In episode four of “In Dialogue,” CPSO EDI Lead and Medical Advisor Dr. Saroo Sharda speaks to Dr. Alex Abramovich, PhD, a scientist and researcher, about 2SLGBTQ+ health and youth homelessness; simple and best practices in creating an inclusive and affirming health care setting; and the mental health effects of the pandemic on an already marginalized population.

Dr. Abramovich is an Independent Scientist at the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH), and an Assistant Professor at the Dalla Lana School of Public Health and the Department of Psychiatry at the University of Toronto. His research investigates the health and social inequities experienced by 2SLGBTQ+ individuals, focusing on understanding and improving the health and service needs of youth and young adults in this population. More specifically, his program aims to provide practice and policy recommendations that will help prevent, reduce and ultimately end 2SLGBTQ+ youth homelessness across Canada.

Related eDialogue Articles

• Creating an Inclusive Space
• Caring for your Trans Patients
• Transgender Health
• Creating a Welcoming Space

CPSO Resources

• Equity, Diversity and Inclusion

Additional Resources

• Assessment of Health Conditions and Health Service Use Among Transgender Patients in Canada, study
• Investigating the impacts of COVID-19 among LGBTQ2S youth experiencing homelessness, study
• Examining COVID-19 vaccine uptake and attitudes among 2SLGBTQ+ youth experiencing homelessness, study
• Rainbow Health training resources for health providers
• The 519
• YMCA Sprott House
• Friends of Ruby
• Central Toronto Youth Services
• LGBT Youth Line — Confidential and non-judgemental peer support through telephone, text and chat services, Sunday to Friday, 4 to 9:30 p.m.
• Finding Your True Voice: A Guide to Gender-Affirming Verbal Communication
• Supporting the Transgender Community: Gender Affirming Care Resources

Interview with Dr. Alex Abramovich

Introduction:
CPSO presents "In Dialogue," a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Saroo Sharda, CPSO Medical Advisor / EDI Lead (SS):
Hi, and thanks for joining us In Dialogue. My name is Dr. Saroo Sharda. I'm a practicing anesthesiologist, in addition to my roles as a Medical Advisor and Equity, Diversity and Inclusion Lead at CPSO. I hope you enjoy this episode. 

I'm really pleased to be in conversation today with Dr. Alex Abramovich. This is a really important topic and I'm really glad that we have an expert that we can converse with. I wondered if you would start by just telling us a bit about yourself and your work.

Dr. Alex Abramovich, PhD (AA):
Yes, absolutely. Thank you so much for having me join you today. So, my name is Alex Abramovich, and I go by he/him pronouns. I'm an Independent Scientist at the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH). I'm also an Assistant Professor at the Dalla Lana School of Public Health and the Department of Psychiatry at the University of Toronto. The overarching aim of my program of research is really to investigate the health and social inequities that are experienced by 2SLGBTQ individuals with a focus on understanding and improving the health and service needs of 2SLGBTQ youth and young adults.

So, I do a lot of work with young people. I lead multiple projects that are focused on understanding the experiences, needs and challenges among 2SLGBTQ youth and young adults who are experiencing homelessness. And that work really has an overarching goal of providing practice and policy recommendations that will help us prevent, reduce and ultimately end 2SLGBTQ youth homelessness across Canada. I've been addressing the issue of 2SLGBTQ youth homelessness for almost 15 years now and I've had the privilege of working with many young people over the years. I also do a lot of work in the area of trans health, as you know. So, I would say, most of the studies that I lead are focused on 2SLGBTQ health and homelessness.

SS: Thanks so much, Alex. It's a really wide, important and varied portfolio that you have in terms of your work in these various positions that you hold, and I imagine that variety of work brings you a lot of joy. You mentioned specifically there the privilege of working with youth, especially in the 2SLGBTQ community, and I imagine also that there have been a great deal of challenges. And I wonder if you might expand a little bit on what some of the greatest joys — as well as what some of the greatest challenges — have been in this work that you do?

AA: Absolutely. Yeah, that's an excellent question. So, I would say that my greatest joys in doing the work that I do, as I mentioned, really being able to work with young people over the years has been the greatest joy of my work — and not just to work with young people, but to really witness their resilience. So many of the young people who I have worked with are — they're just so incredibly resilient. I've had the honour of working with some young people, as I mentioned, who are incredibly resilient and are absolutely brilliant. And so, for me, that has been really one of the greatest joys.

And I would say another great joy has been being able to create a career in an area that I feel so passionate about, and to be able to actually impact such important practice and policy change over the years. I conduct research that is action-oriented. I do a lot of community-based, action-oriented research with the aim of creating positive social change. And so, it is incredible to be able to do such important work that results in, I would say, life-saving programs and interventions. That is really an honour to be able to do this type of work.

But of course, as you know, there's also quite a few challenges that I have experienced over the years and I'm sure will continue to experience, and, I would say, some of the greatest challenges have been around getting issues regarding 2SLGBTQ+ populations to be prioritized and to be taken seriously. And there — I mean, there has been quite a lot of change over the years. So, for example, when I first started doing this work, it was incredibly challenging in terms of just trying to get 2SLGBTQ populations’ health, homelessness onto the radar of key decision-makers. Often, you know, it wasn't even part of their important conversations nationally.

And so that has been quite a challenge over the years, and I have found that oftentimes when it comes to issues that are experienced by 2SLGBTQ populations, people wait until something tragic has happened before responding; and so, the response always ends up being reactionary. And so, it's always this reaction rather than actually taking the time to think about prevention, and taking the time to think about how do we avoid these tragedies from occurring in the first place? And so that continues to be a challenge, I would say.

SS: Yeah, I'm really glad that you're framing it like that for us, Alex, because I think as physicians, as healthcare providers, it's really important for us to understand that these issues that you're talking about, and that your work has focused on over these past years — they really are serious, they are life changing or life threatening events. And, I think, really framing it that way that this is not about us being nice people or just about, sort of, interpersonal interactions that we have with folks, this is actually about systems of inequality that cause harm and that continue to cause harm. So, I wonder then, if you might be able to speak to that a little bit in terms of — you've given us some really good tips in the past for Dialogue articles that we've put out about how physicians can create more inclusive spaces, safer spaces. But I wonder if you could speak a little bit to that idea of being reactionary versus actually looking at this through the lens of health prevention, just like we would look at other things through the lens of health prevention, like diabetes and hypertension, and all of these other things. I wonder if you could explain how physicians can think about this in a preventative way versus a reactionary way?

AA: Hmm, yeah. Okay, well, so I would say that — so, many of the systems that we currently have in place that are meant to actually provide support and are meant to care for people — for all people — and I'm thinking in particular about the health care system — these systems are often not really constructed for or trained appropriately to meet the needs of trans and non-binary individuals, in particular. And so, there's often this sort of expectation in a lot of healthcare settings that every person is going to fit into the gender binary, they're going to fit neatly into these predetermined categories. And that makes it extremely difficult for trans and non-binary individuals to navigate, and to fit into healthcare settings and institutional environments. And so, then you arrive in the settings, and you're kind of — it's like nobody's ever thought about the fact that oh, you know, maybe not everybody fits into these two boxes. And it's just like, everyone's kind of stumbling and not knowing what to do in that moment. And that really creates a challenging and also a dangerous situation for a lot of trans and non-binary people.

And I've worked with so many trans and non-binary individuals over the years who describe being, you know, feeling like they're unable to just bring their full authentic selves to the healthcare setting and to the support services that they access. And they often describe feeling forced into these categories that they don't identify with. And so, it's like no one's ever thought before you come into your appointment, or no one's ever thought that perhaps not everybody actually fits into these categories. And so, then you're in a situation where you're literally forced to put yourself into a category that doesn't, that you don't identify with.

And a lot of trans people experience major challenges just trying to access trans-inclusive, trans-competent services. Because, like I mentioned, a lot of the services that we have in place — that are actually in place to support everybody — are just not designed to support everybody. And so, then it just becomes very difficult to find your place to — especially if you're in a situation you just need medical attention, you need medical help — and so it becomes very difficult to try to access that type of inclusive, safe care. And, you know, then you end up avoiding healthcare, actually, altogether. And that brings you to that sort of crisis emergency situation where it's like, you just end up in the emerg, for example. I mean, you end up in that situation where this could have been avoided right from the beginning.

SS: Absolutely. And I think there is actually some data out there from an Ontario context, which actually shows that trans folks have had very trans-specific negative experiences in those encounters. And so, obviously, they don't want to go back because it's not a safe place for them. And I wonder if we could then link some of what you're saying, Alex, to your recent study, which was published in JAMA, where you and your co-authors actually found not only did trans folks have difficulty, as you said, accessing trans-inclusive and trans-competent care, but they're actually more likely to have a need for perhaps more access to the health care system and health service use than the general population. So, could you talk a little bit about that study, and what some of the complexities and the nuances are around that as well?

AA: Yeah, absolutely. And so, exactly as you mentioned, I did recently lead a study, which was actually the first Canadian study to identify trans, transgender individuals through a primary data linkage. And so we specifically worked with trans-inclusive clinics, specialty clinics that actually collect gender identity data, which, as you know, that doesn't happen at every clinic, unfortunately. And because of these clinics that exist, it made it possible for us to do this work. Unfortunately, gender identity information is not collected by OHIP and is not standardized; it's not collected by all healthcare settings. And so, we were able to work with some of the clinics that actually do collect this information, which made it possible for us to identify the trans clients or the trans patients who these services are serving.

We essentially used administrative health data, which was linked with ICES data. And we were able to identify over 2,000 trans individuals in Ontario, which was a really big deal. As I mentioned, this is the first Canadian study to do this. We're really pleased by the fact that we were able to identify such a large cohort of trans individuals, allowing us to start to look a little deeper into some of these issues that we know from previous research that has been conducted. And as you mentioned, the Ontario Trans PULSE study provided us with some really important data some time ago. And so, this allowed us to look at this issue from a different perspective, using administrative health data. We didn't actually interview any of the participants or any trans individuals for this particular study.

So, this first study, or you could say the first phase of this study, the main objective was to really examine socio-demographic characteristics, health conditions and health service utilization patterns among trans individuals, compared with the general population. So, it was really to just start to kind of characterize and understand who are these 2,000 trans individuals in Ontario? Where do they live? What kind of health conditions are they experiencing? And what is their access into the health care system? What do those patterns look like?

Interestingly enough, previous research, particularly the Trans PULSE study, did report that trans people avoid health care services. Whereas our study showed that trans individuals are using health services at much higher rates compared to the general population. And particularly in terms of the types of health care visits, we were able to break it down and look at — was it primary health care practitioner, specialists, emergency department hospitalizations — and what were the reasons for those visits? Were they mental health related, self harm related? Or were they not mental health related? And so, we found that, particularly for mental health and self harm related visits, and psychiatrist visits, were significantly higher among the trans cohort. And I do want to mention, though, that we assessed trans individuals who are attached to primary care. So, you know, all of these individuals, they were attached to primary care, and some of them were probably medically transitioning either through hormone therapy or transition-related surgeries. And so that may explain some of those higher rates of visits. But it doesn't explain everything; it really doesn't explain the whole picture. And unfortunately, we weren't able to identify trans individuals who might be particularly marginalized in terms of experiencing homelessness and don't have attachment to a primary care practitioner.

I would say that the emergency department visits, in particular, are really quite worrisome, especially if we look at it in the context of that they do have primary care physician attachment, but those ED visits were really quite high. And so, that's something that we still need to understand. And I mean, we do know, based on the work that I have done in the past, my ongoing research and based on other research, we know that trans individuals do experience quite a bit — higher rates of mental health issues and self harm related issues, and this certainly is impacted by the high rates of marginalization and stigma, discrimination that trans people unfortunately experienced quite frequently.

SS: Yeah, I think there's so many important things that you brought up Alex and, you know, really appreciate hearing this from the lens of your research and your expertise. I wanted to pick up on a couple of things that you mentioned there. The first being that we really don't have good gender identity data, I think is very similar for race-based data when we're talking about issues of race and racism. And really, I think you make an excellent point that we need to start to think about that in our healthcare systems, because that data is so important in terms of us being able to really look at system-wide issues and population-related issues. And so how do we do that in a way that meets best standards, meets best practice? And then I wanted to also just pick up on what you said around the 2,000 trans folks that were included in that study that, you mentioned, were attached to a primary care provider. But I'm guessing that there are many trans patients who perhaps are either not connected with a primary care provider or who are perhaps connected with a primary care provider, but in clinics that don't feel trans-inclusive, or aren't necessarily trans-competent. Would that be a fair extrapolation to make? And could you speak to that at all?

AA: Yeah, absolutely. I mean, I think that's an excellent point and absolutely very valid. I mean, a lot of the young people, for example, who I work with and who I've worked with over the years, who are at risk of homelessness, or who are experiencing homelessness or street involved, many of them who are trans or non-binary identified, don't have a primary care practitioner and they tend to avoid the healthcare system altogether because of negative experiences, discrimination they've experienced in the past, and because — for a number of reasons, perhaps their legal identification hasn't been changed to match with their gender identity. And so they would be subjected to being misgendered, being referred to by the incorrect name. And the list really goes on-and-on. And so when you're just trying to get by, you're just trying to access care — maybe you've hurt your ankle or your knee, you end up going to an appointment, and it turns into this whole thing about your trans identity and being asked really sort of inappropriate and invasive questions that have nothing to do with that appointment with regards to your knee or your ankle, or whatever it might be. But you're asked these questions just to fulfill someone's sort of curiosity. And so then, if you've experienced this enough, I mean, even if just one time, it's enough to make a person just avoid the healthcare system altogether.

So, to answer your question, I think that, certainly, we were able to identify a large cohort of trans individuals, but there are many more individuals who are unfortunately missed, and who are often missed. And many of the sort of surveys and a lot of the research — because they’re not included due to institutional erasure or data erasure, they’re not included on key forms, they’re not included on surveys — questions might be asked on one hand, but then not everybody has a chance to fill out those surveys. And so, many individuals are not included. And there’s still so much that we have yet to understand, and to learn about those individuals and their experiences.

SS: Yeah, and I think it also speaks to what I’ve heard other providers talk about and other researchers who do work in this space, about access to care, even from a geographical perspective. You know, you may be more likely to be able to access trans-inclusive and trans-competent care in a bigger urban centre than perhaps you might be able to in certain other areas of the province, where those kinds of clinics are just not available to people.

AA: Hmm, yeah, absolutely. And I’ve certainly heard that as well. Exactly. And, unfortunately, for many people who are living in more rural, or, you know, smaller towns, they may not be able to access that specialized care that they so badly need. And some of those programs that I spoke about are really quite life-saving on many hands, but I think that oftentimes we look at what are some other ways that we might be able to support those individuals in those rural settings. And I think that we have found that peer support, for example, is also really quite life-saving and, especially for among trans and non-binary individuals, we have found that people often do turn to peer support, for example, and that peer support has been found to be a key protective factor when we look at suicide. And so, I think that individuals in those settings often find creative ways to hopefully find the support that they need, maybe not entirely find the support they need, but find ways to connect in some cases; but then, unfortunately, not everybody is able to do that. And we are still in need of these types of specialized programs, obviously, across the country, especially with regards to homelessness. I mean, I think it’s very important to understand that LGBTQ individuals, trans individuals, non-binary individuals, live everywhere in every city and in every setting, not just in larger urban settings. But, you know, queer and trans folks live all across the country in all settings.

SS: I know that you’ve been generous in sharing with us, Alex, some of your own experiences as a transgender man interacting with the health system. And you provided some really, I think, useful tips in the Dialogue interview that we did with you, which I would very much encourage everybody to look at and read if they haven’t. And you mentioned some of those things that they seem seemingly simple. And it’s almost unbelievable that we’re still getting it wrong in healthcare, but, you know, not misgendering people, using the correct name, having intake forms where people can add their pronouns and their preferred names.

What you spoke about earlier, which actually came up in our Rainbow Health Ontario training that we are all doing right now as Council members and committee members of the College, as well as senior people working at the College, is that this idea that if a trans person goes in with a very specific healthcare problem, like an ankle issue or a knee issue or fractured arm, that they don't need to be interrogated about their trans status, or whether they're transitioning. And I think that's an important thing for us to take back as healthcare providers, whilst also recognizing that we do have to make sure we're being inclusive and that we are getting people's pronouns right. And so, could you talk a little bit about how physicians can do that? And really, that balance between making sure we're educating ourselves and doing our own work because it really is the responsibility of every healthcare provider to provide culturally safe and culturally competent environments, whilst also making sure that we're being true to the lived expertise and lived experience of the patients sitting in front of us, recognizing that it's not a monolithic experience.

AA: Absolutely, yeah. I think so much of this just boils down to basic human respect and treating people in ways that you yourself want to be treated. And I think that oftentimes these conversations, people really complicate a lot of these issues when so much of it is actually — it's not that complicated, it really boils down to just basic human respect. Like I mentioned earlier, it's important to know the difference between a question that is relevant to your medical assessment or your data collection versus an intrusive question that really only serves to satisfy your curiosity. I think it's very, very important to be mindful of the questions that we ask and why are we asking these questions — do we need to know this information? I think that many of the solutions to these issues that we are discussing are actually not that difficult to implement. Of course, some of the solutions require a bit more time and resources. But so much of this really boils down to just basic respect, and really taking the time to also prioritize providing inclusive and safe affirming care as well.

For primary care practitioners, for example, understanding that you can actually provide proper care to trans individuals, there's so much that you can do. You don't have to refer every trans patient to a specialist, for example, and that there are medical guidelines on providing care to trans individuals, which have been published and are very easily accessible online. And I would say that overall, I see this oftentimes as an issue that comes down to developing a more standardized model of care, in terms of creating a trans-inclusive and affirming environment, because when we have a more standardized model of care that we offer within the system, then it allows people to actually know what to expect when they access services, when they access health care clinics, which is so often an issue for trans people because oftentimes, for us, many times it depends on who is working on a given day, if you access a particular clinic, and it shouldn't be about that — it should be that all clinics are actually asking inclusive questions, that we're always asking people, “What is your chosen name?” And, “What pronouns do you go by?” and not just looking at someone's legal ID or their OHIP, and just assuming that that is how we're going to refer to this individual.

And that's why when I say that a lot of this is really quite simple, it’s because it's like, just ask people, “What name do you go by?” And, “How can I address you? What pronouns do you go by?” And I think that doing ethical research, for example, doing ethical work, that it actually involves asking the right questions and making sure that we ask inclusive questions that truly capture people's actual identities. Because if we don't ask inclusive questions, then we're actually not collecting accurate data. And we end up erasing people once again. And I think what's key is that people need to see themselves reflected in the services that they access. So, in the response options of surveys and questionnaires that we provide, rather than forcing people into categories that don't represent who they are — so if a person comes into your clinic, they should be able to access a washroom, we should ensure that we have all gender washrooms. And understanding that a one-size-fits-all approach is not going to work because one size does not fit all.

SS: I really liked what you said, Alex, about really just coming back to basic humanity, in terms of ethical and respectful care, being mindful of the questions that we ask. And also, I would maybe add to that, as a physician, something that I found helpful in my own clinical practice, which is also just being really transparent about why we're asking certain questions. I know as an anesthesiologist, I have sometimes assumed that patients know why I'm asking them about substance use, for example, how I'm going to make sure that I'm treating them safely and thinking about all the risks. And yet, I've realized over time, that actually, that can sometimes be interpreted as a very stigmatizing question and an intrusive question. And so, I think for us, as physicians or citizens, to be transparent about why we're asking things and how they're related to the issue at hand.

We're coming to the end of this conversation, Alex, and it's been a really enlightening conversation — your specific work with 2SLGBTQ youth and young people, because you said, that's really one of the highlights of your work, you know, their resilience. And I know that, especially during the pandemic, mental health issues have become much more pronounced for many communities, and perhaps even more so for members of the 2SLGBTQ community, and especially young people. Have you seen that transpire over the past two years in the pandemic? Are there services that people can access, especially when the regular health care system is sort of overburdened? And perhaps those folks were having difficulty accessing that even pre-pandemic. Now, are there any specific resources that you know of, especially for 2SLGBTQ youth?

AA: Yeah, absolutely. Thanks so much for asking this question. Because, yeah, so you know, a lot of my work has, as you mentioned, focused on to LGBTQ young people, particularly those who are at risk of and experiencing homelessness. And when the pandemic started, I think for a lot of scientists, we really sort of had to shift gears and start to make our work more relevant for the time, obviously, and to really understand like, okay, so what is happening now with the pandemic? And how is it impacting the populations that we work with? And so for myself, I've been leading a study, which is coming to an end now, actually, and this is a study that focuses on the impacts of the COVID pandemic on 2SLGBTQ youth at risk of and experiencing homelessness in the GTA [Greater Toronto Area].

So, for this study, it's a mixed methods study, we implemented a survey — an online survey — which young people completed at three different time points. And this survey assessed a variety of variables, mainly focused on mental health, and on their access to health care services, as well as their community and family connections, and their ability to access the support that they required. I would say consistent with findings from other research that has come out, mental health was a major concern for the majority of youth participants in this particular study. And I should mention that we also interviewed these young people. And so, many of the young people participated in in-depth interviews to really understand what was behind those numbers.

We looked at a lot of mental health variables, and we saw that mental health was a major concern. And we found really high rates of severe anxiety, depression, self harm, suicidality, with about one in three youth having attempted suicide since the pandemic began. And so, a really, really difficult situation for so many and particularly for those who are marginalized on multiple levels in our society. And so we did conduct these interviews as well to just really understand what is going on, what is happening for these young people? And we know that homelessness, discrimination, social stigma, have serious consequences on the health and wellbeing of 2SLGBTQ people, and that is often what leads to significant mental health issues, such as the high rates of anxiety, depression and suicide that we see, as well as the increased rates of alcohol and substance use among many of the young people who I work with.

And even though a lot of these youth were reporting alarming mental health concerns, the majority of them also experienced changes to their access to health care, as you mentioned in your question, and I think that's something that many people experienced, that it has been difficult to access the healthcare system throughout the pandemic. And so, for a lot of these youth, they found that there were cancellations, delays to their appointments; in particular, for a lot of the young trans people, their transition related appointments, for many of them, they had waited for a very long time for these appointments. And these might be, you know, assessment for hormone prescription, for hormone or for transition related surgery — well, those appointments were canceled, or they were postponed. And so then they had to wait once again. And we know through previous research that young trans people are at the highest risk of suicidality, particularly when they are at that period where they have a desire to medically transition, but are not able to do so yet, whether they're on the waitlist, or they just can't access the care that they require. No surprise, a lot of these young people, their risk of suicide is really quite high in this type of situation. And unfortunately, for many of them, they weren't able to access the care that they required.

And I know there has been a shift towards virtual care, which I think works really well for many people. But unfortunately, for the young people that I work with, for many of them, it doesn't work well because some of them were forced back into their family homes, into living with their parents, who, in many cases, were quite abusive. And so, for these youth to try to access a mental health care appointment, virtual appointment, there's a lot of fear that okay, my parents might hear what I'm talking about in the next room. And so then, that's not safe, right? Then they can't actually access the appointment. I think for a lot of them, they're left in a situation where they just weren't able to access the care that they required, that they needed so badly.

I think I mentioned earlier that peer support is really life-saving. And a lot of these different situations that we've been talking about for many of the youth, they do tend to turn to peer support. And whether that be within their peer group or online, I think a lot of the youth talk about different groups that are available online, whether it be through YouTube, like they create communities and end up supporting one another through these really difficult times. I'm mentioning this because it's something that really does come up quite often among the youth who I have worked with over the years. But then, of course, there are specific resources that are available to youth and whether that be specialized services, in many cases, these are population-based services. When I say a population-based service, I'm thinking about something like, The 519, Toronto's LGBT community centre; they offer many different types of programs that are available, that are youth-specific as well. And so those types of services are really great, to be able to access a specialized, population-based service. YMCA Sprott House is a service that I work very closely with, which is actually, was Canada's first transitional housing program for 2SLGBTQ youth located in Toronto; they work specifically with youth who are experiencing homelessness, who are street involved. And then there are other services that do offer population-based programming, like Friends of Ruby, CTYS, which is Central Toronto Youth Services, LGBT Youth Line.

I would say that there are a number of services that are specialized in, that do provide that support. But I think the pandemic really created a very difficult situation for many individuals because so many of those services and programs, unfortunately, we're not open to that in-person programming. And so, hopefully, many of these programs have started to open up and in some capacity. And so, my hope is that many of these young people who participated in our research have been able to actually access the support that they so badly require.

SS: Yeah, thank you so much, Alex, for highlighting some of those important resources because I think it's important for us, as healthcare providers, to be aware of those as well. And actually, another thing I learned from the fantastic folks over at Rainbow Health Ontario is that they also hold peer support for physicians who are taking care of this population of patients. So that, as you were saying, there's so many great resources out there, where we can actually go and turn to and learn as physicians, and recognize that we're on our own learning journeys with this, and it's the responsibility that we have. And they actually have these groups where you can connect with other physicians, and talk about things that you might be struggling with in terms of your patient population, and get support so that you can then support patients appropriately. So, I really appreciate you bringing that up. And overall, we just really appreciate your time.

This is an issue that causes real harm to people and we all have a responsibility as people working in the healthcare system, as physicians, to make sure that we are aware of that harm, that we're not minimizing what happens, and that we're training ourselves to be trans-inclusive and trans-competent, as well as recognizing the needs of other communities within the 2SLGBTQ population. So, Alex, before we let you go, and I know we've taken a lot of your time, I have heard sometimes from certain folks, well, you know, “I'm just too far along in my career to think about this now. This is all too much for me. I can't even wrap my head around the acronyms.” What would you say to somebody like that, who is expressing that kind of sentiment?

AA: I would say that over the years, a really important lesson that I have learned in my own work is that even the most resistant people can change; even the most resistant people, and including people who have the authority to implement real world change, as well as organizations, perhaps, who have been historically homophobic or transphobic, as well as friends and family members, people can change and I have seen, I have witnessed this. Sometimes people just need a little bit more time and resources. And I think it's incredible, because today we have those resources. We have some really amazing resources that are so easily available to everybody actually, available online, for example, that could help with that shift, and that can help educate, and that could help people on their way to turning that corner, and creating a more inclusive, safe and affirming environment in healthcare settings.

SS: What an amazing thought for us to close on. Thank you so much for sharing that, Alex, and thanks for your time today.

AA: Thanks so much for having me.

SS: Thank you for joining us. Please visit www.cpsodialogue.ca for more in-depth discussions about health care.