Efforts de défense des intérêts
We believe that the experiences and inputs of trans & NB patients are necessary in the process of developing acceptable trans & NB medical care standards. As such, we consult with the Student Society of McGill University, other LGBTQ+ and medical student organizations, and the EDIC Subcommittee on Queer People, to advocate for better standards of care at the McGill Student Wellness Hub for trans & NB patients.
As such, the TPU meets at least once a semester with members of the McGill Wellness Hub, including the one doctor providing trans-related care, to discuss issues patients have raised regarding access and health practices.
The TPU advocates for changes to care based on agreed upon policies by our members, see our current policy made with the help of SSMU and the CEHI.
Proposed Changes to Gender Affirming Care at the McGill Wellness Hub
This document was produced by the Trans Patient Union at McGill with the support and counsel of the Student Society of McGill University (SSMU), the HealthQueer Professionals (HQP) of the Medical Student Society, and Community Educators for Healthcare Inclusion (CEHI) of the Medical Student Society.
The Trans Patient Union (TPU) is a Queer McGill and Union for Gender Empowerment coalition group by and for transgender and non binary McGill patients. The TPU provides resources to help trans McGill students navigate their transitions at McGill and in Montreal, as well as advocate for the improvement of the healthcare available to patients at McGill.
In order to properly understand the state of gender-affirming care (GAC) at the McGill Student Wellness Hub (the Hub), the TPU has extensively interviewed over 25 trans patients and surveyed 16 about their experiences receiving GAC at the Hub. These interviews have guided the recommendations listed below. The TPU hopes that this document can function to initiate a dialogue with the various healthcare providers and representatives of the Hub to improve GAC following the spirit of the recommendations below. The TPU further hopes to be recognized as a trusted partner of the Hub in supporting the trans community on campus.
Streamlining the HRT process from three appointments to two
The TPU wishes to highlight changes that could be made to the Hub’s current hormone replacement therapy (HRT) process that would simplify the process and make it more inline with the practices by many clinics in Montreal and beyond. Currently, the informed consent process at the Hub involves a minimum of three appointments before HRT can be prescribed, whereas patients at other clinics in Montreal are able to access HRT after one or two appointments. At other clinics, patients can sign a consent sheet and are given a referral for hormonal blood work at their first appointment. Patients can review their test results and (assuming their results are not problematic) get a referral for HRT on their second appointment. At some clinics, trans patients are even able to get a prescription for HRT after one appointment by being asked to sign a consent sheet, being given a blood test requisition, and being given an HRT prescription all in one appointment, and are later contacted for a second appointment only if their blood test results are problematic. In contrast, Hub patients are currently not permitted to sign the consent sheet upon receiving it at their first appointment; they must return for a second appointment to hand it in, then they can get a blood test requisition at their second appointment, and can return to review blood test results and possibly start HRT on their third appointment.
Given the difficulty for many students to book appointments at the Hub, additional appointments can mean a significant additional wait period before patients can begin HRT. The TPU believes that an informed-consent model that involves only 2 appointments can help prevent negative mental health impacts for patients associated with delays to accessing HRT. Considering the precedent for less appointments at other Montreal clinics, and the negative impact a longer process can have on patients, the TPU feels strongly that it is important for the informed-consent HRT process at the Hub to be streamlined to involve a minimum of 2 appointments to receive a prescription for HRT. The following chart elaborates more on a proposed process for HRT at the Hub where patients get a blood test done between appointments one and two so they can hand in their consent sheet as they review test results. This process is in line with WPATH recommendations (Appendix C) and the Association des médecins endocrinologues du Québec guidelines. The TPU recognizes that this chart does not capture the only way to streamline the HRT process into 2 appointments and is open to other processes that would result in fewer appointments and delays for trans patients, including allowing patients to sign the consent sheet on their first appointment, or allowing patient to review and consider the consent sheet before their first appointment.
| Appointment 1 | Discussion of transition and medical options (effects and risks), Offer of Pride Team mental health services, Explanation of the informed consent process , General physical exam, Provide the requisition form for blood work. |
| Blood Work | Reduce delays (possible solutions: perform right after Appointment 1, schedule Appointment 2 two weeks later after blood work analysis). |
| Appointment 2 | Review blood test results and viability for HRT, Discuss future of care, Signature of consent form, Prescription of HRT. |
| Appointment 3 (optional) | Nurse teaches and supervises HRT injection, Offers another appointment the following week at patient’s request |
Providing bicalutamide according to the Fenway Health guidelines
The only anti-androgen medication currently prescribed by the Hub is spironolactone, the standard anti-androgen in Canada and the US. The literature evaluating spironolactone’s antiandrogen capacities often finds spironolactone to be ineffective in lowering testosterone in assigned-male-at-birth participants (Ally, 2021). As such, many transfeminine patients are looking for alternatives; of much interest to many of the patients we have consulted with is bicalutamide.
The TPU acknowledges that some medical professionals have reasonable concerns regarding the use of bicalutamide, while others have already incorporated bicalutamide into their practices. Notably, bicalutamide has not yet been widely studied in clinical trials on transfeminine patients, and existing literature on bicalutamide used to treat elderly cis male prostate cancer patients highlights rare instances of liver failure. This said, studies within this population of cancer patients demonstrate that not a single case of liver failure occurred when patients’ liver function were properly monitored and care was appropriately adjusted or discontinued. In these studies, discontinuation was only necessary for 0.5-1.5% of participants (Blackledge, 1996; See et al., 2002). In addition, transfeminine patients would be taking lower doses (25-50 mg vs 50-150mg), and do not possess the same comorbidities and risk factors as cancer patients (Ally, 2020). Thus, the risk of liver toxicity is considered extremely low for transfeminine patients, so long as liver function is carefully monitored (Ally, 2020).
Some guides like WPATH do not recommend using it, citing the lack of widespread studies on transfeminine patients (Coleman et al., 2022). However, the guide produced by Fenway Health – the National LGBTQIA+ Health Center in the US – says it is acceptable to carefully consider it “after alternative options have been trialed or offered, and an in-depth discussion of these potential risks have been had.” Also notable is that the primary author of the Endocrine Society’s 2009 and 2017 HRT guidelines (Hembree et al., 2009; Hembree et al., 2017) has written positively about bicalutamide for transfeminine patients (Fishman, Paliou, Poretsky, & Hembree, 2019). Preliminary research into the use of bicalutamide on adolescent transfeminine patients has had positive results (Ozturan et al., 2023). While we understand that some providers feel it is their responsibility to always choose the option with the least risky side effects for their patients, providers should also consider the impact of living for years with underwhelming transit results. We believe that this is why bicalutamide has become an option for some transfeminine patients who are unsatisfied with the results of spironolactone, and are comfortable taking on additional risk for a better chance of achieving their transition goals.
Considering the above, the TPU recommends that the Hub’s doctors implement a bicalutamide policy similar to Fenway’s. Transfeminine patients for whom spironolactone is not a good fit, and who have carefully considered the pros and cons of bicalutamide with their doctor through shared decision making, should be able to consent to its use. In particular, patients should be able to renew their prescriptions. In the status quo, patients are often forced to go to other jurisdictions or access their medication through illegal means to avoid the physiological and psychological consequences of a sudden lack of anti-androgen. The TPU sees this as unacceptable, and recommends that the Hub find a remedy to this situation as soon as possible.
Ensure that new doctors at the Hub are adequately trained to provide care for trans patients
In order to limit the barriers of access to gender-affirming care, an increase in the number of trans-care providers is necessary. More providers will increase appointments available, lower wait times, and produce a less rigid network of care. The TPU recognizes that the Hub is currently making progress on this front, and is very excited to hear that a new HRT providing doctor is expected to join the Hub team next school year and that a doctor returning from maternity leave will likely provide gender affirming care as well. We hope that the Hub will continue to build on this momentum and going forward, ensure that all physicians are trained in providing gender-affirming care to trans patients at McGill.
Getting doctors to provide recommendation letters for gender-affirming surgeries
Recommendation letters are required by surgery clinics like GRS Montreal to perform gender-affirming surgeries for patients. Currently at the Hub, physicians refer their patients to psychologists who are responsible for writing recommendation letters on behalf of patients requesting gender affirming surgery. Unfortunately at the present, these letters from Hub psychologists are often rejected by GRS Montreal. Patients report that psychologists are often unaware of requirements for such letters. It is imperative that these letters meet the criteria set out by gender affirming clinics, otherwise this results in undue delays for patients (which impacts patient mental health), and additional unneeded time and resources from the Hub. The process of being referred to a psychologist and scheduling appointments to make and remake letters can take months. Those drafting such letters must be provided sufficient guidance to provide letters that are accepted by GRS, and other clinics, after a single appointment with a patient. At times, the Hub’s GPs has provided such letters, as any GP in Quebec can do so. This has been associated with shorter delays as the letter was provided after the necessary health assessment. The TPU would like to explore the possibility of Hub GPs once again providing such letters.
Providing realistic expectations for fertility preservation
Preventing bias in fertility preservation is essential to gender-affirming care. Fertility preservation can be presented in a biased way when a clinician assumes fertility preservation is always the best or safest route for trans patients, or fails to establish realistic expectations about the preservation process. Providing realistic expectations for care is a critical part of informed consent. Failure to do so risks the mental wellbeing of patients, and it can lead patients to accept a preservation they later regret, a reality expressed by several patients consulted. Some transmasculine patients reported that had they known how much preservation would delay their access to HRT and how invasive and painful the procedure would be, they would not have agreed to go through with preservation. The TPU believes that a bias-prevention policy would reduce the number of patients expressing these experiences.
Further, the TPU believes that Hub providers should encourage patients to consider fertility preservation because of the value it brings to their own health, wellbeing, and future – we do not encourage providers to suggest that patients make important healthcare decisions by speculating on what third parties may think of a patient’s decision. Many TPU members report that providers have suggested fertility preservation to them as a way to encourage others to support their transition, a factor we do not think should be relevant in medical decision making.
The TPU worries that without changes to the information provided on fertility preservation and how that information is framed, future patients may continue to report regret in undergoing fertility preservation. The TPU would like to see a policy that encourages providers to: (1) provide patients with reasonable estimates of expected delays to HRT in order to preserve their fertility, based on delays experienced by recent patients; (2) mention the possibility of emotional challenges when fertility preservation delays access to HRT, and ask if this is a concern the patient has; (3) provide patients a realistic idea of the egg or sperm freezing process so that they can be better informed about the possible emotional and physical challenges when they consent to preservation; (4) not bring up or assume the opinions that third parties (like parents) may have about a patient’s choice to transition or decline fertility preservation.
Providing HRT to 17 year old patients
The TPU would like to see the Wellness Hub develop a Hormone Replacement Therapy policy for those students under the age of 18. In email correspondences with the TPU, the Hub has stated that it is not set-up to provide trans care to those under 18, referring to it as “specialized care”. As such, those who want this care must either wait until they are 18 or be referred to a Montreal pediatric clinic that provides gender affirming care. Being referred to a clinic that specializes in gender affirming care for minors takes months or years. The minors in question have been 17 year old first year students with birthdays in September to December who are a few weeks or months away from turning 18. This means the referral to a youth clinic is not an effective referral, since these patients would age out and qualify for care at the Hub before the referral leads to care.
Additionally, it is not clear to the TPU why the Hub’s doctor considers this care to be specialized. The Hub uses an informed consent HRT process, the age of medical consent is 14 in Quebec, and HRT counts under these consent models both in the WPATH standards of care and Quebec’s own health insurance system. Usually, clinics that do not offer gender-affirming care to minors refuse to do so because they either don’t offer gender-affirming care or because they don’t serve minors. In contrast, the Hub both serves minors and provides gender-affirming care. The result of the current policy is the same as refusing care for patients under 18, adding weeks or months to their process unnecessarily as they wait for their 18th birthday. For these reasons, the TPU would like to see the Hub’s clinicians provide HRT to patients under the age of 18.
If you’d like to learn about the changes to the HRT process that have happened since the TPU has been active, see our document on the History of HRT and Proposal for HRT Process at the McGill Wellness Hub.
