How I got started working with Saskatchewan’s trans and gender diverse community

I started working with trans and gender diverse (TGD) people by accident. This is in keeping with the spirit of versatility and community responsiveness of family medicine—and a haphazardness in line with my own privilege and prior ignorance of trans issues. I've been interested in equity in healthcare since I started volunteering at an after-hours inner-city clinic during university. New to Saskatoon from a small Saskatchewan “city” of 18,000, a white, middle-class cisgender woman descended from Ukrainian settlers, I first became truly aware that Canada’s universal healthcare system really doesn’t work universally at the Student Wellness Initiative Toward Community Health. There, as a volunteer and eventual board member, shift supervisor and even sometimes cook, I gained an understanding of my privilege and power to commandeer the system. Read: WATCH: Short film 'The Clinic' portrays how trans patients can experience healthcare differently Learning about social determinants of health, I realized our society has done much of medicine’s work for me: nutrition, antibiotics, sterilization, clean water—for most, anyway. Our healthcare system’s costs keep ballooning—we're living longer, with more interplaying chronic diseases. As an FP, I spend a lot of my time convincing people of similar demographics to mine that we can whittle down a long wishlist of investigations. I have long conversations discussing medications with minute benefits, like statins for primary prevention in a mid-50s cis, white man. But I’ve learned I can be most useful by working with those underserved by the healthcare system and society at large. This work expands the richness of my human experience by working with people whose experiences are outside my own, and moves incrementally towards a more just, inclusive society. It wasn’t until a patient presented for a medication refill of her estradiol and spironolactone to my second-year family medicine resident clinic that I became aware of TGD healthcare issues. She'd been on the hormones for several months after consultation with a local psychiatrist who saw many trans and gender diverse people. She's close to my younger brother's age, so I think my big-sister instincts activated. It was a privilege to walk with her through her transformative time as a cheerleader and confidante. She stuck with me when I became an attending physician, and I'm honoured to say, she's still my patient. The local psychiatrist had recommended starting hormone therapy, and directed my now-colleague at the academic clinic to some guidelines on this process. We acted as her endocrinologists, as there's a one-plus-year wait to see an endocrinologist for any issue in notoriously understaffed Saskatchewan. I now know that gender-affirming hormone therapy can and should be prescribed by primary care providers, generally without a psychiatrist assessment, as TGD people, like all people, can provide informed consent. Read: The 'fragile joy' of being Elliot Page My patient kept asking me, her almost-fully-minted doctor, how long she'd have to wait for vaginoplasty. I didn’t know. I didn’t know how the surgical referral process worked. I remember my frustrated dismay after digging through webpages and calling clinics to find out she had to wait another year to see a psychiatrist specializing in gender in Edmonton. Just a few years ago, Saskatchewan’s wait time to see a psychiatrist for the Ministry of Health-required evaluation prior to out-of-province gender-affirming surgery was over two years. I regret to say that like many TGD people, my patient had to educate me on transness and wait patiently while I, who was supposed to be the knowledgeable one, said ignorant things. I had to look at the B.C. guidelines for how to adjust her hormones, as this wasn’t something I'd learned about in medical school or residency. This is a common issue, as 2SLGBTQ+ issues are underrepresented across medical school curricula and for this and other reasons, many healthcare providers don’t feel comfortable providing healthcare to trans and gender diverse people. So got down to reading more, attending conferences and speaking with local colleagues, and I learned that prescribing gender-affirming hormone therapy is a lifesaving, evidence-based, harm-reducing, safe intervention, endorsed by medical bodies including the Canadian Pediatric Society and the Endocrine Society. Not only is transition-related care like hormone therapy and surgical referrals lacking, trans people still struggle on a daily basis with misgendering and discrimination in healthcare. Other health issues are erroneously attributed to transition, a phenomenon called “trans broken arm syndrome.” These errors of the healthcare system are dangerous: they lead to misdiagnosis and TGD people feeling so unsafe that they avoid healthcare entirely. Indeed, 12% of respondents to the Trans PULSE national survey in 2019 said they avoided an emergency room when they felt they needed one due to being TGD. I hope we will continue to learn and walk forward together. Usually able to maintain the poker face I’ve been taught is professional, I teared up as I walked her out of the clinic from her last visit before her vaginoplasty in Montreal. She left nonchalantly, more than ready. The surgery went well, and we now spend more time discussing her university career and ingrown toenail than her hormone therapy renewals. Eventually, she brought a friend to me as another patient. This has blossomed into a practice of over 200 trans and gender diverse people who've graciously included me on their journey. Now I, along with a trusted colleague, run a consultation service for hormone therapy and surgical referrals out of the academic clinic where I met my first trans patient. It's so rewarding to hear life stories, sometimes of journeys across oceans in search of a more inclusive place. I've watched a patient take off his bandages in my exam room after gender-affirming chest surgery—a surgery for which I referred him and helped him prepare—and see himself in the mirror for the first time. I see the deep interconnectedness of the trans community, with peer education and support: most patients come to me already well familiar with the risks and benefits of hormone therapy. I see the power in the TGD community, who've mobilized in Saskatchewan, including to expand surgical referrers, taking us one step closer to the World Professional Association of Transgender Health guidelines. Dr. Megan Clark is an assistant professor in the Department of Family Medicine at the University of Saskatchewan.

How I got started working with Saskatchewan’s trans and gender diverse community

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