While the Ontario government is making strides to upgrade transgender medical care, there’s still a long road ahead in terms of improving accessibility
For many Canadian boys, turning 18 marks a big milestone in their lives, since it symbolizes a transition away from the carefree days of childhood and into manhood.
This is true for Brynn Emond as well, except the celebration for his passage into male adulthood will have to be put on hold until an arbitrary date in the future.
As an 18-year-old transgender youth living in Ottawa, Emond knew that he was born in the wrong body since he was two years old, and since 2014 has begun taking steps to transition away from his female sex using male hormone injections.
But despite receiving support from his family and the local trans community, Emond has been left in a state of limbo with regards to the final stage of his journey—sex reassignment surgery.
“The process that you have to go through right now is long and rigorous and really just unnecessary,” he said, having been put on the waiting list to get a referral for this surgery back in August of 2014. As of this month, he still has no idea of when he will be able to move forward with the process.
Recently the Ontario government announced plans to fast-track this system by expanding access for gender affirming surgery, in the hopes of streamlining the process and cutting down on these long wait times.
While Emond claims that these proposed amendments are a step in the right direction, is it enough to help balance the scales of how health care is administered to transgendered people in Ontario and Canada at large?
Most of the transgender population throughout the province is in the same boat as Emond.
Even though over 10 different kinds of sex reassignment surgeries are covered by the Ontario Health Insurance Plan (OHIP), the process to apply for these insured operations is fraught with bureaucratic red tape and limited access points.
Currently, the only health clinic in Ontario that can clear patients for the surgery is the Centre for Addiction and Mental Health (CAMH) in Toronto, and the amount of applicants their staff has to process has swelled exponentially over the years. Today, the number of applicants on the wait list is nearing 1,200, which means that trans people such as Emond might have wait several years until they are even given the green light for their surgery of choice.
Obviously this situation isn’t ideal, especially given the fact that CAMH’s history has been littered with controversy surrounding their questionable therapeutic and screening practices.
While some might claim that these operations are superficial and can be put off, Emond argues that these procedures are not just cosmetic in nature. In some cases, they’re life-saving.
After all, rates of suicide are at epidemic levels in the trans community, a reality that is exacerbated by the fact that some have identified the waiting period in between getting approval and getting surgery as being the most vulnerable time for some members of the transgender population.
“When you have to wait upwards of two years for something to happen, that’s very frustrating,” said Emond. “More than frustrating, it’s dangerous, because there are people who are suicidal because they can’t get the surgery.”
This sentiment is echoed by Tamara Chipperfield, the director of the mental health and addiction program at the Centretown Community Health Centre here in Ottawa. Chipperfield helps coordinate counselling services and hormone replacement therapy for the local transgender population and has witnessed this kind of despair first-hand.
“When we screen people for the hormone readiness assessments, over 40 per cent at intake express that they’ve either currently experiencing suicidal ideation or have in the recent past.”
The research group TransPULSE projected similar numbers with a suicide rate of 30 per cent, although that number did drop to 11 per cent if the respondents had the option of accessing full medical transitions.
Admittedly, this study also highlights the fact that a severe lack of social support amongst many trans people is also a strong determining factor in this high suicide rate.
But not only does this prolonged waiting game encourage some trans people to give up hope, it forces others to explore dangerous methods of self-medication in the interim.
According to another TransPULSE study, 25 per cent of the subjects they surveyed who use hormones admitted to acquiring them from non-medical sources. A small percentage of respondents even confessed to conducting crude sex reassignment surgeries on themselves.
Thankfully, Dr. Eric Hoskins—the Ontario Minister of Health and Long-Term Care—recently announced plans to make amendments to Ontario’s Health Insurance Act, which would allow any qualified health care-care provider (not just CAMH staff) across the province to refer patients for this kind of surgery.
These changes would be particularly beneficial to someone like Emond, since he could obtain a referral for surgery at a local health clinic like Centretown.
As described by Ottawa Centre MPP Yasir Naqvi, this screening process could be carried out by “(any) doctor or a nurse in a community health centre in Ottawa, as long as they are trained and certified by Rainbow Health Ontario under the internationally recognized standards which is under the world association profession for trans-gender health.”
Even though the specifics of how these amendments will be rolled out is yet to be determined, Emond is just happy that the wheels of change are finally in motion.
“If every health-care practitioner can offer it, then that’s what we want. That’s perfect.”
All paths lead to Montreal
While Emond and Naqvi are extremely enthused about the possibilities of these new amendments, Quinn Blue, a coordinator for the Student Federation of the University of Ottawa’s Pride Centre, remains “cautiously optimistic.”
As someone who specializes in trans health issues, Blue has reservations about the practicality of employing these new amendments, and is unsure if our current health-care system can support the flood of individuals who will be seeking these kinds of specific operations.
“It’s something that’s very minimally taught in schools, so they are not necessarily learning how to provide trans health care and are not seeking out the resources that are available to learn more.”
If anyone were to take a surface-level glance at the nation-wide resources available to our trans population, they’ll find that Blue is right.
Similar to the situation with CAMH, one’s options for finding proper trans-specific surgery is limited to a single location. Right now there’s only one clinic in all of Canada, the GRS clinic in Montreal, that performs the kind of operations that can accommodate someone in Emond’s shoes (bottom surgery).
In an interview on CBC’s The Current, Dr. Pierre Brassard—a cosmetic plastic surgeon who owns and operates out of this clinic—reveals that he and his partner can only process 300 patients a year.
Even someone with poor math skills can tell that this doesn’t bode well for the close to 1,200 people who are still waiting to be given referrals at CAMH, let alone 75 per cent of the trans population in Ontario who state that they require medically-assisted transitions.
So, it seems like people in Emond’s position might be trading one bottleneck for another, and will be forced to spend money out of pocket to travel out of province or to the United States for the surgery they need.
As in most cases where inequality runs rampant, a shortage of education is at the centre of this lack of understanding surrounding transgender health care.
“It’s not well taught in universities and in residency programs,” said Dr. Brassard in his interview on The Current, believing that it could take several months to a year to properly train new physicians on how to complete these operations.
“It’s intricate, it’s difficult, it has many possible complications and you have to rely on experience… and really learn the trade.”
While Minister Hoskins has promised more funding to places like CAMH and the Rainbow Clinic to cope with the increased demand of patients, Naqvi says that they have no specific plans to widen the educational scope of medical programs in the province. Instead he is hoping to lead by example with the proposed amendments to the referral system.
“Our hope is that through this change and making the system far more streamlined and focusing on the health of the transgender community, that it will incentivize more medical practitioners to be able to perform that service right here in Ontario.”
Detours and roadblocks
Unfortunately, healthcare barriers for the transgender population transcends beyond a lack of accessibility to cosmetic surgery and hormones.
According to Blue, “accessing primary care can be challenging for trans folks. So if your doctor isn’t informed about trans health care they can neglect providing even just basic health care.”
This sentiment lines up with Chipperfield’s experience as well, revealing that the hostility and outright transphobic attitudes that some of her patients received from health-care providers is so bad that “a lot of folks just avoid dealing with the health-care system because of negative experiences that they’ve had in the past.”
This kind of overt discrimination is highlighted in detail in a recent report published by Western University, which surveyed different transgender people from across Ontario. Reportedly, 40 per cent of the people they talked to recalled some forms of unsavoury treatment from their family physician, ranging from demeaning language to outright refusal of care.
These same feelings of belittlement and dejection even extend to situations that could be described as life and death. The same report details how 21 per cent of their respondents actively avoided the emergency room when they needed it.
And even though Naqvi believes that the government’s latest amendments prove “that Ontario is an open and inclusive society”, the same can’t be said for the status of trans health care at a national and federal level, which is inconsistent at best, and outright discriminatory at worst.
For one thing, gender-affirming surgeries are not insured across the board, with Northwest Territories, Nunavut, and New Brunswick not offering any kind of government sponsored coverage whatsoever.
And that’s to say nothing of the Senate’s decision to gut the important stipulations of Bill C-279 in February, which would have allowed “gender identity” to be protected under the Canadian Human Rights Act and Criminal Code in all public institutions.
Even though these inconsistencies serve as an uncomfortable reminder of the hurdles that many trans people still have to overcome to access health care in the year 2015, the Ontario government is still planning to move forward with their plans to improve access to gender-affirming surgery.
Naqvi remains optimistic that these amendments will pass the month-long consultation period and come into law in early 2016.
Meanwhile, Chipperfield and her employees are prepped and ready to take advantage of the new potential services at a local level, and would definitely be in favour of giving out referrals to transgender Ottawans for surgery if given the opportunity.
“We’re still waiting for more information, but we would definitely advocate that decreasing barriers and increasing accessibility for folks is at the top of our priority list.”
As for Emond, he will be forced to play this anxiety-driven waiting game for a little while longer. However, he remains in good spirits of now that a little glimmer of hope has appeared on the horizon.
“Not to be overly melodramatic or anything but it’s good. It’s really nice to see that stuff is potentially going to change.”
Hopefully these policy changes can eventually be replicated nationwide and Canada’s reputation for administering universal health care can get some legitimate backing.