Ask an expert: Barriers to care for transgender and nonbinary people

In many areas of life, people who identify as transgender and nonbinary experience discrimination even where there are laws to protect transgender human rights. Health systems also pose barriers for transgender and nonbinary people, who are often more likely to delay obtaining medical care because of fear of discrimination and other factors. 

There are few Canadian studies on the surgical experiences of people who self-identify as members of these populations but a new paper by researchers, including Dr. Hilary MacCormick and Dr. Les Tyler Johnson of Dalhousie, describes the experiences of transgender and nonbinary people in accessing gender-affirming surgery. 

They found that study participants reported facing barriers, stress and marginalization, which can cause additional trauma in a situation where patients of any background might feel stress and anxiety because of surgery. 

Dr. MacCormick (shown left), an anesthesiologist in the Department of Women's and Obstetric Anesthesia and assistant professor at Dalhousie, outlines participant responses and the stress of negotiating the presurgical process. 

What kinds of barriers did transgender and nonbinary people face in accessing surgery and the health system in general?

There was a wide range of barriers described by the study participants. This included structural discrimination, stigmatization, both subtle and overt transphobia, lack of trans-competent (or sometimes even trans-friendly) health-care professionals, complicated bureaucracy to navigate access to gender affirming care, and financial barriers. We found that for many people we spoke to, the barriers and challenges in accessing gender affirming care (for example, hormone therapy) was so significant that it overshadowed their experiences to the extent that recollection and discussion of the remainder of the perioperative period was more limited.  

How did those barriers affect people seeking that kind of care? 

Most people we spoke to expressed frustration and often experienced a heightened sense of vulnerability when interacting with the health-care system. Many had negative experiences with the health-care system in the past and also described health-care professionals as gatekeepers, which made them feel as though they had to fight for validation of their very existence. There were some people who described positive interactions with health-care professionals, such as instances when health-care professionals displayed genuine enthusiasm and excitement and acknowledged the importance of gender-affirming care. 

Were there particular stories or participants who stood out to you and illustrated the difficulties in accessing good care? 

I think every participant’s story made a strong impression. Many people described feeling burdened to educate health-care professionals about trans health needs and feeling as though they had to be their own case worker to navigate a complex system with little to no external guidance. One participant shared that it’s "not uncommon to have people react in ways that make you acutely aware that they're having some kind of an emotional reaction that is distracting to them taking care of you for the reason that you’re there. Another summed it up when they said, “It’s more than cosmetics. It’s our lives. It’s who we are”.  

What do your findings tell you about what is needed or what needs to change in order to provide compassionate, timely and accessible care? 

Our findings show persistent gaps in Canada’s health-care systems, with trans and nonbinary people reporting that they did not experience a safe environment. There is still so much work to be done. Change is needed at all levels - from individual to institutional to governmental. We need more research, that includes and prioritizes the voices of trans and gender-diverse people, to help guide the development of educational materials for all stages of medical training. As health-care professionals, it is imperative that we advocate strongly for trans rights and do everything in our power to fight back against politicization of access to gender-affirming care.