TORONTO — Demiyah Perez is worried. Anxious, even. Her disposition usually leans toward optimism, but when it comes to money, an unsettling discomfort replaces her routine certainty. At 22, she’s already saddled with the low income and high expenses that disproportionately affect transgender women, who statistically make far less income than most other Canadians.

Over the phone, Perez, who lives in Toronto, rattles off her bills as if running through a grocery list — rent, food, WiFi — but she tacks on a monthly payment for a prior breast augmentation, a transition-related procedure from October that her health care plan didn’t cover.

Soon enough, she says, when she ages out of her Ontario Health Insurance Plan (OHIP+, a plan that covers some medications) at 25, she’ll need to start paying for her hormones, too.

For many trans people, hormones are as essential to their health as, for instance, diabetes or blood pressure medication is to anyone else.

“I was never more depressed than I was before I started taking hormones,” Perez says. As she hit puberty, her body began doing things that made her uncomfortable. She grew hair on her body, which repulsed her — she thought it was “dirty” — so she stole razors from her mother’s bathroom to try to remove it. Only, she often ended up hurting herself by accident, which caused even more of a frenzy.

Joshua Rille Demiyah Perez, 22, works as a DJ under the moniker "Demiigoddesss"

Later, while taking estrogen, she experienced changes that helped her feel more feminine — reduction of hair growth, shifting of fat distribution, the growth of her breasts. She also needed to take them for a year before getting her reassignment surgery.

Hormones, she says, combined with testosterone blockers, alleviated some of this crushing gender dysphoria, and allowed her to move toward the body she wanted before she was able to do any surgery. “Those were some of my first steps in trying to pass,” she says.

“Passing,” in this case, refers to a transgender person’s ability to be correctly perceived as the gender with which they identify, and to not be perceived as trans. For many people, this distinction is what reduces their risk of experiencing violence.

In February, the House of Commons Standing Committee on Health began a study. The plan was to research the state of LGBTQ+ health in Canada — to identify any concerns the community faces and, if possible, to offer corrective measures.

“It is clear,” said the chair of the committee, “that we need to do more to ensure that LGBTQIA2 Canadians have safe and equitable access to health care across the country.”

Watch: Writer, director and producer Janet Mock talk about her experience transitioning in high school. Story continues below.

Last week, having heard from 33 witnesses and after combing more than 44 briefs from frontline community organizations, the committee officially released its report, recommending, as they did last year, that the Canadian government provide full coverage for the cost of hormones and gender-affirming procedures.

Many trans and gender nonconforming people require regular use of hormones, to varying degrees, but might not have access to them for any number of reasons. And while hormones would be a minimal cost for the government to incur, the cost for the individual who needs them can, in tandem with other related procedures, become too prohibitive for the person to manage.

“Trans people have a high rate of education, but the lowest rate of employment, which means less access to health care,” says Kusha Dadui, a youth resource worker and trans program coordinator in Toronto.

Between troubles getting employment references with their current pronouns, inability to access academic transcripts with the proper sex designation and outright employment discrimination, there is a litany of barriers impeding trans people from having a fair shot at job opportunities.

ASSOCIATED PRESS Accessing hormones continues to be an issue for many transgender and gender nonconforming people.

“It’s ridiculous, what some trans people, what most trans people, live on,” he continues. If “ridiculous” means “alarmingly below average,” or “less than 15K a year,” then Dadui is right on the nose — this is the reality for half of trans people in Ontario.

In some ways, this is a simple way of thinking about the argument against the government covering hormones. Sure, the cost doesn’t appear to be too scary, but it adds up, and the fact is that those who need access to them are often already disenfranchised, juggling residual bills from other operations, or dealing with poverty.

“Hormones are a relatively low-cost thing. I mean, this is pocket change for a provincial or federal government,” says Alex Verman, a writer whose research focuses on gender, transition, and various other subjects.

Mallika Makkar Writer and researcher Alex Verman says hormones are just a small piece of the larger puzzle in transitioning.

Coverage for transition-related care across Canada is patchy, inconsistent. Ontario, for example, subsidizes several gender confirming surgeries, but not necessarily those procedures it deems “cosmetic” — breast augmentation, facial feminization.

Before getting a phalloplasty, for example, which is covered in Ontario, the patient is typically required to do several sessions of laser hair removal, which, though the average session costs around $300, are unaccounted for.

That official term — “cosmetic” — implies something nonessential, in spite of the fact that many procedures deemed “cosmetic” are actually a way of more closely aligning the person’s secondary sex characteristics with their gender.

For most people, Verman says, “your face will gender you right away,” and cosmetic procedures are often instrumental in cultivating passability.

But, there’s also the matter of medical ignorance. When she was transitioning, Perez says, there was much less knowledge than there is now about how to work with trans patients.

Dadui, too, found himself surprised when, in the initial stages of his transition, he ended up switching roles with his doctor. Like many trans people, he seemed to be the one guiding the professional who was supposed to be guiding him.

“The medical curriculum has been lagging behind tremendously in the area of trans care” - Dr. Raymond Fung

Worse, still, he explains, is the fact that many doctors refuse to treat trans patients, or aren’t willing to get the training, or simply make referrals to each other in an effort to avoid dealing with the concerns of their patients themselves. “Let’s call that what it is,” he says, “it’s transphobia.”

Medical curriculum ‘lagging behind tremendously’

Dr. Raymond Fung — an endocrinologist at Michael Garron Hospital in Toronto who works with trans people and argues in favour of government coverage for hormones — says the problem of medical ignorance around trans care seems to begin on an institutional level.

“The medical curriculum has been lagging behind tremendously in the area of trans care,” says Fung, noting the recency of trans people being included in medical education on basic physiology. “There have been pockets of people who have been more progressive in learning about trans health, but the majority of doctors, I would say, because they haven’t been exposed to trans care in their curriculums, are unfortunately ignorant.”

Dr. Fung says in his endeavours to educate physicians about trans care, he’s noticed a lack of understanding in the field of gender identity, and a reticence in prescribing hormones if the patient has not done a psychiatric evaluation.

PHILIPPE HUGUEN via Getty Images Some physicians won't prescribe hormones unless the patient has undergone a psychiatric evaluation.

“It’s not a required thing, but some physicians still feel uncomfortable with providing hormones if that hasn’t happened,” he says. “The problem is even getting that assessment is associated with a lot of stigma, and there’s enough difficulty with even accessing mental health professionals who would be willing to provide those assessments.”

As it stands, long delays in access to gender affirming procedures increases the already high risk of depression and suicidal ideation in trans people, as noted in the report. “What about people who start to transition later in life, after 25, when health care no longer covers any of those surgeries?” Perez says.

She considers herself lucky for her own transition experience — having gotten her hormones and surgery relatively quickly, due to a longstanding relationship with a doctor at the Centre For Addiction And Mental Health (CAMH) in Toronto — but wonders what might have happened if she hadn’t been able to start hormones when she did.

“The more the cost of transition-related care is offloaded from the person and onto the state, the more benefits that will have for people as a whole,” says Verman. She says that hormones are just a very small piece of an enormous and complicated puzzle that needs more attention from the government.

“We need to recognize that LGBTQ health care should be looked at in the same way we look at any other health care,” she says.