N.W.T. drops psychiatrist's diagnosis as requirement to receive 'gender-affirming' care

N.W.T. health authorities have eliminated a requirement for transgender people to receive a psychiatric diagnosis before they can be referred for "gender-affirming" care.

The guidelines, which apply to all transgender, non-binary and gender non-conforming patients, were updated in December but distributed to media earlier this week.

Previously, people seeking hormone therapy or gender-reassignment surgery needed a psychiatric diagnosis of gender dysphoria, defined as a "marked incongruence" between a person's biological sex and their expressed or experienced gender.

The requirement for a psychiatrist's sign-off meant "lengthy wait times for these health-care services," according to a release from the territorial government.

The new guidelines state that hormone therapy can be prescribed following only an assessment by a clinical expert.

Guidelines for approving gender-reassignment surgery are less clear. Patients require both evidence of "well-documented gender dysphoria" and an assessment of "mental health needs," but a psychiatrist need not be involved.

Patients must be over 19, be capable of informed consent, and have 12 continuous months of hormone therapy before any surgery — though for breast surgery, this is only recommended.

They must also undergo a formal clinical assessment, which includes a "psychosocial" component. A second assessment is required for genital surgery.

Neither gender reassignment surgery is performed in the N.W.T., meaning health workers must refer patients to clinics in the South. If patients are sent to a private clinic, they may end up bearing the cost of the surgery.

While the removal of breasts is covered by the N.W.T.'s health plan, the augmentation of breasts is not, unless a patient is proven to not respond well to hormone therapy.

Genital surgery, and any resulting complications, is covered by the health plan where patients "consider genital surgery an essential component of their gender transition." The Department of Health and Social Services must also approve these surgeries.

Taking aim at discrimination

The bulk of the new guidelines, however, focus on making health care in the territory more inclusive and respectful. 

Transgender patients suffer routine discrimination in the Canadian health system. The Canadian Professional Association for Transgender Health reports that more than half of transgender Canadians had negative experiences with health care as a result of their gender expression, "ranging from insulting or demeaning language to outright refusal of care."

The territory's new guidelines urge health workers to adjust individual behaviours to provide more inclusive care. They ask staff to "recognize how unconscious bias may influence patient treatment" and reject "stereotypical thinking."

It advises building rapport with open-ended questions about their experience, and recommends mirroring the language patients use "to talk about their transition, their bodies, and their relationship to their gender."

The guidelines also stress cultural sensitivity, telling health workers to respect Indigenous family ties and traditions of gender expression.

Respecting children's gender expression

That extends to children and youth, who the guidelines say "are still experts in their transition and their experience."

The guidelines acknowledge "complex" factors around diagnosing gender dysphoria in youth and the role of parental consent in the process.

But "while there are steps that parents need to provide consent for, it is imperative that transgender, non-binary and gender nonconforming children and youth feel heard and respected during this process," the guidelines state.

"They will eventually grow to be adults that will have full control of their own health care," the section continues, "and establishing positive relationships and trust with health care providers in an early stage" is essential.

The guidelines were produced using input from the Rainbow Coalition of Yellowknife and other patient advocates, according to Thursday's release.

The document notes that they are intended to be "flexible" and evolve to meet the needs of future patients.