CHARLOTTETOWN, P.E.I. —Cadence O’keefe says she has socially transitioned from male to female.
Originally born male, O’keefe has become more confident in identifying as female after years of self-denial. She wears dresses and makeup, and proudly displays the “F” – for female – marker on her provincial ID card.
"As stupid as it is, that little "F" is one of the most meaningful things in my life," O’keefe says.
But the 34-year old Summerside resident has hit a roadblock in her effort to transition fully to female. She has been on a waiting list for five years for a medical assessment that she was told was required to obtain hormone replacement therapy.
O’keefe describes hormone replacement therapy as being “medically necessary” for her due to her experiences with gender dysphoria – a strong, persistent feeling of disconnection with her biologically-assigned sex. Hormone therapy will be her first step in a process of medically transitioning from male to female. She plans to then pursue facial feminization surgery and gender-affirming surgery.
"Just looking at yourself in the mirror makes your skin crawl. Because it's not your skin,” O’keefe says.
“I can tell you this much, it is the scariest feeling ever.”
Like other members of the Island’s transgender community, O’keefe has found that family doctors often lack basic information about where to refer patients for assessments required to access transgender-specific health services. Confusion exists about which treatments even require assessments. A statement from Health P.E.I. said assessments were not needed to access hormone therapy.
These assessments are required to access coverage for gender-affirming surgeries, such as a chest-saving mastectomy or more complex surgeries such as a vaginoplasty.
Last May Health Minister Robert Mitchell announced the Island would provide coverage for transgender-specific health services, including gender-confirming surgery.
The announcement was celebrated within the Island’s tight-knit transgender community as a positive step forward. The announcement brought P.E.I.’s healthcare system in line with most other provinces in Canada. P.E.I. had been the last province not to cover gender-affirming surgery.
But very few doctors have the training to offer the assessments to access this care.
"Accessing those assessments here on the Island is virtually impossible. People are going off-Island to get those assessments," said Cybelle Rieber, executive director of PEERS Alliance, which provides support programming for LBGTQ+ youth.
“There is a lack of family doctors who have knowledge and comfort around working with trans-people and trans-bodies."
Rieber knows of one health professional who was been carrying out assessments. This physician has been forced to stop doing the assessment because of a lack of capacity, she said.
A statement from Health P.E.I. confirmed that there is only one physician with the training to provide assessments. A representative from Health P.E.I. said this individual was still carrying out assessments.
Since May, close to a dozen Islanders have applied for or inquired about gender-affirming surgery. A statement from Health P.E.I. said all applicants are currently being evaluated – no surgeries have taken place since the province’s funding commitment.
Rieber said most medical professionals are willing to work with transgender patients but have received little training or information about referrals.
Advocates like Rieber say accessing this care is essential for transgender individuals. Many individuals experiencing dysphoria undergo a period of intense depression. A study carried out by researchers at Western university found that more than half of transgender people in Ontario have symptoms of clinical depression, while 43 per cent had attempted suicide.
Alana Daley became an active member of the P.E.I. Transgender Network after her child experienced severe gender dysphoria at the age of 11.
She said many members of the network are often unclear about whether an assessment by a psychiatrist is required for individuals to access therapies such as hormone replacement.
"These people cannot move forward in their process without getting these letters," Daley said.
Daley says she has seen the confusion first-hand. After returning from an appointment at the IWK children’s hospital in Halifax, staff gave her a P.E.I. phone number so her child could obtain a hormone readiness assessment. The assessment is required for young children or adolescents who are too young to access hormone replacement therapy.
When Daley called the number, it went to a fax line. After spending time googling, Daley obtained the correct phone number. After calling it, she was told that she needed to call staff at the Queen Elizabeth Hospital. QEH staff agreed to take her son on, but only if she had a referral from her family doctor, even after she was first referred by IWK staff.
“Nobody really knows where to go,” Daley said.
Health P.E.I. says a training program is in the works for healthcare staff in P.E.I.
“Health P.E.I. is in the process of working with the World Professional Association for Transgender Health (WPATH) to establish a training cohort for local physicians,” read a statement from Health P.E.I.
“Already a number of health professionals on P.E.I. have confirmed their interest in obtaining the necessary training to provide WPATH assessments.”
The statement also said training has been “ongoing for Island physicians and physician residents” in the Toronto Protocol for Hormone Therapy, which is a guideline for how medical professionals should approach transgender care and hormone therapy.
Jay Gallant was among the most outspoken transgender advocates in the months leading up to last May’s announcement.
He said the Island’s health system has improved greatly in recent years for transgender individuals and praised the province’s move last May to cover gender-affirming surgery.
"I think it was a very positive step forward. I don't want to take away at all from how incredibly important a step that is," Gallant says.
Gallant says his family doctor is now doing his bloodwork and is able to prescribe his hormones. Previously he would have had to travel off-Island for this care.
But he said barriers still exist for individuals who are just beginning to navigate their treatment of gender dysphoria. Some transgender individuals do not have access to a family doctor, while others have family doctors who are not supportive of them. The costs of travelling off-Island for care is not covered.
Gallant also pointed to a page on the Health P.E.I. website focused on transgender care. The page states that assessments are carried out on P.E.I. according to WPATH standards, and that once an individual receives this assessment “a surgical plan will be developed with a medical team.”
"The government website for trans-health is a bit misleading. It makes it seem that these things are already in place," Gallant said.
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