Canadian evidence suggests transgender (trans) individuals are underserved in both primary and specialty care settings. In Ontario, an estimated one in three trans individuals experienced an unmet health care need that would not be expected were they not trans. Moreover, trans individuals were more likely to rate the quality of care in their community as poor.
Specific programs and services are necessary to address these and other disparities between transgender individuals and the general population.
A collaboration in the North Simcoe Muskoka Local Integration Network (LHIN) is tackling this gap through the establishment of the Trans Health Service. We talked to Angela Munday, Director of Clinical Services at the Couchiching Family Health Team, to learn more about this initiative, which earned them a Bright Lights Award from the Association of Family Health Teams of Ontario in the community and social accountability category. Read more about their award here.
Why was the Trans Health Service established?
The history is interesting. It grew out of the Orillia Soldier’s Memorial Hospital and started with their LGBTQ committee. At first, they were looking internally, finding ways to make their space more friendly for the LGBTQ community. Then they decided to turn their focus outwards to see if there were other ways to make health care more LGBTQ friendly. They opened their committee to community partners, one of which was the Gilbert Centre, which provides social and support programming for individuals and families from the LGBQT communities in the Simcoe County and Muskoka Region.
The Gilbert Centre, in partnership with the hospital and Laurentian University, received LHIN funding to examine the health needs of trans people in the region. The study revealed startling information. For example, only 50% of participants made their primary care provider aware of their trans status and only 21% were offered hormone therapy. Meanwhile, 54% of transgender people avoided needed health care, 33% avoid going to the local emergency department, and 16% reported that they will avoid calling 911 even when they are in an urgent situation because of the fear of how they would be perceived.
The committee knew they had to do something about this. A call for proposal was put out by the LHIN and they applied for funding to create a trans health service. In response, the LHIN insisted that the service be in the community, and not the hospital. The hospital then came to us at the Family Health Team and asked if we would take it on and we didn’t hesitate.
Do you think the service would be as successful if it were in the hospital?
I think it’s wise to let hospitals do the business that hospitals need to do. Our program can be run in the community and that’s where it should be, especially knowing the reluctance of the trans population to walk through hospital doors. Our focus really was on trans health care in primary care, because we want to normalize trans health. Now I will say that we have a very close working relationship with our partners at the hospital. There has been absolutely no discomfort or tension around us taking it and running with it. Everyone just wanted this program to exist, and for people to be aware of it in the community and in the region.
Can you tell me how the Trans Health Service is set up?
It’s a regional program based out of our Family Health Team. We have clients that are part of our Family Health Team, but we also have a growing outreach program. From the start we were aware that this program needed to be LHIN-wide and that we needed to serve all five subregions.
We started with a full-time Nurse Practitioner with expertise in hormone replacement therapy and surgical referrals, and a full-time Peer Support Navigator, someone with lived experience that could be that normalizing voice that can say ‘you’re not alone, I’ve been there myself.’ They will spend a day in Midland, a day in Barrie, Orillia, or Collingwood. They’re going to all these areas with us being the hub here. They travel to where our clients are at so that it’s easy for people.
Since we won the Bright Lights Award, we now have a full time dedicated mental health therapist travelling with the team too.
Another new addition is a speech therapist who specializes in voice feminization therapy. We’ve been working in partnership with the hospital to provide this service on a pilot basis. It’s basically costing us $300 a patient and that’s with the hospital donating the speech language pathologist’s time. Usually this service costs around $1,600 and is otherwise available only in Toronto or privately. It’s a gap and it’s expensive.
Why is speech therapy so important for trans individuals?
Speech is very big sticking point, especially for trans women. For trans men, when they start testosterone, their voice naturally lowers. For a trans women, estrogen doesn’t do that. Knowing that the unemployment rates for trans people are higher than the average anyway, we know that this is important. A lot of trans women won’t use the telephone, they will avoid it. Maybe they have a very feminine sounding name, but they don’t sound female and that might lead to a lot of questions.
I touched based with a former client of mine who is a trans women and went through the voice feminization program. I gave her a call to check in and see how she was doing, and I didn’t recognize her on the phone! She sounded completely different.
Would the Peer Support Navigator always join the Nurse Practitioner at a consult?
Often they’re at the same location together. We do have clients that would want to see both of them and we have clients that would see one or the other. Some people might already have a family physician who’s got them started on hormones, who’s trans friendly and able to do that medical piece. Maybe all they want is a peer support person because, you know, they need advice on how to change their name or they want to know where to go for electrolysis and what will that cost. Some of the basics.
Can you tell me about the Positive Space Committee?
The Positive Space Committee determines how our processes, space, and forms can be inclusive to all, so that that everyone feels welcome. We want to make sure that anyone who comes through our doors or anyone using our programs feels comfortable coming to this family health team. Our peer support person from our trans health team sits on that committee and one of the issues they’ve been tackling is revising forms and policies to make sure they are LGBTQ-friendly.
Can you give us some examples of changes the family health team has made to be more LGBTQ-friendly?
When we first started the trans health service, on our forms we had options for male, female, trans, and other, and then we asked for preferred name. We have since taken that off, because, unbeknownst to us at the time, preferred name is not trans-friendly. Now, our forms will say legal name and just name. So, if the individual hasn’t done a name change yet, they can put their legal name and the name that they use, plus we have a way to put that in our chart so that everybody knows what to call that person. It’s that idea that being trans is not a choice, it’s not a preference, and we don’t want to perpetuate the idea that someone just decided that this is who they are this week.
I’ll give you another example. When we first started, we were initially thinking that we needed to have a referral form, an initial intake form, and we needed to gather all this information up front. Then a trans individual on the committee said, ‘Can’t your NP or peer support person get that at the first appointment, once that relationship has been established?’ They were right. Really all we need is their address, phone number, and their name so that we can build their chart out. You will turn people off if you ask too many questions up front.
I read that patients can self-refer into the program. How does that work?
Some of our clients come from traditional physician referrals and some do not. We wanted to make it as accessible as possible for people so anyone can refer. It could be a mother calling on behalf of their trans child, it could be a pediatrician, it could be an endocrinologist referring, and it could absolutely the person themselves or a friend calling on their behalf. We just wanted to make sure our door was wide open.
In order to keep it very friendly and not too heavy in the front, because we know these people are reluctant to engage with health care, we ask very few questions at the beginning. There’s no form to fill out, they just need to call to make an appointment. Our admin at the front desk will say, 'Absolutely, here’s what I have: I have a Nurse Practitioner, I have a Peer Support Navigator...where would you like to start?'
Tell us about the Safer Spaces training.
The Safer Spaces training is something that the Gilbert Centre offers, and we did the training as a Family Health Team. Staff have undergone Safer Spaces training and it is mandatory for new employees. We talk about basic things we can do, everything from when you go out in the waiting room and call that person’s name, that you’re not outing them.
We’re also trying to build the capacity within our region, so that trans health care becomes part of regular health care. We now offer Safer Spaces training for health care professionals across all five subregions of the LHIN to help create more inclusive health care environments for the LGBTQ population.