Coming out as transgender to his family was just the first struggle for Vincent Bolt. At the age of 16, he found himself having to explain to doctors in northern Ontario basic concepts of what it meant to live as a transgender male. “You go in with whatever ailment or medical need you have, and have that on your mind while at the same time having to give a whole dialogue of being born as female and now living as male.”
In 2006—nine years before celebrities such as Laverne Cox and Caitlyn Jenner helped usher transgender issues into the mainstream—doctors in his hometown of Sudbury had no idea how to help Bolt with transition-specific health care.
“It was still quite unheard of to be trans in Sudbury,” says Bolt, who is now a project co-ordinator at TG Innerselves, a support network program for transgender communities in northern Ontario. “I remember struggling to find someone who’d help me with the medical transition.”
A transition process looks different for any transgender person. Bolt’s included hormone replacement therapy (HRT) – regular injections of types of testosterone, and consistent monitoring of hormone levels. Though it’s a specialized type of care, it’s a treatment that any family doctor or nurse practitioner in the province with training in administering it is allowed to provide.
Navigating the health care system as part of a transitioning process is an often-cited challenge for transgender people anywhere. But in northern or rural communities there’s the added challenge of obtaining everyday health care that’s attuned to their needs. It’s difficult to find specialized care, such as transition counselling and support for ongoing hormone therapy, but even the administrative details are hard to come by, such as health care staff using proper pronouns and medical documentation that reflects the reality of name changes or gender identities.
After a lengthy search, Bolt was referred to an endocrinologist in Toronto, where he travelled three to four times a year for bloodwork, prescription refills and hormone level checks. “I saw him for years, and the last appointment I had with him, he said, ‘Your hormone levels are stable, and you’ll be on this dose for a while. There’s no reason why your family physician cannot do this.’”
Six months after that last visit Bolt’s local family doctor agreed to continue his hormone therapy maintenance out of Sudbury. “There does come a point where it isn’t complex anymore.”
Despite family doctors being able to administer simple HRT, Bolt says many still find health care in the north falls short and they must go south to get the care they need.
Part of this is due to overall lack of training, says Jennifer MacKinnon, a primary care officer at the North East Local Health Integration Network (LHIN) in Sudbury.
“A medical school degree does not go into the real detailed teaching of how to provide things like HRT. That’s considered a post-grad course to attain that knowledge to provide that care. In not wanting to do harm, unless they have that knowledge and training, most physicians don’t provide these services,” says MacKinnon.
She describes this hesitance not as instances of outright discrimination—“though a lot of trans patients have experienced that as well,” she says—but a lack of awareness and understanding.
This is exacerbated by the significant shortage of primary health care providers in this part of the province to begin with. Ontario’s general unattached patient rate—patients without a consistent family doctor or nurse practitioner—is close to 6 per cent. In Sudbury, she says, it’s 14 per cent and in Thunder Bay, 12.7 per cent.
For transgender people seeking OHIP-covered sex reassignment surgery, there’s also the issue of travelling to Toronto’s Centre for Addiction and Mental Health, which is currently the province’s only gatekeeper for the procedure. Access to publicly-funded sex reassignment surgery was de-funded by the province in 1998 and re-funded in 2008; since then the waiting list for initial assessments has grown to about 1,000 people long and many wait up to two years for an appointment. This past summer the Liberal government acknowledged the need for a solution to this bottleneck, but no changes to the approval process have been announced.
“We have people who have to travel, and it’s not cheap to do so. Even though there’s a northern Ontario travel grant, you still have to pay for it upfront,” says Bolt. “About 50 per cent of trans people in Ontario make less than $15,000 a year. When you’re making that little on a monthly basis, to take time off work to travel and pay for accommodations gas or a bus ticket—it adds up.”
TG Innerselves and Rainbow Health Ontario, an LGBTQ health care resource arm of Toronto’s Sherbourne Health Centre, have been working with local health care centres to address gaps in training and knowledge.
“Trans people should be able to get trans primary care in the communities they live in,” says Jordan Zaitzow, a program co-ordinator at Rainbow Health Ontario. “[Trans] people from all over the province were coming to Toronto because they thought they could get services there, and wait lists there were getting longer and longer.”
In 2011, Rainbow Health developed transgender health programs for community health care clinics in the province. At clinics in Windsor, St. Catharines, Ottawa, Thunder Bay and Sudbury the group hosted multi-day workshops on clinical care, counselling and transition support. The Sudbury LHIN was one of the health care centres to take the training; they’ll be refreshing it again for new hires in the new year.
“Since 2011, when we completed that training, we started providing services pretty much immediately,” says Juanita Lawson, director of clinical services at NorWest Community Health Centres in Thunder Bay. Since then, they’ve consistently had a doctor or nurse practitioner trained in providing HRT care. Transgender patients are recorded by their preferred pronouns and real names to help avoid confusion over OHIP or government documentation that might still have a patient’s previous or “dead” name.
“This isn’t tricky medicine; it’s not complex,” says Zaitzow. “It’s well within the scope of general health care. It’s a lot about normalizing it.”
Last fall, NorWest launched a chapter of Gender Journeys — an information and support program created at Sherbourne Health Centre. The initiative was the first of its kind in northern Ontario, says Laurie Hollis Walker, a therapist at NorWest. She said the need for such a program became clear immediately.
“I was expecting maybe six people would show up and we had 18,” she says. “The first couple of weeks filled up. It’s completely full now, and testament that people in this area need these services.”
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