Trans health in Canada: reflections and resources from CPATH

At the end of October I attended the CPATH 2017 (Canadian Professional Association for Transgender Health) conference in Vancouver. It was a fascinating event from which I learned a great deal. I’m keen to share some of my thoughts and experiences with others, as I feel there is a great deal that trans health researchers, practitioners and activists can learn from the progress that’s been made in Canada, as well as the limitations of that progress.

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Poster: “In Our Dream B.C….”, by Drawing Change. Based on Trans Care BC consultation with gender creative, trans, and two-spirit youth and their families..

In this post, I reflect briefly on my impressions of the conference, and link to Twitter threads I wrote during various sessions. You can also read my initial thoughts on the conference here.


CPATH took a broadly holistic approach to trans health

Over 300 people took part in the three-day CPATH 2017 conference and two-day pre-conference. In attendance were GPs, nurses, endocrinologists, psychologists, psychiatrists, therapists and counsellors, social workers, healthcare administrators, peer and parent support group facilitators, academic researchers, lawyers, politicians, and various trans campaigners.

CPATH 2017 treated “health” as a social phenomenon as well as a purely embodied matter, and this made for some very productive conversations. For example, numerous sessions explored how trans healthcare might best be provided in the context of primary health. Gender identity services are frequently provided by GPs with support from external specialists, a model of care that is currently under consideration for England. In some Canadian Provinces, organisations such as Trans Care BC help to connect providers in primary care to relevant specialists, and support trans people in obtaining interventions such as hormone therapy and surgeries.

This approach enables continuity of care in a local context, with family doctors enabled to provide trans-specific care for their patients alongside everyday services. It reduces barriers to access such as waiting times and the necessity of long-distance travel. It also enables GPs to help their trans patients access a wider range of specialist services: for instance, trans people with mental health issues might benefit from a referral to a peer support group as well as or instead of formal therapy (depending on patient desire and need). Many practitioners provide services on the basis of informed consent, rather than using mental health assessments as gatekeeping measures. It was heartening to see generalist and specialist healthcare professionals, social workers, trans activists and others engaged in open discussions about how best to manage care through this kind of system.

I was also particularly struck (and moved) by a session entitled Trans and Two Spirit Youth Speak Back! The 40 or so adults in attendance – mostly healthcare professionals or researchers of one stripe or another – were asked not to speak at all during this workshop. We were instead invited to listen to the stories and experiences of trans and two-spirit young people, who sat dotted around the room and answered pre-prepared questions delivered by a youth group facilitator. This session structurally prioritised the voices of young trans people who are so often silenced, and also offered an opportunity for us to hear how the healthcare needs and challenges faced by these individuals were shaped by their cultural heritage, family life, schools and peer groups.


CPATH took intersectional trans voices seriously

Trans and Two Spirit Youth Speak Back! was just one example of how trans voices were frequently centred at CPATH 2017. As an attendee from the UK, I was very impressed by this! Our trans healthcare conferences, seminars and workshops tend to be organised by and for community groups, researchers or healthcare providers, with relatively little overlap between attendees at these events. Very few practitioners are (openly) trans, meaning that trans people tend to talk to one another at community and research events, but are heard less often at healthcare conferences for doctors, nurses and mental health specialists. Moreover, the speaker line-ups at all these events tend to overwhelmingly prioritise the most privileged individuals, such as white people and men. The only possible exception is cliniQ’s Trans Health Matters conference, and that event too feels like it’s taking the first steps towards something better.

During the opening plenary of the CPATH conference proper, we were informed that around one third of speakers at the event were trans, and around a tenth were Indigenous (i.e. of First Nations heritage). I’m not sure how many people of colour were represented at the event more generally, but the all-white panels which are a norm at UK events seemed few and far between.

Importantly, the trans women, trans men, non-binary and two-spirit platformed as speakers and workshop facilitators were usually also professionals. We weren’t simply present at CPATH to represent a “patient perspective”: rather, we were the experts. This reflects the hard work of individuals in pursuing a career, and the collective work of CPATH in supporting trans professionals; it also reflects the actions of local providers in various parts of Canada who have made an active effort to employ trans people, or secure funding for partnerships with trans-led organisations.

In my previous post I noted that the opening plenary of the conference proper centred Indigenous voices. This included a formal welcome from Musqueam Elder Jewel Thomas, and talks by trans and two-spirit Indigenous educators from different parts of North America. I was happy to see that the plenary session on the second day of the conference continued to centre the voices of individuals who tend to be marginalised within even trans spaces. Two-spirit physician Dr James Makokis and Latina trans activist Betty Iglesias – who discussed issues faced by trans sex workers and migrants – were platformed alongside an Member of Parliament from Canada’s ruling Liberal Party, resulting in a thoughtful and challenging debate.


CPATH (and the rest of us) still have a lot of work still to do

I left CPATH with a very positive impression, but Canada is by no means the promised land for trans health. Professionals and patient representatives alike frequently discussed the challenges they faced in providing gender-affirming services. Transphobia and cisgenderism are still very much prevalent within healthcare provision and legal frameworks, particularly outside of urban areas: there is therefore a great need for better education among trainees and further reform of laws and guidelines. Limited funding and different approaches across the country’s Provinces and Territories also mean that not everyone has the same access to treatment, and waiting lists persist for publicly-funded care. These are challenges that exist across the world, and may benefit from greater international collaboration and strategy-sharing.

At the end of the first day of the conference proper, there was a reception specifically for trans people attending the conference. I later reflected on the experience of attending this reception in conversation with a genderqueer colleague; both of us felt ourselves relaxing enormously upon entering the trans-only space. For all the positives of CPATH, it was a huge relief to step away from cisgenderist expectations and microaggressions that quietly persisted throughout the conference proper. These included a range of unspoken ideas about how we should dress, act, and talk “professionally”, limitations on our ability to name transphobia within healthcare settings without fearing repercussions, and the occasional terrible intervention from self-righteous cis professionals.

As ever, facing down these challenges is hardest for the most marginalised trans people, including (for instance) disabled individuals, sex workers, migrants, and people of colour. I was aware that while CPATH 2017 took a broadly intersectional approach, instances of ableism, racism, sexism and so on persisted: and this could take the form of unexamined prejudices on the part of more privileged trans people too. Moreover, white people were still heavily overrepresented among conference attendees; a phenomenon that was particularly noticeable at an event held in a city as diverse as Vancouver.

What I’m taking from this is a reminder that equality work is never “done”; rather, it is something that we should strive to always “do”. We should aim constant improvement in our relations to one another rather than assuming that solidarity and equality are things that we can simply achieve. It is in this spirit that I’ve attempted to use my own privilege as an academic to bring back lessons from Canada for the UK and beyond.

So, I’ll end this post with a serious of links to Twitter threads from the event. I livetweeted extensively from CPATH 2017, sharing summaries of the numerous talks and workshops I attended. This is by no means a comprehensive summary of any of the sessions I was at, let alone the wider conference (as numerous parallel sessions took place simultaneously). However, I hope the ideas and approaches will be as useful and interesting to you as they are to me.


Pre-conference (training) Twitter threads

Day 1:

Introduction to Gender-Affirming Practice

Pre-puberty/Puberty: Addressing On-coming Puberty

 

Day 2:

Adolescence: Moving Forward With Gender-affirming Care for Youth

Cross Country Health Clinic Practice Panel: Models of Care and Clinical Practices

 

Conference Twitter threads

Day 1:

Plenary: Centering Indigeneity and Decolonizing Gender

Interpersonal Communication Needs of Transgender People

Ethical Guidelines for Research Involving Trans People: Launch of a New Resource

Investigating the Medicalization of Trans Identity

Primary Care Approaches to Caring for Trans Youth

 

Day 2:

Plenary: Fostering Safety and Inclusion in Service Provision, Systems and Sectors

Non-binary Inclusion in Systems of Care

Trans Data Collection and Privacy

Legal, Ethical, Clinical Challenges: Youth Consent to Gender Affirming Medical Care

 

Day 3:

Pregnancy and Birth

Plenary: Supporting Older Trans People

 

 

Some reflections on Trans Health Matters 2017

Last week I joined over a hundred other attendees at the Trans Health Matters conference in London. The event (which takes place on a mostly annual basis) was organised by cliniQ, the city’s holistic trans sexual health clinic.

For impressions of the day, you can visit the Twitter hashtag for the event here.

When I attended the first cliniQ Trans Health Matters conference in 2013, I found it to be immensely valuable and informative, but left with a feeling of deep-seated distress that persisted pretty much ever since. For at that event, I gained a better understanding of the scale of the problems that plague trans healthcare provision.

These include widespread ignorance and often also active discrimination from practitioners, plus enormous (and growing) waiting lists for gender clinics. All things I already knew about, but swapping notes with other researchers and activists helped me realise just how common and severe the issues were. My impressions from the conference were also reflected in the initial findings from my PhD fieldwork, which I was undertaking at the time.

By contrast, I left this year’s event with a greater sense of optimism and hope.

That’s not to say that trans health isn’t still a disaster area. It really is. However, I feel that since 2013, there has been a real growth in community health initiatives, and also in cis practitioners’ active engagement in the issues. This was actively reflected in the conference programme, which focused largely on what is being done and what we can do to make things better.


What is “trans health”?

Interestingly, another positive aspect of the conference for me was that gender clinics and transition processes were barely discussed at Trans Health Matters 2017.

That isn’t to say that these aren’t important things to talk about – they absolutely are – but one of my observations over the last few years has been that discussions of “trans health” focus so overwhelmingly on gender identity services that an outside observer would be forgiven for thinking that transition is the only healthcare issue that really exists for trans people.

Which, of course, would be completely wrong. Trans people face extremely high rates of discrimination, harassment, internalised stigma, poverty, physical violence and domestic abuse. These challenges can be be linked to endemic mental health problems, suicidality, substance abuse, “risky” sexual practices and disability within trans populations. Moreover, there is the matter of everyday transphobia and cisgenderism in everyday encounters with healthcare practitioners.

So it was genuinely refreshing to attend a trans health conference that focused largely on sexual health (particularly HIV prevention, reflecting cliniQ’s role as a sexual health clinic), with some additional discussion of matters such as therapy, sex work, data collection, and intersectionality. These are all deeply important issues that really deserve the attention they received on the day.

Of course, the absence of discussion on gender identity services would be a real issue if these conversations weren’t already happening elsewhere. But they are. This year alone, I’ve attended two UK trans health conferences which centred issues of transition, and I know there have been plenty of other such events that I haven’t been able to go to. This is another cause for optimism: a great increase in activist, academic and professional events looking at trans health from a range of angles, reflecting the rapid growth and increasing visibility of our communities.


Towards inclusive care

While there are a growing number of trans-specific sexual health services available in UK cities, it was really good to see a lot of discussion around how trans people can be included in services (and the promotion of these services) more generally. A great example of this was a short film that’s been made about PrEP, from which extracts were shown at the conference.

I was also really heartened to see that Trans Health Matters was a somewhat more intersectional affair this year. Two of the four speakers on the keynote panel were trans women of colour. We got to hear a particularly inspiring speech from Mexican/US activist Alexandra Rodríguez, who explained how she created a pioneering HIV prevention service for trans Latinas in California after realising there were no existing services, and reflected on the importance of providing care and support for trans migrants.

I also attended an afternoon session on barriers to access and strategies for inclusion for some of the most vulnerable trans populations in the UK: black and minority ethnic trans people, non-British trans people, and economically marginalised trans people (these are, of course, groups that frequently intersect!)

Barriers to healthcare access for BAME and/or non-British trans people.
Photos taken with permission during breakout session.

One of the most important lessons from this session was the importance of reaching out for service providers, rather than expecting that the most marginalised people will feel that a service is necessarily for them. This is particularly the case if a service is normally primarily attended by and promoted to a relatively privileged demographic.

The work of reaching out may involve an element of discomfort for white and/or middle class providers; it can involve sensitively negotiating access to new spaces (e.g. club nights and community groups run by and for people of colour and/or working class people), learning from mistakes and being open to listen and learn with humility. But it is vital to ensure that community services are truly inclusive.


Reproductive health survey

The importance of the work of inclusion really came to the fore in a plenary session where we were shown initial findings from a trans reproductive health survey undertaken by Public Health England.

The survey is still open: you can take it here.

This is the first major stastical study looking at trans people’s reproductive health and experience of services in the UK. As the survey hasn’t yet closed and the data still requires some additional processing, we were asked not to report on specific figures. However, what I can say is that (unsurprisingly) there were generally high levels of dissatisfaction with existing service providers and sexual health education, reflecting an urgent need for improvement and trans inclusion.

The aspect of the survey that inspired the most discussion and debate amongst conference attendees, however, was the lack of diversity among existing survey respondents. A majority of respondents had received a university education, and an overwhelming number were white. This reflects a wider trend in trans community responses to online surveys: it is the most privileged individuals who are more likely have access to these.

I asked the speaker if there had been a paper version of the survey produced: these can help obtain a greater number of responses from individuals less likely to access an Internet survey, including trans people of colour, working class trans people, and older trans people. He noted that unfortunately the research team (which I believe consists just of himself and a single support worker) are underfunded and are trying to do their best with the resources they have. However, other audience members noted that there were still things that could have been done to increase the response rate from underrepresented groups. For instance, the research team could have reached out to UK Black Pride and asked for help with dissemination.

To me, this conversation really brings home the importance of active inclusion, which was the main thing I have been thinking about since attending Trans Health Matters. We can’t just assume that all members of our communities will be able to access services and research: rather, we need to make the effort to ensure that they are accessible. This can involve additional work, but the real challenge is overcoming the ignorance that can arise from our own privilege, even if we are ourselves marginalised in different ways.