Nova Scotia may have the highest proportion of trans and gender diverse individuals in Canada, but advocates say those who need to access gender-affirming health care are facing increased barriers and lives are at risk.
In a media release Tuesday evening, the non-profit Halifax Sexual Health Centre (HSHC) said its members learned on Monday of two new and “significant” barriers to gender-affirming care (GAC) access in Nova Scotia.
In the release, HSHC said it was informed by the office of plastic surgeon Dr. Steven Morris that he’ll no longer be offering gender-affirming top surgery procedures (mastectomy, chest masculinization), effective immediately.
The only provider of gender-affirming surgery in the province, HSHC said Morris’s decision was undertaken after years of lobbying for proper MSI (Medical Services Insurance) billing codes “wherein his requests were routinely ignored.”
In addition, HSHC learned that two specialists (endocrinologists) who provide letters required by MSI for patients to get their gender-affirming surgery publicly funded are no longer accepting new referrals.
Both specialists have cited capacity limitations as the reason.
HSHC executive director Abbey Ferguson said in Nova Scotia, endocrinologists, psychiatrists, surgeons, and gynecologists (if the patient is getting bottom surgery) typically write the specialist letters.
The two endocrinologists no longer accepting new referrals were where HSHC sent the majority of patients. Now, patients seeking GAC specialist letters must be referred elsewhere, something Ferguson said will further increase already lengthy wait times.
“The biggest impact there? It’s the run around and the bureaucracy, but it’s the wait,” Ferguson said in an interview Wednesday.
“Delayed care for trans folks is a life-impacting situation. The risk for suicidality and other mental health concerns is massive, and this hindrance is huge.”
Nova Scotia GAC patients will also now face the “considerable burden” of accessing surgery in Montreal, something HSHC said impacts surgery wait times, travel costs, and post-operative care and increases the amount of bureaucracy and paperwork for patients and providers.
HSHC has more than 850 patients receiving gender-affirming care, and about 60 more on a waitlist. These individuals include 22.8% of all Nova Scotians who self-identified as trans and/or non-binary in the 2021 Canadian Census released last week.
“That census data that just came out couldn’t have come at a better time…It’s not niche, and we should be a leader in care,” Ferguson said.
“We have the highest proportion, and it’s just no longer appropriate for them to hope that there’s a couple of kind-hearted providers out there that are willing to be uncompensated or underpaid and overburdened with sheer capacity of patients, thinking that that’s totally fine.”
‘A systemic failure’
In an emailed statement, Gender Affirming Care Nova Scotia (GACNS) said these recent developments surrounding the availability and provision of gender-affirming surgeries in the province aren’t surprising.
“Our system of gender affirming care generally, including surgeries, has remained underfunded in the face of increasing demand,” they wrote.
Before these latest developments, GACNS said the average wait time to access gender-affirming surgery in the province was about 24 months. They said the loss of those providers will lengthen the time it takes to access life saving care, putting at risk the lives of “some of the most vulnerable people in our province.”
“This is a crisis. But it has been a crisis for years. It goes beyond the provision of surgeries. This is a systemic failure to provide for and respect the transgender, intersex, and gender diverse community,” GACNS wrote in its statement.
“We deserve better from our government. We deserve comprehensive funding for all aspects of our healthcare, not just surgeries. We deserve to have our voices centered in our care.”
GACNS is calling for decisive action.
“The failure of three different governments over more than a decade of provincial gender affirming care will kill people. Members of our community have been screaming for help with no action, and now the system risks collapsing,” GACNS wrote.
“We need decisive action by the provincial government to properly fund all aspects of gender affirming care, including, but not limited to, surgeries.”
Under compensated, overburdened providers
Ferguson said many organizations including HSHC have been reaching out to various levels of government about the gender-affirming care crisis for years. She said the provincial government and Nova Scotia Health (NSH) have continued to rely on a handful of under compensated and overburdened providers and community health clinics to provide gender-affirming care in the province.
“This province has been thinking that transgender health care or gender diverse health care, gender-affirming care, is niche and that it’s totally appropriate for them to funnel every single patient into Halifax Sexual Health Centre, that it’s appropriate that this is not a core competency taught in medical schools,” Ferguson said.
“And family doctors are not being encouraged to do this care and understand the process, and it’s been ignored and it’s not appropriate.”
The non-profit said gender-affirming care requires “comprehensive coordination and compensation.” It’s calling for decisive action by the provincial government to properly fund all aspects of gender-affirming care — including surgeries — and is asking MSI to reassess its requirements for gender-affirming surgery approval to reduce barriers and delays.
“Lots of folks tend to think…that we as Halifax Sexual Health Centre make these decisions for all the sexual, reproductive, and gender affirming health care for the province, but we are a non-profit clinic,” Ferguson said.
“We are not a service of the NSHA. This is something that we do by our own missions and values statement, but there is no system in place that if we were to suddenly close, that our 63,000 patients would have anywhere to go…These decisions must be changed on an MSI and a governmental level.”
In addition to NSH, MSI, and the provincial government engaging with Dr. Morris to fix the billing code issue and more appropriately compensate him, Ferguson said she wants to see the “burdensome and uncompensated” specialist letter requirement removed. She’s also advocating for a general overhaul of the entire application process.
Ferguson said HSHC’s decision to issue a media release about this situation speaks to its seriousness.
“We are thinking about our patient load and coming together as clinicians,” Ferguson said. “We don’t have anywhere to send them for their specialist letters that can give appropriate, timely care, and that is horrifying.”
The Halifax Examiner did reach out to the province and is expecting a response from the Department of Health and Wellness. We’ll update the story when we receive it.
To learn more about policy alternatives for gender-affirming care — or for more information on gender-affirming care in general — reach out to GACNS.
Early Wednesday evening, a spokesperson with the Department of Health and Wellness provided an emailed statement.
“We recently learned of the doctor’s decision and our immediate concern is the well-being of his patients. We are assessing the situation to understand the impact on patients and how we can support them to receive the care they need,” spokesperson Marla MacInnis wrote.
“Nova Scotia has had a fee code in place for gender-affirming top surgeries since 2017, which was recently updated this year. For patients who are currently approved to receive surgery in Montreal, they do not need to reapply or request a new surgery readiness letter.”