Why Trans People Are Forced to Self-Advocate for Decent Healthcare

Image: G.C. Houle

From the first phone call with my doctor, I knew there’d be obstacles ahead. Seconds after picking up, he started asking questions about my transition that made me uneasy. Right away, he brought up gender-affirming surgery—he wanted to know when I planned to get vaginoplasty.

I knew what he wanted to hear: that I wanted the surgery as soon as possible. The truth was, I didn’t want it at all. I’m non-binary and the way I experience gender is that the concepts of “man” and “woman” exist on opposite ends of a sliding scale. I needed transition care, which for me meant hormone replacement therapy, but not that particular surgery. The immediate focus on genitalia made me uncomfortable. I was just starting to transition and wasn’t thinking about surgery.

Many doctors—even trans specialists—expect patients to accept the care most commonly associated with a male-to-female or female-to-male medical transition, which is hormone therapy leading toward either vaginoplasty or mastectomy. I swallowed my pride and told the doctor that I wanted vaginoplasty, even though I didn’t. His tone shifted right away. When I agreed, at least in theory, to treatment that adhered to the gender binary, he seemed to understand the path forward for me under his care. It was demoralizing, but I was one step closer to the care I deserve and the medications that would change my life, which for me were testosterone blockers and estrogen.

Sadly, my experience isn’t unusual. According to The Canadian Journal of Human Sexuality, there is an overemphasis on stereotypical gender norms within trans health care. In my experience, many medical professionals assume that if you don’t conform to male identity, you must be female—or vice versa. The medical model of transitioning is grounded in the gender binary, which creates problems for non-binary patients like me, who, as the study notes, commonly have to prove they’re “trans enough.” Making matters worse, studies have found that medical professionals don’t receive education about trans health care. In a poll published in the Canadian Medical Education Journal, 71 percent of family doctors said trans care was within their purview, but just 10 percent felt prepared to provide it.

Making my way through the health care system as a non-binary person has felt like taking a series of tests where a “wrong” answer could halt my care. When it comes to trans health care, there are long wait times just to get in the door and patients commonly face systemic transphobia within the medical care system. Doctors and other health care providers wield great power over trans patients, too. I felt like my care could be rescinded without warning. So in that moment, on the phone with my doctor, I realized that being transgender means becoming your own health care advocate. Armed with research and self-knowledge, I’ve stood up for myself and demanded to transition on my own terms. These are the lessons I’ve learned.

Finding a trans-affirming doctor is the first test

Finding a doctor is exceptionally difficult for trans folks. Queer community centres or associations are a good place to start—they often offer resources for trans folks looking for medical care. You can also try Googling “queer non-profit” or reaching out to a local Pride or PFLAG group. In Ontario, for example, I recommend 2SLGBTQ+ organizations like The 519 or AIDS Committee of Toronto. They often offer resources for trans folks looking for medical care, though they can be harder to find in smaller cities or towns.

In Toronto, I saw a wonderful queer doctor at a queer clinic. He connected me to a counsellor who was the first person I spoke to about transitioning. “If you are trans,” she asked me, “would you transition?” The question showed me she had an open mind and knew that not every trans person wants to medically transition. At every turn, she put me in the driver’s seat; there was no pushing of any particular narrative about the “right” way to transition.

When I moved to Montreal a few years back, I received a list of trans-friendly doctors from Action Santé Travesti(e)s et Transsexuel(le)s du Québec. I spent a month calling every name on the list only to discover that the average wait was two years just for an appointment. When I finally landed an interview with the man who is now my doctor, I knew he wasn’t the right fit, but I was tired of waiting. I needed care.

Your gender will be tested against stereotypical norms

The next test came when you’ve decided on your transition trajectory. In my experience, doctors expect you to reaffirm their version of what a transition should look like.

When I started seeing my doctor in Montreal, he pushed back on nearly everything, from the medications I wanted to my surgery choices. But things improved drastically when I started to conform to his notions of femininity. Before appointments I would shave my arms and legs, then put on mascara, blush and a padded bra. It was performative, but it felt like my only route to care. (A 2021 Canadian study revealed that physical appearance, including gender expression, plays a factor in whether trans patients are given access to transition-related care.)

Having to “prove” my femininity really hurt. At that moment, I had to remind myself that it didn’t mean that my journey or how I want to transition isn’t valid, it was just something I had to do to get through.

Even if you pass a test, your doctor’s advice can be harmful

My doctor’s neglect in understanding what my body means to me as a non-binary person has even led to harm. When I was finally prescribed a testosterone blocker, he failed to mention the impact it would have on my penis. On blockers, blood flow to your penis is stunted and if you don’t exercise the muscles, such as with masturbation, you can lose the ability to have an erection.

After a physically painful experience, I did my own research and found out what was going on. I also found a solution: a low dose of Cialis. When I suggested it to my doctor, he immediately brought up vaginoplasty again in a way that I felt questioned my transness. He assumed that because I was in the process of transitioning, I wouldn’t want a functioning penis. His notion of transness was wrapped up in sex rather than gender and didn’t allow room for me to have a healthy non-binary body on my own terms.

I dug in my heels. No one was going to tell me that my body functioning healthily was incompatible with my transition. Eventually he relented, but I had to fight for myself.

When the system fails you, you have to take care of yourself

Through all these tests, there’s one thing I’ve learned: I have to take care of myself. My doctor wasn’t providing the care I needed, so I had to learn to take care of my body—and love it—myself.

For me, that meant putting my lifelong love of exercise in a context that aligned with my gender. I’ve never felt more affirmed than when I put on athletic wear and a sports bra for a run.

Depression and anxiety often go hand in hand with transitioning, so my advice is to start small and, slowly, you’ll find what’s right for you. Remember: even if the best health support you receive comes from within, you’re worthy of that care.

*Name has been changed to protect the identity of the author. 

Next: ‘We’re Not Doing a Good Enough Job’: How Canada’s Health Gap Is Affecting Women