761 trans patients on CAMH wait list
2016 provincial decision made just a dent in massive line for gender-confirmation surgery
The first of March last year read like a victory for transgender Ontarians.
Across the province, more than 800 primary care physicians and nurse practitioners were granted the ability to assess patients for gender-confirmation surgery. The provincial change released a burden on Toronto’s Centre for Addiction and Mental Health (CAMH), formerly the only site able to complete medical referrals. Their wait-list had skyrocketed to 1,516 patients.
So why — over a year later — are there still 761 patients on the list?
Inside the halls of CAMH, Adult Gender Identity Clinic psychiatrist Dr. Chris McIntosh spoke to the Star on Tuesday, immediately following a lunch meeting about recruiting a new psychiatrist.
Though part of a $2-million sum the Ontario Ministry of Health’s slotted last year to clear the referral bottleneck went to hiring two social workers and a psychologist at CAMH, the clinic needs more physicians.
“We’re just trying to get some more folks to come and help us out,” McIntosh said. Despite all the changes over the last year — including an announcement on Thursday from Ontario Health Minister Eric Hoskins on genital procedures being expanded into Ontario—access to genderconfirmation surgery is still a tangled process.
“Our role in a new system can be about doing the assessment for folks that might be more complicated from a mental health perspective,” McIntosh said.
While any health care professional trained in the World Professional Association for Transgender Health assessment criteria is now able to handle gender-confirmation surgery referrals, complicated — and often time-consuming — cases are still being funneled back to CAMH.
The way the process works depends on the patient. The first task is to assess for gender dysphoria, for which the diagnosis criteria changed in 2012. Previously, the diagnosis required a patient to identify with the opposite gender in a binary system. New criteria allows for identification with any gender that is different than the patient’s natal gender.
McIntosh then often has to consider a host of other psychiatric and social markers. Cases can be complicated by a lack of stable housing, for example, which would present a risk during recovery. Mental health conditions like depression or PTSD are factored in. The most problematic cases, McIntosh said, come when patients have intellectual disabilities and the clinic faces questions of informed consent.
“It can be more difficult to assess their capacity to understand what gender is,” he explained. The clinic has some psychologists with backgrounds in neuropsychology that can assess IQ, but the process is knotted with ethical dilemmas and often labours on for a while.
The time spent waiting for referrals has dropped by 33 per cent over the last year, but the CAMH website still warns that “as our clients have waited for a long time, our social worker calls all new clients a month or two before we’re ready to schedule your first appointment.”
For 761 patients, that limbo is their reality. Once they’re in, the referral process can be anywhere from two appointments to a whole row, culminating in pre-approval paperwork sent to the Ministry. Four-to-six weeks later, patients must contact a clinic called GRS Montreal — which, until next year, remains the only clinic in Canada that does all genderconfirmation surgeries.
The first genital surgery outside Montreal is slated to take place in 2018 at Women’s College Hospital in Ontario, Hoskins’ Thursday statement announced. Until now, the province has been spending $4 million a year sending patients outside Ontario — $2.7 million for those headed to Quebec, and $1.2 million for operations outside Canada.
Across the border, San Francisco, California and Austin, Texas, are frequent choices for patients who can secure a recommendation by an Ontario physician. Though the procedure is covered by OHIP for preapproved patients, going to the U.S. can incur significant transportation and accommodation costs. The Ministry also confirmed they’ve sent patients to Belgium, Thailand, Serbia, England, Italy and Germany.
Staying north of the border, patients have had to wait anywhere from another three months to another year after Ministry approval — with particularly long holdups for a phalloplasty. “It’s a surgery that requires a high level of expertise, but at the same time, that should really mean that we’re starting to develop that expertise,” McIntosh said. Hoskins’ announcement makes Ontario only the second Canadian jurisdiction with surgeons trained to provide genital transition surgery. Patients from all other provinces and territories are still forced to travel substantial distances.
Moving forward, the Trans Health Expansion — which partners CAMH with Women’s College Hospital, Sherbourne Health and Rainbow Health Ontario — is in the early stages of a “complex, long-term” reform process. The 2016 change and Hoskins’ Thursday announcement make a dent in the problem, but are far from a solution.
“One of the keys will be building surgical capacity in the system,” Trans Health Expansion wrote in an email to the Star. “However, surgery is just one issue; to sustainably improve trans health, the disparities in social determinants of health for this population — like housing, poverty and unemployment — will also need to be addressed.” With files from Rob Ferguson