Adrian Zhang knows firsthand the challenges that transgender people face in British Columbia. He came out to friends and family as a transgender male when he was 15.
With the support of his parents, he began seeing child psychologist Dr. Wallace Wong to begin his transition from the female gender he was assigned at birth to the male gender he knows he is.
He changed his name, the gender listed on his driver’s licence, and began answering to “he” and “him” instead of “she” and “her”. Now, after a year and a half on hormones, he is on the waiting list to have top surgery as the next step in his physical transition from female to male.
Although it will likely take more than two years until he gets his surgery, he is one of the lucky ones.
[pullquote align=right]This time we have a little bit more voice and we have a little bit more say[/pullquote]If Adrian were pursuing bottom surgery (genital reassignment surgery), he would be one of many on a list of people waiting to be approved by the one and only person in B.C. who can authorize this procedure: the chief assessor. Once approved, he would have to travel all the way to Montreal, the only place in Canada where the surgery is performed.
This arduous and expensive process is something that specialists say is not only frustrating but can be harmful. “If you have a major sexual organ that you need to have and you have to wait for that, that’s a lot of unnecessary trauma to put on the clients,” said Dr. Wong.
Transgender health care in B.C. is uncoordinated, complex and challenging, especially for people trying to access critical surgery. Transgender advocates have been voicing their concerns for years with little success, but new changes proposed by the Ministry of Health last October have them cautiously optimistic about the future.
“This time we have a little bit more voice and we have a little bit more say and politicians seem to be a little bit more accountable to pressure from us and our families,” said transgender advocate Morgane Oger.
From the very start, a medical transition is complicated, costly and time-consuming in B.C. To receive a prescription for hormones, Adrian could have given informed consent. Instead he opted to undergo a psychological assessment, which is necessary to get an official diagnosis of gender dysphoria.
That diagnosis is, however, required by the Ministry of Health for any surgery. After hormones, candidates have to undergo another psychological assessment to be approved for top surgery. The surgery and assessments are covered by B.C.’s Medical Services Plan (MSP), but the wait list is long. Those who can afford it can jump the line by paying out of pocket.
Adrian Zhang on the challenges of transitioning
All female-to-male procedures are covered by MSP. But for male-to-female transitions, breast augmentation is still considered cosmetic and therefore not covered.
For people who need bottom surgery to complete their transition, the process is the most complicated of all. They have to be psychologically and physically approved by two assessors, one of which must be the chief assessor and there is only one in the whole province. Once the procedure is approved, the wait list for surgery is long. Some people have waited up to six years.
There is one physician in B.C. who is trained to perform bottom surgery. However, Dr. Cameron Bowman cannot legally perform the procedure without a second certified surgeon in the province. And there isn’t one. As a result, patients must fly to Montreal for surgery.
Although MSP does fund bottom surgery, the additional costs required to access this procedure – flight and accommodation – are not covered and can add up to thousands of dollars. Phalloplasty, female-to-male genital surgery, has been covered by the province since 2012, but to date none have been completed.
It is unclear why, but experts speculate it is because of the high costs. “My own opinion is that it boils down to cost. I think a vaginoplasty is like $20,000 and a phalloplasty is like 80 or $90,000,” said Catherine Jenkins, secretary of PFLAG Vancouver, a support organization for friends and family of LGBTQ+ people.
Patients also do not have control over the date of their surgery and have to take time off work and school. Once they return to British Columbia, there is limited aftercare. If there are complications people have to communicate with surgeons in Montreal.
“We’ve had a number of experiences where the answer was ‘Take a picture of your privates and e-mail it to us’ and that was the extent of care available in British Columbia,” said Oger.
Although not all transgender people are interested in surgery, it can be an important part of presenting their affirmed gender in public. Psychologists say this is significant for confidence, social integration and safety.
“A lot of people look at surgery for trans people as an elective, it’s cosmetic, or something of that nature, but it is medically necessary,” said Jenkins.
Many in the transgender community reject imposed assessments altogether. They feel it is discriminatory to have to be diagnosed with a mental illness in order to get gender-affirming surgery. This process is unique to transgender health care.
“I know what is best for me more than someone else,” said Telyn Kusalik.
All of these medical challenges come on top of the social discrimination that transgender people face. Few general practitioners are knowledgeable about the transgender community. This means that access to even basic health care can be difficult and varies across the province depending on where people live.
Kusalik, who lives in Burnaby, has found it challenging to find a doctor who has experience with transgender people. “Trans healthcare isn’t just about hormones and surgery, it’s also about mental and emotional health,” said Telyn. Finding a physician who is knowledgeable about the transgender community is not easy. She hopes that one day transgender individuals will be able to rely on their family doctors for comprehensive care.
This is something that many in the community are hopeful for, but it will require much more widespread education.
“[Medical professionals] don’t have the information they need and thus don’t always provide as welcoming and inclusive a space for transgender people and I think that’s got to change,” said MLA Spencer Chandra Herbert.
Adrian Zhang on awareness and education
But changes have been underway in the province since October 2014. In response to repeated pressure from the transgender community, the province is putting the Provincial Health Services Authority in charge of the coordination of transgender health care starting April 1, 2015.
The province has now organized working groups that, with the support of health care practitioners and members of the transgender community, are planning a province-wide strategy that will aim to equalize care across British Columbia. Promised improvements include expanded services, increased access to care, and education.
While transgender advocates support the proposed changes, the success of these measures remains to be seen.
“The province has not yet earned our trust as a community and so it’s important to participate and watch what they’re doing so we can call them from a place of knowledge if things don’t work out the way they said they would,” said Oger.
The B.C. Ministry of Health, Vancouver Coastal Health and the Provincial Health Services Authority did not respond to repeated requests for comment.