Bread, Roses & Hormones launches a campaign to fight against Canada’s public medical system discrimination
For trans people in Canada, universal healthcare is a myth, and trying to access care as a low-income trans person is often a nightmare. Bread, Roses & Hormones (BRH) is a trans liberationist group led by low-income trans women and non-binary people based in Vancouver and, more recently, Nanaimo. We began organizing in 2018 and are currently working on a survey of trans people in BC. From our years of organizing, our preliminary survey data, and our own experiences trying to access care, we have seen that healthcare is a major issue for low-income trans people. We regularly confront low quality of care, long wait lists for hormones and surgery, high costs for hormones and other forms of care, and frustrations with our transitions so severe that we think about suicide or try to take our own lives.
Given the wide range of negative experiences with the healthcare system among trans people, including from trans-specific programs and “trans-knowledgeable” providers, BRH is launching a campaign to fight for a healthcare system where every single healthcare professional is held accountable for providing us with the quality healthcare we need. The only way to ensure the healthcare system meets our real needs is for trans people to set and enforce standards of care ourselves. To do this we need to form our own patient organizations and networks that name, expose, and fight back against medical discrimination in all its forms. This is the goal of the Universal Trans Care Now! campaign.
BCs healthcare is not accessible and quality healthcare!
The doctor-patient power relationship, which is heightened for trans patients because in many cases there are only a handful of doctors who agree to treat us, is the structural condition that allows for abuse to occur and go unchecked.
It was not until recently in BC that trans people could access Hormone Replacement Therapy (HRT) without a diagnosis of “gender identity disorder” or, as it is called now, “gender dysphoria.” To get this diagnosis you had to sit through a humiliating psychiatric evaluation. Laura, a member of BRH who tried to get on estrogen in her early 20s was prescribed testosterone because “men with depression sometimes do not produce enough” of that hormone. The consequence of this was that she went back in the closet and did not begin her transition for three more years.
Although we are no longer required to have a psychiatric diagnosis to receive care, getting to see a doctor willing to do the required “hormone readiness assessment” is no easy task. Although any general practitioner, family physician, and nurse practitioner with some basic training can approve hormones for trans patients, it is common for healthcare professionals to refuse to do the assessment, claiming they do not have that training. If we cannot access hormones through our regular healthcare provider, we can reach out to the Trans Care BC to connect us with a trans-friendly doctor. But there aren’t many trans-friendly doctors around, and even for those of us living in Metro Vancouver where there are more trans-friendly doctors, getting an appointment can take over a month or longer.
The problems do not end once you get an appointment. To get on hormones, you have to pass a hormone readiness assessment, which, according to the Provincial Health Authority Services website, takes a couple visits with a healthcare professional over the course of 2-6 months or even longer if you have “medical, health, or substance abuse issues.” Trans Care BC states that using substances does not bar people from accessing care but that the substance use should be “reasonably well controlled before starting” hormones. Many trans people who use drugs are self-medicating because of the alienation we experience from ourselves, and in these cases HRT may help us to mitigate our use of substances, while on the other hand, not being on HRT may be a condition for continued substance use that the HRT gatekeepers consider abuse.
Part of the hormone readiness assessment includes a physical examination and blood work. One member of BRH was sexually assaulted by a “trans friendly” doctor in a small town in BC. During their physical examinations the doctor told them it was normal to strip naked and be touched. This is not part of the regular physical examination. The doctor-patient power relationship, which is heightened for trans patients because in many cases there are only a handful of doctors who agree to treat us, is the structural condition that allows for abuse to occur and go unchecked.
Hormone readiness assessments also include questions about your relationship to your gender and what you desire to get out of HRT. Trans women who are butch or “tomboys,” femme or “effeminate” trans men, and non-binary people have a hard time being assessed as “ready” because they do not match the “True Transexual” story that assumes trans expressions of gender should correspond to typical cis-heterosexual expressions of femininity and masculinity.
While the path to hormones is riddled with stumbling blocks, the obstacles to getting surgery are even greater. On top of having to demonstrate “persistent gender dysphoria,” you need to have been on hormones for at least 12 months to get any feminization or masculinization surgery, excluding chest reduction, and have to go through a readiness assessment with your primary care physician. If you are approved you are then sent to one of the few surgeons in Canada that perform gender-affirming surgery.
We are subject to the prejudices and even desires of that particular surgeon. Trans people we have talked to have complained about how it may take years to get these surgeries done and in some cases have mentioned that they were unhappy with the results. In one particularly offensive case, a trans woman who got breast augmentation surgery was upset with the surgeon because he made her breasts much larger than she asked for.
Trans people are not alone in these surgery queues. Major procedures, like hip replacement surgery, generally mean painfully long wait lists and a barrage of readiness assessments. The fact that people have to wait for months and years to get necessary medical attention is a reflection of the abysmal doctor to patient ratio in Canada and therefore one of many reasons for trans and cis people to unite towards healthcare reform.
In the case of surgical assessments, we agree we need them as far as surgeons need to make sure we are giving informed consent, but we can’t help but feel like the same cis-heterosexual standards that mediate the gatekeeping of hormones are applied to our decision to undergo surgey and dictate whether we are eligible or not. It is tough to know when doctors’ personal and patriarchal standards come into play and when they do not, but the only thing that can ensure these standards have no more power over our lives is to normalize transition by expanding and expediting access to trans health.
Charging for hormones and surgery is anti-poor medical negligence!
For many trans people our hormones are our antidepressants, antipsychotics, and mood stabilizers and so by forcing us to pay for them healthcare providers are putting a price tag on our well-being and lives.
It is difficult to access hormones because they are prohibitively expensive. In BC testosterone treatment ranges from $10 (shots) to $130 (patch, oral, gel) a month. Estrogen, and the accompanying testosterone blocker that is needed before certain surgeries, is also quite expensive. To be on a stabilizing dose of both medications comes out to around $130 a month. The 2015 Trans PULSE survey of trans people in Ontario found that their median income was $1250 a month. Trans people disproportionately live in poverty and most of us are struggling to pay for our hormones.
First comes rent. The Province of BC defines “affordable housing” as 30% of a person’s income, so if we assume an income of $1250, “affordable” means paying $375 a month in rent. In BC, it is next to impossible to rent a home for this amount, which means many trans people are either homeless or are paying way more than 30% of our income on rent. Let’s say we live with friends and pay $500-750 for a room. After rent and hormones, we would have $12-20 a day to survive, hardly enough to pay a phone bill or buy groceries. If we are on welfare or disability and living in subsidized housing, after paying for hormones we have $12-25 a day to survive.
On top of paying for hormones there is the cost of surgeries. Some “masculinization” and “feminization” surgeries are covered under the BC Medical Services Plan (MSP) and others are not. For example, facial feminization surgery and electrolysis (hair removal) are not covered by MSP and are ridiculously expensive. But as discussed above, surgeries that are covered, for example “top” surgeries that get rid of or reconstruct breasts and “bottom” surgeries that change our genitalia, have “additional criteria” stipulating you have to consistently be on hormones for months and over 19 years of age before being assessed.
Charging trans people for hormones, surgeries, and procedures like electrolysis puts a prohibition on low-income trans people to transition. In BC, low-income people who take psychiatric medications are covered by Plan G and Pharmacare. For many trans people our hormones are our antidepressants, antipsychotics, and mood stabilizers and so by forcing us to pay for them healthcare providers are putting a price tag on our well-being and lives. This price is much too high, given the fact that according to the Canada Mortgage and Housing Corporation trans people are five times more likely to have mental health problems and five times more likely to attempt suicide than cis people.
Refusing us care can be lethal malpractice!
At one of our meetings Maya, a member of BRH, described an all-too-common trip to the clinic. “The doctor I was asking to refill my prescriptions refused to do so because one of them was hormones. The doctor had no issue refilling my medication until I got to the last on my list, estrogen. She then retracted the entire prescription and said she would not treat me and that I have to see a specialist.”
In this situation Maya couldn’t even get meds that had nothing to do with her transition because she is trans.
Because of such horror stories some trans people refuse to access the public healthcare system at all and decide to save up money to procure hormones from their trans sisters, brothers, and siblings and/or to pay for private surgeries out of the province.
Natalia, a young trans woman who responded to BRH’s survey, works in a kitchen and does sex work to save up for her surgery. Even with two jobs she says that sometimes she has to go off her hormones to put sufficient money away. She said that, for her, getting gender affirming surgeries is “life or death” and that if she cannot get them she will kill herself.
Similarly, Sonya, a 58-year-old trans woman who has been living on the streets since she was 14 said that for trans women that want to medically transition, “hormones are your best friend until you can get the surgery.” She told BRH members that if we’d met her before she had her gender-affirming surgery, we would have seen that she was “ready to jump off a bridge.”
Trans people should not be thinking about committing suicide or sinking into depression because we cannot afford or access our basic health needs.
We need free, accessible, and quality trans-competent care!
Fighting for and realizing the demand for Universal Trans Care Now! would mean an increase in the number of healthcare professionals that could meet our needs, free hormones and surgery, and ready access to mental health resources. It would do away with the waitlists, gatekeeping practices, and instances of abuse we come up against in the healthcare system. It would also give us a sense of our own power as trans people and would work to end the idea that there is something unquestionably normal about not being trans and something exceptional about being trans.
Universal Trans Care Now! campaign demands:
Surgeries are not luxuries! Every single trans person should be able to walk into a clinic and get a prescription for their hormones, a referral to surgery, or set up with a therapist without any hassle or judgement.
- We need free hormone replacement therapy over the counter!
- We need facial feminization surgery and electrolysis be covered under existing MSP coverage!
Trans healthcare is mind and body! Because of abuse and violence trans people are more likely to use drugs and struggle with depression, suicidal ideation, and psychosis.
- We need free and accessible therapy and trauma counselling!
Break the barriers to trans health care! Even if all forms of “gender-affirming care” were covered by MSP, many trans people would still be prohibited from accessing the care we need.
- We need all “additional criteria” for feminization and masculinization surgeries to be dropped!
- We need to be able to access HRT and gender-affirming surgeries and care without parental consent!
Trans healthcare everywhere! Even if all restrictions preventing trans people from accessing care were dropped, there would still be a lack of healthcare professionals to deliver the resources and services.
- We need to hold every single healthcare professional accountable for delivering free and adequate basic healthcare services to women, queer, and trans people including prescriptions, refferals, and regular check ups!
BRH has launched a campaign for Universal Trans Care Now! by pamphletting outside of clinics that have trans-friendly services and compiling a list of doctors who refuse us care to organize protests outside of the clinics where they work. Join our network of people who are sick of being denied care, caught in waitlists, and mistreated so we can start to fight for a healthcare system in BC that does not discriminate against trans people.
If you are interested in joining the campaign get in contact with us at: