Access to Quality Healthcare for People who are Trans and Gender Diverse in Saskatchewan

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People who are trans and gender diverse (PTGD) are a medically underserved population in Saskatchewan.³ An overburdened healthcare system has struggled to provide access to care of any kind for PTGD, let alone care that is inclusive and non-judgmental. There are also social and legal barriers—strictures within the healthcare system itself—that further impede access to care.

PTGD are a small population—trans, gender diverse, and non-binary people collectively comprise approximately 0.3% of the population in Saskatchewan,⁴ yet they face important health challenges relative to the cisgender population, including an increased likelihood for comorbidities and more frequent healthcare visits, in part because transition related care requires a strong relationship with a healthcare provider.⁵ Only 54.4% have a primary care provider with whom they feel comfortable discussing trans issues, which is similar to the national average (52.3%) with 36.2% reporting an unmet healthcare need in the last year (compared to 44.4% of PTGD nationally).⁶ PTGD youth were also more likely to have a doctor who knows about their trans identity,⁷ but a national study also found that the COVID-19 pandemic further reduced access to both general and gender-affirming healthcare for PTGD.⁸ Importantly, Two-Spirit People may face additional barriers given the intersecting and overlapping experiences of discrimination in the healthcare system, colonialism, and racism in addition to the barriers they may experience as PTGD.⁹ In a climate of increasing transphobic discourse and misinformation, access to safe and gender-affirming healthcare is more important than ever.¹⁰

In this brief, we discuss three significant barriers to delivering healthcare services to PTGD in Saskatchewan, namely: 1) challenges with finding inclusive and affirming primary care; 2) challenges finding inclusive and affirming specialist care and; 3) care challenges related to other social, economic, and policy-related factors. Drawing on the existing literature and our team’s ongoing community-based research, the concerns addressed in this brief inform a series of recommendations about interventions that both healthcare providers (HCPs) and the province of Saskatchewan might undertake to improve access now.

A critical barrier for PTGD is access to care that is gender-affirming. By that we mean “any combination of social, legal, and medical measures that help people feel happy, healthy, and safe in their gender.”¹¹ PTGD are often not receiving primary care that is gender-affirming: their voices go unheard and their identities unvalidated by their HCPs, with negative outcomes.¹²

In a study with six PTGD in Saskatchewan, participants reported experiencing “referrals not being sent by doctors as they said they would be, being misgendered by practitioners, being asked invasive questions about their genitals, sexual identities, and sexual histories, and having doctors suggest they experience heterosexual intercourse to make sure that they really are transgender.”¹³ In the same study, one collaborator described having strep throat and being in need of antibiotics, but “the doctor did not focus on her throat and instead gave her ‘the beat down’ about her gender.” Incidents like these occur so often that they have garnered the moniker “trans broken arm syndrome,” where “a doctor assumes any medical condition a trans person experiences—from a broken bone to headaches—is related to the fact they’re trans, like a side effect of hormones.”¹⁴

An important barrier to affirming primary care also lies in HCPs’ comfort in providing trans-specific healthcare. Primary care providers can deliver most healthcare needs for PTGD, and with some training and support “should be able to prescribe hormones, monitor for potential effects of hormone therapy, assess for gender dysphoria and make referrals for transition related surgeries for transgender people who choose to transition medically.”¹⁵ Yet, many primary care providers feel they do not have the knowledge or skills to care for PTGD, including prescribing relevant hormone therapies. A recent survey in Saskatchewan reported that 30.3% of primary care providers indicated they would be comfortable providing trans-related medical care to patients (“including hormone therapy and trans-related surgical referrals”) with 95.8% indicating they “would be comfortable providing non-trans-related medical care to [PTGD].”¹⁶ The combination of primary care physicians who are not gender-affirming at all and the hesitance of others to provide hormone therapy means that PTGD face long wait lists to access a primary care physician who will address all of their care needs. Training for HCPs on the identities and health needs of PTGD has, in fact, been proven to improve HCPs’ knowledge about, and comfort with, providing trans-specific care.¹⁷

It should not, however, fall to PTGD to educate their doctors and other HCPs about their trans-specific care needs. Nor should PTGD need to seek secondary appointments and referrals for care that a family physician could easily provide.

In addition to challenges in primary care settings, PTGD also experience bureaucratic barriers and long wait times in accessing essential specialist care. These services include access to surgeons who perform gender-affirming surgeries; to other gender-affirming procedures; and to critical mental health support.¹⁸

The barriers to accessing gender-affirming surgeries are complex. Nationally, PTGD report waiting at least 3 to 12 months for gender affirming care, mostly surgery.¹⁹ There are long wait times for many types of surgical procedures province-wide, but for gender-affirming surgeries, actual wait times are unknown because they are not tracked by either provincial or national health authorities. While reported wait times vary from province-to-province, they also vary depending on the nature of the surgery. Some surgeries are not offered in province at all. For PTGD in Saskatchewan undergoing “bottom” (or “lower”) surgery (e.g., phalloplasty, metoidioplasty, vaginoplasty),²⁰ the Saskatchewan Health Authority (SHA) will only fund procedures performed at the GrS Clinic in Montreal. The wait times for these surgeries are extensive (~12 months for vaginoplasty and ~18 months or more for phalloplasty),²¹ and, the costs of travel, meals, accommodations, or post-operative care are not funded.²² The surgical approval process also requires PTGD to obtain references from both a psychiatrist and a “recognized authority.”^23,24

The fact that PTGD must consult with a mental health professional in addition to their primary care provider to obtain any provincially-funded gender-affirming surgeries constitutes a particularly challenging barrier to gender-affirming surgical care. Researchers in British Columbia indicated that while some PTGD find these assessments affirming and useful to prioritize the next steps for their care, others found it to be an ongoing form of medical gatekeeping. Many PTGD experienced psychological assessments as an obstacle to care, because of long wait times or because they had to pay out-of-pocket.²⁵ In our team’s own research, a focus group participant indicated they were referred to a psychiatrist in Alberta—listed as one of Saskatchewan’s recognized authorities—for surgical approval, paying travel costs out-of-pocket and dedicating an entire day to travel.²⁶ Professional guidelines for trans care recommend only one assessment, because “the requirement for two independent assessors reflect[s] paternalism in health care services and raise[s] a potential breach of the autonomy of [trans] individuals.”²⁷

Other gender-affirming procedures provided either in-province or elsewhere are not covered by provincial health insurance, and PTGD must pay for such procedures themselves or go without. These include but are not limited to: breast augmentation, chest contouring, facial feminization, tracheal shaves, and electrolytic hair removal.²⁸ Several participants in our focus groups indicated that these issues disproportionately affect trans-feminine people.

PTGD are also particularly likely to require access to a range of mental health services relative to the general population—with PTGD having a higher prevalence of mental health challenges than cisgender²⁹ people, including “depression and anxiety disorders and suicidality, related to various levels of oppression and marginalization.”³⁰ Research from Trans PULSE Canada indicates that among PTGD surveyed in Saskatchewan, 52% report being a “psychiatric survivor, mad, or person with mental illness,” with 59% of respondents indicating that they have “fair or poor” self-rated mental health,³¹ compared with 11.7% of Canada’s general population aged 12 or older.³² Research conducted in 2016 with PTGD youth also reported that 60% of survey respondents in Manitoba and Saskatchewan (grouped as “the Prairie Provinces”) had “engaged in self-harm behavior in the last year,” relative to 24% nationally.³³

Despite this demonstrated need, adequate mental health supports are not available to PTGD in Saskatchewan. A lack of targeted mental health supports for PTGD and limited awareness of trans-specific issues among providers have both been cited as “barrier(s) to completing mental health treatment”.³⁴ OUTSaskatoon provides counselling services, but there is a waitlist,³⁵ and clients can only access these services on a short-term basis³⁶ which does not address long-term mental health concerns.

Low socio-economic status also impacts PTGD’s access to care. According to a 2016 Trans PULSE survey in Ontario, 36.9-52.8% of PTGD live below the poverty line.³⁷ In 2019, Trans PULSE Canada found that 58% of respondents had annual incomes below $30,000.00; substantially lower than the median income for Canadians aged 25-48. Survey respondents linked their reduced incomes to a decrease in safe and well-paid employment opportunities for PTGD.³⁸

In addition to costs associated with travelling out-of-province for care, many PTGD in Saskatchewan must bear the burden—investments of both time and money—of travelling within the province to find supportive, culturally-safe care of any kind. The majority of Saskatchewan’s gender-affirming HCPs, including all surgeons, but also most primary care providers, are in Saskatoon and Regina,³⁹ and according to the 2021 Census, 26.6% of PTGD in Saskatchewan live outside these cities.⁴⁰ Several participants in our focus group, who lived in rural or remote locations, indicated that transportation and accommodation costs made it difficult to access culturally-safe healthcare. Access to healthcare in rural areas is a widespread challenge—32.4% of Saskatchewan residents from rural and/or remote areas must travel over 200km to access specialist care⁴¹—still, higher levels of poverty among PTGD may prevent them from getting the healthcare they require.

Another significant barrier to accessing affirming care is obtaining identification and legal documents which align with one’s lived gender. Having ID accurately reflecting their gender identity and chosen name make it possible for PTGD to obtain healthcare without being deadnamed or misgendered, as well as vote, enroll in university, and anything else requiring identification. The benefits of having gender-affirming identity documents are significant: research from Ontario shows it can reduce both suicidal ideation and suicide attempts in PTGD.⁴²

The process of changing one’s gender marker on health cards and birth certificates is complicated. PTGD must first acquire a letter from a physician or psychologist affirming their gender identity—which means that they must have a trusted provider who knows them well.⁴³ Requiring a healthcare provider to validate one’s gender identity denies PTGD the autonomy to self-define their gender identity,⁴⁴ and infringes upon the fundamental dignity and personhood of PTGD guaranteed by the Saskatchewan Human Rights Code.⁴⁵

Changing one’s legal name is also complicated and costly. The forms to change one’s name are not easy to navigate, the costs of changing one’s name $135.00⁴⁶ before notary public fees for various forms, and also requires the reissue of all other identification documents (at additional cost).⁴⁷ The social costs of changing one’s legal name are also high: PTGD are actively outed as transgender by the provincial government when they legally change their name, as the information—including their previous and their new name—are made public in the Saskatchewan Gazette.⁴⁸ Further, the Government of Saskatchewan requires a criminal record check for all name changes in the province, which can be a source of stress for PTGD who have experienced criminalization.

Given the numerous barriers to healthcare PTGD face, it is particularly important to improve their access to culturally-safe, gender-affirming care.

• Ensure all primary care providers are knowledgeable about, and able to provide, trans-specific healthcare. If primary care providers throughout Saskatchewan experienced greater comfort prescribing hormones it would reduce wait times for care and the travel required for those living in rural and/or remote areas. Both medical education and cultural safety training could work to increase the number of primary care providers who feel knowledgeable and comfortable enough to provide gender-affirming care, while simultaneously creating safer and more validating environments for PTGD to receive care. This could be provided in part by the creation of Saskatchewan-specific trans healthcare guidelines for medical practitioners, including primary care providers, that draw on the World Professional Association for Transgender Health (WPATH) guidelines for PTGD care.”⁴⁹
• Establish permanent funding for a peer navigation program. Emerging research from our team—building on successful programs elsewhere (particularly TransCareBC⁵⁰)—indicates that peer navigators can both educate providers and directly improve access to affirming care for PTGD.⁵¹ Peer navigators use their personal knowledge and experience to educate providers, help connect PTGD to care, assist with changes to legal documentation, and advocate on their behalf if needed. In 2021-2022, our team piloted a peer navigation program in Saskatchewan. Our early results indicate that it is working, with 91.07% of post-navigator survey respondents reporting that they were “satisfied” or “very satisfied.” The navigators saw a total of 70 HCPs and 259 trans clients, with 95.75% of clients returning for repeat service. Permanent funding for trans health navigators, with services available throughout province including rural and/or remote areas, would increase PTGD’s access to, and quality of, care.
• Change the requirements to access funded surgical care to only requiring the signature of a single practitioner. Saskatchewan currently requires referrals from two physicians (one of whom must be a psychiatrist, and one of whom must be an “authorized provider”) to access transition-related surgeries. WPATH recommends only a single signatory from any culturally-knowledgeable healthcare provider, not necessarily a psychiatrist.⁵² Currently, most provinces and territories require a referral for surgery from only a single qualified provider.⁵³ Saskatchewan should change its requirements to align with these jurisdictions and the WPATH recommendation.
• Increase the availability of mental health supports for PTGD. Research has shown that mental health struggles for PTGD can be aided by formal and informal social support networks, with high levels of social support connected with a 49% reduction of suicide ideation and 82% reduction in suicide attempt risk.⁵⁴ Continued and greater funding of culturally-safe and informed counselling services and support groups (like those run by community organizations) could help alleviate this mental health disparity.
• Improve processes for making changes to legal documents and identification. There are several ways that changing legal documents and identification should be made easier. First, eliminating the requirement for an HCP to validate gender marker changes to health cards and birth certificates will allow people to access care without being misgendered, and supports the dignity and human rights of PTGD. Second, because the costs of changing one’s name and gender marker can also be prohibitively high, waiving relevant fees for PTGD can improve access to care. Third, because the publication of name changes in the Saskatchewan Gazette can expose PTGD and make deadnames accessible to the public, the publication of name changes in the Saskatchewan Gazette should shift immediately from an opt-out to an opt-in model, and those who have had their names published should be given the option to have them removed.
• Establish a multidisciplinary network or health centre dedicated to addressing PTGD care. Accessing timely gender-affirming primary and specialist care, as well as mental health services are, as noted throughout this brief, a significant challenge for PTGD. Creating a multidisciplinary health centre, or a network focused on PTGD care would improve access to a range of services and reduce wait times by coordinating appointments (also reducing the need for multiple visits and relevant travel). A multidisciplinary approach could also reduce cost by allowing HCPs to better coordinate care, while supporting education and expanding expertise and training opportunities in PTGD health.

The Saskatchewan health care system is stretched thin—there are fewer health care resources than there are people who need them, but PTGD deserve access to the same quality of care as cisgender people. Access to adequate healthcare services for PTGD is life-saving; it is not negotiable. The recommendations we make—increased education, a peer-navigation program, reducing requirements for surgical care, improved mental health supports, easier and cheaper process for changing legal markers, and a network of providers—are not particularly costly. But they will go far to immediately and substantively improve access to, and quality of, healthcare services for PTGD in Saskatchewan.

JSGS Policy Brief Series

Alana Cattapan (she/her) is the Canada Research Chair in the Politics of Reproduction and an Assistant Professor in Political Science at the University of Waterloo, and an adjunct professor at the Johnson Shoyama Graduate School of Public Policy (University of Saskatchewan campus). She studies gendered inclusion in policy making, identifying links between the state, the commercialization of the body, and reproductive labour.

Gwen Rose (she/they) is a research assistant with the Trans Research and Navigation Saskatchewan (TRANS) project, and a PhD candidate in English at the University of Saskatchewan. Gwen’s research interests include modernism and the lived experience of marginalized peoples. Her dissertation combines these interests, examining the representation of transgender characters within literary modernism.

Mel Reid (they/them) is the Undergraduate Research Assistant for the TRANS Project. After completing their Bachelor of Arts in history with the University of Saskatchewan they began their Bachelor of Social Work with the University of Regina. There they study community development with queer peoples and end-of-life care.

1 Co-first authors.

2 The authors are part of a larger research team currently investigating the healthcare quality of people who are transgender or gender diverse in Saskatchewan. See https://research-groups.usask.ca/transnavigator/the-project.php. The project was supported by the Saskatchewan Health Research Foundation and the Saskatchewan Centre for Patient-Oriented Research, as well as through partnerships with community-based organizations including TransSask, OUTSaskatoon, and UR Pride Centre. The authors would like to thank all the members of the TRANS team and others who have supported our work. In particular, we would like to thank Eisha Ali, Stéphanie Madill, and Megan Clark for their contributions to earlier drafts of this work, and Dale Eisler and the anonymous reviewer for their helpful feedback.

3 Ayden I. Scheim et al., “Health Care Access Among Transgender and Nonbinary People in Canada, 2019: A Cross-sectional Survey,” CMAJ OPEN 9, no. 4 (2021): E1213-1222, https://doi.org/10.9778/cmajo.20210061.

4 Statistics Canada, “Broad Age Groups and Gender: Canada, Provinces and Territories.” Table 98-10-0036-01. Statistics Canada, April 27, 2022, https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=9810003601.

5 Alex Abramovich et al, ”Assessment of Health Conditions and Health Service Use Among Transgender Patients in Canada,” JAMA Netw Open 3, no. 8 (2020):1-12, doi:10.1001/jamanetworkopen.2020.15036

6 Scheim et al., 2021

7 Tamara Edkins et al., “Being Safe, Being Me in the Prairie Provinces: Results of the Canadian Trans Youth Health Survey in Saskatchewan & Manitoba,” Stigma and Resilience Among Vulnerable Youth Centre, School of Nursing, University of British Columbia, Vancouver, BC, 2016, https://apsc-saravyc.sites.olt.ubc.ca/files/2018/04/SARAVYC_TYHS_Prairies-Final-WEB.pdf 

8 Hannah Kia et al., “Impacts of COVID-19 on Trans and Non-binary People in Canada: A Qualitative Analysis of Responses to a National Survey,” BMC Public Health 22, no. 1284 (2022): 1-11, accessed Sept 26, 2022, https://doi.org/10.1186/s12889-022-13684-x.

9 For example, Two-Spirit People may (in addition to the other barriers identified in this brief) encounter challenges accessing care when they have Indian Status. The healthcare of people with Indian Status falls under the jurisdiction of the federal government, yet access the provinces provide healthcare services; therefore, complications arise over who is responsible for services provided out-of-province, or how to access relevant care. Anecdotally, these jurisdictional problems can create additional delays in accessing care.

10 The World Professional Association for Transgender Health (WPATH) has repeatedly addressed such misinformation as it arises. See: “WPATH/USPATH Public Statements,” https://www.wpath.org/policies.

11 Donald Collins and Rayne Whitington, “Everything You Need to Know About Gender Affirming Care,” Healthline, May 27, 2022, https://www.healthline.com/health/what-is-gender-affirming-care 

12 For example, a 2014 Ontario study noted that “an estimated 21% (95% CI 14% to 25%) reported [avoiding emergency hospital] care because of a perception that their trans status would negatively affect such an encounter. Trans-specific negative [emergency] experiences were reported by 52% of users presenting in their felt gender.” Greta R. Bauer et al., “Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results from a Respondent-Driven Sampling Survey,” Annals of Emergency Medicine 63, no. 6 (2014): 713-720, accessed Sept 26, 2022, https://doi.org/10.1016/j.annemergmed.2013.09.027 

13 Avery Eros Finley Zieger, “Transgender Identity and Ethics of Care: Narrative Analysis of Transgender Identities and Experiences of Care in Saskatchewan,” (Master’s Thesis, University of Saskatchewan, 2017)

14 Stuart Foxman, “Doctors’ attitudes can make a difference,” eDialogue: A Publication for Ontario Doctors, accessed Sept 26, 2022, https://dialogue.cpso.on.ca/2021/06/caring-for-your-trans-patients/?print=print.

15 Ayden I. Scheim et al., 2021.

16 Lisette Christopherson et al., “Assessment of Knowledge, Comfort, and Skills Working with Transgender Clients of Saskatchewan Family Physicians, Family Medicine Residents, and Nurse Practitioners,” Transgender Health, 2021, Oct 27, 2021, https://doi.org/10.1089/trgh.2020.0181.

17 Burgwal et al., “The Impact of Training in Transgender Care on Healthcare Providers Competence and Confidence: A Cross-Sectional Survey,” Healthcare, 9, no. 8 (2021): 967

18 There are other barriers to receiving specialist care that are beyond the scope of this brief. For example, many PTGD experience struggle with accessing reproductive health care. See Sarah James-Abra, “Trans People’s Experiences with Assisted Reproductive Services: A Qualitative Study,” Human Reproduction 30, no. 6 (2015):1365=1374, doi:10.1093/humrep/dev087

19 Ayden I. Scheim et al., 2021.

20 Bottom surgery includes, but is not limited, to phalloplasty, metoidioplasty and vaginoplasty. The former two procedures involve different processes for creating a penis for transmasculine people, while the latter involves the creation of a vagina and vulva for transfeminine people. See Provincial Health Services Authority, “Gender-Affirming Surgeries,” accessed Sept 26, 2022, http://www.phsa.ca/transcarebc/surgery/gen-affirming.

21 Saskatchewan Trans Health Coalition, ”Saskatchewan Medical Transition Guide,” January 2019, https://www.transsask.ca/wp-content/uploads/2019/02/Saskatchewan-Medical-Transition-Guide-Final-Draft-1.pdf. 

22 Saskatchewan.ca, “Gender Identity, Gender Diversity, and Transgender Support,” Saskatchewan.ca. Accessed Sept 26, 2022, https://www.saskatchewan.ca/residents/health/accessing-health-care-services/gender-identity-gender-diversity-and-transgender-support. Travel costs are also not funded for other out-of-province surgeries, see for example: Mickey Djuric, “Saskatchewan to Send Patients to Alberta for Privatized Surgery; Won’t Pay for Travel,” CTV News. Accessed Sept 26, 2022. https://regina.ctvnews.ca/saskatchewan-to-send-patients-to-alberta-for-privatized-surgery-won-t-pay-for-travel-1.6031462 

23 There are only nine such recognized authorities, only five of whom practice in Saskatchewan. See: Saskatchewan.ca.

24 Saskatchewan.ca, “Gender Identity.”

25 Hélène Frohard-Dourlent, Margaret MacAulay, and Monica Shannon, “Experiences of Surgery Readiness Assessments in British Columbia,” International Journal of Transgender Health 21, no. 2 (2020): 147–62, https://doi.org/10.1080/26895269.2020.1742842 

26 The results of this qualitative research are forthcoming. This research included—amongst other methods—two online focus groups with PTGD, assessing their thoughts on trans healthcare in the province. These groups, held with participants who had not accessed the navigator service, was intended to provide an initial “baseline” report of the state of healthcare in the province for PTGD.

27 Eli Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health 23, sup. 1 (2022): S1-S259, DOI: 10.1080/26895269.2022.2100644.

28 Saskatchewan Trans Health Coalition, 2019.

29 María Paz-Otero et al., “A 2020 Review of Mental Health Comorbidity in Gender Dysphoric and Gender Non-Conforming People,” Journal of Psychiatry Treatment and Research 3, no. 1 (2021):44-55, DOI: 10.36959/784/425.

30 Tommy Hana et al., “Transgender Health in Medical Education,” Bulletin of the World Health Organization 99, no. 4 (2021): 296–303, https://doi.org/10.2471/BLT.19.249086.

31 Ayden I. Scheim et al., 2021.

32 Statistics Canada, “Perceived mental health, by age group,” Table 13-10-0096-03, Statistics Canada, August 26, 2022, https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009603.

33 Tamara Edkins et al., 2016.

34 The authors discuss mental health care for the broader 2SLGBTQ+ community, which is inclusive of PTGD. See: Jacq Brasseur, Celeste Seiferling, and Suzy Yim, “2SLGBTQ+ Mental Health,” Women for  Saskatchewan (blog), October 27, 2020, https://web.archive.org/web/20210212105223/https://womenforsaskatchewan.ca/2slgbtq-mental-health/.

35 Brasseur, Seiferling, and Yim, 2020.

36 OUTSaskatoon, “Counselling,” OUTSaskatoon, accessed Sept 26, 2022, https://www.outsaskatoon.ca/counselling/.

37 The percentages varied based on how participants responded: online (n=6021), or by in-person paper (435). The higher percentage of respondents living below the LICO poverty line reflects the low socioeconomic status areas in which this methodology was deployed. Ayden I. Scheim et al., “Sociodemographic Differences by Survey Mode in a Respondent-Driven Sampling Study of Transgender People in Ontario, Canada,” LGBT HEALTH 3, No. 5 (2016), https://doi.org/10.1089/lgbt.2015.0046.

38 Ayden I. Scheim et al., 2021.

39 Janis Renner et al., “Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case Scoping Review,” Frontiers in Endocrinology 12, no. 717821 (2021): 1-12, doi: https://doi.org/10.3389/fendo.2021.717821.

40 This figure was derived by deriving the total number of PTGD residing in Saskatoon and Regina from the following: Statistics Canada, “Infographic 3: The Largest Proportions of Transgender and Non-binary People in Large Urban Centres are Observed on the Canadian East and West Coasts,” Statistics Canada, accessed Sept 26, 2022, https://www150.statcan.gc.ca/n1/daily-quotidien/220427/g-b003-eng.htm. This was then compared to the total number of PTGD living in Saskatchewan as also recorded in the census; see footnote 4. 
Total populations of Saskatoon and Regina were taken from: Statistics Canada. “Population and dwelling counts: Canada and census subdivisions (municipalities).” Table 98-10-0002-01. Statistics Canada, April 27, 2022, https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=9810003601.

41 Chandima P. Karunanayake et al., “Access to Specialist Care in Rural Saskatchewan: The Saskatchewan Rural Health Study,” Healthcare 3, no. 1 (2015): 84-99, doi: http://dx.doi.org/10.3390/healthcare3010084.

42 Bauer et al., 2015.

43 eHealth Saskatchewan, “Combined Application for a Change of Sex Designation on a Saskatchewan Birth Certificate and Saskatchewan Health Card,” eHealth Saskatchewan, accessed Sept 26, 2022. https://www.ehealthsask.ca/residents/Documents/Combined%20Application%20for%20a%20Change%20of%20Sex%20Designation%20on%20a%20Saskatchewan%20Birth%20Certificate%20and%20Saskatchewan%20Health%20Card%20.pdf 

44 Jena McGill and Kyle Kirkup, “Locating the Trans Legal Subject in Canadian Law: XY v. Ontario.” Windsor Review of Legal and Social Issues 33, no. 1 (2013): 96.

45 McGill and Kirkup, 2013, 133; The Saskatchewan Human Rights Code, 2018.

46 JusticeTrans https://justicetrans.org/en/saskatchewan/ 

47 If requests for changes of both gender marker and legal name were submitted simultaneously, all identification documents would only need to be issued once, eliminating this additional cost.

48 eHealth Saskatchewan, ”Register a Legal Name Change,” eHealth Saskatchewan, accessed Sept 26, 2022, https://www.ehealthsask.ca/residents/name-changes/Pages/Register-a-Legal-Change-of-Name.aspx 

49 Eli Coleman et al., 2022.

50 Provincial Health Services Authority, “Improving gender-affirming care across B.C.” Provincial Health Services Authority, accessed April 5, 2023, http://www.phsa.ca/transcarebc/ 

51 Provincial Health Services Authority, ”Help Navigating Care,“ Provincial Help Services Authority, accessed Sept 26, 2022, http://www.phsa.ca/transcarebc/care-support/access-care/navigate-care.

52 Eli Coleman et al., 2022.

53 British Columbia requires a “readiness assessment,” while the Northwest Territories, Ontario, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador require a single letter. See Emily Mertz, “Gender-Affirming Health Coverage by Canadian Province, Territory,” Global News, June 23, 2022, https://globalnews.ca/news/8900413/gender-affirming-healthcare-province-territory-transgender/ 

54 Greta R. Bauer et al., “Intervenable Factors Associated with Suicide risk in Transgender Persons: A Respondent Driven Sampling Study in Ontario, Canada.” BMC Public Health 15, no. 525 (2015): 1-15. https://doi.org/10.1186/s12889-015-1867-2.