Tripp Smith was relieved. He had been trying to access medical care that would help him to transition for years, but was at a loss about how to do it. He felt completely alone. “My GP at the time had no clue [about the transitioning process] and didn’t even appear to want to learn,” he says.
Then, about three years ago, Smith’s friend turned his life around during a casual coffee. The friend, who is also trans, was well-versed in the long hunt for competent providers that trans patients face. He told Smith about Erin Ziegler, a nurse practitioner, and he was able to get an appointment with Ziegler a few weeks later. After Smith met her, he knew everything about his access to health care would be different.
“I remember leaving the appointment feeling hopeful. A feeling I hadn’t felt in a long time,” the 33-year-old says. “It was a turning point for me…. It felt like, for the first time I could take a breath and I didn’t have to hide. I felt seen, heard and respected.”
Ziegler worked at the Wise Elephant Family Health Team (WEFHT) in Brampton, Ontario, about a half-hour drive outside of Toronto. She’s widely known as the go-to person for trans health care in the city and the Greater Toronto Area (GTA). Ziegler fell into the work in 2012, when a patient she’d been seeing for years came out to her as trans and asked for her help with hormone therapy. She was happy for them and wanted to do everything she could to support them, but realized she knew almost nothing about how to do that.
Around the same time, Rainbow Health Ontario (RHO) was conducting research in the GTA to find out more about the level of health care available for queer and trans people. Ziegler decided to partner with the organization, and found that “services were non-existent.” Often, the closest obvious queer care was located in downtown Toronto; this was the case not only with the region’s services and programming, but with identifiable safe spaces, too.
To begin remedying this gap, Ziegler trained with the folks at RHO, an organization that specializes in providing exactly this kind of education, and learned what it means to provide queer care. As it turns out, caring for LGBTQ2S+ people doesn’t mean a whole separate understanding of health care.
“Primary care is primary care, it doesn’t matter what your gender identity or sexuality is,” Ziegler says. What does matter is that she takes a sexuality and gender-affirming approach in her work, which very few clinics do. That means not assuming someone’s orientation or gender identity, their pronouns, their partner’s sex or other parts of their identity. Maybe someone’s name or gender identity doesn’t match the one on their health card—Ziegler doesn’t give them grief about that. She also helps people access hormone therapy and puberty blockers, and refers patients for gender-affirming surgeries.
“Caring for LGBTQ2S+ people doesn’t mean a whole separate understanding of health care.”
By word of mouth, people learned that Ziegler was providing gender-affirming care in a positive space and using informed consent. For a while, trans patients contacted Ziegler directly and would leave her messages asking to get back to them. But after seeing a handful of trans patients, she realized the whole clinic would have to learn to be trans-friendly in order to provide safe health care.
By 2018, after participating in group training provided by RHO and a great many lunch-and-learns, everyone who worked at the WEFHT knew how to provide competent care. Staff were well-versed in correct pronoun usage, clinicians and receptionists made sure to use the words patients used to refer to themselves and the clinic’s washrooms were genderless.
“All of those things are potential traumas,” Ziegler says. If staff did make a mistake, they took it seriously, apologized and corrected themselves. There was accountability.
The space offered just about everything trans people look for when seeking health care but often can’t find. By 2021, Ziegler had more than 150 trans patients ranging in age from 11 to 68, most of whom sought her care to start hormone therapy.
But that may all end. At the end of May, the WEFHT closed its doors due to a lack of government funding, and patients have since been forced to start their search for care all over again. For Smith, the old fear that he’ll be left without health care has returned. He doesn’t know what he’ll do now that the clinic is closed. But Brampton is not the only mid-sized Canadian city where trans residents are facing a lack of health care.
What’s happening at the WEFHT is emblematic of a wider problem: despite more outward support for the community, legal protections and greater visibility, trans and other LGBTQ2S+ care isn’t being prioritized in Canada. When it is, by practitioners like Ziegler, funding and other barriers frequently arise. More often than not, affirming care is seen as an afterthought, if it’s considered at all.
In Ontario, family health teams like the WEFHT are staffed by a variety of health care workers, including nurses, nurse practitioners and mental health workers; they’re designed to support doctors, who can refer their patients to a specialist if needed. Family health teams need to be connected to what the province calls a Family Health Organization—a doctor’s office—in order to operate. The setup makes for faster, more specialized care, and also gives doctors more space to see other patients.
The WEFHT’s contract with Ontario’s Ministry of Health, however, stipulates that it must work with the Wise Elephant Family Health Organization only—and its relationship with the doctors behind that organization is fraught. It includes long disagreements over the use of funding, two lawsuits and an eventual split, in 2019, between the family health organization and the family health team.
After that, a new board took over. It set about trying to find a different doctor to work with so that WEFHT could stay open, but received no reply from the ministry about whether this could be done. Instead, it said it was closing the clinic “for convenience.” Now, the ministry is providing funding to two other family health teams in Brampton so that the WEFHT’s former patients will have a place to go. Staff at the Queen Square Family Health Team, according to a ministry spokesperson, are going to begin developing the skills needed to care for trans people in the city.
“For affirming practitioners, it’s daunting to come into a new workplace and immediately shift its entire culture by yourself.”
But that’s no easy task. For affirming practitioners like Ziegler, it’s daunting—and often incredibly difficult—to come into a new workplace and immediately shift its entire culture by yourself. You have to start off slow, get to know people and start talking to those you suspect might be sympathetic to this type of care. Building a trans-affirming culture isn’t always possible, and when it isn’t, trans people are unable to access health care: either they don’t feel safe, or doctors who are prejudiced against them (or simply refuse to learn to do better) deny them care.
And now, Brampton’s queer care landscape is in danger of becoming like those in other Canadian cities: barren. It’s a common perception that LGBTQ2S+ care is widely available in urban centres, but not so much in rural areas. The truth is that it’s rare throughout the country, regardless of the size of the region, and medium-sized cities are often without adequate care, too. Where the care does exist, it’s often embroiled in funding problems, and providers are difficult to track down. A total of 13 practitioners in Toronto are certified providers with the World Professional Association for Transgender Health (WPATH). According to the WPATH directory, there are just six in Saskatoon, Saskatchewan; in Saint John, New Brunswick, and St. John’s, Newfoundland, there are none. These numbers don’t cover every doctor providing services to trans people, but they do give a sense of how few people are practising in a qualified way.
Wherever adequate, competent, knowledgeable care for LGBTQ2S+ folks does exist in Canada, there is usually one superlative individual behind the scenes: an empathetic person who sees each patient as a fully-rounded, unique being, whose love for patients is obvious and radiates outward to inform the way their entire clinic is run.
In Fredericton, that person is Dr. Adrian Edgar.
Edgar ran Clinic 554, first opened in 2014. The family practice was well-known for being the only clinic-based abortion provider in the province, but Edgar also provided affirming care to the city’s LGBTQ2S+ community. He asked for and used patient’s pronouns, offered hormone therapy and referred people for gender-affirming surgery. He’s a safe person. But his clinic had to close in February due to lack of funding; its survival over the years depended on community crowdfunding.
Formerly a Morgenlater Clinic, the little building in Fredericton’s downtown with a rainbow painted on its side has been targeted by successive conservative provincial governments who called it a “private abortion clinic” that shouldn’t be funded by the province. In reality, it provided general health care, and was one of only a handful of clinic-based abortion settings in Atlantic Canada—and one of the only sites for safe queer care.
Credit: The Canadian Press/Kevin Bissett
It’s tough to count LGBTQ2S+-friendly clinics in Canada: there’s no real database, and their names usually don’t reflect their specialty—and often Google doesn’t either. Aside from the Wise Elephant Family Health Team, other centres for LGBTQ2S+ care across Canada include the Halifax Sexual Health Centre, Toronto’s Sherbourne Health Centre, the Transgender Health Klinic in Winnipeg, Vancouver’s Three Bridges Community Health Centre and, for those under 25, Montreal’s Head & Hands. There’s also Calgary’s Metta Clinic for trans youth, but that, too, has faced funding problems; until a few years ago, it was only open one half day per month. The Alberta Health Services eventually beefed up Metta Clinic’s funding slightly. Today, it’s being run with fewer staff due to the pandemic, and a call made two weeks ago to check on its status hasn’t been returned.
What’s happening in New Brunswick is in many ways similar to what’s happening at the WEFHT. Both boil down to bits of bureaucracy, one-liners in the law that stunt their ability to operate: in New Brunswick, it’s Schedule 2 of Regulation 84-20, a pre-Morgentaler piece of law banning clinic abortions. This means all health care a patient receives at the clinic is covered by Medicare except for abortions. Those who have abortions must pay up to $800 of their own money.
But because so many people went to Clinic 554 for these procedures—and so many people can’t afford to pay for them—Edgar ended up providing pro bono abortions. And because he can’t get reimbursed by the government, the clinic became financially unsustainable.
As a result, it had to close. Edgar still helps out some people with abortions, but he’s had to get another job as a doctor at the local military base. Mostly, the clinic stands empty, and LGBTQ2S+ people in the city are left on their own.
Ryan Jones, a former patient of Clinic 554, is one of these people. He started seeing Edgar for reproductive and transition-related care years ago. He says the clinic’s closure—and with it, the disappearance of compassionate care—has left a massive void in his life.
“The clinic closing put me through the wringer, and it was more than once since that I’ve been really close to walking down to the bridge and taking a permanent swim. Sorry if that’s blunt, but it’s how it is,” he admits. “I have a therapist and have had one for years—but therapy can’t fix inaccessibility.”
Ryan Jones isn’t his actual name. It’s a pseudonym. Jones doesn’t want to share a name anyone would recognize because he’s been maintaining his daily health using technically illegal means. It’s not his first choice, but it’s the only way he can access the care he needs.
Originally, Jones started taking testosterone at Clinic 554. It was hard enough to find somewhere that would give it to him—he didn’t hear about the clinic until he joined a local LGBTQ2S+ advocacy and support group. Now that it’s closed, he has to order testosterone online.
He has to scroll through a bodybuilding site to buy his medicine. The site uses obscure URLs that change frequently so that it doesn’t get shut down. Its design is bright, white and clinical. He pays $150 per bottle; when it arrives, the packaging is unmarked and devoid of instruction. It lasts him about five months.
He worries a bit, and his partner worries even more. They’re lawful types—they didn’t smoke weed before it was legal, and they didn’t drink until they were of age, either. They worry about the dosage. They would both feel better if this was prescribed by a doctor, but none offering the type of care Jones needs seem to exist, despite his best efforts to find one.
When Clinic 554 had to stop caring for trans patients, the New Brunswick premier’s office said that patients could find health care elsewhere. Yet the province’s own website still refers people to Clinic 554 if they don’t have a primary care provider—much to Jones’ chagrin. The doctor Jones went to before Edgar wasn’t knowledgeable about LGBTQ2S+ health and was “eminently unhelpful for literally anything I’ve ever gone to them about,” Jones explains. So he didn’t feel comfortable approaching the idea of starting hormone therapy with him. Since Clinic 554 closed, he’s been without a family doctor. In the meantime, it’s not clear where to go to seek care.
“Educating and convincing doctors to validate your identity isn’t ideal and doesn’t set up a safe relationship.”
“I invite the government to provide me with a list of where I can go,” Jones says. “What doctor in Fredericton is accepting patients for hormone replacement? What doctors are trained in WPATH standards and can provide my assessments for [gender-affirming] surgery? What mental health care providers are there for the same?” Two doctor approvals are still needed for most gender-affirming surgeries, and it’s hard enough to access one. People sometimes wait years for the care they need, if they receive it at all.
Educating and convincing doctors to validate your identity isn’t ideal and doesn’t set up a safe therapeutic relationship, but that’s the reality for many LGBTQ2S+ people in Canada. For Jones, the general awkwardness and discomfort of reproductive care, coupled with dysphoria, means seeking care can be terrifying—and with the exception of Edgar, health care providers have done nothing to dispel this hell. If anything, Jones knows they’re likely to make it worse by misgendering him or treating him rudely. “I can’t just repeat to myself, ‘All of this is normal. I am normal. It’s okay, they’ve seen it all before,’” he says. “They probably haven’t—and I can’t say I’m enthusiastic to be their learning experience.”
It’s a familiar story to many of us. Just about every trans person who has good health care has had to fight for it, and finding it can change everything. It’s widely known that seeking affirming care lowers our suicidality rates and can help us feel happier. On the other hand, being ignored is misery-inducing. New Brunswick was among the last provinces to cover transition-related care, and as a result, many people have been suffering. Smith has been there, too. “If I didn’t meet Erin Ziegler, I have no idea where I would be right now,” he says, after a long sigh and an even longer pause. “I was in such a dark place.”
Though these clinics make life liveable for so many queer and trans people, their unique and much-needed care is not seen as a priority by government.
Instead, trans health care is seen as optional or, in the worst cases, an abomination. And it’s not just in Canada. In the U.K., the high court ruled last year that youth under 16 could not access puberty blockers without court approval, effectively shutting down a huge chunk of treatment options at Tavistock and Portman NHS Foundation Trust, England’s only youth-focused trans clinic. In Arkansas, teens under 18 are now banned from accessing gender-confirming treatments and surgeries. Doctors cannot provide puberty blockers, or refer patients to other providers for these reasons. Nineteen other bills in 12 states also aim to block access to trans health. And even before this new wave of legislation, the Donald Trump administration rescinded protections for queer and trans people, removing all references to gender identity, sexual orientation and LGBTQ2S+ people from the nondiscrimination provision of the Affordable Care Act. While Joe Biden’s government later reversed that decision, making sure trans people are covered under discrimination in health care legislation, these decisions show that trans rights to health care often depend on the whims of majority cisgender elected officials.
And though trans rights are supposed to be included in Canada’s anti-discrimination law and under many provincial laws as well, that doesn’t translate to fair and equitable treatment. We’re at the mercy of those in power, which can be triggering in its own right for people whose needs routinely go unmet.
Just before the Wise Elephant closed, access wasn’t much better than when Ziegler surveyed the GTA for obvious queer care nearly a decade ago.
“I have patients telling me that they didn’t know where to go, and they still don’t know where to go! It’s a huge gap,” she says. She sees patients from all over, from both rural areas and nearby cities: Oakville, Mississauga, Burlington, Guelph and Kitchener.
Ziegler says many of the access challenges come from the fact that health care providers simply have no literacy on LGBTQ2S+ issues. There’s still a serious lack of queer and trans health taught in medical schools. It’s getting better—Ziegler teaches everything she knows at Ryerson’s School of Nursing, for example, and the University of Toronto is making an effort to advance knowledge of LGBTQ2S+ health in its medical school, too—but what’s taught depends on the schools’ professors. Many professionals in the field were trained 10 or more years ago, and likely weren’t taught anything about LGBTQ2S+-specific care. And there’s no oversight body to make sure the education of health care providers is kept up-to-date.
“There’s still a serious lack of queer and trans health taught in medical schools.”
“Practitioners will tell me, ‘It’s interesting, but doesn’t apply to me because there are no LGBTQ2S+ clients in my practice,’” Ziegler says. “I hear that all the time and it boggles my mind.”
This perception is a self-fulfilling prophecy: if you don’t make clear that you’re safe to come out to, people won’t come out to you. They’ll keep their identities to themselves in order to get in and out of your office in one piece.
Ziegler says it’s not as simple as suggesting people find another provider, since there’s a known lack of people providing competent care. She said the team at the Wise Elephant is planning to move to a different clinic, but couldn’t yet say where.
She says her patients are checking in constantly, wondering what will happen. Before the clinic closed, she promised, “If the clinic isn’t funded, I’m going to do everything I possibly can to get them care that is safe and affirming for them.”
As for Smith, he got a call from Ziegler’s office suggesting another clinic, and he’s waiting to hear back to see if they’ll see him. He doesn’t know if the standards of care will be the same, but he has hope. He says most people will probably try to follow Ziegler wherever she ends up, since she’s their health care provider and the only one they’ve been able to depend on.
But I’ll send him Ryan’s bodybuilding site, too—just in case.
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