LOST IN THE SYSTEM
Many transgender people struggle to navigate medical care for transition services in Alberta. Why?
This story uses specific terms to describe parts of the medical system. While not everyone who accesses these services may identify as transgender, this story focuses mainly on the experience of transgender individuals seeking medical care.
CONFUSING MEDICAL SYSTEM
Alberta spends the most money of all the provinces — $56 billion in 2017 — on health care. Of that $56-billion, the health budget was $21.4-million. $1.1-million was budgeted for "gender affirmation surgery," which includes vaginoplasty, phalloplasty and metoidioplasty.
Yet Alberta’s is far from a perfect system. For many people trying to access health care, the gaps are more obvious. That is especially true for transgender individuals.
Many trans-patients access care that includes things like hormone replacement therapy, top surgery and bottom surgery. These services and surgeries all vary from person to person, and their goal is to change a person’s body to align closer to their gender identity.
In Alberta, these procedures can be covered by the government. However, understanding how to navigate the public system isn’t easy. The information is limited. It’s confusing. And there are few people who can help.
Skipping Stone Foundation is one place people can go to find that information. As an organization that works with trans-youth, one of their goals is to provide “low-barrier access to mental health support and medical transition-related services.”
As it stands now in Alberta, there is no linear method for accessing transition services or even a consistent process when seeing a doctor, psychiatrist or anyone else involved in transitioning.
Lindsay Peace, co-founder of Skipping Stone, found this out first-hand when seeking information for her son.
“I actually spent nine months full-time trying to figure out ‘what do we do?’” Peace explains.
“People don't have that luxury of having somebody do that for them and you see families basically in crisis … they don't have the privilege or ability to be doing that — looking and calling.”
After doing the research for her son, Peace realized that this was something the community was in dire need of. Skipping Stone’s goal wasn’t initially to provide medical services or to assist people transitioning. They first started as a foundation that provided scholarships to trans-youth. But as doctors called their organization with the hopes of referring patients to them, the foundation grew into something more.
Now, the organization is well known for being a source of information on accessing transition services. They still provide folks with community support, like peer mentoring and scholarships. But they’ve expanded their professional services to include system navigation and medical and mental health services.
Peace and her team are trying to take some of the weight of learning how to transition off the individual so that they can access the information and services they need easier.
Many patients start their process by seeing a psychiatrist to receive a “gender dysphoria” diagnosis that Alberta Health requires to access public funding.
“We would prefer to see an informed consent model,” Peace explains.
This wouldn’t require a diagnosis, but rather the doctor would inform the patient of the effects of what they will be doing to provide a full idea of the risks and benefits of any medication or procedure. Unfortunately this requires, for most practitioners, that the patient be 18 years or older. Only a select few doctors who use this model will see patients who are 16 years or older.
Joe Raiche, a psychiatrist who primarily works with transgender adults and youth in Calgary, says from a contemporary psychiatry lens, he seeks to shift the focus.
“The assessment part isn't really about the diagnosis. I mean, that does happen but it takes 30 seconds. It's like, ‘What's your gender identity, how do you identify. Okay cool. Let's move on.’”
Raiche stresses that not all trans patients need psychiatric help, but as a result of the difficulty of navigating the medical system and outside factors, individuals can face other problems.
“It's about here's what's going on, let's get you the help that you need so you can you can start living life as your authentic self and start enjoying things. But with that there often can be mood or anxiety challenges or other things that have happened in somebody's life that may lead to trauma and substance use and thoughts of suicide. So that really formed the bulk of the assessment piece.”
Navigating the system
Once individuals begin transitioning in some medical sense, they are faced with many more problems.
Part of the problem is how difficult it is to actually understand the process of transitioning. That’s why Skipping Stone created assistance with system navigation. However, this service is still accessed on a one-on-one basis.
Raiche says the difficulty is partly because of the lack of doctors with knowledge about transitioning.
“You have these pockets of specialized knowledge, basically sub-specialist clinicians and they're kind of the keepers of that knowledge. And so by default you have these really long waitlists. That's part of the problem for sure,” he says.
The other, he believes, is the extremely long wait times that come with the handful of providers who have the knowledge to provide care.
This is where private care comes in.
Because individuals don’t want to wait for public care, they seek out private care, and then only have information to share about private care. Navigating the public system is more difficult when so few people hold current, up-to-date information about the process.
Much of the information available online from individuals who have already navigated the process might be incorrect, at no fault of their own.
“The answers to those [questions] have changed even in the last five years,” Raiche explains. “What you needed to do to start hormones is different now than it was 10 years ago. What you need to do to change your name and gender marker is different now than it was three months ago. So I think there is a lot of information out there in the world that at one point time was correct — it's just not anymore.”
System navigation is also so difficult because it changes from person to person. An individual could go through the exact same procedure, like top surgery, but have completely different experiences. This is because different doctors require different things, such as a diagnosis of gender dysphoria, or in other cases, informed consent. Doctors might require you to be on hormone therapy before getting surgery, or not. Then there is publicly funded surgery, in which there are requirements you must meet to be able to have your surgery paid for, which can look a lot different that privately funded surgery.
When it comes to interacting with transgender patients, there are no provincial guidelines for doctors to follow. Typically, doctors will look to the World Professional Association for Transgender Health (WPATH) guidelines, which are an overarching set of standards of care.
Unfortunately, Alberta’s medical system does not work the same for everybody who accesses it. It’s difficult to understand how to begin transitioning in the way that you want to, especially when the system still sees transition services as a “specialty,” as Peace puts it.
“What we're trying to do here is basically make the system navigate right. But we need that across the province. Everybody should have the same access to the same information and it shouldn't depend on which waitlist you happen to get referred to; which psychiatrist,” she says.
“It's just the lack of cohesiveness.”
Note: A previous version of this article stated that Alberta Health Services (AHS) requires a diagnosis of gender dysphoria for patients to access public funding. It is actually Alberta Health who requires this diagnosis.
Lindsay Peace speaks about her own frustrations with the medical system. Video by Rayane Sabbagh.
Lindsay Peace discusses why access to information is important for transgender youth. Video by Rayane Sabbagh.
Joe Raiche explains what access to psychiatric services looks like for transgender people in practice. Video by Rayane Sabbagh.
Joe Raiche on why information available online about transitioning can be confusing and outdated. Video by Rayane Sabbagh.
The 2018 Canadian Trans Youth Health Survey collected statistics from Canadian youth, like Lindsay Peace's son, about their medical care. Graphic by Amber McLinden.
I want to be'
Photo courtesy of Ben Laurin.
Benjamin Laurin remembers coming out as a transgender man in October of 2014.
“I mean, it kind of started when I was younger. I always wanted to be Danny from Greece,” he jokes.
“My sister and I, we didn't want grilled cheese sandwiches, we wanted boy cheese sandwiches because we thought it was a girl cheese.”
That’s the thing about coming out. As many others experience, it’s gradual. It isn’t all at once.
“It wasn't one specific defining moment. But everything from my childhood led up and exploded,” he explains.
In high school, Laurin started finding the words to properly describe who he was. Shortly after graduation, he took his first steps towards medically transitioning.
“I had like one last shebang as like a ‘girly girl’ at grad,” Laurin quips. “Then the day after grad, I chopped my hair off. And from there I haven't looked back.”
More than four years later, the medical process is still not complete.
“They kind of said that it would be about two or three years for bottom surgery to start. So, that's probably another five or six more years before everything is complete,” Laurin explains.
In total? “I would say a good nine or ten years of transitioning from start to finish.”
Finding the words
Even before beginning his transition, Laurin says it was difficult to find information from doctors or medical resources.
“The term [transgender] I found in an abnormal psychology textbook, so that right there was kind of defeating right off the bat.”
Once he found the language to articulate who he was, Laurin tried to seek help from his doctor on transitioning.
“She literally knew nothing about it,” he says. “She was like, ‘I have no idea where to start or where I'd like to give you any advice.”
When it comes to navigating the process, many transgender individuals have to do the research themselves. That’s what Laurin did.
“[Learning about the process] was pretty much all self-directed,” he says. “Everywhere you need to go to get information from people you have to wait.”
The cost of transitioning
Once Laurin was ready to begin the medical process, he spoke with a psychologist to get a prescription for testosterone. In July of 2015, he started on hormones. For a year, he waited to get into a psychiatrist here in Alberta to get a referral for top surgery, but ended up paying out of pocket in June of 2016 — for a procedure that cost approximately $10,000.
Laurin crowdfunded part of the cost for this surgery. With the help of friends and family, crowdfunding covered about half the cost of top surgery. But Laurin still had to pay the other half, along with hotels and travel costs, which he estimated to be close to $3,000.
He’s explored the option of paying out-of-pocket for bottom surgery, a series of three to four surgeries, but found out it would likely cost $70,000 or more in its entirety.
“If I had the money to drop to do that, I totally would. But that's just not realistic for anyone, really,” Laurin says.
Most privately funded surgeries are costly. Unfortunately, when so few people do surgeries publicly in Alberta, and have waiting lists that take as long as three years, private care is a necessary consideration.
Navigating medical professionals
Cost and wait times weren’t the only barriers Laurin dealt with during the process. One of the reasons he felt privately funded top surgery was the best option was so he could choose his surgeon.
While seeking surgeons, Laurin saw one Calgary based-doctor who he felt wasn’t sensitive to what Laurin wanted.
“He was like, ‘We'll go in through your nipple, we'll do liposuction and then you'll wear this binder for 24 hours a day for three months, and then it might not be perfect but we'll go back in and fix it and you won't have any scars, and the scars are really ugly.”
Many transgender men have double mastectomy scars, and it’s sometimes a defining feature of their transition. It’s not something Laurin, and many others, believe is “ugly.”
Laurin chose to see a doctor who mainly focused on top surgery for transgender individuals based in Ontario. For Laurin, that doctor had more of a nuanced understanding of the surgery.
To access funding for transitional surgery in Alberta, you have to have been diagnosed with “gender dysphoria.”
“That was the most frustrating part of this, I think, because you have this straight white man telling you whether or not you're trans enough, basically,” Laurin explains.
Laurin’s psychologist was a woman who he felt was, for the most part, very inclusive. But parts of the process of being diagnosed seemed very invasive.
“They ask you about your sex life, and how you feel about your genitals. Just things you're like, ‘I don't know how to answer this to you.’ They ask you all these general questions about it and see if you're mentally fit and if you have a good enough support group.”
Laurin says, looking back, that if he were to have to do the whole process over again, he would be a more “difficult patient,” in his words.
“I think if I were to go to her now, or any psychologist to get diagnosed, I would question a lot more."
With such minimal and confusing information available to assist people in their transition, many people seek out others to tell them their experiences with transitioning. Even Laurin himself sought advice.
“Luckily the summer after high school I met another trans guy who I worked with and … he had just started on testosterone so I kind of had a little bit of direction there,” Laurin says.
For him, even though he’s not done his medical transition yet, he sees helping others as an amazing part of his experience.
“The coolest part is being able to help people who are thinking about transitioning and be like, ‘Okay I did this, and these are the steps that I took and maybe this can help you out.’”
“And, obviously, becoming who I want to be,” he adds.
Laurin’s advice to those seeking help?
“Make sure you find professionals who you feel comfortable with,” Laurin says. “If you feel a red flag, just leave, don't go back to them, because it's going to affect the way that you transition for the rest of your life.”
“Number one thing is don’t take shit. From anyone. No matter how easy it is.”
Ben Laurin explaining his journey to coming out and finding the words to describe who he is. Video by Rayane Sabbagh.
Some aspects of the medical system can be uncomfortable to encounter. Ben Laurin talks about his experience with this. Video by Rayane Sabbagh.
Ben Laurin debates gender dysphoria as a diagnosis, but also something that gets transgender people funding for medical services. Video by Rayane Sabbagh.
Photo by Amber McLinden.
Izzy Stoodley doesn’t know how to feel about the word “finished.”
“Finished is an interesting term,” she says, thinking carefully about how to phrase her thoughts on transitioning.
“Personally, I have three procedures that I'm looking to have done ... three years has been that process if not maybe a little bit before, or a little bit after, but it's been that gradual kind of three years. I’d like to get everything done. Sooner rather than later. But whether I'll ever be finished, I don't know.”
Like others, she doesn’t see a start or end point to her journey. Rather, she talks about it as a series of non-linear events that simply gave her the words to explain who she is.
“I learned about puberty and family life in Catholic high school … I remembered like, ‘Oh I'll get through all of this weird stuff if my voice lowers and then grow a sick-ass mustache like my dad, right?’ Not how it worked.”
As someone who graduated from the University of Calgary with a degree in sociology, Stoodley views the world with an analytical mindset. This is how she thinks about accessing medical services for trans-people.
“Any sort of thing where you have to look [at] yourself in the mirror, or you have to question who you are, or what you've done, or whether this was the good thing to do or pursue is always challenging,” she says.
“When you have been told from day one that not only this is something you shouldn't or couldn't explore, but all of this other stuff in how you're supposed to treat yourself and other people latched onto that. When that comes from a source bigger than you, your culture, your world, it’s lot to unpack and it's a lot to go through and I think I'm still working on some of that.”
A critical look at health care
Stoodley talks about her experiences with the world of health care through a critical lens.
“For the most part I've been extremely lucky. But I'm also, you know, a middle-class white girl in Calgary,” she says.
Even still, Stoodley says, “It took a long time to even be able to get any help or figure out how to ask for it. And when I did, it was great. Outside of being bounced around everywhere.”
Even though doctors, psychiatrists and nurses are considered “health care professionals,” Stoodley points out the contrast between professional knowledge and experiencing something.
“There’s a difference between living through something your whole life and only getting an hour lecture on the subject,” she explains. “It's not the same, right?”
It can be difficult to see a professional for clarity only to end up explaining to them the knowledge you’d expect them to have.
Her experiences speak to the discrepancy in treatment that many trans-people are faced with — a lack of knowledge from Alberta’s health professionals.
“Even the good can be such a nightmare; in just that it's all over the place.”
Stoodley has sought out public care rather than private, but says that shouldn’t be the topic of discussion.
“The debate always ends up being about private versus public, which I think distracts from the real issue, which is access ... Any system should focus on that first.”
Stoodley is frustrated with the ways transgender people’s experiences are hyper-medicalized.
She poses a question. “Should I talk about your genitals?”
Many people incorrectly assume that if you identify as male or female, your genitals should match. That isn’t always the case. But Stoodley’s point stands — nobody wants to be asked about their junk.
“The mechanical views of medicine like, ‘We are machines to be fixed’ has it backwards. It's not that we are machines, machines are flawed imitations of us … it's nowhere near as complex and as interesting as a person,” she says.
Stoodley says the best way to operate isn’t to think about transgender people as something to be diagnosed, fixed or otherwise altered. Instead, she points out what some doctors may recognize as the “patient-centred care” approach.
“Health care needs to be about people. It's about community. It's about quality of life and sometimes quality of life is not about cures. It's just about help.”
Gender dysphoria and gender euphoria
Currently, many doctors who are able to prescribe hormones or refer individuals for top or bottom surgery also require you to have been diagnosed with “gender dysphoria,” as previously mentioned.
But Stoodley says these don’t necessarily go hand-in-hand.
“The idea that transness has to be about gender dysphoria is just saying, ‘Well that's what transness is.’ … It's the hyper-medicalization of where, you have to have these things to be [transgender], or you're not X because you don't have X part.”
To put it simply, she uses a metaphor. “All bees are bugs but not all bugs are bees.”
While many trans-folk experience gender dysphoria, not everyone who is transgender does. Stoodley explains, though, that it eliminates something else.
“Gender dysphoria erases gender euphoria entirely from the conversation,” she says.
Gender euphoria is the exact opposite of gender dysphoria. While dysphoria is essentially defined as the distress one might feel when their gender identity does not align with how they physically look or feel, euphoria is the positive feeling.
“I don't know how to phrase it other than seeing yourself in the mirror for the first time,” Stoodley explains.
“When I talk about gender euphoria being for me, for the good parts .... It's not about being happy all the time.”
Bringing it back to the computer metaphor, she says,“It's when the control panel that was turned off comes back on again. It was like if I was a computer or a machine realizing that there's large sections of memory that I didn't have access to that's being used. There's parts of the circuit board that are being activated and stimulated that had never come up.”
It can be incredibly frustrating to explain the feeling of euphoria, as Stoodley expresses, but to her, the feeling is worth the struggle.
“The reason why justifying our existence over and over again is so annoying, is not because you have no idea of what the lows are, but because you have no idea what the highs are, and what giving us that can do for us.”
Stoodley has some words for folks going through their own process of coming out, transitioning and everything before and after.
“You don't owe anyone anything,” she says.
Transgender people feel the burden of navigating the medical system, including Izzy Stoodley. Video by Rayane Sabbagh.
Izzy Stoodley puts the medical system into an academic frame. Video by Rayane Sabbagh.
Izzy Stoodley gives advice to transgender people watching this video. Video by Rayane Sabbagh.
'There's no one way
or right way to
Photo by Amber McLinden.
Jamie Anderson considers himself lucky.
“I'm coming from a place of privilege because I had financial support to access private care and then also because of my age, was able to access hormones without having to rely on somebody else's permission.”
Anderson has been teaching in Okotoks for the past five years, which he says allowed more leeway for his transition, which started at 27.
But even though he’s had access to the services he’s needed, his transition has still been fraught.
“For some folks the first puberty is hard enough, but why not go for a second one?” Anderson says, laughing.
Anderson’s journey started in 2015, after coming out to family, friends, his partner and place of work.
When he decided to begin the medical process, he felt it wasn’t too difficult.
“I was really lucky because I have friends in the community who found this doctor in downtown Calgary willing, on informed consent basis, to prescribe testosterone.”
“But again, that also comes with my age,” Anderson explains. “I was in my late 20s at the time.”
In order to give informed consent, the patient must understand the risks, benefits, and other options for treatment.
Doctors who use an informed consent model require that children under the age of 18 must have a parent or guardian provide informed consent on their behalf to administer hormone prescription. If someone falls under that age limit and has unsupportive parents or guardians — that becomes a barrier.
Private versus public
After approximately a year of hormone treatment, Anderson packed a car with a close friend also accessing the same procedure and set off on a “top surgery road trip” to Ontario.
Anderson had the option to pay for his top surgery privately. In general, accessing private care is something many people seek information on, but not many can afford.
“The surgery itself cost just over $10,000,” says Anderson.
And since the clinic is in Ontario, that number doesn’t include accommodations or flights. “You have to see them for follow-up appointments and after surgery there are some restrictions around when you should fly,” Anderson explains.
“Then on top of that you're supposed to have a support person who's able to take care of you,” Anderson says. “I have a supportive partner who obviously came. But in terms of paying for flights and accommodations for the both of us — it was well over $16,000.”
Financial considerations aside, just accessing the clinic in Ontario wasn’t easy.
“Top surgery is provincially funded but unfortunately the wait time for that is sometimes like three to four years. So, I opted for private because I was working at the time so financially speaking I was able to access top surgery through a private clinic.”
The options people have when looking to begin medically transitioning are very limited. In order to go private, money is needed. A lot of money.
So why did Anderson choose to go private?
“When you’re paying for private service the experience can be more positive than the publicly funded services,” Anderson says.
“In order to accept treatment you also have
to accept this diagnosis, and that's not
something that a lot of people identify with.”
- JAMIE ANDERSON
“The surgeons that are on the list to provide services don't necessarily have the plastic surgery expertise that other folks have in private clinics so there's also this sort of divide.”
Another positive part of accessing private care was that Anderson did not need to be diagnosed with gender dysphoria, as he would if he took the publicly funded route.
“I have conversations with my friends about this,” Anderson says of transgender individuals having to be diagnosed with gender dysphoria.
“In order to accept treatment you also have to accept this diagnosis, and that's not something that a lot of people identify with.”
“I mean, I've experienced dysphoria, but I see that more as a product of binary normative gender that in our Western society we exist in,” Anderson adds.
“It diminishes the presence of multiple gender identities and the experience of gender fluidity.”
Even after changing the markers on his health care card and other government IDs, Anderson still felt pressure from medical practitioners during visits.
“I've had a lot of really negative experiences with people who just don't have enough information, who either publicly misgendered me … they would ask ‘why is one gender marker like this? And why is the other like this? Why is there this discrepancy? Can you explain it to me?’ and pressure me to out myself in a non-private setting,” Anderson says.
Often the medical system is fitted for the gender binary, assuming that if you have certain body parts, you identify as a woman or a man.
“My partner got mail from Alberta Health Services about pap testing, saying ‘all women this age need to make sure that they get their testing’ and then I think a couple of weeks later I got the exact same letter.”
“So even though my gender markers changed … I'm still in this program, and obviously I still need to access that service … like people with a uterus need to get this testing, it doesn’t mean it needs to be gendered.”
Walking into offices or spaces created solely for women, rather than “people with a uterus” can foster a lot of anxiety of being publicly outed and outcast.
Luckily Jamie has his partner, Laura Shiels, who has been an advocate for him and there to support him throughout his entire transition.
“[Shiels] works for the Calgary Sexual Health Centre [recently renamed the Centre for Sexuality] and they do a lot of work to support the LGBTQ community. She’s able to share that with me and help guide me.”
It’s not black and white, it’s grey
“Everybody’s journey is so different,” Anderson begins explaining.
“There's a narrative of transitioning where it's like, you get your whole hormone therapy, then you get your top surgery, then you can have a hysterectomy, and then you can have bottom surgery. They explain it in a very linear way, and for a lot of people, that's not the case,” he says.
Anderson’s process looks different than this linear process.
“For me, hormone therapy was something that was really important, and that top surgery was to deal with the dysphoria at the moment, but I'm not entirely sure what my future needs are in terms of medical interventions.”
And for many, maybe it stops at just hormones, or just top surgery — and that’s okay.
"Responses from not only doctors, but people in the community as well have said, ‘in order to be [transgender] you need to do this, in order to fully transition you need to be on hormones.' There's a lot of frustrating pressures within the community and within the medical community around that.”
“There's no one way or right way to do things.”
“Finally feeling at home in my own body”
“I struggled a lot with mental health over the whole course of my life,” says Anderson. “Especially when I was younger and going through puberty the first time, it was really challenging to not feel like I was in control and to feel like something was happening to me that took me further away from who I actually was.”
Being able to access top surgery was a changing point for Anderson.
“The feel and look of a t-shirt for the first time without having anything underneath was a really important feeling to me.”
“I feel much more comfortable in my body now, but also, I've been working on letting go of a lot of normative pressures as well, working on my understanding of masculinity and how to embody it in a way that’s not toxic.”
“I'm interacting with the world in a new different way and that's been really exciting learning journey.”
Anderson says this to others beginning their journey: “Find ways to love your body or find treatments that work for you to help you love your body, and maybe that's no treatments, maybe that some, maybe that's all. Find things that work for you.”
Jamie Anderson on how doctors assume things about his body based on his gender marker on identification. Video by Rayane Sabbagh.
Jamie Anderson asks how medical spaces can be made safe for all those who have to access them. Video by Rayane Sabbagh.
Jamie Anderson doesn't use the word finished, or even on pause to describe his medical transition. He says he doesn't know what future him might need. Video by Rayane Sabbagh.
EVOLVING MEDICAL RIGHTS
Whether it be three months or 10 years, medical care for transgender people in Alberta is still evolving. What has happened so far?
FALLING THROUGH THE GAPS
Lydia Liang, a nursing student at Mount Royal University, didn’t learn much about caring for transgender patients, let alone LGBTQ patients.
“We haven’t been taught a lot, because there aren’t any resources, there aren’t even any that exist, so when people need support … where do they go?” Lydia Liang, a nursing student at Mount Royal University, says.
Herein lies the problem. If future medical professionals aren’t being taught about transgender care and transition services, how can they provide Albertans with the information they need?
“We hadn’t learned about it until fourth year,” Liang says. “Just recently, I had a class on leadership and how we can advocate on how these people [who] are mistreated in the health-care system. I feel like we even only got that class because we had a professor who was really passionate about it and she was like, ‘Okay, I’m going to squeeze this into the curriculum because it’s really important. If we didn’t have this professor, we would’ve gone the four years without learning about it.”
“We kind of learn about health issues with vulnerable populations ... and how we can advocate for them and how certain issues can affect them differently,” Liang explains of her learning.
“We kind of learn about general terms and general concepts that we can apply when it comes to that population, not specifically the challenges that they face though.”
What are students of medicine taught?
“I think it's a really big area that's lacking in medicine across Canada,” Megan Howlett, a psychiatry resident based in Calgary, says.
Howlett, who graduated from the University of Alberta’s medical school, explains that in recent years, the university has begun to integrate more LGBTQ+ care learning into the program.
The first two years of training, Howlett says, is mainly spent in the classroom learning through case studies and other methods.
“We had one week basically spent on a case that was a transgender individual and working through from a psychiatry perspective what it's like to help them transition,” she explains.
Her class also had an opportunity to hear from individuals in the LGBTQ+ community in what is called “physicianship lectures.”
Howlett also attended a conference with the Canadian Federation of Medical Students, where she had a chance to talk to students from around the country.
“When we compare what other schools were learning, there was definitely a lot more lacking than even what I was getting,” Howlett says.
Joe Raiche, a psychiatrist who primarily works with transgender adults and youth through Alberta Health Services, also teaches residents through the University of Calgary. He says things are getting better,but there is always room for improvement.
“When I was in medical school, of the four years that I spent there, I think maybe there was one half day where we took an hour or two and learned about LGBTQ topics and then that was it,” Raiche says.
“If we fast forward five, 10 years now, and I can only speak to [the University of Calgary] because that's what I'm familiar with, they've made some really substantial curriculum changes spearheaded by students. They recognize that there's these huge knowledge deficits, and they're getting into their clerkship and graduating medical school and getting into residency and realizing they don't have any knowledge to work with us.”
“I'm sure other schools are realizing a similar approach, but definitely come a long way in the last five years and there's probably still more to go but we're on the right track,” Raiche adds.
A required diagnosis
When it comes to obtaining a referral from a psychiatrist to access publicly funded surgery, you have to be diagnosed with “gender dysphoria.” Not everyone believes that this is appropriate, because while cases of gender dysphoria are typically experienced by transgender individuals, not all trans-folk experience gender dysphoria.
In 2012, the Diagnostic and Statistical Manual of Mental Disorders, a manual that psychiatrists use as reference when diagnosing mental disorders, identified gender dysphoria as “gender identity disorder.” When the most recent update, the fifth edition, came out in 2012, it changed the diagnosis to gender dysphoria.
Part of the reason for diagnosing transgender people with a mental disorder is so they can receive funding for surgery from Alberta.
“If someone wanted, similarly to top surgery, if someone wanted a breast reduction but didn't have a medical diagnosis reason for it, then they would probably have to pay electively for that surgery,” Howlett explains.
“I think maybe there's a less negative connotation, pathologizing way of doing it in gender transitioning than it is right now. But I do think typically we need to justify whatever we're doing medically so we need a name for it, so that it's across the board between different doctors.”
“I think eventually we'll just start naming it whatever the mental health concern is rather than pathologizing gender identity. At least that's my hope anyway,” says Howlett.
The required diagnosis can be seen as stemming from a historical lens, Raiche explains. In many ways, it was a method of gatekeeping, which made sure that people seeking surgery were the right kind of person: Completely mentally stable, understood what they were doing and other checkboxes.
“Much like pregnancy is a diagnosis that we would give people because they need to access pregnancy related care, I see that happening in the world of gender dysphoria.” - JOE RAICHE
“It was sort of a way of making sure that somebody was trans and that they [were trying] to minimize the perception of regret that somebody would have,” Raiche explains. “And I think that really stemmed from a complete lack of understanding of what these people go through and the experiences that they have, and very much of, you know, ‘Prove to me how trans you are and if you play by our rules then we'll we'll let you transition.’”
In this sense, the medical system was oppressive to trans people, because the rules were not based of a true understanding of what it means to be transgender. Now, as the Alberta Health Services and the medical community at large advances to a more progressive model, Raiche says, at least for him, the diagnosis means something else.
The International Classification of Diseases (ICD), a manual similar to the DSM, is used outside of North America and uses a different term: Gender incongruence. Raiche says this is less stigmatizing and focuses more on a health diagnosis rather than a psychiatric one.
“I think we're going to see that incremental shift out of the mental health realm and probably into just general health realm,” Raiche explains.
“Much like pregnancy is a diagnosis that we would give people because they need to access pregnancy related care, I see that happening in the world of gender dysphoria. It's just going to be something on a medical record because people need care, but not so much of, ‘Jump through all these hoops to prove to me that you're trans.’”
Some transgender individual’s interactions with care as a whole can be built on sex and gender and can often incorrectly assume that if you identify as male or female, you have certain body parts.
Howlett says this may stem from the way medicine is taught as a whole.
“I think as society changes, medicine will start to change too. I'm positive that the new doctors coming out have a very different lens than the ones who trained even just ten years ago,” she says.
“But I do think in terms of our formal training, and the habits we pick up from watching preceptors, it's going to lag behind society quite a bit.”
A preceptor is a professor in medical school that students can watch practice to learn. According to Howlett, they typically have extensive experience in the field.
“They still are very dichotomous - male, female. What do you look for if someone presents with chest pain or abdominal pain - and their male or female,” she explains. “I've really tried to, in my own practice, get away from that.”
When health-care providers talk about health in a gendered way, it erases the experiences of trans-individuals. Take, for example, hysterectomy (a surgery many trans-men get). It is assumed that only women have uteruses, but trans-men can also have uteruses. This assumption leads to post-surgical literature being gender towards women, which can leave trans-men out of the narrative.
At its most basic definition, sex is the anatomy of an individual’s reproductive system and gender is the outward identification with an identity. They are two different things. When they are conflated as the same, trans-folks are left out. This is what happens when medical professionals gender health care.
Raiche says that, at least in Alberta, many of the gender psychiatrists take on the role of referring and vetting surgeons and care providers. Raiche asks all his patients about their experiences with these people and then makes referrals accordingly.
This results in relatively positive interactions with surgeons for most people, but the gap is in their aftercare.
“[After care], that's not something that the surgeon themselves really has any control over,” explains Raiche. “That's an AHS brochure that gets given to everybody. What their electronic medical record, or what their wristband might say —again, that's a system issue.”
The experience also changes depending on whether you see an affirming provider or not, meaning that trans-individuals might see someone who doesn’t use their correct pronouns or doesn’t have the right information about transgender care.
However, word travels fast, and if enough people have bad experiences with a doctor, then pretty soon they won’t have patients, Raiche says.
“[This] isn't always the case in other aspects of health care. You don't have support groups for people with diabetes talking about you know, who's the good endocrinologist to go see, who to give them the right kind of insulin. You just go to see who you see and everybody's practice is more or less the same,” he says.
“We’re not there yet. And hopefully that's a good goal that we can reach.”
How to fix the broken loop
It seems medical school is a feedback loop. If students are not taught about gender transition surgery as a field they can specialize in, or as gender-related care as something they can practice, then there are less professionals in the field who can provide those services. There is less informed family physicians who then cannot refer you to the proper surgeon or doctor. In turn, these doctors teach at medical schools across Alberta. If there is only a handful of doctors who can provide the services, there is only a handful of doctors who can teach students about them.
“I think that if you don't see the need and you're not taught about it, then you just don't know about it. But I think a lot more people would have an interest for sure,” Howlett says.
So how do we break out of the cycle?
When it comes to psychiatry, Raiche says it actually isn’t that hard.
“Technically, any psychiatrist could be a gender psychiatrist,” Raiche says. “It's a lot more flexible now, and so it really comes down to the individual psychiatrist to say, 'Hey, this is an area that I feel comfortable in and an area that I want to pursue,’ and you are a gender psychiatrist now,” he says.
The same is true for family doctors. Raiche says the ability to refer folks to psychiatrists, as well as the ability to prescribe patients with hormone replacement therapy, really comes down to two elements: Comfort and competency.
“There's lots of ways to acquire that knowledge but it's not it's not overly onerous, and in terms of the work itself, fairly straightforward. The other side of that coin though is the comfort and interest, and I would argue that a lot of psychiatrists have the competency to work in this area but they all don't have the willingness or desire or or motivation to do that,” he says.
This could be for a number of reasons, but Raiche says it mainly might be a gap between older and younger physicians.
“There's also perhaps a little bit of a generational gap with older physicians that having trained in a time where this was either not as widely known or there wasn't much as much awareness, or education about it seems very foreign … versus newer grads or people in medical school or other allied health professions training now,” he says.
“It's much more salient of a topic, and I think that sort of scary factor of the unknown, we don't see that much. So there's much more willingness to just jump right in.”
Younger doctors entering the field might be changing the way medicine as a whole looks at LGBTQ+ care, and more specifically, transitioning.
“Residents or students who have worked with me are now finishing their training and going into family practice and opening their own clinics,” explains Raiche. “They're just seeing trans-folks, and it's really not rocket science.”
This normalization of health care for transgender people will hopefully free up psychiatrists like Raiche to do a more specialized type of work, such as seeing people who need assistance exploring gender, complex mental health problems or other forms of therapy.
“People go into medicine because they're compassionate and want to help people.”
- MEGAN HOWLETT
“But that's not the majority of trans folks,” he says. “That's the minority. Most are very, very straightforward. They have a good sense of themselves. They know what they want. And they just need help getting there.”
There are students of medicine and nursing, like Liang, who want to learn.
“Why aren’t we learning about specifically LGBTQ [patients] and the challenges they face when they transition, how they can be supported? Because they’re obviously in and out of the health-care system mental health wise and physical health — we’re not taught how to deal with it,” she says.
There are also doctors and other providers, like Raiche and Howlett, who see the work as a vital part of the health-care system in Alberta.
“People go into medicine because they're compassionate and want to help people,” says Howlett. “I think that if more people saw this need and just how rewarding it can be to have such a gratifying experience for the patient, then a lot more people would definitely go into the field.”
After Ben Laurin got a hysterectomy, he received some after care literature that was geared towards women. Photos courtesy of Ben Laurin.
Resources and doctors available as of December 2018. Purple indicates doctors and yellow indicates resource hubs. Map by Simran Sachar.
The 2018 Canadian Trans Youth Health Survey collected statistics from Albertan and Canadian youth about their experiences with medical care. Graphic by Amber McLinden.