Related articles in this issue highlight substantial barriers that exist for transgender and gender-diverse people to access gender-affirming surgery in Canada.1–3 Two qualitative research studies offer deep insight into the way that health care interactions often leave transgender and gender-diverse patients feeling stigmatized, traumatized, or let down by health care systems.1,2 They highlight gaps in the delivery of care to this population group in Canada that practitioners can address. If nothing else, it’s clear that we as health care practitioners can work to deepen our capacity to deliver compassionate care to patients who already face a host of structural barriers to accessing care.

The Canadian Census of 2021 — the first to ask questions about gender identity — showed that about 1 in 300 people (0.33%) older than 15 years in Canada self-identified as transgender, nonbinary, or gender diverse, with higher prevalence among younger people.4 Surveys of cohorts of adolescents and youth globally have suggested prevalence ranging from 0.6% to 1.7%, with a rising trend.5 Data from the 2019 Canadian Health Survey on Children and Youth showed that 0.5% of youth aged 12 to 17 years identified as noncisgender.6

Not all people whose gender is other than that assigned to them at birth seek gender-affirming medical or surgical interventions, but most would like to be able to express their gender in their physicality and seek medical care to do so.3 Ashley, in their Medicine and Society article on gender self-determination as a presumptive right, uses the term “gatekeeping” to refer to the formal and informal barriers transgender people face in accessing gender-affirming health care, which may include medications, cosmetic procedures, or major surgeries.3

Patients interviewed by McCormick and colleagues described frequent interactions in which health care practitioners dismissed or invalidated their transgender identity, were insufficiently knowledgeable about trans health care, or were reluctant to engage with complexities of referral systems.1 Patients interviewed by Lorello and colleagues described how walking into a health care space could trigger anticipatory anxiety due to repeated experiences of stigmatization and discrimination.2

Ashley unpacks the related concepts of autonomy (a person’s right to decide the shape of the life they want to live, which “includes their right to make bad decisions”) and gender self-determination (the right to be able to express one’s gender fully in living one’s life). They argue that barriers to gender-affirming care interfere with transgender people’s ability to live as themselves and exercise full autonomy.

Limited access to interventions and surgeries of all types is a reality in Canadian health care. No health system is truly universal and, no matter how health systems are structured, a utopian scenario of unfettered access to desired health care is unachievable. The health care consultation, however, is a place where practitioners have personal agency to improve things for patients. Participants in both the related research studies remarked how effective communication, empathy, and compassion in health care encounters led to positive experiences and heightened their trust.1,2 Practitioners who were compassionate, respectful, and knowledgeable effectively became agents of health care delivery rather than gatekeepers, and it made a world of difference.

Participants interviewed in the 2 related studies spoke about interactions with health care professionals that occurred over many years.1,2 The professionals they encountered may not have had any undergraduate education in care for transgender people and may themselves have faced frustrating system barriers to serving their transgender and gender-diverse patients. Fortunately, medical curricula in Canada now include components on delivery of transgender health care. Moreover, good continuing medical education resources are increasingly available and accessible, including 2 articles published recently in CMAJ.7,8 Receiving care that validates their chosen identity is associated with better physical and mental health for transgender and gender-diverse patients.9 Even if access to interventions is limited, compassionate and kind care need not be.

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