Gail Knudson, MD, MEd, FRCPC

Transgender health is a rapidly evolving field that is moving away from pathology toward gender-affirming practice. Over the last 2 decades, the field has also moved from a binary model of gender identity to one that embraces a gender spectrum. This has been mirrored in the classification manuals published by the World Health Organization, American Psychiatric Association, and World Professional Association for Transgender Health (WPATH). As you will read in this series of six articles over two BCMJ issues, much of the care for transgender and gender-diverse individuals in BC has moved from being heavily centred in tertiary care institutions to being provided in primary care settings.

Wherever possible throughout these two issues, “transgender and gender-diverse” is used as an umbrella term that covers the spectrum of transgender and gender-diverse identities. The term “gender dysphoria” describes the distress that emerges from a body/mind incongruence. No one’s identity is a disorder; the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders-5[1] and WPATH’s Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People-7[2] diagnoses are based on the distress of body/mind incongruence. In BC, the manuals used in classifying and coding with respect to transgender health care are the International Classification of Diseases-10[3] and the Diagnostic and Statistical Manual of Mental Disorders-5.[1] The International Classification of Diseases-11[4] heralded a significant move forward in the field of transgender health. Two major revisions were made: transsexualism and 11 other diagnoses related to gender identity and sexual orientation were removed from the “Mental Health Disorders” section. A new chapter was created, “Conditions Related to Sexual Health,” separate from “Mental Disorders,” and a new term, “gender incongruence,” is used, with the intention of maintaining or increasing access to health care.[4] Now that gender incongruence appears as a diagnostic code, the next step is lobbying for the removal of “gender dysphoria” as a term in subsequent revisions of the Diagnostic and Statistical Manual of Mental Disorders.

The World Professional Association for Transgender Health, formerly known as the Harry Benjamin International Gender Dysphoria Association, is an interdisciplinary professional and educational organization of more than 3000 members who are devoted to transgender health (www.wpath.org). Its mission is to promote evidence-based care, education, research, public policy, and respect in transgender and gender-diverse health. The association publishes the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (www.wpath.org/publications/soc), which articulates an evidenced-based approach to gender-affirming care. The association has published seven versions of the Standards of Care (1979, 1980, 1981, 1990, 1998, 2001, 2012); version 8 is expected to be published in 2022. The goal of gender-affirming care is lasting personal comfort with the gendered self to maximize overall psychological well-being and self-fulfillment. The Ministry of Health in BC was the first in Canada to adopt the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People-7. With version 8, it is anticipated that the term “gender incongruence,” as defined in the International Classification of Diseases-11, will be one of the codes available to access care.

BC has a long history of providing transgender and gender-diverse health care dating back to the establishment of Vancouver Coastal Health’s BC Centre for Sexual Medicine in 1979. At present, three provincial programs are in place. In 1998, the Gender Clinic at BC Children’s Hospital began seeing transgender and gender-diverse youth and young adults, and it continues to be one of the busiest clinics in North America (www.bcchildrens.ca/our-services/clinics/gender). The team at BC Children’s (endocrinologists, endocrine nurse clinicians, and social worker)—working in partnership with BC Children’s and community mental health professionals (psychiatrists and psychologists), Trans Care BC, and the BC Transgender Clinical Care Group—functions as a “clinic without walls” to deliver endocrine care (puberty blockers and gender-affirming hormone therapy) to this population. As elsewhere across BC, their care is delivered according to the World Professional Association for Transgender Health’s Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People-7. The BC Children’s team partners with Trans Care BC to train and support community clinicians in advancing their practice with gender-diverse young people. Many pediatricians, family physicians, and nurse practitioners now provide this care in their communities.

In 2015, the Provincial Health Services Authority became responsible for the provincial coordination of transgender and gender-diverse health services through Trans Care BC (www.phsa.ca/transcarebc). Trans Care BC plans, coordinates, monitors, and provides limited direct funding for transgender health and wellness services. The program also helps clients navigate the health care system, and provides clinical education and ongoing support to health care professionals in the form of live and online training on clinical practice. Since its inception, Trans Care BC has worked to improve client access to care, with an emphasis on providing primary and surgical care closer to home. It has led the increase in gender-affirming surgeries in BC, developed a central pooled wait list for 15 surgeons who offer upper body gender-affirming surgeries, and helped create Vancouver Coastal Health’s Gender Surgery Program BC (www.vch.ca/Locations-Services/result?res_id=1457), which provides lower body gender-affirming surgeries.

The Gender Surgery Program BC, including the Gender Surgery Clinic, opened at Vancouver General Hospital in September 2019; it is Western Canada’s only hospital that performs lower body gender-affirming surgeries for transgender and gender-diverse people. The Gender Surgery Program BC is a multidisciplinary team of surgical specialists and health care providers who are devoted to providing high-quality gender-affirming treatment and surgical care. The program offers surgical procedures that are consistent with the guidelines established by the World Professional Association for Transgender Health.

This first part of this BCMJ theme issue highlights health care service delivery and educational products provided by the three current provincial programs: BC Children’s Gender Clinic, Trans Care BC, and the Gender Surgery Program BC. The first article provides suggestions on how to create a gender-affirming clinical environment for transgender and gender-diverse people, and includes educational and support resources on transgender and gender-diverse health care. The second article reviews the use of hormone therapy to help transgender and gender-diverse people achieve their goals for physical changes. The third article describes gender-affirming surgeries that are available in BC. The March issue will feature three more important areas related to transgender and gender-diverse health: BC law with respect to minors consenting to surgery, including recent BC court decisions (Findlay); contraception options for transgender and gender-diverse people (Todd); and available reproductive options (Wisenthal and colleagues).
—Gail Knudson, MD, MEd, FRCPC

Competing interests

Dr Knudson receives an annual honorarium for serving as a co-chair of the WPATH Global Education Institute.

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This editorial has been peer reviewed.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: APA; 2013.

2.    Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend 2012;13:165-232.

3.    World Health Organization. International classification of diseases-10. Geneva, Switzerland: WHO; 1992.

4.    World Health Organization. International classification of diseases-11. Geneva, Switzerland: WHO; 2019.

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Dr Knudson is a clinical professor in the Department of Psychiatry at the University of British Columbia.