When Lucas Silveira – then going by his female name – told his Toronto-based family doctor he identifies as male, the doctor’s discomfort was palpable. She stumbled over her words, and then said, “I don’t really know how to help you,” recalls Silveira, a musician with the rock band The Cliks.

The doctor agreed to do some research into hormone therapy or surgery options. A few months later, she called Silveira saying that she couldn’t help him and suggested he go to the city’s Sherbourne Health Centre, which specializes in marginalized communities, including lesbian, gay, bisexual and transgender (LGBT) people. “She was firing me as her patient,” says Silveira, who did become a patient at the Sherbourne clinic, which he describes as “an amazing place for trans people.”

Despite isolated sites of excellence, transgender people are often made to feel unwelcome in medical settings, if not completely cut off from care.

Statistics Canada doesn’t collect data on gender identity but a recent U.S. survey estimated 0.5% of the population identify themselves as transgender (whether or not they physically present as their felt gender). Transgender people remain heavily discriminated against, but with greater societal awareness and acceptance of transgender identities, more people are able to live as their true gender, says Jordan Zaitzow, coordinator for Trans Health Connection (a Toronto-based organization that trains health providers in transgender care). “People will say, ‘This was how I felt but I didn’t have a word for it until I saw this movie with a trans person,’” explains Zaitzow.

Transgender people at greater health risk

Silveira’s experience is not uncommon, says Marni Panas, a patient engagement consultant with Alberta Health Services and a transgender woman. “Many transgender people have had previous interactions with a healthcare professional who said, ‘I can’t help you because you’re transgender.’ Yet, you’re going in for something completely unrelated,” says Panas. In other cases, transgender patients might avoid going to a doctor’s office or hospital because of offensive language or the noticeable discomfort of health workers and front desk staff.

Little research exists on the health outcomes of transgender people. It’s unknown if barriers to accessing primary health care increase the risk of, for example, diabetes or cancer in transgender populations.

Here is what is known. Comprehensive surveys conducted by the Trans PULSE research project in 2009-2010 reveal that 50% of transgender Ontarians have considered killing themselves because they are transgendered. Due to the stigma they face, studies show that transgender people are more likely to abuse substances and alcohol, are more likely to engage in sexually risky behaviours and are more likely to smoke. Additionally, one out of every two transgender people have experienced sexual violence, according to the U.S. Office for Victims of Crimes.

Panas notes that with all of the above risk factors, “it’s not being trans that’s the issue. It’s societal acceptance or non acceptance that’s the issue.”

Poor access to transition-related medical care exacerbates health risks

Various hormone therapy regimens and surgeries can help transgender people align their physical appearance with their identity. “The vast majority of transgender people do want to seek hormonal treatment,” says Dr. Carys Massarella, a transgender family and emergency doctor at St. Joseph’s Hospital in Hamilton and Quest Community Health Centre in St. Catharines. Anecdotal reports suggest that a much smaller number seek surgeries. But Zaitzow stresses that “someone’s transition path is really personal and really specific…some people are going to need hormone therapy, some won’t, some will just want a little amount of hormones and some will want surgery and no hormone therapy.”

The Endocrine Society recommends that a transgender person be at least 16 before commencing hormone therapy (hormone blockers can be available before then). Hormone therapy can be commenced after an assessment by a physician or nurse practitioner. Generally, physicians across Canada turn to the guidelines created by the World Professional Association for Transgender Health  and by Rainbow Health Ontario and the Sherbourne Community Health Centre in conducting these assessments.

To access gender affirmation surgeries in Canada, a person must be at least 18 years, and must have been approved by at least one psychiatrist. Most provinces now publicly fund surgeries, but many patients are on waiting lists for years. Alberta only funds 25 patients per year for the surgeries, and waiting times can be more than two years, says Lorne Warneke, a psychiatrist at Grey Nuns Community Hospital in Edmonton who predominantly sees transgender people. Access to the few psychiatrists who approve transgender patients for surgery poses another bottleneck but the Ontario government announced last week that it will increase the psychiatric approval sites for gender affirmation surgeries. (Sex reassignment surgery is the term used by the Centre for Mental Health and Addiction, or CAMH, but people in the transgender community disagree with the term and prefer gender affirmation surgery.)

Access to hormone therapy is also fraught. Across Canada, most family doctors don’t feel comfortable initiating patients on hormone therapy, and subsequently refer patients to psychiatrists and endocrinologists. In a recent open letter, staff at the Gender Identity Clinic at CAMH encourage doctors to provide access to hormone therapy to their transgender patients rather than sending them to the CAMH clinic. As with surgery, few psychiatrists feel comfortable assessing transgender patients. Meanwhile, Dr. Raymond Fung, a Toronto-based endocrinologist known for being trans-positive, says that many endocrinologists are unwilling to initiate transgender patients on hormone therapy.

“The line that I hear from [family] physicians is, ‘Trans care is outside of my scope of practice,’” says Zaitzow, who facilitates two-day educational workshops for health providers at their institution’s request around five times a year. “We explain that transgender care is absolutely primary care. It’s not specialized care.” Zaitzow argues that doctors routinely prescribe hormones already to non-transgender patients. He argues doctors’ arguments for not providing hormone therapy mask a deeper issue. “This reluctance, I think, is about transphobia,” he says.

Health providers’ discomfort with transgender patients is not addressed by medical schools and training institutions. For the most part, there is no education and training on transgender health issues in the medical school curriculum, says Zaitzow. That said, Dr. Amy Bourns, a family physician at Sherbourne Health Centre, was hired last year by the University of Toronto to develop an LGBTQ curriculum for medical students and supervise residents in LGBTQ health. Earlier this year at the University of Alberta, third-year student Ian Armstrong and classmates spearheaded a day-long conference on LGBTQ health, with a session on hormone therapy.

Martin Harvey is a family physician in Calgary, Alberta who is known for being trans-positive and now has about 30 transgender patients. He became comfortable initiating hormone therapy after consultation and learning from his colleagues. The Sherbourne Health Centre and Rainbow Health Ontario has published a comprehensive 64-page resource to guide doctors through starting patients on hormones and monitoring them. While there are some risks of hormone therapy – chief among them that patients can be at a higher risk of blood clots – Harvey says these risks are “relatively small” compared to the benefits for the patients and can be managed, through blood thinning medication for patients who are predisposed to blood clots, for example.

Access to transition-related care can make a significant difference. Among those who wished to medically transition, those who had already begun hormone therapy were about half as likely to commit suicide, according to Trans Pulse.

“Once patients go on hormone therapy, they blossom,” says Harvey. “I’ve had people who may have been on numerous anti-depressants [before hormone therapy] and now they just take hormones.”

Patients who are denied hormone therapy or don’t have a doctor from whom they feel comfortable requesting hormones are not just at higher mental health risk, but face the physical risk of what Trans Pulse refers to as “do it yourself” therapies. In an Ontario survey of 233 transgender people currently on hormones, 27% indicated they had used non-prescribed hormones in the past, such as hormones available on the internet. Five people reported they had attempted or completed surgeries.

How health providers can create safe spaces for transgender people

The most egregious mistreatment Silveira experienced happened when he was referred for an ultrasound. He had to explain to the incredulous receptionist, nurse and ultrasound technician at three separate times that he was a transgender man, as his gender was indicated on his health card as female. While he was changing, he overheard the ultrasound technician say to the doctor, “He says he’s a boy but he’s a girl.” The doctor snapped back, “Well which one is it, a male or female?”

“I was so upset,” says Silveira.

After the struggle that transgender people endure to “authentically live their gender truth,” being called by a former name or pronoun can be a “devastating moment,” says Massarella. A lack of an apology, joking and rude behaviour can make a misgendering situation far worse. A major US survey of 7500 transgender people found 28% reported verbal harassment in a medical centre, 19% reported being denied care because of their gender identity and 28% postponed health care in fear of discrimination.

Even when transgender people have access to trans-positive family doctors, they are routinely disrespected when referred for other medical services. For this reason, Zaitzow recommends that family doctors call referral sites to ensure they are comfortable seeing transgender patients and will take measures to ensure the patient is called by the correct name and gender.

Massarella says training in transgender health is necessary for all staff in a clinic. “You can be the most positive nurse practitioner or physician in the world but if your front office isn’t pleasant, that ruins the entire encounter for your client,” she says.

Major medical institutions, including the U.S. Joint Commission, recommend that health providers ask all patients – regardless of how they present – about sexual orientation and gender identity. Many health providers assume that transgender men will have intimate relations with females, and that transgender females, with males. But that assumption does not always hold true, says Panas, who is married to a woman.) Those who identify as transgender should be asked what pronoun and name they would like to be used, adds Massarella.

Health ministries can create policies to ensure “transgender” is an option in electronic medical records. Currently, in Ontario, the minimum requirements for gender on EMRs is male, female, unknown and other, says Katherine Tudor, a spokesperson for EMR consultancy OntarioMD. Many transgender people find the ‘other’ category offensive. In Alberta, most EMRs don’t have categories outside of male and female, according to Harvey. (Massarella adds, however, that health providers can work with their EMR company to ensure a preferred name and gender pronoun is mentioned prominently, such as in brackets on the same line as the legal name).

Given that transgender patients often still need the cancer screenings associated with their birth sex, Panas advises the health workers she educates to use careful language. “If a doctor says ‘you have boy parts and we have to test them’…that’s incredibly offensive because there’s nothing boy about me,” says Panas, who recommends something along the lines of, ‘You have parts that have to be tested because they’re susceptible to cancer.’”

When health providers need to verify a transgender person’s record, Silveira recommends the health professional do so in a private area, as a paramedic and nurse did when he visited an emergency room in the past. “I’m really sorry to ask this question but I have a different name for you on file,” Silveira recalls the nurse saying. There were none of the blank stares or dropped jaws he’s routinely seen in the past when he explained he is transgender and has changed his name on his ID. Instead, the health professionals thanked him for the clarification. The experience left Silveira feeling as though medical professionals “have become more open to transgender people lately.”

For Armstrong, that openness is an obligation. “When you look back at the ways that homosexuality and transsexuality were pathologized within medicine, there is a moral obligation to right that wrong,” he says.

With special thanks to Alex Abramovich for his editorial assistance.