What Barriers Do Canadian Patients Face?

Two qualitative studies recently detailed significant barriers to care for transgender patients seeking surgery in Canada, providing a better understanding of how the discrimination that transgender populations experience may limit their access to care.

The first study, by MacCormick and colleagues, looked at lived experiences during the perioperative period by interviewing 21 Canadian patients who identify as transgender or nonbinary and had undergone any type of surgery in the past 5 years. The other study, by Lorello and colleagues, interviewed 15 participants who had undergone penile inversion vaginoplasty at Women’s College Hospital in Toronto, Ontario, Canada, since June 2019.

While the studies focused on surgical contexts, most participants discussed their experiences interacting with the healthcare system more broadly. Significant barriers, including finding providers who are willing and well equipped to treat these patients, “really overshadowed the rest of the experience,” study author Hilary MacCormick, MD, an anesthesiologist in the Department of Women’s and Obstetric Anesthesia and assistant professor at Dalhousie University in Halifax, Nova Scotia, Canada, told Medscape Medical News. “What we all need to do is make entering and interacting with the healthcare system a safer and better experience, and then we’ll be able to focus more on our niche.”

The two research papers — as well as a related humanities article and an accompanying editorial — were published on July 2 in the Canadian Medical Association Journal.

The Perioperative Context

Undergoing surgery can be difficult for all patients. “Regardless of the reason you’re having a surgery…there’s still something being changed in your body by other people,” which puts the patient in a vulnerable position, said MacCormick. As an anesthesiologist, she must quickly gain patients’ trust. “I’m not just looking after their bodies. I’m supposed to create a safe environment for them all around.”

This aspect of the job is particularly important for the transgender population, who often experience additional fear and mistrust of the medical system, MacCormick added. The transgender population encompasses anyone whose gender identity does not align with the sex assigned at birth, including transgender men and women, nonbinary people (who do not identify as a man or woman), and Two-Spirit individuals of Canada’s Indigenous population.

MacCormick chose a semistructured interview format for her research because “it’s really important to center the voices of the people who are experiencing the issue we’re looking at.” During the interviews, participants described having to justify their need for healthcare, feeling fearful from previous traumatic experiences, and leaning on community members for support and information.

Barriers to Care

The studies highlighted common barriers to care, including long wait lists, a lack of qualified professionals, discrimination (often referred to as “transphobia”), and a lack of family support. A 2020 Canadian national survey found that 45% of transgender and nonbinary people reported having at least one unmet healthcare need. Some patients also face significant financial costs, depending on insurance coverage, which varies between provinces. Top surgery, for example, can cost several thousand dollars if not covered by insurance.

Although qualitative studies like these depend on the individuals surveyed, “I did not find any part that didn’t resonate,” Margaret Lawson, MD, senior scientist emeritus at the Children’s Hospital of Eastern Ontario Research Institute and full professor emeritus at the University of Ottawa, Ottawa, Ontario, Canada, told Medscape Medical News. “Identity is critical. Not being accepted for who you are, having to prove who you are, is something I’ve heard many times from patients,” said Lawson, who worked with transgender youth as a pediatric endocrinologist for 17 years. These findings largely apply to both youth and adult patients, she added.

Another common barrier transgender patients face is a lack of family support. “These are not easy surgeries,” said Lawson. Follow-up care can be extensive, and “without family support, that’s incredibly difficult.”

Improving education for providers, such as by including gender-affirming care in medical school curricula, is one way to address these barriers. It’s also important that individual providers be willing to learn and that governments protect the transgender community’s rights and access to care, said MacCormick.

Providing Safety

While it’s important to discuss these barriers to care, the studies’ findings don’t provide much new information, said Jordan Zaitzow, a coordinator for Families in TRANSition, a program through Central Toronto Youth Services that facilitates discussions with families of transgender youth. Zaitzow, who was not involved in either study, has more than a decade of experience supporting health and mental health teams in improving care for gender-diverse populations. Zaitzow gave personal opinions and did not speak to Medscape Medical News on behalf of any organization.

“We’ve been talking about this for decades,” said Zaitzow. “What I think shifts the conversation is talking about gender-affirming care as providing patients with safety.”

In a previous role, Zaitzow helped develop accredited continuing education sessions and worked with community healthcare providers. During these sessions, some primary care providers said that they felt overburdened and didn’t have the capacity to become experts in transgender care, which they view as a specialized field. “There’s no designated pathway for care, and a lot of providers say, ‘It’s outside of my scope of practice’,” said Zaitzow. This tension can create additional barriers for transgender people.

To improve care, structural changes are needed to counteract the negative messages transgender patients often receive, said Zaitzow. Providers can start by, for example, ensuring that entry forms are inclusive and that appropriate restrooms are available, or posting signs embracing LGBTQ+ patients. “The first step is welcoming trans people into your practice,” said Zaitzow. Additionally, organizations including Rainbow Health Ontario and Trans Care BC provide educational resources and courses for providers.

“Start with the intuitive stuff. Start with creating safety in your practice and then go from there,” said Zaitzow.

The research by MacCormick and colleagues was supported by the Department of Anesthesia, Pain Management, and Perioperative Medicine at Dalhousie University. The study by Lorello and colleagues was supported by a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada. Lawson and Zaitzow reported no relevant financial relationships.

Gwendolyn Rak is a health reporter for Medscape Medical News based in Philadelphia.