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#77 Trans Health: True to Self

Sly Sarkisova is a Toronto-based psychotherapist and registered clinical social worker. Photo by Mitchel Raphael

April 2, 2020

Acceptance of transgender and non-binary folks in Canada has come a long way in the last decade and arguably much of this progress was made in just the last few years. While many of us take for granted the ability to express our true selves, it was only in June of 2017 that gender identity and expression was officially recognized and protected from discrimination under the Canadian Human Rights Act. This and many other policy changes, including those related to healthcare, stem from decades of effort and courage from the trans community. On this episode, you'll hear several perspectives on the past, present, and future of trans health. We spoke to Susan Gapka, a trans-rights advocate and Education and Training Program facilitator at The 519, who discussed her work at The 519, political activism, and lived experience as a trans individual. We also spoke with Sly Sarkisova, a psychotherapist and a registered clinical social worker specializing in trauma and LGBTQ+-related mental health, who walked us through the challenges faced by trans and non-binary folks and how they might interact with the healthcare system. Finally, Dr. Mitchell Brown, an Associate Professor in Department of Surgery at University of Toronto and plastic surgeon at Women's College Hospital, spoke to us about the Transition-Related Surgery Program, the first public hospital-based surgical program in Canada focused on providing safe and timely access to transition-related surgical care.

Written by: Tsukiko Miyata

Rainbow Health Ontario
Sherbourne Health
Women's College Hospital - Transition Related Surgeries Program
The 519
Toronto Trans Coalition Project
CAMH Gender Identity Clinic
Glad Day Bookshop
Flamingo Rampant - A micropress with a mission
Sly Sarkisova

Susan Gapka [0:03] I think that same evolution is going to happen over the next 10 to 20 years with trans right. Having that legal framework for all its faults and all its advantages and disadvantages tells people we do belong in the society. I am loved and protected. There will be role models, and people like me get to be one of them that we didn't have when I was growing up.

Melissa Galati [0:31] April 11, 2012. The Human Rights Tribunal of Ontario rules that gender confirming surgery is no longer required for change in registered genderon Ontario document.

Nathan Chan [0:41] March 20, 2013. The House of Commons passes Bill C279, a private member's bill sponsored by Randall Garrison, which officially extends human rights protections to transgender and transsexual people in Canada.

Atefeh Mohammadi [0:53] March 1, 2016. The Ontario health Insurance Plan changes funding criteria for gender confirming surgery by allowing qualified providers throughout the province to assess issues.

Melissa Galati [1:04] June 12, 2017. Ontario unanimously passes the Trans Day of Remembrance Act, officially recognizing trans Day of Remembrance every year on November 20 and requiring the Legislative Assembly of Ontario to hold a moment of silence.

Nathan Chan [1:18] June 19, 2017. Bill C16 is passed by the Parliament of Canada and receives Royal Assent. The law adds gender expression and identity as protected grounds to the Canadian human rights.

Atefeh Mohammadi [1:28] June 12, 2019. The possible program offers a third gender option X, along with M and F on Canadian passports.

Susan Gapka [1:38] I hoped it gets better, and it eventually did. You know, you've got to go through the deep valleys and the jungles to see the beauty of the mountain top.

Melissa Galati [1:51] Across Canada, health care access and services for transgender persons have undergone massive transformations in the last few years.

Atefeh Mohammadi [1:59] Historic, however, this population experienced and continues to experience significant health disparities due to factors like discrimination, erasure of identity, and lack of medical providers with sufficient expertise. On today's episode, we wanted to shed light on the experiences of transgender persons, how this legacy of oppression has led to inequities and health, and in what ways we can do better.

Melissa Galati [2:26] To say we learned a lot in producing this episode is an understatement, and we truly wish we could share all three hours of audio with you folks. But, we hope that what content we have shared inspires you to pause, listen a bit more, and treat others with less judgment and a bit more kindness. Our guests today shared their perspectives and personal and professional journeys with us. Forgive us in advance. Several of our interviews today were conducted remotely due to the recent pandemic, and the audio isn't perfect, but hopefully you'll enjoy the discussion too much to notice.

Nathan Chan [2:56] This is Nathan, and I use he him pronouns.

Atefeh Mohammadi [2:59] This is Atefeh, and my preferred pronouns are she and her.

Melissa Galati [3:03] And this is Melissa. My preferred pronouns are she and her. Welcome to Episode 77 of RawTalk.

Nathan Chan [3:18] We were extremely fortunate to sit down with two individuals who have worked extensively through activism, writing, and education. They've helped our society define and understand concepts like transgender, non-binary and gender non-conforming. You'll hear from them both throughout the episode as they share their wealth of knowledge, lived experience, and historical perspectives on transgender health in Canada. I sat down with Sly Sarkisova , a social worker and psychotherapist based in Toronto who specializes in trauma, mental health, addiction, and psychotherapy for people who identify along the LGBTQ+ spectrum. You'll hear more about his practice and personal journey a little later in the episode. But first, we asked him to help orient us and you, our listeners, with a short lesson in gender studies 101.

Sly Sarkisova [3:59] So, gender identity is basically just your sense of your gender. So it's an internal idea of who you are. Some, some people don't really think of themselves in a gendered way, and others think of themselves in a very gendered way. So it's your internal self concept in relation to the things that we externally reference as masculine, feminine, neither nor, androgynous traits, behavior, likes, preferences. But mostly, it's your internal sense of yourself in relation to gender. Gender expression is how you're comfortable to express your gender in the world. So it's the signals that you get, give to others about who you are in a gendered sense, to include your way of presenting yourself in the world to your dress preferences, the kinds of activities that you're interested, in the way that you hold yourself, the way that you are affectively, emotionally, socially, those sorts of things.

Nathan Chan [4:55] And so what does it mean to identify as trans or non-binary?

Sly Sarkisova [4:58] Basically, being trans person means that you don't identify with the social construct of gender that was placed upon you at birth. So traditionally, historically, we've looked to biology, physiology, the body, whatnot, and looked at people's reproductive organs to determine what their internal sense of their self is, their gender identity. And trans people have really created a space for folks to push back against that limited understanding of gender and identity. And to look at the ways in which your identity does not necessarily have to be about your reproductive organs. You know, it's sort of a space where you develop your own sense of your internal self, it might be oppositional to what you were assigned at birth, or it might be something more diverse than that, it might be a non binary identity or something else. So non-conforming simply just means that you don't adhere to the gender expectations of your biological sex. So we say in the trans community "assigned sex at birth", because typically, folks are designated into female or male on site at birth-based on what people think of their genitals. So, in gender non-conforming can be socially; it can be in in various ways.

Sly Sarkisova [6:10] You know, I helped coined the word trans persons in 2003, with Rupert Raj with Ontario Public Health Association when we were using "trans person" or "trans man" and "trans woman" is one word actually back then with capital letters, too, and for many people, younger people find those terms offensive, but in our times, we, those were the terms that we knew and understood.

Melissa Galati [6:39] You might recognize that voice from the beginning of the episode. That was Susan Gapka. Susan is a Toronto based trans activist who helped define trans as our society understands it today. We won't even attempt to tell you about all of her advocacy work, but Susan has led and been part of the campaigns for everything from gay marriage rights to the funding of gender confirming surgery in Ontario.

Sly Sarkisova [7:00] Hi, my name is Susan Gapka. I use she and her pronouns; elle en francais, s'il vous plait. I'm a trans activist employed at the 519 in education and training. I do a lot of media sometimes and intergovernmental relations. As a member of the 519, I also am on the member of CUPE, which means that I'm on the Ontario executive board and for the Pink Triangle Committee's Chair, so that's more political. My work at 519 is more around we do things like facilitating meetings, consultations. My specialty is trans and non-binary people, but of course, I'm versatile. As trans people, we got to be good at everything to survive in this world. But I'm thrilled to be with you today and thrilled that you asked me to participate in this conversation.

Tsukiko Miyata [7:58] And what is your typical day working at the 519 as a facilitator of the education and training services?

Sly Sarkisova [8:06] There are no typical days for me, cuz I'm usually project-based. But when I'm doing facilitating and training, I can tell you a little bit about. We do workshops, and I do kind of the lunch and learn workshops, where an organization will call us on; I went to Seneca College in January, and they were getting ready for the new year, and the staff wanted to know more about how to be more trans inclusive for their students and curriculum. Now, this is something we didn't have when I was growing up, a lot of education on this. I get really excited about reaching out and working with media and universities and colleges, because it's an educational piece. I think trans identities and putting a human face on and trying to have an interaction around who we are and what our needs are, I think is it's a human connection kind of thing. And you know, not everybody's gonna agree with us, but I think so many more people are being more compassionate, and more understanding, and eager to learn more about how to be respectful and to treat people with respect and dignity. So, I'm excited to be part of that process. But sometimes, we'll do like consultations on on issues like when the provincial government, when they were changing the identification requirements, or when the Ministry of Health was changing, access to transition related surgeries and what the criteria are. So, one thing that we do really well, I think, is whole those community consultations in our space, and what the 519 also does something remarkably well is we hold space for trans community members for like trans day of remembrance, which is every November, is made up of community members and facilitated by other staff. I do the memorial part of that day. We also start in the morning with Breakfast Television interview, and it's so it's like a 20 hour day. But, it's really mostly we hold space and facilitate conversations for trans community members and trans and non-binary people, so they can bring their energies, their talents, and their artistry to our building, and we hold space for that to happen. So I'm very proud of the work that we do.

Tsukiko Miyata [10:26] Why do you do this work? And why is it important to you?

Sly Sarkisova [10:31] You know, as a young child growing up, I was outlawed. I was criminalized. I was an outcast. And I saw really no future in my life. I experienced suicidality. I really didn't have hope. I ended up on the streets of Toronto for 10 years. And suddenly then, I came to terms. I figured that midlife, midlife being the operational word here, just that realizing it, what I hope to be my midlife that it's not a passing phase; there was something to this, and I had to look into it. And since then, it's been like, I've been like a seed in the desert that suddenly has gotten water and God, love, and nutrition that I didn't have growing up. And to be able to do, to be my authentic self in the workplace, in the media, and in my public life, and in socially included in Ontario and Canadian society is such, there are no words in the language to describe the feeling of finally overcoming my challenges and being recognized, and having like people who like to see me, people asking me for interviews, and to be an educator and to become an educator for a generation of people who are coming up so that it's, and really my original purpose is, the same purpose today at this very moment, is that younger people can have a better life than the hardship I struggled through as a child. And, that's reward enough to actually have an apartment in downtown Toronto, the best employer that I could possibly ever find, the most political union that I work with, and to have all of that in my life is such a pleasure, and such a treasure. I get to be a generation for younger trans children coming out and trans families. I get to be the wise elder that I didn't have growing up. And that's, you know, that's, that's just beautiful. And I, I just feel that's worth getting up in the morning for.

Nathan Chan [12:46] You're a psychotherapist and a counselor in mental health, addiction, trauma and LGBTQ therapy. How did you kind of get to where you are today?

Sly Sarkisova [12:54] Yeah, that was a long and circuitous route. But, I started, I started my career in Vancouver in the downtown South at a mental health drop-in center. And then, I sort of tailored my education from there to get more specifically into psychotherapy. So, I work to the mental health drop-in center, and I did various frontline mental health roles, outreach worker, and things like that, homeless outreach, all sorts of things for six years. And then, I moved directly into the Downtown Eastside and was doing trauma-informed psychotherapy, and like co-occurring disorders therapy, so a lot of heavy in trauma-informed work around addiction management, and that was a couple of years, and then I moved out to Toronto and did my Master's in Social Work. I had a, an undergrad originally in Psychology, and then I did a second undergrad in Social Work and did some social work, came out here. I did a Master's in Social Work and then started working at a local LGBTQ centric health center for several years on their interdisciplinary health team. And then, after that, I established my private practice and I've been doing that for the last seven years.

Nathan Chan [13:58] I guess the obvious next question is, what kind of services do you offer through your private practice?

Sly Sarkisova [14:04] So in terms of one-to-one, individual psychotherapy, I basically just offer an integrative theoretical space where we can look at the ways in which systemic issues interplay with personal responses to stress, distress, harm, intergenerational cycles of violence, and racism, colonialism, homophobia, and transphobia, the systemic pieces that people have to live with, so just a very trauma-informed space to do a work to help people understand what they're coping with, and in terms of distress and harm, and help them process through and develop a different way of coping if that's helpful, to change their mindset, or change the way they deal with their emotions, or change the way that they respond to their, their body and their whole entire ecosystem. So looking at coping strategies. In addition to that, I do workshops and trainings for organizations around mental health trauma addiction and gender identity and offer clinical supervision, as well, to a number of folks.

Nathan Chan [15:01] And what are some of the challenges that trans people and non-binary people face today?

Sly Sarkisova [15:06] It's an interesting time. It seems to be a quite an explosion of knowledge around trans issues, and especially non-binary issues. So, I think there's been tremendous education happening that has really taken off from decades of like, on the ground activists fighting for your life or death sort of variances of trans people fighting for care and access. So, I think we're at a very opportune time. What are the challenges? I think that, with more access, people tend to believe that the problem is solved. So, for folks that are not younger and receiving unconditional care and support, for example, if that's the case, it's more likely to be the case these days, which is fantastic. But for older folks, people, over 30 people, over 40 people, over 50, if they're coming into themselves now and accessing trans health care, their legacy of ability to in there so authentically is much different. And there's a different way to the legacy of oppression. So that tends to get erased.

Nathan Chan [16:08] We'll come back to this idea of a legacy of oppression. It's important to understand the history that trans people have faced and continue to face. As Sly mentioned, in today's society, the experiences of trans youth compared to trans adults at various life stages can be dramatically different. And some of the differences routed in the erasure of identity that many older adults would have experienced. While we've made strides so that this isn't the case for many youth today, we need to keep on learning. We asked Sly to walk us through what the experience of trans youth might be.

Nathan Chan [16:38] Focusing a bit more with younger people now, what age might a person who is thinking that they might be trans or non-binary start to, start to question their gender identity?

Sly Sarkisova [16:49] I think that kids know who they are quick, and they, so trans kids, non-binary kids, they often know who they are, and they get told that it's unacceptable. And, there are Identity at around two or three starts to get expressed. As soon as you're able to walk, talk, choose things, you're expressing your identity. But then, there's this whole system of like repercussions and shaming for people going outside of what they are expected in terms of being a man, or being a boy, being a girl, you get social repercussions. So, for example, a lovely friend of mine that I went to high school with contacted me recently, and her boy's in elementary school, and they don't know what his gender identity is, they don't know, you know, his romantic or sexual identity is; he's young. And but, he wanted to wear like a sparkly dress to school one day, because it's dazzling, and who doesn't want to wear sparkly frigging dress. So that you know, he immediately is getting bullied by some of the more sort of "socially conditioned to be very masculine in traditional ways" kids. So the kids that have been taught to believe that femininity is gross, or wrong, or sick, or weak, whatever, especially, for being a boy, you know, they get the social repercussions from that. And that's where bullying happens. And that's where you start to tuck away your identity and you don't feel safe to express it.

Nathan Chan [18:12] Does gender nonconformity always lead to gender transition? Now, how should young parents be thinking about their children's gender identity and expression?

Sly Sarkisova [18:19] Yeah, I just want to clarify it. So gender non-conforming doesn't necessarily mean you're trans. You could be gender non-conforming and trans; that is true. But, I just want to clarify, because if someone's watching this thing, oh, my kids gender non-conforming, they're automatically trans. You don't have to get so worried around how to support your kid, but it's good to know what the differences are. And so I think basically, if kids identify as trans, not just gender non-conforming but also trans, like their, their, you know, their identity doesn't fit in terms of how others see them. They know they are they're expressing, you know, a different gender identity. And let's say they are very, very uncomfortable around what their body might be doing in terms of approaching adolescence. That's when, like, trans youths often express a lot of distress. So around puberty is when gender role is really getting or have, have traditionally gotten revved up. And the things that their body are starting to do start to cause extreme distress. And that's when they might tell a parent, "I need to transition", and they will look into medical options, but that process takes a few years. It's not just available necessarily on demand. Trans youth care is evolving. And, you know, usually the youth are put on blockers for a time if they feel extremely consistent and solid in their identities and very strongly that they are, you know, who they who they are. They are supported to go on blockers for a time to stop the feminization or masculinization of their body so that they can have some time to see if they feel comfortable. And usually it's the children or youths that are extremely adamant about who they are. The adults sort of hold back, so they might have to wait for a few years before they actively start taking cross-gender hormones, but they could have access younger if they're in a lot of distress and very adamant about who they are.

Melissa Galati [20:11] Sly just mentioned that youth who feel extremely consistent in their identities can sometimes be put on blockers. He's referring to puberty blockers. As you might imagine, puberty can be an especially stressful time for those who identify as trans as they start to develop secondary sex characteristics they don't identify with. Puberty blockers are medications that delay puberty by blocking the hormones, estrogen and testosterone. Blockers aren't a permanent solution by any means, but they allow trans youths to hit the pause button, so to speak, until they're able to explore other options, which may include taking cross-gender hormones or hormone therapy.

Nathan Chan [20:49] What is hormone therapy, and why are trans and non-binary people interested in it?

Sly Sarkisova [20:54] So, hormone therapy is the ability to take hormones that your body produces maybe not in the ideal amounts that you would hope. So we all have estrogen and testosterone in our bodies, but for for folks who want to attain more cross-gender effects, so to speak, so to masculinize your body, you would take testosterone as hormonal therapy and to use effects that are in line with how comfortable you feel in your gender and, and or you could take estrogen therapy and you could feminize your body. So you get the secondary sex characteristics basically, of a second puberty, puberty that you felt most comfortable with when you start taking hormones, and that's through your doctor.

Nathan Chan [21:33] Do you have any advice or thoughts for healthcare professionals when they're working with younger clients to ensure that they're delivering their care in a responsible and ethical manner?

Sly Sarkisova [21:42] As I understand that there's no age of consent in province of Ontario. So, you basically just need to take a client-centered approach and really listen to the youth in front of you and see what they're telling you. Like, I know that sounds really simple, but it's like what is the youth telling you about who they are, has that been consistent, and how can you support them? it's unlikely that people will get hormones at a very young age because they have to hit puberty first. That's just how it works, medically speaking; I'm not a doctor, but I know that they have to reach a certain age, 10 or age 12 something like that, a puberty in development before they can even go on blockers. And then there's some time in between there and starting them on hormones, but just to listen and support the family and see what is needed. And they might need a social worker, they may need some peer support groups, they might need a therapist, but usually they know who they are, and they're just persistent about it and need to be listened to.

Atefeh Mohammadi [22:37] So far, you've heard a lot about the journey and supports available for transgender youth. But as you heard with Susan's, and as you're hearing Sly's, these kinds of supports weren't always available. It's because of advocacy from folks like Susan and Sly that society has come to better accept and understand non-conforming, non-binary and trans individuals. You heard Sly mentioned that in his practice, he provides trauma-informed psychotherapy for folks to cope with legacies of oppression. So we asked him about the experiences of older adults who may realize that gender nonconforming, trans, or non-binary much later in life.

Nathan Chan [23:20] Do you have any advice for adults who are, you know, say like 40, 50, 60 years old, and they're thinking about transitioning now because circumstances in their lives have changed?

Sly Sarkisova [23:30] Yeah, I think a lot of the work, again, is emotional and social, and sense of like, you have to sort of come to terms with the fact that you've had to live in your body and in your identity a certain way for a lifetime, right? And, you might have, might have gone through various different identifiers, you might have identified as a lesbian at one point, then weren't sure, then non-binary, and/or all the above, and trans. like, for example, or you might have identified as a gay man because that was the only option available and suddenly like in your 40s, realize, "wow, like, I'm actually trans, and I've been trans this whole time, but I've been operating under the assumption that I couldn't be." So a lot of the work there is less about medical care access and more about, "wow, can I really do it? Can I actually have access to this thing that I've always sort of identified with but has been sort of compartmentalised a way of existence? And how to bring it back? And how do I, how do I integrate all the ways in which I've lived this life so far so that I don't feel like I have to shun different parts of myself in my experience, and, and to have a cohesive identity," regardless of where you identified along the way, that's necessity.

Nathan Chan [24:39] To explain what the situation would have been like for his own generation, Sly generously shared his experience.

Sly Sarkisova [24:45] So one of the reasons I moved to Ontario was to transition, and I had been thinking about it for a decade. And but, around 2003, I became aware that trans men existed; it was the first time I saw them represented in local media. And there were very few trans-identified people in my community, and the identification was very binary. So if you were a trans man, you were a man full stop. And there was no room for gender variants or understanding your identity as non-binary. And I am a non-binary person, I always have been. So I had to really fight in my own space for, for 10, 15 years to understand that I could exist and then spread that outward. So when I moved out to Ontario, again, I did not hear people talking about non-binary identities as being trans and had to do a lot of work personally in my community, went to community events, to question traditional gender options in our inner identified spaces like LGBT spaces. In my work, I was constantly educating doctors and my colleagues around non-binariness, writing about it, so I had to fight really hard to have access a decade before people were talking about it. Now it's very common. Everybody seems to get it. That was not the case. You could not get care if you're non-binary. And so, I had to really fight on my own with no support and also providing support for others. So it's been quite a process. And that tends to get erased, because people think, "oh, well, you know, non-binary is a thing now." So, you know, but when you're a person caught in between generations where that wasn't possible and you're doing that fight, there's a lot of work there to make yourself a valid person with no reference points.

Melissa Galati [26:25] Yeah, thank you for sharing that. I really appreciate it. And I'm sorry that you had to go through that. Yeah. I can't even imagine.

Sly Sarkisova [26:34] A glimpse into what some people carry, right? I'm not the only one, but that's just my experience.

Nathan Chan [26:39] For yourself personally, how did your period of transition help your mental health and general well being? How did kind of change over that period?

Sly Sarkisova [26:47] Yeah, again, it's a tough, tough one, because in order, again, that's a generational difference. In order for me to be who I am, I have to sort of leave everything and everyone behind, so there's that legacy. And, and you kind of think, or you're told even by community who are not trans that are when you choose a transition, you're going to have all this privilege. And for sure I'm perceived, you know, mostly as a, as a non-trans man in the world that a white man, but that's also influenced by how people read your masculinity. And so, I'm a short person, I am non-binary, and I am very emotional, and I have an aura about me that it's very gentle and empathetic. And I've experienced, you know, so much violence so from other men who don't even read me as trans but pick up something about me that doesn't match their expectations of being a man. I had multiple, I think it was six, I lost count, on the spot death threats from men just out in the world raging about for various reasons. So and, I think my experience is somewhat exceptional, I'm not sure what the deal is. But in my person, I feel fantastic, in my body, I feel fantastic, and in my identity, I feel fantastic. Out in the world, dealing with other people and their gender expectations, man, wow, that's a lot to do, right? And that's a lot of what people report.

Nathan Chan [28:11] Yeah. Thank you for sharing that. That's really impactful.

Melissa Galati [28:15] Susan and Sly's professional work has been essential in advancing knowledge and trans health today. It's because of their work that healthcare teams today are better educated and equipped to help trans folks feel comfortable in their own skin.

Dr. Mitchell Brown [28:28] For some people, that involves surgery and gender confirming surgery, and some people are able to accomplish those goals without surgery.

Atefeh Mohammadi [28:37] You just heard from Dr. Mitchell Brown, a plastic and reconstructive surgeon at the University of Toronto, Faculty of Medicine, who practices primarily at Women's College Hospital. His practices focus largely on reconstructive and aesthetic breast surgery as well as transition-related top surgery in the last few years. We'll come back to him in just a moment. But before we do that, Let's hear Susan's share about her experience with transitioning and gender confirming surgery.

Sly Sarkisova [29:05] When you're talking about transitioning, you're talking about a specific trans experience. And for me, it was very binary growing up. It was like, either you are a man or a woman. And now in today's society, transition has different meanings for people. So there's different thoughts on that. But like, for me, transitioning was very challenging. Because I was a political activist, I actually had to change a bunch of laws to get access to health care that I required, needed. I make a little bit of a joke, you know, if you could see me here. I didn't get this beautiful on my own; I had to like change laws to do it. But I say that tongue in cheek. It's easier to change your legal status. So I'll do a little Foucault here. Maybe, it's like so, we're regulated by society on our legal documents through legal means and medical means, so gatekeepers around access to hormones and surgery for those people. And nowadays, some people, there was, in 1969 model at the gender identity clinic at what is now known as Center for Addiction and Mental Health, it was a single track surgery option without a little bit of understanding about, around all of the social supports required. So, people socially transition, and they medically transition. And so there's a lot going on with that because I change it, you change your name, for me, that was necessary, change your legal ID, but you also have to come out to a lot of people, and it's a real challenge. And, there's appropriate disclosure. And, I have found myself already working in a lot of organizations, I hadn't realized how extensive and significant that would be. For me, 20 years ago, the first time six to eight months were damn near impossible.

Melissa Galati [31:03] Susan acknowledges that improvements have been made for trans individuals since the beginning of her trans rights campaign and her own personal journey.

Sly Sarkisova [31:11] The access for funding is so much better. It didn't exist until 2008, after a lengthy campaign, but that coupled with human rights, I think is making it so much better. I'm surprised to hear from younger people that they have to wait three or six months for an assessment to access health care, transition-related health care. Heck, we had to wait a decade. I think it's okay that people are demanding better, because that's what we did back then. And it's going to be even better for the next generation. It just is hard for me as a, as a person who like we didn't even know if we'd ever get it done back then, right?

Melissa Galati [31:56] It's clear that Susan's challenged to access health care services was long and difficult, but her activism has helped to make enormous advances. Nevertheless, there's more to be done. Let's hear again from Dr. Brown who sees a bright future for trans health services.

Dr. Mitchell Brown [32:11] Fortunately, we're living in a world today where there is more openness and understanding and inclusiveness. And, we're able to be, we're able to really offer programs to people that allow them to identify and express as they feel about themselves inside.

Atefeh Mohammadi [32:29] Women's College Hospital, Sherbourne Health Center, Rainbow health Ontario, the Center for Addiction and Mental Health, as well as some dedicated community members came together to create the trans health expansion partnership. The Transition-related Surgery Program is an initiative rising from this partnership that's led by Women's College Hospital, and it aims to improve access to specialized trans health services. Now, this is the first public hospital-based surgical program in Canada to provide accessible and safe surgical services for trans and non-binary people. Dr. Brown is an active member of the surgical team. And he told us more about how the program came about.

Dr. Mitchell Brown [33:15] It was really an identification that there was a need. And, and Ontario, as in many places in Canada, people had to travel great distances frequently to Quebec, to the United States, outside of continental North America in order to obtain appropriate services for transition-related surgery. And so, in cooperation with the government, Women's College Hospital and the government created this collaborative program. I believe we're now in our third year. We've had tremendous growth. We started slowly. You know, when you have a program like this, you need to create infrastructure. You need to create an environment of safety and comfort and respect that we try to provide to everybody, but in, in a new world, you need to understand and learn some of the basic things you may not have appreciated before: proper use of pronouns, changing electronic medical record system so it adequately reflects more than just a he or she, which some basic old systems don't reflect. So I think we've developed that nicely over the last several years. We've been on an exponential curve in terms of the number of individuals we've been able to treat and manage, and we look to see that grow over the next several years.

Melissa Galati [34:30] The process of transition is multifaceted. There's no sole healthcare professional that is able to provide all the necessary services for trans patients alone. Susan explained earlier how her transition process was challenging, and one reason was the lack of access to different specialized medical professionals. This highlights the particular need for healthcare teams that are collaborative and comprehensive.

Atefeh Mohammadi [34:52] We also talked to brown about the team involved in the care of trans and non-binary people in the transition-related surgeries program.

Dr. Mitchell Brown [34:59] Yes, it's a very inclusive program. It's much more than just about surgery. And, the team really involves everything from counselors and psychologists and, when appropriate, psychiatrists through primary care physicians and nurse practitioners and social workers, and to some degree, the surgeons are at the end of the line. You know, we're able to provide, hopefully, thoughtful and good quality care, but in conjunction with an entire team in the world that I live in as plastic surgeons, there's certain things that we're capable of doing. But we work with our other colleagues. There's dermatologic changes dealing with issues of the skin and hair patterns that can be critical in transitioning. We deal with otolaryngologist to deal with things like the Adam's apple, for example, or voice manipulation. And then I haven't talked at all about bottom surgery, which is something that we do offer at Women's College, especially for our trans female patients. And that is performed through a combination of surgeries with plastic surgeons, urologists, and gynecologists.

James Saravanamuttu [36:06] I was curious as to what types of these surgeries are there.

Dr. Mitchell Brown [36:08] The work that we focus on primarily in our gender confirming surgery program at Women's College is largely what we would call top surgery, and top surgery is essentially breast or chest surgery, and that might be masculinization of the chest, that kind of looks like the removal of the breast tissue, reducing the size of the nipple and areola from a female areola to a male looking areola, and repositioning it in an appropriate place on the chest, perhaps removing redundant or excess fat all in a way to try to make the chest look more masculine. In trans female surgery, we might be taking a breast that might have grown a little bit through hormone stimulation and then try to increase its volume through either technologies like fat grafting or through the insertion of a breast implant. And, interestingly enough, they're not necessarily binary choices. And there are some individuals who wish to essentially demonstrate themselves as a non-binary individual and may wish to just not have a expression of a breast but not necessarily look for a masculine ches, just don't wish to have a breast there, and they wish to have a flat chest. So it's, it lives within a spectrum, I would say.

James Saravanamuttu [37:25] I think you mentioned earlier again, you mostly focus on top surgery, but there is some bottom surgery offered, I believe that would be by urology?

Dr. Mitchell Brown [37:33] Largely through urologist with the assistance of plastic surgery; it's a bit of a combined type of procedure

James Saravanamuttu [37:39] okay, and is that procedure called vaginoplasty or?

Dr. Mitchell Brown [37:43] So, for trans females, it would be called a vaginoplasty, where you're essentially removing the penis and the testicles and using that tissue to some degree to create a functional vagina. And that procedure is done by two of our urologists at Women's College Hospital. And we've done several of those procedures now. It, for trans male individuals, that procedure would be called phalloplasty or trying to create a phallus, a bit of a different kind of operation. It requires some sub-specialized microsurgical technology. We don't provide that service at Women's College at the moment, of course because it's primarily an outpatient facility, a Women's College, and when microsurgery is involved, it's a larger procedure that requires a number of days of inpatient care. We may be looking for collaborative partners in Toronto and one of the downtown teaching hospitals to be able to offer phalloplasty services, but at the moment, we're not offering that.

Atefeh Mohammadi [38:44] Could you give us an insight into the age range of the patients that you see?

Dr. Mitchell Brown [38:49] It's a wide spectrum. So we certainly see teenagers that brings its own level of conversation around informed consent and age of consent and reversibility. And, I have seen individuals up into their 60s, which is remarkable. And, I think we have to think back and say, you know, if you're 65 today, when you were 30, what sort of understanding, appreciation, or access was there for people who had questions about their gender identity? I mean, it was a different world then. And I'm glad that we live in a world today that is starting to open up and be more open minded to allow people to express themselves in a way that they're more comfortable and provide access for them to manage that.

Atefeh Mohammadi [39:36] The decision to go ahead with gender confirming surgery is undeniably a large one. Dr. Brown told us more about how the program and their team supports patients who are considering surgery.

Dr. Mitchell Brown [39:47] You know, one of the most important things to recognize is when someone moves towards surgery, they're entering the world of, of irreversible decision making. So, when you remove a breast, there's no putting it back. When you put it In an implant, you've changed the tissue, and there's no going back to the way that it was before necessarily. So, these are critical decisions that need to be analyzed carefully. So, we're fortunate in Women's College to have a nice program where individuals that are looking for gender confirming surgery come through a program where they have had counseling, they've met with appropriate healthcare professionals to be able to discuss individuals goals and expectations and barriers and challenges. Often, individuals may have lived in the gender that they're looking to express themselves as for a period of time. They may or may not have had hormone manipulation or hormone therapy. They will have had conversations and counseling about the irreversibility of surgery and come to us usually having been quite thoughtfully and appropriately dealt with so that when we get to see them as surgeons, we're able to discuss the surgical aspects of what we're going to do. The experience that I've had is that when you perform the surgical procedures on people who have considered this carefully and have wanted this often for so long that once you provide these opportunities and these physical changes to people, it lifted a tremendous burden off their minds. I think these are some of the most grateful and appreciative and happy patients that we see.

Nathan Chan [41:22] Although we have come a long way and seen many improvements related specifically to gender confirming surgery, there are still many gaps to be filled and steps to be taken. We spoke with Sly but the challenges remaining today.

Nathan Chan [41:32] So, Ontario started covering gender confirming surgery around 2016. But, has this access actually improved over the last, you know, five, six years?

Sly Sarkisova [41:42] Yeah, it's an amazing question. I've seen some systemic barriers in that you need to have a doctor or a social worker or a nurse or a psychologist who can do the letter in support of you in order to get that funding approved. So, I've seen that like, you know, very few people are trained. There is training available, but it's often outside of the city, so and no one really knows. It's not really clear. Do I take a workshop? Do I take a training? You can actually read the WPATH guidelines, a World Professional Association for Transgender Health, and be educated and have resources to assess people or support them, but I notice the backlog in terms of the supportive letter piece, which is what people need in order to get the funding. And also, once they get the funding, a lot of the surgeons now have extremely long waitlists, because more people have funding, so now, people are getting their funding, they actually, the ministry had to extend it for an additional year, because waitlist for to access a surgeon are now two years long or and then for various different surgeries.

Nathan Chan [42:45] When someone is seeking gender confirming surgery, is it entirely covered by the government? Or do they have to do, they have to pay for some of that themselves?

Sly Sarkisova [42:53] So top surgery, actually for, for transplant in top surgery is, is, is barely covered, and that is a, that's a really crummy sort of piece there. I'm not sure what, why the government has determined that, for trans women, breasts are optional, but that's a really glaring, discriminatory piece that's sort of embedded in how funding gets sorted out. So, it's very rare that women will get funding for breast augmentation. So, there's a funding piece for trans masculine people who are pursuing top surgery. Most of the surgeries covered, I believe, they're still, sometimes, with different surgeons. Depending on who you're with, you might have to pay $2,000 out of pocket for the anesthesiologist. You have to check with the surgeon as to where that's at. Sometimes it's covered. It varies from surgeon to surgeon. Everything outside of your medical experience, as well, is not covered. So, time off work, if you don't have benefits is not covered, if you are seeking care outside of your province or outside of your city or outside of the country, the travel expenses, and the time that you spend in a country recovering, everything related to that is not covered. So, Your flight ticket, if you have to return to the surgeon, if you have complication or repair, you know, you have to pay for that out of pocket. So, those things are not covered. But lower surgery, the surgery itself is largely covered. And that is a huge chunk of funding. It is fantastic.

Nathan Chan [44:15] Is there anything that you're looking forward to, in particular with health or surgical advances in trans and non-binary health?

Sly Sarkisova [44:22] I mean, I think we've had amazing advances so far. I think the procedures are evolving in terms of technique. And, I would love to see more money, funding research into different ways of doing surgery. I think, you know, I'm not a medical professional. I don't know how it's evolved so far, but sort of been surgeon to surgeon, and they've sort of evolved their own technique, and they become masters at it, and then that has set the bar for other folks. But, it'd be really great to have more research and funding for trans healthcare in general to know what works and what doesn't and to evolve. I'm sure we have the means to do it, but we just don't have the political will, maybe, to fund it. So, we could probably advance care outrageously, amazingly, very quickly if we threw a bit more money into research, but that would, that be something I would be looking forward to.

Atefeh Mohammadi [45:13] We also asked Dr. Brown if there was anything he was looking forward to with regards to trans and non-binary health.

Dr. Mitchell Brown [45:20] Well, the answer is always yes. You never want to be stagnant in surgery. You want to look for developments and ways to do what we do today but to do it better. I think one of the things that we're paying close attention to is how to assist in the identification of individuals at an earlier stage in life. We work collaboratively with the Hospital for Sick Children. We see a number of individuals that come to us as teenagers from Sick Children's Hospital. They've undergone counseling and therapy related to their gender identity and can imagine that the challenges of going through puberty. When you're developing in a certain way physically that is different from how you identify internally is a tremendous challenge. And, we're trying to find ways to identify those individuals earlier and assist them as best as we can through those critical formative times. From a purely surgical point of view, yes, we're always looking at how can we do things that look better, that provide less stigma of surgery, that provide fewer scars, how to create a female breast form that may not be as reliant on a medical device like a breast implant and better ways to use fat and stem cells to almost regenerate or build tissue. So, there's tremendous change on the horizon. We look at things that we may use for feminization of the face, fillers, injectables, Botox... I mean a variety of ancillary small procedures, if you will, but added up, they make quite a difference in the end. So, there's constant change, and we certainly look to continue to evolve.

Melissa Galati [47:10] Dr. Brown is optimistic about the future accessibility of these services for trans folks. In this episode, we learned lots about trans and non-binary health as well as gender confirming surgery. We know that this may have been a lot of information. So, we wanted to share some advice our speakers had for us and for you, our listeners.

Susan Gapka [47:28] Decent human dignity. It's about respect and dignity for fellow neighbors, co workers, fellow students. It's about treating people with kindness instead of hostility. And, I think that's just the decency of society. We want to be better people in society. I find sometimes that people can be our opposition, or some people on social media can be so awful and so rude. But, I think that's really the wrong way to organize our society. Some of us treat our pets better than people treat us in pronoun land and on social media. And, I think, you know, we can do a lot better as a society. We need to be there for our most vulnerable. So, I would say, you know, move past what your assumptions are. If you don't understand, you can ask questions, have conversations, but really, we're human beings just like everyone else. We can find that common ground once we get past our differences.

Dr. Mitchell Brown [48:37] What I've learned in this process is not to assume to understand what people are looking for. And then when you listen, you understand, you realize everybody's concept of how they wish to express their gender and have their own particular identity is different. So, there is no cookie cutter approach. I think you do have to look at it on an individual basis and try to meet people's objective individually as best you can.

Melissa Galati [49:02] Our sincere thank you to Sly Sarkisova and Susan Gapka for the valuable knowledge they've shared with us. Susan's political and professional contributions to healthcare have led to significant improvements and a measurable impacts in the care that trans folks receive today. And thank you to Dr. Mitchell Brown for walking us through what is truly a remarkable program at Women's College Hospital. Finally, thank you for listening. In addition to the wealth of information you heard here today, our guests also provided us with a list of resources for those of you interested in learning more or seeking support. You can find them in the show notes of the episode description and on the episode page on our website, www.rawtalkpodcast.com. If you liked what you heard, please let us know and share the episode with a friend, family member, partner, or colleague to start the conversation around this important topic. This episode was hosted by Nathan Chan, Atefeh Mohammadi, and myself, Melissa Galati with interviews and content development from Tsukiko Miyata and James Saravanamuttu. Audio engineering and editing were done by Esther Silk, and I was the Executive Producer of the episode. Raw Talk Podcast is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine, or the university. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook @rawtalkpodcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.