Sex Reassignment Surgery
Ontario is expanding access to referrals for medically necessary sex reassignment surgery (also known as gender confirming surgery). As of March 1, 2016, the Ontario Health Insurance Plan (OHIP) has changed the funding criteria for sex reassignment surgery by allowing qualified providers throughout the province to assess patients for the surgery.
The amended OHIP criteria for sex reassignment surgery align with the internationally-accepted standards of care for gender dysphoria, which are established by the World Professional Association for Transgender Health (WPATH). Gender dysphoria is the medical term that WPATH describes as referring to discomfort or distress that is caused by a difference between a person’s gender identity and their sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).
Prior approval for OHIP-funded surgery
Sex reassignment surgery is only insured when prior approval has been obtained from the Ministry of Health and Long-Term Care.
A physician or nurse practitioner needs to submit a prior approval form on behalf of their patient, which includes supporting assessments recommending surgery from specified qualified health care providers confirming that the OHIP funding criteria have been met.
Recommendations for the surgery
For chest surgery, a patient will need one supporting assessment recommending surgery from a qualified physician or nurse practitioner who has the appropriate training.
For genital surgery, a patient will need two supporting assessments recommending surgery from qualified physicians, nurse practitioners, registered nurses, psychologists or registered social workers who have the appropriate training with the following restrictions:
- At least one of these assessments must be from a physician or nurse practitioner.
- A registered social worker refers to a social worker that has a master’s degree in social work and holds a current certificate of registration from the Ontario College of Social Workers and Social Service Workers.
Health care providers recommending surgery must have training in the assessment, diagnosis and treatment of gender dysphoria in accordance with the WPATH Standards of Care that are in place at the time of the recommendation.
The specific requirements for OHIP-insured sex reassignment surgery are listed in Appendix D of the Schedule of Benefits for Physician Services.
Location of the surgery
This prior approval form will also need to include details about the proposed hospital or health facility where the surgery will take place. Currently, there is only one site in Canada that performs genital sex reassignment surgery.
If a patient is requesting that their surgery take place in Ontario or in another province, the prior approval form may be completed by the attending Ontario physician or nurse practitioner. If a patient is requesting that their surgery take place out-of-country, part of this form must be completed by an Ontario physician only.
Confirmation of approval
Patients will be notified about the outcome of their application by the health care provider who submitted the prior approval form. Applicants must receive written confirmation of funding approval before any surgical procedures or services take place.
If a patient receives any surgical procedures without prior approval, these services are not insured under OHIP and will not be reimbursed. Even if the patient later provides supporting documentation that shows they met the requirements for sex reassignment funding, the patient will not be reimbursed.
OHIP insured surgical procedures
The OHIP-insured surgical procedures related to sex reassignment are listed in the Schedule of Benefits for Physician Services.
Procedures that OHIP covers include:
- Reproductive and external genital surgery, including clitoral release, glansplasty, metoidioplasty, penectomy, penile implant, phalloplasty, scrotoplasty, testicular implants, urethroplasty, vaginectomy, vaginoplasty, salpingo-oophorectomy, hysterectomy, orchidectomy
- Augmentation mammoplasty for the purpose of sex reassignment surgery is also insured for individuals with no breast enlargement following 12 continuous months of hormone therapy
When prior approval from the ministry has been received, OHIP-insured mastectomy procedures include the removal of breast tissue and reconstruction, including removal of excess skin, reduction and proper positioning of the nipple and areola, and minimization of chest wall scars.
Sex reassignment surgical procedures that are not listed in the Schedule of Benefits for Physician Services are not covered by OHIP.
Additional surgery that is required because of complications causing significant physical symptoms or functional impairment is insured when prior authorization has been obtained from the ministry.
The prior authorization request must be made by the surgeon proposing the surgery.
There is no minimum age requirement for sex reassignment surgery that must be met for OHIP to approve funding. The responsibility for determining whether a patient is capable of consenting to treatment is that of the treating provider.
Primary care providers can seek assistance about health care for transgendered people from Rainbow Health Ontario, the Sherbourne Health Centre, the Centre for Addictions and Mental Health, and other community health centres.
There are only two surgeons in all of Canada that specialize in complicated sex reassignment surgery, according to experts. And they both work at the same clinic in Montreal.
Glowing news articles on celebrities such as Caitlyn Jenner in recent months are certainly inspiring, but the reality for Canadians who identify as transgender is not quite as heart-warming.
To be clear, not all people who identify as transgender want to undergo sex assignment surgery, but for those who do it’s a long, hard and often expensive process.
Waiting a ‘really long time’
“People have to wait a really long time,” said Jan Buterman, president of the Trans Equality Society of Alberta (TESA), in a phone interview with Yahoo Canada.
Indeed, because there are so few doctors and surgeons specializing in the field there are really long wait times in Alberta, as well as in the other provinces and territories.
Funding for the surgery was halted in Alberta in 2009, but reinstated in 2012 after a public outcry. These days there are currently only two doctors in Alberta, both located in Edmonton, who can do an evaluation and decide if someone is eligible for surgery, said Buterman. The wait list to see those doctors is about 18 months, said the TESA head. But there are many barriers to even getting to that point. To see a specialist a person must be referred to them by a family doctor first. Getting a family doctor with the current shortage can be a challenge, Buterman noted. Then there are the out-of-pocket costs of travel and taking time off work if a person is coming from outside the Edmonton area.
Once Albertans clear that first hurdle and get the OK for surgery there are many more hurdles to come. Surgeries are not done in the province, with people usually sent to the Centre Métropolitain de Chirurgie Plastique in Montreal. Both surgeons at the Quebec clinic are currently on vacation and unavailable for interviews. The wait list to get surgery at the private clinic, which attracts patients from around the globe, is about two years, said Buterman. Again, while the actual surgery is usually covered under most provincial health-care plans related costs, such as travelling are not generally covered.
“Other things are not covered,” said Buterman. “Things like taking care of facial hair, such as adding facial hair -- which can be a very expensive procedure.”
Some Canadians get so fed up with the long process that they opt to pay for everything themselves and get surgery overseas, in places like Thailand, noted Buterman. While the prices vary, a 2010 CNN report pegged costs at between $9,000 to $20,000 (USD) for male-to-female surgery and about $12,000 to $20,000 for female-to-male surgery.
For those opting to get surgery at home there are similar barriers and hoops people must jump through across Canada. In Ontario, for example, those seeking hormones and/or surgery must meet several criteria, including having received a diagnosis of Gender Dysphoria and being over the age of 18.
For kids and youth
The process for youth who identify as transgender is even more convoluted, and as with all health-care differs province-by-province.
In British Columbia, children and youth who are presenting with gender questioning usually travel to Vancouver for treatment after a referral from their family doctor, said Dr. Daniel Metzger in a phone interview.
Dr. Metzger, who is a BC Children's Hospital endocrinologist and is on the provincial Transgender/Trans* Health Steering Committee, says about 40-50 children and youth get treatment every year in the province, with kids as young as four and five seeking care. Again, for those coming outside of the Vancouver area there are out-of-pocket costs, such as having a parent take time off work to accompany their child. Dr. Metzger says there are several groups that will help families with those costs, if needed.
Every child will take their own path, but generally, a specialist will offer the option of taking hormone blockers to delay puberty in a bid to “give them some breathing room” to decide what they want to do later in life, explains the pediatric endocrinologist.
Generally, youth must wait until they are 18 to undergo sex reassignment surgery and then would go through the same process as other adults in Canada. Like Alberta, B.C. currently does not have any surgeons who do sex reassignment surgery. But, Dr. Metzger says the province is working on that and he is hopeful there will be one surgeon doing sex reassignment surgeries in B.C. within a few years.
While many people, under and over 18, who identify as transgender still face serious obstacles and discrimination there is hope among experts and advocates that access to health care and acceptance of the trans community will continue to flourish in Canada and elsewhere.