Why have you focused on providing care for transgender and non-binary individuals?
A couple of years ago, a friend, knowing that I worked in the inner-city family health clinic, approached me when her child was transitioning. Most of my transgender patients were older and had managed to navigate the system the best way they could, so I had never thought about bringing the families into the process. It was a gap. This friend had substantial resources, a higher education and privilege, in many ways. All she wanted to do was to support her child, and yet she was facing so many barriers. I realized in that moment how incredibly difficult it must be for transgender individuals and their families to access safe care. I wanted to do something about it.
What are the hurdles that trans women face in getting health care?
While transgender and cis women face some shared challenges that impact health – like adequate housing, education and food security – trans women often face additional hurdles. They are more likely to be exposed to physical violence and transphobia, and to feel unsafe. It’s even worse for trans women of colour and trans women who are in the sex trade, who don’t access health care as often which puts them at increased risk. For example, trans women and men may not know they can use pre-exposure prophylaxis (PrEP), which will reduce their risk of contracting HIV. Many shelters won’t accept trans women, placing an added burden on those experiencing homelessness, who are precariously housed, or who are experiencing intimate partner violence (IPV). Sistering, a multiservice agency in Toronto, is an exception.
Another problem is the inequity in accessing gender-affirming surgical care. While the Ministry of Health covers top surgery for trans men, as well as genital surgery for both, it doesn’t cover breast augmentation for trans women, except in rare circumstances. It also does not cover other services, such as voice therapy and tracheal and brow shaves, as well as facial feminization procedures, to minimize male-identifying features – changes that are essential to a feminine identity. We have more advocacy to do.
So how can we do better?
My main message is this: there should be no distinction between providing primary health care to someone who identifies as transgender and any other patient. After all, most of the health care trans individuals need has nothing to do with being trans. So it’s important we teach our medical students and learners about providing gender-affirming care, and integrating it into our regular care – rather than siloing it.
That said, some health-care providers don’t feel qualified to treat transgender patients. And more than anything else, what most health-care providers want is to not do any harm. I see part of my role is to support my colleagues in providing this care.
The most important thing is to provide a safe, respectful and gender-affirming space for our patients. That’s simple to do. It starts with making people feel welcome by teaching our front staff about proper pronouns and using authentic names. It also means providing gender-neutral bathrooms, so trans patients don’t feel like they’ll be harassed or subjected to disparaging incidents.
What are we doing better?
We’re getting better at asking more gender-affirming questions and taking better gender-focused histories of our transgender patients, and, when we make mistakes, acknowledging them and moving on.
I often take my cues from my patients. I’m in awe of them. They’ve taught me so much and helped me become a better doctor, as I don’t have their lived experience. There’s no other area in medicine and health care where patients teach their providers so much about their health and identity. I have to say, learners today are much more attuned to the needs of trans people. Many know or have family members who are trans.
And we are getting better at strengthening our partnerships with other trans-affirming service providers. One such partnership is with the Women’s College Hospital for their Transition Related Surgery program. Another is with the Hospital for Sick Children’s Gender Clinic. As transgender youth transition out of pediatric services, they require ongoing primary care with providers knowledgeable in trans health.
Is there a moment that stands out to you that affirmed, “This is why I’m doing this work”?
Many. But here’s one, because it relates to that first ‘aha’ moment. I gave a talk with Sue Hranilovic, a nurse practitioner with whom I work, to a group of parents of gender questioning children and children undergoing transition. The parents just sat there. They had so many questions. They were scared and needed support through the process. All they wanted to know was, “How can I help my child, and how can I learn more?” And it wasn’t just birth parents. Because families can look very different – it might be a grandparent or someone from their community. I admire people who are asking questions and want to learn more. I believe people really just want to do the right thing.
And yet?
There are still lots of barriers we need to eliminate to gain trust in the trans community because historically we’ve not done a good job of delivering care. It’s hard to believe they are still facing so many hurdles – just for wanting to be themselves.
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