Photos submitted by AccessBC

A prescription model could reduce barriers for trans and non-binary people

The BC NDP was elected on a platform that promised to make all prescription contraception free, affirmed by Minister of Health for BC Adrian Dix’s mandate letter. That still hasn’t happened, limiting access to care for anyone who can become pregnant across the province. That can include trans men, non-binary people, gender-fluid people, and intersex people, not only cisgender women.

AccessBC is a collective of almost 70 advocates who encourage policy on free contraception across the province. They have spent the past four years rallying for municipalities to write letters to the Premier in support of their cause, and 18 have agreed so far, including Vancouver, Burnaby, and Victoria. 

Cost remains the most significant barrier to accessing contraception for all British Columbians. Intrauterine devices can cost between $75 and $380, pills are around $20 a month, and injections can be up to $180 per year — a hefty price tag for what AccessBC considers a basic human right.

Teale Phelps Bondaroff, chair and co-founder of AccessBC, says the barriers to getting contraception in the province are broad, ranging from taking time off work or school to paying for childcare and transportation.

“One of the stories that one of our members told us was that she grew up outside of 100 Mile House and would have to hitchhike into town to go to a clinic and get a prescription for an IUD filled. Then on another day, they had to hitchhike into town to get it inserted, then hitchhike home,” says Phelps Bondaroff. 

“I’ve never had an IUD inserted, but my understanding is that leaves you in a rather vulnerable position — not a situation where you want to be hitchhiking and not a location in the province where you want anyone to be hitchhiking, given the dangers.” 

The process is even riskier for trans and non-binary folks who have to deal with harassment and sometimes rejection from healthcare workers along the way. 

James Demers is a trans man and professional diversity educator in BC who understands that firsthand. He says trans and non-binary people often have to educate their doctors about their health, and healthcare professionals often make the false assumption that all trans or non-binary patients are mentally ill. This demonstrates the need for mandatory education about trans and non-binary health in medical schools in addition to free contraception.

“Trans people are terrified of going to the doctor because they’re scared of being treated badly or mocked, and that happens,” says Demers. “If you avoid going to the doctor, things pile up on you – things like ovarian cancer or prostate cancer. It prevents people from getting the daily access to care that they deserve.” 

In his experience, doctors are “more likely to deny working with a trans patient than take a chance.” If there’s an opportunity for them to be educated sooner, they can learn how “the othering of bodies that don’t look like the established hierarchy has a real impact on health.” 

Demers suggests doctors take a collaborative and consent-based approach to serving anyone who isn’t cisgender. There’s such a training model already being run in Calgary, where 16 doctors and 16 trans and non-binary people come together to connect and answer one another’s questions in a positive learning environment.

“If no one checks your gender at the door, people will access that service,” says Demers. 

That model was proposed by Nicole Thompson, a resident physician at the University of British Columbia’s obstetrics and gynaecology residency who works primarily with trans and gender diverse patients. Her study on curriculums about gender affirming and primary care for trans people in Canadian medical schools led to the creation of an operational program in Calgary. 

Still, many practitioners outside of that program don’t understand her patients’ needs, she says. As a result, clinics need to adapt their operations to be more gender-affirming by taking initiatives like asking all patients for their pronouns and preferred name. There are plenty of other “little things” providers can do to help improve the experience too, such as learning how to provide a gender-affirming pubic exam to reduce gender dysphoria among patients with cervixes who aren’t women.

“Even if you have a prescription, even if you’ve been able to find a provider who will work with you on finding an appropriate contraceptive method, going to the pharmacy is really difficult. You might get questioned as a trans man showing up at the pharmacy trying to fill a prescription. There’s a lot of potential for harassment,” says Thompson.

“Let’s make it safe for trans and gender diverse folks to approach a clinic. It removes a socioeconomic barrier. People might feel safer accessing methods they feel more comfortable with.”

This way, the next generation of graduates from Canadian medical schools will have knowledge about trans and non-binary health, and how access to free contraception affects them. 

Trans and gender diverse people are also disproportionately represented in lower socioeconomic brackets, making it even harder for them to cover the bill. An IUD is a five-year solution that only has to be administered once, making it a great solution for folks who are able to afford it, but few can. 

Even then, patients going into the procedure for the first time have no way of knowing how their bodies will respond. If unexpected side effects become debilitating, patients either have to suffer the consequences or remove the device they saved up to pay for. Then the process of finding contraception that works begins all over again, a cost some can’t pay.

The current system offered in BC provides services through programs like PharmaCare, but they’re income dependent, meaning applicants have to pass a means test or face financial burdens in order to freely exercise their right to make choices about their reproductive health. Up-front payments and extensive paperwork only complicate the process further, adding cost and confidentiality barriers.

In a report released this month, AccessBC proposed that BC adopt a policy where no-cost prescription contraception is universally available to all residents — a suggestion also made by the Canadian Medical Association, Society of Obstetricians and Gynaecologists of Canada, and the Canadian Pediatric Society, among other groups across the country. 

“This policy could be delivered using a similar method to Mifegymiso, the abortion pill that was made universally available at no cost in January 2018,” suggests the report. It would be administered similarly to how psychiatric drugs are now, with general practitioners, tele-healthcare providers, or walk-in doctors sending prescriptions to pharmacies for pickup.

The UK, France, Spain, Sweden, Denmark, the Netherlands, Luxemburg, Italy, and Germany have already subsidized universal access to contraception, and a 2015 study in the Canadian Association Medical Journal estimated the government’s savings, in the form of direct medical costs of unintended pregnancy, at $320 million. That’s more than twice the cost of making the program happen.

Ruth Habte is a resident ObGyn physician and researcher in the area of trans health education for healthcare professionals. During her time as a pharmacist, she saw how harmful the high price of contraception could be, sometimes forcing people to reshape their lives around unwanted pregnancies. 

Early on in her residency in B.C., she worked with a single mom with a job who couldn’t afford a $400 Mirena IUD. To avoid the severe side effects she suffered from other birth control, she applied to a now defunct government program that offered a limited supply of IUDs on a “lottery” system. Months into trying to get one at no cost, she got pregnant.

“This person who’s a single mom — who in the first place didn’t want to get pregnant but did, chose to keep the pregnancy, and now she’s still trying to figure out to get an IUD for herself? That’s ridiculous,” says Habte. 

“Sometimes you just try and try and the system is just not set up to help you, to help people, and this is just one of the very many instances in health care of that.” 

All British Columbians could have their reproductive needs met through free prescription contraception, she says. Some birth control can also help with menstruation symptom management, with IUDs sometimes totally eliminating period pain. 

“This policy is about reaffirming people’s choices, and I think policy can be immensely powerful,” Habte adds. “British Columbia would be the first province to approve of it, and that could really send ripples across the country to help people advocating for a policy like this get access to these kinds of medicines.”