Transgender Canadians face health-care barriers and wait times all across the country for services including hormone therapy, psychiatric treatment and gender-affirming surgery.
There has never been more visibility for transgender issues, thanks to the work of activists across the country and the popularity of celebrities like Caitlin Jenner and Laverne Cox.
“The public is really interested right now because of a confluence of things, the celebrities and the human rights issues that are getting a lot of play in the media,” Graeme Imrie, director of corporate affairs for Sherbourne Health Centre, tells Yahoo Canada News.
But that interest hasn’t lessened the wait times transgender people across the country face at every step of the process of transition. And those wait times can be deadly: up to 43 per cent of transgender people in Canada, the United States and Europe have attempted suicide at least once, according to TransPULSE research.
“What we know, according to the research, is that if people are able to transition — whether that’s medically, socially, in terms of their vital statistics and their gender markers and all that stuff — if they’re able to transition, then those suicide rates, the depression, the anxiety drops off completely,” says psychologist Amy Otteson in On Hold, a documentary on transgender health-care access released this month by VICE Media.
The situation is complicated by the fact that it varies province by province, both in terms of access to health services related to gender dysphoria and in which surgeries and treatments are covered by provincial health care. And there is no national strategy in terms of treatment guidelines or research protocols.
“Provincial delivery is apropos of the system,” Imrie says, “but there’s potentially a national role in terms of a strategy.”
The result is long wait times at every step along the way, from seeing a psychiatrist to getting approval for hormone therapy and gender-affirming surgery, to getting the surgery itself.
“The current wait list for the clinic is at 1,064 clients.” Kate Richards, senior media relations specialist at the Centre for Addiction and Mental Health (CAMH) in Toronto, tells Yahoo Canada News. “New clients will receive a letter letting them know that the wait for an appointment is 24 months at minimum.”
All transgender patients in Ontario who seek gender-affirming surgeries require approval from CAMH, which means being seen at its Toronto Adult Gender Identity Clinic. The Ontario government is currently considering an expansion of the number of clinics in the province that can provide approvals for the surgeries.
Access to the approval needed for publicly-funded, gender-affirming surgeries varies considerably across the country. Patients from Newfoundland and Labrador also need to go through CAMH, which requires them to travel to Ontario. In British Columbia, the chief assessor is the only person in the province who can give approval for genital reassignment or “bottom” surgery. Transgender patients in Saskatchewan have to travel to a clinic in Edmonton to get a recommendation for treatment. At the other end of the spectrum, Nova Scotia allows family doctors to grant approval for gender-affirming treatments according to the standards set by the World Professional Association for Transgender Health.
And once the go-ahead for gender-affirming surgery is received, there is the barrier of access and cost. The only clinic in Canada that can perform all gender-affirming surgeries — including “bottom” surgeries that include genital reconstruction — is located in Montreal.
And the surgeries covered by provincial or territorial health care vary by location. Hysterectomy, oophorectomy, metaoidioplasty and phalloplasty (bottom surgery for female-to-male patients), penectomy (penis removal for male-to-female patients), orchiectomy (testes removal) and vaginoplasty (creation of a vagina) are all covered by British Columbia, Alberta, Ontario, Quebec and Nova Scotia, as reported by Daily Xtra. Others cover a mix of surgeries — Newfoundland and Labrador, for example, doesn’t cover metaoidioplasty or phalloplasty but does cover scrotoplasty (creation of a scrotum).
New Brunswick is the only province that still doesn’t provide funding for any gender-affirming surgeries. Nunavut and the Northwest Territories also do not fund any of the surgeries. And even if a province covers surgeries, they may have a quota. In Alberta, for example, only 25 gender-affirming surgeries are covered annually.
And there are other steps in the transition process that are not necessarily covered by provincial health care, such as hormone therapy (which should precede surgeries), electrolysis for hair removal, chest contouring with mastectomy. No provinces cover tracheal shaving or facial feminization, and only B.C. covers breast implants for male-to-female patients.
Some patients pay out-of-pocket for surgeries in order to avoid wait times or to get those that are not covered by provincial health care, or both. This can cause serious financial stress for a population that is already economically vulnerable. Research has shown that transgender people are more likely to live in poverty or be unemployed, according to the Williams Institute.
But while not every transgender person wants gender-affirming surgery, for those who do it’s considered medically necessary. The VICE documentary included interviews with several transgender people who discussed their struggles with mental health during the transition process, and Dr. Adrian Edgar, medical director of Clinic 554 in Fredericton explains in the film that delays and barriers in accessing transition and gender-affirming treatments can have fatal consequences.
“That delay equals death,” Edgar says.