Building Capacity for Gender-Affirming Care
Capacity issues and long wait lists abound as too many health care providers see gender-affirming care as a ‘speciality.’ It isn’t. Meet some of the health care professionals who are stepping up to meet the need while the broader system catches up.
Dr. Kate Greenaway would like nothing more than to see a plummeting demand for her medical services. But at the rate that new patients are clamouring to be seen at her telemedicine clinic, it is not likely something that will happen any time soon. That’s because her practice offers services to trans and gender diverse individuals.
“I suppose it’s nice to be popular,” she said with a rueful laugh, “but never did I imagine that the gap in (gender-affirming) care was so large that we would be struggling to see patients in a timely way.”
Self-referrals to Connect-Clinic from patients interested in hormone therapy have increased so much that the practice, which began in June 2019 with just Dr. Greenaway, has now expanded to nine part-time physicians and still has an ever-growing wait list of four to six months.
Of the more than 30.5 million Canadians aged 15 and over who were counted in the most recent census, 100,815 of them identify as transgender or non-binary. That’s 0.33 percent of the total population, or about one in 300 people. And a growing body of research finds that the vast majority struggle to find gender-affirming care — defined as medical and psychosocial health care designed to affirm individuals’ gender identities.
Before starting the clinic, Dr. Greenaway had been providing gender-affirming care as a component of her downtown Toronto family practice for nearly 15 years. It was as important a facet of her practice as immunizing toddlers, performing comprehensive wellness exams, and overseeing chronic health conditions. But with a limited number of physicians providing gender-affirming care, the number of people calling her office and asking to be taken on as patients was growing. More concerning, she said, was that a significant portion of the calls were from people living in rural and remote communities unable to find a physician in their area willing to provide trans care.
“I started to notice the number of people requesting to join my family practice were from further and further away. And of course, that becomes problematic. If your primary care provider is hundreds of kilometres from where you live, are you really going to see them for abdominal pain?”
As the demand grew, so did her discomfort with the situation. After all, she was acutely aware of the mental and emotional toll faced by transgender individuals unable to access gender-affirming care (which, for some, includes hormone treatments and surgeries). Studies show that these individuals have higher rates of suicidal ideation and of death by suicide than those who have access to care. People who were planning but had not yet begun a medical transition were most at risk for considering/attempting suicide.
After some consideration, Dr. Greenaway decided to leave her family practice and dedicate herself solely to providing virtual trans health, thus sparing patients from longer wait times that could worsen gender dysphoria. At least two thirds of her patients live in rural or remote communities. Because the clinic does not provide comprehensive primary care, patients who do not have a family physician are encouraged to find one.
The need for gender-affirming health care for transgender people is intense across Ontario, but nowhere is the situation more felt than in rural and remote communities, said Dr. Jordan Goodridge, a Toronto family physician with a practice focused on LGBTQ+ health and HIV primary care. “There are a limited number of rural health care providers who advertise themselves as being comfortable and knowledgeable about trans health concerns and are actively taking new patients,” he says. “To address this concern, some providers will see patients virtually — such as Dr. Kate Greenaway — but the demand for these resources are high. Wait times fluctuate but it generally takes several months to get an appointment.”
Over the last several years, Dr. Goodridge has been dedicated to building capacity for gender-affirming care, working closely with health providers in various stages of training to help build confidence and competence. He works through Rainbow Health Ontario (RHO) providing education, clinical support, and mentorship to primary care providers across Ontario. More recently, he became part of a program through ECHO Ontario Mental Health focused on increasing capacity across the province so that people can get the gender-affirming care they need closer to home.
This initiative provides a trans-affirming space for health care providers from across the province to learn from one another about medical and other aspects of transition.
The program is a response to the Ministry of Health’s decision in 2016 to change the Ontario Health Insurance Plan’s funding criteria for transition-related surgery so that it aligned with the World Professional Association for Transgender Health’s internationally accepted standards of care for Gender Dysphoria. This decision allowed qualified health care providers to assess and refer patients for surgery.
It quickly became apparent how beneficial ECHO — with its much-acclaimed hub (the team of experts) and spokes (the multiple participants) model of learning – could be in supporting primary care providers with this policy change. Since its launch in May 2018, ECHO Ontario Trans Gender and Diverse Healthcare has delivered 57 sessions to 270 health-care providers from 192 organizations across Ontario. Physicians usually comprise about 25 percent of the number of attendees, the vast majority being family physicians. Pediatricians and psychiatrists are also regular attendees.
Following their participation in the ECHO group, health care professionals report an 80 percent increase in their perceived competence to deliver transgender and gender-diverse health care. “We no longer have to send our patients 6+ hours out of town to get the health care they need,” wrote one participant about the experience.
Rowen Kae Nyman, a trans researcher and educator, joined the most recent ECHO cycle as a Community Member Educator, helping to centre the lived experiences of trans people in the learning discussions. Nyman says seeing health care professionals return to their community with a new confidence in caring for their most isolated patients is heartening. “We will sometimes have a [former participant} tell us that they just started their first hormone treatment with a patient and they only were able to do it because of the confidence they gained through ECHO. And I think, “Oh, wow, that’s really tangible.’ It feels really cool to have that feedback and feel like we were actually part of something that made a clear difference to someone’s quality of life.”
Dr. June Lam, a psychiatrist at CAMH’s Adult Gender Identity Clinic and part of the Hub team, says having access to health care professionals willing to provide gender-affirming care in remote communities is critical.
“I think growing up in a small community when you wish to transition can be a pretty lonely experience,” he said. “I’ve heard [patients] say that the one person who can often really make a difference in these smaller communities is their health care provider. So when that person ends up not being affirming of who they are and is not supportive of their transition goals, it can be quite devastating and distressing for people.”
Nyman, who initially accessed gender-affirming care in Alberta, said their experience in accessing care was better than most. A doctor from Toronto had just moved to Calgary and word spread quickly throughout the trans community that she was providing gender-affirming care. After being on the waiting list for two months — a relatively brief period of time — Nyman was able to become her patient. “I got very lucky with my timing,” they said. “But if you were to do a Google search for a physician who did gender-affirming care, it would be a three-year wait normally.”
“The demand greatly outweighs the resources,” agrees Cathy Maser, a nurse practitioner who helped initiate the Transgender Youth Clinic at SickKids. “The wait list for hospital-based clinics is two years now for a youth, and that’s ridiculous,” she said. “It’s just completely wrong. And the other challenge is that those few providers that are trans-informed and can provide that care don’t only want to do that. They want to have a mixed practice. For that reason, they don’t necessarily advertise on the Rainbow Health Ontario provider list because they know they would be overwhelmed.”
Dr. Lam says that he wants to see medical schools devote more of its curricula to trans health as a competency of primary care. “I was never really taught in medical school or residency about trans health, how to prescribe [gender-affirming] hormones or how to support trans people through their life’s journey. There were a couple of one-off sessions where LGBT health issues were grouped together and discussed, but it was honestly nowhere near enough,” said Dr. Lam, who graduated from residency in 2019.
Surveys have been conducted to assess the LGBT-related content in medical school curricula in Canada and the United States. White et al. (2015) found that medical schools teach a median of five hours of LGBT content in their required curricula. Most students felt prepared to provide generalized sexual health care to the LGBT population, but unprepared to address transgender health-care issues. A cross-sectional study of 365 Canadian medical students found that just 24 percent thought transgender health was proficiently taught and only six percent felt they had sufficient knowledge to care for transgender individuals (Chan et al., 2016).
As a result of the lack of exposure in medical school, said Dr. Lam, trans health is perceived as — and treated like — a specialty by physicians. “And I think what happens is that primary care providers don’t feel a responsibility to learn and incorporate trans care into their practice. A patient approaches them about medically transitioning. They’ll say ‘go to CAMH’s Gender Identity Clinic or to SickKids, because I don’t do that in my practice’. And that’s the point we convey to our ECHO participants– trans care is not specialty care. It needs to be a part of your primary care front-line setting.“
Dr. Greenaway loves making a difference in the lives of her patients and finds the work rewarding, but she makes it clear that trans care was never a market that she wanted to corner. In fact, her expectation in opening Connect-Clinic was that it would be a temporary solution, a stop-gap measure to address a systemic issue. “I saw it as a bridging solution. I would see these patients desperate to start receiving gender-affirming care and at the same time, help their family physicians get comfortable enough so that they could begin to take on that aspect of their patient’s care,” she said.
When she takes on a patient, she will take a history, do an assessment, arrange the blood work, perhaps start hormones. In a recent article Dr. Greenaway wrote for the Canadian Family Physician, she explains why telemedicine works as a good fit for non-binary and gender diverse people in rural or remote communities, as well as for people in urban and suburban environments that lack access to culturally appropriate care. If she obtains consent from the patient, she will reach out to the family doctor to ask if they would like to see her process for providing care.
The reactions, she said, have been mixed. “Some physicians are immediately on board and supportive and want to learn more. Other doctors have said that they are just not comfortable with a patient who wants to transition, and they make it clear they don’t want to be a part of the care.”
The lack of interest shown by some FPs to learn gender-diverse health disappoints her. “Transgender care is family medicine,” she says. “FPs are uniquely situated to care for their patients who wish to use hormones.” She points out that FPs have the advantages of already knowing the patient; as well as knowledge of hormone and screening tasks in other populations, such as post-menopausal women or hypogonadal men. More significantly, they are accustomed to empowering patients through education and shared decision-making.
“I’ve spent my career trying to dispel the myth that transgender care is complicated,” says Dr. Greenaway. “Primary care is complicated, but I don’t feel that transgender care is more complicated.”
Dr. Greenaway says like other aspects within family medicine, family doctors need to self-assess as to whether the assessment for transition surgery is within their scope “It is within the scope of family medicine, but not every provider has attained the skill. I tell colleagues that if they feel comfortable taking a gender history, diagnosing gender dysphoria and reviewing risks and benefits of surgery, they are able to provide this assessment. If they need help with any of these things, they could do the RHO course/ ECHO or mentor support to gain the skills.”
When physicians are open to learning about the trans care that is being provided to their patients, Dr. Greenaway makes her process as transparent as possible. “By and large, the questions are less about the treatment itself and the monitoring and are much more focused on the approach to care. They want to know, for example, how I ask certain questions or perhaps how I set up my chart. I try to make it so they could actually template my care.”
Additionally, she offers her expertise on trans standards of care — via the eConsult Program of the Ontario Telemedicine Network (OTN) — to any family physician wishing to learn more. She has also written the clinical portion of the Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients, which is now referenced province wide.
“Throughout my career, the most important thing for me has been to build capacity in the health care system for these patients,” she said. “That is why I am so committed to providing guidance to my peers and helping them embed gender health in their practices.”