Health Committee on May 7th, 2019

[The Chair, Liberal, Bill Casey]

Welcome to the 142nd meeting of the Standing Committee on Health.

Pursuant to our study on LGBTQ2 health in Canada, we welcome our guests.

I'll just point out that the Conservative members aren't here yet. There's a little ceremony going on in the House for one of their members. They'll be right along, but I think we'll start to make sure we get everything in.

I will introduce our guests. From the Canadian Professional Association for Transgender Health, we have Jack Woodman, president. From KW Counselling Services, we have Washington Silk, a registered social worker and psychotherapist, and OK2BME program coordinator; and Scott Williams, who is the communications and development coordinator. From the Provincial Health Services Authority, we have Lorraine Grieves, provincial program director with Trans Care BC; and Quinn Bennett, provincial lead for peer and community support networks with Trans Care BC. As well, from YouthCO HIV and Hep C Society, we have Sarah Chown, the executive director.

Each group will have 10 minutes for an opening statement.

We'll start with the Canadian Professional Association for Transgender Health, Mr. Woodman.

[Jack Woodman, President, Canadian Professional Association for Transgender Health]

Thank you, Mr. Chair and members of the Standing Committee on Health for inviting me to speak today about the health and well-being of transgender and gender-diverse Canadians.

My name is Jack Woodman. My pronouns are they/them. I'm the president of the Canadian Professional Association for Transgender Health, CPATH.

CPATH is an interdisciplinary health professional association of over 600 members. Our vision is a Canada without barriers to the health, well-being and self-actualization of trans and gender-diverse people.

CPATH is a volunteer-led organization, and in my day job I'm the chief strategy and quality officer at Women's College Hospital in Toronto, which is Canada's first publicly funded academic hospital to offer a gender-affirming surgery program.

I'm a genderqueer Canadian, and so this work and the efforts you are undertaking in this first national LGBTQ2S study hold a distinct passion and purpose for me and my community.

Today I'll use the word “trans” as an overarching term that includes a wide range of people whose gender differs from the sex that was assigned to them at birth. The term “trans” may hold a broad spectrum of identities such as transgender, genderqueer, non-binary and two-spirit; however, not all individuals with these identities identify as trans.

You can see that we're already navigating expansive realms where gender exists well beyond a binary of male/female and doesn't fit nicely into two check boxes. The good news is that we're beginning to catch up. Since 2017, our Charter of Rights and Freedoms identifies gender and gender expression as prohibited grounds for discrimination and, as of 2018, Canadians can indicate they do not identify as male or female on their passports.

The future will most certainly include more expansive ranges of gender diversity. It will be a future where notions of presumed gender and expected behaviours and identities based on sex at birth will be old and obsolete ideas for the next generations of Canadians.

It's estimated now that there are 25 million transgender people in the world. Consider that close to 12% of millennials identify as trans. In Canada, a conservative estimate of 0.6% suggests that there are approximately 200,000 trans individuals aged 18 or older living in Canada.

There has been exponential growth in the number of trans people seeking health care, perhaps due to greater public awareness and acceptance of trans issues and greater connection and availability of information via the Internet. Reports on numbers of trans youth being served are indicating fourfold increases per year. In Ontario, there has been exponential growth in those seeking gender-affirming surgeries.

I want to emphasize here that not all people who are trans want or require surgery, or a medical intervention at all for that matter. For those who do require surgeries to optimize health, the range of procedures is very individualized. The numbers are quite astounding: In 2010, there were 59 approvals for transition-related surgery. In 2016 we saw it grow to 216 approvals. Last year, in 2018, the number grew to 1,460 approvals in Ontario alone.

Canada has just one small private surgical centre located in Montreal offering transition-related surgeries that include genital surgeries. Wait times are typically over two years to consult, let alone access to in-country services, and insurance coverage differs widely across the country, creating a sort of provincial lottery based on where you live. Imagine any other surgery deemed medically necessary that improves and saves lives being offered at one small private clinic in one province with vast variability in coverage depending on where you live.

Travel to and from surgical sites and lack of access to local surgical aftercare pose additional barriers and increased risk.

I'm incredibly excited that Women's College Hospital launched a new surgical program in Ontario last year that will broaden its scope of services to include vaginoplasty by June 2019. British Columbia is now poised to open a program in western Canada, and we are rising to the challenge to meet the health service needs of trans Canadians with an eye to offering services closer to home.

While universal access to health care is a tenet of our health care system, in reality this has yet to be reconciled for trans people, many of whom face barriers when seeking both general care and also gender-affirming care. Barriers range from lack of provider knowledge on trans issues to stigma and refusal of care. An estimation of health care inequalities between trans and cisgendered individuals in Canada highlighted that 43.9% of trans people reported unmet health care needs in the past year compared to 10.7% of the cisgendered population.

We know that many trans individuals underutilize or avoid health care services altogether, and there are lots of reasons for that. Of those who had accessed emergency departments while expressing a gender different from their birth-assigned sex, 52% experienced negative treatment due to being trans, ranging from insulting or demeaning language to outright refusal of care.

Understanding what prevents trans people from accessing health care—including stigma, environmental, social, policy and legal barriers—is crucial for improving health and well-being.

I understand that the committee has previously heard presentations that included evidence on health outcome disparities, including the crisis-level suicide attempt and completion statistics, with transphobia, lack of health care access, and low levels of family and social support creating the highest risk for suicidality. I won’t go into more detail on this here, but I will emphasize that the social conditions that produce these health disparities are critical.

I now have a few recommendations to improve health and health care for trans and gender-diverse Canadians.

The first is to amplify the federal government's role in ensuring equitable health care access for all trans Canadians. Access to gender-affirming care, such as surgery and medications, is limited by variability in provincial funding that sees coverage in some provinces and not in others. A national body to review and support provincial and territorial efforts to serve trans populations equitably should engage all levels of government. It should be inclusive of trans people with diverse lived experiences, policy-makers, researchers, service providers and community leaders responsible for health and social services. With consideration to federal transfers, provinces and territories could be required to include provisions for improving access to and coverage of medically necessary gender-affirming health care—which currently places an undue burden on trans populations who generally experience lower socio-economic status and greater barriers to employment, and of course extended health benefits.

The second recommendation is to eliminate conversion therapy across Canada through legislative means. Gender conversion therapy is an intervention aimed at changing a person’s sexual orientation to heterosexual and/or a person’s gender to cisgender. Evidence consistently rejects this type of therapy as ineffective, harmful and unethical. Conversion therapy should not be allowed to continue with the support of public funds or under Canadian law.

The third recommendation is to strengthen and fund research, data capture and analysis on the health, social, economic and policy factors that impact trans Canadians. Trans health and health service data is critical to drive evidence-based policy and practice shifts within the Canadian health care context. Government data collection and informatics should inclusively capture the gender demographics of Canadians and be used to address health inequities. Health surveys and forms should not only represent male and female genders, but should be inclusive of capturing non-binary, trans and intersex populations. Just of note, our research committee recently completed the CPATH ethical guidelines for research involving transgender people and communities in 2019. As interest in researching trans experience increases, these ethical guidelines should be considered and applied.

The fourth recommendation is to implement a national gender diversity education strategy. A national education strategy that decreases stigma and promotes understanding of gender diversity and the safety, health and well-being of trans children, youth and adults should be supported and funded in all public sectors and at all levels of government, as well as the general public. Such a strategy also presents an opportunity for trans-inclusive sex and gender education from elementary schools to health professional programs at universities and colleges.

Finally, the fifth recommendation is to shift the balance of power to give more voice and power to the people with lived experience and ensure an intersectional approach. This means inclusive planning and co-design for equitable policy, research, education, services and supports. Our work at CPATH has been strengthened immeasurably by engaging and collaborating with those who have lived trans experience. To understand the factors that influence health and access to care amongst trans individuals, it's critical to consider intersectionality. In the trans context, stigma based on gender identity is often compounded by stigma based on race, age, sexual orientation, disability and socio-economic status. For example, higher rates of discrimination are experienced by indigenous transgender individuals, at 36%, than white transgender individuals, at 17%. These intersecting life circumstances create additional risks or marginalization for trans individuals.

Canada, as a human rights leader, has the opportunity and the responsibility to advance the health and well-being of trans people here in Canada, with reverberating impacts around the world.

Thank you—personally and on behalf of CPATH—for your invitation to present, and also for your study on LGBTQ2S health in Canada.

[The Chair, Liberal, Bill Casey]

I want to ask you a question. In your very first sentence you said, "my pronouns are 'they/them'”. Help me with that.

[Jack Woodman]

When you introduced me, you introduced me as Mr. Jack Woodman.The name Jack has a masculine connotation in our culture. As a non-binary, transgender, queer-identifying person, I don't fall into a category of either male or female. Rather than using “he” or “she”, I choose to use “they” and “them”. It's quite common in the community to use they/them pronouns.

[The Chair, Liberal, Bill Casey]

When I introduced you, how should I have done it?

[Jack Woodman]

You could just introduce me as Jack Woodman. Different people use different.... There's an honorific “Mx.” that some people use, but just “Jack Woodman” would be great.

[The Chair, Liberal, Bill Casey]

Thank you.

In that case, next we have Washington Silk to make a presentation on behalf of KW Counselling Services for 10 minutes—or is Scott Williams going to do it?

[Scott Williams, Communications and Development Coordinator, KW Counselling Services]

We're going to go back and forth.

[Washington Silk, Program Coordinator and Registered Social Worker, Psychotherapist, OK2BME, KW Counselling Services]

Thank you, Mr. Chair and members of the standing committee. It is a privilege to address you this afternoon and take part in this historic study on LGBTQ health.

My name is Washington, and I am a transgender social worker and psychotherapist. I coordinate an LGBTQ program called OK2BME at KW Counselling Services in Waterloo region.

I'm here today with my colleague, Scott Williams, our communication and development coordinator, who is also a member of the rainbow community.

[Scott Williams]

KW Counselling Services is an organization that provides both walk-in and ongoing counselling to individuals, couples and families.

In 2005, we recognized that in order to best serve the LGBTQ2+ community we needed specialized supports, and the OK2BME program was born. We provide free counselling to rainbow youth aged five to 29, we have four different youth leadership and recreation groups, and we offer public education services that include providing free, ongoing support to our local school boards and their GSAs, or gay-straight alliances, as well as education and consultations to such organizations as our police force, hospitals, municipalities and local businesses.

We would like to share some data from Waterloo region. We are fortunate to have what we call the “OutLook” study, which is the largest study of its kind in Canada. It looked at levels of harassment, discrimination, victimization, outness, safety, isolation, inclusion, health and mental health care experiences amongst LGBTQ2+ people.

In this study we found that 42% of trans people and 30% of lesbian, gay or bisexual people had to move away from their friends and family because of their gender identity or sexuality; that 50% of trans respondents and 45% of cisgender, gay, lesbian and bisexual respondents experience verbal harassment in our community; that a majority of trans people, 72%, feel unsafe in hospitals, emergency rooms, medical offices and urgent care clinics; that 26% of trans respondents were either hit or beaten up because of their gender identity; and that a majority, 73%, of respondents said they feel they will die young.

[Washington Silk]

Mr. Chair and committee, my area of expertise is mental health. Simply put, when people are not treated well, they don't feel very good.

You've heard this before, and your other report has referred to it as “minority stress”. If I could explain minority stress as a math formula, it would be internalized homo/bi/transphobia, with the addition of stigma, the expectation of rejection and discrimination plus actual experiences of discrimination and violence. This equals minority stress.

Minority stress is directly linked to mental health distress and suicide. A recent report found that LGBTQ people and indigenous people in the Waterloo region have three to four times higher rates of mental illness and suicidal behaviour. This is why we need to change the landscape of our community and end homo/bi/transphobia and stop minority stress.

I'd like to share an example with you. Since 2005, we've helped start more than 30 GSAs in Waterloo region, in public, Catholic and private schools. As you know, GSAs are vital, offering psychological, social and physical protective factors for LGBTQ youth.

Today, young people are coming out earlier and earlier. I believe this is due to the shifting social and legal landscape in Canada. Research indicates that when young people come out, they often face victimization from their peers. This can have really lasting negative effects, given the developmental phase that teens are in. Because of our work in schools, we are presently surprised with the OutLook data, which shows that the majority of LGBTQ students receive supports from their classmates and teachers. In fact, and unfortunately, in Waterloo region, students receive more support from the schools than they do from their parents.

A recent study on GSAs in Canada was able to survey one-third of Canadian school districts and only a half of them reported having GSAs.

The well-being of LGBTQ people does not begin when they enter a doctor's office or my therapy room; it begins at birth. Having GSAs, resources and education to support LGBTQ youth is vital. This definitely includes the privacy of students being able to attend these groups without parental consent or knowledge.

Our counselling team supports many transgender clients. Often those who want to medically transition are not able to get the medical care they need from their doctor, so we do our best to help navigate the health care system and help them find the services they need.

I'm also often asked to write letters of support verifying someone's transgender identity before they're able to access medical service. This is sometimes known as a psychiatric or readiness assessment. I myself was asked to get one of these letters before I was able to access my own trans health care services.

As a social worker, I find this very odd. In no other circumstances do you have to write a letter to access the medical care that you need in Ontario. Like other health care services, trans health needs to operate on an informed consent model. Currently, too many people have to jump through hoops proving to often cisgender professionals, such as social workers or doctors who lack training, that they are trans enough in order to receive the medical care they need. This needs to change.

Effective trans care services include the patient-first, informed consent approach. It should not be left in the hands of me or a doctor to decide what somebody's gender identity is or is not, especially when research suggests that transgender clients are the ones educating their doctor—at 48%—or their mental health provider—at 53%—on what trans health issues are, in part because trans health is not included in formal education for medical or mental health providers.

We need to invest in our young people's well-being and their families.

I would like to share a story about myself. When I was 12 years old, I asked my brother if he would still love me if I were gay, and he said no. As you can imagine, I didn't talk about it again. I went away to university and I came back and decided that that was when I was going to talk about it, and so I told him. He took a deep breath and he turned to me, and he said, “Me too”. That means that we lived decades of our lives in silence. We weren't able to share a big part of who we were with each other, and it's not because our community was particularly homophobic or transphobic, it's because our identities just didn't exist—we were erased. There were no resources for my brother, for my family, or for me; and my story is not unique.

To me, one of the worst statistics, but not the most surprising that is coming out of the OutLook study, is that the majority of LGBTQ people have pretended to be straight or cisgender. They have erased who they are in order to function or feel safe in their community. I don't want another young person to have to erase who they are so they can get the medical care that they need, so they can go to school, so they can feel safe or so they can get a job.

We need to grow this idea of affirming supportive care and opportunities for LGBTQ youth across the country so that they can not only survive but thrive. This means that at a minimum we need to ban conversion therapy across Canada. We need to ensure that child protection workers, medical and mental health providers have adequate training and resources to effectively support LGBTQ youth and their families.

Transgender health care needs to operate on an informed-consent, patient-first model. We need GSAs to be supported in all schools across the country, LGBTQ content in the curriculum and comprehensive sexual health information.

I am proud to say that we are working to change homo/bi/transphobia in Waterloo region, knowing that just providing counselling in our community is not enough. We need to change how people are treated in our community, in order to improve their overall well-being. We knew we had to get involved in our community, with our schools, our police, our doctors and our businesses to try to create a community where no one is left behind.

Unfortunately, much of what we do in the OK2BME program is precarious, as our funding is not consistent or secure. I do not know what the future of my program will look like without adequate support and resources. I do know, however, that our holistic approach has benefited our community, and this is my ultimate recommendation to the committee.

Quite simply, we need to change our existing services, from data collection to the overall health care system, so we stop creating barriers and environments where people feel it necessary to hide or erase who they are, or worse, not get the care they need. We can change our data collection processes, but if people don't feel safe enough to identify, then the system change will not solve the problem alone. This also matters in hospitals.

In Waterloo region, and I suspect it's not different for the rest of the community, we know that 26% of transgender people have avoided the emergency room when they needed to access care, because of their gender identity. We need to start creating system changes that effectively support LGBTQ people, so they can feel safe and supported in every sector.

Our OK2BME program is an excellent holistic model for bringing change. I'd like to share that in the last year, we have helped get rainbow crosswalks installed in Kitchener and Waterloo; provided counselling to 454 individuals, families and couples; and 5,149 people have benefited from our youth group, public education and consultation services, all with very little funding, and a dedicated team.

Lastly, I want to share that the LGBTQ community is incredibly diverse in terms of both opportunities and inequities. That means that racialized, two-spirit, LGBTQ newcomers and individuals who live rurally may be further marginalized and disproportionately affected by inadequate health care and mental health supports. Targeted consultations, supports and resources will be needed to effectively support these communities.

Thank you for inviting us to this consultation. I hope you continue to engage with the diverse LGBTQ community, as you continue on this journey to improve the lives of LGBTQ Canadians.

Thank you.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we go to Lorraine Grieves and Quinn Bennett of the Provincial Health Services Authority. You have 10 minutes.

[Lorraine Grieves, Provincial Program Director, Trans Care BC, Provincial Health Services Authority]

Thank you for the invitation to be here today. We're greatly honoured to have travelled here from Vancouver, B.C., where the two of us work on unceded indigenous territories of the Squamish, Musqueam and Tsleil-Waututh nations.

I'm Lorraine Grieves, provincial program director with Trans Care BC.

[Quinn Bennett, Provincial Lead, Peer and Community Support Networks, Trans Care BC, Provincial Health Services Authority]

I'm Quinn Bennett, lead for peer and community support networks with Trans Care BC. I'm also from the ancestral lands of my people, the Mi'kmaq on the west coast of Newfoundland, and I'm a trans and two-spirit person living in B.C.

[Lorraine Grieves]

I feel very privileged to be the program director, as a Cree Métis and British Columbian. I also identify as two-spirit, and am the proud parent of a 29-year-old.

We've submitted a brief for your reference, with 10 recommendations in it, and we'll be focusing our presentation today on health and wellness for transgender, gender-diverse and indigenous trans and two-spirit individuals in Canada.

Trans Care BC is a provincially funded program, created in 2015. We have a mandate to coordinate and improve trans health and well-being services across the province of B.C. The first of its kind in Canada, the program was developed to build and improve timely and relevant health care options for transgender British Columbians.

The work of Trans Care BC has been guided by the expertise of those with lived experience accessing gender-affirming care, along with health care providers and researchers. Trans Care BC's focus is on building capacity in the health care system, care provider education and increasing access to person-centred care closer to home.

As you've likely heard from other presenters, gender diversity is a natural part of human diversity that's existed across time and cultures. We're using the word trans today as an umbrella term, to include a wide range of people whose felt sense of gender differs from the expectations of gender based on the sex assigned to them at birth.

[Quinn Bennett]

We're often asked how many people are trans. This is difficult to estimate. However, prevalence estimates continue to rise. As Jack mentioned earlier, 12% of millennials identify as trans or non-binary based on a U.S. survey. Trans Care BC uses a prevalence rate of 1% to 3%, with 0.3% to 0.6% of people needing medical intervention related to gender transition. Even using current conservative prevalence estimates like this, the number of trans individuals in Canada registers in the hundreds of thousands. While many transpeople do not require gender-specific medical interventions to live comfortably in their gender, those who do often experience significant challenges in accessing this needed care.

Canadian researchers have documented high rates of harassment and violence towards trans adults. A national survey of trans youth revealed concerning outcomes surrounding mental health, psychosocial supports and access to care. Many transpeople in Canada have positive health outcomes, which can be attributed to strong support networks and access to health care, education, employment, housing and other services. Others lack the supports necessary to thrive. Gender-based marginalization can be magnified as a result of intersecting oppressions related to such factors as race, ethnicity, class and age.

Intervention is needed at multiple levels to address social determinants of health for all trans Canadians. Based on our expertise and experience in improving health services for transgender individuals in communities and the ongoing input we receive from those we serve, we offer recommendations for ways in which Canadian policy-makers can improve the health and well-being of transpeople in Canada.

[Lorraine Grieves]

In B.C. it has been essential to undergo policy, service planning and educational resource development work by including, consulting and directly collaborating with those who have trans lived experience. This includes youth, adults, parents, caregivers, indigenous trans and two-spirit communities. There are many other populations within trans communities who require dedicated planning and resources. These are refugees and newcomers, those living with disabilities, neurodiverse people and other who face increased barriers to care because of their unique intersecting identities and the social locations they experience. Understanding the diverse care journeys of trans individuals has been essential to our work as we address the most significant health disparities and inequities.

Through steering committees, focus groups, advisory committees, surveys and research projects, we've found multiple ways to engage and include a range of stakeholders in codesigning the work. By involving those with local lived experience, we've been able to attune our action plans as much as possible to the needs that are being identified. We recommend that work undertaken to improve trans health in any jurisdiction should involve those impacted directly, including trans individuals and their loved ones with diverse lived experience. Families and loved ones bring critical information to the planning process, as do care providers, in a networked approach to planning and implementation.

For the rest of our presentation, we'd like to highlight issues on access to care. There's much data to show that transpeople in Canada experience barriers to basic services. By this we mean general health care, employment, education, housing and so on. Providing name and gender marker changes without special requirements, inviting self-identification of gender and pronouns, removing gender markers from government identification, providing gender-affirming care to individuals who are incarcerated and adding gender identity and expression to human rights codes can improve service accessibility. Many trans Canadians are benefiting from such policy changes; however, inequities still persist due to differences in provincial and territorial laws and inconsistencies in policy application.

Broad work is required to review trans inclusion and cultural safety factors related to all levels of government and public services. There are many groups doing this work on limited funding and support. Our program has been developing free online learning modules to begin to help address the education needs connected to this work. We acknowledge that this is just a beginning step and specific to B.C. We recommend that appropriate funding be allocated to the public system to support needs assessment, cultural safety education and actions to improve accessibility.

[Quinn Bennett]

Now we'd like to talk about gender-specific care and supports. Like people of all genders, trans and gender-diverse people need access to supportive primary care and other basic health services. This access can be improved by training and supporting the existing system of care to gain competency and culturally safer care. Some transpeople require gender-specific health care related to transition or gender-affirming goals. This can include hormone therapy, supportive counselling related to transition, gender-affirming surgeries, voice training and assessment related to some of the more irreversible interventions.

Trans individuals who require gender-specific health care, such as hormone therapy or gender-affirming surgeries, frequently experience barriers to this care. Stigma, discrimination and gender-based harms in our health care system result in avoidance of care, directly contributing to health disparities. Improvements are needed in timely access to endocrine care, surgical care, psychosocial care and peer support services for transpeople and their families. In order to make a measurable difference to this issue, we believe a strategy is required. We've been lucky enough to have resources to work comprehensively in B.C.

In order to make national improvements, we suggest that federal opportunities for enhancing the work be funded. One idea would be to work with a group such as CPATH to create a well-supported national network of provincial and territorial coordinating bodies or key service providers and programs responsible for trans health work. For example, these groups can include Trans Care BC and Rainbow Health Ontario. There are strengths in every province. It would be of great utility to be able to leverage these strengths to improve care across the country. The national network, with peer support and convening dollars, could create an aspirational framework and/or national standards to support provincial and territorial work to ensure that trans populations are served equitably across Canada.

[Lorraine Grieves]

Lastly, we want to highlight the diverse needs of gender-creative and trans children, youth and their families.

Psychosocial care, peer support and access to health care are key determinants of health for trans and gender-diverse children and youth. We know from research that many young people do not feel it's possible to tell their health care providers about their gender if they are trans or non-binary. Even worse, sometimes they face latent discrimination in care settings, thus disengaging them from future care.

Service providers who work in trans health across Canada have been discussing the increase in requests for care from trans and gender-questioning young people and their families. Many providers have seen a tripling and even a quadrupling of requests, and that's just in the last year or two.

All youth need attachment to supportive health care and services. A smaller, but significant number of youth require access to gender-affirming medical interventions, and many experience barriers when attempting to access this care.

Research demonstrates the critical role that parent and family support plays in the lives of these young people. While many families are supportive of their children, some struggle to understand and accept their child's gender. In some cases, family rejection leads to homelessness and other negative health outcomes.

Support services of all types are needed for children, youth and families as they navigate their gender journeys. The western world is generally built for cisgender people, and anti-trans bias and related harms have been well documented in literature.

Due to this enacted stigma, when unsupported, trans youth face higher rates of mental health concerns, such as suicidality, anxiety and depression. When connected to timely and effective supports, many of these concerns are seen to be alleviated.

Counselling and peer support are low-cost, high-impact interventions, essential for improving the health and well-being of kids, youth and families.

Greater engagement of youth and parents is needed in guiding cross-ministerial approaches to ensure that policy, education, services and funding are in place to support gender-diverse and trans children and youth across all environments, including home, family, health care services, social services, other government services, school, community services and peer support programs.

Many programs serving gender-creative and trans children, youth and families have been eked out of existing services that were never originally planned to serve this population. Because of this, many are now overextended and inadequately resourced. As a result, children, youth and families are challenged to access timely care, and often they travel great distances to access the more specialized supports.

Time-sensitive, closer-to-home access for gender-creative and trans kids and youth is critical and potentially life-saving. Addressing this need nationally should be of the highest priority.

In summary, we thank you for the opportunity to present today. We've been fortunate to be able to do this work on a provincial scale, and we'd be very happy to share our learnings from this. We welcome any questions about our presentation or the brief we've provided.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you.

Now we go to YouthCO HIV and Hep C Society, and Sarah Chown.

[Sarah Chown, Executive Director, YouthCO HIV and Hep C Society]

Mr. Chair and members of the standing committee, my name is Sarah Chown. I am a settler on the unceded ancestral lands of the Coast Salish peoples, and I use the pronouns she and her.

Since 2015, I have worked at YouthCO, a youth-led agency that addresses the impacts of HIV and hepatitis C stigma. We use peer education and peer support to connect with indigenous youth, youth living with HIV and hepatitis C, and queer and trans youth.

While our organization's mission is about HIV and hepatitis C, these viruses disproportionately affect many LBGTQ2 people. For us to address HIV and hepatitis C, we must consider the broader health and well-being of queer and trans youth. This is what brings me here today.

This afternoon, I will talk about the experiences of youth in our programs who are queer and trans, and who may also be indigenous and/or living with HIV.

Before I can do these things, I must share my first recommendation with you: This study must heed the calls to action of the Truth and Reconciliation Commission. Specifically, as per call to action 18, this committee must recognize the impact of colonization on the health of indigenous peoples today, and implement aboriginal people's health care rights. This committee should seek the continued participation of indigenous queer, trans and two-spirit people as it moves forward. At a minimum, this includes incorporating LBGTQ2 narrative and research from and by indigenous people.

Many indigenous people are queer and trans, and this has been true before these words even existed in English. In the LBGTQ2 acronym, the 2 stands for “two-spirit”, an English word introduced in 1990. Métis scholar Chelsea Vowel tells us the term was chosen by indigenous people to be a “"pan-Indian" concept [encompassing] sexual, gender and/or spiritual identity.” It does not replace terms and teachings from each unique indigenous nation, nor is it a word all indigenous people who are queer and trans use to describe themselves.

To speak about indigenous youth, we must name past and—as importantly—ongoing forms of colonization. In what is now called Canada, colonization has deprived generations of youth of the chance to learn in and from their own families and communities. Without these opportunities, some communities no longer have pre-colonial knowledge about the role of two-spirit people or the words in their language to describe these identities. Upon arrival, colonial powers imposed overt transphobia, homophobia and biphobia, the belief that it is wrong to have gender roles outside western norms of men and women, and the belief that people can only be straight and cisgender. Together, these concepts can be referred to as “cissexism and heterosexism”. Both refer to prejudice towards queer and trans people. Due to these beliefs, colonizers also actively persecuted two-spirit people.

As a result, today's indigenous youth may not know that in many communities, two-spirit people were an important part of indigenous life, and they may not have two-spirit role models. Limited access to two-spirit teachings and community can be an isolating experience and have direct impacts on mental health. Without community support and adequate counselling services, substance use and suicide can become realistic options for young people. Combined, these structural factors and health inequities shape a syndemic—intertwining, mutually reinforcing epidemics—that worsens the impact of any one of these factors and contributes to the disproportionate numbers of queer, trans and two-spirit youth who die preventably each year, whether by suicide, untreated HIV or as missing and murdered people.

In response, I recommend that the federal government fully resource indigenous communities to lead responses to the intersections of colonization, cissexism and heterosexism. As a non-indigenous person, I hope by sharing some of these needs, this committee will do further work to hear directly from more indigenous queer, trans and two-spirit people.

Whether or not we are indigenous, too many queer and trans youth are not getting relevant information about our health. Last year, my colleagues Ghada and Avery conducted a survey with over 600 high school students in more than 80 communities. We embarked on this work because we suspected many youth were not getting the knowledge they need to make informed decisions about HIV.

What we learned was disappointing. Forty-five per cent of students told us that their sex education did not recognize that their sexual and gender identities even exist. Practically, this meant many students were only learning about penis-in-vagina sex, which is not the only way queer and trans people have sex. Furthermore, it is not the type of sex that accounts for most new cases of HIV in British Columbia. Heterosexism and cissexism mean many educators are not equipped to talk about the sex that is relevant to all their students, and as a result many queer and trans youth are not getting safer sex information.

In our survey, 84% of students agreed that school is an important place to get sex ed. Students told us they wanted sex education that is standardized, relevant to their experiences and delivered by someone who is knowledgeable and able to create safer spaces. Therefore I recommend the federal government implement the 2019 Canadian guidelines for sexual health education and fund community-led sex education classes and campaigns to bypass the current patchwork of sex education in this country.

Heterosexism and cissexism also mean that health information does not address queer and trans people and that queer and trans people are not always counted in research and surveillance data. Without this information, organizations rely on queer and trans people in our programs and on our staff teams to provide this information from their own experience.

At YouthCO, this approach to getting information has meant we have left out facts and context that are specific to trans, non-binary and two-spirit youth when it comes to HIV and hep C. One way we are responding to our shortcomings in this area is to advocate for research to include these youth. Without this research, trans, non-binary and two-spirit youth are not represented in the data governments use to fund interventions and services. I recommend the federal government ensures existing public health surveillance systems count trans, non-binary and two-spirit people within the ethical framework Jack mentioned.

The federal government must also ensure queer and trans people are updated on all surveillance systems and CIHR-funded research projects across health domains. With this new data and existing data about queer and trans health inequities, I recommend the federal government continue to introduce funding dedicated to queer and trans health beyond just HIV.

Now I want to talk about the queer and trans youth in our programs who are living with HIV. The stories of these young people have many threads in common. First, youth are not being offered information about HIV, or the medication that treats and prevents it, as part of their regular health care.

Second, youth who sought mental health or addictions support were not always able to find it. Too often, support was only available through private programs or after a long wait-list. In many cases, support that was available did not have the capacity to address queer and trans-specific issues. For example, many addiction facilities are divided into men's and women's programs and in these scenarios some youth are left to choose between being misgendered in the program or not getting the addiction treatment they need.

Housing and employment insecurity disproportionately affect queer and trans youth who are less likely to have safe families they are able to ask for help. These factors can push us to have sex or use substances in ways where we are more likely to come into contact with HIV. Many emergency housing options are also gendered, leaving youth to choose whether they will be safer on the streets, in a gendered shelter or spending the night as a sex worker.

I recommend that federally funded institutions that house people, like corrections facilities, shelters and addiction treatment programs provide gender-neutral options and be staffed by people who have received queer and trans competency training. This recommendation would address this syndemic that drives health inequities among queer and trans people today.

Queer and trans youth living with HIV worry that they cannot afford HIV medications if they leave British Columbia. This is one reason I recommend the federal government introduce a national pharmacare program. This program must ensure access to HIV medications as well as gender-affirming medications such as hormone therapy.

Across our work at YouthCO we encounter people who still have more misinformation than facts about what it means to be queer and trans and what it means to be living with HIV. Some of this misinformation comes from the current policy of the federal government, like the deferral period for male blood donors and the criminalization of HIV non-disclosure. This misinformation fuels stigma and makes it harder for us to talk openly about our lives and get the health care we need. As long as this is the case, health inequities for queer and trans people will persist.

Thank you for your time. I look forward to your questions.

[The Chair, Liberal, Bill Casey]

Thanks to all of you.

Now we're going to our question period. Before I start, I want to remind everybody we'll go in camera at 5:10 to do some committee business.

Ms. Sidhu, would you like to start us off?

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Chair.

Thank you all for being here.

I'm sharing my time with Shaun Chen.

Jack Woodman, you said that health services need to be improved by including LGBTQ2 and when we heard from KW Counselling Services they said we need to change the way of doing data collection.

Can you explain to me what kinds of initiatives are necessary?

[Jack Woodman]

I'll start; and KW, feel free to jump in.

In terms of the challenges, often in the surveys we'll be asked to identify our sex and it might just offer the options of male and female. As you've heard, across gender spectrum, that doesn't capture the diversity that exists in gender. Sometimes people will use terms such as “other”, but again, you're still missing a lot of that diversity. When there's actually an opportunity for people to self-identify their gender, that is very helpful. Sometimes people do ask the question, “What is your sex assigned at birth?”, which is often a less relevant question than gender identity.

The other thing nationally that exists, just thinking of my Porter flight here or whenever I'm asked to fill out a form, or with honorifics and that type of thing, is that I'm required to put in Mr., Miss, Ms. or Mrs., or Dr., which I can use sometimes as well.

Those things need to be considered, especially for health surveys, because that information about gender can then be stratified against health outcome information. That's really the critical piece: Can we stratify that information to see where there are disparities and gaps in our health?

[Washington Silk]

I just want to emphasize again that collecting socio-demographic data will lead to better health outcomes and how we deliver our services.

Changing the form is not enough, if we don't create a system where people feel safe enough or have enough information to self-identify. I didn't know what the word “transgender” was until I was in my late 20s. I would never have put that on my form when I was 12, because I didn't even know the word existed. My doctor didn't either.

It's not just changing the form. Yes, it's very important for health outcomes, but it's also about training our doctors. It's about training nurses on how to have our conversations, making it a part of our regular, everyday functioning society, because trans and gender non-conforming people are a regular, everyday part of our society, right?

My point is that the effort needs to be holistic. Does that make sense?