Barriers to care: Transgender and gender-diverse people's health care experiences

Transgender, nonbinary, and gender-diverse people face barriers to accessing surgery and to the health system in general, describe authors in two new research papers published in Canadian Medical Association Journal (CMAJ).

In many areas of life, people who identify as transgender, nonbinary, and gender diverse experience discrimination even where there are laws to protect transgender human rights. Health systems also pose barriers for transgender, nonbinary, and gender-diverse people, who are more likely to delay obtaining medical care because of fear of discrimination and other factors.

In two research articles, authors describe the experiences of transgender, nonbinary, and gender-diverse people in accessing gender-affirming surgery. A related humanities article argues that gender self-determination is a medical right.

As there are few Canadian studies on the surgical experiences of people who self-identify as members of these populations, the authors sought to understand the experience of transgender, nonbinary, and gender-diverse people when seeking gender-affirming care. Participants in the research studies reported barriers in accessing gender-affirming care, which also affected their general experiences with the health care system.

"The stress of negotiating presurgical bureaucracy often stood in sharp contrast to the positive feelings [participants] experienced when deciding to seek gender-affirming surgery," writes Dr. Hilary MacCormick, an anesthesiologist in the Department of Women's and Obstetric Anesthesia, IWK Health, and assistant professor at Dalhousie University, Halifax, Nova Scotia, with co-authors in one of the studies.

"Participants described the need to self-advocate when interacting with health care professionals who had a lack of experience with or negative attitude toward [transgender or nonbinary] people."

These barriers and marginalization can cause additional trauma in a situation where patients of any background might feel stress and anxiety because of surgery.

"Our data support the need for more in-depth and nuanced discussions surrounding shared decision-making, and consideration of potential effects of past traumas, instances of invalidation, or negative interactions within health care," the authors conclude.

The findings of the study on the lived experiences of people seeking publicly funded penile-inversion vaginoplasty were similar. "Health care systems need to improve access to gender-affirmation surgery, reduce wait times for care by increasing capacity for gender-affirmation surgery, and improve care experiences," writes Dr. Gianni Lorello, a scientist at the Women's College Research and Innovation Institute, anesthesiologist at University Health Network, and associate professor at the University of Toronto, Toronto, Ontario, with co-authors.

In a related humanities article, Florence Ashley, assistant professor, Faculty of Law and John Dossetor Health Ethics Centre at the University of Alberta, Edmonton, Alberta, argues that gender self-determination is a medical right and that health care providers are ethically bound to respect this and examine their gatekeeping practices.

"The burden of justifying barriers to care should fall on the health care providers who erect them and not on those seeking care to affirm their gender," Ashley argues. "Health care providers working with transgender communities should carefully examine their gatekeeping practices to ascertain whether they are justified by clear and compelling evidence and abandon those that cannot meet this justificatory threshold."

Dr. Kirsten Patrick, Editor-in-Chief of CMAJ, comments in an editorial that "receiving care that validates their chosen identity is associated with better physical and mental health for transgender and gender-diverse patients. Even if access to interventions is limited, compassionate and kind care need not be."