Robyn Thom is a PGY 1 psychiatry resident at Harvard Longwood
It was a winter afternoon when I came to the shocking realization that although I was only months away from becoming a doctor, there was a significant subset of the Canadian population that I lacked the medical knowledge to care for. I was working at the Gender Identity Clinic at the Centre for Addiction and Mental Health (CAMH), where patients undergo psychiatric assessment to qualify for provincially-funded gender reassignment surgery. There, not only did I find myself listening to my patients rattle off multiple behavioural, hormonal, and surgical options for gender transition that I had never heard of before, but I also gained an appreciation for the degree to which skilled healthcare for transpeople in Ontario is lacking. One transman’s (female to male) family doctor ‘fired’ him after he declined the pap test. Although he understood the benefits of cervical cancer screening, it was a highly uncomfortable test because that part of anatomy felt foreign. Another transman who was seeking chest surgery admitted to having multiple painful breast lesions that he could not bring himself to seek medical attention for.
Although my time at the Gender Identity Clinic was brief, it became apparent to me that transpeople face a number of unique health needs, not least of which is the medical gender transition process, which is inadequately addressed by the Canadian healthcare system. Most Canadian family physicians are ill-equipped to counsel a patient on the several behavioural, hormonal, and surgical options for gender transition, resulting in insufficient or delayed care. Provincially-funded surgeries are further delayed by the required psychiatric assessment at the Gender Identity Clinic, where the current wait time is 18-24 months. And even after receiving psychiatric clearance, Ontarians must travel to Quebec or the United States for surgery; there are no Ontario surgeons who accept provincial reimbursement for gender reassignment procedures. Adequate surgical follow-up for patients who return from surgeries performed out-of-province or out-of-country is yet another challenge for delivering high quality care.
Medical gender transition aside, research has shown that transpeople suffer from poor health outcomes across multiple domains. In terms of mental health, transgender youth face a 2-3 fold increased risk of negative mental health outcomes. Furthermore, 41% of transpeople report a previous suicide attempt, compared to 1.6% of the general population.
Transgender people also report higher substance use rates and receive fewer preventative health screening exams than the general population. In Ontario, a few LGBTQ-specific health services exist, but these services are limited to urban centres and are poorly integrated, requiring patients to direct and integrate their own care. In Toronto for example, the Sherbourne Health Centre offers primary care to transpeople, but patients must travel to other, often distant sites for their endocrinologic, surgical, and psychiatric care. Care becomes fragmented and there is no built-in infrastructure for communication across teams.
The Canadian healthcare system’s oversight in addressing the unique healthcare needs of transpeople should begin at the level of undergraduate medical education. Although I was fortunate enough to gain some exposure to transhealth care during my experience at the Gender Identity Clinic, basic transhealth is not a core component of the medical school curriculum. I recently sat the Canadian medical licensing exam, where I answered hundreds of medical and surgical questions, yet not a single transhealth question appeared. In medical school, we learn to rhyme off the presentation and management of numerous esoteric diseases. When it comes to learning about how to empathize with, identify, and address the health needs of transpeople however, zero mandatory didactic or clinical time is allotted. Reports exist that an estimated 2-5% of the population identifies as trans. It seems clear that all Canadian physicians will statistically inevitably treat transpeople during the course of their careers. And while the Canadian undergraduate medical curriculum has recently increased efforts to highlight the unique health needs of other minority populations, including Aboriginal as well as lesbian and gay populations, exposure to transhealth needs remains overlooked. Transpeople have unique physical and mental health needs, and as a recent Canadian medical graduate, I feel ill-equipped to manage this group.
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