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The crisis of trans health care in Canada

Public health coverage in Canada needs to expand to include a wider range of interventions and gender affirming procedures

Human RightsFeminismQueer

For most Canadians, health care became more difficult to access during the pandemic. The overcrowding of hospitals worsened alongside deteriorating conditions for nurses, paramedics and support staff. Similarly, many social support systems became overloaded: shelters suffered from unprecedented congestion while workers experienced collective burnout due to chronic stress. These are the hallmark symptoms of a systemic and political failure to sufficiently respond to crises the pandemic only widened.

These issues have been extensively documented, and rightly so. Yet, further from the public eye, another smaller-scale epidemic raged on. While a sliver of the general population, trans people faced a staggering rate of suicide attempts and ideation during the pandemic.

Having worked on initiatives supporting trans youth and adults in rural and suburban areas for the past two years, I can attest to the many challenges and barriers to treatment faced by the community. Simply put, things got worse during the pandemic. Trans health care underwent further privatization, primarily impacting the poorest, most isolated and vulnerable members of the community. Most of the rural and suburban trans people I interacted with received gender affirming care—or attempted to—on the island of Montréal, as these services are often functionally non-existent outside of major urban areas.

The state of trans health in Canada was appalling well before COVID became a household name. The Being Safe, Being Me survey on trans youth health, conducted by the University of British Columbia in 2019, concluded that “almost two thirds of the trans and/or non-binary youth… have self-harmed (64%) and/or seriously considered suicide (64%) within the past year.” Of these youth, 63 percent reported severe emotional distress, and 21 percent attempted suicide. The other statistics reported in the survey shed light on strong environmental factors contributing to poor mental health: trans youth reported feeling unsafe in their homes, experiencing higher rates of domestic and sexual violence, and contending with discrimination in various public locations, as well as in school and in the health care system. As these youth were often confined to threatening domestic spheres and further isolated from their communities during pandemic lockdowns, it is likely that health effects and outcomes have worsened considerably since the pre-pandemic period.

June 1, 2020 was Devera Romero’s first visit to Dr. Gabrielle Landry’s office at L’Actuel, a clinic specializing in gay male sexual health. Then aged 21, Romero had waited a month for this appointment, and it came with high expectations: though not without her critics, Landry was one of the doctors most often recommended in trans circles in and around Montréal. Unlike many other doctors who prescribe endocrinological treatments, Landry was relatively knowledgeable about the realities faced by trans people. She would write some of the most commonly sought-after prescriptions, namely injectable estradiol and bio-identical progesterone. The latter in particular has been the object of controversy due to the World Professional Association for Transgender Health’s reluctance to endorse it in their Standards of Care manual. Anecdotally, it is valued for its enhancement of breast growth.

While this may seem surprising to a layperson, the doctors who prescribe hormones to trans people often have very limited knowledge of the community. In many cases, this lack of knowledge results in clinics informally adopting conversion practices—requiring patients to “prove” that they are trans, doubting self-identification, and withholding treatment. The result of these approaches is, more often than not, devastating.

The findings of the University of British Columbia’s landmark study on transgender youth health make this point unambiguous: among this highly marginalized population, “those who lived in their felt gender all the time were almost 50 percent more likely to report good or excellent mental health.”

Many trans people—sometimes out of fear of the medical system, lack of access to medical resources, or both—will delay treatment for years and even decades before finally seeing a doctor. Mistrust of physicians extends further than to health care providers who specifically attend to trans issues. Often trans people are scared to see doctors about routine health issues for fear of outing themselves and suffering medical violence or malpractice.

Romero’s first visit was positive: she was prescribed spironolactone and estradiol. Combined, her prescription cost her around $20, and her visit to Landry’s office was completely covered by Québec’s public system. I sat with her as she recounted the event. When I asked her how she had felt, she explained that she cried with joy, and went out to celebrate with her friends. During the next year, she would become disillusioned with spironolactone and its host of adverse side effects, but nonetheless decided to continue with her estradiol treatments. When asked to return to the clinic for further blood tests to monitor her hormone levels, she deferred the procedure, having just learned of the death of a loved one.

Romero’s experience was, in some ways, typical among the trans people I have spoken with in Montréal, many of whom started out seeing Dr. Landry, or another specialist in endocrinology, rather than going through their family doctor (if they have one). Trans people will often report first seeing a general doctor who refuses to treat them. The wait for specialized clinics usually ranges between six months to a year, with extreme cases waiting up to two years before being seen. Some clinics, such as the Meraki Health Centre, were closed for many months during the pandemic due to a surge in applicants. The timeline for receiving hormonal replacement therapy (HRT) in Montréal is also different from Toronto’s, where patients can be seen within a month at Planned Parenthood.

Many trans people turn to the so-called grey market in order to find treatment: they purchase hormonal drugs from a number of online retailers, and sometimes even obtain blood tests from private clinics to understand how their dosage is affecting their hormonal levels. This avenue of treatment is especially popular in countries with private health care systems, but it is also well travelled by people residing in Canada. The term “grey market” here speaks to the fuzzy legality of ordering drugs without a prescription (testosterone is considered a controlled substance, for example, due to its apparent potential for abuse by athletes). While this method of obtaining hormones can be cheaper, and can circumvent the necessity of navigating a hostile medical systems, it also relies on an individual’s medical and scientific literacy to be effective.

Privatization can occur in multiple ways. The most classic form, in which a public service succumbs to economic or political pressure and starts to erect barriers to access, is a common outcome of neoliberal economic policies and austerity, which prescribes disinvestment from social services and the selling off of publicly owned enterprises.

A more subtle form of privatization occurs when gradual disinvestment⁠—or even just a lack of new investment as inflation rises⁠—renders existing public services too hard to access, or even obsolete, and therefore drives users to either opt for private options or go without services.

When Romero next visited Dr. Landry’s clinic, she was homeless. Cut off from traditional support systems, she still pursued treatment, overcoming tremendous hurdles to do so. Landry’s clinic had, at this point, adopted a new private model. The cost of the appointment alone was between $200 and $300. Likewise, the price of her medication jumped up to over $90. The effect on Romero was devastating. While many middle class patients can afford the extra cost of these appointments and drugs, homeless and precariously housed patients will forgo appointments and even treatment at great personal costs. Unless they come from supportive families or have already joined the workforce, teenagers are also de facto barred from accessing services.

In 2022, I took it upon myself to call the majority of Montréal’s public clinics which state they provide gender-affirming care. Of the ten clinics I contacted, only two had open waitlists. Trans people in my circles reported waiting for six months to a year, and in exceptional cases, up to two years to receive treatment.

Hormonal therapy is not the only aspect of trans health care that proved difficult to access during the pandemic. The GrS clinic, tucked away on the very edge of the island, is the only facility to offer gender-affirming surgeries in Québec. In fact, it is one of only three clinics to provide these surgeries in the entire country. Even so, not every procedure and technique is offered at GrS, and many trans people choose to pursue procedures in other provinces, shouldering large financial burdens to do so.

This kind of de facto privatization has led some trans people to organize patients’ unions. Medical and institutional information also travels fast within the community, with patients relying on each other for important insights into their dosages, the best places to access services, and the timeline of changes they can expect from different procedures and medications. While informal networks of experts such as these can carry their own dangers⁠—misinformation and anecdotal evidence often fill the void created by a lack of large-scale, verifiable studies⁠—it is true that many trans people are more knowledgeable about the ins and outs of their own course of treatment than the practitioners on which they are relying.

These networks help vulnerable trans people navigate systems that are often hostile to them and help bridge the gap created by the lack of investment in trans health care. The other gulf created by privatization⁠ can only be addressed through strengthening the existing social safety net.

A so-called universal health system can truly show its cracks when it comes to the experiences of the vulnerable, the marginalized, the colonized, and the poor, and these cracks can become gulfs in moments of crisis. The very systems that are supposed to help people and prevent social suffering become carceral and deadly from the perspective of the oppressed. This is not a new realization for LGBTQ+ activists: the AIDS crisis was met with some of the fiercest and most powerful movements of organized resistance in our communities’ history.

In Québec, the trans community organized swiftly to amend and repeal Bill 2, a discriminatory law that was slated to pass earlier last year. In the case of the overlapping points of failure in trans health care, a multi-pronged approach to tackling systemic inequality would likely be most effective. A mandate for general practitioners to learn appropriate protocols for trans health could also have a significant impact. Treatment should not have to be conditional upon a practitioner’s personal opinion of the community in question. If general practitioners were obligated to provide appropriate treatment for trans youth, and were equipped to give them scientifically accurate information about their health, these doctors could make a substantial difference in trans health delivery. This point is particularly salient when it comes to the health of rural trans youth, where a general practitioner might be one of the few resources available.

It would likewise be meaningful for public health coverage in Canada to expand to include a wider range of interventions covering gender affirming procedures, instead of arbitrarily deciding that some of these fall under cosmetic interventions.

Trans people themselves should also spearhead efforts to address the disparity in their treatment. While they are often excluded from the regular workforce, there is no shortage of community members with the ambition to become doctors, nurses and practitioners themselves, and they should be given more funding and support to do so. A more thorough public investigation into the prevalence of conversion therapy across different institutions could also shed light on significant cases of malpractice, and begin to redress some historical injustices. These approaches could go a long way towards rebuilding community trust in the medical system—and saving lives.

Carl Bystram is a community researcher, support worker and organizer based in Montréal (Tiohtià:ke). Their research interests include trans issues, homelessness, colonialism and imperialism.

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