Part 2: Gender affirming care in Kingston: in conversation with Dr. Ashley Waddington

Part 2: Establishing a Clinic and Caring for Patients

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 second part of an interview with Dr. Waddington. The first part defining gender affirming care and how you can be supportive can be found here: https://museumofhealthcare.blog/gender-affirming-care-in-kingston-in-conversation-with-dr-ashley-waddington/

You established the Transgender Care Clinic in 2017. How did you know it was the right time or that you would be able to meet those needs?

Yeah, so it was sort of two main things that were happening. So one was I was starting to just get a lot of referrals for transgender people who were seeking menstrual suppression, enough to the point that I thought there's probably enough volume here to be its own clinic. Then, I also had a colleague who was retiring around that time, and he was a reproductive endocrinologist. He had sort of quietly been doing some hormone prescribing for some gender diverse people over the years. He wasn’t really advertising that as a service, but he had just kind of filtered into his practice over time and he had had long term follow up with many patients. He was looking for somebody to continue that care when he retired and asked if that was something that I would take on. And I thought, well, “I'm already contemplating changing my practice or creating a new clinic for that.” So, that was kind of what spurred it on.

 I don't want to take all of the credit. There were a lot of other people who were finding that they had patients coming to them seeking gender affirming care- a number of family doctors, social workers, nurse practitioners, and counselors. We organically developed this group of people who were seeking to improve access to care in Kingston.  We called ourselves the Trans Health Connectors and we talked about…

How do we improve education for healthcare providers in our community? 

How do we create some pathways to care so that people can access care?” 

That group, both confirmed the need for this care, and allowed me to get a better sense of just what the population in our community looks like, and how little access there was to care. But it also gave me some support in terms of finding other healthcare providers who were either providing this care or interested in providing it. We could be resources to one another and share patients, tips, and ideas, as we got our practices up and running. So I don't want to suggest that I'm the only person in Kingston who's providing that care, nor that I kind of took it on without the support of colleagues and the collaboration of others. 

I understand that the clinic has kind of evolved into several different options. There are about three currently running?

 When I started my clinic, I had two collaborators with me at the time, a family doctor and another gynecologist. We figured we would do one clinic a month, and that would probably be adequate. We were wrong. Because very quickly, the waitlist to get into our clinic grew to over a year for people to get in. We just didn't have the ability to see the volume of patients that needed care and we already all had full time practices. It was very clear that this somebody needs to take this on as almost like a full time job.

Through that Trans health connectors group, we made some connections with leadership within what's called the Local Health Integration Network and the Kingston Community Health Centre. We came up with a plan to create a nurse practitioner led clinic through the Kingston Community Health Centre that would provide gender affirming care. The vision for that clinic would also include mental health support because that was something that was missing from my clinic. So we got that up and running about a year to a year and a half after my clinic opened its doors and that was a full time clinic, and started to take a lot more of the volume of the patients. Around the same time, we had a family practice colleague who started doing the Trans Health Clinic through her family practice and that also relieved some of the pressures in the system of not having adequate capacity. 

A big part of all of this has been an effort to also just train more healthcare providers. This does not have to be specialized care and it's not medically super complex. It is something that primary care providers (family doctors, nurse practitioners, etc…) can provide within their own practices. There are quite a few in Kingston now who are doing it, but I wouldn't suggest that all primary care providers in Kingston are providing this. I also am aware that many patients in Kingston just don't have access to a primary care provider. But, the ideal situation is where people have a family doctor and that person can provide their gender affirming needs.

People might view this as a specialized training or specialized care. Have you seen a change with how gender affirming care is included in formal medical education?

I'm an associate professor here at Queen's University, and I teach both at the undergraduate (medical school level) and postgraduate (residency and fellowship level). We have had teaching within the undergraduates in the medical school which started almost around the time that I started my clinic. It became a more formal part of the curriculum around that time. In postgraduate studies, our obstetrics and gynecology residents who train with me come to my clinic, and we also have some formal sort of didactic teaching around trans health. Then for the family medicine program, we also do teaching. So that's a formal part of the curriculum for family doctors who train through Queen's. So it's improving.

I do want to say that it needs to become more established in all specialties, but particularly in those like family medicine, where it's going to live most of the time. One lecture where I go and talk to the family medicine residents once a year about this topic is not going to be enough. They need to see it modelled. They need to have the experience of interacting with a trans person and doing the counselling or prescribing the medications. While it's an improvement that now it's there, what would be ideal is that the family medicine would be able to model that care. As I said, there are certainly way more family doctors now who are providing that care. So then when it's modelled as a part of family practice and trainees see that, learn from it, and see that that's something that they can do, then that's something they're more likely to carry on and continue doing into their future. So it's improving. We're not where we need to be just yet, but it's definitely better than it was, say, like 10 or 15 years ago, definitely.

Often when we discuss gender affirming care, topics of oppression or lack of access to care are highlighted. So I was just curious, what do you find fulfilling about your role and helping your patients?

Oh, yeah, so much. I have these long term relationships with these patients, because I tend to follow them over the years. When people come to you, and they're sort of contemplating going through a medical transition and then sort of exploring what the options are and what that might look like for them. They're often in a place where they're not living as their authentic selves, and they're looking to make a change that's going to help them to move closer to living as their authentic selves. As you sort of facilitate that transition and get them where they want to be, you really see them just thrive. They just become more confident in themselves, they feel like they're more ready to face the world as the person that they are and have always known themselves to be. It's just it's really, it's really wonderful to watch that happen.

I don't want to suggest that there's never hiccups along the way, or that everybody's transition is smooth sailing, and they go off into the world and everything is happy. There can certainly be bumps in the road, there can be setbacks, and there can be challenges of oppression or lack of support that they still have to face. But I find they feel more empowered to face those challenges when they have the support of a healthcare provider who believes in them and wants to help them get where they want to be. It's a very just lovely long term relationship to have with patients and see as they move through the world, in most cases in a much happier place or in a way where they feel like they can interact with the world as their authentic selves.

In other areas of my practice, it's a little bit more episodic. I might see patients for a few visits, but then usually whatever issue they came to me with is better. They go back into the world and I don't continue to follow them for years and years. So this has just been really a fulfilling part of my practice that I didn't really anticipate. I thought I would feel good about helping people, but I never thought that it would be so exciting to see people as they transition and sort of come into their best selves. 

I've also met more people through different networks and connections between health care providers, trying to find solutions and care for people. I've interacted a lot with primary care colleagues that I maybe haven't hadn't had as much interaction with previously, like the relationship that I had with the leadership of the Kingston Community Health Centre when we were establishing that clinic. It's just very nice. Sometimes when you work as a specialist in a hospital, you don't feel as connected to the community of other health care providers and supporters. It's been an unexpected benefit of being able to be a part of a community of providers that learn from one another and share ideas and support.