N.S. advocates say loss of specialists supporting gender-affirming surgeries will cause a crisis

Advocates for Nova Scotia's transgender and non-binary communities say the state of their health care is in crisis after three specialists announced this week that they would no longer accept new patients.

Two of the specialists are endocrinologists who write letters required to qualify for gender-affirming surgery. The third is one of the only surgeons in the province who performs mastectomies and chest masculinization, commonly referred to as top surgery.

"It doesn't surprise me. We have overloaded a system that is criminally understaffed, underfunded," said Riley Nielson-Baker, a spokesperson for Gender Affirming Care Nova Scotia.

"We have a system that's in rapid collapse. And it's going to end up killing people, to put it bluntly."

The World Professional Association for Transgender Health says in a policy statement that gender-affirming surgeries are life-saving and not elective. Without it, it says transgender people are at an increased risk for suicidality.

Out-of-province care

The Halifax Sexual Health Centre says patients who require most of the other gender-affirming procedures are sent to Montreal. Now that's where most transgender people requiring top surgery will also have to go. 

"Gender-affirming care is life-saving care," said Abbey Ferguson, the centre's executive director. "This is horrifying that we're going to have to explain to [patients] that their wait time was however long and now it's going to be this much longer."

Nova Scotia's health minister, Michelle Thompson, said she is aware of the situation. She said some surgeons have offered to take on some of the procedures while the province works out a long-term plan.

Ferguson and Nielson-Baker said this week's developments are just the latest in what has been years of advocacy to improve transgender and non-binary health care in Nova Scotia, and they're calling for an overhaul of the system.

Currently patients need three letters to qualify for gender-affirming surgery: one from a specialist that includes a psychosocial assessment, one from a primary care provider, and a third from an additional specialist saying the person requires the surgery.

Approval process a 'burden'

It's that third letter that the two endocrinologists say they will no longer write, citing workload concerns, said Ferguson. She said the third letter is unnecessary, and simply prolongs the process to get approved for surgery.

She pointed out the third letters come from practitioners who have nothing to do with the care of the patient.

"It feels bizarre for us as clinicians. It definitely feels bizarre from a patient perspective, and they're a massive burden. And then also taking up the time of specialist," she said. 

Nielson-Baker has been trying to get approval for top surgery for nearly two years. They know of someone who had to wait 11 years to have the procedure.

"If I was someone who had another life-threatening condition that required immediate care, I wouldn't have to jump through hoops and get two to three recommendations in order to access life-saving care," they said. "That's absolutely ridiculous."

The health minister said her department is working on a review of transgender and non-binary health care.

"We've heard that we need to do better in regards to this policy," said Thompson. "That work has begun. It is in its early stages, but we are committed to seeing it through."

Government seeks input

Nielson-Baker said they were invited to be part of the review, but they were told the review was only focusing on surgeries, not health care as a whole. Thompson said she did not know if that was the case.

She said it's important for the government to hear from the transgender community about "what it is that they need and where they feel the gaps are and how do we support that."

Last week, Statistics Canada released data that revealed nearly 5,000 Nova Scotians identified as transgender and non-binary in the 2021 census. That's the highest proportion in Canada.

Nielson-Baker said despite the strong community, repeated governments have put Band-Aid solutions on trans and non-binary health needs.

They pointed to prideHealth, a part of the provincial health authority that is supposed to advocate and help patients navigate safe spaces within the system. Nielson-Baker said there's just one employee.

"The government is not providing training or funding for those people who are already practising medicine to learn about trans people, to learn how to treat us both socially and medically."

Ferguson said gender-affirming care is incorrectly thought of as "niche."

"It's not niche," she said. "That census data tells us that we have the highest proportion of gender-diverse or trans folks, so we know that this province should be a leader in paying attention to gender-affirming care. "