FALLING THROUGH THE GAPS

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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.”

 

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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.

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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.

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“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

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“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.’”

 

Gendering health

 

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.

 

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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.

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“People go into medicine because they're compassionate and want to help people.”

- MEGAN HOWLETT

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“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.”