Health care access among transgender and nonbinary people in Canada, 2019: a cross-sectional survey

BACKGROUND: Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions. METHODS: We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data. RESULTS: The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider (n = 1803; 81.4%, 95% confidence interval [CI] 79.8%–83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%–84.1%) in the territories to 92.9% (95% CI 83.5%–100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% (n = 1150; 95% CI 50.3%–54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% (n = 978; 95% CI 42.3%–46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment (n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%–32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%–65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study (n = 1046), 40.7% (n = 416; 95% CI 37.8%–43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region (p < 0.05). INTERPRETATION: Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist.