Why has it become harder to get gender-affirming healthcare in Ontario?

CLIP You’re listening to a frequency podcast network production in association with City News.

Jordan Heath-Rawlings All you have to do is pay attention to the news for a few minutes, and you’ll understand the threats faced by transgender people. Right now, Arkansas passing a bill blocking gender affirming care for trans youth.

CLIP The British government says it’ll block a bill passed by the Scottish Parliament, making it easier for people to change their legal gender.

CLIP Utah trans kids are now prohibited from seeking gender affirming care in this state. The Gender affirming medical care for minors allows teachers to ignore a student’s preferred pronouns and trans students from using the restroom tied to their gender identities,

CLIP Calling a quote, the single most extreme anti-trans law to ever pass through state legislature.

CLIP This arc brings us to this moment where we are absolutely in crisis.

Jordan Heath-Rawlings This is one of those situations where as we do all too often, we’d like to hope that we’re better than that here in Canada, that we see gender affirming care as a service that’s critical to the survival of trans Canadians and that we allocate the money and resources that it deserves. I regret to inform you that’s not the case. It’s more of a difference of degrees. Anti-trans rhetoric and actions like protests at drag queen story times aren’t as common here as they are in America, but they are here and the danger is growing. And while Canadian lawmakers may not outright legislate away access to gender affirming care, they don’t seem particularly moved to protect it. Today you’ll hear the story of an Ontario clinic that exists to provide gender affirming care to trans and non-binary people across the province. Only right now it doesn’t because changes to the way Ontario funds virtual care have made it impossible. For this clinic to operate. There have been exceptions made to these new rules, but not apparently for this sort of work. Why not? Who determines what kind of care is prioritized when legislation like this changes? What kind of work does this clinic do, and who does that serve and what happens when the only doctor who can help you is online and then isn’t? I am Jordan Heath-Rawlings. This is the big story. Kai Jacobson is a graduate student at Carleton University, a member of the steering committee of Trans PULSE Canada, and one of the co-authors of an article in the conversation about the potential consequences of cuts to virtual healthcare. Hello, Kai.

Kai Jacobsen Hi. Thanks for having me.

Jordan Heath-Rawlings You’re very welcome. The first thing I wanna ask you is, To set the table, what is the Connect clinic and what kind of care does it provide?

Kai Jacobsen Yeah, so the Connect Clinic is a healthcare clinic that’s based out of Toronto, but they operate entirely virtually, so they don’t have in-person appointments, and they specialize in providing gender affirming care for trans and non-binary people. So the two main things that folks go to the Connect Clinic for are, um, a prescription for hormones and then a referral for surgery. And in Ontario hormones can actually be prescribed by any primary care provider. They don’t need a specialist. However, that doesn’t mean that all primary care providers will provide them, um, because Transhealth and gender affirming care is really given very minimal coverage in medical education. A lot of doctors don’t, aren’t experienced with working with trans folks, and they don’t feel like they have the skills or the ability to prescribe hormones for a trans person. And for the trans person, because they don’t know their doctor’s experience with working with trans feeble, they just might not feel comfortable going to any doctor to ask for a hormone prescription.

Jordan Heath-Rawlings Right.

Kai Jacobsen Especially because many trans folks have had negative experiences with healthcare providers in the past. And then in terms of surgery is the other main one. Um, so surgery is a bit more complicated in terms of you do need a readiness assessment or a mental health assessment from a qualified assessor before you can be referred to a surgeon and a qualified assessor here is a doctor who has particular experience or training in gender affirming care. And so if your family doctor doesn’t have that training, um, or you don’t feel comfortable going to ask them, Then you might go to the Connect clinic for someone that you know is gonna be experienced working with trans people. Um, and we know from, from data on Trans Post Canada, the large community-based research project I work with, that we found in 2019 that 52% of trans and non-binary participants in our survey across Canada. Said they did have a primary care provider that they were comfortable discussing their gender and translin healthcare needs with, so that other 48%, uh, might not feel comfortable going to their primary care provider. And so they might go somewhere like the Connect Clinic for specialty trans-inclusive care. But they won’t go there right now because it has paused appointments. Why is that? So the Ontario government has a new physician services agreement that took effect on December 1st of last year, and the physician services agreement basically lays out how the government reimburses doctors for healthcare appointments. So it covers billing codes that doctors. This new physician services agreement gets rid of these temporary billing codes that were created during the pandemic that let doctors bill for the same amount for a phone appointment or a video appointment that they would for an in-person one, and instead they use new billing codes. The rate of reimbursement is a lot lower, um, in terms of money. So the Connect Clinic used to be able to bill $67 for an appointment, but now they can only bill $20 for a video appointment or $15 for a phone one. There are some exceptions in the physician services agreement. Like if you’re rostered at a clinic and you’ve been to that clinic in person before in the past two years. Then the doctor can bill at the old rate, but none of those exemptions apply to the Connect Clinic. And so it became just like not financially viable for them to keep providing appointments.

Jordan Heath-Rawlings Is this only about the Connect Clinic or are there other, um, gender affirming care providers who are impacted by this?

Kai Jacobsen Connect Clinic is the only virtual dinner from a care clinic that I know of in Ontario, but the, the ripple effect of the Connect Clinic closing is gonna have a big impact on other providers because I believe they have around 1500 patients and 2000 people are on their wait list. And in terms of trans people, , that’s a large number within the province of Ontario.

Jordan Heath-Rawlings Mm-hmm.

Kai Jacobsen And so those folks are now scrambling to find care and that’s gonna just add to the already really long wait list of other, other clinics.

Jordan Heath-Rawlings Well, speaking of that, how rare or hard to access is this care, not just uh, across Ontario, but across all of Canada? You know, if. If one clinic no longer seeing patients, uh, can have that kind of ripple effect, you know, how much capacity is there?

Kai Jacobsen Yeah, I mean, the fact that one clinic closing has such a major impact on care for trans folks really tells you that the system is not as, as robust net full capacity as it could be. We know that there’s that wait lists and barriers to accessing care. Um, and just challenges in general are a big problem for Jennifer and care across the country. There’s a lot of variation, uh, both within Ontario, depending on if you’re in a more urban area like Toronto or Ottawa, there might be, um, a trans clinic in your area. That’s likely not the case if you’re in a rural area and across the country as well. There’s, there’s really wide variation in what different provinces cover and what the, the pathway to access and care is like in those areas. A lot of times people end up meaning to travel. Outside in their city, outside the province, even outside the country to access care. And so that’s part of the gap that the Connect Clinic was filling by being able to provide virtual care. Hmm. And long wait lists in general are a problem in Ontario to receive gender affirming surgery, you have to apply for OIP funding. It’s not automatically covered. And just getting that piece of paper process is taking up to eight months right now. And that’s just, that’s just one phase of the, the complex process of accessing surgery. And our project transports Canada has some data that shows sort of the impact of these barriers for accessing care. So in 2019, we surveyed about 3000, or just under 3000 trans and non-binary folks across Canada. And of those folks, 44% said they had at least one unmet healthcare need in the past year. So something they needed healthcare for that they couldn’t access. And in comparison, about 6% of the Canadian populations said that in 20.

Jordan Heath-Rawlings How important is specifically gender affirming care? Uh, what do we know about the results of places like the Connect Clinic?

Kai Jacobsen We have a lot of research that shows just how important gender affirming care is. That it’s, a lot of folks refer to it as lifesaving care. Um, and it really is, we have lots of research that gender affirming care significantly improves trans folks’ mental health and wellbeing, um, and especially reduces suicidality. So a previous iteration of our project Trans Pauls, um, was conducted just in Ontario in 2009, and research outta that project found that folks who had access to or having access to all desired gender affirming medical interventions reduced suicidal ideation by 62%. And when we’re talking about trans folks who have quite high suicide rates, so one in three folks in our data set had considered suicide just in the past year alone, 62% less is a lot of people. Yeah. And we have lots of other research that shows that trans folks who have access to the kinds of medical care that they want and are affirmed as their gender by their community have really much better mental health outcomes.

Jordan Heath-Rawlings One of the reasons we wanted to talk about this issue is because it can put a local spin or a local face on a much bigger issue, so, so I wanna ask you about the current context right now, because I know we’re talking about Ontario, specifically and the Connect Clinic specifically, but what is the climate like for trans people everywhere in the world these days?

Kai Jacobsen Not great, you know, um, yeah. Especially in the US we’re seeing just every day they see on the news that there’s a new threat to gender affirming care in the us. A ban that that criminalizes or otherwise restricts access to gender affirming care, especially for young people. But we’re seeing, um, bills that are targeting adults as well in the us. And while we have seen a lot of progress for trans folks in the past, you know, few years and few decades in terms of visibility, that visibility brings negative attention too. And so we’re getting this, this backlash or this moral panic about trans people and gender affirming care, and we’re not. You know, we’re not seeing these kinds of bands in Canada right now, but that transphobic rhetoric in hate is really alive and well here. It’s not restricted by the border, and I think it’s really important that we stay aware and vigilant of, um, the situation that trans folks have in this country, and access to gender affirming care in Canada. What do we do to change that rhetoric? And, and yes, in one sense, you know, in the bigger picture, like change the narrative and push back against the hate.

Jordan Heath-Rawlings But in the other sense, like what specifically can we do to make sure that, uh, this kind of stuff doesn’t increase here the way it has around the world?

Kai Jacobsen It’s a big question. I think it’s a question that the trans folks I know think about every day. I think for me, we need to move past. Debating trans people’s existence and our right to access medical care and basic human rights. I think we’re really past that point and we need to start seeing much larger investments into trans, non-binary people’s communities and our healthcare in particular, and policy changes that make it easier for trans and non-binary people to, to live and thrive in our communities. And that’s part of what TPOs Canada is doing, research and data collection. Buy for and with trans communities so that we have that data that we can use to advocate for changes to, uh, improves our lives and, uh, the lives of our communities.

Jordan Heath-Rawlings Can you gimme a couple of examples of specific policies that you guys have found work or could help at least?

Kai Jacobsen For sure. I mean, so having access to dinner for main care and so we know. You know, our group has advocated that we need an exemption to the virtual billing, uh, fee reductions for the Connect clinic, but we know it’s a stop gap solution and we need a much larger provincial approach to investing in capacity building, um, and training for primary care providers to be able to provide gender affirming care. It’s other things like, I mean, OIP doesn’t cover all of the range of possible Jennifer care interventions. So there’s things that folks have to pay out of pocket for, and they’re very expensive. So expanding coverage of what is covered by public healthcare, as well as, um, being able to change the name in the gender marker on your ID on your passport. Hopefully fewer bureaucratic barriers and costs or needing a doctor to sign off on your gender before you can have it changed on id. It’s things like that that really make a huge difference in terms of this specifically and its impact on the Connect clinic. You know, you mentioned that this is part of a larger reform.

Jordan Heath-Rawlings Has the Ontario government been asked specifically about like this impact directly and whether or not an exemption is possible and why not?

Kai Jacobsen If not, they have been asked. The Connect Clinic started a petition to the Ministry of Health. It was also raised in, um, the Ontario legislature, I believe, and our group transports Canada did send a letter to the Minister of Health on this issue. We didn’t receive a response. Not yet, at least the government’s general position has been. They want virtual care to be in addition to in-person care and not replacing it. But for trans folks right now, virtual care is not an adjunct to in-person care. It’s often the only care that is available. So it’s a choice between virtual care or no care at all. The government has pointed to investments in things like community health centers and family health teams, but those community health centers are overwhelmed to not. Every community health center has a transhealth program. The ones that do are often full or they have long wait lists and they just, they don’t have the capacity to provide care to every trans person in the province. The Ontario Medical Association called the impact on the Connect Clinic, an unintended consequence of the agreement. But what’s an unintended consequence at a policy level is just a, a devastating impact for trans and non-binary people on top of the barriers that we already face to accessing.

Jordan Heath-Rawlings So what options do trans people in Ontario have without the Connect Clinic, and I guess more specifically, because some of them may be listening, what would you tell a trans person who has lost their access to care and, and what should they do?

Kai Jacobsen It’s really hard. I, I really feel for those folks. I think a lot of folks are scrambling to access the care they need right now. There’s a lot of, of fear and anxiety in our community. I think if you have a primary CareProvider, that is always a good place to start. Rainbow Health Ontario has resources that you can use and bring to your doctor to outline where they are able to provide gender care, where there might be someone they can refer you to. Or also in some areas there is a, um, A telehealth consult service where your doctor can talk to a doctor who is more experienced or specialized in trans care, um, and then use that information to help deliver the best care possible for you. So there are options like this across the province, but they’re not at the sort of like system-wide provincial level that we need.

Jordan Heath-Rawlings Is there anything elsewhere? In Canada that Ontario could learn from? What are other provinces and territories doing to provide this kind of care?

Kai Jacobsen Yeah, there’s been a couple of initiatives in the past few years. The Yukon Territory recently expanded coverage for what is covered under their public healthcare plan to include a lot of surgeries that OHIP currently doesn’t cover. I believe there’s been some implementation challenges there because a lot of those services are provided in private clinics and that. Sort of funding issues for how you do that operationally, but it. I mean every trans person I know when the Yukon came out with that policy, we were just amazed and impressed to see that they’re actually covering all the services that we know are medically necessary for our community. And I’m from bc so there we have Transcare bc, which is a program that was started in 2015, and they provide care coordination and direct support to both trans folks and healthcare providers. And they’re able to connect people to doctors who are trans affirming in their area. They manage essential wait list for some surgeries. Um, and they do a lot of that provincial level advocacy and have been able to really expand access to Jennifer and care across the province and reduce some of those, those wait times and wait lists that we see.

Jordan Heath-Rawlings What can people who want to help do about this? Is this a like write your MPP and pray kind of thing, or is there more tangible things that, that we could do?

Kai Jacobsen I mean, there’s, there’s certainly a role for, um, writing your elected representative and praying . Um, but I think in terms of more specific actions, if you work in healthcare, think about what the experience that trans folks have coming into where you work, and are there ways that you can make where you work more inclusive and welcoming for the trans folks that are seeking healthcare there. As I mentioned, there’s resources from Rainbow Health Ontario, transcript BC and BC also has some really great toolkits and training sessions and sort have tip sheets on things that might be helpful and. . You know, I, I’ve said that we need a broad, provincial, systemic approach, but there are also small things that make a big difference, like asking someone for their pronouns, not assuming their gender based on what’s on their ID or their name, or how they look.

Jordan Heath-Rawlings Mm-hmm.

Kai Jacobsen These small things can make a big difference. In trans folks feeling safe and comfortable in healthcare settings and in other workplaces, I think everyone can think about the trans folks in their life or who they might encounter and how they can make their space more inclusive and welcoming for trans folks.

Jordan Heath-Rawlings Kai, thank you so much for this.

Kai Jacobsen Thanks so much for having me.

Jordan Heath-Rawlings That was Kai Jacobsen, and that was the big story. For more, you can head to the big story podcast.ca. You can also talk to us on Twitter at the Big Story fpn, or you can write us an email hello at the big story podcast.ca. If you wanna find this podcast, head to your favorite podcast player and search for it. If your favorite podcast player happens to be Apple Podcasts, first, you can subscribe to TBS Plus if you want this show without commercials, but more importantly, you can give us a rating and leave us a. So we know what you think. Thanks for listening. I’m Jordan Heath Rawlings. We’ll talk tomorrow.