The Road to Inclusion: Transgender Health Care in Canada

The doctor’s office was only a block and a half away, so Natasha decided to walk. It was one of those unpredictable September days, the kind that’s apt to switch from cloudy to sunny without warning. Natasha, hoping the sun would prevail, wore a black and white print dress.

Though today’s trip was short, the journey leading up to the visit had been much longer. Natasha, a 58-year-old transgender woman living in Calgary, Alberta, wanted to begin hormone therapy — a regular regimen of drugs to help feminize her body — but first needed a physician’s referral. This was the sixth doctor she had seen in three months. The previous five had asked her to leave. “Unless you have female parts,” they said, “we’re not referring you.”

Doctor number six proved much the same. Natasha found herself sitting nearly naked on the examination table, her carefully chosen dress lying in a heap on a chair. The doctor felt her rubber breast forms and looked for evidence of a vagina. “I don’t have any physical [attributes] of a female,” Natasha tried to explain, “I’m saying it’s more mental.”

Unconvinced, the doctor continued his search for some indication that Natasha was biologically a woman. He also checked her blood pressure, used his stethoscope and ordered blood work.

Despite the unpleasant experience, Natasha felt better on the walk home. “I figured at least I didn’t get thrown out of the office,” she says.

The tests the doctor ordered indicated, not surprisingly, testosterone levels too high for Natasha to be deemed biologically female, and resulted in a $200 prescription to lower her cholesterol levels. Having thought that might be all, Natasha breathed a sigh of relief when, after a final, just-to-be-sure physical examination, he also gave her the referral she needed.

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Trans is an umbrella term for people whose gender identity doesn’t fit with societal expectations. Members of this group might use the words transgender, transsexual, transitioned, genderqueer or two-spirited to describe themselves. Transgender people are those who are biologically male or female, but feel like a member of the opposite sex.

Though many advocates wish it weren’t, trans is listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders under the heading Gender Dysphoria. The condition is defined as “a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender.”

Despite its place in North America’s psychiatric bible, the trans community is not easily quantifiable. Most studies focus on the most easily counted subgroup of trans individuals, namely, those who show up at gender clinics. According to these stats, trans people are rare, with estimates ranging from one in 11,900 to one in 45,000 for male-to-female individuals, and one in 30,400 to one in 200,000 for female-to-male. However, not every trans person chooses to transition medically, nor does everyone experiencing gender dysphoria seek the advice of a gender clinic. For these reasons, many researchers believe the number of trans people to be much higher, with some doctors citing rates as high as one in 500.

The effect transphobia has on the health of the community is staggering. Over 75 per cent of trans people in Ontario have seriously considered suicide at some point in their lives, according to the community-based research project Trans Pulse. While no comparable data exists for other Canadian provinces, the Trans Pulse survey suggests the danger members of the trans community face. It also shows how health care providers can help. For those trans people who had completed a medical transition — beginning with hormones and often leading to surgery — the study showed the number considering suicide was cut in half.

While these numbers clearly indicate the value of sex reassignment surgery (SRS), funding for the procedures varies from province to province, with many jurisdictions covering some surgeries but not all. Equally shocking are the barriers trans people face during visits to the doctor, where they’re routinely ridiculed, shamed, or denied service altogether. As increasing numbers of trans people come out of the closet, Canadian health care workers must be better able to greet them when they emerge. This means better training and more funding, and perhaps most importantly, leaving prejudices at the door.

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Despite the innumerable hurdles she faces in completing a medical transition, Natasha is patient. Now 61, she has, after all, waited decades to express something she’s felt since childhood. She began living as a woman off and on in her early 50s, then full time in December 2010. Until hormones and surgery alter her body permanently, Natasha has found other ways to “pass” — the transgender community’s word for being read as the gender of choice. She wears breast forms sizeable enough to match her 5'8", 200-pound frame, and padding to alter what she calls her “small bum.” She dyes her salt and pepper, chin-length hair light brown and keeps her nails well manicured. Sometimes they’re leopard print, other times, pink.

As a child growing up in Trail, British Columbia, she remembers wanting to play dolls with the other girls. Instead she was given a toy truck. Playtime proved good practice when, as an adult, Natasha spent three years as a long-haul truck driver. During this time she drove a trailer from Calgary to Los Angeles and back again. The week-long trips would often begin in Taber, Alberta, where Natasha would fill her 75-foot rig with McCain french fries. After each driving day she would sleep in the six-by-seven bunk behind the driver’s seat. Once in L.A., it would take a full day to switch loads, exchanging french fries for Ikea furniture in Kern County, wicker chairs in Tijuana, or organic bananas in San Diego. And then it was back north, taking her new load to Saskatoon or Prince Albert, Grand Prairie or Fort Nelson, before returning to Calgary.

“It took its toll,” Natasha says of the job. “I ended up with all these ailments because of the road, living on it 16 hours a day.” First it was gallstones, then chronic bladder infections, and finally, an enlarged prostate. After an operation on her prostate, Natasha was impotent. “That became my turning point,” she says. “I said to hell with it, I’m going to go this route.”

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In Alberta, Natasha’s route to becoming a woman will necessarily lead to the office of Dr. Lorne Warneke. In fact, the letter she so desperately needed from any one of the six doctors she visited, was to allow her to see Alberta’s “gender specialist” at his psychiatry practice at Grey Nuns Hospital in Edmonton. Warneke is one of only two psychiatrists in Alberta who diagnoses, assesses and provides patients with the referrals they need to access hormone therapy and sex reassignment surgery.

“Transgenderism was once thought to be very rare, and in fact it’s much, much more common than once previously thought,” he says. “Certainly, I’m so backlogged that there could be two or three or four transgender psychiatrists, maybe not full time but at least seeing transgender patients.”

Over the years, the continued existence of Warneke’s practice has depended on his enthusiasm and commitment. Warneke has worked at Catholic hospitals in Edmonton for 34 years. In 1996, he started seeing enough trans patients to make it a specialized service at his clinic, and after some lobbying, the Alberta Health Services Capital Region provided him with an additional staff member.

In April 2009, when SRS was removed from the list of provincially funded services in Alberta, multiple news outlets asked Warneke to comment on the policy change, making the Edmonton diocese more aware of his work. Warneke was told he was to stop seeing transgender patients. Assisting them in “changing their body” went against Catholic dogma. In an effort to deflect the administration’s anger, Warneke sought support from the Alberta Medical Association, the Alberta Psychiatric Association, the College of Physicians and Surgeons of Alberta, the Canadian Medical Protective Association and members of his own department. All of them turned their backs. As a result of the dust-up, Warneke now carries out all clinic correspondence on his own letterhead, but for the most part has proceeded as usual. After a three-year hiatus, SRS was relisted in June 2012.

Warneke’s persistence stems in part from his own experience. As a gay man who didn’t come out until his early 40s, he has a sense of the stigma many trans people still experience today. “I love to fight for their rights,” he says. “It’s just my passion.”

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The word transsexual was first coined in 1923 when German sexologist Dr. Magnus Hirschfeld used the expression “seelischer transsexualismus” (psychic transsexualism) in a journal paper. Since Hirschfeld wrote about a wide range of topics in sexuality, it wasn’t until another German born sexologist, Dr. Harry Benjamin, published The Transsexual Phenomenon in 1966 that transsexuality truly entered the medical literature.

Benjamin was one of the first physicians in North America to work with trans patients and became influential in the development of trans care. He wrote The Transsexual Phenomenon at the age of 81.

The book isn’t an average piece of medical literature. Benjamin’s writing is often poetic, especially as he describes the moral and political notions surrounding trans care. “I have seen too many transsexual patients to let their picture and their suffering be obscured by uninformed albeit honest opposition,” he wrote. “Furthermore, I felt that after fifty years in the practice of medicine, and in the evening of life, I need not be too concerned with a disapproval that touches much more on morals than on science.”

Founded in 1979, the World Professional Association for Transgender Health—an international group that provides standards of care for trans patients—was originally named after Benjamin. The WPATH standards guide the better part of the work of trans health care providers across Canada, such as the Sherbourne Health Centre, a community-based clinic in downtown Toronto. They state, for example, how many letters of referral a patient needs for chest surgery (one) or genital surgery (two).

Despite the time that has passed since Benjamin published The Transsexual Phenomenon, certain observations remain true. “The difficulty in procuring surgical help is not the only plight of the TS patient,” Benjamin wrote. “Any medical help, including hormone treatment, may be denied him by overcautious and over-conservative physicians.” Benjamin also included his vision for the future: “It is my hope that this volume may induce doctors as well as laymen who may come across the transsexual phenomenon to assume a tolerant and rational attitude and let the light of facts replace the ever-present twilight of prejudices.”

Forty-eight years later, Benjamin’s words seem naively hopeful. With the exception of heavily populated regions like Ontario and British Columbia, most provinces have only a handful of primary health care providers familiar and comfortable with trans issues. As the number of trans patients grows, the future care of trans Canadians can no longer rest in the hands of just a few physicians.

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Sex reassignment surgery is often used as a catch-all term for multiple procedures. For male-to-female patients the list may include facial feminization, breast augmentation, and vaginoplasty (the creation of a vagina), and for female-to-male patients, mastectomy, hysterectomy, or phalloplasty (the creation of a penis). While not every trans person opts for hormonal or surgical treatment, research suggests an overwhelming majority do: In Ontario, over 75 per cent of trans people have either completed a medical transition, are in the process, or plan to begin in the near future.

Opponents of sex reassignment surgery, particularly opponents of government funding, often put the procedure in the same category as cosmetic surgery. It’s a dangerous misunderstanding. “There is mortality associated with untreated gender dysphoria and it’s usually in the form of suicide,” says Dr. Ian Whetter, a physician at Trans Health Klinic in Winnipeg. Numbers from the Ontario Trans Pulse survey back up Whetter’s conviction: Of the respondents still waiting to begin a medical transition, 46 per cent were considering suicide. That number dropped to 23 per cent for those who had completed the process. “There are known treatments that reduce the mortality associated with [transgenderism],” Whetter continues, “which are crossgender hormone therapy and sexual reassignment surgery.”

Satisfaction rates among those who undergo sex reassignment surgery are increasing steadily, according to the WPATH Standards of Care.

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Anna Travers is director of Rainbow Health Ontario, a province-wide initiative designed to promote access to health services in the LGBT community. “I don’t exactly know,” she says, “but I think there’s something about people crossing gender lines that really freaks people out.”

Transphobia, whether it manifests itself in violence or stubborn ignorance, is, without question, one of the reasons trans health care in Canada is inconsistent and inadequate. Through education and training, Rainbow Health is doing its part to remedy the situation. It runs a service called Trans Health Connection, which partners with health care organizations in communities across Ontario. Launched in April 2011, the program offers training sessions to health care teams working with trans people. The topics discussed in the four day-long sessions range from respectful language to pre- and post-surgical care, and are open to all primary health care providers, be they doctors, nurses, counsellors, or social workers. No similar training model exists elsewhere in Canada.

“It’s important because no one else is doing work like this,” says Jordan Zaitzow, Trans Health Connection coordinator. “I get calls from trans people across the province every single week looking for [support],” he says. “And I get even more calls from providers [who say] I would love to do this work, but I don’t have the resources. I need more training.”

Now in its fourth year, the program is a success. Training sessions held across Ontario communities are attended by as many as 80 health care and social service workers per day. While pleased with the program, Zaitzow is conscious of the magnitude of the problem he’s trying to fix. The popularity of the sessions is in large part due to the lack of LGBT education in medical, nursing and social work schools. “I think for trans health in particular it’s been seen up until very recently as a very specialized area,” Travers says. “It’s only recently that it’s being seen as something that’s within the scope of a family doctor.”

Both Travers and Zaitzow would prefer LGBT health to be a part of the curriculum at the professional school level, rather than having organizations like Rainbow Health deliver training as a part of continuing education. Others agree. “I think that there should be standard medical education,” Whetter says. “It’s trickier to diagnose depression than it is to diagnose gender dysphoria.”

While policy makers debate who should shoulder the burden of trans health training, patients are often the ones educating their doctors—if they’re brave enough to visit the doctor in the first place. “Trans people don’t see themselves in any health studies, health information and health literature,” Zaitzow says. “So then if trans people don’t see themselves reflected in [the medical world], the message is that primary health care services are not for them.” Because so many trans people have had bad experiences accessing health care, many choose not to go at all, adding to their list of health concerns.

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After 10 months on the waiting list, and three and a half hours driving from Calgary to Edmonton, Natasha was happy to spend a mere five minutes in the waiting room at Grey Nuns Hospital before her name was called. First, an intern interviewed her, taking note of her history and her experience living as a woman. When finally Natasha met Dr. Warneke, the meeting was short.

Going into the appointment, Natasha hoped Warneke would provide her with one of the referral letters she needs for genital surgery. Instead, she discovered she must spend nearly a year before surgery on spironolactone, an androgen inhibitor, as well estrogen, which she will be on for the rest of her life. Adding to her frustration is the fact Warneke remains the only gender specialist in the province. “It seems like I’m going to be doing a lot of commuting between here and Edmonton to maintain my program,” she says dispiritedly.

Despite feeling weary, in a way, Natasha’s experience as a truck driver was preparation for the process she’s going through now. Years ago, the long stretches of highway between Calgary and Los Angeles would put her in an almost meditative state, helping to pass the time between the two cities. It’s this kind of patience Natasha continues to draw on to this day. She uses the word transgender to describe the stage she’s at, as though it were just a pit stop on the way to place she’s going. “It doesn’t fit my mind,” she says of being transgender. “To me it’s just a journey you go through.”

Like the long distances she used to travel, Natasha’s transgender journey is also coming to a close — or at least moving on to the next pit stop. About two years after her first appointment with Dr. Warneke, Natasha is scheduled for genital surgery in September 2014. Given all she’s been through she’s hesitant to celebrate just yet. “I’m still beside myself,” she says. “It’s still a fantasy. I won’t believe it until it’s here.” Occasionally, however, Natasha allows herself to imagine what life might be like after her operation. “I’m looking to re-establish myself as a human being,” she says.