Breaking Down Healthcare Barriers for Transgender British Columbians
by Zak Matieschyn, BSN, MN, RN, NP(Family)
I am always amazed, and a bit shocked, when I think about how much the world has changed in the 20 years since I began my nursing career as a student at the University of Victoria. We were still in the early days of the Internet back then, and had no idea that two decades later we would all be carrying mini computers and smartphones around everywhere we went. We were plugged into our discmans in the pre-iPod era and were still recording TV shows on big black VHS tapes. Healthcare was a completely different world – HAART therapy had still not been unleashed on the AIDS epidemic, smoking was still prevalent in nearly half of the population, the Botox era hadn’t started and no one had even considered that there could be a vaccine like HPV for teens that could prevent cancer later in life.
In the midst of all of these changes, complicated social debates that had previously seemed irreconcilable were firmly decided and put to rest: gay marriage, access to abortion, medical assistance in dying and the legalization of marijuana. Much was done to reduce stigma for those living with HIV and mental health issues. Healthcare and society have undergone significant positive change.
One of the most important changes for B.C. occurred in July, when the province amended its human rights code to ban discrimination on the basis of gender identity and expression.
I can’t profess to understand the emotional, psychological or physical challenges faced by those whose gender expression varies from what they are assigned at birth. But as a health practitioner and a human being, I recognize the systemic barriers that transgendered individuals feel when seeking health services in a system that forces you to tick ‘female’ or ‘male’ on most paperwork. And while transgender health services will hopefully become an aspect of health as routine as managing a thyroid condition, it is still considered a specialized area, with many healthcare practitioners feeling inadequate and uninformed when it comes to providing transgender health services.
Earlier this year, the sole healthcare practitioner who had been offering specialized care for transgendered people in my region needed to close his doors to any new referrals. This would effectively leave people needing to travel to larger centres in our province for their appointments (at least a four hour drive). Not only do people have the right to caring, non-judgemental health services, they should also be able to access them close to home wherever possible. In light of this, I was happy to complete some further studies and step in to fill this gap. I can truly say that this is some of most fulfilling work that I do – to help support and facilitate someone’s process towards their true gender expression.
I believe that most of us have the best interest of all patients at heart, and I know I still have a lot to learn about how to support and provide care for those who identify as transgender. I also know that it is part of my responsibility to understand, to learn and to continue to grow so that the divisions and barriers that these individuals currently face when seeking health care, are permanently eradicated. The truth is that our society, and by extension, our healthcare system, is still very entrenched in two gender, what-you-were-born-with-is who-you-are understanding. Just last week Saskatchewan announced that it would cover up to 100% of gender reassignment surgery – an important and groundbreaking move that will give hope to thousands of people. And yet the public reaction to this announcement has been overwhelmingly laced with homophobia, anger, distrust and scorn. This is not the response that we, as a society, need to be giving to a group of individuals that already face significant challenges.
As a profession, nursing could be better at preparing nurses to support transgender individuals. It goes further than just helping to ensure specialized transgendered care exists regionally where people need it. We all need to work towards a healthcare system that is barrier and judgement free. Great progress has been made over the past decades towards reducing discrimination on the basis of race and sexuality (although the work is certainly not yet complete). General acceptance of a broader comprehension of gender identity and expression is really still in its first steps.
I urge all nurses to consider what actions you might need to take to change the healthcare experience of the transgender patients you meet. For individuals, Trans Care BC has some modules they offer to targeted social service and healthcare workers who specifically work with trans people. For organizations such as ARNBC, there are programs like the VPD Safeplace program, of which we are a proud member. Safeplace allows anyone from the LGBTQ community who feels unsafe to seek out our office where staff will ensure they can talk to someone, rest and call police if necessary.
By our actions, by our willingness to learn, by our assuredness that every single person has the right to express themselves in the way they see fit – we can model leadership for the healthcare community. More importantly, we can demonstrate our belief that every single Canadian deserves competent, supportive and accessible health care.
ABOUT ZAK MATIESCHYN
Zak’s interest in health and healing began at the early age of nine years old when he would carry a small first aid kit while playing with friends. Since then, his passion for healthcare and health policy has been unwavering. He was particularly inspired by concepts of family, community and societal health, as well as the social determinants of health during his undergraduate (BSN UVic, 2000), graduate work (MN UVic, 2008), and clinical experience in urban, rural and remote B.C. communities.
Zak has served on numerous boards and committees, including the BC Nurse Practitioner Association Executive and was the first Nurse Practitioner in B.C. to be invited to sit on a Division of Family Practice Board (Kootenay Boundary, 2010 – 2014). Through this work he has gained valuable experience in member engagement, optimizing board governance, and relationship building among diverse stakeholders. In his clinical practice, Zak has worked med/surg, emergency, intensive care, vascular access and outpost nursing. After obtaining his NP education in 2008, he began a practice in a West Kootenay family clinic, providing primary healthcare to the general public with a focus on marginalized populations. Zak is President of the Association of Registered Nurses of BC.
I love everything about this post. As a nurse in a way more rural community than yours (ha) I find it gut-wrenching how little education and interest there can be amongst many of my neighbours when it comes to understanding, empathizing and trying to be supportive of anyone who identifies as different. In our small town we have an older male who identifies as trans, and he suffers what to my eye is endless abuse from his peers, the kids, the rednecks (yes we have those). It makes me wonder if there are others who desperately seek the opportunity to come out, but witness what he goes through and think it isn't worth it, when it truly is worth every single person feeling that they can freely be whoever they want to be.
Thanks for this post Zak. I would be interested in knowing what additional education you took. I wonder if ARNBC or someone could advocate for some sort of specialty certificate or certification or something like that? It's not the same as cultural competency, but there are similarities in that we need all health providers to start learning the very basics of human rights and human decency. I think a lot of us out here are interested and supportive, we just don't really know where to begin. Nice to see ARNBC and you reaching out on this important topic.
My daughter (now 19) told us during the 2010 Winter Olympics that she would be better suited to play on a team with Hayley Wickenhauser than Sidney Crosby. It took my husband and I a few minutes to realize what she was saying to us, and leave it to our kid to do it in such a weird way. But we got it. Despite mom's love for boys in hockey, I now had a girl in hockey.
We have learned a few important things since then, about the barriers my kid is going to face, simply because she wants to be who she was born to be - a girl. 1) Legislative - that there are places in this world my kid can't travel to without fear or shame - and yes, I'm looking at you America, 2) That hockey leagues in BC have figured out how to have girls on the boys team, but not how to have trans kid on the hockey team, 3) That people ask stupid and inappropriate questions about my kids body. Would you ask me what kind of equipment I have under my clothes? Why would you think it's ok to ask me about my kid's genitals? And why do you care? 4) That health professionals have the same biases as everyone else, and that many just have no idea how to manage a hard-headed, strong-willed kid who knows exactly who she wants to be. It's hard enough to find a doctor in BC. Harder still to find one you like. When you're trans, and your mom insists on regular doctor visits, it's almost impossible.
Please think about this all of you remarkable, nurturing, caring nurses. Unless you're one of those ridiculous people who think my kid chose this difficult path (in which case, America might be a good option), please take the time to learn what my kid, and all the other trans kids, needs are. Get to know the amazing, smart, loving, funny people they are and I think you too will want them to be the best version of themselves. They'll make you want to cheer for them - and they'll make you want to provide the best health care possible. And here's a little secret - you can screw up and refer to my kid as 'he' if you forget - she gets that and will laugh it off. You should too. All that she'll remember is that you didn't judge. That you cared for her like every other person you saw. And that you looked at her and saw an amazing, emerging young woman.
Yes, "nurses need to work towards a healthcare system that is barrier and judgement free for all".
It is important not to conflate sex with gender. Dr. Kathy Scarborough's article: " Women's Liberation is based on Sex not Gender" articulates this concept well.
The term gender is a social construct that has delineated and enforced "feminine" and "masculine" ways of behaving that have been harmful to men and, more particularly, women.
Sheila Jeffreys "Gender Hurts", explores the hierarchical nature of gender and gender roles.
Female erasure is something nurses should work toward preventing.
Forgive me if I'm wrong, but your comment seems to redirect the conversation away from transgender people's needs and towards women's needs - a perfectly legitimate topic, but not the one addressed here. Transgender people do not somehow diminish women's issues or value by virtue of having their own issues and experiences of profound societal devaluation and erasure, not to say outright hatred in many cases. Sheila Jeffreys is well-known for her vociferous transphobia and cannot be relied upon as a commentator on transgender needs in healthcare or anywhere else.
My ongoing frustration with discussions of transgender health care needs, when they happen at all, is that the conversations only seem to extend as far as what services transpeople need in order to transition from one gender to the "other." And in healthcare research, it is very common for researchers to claim in the title or keywords for their papers that they are studying LGBT healthcare needs, when in the actual body of the paper, only cisgendered gay men and lesbians are actually ever considered. What is needed is thoughtful awareness of the needs of transpeople from healthcare providers when transpeople have any other medical needs as well. For instance:
The commentary above mentions the challenges of finding a receptive family doctor. A transman myself, I left my former family doctor when it was apparent that she was hostile to my newly announced status, and then I spent a number years without any replacement for lack of a way to find someone more compassionate. Middle aged, increasingly in pain from a work history of heavy labour, and so on, I could well have used a range of services that many middle-age people get to take for granted.
In hospital situations, special provisions may be needed to maintain the safety and confidentiality of transgender patients - who are at risk of violence from other patients, visitors or possibly even staff, if their identity were revealed. Several times I have lain in emergency departments, protected only by a thin curtain from the adjoining bed, having to announce my trans status clearly and repeatedly to each new nurse, doctor or technician who comes through - and wondering just who is hearing me on the other side of the curtain. As a nurse, my observation is that full confidentiality is a rare thing for many hospital patients - but for a transperson the effect goes far beyond a violated sense of privacy to questions of immediate, basic safety.
Provisions are also needed for dealing with non-binary gender variant people - who reject an either-or gender identity of any sort: how well prepared are healthcare providers to respect people's wishes for pronouns, for how non-binary people are characterized both socially and even biologically within medical care?
In healthcare research it seems that very few (if any) inquiries have been made into how exogenous hormones affect the body's own hormonal activities and broader health issues. For instance, I have no idea whether I should follow male or female guidelines for safe levels of alcohol consumption or daily vitamin and nutrient requirements. What hemoglobin level would a doctor consider normal for me, a male's or a female's? What considerations should be addressed in working with aging transpeople, in all kinds of areas of gerontological medicine and societal supports?
I also feel strongly that health care agencies need to have trans advocates/ombudspeople in a similar way as some have advocates for First Nations people. For instance, I need to have a particular cancer-screening procedure - and even though I am myself a nurse on a cancer unit, I have not been able to bring myself to book the appointment, for fear of having to face unkind, unsympathetic technicians and care providers. This is a very common problem for transgender people and I repeatedly wish I could call on the services of a support person/advocate familiar with trans issues, to have someone with me at the test to support me if I meet disdain, disrespect or aggression.
These are only a few of the issues that our healthcare services have largely failed to address or understand. Many thanks for the editorial.
You raise many excellent points here, Darach. It is true that many healthcare encounters for transgender people become centred around the transitioning aspects of their health (e.g. hormones, surgery, etc) at the expense of any other aspect of health. While this may be the topic of some interactions, sometimes it is just an ear infection, or a strained lumbar, or acid reflux – issues that can be explored without needing to obtain a full and detailed trans health history!
I also appreciate your comments on non-binary / gender fluid identification. If society and the healthcare system has begun to wrap its collective mind around the concept of complete gender transition, the idea of non-binary gender represents a further stumbling block for many. Gender expression and identification is varied for many and may not take the form of full masculinizing or feminizing using every available intervention. As health care workers, our understanding of a person’s gender can start with the simple open-ended question of “How would you describe your gender?” instead of trying to tick one of three available boxes.
We will get to where we need to be. Painfully slow at times, but I am certain we will get there nonetheless!
What could you see the ARNBC doing to further these needed changes?