Access to Trans Surgical Health Care in BC

Access to Trans Surgical
Health Care in BC
Gail Knudson MD, MPE, FRCPC
Clinical Associate Professor, University of British Columbia
Medical Lead, Transgender Health Information Program
Vancouver Coastal Health
Vancouver, BC, Canada
Outline
∗ World Professional Association of
Transgender Health
∗ Canadian Medical Association
∗ Canadian Professional Association for
Transgender Health (CPATH)
∗ Health Care Delivery in British Columbia
∗ Access to Trans Surgical Health Care in
BC
∗ Resources
Standards of Care for the
Health
of Transsexual,
Transgender, and
Gender Nonconforming
People
Version 7
∗Who are we?
•The World Professional Association for Transgender Health
(WPATH) is an international association devoted to the
understanding and care of transgender, transsexual and
gender nonconforming individuals.
•Founded in 1979, and currently with over 700 physician,
psychologist, social scientist, and legal professional
members, all of whom are engaged in research and/or
clinical practice that affects the lives of transgender and
transsexual people,
•Oldest interdisciplinary professional association in the world
concerned with this specialty.
∗Mission and Vision
•Mission: As an international multidisciplinary professional
organization, the mission of WPATH is to promote evidencebased care, education, research, advocacy, public policy and
respect in transsexual and transgender health
•Vision: We envision a world wherein transsexual,
transgender and gender non-conforming people have access
to evidence-based healthcare, social services, justice and
equality.
Copyright © 2013 World Professional Association for
Transgender Health
PURPOSE AND USE OF THE
STANDARDS OF CARE
• To provide safe and effective pathways to
achieving lasting personal comfort with their
gendered selves in order to maximize their
overall health, promote psychological well-being
and self-fulfillment.
Gender Dysphoria
•Defined criteria based on own definition:
• Gender dysphoria: Distress that is caused by a
discrepancy between a person’s gender identity and
that person’s sex assigned at birth (and the
associated gender role and/or primary and secondary
sex characteristics)1.2
•Did not want to be tied with either the DSM or the
ICD as both were in draft form at that time and will
continue to change
1 Fisk,
2
1974
Knudson, De Cuypere, & Bockting, 2010)
∗DSM – 5 (2013)
∗…from transsexualism to gender
dysphoria
∗ICD 11 (2017)
∗…from transsexualism to gender
incongruence
∗…move from mental disorders
chapter to new chapter including
sexual health
6
Genders dysphoria
Gender Incongruence
No diagnostic code
Moved out of Mental Disorders chapter
CMA Transgender Health
Related Policies
Four transgender health related motions
were passed at the CMA 2014 General
Council held in August, 2014. The CMA:
1.Will amend its Code of Ethics sections
related to discrimination in providing
medical services to include the issues of
gender identity and gender expression
2.Supports the position that all adolescent
and adult persons have the right to define
their own gender identity
CMA Transgender Related
Policies Health Related
3. Calls for accessible, comprehensive,
and high-quality care for
transgender patients
4. Calls for the integration of sex and
gender diversity education into
medical school curricula and
programs
Canadian Professional Association
for Transgender Health (CPATH)
∗ Largest national professional organization
for transgender health in the world.
∗ Formed in 2007
∗ Approximately 150 members
∗ Recognized as the voice for transgender
health care nationally
∗ Host conferences biannually
∗ Provide clinical training programs
∗ Website (www.cpath.ca) and list serve
Health Care in British Columbia
Health Care in British Columbia
∗ Managed by the Ministry of
Health in BC
∗ Money transferred to six
Health Authorities
∗ Public funding is available
for gender confirming
surgeries throughout the
province
ACCESS TO TRANS HEALTH CARE
IN VANCOUVER
Education/Information/Support
Vancouver Coastal
Health
Transgender Health
Information
Program
Community Health
Liaisons
Youth Drop-in
Changing Keys
PRISM (LGBTQ)
Education Program
Peer Volunteer
Program
Call Out (provincial
youth project)
Taking Care of
Business
(sex trade worker
support)
Clinical Care (Adult and Youth)
VCH
BC Trans Primary
Care Consultation
Service
Urban Primary
Care Clinics
Provincial Health
Services Authority
Joint Health
Authority
Initiative
BC Children’s
Hospital Youth
Endocrine Clinic
Rapid Access to
Consultative
Expertise (RACE)
Line
Clinical Training and
Supervision
Vancouver Coastal
Health
Primary Care
including endocrine
therapy
Joint Health
Authority Initiative
Transgender Health
Education Program
RACE Line
Assessing Eligibility
for Hormone
Therapy
Assessing Eligibility
for Gender
Confirming Surgery
Autonomous Group
(no health
authority)
BC Trans Clinical
Care Group
(supervision of care
providers)
Telehealth Access
“Face-to-face appointments over
videoconference”
Telehealth:
∗Improves access for remote clients
∗Reduces travel expense, stress, and
burden for both provider and client
∗Enables private and secure remote
appointments
Access to Surgery
Publically
Funded
• Bilateral mastectomy and chest
contouring
• Breast augmentation
• Hysterectomy and Oophorectomy
• Orchiectomy
• Vaginoplasty*
• Phalloplasty*
* Must travel to another province for surgery
Access to Surgery
Privately
Funded
• Voice surgery
• Tracheal shave
• Hair removal
• Facial feminization
surgery
∗One letter is needed
Criteria for Adults
1 letter
Hormone
Therapy
Chest
Surgery
FtM
Breast
Surgery
MtF1
Persistent, well-documented
gender dysphoria
*
*
*
Capacity to make a fully
informed decision and to
consent for treatment
*
*
*
Age of majority in a given
country
*
*
*
If significant medical or mental
concerns are present, they must
be reasonably well-controlled
*
*
*
1Although
not an explicit criterion, it is recommended that MtF patients undergo feminizing
hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is
to maximize breast growth in order to obtain better surgical (aesthetic) results
Two letters are needed
Criteria for Adults
2 letters
Gonadectomy
Genital Surgery1
Persistent, well-documented gender dysphoria
*
*
Capacity to make a fully informed decision and
to consent for treatment
*
*
Age of majority in a given country
*
*
If significant medical or mental concerns are
present, they must be reasonably well-controlled
*
*
12 continuous months of hormone therapy as
appropriate to the patient’s gender goals (unless
the patient has a medical contraindication or is
otherwise unable or unwilling to take
hormones);
*
*
12 continuous months of living in a gender role
that is congruent with their gender identity
1Although
*
not an explicit criterion, it is recommended that these patients also have regular visits with a
mental health or other medical professional.
Coverage for Gender Affirming
Surgery
∗ Medical Services Plan (MSP) Coverage for Gender
Affirming Medical Treatment.
∗ The Ministry of Health has reviewed provincial
coverage for gender affirming medical treatment and
British Columbia residents do not need to apply for
MSP coverage, for insured gender alteration surgery.
Route
∗ 1. Your Primary Care Physician (PCP) will send a
referral for an assessment to the Chief Assessor’s
Office:
∗ Dr. Gail Knudson, Chief Assessor
∗ #201 1770 Fort Street
∗ Victoria BC V8R 1J5
∗ Phone: 1-250-592-6183
∗ Fax: 1-250-592-6123
∗
Route
∗ 2. Your assessment(s) will take place with one or two
Qualified Assessors*:
∗ i. one assessment for breast augmentation or chest
surgery
∗ ii. two assessments for orchiectomy, vaginoplasty,
hysterectomy/bilateral salpingo-oophorectomy,
clitoral release, metoidioplasty or phalloplasty
Route
∗ 3. The Qualified Assessors(s) will make one of these
recommendations:
∗ i. surgery approved,
∗ ii. surgery not approved, or
∗ iii. return
∗ 4. The Qualified Assessor(s) will send your
recommendation(s) to the Chief Assessor’s Office.
Route
∗ 5. Once received, the Chief Assessor will forward the
recommendation to you and your PCP. (If there is a
disagreement amongst the assessors as to the
recommendation, you may be contacted by the Chief
Assessor’s Office for an additional assessment.)
Breast Augmentation
∗ If a Qualified Assessor recommends one of the
following gender affirming surgeries, your PCP may
refer you to a surgeon in BC for:
∗ Breast augmentation
∗ 1. Your PCP will refer you to a plastic surgeon for a
medical consultation. If the surgeon determines
surgery is medically necessary, the surgeon will send
a funding application to Health Insurance BC (HIBC)
to confirm MSP coverage.
∗ 2. If HIBC confirms MSP funding for augmentation,
your surgeon will contact you to arrange a date, for
surgery in BC.
Chest Surgery
∗ Your PCP will refer you to a plastic surgeon, for
surgery in BC.
Gonadectomy
∗ Hysterectomy and bilateral salpingo-oophorectomy
∗ Your PCP will refer you to a gynecologist, for surgery in
BC.
∗ Orchiectomy
∗ Your PCP will refer you to a plastic surgeon or urologist,
for surgery in BC.
Genital Surgery
∗ If two Qualified Assessors recommend one of the
following gender affirming surgeries, your PCP may
refer you to a surgeon in Montreal for:
∗ Vaginoplasty, clitoral release, metoidioplasty or
phalloplasty
∗ 1. Your PCP will send a referral letter, with a copy of
your surgical assessment, to the GRS clinic in
Montreal.
∗ 2. The GRS clinic will send a form to HIBC to confirm
MSP will fund out-of-province surgery.
Genital Surgery
∗ 3. You will contact the GRS Clinic to confirm a date for
your surgery in Montreal
∗ 4. Your PCP may also send pre-op lab work results to
the GRS Clinic, prior to your surgical date.
Gaps in Care
Resources
∗ World Professional Association for Transgender
Health (wpath.org)
∗ Canadian Professional Association for Transgender
Health (cpath.ca)
∗ Vancouver Coastal Health’s Trans Health Information
Program (THiP) (transhealth.vch.ca)