Working to meet the needs of our increasingly diverse population

Dr. Megan Clark | Photo by Kristen McEwen

By Greg Basky

Regina family physician Dr. Megan Clark still remembers a patient she first met when she was a resident. “She was a young trans woman. She was smart and sweet, and she just needed someone to follow her through her hormone treatment. We bonded over a shared love of Harry Potter,” recalls Dr. Clark, who now provides care to about 50 transgender and gender diverse patients as part of her practice in the Family Medicine Unit at Regina Centre Crossing. Dr. Clark remembers her young patient being confused; she’d started hormone therapy and needed to get an appointment to see an out-of-province psychiatrist. “I was waiting with her, to see her through all the steps involved in getting gender reassignment surgery. It was just so rewarding.”

Transgender and gender diverse people are part of Saskatchewan’s growing and increasingly diverse population. With that diversity comes unique health-care needs that doctors like Clark are stepping up to meet. She and other physicians in the province are working to make their practices safe and welcoming places for patients who can often feel vulnerable or marginalized at work or school.

While reliable figures on the number of transgender people in Saskatchewan aren’t available, Dr. Clark said U.S. data would suggest that between 0.6 per cent and 0.7 per cent of the total population likely self-identify as trans or gender diverse – which would translate to somewhere between 7,000 and 8,200 people (based on a population of 1,169,131 as of April 1, 2019).

Other physicians see trans and gender diverse patients, but there are only about 10 in this province who specialize in or get referrals for this population, according to Dr. Clark; she is one of four doctors that the Ministry of Health relies on to make recommendations about which patients should be approved for out-of-province gender reassignment surgery.

At Regina Centre Crossing, Dr. Clark and her colleagues use appropriate names and pronouns starting when patients first contact the clinic. “This helps patients feel safe, as does my familiarity with the local organizations and health-care systems supporting trans people and transition-related health care,” said Dr. Clark.

She applies the same principles of patient-centred care and shared decision-making she does with any of her patients.

My mindset is that trans and gender diverse patients have some unique health-care needs, but the most important practice is to treat them with the same respect that everyone deserves.

Attitudes in the medical community are improving, according to Dr. Clark, but some doctors continue to pathologize this patient group.

It’s the close patient-physician relationship she develops with her transgender clients that Dr. Clark finds most rewarding. “You are often working together long and hard through the process (of hormone therapy and gender reassignment surgery).” She gets tremendous satisfaction from seeing how much happier her patients are, and how much more positive their outlook, after the first few months of hormone therapy.

Dr. Mahli Brindamour | Photo by Emma Love

Wednesday mornings, Saskatoon’s Refugee Engagement and Community Health (REACH) Clinic is buzzing with activity. Most weeks, the majority of people sitting and standing in the waiting room are from Eritrea, Ethiopia and Sudan, but there are also adults and children from the Democratic Republic of Congo, Burundi and neighbouring countries as well. Kids are running around; about half of all refugees who come to Saskatchewan are children. Staff from the local settlement agencies – Saskatoon Open Door Society and Global Gathering Place – are there as well, coordinating appointments and transportation for families.

While she’s worked at REACH since it opened in February 2017, Saskatoon pediatrician Dr. Mahli Brindamour still regularly picks out new languages she hasn’t heard before. “And every week, there are families waiting who aren’t even on our list ... but we just roll with it,” said Dr. Brindamour, whose home base is Saskatoon Paediatric Consultants.

The REACH Clinic, which is housed within Saskatoon Community Clinic’s downtown location, is a collaborative partnership involving the Saskatchewan Health Authority’s primary and public health teams, the settlement agencies, TB Prevention and Control, and the University of Saskatchewan’s College of Medicine and Community Health and Epidemiology.

REACH provides a one-stop shop for refugees who can, during their first year in Saskatoon, access an interdisciplinary team of primary and specialized care physicians, and nurse practitioners (for urgent care needs), as well as prenatal care, pharmacy, and lab and diagnostic testing. During its first year, REACH provided care to 218 patients. In 2018, the clinic served 322 clients.

In many cases, refugees may have previous negative experiences with health care or with authority. Dr. Brindamour and her colleagues move slowly with refugee families, to build trust. “I make sure that I book enough time. Usually visits will be two to three times longer than in my other offices, and often it will take much more than one or two visits before people will feel comfortable enough to share difficult elements of their stories,” said Dr. Brindamour, who also does clinics in La Loche, Ile à la Crosse and Stony Rapids, and looks after newborns at Sanctum 1.5, a transitional home for at-risk women and their babies.

The team at REACH strives to communicate in the language of the family’s choice; they have interpretation available at all times, preferably from in-person, trained interpreters. As well, Dr. Brindamour and colleagues are attentive to the subtle signals they pick up during care encounters.

“We work to understand family dynamics and power differentials between family members, but also between the health-care team and the family members.”

Dr. Brindamour said it’s the hope she sees in her young patients that she finds most gratifying.

They have lived through such difficult things – the trauma and the reasons they had to leave their home. And the difficulties they face with learning a new culture, a new language, in a new country, going to a new school,” she said. “Despite that, these kids are so resilient and adapt so well. It just gives me so much joy to see this happen.

Drs. Clark and Brindamour both say demand for the services they provide currently outstrips supply and that more resources need to be invested to meet the unique care needs of these patient groups. On a more positive note, they are buoyed by the interest shown by medical students who are reaching out to them to learn more about working with refugees and transgender people.

Dr. Clark continues to care for the transgender patient she first met as a resident physician. And she continues to hold out hope that, over time, Saskatchewan can do better for trans and gender diverse patients. “As we as a society and a health-care system become more accepting, we can get closer to providing truly patient-centred care for this population.” Physicians have a social accountability to care for the populations who need it the most, said Dr. Brindamour. “We (physicians) need to be committed to providing care to marginalized and underserved people, first and foremost in our own communities.” ◆

Resources

REACH Refugee Health Clinic www.saskatooncommunityclinic.ca/reach-refugee-healthclinic

Gender Identity, Gender Diversity, and Transgender Support (Saskatchewan Ministry of Health) www.saskatchewan.ca/residents/health/accessing-healthcare-services/gender-identity-gender-diversity-andtransgender-support

Saskatchewan Medical Transition Guide (Saskatchewan Trans Health Coalition) www.transsask.ca/resources/guide

Canadian Professional Association for Transgender Health http://cpath.ca/en

Trans PULSE Canada (community-based survey on the health, well-being of trans and non-binary people in Canada) https://transpulsecanada.ca