Transgender hormone therapy, provided to individuals in a

access to gender-affirming surgery (GAS) is becoming a prominent subject. The
transgender community appears to be one of the most underserved and vulnerable
populations in our current health care system. Although a guideline is present
and being followed, access is difficult. Several considerations and the process
are very unique. Transition-related care could help alleviate health related
issues and can promote positive health outcomes (Wong, 2016). 

GAS is
considered to be a broad category and this includes counselling, surgical
interventions and hormone therapy, provided to individuals in a way that is
gender affirming (Frohard-Dourlent, Strayed & Saewyc, 2017). It is
important to note that not all transgender individuals are able to access GAS due
to various reasons, which include but are not limited to, finding a physician,
ability to pay Medical Services Plan (MSP) and availability of social support.
Transgender individuals face a unique hurdle. The inaccessibility to GAS is
contested and definitely categorized as discriminatory (Wong, 2016). Inequality
is present and the fact that GAS has a big impact on a transgender individual
makes it a pressing issue that needs to be dealt with. Support in accessing GAS
can help a transgender individual affirm their identity.

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Inequality is
not only seen with the access to GAS but also in different aspects of the lives
of transgender people. Being misgendered is one of them, the use of their
preferred name and pronoun. Confusion with the billing system is rampant as at
times they can be rejected due to apparent gender discordance
(Lelutiu-Weinberger, et al., 2016). Johnson (2015) illuminated that restroom
use and attire in the workplace can create a challenge for some transgender
individuals since their appearance does not match their inner gender identity.
He also added that discrimination in the workplace is visible in relation to
hiring and firing practices (Johnson, 2010) and inequality is associated with
depression, anxiety, job satisfaction and other health-related issues. Access
to basic healthcare is another barrier due to financial concerns and lower
employment rates. (Witten, 2014; Emlet, 2016). Some of them are living below
federal poverty line and the growing economic disparity is quite alarming.
Training in transgender care is also lacking wherein some health care
professionals are not knowledgeable about the services required for the
transgender population; thus, the increase of discrimination and victimization
(Porter et al., 2016).

concept of distributive justice plays a huge part in the access to GAS. It
implies that all individuals are entitled to benefit equally from the services
provided by a health care professional and how these benefits and burdens ought
to be distributed regardless of any personal characteristics or status (Toivonen
& Dobson, 2016; Maiese, 2003). The issues of access to GAS specifically to
Sexual Reassignment Surgery (SRS) are a big impediment to distributive justice.
One good example, there is only one publicly funded site in Canada which is
located in Montreal, Quebec where a transgender person can avail and receive
the full array of chest and genital SRS surgery (Toivonen & Dobson, 2017).
Wait times are an added problem to the access to SRS. Media reports estimated
that hundreds of transgender women go to Thailand annually to have SRS. The
cost of SRS is another barrier. There are instances as well where some
transgender individuals are seeking other alternatives in relation to GAS such
as the purchase of unregulated hormone treatments or cheap surgery. The
geographic location also affects as how these resources are accessed, if there
is only one physician in town and not well versed in transgender medicine, it
creates a huge problem to their overall status.

GAS has an
effect on the transgender individuals’ physical and mental well-being. Coverage
of some surgeries is important to support the transgender population. Some of
them are experiencing discrimination, poverty, ostracism and other issues being
part of the gender minority. Support to access GAS can be life- changing to a
transgender individual. A positive assumption with regard to GAS would mean
that individuals who are able to start GAS could have a significant reduction
in depression and anxiety. High rates of suicidal behaviour are also seen in
the transgender community. Toivonen and Dobson (2017) found out that suicide
among transgender individuals is high. Canadian research suggests that 26%
attempted suicide at least once while in the process of transitioning. Thus,
having an easier access to GAS would support and mitigate all these other
issues that a transgender person is going through while undergoing transition.


is a Transgender?

Transgender, as
defined by Persson (2009) pertains to individuals whose sex assigned at birth
does not match with their gender identity and it includes
trans men, trans women and non-binary people. Transgender individuals require
access to surgeries in order to address gender dysphoria. According to the
American Psychiatric Association (2017), “gender dysphoria involves a conflict
between a person’s physical or assigned gender and the gender with which he/she/they
identify”.  Some individuals diagnosed
with gender dysphoria may find it difficult to assimilate into the environment
they are living and be able to express one’s self.

individuals may feel uncomfortable with the gender they were assigned. At times
they will verbalize that they are not comfortable with their body or they are
trapped in the wrong body.  It affects
the individual due to the conflict. Gender dysphoria diagnosis creates distress
to the individual and the marked incongruence with their gender is one of the
steps needed to identify the course of action required to affirm the gender
they identified with and that includes GAS.


is Gender Affirming Surgery (GAS)?

History provided
us with what may seem to have influenced how treatment was administered to
transgender individuals (Vineham, 2010). Christine Jorgensen’s treatment prior
to her surgery also included a psychiatric evaluation. In present time in BC,
the Surgery Readiness Assessment (SRA) is the key standard by Trans Care BC in
order to be eligible for the surgery. Similar to Christine Jorgensen’s time, it
is needed to undergo Hormone Replacement Therapy (HRT) first before SRS is
considered (Denny, 1998). During Jorgensen’s time, often, a two year period was
needed living full time as the opposite gender prior to genital SRS while at
the moment, one year of HRT is recommended before undergoing surgery portion of
the GAS.

GAS access by a
transgender individual starts from their initial contact with their primary
care provider (PCP) whether it is the initial phase of referral to a counsellor
regarding their feelings about being trans or starting HRT. Prior to access to
surgery, one-year HRT is part of the criteria for the referral for the SRA. Therefore;
it is imperative that the individual has already undergone at least a year of
HRT with the exception of chest surgery.


GAS works?

Trans Care BC is
a provincial resource for transgender individuals. They provide services such
as gender-affirming health and wellness support to the people of BC.
Transgender Health Information Program (THIP) was the one previously providing
service and now Trans Care BC is the new resource that assists trans
individuals from assessment to surgery to post-surgical care and support.
According to Trans Care BC (2017), MSP provides coverage for certain surgeries.
Feminizing surgeries include orchiectomy, vaginoplasty and breast construction.
On the other hand, masculinizing surgeries consist of chest surgery, hysterectomy,
clitoral release, metoidioplasty and phalloplasty. There are steps needed in
order to be qualified for the surgeries stipulated by the THIP.

The PCP plays a
big role in order to get things done. They would do an initial check-up with
the client and then will refer them for assessment. Qualified assessors are the
ones who will give you the go-signal for the surgery. It is to confirm that the
client meets the World Professional Association for Transgender Health (WPATH).
Wylie et al., (2016) discussed that WPATH standard of care ” is an
international, multidisciplinary professional association that promotes
evidence-based care, education, research, advocacy, public policy and respect
in transsexual and transgender health care”. The process is to ensure that a
transgender individual is prepared for the surgery and will have the best
possible post-surgical outcomes (Frohard-Dourlent, Strayed & Saewyc, 2017).
The SRA is part of the WPATH standard in order to become eligible for GAS.

SRA is crucial
and this is a step where an assessment is conducted. The SRA is a requirement
by the surgeon, which aligns with the WPATH Standards of Care. The assessment
is focused on the individual by asking about readiness for the procedure. The
assessors will ask as well about the supports that the trans individual put in
place for before and after the surgery. General Practitioners (GPs), Nurse
Practitioners (NP’s), psychiatrists, and psychologists can do the
assessment.  The range of qualified
health care professionals can pose a problem as these practitioners have
different training and practices which can affect the process and also suggests
the lack of standardized practice in BC (Frohard-Dourlent, Strayed &
Saewyc, 2017).

One has to
consider not only the location of the assessors but also where the surgeon is
situated in relation to distance from the client. Currently, there are no
surgeons in BC that can do lower surgeries which are vaginoplasty and
phalloplasty.  The lower body surgeries
are considered as publicly funded surgeries and by the MSP guideline, surgeries
that are out of the province are paid and accessed by MSP. Out of the country
is also another option for an individual but stipulations are considered strict
which makes the process more tedious and frustrating for some. Wait times vary
in different provinces but BC has “150 days or less between the referral and
their most recent SRA appointment” (Frohard-Dourlent, Villalobos & Saewyc,
2017, page 14). Approval of the surgery follows, then the day of the procedure
and post-surgery care. Frohard-Dourlent, Villalobos and Saewyc (2017) stated
that extensive lower body surgeries require after care for up to 10 days after
vaginoplasty or phalloplasty.