Part 1: Gender affirming care in Kingston: in conversation with Dr. Ashley Waddington

Part 1: What is Gender Affirming Care and How can you be Supportive?

To explore the topic of gender affirming care, we spoke to Dr. Ashley Waddington, an Associate Professor in the division of Reproductive Endocrinology and Infertility in the Department of Obstetrics and Gynaecology at Queen’s University. This is the first part of an interview with Dr. Waddington. The second part exploring the medical and administrative perspective of administering gender affirming care can be found here https://museumofhealthcare.blog/part-2-gender-affirming-care-in-kingston-in-conversation-with-dr-ashley-waddington/ 

​Gender affirming care can be a broad concept and include a range of services depending on the goals of the patient and their desires. What can gender affirming care entail?

Sure. You're absolutely right. It is a very broad definition and a broad category of care that needs to take place because not all gender diverse people are seeking the same end results. So they may be going through a number of ways that they may be sort of transitioning their identity. 

Social Transition

For example, we sometimes talk about a social transition. So people socially transition when they start identifying to others that their gender identity is changing or developing. They may undergo things like changes in hairstyle and clothing choices. They may select a name that they would like to be referred by. They may change their pronouns. 

Sometimes we think about the colloquial term like “coming out”. It has a lot to do with what somebody's social transition is. And that may or may not require the support of a healthcare provider. Sometimes, there may be a need to provide counseling support especially if that person's social transition is complicated by things like an unsupported family, friends, school, or workplace- that kind of thing. But generally, it doesn't require medical assistance in most cases. 

Legal Transition

Then alongside that or maybe subsequent to it, there may be situations where they want to legally transition. So that might be things like legally changing one's name or gender identifier on your passport and your driver's license. And so those steps, although not considered medical, occasionally do require support. For example, a physician needs to sign off if somebody is going to change their gender identifier on their documentation. And so that’s a request that we get, which is kind of weird because it's not necessarily a medical thing. There's no requirement that they be undergoing medical treatment to be able to make that change. But, for whatever reason, it requires the signature of a physician.

Medical transition

Then there's all the options for medical transition as well. So those can include things like being on hormone therapy and there can be surgical options. And so once again, not everybody who is gender diverse undergoes a medical transition. It's not like there's a correct set of steps that everybody needs to follow. People can certainly choose what they do or do not want to do in terms of a medical transition. There is no sort of set end goal that they are always trying to attain that can vary between individuals. That's really where a medical personnel gets involved is at the point of the medical transition, but there can certainly be contact with the medical system in the other steps as well.

What is your clinical research area and how does that intersect with gender affirming care?

My main clinical focus, research, and academic focus is in family planning care; so contraception and abortion care. One would question how that overlaps with gender care, and how I became involved in that. So one thing is when you are talking to people a lot about their contraceptive choices, we're very familiar with counseling people about hormone use, and the various sorts of side effects and risk profiles of various types of hormonal manipulations. That's a very comfortable place for somebody like myself, who spends a lot of time in the contraception space. There's also within people who are family planning specialists, a very strong social justice and reproductive justice mindset. And so, being open minded and really believing that people are allowed to make informed choices about what they do with their health and how they navigate the world.

The mindset was already present for me to be open minded to the idea of gender care. When I started to become involved in contraception care, we got a lot of referrals, not necessarily for pregnancy prevention, but for using contraceptive products to suppress menstruation. So that can be a side effect of many contraceptive products. Because of our expertise in using those products for contraception, we would often get referred patients who are seeking menstrual suppression, including transmasculine people. So transmasculine people who still have a uterus and might be menstruating and are looking for options to suppress their menstruation, because it aggravates their gender dysphoria. So that was really where I started to have a lot of contact with gender diverse people and it occurred to me that I wasn't providing adequate care if all I was offering was contraception options. One of the main ways of suppressing menstruation in transmasculine people is testosterone therapy. And many have the goal of going on to testosterone therapy for masculinization. It occurred to me that it wasn't adequate for me to be offering them contraceptive methods, when there was also something that would achieve the goal that they had been referred to me for.

I started to explore and get some training in prescribing testosterone, which is not typical of a gynecologist or a family planning person, but it sort of aligns with a comfort level that we have with prescribing hormones in general, and discussing risks and benefits of those. Then as word got out that I was starting to see patients in that context, people started to clue in that I would also be comfortable prescribing feminizing hormones.  Feminizing hormones are reproductive hormones, they're the hormones that are in things like birth control pills, obviously used at different doses and in different contexts. But that also aligned with something I was already doing and was already quite familiar with and so my practice became open to gender diverse people of all gender identities who were seeking medical care.

Then as a gynecologist, I am also a surgeon. So I'm pretty familiar with surgical techniques. Now, I don't do gender affirming surgeries myself, but things like managing pre and post op conditions and looking after complications was not unfamiliar to me. So when people were having gender affirming surgery, I was also able to be a resource to help care for people in that context, even if I wasn't the surgeon doing the surgery. So I sort of developed a pretty full service clinic that was able to provide a lot of the aspects of gender affirming care.

What would you suggest to anyone whose loved one is undergoing gender affirming care?

 So there's lots of good evidence from research, but also just anecdotally that when people are allowed to explore who they are, explore what options are available to them and support in being able to choose options that feel best for them, their outcomes are the best in terms of life satisfaction. Do your best to support that person in your life at whatever stage they're at. Often when this question comes up it is like, “Oh, my goodness, my cousin just came out to me, what do I do?” At that stage, first of all, you should just feel honored that that person felt comfortable coming to you and being somebody that they confided this in because that took a lot of thought. They have been very carefully contemplating who in their life they're ready to have that conversation with. Just be supportive of what they need to do. 

Not everybody's transition looks the same. The end goals are not always the same. The steps and the time frame by which people undergo any kind of a transition is unique, there are no correct landmarks that need to be met. 

If they…

• …want you to refer to them by a new name, incorporate it into your language and respect it.

• …are now using a new pronoun, use that pronoun when you're talking with or about them. 

So I see things kind of sometimes go both ways. So you have a completely unsupportive person in somebody's life and that is always unhelpful. But then I do sometimes see people trying so hard to be supportive, that they almost push the process along, not allowing the individual to lead the process and set the pace. So while I would always say being supportive is number one, allow them to also guide you in what support they need during that time. Whether somebody chooses to transition, not to transition, or detransition, allow them to have choice and support throughout the whole process. Say “I'll love you no matter what”, that allows them to end up in the place that's correct for them.