Have ongoing training for all staff levels (front desk, clinicians, paramedics, administrators, etc)
Trans Health Connection is a project whose goal is to increase the capacity of Ontario’s primary health care systems to provide high-quality, comprehensive care to gender-diverse communities. We provide support to health care providers across Ontario through training, education, mentorship, resources, and networking. Gender-diverse people in Ontario are frequently denied health care, or are treated with disrespect within health care settings. Trans primary health care (including hormone initiation and monitoring) is not currently a part of the standard medical education curriculum, and many clinicians have never seen (or believe they have never seen) gender-diverse people in their practice and think that providing care to gender-diverse individuals is specialist care. Because of these misconceptions, people are continually referred “elsewhere”- when their health needs are routine and also even when their health needs are urgent. Everyone has a right to basic health care close to home and Trans Health Connection is working to make this happen.
About the author: Rainbow Health Ontario’s Trans Health Connection program
Through Trans Health Connection, we offer:
- Training and education for health care providers. This means building partnerships across the province with in-person and virtual clinical and medical learning opportunities, engaging with students and professional schools to influence curriculum, developing online content and delivering sessions over Ontario Telemedicine Network for optimal rural and remote access, and getting professional accreditation to support participation, particularly from physicians.
- Ongoing supports to clinicians to do the work. This includes a weekly mentorship call which hosts a panel of clinical mentors available to answer questions that come up in practice, consultation with agencies around their intake/policies/documents/campaigns/procedures and how to make them optimally inclusive of gender diversity, providing access to a virtual interdisciplinary network of providers across Ontario doing trans care, and access to print and other resources and ongoing learning opportunities.
- A referral source for service providers who are looking for specific resources or supports in delivering trans care.
- A referral source for trans and gender-diverse folks and their families. One result of Trans Health Connection is that trans and gender-diverse folks and their families and loved ones frequently make direct contact looking for support in navigating and accessing health care options. This may include seeking information about: local medical/clinical/social resources, regionally available specialists, advocacy pathways, systems navigation support, peer supports, general or specific trans health information, and other issues.
- Policy work. This may include consulting with agencies and/or government to effect systems change in regards to trans health issues. Most recently this included supporting the Ministry of Health and Long-Term Care in Ontario to develop a new system for gender-diverse individuals to access referrals for transition-related surgeries. We also support agencies (hospitals, Community Health Centres, etc) to develop internal policies around trans health and trans inclusion.
Join the Conversation
When Trans Health Connection was initiated in 2011, there were barely any primary care services for trans and gender-diverse people anywhere in the province. While a few other clinics were offering comprehensive primary care that included clinical and medical support, Sherbourne Health Centre in Toronto still had the reputation for being the only place to offer such services.
People were often leaving their communities to move to Toronto to access basic health care and to transition (genders) with relative safety, but were often met with significant challenges still in getting that care, as well as with securing housing, employment, income, supports, and community in a new place. The few services offering supports had long wait lists and could not accommodate the demand.
As we developed training and education for medical providers, it became clear that transition-related primary care is not complex medicine; it fits within the scope of primary care. However, many providers have little experience in doing this kind of care, and/or have not had the opportunities to question popular assumptions about sex and gender.
The TransPULSE Project has clearly documented that trans folks are at exceedingly high risk of suicide and suicidality generally, and that peak suicidality occurs when someone has indicated that they plan or need to transition but have not yet been able to start (TransPulseProject.ca, 2010, 2013, 2015). It is crucial to transform this notion that not treating patients is “do no harm”. When people have timely and competent health care access – including access to transition-related medical interventions when needed – it can mean the difference between life and death.
Since 2011, many different clinics have emerged across the province that offer strong clinical leadership, and robust supports to gender-diverse folks, their families, and loved ones. Many of these clinics offer programs, groups, interdisciplinary clinical supports as well, and act as a central regional hub for community resources and connection. There is a true decentralizing of supports beyond Toronto in Ontario. Much of the success of these service hubs is due to strong community activism, consultation, and leadership.
What Impacts Trans Health?
The whole framing of social determinants of health reminds us that our identities (being racialized, poor, dis/abled, queer, trans, etc) are not pathologies. However, the experiences of discrimination we endure – both in distinct moments of oppression and in the (not so) subtle day-to-day ways we are marginalized – can have profound effects on our health. When we experience racism/ misogyny/ transphobia/ homophobia, etc. our health suffers. We may experience violence, harassment, or other direct threats to our person, our anxiety and depression may increase, our self-worth may be compromised which can impact compliance with treatment, and our capacity to trust, engage with, or access mainstream health care is often damaged.
The dominant cultural norm in Canada describes sex and gender as binary systems, meaning that there are only two options: man or woman, male or female. That system is not “natural” or objective, it is just one idea about how sex and gender should work, and our society, including the health care system, relies on these norms. Health care classifies bodies into two distinct and opposite groups with corresponding health needs. Men will have prostates and need prostate exams, some women will become pregnant and need prenatal care, and so on. Assumptions about chromosomes, body parts, and hormones dictate care and service access. Medical charting, documentation, and insurance policies are set up according to these two categories and health care policies, education, and practices just further reinforce them. People whose bodies are beyond the medical categorizations of “man” or “woman” (e.g. pregnant men, men who need pap tests, or women with prostates) will therefore encounter barriers in accessing informed and welcoming health care.
Trans people also experience health disparities because of our social expectations of being able to have rigid categories of “men” and “women”. The idea that there are only two possibilities, and that those two groups should look and behave in a particular way is very much still alive and well, and punishments for falling outside of those norms are by now ubiquitous. People who present their gender in a way that falls outside of the gender binary (i.e. “look trans” or look different, look neither male nor female, or have genders that are different than what we might expect) will likely experience tremendous amounts of discrimination and violence. This includes street harassment and attacks, intimate partner violence, family disownment, access to safe and affordable housing, employment, income, and community. Gender norms are also based on particular prototypes (white, able-bodied, middle-class, for example). These factors combined mean that trans women – especially if they are racialized, poor, disabled, or any combination of the above – experience tremendous health disparities as a group. Transphobic hate crimes, particularly in the US, are high, with Black Trans Women comprising the most vulnerable targets.
Barriers to Health
Barriers to health care for trans people include lack of knowledge and unawareness, or transphobia from health care providers, a lack of knowledge, experience and skill in working with trans communities, invisibility of gender diversity in health/health research/health education, and a lack of local standards of care for health care delivery for trans people, meaning that there is no consistent information on how trans care should be done at a systemic, provincial, or national level.
What’s your relationship status?
There is a legacy of mistrust between trans communities and health care institutions. This is due to a long and ongoing history of mistreatment and violence against trans folks at the hands of health care providers, particularly but not limited to mental health (CAMH CYF GIC Review, 2015). Trans people are often quite reluctant to seek mainstream medical care, or will do so very tentatively.
While this is changing, trans people continue to have bad experiences when attempting to access health care. Often health care providers are unwilling to work with them, but even when receiving care, trans people experience humiliation, violence, and breaches of confidentiality in health care settings.
Tremendous work is being done to support trans care within primary care and other settings, and to fully depathologize gender identity. There are amazing and progressive providers – many of them gender-diverse – who are creating new systems and health care options for trans people based on informed consent, patient-centred practice, and guided by progressive and informed standards of care.
Quick Tips: Identifying Key Moments
While there are many challenges, solutions do exist. Here are some possible scenarios and suggestions to help build positive relationships for healthy bodies, healthy communities and healthy partnerships.
There is an emergency and you need to get care as soon as possible
Everyone in emergency care settings needs training on working with trans and gender-diverse folks. Getting emergency care can be perilous when emergency workers, including paramedics, triage nurses or hospital staff, are unwilling to work with their bodies, misgender them, out them to other patients, treat them with suspicion, etc. Trans folks report being harassed, brutalized, humiliated, assaulted, sexually assaulted, have security or police called on them, and/or ignored while seeking emergency care. According to transPULSE, 21% of trans people in Ontario have avoided emergency care when they needed it, for fear of a transphobic incident there (www.transpulseproject.ca). Here are some easy pointers for addressing this issue.
Have robust institutional policies that protect the human rights and treatment of trans folks
Have a standardized and established process for how to document and refer to someone’s true name when it differs from what is on their OHIP card. This must be implemented in EMR, on charts, and anywhere else where a patient’s name is recorded. Support medical secretaries and all essential front line staff and points of patient contact to build skills and consistent practice around this.
Hire trans people as staff, and not just for trans-specific positions.
Have signage that indicate that you serve trans patients. This creates safety and awareness for gender-diverse and also gender-typical people accessing services, and reminds clinicians and patients that your health care facility anticipates that trans people exist and will need to access care.
Have health information (pamphlets, flyers, etc) that includes data/images/content that is trans-specific or trans-inclusive.
For paramedics, ER medical staff and anyone dealing directly with the patient, check your gender assumptions. Ask specific questions (for example don’t assume that someone who looks male to you does not menstruate).
For paramedics, ER medical staff and anyone dealing directly with the patient, have a clear internal distinction between your own personal/clinical curiosity, and what is medically necessary to know. Make sure that your questions and comments are strictly the latter.
Maintaining and nurturing support systems for our patients
Trans people, like all people, have a range of sexual orientations. Some trans people are gay, some are straight, some are bisexual, pansexual, graysexual, asexual… just like anyone else. Do not make assumptions about trans people’s partners, families, or intimate relationships.
Something is off but you don’t have time and/or don’t want to go to the clinic and/or there are no available services
Because of the long history of mistrust and mistreatment, DIY care and health management is more accessible and timely than going through mainstream medical channels. It is important for service providers to keep that in mind and not shame patients for accessing care from various sources when they are able to support someone’s health care plan and/or treat them.
At the walk in clinic
Many trans folks are wary of walk in clinics because of the unknown factor. You may encounter providers who are very knowledgeable and respectful, and you may not. It is a gamble.
Make sure that all clinic staff, including reception staff and physician assistants, get robust and ongoing support to do their crucial front-line work. This includes having inclusive intake forms that ask the right questions, charting and EMR policies that allow for consistent documentation of patients’ real or preferred name when different from their legal name, and other considerations.
Have accessible bathrooms that anticipate multiple genders and multiple abilities.
Make efforts to ensure that trans patients and cis patients know that your services are inclusive and welcoming. Include posters, pamphlets and other materials in the waiting room to indicate this.
Make sure to ask about partner(s), sexual practices, and intimate relationships without relying on normative or gendered assumptions or language. For example, services that don’t consider the possibility of multiple simultaneous partnerships or different genital configurations is not inclusive.
Ask specific health related questions. Be as transparent as possible as to what you are asking and why. Trans people may not feel comfortable disclosing about the surgeries they have had, for example. There is a long history of trans people – especially trans women – having their genitals sensationalized and scrutinized by health care providers. The more information you can provide, and the more specific you can be about why you are asking certain questions and why some tests may be warranted, the more trust you can build with your client. For example: “Do you have a cervix? I ask because you may want to get a pap done. Here are the regulations around pap tests and the health benefits of getting them done regularly”.
First Visit Quick Tips
Addressing people by the real or chosen name, and using the right pronouns will go a long way to create and nurture trust. Refer to your intake form, which should have a clear place for all patients to indicate the name they wish to go by in your practice, regardless of what is documented on their health card. All communication should reflect the name that is specified there. You can also check in with your patient: “do you want me to use this name? only in my office? In the waiting room? When I leave a message on your phone?” The intake form should also include a variety of gender options to choose from, and inclusive language around partnerships and family. Many progressive agencies have intake forms that include these elements and could be contacted to provide examples.
Accessible and welcoming spaces could include:
- Community based programming (for example harm reduction material, supplies and information, peer supports, arts based programming, low barrier access)
- Clear trans inclusion signage (posters, policy, health information, etc)
- Accessible washrooms that anticipate that people of multiple genders and abilities will use them
- Diversity of staff and patients being served
- Broad considerations around accessibility, including but not limited to be responsive to accommodations re physical accessibility, scent, audism, class/financial access ( bus tokens, etc)
- A variety of different health practices/treatments (for example, acupuncture, meditation, and other kinds of complimentary therapies)
- Include a space to reference your legal name (as it appears on your health card) and your real or preferred name (how you would like to go by in the clinic). This will benefit many clients, not just trans clients.
- Include a list of different sexual orientations, and/or space to self-define
- Include a list of different gender identities, and/or space to self-define
- Include specific questions about relationship status. Single/married is based on a number of assumptions that will not get at the desired medical information. Instead you can ask: are you currently in a relationship? Are you currently sexually active? What is/are the gender(s) of your partner(s)?
Don’t ask for health cards if possible. Provide informed, competent and non-stigmatized care to trans sex workers.
- That trans folks are not easily able to access competent health care. Trans people may have already seen a number of health care providers and/or been denied care before they connect with you.
- Anything about the previous experiences of trans people accessing care and what that’s been like for them is important to keep in mind to be mindful in building trust within the relationship. Even if trans folks have not ever had negative experiences in health care settings themselves, there is a long legacy of distrust between trans folks and health institutions, due to a number of factors (lack of access, complete erasure in health information/ research/ curriculum/etc, legacy of mistreatment and abuse of trans bodies in health care, terrifying tales of encounters in primary care/emergency care and other health care settings, etc).
- The stereotype that all trans patients are “high maintenance” or “drama” or unnecessarily angry. Trans people might be entering your practice having already experienced any number of negative encounters in other health care environments, or even with other providers on your team. Part of the initial work with any patient is establishing trusting and respectful relationships. With trans folks this might mean validating their experiences, and affirming your commitment to their care.
- Keep in mind that someone’s presented gender does not give you particular information about their body (tests, screening, blood work, etc). When collecting medical information, try to be as explicit as possible about what you need to know and why. For example: “do you have a prostate? We need to know so that we can assess your need to be screened for prostate cancer”.
- Keep in mind that someone’s presented gender does not give you particular information about their sexuality, partners, preferences, risk factors, etc. Trans people, just like cis people, will have a range of possible sexualities (gay, queer, pansexual, asexual, lesbian, non-monosexual, graysexual, etc). Again, be specific and non-gendered about the questions you ask. For example: “do any of your sexual partners produce sperm? Do you have insertive sex?”
- Keep in mind that you cannot assume someone’s sex or gender by looking at them. Some people may not be safe presenting in their true felt gender. Some folks may “pass” or blend as non-trans (cis) but may identify as trans or have a trans history. Health inquiries and intake forms that are trans-inclusive will be helpful to get at the health-related information you need to work around these assumptions.
- Keep in mind that not all trans folks have had “the surgery” or wants to have “the surgery”. There is a long standing myth about “sex reassignment surgery”. The phrase is incredibly misleading: it assumes that a single surgery “transforms” someone from one sex to the other. Many trans people will never have any surgeries. Some trans people may have some surgeries which may or may not include genital surgeries. For some trans people, genital surgeries occur over years and include multiple procedures. For all trans people, their surgical history or status has no influence on the validity of their gender.
- Make sure that your referrals to specialists/etc will be trans positive and respectful. Providers may need to support the referral process by working within their professional networks, building those connections and ensuring that supportive and informed referrals are possible.
- Don’t assume that necessary services/procedures/surgeries are covered. Often they are not. For example, procedural and surgical coverage in Ontario is extremely biased against trans women. It is our role as health care providers to be informed of biases and barriers in access, and advocate for equitable services.
- Be mindful of your practice being a safe space to “come out”. Don’t assume it is. Patients may or may not feel comfortable disclosing to you that they are trans, regardless of your intentions. Being trans positive and welcoming is an ongoing practice.
- Queer/trans visibility among other patients as well as staff
- A reputation for seeing trans patients and being trans positive
- Questions, interview practices, forms and screening practices that don’t rely on assumptions around gender and/or sexuality
- Open, compassionate and humble approach to care
- Practices that centre harm reduction and informed consent approaches
- Health care providers being focused on someone’s trans narrative when it is not the reason they were seeking care that day. It is important to follow the patient’s needs and focus on what they are identifying as their concerns.
- Health care providers avoiding the subject of trans identity can make it difficult to be honest about what someone’s health care needs are.
Your Clinic: A Welcoming Space
Some tips and tricks to make your office, clinic or space more welcoming and accessible. When organizations are looking to make their spaces more trans positive and welcoming, there are a few key areas of focus that come up again and again.
Create or feature posters that speak to trans inclusion and visibility. Especially for services where trans people may feel especially vulnerable (perinatal care, cancer screening, etc), promote the fact that trans people are welcome and expected.
When speaking more broadly, it’s best to use terms like lesbian, gay, or bisexual or acronyms such as LGBQ.
Many individuals identify as queer. Queer is an example of reclaimed language: while it was originally a derogatory term, many LGBT people have reclaimed the term and now identify with it. At the same time, this term doesn’t work for everybody: for some, it still has negative connotations. The term should only be used with clients who use it for themselves and have indicated that they are comfortable with you also using the term.
Principles, diversity, social justice and inclusion generally. Trans people are not all white/settler/middle class, etc.
For everyone, including medical secretaries. Medical secretaries are the glue of the health care system.
To ensure consistency of approach and care re documentation, charting, EMR, questions that are asked, etc.
Here is an important caveat on language when we talk of health care and trans and gender-diverse communities. Language is not static, it is a living, culturally-grounded thing that constantly evolve. Preferences vary too.
It is hard to offer a concise and comprehensive list of terms and definitions to use when working with trans and gender-diverse communities here is a suggested process which can be used to guide interactions with trans and gender-diverse people and that centre on respect and dignity.
Know, for yourself, that you will make mistakes with language, pronouns, assumptions, etc. Nobody expects you to always get it right, but as a health care provider with power over patients seeking services, you do have a responsibility to know what to do when you mess up. For example if a patient is frustrated or angry because they have changed their name and you continually refer to them using their old name, you should:
Be kind to yourself and allow for mistakes to happen, as best you can. It will be hard for you to extend kindness outwards if you cannot extend it to yourself.
Acknowledge your mistake to the patient, succinctly.
Apologize, again briefly. This is not about you and how bad you feel, this is about the continued disrespect of your patient.
Make a commitment around changing your behaviour. This could be “I will practice your new name so I won’t forget again” or “I will educate myself on trans issues so that I have a better understanding of why this is so vital for you and for our relationship”.
Actually make change to your behaviour by being mindful of transphobia and your interactions with this person.
Making lists of terms that people use to describe gender identity or experience is something that many organizations and groups have already diligently compiled. There are endless lists available, here are some that include contemporary variations of community terms, starting with the list on the Rainbow Health Ontario website.
Key Terms related to Trans Health
Refer to surgical procedures that are a part of someone’s gender transition. Transition-related surgeries are often referred to as Sex Reassignment Surgery, or SRS. However this terminology is offensive to many trans and gender-diverse people, and may be experienced as disrespectful. SRS references an inaccurate notion that there is only one surgery – meaning genital surgery, and most commonly meaning genital surgery for trans women – as opposed to the many possible surgeries that an individual may need as part of their transition. It also perpetuates the stereotype that you are not “really” a man or “really” a woman unless you have had genital surgery, and that everyone’s transition culminates with genital surgery. This myth has profoundly negative health impacts on trans and gender-diverse people, particularly trans women.
Refers to the gender identity of individuals who identify as not exclusively male or female. The World Professional Association for Transgender Health Standards of Care version seven (WPATH SOC7) specify that providers cannot impose a binary gender identity or presentation on their clients as a prerequisite for medical interventions.
For many years, “trans” has been used as an umbrella term to describe people with gender identities or presentations that differed from what was expected. More and more, “trans” is being replaced by “gender-diverse”, to acknowledge the cultural limitations of “trans” as a word to describe all atypical gendered ways of being.
Community mapping is a proactive approach in which a community or organization seeks to discover what services are available within the community, where they are located and develop relationships with them. This can serve two purposes:
- At an organizational level, this ensures that service providers know where to refer patients when services are not available at their organization. This also allows for the development of more formal relationships between these services.
- At a community level, this allows the community to determine if the right set of services is available to meet patient needs.
It is important for service providers to map out what are important services and resources they can refer to ensure people’s optimal health. Do you have any recommendation for such resources/services going from prevention and education resources to practical services to advocacy campaigns? Let us know what you think are important resources to link that contribute to holistic care.
The Canadian Professional Association for Transgender Health (CPATH) used to produce a provincial update of services for each province every other year at their biennial conference, for exactly this purpose.
Here is a list of known clinical-based regional hubs where trans people in different provinces are accessing supports, referral, health care, and information about what might be locally available to them.
One of the services provided by the Rainbow Health Ontario website is a provider database. This is a listing of LGBT health and mental health providers across Ontario. Providers are invited to self-list with a profile of the services they provide, and community members are invited to search for providers based on region, profession, competencies, or other factors.
If you are a trans person looking to connect with clinical or social supports where you live in Ontario, you can contact Jordan, the Trans Health Connection Coordinator, for support and referral.
If you are a health care provider, you can contact Rainbow Health Ontario to coordinate training and education on a number of different clinical topics related to trans (and LGBQ+) health. We have several CME-accredited workshops and will travel to you to offer in-person training that best meets the learning needs of participants.
Sherbourne Health Centre and Rainbow Health Ontario have developed Guidelines and Protocols for Hormone Therapy and Primary Care to guide clinical practice in working with trans and gender-diverse patients. This is a practical and extremely comprehensive step-by-step guide to assessment, monitoring, blood work, drug costs, timelines, preventative care, and other primary health factors. The protocols document is available for free download, and we recommend it to any health care providers who are involved in any aspects of trans care.
The Trans Health Information Project (THIP) offers a similar service in BC. It is a repository for local trans health information for both patients and providers, offers training and education, referral, and other supports around trans health.
The Catherine White Holman Wellness Centre in Vancouver is a unique clinical service. Comprised of clinicians volunteering their time to provide radically community-based patient-centred services, the Centre offers free medical and alternative health care that is low/no barrier. The Clinic was community founded and many of the staff are trans/gender-diverse.
Klinic Community Health is a unique service hub for trans and gender-diverse folks in Manitoba and north-western Ontario. They offer similar services to the other clinics mentioned here (primary care, peer groups, mental health supports) as well as training and education for service providers and dedicated advocacy countering transphobic injustice.
Clinic 554 is the only clinic in New Brunswick currently consistently offering informed access to trans care. Dr. Adrian Edgar is a strong advocate for trans rights and is a prominent member of the Canadian Professional Association for Transgender Health (CPATH).
PrideHealth in Nova Scotia also offers a hub for health care services, information, referral and advocacy for trans people in the province. They also have a local service directory and are committed to providing accessible services.
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