What does affirming, respectful, and safe health care look like for transgender and gender diverse individuals- and why does it matter now more than ever? In this episode, we discuss the importance of gender-affirming care and how we can make health care safer and more inclusive for transgender and gender diverse individuals.
What does affirming, respectful, and safe health care look like for transgender and gender diverse individuals- and why does it matter now more than ever? In this episode, we discuss the importance of gender-affirming care and how we can make health care safer and more inclusive for transgender and gender diverse individuals.
Dr. June Lam, MD, PhD, FRCPC is an Associate Scientist with the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH) and an Assistant Professor in the Department of Psychiatry at the University of Toronto. He is also a psychiatrist working in the CAMH emergency department and the Gender Identity Clinic. He completed a Bachelor of Science Honours Pharmacology program at UBC, his medical training at McGill University, and his psychiatry residency at the University of Toronto. He also completed a transitional age youth and transgender health research and clinical fellowship, as well as a PhD program in Clinical Epidemiology and Health Care Research (at the Institute of Health Policy, Management and Evaluation or IHPME) at the University of Toronto. Dr. Lam's academic and clinical focus is on care for 2SLGBTQIA+ communities, particularly using health services research to examine and improve access to mental healthcare for transgender and gender diverse (TGD) people. He has developed expertise in mixed methods research, uniquely integrating health administrative data and qualitative research to leverage the strengths of participant lived experience and population-level data.
Dr. Victoria “Tori” Anderson (she/her) is a resident physician, educator, and advocate passionate about creating inclusive, affirming mental health care for gender diverse youth and their caregivers. She is a senior resident in the Child and Adolescent Psychiatry subspecialty program at the University of Toronto. She completed her general psychiatry training at the University of Toronto, where she was recognized with a departmental award for her achievements in scholarship in the areas of sexual and gender diversity in mental health care.
ICES research you heard about
Misty Pratt
When we go to the doctor or visit a hospital, we all hope to be treated with respect and dignity. Yet for many transgender and gender diverse people, healthcare experiences can be fraught with trauma, discrimination and poor quality care. Research is clear that gender affirming care saves lives by reducing depression and suicidal thoughts and behavior. So why does there continue to be a gap in what we know improves these mental health issues and what plays out on the ground in our health care system? We're going to try to answer that question today. I'm your host, Misty Pratt, and this is In Our VoICES, the podcast that brings you the health data without the drama. I'm joined today by two very special guests from the Center for Addiction and Mental Health in Toronto. Dr. June Lam works to improve mental health care for 2SLGBTQIA+ communities, especially transgender and gender diverse people. And Dr. Tori Anderson is a child and adolescent psychiatry resident and advocate and focuses on creating inclusive mental health programs for trans and gender diverse youth, and helps providers build more affirming practices. Also, a heads up that we discuss suicide in this episode. If you or someone you love is in distress, there is a suicide crisis helpline here in Canada, when you dial 988. Please take care. So June and Tory, welcome to In Our VoICES.
Tori Anderson
Thanks for having us. Yeah, so glad to be here.
June Lam
Thank you. Thank you so much.
Misty Pratt
I've been very excited for this episode. So, I would like to start with a definition, and maybe June, we'll start with you and Tori, you can jump in as well. Can you describe what gender affirming care is?
June Lam
Many times, folks think that gender affirming care refers specifically to medical transition, which I'm sure we'll talk more about later. But actually, gender affirming care includes a whole range of things. It's more of an approach, rather than a specific procedure. In my perspective and experience, gender affirming care includes respecting folks identity, including their chosen name and pronouns, having safe and inclusive environments. It includes primary care, mental health care, including therapy and gender affirming mental health care, as well as medical transitions such as hormones and surgery when it's desired. But I think it includes all of these other things, and it's really important that we remember that.
Tori Anderson
Yes, I totally agree with many of the points that June's raised. I think it's really important again, just to double emphasize just, you know, we can often be very focused on when people are coming to care, talking about like hormones or surgeries, for example, but just how comprehensive like care can be for trans and gender diverse people. And it's really important to be thinking about like that there's other components, whether it's speech and language or hair removal or other like physical ways that other people might want to change their expression, that you know, will be included within gender affirming care more broadly. And you know, I think you know, we're here to talk about trans and gender diverse people. It's really important to acknowledge some of these things that we're talking about aren't unique to trans and gender diverse folks. I would guess that most people listening have engaged in some form of way of affirming their gender. You know whether that's getting your nails painted or wearing clothes typical to your gender in some way. But there's other domains of care as well, like we know that hair transplants or other forms of like plastic surgery or a variety of different care can all be considered, you know, gender affirming to even cisgender people. So a lot of these interventions that can be really meaningful for trans people aren't particularly unique or special.
Misty Pratt
That's such a good point. And I really like that idea of, well, not idea, but the concept of the approach. It's the fact that it's sort of this whole wrap around thing about, you know, caring for somebody's well being and for who they are as a person, which is really important. And I mentioned in the introduction that gender affirming care saves lives. Can you tell us a bit about the research behind that statement?
June Lam
Yeah, well, gender affirming care, which is really, as Tori mentioned, just good care for trans folks, which includes affirming who they are. Gender affirming care has been shown to reduce distress for trans and gender diverse folks, reduce depression, reduce suicidality, and specifically in some of the research that we have done, we looked at trans and gender diverse folks who have presented to the emergency department for their mental health, and after being discharged from the emergency department, trans folks were much more likely to get follow up in the month after they were discharged. Which, it suggests that there's a greater need for post discharge access to mental health care for trans folks compared to the general population. However, after a psychiatric hospitalization, trans folks were actually 20% less likely to receive follow up in the month after their hospitalization. And this discrepancy between post hospitalization versus post ED care suggests that there's something about the hospitalization that leads trans folks to not wanting to come back to get their mental health care within the system. So, we suggest that actually the experience of the hospitalization might be harmful, transphobic, exhausting, may not fully address their needs, and that's why trans folks actually don't want to come back for their mental health care after their hospitalization. So, not only does gender affirming care save lives in terms of improving mental health outcomes, reducing depression and suicidality, but when there is a lack of gender affirming care, it actually worsens their access to care, and therefore is harmful from a system perspective.
Misty Pratt
And I don't know if your research showed this, but you know, is it the emergency department are physicians and nurses there just doing a better job of providing that gender affirming care, and the hospital is not necessarily like, what is the difference there, of like me staying longer somewhere, versus me going for a short term, kind of acute problem?
June Lam
It's a great question, because we we tried to understand that as well. We found this difference between post ED care and post hospitalization care for trans folks using population based, you know, health administrative data, which are quantitative data, you know, using numbers. But we found that we really couldn't get the full answer without using qualitative research, which is where we interviewed trans and gender diverse people, former patients, who've had this experience themselves. And so, when we interviewed trans and gender diverse patients they explained the difference between emergency department care and hospitalization. Specifically, they said that the longer they stayed in hospital, the less likely they were to come back, and this is because often when you're hospitalized, there's a greater likelihood of it being because of involuntary hospitalization, meaning they didn't choose to stay. So, one theme that came out of the research is agency and autonomy, the ability to choose how to access their mental health care, was really important, especially for trans and gender diverse folks, often because they've had prior experiences in their lives in other domains of their life of agency and autonomy being taken away from them because of transphobia in other parts of their life. And so having choice in how to access their mental health care was really important to them. In addition, the longer they stayed in hospital, every day that they stayed in the inpatient environment, unfortunately, those spaces were not created with trans people in mind, and so oftentimes it was exhausting. They had to navigate a lot of bureaucratic barriers, such as people not using the right name or pronouns for them. This is not only staff, but other patients in the inpatient environment as well. Their ID bands, their wristbands, their patient wristbands, did not have the right chosen name or gender marker for them. All of these, what other people may perceive to be little things, really caused a traumatic experience, a re traumatizing experience for many of the folks, such that the longer they stayed in hospital, the less likely they were to come back to the system to access care.
Tori Anderson
Just to add to what June's saying here, I think when we're thinking about this care, and Misty, to your question of, "is this care life saving?", I think the evidence suggests that it truly has, it is. The evidence has demonstrated that for many years, it's important to kind of recognize that people were researching gender affirming care and these outcomes for trans people, even like a century ago, in the 1930s in Europe, before a lot of that evidence was unfortunately removed and erased. And so, you know, it's really been the last kind of quarter century that we've been trying to rediscover and look into outcomes around this care, and there's been an overwhelming number of reviews and studies that have come forward demonstrating how positive this care has been in terms of improving mental health outcomes and depression symptoms and suicide outcomes for young people or trans people of any ages, really. And so just to emphasize that, like that, evidence base has been like established and now we're trying to move forward with, how do we enact this care? How do we implement it? How do we bring it into the healthcare systems that we all work in?
Misty Pratt
And I think that's so important for folks to understand that the research we have now isn't anything new.
June Lam
And I really like the way that Tori frames sort of the question as moving towards like, how do we help people access the care that they need and deserve? Because one of the studies that I often cite is from the Trans PULSE Ontario study, which surveyed 433 trans and gender diverse people in Ontario. And one of its findings was that the highest risk of suicidality was during the time when people were waiting for access to medical transition, such as hormone therapy and or surgeries. And so that shows that part of the issue, or one of the biggest issues is actually waiting for access to care. And so that's why I think this conversation is really important in focusing on the health system and how access to care is really a major barrier for a lot of our folks.
Misty Pratt
And I think that leads into my next question a bit of you know how much of this is like mental health issues that are pre existing, or perhaps like recurring versus "I'm having mental health issues because I'm not receiving the care that I need". How do we kind of tease that apart?
Tori Anderson
I think it's such an important question, and I like the way that we're framing this to be explicit that, like gender diversity in any form isn't in itself, like a mental illness or condition. And it's important to be thinking about this complex intersection of being a minority group and experiencing the world that isn't kind of affirming or built for you in some ways. And like, the toll that it can take on on anyone. And so, I think when we're talking about accessing care, I think it's important for us to think about there are the physical, like components of dysphoria that people experience, and it's also a psychological toll, and of itself, to not be in a body that aligns, to not be treated in the world in the way that aligns with you and how that can impact you. In addition to all the layers that people can have in their life experiences that also can manifest down the road in mental health symptoms. So lack of schooling, lack of housing, lack of like, emotional attunement, lack of financial opportunities, All of these also can take a significant toll on people's mental health, in general. And I think it really is a web and so when we're talking about like helping people with their mental health, I think any clinician that's providing like gender affirming psychotherapy needs to be thinking about all these different variables.
June Lam
So, if you imagine, like a Venn diagram, a Venn diagram of three overlapping circles. Trans folks mental distress can come from three kind of overlapping, intersecting aspects. So one is just general mental illness that anybody in the general population can be susceptible to because of a host of different factors, which is beyond the scope of you know, our conversation today. Another part of the Venn diagram is gender dysphoria, which is the idea that aspects of trans and gender diverse people's bodies gender expression is not congruent with who they are, and that causes a lot of distress. That's why they need access to social and medical transition to affirm their identity, to match their body with who they are on the inside. And then the third category of mental distress is minority stress, which is a lot of what Tori has already mentioned. Which is this idea that trans and gender diverse people experience disproportionate mental health issues and challenges, because the world is not designed for trans people, and there's a lot of discrimination, transphobia, outright violence, sometimes towards trans people, and all of this trauma leads to disproportionately high rates of mental illness and mental distress. And so you can imagine these three overlapping categories are sort of three different aspects of mental distress for trans and gender diverse folks. And as Tori mentioned, it's important to understand that all of these elements intersect and interact with each other. And so, gender dysphoria intersects with minority stress, and vice versa. And so, all three, I think, contribute to why there is a disproportionately high rate of mental health challenges in this population.
Misty Pratt
Speaking about minority stress, how does that play out in the healthcare system? Because, you know, the healthcare system was designed to really treat specific sort of physical and even at this time, a bit of the mental side of things, not necessarily those social challenges that you just talked about. So how are we seeing minority stress in healthcare itself?
June Lam
I think it's an important question, because the system, as you said, Misty, is not designed to address what we sometimes call the social or structural determinants of health. So these are things like access to safe housing, employment, financial security. I would say that oftentimes those social determinants of health are being addressed at least partly. That's why we have social workers in our emergency departments, in our inpatient units, because we recognize that these are often, these social determinants of health often underpin or drive a lot of the mental health challenges that many of our patients struggle with, not just trans and gender diverse patients. So when I sort of try to talk about this with in sort of teaching or trans health education, my approach is to suggest that it's really just a shift, perhaps, the priority towards more addressing these social and structural determinants of health. These are things that we are already thinking about. In psychiatry we think about the bio psychosocial approach to addressing mental health. So, psychosocial is already, you know, a core part of our approach, and so it's just really shifting that priority even more so for trans and gender diverse people. So oftentimes, a lot of our trans patients, especially trans youth, struggle with homelessness, and that's often related to housing discrimination, landlords not wanting to rent to what they perceive as trans and gender diverse people and or there's a lot of family rejection, a lot of young trans people are kicked out of their families of origin, their homes of origin related to their gender identity. It's just a recognition that our trans patients experience disproportionately high rates of challenges related to social determinants, and so when they present to acute care, the emergency department, for example, it's important that we look at those social determinants as an important priority for addressing, because if we don't, then I think we are at risk of really not addressing their underlying challenges that underpin a lot of their mental health challenges.
Tori Anderson
To your question of, like, how does minority stress show up in healthcare systems? I think there's a variety of different ways. And as Junes research has shown, and some of these may even be, like, really subtle, it might not show up on, like, a survey, but I know, like trans people who, even for them, like calling a clinic is hard because, you know, their voice may indicate that some other gender features that they're not wanting to express, and so they might try to avoid interactions, or even just on a form, writing down their name. Do I write my legal name? Do I write the name that I use? I use some names in some contexts and some names in others? How do I know what's safe for me to write here? Especially when you haven't accessed the service to begin with? Now, all of these things are additional variables that a trans person is maybe like thinking through each time they access the healthcare system in of itself, and there's all these little kind of micro nicks or moments that add friction to somebody's experiences within the healthcare system. It can be really detrimental that other patients may not be thinking about, in general.
June Lam
And what Tori said made me think of more of our qualitative research, where we interview trans and gender diverse folks who've been hospitalized for their mental health, and they highlighted a lot of other specific examples of barriers and stigma within the mental health care system. So, when they're admitted to hospital, they talked about how, as I mentioned earlier, staff and other patients were not using their chosen name and/or pronouns. Their hospital patient wristband did not have their correct gender marker or their chosen name on it, their meal tray, when their hospital meal tray comes, did not have their correct chosen name. The electronic medical record did not have a way of identifying easily their chosen name and pronouns. And so, that led to hospital staff again not using the correct chosen name and pronouns. Some of them were on gender affirming medications such as hormone therapy, and some of the patients talked about how their gender affirming medications were not continued in the inpatient environment. They also talked about when they were assigned hospital rooms that they were based on their assigned sex at birth as opposed to their gender identity. And for some people that was really invalidating because their assigned sex at birth was prioritized over their gender identity. And again, for some people that recreated some of their traumatic experiences outside the hospital when people saw them for their sex assigned at birth as opposed to their gender identity. And so these were just some examples that they talked about. And the last thing I would mention is there was a lot of priority in the hospital of their biological family. Often we need information from, what we call collateral information, which is like information from people who know them outside of the hospital, to give us more information on how to provide the best care while they're in the hospital and how to plan for discharge and their treatment. And oftentimes, I work in the emergency department as well. Oftentimes we prioritize a person's biological family, and one of the participants in my qualitative research told me, oftentimes the only people I could talk to in the hospital were the people that were actively perpetuating harm outside of hospital. And so the fact that hospital policies really prioritized biological family instead of chosen family was another source of distress for a lot of the folks I talked to.
Misty Pratt
It sounds like it's amplifying all of that stress that they're already experiencing.
June Lam
Yeah, exactly.
Tori Anderson
Sure.
Misty Pratt
I'm curious if virtual care would potentially help to deal with certain barriers and certain challenges that trans folks face. Has there been any research on virtual care?
June Lam
Yes, maybe I'll start, and then I would love to hear what Tori has to add as well. I think there is some research. I think it's a really good thought in terms of virtual care. So I work at the CAMH gender identity clinic,
Misty Pratt
And I'll just interrupt to say, Center for Addiction and Mental Health, just in case anyone didn't know what CAMH is.
June Lam
Perfect. Thank you. So, the CAMH Gender Identity Clinic provides support for trans and gender diverse people across the entire province of Ontario, and so we see many folks from outside of the Greater Toronto Area or GTA, and so many folks we see virtually. And this has been really important in many folks being able to access care from especially geographic regions that have difficulty traveling to CAMH and so certainly, anecdotally we've from our clinic, we can see that virtual care has been a really important way of for trans folks to access care, especially because trans care is often so regionalized. And this is true not just in Canada, but in the United States and other parts of the world as well. And there has been some research that has shown that virtual care does help facilitate access to care.
Tori Anderson
I totally agree with what June's saying there, that it's an option, and it's important to, like, keep it as an option for people, especially as remote areas, particularly in my work with like, younger people, are even harder to access. And so helping kind of create pathways for people to be able to access care from a great distance away from the major centers is exceptionally important. And at the same time like I hear from young people saying that, you know, sometimes it might not be safe to talk about their identity or their experiences once they're virtually from home, for example. So these are just additional considerations that we should have just when we're offering these things. Is it's not necessarily the same confidential environment as our office.
Misty Pratt
That takes me to my next question, which you talked about some specific challenges youth face with virtual care. What about what children and youth face more generally when seeking gender affirming care?
Tori Anderson
Yeah oh gosh, if we had hours upon hours to talk about this. But, you know, I think we've touched on a few of them, but just to highlight in general, so working here in the province of Ontario, and the same patterns kind of exist in most regions in North America, there's many different barriers that, additionally, like young people, like adolescents or even younger people, have in terms of accessing many components around like gender affirming care, a lot of the issues stem from how centralized a lot of this care is, and so like here in Ontario, You know there may be a center in Ottawa and Toronto and Hamilton, but it can be hard to access in northern Ontario and other places as well. And because of that centralization, you know, wait times can be like, very extensive. It's harder to walk into, you know, a family doctor and ask for this kind of service without family doctors being worried and wanting to refer out because they feel like it's maybe not within their scope of practice, which we can talk about. But, I think there's a lot of different- a lack of providers in general. Additionally, like when we think about young people, there's financial considerations as well, and so some avenues within gender affirming care in general take money and time, and some adults may have the privilege to be able to access that. And even younger folks can have further barriers in terms of accessing like clinics that are tailored towards adolescent care from that.
Misty Pratt
Because maybe you're depending on a parent to be able to pay for something.
Tori Anderson
Exactly, exactly. And then that brings up all these other considerations of like working with families, and how tricky that can be, including families in these discussions. Sometimes families aren't quite at the same stage about thinking about transition and being ready for transition as a young person is so there's Canadian data from like the Trans Youth CAN studies and other centers here in Ontario showing trans people, young trans people, can often recognize that they have, like, a gender diverse identity even years before they even tell their parents or they're ready to go and live with that identity, and then again, it takes years, potentially, to access care beyond that. So for some parents, it might feel like all of a sudden things are changing, but really, young people have been thinking about this for a long time, which can sometimes lead to a bit of friction in terms of how they're able to access care as well.
Misty Pratt
And we actually had an episode, a few episodes ago, with Tara Kiran and patient partner, Sandy Epp. And Sandy shared about her child's journey and when he was seeking care. It's exactly as you said, Tori. They went into the primary care provider, they got referred, and were told you have a year's wait. And Sandy really emotionally communicated how hard it was to watch her child, just like losing her child a little bit every day. And so it got to the point where she was considering GoFundMe. She was she was considering anything she could possibly do. So is this really that that the key issue there is like, well, primary care is one, but then the wait lists are just so long? Or is it more that, like youth are being sort of pushed off to say you need to wait a certain period of time?
Tori Anderson
Yeah, you know, I do think that the way our healthcare system has approached gender affirming care has been kind of approached uniquely compared to, if I think about other like domains of healthcare and like the requirements and the challenges and hoops that people are asked to be put through. You know, if somebody is seeking support for their asthma or their diabetes, you know, I think a lot of care providers feel a lot more confident in either addressing that care or even learning about their gaps. But for some reason, gender care is a completely different box for some people. So certainly provider knowledge is one part, and then the additional hoops that people are going through. Gender care for young people can be different than it looks like for adults. And I think some of that is really important for us to hold that that can be developmentally appropriate, that young people are kind of exploring their identity. This is a stage where people are figuring out who they are and what they want in life. And so compared to if one meets a trans or gender diverse person at 30, you know, their needs in life or their readiness in life can be different than if somebody's 14, for example. And so a lot of the times, this care can be iterative. And as a provider myself, I often meet with kids on their own, and then parents on their own. And so there's multiple appointments that all take up clinical time that's important for us to do, to make sure that everybody's on the same page and that we're rolling in the direction that feels affirming and appropriate. And so it creates a bit of this challenge, of there's not enough providers doing this work, wait lists are long, and then, you know, appointment times, consult times, can take additional months to kind of put together. That eats up clinical time and also can extend until somebody's actually accessing, you know, medical treatments, for example.
Misty Pratt
So it sounds like a lot of different factors, not just one, one issue.
June Lam
I would just add to what Tori has said already, which is, I think that right now we can't ignore that there's a lot of politicization and debate and stigma around care for gender affirming care for young people. And I would just say that that actually doesn't help. Certainly not in terms of facilitating access to care, but it also makes providers fearful of learning how to provide this care in a safe and inclusive and affirming way. And so this leads to less providers being willing and able and wanting to provide this care, which makes access even worse. And I think the more we stigmatize and politicize this area, I think that ultimately it does a disservice to a lot of these young people who need support and deserve care, and it makes it harder for us to figure out what the best care looks like for these folks when we are in the environment that we are currently in.
Misty Pratt
Such a good point, and both of you are working in this environment, in this politicized world of- we live in. How are you both doing? How are you taking care of yourselves through all of this? Because I can imagine, has not been an easy number of years.
June Lam
It's a very kind question, and I think what I've been trying to do is to be very boundaried around my social media and my news consumption,
Misty Pratt
Don't we all need to be like that.
June Lam
I'm also..., right? I think that's true for everybody, and then also connecting to supports. I think Tori is one of my supports, and I hope I'm one of hers as well. I also have a group of other folks who I can text regularly to complain about the world, but also to reach out for support. I have different groups that I'm part of. I'm very fortunate that I'm part of other groups where I can always reach out and commiserate and celebrate when there are, you know, wins, you know, or things are moving forward in the right direction. And I think those two things for me are the most important ways of, sort of staying well and sort of challenging burnout, especially in this area of care. What about you Tori?
Tori Anderson
Well, you're correct that I do consider you a support, and I aspire to be as balanced as you are as well June. But agreed. I think the last few years have been tricky, and we know that hundreds of millions of dollars have been put in by particular bad faith actors to kind of taint the information pool and kind of intentionally target trans people, and I think it's an exceptionally hard time to be working with this community as people are navigating these repercussions. I do think that there are glimmers of times to see the community's resilience and to see moments of like trans joy throughout my practice and my life, to be able to hold why this care, why like what we're here to talk about today is so important, and to remind myself that our communities have been through a lot for centuries, and that one political time or period hasn't ever erased gender diversity in any way.
June Lam
As Tori was talking, it also made me think of another way that I sort of, I can I was just thinking, it's such a thoughtful question that Misty asked about like, how do you stay, like, afloat, you know, how do you, how do you maintain kind of your ability as care providers in this field to keep moving forward? And I think one thing that I have not mentioned. We have not mentioned is, for me, what keeps me grounded is actually working with trans patients at the Gender Identity Clinic, because I in the in the midst of all of this political nonsense that we have to deal with, I try to just focus on the person in front of me, and that really is a privilege, and also really is an honor, to be able to walk with trans folks who just want to live their lives, and I am able to support them in their gender journey and provide support around accessing transition related care. And I follow some of these folks over time, I see how having access to hormones, having access to top surgery, how that has made a tangible difference in their lives, how much, how much more settled in their body and in themselves they are. How much better their mental health is. Often, folks tell me, "Oh, I didn't realize that I was using substances to cope because I have been trying to numb I have had to numb myself because I didn't feel comfortable in my body." And after they access transgender related care, they no longer feel the need to use substances to cope. Or they feel really anxious, a lot of social anxiety. But some of that, or even a lot of that was because their gender expression didn't match who they were on the inside, and so they were always worried about being misgendered in public people using the wrong pronouns, calling them, you know, sir instead of ma'am. And those things really got a lot better when they were able to access medical transition. And then they come and they tell me about it, and they tell me how much better they feel in their body. And so, I'm lucky because I get to see folks on a daily basis and see how much medical transition and transition related care really helps people. And I hold on to that, and that's what drives me and gives me purpose, and gives me the ability to keep doing what I'm doing on a daily basis.
Misty Pratt
Yeah, that's really beautiful. And I feel like all of your patients, both of you, are probably very grateful for your support. So what are the practical challenges then, of trying to make care safer and more inclusive?
June Lam
I think there are so many barriers. I think the healthcare system is already stretched. In terms of resources, in terms of health care providers, staffing issues, especially, we are still in the post pandemic era, where we are already losing a lot of health care providers. People are feeling burnt out for reasons beyond what we're talking about today. And so, I think in this healthcare resource environment, folks, the system is already stretched, and so I think that's really important to recognize. And then in addition to that, specifically around trans care, I think there's a lot of health policy inertia. I think making change is really, really difficult, like even talking about making single stall bathrooms, making them gender neutral. That's even at the institutions that Tori and I have worked at. That in and of itself, is really difficult, because there's a lot of inertia. There's a lot of bureaucracy, changing the electronic medical record systems, the systems that we use, you know, to document and chart our patient care changing that is so difficult and takes a lot of discussion with IT people with multiple stakeholders. I think training our workforce, again, is difficult when our workforce is already stretched. I think the care providers are afraid of getting it wrong and making mistakes, especially in this field, especially in this politicized time that we are living through and working through. And you know, in our research, we found that there needs to be less silos across sectors, but especially in trans care, there's a lot of silos separating the medical system and the community supports and the community organizations in this area. And my research has found that if we can bridge that divide, that will really especially the divide between medical systems and trans community organizations that will potentially really improve care with and for trans folks, but there's a huge silo that separates those systems.
Tori Anderson
I think you've really touched on how widespread and how like there isn't necessarily a single intervention that we can do that will just fix this entire like situation and and often thinking systemically, it's just a reminder of like, how these healthcare systems weren't built with like, trans and gender adverse people like in mind from the very beginning. And even our concept of like, what is care like, as we were talking about earlier. You know, a lot of the care mentality of like it's you go in, you get your hormones, or you get your puberty blockers or whatever, and then that's it's and not necessarily thinking about an entire system of all these other non medical but important interventions that people might need along the way. In addition to how the system wasn't made for patients, it is also like a lack of representation within like leadership and like healthcare providers, in and of itself, from the trans and gender diverse community, to be able to lend our voices to, you know, the systems that we work in, and then, you know, maybe just to touch on, you know, we've talked a lot about, like, the systemic barriers, but I think there's also a lot of like individual barriers for people within their own individual practices. A lot of people are afraid of saying the wrong thing or making somebody uncomfortable, and that can actually go many different ways too. Like I've had times where I've felt uncomfortable, maybe sharing my pronouns in front of patients, because how might they react to me, or it's even the identity of bringing up gender identity to people can be- can bring up stuff that you might not know, what you might be walking into. And I think in connection to this political environment that we're in, it can be really hard navigating that line of being inclusive to, you know, the patients that we have, and also wanting to keep ourselves safe in the care that we provide. So I think there's lots of different domains that we've touched on, which is good news, because there's lots of potential areas for improvement.
Misty Pratt
Yeah, I hadn't even thought of the individual challenges of the fact that it could potentially be dangerous for somebody to disclose or you know that that may prevent somebody from even being able to speak about it. So that's super important.
Tori Anderson
Like, even, you know, to come back to, like, June's research, and, like, a lot of the work that's been done about patients experience in hospitals, in emergency departments, like, there can be a practical challenge if somebody's admitted to hospital where they may not even feel safe reporting their identity because of, like, the other patients that they're around, or even the clinicians that they're around, and then it's hard to be affirming if you don't know, you know, how to affirm someone. So like, there's even like, from the get go, really hard considerations that to be thinking about. Like, when people are stepping in into the room, oftentimes, for a lot of gender based people, they're already filtering themselves to be kind of more acceptable or more presentable to the healthcare system that maybe they even might in their typical life. And just I think our healthcare system would do a lot better of being accepting of wherever people are at when they come into our settings.
Misty Pratt
And going back to what June said before about the community based care, I feel like that freedom may be there more to be yourself within a supportive, safe community. So I just wonder, like, what are, what do some of these programs look like that people can can access after, potentially they were at the ED or hospitalized?
June Lam
Several folks talked about access to a type of therapy called dialectic behavior therapy, or DBT. Actually, four of the participants specifically talked about that therapy being really helpful. It's a way of balancing two things or two ideas that might seem dialectically opposed, but actually both things can be true at the same time, and particularly, DBT can be helpful for trans folks, because we talk about how for trans and gender diverse people living in this world, both things can be true at the same time that this world is transphobic, and it is not their fault at all that they live in a transphobic world, and at the same time, they have the capacity and the ability to make changes in this world that improve their life and their circumstances. And so even though it's not their fault that this world can be transphobic, is transphobic, they, at the same time, have the capacity and the skills to improve their own lives. And so that's kind of one example of how DBT can be particularly helpful for maybe trans and gender diverse folks. And then the last kind of pathway that trans and gender diverse patients talked about after they were discharged, connecting to is this community care. And so for some folks, they already had connection to community organizations in Toronto, this can look like Sherborne Health or Friends of Ruby or other community organizations, many of whom are specifically designed for queer and trans, often they're targeted towards queer and trans youth because that is a specific age group that where you know being queer and trans can be particularly difficult and requiring of more supports. And so these community organizations were described by the qualitative participants that I interviewed as being non medicalized and therefore de pathologizing, as opposed to the hospital system. Often they're pure led, meaning the providers there are explicitly identifying as queer and trans themselves, which often is not the case in the hospital system. It's not part of the culture. And so the community organizations, many of those leaders and providers do identify explicitly as queer and trans, and so that is identified as helpful. And then these organizations also address many of these social determinants of health issues that we've talked about that the biomedical or formal mental health system doesn't address, so things like housing stability, connection to like case managers who can help them navigate systems, accessing legal transition. So if folks want to change their legal name or gender marker, they have people in these community organizations that can help them access and address those needs. And so, if trans folks often have minority stress and the social determinants of health issues and the community organizations are better positioned to address these kinds of needs. Why is the formal mental health system the hospital based systems where we work? Why are we not making more explicit connections between our system and the community care system? That hopefully addressed what you were asking about Misty.
Misty Pratt
Yeah, absolutely. And that would be like a follow of a question of what, why are we not doing a better job of connecting these? You know, most people, it sounds like from the research, want care in their community from somebody that they trust, rather than a medicalized environment where they they don't feel overly safe. And so why are we not doing more? Is it just, is it just all the things we talked about so far?
June Lam
I think it's all the things we talked about so far that are that are barriers, but I think there are a lot of low hanging fruit, for lack of a better phrase, in terms of - there are things that can be addressed. And so I think part of it is addressing the acute care system, the hospital based system. There are things that we can change. And so there's this paper that you know, that is going to come out soon, that Tori and I are both part of that will be published in the journal Healthcare Quarterly, that will address ways that we can address, how we can change the acute care system to be more gender affirming. Then some of those things are things that can be done. So, instead of just including family of origin or biological family, can we change some of our policies so that we allow trans patients in the acute care setting to connect to their chosen family. And chosen family is, as the name implies, just family that the person chooses for themselves, and they can be non biological, right, making sure that if there is hormones or other types of gender affirming medications that a person is taking outside of the hospital, that we don't just stop those hormones when they're admitted to hospital for no reason, making sure we document a person's chosen name and pronouns, trying to integrate that throughout the electronic medical record system so that it's clear for the next provider- what is the person's chosen name and pronouns, trying to work with IT systems in your institution to integrate those markers in hospital, wristbands, meal trays, throughout the chart, etc, teaching your staff, you know, ways of providing trans care. So, there are many things we can do within the you know, health care, hospital based institutions that we work with. And then I think the last thing I'll just add is connecting to community organizations. I think the reason why we don't do that is really just cultural. It's really just because there's no history of doing that. It's because it's going to break this kind of like unspoken, you know, cultural divide that exists, but I think that we can do that. You know, there's certainly a lot of precedent to do that. So for example, in the Toronto setting, there's ICHA, you know, the Inner City Health Associates, where a lot of physicians, a lot of clinicians, are based in shelters. And I've worked in one of those shelters. And so, that's really a good model of care, where we can implant or transplant clinicians, providers more so within these trans care community based organizations, so that we make sure that we go to where the people are, instead of waiting for trans folks to come to us where, oftentimes they are presenting, oftentimes they're avoiding care, and then when they do present, they are presenting with more severe and acute symptoms. And so, if we are able to meet them where they're at, maybe they we can make sure that they get the care they need much earlier before they have a more severe and acute need.
Tori Anderson
I think that a lot of it, again, comes to this point that maybe the healthcare system wasn't ever really made, you know, with trans people in mind, or even just community care in mind. Like there's been writers for decades that have been kind of talking about how important being in community and being seen and heard for who you are is, like, exceptionally important to people's well being. And I think our approach in psychiatry and many other fields has kind of been the hospital is the place that you come to to get better. And I think we've really missed, you know, the global picture. I think it's really important for us now to be thinking kind of systemically of, yeah, how do we integrate and recognize that maybe the hospital isn't the place where people all need to come to become well, in and of itself, in this medicalized model. I think our mindset has been for a long time. The hospital is the place where we go. We're going to study cognitive behavioral therapy, dialectical behavioral therapy, gather all this evidence, and it's certainly important. I think we've maybe lost the narrative, community based lens, and just thinking about some of the practicalities of like, how can we actually help people access care? And so I think some people are interested in working with community partners, but I think there's a lot of work yet to be done.
Misty Pratt
If you could offer folks one takeaway message from our conversation today, and you can direct who you want to send this message, message to. What would it be?
Tori Anderson
You know, listening, you know, I imagine many people may be kind of aware that trans care is, like, under resourced, and that there is, like, a lot of systemic barriers to us being able to provide this type of care. And like, maybe the take home is that, you know, there's a lot of opportunity for people to consider building their practice, building their settings in more affirming way. It doesn't require them, you know, global expert or getting specialized care in this way like certainly it's important to be informed and have appropriate training. But I think everybody you know, if you're in clinical practice, can think about ways to adapt our clinics, our intake form, our electronic medical record, all to be kind of affirming. To have signs up, to have resources available for people from entrance into the clinic, to make sure that people feel welcome and know that this is an affirming space like I think all these things are small, kind of seemingly points to make, but can go a long distance in terms of helping people feel safe in accessing the care that you're looking to hopefully provide. If people are curious, like Trans Care BC is an organization that has provided a lot of training and a lot of information for clinicians, and they have specific resources out there in terms of how to reflect on your own practice, how to reflect on your organization and how like trans affirming you are now, how to like develop your skills. And so I think there's lots of opportunity beyond these larger scale discussions about like, how do we fund this care? How do we integrate with community services that even like any audience member can maybe take home from today to think about implementing into their own practice.
June Lam
So one takeaway or message from our conversation today that I hope folks would take from this episode is that gender affirming care is really just providing good care that you would for any patient or client you see, but for trans and gender diverse people, it just involves affirming the person in front of you and showing them that you see them for who they are. And there are a lot of barriers, including funding and other barriers that we've talked about today, but there are also a lot of things that you can do, in whatever capacity that you are in to make a difference for the trans or gender diverse person in front of you. We've mentioned a lot of them, but if you are a provider, introducing your own pronouns, I always say my name is June or Dr. Lam, I use he/him, pronouns, even if the person in front of you is not ready or able to share their own pronouns with you, just those little symbols of allyship or inclusion go a long way. I know that for many folks, if you wear like a pronoun pin, that can be a similar symbol of inclusion and safety, that makes a big difference. So there are a lot of things that you can do. And from a systems perspective, if there are any policymakers out there listening, I would say that I think ultimately, our research has shown that gender affirming care can also save the system money, in the sense that if folks are avoiding the system because it is not affirming at this moment, they will often come back with more acute and severe symptoms that will often be more difficult to treat and require more resources to treat. And so, preventive- access to preventive care is, as you know, really the solution, the long term solution for reducing the stress for trans and gender diverse people, but also reducing long term costs on the system as well. And so, I think gender affirming care is not just good for trans and gender diverse people, which is the number one goal, but I think ultimately it's better for the system as well.
Misty Pratt
Very well said. Thank you both so much for the care that you put into your research and also your clinical work, and it feels very essential to me and also this. You know, I'm just honored to have been able to have this conversation with both of you today.
Tori Anderson
Thanks for having us Misty. It's been great.
June Lam
Thank you.
Misty Pratt
Thanks for joining me for this episode of In Our VoICES. Check out the show notes for links to research and any other information that we've referenced in this episode. A reminder that the opinions expressed in this podcast are not necessarily those of ICES. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you've heard on In Our VoICES, please email us at communications@ices.on.ca and we will get back to you. All of us at ICES wish you strong data and good health.