Still a long way to go for transgender people and fertility treatment


(Photo: Courtesy of Alex Abramovich)

The baby’s room is painted pale yellow. The crib is assembled. There are piles of adorable newborn outfits. In short, Alex Abramovich and his wife, Caroline, are ready for their first child and they are over the moon. Caroline’s due date is July 29.

But their journey to parenthood has been rocky. The healthcare that Abramovich, a transgender man, received at a Toronto fertility clinic was discriminatory because of his gender identity, he says. Now the 35-year-old is considering filing a complaint with the Ontario Human Rights Commission.

“The experience was really dehumanizing,” said Abramovich, a scientist at Toronto’s Centre for Addiction and Mental Health who has researched LGBTQ youth homelessness for 10 years. “They made me feel like a disease.”

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This is a story about people’s discomfort with transgender Canadians. It is about healthcare standards that need improvement. This is a story about love, and our ability to make love and share love. Ultimately it is about understanding the beauty of the changing architecture of families.

The story begins in early 2015 when Abramovich expressed his desire to have a child who would be genetically related to him. He and Caroline, married since September 2014, decided to fertilize his eggs with donor sperm and implant the embryo in Caroline for her to carry.

There was an impediment though; Abramovich’s doctors didn’t discuss egg freezing with him before he began testosterone. This meant Abramovich had to wean off his male hormones for several months before he could begin a round of ovary (or follicle) stimulating hormone injections in order to produce multiple eggs. These would then be retrieved and fertilized in a lab prior to being implanted in Caroline, who is now 33.


(Photo: Courtesy of Alex Abramovich)

The clinic

Abramovich and Caroline did their research and settled on a busy hospital in downtown Toronto. This is how Mount Sinai Fertility describes itself online: “We thrive on being an inclusive and positive community: Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) people are welcome and encouraged to attend.”

The couple felt safe. “We thought, OK, here is a hospital that has gone out of its way to crate a trans-inclusive policy,” Abramovich says.

In July 2015, some three months after he stopped taking testosterone, Abramovich had his first ultrasound. He was instructed to put on a hospital gown and sit in a waiting room with female patients.

“Obviously people were thinking, ‘Why is this dude here?’” he says. A nurse looking for another patient saw Abramovich and her jaw dropped. She started to walk away, paused, and looked back. She gawked at him three times.

“I wanted to say, ‘Yes, what you see is real. I am actually a person sitting here,” Abramovich said. “But in the situation you just freeze and feel shame.”

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He stared at the wall before him and saw a large trans-inclusivity poster. “It was ironic that I was made to feel like a freak while I was staring at a picture of three trans people.”

He had to deal with the same nurse in the ultrasound room. “There was a power imbalance with two doctors and that nurse,” he said. “That ultrasound room was awkward and silent.”

After the appointment he called Mount Sinai to file the first of three complaints and he suggested that, in future visits, he change his clothes in the ultrasound room and wait for the medical team. The nurse practitioner agreed and assured him there would be a plan of care in place.

Yet a month later he was again directed to change into a gown and sit in the waiting room surrounded by female patients. He was crushed. The duty nurse referred to Abramovich as “she.” Caroline spoke up, “He, you mean he.” But the nurse continued to use the wrong personal pronoun even as Caroline corrected her.


(Photo: Courtesy of Alex Abramovich)

Abramovich described another appointment in which the doctor was so uncomfortable that she trembled while conducting his ultrasound. “It was obvious she couldn’t bear to look at me. Instead she stared at the wall,” he said. “I wanted so badly to say, ‘Just relax. I’m not going to bite you.’”

During his final ultrasound the same nurse who had repeatedly referred to Abramovich as “she” was present and said “she” for the third time. The medical director was present and she corrected the nurse.

Afterwards, Abramovich told the medical director he didn’t want that nurse present during the egg retrieval procedure. The director told Abramovich: “We’ve all received training but it just doesn’t stick for some people.”

Abramovich was dumbstruck. “I never had high expectations [but] in Canada, and in a city like Toronto that is so diverse and in a major urban hospital, it should not be so difficult to treat patients with dignity and respect, like a human being.”

While he says he understands that transgender fertility and reproductive health may be a newer area for some fertility clinics, if a clinic states it has a transgender-inclusive policy, then this should never happen. “Telling a patient ‘all of our staff have received training in this area but it just doesn’t stick for some’ is not acceptable,” he said.

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Mount Sinai did not comment on Abramovich’s case but in an email statement said it encourages feedback from patients.

“We work very closely with leaders of LGBTI2S Community to ensure that access to care, including fertility, is inclusive, accessible and compassionate. This includes extensive training and ongoing research about how to improve access to care,” wrote Dr. Ellen Greenblatt, the fertility clinic’s medical director, and Marylin Kanee, the hospital’s human rights director, in a joint statement.

“The health-care sector must continue to work as allies to ensure that we are addressing the needs of the trans community, and Sinai Health System is committed to upholding our reputation for leading in this area.”

Abramovich was so stressed by his experience that he hesitated before agreeing to be interviewed. Caroline declined to talk about what happened. Abramovich texted: “It was a traumatizing experience and it was really difficult for her to witness how they treated me.”


(The City of Toronto marks its first official Transgender Day of Remembrance with a flag-raising ceremony on November 20, 2014. Photo: Newzulu)

Family planning

Abramovich isn’t the only transgender man in the world raising a family.

A 2011 Belgian study published in the journal Human Reproduction, reported that 22 per cent of transgender men already had children while 37.5 per cent said they would have considered freezing their eggs before transitioning if the procedure had been available. In addition, 54 per cent of respondents said they wanted to have children.

In December 2015, new coverage from the Ontario government came into effect providing one cycle of IVF treatment regardless of sexual and gender orientation or family status. For transgender people, the funding covers the cost of monitoring menstrual cycles and it pays for the retrieval and freezing of eggs and sperm.

Ontario residents pay out-of-pocket for annual storage fees and for fertility drugs. And in May this year the federal government introduced Bill C-16, an act to amend the Canadian Human Rights Code and the Criminal Code to protect transgender people from discrimination and hate propaganda.

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Abramovich began his hormone treatment before Ontario’s coverage came into effect. He and Caroline spent approximately C$20,000 on fertility medication, egg freezing, embryo transfer, and IVF.

He noted that as Canada passes bills and policies protecting trans people, and community members feel more comfortable ‘coming out.’ they also need to have access to health care. To that end, he feels doctors need more training. In addition there’s a needs for more research and cultural competency resources for medical professionals.

His advice to trans people planning to start a family is to have an honest conversation with the potential fertility clinic and to ensure staff have received cultural competency training.

Healthcare without care

A report released this month in the journal Lancet noted that, “many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care.”

And an October 2015 report by the National Institute of Health in the U.S. found that although programs providing health care for transgender people have grown in recent years, there remains “a gaping chasm” between what transgender people need and what is taught in health professional schools and postgraduate training programs.

“As a result, many health professionals are unprepared to provide quality care,” the report noted, adding that this is true throughout the basics of supporting and affirming gender affirmation, cross sex hormone therapy or a variety of surgeries, as well as routine primary care.

In short, trans-competent or trans-friendly healthcare isn’t widely available and the word care isn’t an integral part of many healthcare facilities.

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Andy Inkster is a transgender man and health promoter at Toronto’s LGBTQ Parenting Network which offers cultural and clinical competency workshops to fertility specialists in the GTA. He points out that “fertility clinics are hyper-gendered environments where women are in one area and men are in another. For a trans person it makes for a very difficult clinical experience.”

In the last five years, though, he has observed administrators at fertility clinics making an effort to establish procedures to accommodate trans clients. But there’s a difference between establishing protocols and executing them, he says, adding, “It has to be a conscious process.”

While he didn’t comment on Abramovich’s case, Inkster did suggest that clinics examine all aspects of their healthcare protocols, from the reception area to booking appointments to the referral forms. The physicians, nurses, and lab technicians need to “examine every aspect of how they can support and celebrate trans people in their practice,” he said.

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For example, a lab technician can explain to a trans man that the clinic is going to use the name the client prefers but it does need to freeze the embryo under the client’s legal name. “And then you just have to ask him to spell it out,” he said. “People can do their job in a respectful way and the trans patient gets the best care possible.”

He also encourages clinics to create a workflow that increases patients’ privacy and reduces awkward encounters; the result is that dozens of patients won’t be sitting in a waiting room dressed only in a gown. “It’s also less uncomfortable for cis women who might be sitting there and they see a guy there and feel vulnerable, too,” Inkster said.


(Photo: Courtesy of Alex Abramovich)

Home stretch

It’s just four weeks to the due date and Abramovich is nervous and excited about fatherhood.

“All that matters is that we provide a safe and loving environment,” he said. “I hope our child doesn’t have to face the type of discrimination I’ve had to face. I hope our child grows up in a world where people are kind to each other.”

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