informed consent. I’m assuming that at least some of the physicians who perpetrated these kinds of offences would have believed that they had some kind of informed consent, but I would also dare say that they felt that they perhaps were doing what they considered best from their own purview around protecting a population.

From our perspective as physicians, we must know exactly where the line is. We’re not supposed to be giving care that is unwanted by the client. If a woman has not asked for sterilization, the physician, regardless of how righteous they feel working from their position, is not allowed to intercede. That is going beyond the scope of their work. I’m also curious why there hasn’t been prosecution of physicians who have done this. I think it is, in part, because we are only just learning how to complain about physician offences. I think we’re also only just learning to question authority in an effective way. For instance, you might have physicians saying, “Well, isn’t this part of my work? Why are you talking to me this way?” Physicians, generally, are not questioned about their actions in the way that I think other workers are questioned about their actions, but we can definitely learn to do that.

Lastly, part of what physicians can and will be learning is that there is oversight on their work. Who is the boss of them? They’re not just independent contractors. Who has a say in how they practise? At the First Nations Health Authority in British Columbia, the chiefs did flex their right to have a say over how physicians practise with their population and in their territories.

Senator Wells: Is the brick wall that rests between the public or the law, and the concept or the practice of very strict patient-doctor confidentiality also an impediment? Maybe one of our guests who hasn’t spoken yet could answer this better or as well. Is that also an impediment to knowing what happens beyond the medical door?

Dr. Adams: I’m not sure I understand the question. Perhaps there are others who would like to answer.

Senator Wells: The question relates to that strict confidentiality requirement between the patient and the doctor. If something is happening behind that curtain that could be considered a breach of the law, is that an impediment to actually getting to the source of the issue that could result in prosecution?

The Deputy Chair: We just have 30 seconds left for the response to this question.

Senator Wells: I hope it can be addressed in the time we have left in some of the comments from one of our other witnesses. Thank you, Dr. Adams.

Senator Omidvar: Thank you so much, Dr. Adams, for your presentation and for being with us today. Senator Wells explored some of the lines of my question, so I’ll pivot a little.

You mentioned Indigenous-led midwifery as one of the solutions to address this very troubling problem. You noted that money had been allocated to ensure that Indigenous-led midwifery is enhanced, encouraged.

Even at this early stage, Dr. Adams, can you tell us if you see any progress in this particular field? Are more Indigenous women or men signing up to be midwives? If not, what do you think the government should do with this $33.3 million to encourage that?

The Deputy Chair: I’m sorry, Senator Omidvar. I think we’ve had some technical issues and we’ve lost Dr. Adams. I wonder if either of the other guests would like to respond to your question.

Aimie Hillier, Acting Director, Healthy Children, Youth and Families Division, First Nations and Inuit Health Branch, Indigenous Services Canada: I can take a stab at it. Thank you very much, senator, for your question. I think that what we are seeing are some promising practices. The $33.3 million announced as part of Budget 2021 really did come late last year. That money is just now being allocated. Through the Budget 2017 investments that Budget 2021 built off of, we’ve seen some powerful demonstration projects. The first birth in their Indigenous community in 50 years happened last month in Sturgeon Lake First Nation in Saskatchewan. You’re starting to see those midwifery projects actually come to fruition. It has taken some time. The infrastructure, the training and making sure that it’s done in a culturally safe way has needed some time to mature, but those projects are being undertaken.

Similarly, in the next bit of time, through the Innu in the Atlantic region, there are lots of promising factors around Indigenous midwives being trained in Indigenous communities by other Indigenous midwives. The strength of those types of models is starting to be shown. They are increasing the numbers of Indigenous midwives. We do see some gaps in that, mainly access to education programs. First Nations University in Saskatchewan has a wonderful program, but access to it remains challenging, and having to leave a home community to access that training remains a barrier.

Through that investment, we are increasing supports for communities where they can access different models or create their own model. We do appreciate, though, that the Budget 2021 investments are a start; $33.3 million is a lot of money. Is it enough for every person to access the care that they should have locally? Probably not, but we are working toward it.

Senator Omidvar: Ms. Hillier, would you like to see this next study on forced and coerced sterilization make a recommendation on continued investment and action on ensuring that Indigenous-led midwifery takes hold in this country? If so, can you provide us with a few specifics on what that recommendation would look like?

Ms. Hillier: Of course we would like to see Indigenous midwifery expanded and the scale to which it is offered in a safe way be accessible to as many communities as possible. We do anticipate the $33 million over the last fiscal year and the next two fiscal years is still time-limited in the sense that we do anticipate a return to cabinet at that point, so I also think there is room for further opportunity.

[Translation]

Senator Audette: It is unfortunate that Dr. Adams is no longer with us, as I wanted to thank him. We were very young in our communities in Quebec, so Dr. Suzy Basile has probably seen the posters on which Dr. Adams was one of the Indigenous models. Those awareness raising campaigns that promote wonderful people are worthwhile.

In my family, just among Inuit, many women have died, and the last news they were given was that they had an IUD. They did not speak English or French, so they did not know they had that contraceptive imposed on them.

My aunt is among those victims. She is still alive, and my nieces, who are young women, will have contraception imposed, without even being explained that they have rights and sexual health. It was the same for me. In the community, Health Canada imposed on us a way to do things instead of promoting sexual health.

I don’t know whether this is still the case for young women who live in the communities. However, there are no hospitals in those communities, so they have to travel to Joliette, Montreal or Sept-Îles, where they will experience racism and be denied cultural safety. Doctors may be acting unconsciously or consciously in those places.

How do you see those two silos, which are so important and so difficult for many Indigenous women, and how can we get around jurisdictional silos?

How can we ensure that young women are told they have rights and that those who have lost their rights are defended even if that happened in a Quebec hospital?

Finally, I don’t know what the situation is for government representatives, but are there any discussions?

[English]

Tasha Stefanis, Associate Vice President, Public Health Agency of Canada: I think Dr. Adams spoke about the national dialogues that were held, and that was the first time there had been such an open conversation about the experiences Indigenous peoples have faced regarding racism in the health care system. Those conversations were the start of action in this area and bringing together Indigenous health care providers, representatives from other levels of government as well as the federal government.

One of the tangible things that has happened since then was investments through Budget 2021 to address systemic racism in health care delivery. For example, Health Canada has just launched a call for proposals for $13 million to address cultural safety and humility training, curriculum and accreditation requirements and looking at ways of integrating culturally safe practices into acute care settings and integrating traditional approaches into health care delivery. All of these actions are intended to look at how to make the health care system more equitable and free from racism and discrimination.

The Deputy Chair: We’re out of time for this panel. I see Senator Gerba has raised her hand, and I had a question I wanted to ask as well. We are still trying to reach Dr. Adams to see if we can bring him back. If the committee is in agreement, we will continue for a few more minutes.

[Translation]

Senator Gerba: I am not sure to whom to put my question.

The United Nations Committee Against Torture recommended that Canada ensure that all allegations of forced and coerced sterilization be impartially investigated, that the persons responsible be held accountable and finally, that adequate redress be provided to victims. In response, Canada, in its Criminal Code, said that forced and coerced sterilization is a crime in the country and an offence under sections 265, 267 and 268.

However, as we have seen, the phenomenon has persisted in various regions of Canada. Ms. Stefanis, through your experiences, you have had an opportunity to discuss with women and to gather testimony from Indigenous individuals who were subjected to sterilization.

Do you think existing Canadian criminal law is sufficient to put an end to the scourge of forced sterilization? How can actions be improved to address this effectively?

[English]

Ms. Stefanis: I think the questions around the Criminal Code are probably best answered by the Department of Justice. I’m not a lawyer or able to explain the scope of our criminal justice system.

The Deputy Chair: Thank you. I’ll go to the last question, and it could be for any of the witnesses still with us. As our committee prepares to hear from survivors during this study, we are considering ways to ensure that the process is culturally appropriate, safe and trauma-informed. Based on your experiences working with survivors and appearing before our committee, could you offer us any suggestions to ensure our approach is sensitive to the needs of survivors?

Ms. Hillier: With your permission, I can start and if Tasha wants to add, I would welcome that. I suppose from my perspective, I would start by asking survivors what those needs are. I think often we tend to make assumptions about what those needs might be. We recognize that not all survivors have the same level of comfort describing their experiences or wanting to come forward. This committee’s work, phase one of your study, demonstrated the critical importance of hearing from survivors. We don’t want to make policy decisions without that voice being central to the direction of that policy feature. I think it’s important to ask those questions and to let survivors identify for themselves what their needs are and to be sensitive and recognize that the degree to or the platform through which survivors might feel comfortable coming forward to share what can be pretty horrific experiences may not be the same. We have to be nimble and sensitive.

The Deputy Chair: Thank you. Do you want to add anything, Ms. Stefanis?

Ms. Stefanis: I think that my colleague gave a great response. I might just add that you should consider the importance of mental health and other supports to survivors who are part of your process.

The Deputy Chair: Thank you both for being here this evening. Given the technical problems that Dr. Adams had, we’re especially grateful that you were able to be here and that we could continue with questions that you were able to answer for us. Thank you both.

We will continue our review of the Forced and Coerced Sterilization of Persons in Canada. I would like to introduce our next witnesses: from the First Nations Health Authority, Dr. Unjali Malhotra, Medical Director of Women’s Health; Alisa Lombard, lawyer with Lombard Law; and Professor Suzy Basile, Professor and holder of the Canada Research Chair in Indigenous Women Issues, Université du Québec. We will begin by hearing from Dr. Malhotra, followed by Ms. Lombard and then Professor Basile.

Unjali Malhotra, Medical Director of Women’s Health, First Nations Health Authority: Good afternoon and thank you for having me. I’m calling in from the traditional, unceded lands of the Westbank First Nation on Syilx territory.

I humbly come to you today as a reproductive health physician who has practised and trained throughout Canada for the last 20 years. I grew up in Northern Saskatchewan. I’m the proud daughter of Drs. Lalita and Tilak Malhotra who served our Indigenous community of Northern Saskatchewan for nearly 50 years.

One layer of my experience is working in their clinic — a safe space for all. Another is growing up side by side with many girls who had little voice or privilege. During my own training, when in contraception, abortion and gynecology clinics, I recall a chilling silence among many Indigenous women. The silence is a learned behaviour. It is based on abuses, including coerced sterilization and generations of screams ignored. As a practitioner and administrator, I commonly encounter women who would rather not access care than face the possibility of coercion.

Please consider this. No one likes getting a pelvic exam, but imagine paralyzing fear at the thought of getting one because you could, for good reason, think you will be sterilized at the time. Imagine not being able to access specialty care or cancer care due to your crushing concern of an unknown provider’s bias toward your reproductive future. Imagine not wanting to deliver your baby in a health care facility as you can’t ensure you won’t be sterilized if you don’t understand the forms you’re asked to sign, have a strong advocate and have a health care team by your side.

These stories are truth being told to us that require us to challenge the system to make meaningful and relevant change. It is important to remember our health care system has been built on racism. The Sexual Sterilization Act and the Eugenics Board — how can Indigenous women trust our system when it was not built to protect them? Instead, our health care system is one that requires an understanding of complex terms and concepts. It works with a web of forms, which I consider a living piece of care, which can be poorly understood but, sadly, not challenged. It embeds power in provision of care versus attainment of care. It concedes to the idea that protections and advocacy are the job of the patient without considering or making space for those who are not able to raise their voice and be heard.

Women have been forced to make life-changing decisions under duress and threat. At times, they are not provided the opportunity to change their mind or be a significant part of their own care. With our privilege, it is vital we move towards system change.

Let me share the ground-level work we have done, knowing it is just the beginning and further protections are needed.

With the honourable Senator Boyer and Perinatal Services British Columbia, we created a shared decision-making consent for contraceptive provision, targeting coerced sterilization. Also with The University of British Columbia, we are embarking on a storytelling project to hold a safe space for Indigenous women to share their experiences in reproductive health care access, to work towards offering care in the safest way possible.

This stems from several much-needed changes in our health care system: conversation-based consent; empowerment versus extraction in history taking; consent over time versus in acute settings; frame-of-mind and confounding-impact considerations; acknowledgment of a care directive being initiated by patient or provider — asking who is bringing the conversation up; accountability outside of subjective chart notes; and a consideration of someone’s entire life journey versus one moment.

This is, of course, a change in how women are consented, which requires a significant system shift. It requires practice, workflow, thought and ideology change. We are collectively spotlighting the issue of coerced sterilization with every educational half day and grand rounds that we are giving to current and future providers nationwide. We are clearly saying that any form of coercion, guised or not, is unacceptable.

Now, let’s come together. Let’s raise women up with our collective skills, abilities and talents to ensure our system protects and serves them. I thank you for having me.

Alisa Lombard, Lawyer, Lombard Law, as an individual: Thank you for inviting me to speak here today. I’m coming to you from the unceded and unsurrendered territory of the Algonquin people in Ottawa, Ontario. It is indeed unfortunate that three years have passed since our last encounter, and I regret that very little has changed for my clients. I’m trying to put myself together after Dr. Malhotra’s presentation, so bear with me.

In fact, the pandemic has generally exacerbated the trepidation that my clients experience with the health care system, and to be frank, the death of Ms. Joyce Echaquan has impacted them very deeply.

I continue to hear stories of women torn apart by forced sterilization in Saskatchewan, and indeed, in every Canadian province. We’ve heard of an increasing number of non-consensual abortions as well.

The restrictions presented by the pandemic and a measure of retreat, and with an increased legal understanding of systemic negligence, we expect to file amended materials this week or the week following and proceed into the next phases of litigation on the proposed class action in Saskatchewan and elsewhere, culminating in a hearing on certification soon enough.

Obstetric violence has in the intervening years pierced the veil of its trauma’s silence, and we are becoming increasingly aware of its various manifestations and presentations, all of which clearly disproportionately impact Indigenous women and other women of colour.

Since we last met, the National Inquiry into Missing and Murdered Indigenous Women and Girls released its final report and made several Calls for Justice relevant to our work here today. Specifically, the inquiry named forced sterilization as an iteration of gender-based violence and called it an element of the genocide it examined. In its supplemental report, it found the state intends it to be so through its stubborn policies and lack thereof.

My clients are in absolute agreement and, indeed, named the term, the assault, the fundamental indignity of “genocide.” You will hear them say that in their testimony in the weeks to come.

They await the accountability, the preventative measures and reparations the United Nations Committee against Torture strongly recommended to Canada, yet Canada has done nothing for them and their families. Canada has though spilled considerable financial resources into various programming involving cultural safety. Yet the women you will hear from, their daughters and their granddaughters, feel anything but safe still.

Canada has not used the leverage available to it in the Canada Health Act to ensure Indigenous women are safe from forcible sterilization, forced abortions, birth alerts, I could go on. Yet, Canada was quick to exercise that option in New Brunswick shortly before the pandemic. When it was determined that New Brunswick’s abortion framework resulted in user fees to the insured, Canada swiftly responded by holding back the province’s health transfers to the extent of the aggregate user fees, I presume.

Although an Indigenous woman who was forcibly sterilized continues to live infertile, any technology designed to reverse the procedure — to which she did not consent and did not want — costs at least $5,000 and holds little to no chance of success, based on, I admit, my very rudimentary medical understanding. Reproductive technologies cost upward of $50,000, and the losses they experience while not being able to try some of these alternative methods cost them unknown quantities of human dignity on a daily basis. However, they wait, increasing impatiently. They know that legal remedies can only go so far to restore what they have lost. They know that no judicial pronouncement, class action or otherwise, like so many in the past, can replace what they have lost, and most importantly, make future generations of Indigenous women and girls safe from the devastating violations of forced sterilization.

Recently, Spain was issued a serious systemic caution in matters relating to obstetric violence. The Committee on the Elimination of Discrimination against Women, during its 75th session, determined that Spain’s domestic options to remedy a mother’s experience of a non-consensual procedure at the time of her child’s birth was not capable of adequate remedy in Spanish courts. The survivor, SFM, had exhausted domestic remedies and been subject to an abuse of her rights. We don’t know whether that will be the case for our clients, and we certainly hope not, however, the delayed personhood of Indigenous peoples and ongoing intersectional gender deficits need no explanation here. We’re at a two-year inquiry, tasked with examining its every facet, applying thoroughly, recommended clearly and urged desperately. The Special Rapporteur on health has voiced a commitment to the issue of forced sterilization and pledged to examine it deeply as well.

The Deputy Chair: Ms. Lombard, I hate to interrupt you. You have 10 seconds left.

Ms. Lombard: A medical doctor herself of Zulu ancestry from South Africa, she understands the plight, and she continues to support those in her home who require that support. Understand that the empty wounds do not grow tired of pining, and the impunity that our clients consistently see really does stoke the fires that have never dimmed within each of them. They will tell you their stories soon, but most importantly, in the face of those stories, they will ask you to act, and we hope that you do.

The Deputy Chair: Thank you.

[Translation]

Suzy Basile, Professor and Canada Research Chair in Indigenous Women Issues holder, Université du Québec en Abitibi-Témiscamingue, as an individual: Kaskina. Good afternoon and thank you for this invitation. I want to mention that I am of Atikamekw origin and that I come from a long line of women who, like my great-grandmother, experienced the flooding of their territory and who, like my grandmother, spent several years in a sanatorium for tuberculosis. My mother is a survivor of residential schools. It is an honour to share with my sisters some of my contribution, thanks to the research I am carrying out under the auspices of the Canada research chair I have obtained, but also to share other colleagues’ contributions. I thank the Anishinabe Nation for welcoming me on its ancestral and unceded territory here, in Abitibi-Témiscamingue.

I apologize for the redundancy of the remarks you will hear; I took refuge in a book chapter I just submitted for publication, but I still think it is important to bring up some major aspects of the history of Indigenous women’s health in Canada in French. Despite the recent improvement in some socioeconomic indicators and health indicators among Indigenous peoples, significant disparities persist between Indigenous women and other Canadian women. Indigenous women are more exposed to all sorts of violence that endangers their safety, their integrity, their life, as well as the lives of their children. The National Inquiry into Missing and Murdered Indigenous Women and Girls report makes that clear.

For example, their womanhood exposes them to unique risks, such as those associated with reproduction. Canada is on the list of countries that have put in place policies and programs for controlling procreation through sterilization or abortions to achieve so‑called modernity.

According to various authors, birth control had become necessary and it was deemed, at a certain time, that the Indigenous birth rate was much too high. Therefore, something had to be done. Based on that, thousands of Indigenous women were sterilized, as you know very well. Recent research carried out in various Canadian provinces, including research I am currently leading in Quebec, shows that Indigenous women have been and still are victims of discrimination, racism and differential treatments in health care systems, to the point where they avoid going to different points of service, even when they need to.

Although Indigenous women’s mental health issues in a perinatal context are still very poorly understood, the resilience of Indigenous women and the contribution of their knowledge in maternal health are too often ignored. Concerning that, it has been shown that returning to the practice of midwifery, which was just discussed briefly, and to certain rituals related to birth, as well as the revitalization of those women’s knowledge, encourages Indigenous women to regain control of women’s health.

It should be pointed out that the report of the Truth and Reconciliation Commission of Canada and the report of the National Inquiry into Missing and Murdered Indigenous Women and Girls recommend that Indigenous knowledge and related practices be integrated into health care.

Those recommendations are based on, among other things, article 24 of the United Nations Declaration on the Rights of Indigenous Peoples, whose essence I need not remind you of.

Yet the creation of Joyce’s principle—a document that was published following the tragic death of Joyce Echaquan—confirms that the legal protections in health applicable to the general population are likely insufficient to ensure the genuine safety of Indigenous peoples, even though that right is supposed to be recognized for all Canadians.

As sterilization involves surgery that permanently alters a woman’s reproductive capabilities, the parameters around it should be given special attention and the patient should be given full discretion to make a decision without pressure or coercion. There are significant examples of this.

While a number of studies have been initiated on the issue in the western provinces, there is a glaring lack of data and research in Quebec, which contributes to the lack of knowledge and recognition of the seriousness of that issue for Quebec’s First Nations and Inuit women.

In February 2019, I helped write an open letter that was published and denounced the fact that the Government of Quebec had refused at the time to participate in a federal task force to shed light on that reality, by arguing that it was already very aware of the issue and that, in any case, health is a matter of provincial jurisdiction — while the fact is that health is an area of shared jurisdiction.

[English]

The Deputy Chair: Professor Basile, I remind you we have about five seconds left, but there will be plenty of opportunity for questions.

[Translation]

Ms. Basile: In conclusion, I would like to bring up the three findings of the research we are currently analyzing in Quebec: the compromised free and informed consent of Indigenous patients, the differential treatment in Quebec hospitals of Indigenous women and the widespread mistrust of health services, which means that many will not go to the hospital and will not get the perinatal care they need.

I would be happy to come report on the findings of the research we are completing on the sterilization imposed on Indigenous women.

[English]

The Deputy Chair: Thank you very much. We will now go to questions from senators. I want to remind senators that Ms. Lombard is the counsel in a case currently before a Canadian court. I will caution senators when asking questions. According to Senate Procedure in Practice, the sub judis convention is a voluntary restraint by parliamentarians from discussing matters that are before the courts. I encourage members to refrain from providing direct commentary on the details of the litigation.

We have a long list of senators who have questions to ask. Senators, I’ll remind you to please identify whom you’re directing your question towards as we have three witnesses on this panel.

Senator Hartling: My question is for Ms. Lombard. I really liked what you said about “obstetric violence.” The term is riveting, and I think it’s a good term. I’d like to explore it a little bit. What is the line between forced sterilization, coercion and good medical advice? Are there certain groups, certain people who are more vulnerable than others who would fall into that group? Where would that line be? How would we determine that? Could you give me a little more detail on that, please?

Ms. Lombard: Thank you for your question, Senator Hartling. I think that consent in law when it comes to non-essential, non-emergent medical procedures is in no way opaque or difficult to understand. Any measure of stress that a person is experiencing, that a patient is experiencing, is sufficient to kind of put the discussion to another day. We have noted physicians approaching women in circumstances of abject vulnerability, and this is not because of any kind of mental health issue necessarily; it’s because they are giving birth.

Those of you on this call who have given birth or witnessed people giving birth, if I may be so direct, will understand that it’s not the best time to talk about ever doing it again. There are better times to talk about engaging in that activity once more — when you feel like a human being again — and that is not what we are seeing. So if we want to talk about the legal tenets of consent, they’re rather simple. We need capacity. Consent is specific to the procedure and to the physician. Consent needs to be informed, and there also needs to be a sufficient or an adequate environment for the woman to consider what her options are. That is a part of the informed consent component, which brings about the fourth pillar, which is that it has to be voluntary.

Do we see in this particular instance any peaks and valleys of attenuating or mitigating circumstances? Yes, perhaps. But what we see is a dire need for a cultural adjustment within the medical system and the health systems, not a greater understanding of Indigenous culture.

Senator Hartling: Thank you very much.

Senator Boyer: My question is for Ms. Lombard and Ms. Basile, and it has to do with the research that you’ve conducted in this area. What is your opinion about how widespread this issue is? I know you’ve been focusing mostly on Quebec, Ms. Basile, but you may have an idea of how widespread this issue might be. Have you found it is in all of the provinces as well as the North? Specifically, what kind of recommendations would you suggest this committee come up with that might address this issue? That’s directed to both of our witnesses.

[Translation]

Ms. Basile: So yes, we can —

[English]

Senator Boyer: I’m just looking at how widespread it would be. And what you found in your research.

[Translation]

Ms. Basile: So yes, we can say that the practice is also widespread in Quebec and across the country. All that is well documented. Unfortunately, Quebec can also be added to the list.

We are currently analyzing the testimony we have gathered [Technical difficulties].

I can just confirm that there are cases in Quebec and that they come up in a number of Indigenous nations and not only in a single nation.

[English]

Ms. Lombard: I can quickly add to that. I think that the practice is widespread across the country, Senator Boyer. Recently there was an action filed in the Northwest Territories. We know this practice was incredibly pervasive in some isolated locations in Nunavut and Nunavik as well. British Columbia, we have heard reports. We have heard reports from the Yukon, clear across the country.

Ms. Basile: I forgot to mention that a class action has also started in Quebec with the Atikamekw nation. That’s something that we will have to follow.

Senator Boyer: Thank you.

[Translation]

Senator Gerba: Since the Minister of Justice is not here, my question from earlier is the same. I don’t know whether someone can answer it. However, I will put a question to Dr. Malhotra. The federal government has said that the health and safety of Indigenous women and girls was a top priority for the country. What do you think the government should do over the short, medium and long terms to end forced sterilization?

[English]

Dr. Malhotra: I will humbly answer as a physician, clinician and administrator.

From my perspective, there are many layers to what has happened and what continues to happen. It begins in that circle of care that I refer to frequently. Our patient is in the middle of this care circle, and every single touch point within the health care system becomes meaningful to their wellness going forward. So every person that answers the phone, every person that they see in the hospital, every person that they speak to, every person that’s doing surgery on them and also every form that they see. That’s one piece.

Every touch point that this person has within the health care system needs to have education and have accountability for their conversations and their actions within their care that they’re providing, or a part of, in any way.

Past that, our college regulations need to be in line. We need to ensure that physicians and other health care providers are mandated effectively within their governing bodies. That’s one step on the medical side.

As far as past that, we do need more protections from government towards the care of these women. It’s hard to say that we used to have laws that legalized or allowed for sterilization to occur, yet we aren’t necessarily putting these bulk protections in place in all aspects. That’s straight from the education of our providers from entrance right up to the exit of a patient from the care that they are receiving. It is that entire journey of care that needs to be addressed, in my opinion.

From what I’ve seen and what I have heard, it is incredibly heartbreaking to hear that someone, many, will come forward to the safe space of the First Nations Health Authority and come to me and say, “I cannot go and get my colposcopy, my treatment for my cervical disease; I cannot go and get regular, routine screening; I cannot get this because someone in my community was sterilized.” This is because it’s not a given that everything would be okay.

And so from the person that books their appointment right up to the end of their care, everyone needs to have education in creating a safe space and knowing that any type of coercion is unacceptable — and this speaks to a previous question; it is not necessarily the confidentiality of what someone is going to experience in the system but the power that needs to be altered. That interaction between patient and provider, that’s what we’re trying to change with the alteration of consent forms to ensure that we’re giving back the power to the person who is receiving the care, because it is their care. And the biases of our providers, which exist and have been ingrained in our system immemorial, are not being trickled into the care that they are providing.

It starts right from someone accessing birth-control pills, right up to accessing sterilization. It is the entire continuum that has to be addressed. The abuse needs to be addressed very clearly on all levels: medical, governmental, legal.

Ms. Lombard: If I may address the question in terms of concrete measures.

[Translation]

There would be a set of criminal measures and a set of political measures, but I think criminal measures could have a deterrent effect given their straight-forwardness.

Senator Gerba: Do you think the Criminal Code is sufficient to put an end to this scourge?

Ms. Lombard: No.

Senator Gerba: So how can actions be improved?

Ms. Lombard: Legislative amendments must be made to provisions.

[English]

The Deputy Chair: Senator Gerba, we’ll put you on for a second round, if we have time for one. Thank you.

Senator Omidvar: Thank you to all our witnesses for being here with us.

My question is for Ms. Basile. I don’t want to step on Ms. Lombard’s legal toes and limitations, as the chair has pointed out. I’d like to focus on the survivors.

Ms. Basile, did any of your research point you towards the need for compensation of survivors? If so, what role would the federal government have in ensuring some measure of justice for the survivors? Do you think such a recommendation should be in our report?

[Translation]

Ms. Basile: That could definitely be a recommendation you could include in your report. As for what mechanisms to use to do so on a national scale, I cannot suggest any potential solutions. I am less familiar with this because things are done in specific ways depending on the issues in Quebec.

As for compensation, that was not something the participants in our research were seeking. When we asked them a question about a potential class action lawsuit and when we asked them whether they would like to get more information about that — as that aspect was not part of the research and other people would be taking care of the class action lawsuit — the vast majority of participants said they would like to have information about it. However, it was not necessarily with the goal of obtaining financial compensation. I think that could be an interesting way to repair at least a little bit of the damage done to them.

[English]

Senator Omidvar: I guess it’s not just remedy; it’s also preventative. So once there is a cost to the system, whether it’s a cost to the doctor or the medical system or the federal government, perhaps it has sharper teeth. Thank you for your answer.

I don’t know if Ms. Lombard is able to weigh in on this.

Ms. Lombard: I think it better if I do not.

Senator Omidvar: Yes. Thank you.

[Translation]

Senator Audette: Before I begin, Ms. Basile, thank you very much for bringing a voice of four generations of your family, a voice that reflects those of thousands of other Indigenous women of Quebec. Ms. Lombard, thank you for being the gentle warrior behind the rather silent voices to get legislation amended, I hope. Many thanks to my colleague whom I love to death, Senator Boyer, for getting things moving. Once again, from the perspective of a victim, a mother and a woman who does not really understand what provincial and federal jurisdictions are and from a personal standpoint of someone who participated in three summits and in forums on racism in the health community after the death of our sister Joyce, I will tell it like it is. Quebec is absent or it is trying to clearly show that we don’t need cultural safety in the health reform on its territory.

I need you to reassure me. How can we use our research — I know that you talked about criminal and political measures, Ms. Basile — to ensure that, despite jurisdictional complexity, we can get things done? Help me out.

Ms. Basile: That is a good question, Senator Audette. Quebec has actually relieved itself of responsibility in a number of areas, including cultural safety, by saying a few weeks ago that this important notion is not part of Quebec’s public health policy. That is extremely difficult for me to understand, but it is not surprising for a government that does not recognize the existence of systemic racism.

The testimony we have gathered clearly proves there is systemic racism in Quebec’s health system. I don’t want to take advantage of Joyce Echaquan’s death, but that is clear evidence that came just as our research work was beginning. It all speaks for itself.

Perhaps pressure could be put on all the political parties, which adopted a motion unanimously in the National Assembly last fall to put an end to the forced sterilization of women in Quebec. Perhaps they should be reminded that they adopted that motion and that an election is coming up. It would be very important for Indigenous issues, as big as they are, to be at least a small part of the upcoming election issues. This momentum should be used. I will let you take care of that.

Senator Audette: Thank you.

[English]

Senator Boyer: My question is for Dr. Malhotra.

You described the fear that women have when they go for any kind of visit at the hospital, particularly when they’re in a vulnerable position. What about their families? What about accessing health care for their children? How has that fear affected the generations to come if they have had children? Can you describe that, please?

Dr. Malhotra: It truly can. Thank you for the question. It’s truly heartbreaking. In fact, it is quite hard to listen to and advocate within such trauma. It isn’t that one person in a community experiences coerced sterilization. The entire community experiences the sterilization. What ends up happening is someone will come and say to me, absolutely, “I’m terrified to go to this appointment. What can we do? How can I get my care? What are the options?” But they will have children, aunties, mothers and grandmothers who have also had the same fears, generally with very good reason. It says to me that an entire community is now not accessing care effectively. That means their overall wellness, their overall cancer risk and the overall well-being and health of an entire community is now being compromised. How do we hear that and not make change? It breaks my heart to take this information in, because it’s so painful, and it has impacted so many people.

One can imagine, if someone in a community has been sterilized, and then a mother who is a cousin, a friend or a community member doesn’t want to get care, that information is being translated down from multiple generations, and there is no trust within the system for multiple generations.

We see that with survivors of all trauma, from residential schools and from sterilization, that we have to change the entire system, the entire circle of care in every way to ensure that their health and safety is just as much a priority as any other part of care and that we amplify their voice well above anything else we’re doing.

Senator Boyer: Would you say it would be very important to take that into consideration in any type of compensation package — as Senator Omidvar brought up with her question — the legacy, the intergenerational legacy of forced and coerced sterilization?

Dr. Malhotra: Absolutely. As a humble provider, I believe so. I’ve seen the impacts of trauma first-hand from residential school survivors, from coerced sterilization, the community impacts. We have to take that into consideration, I think, because it has impacted so much. People are not able to have their healthiest life forward because of an abuse done within a generation potentially preceding them.

Senator Boyer: It’s especially heartbreaking that there are children involved. Thank you very much.

Dr. Malhotra: Absolutely. I have a daughter, and we worry about what happens when she has to go and have a reproductive care visit. Imagine if you had to also layer onto that the fear of sterilization of your child and of your niece and what that looks like. I think anyone can understand that all children are all our children when we become moms, and we think of our community in a different way at times, and this is one of those times.

Senator Boyer: Thank you, Dr. Malhotra.

[Translation]

Senator Gerba: Madam Chair, I think Senator Boyer asked the question I wanted to ask to shed a bit more light on the testimony of the victims Dr. Malhotra met with. So I will give up my speaking time.

Senator Audette: Because of all my emotions — as these tragedies affect us personally — I forgot to thank Dr. Malhotra. Thank you very much for your work, and thank you for reminding us of the impact of all this. An entire community has suffered.

My question is for Ms. Lombard and Dr. Malhotra. We are talking about criminal and political measures, but despite the fact that the provinces have exclusive jurisdiction over hospitals — because we don’t have it in our territories and our communities — can anything be done quickly to support the women and girls who are afraid to go to hospitals, while waiting for major political debates be held or for legislation or bills to be introduced? How can we support individuals right now, which will be reflected in the community?

Ms. Lombard: Thank you for asking this question, Senator Audette. If I may answer, it is sad to think that the Indigenous women who go to the hospital, regardless of the reason, would need a bodyguard, but I think that is where we are at. Liaisons in hospitals can be useful, but we have to rely on major changes. This is related to the questions Senator Wells and Senator Hartley asked about accountability. It also is related to the question Senator Gerba asked about criminalizing sterilization without consent.

What would we need to ensure that women are, at the very least, less at risk of being subjected to permanent procedures they do not want, especially when it comes to their ability to conceive?

Criminalization of specific acts could serve as a deterrent. So far, there have been no reports of doctors facing consequences, as Senator Hartling mentioned; there have been none. However, the risk of criminal sanctions could have an impact. At least we know that it would be better than what we have at the moment, which is nothing at all. I think that this is a measure that would be immediate. It must be understood that, in order to denounce a practice that is absolutely unacceptable, the measure must equal the harm caused. If doctors know that they could potentially be subject to criminal sanctions, this could change behaviour quite quickly.

Secondly, I believe that support centres in hospitals are very important. Many of my clients come in alone to give birth to their babies, but that’s not an invitation for doctors to do whatever they want with their bodies. In my opinion, this support within hospitals is still pretty important.

Be it the province or the federal government—

[English]

In my opinion, I don’t think it’s a question of inter-jurisdiction immunity in health; I think it’s a question of dual jurisdiction. I don’t say that flippantly; I have looked into it, and I do not think that either the provinces or the federal government have exclusive jurisdiction when it comes to health and Indigenous people, in particular First Nations people. I think they both have jurisdiction, and they do the jurisdictional dance on account of financial resources, to be blunt and frank.

With respect to Dr. Malhotra’s last comment when she said, “Could you imagine bringing your child in, having these discussions about contraception?” — or yourself, your sister, your niece, et cetera — and I think Senator Audette and Professor Suzy Basile have been clear about where they come to this question from. In my case, I do not need to imagine what it feels like. As a pregnant woman dealing with this case, flying to Geneva to talk about how this is unacceptable, there was absolutely no need to imagine the fear. It was very real, and I can tell you it exists regardless of privilege, of which I have a lot.

Senator Boyer: I’m looking at recommendations. What I heard from you, Ms. Lombard, is that you’re suggesting that Criminal Code support and jurisdiction needs to be all looked at in any kind of recommendations. I would like to hear from Dr. Malhotra to see if there is anything she might add to a list of recommendations that this committee might put forward.

Dr. Malhotra: Of course, I agree with those put forward.

Personally, within the medical governance for the recommendations needing to be made — I apologize humbly if that is not the role of this committee, but I believe that is really impactful within health care. If the governing bodies of midwifery, nursing and medicine really changed the language of how this topic is discussed and treated and what ramifications are in place for providers who are embarking upon any coercion regarding reproductive health, that would be really impactful. That would be another piece.

I will go back to what was talked about for a second. I’m an educator, and I was a learner within the medical system not that long ago. I am a teacher at this point. It wasn’t called out in a clear and concise fashion that this was an issue. No voices were being heard. I will be doing a half day for obstetrics and gynecology patients voices next month, and it is one of the first that will be completely designed around this topic. Those will be our future surgeons.

Having these discussions being top-of-mind and in our curriculum is important. I know that no one wants to hear that they could potentially be the surgeon on the other end of this, but they need to hear it. They need to hear what is happening in operating rooms and how patients feel when they enter the consent process. It is one thing to hand someone a consent form that they don’t understand, with words they don’t understand, that only really talks about blood loss and fluids; it is another to talk about what your experience will be when you leave after this period with us, what your life will be like when you leave here. That is the consent part I’m working hard on, with you and others, to try to make a reality.

But that needs our governing bodies’ support to be mandated and be part of our care in a real and meaningful way.

Senator Boyer: With real consequences.

Dr. Malhotra: Yes, with real consequences.

Senator Boyer: Thank you.

[Translation]

Ms. Basile: It is obvious that, at least, an English-French-Indigenous languages awareness campaign should be funded on the issue of consent, which is very much unknown by many of the Indigenous women we had the opportunity to speak with. When some of them tell us that they were pressured to have a tubal ligation every time they got pregnant and they have children in their twenties, we can see that there is a problem. How do you respond appropriately when you don’t know that you have the right to consent or not consent to something? This shows the importance of such a campaign.

I conclude by suggesting that you call on the professional bodies of social workers, nurses, doctors and others to include a mandatory component on issues of obstetric violence in relation to indigenous peoples in their certification programs. A minimum of one course would be required to become a member of the relevant professional body.

This could be, perhaps not immediately, but certainly in the medium term, a way of ensuring that the information gets to the future nurses, doctors and so on in the country.

[English]

Senator Boyer: Thank you, professor. That was very important.

Senator Wells: Legislation was passed about a year ago for new judges to have training in sexual assault law. It strikes me that there might be some parallels in training not only for new doctors but all doctors — certainly doctors who would perform these types of procedures.

Dr. Malhotra, thank you. You mentioned something that might be mandated. We did it for judges. Do you see a parallel that could exist for medical practitioners, along those lines I mentioned, that would be a requirement during training, not just of the law but of the practice?

Dr. Malhotra: Certainly I do. There are many layers to the education requirements that we need to move forward. One is calling this issue out and making it very clear that this is a current, ongoing issue and making it clear what consent actually is.

That is why we work with shared decision-making versus a consent form. We can say that someone consented, but did they understand what they consented to? Not necessarily. That is an indication that all providers and the entire circle of care need to know and understand.

Did this person actually understand what was being told to them, and did they want you to ask them those questions? Is it even the direction they want to go?

That is what the one we created actually starts with the question, “Who initiated this conversation?” It needs to begin with that root. Where are you going, and what does it look like?

As engaging providers in this work, many have said they’re very busy in their offices and things along that line. I understand the burden of time on these things, but I’m requesting, with Senator Boyer and my other colleagues, to change how we consent — not if and how long it takes, but what is being asked. That is where education needs to change in all parts of our process.

I believe that needs to be a mandatory process that all health care providers have to be a part of. I don’t think it is just in one particular consent either. I strive for consent of sacred remains and loss and all of these very traumatic pieces of someone’s life, but we don’t have that training. We don’t have that shared decision-making training as yet in our core curriculum, and we are not taught about true accountability in regard to what is happening in these consent visits, with contraception being the biggest one, including tubal ligation. We can do the consent for the risks of blood loss and all of the rest, but we can actually just say in our chart that the patient agrees to tubal ligation as our accountability of the conversation that needed to be happening. And that needs to be changing. That is where there needs to be mandating about education of providers and how we’re educating providers.

Senator Wells: Thank you. Ms. Lombard, I’m keen to hear for your response.

Ms. Lombard: Thank you for that question, Senator Wells, and Dr. Malhotra for your very thoughtful response. I think you could probably see from my vigorous head shaking that I agree wholeheartedly.

I have a few questions. Consent and content are not an event. It’s a process. I think that Dr. Malhotra keenly and aptly described what that involves, particularly when we’re talking about things as important as whether or not you want to have children again.

As far as what type of training is required, what I can say is that I do think that physicians should have a better understanding of what their legal obligations are and what their fiduciary obligations are to patients. As lawyers, we have those same kinds of obligations when it comes to our clients’ interests. We learn a lot about them during our licensing, et cetera. I think physicians should learn about what those obligations entail, what they include, what they can do and cannot do. They are helpers and humble providers, as Dr. Malhotra has stated. The patient is the boss. You provide information so the patient can think about it and make decisions that are right for them.

The amount of case law that supports this proposition is plentiful. I think physicians should know about it and what happens when those principles are not understood. So I think that ethics need to go a bit deeper, and they do need to explore physicians’ legal obligations to patients. I think that’s probably the end of my knowledge on that particular point.

Senator Wells: Thank you very much, Ms. Lombard.

Dr. Malhotra, my question goes back to what Ms. Lombard said regarding “the patient is the boss.” I know that, and you know that, and maybe everyone on the Zoom call knows that, but for a young, possibly not-highly-educated person or someone who has seen medical practitioners as leaders in communities and things like that, I think it’s not a stretch to think that a patient like that would see the doctor as the boss and that dynamic. While I might go into any circumstance and read what’s put in front of me, especially if you go into a clinic or a hospital, I am sure there are lots of things you have to sign off and a lot of that is pro forma — I’ll sign that and that. It seems that dynamic needs to change as well. That might be part of the training that could be considered. As I look at this topic, I’m shocked that this is something we’re discussing in Canada at this time and in this year. That might be something that should be considered as part of the changing dynamic that needs to happen.

Dr. Malhotra: Absolutely. Health care appointments are a very vulnerable time for anyone, particularly for anyone who has been in any way mistreated in the system or has had a community or family member mistreated within the system. The power dynamic that has occurred over many decades from colonization and sexual sterilization acts that have been created needs to be broken. That is why we need to change how we are speaking to our patients. We as providers need to take that on. That is why mandating providers is a requirement, and changing how our forms are written is required. Any form should be legible, and it should be a conversation. It should be that the power is given back to the user of this system, not the provider of the system. That is semantics to a degree, but it is also the look and feel of a clinic — who is in the room, the entire circle of care. Again, everyone is part of the change; it is vital that this happen.

As a reproductive health physician, I obviously am in a somewhat biased situation. My everyday clinical care is seeing vulnerable people coming into my office, and it is my responsibility as a provider to say: How can I make this better for you? Are you here at a point that we are here to have this conversation? Should we get to know each other a bit more or should we figure other things out that are going on? And that is where cultural safety comes into our system and that is the change that has to happen. We need a culturally safe system, and we aren’t there yet.

The Deputy Chair: I have a couple of questions I would like to ask as well. The first question is to Dr. Malhotra. You talked about the sterilization of Indigenous women not just being about that individual but having an impact on the entire community. We have also heard about the multi-generational harm not only on individuals but on communities. Are there specific recommendations that you would suggest to this committee that we look at as part of our study that would address the multi-generational harm and issues of intergenerational prevention around the harm brought to communities?

Dr. Malhotra: I think the most important piece is to ensure there is an awareness of that and to know that one person being traumatized, one person being sterilized, within the system is not one person. I think any recommendation made needs to harness that. That includes any regulations and any mandates being recommended. It needs to include the entire community. It can’t be viewed as one person has had this harm done to them because it stretches so much past that.

To be honest, that would also be involved in any compensation or regulations — anything. It just needs to be clearly noted that the harm is done to so many when one person is harmed. Anyone, myself included, who has suffered any trauma can know this is passed down and this is spread. We need to remember that. We are in a place of privilege, being in this conversation, in the place that we are. We have to be the bearers and holders of that privilege, knowing that we are responsible to make sure that is represented in anything going forward.

The Deputy Chair: Thank you. I would like any of the witnesses to respond to this second question. This is the same question I asked the previous panel. As our committee gets ready to hear from survivors and considering ways to ensure that the process is culturally appropriate, culturally safe and trauma-informed, based on your experiences working with survivors and appearing before our committee, could you offer us any suggestions to ensure our approach is sensitive to the need of survivors?

Dr. Malhotra: We need to ask them what they need. When someone comes to me with fears and stories, my first question is: What do you need? How can I serve? I feel like that is all of our role.

Ms. Lombard: I think that is great, but they may not always know. This may be a departure from habitual procedure, but I might suggest considering the level of trust and the power imbalance. As senators, you all look great, but you’re a bunch of scary folks to people who have not spoken to senators. That’s extremely intimidating. What I might suggest, humbly, is if you might consider an informal session with the survivors that could last for a short or a long period, where there isn’t a clock ticking so they can see you and get to know you so that they’re not shell-shocked by the experience. That would be my humble advice.

[Translation]

Ms. Basile: If I may, I agree with Ms. Lombard. She has just suggested that we do this in a more friendly context. You are nice, but this is an official setting and that could be uncomfortable for some of them. In the testimony that we have gathered in Quebec, women told us that if we needed to hear more evidence, they would agree to testify, and some of them have given interviews to the media. There are certainly one or two voices that could speak to these issues—in French as well, because it’s important—and share their experiences. That’s certainly the case with evidence collected in the other provinces, which is hair-raising.

[English]

The Deputy Chair: Thank you all very much for being with us this evening. Thank you for your participation in our study. Your assistance is appreciated and your advice is duly noted.

Senators, that brings this meeting to an end. Our next meeting on this topic is next Monday, May 2.

(The committee adjourned.)

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