Gender Affirming Care for Refugee and Migrant Patients
Overview
Transgender and gender-diverse (TGD) refugees and migrants face compounding vulnerabilities: they may have experienced persecution based on gender identity in their country of origin, and may face discrimination, isolation, and barriers to care after arrival. A trauma-informed, affirming clinical approach is essential.
This resource provides guidance for family physicians and primary care providers on initial assessment and care of TGD refugee patients.
Use the patient's stated name and pronouns at all times, including in documentation and when communicating with other providers.
Understanding the Clinical Context
* TGD individuals from many countries of origin have experienced criminalization, violence, torture, or forced medical procedures related to their gender identity
* Many will not disclose their gender identity or history unless they feel safe to do so
* Refugee claimants may need clinical documentation of their gender identity or related persecution for their claim
* Some patients may have received hormone therapy or undergone surgical procedures in their country of origin or in transit, often without medical supervision
Creating a Safe Clinical Environment
* Ask all patients their preferred name and pronouns at registration and at each visit
* Ensure clinic intake forms include options beyond binary gender
* Offer private, confidential consultations. Never disclose a patient's gender identity to family members without explicit consent.
* Avoid assumptions about anatomy. Ask respectfully about the patient's body and history before examination.
* Brief the interpreter on the importance of using affirming language and the patient's correct name and pronouns
Initial Assessment
History
* Preferred name and pronouns
* Gender identity and any history of social transition
* Any prior hormone therapy: type, dose, route, duration, prescriber (if any)
* Any prior surgical procedures related to gender affirmation
* Mental health history: depression, PTSD, anxiety (highly prevalent in TGD refugees)
* Social support: housing stability, community connections, safety
* Immigration status and any pending refugee claim
Physical Examination
Perform only the examinations clinically indicated. Ask for consent before each component and explain the reason.
* Conduct organ-appropriate screening based on anatomy, not gender identity
* Cervical cancer screening: offer to all patients with a cervix, using the patient's preferred approach
* Prostate screening: follow standard guidelines for patients with a prostate
* Breast tissue screening: based on presence of breast tissue regardless of gender identity
Hormone Therapy
Many TGD refugee patients will request hormone therapy or will already be on hormones. This requires individualized assessment and ideally involves a specialist, but family physicians play an important role in initial support and bridging.
Patients Already on Hormones
* Confirm the hormone regimen. Patients may have used non-prescription sources.
* Order baseline bloodwork before continuing or adjusting: CBC, electrolytes, creatinine, liver function tests, lipids, HbA1c, prolactin, estradiol or testosterone level depending on regimen
* Review for contraindications and drug interactions
* Continue the regimen at the lowest clinically appropriate dose while awaiting specialist assessment
Patients Requesting to Start Hormones
Hormone therapy for gender affirmation is effective, safe, and significantly improves mental health outcomes. It should not be delayed unnecessarily.
* Refer to Rainbow Health Ontario Clinical Guidelines, and refer to the adult gender clinic, and/or a specialist with experience in gender affirming care for initiation: endocrinology, or internal medicine.
* In Calgary, refer to the Spectrum Health gender affirming care services or through the AHS LGBTQ2S+ health program such as Foothills Adult Gender Clinic
* If there will be a significant wait time and the patient is in distress, refer to Rainbow Health Ontario Clinical Guidelines or consult with a specialist about bridging hormone therapy
Mental Health
TGD refugees experience high rates of depression, anxiety, PTSD, and suicidality, compounded by refugee trauma and the stress of gender-related persecution.
* Screen for depression using the PHQ-9 at the initial assessment
* Screen for PTSD using the PC-PTSD-5 (see PTSD clinical guide)
* Ask directly but sensitively about suicidal ideation
* Refer to mental health services: Access Mental Health in Calgary (403-943-1500), Centre for Refugee Resilience at CCIS
* LGBTQ2S+-affirming therapists should be sought where available
*In Calgary, refer to community support organizations: Almees Trans Health Access Association (refugee and newcomer focus), Skipping Stone Foundation, Alex Community Health Centre and Foria Clinic.
Legal and Immigration Considerations
Some TGD refugee patients may require clinical documentation related to their claim. This may include:
* A letter confirming the patient's gender identity and history
* Documentation of any medical findings consistent with prior trauma or forced procedures
* A mental health assessment related to the impact of gender-based persecution
Family physicians should provide factual, accurate documentation based on clinical findings and patient history. Do not speculate beyond your clinical findings.
Changing Legal Gender Marker in Canada
TGD patients may wish to update their legal gender marker on Canadian documents. In Alberta, this can be done through Service Alberta at any registry office without requiring surgery or medical documentation. Patients can also update their Permanent Resident card through IRCC. Refer patients to CCIS settlement workers or a legal clinic for assistance with this process.
Key Resources
* Calgary Gender Affirming Care: Spectrum Health, AHS LGBTQ2S+ Health
* WPATH Standards of Care (Version 8): wpath.org
* Rainbow Health Ontario Clinical Guidelines: rainbowhealthontario.ca
* CCIS Settlement Services for LGBTQ2S+ Newcomers: ccisab.ca
* Trans Care BC Primary Care Toolkit: phsa.ca/transcare