Health Committee on May 7th, 2019

[Sonia Sidhu, Liberal, Brampton South, ON]

Anyone can answer this question: What about education? At what age is it necessary, when we are providing the education to the schools?

[Lorraine Grieves]

Education is needed broadly from the age of day care through to the rest of our lives. Young people get gendered and start getting put into those gender boxes right when they start encountering, sometimes at the hospital when we think about what people ask when babies are born: Is it a boy? Is it a girl?

Broad education at all levels is needed, from very basic through to more specialized, depending on the setting.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

I'll pass it over to Shaun.

[Shaun Chen, Liberal, Scarborough North, ON]

Thank you, Mr. Chair.

Thank you to the witnesses today for providing some incredible testimony and for their passion on this issue.

I know a few of you are from Ontario, particularly Jack, Washington and Scott. My background is in education. Before coming to Ottawa, I was the chair and trustee of the Toronto District School Board.

I know in Ontario now the provincial government has scrapped the 2015 sex education curriculum, and with it, lessons on gender expression, gender identity, same-sex marriage, same-sex relationships and sexual orientation. There have been groups and individuals, ranging from the Canadian Civil Liberties Association to teachers, health educators, medical professionals, social workers, parents and students, who have come out very strongly in recent weeks and months against these changes imposed by the Ontario provincial government.

As people who work with the trans and LGBTQ community, can you speak to the impact of those changes within the Ontario education system on young people?

[Washington Silk]

First and foremost, we're going to expose young people to minority stress. From the get-go, you're being told you don't matter and you're being erased, which is directly correlated to mental health distress and suicide.

On top of that, the number of requests we have from the teachers has increased tenfold, because teachers no longer feel confident to support LGBTQ students. They're more worried about getting in trouble than the well-being of their students, and not all teachers by any means, but they're asking for outside support. We've been working for over 10 years to get to an amazing place with the school board, and I just feel as though it's a big step back.

[Jack Woodman]

Absolutely, I concur with that. What I'll add to this conversation, because my organization works with health care professionals, is that education through the entire trajectory into university and professional health care education is critical, because there's just so much lack of knowledge across health care providers that when trans and gender-diverse people are going to see them, they don't necessarily have the skills and knowledge that they need. In fact, one of my greatest career challenges has been the development of the gender-affirming surgical program at Women's College Hospital. To find surgeons to recruit and train at that level is very challenging.

Absolutely, across the whole spectrum of education we need to be promoting that. As Lorraine said, it's really from day care when we start gendering folks in that way.

[Scott Williams]

There's nothing to add, I don't think, to that.

[Shaun Chen, Liberal, Scarborough North, ON]

There was some testimony about racialized and aboriginal communities. Can you speak to some of the gaps in terms of education when it comes to new immigrant communities and racialized communities? How can we do a better job at promoting that education within those groups?

That's open to anyone.

[Lorraine Grieves]

That's a big question. I'll start with indigenous communities, and I'll speak to the B.C. context, because that's where we're working. B.C. has 203 first nations. To begin to understand how Trans Care BC as a program can be relevant to the communities in B.C., we've taken our time to travel, to introduce the program and to try to understand by having direct conversations with people who will show up and meet with us about the intersections of colonization and gender and how colonization has impacted gender.

One story really stands out to me. We had a meeting in a community in the north and, on the way into the meeting, someone who's quite prominent, an elder in the community, was bullied by people outside the meeting saying, “Why are you going to that gay meeting? You shouldn't go in there.” The session then became around this conversation about this idea that they come and talk about trans issues or gender diversity—one was gay—and that the community just literally didn't have safety around being queer, trans, etc. That was directly related to colonization, histories of residential schools in that community and the idea that somehow being gay was attached to possibly a sexual abuse history. It's a very complex and very local understanding.

I think all of that work needs to be really attuned and tailored to the community that it's being addressed to. Similarly with newcomers and refugee communities, people come from a particular cultural understanding of gender and gender diversity, and there are both strengths and sometimes challenges to that. There are many examples of gender diversity around the world.

I'm also a clinical counsellor. I didn't mention that. Some of my conversations with diverse young people from different cultural backgrounds ask if they know about gender diversity in their culture. There are some very good online tools and maps of the world that we can explore and look at the history of gender diversity in Thailand, for example, or other places around the world.

I don't think there's a simple answer, but it's all about dialogical engagement of the people we're working with.

[Shaun Chen, Liberal, Scarborough North, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

Now we go to Ms. Gladu.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you, Chair.

Thank you to the witnesses for being here.

First I want to start by apologizing for our being late. I wanted to make you aware that one of our colleagues, Mark Warawa, who's the member for Langley—Aldergrove, has found out that he has cancer, and it's colon cancer that has spread to his lungs and his lymph nodes, so he was making his final speech in the House today, which was a very sad occasion, and that's why we're late.

I want to focus my questions, if I can, on some things that are specific to being transgender. We've been hearing a lot about LGBTQ health issues, but I want to see if there are ones that are particular and maybe different than the rest.

When it comes to having surgery conversion, are there any specific issues with respect to failed surgeries or complications that would be health issues that transgender people would experience that the rest would not?

That's for anybody.

[Jack Woodman]

I'll take that question.

Speaking to the surgical question that you're asking, there are complications, just as there are to any surgery. But the real complication for transgender communities is that there is not local care. Folks are often having to leave the province or leave the country to get surgical access, and then when they return, if there is a complication, there is not necessarily a provider or a clinic or a service that is able to address those locally. Then they may have to either return to that service or find somebody locally who maybe doesn't have that expertise. That's part of the program we're trying to build out in B.C. and in Ontario, but of course, there are going to be people from farther afield who don't have that access.

In terms of speaking to differing health outcomes and that sort of thing, there are a number—and I'll let my colleagues jump in on this—but the one that is often discussed from the research is the suicidality, which is not in fact related to being trans, because being trans is not a pathology in and of itself. But it is because of the social oppression that occurs, and what we do see is 23% to 43% of trans people reporting a history of suicide attempts. Obviously, mental and psychosocial support for the population is critical.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Is there any other input on that question?

[Washington Silk]

I just want to add a couple of items. One is wait times. People are most at risk of attempting or completing suicide when they're told to wait. You can imagine it as being under water your whole life and finally coming up for a breath of fresh air, asking a doctor or someone to pull you out, but instead they push you back down because they say they don't know enough or you have to wait. When you're ready to change, you've perhaps shed your internalized homophobia or transphobia, you're ready to be who you are, and no one's there for you. You're told to wait. You have to wait two years, you have to wait six months, you have to go talk to someone you've never met, share intimate details of your life, get it written in a letter to prove you are who you say you are. It's very difficult.

I do actually have some local stats that I think are very valuable. I'll just share a couple of them.

Some 76% of trans people had to educate at least four different health care providers about their own health care. I don't know any other situation that's very similar. Some 53% had to educate their mental health providers and 48% their family doctors, 40% the clerical staff, 39% their psychiatrists. Psychiatrists are the ones who have the power to give you the diagnosis. That's pretty serious.

In Waterloo region, we know that most people have a primary care provider, but at least 23% of the doctors said they don't know how to provide that care. So people have to go elsewhere. More than anything else, people avoid hospitals, emergency rooms, medical offices and urgent care because of their gender identity and how they're going to be treated, putting their lives at risk.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

You mentioned there are long wait times. What is the wait time and how long does it take from the time you start hormone therapy until you can complete your surgical finality?

[Lorraine Grieves]

The pathways are really variable for people, so it's a really hard point to speak to.

I think, as you heard, the journey is very long for people. Often, someone might think for a long time about coming out and talking to a professional, and then the search to find that first professional can take a long time. Many people start with hormone therapy and then sometimes after a year, five years, 10 years—it totally depends on the individual—they might think about surgery. Some people will never access surgery. It really depends on where one is in any given province or anywhere in the country, because access is not even.

We found in B.C., as we've explored the client journey, that there are just many bottlenecks along the way and, in fact, big variation in clinical practice, in part depending on when people were trained. It's been really new work to start to bring together providers and people who access services to try to have more standard pathways and more clear standards of care.

For example, our B.C. patients are travelling to Montreal for the most complex surgeries, for genital reconstruction surgery, and then returning home. That wait can be—once the referral is in—anywhere from nine months to two years, for say, a vaginoplasty, which is one of those surgeries.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

In the provinces that don't have the service, do they pay the Province of Quebec or whatever for the surgery? Does the patient have to pay and get it back?

[Lorraine Grieves]

In B.C. the genital surgeries are funded by MSP, which is our provincial insurer, and they have an agreement with the Montreal clinic to pay for services there.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

I have a question for Sarah.

Talking about HIV and hep C, is there a difference between the trans population and the greater LGBTQ population in terms of frequency?

[Sarah Chown]

That's a great question.

I think the answer is that we don't have the best data to answer that question in a Canadian context. We know from the data more broadly that trans women and trans women of colour are disproportionately affected by both HIV and hep C. But we don't have Canadian data that says that at a national level, because the Public Health Agency of Canada HIV surveillance data doesn't include trans, non-binary and two-spirit as a specific category in what's recorded publicly.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

First of all, I want to thank all of the witnesses for being here. I want to thank you for sharing intimate details of your lives. It's very powerful and I can tell you, you're educating us. I learn things every meeting when we talk. You're helping to change minds here, and I want to just point that out.

Jack, I had a number of questions for you to start with. In terms of gender transition surgeries, is there a significant difference in access between males transitioning to females versus females transitioning to male, or is it equally the same weight?

[Jack Woodman]

As I mentioned, there's only one clinic in the country right now that does genital surgeries, and that's in Montreal. We are, in Ontario, going to be offering vaginoplasty but not phalloplasty. In B.C. I believe they're going to be offering all genital surgeries on both sides of that binary.

My answer is no. There's poor access across the board.