The Canada Health Act emphasizes that all Canadians are entitled to the same level of care. This does not appear to be the case for transgender patients, many of whom face barriers when seeking gender-affirming medical treatment.
There are many disparities in health care access between transgender patients and their cisgender counterparts (cisgender denotes people who identify with their birth gender). It seems clear that transphobia, the fear and mistreatment against those who do not conform to gender norms, is present in our health care system.
Here is one example. More often than not, family doctors are uncomfortable initiating hormone therapy for their transgender patients; instead, they refer patients to psychiatrists or endocrinologists, meaning a longer wait time for patients. Hormone therapy is one of the main treatment options for people who are transgender. Non-transgender people who need hormone therapy – such as a non-trans male who has low testosterone levels – are not usually referred to psychiatrists or endocrinologists, however. In fact, family doctors refer transgender patients who wish to initiate hormone therapy to psychiatrists for assessment despite that this has been discouraged by psychologists at the Centre for Addiction and Mental Health (CAMH). And a recent Healthy Debate article revealed that family doctors have the expertise to initiate hormone therapy for transgender people in most cases.
Whatever the reasons for the discomfort on behalf of the doctor, the burden is felt by the patient. It would not be a stretch to assume that some transgender individuals turn to the black market to self-medicate with hormones when they are rejected or felt to be discriminated against by their family doctors. Research from the Trans PULSE project indicated that of 233 transgender respondents using hormone therapy, 27% of them had previously used non-prescribed hormones; negative experiences with healthcare providers were citied as reasons. This poses many dangers for self-medicating transgender people, such as cardiovascular risks and liver damage, where proper dosing of hormone therapy and blood tests are necessary.
Another glaring example of the transphobic nature of our health care system is that a psychiatric diagnosis is a precondition for transgender patients to have access to sexual affirmation surgery. The issue with this is it places transgenderism within a pathological framework. In essence, being a transgender individual who seeks out to be congruent with their gender identity is treated as being mentally disordered and in need of treatment that manages their mental illness—especially prior to any initiation of gender-affirmation treatment. This violates the WHO’s mandate which entitles persons the right to control one’s health and body and to be free from interference from unwanted medical treatment. This echoes the controversies surrounding the possible use of conversion therapy—a form of psychiatric treatment that aims to change one’s gender identity—at CAMH in Toronto. Though CAMH denies using conversion, or reparative, thearpy, its gender identity services for children were ceased in part to questions around the “intensive assessment and treatment.”
While it is true that many transgender individuals also experience some levels of mental distress, it is important to differentiate whether it is rooted in internal and/or external factors, such as gender dysphoria or discrimination from society. Psychiatric referrals ahead of hormone therapy should be reserved only for transgender people who have mental distress that is separate from the discriminatory treatment and isolation they face because they are transgender.
Typically, patients have some degree of autonomy over their health care treatment that does not seem to be extended to transgender patients. What doctors may not be considering is that by the virtue of them being the gatekeepers to medically necessary treatment, the future of their transgender patients is at their mercy. Transgender individuals are already a marginalized group that face disproportionate rates of unemployment and poverty because of prejudice and the taboos associated with gender non-conformity. Health care workers can bridge this gap by being more compassionate about the experiences of transgender people and the importance of being able to affirm one’s gender identity. Access to health care should be universal and gate-keeping access to medical intervention can sometimes result in more harm than intended good.