Saved By Delatestryl: The Importance of Accessible Hormone Replacement Therapy (Part 1)

Posted By Florence Paré

Every time I looked in a mirror, I saw someone else. I was what I was not. But unlike Lindsay Lohan in Freaky Friday, I had no one else to be. It was not until I had taken estrogen and anti-androgens for a few months that my face started changing and I started recognising myself in the mirror. To this day, it varies: on worse days, I feel the dread of self-misrecognition. On better days, I am relieved to see myself as I am. Well-being is unavoidably hampered if you cannot ever feel at home anywhere. Through our bodies, our consciousness is embodied. People typically feel at home in their body, but for many of us it does not feel like home.

Far from being a caprice, hormone replacement therapy, for those of us who wish to receive it, is often a lifesaver. Amongst trans people who have considered medical transition, those on hormone replacement therapy were about half as likely to have seriously considered suicide in the last year. In total, around 35% of all trans people have seriously considered suicide in the last year. Of those who desired to medically transition but had not begun hormone replacement therapy, 53% have seriously considered suicide in the last year.

To this day, it varies: on worse days, I feel the dread of self-misrecognition. On better days, I am relieved to see myself as I am.

Apart from alleviating dysphoria by creating changes in our body which we desire as ends in themselves, those changes also participate in our well-being because of their relationship with what we call “passing as cisgender”.

A person is cisgender if they are of the same gender as they were assigned at their birth; in other words, a person who is not transgender. Someone is said to pass as cisgender if they are read as cisgender. For example, if someone were to believe that I am a cisgender woman rather than a trans woman, I would be said to pass as a cisgender woman. Passing is not a yes or no feature: people may pass in some contexts and not in others, and may pass or not in the same contexts at different times or to different people. Not every trans person wishes to pass, nor can everyone pass; non-binary people cannot pass as cisgender as there are no cisgender non-binary people, and some people’s anatomy puts passing out of reach.

By changing a person’s appearance, hormones help trans people to pass as cisgender. This can alleviate some of the difficulties trans people face: it curtails misgendering, can reduce social anxiety, and decreases the number of opportunities for transphobic violence, discrimination, and harassment. Insurance coverage for hormone replacement therapy across Canada varies by province. My considerations will focus on the situation in the province of Québec, as it is the jurisdiction I am most familiar with. However, many of my comments will also apply to other provinces.

Passing is not a yes or no feature: people may pass in some contexts and not in others, and may pass or not in the same contexts at different times or to different people.

In Québec, hormone replacement therapy is covered under the basic plan established by An Act Respecting Drug Insurance, C.Q.L.R. c. A-29.01. The person is covered either through a private insurer or, if ineligible for private coverage, through the RAMQ’s Prescription Drug Insurance. Under the Act, the person’s coverage through a private insurer must be at least equivalent to the basic plan coverage. Thus, in Québec, hormone replacement therapy is, in theory, covered by insurance. In my case, I am lucky to have a private plan which covers the totality of my hormone replacement therapy costs.

Even when hormone replacement therapy is covered by insurance, other factors work to limit its access by trans people. First, it can often be difficult to obtain a prescription. Only a handful of doctors prescribe hormones on an informed consent basis, meaning without a letter from a psychologist. The waitlist to see those doctors (there seem to be around four in all of Montreal, based on anecdotal evidence) is often between six months to a year, and to this is added the weeks to months it takes between the first consultation and the writing of the prescription.

In the case of doctors who follow the World Professional Association for Transgender Health (WPATH) standards (who can also be fairly difficult to find), the individual must find a therapist ready to write a letter of referral. Those therapists are too few (though not as few as doctors prescribing hormones on an informed consent basis), have long waitlists, and often charge a substantial sum of money for consultations. Those costs can be prohibitive given the prevalence of poverty within the trans community. Trans individuals are more than four times as likely as the general population to have a household income of under $10,000 per year; 15% of trans people live under that household income, and 27% of trans people report a household income below $20,000 per year, a situation that is even worse amongst trans people of colour and trans people living with disabilities.

Depo-Photo-1024x500In addition to global hormone shortages, the prohibitive costs involved in seeking hormone replacement therapy threaten to deny access to trans Canadians who choose this treatment. || (Source: Teen Health Source)

Under An Act Respecting Drug Insurance, a coinsurance payment of 34% of the cost of the drug can be asked of trans people filling their prescription, up to a yearly total of $1,029 (sections 11, 13, and 27). Although in exceptional situations the coinsurance payment can be waived, coinsurance payments are the norm, and can be prohibitive to trans people in precarious economic situations. On the other hand, private plans which are frequently unavailable to less privileged trans people regularly cover the complete costs of hormones.

Many trans people fear that hormones themselves will be unavailable in the future. In the last few years, some forms of injectable oestrogen and testosterone have been in shortage. People I know have an extra vial of hormones reserved for them at their pharmacy, “just in case”, and many people report being unable to obtain injectable hormones. Different forms of hormones have different primary and side effects, and are not interchangeable, and switching to a different form is not possible or desirable for many due to potential adverse health effects. This constantly looming threat remains at the background of many of our minds, and contributes to a state of perpetual anxiety seldom absent from trans subjectivities.

Despite the presence of public prescription drug insurance in Québec, a number of barriers confront trans people who seek to obtain life-saving hormone replacement therapy. In this article, I have considered extra-legal barriers. In the companion article to this piece, I will consider the threat of delisting hormone replacement therapy from drug insurance under human rights law.

Medical Marijuana’s Liberalization and the Legislative Purgatory of Recreational Use

Posted By Colleen Morawetz

As Canadians await the federal government’s plan to legalize and regulate cannabis, expected next spring, this summer has seen unprecedented growth in the dispensary market. In cities such as Vancouver and Toronto, a booming industry of “compassion clubs” has sprung up over the past few months, with some commentators describing a “pot-shop bubble” to rival soaring housing prices.

Dispensaries have the veneer of operating in a legal grey zone, with purported medical professionals “prescribing” medical marijuana for eager customers, but this medical aura can only be for marketing purposes; Health Canada makes it clear that these storefront businesses are strictly illegal. At the same time, beyond the booming market for recreational cannabis, the legitimate medical marijuana system in Canada has experienced dramatic shifts in the past year.

Circumscribed exceptions to the Controlled Drugs and Substances Act have allowed physicians to prescribe marijuana for medical purposes since 1999. In 2013, the Government of Canada implemented the Marihuana for Medical Purposes Regulations (MMPR), creating conditions for licensed producers to compete for medical marijuana consumers in a commercial market.

The most recent judicial challenge to this scheme occurred in a February 2016 Federal Court of Appeal decision, which found that limiting medical marijuana production to Canada’s licensed producers (currently 35) unjustifiably limited patients’ constitutional rights to life, liberty and security of the person by subjecting them to market-driven pricing structures.

Many Canadians are thrilled for the Liberal leadership to follow through on a long-awaited legalization plan for recreational marijuana use and distribution. || (Source: Flickr // Cannabis Culture)

Since Allard struck down as invalid the entire MMPR, the federal government responded by implementing the Access to Cannabis for Medical Purposes Regulations (ACMPR), which came into force on August 24. The part of the new regulations most worthy of attention is the provision on self-production: individuals with a medical document from a health practitioner may now choose to produce a limited amount for their own purposes, designate another individual to produce it for them, or stick to the mail-order system offered by licensed producers.Meanwhile, in July, the Globe and Mail published the results of a large-scale investigation as to the safety of dispensary-obtained marijuana, finding that one-third of cannabis samples from nine storefronts in Toronto would not pass a Health Canada test for safe levels of mould, harmful bacteria, pesticides and other contaminants. This investigation was novel due to its illegality; at the time of the investigation, federally licensed laboratories were banned from testing marijuana samples, and the newspaper did not disclose the identity of lab used.This ban on testing caused particular concern for patients with compromised immune systems or parents who desired extra confirmation as to the safety of the cannabis oil extract they were giving to their children to treat the symptoms of conditions such as epilepsy and brain tumors. Health Canada had safety standards in place for federally regulated medical marijuana producers; however, patients and caregivers wanting to administer a prescribed dosage through cannabis oil must produce it themselves from dried leaves – with no way of testing the finished product under the ban.

Two weeks after the publication of the investigation, according to the Globe, Health Canada sent an urgent memo to federally accredited labs, asking whether they would be willing to start testing for the public under new federal regulations. As of September, 17 such labs had offered to provide independent testing of marijuana for medical purposes.

Even in the face of these significant changes in medical marijuana laws, the nagging question remains as to why we should care. Surely, the logic goes, the promised legalization of marijuana for recreational use will render all of these laws and regulations useless within the next year?

5377506106_060a578a86_zThe current state of federal legislation in Canada means that medical marijuana has not undergone sufficient quality testing before reaching the patient, putting immunocompromised users at risk. || (Source: Flickr // Dank Depot)

However, the details of the legalization plan remain murky as of yet. Although 30 000 Canadians weighed in during an online consultation this summer, it remains to be seen how much (if at all) the responses will inform the recommendations of the marijuana task force, which is on track to issue a report to the federal government in November. It is also unclear whether the task force will incorporate the set of recommendations issued by the Canadian Medical Association in September.One of the CMA’s critical suggestions is for home cultivation of marijuana, other than for medical purposes, to remain prohibited. This recommendation essentially calls for a two-tier medical/recreational cannabis system, with access to the drug for recreational purposes remaining somewhat constrained. The ACMPR, therefore, has the potential to affect the production patterns of cannabis in Canada well into the future.

Of greater concern, perhaps, is the lower profile decision of Health Canada to allow for laboratory testing of cannabis only if it was obtained for medical use. The Globe’s investigation discovered contaminants in much of the cannabis sold in Toronto’s illegal dispensary market, and it is fair to assume that the situation in other cities is no different.

Among its objectives, Health Canada “strives to … prevent and reduce risks to individual health and the overall environment,” indicating that harm reduction is a core tenet of the department’s mandate. However, its measures must also be allowable by law, and, one would assume, toe the party line in terms of current moral-legal narratives.

While allowing for testing of cannabis not proven to be obtained for medical purposes is technically compatible with cannabis itself being illegal, it certainly seems to question the moral legitimacy of the criminal prohibition. But how strong is this claim to moral legitimacy, when the Government of Canada has announced imminent legalization?

If Health Canada is to properly “strive” for its objective, perhaps certain interim measures should be taken by the federal government to allow for regulation in this legislative purgatory, where harsh local sanctions such as raids seem more and more incongruous with the legalization policy proposal.

Cannabis-Counter-Harborside-DispensaryEnsuring the quality of the product with the safety of users in mind, marijuana dispensaries will stand alongside pharmacies and liquor stores as licensed distributors of controlled substances. || (Source: Flickr // Dank Depot)

Though the boundary between medical marijuana and cannabis obtained for recreational purposes may prove enduring in the new policy framework, the present moral uncertainty could benefit from allowing for licensed testing of all cannabis. As Vancouver city councilor Kerry Jang notes, speaking from a city that has started its own licensing of dispensaries absent of federal guidance, the federal government should no longer “hid[e] behind a legal shield” and avoid giving proper guidance for regulation and control.

After all, what is the point holding out on harm reduction measures when the political tide has already turned?