‘Winging it’: Trans health-care coverage spotty, hard to navigate across Canada 

Donna Battaglia knew she was born in the wrong body from a very young age, but it wasn’t until she got older that she learned the words to explain what she knew was true.

“The anxiety of having to take a shower — having to know that I had the wrong parts for all this time and never being able to do anything about it.”

Years later, she was able to describe what she needed and started her social and legal transition.

FULL COVERAGE: Inside Pride

But the years of living with the incongruence with her physical body took a huge toll.

“It got to the point where I was basically drinking myself to death, trying to get away from who I’d been.”

She was eventually able to connect with health-care providers who helped get the “process rolling.” She started on hormone blockers, was prescribed hormone therapy and started researching surgical procedures. But navigating the health system has been a challenge.

“I’ve had some doctors flat-out refuse to deal with me as a woman,” says Battaglia, who is now 66, and lives in Calgary. “It’s not been overly drastic. I’ve probably had 98 per cent that have been amazing.”

Still, she says there are just not enough practitioners to meet the needs of the trans, intersex and gender diverse community.

“I’m involved in a couple of groups and I hear the stories. People are always asking: ‘Please give us some recommendations, tell us where we can go. This person was like this when we went to them and they didn’t really want to see us, didn’t want to talk to us, things they didn’t want to get involved in.’”

‘Gender specialists do not have to be psychiatrists’

Experts want to see more providers — nurse practitioners, general physicians, social workers — trained and authorized to provide gender-affirming care. This would reduce wait times, expand access and eliminate barriers.

“We currently have a system here that requires you get a letter from a psychiatrist, a letter from a psychologist, before you can get on surgical assessment waitlist, let alone get on the surgical waitlist for any gender-affirming care,” says Riley Nielson-Baker, organizer of Gender-Affirming Care Nova Scotia.

“That is reminiscent of a time when trans people were treated as mentally ill.”

Nielson-Baker knows people who’ve had to wait 11 years for chest surgery — due to the requirements in the province. Waitlists for psychiatrists in Nova Scotia are more than 14 months, they say.

“There is no need for me to get mental wellness and stability checks for surgeries. If someone needed their appendix removed and needed to go get their mental health checked once, let alone twice, there’d be outrage.”

Dr. Michael Marshall is a psychiatrist based in Edmonton, with a specialism in transgender wellness.

He says while most provinces and territories require a psychiatrist to “confirm trans-ness,” that’s not actually a requirement in the World Professional Association for Transgender Health (WPATH) standards of care.

“Gender specialists are any person who’s undertaken training. So the requirement for psychiatrists is an extra hurdle that has been placed that is unnecessary.”

He points out that gender diversity was removed from the International Classification of Diseases (ICD) as a psychiatric diagnosis.

“It’s no longer a psychiatric disorder. The pathologizing of trans-ness has been quashed by ICD and so really, governments should listen. Systems should change to reflect that.”

Trans care should be approached as whole-person wellness, he stresses. And others agree.

“Part of the problem with conversations about trans health care is we only talk about transition. We need to be talking about the holistic, general health care,” Nielson-Baker says. “Transitionary care is only half the story.

“We can transition all we want, but if there is no health-care service that can properly serve us and our general health-care needs, then the health-care system is still failing.”

They say trans folks who live in rural Nova Scotia often have to drive over two hours to access respectful, inclusive health care.

Nielson-Baker raves about their primary physician, but said her wait list is years long.

“It meant the world to me to have someone who not only took the time to care about who I am and how I identify, but who does that for everyone.

“I walk into (my doctor’s) office and she has on her wall a poster that says: ‘Guys get paps too,’ which is incredibly affirming for people who don’t identify as female who still need to get sexual health care.”

Yukon is ‘gold standard’ for gender-affirming care

Since health is under provincial jurisdiction, the types of procedures, treatments and medications that are covered vary. The requirements for getting these interventions also vary depending on where you live, as do wait times for psychiatrists and other health-care providers.

“The only province or territory that is close to doing anything right in Canada is the Yukon,” Nielson-Baker says. “They deserve so much credit for the work they’ve done… They are the leaders in the country right now.”

Marshall, who is also an educator with WPATH, helped write Yukon’s latest policy.

At the request of the territory, he and his team also provided free, inclusive health training for any Yukon practitioner who wanted it.

“In North America, there are about two to three hours of teaching on the entire 2SLGBTQ+ health throughout medical school. And if you think of all the different presentations within that community, two to three hours doesn’t come close to training upcoming health-care providers.

“What Yukon did was recognize that and offer free training, after the fact, to all their providers.”

Yukon also removed a lot of the barriers trans and gender diverse folks trying to access care.

“The individuals who get in front of a provider have travelled miles — literally — to be there. What Yukon wanted was that not to be the case, that individuals could go to any practitioner and get that care.”

The territory also expanded coverage for procedures the trans community, advocates and health providers said were important, including electrolysis, facial feminization surgery, body contouring, tracheal shave and voice work.

“Individuals that we care for have made it clear that these interventions are necessary, life-saving health care, and Yukon believed them,” Marshall said.

Access to gender-affirming surgeries

A private clinic in Montreal has, for years, been the only facility performing certain gender-affirming genital surgeries. In the last few years, Ontario and B.C. started offering them at public hospitals — at the Women’s College Hospital in Toronto and through the Gender Surgery Program B.C.

B.C. started offering procedures to B.C. and Yukon residents in 2019 and it’s been an enormously positive shift for patients, their loved ones and providers, says Marria Townsend, medical director for TransCare BC.

“Think about somebody living in Terrace, B.C., who has a vaginoplasty in Montreal and a week later, they’re getting on a plane, flying across Canada, flying to Vancouver, then having to switch planes and fly again to their home community. I cannot personally imagine having to do that a week after surgery.”

Townsend says being able to have surgery locally means improved pre- and post-care, consultations and a closer support network.

“We know that access to care makes a difference. It improves people’s health, their mental health, their quality of life, their wellbeing, there’s plenty of evidence to show that.

“We need to work on building up our health services to meet the needs of the population and reduce the waits for care and ensure people are able to get care as close to home as possible and in the public system.”

It’s taken time for Battaglia to decide what procedures are necessary — and feasible — for her. She submitted an application to the Clinic de Chirurgie in Montreal. But after a long wait, decided to investigate other solutions closer to home.

Due to other health issues, she was working with a Calgary surgeon to have her bladder removed.

“The surgeon that was doing that is very familiar with the whole process, has done work for people coming back from Montreal. I sort of just mentioned it at an appointment. I had no idea or plan where I wanted to go with it — just get rid of the stuff that I don’t want. That’s as far as I want to go with it. He said: ‘It’s easy to do. It’s 20 minutes’ extra work.’

“I got my bladder removed and I got my ‘bottom surgery’ at the same time.”

Battaglia admits she “was winging it” and wishes the process was more streamlined, had fewer hoops to jump through and was available in every province and territory.

“It makes so much more sense to do it locally, where we have these great hospitals here, with lots of staff that are completely understanding and knowledgeable and know what they’re doing. I don’t know why they don’t get utilized.”

Expanding coverage

WPATH recommends mental health service visits (for assessments, diagnosis, referrals and treatments), laser hair removal or hair grafts, facial reconstruction/contouring, voice therapy and voice modification surgery be covered treatments, in addition to hormone therapy, chest and genital surgery — all of which are recognized by the organization as “medically necessary.”

“For some people, having genital surgery isn’t the most important thing. The most important thing is being able to go about your day and be seen for who you are and be safe,” Townsend said.

“Things like facial feminization, tracheal shave, voice therapy, all those things are really, really important,” she stressed. “It affects their daily life — whether they have employment, whether they get harassed, whether they get attacked. It’s actually huge.

“As a society, we should care about that.”

Marshall hopes other governments will follow Yukon’s lead.

“The Yukon policy was a first of its kind in North America and it cannot be that the other provinces and territories sit by and not act.”

Battaglia says voice surgery would be a game-changer for her. She’s on the phone all day with work and is constantly misgendered. But, vocal surgery isn’t covered by Alberta Health and wait times for voice therapy are long.

“I can’t afford surgery for my voice. It’s just not even feasible,” Battaglia says.

“Unless you get into a company that’s got a health-care plan that does have coverage for it or you have a lot of spare money laying around — it’s just cost prohibitive.”

Advocates are also pushing for more inclusive, integrated education for future and current health practitioners.

“It needs to be incorporated into the Health Sciences education — every medical student, every nursing student, every person studying physiotherapy — everybody needs to have exposure to the kind of education that’s going to support them to serve this population,” Townsend says.

For Battaglia, transitioning — social, legal, medical — has been a rollercoaster. She’s waited years on lists and submitted and resubmitted documents. She’s endured medical practitioners misgendering her, not understanding her, and worked alongside health professionals to customize a surgical plan unique to her. She’s waited for referrals and approvals and treatment.

Now, approaching her seventh decade, she’s eager not to wait any more.

“I feel completely natural and complete.

“I didn’t realize how much I struggled with my old body in my mind until the things that were bothering me were gone. It was like day and night, a switch being turned.

“I don’t feel anything but all me,” she says. “Now, it’s how it should have been from the start.”

In the month of June, Global News is exploring deeper issues related to the 2SLGBTQQIA+ community in our series, Inside Pride, which looks at the importance of the acronym and the labels it represents.

If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911 for immediate help.

For a directory of support services in your area, visit the Canadian Association for Suicide Prevention.

Learn more about how to help someone in crisis on the Government of Canada website.