Health Committee on Feb. 28th, 2019

[The Chair, Liberal, Bill Casey]

We'll call our meeting to order. I welcome everybody to meeting 137 of the Standing Committee on Health.

I want to report to the members that we tabled our rare disease report today, and I know that a lot of people have already asked for it, so they're looking for our wise words. I want to congratulate the analysts and clerk for helping us put together a really good report.

Also, our travel to the west was approved today at liaison committee, but it still has to go through the House. We should be able to go ahead on that.

I want to welcome our guests today. This is our very first meeting on our LGBTQ2 health study. We're looking forward to it. I want you to know that it perhaps will be the most extensive study we've done. We plan on having a lot of meetings and hearing from a lot of witnesses. It's not the most expensive. The pharmacare study would be the most expensive. It was two years long.

We're all interested to hear your testimony and to hear where this going to go.

Today we have with us, on behalf of Rainbow Health Ontario, Devon MacFarlane, director; from the University of Toronto, Dr. Lori Ross, associate professor, Dalla Lana School of Public Health; from Egale Canada Human Rights Trust, Richard Matern, director of research and policy; and from Toronto Pflag, Giselle Bloch.

Welcome.

Each of you has 10 minutes for an opening statement. I'll signal to you if you hit 10 minutes, but try to keep it within 10 minutes if you can, because I know everybody is anxious to ask questions.

We're going to start with Mr. MacFarlane.

[Devon MacFarlane, Director, Rainbow Health Ontario]

Thank you, Mr. Chair, and members of the standing committee, for having us come to speak today.

My name is Devon MacFarlane and I work as the director for Rainbow Health Ontario, which is a program of Sherbourne Health. Rainbow Health Ontario creates opportunities for the health care system to better serve LGBT2SQ people and communities. We do this through supporting clinical practice and organizational change, public policy work, catalyzing research and knowledge translation. Rainbow Health Ontario is unique in Canada.

We at Sherbourne are very excited that you've undertaken this study of LGBT2SQ health in Canada, and I am so pleased to be here at your opening meeting.

Today, I'll provide a broad overview of LGBT2SQ health and set the stage for my fellow speakers. I'll touch on the size and diversity of LGBT2SQ communities, health disparities facing our communities, causes and contributing factors, impacts on individuals and society, and actions that could contribute to positive change. We will submit an evidence-based brief that expands on these remarks. For brevity, I'll be using LGBT as an acronym.

Let me begin by painting that broad picture. The image that often comes to mind when we think about LGBT communities is of young, white, fit gay men at pride events. However, our communities are very diverse. People live in big cities, small towns, on and off reserves and up north. Our communities include small children through to people in their nineties and beyond. We're from all cultures, ethnicities, races and faiths. Our communities include francophones, people with a broad range of mother tongues, and newcomers, including refugees. Our communities also include people who are homeless, poor, middle income, and high income.

Rainbow Health Ontario uses an estimate that about 7.3% of the population identifies as lesbian, gay or bi and 0.6% identifies as trans. In Canada, that translates to about 2.9 million people. There are yet more people who may not have that identity but engage in same-sex behaviours.

The best available health data points to clear disparities for LGBT people, some of which are not obvious. We see higher rates of cancer and problematic substance use, and among lesbians and bi women, higher rates of chronic diseases, such as cardiovascular diseases, asthma and arthritis. There also seems to be an earlier onset of some chronic conditions. Not surprisingly, given the increased prevalence, we also see precursors, such as higher rates of cancer-related risk behaviours. There are also higher rates of dental problems, and of pregnancy involvement among LGBT youth. Then, of course, there are STIs, HIV and mental health and suicide, which are what most people tend to think about around health in our communities.

In short, in any area of health and health care, including palliative care, pharmacare and the opioid crisis, there are likely issues for our communities. However, nothing inherent to our identities causes these disparities. To consider possible policy interventions, we first need to look at contributing factors.

LGBT people experience familial and societal rejection, higher rates of childhood sexual and physical abuse, violence, stigma, prejudice and discrimination. Many members of our communities also experience other forms of discrimination, such as racism, which add to their stress. If you've been openly discriminated against by your family and others, attacked for who you are or experienced discrimination in employment, it's no wonder that you might be dealing with depression, anxiety, PTSD and suicidality. Many cope through substance use, including smoking, as self-medication.

Of course, we have lots of areas where there's also resiliency, but in this case, we need to be looking at disparities. Trans youth in Canada, for instance, who don't have family support, and have experienced other forms of discrimination, have a 72% chance of making a suicide attempt in a 12-month period. Youth with strong family support, however, and who experience no other forms of discrimination, have just a 7% chance. Across the lifespan, 45% of transpeople, almost half, have made at least one suicide attempt.

Experiences in accessing health and social care and barriers to clinically and culturally competent care contribute to health disparities. Canada's health care workforce is vast. Most providers have not had any content on LGBT health while in schools. While most providers are well intended, they don't know clinically what to do and what not to do. This results in many people not being out to their health care providers or avoiding care altogether due to previous experiences and fears of discrimination.

In particular, lesbians, bi and transpeople have been found to have a range of unmet health needs. Transpeople have specific concerns, due in part to wait-lists, due to not all required interventions being funded and due to an extremely limited number of providers and agencies that have the knowledge, skills and desire to serve them.

There are also exponential increases in the number of transpeople seeking care. For pubertal trans kids, access to puberty-blocking medications is particularly time sensitive, yet the clinics who serve them are struggling to keep up with the demand and often can't see them for many months while changes are happening in these young people's bodies.

LGBT seniors face specific needs and issues, including in end-of-life care. They are more likely to be aging alone and are less likely to have family or friends who can provide care they may need, and they may struggle to identify a substitute decision-maker. Mistrust in the health care system is significant. LGBT seniors grew up in an era when being gay was a criminal offence, as well as being considered a mental illness. Some were institutionalized and subjected to electroshock therapy.

Although many younger seniors have been out their entire lives, they are afraid that they'll have to go back in the closet to access care. A study found that one-third of LGBT home care users were afraid that their home care providers wouldn't touch them if their sexual orientation or gender identity were known.

Health disparities and impacts of discrimination lead to worse outcomes at the level of the individual as well as Canadian society. This includes outcomes in terms of life expectancy, disability-adjusted life years, or DALYs, loss of economic contributions and avoidable health care costs.

For instance, a U.S. study found a difference of 12 years of life expectancy for LGB people living in welcoming and affirming regions versus hostile regions of the country. Both human and economic costs are huge. When we look at disability-adjusted life years for LGBT Ontarians, over a thousand extra years are lost every year just due to mental health and three specific forms of cancer. In Ontario alone, this translates to an annual loss of GDP of between $11 million and $33 million.

While the health disparities and barriers to competent care are significant, action can be taken to create positive change, both directly to health care and also in relation to determinants of health. For determinants of health, action could include—and we would recommend that action be taken on—increasing support for families to enable them to better support their LGBT loved ones; addressing hate crimes, violence and discrimination that target LGBT populations; and addressing LGBT issues in housing, homelessness and poverty reduction.

Specifically in health care, action could be taken in any federally led health programs, services and initiatives, ensuring that LGBT issues are addressed; making provision for LGBT health in transfer funding and agreements and encouraging provinces and territories to meaningfully address LGBT health; generating commitments and mobilizing health care organizations to address LGBT health care disparities and barriers to care, and ensuring equitable access to care that is both clinically and culturally competent; skills development for health care providers, recognizing that we have a very large health care workforce, most of whom could be more effective given the opportunity; funding for LGBT-specific chronic disease prevention initiatives, including robust evaluation and knowledge translation; and, ensuring that transpeople across the country can get access to needed transition-related care in a timely way.

ln research and monitoring, we would recommend building on the new StatsCan unit and Canadian Institute for Health lnformation's work on equity measures, ensuring robust data collection and reporting, including for health care administrative data; monitoring progress on LGBT health, and health outcomes, including disability-adjusted life years and potential years of life lost and the associated economics costs; significantly increasing funding for LGBT health research, with a focus on population health, improving clinical care, improving health systems, and the impact of interventions. Within this, there need to be significant focuses on lesbian, bi, trans, and two spirit people, and especially on parts of our population who are racialized, newcomers, francophones, and people living outside of major urban centres or who are experiencing poverty.

ln closing, we at Sherbourne are pleased that you are embarking on this study. It is fantastic. The study and any actions taken could have far-reaching impacts. Addressing health disparities for LGBT people is one of the next major frontiers in our work to build an equal and just society where all can healthily participate and contribute.

By building on our human rights successes, Canada could be poised to be a world leader on LGBT health.

Thank you for your attention and for your work on this front.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we'll go to Dr. Ross.

[Dr. Lori E. Ross, Associate Professor, Dalla Lana School of Public Health, University of Toronto]

Mr. Chair and members of the standing committee, I am delighted to have this opportunity to speak to you in this first meeting of your historic study on LGBTQ2 health.

My name is Lori Ross, and I'm an associate professor in the Dalla Lana School of Public Health at the University of Toronto. I've been conducting research on LGBTQ2 health in Canada for the last 15 years, and in the time I have with you today, I'd like to draw your attention to two key issues for consideration in this study.

The first is that there is vast diversity, and in turn there are particular vulnerabilities within subgroups of the larger LGBTQ2 community, which we must attend to in order to meaningfully impact the community's health. The second issue is that enhancements to our current data collection mechanisms are required in order to more fully characterize and ultimately monitor improvements in LGBTQ2 health in Canada.

In making my first point, I'll particularly be drawing your attention to what we know about mental health outcomes within the LGBTQ2 community, given that this is an area where we see especially marked disparities, but please note that the within community vulnerabilities I am describing also pertain to many of the other health outcomes that Devon has drawn your attention to in his presentation.

Our first opportunity to examine LGBTQ2 mental health in Canada using population-based data started in 2003 when a question about sexual identity was first added to the Canadian community health survey, or CCHS. Analysis of these early data revealed that those who identified as lesbian, gay or bisexual were significantly more likely than heterosexuals to report a lifetime mood or anxiety disorder as well as lifetime suicidal ideation.

Subsequent analyses of more recent cycles of the CCHS continue to replicate these findings, showing no substantial decrease in the magnitude of the disparities, which are striking. In the 2003 data, lesbians and gay men were approximately three and a half to four times more likely than heterosexuals to report lifetime suicidal ideation, while bisexual women and men were approximately six times more likely.

This brings me to the first subgroup within the LGBTQ2S community that I would like to draw your attention to: bisexual people. Many are surprised to learn that bisexual people make up the largest sexual minority group, outnumbering gay men and lesbians. Often people are also surprised to learn that bisexual people report the poorest health outcomes of any sexual orientation group. That is, across a wide range of health outcomes, bisexual people fare more poorly than not only heterosexual people but also lesbian and gay people. Research suggests that these poor outcomes are likely attributable to the specific forms of discrimination faced by bisexual people as well as the pervasive invisibility of bisexuality, which in turn leads to a lack of social support. My team's work suggests that bisexual youth may be particularly at risk for poor mental health outcomes, with a recent survey of more than 400 bisexual people in Ontario finding that nearly 30% of bisexual youth reported past year suicidal ideation.

You may have noted that I have so far spoken only to sexual orientation. This is because until very recently—so recently, in fact, that the data are not yet available—we have not had access to any population-based data regarding the health of transgender people in Canada given the lack of a question on gender identity in our population-based surveys.

To understand the health of transpeople in Canada, we need to turn instead to the rigorous community-based research that's been conducted on this topic, particularly the Trans PULSE study, which was conducted in Ontario between 2009 and 2010 and currently is in development for a nationwide version to be launched in the coming months. Trans PULSE data estimated the prevalence of depression among transpeople in Ontario to be more than 60%. Thirty-six per cent of transpeople reported suicidal thoughts in the past year, and 10% reported a past year suicide attempt. Consistent with what Devon has told you about the impact of discrimination, those people reporting high levels of transphobia and low levels of social support were most at risk for these outcomes. These findings are echoed in a recent survey of more than 900 Canadian transgender youth, in which a shocking 65% reported past year suicidality.

The good news is that we have opportunities to change these statistics. Analysis of Trans PULSE data suggests that, by increasing levels of parental support and reducing levels of societal transphobia, it would be possible to dramatically decrease rates of suicidal ideation and attempt. Given this, attention not only to transpeople's health outcomes and health care experiences, which indeed is sorely needed, but also to the social conditions that produce these health outcomes, is critical.

I would next like to turn your attention to mental health among two-spirit and other indigenous LGBTQ2 people in Canada. Unfortunately, this is another area where data are lacking, again due to gaps in our collection of data related to sexual orientation and gender identity in surveys of indigenous health. Here, too, what we know comes largely from community-based research conducted in partnership with two-spirit people to assess health concerns and outcomes. This reveals high rates of depression, anxiety, drug use and suicidality. Qualitative research has highlighted the historical and ongoing impacts of colonization on two-spirit health, noting the critically important roles of intergenerational trauma and loss of language and culture. As for other indigenous people, interventions to redress these and other impacts of colonization must be at the forefront in order to meaningfully address two-spirit health in Canada.

In a similar vein, we so far know very little about the health of LGBTQ2 people who are members of other racialized groups in Canada, given that the sample sizes of population-based surveys have been too small to permit these types of intersectional analyses. Data are also lacking regarding the health of LGBTQ2 francophones and linguistic minorities, but through the lens of the minority stress framework, we would anticipate that discrimination and associated barriers to accessing health care may produce important disparities for these communities as well.

Finally, before turning to a brief discussion of data gaps and possibilities, I would like to highlight the importance of considering socio-economic issues as they impact the health of LGBTQ2 people. The available Canadian data indicate that there are important income disparities associated with sexual orientation and gender identity and that these disparities contribute to the health problems that we observe in our communities.

For example, in our research with bisexual people in Ontario, we found that over 25% in our sample were living below the low-income cut-off, and those living below the cut-off reported significantly higher levels of depression and post-traumatic stress disorder than those living above it. Given the elevated rates of homelessness and evidence of employment discrimination associated with sexual orientation and gender identity in Canada, policy interventions to address these and other social determinants of health for LGBTQ2 people will be an important mechanism for addressing the health disparities we are discussing today.

I would like to close with a brief discussion of the limitations and possibilities regarding data about sexual orientation and gender identity in Canada.

For many years, researchers and community advocates have been struggling with the lack of adequate data necessary to properly characterize health disparities for the LGBTQ2 community. Although the sexual identity question on the CCHS has been essential, the lack of data on gender identity as well as other important dimensions of sexual orientation such as sexual behaviour and sexual attraction has greatly hindered our work. The fact that the sexual identity question has been asked only of respondents aged 18 to 59 also limits our knowledge of youth and older adults, both groups with particular vulnerabilities.

As a result of these limitations, we have largely needed to turn to U.S. population-based datasets or seek funding to develop community-based research projects to address the necessary data gaps.

Statistics Canada's newly established Centre for Gender, Diversity and Inclusion Statistics offers the opportunity for Canada to become an international leader in this area through enhancements and additions to the questions currently asked on StatsCan surveys; the addition of relevant questions to surveys where they are not currently included, such as in the Canadian income survey; support to other levels of government in collecting appropriate sexual orientation and gender identity data; and development of innovations to ensure that the resulting data sets are sufficient to allow for robust analysis of important subgroups within the LGBTQ2 community.

This current study on LGBTQ2 health perhaps offers a natural opportunity to bring together the expertise of the new centre with Canada's ample academic and community expertise in LGBTQ2 health to maximize our opportunities for excellence in this domain.

At the same time, it's important to foster funding mechanisms to support community-driven research in LGBTQ2 health, which will inevitably continue to be essential in identifying emerging areas of concern. Historically, much of the research conducted in the area of LGBTQ2 health has been funded through HIV-related mechanisms. While HIV is certainly a health issue of concern to the LGBTQ2 community, as you are hearing today, our health needs extend well beyond this, and the HIV focus has been limiting.

Further, at present there is no explicit home for LGBTQ2 health research within the Canadian Institutes of Health Research; that is, there is no institute that explicitly includes LGBTQ2 health within its mandate. While the Institute of Gender and Health does include the health of gender-diverse people in its mandate and has funded important research on LGBTQ2 health, not having sexual orientation named in the institute's mandate means that we rely on supportive review committees to consider this type of work is within the institute's purview. Recognizing sexual orientation and gender identity within the mandate of the Institute of Gender and Health or within a variety of relevant institutes, together with priority funding announcements to address specific knowledge gaps, would serve to build a robust evidence base upon which to ground policy and practice interventions to address health disparities for LGBTQ2 Canadians.

In summary, despite major human rights advances and associated improvements in social conditions for many LGBTQ2 Canadians, significant health disparities persist. However, this first federal study on LGBTQ2 health and the new Statistics Canada Centre for Gender, Diversity and Inclusion Statistics make this a historic moment for understanding and ultimately addressing LGBTQ2 health in Canada. I greatly appreciate the opportunity to be a part of the conversation.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you for your contribution.

Now we'll go to Mr. Matern from Egale.

[Richard Matern, Director of Research and Policy, Egale Canada Human Rights Trust]

Dear Chair and members of the Standing Committee, Egale is very pleased that you have undertaken this study on LGBTQI2S health in Canada. Thank you for giving us the opportunity to be here at your opening meeting.

My name is Richard Matern. I'm the director of research and policy at Egale. As Canada's only national LGBTQI2S organization, Egale works to improve the lives of our communities in Canada through informing public policy, inspiring cultural change and promoting human rights and inclusion.

As Lori talked about, and in spite of the many legal advances we've made, significant disparities in equality remain, especially in the health sector. Not only does the LGBTQI2S community in Canada face barriers and stigma within the health system itself, but it also faces significant challenges in social determinants that significantly impact health, such as income and food security, employment status and work conditions, as well as connections to social networks and community. This is especially pertinent for members of our community who are racialized, living with a disability or have other multiple marginalized identities.

Within the health care system, as Devon talked about, people routinely face barriers in accessing appropriate care, rooted in insufficient training for health professionals on cultural competence and population-specific health considerations. This also includes limited and inconsistent coverage for therapeutics and medically necessary surgeries associated with gender transitioning.

Additionally, I would add that intersex people continue to be subjected to non-consensual surgeries, stigmatization and withholding of information, despite these practices being contrary to international human rights law. It is estimated that 30% to 80% of intersex children undergo more than one surgery, and some have as many as five surgeries. Section 268 of the Criminal Code continues to allow non-consensual surgery by medical practitioners to alter the bodies of infants and children whom they perceive to be ambiguous.

Outside of the health care system, the social determinants of health act in complex and compounding ways to negatively impact LGBTQI2S people. Perpetual encounters with homo-, bi- and transphobia at school, in the workplace and elsewhere contribute to isolation and chronic stresses that can directly impact educational achievement, career progression and income levels. This added stress can lower mental health status and include a heightened risk of developing depression, anxiety, substance use and suicidality.

From my colleagues, you've heard a lot of stats around mental health and suicidality in our community. What I'll add is what we found in our Egale Youth Outreach Centre, which is a drop-in centre that we've opened for homeless and under-housed LGBTQI2S youth in Toronto, where we see first-hand the impacts of some of these larger systemic forces on the youth in our community. For instance, since we opened the centre in 2016, we've seen thousands of visits each year averaging over 100 unique client visits per month, with new intakes increasing by 127% and therapeutic interventions increasing by 417%. Last year, over half the youth visiting the centre were either lesbian or gay, while one third were transgender and/or non-binary.

The top three presenting concerns among youth were mental health, employment and family relationship issues. A significant number also expressed that they were at some level of risk for suicidality. Other concerns included housing, social isolation and substance use which, while not as common as the aforementioned specific issues, frequently arise as intersecting and ensuing challenges that staff are called to assist with from month to month.

Many of the youth are homeless or under-housed. They don't feel safe in the present shelter system. Many struggle to meet basic needs. For example, EYO's food program, in which 15 to 30 participants eat per day and rely on for their food per day, has been a crucial service that has required additional resources and partnerships in order to address the food insecurity faced by participants driven by poverty and low incomes.

Seniors in our community are also impacted. What we hear from the seniors we work with is that many in our community are isolated. They lack the familial and social supports of their heterosexual or cisgender counterparts and also in many cases have a lack of access to employer-triggered pension plans due to a lifetime of stigma and discrimination in the workforce.

While there is limited Canadian data available on the specific needs faced by LGBTQI2S seniors, as Lori has talked about, U.S. data quantifies the anecdotal evidence that we hear through our National Seniors Advisory Council. One survey demonstrated that 42% of LGBT older people are very or extremely concerned that they will outlive the money they have saved for retirement, as compared to 25% of non-LGBT older people. U.S. data also demonstrates that disability is overrepresented among LGBT older persons, with nearly half of a large U.S. sample of LGBT older adults reporting a disability.

As was mentioned by Devon, LBTQI2S seniors also fear going into assisted living centres and long-term care facilities. They often feel they must hide their identities and partners to stay safe from abuse and discrimination.

In a national consultation conducted by Egale and its National Seniors Advisory Council, it was shown that the top issue with the largest perceived impact on seniors in our community was the fear of being re-closeted in residential care. Particularly in cases of dementia and/or Alzheimer's disease, many seniors in our community worry whether their identities will be honoured and respected as their consent and autonomy are brought into question.

As you have heard, the study presents a crucial opportunity for the federal government to address the health challenges that remain for LGBTQI2S people to ensure adequate and appropriate actions are taken to establish new priorities, reprioritize key needs, recognize the gaps in services and provide solutions for the improvement of life for members in our community.

In order to address our concerns in this area, we make the following recommendations:

First, conduct large-scale consultations with intersex people living in Canada as an initial step towards reforming subsection 268(3) of Canada's Criminal Code, which continues to allow non-consensual surgery by medical practitioners.

Two, ensure that Bill C-81, the accessible Canada act, incorporates measures to address barriers that disproportionately impact members of the LGBTQI2S community who are living with disabilities, including ensuring safe spaces in health care settings. This includes requiring health care colleges to have frameworks in place to protect service users from our community and mandatory competency training in LGBTQI2S issues.

Incorporate measures that support LGBTQI2S individuals living with a mental illness and in the criminal justice system, including the development of a national harm reduction strategy with specific funding allocated to address the mental health and addiction needs of LGBTQI2S individuals.

Ensure that the national food policy includes a plan to address food security among LGBTQI2S people, including those living in poverty as well as those living in indigenous and isolated northern communities.

Incorporate within the new health accord measures to assess and integrate health care needs that are faced by the LGBTQI2S community, including allocating specific funding towards services that attend to the mental health needs of diverse LGBTQI2S people across the country.

We would add, end discriminatory practices related to blood donation for men who have sex with men, and transpeople.

Also, develop a national gender-affirming health care strategy to ensure comprehensive health care for trans and gender-diverse communities that is physically and economically accessible and addresses their wide-ranging health care needs.

In line with the Canadian guidelines for sexual health education, implement consistent sexual and reproductive health education across all provinces and territories that is comprehensive and inclusive of LGBTQI2S health issues and experiences and is geared for adolescent and youth development.

Provide for accessible and affordable contraceptives, immunization plans and preventative sexual health care, including PrEP, pre-exposure prophylaxis, and PEP, post-exposure prophylaxis, within sexual health coverage across Canada.

Finally, recognize LGBTQI2S family planning and diverse family structures by training health care professionals, including IVF clinics, on inclusive patient care that does not make hetero-normative and cis-normative assumptions about family planning and fertility.

On behalf of Egale, thank you for your attention. We look forward to working with you further.

[The Chair, Liberal, Bill Casey]

Thank you very much. You get extra points for finishing a little early.

Now we go to Ms. Bloch for 10 minutes.

[Giselle Bloch, Board Member, Toronto Pflag]

Good afternoon, Mr. Chair and members of the standing committee.

Thank you for inviting me to participate in this important meeting on LGBTQ2 health. My name is Giselle Bloch, and I'm honoured to be here today.

I'm not a scientist, a researcher or an expert; I'm a parent, and I love my three children, two of whom are LGBTQ2.

As I accompanied one of my adult children along his journey of transition, I quickly learned how poorly society views transgender folks. I resolved to be an ally by supporting this community. Since my personal experience is mainly with trans folks and their families, I will focus my remarks on that segment of the LGBTQ2 population.

I'm a board member with Toronto Pflag, a volunteer-run charity whose mission is to promote the health and well-being of LGBTQ2 people and their families through support and education and to keep their families together. Over the past four years I have heard hundreds of personal stories from transgender individuals and their families, and I will share some of their perspectives today.

The first area that I would like to address is access to services.

Family physicians are typically the first point of contact for patients regarding their health care. Many are reluctant to provide their trans patients with comprehensive health care. Some will flatly refuse to treat them, and some will continue caring for them but are reluctant to prescribe hormone therapy. While many family doctors may claim that hormone therapy is outside their realm for transgender patients, they will routinely prescribe hormone therapy to cisgender patients.

Trans patients are usually referred to an endocrinology specialist, for which the wait time can be six months or longer. Because the highest risk of suicide for a transgender person occurs during the time between declaring their trans identity and actually beginning to transition, this lengthy wait time may be life-threatening for some folks.

Coverage for medical interventions and surgeries varies widely across provinces and territories. The onus rests on the trans individual to find out precisely what the requirements are, to obtain the appropriate letters and sign-offs from their health care practitioners, and to ensure that everything is submitted to their ministry.

Some trans individuals have to fly across the country for their surgery. Should complications arise once they return home, they are forced to go to their local emergency departments, where there may be a lack of competence in treating trans patients.

This past week, a young man very happily told me that he was just approved for his top surgery. He was so excited to be seen as his true gender when he starts university this September. When he called the clinic to book his appointment, he was told to call them back in July just to schedule the consultation, which will likely be in November or December, and the surgery itself maybe six months to a year after that. He broke down in tears when he found out that he may have to wait another year and a half to two years before he can have this surgery he so desperately needs.

The second area I would like to address is respectful treatment.

Some of the personal stories I've been privileged to hear have been very positive, while others have been those of emotional pain, discrimination and trauma. Many health care providers lack the appropriate knowledge or skills to treat and care for trans patients. Some are insensitive or even demeaning to trans identities. Some practitioners will continue to use the wrong name and pronouns even after being asked to use the correct ones when a trans patient's presentation does not align with the sex listed on their health card.

Some trans patients experience overt aggression. I've been told that folks have been ridiculed when their identity has been discovered. They've heard remarks like, “So do you like both men and women?” or “Oh, so you're not a real man.”

Trans patients have heard health care practitioners openly discussing their bodies and their gender identity with other staff in front of patients. Some are asked inappropriate questions unrelated to their visit. One person told me that a technician setting a cast on her wrist asked her how she had sex.

Just a few months ago a woman told me about the time she went to a lab for some blood work. She presents feminine, but she hasn't received her new ID yet. When she handed in her requisition and ID to the receptionist, she politely asked if the technician could please use her new female name when she was called. When the technician bellowed out her old male name, she froze. The technician called the name again and she was immobilized. Then the receptionist stood up, pointed to her and said loudly, “That's him.” Most of the people in that overcrowded room turned and stared at this woman who was just called “him”. They started whispering to each other and she just sat there crying into her hands until she finally found the strength to run out of the lab without getting her blood work done.

These acts of discrimination and transphobia have detrimental effects on trans individuals and deter them from accessing proper health care. They may feel that their health care needs are not as important as those of their cisgender peers.

Many health care practitioners are also unaware of, or choose to disregard, organ-specific screening tests that must also be performed on trans patients, such as Pap tests or PSAs, which may trigger gender dysphoria. As a result, they may neglect their health care altogether, so that when these cancers or illnesses go undetected, it places a greater burden on our health care system in the long term.

The third area I would like to address is the impact on transgender individuals.

Regarding mental health, our society burdens trans folks with stigma and shame. Couple that with discrimination, harassment and even violence. The high level of vigilance that transpeople are forced to maintain takes a big toll on their mental health.

The suicide rate in the transgender community is extremely high. Mental health issues are high and so is substance use, physical and sexual assault and harassment. There is also discrimination in housing, employment, access to health, education and social services, as well as poverty.

While 4% of the general population will attempt suicide, over 40% of the trans population will attempt suicide, yet trans folks comprise only about 1% of the total population. Why is this number so disproportionately high? It's clear that the manner in which our society perceives and treats its trans members takes a very large toll on their mental health.

Regarding emotional well-being, some parents of trans youth have told me that their kids are suicidal, since they think everyone hates them just because they are transgender. Some parents say their kids can't go to school because they've been bullied or assaulted and have anxiety or depression as a result.

I've been told by trans folks that they have been spit on, verbally abused, taunted in public, threatened and physically forced out of washrooms. One woman told me that someone once walked past her on the sidewalk and then turned around and assaulted her from behind, while calling her names that I won't repeat here. Whenever she walks down any sidewalk alone, she is terrified. No human being deserves to be treated that way.

Regarding relationships and family, the strongest indicator of the future success of a transgender person is family support, yet far too many transgender people are rejected by their families when they reveal their trans identities. Some parents may begin to accept their kids after a few years, but especially for youth, the critical time is right at the beginning.

In Canada, 40% of youth experiencing homelessness are LGBTQ2, yet only 10% of the population is LGBTQ2, while 47% of transgender youth consider suicide, but that number drops by 93% when they are supported by their families. These numbers speak for themselves.

Trans youth lacking family support, or any transgender person lacking social support, will often encounter barriers in accessing care and too many of them are unable to advocate for themselves.

I propose that we take a coordinated approach to creating a culture in Canada that is inclusive of gender identity. Gender identity must be taught to all students in schools across Canada, beginning in kindergarten. As a result, transgender identities will not be stigmatized when these youth become our future health care professionals and leaders.

Trans-competent care must be incorporated into the curriculum in medical and nursing schools, as well as in specialty and technician positions.

Members of the transgender community must be involved in the development and implementation of this inclusive curriculum and the protocols for culturally competent care.

Non-discrimination policies must be mandated and prominently displayed in all health care areas and enforced. These facilities should have gender-neutral washrooms and changing spaces should be non-gendered and private.

As an incentive to be more inclusive, federal grants could be awarded to institutions and programs that teach postgraduate-level trans health care.

Finally, as a society, we need to build up a strong system of supports and resources for trans individuals and their families. We need broader community engagement and education. We need transgender-specific mental health services and we need medical care support and mental health services that are readily available and easily accessible.

Thank you for this opportunity to participate today.

[The Chair, Liberal, Bill Casey]

Thank you.

Before I start our first round of questions, I'd like to introduce our new parliamentary secretary, Pam Damoff.

Welcome to our committee.

I want to thank John Oliver, who is not here. John is not running again and he has stepped down as parliamentary secretary. He always added a lot to the committee over the last three and a half years or so, and I wanted to thank him.

We're going to start our first round of questions with Mr. McKinnon.

You have seven minutes.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you, Chair.

Thank you to all of you for being here today. I appreciate your testimony. There's a lot of stuff coming at me, so I'm not sure I captured it all. I may overlap on some of my questions.

I'll start with Egale.

There's still a long way to go for equality, but there have been some gains in terms of rights for LGBTQ2 individuals in recent years. The legalization of same-sex marriage and the addition of gender identity and expression to the Canadian Human Rights Act are signals to the Canadian public that we are all equal regardless of our differences.

What influence, if any, have these legal gains had on discrimination against and the stigmatization of LGBTQ2 individuals?

[Richard Matern]

They're significant. The effect and impact can't be underestimated.

However, we do see a discrepancy between those legal wins and what's actually happening on the ground. It's evidenced through research. It's evidenced through the anecdotes that you hear.

There needs to be a multipronged approach. Winning legal rights is part of it, but there has to be an ongoing transformative societal change around all these gaps. The health sector is a significant one, as you heard, but it also includes other areas, from education to criminal justice to just community change in general. A lot of what we still need to do will happen on the ground. It happens with working in communities, and the health committee study that you are beginning is a big start and an important start because this is such a significant area. It's just continued work.

However, I can't overemphasize and I repeat what Lori talked about, which is collecting data and having adequate data and evidence that show those disparities so we can then take action and have evidence with which to move against.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

It has had an impact on health. Would you say that was a significant impact on health care?

[Richard Matern]

With the legal...?

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Yes, the legal changes.

[Richard Matern]

I'm not sure. I think that's the thing. We're not at the state where we can say whether the legal changes had a significant impact or not, and that's why we need more data.

[Devon MacFarlane]

I could speak to that a little bit.

I spoke to the Senate committee around Bill C-16 and part of what we brought forward was that in the states where protection for marriage is in place, where marriage equality is in place, compared to states where it isn't, the recent mental health outcomes are improving. In Canada, we're in a really strong position given the legal progress we've made. It's now about how we bring this to life, because the health outcomes will follow the legal progress, but it will move much faster, very much faster, if we put a concerted attention into some really strategic places.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

Would anyone else care to comment on this?

[Dr. Lori E. Ross]

I would perhaps just add that different people within the LGBTQ2 community have differential access to those legal gains. It requires some resources to be able to take advantage of those gains in many cases. I think as with all health disparities, those who are most marginalized, we see the greatest disparities there. They're also the people with the few resources to access, for example, legal protections. I think that we may not necessarily see the breadth of health gains that you would hope to see simply because there are so many people who are really at the bottom of the socio-economic ladder and are not experiencing the same benefits as those who are at the higher end of the socio-economic ladder.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

I'll stay with you, Dr. Ross.

The available data on health of LGBTQ2 individuals is often viewed as incomplete or partial. Based on your knowledge, how could the federal government working collaboratively with the provinces and territories help to address this situation?

[Dr. Lori E. Ross]

I think that there are already some important gains under way. I know we have added a question on gender identity to one recent population-based survey and that there's intention to have that question or similar questions included in future Statistics Canada surveys. I think that's an important step.

We do still have a number of federal surveys, though, that don't include questions on sexual orientation and gender identity. I used as one example the Canadian income survey, which currently doesn't have those questions. Knowing that poverty is a very significant determinant of health, it would be important even in understanding health to have those questions there.

There are also data that are collected at the level of other jurisdictions such as the Canadian food security survey, which doesn't currently collect data on sexual orientation and gender identity. There are many opportunities there for collaboration with provincial, territorial and municipal levels of government to ensure that better data are collected at those levels in order to give a national picture.

[Devon MacFarlane]

Perhaps I could expand on that a bit. Another really significant area for improvement would be around health care administrative data. For instance, for those of you with OHIP cards, at registration we could be asking questions about sexual orientation and gender identity in a way that's private and kept protected. That then allows for much a better analysis about what's happening as people move through the health care system.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

Ms. Bloch, the attitude of health care workers is important and has a significant impact, as you said. How do you suppose we could address this problem? Is it a matter of education, training?

[Giselle Bloch]

It's both of those things. I think it needs to start in school with early education. Then there needs to be training in medical school and all the various specialties and different areas, including nursing and social work.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Would anyone else like to comment on that?

[Devon MacFarlane]

There is work happening already.

Part of Rainbow Health Ontario's role is to provide health care training for folks who are already practising. We've been doing that for about 10 years. In Ontario we've reached about 40,000 providers, but when we're looking at 600,000 to 800,000 people who work in health and social services in Canada, that's a small fraction. But yes, we're already able to provide some of that training, looking at the clinical issues in particular.