Samuel Desrosiers met their family physician at the age of three.
“My sisters, my mother and everyone in my family sees him—he’s really the village doctor,” says the 26-year-old from Matane, Quebec, a Gaspé Peninsula town with a population of about 14,000.
From fallen baby teeth and countless growth spurts to coming out in their early teenage years, Desrosiers’ doctor witnessed it all.
But despite openly identifying themself as gay to their general provider (GP) and professionals at other clinics in the rural region, Desrosiers’ queerness went largely unaddressed in their doctor’s office.
“We might think it’s safer to consult someone we’ve been seeing since we were young since they know our entire medical history, but what if that person isn’t necessarily equipped for your reality?” they say. “In my case, I was never told about the potential issues or risks I faced because of [my sexuality].”
Desrosiers considers their LGBTQ2S+ health education to have begun in 2016, when they moved to Montreal, a city where queerness wasn’t subject to the same stigmas perpetuated in rural areas, including their hometown.
At their first visit to a clinic that specialized in trans and queer sexual health, Desrosiers was informed about the increased risk they faced of contracting human papillomavirus (HPV) and HPV-related diseases, such as anal cancer.
“The nurse there was shocked that I had no idea—that’s when I found out about the HPV vaccine, which I had only ever heard about for women,” they say. “Other people in (rural) regions like me just don’t get that sort of information even though we’re out to our doctors.”
Three months after moving to Montreal, Desrosiers tested positive for HPV.
As one of the most common sexually transmitted infections in the country, people of all orientations and gender are at risk of getting HPV.
But Quebec’s publicly-funded vaccination campaign exclusively targeted cis women and girls before it was expanded to include immunocompromised and HIV-positive boys and men in 2014. The cancer-preventing vaccine was made available to trans women, non-binary people and men who have sex with men in January 2016.
As Desrosiers settled in Montreal, they eventually felt comfortable coming out as trans and non-binary.
“I’ve never been afraid to specify my pronouns when I go to clinics in Montreal—they even ask for them each time I walk in and have to fill out a form,” they say. “[Back home], I never have the chance to fill out any document or check any box when I visit my own doctor.”
Having to come out as trans to a doctor they’ve known their whole life isn’t something Desrosiers feels comfortable doing just yet.
While they continue to meet with their physician for routine visits, Desrosiers feels that topics relating to LGBTQ2S+ sexual health care are not being brought up because their doctor knows they can access this care in Montreal.
Desrosiers’ experience is not unlike those of other queer and gender-nonconforming people in rural and remote communities across Canada, where local health services rarely offer care tailored to LGBTQ2S+ people.
Whether frontline health services are properly suited to address the needs of queer and trans communities in rural and remote areas is a question physician Pier-Maude Lanteigne sought to address in a study they co-authored and presented in October at the 2021 Community-Based Research Centre (CBRC) summit. They wanted to determine the barriers health professionals might face when it comes to delivering services that meet the needs of their LGBTQ2S+ patients.
As a non-binary person navigating the medical system from within, Lanteigne has direct knowledge of how queer and trans people in rural and remote regions are affected by the absence of competent health care.
Using an online questionnaire distributed to frontline and sexual health professionals in the Gaspésie-Îles-de-la-Madeleine region, Lanteigne sought to fill a void in the literature on the topic, which seldom focuses on the needs of health care providers.
“I wanted a new approach to better guide us in finding solutions to address this problem which we know is huge—clients have long been calling for help,” explained the doctor, who hails from rural New Brunswick.
In the end, a total of 94 family physicians, nurses and residents participated in the study, which was designed to assess the barriers, comfort level and needs of those offering care in the remote Quebec region.
The study revealed that while 81 respondents said they find it necessary to obtain training specific to LGBTQ2S+ care, fewer than 20 percent feel that they have received sufficient training in this regard. Over half of respondents said they know nothing about best practices for LGBTQ2S+ care.
“Eight in 10 health professionals surveyed didn’t feel comfortable prescribing PrEP and PEP, drugs that can prevent new HIV infections.”
This lack of training has a direct impact on the quality of care LGBTQ2S+ folks have access to in the region. Take treatments like pre-exposure prophylaxis (PrEP), which has been approved in Canada since 2016: Lanteigne’s study found that eight in 10 health professionals surveyed didn’t feel comfortable prescribing PrEP and PEP, drugs that can prevent new HIV infections. What’s more, over 75 percent didn’t know which local resources to send their patients to when they couldn’t provide care themselves.
“In medicine, especially in primary care, you can’t know everything, but you have to know where to get your information and where to go for referral,” says Lanteigne. “It’s unacceptable in 2022 that there are people who cannot access care because the professionals do not even know where to refer them.”
Better training would help, says Lanteigne.
As more people report identifying as LGBTQ2S+, Lanteigne says there is a greater willingness from institutions to provide the community with better service “yet, I don’t feel like my [own education] covered enough information on the subject.”
The sparse and often inconsistent integration of LGBTQ2S+ content in medical education is a problem that has been observed across Canadian health care programs. In an article published in the Canadian Medical Association Journal (CMAJ) in spring 2021, researchers outlined the disproportionately poor health outcomes faced by queer and trans community members as a result of not being able to obtain competent care.
The researchers called for national standardization mandating the inclusion of LGBTQ2S+ care training within undergraduate and postgraduate medical education as a strategy that would reduce inferior health outcomes.
While restructuring programs would undoubtedly help future frontline health workers, research, including Lanteigne’s study, shows an urgent need to bridge the knowledge gap for professionals already operating in rural areas.
Training can help fill gaps
The lack of queer- and trans-competent care by rural doctors can ultimately worsen care in urban centres as well. When queer and trans people from rural areas are forced to travel to larger cities to receive care, those clinics quickly reach capacity. This is especially true in Nova Scotia, where over 30 percent of the population is living in rural areas, according to Statistics Canada’s 2021 census.
Garry Dart is the primary healthcare co-ordinator at prideHealth, a partnership between Nova Scotia Health Authority and the IWK Health Centre. Dart sees first-hand how swamped specialized services in urban settings have become as queer and trans people from rural areas flock to the cities in order to access the care they need.
“Both gender-affirming care and anything to do with (LGBTQ2S+) sexual health will still be seen by most primary care providers as a specialized type of care,” said Dart. “I believe this is in part because it’s not a part of mandatory training for most healthcare professionals.”
Still, they say, treatments like prescribing hormone therapy and PrEP could easily be done by most medical providers, including general practitioners.
The centralization of gender-affirming care in urban centres like Halifax is also an additional barrier for individuals in rural and remote regions, who need to travel up to four hours each way just to meet with a doctor, says Dart. Meanwhile, as referral networks stay clogged, the waitlist for existing patients also expands.
In Halifax, Nova Scotia’s most populated city, wait time for patients seeking gender-affirming hormones at the Halifax Sexual Health Centre’s (HSHC), for example, is currently nine to ten months.
With so few health professionals equipped to meet the needs of LGBTQ2S+ patients, prideHealth recently partnered with the CBRC to increase the number of primary care providers capable of supporting their trans and gender-nonconforming patients.
When the pandemic hit and in-person events were no longer an option, prideHealth and CBRC developed free online training courses for doctors and nurse practitioners looking to learn about sexually transmitted and blood-borne infections (STBBIs), along with how to confidently prescribe gender-affirming hormones and PrEP. The courses also introduce participants to the basics of competent care, such as the use of inclusive language.
The three-hour long courses include recorded presentations by health professionals, an online quiz and a panel discussion between care providers and people with lived experience. Once registered, health care providers can complete courses on their own time; physicians also earn professional accreditation hours.
A few months after it launched in July 2020, over a hundred health care providers had signed up for the course, and the wait time at HSHC for those trying to obtain gender-affirming hormones initially dropped from upwards of ten months to three months. The course’s success, however, could not keep up with the continued demand from LGBTQ2S+ folks seeking care. As the number of physicians added to the referral networks reached its highest point within the first months of the courses being launched, the supply could not meet the growing demand. As a result, the decrease in waiting periods seen throughout the first months could not be maintained—hence the need for more physicians to seek such training.
“Even just being able to know that the patient is going to be referred to using the right name, pronoun and [will leave] knowing how to follow through the process for gender-affirming hormones and or surgery, is just a huge piece,” said Dart.
Out of the 429 health care professionals who registered for a course between July 2020 and June 2021, 183 were from Nova Scotia. Health care providers in every other province, along with one territory, Nunavut, also completed one of the virtual training sessions offered by prideHealth.
A course evaluation completed by 173 participants revealed that 85 percent will use the information they learned to plan or deliver programs and services specifically targeted to the LGBTQ2S+ community.
“Everybody that takes a course really needs to understand that it is up to them as individuals, as healthcare providers and professionals to continue their learning,” said Dart. “This is where we get sources of belonging and action, not just allyship that is performative. Real allyship in action also needs to consider that providing affirmative services requires continued education.”
Improving access to trans-affirming care and services for gender diverse individuals through training is a quest clinical psychologist Françoise Susset embarked on years ago.
Through courses carried out in partnership with Quebec’s public health institute and the Institute for Sexual Minority Health (ISMH)—soon to be relaunched as the Institute for Transgender Health—Susset has trained well over a thousand health care workers across the country.
“The truth is that a big part of the challenge in trans health is getting clinicians to be less afraid of doing the work and of supporting people through their transition needs,” said the ISMH co-founder.
“The focus is always on how do we find ways to get clinicians to reduce their sense of carrying the decisions for trans folks and how do we get clinicians to feel more comfortable because that’s how they can actually be supportive of the clients and patients that they serve.”
During training, Susset emphasizes that a health professional’s job is to recognize that they’re responsible for opening up doors, not pushing patients through them.
In Lanteigne’s study, for example, over 92 percent of respondents considered themselves insufficiently equipped to start gender-affirming hormone therapy treatment. In fact, only 1 percent responded feeling “very well-equipped” to do so.
Susset says this uncertainty is common in clinicians country-wide, and ought to be addressed in trainings specific to trans, non-binary and gender diverse health.
“What I’m constantly trying to hone in on is how to present trans health in a way that’s going to give clinicians the confidence to do the work and develop the understanding that ultimately, they’re not having to make the decision about what the person is going to access,” said Susset.
Whether it’s frontline providers in Quebec’s Abitibi-Témiscamingue and Îles-de-la-Madeleine or in rural Prince Edward Island, British Columbia and New Brunswick, Susset maintains that primary care providers should be the point of entry for anyone seeking transition medical care.“There’s a real need for clinicians to get on board and to do so in a non-gatekeeping manner,” said Susset.
This statement is even truer in remote regions, where health care options are increasingly sparse.
With the rapid expansion of online training during the pandemic, access to care for LGBTQ2S+ folks in rural and remote regions is looking brighter.
But even with individual health practitioners improving their knowledge of LGBTQ2S+ care, there are still limitations that remain in place.
For Desrosiers, this includes the crammed service corridor of Quebec’s health authorities: rushed appointments can ultimately lead to less comfort between patients and practitioners, and create relationships where patients feel hesitant to disclose personal information.
“I told (my GP) a lot of things but in the end though, the patient-doctor relationship was all very superficial,” they said. “Meanwhile, when a person talks to their doctor about (being LGBTQ2S+) it already requires a lot of courage because it’s not easy in those regions to open up about this subject.”
Lanteigne agrees fostering comfortable dialogue is key. “What I want is for people to realize the importance of addressing the challenges of the LGBTQ+ community,” they say, citing that literature proves patients won’t initiate talks about their gender or sexual identity with providers because they are afraid.
“If we start with the prejudice that it doesn’t affect that many people, it already blocks us from making efforts because we will think that our time is not being invested adequately.”
Disclosure: The study quoted in this article was produced as part of the Projet d’érudition en médecine familiale presented as part of the Journée d’érudition et recherche du programme de Médecine familiale at Laval University in June 2021. This research was conducted by Amélie Gauthier, Pier-Maude Lanteigne, Dre Myriam Gosselin and Michael Lessard.
Correction: March 30, 2022 2:19 pm This story has been altered since publication to reflect the correct spelling of Garry Dart’s name.
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