Sexual healthcare for youth needs a revamp
Katie, a 29-year-old retail worker, was searching for an alternative to the birth control pill. A few months ago, she went to a walk-in clinic in Toronto to inquire about the copper intra-uterine device (IUD), a more affordable, non-hormonal birth control option. She figured it would be safe to address sexual matters with her doctor, also a young woman. To Katie’s surprise, the doctor claimed that IUDs are “only for older, monogamous, married women” – end of conversation.
For the record, there is no solid evidence to suggest that younger, non-monogamous women can’t have an IUD – I have one, and I am an unwed 24-year-old. Rather than shutting that door because Katie did not fit her ideals, the doctor should have properly counseled Katie on risks and benefits, or referred her appropriately. As a result of this neglect, Katie left the clinic feeling judged, frustrated, and discouraged.
Katie’s story is not an isolated case. In Canada, youth face numerous and varying obstacles to accessing comprehensive and equitable sexual health services. One issue is that in the country’s health care network, there seems to be a tendency to treat sexual health as separate from primary, everyday care. In reality, taking care of your sexual health is as much a factor in your overall well-being as, say, balanced eating or physical activity. This separation is manifested literally, with a limited number of designated clinics that specialize in sexual health. For LGBTQ2I youth, accessibility is further impeded by discriminatory health care practices. And if you live outside of a big city that can pose its own set of challenges.
While you can turn to your general practitioner for most health issues, for which they can either care for themselves or refer you to a specialist, disclosing details surrounding your sexuality is often more difficult. Mimi, a sexual health peer educator, says, “Young people are reluctant to discuss sex with their doctors for many reasons.” For starters, sex can be too sensitive a subject to discuss with anyone, let alone with a family practitioner that you’ve been seeing since you were in diapers – or, conversely, that you’re meeting for the first time. Maybe you’re worried that your doc will pass judgment on your sexual preferences. If you’re a trans youth, your reluctance may stem from scarring experiences with transphobic practitioners.
Traditional medical settings like family clinics and hospitals compound these anxieties by treating sex as a taboo subject. “We don’t even use the right terminology around sexual health,” says family physician Dr. Sheila Wijayasinghe. “Doctors are taught to use euphemisms to make people comfortable, but at the same time we perpetuate the stigma around [discussing sex].”
This is where sexual health clinics come in. One of the first to open in Canada was Planned Parenthood Toronto (PPT), founded in 1961. Unlike a gloomy hospital setting or doctor’s office, PPT’s waiting room has a welcoming vibe. Mounted high on the wall is a big-screen television airing MuchMusic videos. There’s a computer with internet access. Information pamphlets and youth-centric magazines abound. Sexual health awareness posters cover the front of the receptionist desk. “People come into the waiting room and they feel comfortable,” says Sarah Hobbs-Blyth, the Executive Director of PPT. “It’s youth positive; they know they can hang out. It’s not a traditional medical environment. It’s a non-judgmental atmosphere.”
In Toronto, we are fortunate enough to have numerous clinics like PPT that provide and promote sexual health related services, products, and procedures, many of which are covered by OHIP. These include birth control counseling, discounted contraception pills, free condoms, pregnancy testing and STI testing. These clinics are unique because they operate on a sex-positive and LGBTQ2I-positive premise. They are meant to provide a safe, inclusive, and non-judgmental space for young people to address their sexual health concerns.
But from the perspective of trans youth, there’s room for improvement, within both sexual health clinics and the health care system more broadly.
I met Morgan at The 519 Community Centre in Toronto, where she facilitates various trans-specific programs. She reminisces that her friend Sholma was “a fabulous genderqueer person.” As an epileptic, Sholma would often require emergency room visits. On multiple occasions, the nurses and doctors would openly make fun of his appearance. One night, in 2009, he had a serious seizure. When he came to, he decided to not go back to the hospital. “He didn’t want to be pointed at again and made to feel like a freak.” Later that night, a follow-up seizure ultimately took his life. “If he had gone to the hospital, he would not have died,” Morgan laments. “But he didn’t feel safe to go there.”
Morgan explains that although this event occurred in Michigan, the situation for trans folks in Canada is equally bleak. “Most trans people, myself included – every friend I have, every program participant who comes [to The 519] – we’ve all experienced health-care related discrimination at one point or another in our lives.” Family doctors can be as complicit in this malpractice as hospitals. “More often than not, they will claim ignorance of the subject [transsexuality] and refer you to the Centre for Addiction and Mental Health, which runs a gender-identity clinic,” says Morgan. “Most of the time, they’ll leave you on your own to figure out where to go next.”
Morgan suggests that, unfortunately, it isn’t always better at sexual health clinics. “Even though it says it’s inclusive of trans people, they’re not actually expecting us to be there.” At one clinic she went to, everything about the form pertained to a woman assigned female at birth. “It was asking me about things related to menstruation, things that aren’t relevant to me and my body. There was nowhere for me to write in, ‘I need a prostate exam’.” She adds that many doctors “call people the wrong pronoun, refer to body parts wrong, and do not know what to do with a trans body.”
Such experiences deter many in the trans community from going or returning to clinics. This means that many trans people aren’t getting tested for STIs, which is troubling. Trans people, especially trans sex workers, are considered a high-risk population for contracting HIV. “There are statistics that say as much as 68% of trans women sex workers are HIV-positive in Atlanta, Georgia. In Rome, Italy, it’s 74%,”* Morgan says. “It’s very high percentages, so the fact that we’re not getting tested is a really big deal.”
Sarah also acknowledges that trans youth aren’t getting the services that they need. “There’s a lot more that we can do as a clinic to make sure that services are accessible and meaningful to trans youth,” she says. “Sexual health organizations have an obligation to train their providers, and to ensure that the services that they provide are non-judgmental and don’t discriminate.”
Aside from regular training for all staff, Morgan believes that hiring more trans people can “completely transform the way a place runs.” The trans employee can “advocate for all the tiny changes – like changing the forms slightly – that will change the way a trans person experiences the place.” Further, having trans people on staff at an agency can convey to other trans folks that it is safe space. Across the country, these safe spaces are few and far between. Toronto fares better than many other cities in this respect. According to Dr. Wijayasinghe, “the larger and denser a city, the greater the number of advocacy groups there will be.” In turn, these groups will demand services that cater to specific communities.
While The 519 does not offer health services on site, they do provide counseling and referrals, along with a comprehensive list of trans-specific programs. One such program is Trans Youth Toronto (TYT), created in 2001. TYT provides a social space for trans-identified youth, and is Canada’s longest running trans-youth group.
Another service is Trans Access, which is a training program for social service agencies, including sexual health clinics. The goal is to help these agencies become more accessible through the embrace of trans-inclusive policies. Alongside this list of trans-specific programs, The 519 has a reference list of trans-friendly health care centres in Toronto. These include The 410 on Sherbourne Street, Hassle-Free Clinic, and the Sherbourne Health Centre. Morgan also recommends Women’s College Hospital.
Rainbow Health Ontario (RHO) works to accomplish similar goals as The 519’s Trans Access program, but on a provincial scale and for the LGBTQ2I population more broadly. According to RHO, approximately 70% of Ontarian trans people live outside of Toronto. For these trans folks, comprehensive primary health care is even harder to obtain. With funding from the Ontario Ministry of Health and Long-Term Care, and in partnership with The Sherbourne Health Centre, RHO launched Trans Health Connection (THC) in April 2011. This project aims to foster more accessible health care for trans folks throughout Ontario. Thus far, THC has focused on the regions of Thunder Bay, Ottawa, St. Catharines, and Windsor. It has collaborated with one health centre in each area, with each centre serving as the city’s hub for trans-inclusive services.
The NorWest Community Health Centre (NorWest CHC) in Thunder Bay is one of these hubs. It is an integrated health facility that offers a variety of services, including those pertaining to mental health, primary health and sexual health. Wendy Talbot, Chief Executive Officer of the NorWest CHC, praised RHO for being “a partner and a big support for us in terms of training the physicians on the medical aspects of our trans population.”
In spite of these measures, within the region of Thunder Bay certain barriers exist that impede accessibility to sexual health care. These barriers affect both the LGBTQ2I youth community specifically, and the greater youth demographic more generally. Transportation is one obstacle. “We’re talking about people living, say, 200 kilometers, 300 kilometers from Thunder Bay,” Wendy says. “The only way they can get here is if they have someone to drive them or if they have a vehicle. There’s not the transportation that you will see in urban centres. There’s also not the number of specialists [that you would find in Toronto]. And when you have that small a number, you can’t effectively provide comprehensive care. People have to go to where the providers are.”
There is also the issue of anonymity and a lack of a support network. According to Wendy, “Everybody knows everybody up here. If you have a youth that’s going through gender reassignment, it’s very difficult in small communities. The discrimination can be pretty brutal.” As a result, many young people relocate to Southern Ontario, where there is a safety net of a larger LGBTQ2I community presence. “Thunder Bay is getting better in recognizing the need to support this [LGBTQ2I] population,” Wendy says, “and has made some important steps.”
Progress often demands a degree of patience. However, when it comes to the sexual and emotional health of trans youth these calls for patience belie the urgency of this situation. Change is needed right now. What these calls for patience do reveal is a privileged position afforded to administrators, policy makers, and practitioners far removed from these communities.
As Sarah puts it, “the sexual and reproductive health needs of trans youth are not being met with enough vigor.” The slow rate at which change is occurring is unacceptable. While those outside of the LGBTQ2I community—particularly individuals who identify as white, middle-class, able bodied, cis gendered and live in urban centres—continue to reap the benefits of Canada’s supposed commitment to accessible, affordable, and equitable health care, trans folks are getting sick and do not feel safe to seek the medical attention that they are entitled to. Doctors have a responsibility to provide proper care for every person who walks through their doors, regardless of gender identity or sexual orientation. Unfamiliarity with transsexuality is an inexcusable reason for turning a patient away. “Let’s be real, we live in 2012,” says Morgan. “You can turn on the TV now and see Chaz Bono on Dancing with the Stars. So it’s not as though most people in North America can claim to not know that we exist. Now it’s just about filling in the gaps of knowledge.”
In order to foster more awareness and inclusive medical practices, training and education on the health needs specific to trans folks should be made mandatory for every health care provider and incorporated into high school health curriculums. For the benefit of all youth, there needs to be a revamp of sexual health care throughout Canada. For the trans community in particular, this is urgently necessary
- Source Namaste, Vivane. Invisible Lives: The Erasure of Transsexual and Transgendered People. Chicago: The University of Chicago Press, 2000.