Virtual clinic providing critical care to trans patients at risk due to Ontario funding changes

Transgenderand gender-diverse people in Ontario worry the potential loss of a virtual clinic offering gender-affirming care will leave the community with even fewer options to access what they describe as life-saving support.

"You have a lot of folks who have found their way forward and suddenly feel stonewalled," said Lex, a 28-year-old patient at Connect-Clinic.

"It's a very scary thing and it can be dangerous especially if you're in a situation where this is kind of a life or death thing."

Connect-Clinic, which has 1,500 patients and 2,000 more people on a waiting list offers hormone therapy and surgery referrals for trans and gender-diverse people across Ontario through fully virtual appointments. As of next month, it will no longer accept new patients due to changes in Ontario's funding agreement with doctors.

"My patients are very distressed," said Dr. Kate Greenaway, the clinic's founder and lead physician. "I had one patient who told me they'd waited more than a decade to receive gender-affirming care because they had no way out of their community to access it.

"Certainly that patient still has no way to access gender-affirming care within their community."

The changes, which come into effect Dec. 1, are part of a three-year physician services agreement between Ontario's doctors and the provincial government that was ratified in March. The agreement establishes permanent funding for virtual health-care in the province.

As a virtual-only clinic, Connect-Clinic physicianswill be able to bill $20 per video appointment and $15 via phone lower rates than the previous $67 or more.Greenaway says the new rates won't cover the depth of care her clinic provides, making it impossible to add new patients.

On Friday, Greenaway learned the new rates will also apply to the practice's existing patients, despite earlier assurances theywould remain on the previous billing schedule.Greenaway said that Connect-Clinic is legally bound to continue caring for those patients.

The Ontario Ministry of Health says the new agreement aims to strike a balance between in-person and virtual care. "Virtual care is intended to complement in-person care, not replace it," the ministry wrote in a statement.

The government says it has taken "additional steps" to provide funding for team-based care, such as Community Health Centres (CHC), to improve access to primary care, and that many health-care teams offer programs specific to LGBTQ communities.

Greenaway says CHCs are a good option, but the current system is "overloaded" and those offering gender-affirming care don't reach all parts of the province.

LISTEN | Dr. Kate Greenaway on how changes will impact her clinic:

Day 69:43Ontario gender-affirming care clinic at risk with changes to virtual care

Not all family doctorsspecialized in affirming care

When Lex began her transition, she first approached her family doctor for advice on hormone therapy.

"My family doctor was very supportive of the start of my transition, but wasn't able to answer questions around things like side effects of estrogen, for example," said Lex. CBC is withholding Lex's last name out of concerns for her safety.

"Speaking with a doctor who is an expert in gender-affirming careallowed me to make decisions confidently about my health."

Accessing that care virtually is about more than just convenience for Lex. There's comfortknowing the physician you're speaking with is competent in transition-related health-care, she said.

"I can talk to somebody from the comfort of my own home in conditions that I feel safe in as opposed to, for example, going to a walk-in clinic, asking if they prescribe [hormones] and getting a transphobic doctor who's going to ruin my day," said Lex.

Capacity at clinics specializing in gender-affirming care is also limited, with some patients waiting months or years, depending on the treatment, for access.

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For the first time, census data shows more than 100,000 people in Canada identify as transgender or non-binary. Despite the results being a milestone for the LGBTQ community, some are taking issue with how the 2021 census asked about gender identity.

In a 2019 Trans Pulse Canada survey of transgender and non-binary people aged 14 years and older from across Canada, nearly 45 per cent reported having an unmet health-care need. Of those who had not completed gender-affirming care, 40 per cent of respondents reported they were on wait lists, most often for surgery.

According to the American Medical Association, the majority of transgender and gender-diverse people who receive gender-affirming care report improved mental health and lower rates of suicide.

"People call it gender affirming, but it is life affirming in a lot of ways," Lex said.

"A lot of people who hit a period of transition are not in a good place, and transition is a way to heal and to move forward and to grow as a person and to not be able to access that just prolongs feeling very unsafe."

'I did not understand the number of people that would need our services'

Connect-Clinic was formed in 2019 as a reaction to that lack of capacity, Greenaway said. At the time, she had a family practice in Toronto and was increasingly adding patients far outside the city.

She wanted to see if a virtual clinic offering gender-affirming care could better support people outside of the province's major urban centres.When the clinic analyzed postal code data for its current patients, it indicated two-thirds were located outside of those centres.

"I thought there would be people that would need it, but I did not understand the number of people that would need our services," Greenaway said.

This is not care that you want to interrupt....We're determined to help find a solution for our patients.- Dr. Kate Greenaway, founder and lead physician of Connect-Clinic

Connect-Clinic originated as part of the Ontario Telemedicine Network, but when the pandemic forced all kinds of health care to virtual platforms, the clinic was rolled into general care.

That pandemic-led shift was a boon for people seekinggender-affirming care, said Dr. Wayne Baici, a psychiatrist and clinical head for the Adult Gender Identity Clinic at Centre for Addiction and Mental Health in Toronto.

"It was hard to access gender-affirming care before the pandemic. Certainly the pandemic put in all sorts of obstacles to receiving care as well," he said. "I think virtual care was the one silver lining in terms of improving access.

"So if virtual care is impaired by changes in those [billing] codes, not allowing for health care to proceed, obviously trans folks will suffer."

Medical association says problem is 'unintended consequence'

The Ontario Medical Association (OMA), which represents the province's doctors and negotiated the deal with the provincial government, says the new agreement aims to "encourage the patient-physician relationship" and splits care into "comprehensive" and "limited" practices.

Comprehensive care requires that patients have an in-person relationship with patients alongside virtual care.

In a statement, an OMA spokesperson acknowledged the funding challenges faced by Connect-Clinic are an "unintended consequence" of the agreement.

Greenaway says the government could make an exception for virtual gender-affirming care, as it has for other medical disciplines suchas addictions services, or develop a new funding model that would allow the clinic to bill outside the provincial health-insurance system.

"This is not care that you want to interrupt," said Greenaway. "We know that the mental health of our patients will really suffer, as well as the physical health.

"So that's why we haven't given up. We're determined to help find a solution for our patients."