Exploring the gender-affirming healthcare system in Kingston

Patients and practitioners describe issues with knowledge, support, and access to transgender healthcare 

Health practitioners bring awareness to issues in Queer Healthcare.
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Kingston resident Alex Haagarde first began seeking out medical gender transition in early 2021.

Haagarde, who is non-binary and chronically ill, had faced negative experiences with the medical system in the past but was convinced to make the leap after hearing about other trans people in Ontario who lived with similar health conditions and transitioned with success.

They first contacted the Kingston Trans Health Clinic in January, seeking to be onboarded for hormone replacement therapy (HRT).

Despite their wariness about the healthcare system, Haagarde was disappointed by the barriers they faced while trying to access gender-affirming care in Kingston. Obtaining treatment was a long, complicated process that involved months of waiting.

Throughout much of the process, Haagarde had to be their own advocate. They often found themselves emailing and calling offices to secure appointments and debating with healthcare professionals over treatments.

After the appointment they booked two months in advance was pushed back an extra two months, they were exhausted.

 “I contacted the gender clinic again, and I begged them to consider working with me to get me access to hormone replacement because I need it,” they said in an interview with The Journal.

Haagarde believes the Kingston Trans Health Clinic was hesitant to provide them with HRT, because they were concerned it would interact negatively with Haagarde’s chronic illness. They struggled to convince the clinic they understood the implications of the treatment.

“Part of the reason I actually wanted to pursue hormone replacement was because from other trans people who share my diagnosis, I had heard that it can actually have quite a positive effect on a number of our symptoms,” they said.

To proceed with HRT, Haagarde had to set up an appointment with a family doctor and consult with an endocrinologist, which took several back-and-forths. Although medical professionals wanted to ensure the process was safe, Haagarde spent over a year waiting for treatment as their chronic condition and mental health worsened.

“I've lost years of my life to delayed diagnosis and treatment, and part of the reason I waited so long to pursue HRT was that I wasn't sure I could handle something like that happening to me again,” Haagarde wrote in a follow-up statement to The Journal.

“It's really painful to have the experience of needing medical help and being told you're not sick enough, or you're too sick, or you're not sick in the right way, or you're just mentally ill, or drug-seeking, or attention-seeking.”

Moving in a Circle

Although Kingston ranks as one of the nation’s most gender-diverse cities, local physicians and clinics say they are overwhelmed by the number of people seeking gender-affirming care.

In 2016, the guidelines around providing transgender care in Ontario were rewritten to give all qualified registered nurses, social workers, nurse practitioners, and physicians the power to prescribe HRT to their clients.

Despite this, many medical professionals perceive gender-affirming care to be a specialized practice, rather than an integral part of primary care that any qualified practitioner can offer.

“Unfortunately, we don't see a lot of doctors taking [gender-affirming care] on as part of somebody's comprehensive care, either because of their own prejudice or cis-normative ideas about somebody's health, or because they don't know that this is something that they are able to do,” Carley Hoja, a social worker at the Kingston Trans Health Clinic, told The Journal.

The Kingston Trans Health Clinic, operated by Kingston Community Health Centres (KCHC) in collaboration with the Queen's Family Health Team and the Kingston Health Sciences Centre (KHSC) Gender Clinic, is the only provincially funded gender therapy clinic serving southeastern Ontario. Last year, it supported over 300 patients through 1,400 visits to the clinic.

Although the Trans Health Clinic is not the only place where Kingstonians can access gender-affirming care in Kingston, their other options are limited. Today, the intake waitlist at the Trans Health Clinic stands at 8-12 months due to a shortage of knowledgeable providers and a surge in new patients.

Even as the Trans Health Clinic works to build stronger networks with allied providers in their community, patients can end up in difficult situations due to the sheer demand for care.

Sarah*, a Queen’s PhD student, began seeking resources to help her transition at the beginning of last year. After visiting Queen’s Student Wellness Services (SWS), she was recommended for gender transition, but was met with a physician who was unfamiliar with this treatment.

Sarah was referred to the Trans Health Clinic, only to be sent right back to SWS and informed there were in-house providers who could provide her with the treatment she sought.

Consequently, Sarah felt like she’d “moved in a circle” between clinics, as the doctor she spoke to at SWS was unaware there were others who could have provided her with HRT without being referred away.

“I’ve been looping around from one place to another and had the feeling that nobody really wanted to provide care to me,” she wrote in a statement to The Journal.

After starting on spironolactone at the Trans Health Clinic, Sarah experienced an adverse reaction and eventually switched back to SWS, where she was able to get a second opinion and have her experiences taken more seriously.

Although she said she’s satisfied with the care she gets at SWS now, it took a long, cumbersome process to get there. Sarah believes her experience highlights the need for greater communication between and within agencies, and for more family doctors to support patients.

In a statement to The Journal, Cynthia Gibney, Executive Director of Student Wellness Services, said the SWS maintains a “close relationship with the Kingston Community Health Centres and their Transgender Program.”

SWS offers Queen’s students seeking medical transition access to nurses, doctors, nurse practitioners, and therapists who can facilitate gender-affirming care. Gibney also said SWS is meeting with allied transgender healthcare providers in the area to determine how to best manage referrals.

To Sarah, however, the main barrier trans and non-binary people face when trying to access medical transition is the primary care provider shortage.

With many transgender and non-binary clients lacking a family doctor who can help them obtain gender-affirming care, the Kingston Trans Health Clinic is left to fill in the gap.

“If you can't access a primary care provider, then you have a problem, right? My understanding is, you go to your doctor, you tell them [your] issue, and then they refer you out to a specialist, and sometimes the Trans Health Clinic would take the role on as the specialist,” Sarah said in an interview with The Journal.

“But it seems more like the Trans Health Clinic is a place for people that don't have a family doctor that is willing to provide gender-affirming care.”

A Lot of Financial Burden

Although some gender-affirming surgeries and treatments are insured by the province’s public healthcare plan, this coverage is not exhaustive.

The Ontario Health Insurance Plan (OHIP) provides coverage for “medically essential transgender surgery,” including top and bottom surgery. Other procedures, such as breast or pectoral augmentation, facial feminization, or body sculpting, are considered cosmetic procedures and not covered by the provincial plan. OHIP also does not cover aspects like speech therapy, voice coaching, or the costs of changing identity documentation.

Under the Society of Graduate and Professional Students (SGPS) Health and Dental Plan, students like Sarah can get up to $500 worth of counselling, psychotherapy, or speech therapy covered—but she says this is not enough to meet her needs when rates typically range from $140-200 per session.

The other major source of financial support for transgender and non-binary graduate students is PSAC 901’s gender affirmation bursary, which can be used to pay for procedures that fall outside of OHIP and the SGPS Plan, like laser hair removal.

While Sarah is grateful for this resource, she finds it unfortunate it is the only financial support on campus that can pay for such procedures.

For undergraduate students, the AMS provides up to $1,000 a year of mental health and counselling coverage under its Health and Dental Plan, which can be used towards gender-affirming counselling and therapy. Student fees from the AMS are also used to support the Gender Affirming Assistance Program, which supplies binders, breast forms, clothing, and financial support to transgender and non-binary Kingstonians.

When it comes to therapy and counselling, however, some aren’t fortunate enough to be supported by university or employer health insurance.

Haagarde receives funding from the Ontario Disability Support Program due to their chronic illness. Although the injectable form of testosterone—which they were prescribed—is covered under the Ontario Drug Benefit, a testosterone gel that could be more appropriate for their chronic illness is not. Haagarde already takes several other drugs to manage their illness, some of which must be paid for out-of-pocket.

Beyond the direct cost of treatment, it’s the little things that add up as well, according to Hoja.

“There's an extensive recovery period for many surgeries where individuals have to be off work hours, hours traveling from somebody's home to the surgical center,” she said. “Many [surgeries] are in Toronto or Montreal, so there's a lot of financial burden that comes with trans healthcare in the province.”

“The basic things are [covered], but not when you look at their reality of how much time someone has to take off work for their health.”

I Try to Do What I Can

Meagan O’Leary, Director of Clinical Services at KCHC, acknowledges the current system cannot always address the needs of every patient. With providers already pushed to the limit, she believes Kingston’s healthcare system is making the best they can of a difficult situation.

Like many others The Journal spoke to, O’Leary stressed the importance of “capacity building” within the gender-affirming healthcare system in Kingston—that is, strengthening current organizations’ ability to close the gap between the demand and supply of care.

This includes onboarding interested providers into trainings like those offered by Rainbow Health Ontario. These courses fully equip a doctor, social worker, nurse, or nurse practitioner to prescribe hormones, perform surgical referrals, counsel patients, work with transgender youth, and more.

“We know lack of access has a very direct, negative impact on people’s mental health and wellbeing. We also know that over the last two years marginalized populations were disproportionately impacted by [COVID-19] which further exacerbated issues accessing care,” O’Leary wrote in a statement to The Journal.

Although the nurse practitioners at the Trans Health Clinic can provide most forms of gender-affirming care to patients, O’Leary said it’s standard practice to consult doctors with more specialized training for advice when dealing with patients outside of their scope.

“There is a desperate need for awareness, anti-stigma education, and advocacy in order to secure further support and funding for tailored services for this priority population, while also pushing the education to providers to build capacity within their own practices,” she wrote.

“[Be] mindful that this is hard in a city like Kingston when there is such a huge need for more primary care providers, as current ones are maxed out, and there are 20,000-plus Kingstonians without a family doctor.”

Dr. Ashley Waddington, an associate professor of Obstetrics and Gynecology at Queen’s, helped found and advise the Kingston Trans Health Clinic in its early years. Since then, she’s been at the forefront of the movement to expand access to transgender care in Kingston.

Today, Dr. Waddington runs a contraception and gynecology clinic, where she also sees transgender patients for pre- or post-operative surgical consultations.

According to her, the biggest barrier patients face when seeking such treatment is not that their practitioners are unwilling to treat transgender or non-binary patients, but that many lack the knowledge and confidence needed to provide this type of care.

“Most of the other physicians that I've interacted with are certainly like supportive of their patients. They want their patients to access [gender-affirming] care, but they themselves never had any training in it.”

As a result, she’s been pushing to inform physicians and nurse practitioners about the resources they have to learn about transgender healthcare. Apart from Rainbow Health Ontario, Dr. Waddington pointed to guides like The Sherbourne’s Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients, which offers detailed advice to medical professionals on how to care for gender-diverse patients. According to her, this resource makes the process of prescribing hormones so simple, “it’s almost like a cookbook.”

Dr. Waddington is acutely aware of the unmet need for gender-affirming healthcare and the many ways the current system falls short. According to her, transgender healthcare remains underfunded by the provincial government, which puts pressure on what few supports exist.

While she’s proud of the progress made so far, Dr. Waddington knows there is more that needs to be done. Still, she remains optimistic about the future of trans healthcare in Kingston.

“I do always feel a little bit inadequate because I know that there's so many more patients out there seek care. But I try to stay involved. I try to do what I can,” she said.

Dr. Waddington believes that if more physicians and nurse practitioners are encouraged to learn how to provide gender-affirming care on their own, issues like long wait times will eventually be remediated.

One of the most important solutions is to expose young doctors to gender-affirming care early on in their education so they feel confident in providing it in the future. This is a task Dr. Waddington has taken on personally through her teaching and practice through her work with Queen’s medical students and residents.

“I think that this will all get better with time. There will be better access to care, because people will have had some exposure to it during their training.”

*Name changed for anonymity.

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