The Barriers to Sex Reassignment Healthcare Faced by People in Ontario

This article originally appeared on VICE Canada.

How would you feel if, before getting treatment for a medical condition that was making every day of your life a living hell, you were told that not only did the health system have to check to see if you were sane enough for the treatment, but you would also have to wait three years before finding out?

That's not a hypothetical scenario: For many, it's the painful reality of trying to obtain gender reassignment therapy in Ontario, and there's one clinic at the center of it all.

The Centre for Addiction and Mental Health (CAMH) in Toronto is currently the only place in the province that has the power to green-light the funding needed for a person to get sex reassignment surgery. Opened in 1975, the clinic has two main divisions for gender identity: adult and childhood/adolescent, with the former being anyone 19 and older, and the latter being anyone under.

Both divisions are, according to CAMH, meant to provide "assessment" of the patient and offer treatment in varying degrees. For adults, it's pretty straightforward: On the date of the appointment, the patient will see a psychiatrist and/or psychologist, who will determine whether they are mentally ready for reassignment surgery. If that answer turns out to be a yes, they're good to go and OHIP will cover the costs of both post-op hormone replacement therapy (HRT) and the actual reassignment surgery. If that answer is no, they will either be rejected and have to come up with the surgery money themselves, or will be put back on the waitlist until they can be reassessed.

Unlike their ability to green-light surgeries, it's worth noting that CAMH is not the anointed or sole provider of primary HRT care, yet it is, in a sense, the only ticket to a complete transition. After receiving an appointment date at the clinic, those who are approved for surgery are sent to the office of Dr. Pierre Brassard, a Montreal-based plastic surgeon who, along with his colleague Dr. Maud Bélanger, are the only two doctors in Canada who perform OHIP-funded gender reassignment surgery.

You didn't read that wrong: The only doctors providing care on an Ontario health plan are not even located in Ontario. And that, unfortunately, is not the end of it.

Once a person undergoes surgery, they are allowed to stay in an aftercare facility for a few days before being sent home. For many, this is a trip coming home as a different person, one still trying to get a feel for what they have just experienced. Couple that with the distance traveled, which can be from one end of Ontario to the other, along with the multi-year journey of getting to this point, and you end up with a process that can be incredibly taxing.

In the case of Chrystopher Maillet, a former patient of the clinic who launched a Charter challenge in May against the province's policy on the process, it was a tangled and tormenting path.

Initially visiting the clinic in 2010, Maillet was deterred from jumping on the waitlist after an intake worker told him to "rethink" and "take some time" on his decision. By 2011, Maillet was sure of himself and was put on the list, eventually receiving an appointment date in late 2013. Due to the wait, however, Maillet had gone ahead nine months prior to his appointment and paid for his own double mastectomy, a procedure needed due to the side effect of painful breast development from his prescribed hormone regiment.

When he eventually told the doctors he saw at the appointment of his decision, Maillet said they both agreed it was a good idea. It was only after the appointment that Maillet learned that OHIP would not reimburse him for the treatment on the grounds that patients are obligated to obtain approval before, not after, their procedures. Thus, the debt began to climb and the battle began.

"It's put me in an incredibly tough situation financially," he said. "I never thought it'd turn out this way."

Since his original appointment in 2013, Maillet has had two appeals about the decision shot down: the first one before CAMH and the second one before an advisory board in Ottawa. Now around $10,000 in debt after taking the surgery out on a line of credit, Maillet says his concerns were not taken seriously, adding that at the second appeal, he was convinced that his argument had won until the decision came through and informed him that he would not be reimbursed. It's just one experience in a never-ending battle that's left a bitter taste in his mouth about the clinic.

"It's not healthcare," he said. "It's a bottleneck system to convince people to not have surgery. I spent more time answering questions and giving my life story to my plastic surgeon than I did to the people at CAMH."

Maillet's tale is just one in many horror stories from the clinic. In February, CAMH announced that they were conducting an internal review into the clinic's practices after accusations arose that the head honcho and chief psychologist, Dr. Kenneth Zucker, had been performing conversion therapy on patients of the pediatric wing, a claim supported by both witnesses and patients and Zucker's extensive history of research into the controversial treatment method.

NDP MPP Cheri DiNovo, who brought forth a bill aiming to ban conversion therapy in Canada to Queen's Park in March, says that the discovery of CAMH's activities were a surprise to her.

"I was as shocked as anyone that this was ongoing," she said. "It shouldn't be happening."

DiNovo's Bill 77, which passed second reading in May, has received unanimous backing from political parties in the province and has garnered vocal support from the Liberal government's Minister of Health and Long Term Care, Dr. Eric Hoskins. What's surprising, however, is that, DiNovo says the resistance to the proposed reformations is actually coming from doctors themselves.

"There's an incredible pushback from the medical community," she said. "It is kind of a protectionist community. Whenever they're challenged, their tendency is to fight back and it's a problem. It's a real problem."

CAMH's process of accepting and approving new patients has also come into question. Prior to the 1990s, the rejection rate for the clinic was 90 percent, and it wasn't until recently that the requirement for incoming patients to live in their chosen gender role for two years was dropped to just one.

The most troubling about CAMH's handling of their responsibility as Ontario's sole decision-maker for trans people is the fallout for those struggling to have their concerns taken seriously. A 2013 paper published by TransPULSE, a community-organized trans research group, revealed that at least 25 percent of all trans Ontarians treating with hormones had obtained them through nonmedical routes at one time or another. What's even more concerning and frightening, some five participants in the study of 433 admitted to conducting self-surgeries on themselves.

While the risks of self-operation are clear in and of themselves, the dangers of self-medication through hormone use are a little more pervasive. Purchasing synthetic hormones illegally can sometimes lead to the user finding themselves with botched drugs or inaccurate dosages, not to mention the side effects of using hormones, which require other pharmaceuticals to counteract.

For example, a female-to-male transition would require the administration of the male sex hormone, testosterone. But an increase in testosterone will simultaneously cause an increase in a process called aromatization, which is the body's mechanism of balancing out hormone levels by converting excess testosterone to estrogen, the female sex hormone. Without the use of an estrogen blocker or aromatase inhibitor such as anastrozole—a drug used in the treatment of breast cancer—the person may see abnormal, sometimes painful, breast development.

According to Jordan Zaitzow, Trans Health Connection Coordinator of Sherbourne Health Centre in Toronto, both the inability for trans people to access hormones safely and Ontario doctors' lack of training in hormone therapy have pushed a lot of those seeking to transition to obtain the drugs through other means.

"I think it's happening really often and, of course, as you would suspect, in Ontario, if you are in a super-remote area or in a small town where there aren't many options, getting trans care requires you to know the system really well and do a lot of self-advocacy," he said, noting the trickiness of getting prescribed treatment in Ontario. "There aren't enough places that are providing treatment. I know people who will travel all the way from North Bay to St. Catharines because that's the only place that's providing primary care."

In a 2013 open letter, CAMH clinic head Dr. Christopher McIntosh urged more family doctors to employ the use of hormone therapy on their patients before referring them to the Toronto clinic, noting that CAMH was "managing increasing demands with very limited staff resources."

McIntosh, who joined CAMH in 2009 before being promoted to clinic head in 2011, said that he believes that process of obtaining the OK to transition needs reworking.

"The whole process needs to change," McIntosh told VICE during a phone interview. "It used to be that [transitioning] was a highly unusual thing, that a very small number of people were going forward with, and nobody in any other part of the system had any idea what to do with individuals who wanted to change their gender… But I think things are changing."

McIntosh defended the clinic as not being solely responsible for the wait times, pointing out that CAMH is limited in the number of specialists it has on staff and can only process so many requests at once. He also added that the lack of access to surgeons is largely due to the complexity of reassignment surgery itself.

When asked about the accusations of childhood conversion therapy under the supervision of his colleague Zucker, however, McIntosh declined to comment.

Zaitzow, who also acts as a coordinator for Rainbow Health Ontario, an LGBTQ-focused medical advocacy and education organization that provides training and knowledge on trans issues to doctors, says that one of the biggest hurdles to overcome is teaching doctors to know how to safely treat patients willing to transition.

"A lot of doctors will say, 'This is outside of my scope of practice, so I can't do it,' and part of that is good—it's good to know what doctors are capable and not capable of doing—but a lot of the time we find that this is really just transphobia," he said. "The class of hormones that refer to transition are viewed as really complicated by default because [doctors] don't know about trans people. It's not in medical school, it's not in curriculum, so they're entering into the field without any knowledge."

The barriers on the path to transition in Ontario are many and for Maillet, as well as many like him in the trans community, the ability of the medical community to control the fate of trans people is one that is unacceptable.

"Healthcare professionals always worry about whether you're healthy enough to go through with this decision," he said. "No one's ever 'healthy' enough to go through with that kind of decision. Until you're on the other side, you're not going to know."

Follow Jake Kivanc on Twitter.