The following section outlines introductory information pertaining to the provision of gender-affirming care for Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) individuals. The materials in this section are both visual and written, and review the following topics: creating affirming clinical spaces, informed consent model, gender-affirming health care options, and the role of the PCP. Each section provides instructions or an explanation of how to engage with the material, as well as an estimation of the length of time the section will take to complete. Although it is not required, we recommend that Trainees complete each sub-section in chronological order.
The following section outlines the most up to date practices in creating affirming clinical spaces using a community-informed approach. This section is comprised of both visual and written material, and should be completed in the following order:
Watch the Community Based Research Centre and the Trans Wellness Initiative’s Introduction to Affirming Spaces training which contains 3 core lessons: 1) Introduction to Intersectionality, Inclusive Language, & 2SLGBTQ+ Terminology, 2) Introduction to Affirming Clinical & Health Care Settings, and 3) Intersections of Identity and 2SLGBTQ+ Community Perspectives on Affirming Spaces.
Complete the Service Provider Reflection Tool: Here.
Watch the CBRC's 24 minute presentation on the Informed-Consent Model located in the hormone training. This step may be completed in conjunction with part 5 of the education package.
We would like to highlight the importance of cultural competency, not just for PCPs, but for all individuals working and volunteering within the health care system. We would encourage you to share these resources with all involved, as all staff and volunteers will be working in some capacity with Indigenous patients.
Capacity to Consent
As with any other medical intervention, patients must demonstrate an understanding of the risks and benefits of GAHT. Obtaining informed consent is a process that PCPs engage in daily, and when prescribing hormones to Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) patients, the same basic principles apply. Questions may arise around capacity to consent in individuals with cognitive or developmental disabilities, significant mental health challenges, and/or in younger patients. In Canada, there is no specific age at which an individual is considered eligible to provide consent for medical interventions; this is determined on a case-by-case basis and at the discretion of the provider in collaboration with the patient. If there are persistent, evidence-based concerns regarding a patient’s capacity to consent, a referral to a psychiatrist with experience working with 2STIGD people may be helpful. For instance, while a mental health diagnosis is not reason enough to deny a patient GAHT, a patient who is actively experiencing mania or psychosis may need to see a mental health professional before beginning GAHT.
Both historically and contemporarily, patients who are disabled and/or neurodivergent have experienced barriers in accessing gender-affirming care as a result of their perceived lack of capacity to consent. It is important to make sure Disabled and Neurodivergent patients have all the necessary information to make informed decisions regarding their gender-related goals. However, it is just as important to make sure that they are able to exercise autonomy over their own bodies, and that they are supported and affirmed in the decisions they make for themselves. If there are evidence-based concerns regarding an individual's capacity to consent, the PCP should work with a mental health provider to help determine the individual's ability to make an informed decision.
Gender-Affirming Health Care Options
Gender-affirming health care must be individualized according to a patient’s needs and goals and can involve many different aspects of social, medical, and legal care. The care and support provided by PCPs is intended to provide 2STIGD patients with the means to safely reach their goals. This approach has many benefits, including improved mental and physical health outcomes for patients, and improved PCP social and occupational capacity.
PCPs have an important role to play in discussing gender identity and gender-related health goals with patients, whether they provide or make a referral for gender-affirming care. The options outlined in this guide include the social, medical, and legal care that individuals may seek out. Importantly, individual patients may require some, all, or none of these options.
Social forms of transition involve the non-medical options for changing how one presents, including changing one’s name, gender marker, pronouns, and the way someone dresses and expresses themself. Some 2STIGD people may look to their PCPs for support with non-medical aspects of gender affirmation and PCPs can take initiative to ask patients about their pronouns, as well as to confirm the name they use. Simply ask, “What are your pronouns?” rather than using the term “preferred” pronouns (as it implies their pronouns are optional, which is not the case for many 2STIGD individuals). Additionally, when navigating a patient’s name (which they may not have legally changed yet), simply ask, “What is your name?” or, “How would you like me to refer to you?” to know the name they use, as well as “Is the name on your Medicare card different?” rather than asking for their “real name.” The name that the patient uses (rather than what is on their Medicare card) should always be used and respected, with the exception of on medical forms that need to be submitted.
Some other social forms of transition include: education about safer chest-binding or genital tucking, or counselling about common concerns such as coming out to friends and family or coping with transphobia. In most instances, the PCP should have the knowledge base to be able to provide guidance on the social aspects of transition (i.e. safer chest-binding or genital tucking). However, in other instances it would be appropriate for the PCP to facilitate connecting a patient to a mental health professional who could provide further support and guidance.
Historically, the lack of education and formal training provided to PCPs on gender-affirming care has caused gender-specific care to fall exclusively under the domain of specialist care. However, since PCPs usually have familiarity and a sustained relationship with patients, they are ideally situated to facilitate and support a patient’s gender-affirming health care needs. In most cases, providing GAHT is within the scope of primary care practice, as is providing affirming sexual, reproductive, and mental health supports or referrals.
The primary role of the PCP is to provide patients with gender-affirming social, legal, and medical care, and/or to make appropriate referrals when necessary (e.g., surgery or mental health). The PCP should do this in collaboration with patients to ensure they are meeting their individual needs and goals. In other words, the role of the PCP is not to investigate or interrogate an individual about their gender identity or expression, but rather to listen, validate, and help the individual explore the options available to them.
Extensive research has shown that access to a supportive PCP dramatically decreases depressive symptoms and suicidal ideation in 2STIGD patients, and is further attributed to postive social, physical, and mental health outcomes. When equipped with the proper tools and information, PCPs are positioned to facilitate timely access to gender-affirming care and support patients in meeting their needs and goals.
Referral to an endocrinologist may be appropriate and helpful, particularly in the case of a medically complex patient, but it is not required for all 2STIGD patients. Notably, involving an endocrinologist may result in unduly long wait times due to limited capacity. If consultation is necessary, Rainbow Health Ontario suggests that it may be helpful to consider starting an androgen blocker with or without the addition of low-dose estrogen for patients desiring feminizing effects or low-dose testosterone for patients desiring masculinizing effects until the consultation can be obtained.
While most patients do not require referral to a specialist to begin GAHT, this does not negate the important role that endocrinologists can have for some patients. For instance, there is usually active involvement of an endocrinologist in the case of youth who have not completed puberty. If a patient has not completed puberty and the PCP is not knowledgeable in providing care to youth, Rainbow Health Ontario suggests providing care under the guidance of an expert or making a referral to another provider with expertise in supporting 2STIGD children and youth.
Given the spectrum of gender identity and the variation in each person’s expression, there is no single pathway that 2STIGD people follow in order to meet their desired goals. While hormones and/or surgeries are medically necessary for many 2STIGD people, for others it may be sufficient to modify their presentation through changes in legal identification and modifications to their gait, dress, voice, and/or through hair removal. Additionally, medical transition tends to come with a significant financial barrier which can often delay or limit patients by what they can afford. Care should be taken to recognize the validity of all patients, regardless of the ways in which they choose to transition, and regardless of the reasons behind these choices.
When hormones are required as part of a persons care, some patients may seek maximum feminization/masculinization, while others may seek a more androgynous appearance. GAHT may also be helpful for patients who do not wish to make a social transition or who are unable to do so. Both the dose and route of GAHT should be individualized to meet a patient’s specific goals. The duration of GAHT may also be personalized depending on patient goals. For example, patients who have not undergone gonadectomy (i.e., surgical removal of either the testes or ovaries) may opt to discontinue GAHT if the irreversible changes are adequate to maintain their desired presentation.
While GAHT is generally required prior to genital surgery or gonadectomy (unless contraindicated), it is not considered a requirement prior to breast, chest or other gender-affirming procedures (see Part 5: Gender-Affirming Surgery for more details). The decision to undergo surgical interventions is also highly individual.
A Framework for Providing Gender-Affirming Care
Gender-affirming primary care falls into two distinct branches: delivering transition-related care and addressing general primary care needs of 2STIGD patients in a way that is tailored to the unique needs of these individuals. This section provides a high-level overview of what gender-affirming primary care includes, and in doing so introduces the various aspects of care detailed in the education package.
In Canada, the core protocols and guidelines addressing transition-related medical/surgical care are the Standards of Care developed by the World Professional Association for Transgender Health (WPATH) and the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-V). While generally considered the gold standard, WPATH’s SoC does not provide specifics for hormone provision or direction around certain aspects of primary care. As such, additional guidelines have been developed by Trans Care BC and Rainbow Health Ontario to include more specific details on their practices of gender-affirming care. As previously mentioned, the core of this education package has been developed from the guidelines provided by Trans Care BC and Rainbow Health Ontario.
The second broad area for delivering primary care to 2STIGD patients is consideration of how a patient’s gender identity requires a different approach to providing care that is not directly related to medical or surgical transition. For instance, 2STIGD patients can experience many of the same issues and conditions as cis patients, and, in most cases, there is nothing medically that needs to be done differently. The key difference in delivering general primary care to 2STIGD patients is in the language and approach used by the PCP.
Gender-affirming practices include, but are not limited to: inclusive posters on office walls, patient handout materials, and processes for data collection and management that can help eliminate suboptimal patient encounters and negative impacts on health (i.e., misgendering, using the wrong name, or failing to conduct proper preventative screening). During clinical encounters, the PCP should also reflect on their approaches for engaging 2STIGD patients, such as asking what would make them most comfortable or what terminology they use to refer to themselves or specific parts. For instance, because Pap tests can cause distress and discomfort for transmasculine or non-binary folks, you may want to consider: offering to use a side-lying rather than lithotomy position when doing a Pap test; asking what would be most affirming for them; and referring to body parts using the terminology each individual patient prefers (e.g. some transmasculine people will refer to their clitoris as a penis or “T-penis” and will refer to their vagina as a “second hole” or “frontal genital opening”).
It is important to consider how 2STIGD patients may need a slightly different approach in some areas of primary care practice: disease prevention and screening (e.g., when and how to approach Pap or prostate testing with 2STIGD patients), or discussions about fertility, sex, and STBBI testing. Unfortunately, preventive and sexual health are often divided into gendered categories (i.e., F and M), with the assumption that these align with a particular type of body. For example, cisnormative assumptions lead us to think that breast cancer screening is part of “women’s health,” when, in fact, breast cancer does not just impact cisgender women. Providing gender-affirming care will require PCPs to work collaboratively with each individual patient to determine what their needs are and how best to meet them.