A prescription for 450 mg of the anti-psychotic drug Seroquel.
This was the answer Rachel Lauren Clark received when she told doctors at a Toronto hospital she wanted gender reassignment surgery (GRS). The regular adult dose is 50 mg.
“I was a zombie,” she said, “a complete and utter zombie. I took it at eight o’clock at night and woke up at eight in the morning and couldn’t even function. So then they gave me another drug called Modafinil, which they give to narcolepsy patients to wake them up.”
Clark took the pharmacological cocktail for a year before she realized the only drug that could fix her gender dysphoria was estrogen. A psychiatrist suggested to then 40-year-old Clark that if she was even remotely considering GRS, also known as sex reassignment surgery, she should start the process immediately. Clark did. She received a date for her surgery: June 8, 2015. Just 11 days shy of her 46th birthday.
Why the six-year delay in treatment? Because the Ontario Ministry of Health has designated only a single site to evaluate the eligibility of transgender people seeking surgery. In fact, the Adult Gender Identity Clinic at Toronto’s Centre for Addiction and Mental Health (CAMH) is the sole gatekeeper for access to GRS – not only for patients across Ontario, but also those in Newfoundland and Labrador.
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The surgery, even once an initial meeting with a doctor has been completed, is still years away for those who want it. The process looks something like this: a transgender person seeking surgery must have completed a year of hormone replacement therapy, as well as lived for at least a year in the gender for which they‘re undergoing GRS before a doctor will consider advancing their case. Then the person needs additional consultations with at least two different CAMH doctors, and both must agree the patient is a strong candidate. Only then will gender reassignment surgery be covered by OHIP.
Once the surgery has been approved, there’s only one clinic in Canada, located in Montreal, which performs the entire range of gender reassignment surgeries. It has a six- to eight-month waiting list. CAMH Gender Identity Clinic Head Dr. Chris McIntosh said the waiting list will continue to grow unless the Ministry also develops expertise in other parts of the province.
“The number of people seeking intervention surgery is so much greater than it ever was before,” he noted. “It’s probably due to the general awareness of transgender issues. It’s expanding all the time, and people who would have never thought that this was something they would do start to consider it as a possibility.”
Bypassing the CAMH process and paying out of pocket is also an option. The Montreal clinic performs private surgeries with the same prerequisites for candidates as public surgeries (hormone replacement therapy and a year of living experience), but accepts letters of recommendation – two for SRS and one for breast augmentation or top surgery – from a therapist, counselor, psychologist, psychiatrist or social worker. One letter must be from someone with a Ph.D., and the other from someone with at least a master's degree.
The clinic charges approximately $20,100 for male-to-female sex reassignment surgery and $8,000 for breast implants. The female-to-male process costs approximately $10,000 for top surgery, and $45,000 for a phalloplasty. Many transgender Canadians also travel out-of-country, to places such as Thailand, where the cost of gender reassignment surgery is only 30-50 per cent of North American prices. As of 2014, two to three patients receiving male-to-female reassignment surgery per day in Thailand are foreigners.
One of the biggest concerns around the long wait times for Ontario is the adverse effects it has on the mental health of transgender people. For Rachel Lauren Clark, her stress levels were off the charts.
“I have a female brain and male sex characteristics,” she said. “It caused me a lot of anguish and psychological pain. There’s a lot of risk around being a trans person. You hear comments like, ‘If I saw a trans person in the change room with my wife, I would kill them.’”
Suicide is a serious risk for transgender people awaiting gender reassignment surgery. Trans PULSE, a research project created to look at problems related to transgender communities, found 50 per cent of transgender Ontarians seriously considered suicide because they were transgender. Around 43 per cent had actually attempted suicide.
“Trans people are at the highest risk of suicide and self-harm between the period that they’ve mentally decided to transition and when they complete their medical transition,” said N. Nicole Nussbaum, former president of Canadian Professional Association for Transgender Health and staff lawyer at Legal Aid Ontario.
Most medical professionals in Ontario are also not trained to deal with transgender issues, making reducing suicide rates particularly challenging.
“We’re very concerned because there isn’t very good education in most medical schools about trans issues,” CAMH’s Dr. McIntosh said. “Most of the people who practice now would have received no training in this. Gender dysphoria is quite distinct from psychosis. Anti-psychotics are not an appropriate course of treatment.”
Mental health is just one of the many areas affected by inordinately delayed surgery times. According to Clark, a current student at U of T’s Emmanuel College, who moved to Toronto from New York in 2003, she can’t get a student loan because she can’t change her name on her Permanent Resident card until the surgery is complete. Also, her PR card is expired because she has to appear in person to renew it. The problem: she has been living as a female for the last three years.
“My PR card has my name and gender as male,” she explained. “They’ll let me renew it with the old information but I have to appear as that former person and gender to do that, and I look nothing like the old photo.”
Because of the PR card dilemma, Clark hasn’t visited her mother in three years. Whenever she enters or exits Canada, she’s interrogated by border control officers.
“You get dragged into customs and they ask a load of questions,” she said. “They’re not doing this in a private room, it’s in front of everybody and it’s a hugely embarrassing situation that’s very, very difficult. For me, it’s not even worth it to travel.”
Employment is another issue affected by delayed wait times for surgery. Despite an almost 30-year career in IT, it was very difficult for Clark to find a job when she came out as a transgender woman.
“There’s quite a bit of employment discrimination,” Nussbaum said. “We know transgender people have trouble getting references in their current name and gender. We need some policy at the federal level.”
Bill C-279, a federal transgender rights bill that would add gender identity to the list of grounds protected from discrimination under the Canadian Human Rights Act and under the hate propaganda section of the Criminal Code, has been stalled in the Senate for three years. Calgary MP Rob Anders strongly opposed the bill, saying its goal is to give men access to women's washrooms, which led to the nickname "bathroom bill."
“Instead of making it about basic human rights, they’ve made it about whether transgender women are going to go into the washroom and rape women and children,” said Clark. “They’re saying, ‘Rachel’s going to walk into the washroom with her completely useless penis and rape my wife or my granddaughter.’ The idea behind that reaches all new levels of absurdity.”
A Ministry of Health spokesperson said the government’s exploring options around wait times and points of access to surgery, but didn’t provide specifics. CAMH’s Dr. McIntosh stressed the urgency of the Ministry getting involved.
“We really want the province to help us,” he said. “Often times, people may decide this is really what they want to do and be quite sure about it. Then they contact CAMH and are told that we’re currently seeing people who were referred 18 months ago. Unfortunately we are seeing increased rates of suicide ideation, and because our clinic is so small, we can’t offer any treatment ourselves.”
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