When Terrence Rodriguez started looking for a new family doctor in 2011, he didn’t realize the process would take eight years.
The North Etobicoke resident had begun transitioning about a decade prior. He liked his doctor, and felt lucky to have access to a physician who provided him with gender-affirming health care in downtown Toronto. But his commute to the clinic took an hour each way, and his visits were frequent: on top of transition-related care, he was being treated for nodules on his thyroid, among other issues, and at one point needed monthly bloodwork. He often found himself taking unpaid days off work to attend appointments. When he couldn’t take time off, it interfered with his prescriptions. More than once, he had to miss doses of testosterone because he wasn’t able to get his hormone replacement therapy (HRT) prescription renewed in time—which affected both his transition and his mental health.
Whenever he heard a doctor closer to his home was taking new patients, he’d reach out. He quickly grew discouraged. Over nearly a decade, Rodriguez was either ignored by or turned away from almost a dozen clinics. This denial of care wasn’t explicitly hateful, he says—no one used transphobic language or told him trans patients were unwelcome. But he suspected it was discriminatory nonetheless: after he’d disclose that he’s trans, staff would tell him that they weren’t taking patients after all, which he found odd because he’d specifically heard that they were. “Or the other response was that they didn’t feel comfortable working with the trans community,” Rodriguez says.
It was only in 2019 that a nurse practitioner at a nearby community health centre agreed to become Rodriguez’s primary care provider. The nurse practitioner was queer, but had never had trans patients before, so he asked that Rodriguez bear with him while he learned. Rodriguez was just relieved to have found someone who was willing to put in the work. “We’ll do this together,” he told the nurse practitioner. “It’s all good.”
In order to offer Rodriguez the type of care he actually needed, the nurse practitioner signed up for training sessions with Rainbow Health Ontario (RHO). Since 2008, the organization has offered a growing list of on-demand courses, both online and in person, for health care workers who want to learn to provide competent care to queer and trans patients. Their foundations course is self-directed, and open to everyone online. In more specialized modules, primary care providers learn from a facilitator how to prescribe HRT and help care for patients experiencing post-surgery complications, among other topics.
Training programs like RHO’s are vital for filling gaps in care: they improve access by teaching health care workers the skills they need to adequately treat trans, non-binary, and gender-diverse patients—skills they rarely learn in medical school. But experts who offer this training say that in recent years, signups have started to slow. The rising global backlash against trans rights has created a chill among medical professionals, making them more reluctant to seek out or participate in courses—or consider offering trans-affirming health care to patients at all. As this chill grows, it threatens to undo the progress that trainers and other health care advocates have been gradually building.
In Ontario, it’s difficult to know exactly where gender-affirming care is offered. Gender-affirming care includes a range of social, psychological, and medical interventions for trans and non-binary patients, everything from trans-competent mental health care to laser hair removal to gender-affirming surgeries. Medical care, such as the prescribing of hormones, is provided through a mix of specialized health centers, hospital-based clinics, and individual doctors’ offices, and clinics don’t always specifically advertise that they are trans and non-binary friendly. Outside major urban centres, even in suburbs like Etobicoke, access can be particularly spotty, and rural areas tend to be gender-affirming care deserts, where few or no practitioners offer this care. That means many patients have to travel long distances or rely on virtual clinics. In major cities, where care is more accessible—take the gender clinics at Sherbourne Health and CAMH in Toronto, for example—wait times can still be long, stretching into months or years.
In theory, patients shouldn’t have to wait: across the province, and nationwide, any primary care provider can offer prescriptions for HRT, or referrals for gender-affirming surgeries, says Sil Hernando, director at RHO. The same is true for puberty blockers, the medications given to trans youth in order to delay the onset of puberty. But in practice, it’s up to individual providers to decide whether to offer care.
When health care staff refuse to do so, it’s often because they don’t feel they’re properly informed. In a 2016 study, the last time this question appears to have been the subject of research, only 24 percent of Canadian medical students felt they received adequate training on how to provide gender-affirming care. This can lead to providers refusing to administer transition care, or, as Rodriguez’s experience showed, declining to take trans people as patients at all. It can also result in a lower standard of care when primary care staff don’t properly grasp the needs of trans patients. If a care provider doesn’t realize that both trans men and trans women who take HRT need screenings for breast cancer, for example, patients may not receive life-saving preventative care. A trans or non-binary person’s ability to get access to competent health care—or any health care at all—often comes down to whether they’re lucky enough to have a primary care provider who’s willing and knowledgeable enough to engage with them. And even when they do, discomfort and the fear of medical discrimination often lead trans and non-binary patients to delay or avoid seeking medical attention altogether. All of this ultimately means gender-diverse patients experience serious gaps in care: according to a 2020 Trans PULSE Canada report, 45 percent of trans Canadians reported having an unmet health care need.
That’s why training programs are so important, Hernando says. “If you have an affirming clinic where you are welcoming of trans and non-binary people—regardless of whether you provide hormones or not—they will come there. Everything from their cancer to diabetes to cardiovascular issues will be taken care of at an appropriate time.”
Today, RHO offers 14 training courses aimed at different workers in the health care sector, each of which takes about four hours to complete. While the Toronto-based organization will travel for a fee for in-person training on request, most sessions are done online, which has allowed them to reach care providers all over the province—from Sarnia to Peel region to North Bay. By training practitioners in more remote areas, the organization hopes to slowly improve access in those regions. Each year, RHO reaches about 3,000 participants over an average of one facilitated training a week. The cost of the training is minimal, never more than $50 per participant depending on the course, and participants receive ongoing support and mentorship from RHO once their sessions are complete. Care providers can ask for advice any time on clinical questions they encounter while they’re treating their patients—the feedback they receive, Hernando says, helps physicians and other providers to make sure their patients are getting the most tailored care possible.
But RHO has noticed that demand has slowed slightly as anti-trans rhetoric and misinformation about gender-affirming care has gotten louder—online, in the media, and from politicians both in Canada and south of the border. Hernando says that signing trainees up has become more difficult. While there has always been a steady demand for their programs, it was already difficult sometimes to convince doctors to take an afternoon off work. Now, misinformation has created “a climate where gender-affirming care doesn't seem important, or where people are scared to provide it,” she explains. “It has created a bit of a chill in terms of providers who want to attend. We are still very full…but there's certainly been a change in the last couple of years.”
This chill is touching other training programs, says physician Avery Hart, executive director of the Trans Resource & Education Committee (TREC), an initiative dedicated to advancing trans-inclusive medical education. Through the Trans Health Bootcamp, Hart, who uses he and they pronouns, has worked with colleagues to lead training sessions with more than 400 students in medical schools on topics like how to safely use a binder, or best practices for hormone injections. The program has run at McMaster University and is set to soon expand to Toronto Metropolitan University.
“A lot of medical students think, ‘If I'm not providing this care, it doesn't affect me’…and that’s enabled by schools who are teaching trans health as if it's a niche topic instead of a competency that all physicians should have,” Hart says.
While most students have been enthusiastic and engaged in training sessions, Hart has noticed an increased resistance from both schools he’s approached, and from individual trainees. In recent years, medical providers have been restricted from providing gender-affirming care to youth (and sometimes even adults) in jurisdictions both in Canada and the U.S.—in Alberta, for example, doctors are newly prohibited from prescribing puberty blockers or hormone replacement therapy to patients who are 15 and under. (Patients who are 16 and 17 must receive parental consent in order to access this care.) As prohibitive policies have spread, Hart says uptake on training has slowed.
“The major barrier I’ve come up against is schools not wanting to put themselves out on the line, and risk blowback for teaching something that they think is controversial,” they explain.
Hart has deliberately chosen to expand their training program slowly, and to be very picky about whom they approach to pitch sessions, out of a desire to protect themself and the other practitioners they train alongside. “The longer I do this work, the more I actually fear for my career,” they say. “I’m definitely more guarded than I used to be.”
Sometimes that fear stems from interactions with colleagues, says Hart, who knows firsthand that the system has a long way to go in providing equitable care to trans patients. During his own time in medical school, sitting in on a gender-affirming surgery, Hart recalls that medical staff misgendered the patient multiple times after they were put under anesthesia. He wanted to push back and correct the staff, but he was scared that doing so might cause them to view him as a problem, or that saying something could put his career at risk. “One of the worst things about me being socialized in this system is that I have become complicit as a way to survive,” Hart says.
After the patient woke up, the doctors continued using incorrect pronouns, and Hart still felt unable to speak up. “I remember that I did go and cry really hard that day, because I just felt so defeated,” they say. “I felt like I couldn't do anything, or nothing was changing.”
When practitioners approach their work sensitively though, they can play a role in pushing back against rising discrimination, especially if they don’t allow care to become further politicized. “Physicians are a barrier in between patients and politics,” Hart says. “It’s the physician's responsibility to protect their patients. I want to get to [doctors] early and help them understand that they can fight for their patients, regardless of if they’re providing gender-affirming care, or just general health care to trans people.”
When primary care providers are able to support their trans and non-binary patients, the results can be formative for everyone involved.
Miles Smith, a Rexdale-based doctor who works with Terrence Rodriguez, first graduated from medical school with an understanding that physicians play a role in removing the barriers gender-diverse communities face. But he’d been taught only a little about caring for trans and non-binary patients in medical school, and by the time he got his first job in a community clinic in 2015, he still wasn’t confident enough to actually administer the care.
He decided that needed to change. At work, he spoke with Rodriguez about trans patients’ access to gender-affirming care. The centre where the two work also hosted an art program for LGBTQ2S+ teens that Smith would contribute to from time to time, dropping in on activities, and helping the group make Thanksgiving dinner one year. There, he met gender-diverse youth and witnessed firsthand what a difference it made to have access to adequate care. Kids would go from being withdrawn, to outgoing and happy, Smith says. Both their physical and mental wellbeing would visibly improve.
Smith saw in this the future he wanted for his own patients. To fill in the knowledge gaps he felt he still had, he signed up for RHO’s courses in 2018. After completing the training, he began seeing a growing roster of trans patients. Today, he oversees the care of about 20 gender-diverse people, attending to both their medical transitions and their general primary health care concerns.
Despite the continued erosion of trans health care, Smith hopes more practitioners will step up to support patients.
“Ultimately, [it] comes down to what motivates us as primary care providers,” he says. “Knowing that patients are thriving in their everyday lives is extremely gratifying to me as a health care professional.”
And Rodriguez’s experience shows patients really do thrive. He did have to find another nurse practitioner when his original primary care provider eventually left the clinic a few years back, but he ultimately landed with someone at the same centre, from whom he is equally happy to receive care. His new care provider gives him the agency he needs, Rodriguez says, and is transparent with him. When she doesn’t know something, she’s honest about it. When she is performing a vulnerable exam, like a pap test or a mammogram, she communicates with Rodriguez and checks in with how he’s feeling before and after. When she has to send him to a specialist for a referral, she’s honest about what she does or doesn’t know about the clinic—she tries her best to find trans-friendly places, and if she can’t guarantee that a clinic will be knowledgeable about trans health, she’s upfront with Rodriguez about that so that he can be prepared.
Without all this consideration, Rodriguez says, he would likely feel tempted to avoid seeking care. But knowing he’s supported means he can comfortably be proactive about his health. “I feel safe with her,” he says. “I don't take it for granted either, and I'm totally grateful.”
This story was produced in partnership with The Local magazine.
