Health-care providers have a responsibility to remove barriers to care at every opportunity
Health care for all
Early in her career, Dr. Sue Atkinson was approached by someone she knew from the two-spirit, lesbian, gay, bisexual, transgender, queer, plus (2SLGBTQ+) community with a question: would she take a transfeminine person who was having difficulty accessing health care into her practice?
“I am part of the 2SLGBTQ+ community, so I’ve had an interest in queer health all along,” said Dr. Atkinson, a family physician in Halifax. “However, I knew nothing about trans health when I finished medical school and residency. I started learning as much as I could so I could give her appropriate care, and things went from there.”
For nearly 30 years, Dr. Atkinson has been a beacon in Nova Scotia’s 2SLGBTQ+ community and a champion for her patients. Since 1992, she has been delivering care to queer and gender-diverse individuals at the Halifax Sexual Health Centre (HSHC), an inclusive, pro-choice clinic with a focus on youth, reproductive and gender-diverse care. Dr. Atkinson and her colleagues approach sex and sexuality in a non-judgemental way.
Caring for gender-diverse patients starts with an unbiased understanding of their unique needs. People who don’t fit the typical cis-gender profile (meaning those who identify as their assigned gender at birth) may identify in a range of ways, such as transgender, two-spirit, gender-queer, gender non-conforming and non-binary.
Many patients choose to transition into their authentic gender by using hormone therapy and having surgery. Through this transition, they can be in a body that reflects their identity, enabling them to live to their fullest potential. In supporting their patients’ transitions, doctors are delivering what’s called gender-affirming care.
But serving this population presents challenges. One of the main concerns for gender-diverse patients is wait times. Current guidelines recommend a psychosocial assessment prior to starting gender-affirming hormones and before receiving funding for surgery from MSI.
This means patients must wait to be assessed by community mental health, which can take six to 18 months. People with health insurance or who can afford an assessment move more quickly through the first step of the process, which is to receive a referral for hormone readiness. All patients must wait another six to 18 months for surgical readiness letters, and finally, six to 18 months for referral to Montreal for surgery.
“We have a long waitlist at the HSHC for seeing gender-diverse individuals who are wanting to start hormone therapy or to be referred for surgeries,” said Dr. Atkinson, who also teaches medical students and residents at Dalhousie’s Department of Family Medicine and works at the Dalhousie Family Medicine Mumford Site clinic.
Additionally, many patients may struggle with mental health concerns connected with their gender identity. They may experience gender dysphoria, which the Canadian Medical Association Journal describes as distress experienced by an individual when their gender identity and their gender assigned at birth are conflicting. With wait times compounding their struggles, the rates of self-harm can be high.
Moreover, the HSHC faces another barrier. As a non-profit charity, it’s seen as a boutique clinic by government. “We receive the same rate of pay as those who work in walk-in clinics, which is less than what family doctors are paid working in their own practices,” Dr. Atkinson said. Funding to operate the HSHC comes from the province and donations through a network of community-based sexual health centres in Nova Scotia, of which HSHC is one of six throughout the province.
For these reasons, the centre has struggled to recruit physicians. Most family doctors in Nova Scotia are not salaried but are paid a set fee for each service they provide to a patient. Dr. Atkinson believes that an alternative to the fee-for-service model would boost physician recruitment at the centre and cut down on wait times for patients requiring routine sexual health care and gender-affirming care. “The work is very rewarding in many ways, but because it takes extra time, it is not well-paid work in a fee-for-service world. It can be, for some, a difficult choice to make to do the work.”
To help relieve the pressure, Dr. Atkinson thinks 2SLGBTQ+ patients should be able to access gender-affirming care through their primary care provider. She encourages physicians who want to show their allyship to put up a rainbow poster or a pride flag sticker in their waiting area or exam room, re-label washrooms to be gender-neutral and work with their front staff to treat patients from this community with respect.
“At its most basic level, it’s about asking for and using the individual’s chosen name and pronouns,” Dr. Atkinson said. Don’t make assumptions about how a person looks – ask them directly how they wish to be called.
She encourages physicians and other health-care providers working with gender-diverse people to say “assigned female” or “assigned male” at birth, rather than “born a girl” or “born a boy.” When discussing body parts, she recommends saying “people with penises” rather than “men” or “people with ovaries” rather than “women.” If doing a breast exam on a transmasculine individual, consider calling it a chest exam.
Fundamentally, it’s about respecting that a person knows their own identity and gender – even if their appearance might not match their perceived gender. “People who identify as women are actual women, and people who identify as men are actual men,” said Dr. Atkinson.
“We need to broaden our definitions of men and women, and the anatomy they may have. Remember that there are people who identify as non-binary and thus, either don’t identify as male or female or identify as both.”
Dr. Atkinson says 2SLBGT+ people have been underserved in health care – often denied care outright or unable to access care that addresses their needs. They may face myriad issues in their lives, such as discrimination and challenges with housing and employment, and are at high risk for suicide and domestic violence. “Health-care providers have a responsibility to remove barriers to care at every opportunity,” Dr. Atkinson said. Through her work training medical learners, she’s ensuring that physicians are educated and confident caring for Nova Scotians of all sexual orientations and genders.
Ultimately, she says the majority of their health-care needs are the same as everyone else. Given the advancement of 2SLBGT+ legal rights, Dr. Atkinson is optimistic that more primary health-care providers will be confident serving these patients. “I believe that for most healthy individuals that is where this care belongs,” she said.
Art installation by Halifax artist Margot Durling
If you are someone who is experiencing thoughts of self harm, sucicide or just need someone to talk to, there is help available. Trans Lifeline is a free service available from anywhere in Canada: 1-877-330-6366.