Canada’s physicians are increasingly taking on public advocacy roles. Dr. James Makokis, a Cree two-spirit family physician (and, yes, the winner of the 2019 Amazing Race Canada with his husband, Anthony Johnson), serves transgender people in both Kehewin Cree Nation and Edmonton, Alta. He spoke to the CMA about how physicians can make health care more inclusive and practise gender-affirming medicine.
How do 2SLGBTQI patients experience health care?
Most people automatically have trust in their health care providers. But for members of my community, the questions you ask yourself are: Am I being treated as a human? Am I being provided the best possible care? And am I having to advocate for myself?
Two factors that come into play when I personally access health care involve the intersection of being visibly Indigenous and gay. We know Indigenous people and members of the 2SLGBTQI community continue to face discrimination and racism within the health care system.
There is always a sense of unease and being on guard — behaviours two-spirit people have had to develop for their own protection. And listening to the experiences of my trans patients highlights that the health care system can be discriminatory and cause trauma.
It’s really unfortunate because health care is supposed to be kind, compassionate and loving, and a safe space for people. We need to move toward creating that space within medicine and within health care.
What are some of the unique barriers for trans patients?
The experiences of my trans patients — for the most part — are awful. They are trying to navigate a system with very few physicians who know anything about trans care, know how to provide medical hormone replacement therapy (HRT) or even know how to refer people for gender-affirming care or surgery.
It’s common for my patients to tell me they experience long delays when seeking treatment, often for years. Sometimes they have been kicked out of physician offices for the mere reason they are a trans person. It wastes their life and puts them at risk for self-harm and mental health issues.
And when I tell them, “I’m sorry you’ve had that experience but by the end of this visit we can probably start you on your medication and get your referrals in place,” they cry. They have never experienced what it’s like to have medical care that respects who they are as a human being.
For that reason, the work I do includes educating trans patients about how to make complaints about transphobic, racist or homophobic behaviours by health care workers. Physicians are scared to report colleagues, but we have to in order to change the culture of medicine.
We have to be constructive allies, instead of relying on performative allyship.
What are some examples of how trans health access can be improved?
Like Indigenous health, there is a long way to go in trans health.
When we think about both of these areas, they’re usually add-ons within the medical school curriculum and educational opportunities are organized largely by student interest groups. The existing curriculum around these issues is generally very minimal, although in some universities it is improving.
When we think about why there are such gaps in knowledge, it’s because Indigenous and trans health both need to be taught as core issues. That means dedicated time integrated into the curriculum, taught by physicians and experts in these areas.
Learning about trans health is one of the most critical ways physicians can help to transform statistics around trans people, who do experience some of the highest rates of suicide of any group. We can help turn the tide of that epidemic and see good patient outcomes, while making society a more inclusive place.
What do you tell your physician colleagues who want to be better allies?
One of the best things we can be with ourselves is honest. Acknowledging when you don’t know something is the first step to being a good doctor. Putting our egos aside and saying, “I’m a lifelong learner. I recognize I have gaps in knowledge and limitations and I’m willing to learn with my patients.” Doctors are excellent at having their patients teach them if they are open to it.
Second, what we do in trans medicine with HRT is no different than what we already do for other issues. Physicians already prescribe hormones, whether it’s birth control, medications to help postmenopausal women or testosterone to treat hypogonadism.
Physicians need to get over the fear that we are going to cause irreversible harm or psychological changes if we provide someone with medical HRT. My attitude is: When someone says they are trans, they are until proven otherwise.
They have been thinking about HRT for years. Your job as a physician is to ensure there are no medical contraindications in starting their HRT and then educating them about the side effects, risks and benefits.
What physicians find is that HRT is a life-saving intervention. It’s one of the most gratifying parts of my practice, where people are immediately happy, to the point where they cry when they get their prescription.
They have waited their entire life to be who they are.
How are you encouraging more family physicians to facilitate trans health care?
Every family doctor can be doing trans medicine. I started inviting family doctors to come and shadow me in my practice, to try to increase the number of family physicians doing this work.
Six years ago, I was probably one of two or three physicians in Edmonton doing this, but now I’ve trained at least seven physicians who feel comfortable with trans medicine and are part of a care network.
Of course, we still need to do more. Trans care is very ad hoc and uncoordinated. We need to create a space where people are not waiting years to access basic care.
What is your favourite part of being a physician?
One of my favourite things is the privilege I have to learn about people and their lives, where they come from, what makes them happy, what makes them sad and what things they have overcome.
The incredible ability for human beings to overcome adversity and still be kind, loving people speaks to the potential we have as a human species to change, improve and learn to do better. And to be able to live in a good, kind way with one another on this Earth.
This interview has been edited and condensed for clarity and length.