Meeting the health care needs of trans patients

An overview for primary care providers

Transitioning is not a linear, rapid process from one binary gender to the other. Each patient may have a different pathway, journey and end goal in actualizing the expression of their true self. Use the diagram below to familiarize yourself with the various health care needs of trans and non-binary patients.

Click on the labels in each step of the diagram in order to learn more

An individualized process

Assisting patients in actualizing their gender identity can yield profound improvements in overall well-being. The patient is at the center of this collaborative process. Trans people are experts on their own experience, listen carefully to their needs and goals.

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Create an inclusive clinic environment for trans people:

  • Provide intake forms that allow for trans patients to self-identify
  • Assume that any patient may be trans
  • Ensure that all providers and staff use pronouns and names appropriate to a patient's gender idenitity. It is important to ask the person if you are in doubt
  • Use posters/signs to indicate a trans-friendly environment
  • Develop resources for referral to trans-friendly providers, where needed

There are several more components to creating a safe and welcoming clinic setting. Read more in UCSF Transgender Care's Guidelines: Creating a safe and welcoming clinic environment

Transition-related care

Trans people may or may not require access to medical transition-related care. Transition is a process that refers to a host of actions that people may undertake in order to affirm their gender identity. This may or may not include a change of name, pronouns, or physical changes from medication/hormones or surgery, or a change in clothing, hair style, etc.

Societal roles and personal expressions are becoming more gender diverse and fluid. This approach allows for a range of trans identities and treatment options. If your patient is ready to initiate their gender transition, but presents in a manner which does not fully conform to societal expectations of masculinity or femininity, this should not impede access to hormonal treatment.

Basic medical care

Keep in mind that not all trans and non-binary people experience body discomfort. Your patient may just need general medical advice from you.

Long-term preventive care

An essential part of primary care is ongoing follow up with patients:

See long-term preventive care recommendations for transfeminine patients
See long-term preventive care recommendations for transmasculine patients

Non-medical transition care

Though hormones and/or surgery are medically necessary for many trans people, others may obtain relief of gender dysphoria/gender incongruence through other means of modifying their self-expression such as changes in legal identification and modifications to their dress, gait, and/or voice.

Legal changes in name and sex markers

One of the various non-medical components of transition that help a patient affirm and realize their gender identity may include changing legal identification with changes to sex markers and name.

You can advocate for your patient by providing letters of support attesting to the fact that they agree a change in sex markers designation is appropriate. Below are support letters that primary care providers are frequently asked about.

Download
Template Letter in Support of an Application For Change of Sex Designation on an Ontario Birth Registration
Download
Template Letter in Support of an Application For Change of Sex Designation on an Ontario Driver’s License

Psychosocial transitioning

There are various non-medical components of transition that help affirm and realize a person’s gender identity. Having an outer presentation that reflects a person’s own sense of self can profoundly increase a person’s well-being.

Examples of changes to a person's gender expression/role may include:

  • Changes in posture or gait
  • Changes to clothes one wears, including binding or padding of chest, hips or buttocks, penile tucking or use of prostheses.
  • Changes to voice and communication
  • Hair removal

Medical transition care

The health care needs of most trans patients are not medically complex. However many patients will seek medical assistance in order bring their physical appearance in line with their gender identity. This could include hormone therapy and/or surgery/surgeries.

Common primary care services needed by trans patients:

  • Assistance in exploring hormone therapy and surgery options
  • Initiation and maintenance of hormone therapy
  • Surgery planning and referral
  • Support and guidance

Supporting Patients with Transition-related surgery (TRS)

Disclaimer: This section provides a brief overview of the Ontario system for TRS assessment and referral. It is not exhaustive nor intended as training for conducting TRS planning visits.

Since TRS was relisted under OHIP coverage in 2008, surgical referral was delegated solely to the CAMH Gender Identity Clinic. However in March 2016, the Ministry Of Health and Long Term Care (MOHLTC) announced a regulatory change that allowed Qualified Providers outside of CAMH to conduct TRS Planning Visits and TRS referrals. This positive change has increased access to TRS for trans Ontarians and has encouraged a shift towards the provision of trans-related health care in the primary care setting.

Benefits of surgical referral coordination in primary care:

  • Depathologizes gender diversity
  • Recognizes the relationships that are built in primary care over time
  • Allows for increased access, particularly for rural and remote trans patients with limited access to travel
Learn more about the Ontario Process for Transition-related surgery (TRS)

Current MOHLTC-fundedi Transition-Related Surgeries include:

For patients assigned male at birth For patients assigned female at birth
Upper body Augmentation Mammoplastyii Mastectomyiii
Gonadal Orchiectomy Hysterectomy
Salpingo-oophorectomy
External Genital Vaginoplasty Clitoral Release with vaginectomy
Metoidioplasty
Phalloplasty
Testicular Implants with scrotoplasty
Penile Implant

For more detailed information on individual Transition-Related Surgeries, please download the Sherbourne Health TRS Summary Sheets

  • i) MOHLTC Funding criteria includes “Additional surgery that is required because of complications causing significant physical symptoms or functional impairment is insured when prior authorization has been obtained from the ministry.”
  • ii) MOHLTC funding criteria includes having “…completed twelve (12) continuous months of hormone therapy with no breast enlargement (unless hormones are contraindicated).”
  • iii) Masculinizing chest contouring is not currently MOHLTC-funded. Patients may choose to pay for this privately. Surgeons’ fees for masculinizing chest contouring may vary.

Hormone therapy

When appropriately prescribed and monitored, hormone therapy can profoundly improve the well-being of trans people. Delaying or denying hormone treatment can cause significant harm.

Our approach

Although the decision to implement treatment with hormones for a trans patient is individualized, there are some common guidelines undertaken by Sherbourne Health. Our approach to the process for initiating hormone therapy aims to shift the patient-provider dynamic from "gatekeeper" to “collaborator”. The focus is on informing, educating, guiding and supporting each patient through their unique transition, while ensuring that they are mentally and emotionally prepared for the particular changes and challenges that transition will bring.

Learn how to plan for new/newly transitioning patients interested in hormone therapy

Management of hormone therapy

The goal of hormone therapy is to alter secondary sex characteristics. Click the links below to learn more on the management of hormone therapy:

Learn how to manage feminizing hormone therapy
Learn how to manage masculinizing hormone therapy

Hormone Planning Period

Feminizing Hormone Therapy

Masculinizing Hormone Therapy