As part of an ongoing series investigating the research CBS claims to have in support of their new policy, you can follow the progress of my communications with related parties here (list updates with every new related post):

1. One Step Forward, Two Steps Back
2. That’s Not The Question I Asked
3. You’re Like, Halfway There

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Following the announcement from Canadian Blood Services that pre-operative trans women who’ve had sex with men would be considered “males who have sex with males, (MSMs)”–and therefore subject to the 12-month abstinence requirement for blood donation eligibility imposed on gay men–I sent a letter to their public inquiry box stating a concern with the methodology. I have reproduced my communications so far.

I establish that health statistics on trans folk is shoddy and incomplete because of medical establishments subsuming us into cisgender male and female populations; and also that CBS, in lumping pre-op trans women with MSMs, was not only perpetuating misinformation, but also doing something flatly unscientific.

Their public email clerk responded thusly: (emphasis added by me in all emails)

Siobhan

Dear CBS,

My name is [Siobhan], and I am a transgender woman affected by the policy you’ve recently announced.

I wanted to raise a concern with the proposed policy and how it contradicts the Interagency Coalition on AIDS and Development’s recommendations cited in this CBC article.

In the cited paper, “HIV and Trans Communities” by the Interagency Coalition on AIDS and Development, the authors advise that the very statistics they have devised have been confounded by the practice of coding trans women as “male.” They conclude not only that the cited “27%” is an unreasonable representation of HIV prevalence in trans women as it also includes some men who have sex with men (“MSM”), but that there are a number of causes for the increased rate–all of which are related to socioeconomic status, which is a highly variable element that not any given individual experiences uniformly.

Canadian Blood Services, as represented by Dr. Mindy Goldman, is blatantly disregarding the paper’s recommendation when she states “If a trans woman has not had [gender confirming surgery], that person would be considered as a male having sex with a male.” Yet Dr. Goldman states there is a “very high” prevalence of HIV in trans women–despite the confounding influence on stats by categorizing heterosexual pre-operative trans women as MSMs. It is specious to claim the rate is “very high” when it is bloated with the inclusion of MSMs.

I don’t doubt that the CBS will likely continue with their blanket abstinence requirements for Queer donors (a topic which I will happily write about another day), but if you insist on coding trans women as “male,” you are furthering the inaccuracy of health data affecting trans populations, not to mention propagating tremendous disrespect for trans women. You may find that your policy becomes unnecessary simply because we will not volunteer ourselves to abuse from your agency, even if we are eligible donors under the additional scrutiny.

If nothing else, please reconsider how you code trans women in your system and policy.

Thank you,

[Siobhan]

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Canadian Blood Services

Dear [Siobhan]:

Thank you for your email.

In June, Health Canada approved our request to reduce the blood donation ineligibility period for men who have sex with men from five years to one year. As part of this application, a new screening process and eligibility criteria for trans* (this term is inclusive to all transgender, non-binary and gender non-conforming identities) donors was also approved. These new processes and criteria will come into effect on Aug. 15, 2016.

Our new screening process for trans* donors takes into consideration the assigned birth sex of the donor and whether they have had genital surgery. Trans* donors who have not had gender-affirming genital (sometimes referred to as “bottom”) surgery will be screened by their assigned birth sex. We recognize their assigned birth sex may be different than the gender with which they identify. Trans* donors who have had gender-affirming genital (bottom) surgery will be asked to wait one year after surgery before donating blood. After this one-year waiting period, they will be screened by their chosen sex.

If pressed to clarify gender-affirming surgery

• Gender-affirming surgery is the surgical procedure to change one’s body to conform to one’s gender identity.
• Specifically, our focus is on the altering of genitals, which is sometimes referred to as “bottom surgery.”

If asked about birth sex/TRALI

• TRALI, which stands for Transfusion-Related Acute Lung Injury, is a rare but potentially fatal complication that can occur in certain patients after a blood transfusion.
• Patients who have been pregnant* are at highest risk to develop the antibodies that may trigger a TRALI reaction. (*this includes miscarriages, abortions and ectopic pregnancies)
• Donations from donors whose assigned birth sex is female are processed differently to reduce the risk of TRALI for patients.
• For example, the liquid part of the blood (plasma) from donors whose assigned birth sex is female is used to produce products such as immune globulin, instead of being transfused directly to patients.
• All parts of the donation from donors whose assigned birth sex is female are used for essential products, and donors will not experience anything different during the donation process.

Our goal is to be as consistent as possible in order to implement the simplest and most respectful approach for all donors and clinic staff. We will continue to communicate with the trans* community in order to remain informed prior to making any new submissions to our regulator.

Sincerely,

 

[Probably underpaid email clerk]

National Feedback Team

Canadian Blood Services

 

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Siobhan

Dear [Clerk],

Thank you for your timely response.

I do not wish to be ungrateful but I would like my letter to be referred to either a supervisor in CBS’ communications or someone with more familiarity with transgender health statistics and HIV. My concern was that CBS was adopting a flawed methodology that would perpetuate misinformation about HIV and trans communities; you appear to have copied and pasted an internal instructional memo related to immune complications in transfusion recipients from donors who have been pregnant. As the topic is trans women, pregnancy and its associated effects on blood are irrelevant.

Certainly as a trans woman, I do not need to be instructed on what is meant by “gender confirmation surgery.”

Your continued cooperation will be appreciated.

[Siobhan]

To recap, the point I raised in my letter was that the Interagency Coalition on AIDS and Development specifically cites the improper categorization by medical establishments of transgender patients as cis male or cis female. So far, I have not been provided justification for continuing this practice, merely that pre-op trans folk will be screened according to their assigned sex, according to the Clerk. Oh–but only if they’re pre-op. You know, fake.

The Coalition goes on to describe how the count for HIV among trans women is bloated because it includes gay men, sex-workers, and needle-sharers. Yet Dr. Mindy Goldman, the only person representing CBS in the media right now, insists the rate is “very high.” This is a bit like throwing a brick through your own window and then claiming it proves how dangerous your neighbourhood is. The rate for STIs is higher among sex-workers, cis or trans. Ditto for drug users. It would seem that even in South America, 3 in 4 trans women avoid either of those behaviours. Do they contract HIV by osmosis simply for being trans?

If you want to make claims specific to the transgender population, you need stats specific to the transgender population. While most trans advocates do not want our identities to be understood as entirely separate from men and/or women, you cannot claim to have data on health issues specific to trans people, if you don’t collect health stats recognizing trans people as trans.

There is another point, of course: Which is that a transgender sex-worker who shares needles with her colleagues and has unprotected sex with her clients is going to be just as much an HIV risk before and after her bottom surgery (or “gender confirmation” as CBS so condescendingly provides). As a friend of mine so bluntly put it, “it’s not like they’re performing an oil change while they’re down there.” In other words, there is no evidence that “gender confirmation” actually reduces the likelihood of contracting HIV, which is certainly implied by the bizarrely specific exemption.

That this HIV risk is due to the unprotected sex with multiple people and the act of needle sharing is a nuance both demonstrated by behaviour-based research on blood screening coming out of Italy and yet another point that CBS fails to address:

When comparing the period before (1999) and after (2009–2010), the implementation of the individual risk assesment policy in 2001, no significant increase in the proportion of men who have sex with men compared to heterosexuals was observed among HIV antibody-positive blood donors, suggesting that the change in donor deferral policy [from orientation-based to behaviour-based] did not lead to a disproportionate increase of HIV-seropositive men who have sex with men.

…

The proportion of those who admitted to having engaged in sexual risk behaviours in the 4 months prior to donation was similar among MSM (52.8%) and heterosexuals (50.0%) (P =0.94)

 

Actually making these points to Canadian Blood Services has so far proved difficult, as no media outlet has managed to get a hold of a spokesperson in the past 30 hours, other than CBC–the same article Goldman already made an arse of herself and the CBS by insisting on pre-op trans women being “screened as male.”

Most agencies complying with the Access to Information Act post large portions of their information publicly, and indeed, CBS has an ATI page as well as a page attempting to justify their Men Who Have Sex with Men policy. So we don’t have to navigate bureaucracy to at least get the organization’s publicly held positions on this topic:

In June 2016, Health Canada approved Canadian Blood Services’ proposal to reduce the blood donation ineligibility period for men who have sex with men from five years to one year.

In 2013, the ineligibility period was reduced to five years. Before that, men who had sexual contact with another man even once since 1977 were ineligibile to give blood. Moving to five years was a prudent first step in updating Canada’s donor eligibility criteria for MSM. Before making another submission to Health Canada, a minimum of two years of data was required to support further changing the deferral period.

Of course, Health Canada wants data (minimum two years) before changing policy. This, in and of itself, is not a problem–but we just established how MSMs include trans women and how the stats on trans women include MSMs. CBS isn’t collecting accurate data in the first place, so their data is going to be skewed accordingly.

Both Dr. Mindy Goldman and CBS have a throwaway line about how the new policy was developed in conjunction with LGBTQ consultants who “support” the new change:

Canadian Blood Services held a series of consultation meetings with affected patient and community groups. This process resulted in people sharing their many different points of view, resulting in a greater understanding of their positions.

The feedback participants provided helped shape our request to Health Canada to change to the current MSM deferral policy. Letters of support for this incremental change were sent to the Federal Minister of Health and shows the will and desire to work together to reach a common goal.

But if you actually look at the letters from those same lobbyists, you see something that looks a bit… odd, to be considered “support.”

(All emphasis added)

EGALE Canada Human Rights Trust wrote:

The need for change was never more evident than in the consultations that CBS convened with patient groups and LGBTQ groups earlier this year, in which we participated. It was both encouraging and inspiring to hear that even among heavy blood user groups (some individuals using upwards of 40 units per week) there was a clear acknowledgement that the MSM deferral was discriminatory, that it was alienating young donors, and that it ought to be changed. It was further heartening to find that there was general consensus that the end goal should be a behaviour-based screening process that assesses each individual’s level of risk based on individual behaviours and characteristics, rather than relying on broad and discriminatory generalizations. While there was general agreement amongst all participants that the proposed move from 5 years to 1 year would be a positive step, there was also an understanding that this move would be insufficient if not accompanied by a commitment to take concerted steps to produce the research necessary for the implementation of a behaviour-based protocol. Without this additional step, moving from a 5-year deferral to a 1-year deferral equates to little more than moving from one discriminatory system to another, equally discriminatory system.

The Canadian Centre for Gender & Sexual Diversity wrote:

Our organization recognizes the challenges to this change, however following recent events with stakeholders there has been broad consensus that the existing policy needs to be abolished, and that we need to follow research as opposed to reactionary decisions. This suggestion comes from both people who want to donate and people who need blood. As Canada’s LGBTQ organization, we see the bullying and discrimination that manifests as a result of this policy, and ask that you consider this part in mind, as you make your decision.

The Community Based Research Centre for Gay Men’s Health wrote:

CBRC sees such a change as another incremental step toward a gender-neutral policy supported by behavioural screening, once research on the protocol is in place. CBRC conducts gay men’s health research across Canada. We know that a majority of gay and bisexual men have found the current five year deferral policy unacceptably discriminatory even though it was considered a large step forward from the earlier lifetime deferral. The implementation of a one year deferral will undoubtedly be seen as a positive step.

However, we are also aware that many will feel that even one year falls short of real social justice. Youth are especially affected by this interpretation of blood policy. The future of the blood supply depends on their trust and support of the collection system. In this regard, CBRC believes the shift to a one year deferral would be seen as an important incremental step toward a gender-neutral donor protocol, aligned with your government’s affirmation of evidence based policy.

And the Canadian AIDS Society wrote:

The Canadian AIDS Society worked closely with Canadian Blood Services to realize the 2013 change to the blood donation deferral policy affecting men who have sex with men (MSM) from indefinitely to a period of five years (since last sexual encounter). At the time, we saw this change as a positive incremental step toward a deferral policy that would ultimately focus on genderneutral, behaviour-based risk factor criteria rather than on sexual orientation.

This is what the Canadian Blood Services considers “support” from LGBTQ lobbyists: Four lukewarm letters which state the policy is “less bad, I guess,” but that the appropriate move is to assess the actual risk factors and eliminate blanket year-long abstinence bans for Queer donors, imposing instead abstinence bans (some permanent, some short-term) based on a given individual’s behavioural choices.

Imagine that.

To CBS’ credit, their policy includes this:

Canadian Blood Services is exploring the possibility of moving toward behaviour-based screening.

Our aim is to identify a long-term solution that prioritizes patient safety while minimizing the societal impact on certain groups of people. We established a working group, which includes representation from patient advocacy groups, as well as LGBTQ community organizations, to serve as a forum for ongoing discussion and consultation as we develop further changes in policy. We have also committed to research funding, as described below.

Although, once again, CBS has demonstrated an extremely flawed methodology already in their attempt to collect epidemiological statistics.

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So what happens next?

Next, I contact the LGBTQ lobbyists that have shared the above lukewarm “support” letters. I am going to ask them to ensure any attempt at epidemiological research conducted over the next two years actually distinguishes between cis donors and trans donors, in addition to assessing behavioural risk factors. Trans people are in dire need of accurate data and this is a wonderful opportunity to discover health trends in Canadian trans women–an important distinction, given how every article is about socioeconomics and its impact on health. Assuredly trends in South America are not going to translate perfectly into a country that is Socialist, stable, wealthy, and in the process of explicitly coding trans rights.

In addition, I shall continue using public channels to issue informal requests for the sources that have informed Canadian Blood Services’ new policy. Invoking the ATI would only be necessary if I find myself being given the runaround–which is certainly a plausible outcome, but I’ll at least give the CBS a few chances to put me in touch with… well, someone besides an email clerk, before bringing in the Information Commissionaire.

-Shiv