This clinic for gender-affirming health care went private. The founder wishes it didn't have to

White Coat Black Art26:30Fighting to provide gender-affirming care

Kit Sparrow was faced with two options when he sought out gender-affirming care: wait months for a specialist appointment, or pay out of pocket for a privately run, virtual service.

The Ontario-based accessibility-technology engineer had spent years trying to understand his gender identity. Last March, he decided to visit his family doctor and begin transitioning.

While his physician responded positively, they didn't have the training or experience to prescribe hormone treatment and instead referred him to an endocrinologist. That referral, Sparrow says, came with a seven-month wait.

"Hearing that I had to wait even longer was just a punch in the gut," he told White Coat, Black Art host Dr. Brian Goldman.

Depending on where a patient is located in Canada, wait times for gender-affirming care can be months to years a precarious position for people who are already struggling with their mental health, experts say.

Meanwhile, advocates worry that heightened political rhetoric surrounding gender-affirming care for youth could further strain availability within a health-care system that is already under-resourced.

Foria Clinic a privately run, virtual-only service wants to help reduce those wait times.

It was born out of the Ontario-based Connect Clinic, a similar online service founded in 2019 by Dr. Kate Greenaway that aimed to make gender-affirming care more accessible for patients in rural parts of the province. Changes to the provincial funding formula in 2022 meant the clinic had to close shop, leaving 1,500 patients and 2,000 more on the waitlist without a gender-affirming care physician.

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In order to continue offering care to an underserved population, Greenaway decided to go private. It wasn't her preferred choice, she said, but the province offered no alternative funding options that would cover her costs.

"This is the last population we want to charge for care," she told Goldman.

'A tough sell'

The changes to Connect Clinic stemmed from the Ontario government's move to a hybrid model for funding. The shift meant family physicians like Greenaway would have to pair virtual care with in-person visits.

But Greenaway's practice was based in Toronto, far from her patients in rural Ontario, which ruled out in-person visits. If she had to switch to the hybrid model, her goal of reaching rural Ontarians would be impossible, she said.

After her clinic's closure, Greenaway joined Calgary-based health-care startup PurposeMed, which bills itself as "improving access to complex care for underserved communities," to start Foria.

"It was a tough sell to me," she said. "I am a very strong supporter of our public health system."

But she realized the Ontario government no longer considered virtual-only care to be a "viable option."

"I think to me, [that's] a frustration, because it is so cost effective and so important for patients in rural locations," she said.

LISTEN | Dr. Kate Greenaway on going private:

White Coat Black Art1:37'I couldn't find another way': Why an Ontario doctor took her gender clinic private

Dr. Kate Greenaway speaks with White Coat, Black Art host Dr. Brian Goldman about how she made the decision to pivot her publicly funded clinic to a patient-pay model.

Ontario's Ministry of Health did not answer multiple questions about gender-affirming care access and waitlists in the province.

In a statement, ministry spokesperson Hannah Jensen said changes to the billing agreement for physicians were negotiated between the ministry and the Ontario Medical Association. The current agreement expires in March, and negotiations for the next agreement started last October.

Fears of two-tier health system

Foria is available to patients 16 and older in Ontario, where appointments are paid by patients, and 18 and older in Alberta, where services are covered by the provincial health plan.

The cost to start hormone therapy with the clinic in Ontario is around $600, which includes an initial consultation, a hormone initiation appointment and a three-month follow up, with each appointment provided by a nurse practitioner. Patients can also get referrals for gender-affirming surgeries through Foria, as well as mental health support.

Foria's launch last summer was criticized, including by members of the 2SLGBTQ+ community who said the cost could be a barrier for some trans and non-binary patients. Almost half of the respondents in a 2019 Canada-wide survey of trans and non-binary people, conducted by researchers at Western University, reported earning less than $30,000 annually.

This is life-saving care, and I will be honest in that I don't think I would be here today without it.- Kit Sparrow

Transgender health researcher Avery Everhart says the trans and non-binary community isfacing a "crisis of access" to gender-affirming care and there may be value in "trying to throw every possible solution at it."

But she warns that further privatization of health care risks creating an inequitable two-tier system, where those with funds can get care quickly andthose without have to wait, while investorsprofit off a marginalized community.

"This is something that disincentivizes us from fixing what's wrong with the existing, publicly funded health-care system," said Everhart, an assistant professor of geography at the University of British Columbia.

Facing a seven-month wait to begin hormone treatment and worsening mental health Sparrow decided to go with Foria.

Within a few weeks, he had a prescription for testosterone.

"I am lucky enough to have been able to afford it, but I'm very disappointed that it's not already covered," he said.

"This is life-saving care, and I will be honest in that I don't think I would be here today without it."

Politics can hinder access: researcher

Earlier this month, Alberta Premier Danielle Smith announced proposed restrictions on gender-affirming care, which would ban puberty blockers and hormone therapy for patients 15 and younger, and gender-affirming surgeries for patients 17 and under. (Certain surgeries are already restricted for patients under 18, or are not covered by the provincial health plan.)

The changes, Smith said, are intended to prevent youth from making "permanent and irreversible decisions" that can "severely limit [their]choices in the future."

Similar policies have been proposed and passed in several U.S. states and parts of Europe.

Elizabeth Saewyc, a professor of nursing at UBC who researches stigmatization among gender-diverse youth, says political messages around gender-affirming care can further affect access a lack of clarity in what treatments and procedures are allowed can discourage providers from offering care to some patients.

"For trans and non-binary people, that lack of access to care can affect every aspect of their life, including their ability to be effectively employed and to succeed in their careers, and to avoid discrimination and violence and harassment," she said.

A spokesperson from the office of Alberta's Minister of Health says its proposed rules on gender-affirming care are based on guidelines developed by public health authorities in several European countries.

The government is also recruiting at least one medical professional specializing in gender-affirming surgeries to practise in Alberta, creating a registry of gender-care specialists and developing a pilot project that will offer counselling services for youth and their parents, they said.

Ontario Premier Doug Ford says his government has no plans to change existing rules around gender-affirming care.

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Clinic looks to expand

Foria plans to expand its services further across Canada. The company is currently looking at launching in Manitoba, Greenaway says.

The politics that have emerged around gender-affirming care have only emboldened her to continue the mission.

"Two weeks ago, if you'd asked me what I thought about Saskatchewan and New Brunswick, I would have said, 'Oh, I'd be worried about entering into that province right now,'" she said, referring to the provinces'restrictions around gender identity in schools.

"But the climate in Alberta is so much worse and I'm already there, [so] now I feel like maybe I have to be open to going into those provinces sooner."

Sparrow has since transferred his care from Foria to the provincially covered endocrinologist he was originally referred to. It's been about seven months since he started his hormone regimen, and he's started to see physical changes.

"I've got a little beard that's coming in," he said.

Sparrow says gender-affirming care has made him more confident, happy and content something he struggled to imagine just a year ago.

"It feels like I was walking around without glasses. Like the world was blurry and I couldn't see myself in it. And now I can," he said.

"Everything is crystal clear."

With files from Jennifer Warren and CBC News