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.
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What we do know is that we are systemically sterilizing young kids long before they have the wisdom to understand the consequences of this action because society has gone stark raving mad on this issue. The endocrine gland system is compromised and HRT is correlated with higher risks of cancer, and yet we continue to be nuts about it. In the past only eugenics monsters sterilized kids, now it is the height of fashion. I hope these kids are keeping a list of names of advocates and anybody actively involved in facilitating their sterilization, including their parents, so they can sue them later. My personal opinion is that sterilizing kids with puberty blockers and hormones should be a crime against humanity and a prison offense, even if the parents do it. I mean sterilizing? Really? You cannot let your kids sleep with an adult under law even if the kid wants to, but you can sterilize your kid if they have an obsession? We are all horrified by genital mutilation in other parts of the world, yet here sterilizing kids and changing their bodies long before they understand what they are doing is considered normal, because, again, society is going insane. I saw a documentary where a three year old declared herself a boy and the parents said they instantly “knew it was true”; that is what I call actionable ignorance. Incidentally, I am transgender maletofemale, since the 1980s, but never used hormones because getting them was a problem and it really was stigmatized then — I am actually glad it was. I am glad I did not go on hrt and puberty blockers when I was a tween to sterilize myself or turn my genitals in to malfunctioning jello, although if somebody had given me option I am sure I would have (but I was a kid). But, it is a pop culture trend, a fad, and a kind of insanity — the pervert ghouls in Hollywood say it is good so it is — so enjoy and keep pretending this mad sterilizing science project is good healthy behavior, even though suicide rates do not change in transgenders after transition …. so what is the excuse for sterilizing kids? Because they are so smart and wise when they are kids? My experience with doctors incidentally is that none of them are shocked anymore, so I do not know what backwoods hillbilly doctor you saw, but that is not my experience. I have seen multiple doctors over the years and not one batted an eye at the subject, nor do the girls at the salon where I get my nails done …. and I am 50-ish. Special interests are always looking for special treatment. Society needs to stop being politically correct on this issue and start using their brains. Sterilizing kids is monstrous behavior. If somebody had done that to me, you are damned right there would have been law suits. Please watch my video: https://youtu.be/fGDFrIx6dQk and think.
thank you for writing this
I’m a bit late on this thread. just to esatblish certain things I’m a ciswoman. had an ex fiance who was a transman. Have a close buddy who is a transman. And I live in a country where intersex people and transwomen are worshiped and feared for having divine powers. So that’s how I’m here on this website and have been for some time. Anyway, Grtransguy you’ve taken the words out of my mouth.I feel it’s good that you are open to talking about answering questions. To answer or not, is everyone’s prerogative. Everyone’s circumstances vary. No one should stand in judgement of another person. What works for one transperson need not work for another. And each to his own, I say.But I feel it is better to learn about trans issues from a transperson themselves.Since it is so much more personalized. Turning to the media (books, tv, internet) for answers is not the same.Also to assume most cispeople are out to get transpeople, make fun of them or ask questions for their cheap thrills is unfortunate and very demeaning.In every culture what can be asked and what cannot be discussed varies. In a place like American which is so multicultural and heterogenous, it must be much tougher to decide what the boundaries are. what is okay with one group of people may not be okay with another group of people.Personally I am very grateful to transpeople who take the time off to educate. Who are kindhearted about the unintentional lack of finesse some cispeople may have and make allowances for them.My first brush with transwomen was with the Hijra community, in my country was when I was younger. They used to come to collect alms. People used to be afraid to open their doors to them. I was secretly a bit scared. Fear is learned. Later on, I clearly remember being in the 6th grade and my mom was waiting with me for the school bus and a group of transwomen were going about collecting alms. One of them, a lovely, very beautiful transwoman smiled at me. It was a kind smile. She figuratively put her hand out to me, and I was a changed person. I have never feared the hijra community after that. What you dont know, you fear, and what you fear you hate. Anyway I used to frequent an LGBT center in my city and I eventually had the opportunity to talk to some ladies from the hijra community. And that deepened my great respect for them. If I ever thought I was different’ from them, after speaking to them I realised that we were the same in many of our likes and dislikes and attitudes. It’s always good to mix and mingle with people who you perceive to be different. You’ll see that many times, we are more like than unlike each other.I feel every relationship is a two way street. You have to give to get. I’m glad there are men like you grtransguy. Everyone is different about the Q&A part which is but natural. But what you put out you get back. I say spend some time educating people and you will get an educated response. Ignore the ignorant, and you will get only ignorance. This is my personal opinion. Saying that, I’d also say it is physically and mentally and emotionally demanding to open yourself to people. As a muslim woman who has to constantly deal with stereotypes and people thinking all muslims are terrorists and all muslims demean their women, gosh it can get really quite tough to educate people. Some days I snap off answers and bite peoples heads off. Other days I just get jaded and ignore. And thank God that when it really matters I have found the strength to open my mouth and talk somehow I find the strength to, and educate an ignorant person. I cannot do it all the time, it is EXHAUSTING. But when I can, I do.Like I say, each to his own.
Well written article.%featured% Even trans positive GPs have to be educated. BTW. Service Providers can use the wrong pronoun at times. Its not just the wrong name or gender but also pronoun that can be in error. Nurses and Doctors should be required to have a minimum number of hours on Trans* issues. Right now LGBTQ related courses are, in general, electives and the time can be as little as a few hours!%featured%!
Well written, insightful, accurate and informative article. Thank you.
Congratulations on a comprehensive and well written article on an important topic. I am pleased to hear about the LGBTQ education initiatives described at U of T and U of A and to see the excellent Sherborne Health Centre guide referenced. We need more resources like this to help primary care physicians and specialists (as well as all members of the health care team) feel confident providing care and support to transgender patients