Access to Trans Surgical Health Care in BC

Transcription

1 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

2 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

3 Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7

4 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.

5 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.

6 Copyright 2013 World Professional Association for Transgender Health

7 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.

8 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, Knudson, De Cuypere, & Bockting, 2010)

9 DSM 5 (2013) from transsexualism to gender dysphoria

10 ICD 11 (2017) from transsexualism to gender incongruence move from mental disorders chapter to new chapter including sexual health

11 6 Genders dysphoria Gender Incongruence No diagnostic code Moved out of Mental Disorders chapter

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13 CMA Transgender Health Related Policies Four transgender health related motions were passed at the CMA 2014 General Council held in August, 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

14 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

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16 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 ( and list serve

17 Health Care in British Columbia

18 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

19 ACCESS TO TRANS HEALTH CARE IN VANCOUVER

20 Education/Information/Support Vancouver Coastal Health Transgender Health Information Program PRISM (LGBTQ) Education Program Call Out (provincial youth project) Community Health Liaisons Youth Drop-in Changing Keys Peer Volunteer Program Taking Care of Business (sex trade worker support)

21 Clinical Care (Adult and Youth) VCH Provincial Health Services Authority Joint Health Authority Initiative BC Trans Primary Care Consultation Service Urban Primary Care Clinics BC Children s Hospital Youth Endocrine Clinic Rapid Access to Consultative Expertise (RACE) Line

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23 Clinical Training and Supervision Vancouver Coastal Health Joint Health Authority Initiative Autonomous Group (no health authority) Transgender Health Education Program RACE Line BC Trans Clinical Care Group (supervision of care providers) Primary Care including endocrine therapy Assessing Eligibility for Hormone Therapy Assessing Eligibility for Gender Confirming Surgery

24 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

25 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

26 Access to Surgery Privately Funded Voice surgery Tracheal shave Hair removal Facial feminization surgery

27 One letter is needed Criteria for Adults 1 letter 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 Hormone Therapy Chest Surgery FtM Breast Surgery MtF 1 * * * * * * * * * * * * 1 Although 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

28 Two letters are needed Criteria for Adults 2 letters Gonadectomy Genital Surgery 1 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 * 1 Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

29 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.

30 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 # Fort Street Victoria BC V8R 1J5 Phone: Fax:

31 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

32 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.

33 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.)

34 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.

35 Chest Surgery Your PCP will refer you to a plastic surgeon, for surgery in BC.

36 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.

37 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.

38 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.

39 Gaps in Care

40 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)