is gender reassignment covered by ohip

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OHIP Covered FTM Criteria

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Completing the FTM transition can involve many different steps. You can make alterations through hormone therapy, changing the tone of your voice, or building muscle.

But the ultimate change comes when you undergo FTM surgical procedures. Unfortunately, surgery can be costly. Out of all the changes you can make, having a FTM procedure can be the most drastic and expensive. Thankfully, your gender confirmation surgery may be covered by the Ontario Health Insurance Plan (OHIP). The following are the criteria you need to meet in order to have your FTM procedure covered by OHIP:

• Receive A Proper Diagnosis : The first step to having your FTM procedure covered is to be professionally diagnosed with gender dysphoria. This requires seeing a mental health specialist, such as a psychologist, psychiatrist, or a behavioral therapist. After speaking with you in-depth about the issues you’re facing, they’ll be able to make a proper diagnosis.
• Demonstrate That You’re Prepared For Treatment: In addition to receiving an official diagnosis, you must demonstrate that you’ll be comfortable permanently living as a male. You can complete this step in a number of ways including:
• Living in your community as a male
• Altering your appearance to match your target gender
• Talking to family members about your desire to have the FTM procedure
• Spending time in counselling to confirm that gender reassignment is right for you
• Receiving testosterone treatments
• Choosing to be addressed by a male name
• Acceptance Of The Risks
• Get Approval From The Ministry Of Health And Long-Term Care

Once you complete these four steps, you’ll be on your way to an OHIP-covered FTM procedure.

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Transition Related Surgery

As you all know, these are unprecedented times. Currently our Transition-Related Surgery (TRS) Program at Women’s College Hospital is focusing our efforts on catching up on the backlog of cancelled surgeries and consultations after our program was on hold for several months. We recognize that this is an incredibly difficult time and that there will be significant negative impacts on our trans, non-binary and gender diverse communities as a result of this situation.

We believe that TRS is an essential and life-saving service. We are also part of the health care system that must respond to our current situation by doing what we can to keep you, your family, and your loved ones safe. We will be in touch with you when we are able to schedule an appointment. We appreciate your patience with delayed response times.

If you have questions about the referral process, please first review the “For Providers” tab below for detailed explanation of the elements required in a surgical referral.

If you are inquiring about the status of your referral, please first reach out to your referring physician. Upon receipt of any referral, we always send a response to your referring physician indicating that the referral has either been: accepted, declined or incomplete (requires further information). If your referring provider has not received such a response letter, please have them re-send the referral.

Transgender healthcare access issues are prominent in Canada and worldwide, with significant health gaps in access to skilled primary, emergency and specialty care services, which may include, for some individuals, access to medically necessary surgical services.

In response to a significant wait list for surgical referrals and lack of access to surgical services in publicly funded hospitals, Women’s College Hospital (WCH) has partnered with Sherbourne Health Centre including Rainbow Health Ontario (RHO), and the Centre for Addiction and Mental Health (CAMH), along with a group of committed individuals from the community, to form the Trans Health Expansion Partnership (THEx).

THEx supports the expansion of health services for trans individuals and communities across Ontario. Under the umbrella of THEx, the Transition Related Surgery Sub-committee led by WCH, is charged with the goal of creating an accessible, and quality surgical program.

WCH is dedicated to supporting the health and wellness of our transgender and gender diverse clients. The surgical team of the Transition-Related Surgery (TRS) Program includes specialists in plastic surgery, urology, gynecology and anesthesiology as well as nurse practitioners, nurses and other health care providers. This program represents the first public hospital-based surgical program in Canada focused on providing safe and timely access to transition-related surgical care.

At WCH, we are dedicated to offering the safest proven surgical options for TRS. Working in partnership with our patients, we bring expertise, experience and a commitment to the highest quality of care and patient experience.

If you have questions about the TRS Program, the team can be reached at 416-323-6148 or [email protected] .

Surgeries Available

Through training and recruitment of clinical staff with specialized expertise, we are building a comprehensive trans surgical program. At this time, the following surgeries are available at Women’s College Hospital.

• Mastectomy with Chest contouring*
• Breast Augmentation**
• Hysterectomy
• Bilateral salpingo-oopherectomy
• Orchiectomy
• Scrotectomy
• Vaginoplasty
• Vulvaplasty

*currently not covered by OHIP, there is a $1500 +HST cost for this procedure

**currently covered by OHIP following 12 months continuous hormone therapy with no breast growth defined as Tanner Stage 1

Yonah Krakowsky, MD FRCS(C), TRS Medical Director Emery Potter, NP-PHC, BSCN, MN, TRS Program Nurse Practitioner Nahir Anashara, Nurse Practitioner Olivia Drodge, TRS Physiotherapist

Plastic Surgery

John semple md, msc, frcs(c), facs .

Dr. John Semple is Head, Division of Plastic Surgery at Women’s College Hospital and Professor in the Department of Surgery, Faculty of Medicine at the University of Toronto.  Areas of specialty and interest include Breast Surgery, Breast reconstruction, Tissue engineering, Lymphedema, Mobile health technology and high-altitude meteorology and global waning in the Himalaya.

Mitchell Brown MD, MEd, FRCS(C) 

Dr. Mitchell Brown is a Professor of Surgery in the Department of Surgery at the University of Toronto.  Founder and co-course director of the Toronto Annual Breast Surgery Symposium and Breast Reconstruction Awareness (BRA)Day.  Dr. Brown specializes in aesthetic and reconstructive breast surgery, body contouring and facial aesthetic surgery.

Dr. Kathleen Armstrong

Dr. Kathleen Armstrong is an award winning teacher and expert in gender affirming top surgeries. She completed fellowship training with Dr. Hugh McLean at the McLean Clinic and performs over 250 top surgeries per year. She has extensive experience as an educator having participated in medical student and resident education for the last 10 years in various roles. In her role within the Division of Plastic, Reconstructive & Aesthetic Surgery at the University of Toronto, she trains medical students, residents and fellows in top surgery providing core lectures, office based and technical experience. She has a MSc in Health Services Research specializing in Health Economics. Her presentations have garnered various awards and she has published in multiple prestigious journals including CMAJ, JAMA and JAMA Surgery. As an Early Career Researcher at Women’s College Research Institute, she aligns her surgical and research interests to focus on gender affirming surgeries.

Urologic surgery

Ethan grober md, med, frcs(c) .

Dr. Ethan Grober is the Division Head Urology and Assistant Professor at the University of Toronto, Department of Surgery.  Dr. Grober’s clinical activities focus on vasectomy reversal microsurgery, male reproductive and sexual medicine and testosterone deficiency.  His research interests include the assessment of technical competence and operative judgement, the integration and evaluation of new technologies in surgery and the validation of surgical simulation and laboratory-based surgical skills training.

Yonah Krakowsky, MD FRCS(C)

Dr. Yonah Krakowsky is the Division Head of Trans Surgery and a Surgeon-Educator at the University of Toronto.  His clinical and research interests are in peyronies disease, erectile dysfunction, female sexual medicine and increasing access for Trans Surgery in Canada.

Lisa Allen, MD, FRCS(C)

Women’s College Hospital 76 Grenville Street Floor 5 Toronto, ON M5S 1B2

Phone : 416-323-6148 Email : [email protected]

OHIP funded Transition Related Surgery (TRS) is applied for by qualified health care professionals. This includes providers who are trained in the assessment, diagnosis, and treatment of gender dysphoria in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care. This may include a Physician or Nurse Practitioner (NP) as well as a Registered Nurse, Psychologist or Registered Social Worker with a Master’s degree. If you are one of the aforementioned professionals interested in becoming a qualified provider, please see our Community Resource page for more information. 

Making a Referral

To make a referral please submit.

• Transition Related Surgery Referral Form
• Prior Approval Funding Confirmation Letter -   Prior Approval for Funding of Sex-Reassignment Surgery Form (.pdf). (unless previously discussed with TRS Program NP)
• Comprehensive   referral template (.docx)  or brief referral with TRS planning visit notes

Before making your referral ensure

The patient meets OHIP eligibility for surgery (unless contraindicated)

You have provided the patient with comprehensive TRS planning visit(s)

Once you receive the OHIP approval form, have completed the referral and have attached a completed cover page, please fax the referral to: 416 323-6310. If you have any questions about the referral or referral process please call: 416 323-6400 x 4339 or x5333.

Once the referral is received, it will be assessed by someone from the TRS team. If incomplete, it will be returned by fax requesting the missing information.

If the referral is complete, it will then be sent to the appropriate surgeon’s secretary and they will be in contact once they have an appointment available.

For OHIP Funding

The TRS Frequently Asked Questions (.pdf) is a guide to the assessment and referral process for Ministry of Health and Long-Term Care Approval for OHIP funding. The resource is intended for persons considering transition-related surgery in Ontario, and the people supporting them.

The Ministry of Health and Long-Term Care’s  website  outlines the Ontario Health Insurance Plan (OHIP) funding criteria for transition- related surgeries. There is a specific form, the  Request for Prior Approval for Funding of Sex-Reassignment Surgery Form (.pdf) , you must complete in the current referral system to gain access to OHIP coverage. This form can be found  here.

The form is completed and faxed to the MOHLTC at (613)536-3188 once

• The patient is confirmed to meet the criteria for surgery
• TRS planning visits  have been completed and the patient wishes to move forward with surgery
• A surgeon has been chosen (see Our Team)

Once the form is faxed to the MOHLTC, they will fax back a letter with the decision (typically within 1-4 weeks). This Prior Approval Funding Confirmation Letter will be sent to the patient and the referring provider. The form will not be sent to the surgical team as of November 1st, 2019.

Criteria for Surgery

Criteria for surgery must be met prior to referral to a surgeon/program. The criteria for surgery are outlined in the box below. Please ensure your client has met these criteria, unless contraindicated, and please make comments on your referral letter. Criteria for all surgeries, including what is listed in the table, must include  persistent and well documented gender dysphoria, capacity to make a fully informed decision and consent to treatment. 

Surgery Planned Visits

For upper body surgeries including mastectomy with chest contouring and augmentation mammoplasty, only one provider (physician or nurse practitioner) is required to complete surgery planning visit(s) and complete the  Request for Prior Approval for Funding of Sex-Reassignment Surgery Form (.pdf).

For lower body surgeries, including but not limited to orchiectomy, hysterectomy, phalloplasty, metoidioplasty and vaginoplasty, two providers are required to complete separate surgery planning visits and complete the Request for Prior Approval for Funding of Sex-Reassignment Surgery Form (.pdf). One of the providers must be a physician or Nurse Practitioner and the other may be any of the listed qualified providers.

TRS planning visits are to be completed as you wish, however, to assist you we have created a list of key topics to discuss and include during these appointments. Documentation should confirm that these topics have been reviewed.

Gender History

Discuss the patients current gender identity and process of transition.

Confirm persistent Gender Dysphoria, the patients experience with transition so far, medical and social steps taken or considered Include Eligibility as per the Ministry of Health and Long Term Care and the World Professional Association of Transgender Health (i.e. duration of hormones, gender role experience)

Goals for surgery

Why does the patient want surgery? How will surgery help the patient achieve their gender goals/reduce dysphoria? Are their expectations for surgery realistic? Aware of alternative non-surgical and surgical options If relevant, discussion around fertility and options for preservation reviewed

Detailed surgery discussion/capacity for informed consent

Description of desired surgery, realistic outcomes, risks, side effects (irreversibility), alternate options. (A more detailed and focused discussion about surgical details will take place between the surgeon and client)

Readiness (medical and psychosocial)

How well controlled are medical and mental health conditions Smoking, alcohol, substance use Supports in place (including financial), and aftercare planning

Criteria for Transition Related Surgery

Criteria for surgery must be met prior to referral to a surgeon/program. The criteria for surgery are outlined in the box below. Please ensure your client has met these criteria, unless contraindicated, and please make comments on your referral letter. Criteria for all surgeries, including what is listed in the table, must include  persistent and well documented gender dysphoria, capacity to make a fully informed decision and consent to treatment. 

Provider Resources

If you would like more information on how to become a provider qualified to make referrals for Trans Related Surgery please see the  RHO website  for trainings and information

For information on the referral process for surgery in Ontario see  Rainbow Health Ontario’s Frequently Asked Questions.

For information about specific transition related surgeries, please see these surgical info summary sheets.

RHO provides a weekly mentorship call from Wednesday from 12-1. Providers are encouraged to call in to ask any trans related health care questions. Register at the bottom of the page on their website.

If you are looking for a primary or secondary provider to support trans pre-surgical planning visits you can make a referral to CAMH .

Visit the  RHO Newsroom  to be kept up-to-date as our program and website expands to include helpful resources and ensure access to care.

Referral Process for Patients

If you wish to access Ontario Health Insurance Plan (OHIP) funded TRS, please make an appointment with your physician or nurse practitioner. TRS planning visits can occur in a primary care setting, with a specialist or at the CAMH Gender Identity Clinic (or in combination depending on your needs and local resources). TRS planning visits will take place with your health care team. You may be asked to see one or two providers depending on the surgery you are requesting. In addition to a physician or nurse practitioner, this might include a social worker, a registered nurse or a psychologist

Your health care provider will arrange or provide the necessary surgery planning visits prior to referral for surgery. In these appointments the provider will ensure that you have met all the OHIP funded surgery criteria in addition to having an in depth conversation with you about your goals, different surgical and non-surgical options, risks and benefits of surgery and other relevant medical and mental health issues.

Once you have completed your TRS planning visit(s), your health care providers will complete a special medical form seeking OHIP funding for transition- related surgeries. Once this is approved, a referral will be made to your chosen surgeon. If the referral is complete and accepted, you will receive a call to set up an initial appointment with the surgeon. The TRS Frequently Asked Questions (.pdf) is a guide to the assessment and referral process for Ministry of Health and Long-Term Care Approval for OHIP funding. The resource is intended for persons considering transition-related surgery in Ontario, and the people supporting them.

The first appointment is a surgical consultation. At this visit you will meet with your surgeon and possibly the Nurse Practitioner or Social Worker. During this visit, we will take a comprehensive history, there will be a detailed discussion about surgery, a physical exam will take place, photos may or may not be taken and consent to communicate with your primary care team will be sought. A pre-op medical questionnaire will be completed.

After this consult visit, if surgery is the next step, the surgeons secretary will follow up with you in order to book surgery. Once surgery is booked, you will get another appointment for pre-admission clinic. This visit typically occurs in the week or two before surgery.

At the pre-admission visit you will be given more details about your surgery, pre-operative instructions, review an after-care plan and you may be given information to take home. You may also meet with anesthesia and possibly pharmacy or internal medicine at this visit.

You are expected to have someone to pick you up from surgery and stay with you for 24 hours afterwards. If you do not have such a person, we will discuss options available to you including the ARC program at SHC.

Post Surgical Resources – Vaginoplasty

• Consent for vaginoplasty
• VaginoplastyGuidebook
• Vaginoplasty Surgery Timeline
• Post-Operative Vaginoplasty Guide to the First Year
• Digital Care Coach
• The role of pelvic floor physiotherapy
• Pre-surgery exercises
• Dilation instructions
• Dilation assistance
• Getting the pelvic floor ready for dilation
• Hypergranulation tissue
• ILU Abdominal massage
• Kegels and Stretches
• Medication Schedule
• Support from a Social Worker
• Common Vaginoplasty Complications
• Understanding what Recovery may look like
• Accessing Vaginoplasty Surgery in Ontario

Post-Surgical Resources – Chest Surgery

• Chest Surgery timeline
• Track Your Drains
• Chest Masculinization Guidebook
• Accessing Chest Surgery in Ontario

Advertisement

Ontario to expand medical referrals for sex reassignment surgery

Ontario Health Minister Eric Hoskins is proposing a change that would allow all qualified health-care providers in the province to refer transgender patients for the surgery. (Frank Gunn / THE CANADIAN PRESS)

TORONTO -- Ontario wants to make it easier for transgender people to get a medical referral for sex reassignment surgery, but they will still have to leave the province for the procedures.

Currently, only the Gender Identity Clinic at the Centre for Addiction and Mental Health in Toronto can refer a patient for sex reassignment surgery, which is covered by the Ontario Health Insurance Plan.

Health Minister Eric Hoskins announced proposed changes Friday that would allow qualified health-care providers anywhere in Ontario to refer transgender patients for surgery. Exactly who should be trained will be worked out after the government's 45-day period for public comment on the new regulation.

"Ontario is taking action to reduce wait times and improve access for sex reassignment surgery," Hoskins announced at Toronto's Rainbow Health Clinic. "We will be moving from what currently is a single site to potentially what could be hundreds and hundreds of sites."

Hoskins said every Ontarian has the right to be who they are, and the health-care system should reflect that vision.

"I recognize that this is only a first step in our government's work to strengthen health supports for the trans community," he said.

There's been a big increase in the number of people in Ontario seeking gender identity services, and the waiting list for sex reassignment surgery referrals at CAMH has grown to more than 1,150 people.

Even after people get a referral for sexual reassignment surgery, they often face a years-long wait and must travel to Montreal or the United States to get the procedures performed.

"I can only imagine the additional anxiety of knowing the path one has to travel to seek out and receive support, and be affirmed, must dramatically increase that anxiety," Hoskins said as he pledged to build Ontario's capacity to offer the surgery.

Ontario has spent about $9 million to pay for out of province sex reassignment surgery for trans patients since the Liberals reinstated OHIP coverage in 2008, which grew from five patients in the first year to 136 in 2014-15.

One of the most vulnerable times for transgender people is when they are ready for surgery, but face a prolonged wait, said Anna Travers of Rainbow Health.

"This change would reduce wait times by allowing many trans clients to get surgical approvals from their own local primary care teams," she said.

Martine Stonehouse, who was in the middle of her sex reassignment surgeries when the Progressive Conservative government of Mike Harris de-listed OHIP coverage, called Friday's announcement "great," but a long time coming.

"Having only one assessor site isn't practical, and has caused a bottleneck since we got the surgery re-listed in 2008," Stonehouse said. "There's so many people out there who need services but can't get access."

Nicole Nussbaum, a lawyer who works with the transgender community, said forcing every trans person in Ontario who wants surgery to go through CAMH has created a logjam and unmanageable workload that will be eased by other doctors.

"While there is certainly a great deal of expertise at CAMH, many health and mental health professionals in this province are already providing high quality transgender or transition-related care," she said.

New Democrat Cheri DiNovo called Hoskins' announcement "a wonderful first step," and a direct result of a resolution unanimously passed in the Ontario legislature in June affirming the rights of lesbian, gay, bisexual, transgender and queer people.

"Now that trans folk actually have human rights they are exercising them," said DiNovo. "The fear is once we have broader access points (to sex reassignement surgery referrals) then what happens? We don't have the surgeons in Ontario to perform the procedures."

Hoskins promised more funding for CAMH and the Rainbow Clinic to help them cope with increased demands while the province gets other health care professionals trained and ready to do the referrals.

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Trans Pulse

Building Our Communities through Research

Estimating Unmet Need for OHIP-funded Sex Reassignment Surgeries

A report prepared for the ministry of health and long-term care of ontario.

The objective of this report is to provide information from Trans PULSE Project data to inform health systems planning with regard to sex reassignment surgeries covered under the Ontario Health Insurance Program (OHIP). Hormonal care and non-listed medical procedures are thus not included, though they represent important additional components of transition-related care.

Reference: Bauer G, for the Trans PULSE Project. Estimating Unmet Need for OHIP-funded Sex Reassignment Surgeries: A Report Prepared for the Ministry of Health and Long-term Care of Ontario. 16 August, 2010.

Transition-Related Surgery

Transition-related surgery (TRS) refers to a range of surgical options that can help people feel that their physical characteristics more closely reflect their gender identity or expression. These options can support one in feeling more comfortable in their body and may help to improve your mental wellness.

In order to receive provincially-funded transition-related surgeries, you will need a surgery assessment from one or two health providers, depending on the surgery, one of which being a qualified primary care provider like a Physician or Nurse Practitioner. 

If you have a primary care provider and would like to start a discussion with them about transition-related surgery, you can click here for tips on how to start that conversation. 

If you do not have a primary care provider and would like to access transition-related surgery, you can reach out to Centretown Community Health Centre’s Trans Health Program to get connected with surgery referral support.

Provincially Funded Transition-Related Surgeries

Disclaimer: this section uses medical terminology.

Upper Surgery (Chest or Breast Augmentation) needs one assessment by a qualified Physician or Nurse Practitioner. Lower Surgery (Genital Surgery) needs an additional assessment from any qualified Physician, Nurse Practitioner, Psychologist, or Registered Social Worker (Master’s Degree).

Under the Ministry of Health and Long-Term Care (MOHLTC), the following surgical procedures are provincially-funded:

For “Assigned Male at Birth” individuals:

• Vaginoplasty 
• Orchiectomy
• Augmentation Mammoplasty a (breast enlargement)*

*Patient must have completed twelve continuous months of hormone therapy with no breast enlargement unless hormones are contraindicated

For “Assigned Female at Birth” individuals:

• Hysterectomy
• Clitoral release with vaginectomy
• Metoidioplasty
• Phalloplasty
• Testicular implants with scrotoplasty
• Penile implant

Eligibility

Prior to beginning the referral process for transition-related surgeries, the following eligibility criteria must be met: 

• Has a diagnosis of persistent gender dysphoria 
• For breast augmentation surgery: Has completed 12 continuous months of hormone therapy with no breast enlargement (unless hormones are not appropriate for the person)
• For External Genital Surgery Only: Has completed 12 continuous months living as gender(s)

Not Covered

As of right now, OHIP does not cover the following procedures identified as medically necessary by the World Professional Association for Transgender Health:

• Liposuction
• Electrolysis
• Chest contouring/masculinization
• LASER hair removal
• Hair transplants
• Tracheal shave
• Voice modification surgery
• Chin, nose, cheek or buttock implants
• Facial feminization/masculinization

*OHIP does not cover travel costs involved in obtaining surgery. If you are in financial need and must travel to obtain an OHIP approved procedure, Hope Air can provide free air travel and accommodation. You can learn more about this option here.

For an overview of transition-related surgeries, risks, benefits and additional information, review Rainbow Health Ontario’s TRS Summary Sheets here .

The Referral Process

Step 1: Connect with Qualified Providers. 

The MOHLTC requires 2 qualified providers submit a “Request for Prior Approval for Funding of Sex Reassignment Surgery” form (can be found on the “Clinical Resources” section of our resource library ).

Who is a qualified provider? 

The MOHLTC criteria for a qualified provider includes Physicians, Nurse Practitioners, Registered Nurses, Psychologists and Registered Social Workers. Eligible providers are expected to self-assess if providing transition-related surgical referrals is within the scope of their practice. There is no single training course that “qualifies” a provider, but providers are encouraged to undertake professional development and training activities to build their capacity on trans health services.

If your primary care provider is not able to submit a Prior Approval form on your behalf, Centretown Community Health Centre can help.

Step 2: Participate in a Transition-Related Surgery (TRS) Planning Visit

A TRS planning visit is a collaborative visit between a patient and a qualified provider to discuss TRS and how to optimize the patient’s experience and outcome. Topics discussed include reviewing World Professional Association for Transgender Health (WPATH) and MOHLTC criteria, confirming the diagnosis of gender dysphoria, reviewing the stability of medical and mental health conditions, confirming surgery-specific informed consent and planning aftercare.

Step 3:  Complete the Prior Approval Form

Following your Transition-Related Surgery Planning Visit, your provider can complete, sign, and submit the “Request for Prior Approval for Funding of Sex-Reassignment Surgery” (also known as the “Prior Approval” form) to the MOHLTC.

The number of qualified providers who must complete independent TRS surgery planning visits and sign a Prior Approval form is based on the type of surgery requested. 

Upper body surgery requires a TRS planning visit(s) by one qualified provider (either a P hysician or Nurse Practitioner). 

Gonadal or external genital surgery requires independent TRS planning visits with two qualified providers, one of whom must be a Physician or Nurse Practitioner, while the second can be a Physician, Nurse Practitioner, Registered Nurse, Psychologist, or a Registered Social Worker with a Masters of Social Work. 

Once the application is submitted, the MOHLTC will then send a response letter with the outcome of the funding application. 

If approval is not received, your qualified provider can contact the MOHLTC to provide additional information, the application can be resubmitted, and/or an internal review of the initial application can be requested by your provider.

Step 4: TRS Referral Letter Sent to TRS Surgeon 

Once an approval letter is received from the MOHLTC, your provider can send a referral letter to the transition-related surgery surgeon. TRS referral letters are often more in-depth than typical referral notes and often include details about your TRS planning visits. Surgeons will often request additional documentation, including medication lists, lab results and other information.

Step 5: Complete TRS and After Care 

Once referred to a TRS surgeon, you will be contacted by the surgeon or clinic to sort out additional details, and will receive more information as your surgery date nears.

In partnership with:

Ontarian takes OHIP to court for gender-affirming surgery funding

An Ontario resident is fighting the government to secure public funding for a specialized gender-affirming surgery argued to be "experimental" by the provincial health insurer.

The prospective patient, identified only as K.S. in documents filed with the provincial Health Services Appeal and Review Board (HSARB), is seeking coverage under the Ontario Health Insurance Plan (OHIP) for a penile-preserving vaginoplasty, a procedure in which a vaginal cavity is surgically created while keeping the penis intact. 

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“There have been so many times that I have had to justify myself to just be,” K.S. told CTV News Toronto in a statement submitted through her counsel. “People who aren’t trans or nonbinary don’t have to get that permission to exist.”

K.S., whose identity is protected under a publication ban, identifies as nonbinary. She presents as predominantly female and uses she/her pronouns, but does not align with the gender binary.

The procedure she seeks is not widely practiced. In what most consider a traditional vaginoplasty, the erectile tissue is inverted to create a vaginal cavity. In a penile-preserving vaginoplasty, the vaginal cavity is created using a skin graft instead. There is currently no peer-reviewed research on the outcomes of the technique, only offered by a small number of private clinics, none of which are in Canada.

Since 2023, K.S. has been engaged in a series of appeals put forth to the review board following an initial denial by OHIP to cover the surgery.

Having experienced gender dysphoria since her teenage years, K.S. first applied for funding in 2022, seeking to have the surgery performed at the Crane Center for Transgender Surgery in Austin, TX. OHIP denied her request, claiming it wasn't included in the list of insured services under OHIP. 

Without coverage, K.S. said undergoing the procedure would be nearly impossible – it costs tens of thousands of dollars that she doesn’t have.

READ MORE : What gender-affirming care is and how it can be life-saving

The legal battle that has played out in front of the review board has seen K.S. repeatedly make her case for why such a specialized procedure is medically necessary, measuring years of suffering through gender dysphoria against the assumed risk of a procedure not yet in the mainstream.

“The absurdity of managing to get through all the unjustly imposed barriers only to still be told that my surgical request is not valid has been heartbreaking,” she said.

When reached for comment, the Ministry of Health, which oversees health insurance in Ontario, said it could not comment on cases that are before the review board.

The case unfolds a critical juncture for transgender care in Canada  — just weeks ago, Alberta unveiled sweeping policy changes including a ban for all gender-affirming surgeries for minors aged 17 and under  — and, according to experts, could stand to inform national conversations of access to healthcare faced by non-binary population across the country.

Legal lens on gender identity

With no options to secure the surgery outside of insurance, K.S. appealed the government’s initial denial of funding in April 2023 .

“I felt I had no choice," she said. “There quite literally is no ‘do or don’t’ when it comes to treating gender dysphoria.”

Throughout the two-day hearing, lawyers representing the province argued that for a vaginoplasty to be considered an insurable service, a patient also needed to undergo a penectomy, as is considered the standard of practice in Ontario.

It called upon Dr. Yonah Krakowski, a sexual medicine surgeon at Women’s College Hospital, to provide expert testimony. Krakowski said that, while he supports patient autonomy, he believed wider expert opinion would deem the procedure sought by K.S. as “experimental” at this time.

Self-represented, K.S. argued, in part, that the denial singled her out based on gender identity and that nowhere in the provincial legislation or regulations was it a requirement that someone transition from one binary gender to another in order to be eligible for funding.

During the hearing, K.S. put forth “impressive legal challenges,” lawyer John McIntyre told CTV News. McIntyre, now representing K.S. in OHIP’s recent appeal.

“The process was incredibly challenging for her, as she was not only up against lawyers and the government, but she was having to fight against the view that her identity was not valid,” McIntyre said.

The challenge proved worth it – five months later, the three-person review panel ruled in K.S.’ favour . Her procedure, now deemed an insured service, would be paid for.

The victory didn’t come easily, K.S. said. “More than once during the legal process, the impacts of statements and opinions expressed by OHIP and its lawyers drove me to tears, messed with my sleep, and caused significant anxiety, unintended weight loss, and chest pains,” she said.

But it wasn’t long before OHIP filed its own appeal. Now, despite the unanimous ruling last year in her favour, K.S. must make her case for the panel for a second time — the thought of which brings her “despair.”

“The very idea that one should have to endure the significant legal process after already having to fight every single aspect of the medical system to just meet the criteria is unfair,” she said.

McIntyre called his client one of the “bravest people” he’s ever met.

“The only reason why she keeps pushing is the hope she can protect other trans and nonbinary folks from having to endure the same problems,” he said.

The case reflects wider issues: experts

This time, K.S. isn’t alone in her fight for funding. McIntyre and Egale, a non-profit organization advancing equality and justice for LGBTQ2S+ Canadians, are helping her navigate OHIP’s appeal.

In early January, Egale signed on as an intervenor in the case .

"The concern I have is this a tendency to treat these requests [...] as experimental," counsel for Egale, Daniel Girlando, told CTV News Toronto.

Girlando said the organization decided to step in, in part, because it feels that the ability to express one’s self in a way that doesn’t “necessarily reflect a binary gender” is important. “That means that some [OHIP applicants] will have customized requests,” he said.

The lawyer pointed to the World Professional Association of Transgender Health (WPATH), a leading authority on gender-affirming medical and surgical care, for guidance in this case. The WPATH’s Standard of Care guidelines note that “gender diverse presentations may lead to individually customized surgical requests some may consider ‘non-standard.’”

“In this evolving world, where standards are fast-changing and when we’re dealing with a small number of population, are we supposed to wait, what, years before there is enough data to deem these procedures experimental?” Girlando questioned.

Some experts say that’s exactly what Ontario should do.

Kinnon MacKinnon, an assistant professor at York University who studies the intersection of healthcare and gender, said in this case, the province will have difficulty establishing a risk-to-benefit ratio, as it has no data to draw from.

“In terms of medical ethics, clinical decision making, and funding, the risk-to-benefit ratio has to be favourable and with there being no studies, it would be hard to make the argument that the procedure is medically necessary,” he told CTV News in an interview last week.

“I think the priority right now should be to collect higher quality and long-term outcomes data to inform better care because I think we need a better sense of long-term outcome following certain surgeries,” he continued.

K.S. agrees more data collection is needed, but claims the province is failing to invest in the effort.

"They never get to collect the data because people like me are generally firewalled before we can get there," she said.

While K.S. said the harm done to her over the last two years has been “irreparable," she hopes to pave the way for others to express themselves freely. 

“Our fundamental existence is not optional," she said. "There’s a reason we see higher suicide rates for trans and non-binary people, and a positive ruling will save lives."

OHIP’s appeal will be heard virtually on Feb. 27.

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Why the long wait for sex reassignment surgery isn’t about to get better

Written by Erica Lenti

Mar 10, 2016

As of March 1, the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery.

If bodies were Airbnbs, Marcel’s would be a one-star stay. The bed sheets would feel too staticky, the light in the bathroom unflattering, the carpet a little too rough. Like renting an uncomfortable room from a stranger, such is how Marcel describes his dysphoria. But while shoddy rooms for rent can be left, Marcel can’t escape this. A transgender man in the throes of transition: he can’t feel at home in his body.

Marcel, whose name has been changed to protect his identity, started his transition four years ago. The first step was hormone replacement therapy, a ritual of two-millimetre needles of testosterone that he will give himself every day for the rest of his life. For the first few months of the therapy, Marcel rode his bike from downtown Toronto to suburban Mississauga to receive his shots from a transgender-friendly doctor.

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By 2012, Marcel was ready for top surgery – a bilateral mastectomy. At Toronto’s Centre for Addiction and Mental Health, the only institution in the province at which reassignment surgeries are covered by health insurance, a queue had formed. Faced with a minimum wait of two years, he scrounged up as much money as he could—a loan from his sister, funds raised by friends, paycheques from a nine-to-five job—and had the surgery at a private clinic. The procedure set him back $6,000. Today, Marcel awaits one last surgical procedure: lower reassignment surgery.

Marcel is among a large group of transgender Canadians seeking this procedure to reconstruct the genitals. Not all people who identify as transgender seek to transition medically or physically, but prospects remain grim for those who do. Several years have passed, but Marcel still doesn’t have the body he says he needs.

Even in a country as accepting and progressive as Canada, Marcel’s transition from female to male has been difficult. The situation has improved only slightly: As of March 1 , the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery. The Ontario government has also set aside $2 million to reduce the backlog from CAMH. But while the province’s efforts are intended to relieve the referral wait, such a move also threatens to create an even larger bottleneck at the only institution near Ontario that offers the surgeries.

Since 2008, when provincial funding for the procedures began, transgender Ontarians have had to work through a seemingly interminable process to fulfill their surgical requirements for transition. Top and lower surgery can cost upwards of $8,000 and $100,000 respectively (though the costs fluctuate depending on the surgeon). Typically, OHIP will cover these fees, provided that the person transitioning passes psychological and psychiatric assessments and is referred to a surgeon by a designated doctor or clinic.

Each province has its own policies and procedures, but a pattern has emerged: the number of institutions at which transgender people can be assessed in each province is paltry, so there’s almost always a queue. Alberta boasts two qualified doctors. In B.C., there’s one. Prior to the province’s announcement, in Ontario the wait list for assessments at CAMH had swelled to more than 1,500.

“Certainly the demand has increased over the past five to 10 years, as people have found a word to describe their circumstances,” says Dr. Amy Bourns, a physician who specializes in transgender care at Toronto’s Sherbourne Health Centre.

Under new legislation, health-care providers who want to make assessments and referrals for transgender patients must undergo training that complies with standards set by the World Professional Association for Transgender Health, an Illinois-based organization. Currently, there is no word on whether this training will be mandatory.

Meanwhile, as the Globe and Mail has reported, doctors are urging transgender Ontarians to stay on the CAMH waitlist until “things get sorted out .”

On a Sunday in 2014 Marcel gave up waiting. No point in trying to get cozy in his body, he told himself. At that point, his wait for an appointment at CAMH could have taken as long as five years. He was just 26; he would be into his 30s before getting a referral. With no easy fix in sight, he says he hid under the covers and sobbed, his brain flooded with negative images. In his bedroom that night, he attempted suicide. His last thought before unconsciousness: I can’t believe I’m going to be another statistic.

Hours later, Marcel’s best friend found him passed out in bed. “I did not expect to wake up,” Marcel says. “That was hellish in its own right.” Even worse, he feared the idea of going to the hospital and being misgendered by doctors. His loved ones were able to convince him to visit his family doctor, who assessed the situation.

“The [prolonged] wait is something I couldn’t mentally last,” Marcel tells me a year and a half after his suicide attempt. While the long wait for assessment can perpetuate mental health issues in transgender Ontarians, acknowledging these issues can create setbacks for them; psychologists will often deem suicidal patients unfit for referral.

Even if assessments become more widely available, yet another bottleneck will occur: a queue for the actual surgeries. Just one clinic in the country performs lower surgery, and it’s in Montreal, headed by Dr. Pierre Brassard and Dr. Maud Bélanger; as a result, many are already choosing to have the surgery elsewhere, in the U.S. or Europe. The current wait list at Brassard and Bélanger’s clinic is six months.  According to Bourns, the two surgeons could increase their output, but not enough to prevent an even longer queue from forming.

Bourns says some surgeons have shown an interest in learning the ins and outs of reassignment surgery, but many aren’t committed to perfecting the craft. “There have been inquiries from surgeons who want to come for a week to train with Dr. Brassard, but it would require something more like a six-month residency for them to learn to do the surgery,” she says. In recent years, medical schools have begun to incorporate training specific to LGBTQ patients, with organizations such as Rainbow Health Ontario spearheading the cause. But only those with a specific interest in performing reassignment surgery are likely to learn about and train to execute the procedure.

As a result, patients are searching for alternatives. Marcel considered heading to Thailand for the procedure, but his doctor advised against it. (Many Canadians go anyway, because of the low cost. Vaginoplasty, for instance, starts at just $12,000, in comparison to about $50,000 in Canada.) Instead, he ponied up as much cash as he could and found a private gender therapist with the qualifications to assess and refer him to an OHIP-approved surgeon in San Francisco; so long as a transgender Ontarian has letters of assessment (from a CAMH therapist or a much more costly private therapist), OHIP will cover the cost of surgery out-of-province. Patients who go this route have to pay for their own travel and accommodations. After a half-year wait, Marcel has a consultation with the San Francisco surgeon this month, but what comes after that is still unknown.

Bourns suggests travelling for reassignment surgery could raise other issues. For one, she says, Canadian doctors could be unwilling to work with patients who experience complications from surgeries abroad. “That means they'll have to hop back on a flight to correct something like issues with urination,” she says. Until more surgeons practise in Canada, small corrections to these major surgeries could be incredibly costly.

“I realize I’m privileged,” Marcel says. He has a career, a modest but homey apartment, a puppy. These are not common comforts: Many transgender Ontarians live below the poverty line and private therapists are not an option.

Marcel says he thinks about time often. It is the barrier that keeps him from his true self. It’s what stops him from using public washrooms. There is no fast-forward button.

“I’ve always yearned for transition to end,” he says. “I feel stagnant right now. I don’t know where I’m moving.”  But, the way Marcel puts it, he does know where he’d like to be at: the sensation of coming home, of leaving a strange abode. Here, the sheets are crisp and the light natural. Here, there is comfort.

Erica Lenti is a Toronto-based freelance journalist who covers mental health, LGTBQ and women’s issues.

Erica Lenti

Erica Lenti is a Toronto-based writer and the deputy editor, features at Chatelaine. 

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What OHIP covers

Find out what services you can get through OHIP .

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Services covered by ohip.

OHIP covers part or all of the following services:

• visits to doctors
• hospital visits and stays
• laboratory testing in community labs or hospitals 
• medical or surgical abortions
• eligible dental surgery in hospital
• eligible optometry (eye-health services)
• podiatry (foot-health services)
• ambulance services
• travel for health services if you live in Northern Ontario

Whether you visit your doctor, or if you see one in a walk-in clinic, OHIP covers the full cost of your services – as long as they’re medically necessary.

Learn about the services doctors provide .

Find a doctor .

Hospital visits and stays

If you need to go to the hospital, OHIP covers:

• doctor and nursing services
• services to diagnose what’s wrong (such as blood tests and x-rays)
• medications for in patients (once a patient is discharged, prescribed medications are not covered)
• some medications for out patients (certain limited medications are provided to out-patients for home use)
• if you want a private or semi-private room, you or your private insurance will have to pay some or all of those hospital fees

Laboratory testing

OHIP  covers lab tests taken in hospitals that are medically necessary.

Hospital patients should have their tests taken at the hospital to avoid any possible out-of-pocket charges.

OHIP also covers medically necessary lab tests taken in non-hospital settings, such as community labs. Read the full list of covered tests in the community setting .

Non-hospital patients should have their test done in a community lab if they have a lab order from a clinical provider such as a licensed physician, midwife or nurse practitioner.

Before you have your laboratory testing done, speak to your health care provider about:

• OHIP coverage to avoid unexpected costs
• where to get lab testing done if you are unsure

See below for community lab providers that offer laboratory services in Ontario:

• Find a specimen collection centre
• Find an Alpha Labs location

What is not covered by OHIP

OHIP does not cover some specialized, non-routine tests. For other tests, OHIP will only cover them if you meet certain eligibility criteria and a particular health care provider (physician, midwife, nurse practitioner) ordered the test. A few examples of tests that are not covered by OHIP except under specific circumstances include:

Prostate-specific antigen ( PSA ) is covered by OHIP if either of the following apply to you:

• you have been diagnosed with prostate cancer and are receiving treatment or following up after receiving treatment for the disease
• a healthcare provider (for example, physician) suspects prostate cancer because of your history and/or the results of your physical examination (including digital rectal examination)

For all other scenarios, you will need to pay for PSA .

Learn more about PSA testing and eligibility criteria.

Aspartate aminotransferase test ( AST ) is covered by OHIP if ordered by a physician who specializes in liver diseases.

For all other scenarios, you will need to pay for AST.

25-hydroxy vitamin D test is covered by OHIP if you have any of the following conditions:

• osteoporosis
• malabsorption syndromes
• renal disease
• drugs that affect vitamin D metabolism

For all other scenarios, you will need to pay for a vitamin D test.

Abortion services

OHIP covers the cost of:

• surgical abortions that take place in a hospital or clinic
• Mifegymiso (a pill that induces an abortion in early pregnancy), if you have a prescription from your doctor

Contact an abortion clinic near you for more information about ending a pregnancy.

Dental surgery in hospital

Some dental surgeries need to be performed in a hospital because they are complex and/or you have another medical condition that needs monitoring during the procedure.

OHIP covers in-hospital dental surgeries such as:

• fracture repair
• tumor removal
• reconstructive surgeries
• medically necessary tooth removal (prior approval by OHIP is required)

Optometry (eye-health services)

Children and youth 19 years old or younger are eligible for the following OHIP  covered services:

• 1 major eye exam   (for vision and general eye health) every 12 months
• any minor assessments needed

If you are  20 to 64 years old, and you have an eligible medical condition  affecting your eyes,  OHIP  will cover:

• 1 major eye exam for you once every 12 months
• 2 additional follow-up minor assessments

Eligible medical conditions are:

• diabetes mellitus
• glaucoma requiring or having had treatment with medication, laser (excluding prophylactic laser peripheral iridotomy), or surgery
• cataracts / posterior capsular opacification with a visual acuity of 20/40 or worse in the best corrected eye, or when a surgery referral is made
• retinal disease that is acute, or is chronically progressive
• corneal disease that is acute, or is chronically progressive
• uveitis that is acute or chronic during episodes of active inflammation
• optic pathway disease that is acute, or is chronically progressive
• acquired cranial nerve palsy resulting in strabismus during the acute phase or until the condition resolves or stabilizes
• ocular drug toxicity screening for patients taking hydroxychloroquine, chloroquine, ethambutol or tamoxifen

If you are 65 years and older and you do not have an eligible medical condition affecting your eyes, OHIP will cover:

• 1 major eye exam for you once every 18 months and 2 additional follow-up minor assessments.

You may be eligible for additional eye care if you are on the  Ontario Disability Support Program  ( ODSP ) or  Ontario Works .

Podiatry (foot-health services)

OHIP covers between  $7-16 of each visit to a registered podiatrist up to $135 per patient per year , plus $30 for x-rays . You will need to pay for the remainder of the cost of each visit.

Surgeries performed by podiatrists are not covered by OHIP .

Find a registered podiatrist .

Ambulance services

If you need an ambulance for a medical emergency, OHIP covers part or all the costs depending on the circumstances .

Travel for Northern Ontario residents

If you have to travel long distance for specialized medical care and live in one of the following areas, OHIP might help pay for your travel and accommodation through the Northern Health Travel Grant:

• Parry Sound
• Rainy River
• Thunder Bay
• Timiskaming

Find out if you qualify and how to apply to the Northern Health Travel Grant .

Services not covered by OHIP

OHIP does not cover:

• prescription drugs provided in non-hospital settings (such as antibiotics prescribed by your family doctor)
• dental services provided in a dentist’s office
• eyeglasses, contact lenses
• laser eye surgery
• cosmetic surgery

Protect your health card number

Only share your health card number with health care professionals who are entitled to have it , such as:

• nurse practitioners
• chiropractors
• optometrists

You can use your health card as a form of identification for other reasons, but no one else can record or copy your health card number . If your health card number falls into the wrong hands, it could be used to access to your personal health information or for OHIP fraud.

Help prevent OHIP fraud

You can help stop someone who:

• knowingly uses an Ontario health card that is not theirs
• receives health services covered by OHIP but is not an Ontario resident
• knowingly gives false information to get OHIP when they know they are not eligible

To report suspected cases of OHIP abuse or fraud:

• call us anonymously at  1-888-781-5556
• send us an e-mail

We investigate every report and will cancel OHIP coverage if someone cannot prove they qualify for OHIP . We also refer suspected fraud to the Ontario Provincial Police for investigation and possible prosecution.

Court to decide if Ontario must pay for surgery to make vagina if patient also wants to keep penis

A non-binary Ontario resident is locked in a legal battle over public funding for surgery to create a vagina while leaving the penis intact

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In a lengthy legal battle that could lead to more requests for individually customized and unorthodox gender-affirming surgeries, an Ontario resident is seeking publicly funded surgery to construct a vagina while preserving the penis.

The case, now before the courts, reflects a small but growing demand for niche surgeries for people who identify as non-binary, meaning neither exclusively female nor exclusively male.

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To critics, the procedures are risky experiments that illustrate “how far off the rails” gender-affirming medicine has gone and the excesses of “consumer-driven gender embodiment.”

“Our public health-care system is at the breaking point and really needs to focus on procedures that are medically necessary,” Pamela Buffone, founder of the parents’ group Canadian Gender Report, said in an email to the National Post.

“Is this type of surgery health care? The patient will not be physically healthier because of the operation, which is likely to result in complications and the need for corrective surgeries and further demands on the health system.”

LGBTQ rights groups say such surgeries can profoundly improve a person’s quality of life and reduce the distress and deep sense of unease from gender dysphoria. Health-care providers shouldn’t make assumptions about what care may be medically necessary, Egale Canada argued in a written submission to the court.

“Ultimately OHIP’s interpretation (of a vaginoplasty) is exclusionary and discriminates against nonbinary people on the basis of their gender identity,” Egale said. If there is any ambiguity in what should be publicly covered, it should be resolved in favour of the claimant, they said.

As National Post columnist Jamie Sarkonak first reported in September , the case involves 33-year-old K.S., as she is identified in court documents, who was born male but who identifies as female dominant and uses a feminine name.

Ontario’s Health Insurance Plan (OHIP) originally denied K.S.’s request in 2022 for funding for a penile sparing vaginoplasty, a procedure that isn’t available in Canada. The surgery was to be performed at the Crane Center for Transgender Surgery in Austin, Texas.

Is this type of surgery health care?

According to legal documents, K.S. argued that “to ignore ‘the other third’ of her and how she presents would be invalidating; she is ‘both,’ not exclusively one or the other but literally a mix.”

OHIP argued that, while it may be of medical benefit to K.S., a vaginoplasty without penectomy (removal of the penis) is considered an experimental procedure and isn’t listed as an insured service under its schedule of benefits.

K.S. complained to Ontario’s Health Services Appeal and Review Board, which overturned OHIP’s decision, ruling that a vaginoplasty is among the 11 external genital surgeries listed for public coverage, and that it shouldn’t inherently include a penectomy.

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OHIP, in turn, appealed the review board’s decision to Ontario’s Superior Court of Justice. The case was heard in late February. “We do not yet have a decision — it could still be months,” K.S.’s lawyer, John McIntyre, said in an email.

K.S., who has experienced gender dysphoria since a teen, doesn’t completely align with either the male or female genders, the appeal board heard. Her doctor, an Ottawa endocrinologist, supported K.S.’s request for a specific type of bottom surgery.

“It is very important for (K.S.)  to have a vagina for her personal interpretation of her gender expression but she also wishes to maintain her penis,” the doctor wrote in a letter to OHIP supporting the request for prior funding approval. “(K.S.) is transfeminine but not completely on the ‘feminine” end of the spectrum (and) for this reason it’s important for her to have a vagina while maintaining a penis.”

K.S. argued that forcing a non-binary person to undergo binary surgery — male to female, or female to male — would only exacerbate her gender dysphoria and would be akin to an act of conversion therapy, which has been banned in Canada since 2022.

She also wishes to preserve her penis for sexual health reasons and out of concern the “urological rerouting” could create urinary incontinence problems, a recognized complication.

In its decision, the health services appeal tribunal referenced standards of care as set out by the influential World Professional Association for Transgender Health, or WPATH, which considers a penile sparing vaginoplasty a valid treatment option for non-binary people. The board said it adopted the trans care group’s logic that “gender diverse presentations may lead to individually customized surgical requests some may consider ‘non-standard.'”

The Ontario health ministry said it doesn’t comment on matters still before the courts.

K.S. declined to comment when contacted through her lawyer.

In a similar case reported last year by the Globe and Mail, OHIP initially denied coverage to a 41-year-old Ottawa public servant who identifies as transmasculine non-binary and who was seeking the surgical construction of a penis without the removal of the vagina and uterus.

Nathaniel Le May and his lawyers argued that phalloplasty, on its own, is listed as an insured service, and that OHIP was wrong in interpreting that it was only insured if also accompanied by a vaginectomy. The additional procedures, they also argued,  amounted to coerced sterilization.

Two days before the case was set to be heard by the appeal board, OHIP reversed its decision and agreed to fund the surgery.

“My outcome is the same as K.S. We will both have a penis and a vagina,” Le May said in an email to the National Post.

“Why is it considered experimental in her case to have a vagina and a penis, but not in my case? Why did OHIP concede that it is an insured service for me but continue to fight that hers is not? OHIP is being inconsistent,” Le May said.

The Crane Center in Texas offers several non-binary surgical options. “We offer everything you could think of,” Dr. Curtis Crane, a plastic surgeon and reconstructive urologist with fellowship training in transgender surgery, said during a Facebook live Q&A session for patients three years ago. “I can’t think of a time that a patient has come up with a surgical request that I haven’t been able to fulfill.”

Hundreds of messages recently leaked from WPATH’s internal forum included discussions about an anticipated “wave” of requests for non-binary affirming surgeries such as mastectomies without nipples, “nullification” (removal of all external genitalia, just smooth skin) and phallus-preserving vaginoplasty — “non-standard” procedures resulting in bodies that one therapist said “either don’t exist in nature or represent the first of their kind and therefore probably have few examples of best practices.”

Crane argues that vaginoplasty without penectomy surgery is not experimental. “I probably do 10 or so a year; it’s not uncommon,” he said in an interview with National Post. Bodies with mixed genitalia “absolutely do exist in nature,” he added. “There are disorders of differentiation of sexual genitalia that will leave both parts.”

Techniques vary, but with the standard male-to-female vaginoplasty — penile inversion vaginoplasty — a vaginal canal is created and lined using penile tissue. “Next you would move on to surgically dissecting out the phallus, shortening the urethra and making a clitoris,” Crane said.

With penile preservation vaginoplasty, the vagina can be created using scrotal tissue or tissue from other parts of the body, like the abdomen or colon.

Crane said some patients seeking vaginoplasty get sexual gratification from their phallus and don’t want to have to sit to urinate.

“There are all kinds of reasons. I don’t say one reason is not a good enough reason. It’s the patient’s body,” he said. During the Facebook session, Crane said, “It’s kind of assault to make a patient remove an organ that they’re enjoying.”

But Dr. Yonah Krakowsky, a staff urologist at Women’s College Hospital in Toronto and medical lead of the hospital’s transition-related surgeries program, told the review board that phallus-sparing vaginoplasties are considered experimental by most surgeons, published reports on the “functional or psychological outcomes” are lacking and that the surgical technique used in the process is poorly understood.

Crane said he couldn’t recall, “off the top of my head,” the cost of a penile preserving vaginoplasty. When Sarkonak, the Post’s columnist, called the Texas clinic, she was told gender-affirming surgeries can range from US$10,000 to US$70,000, depending on what’s done.

“If someone just has an agenda to say, ‘no,’ (to public funding), you can never compete with that,” Crane said. “And unfortunately, that’s what it is the majority of the time: ‘I’m just gonna say no, because I don’t like this.’”

Others said it’s hard to justify the public coverage when Canadians across the country are facing lengthy wait lists for standard surgeries, and standard diagnostic tests.

“It’s hard to call this actual health care,” said Dr. Roy Eappen, a Montreal endocrinologist and senior fellow at Do No Harm, a medical and policy advocacy group. “There is no evidence that it improves anything physically, and the evidence that it helps mental health is not there either.”

“I can’t see the justification for paying. This is not something that really exists in nature and there is a very high complication rate for these kinds of surgeries,” Eappen said.

“WPATH wants to separate this all from any psychiatric diagnosis and call this ‘consumer driven.’ If that’s the case, then you can pay for it.”

While more people are identifying as non-binary, Crane said there are “plenty” of non-binary people who don’t want any surgery.

Eappen agreed. “I don’t know how many of them will want this kind of surgery. But I think this (case) would encourage them to ask. And I’m not sure we’re actually doing anyone a favour.”

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Plastic surgeons provide gender-affirming surgeries for the treatment of gender dysphoria with the aim of helping a person physically actualize their internal sense of self. The goals of these procedures are therefore patient specific and can vary beyond the gender binary.

Gender-affirming surgeries can be grouped into four main domains: facial, chest, body and genital procedures. Talking to your plastic surgeon about your individual transition will help direct which surgery options are best for you. Below are some commonly performed procedures, however, all patients should discuss both variations and the spectrum of options with their surgeon individually to make sure their chosen procedures match their individual needs and goals.

Please click here ( https://www.wpath.org/publications/soc ) for information from the World Professional Association of Transgender Health (WPATH) on information on preparing for Gender-affirming surgery.

Facial Gender-Affirming Surgery

Facial procedures can either masculinize or feminize the appearance of the face.

To enhance a feminine appearance, both bony anatomy and soft tissue augmentation can be done. Hairline lowering, forehead shortening and forehead contouring are typically done in a combination to achieve an overall feminine appearance of the upper face. Alterations to the middle face include rhinoplasty and upper lip lifts. Fat grafting can also be used to create fuller and softer cheeks. For the lower face, the jawline can be softened and reduced with mandible contouring. Finally, the thyroid cartilage can be reduced to feminize the appearance of the “Adam’s apple” and voice procedures can be used to increased vocal pitch.

Due to the effects of gender-affirming hormones therapy (testosterone) on the skin and facial hair growth, facial masculinization surgery is much less common. Some examples of surgical procedures include facial implants for augmentation of the jawline or chin.

Gender-Affirming Chest Surgery

Gender-affirming mastectomy is the most commonly performed gender-affirming surgical procedure, often referred to as “top surgery”. The most frequently performed technique is the “double incision with free nipple graft” where the breast tissue and excess skin is removed in addition to removing, re-sizing, re-shaping and replacing the nipples as free grafts. Some patients choose not to keep their nipples. Alternative techniques exist when minimal skin removal is needed. Additionally, chest reduction surgery is an option for patients who wish to keep some of their breast tissue.

Breast augmentation is available for patients who aim to increase their breast size. A minimum of 12 months of gender-affirming hormone therapy with estrogen should take place prior to considering or evaluating an individual for breast augmentation. Usually, silicone implants are used. Your surgeon will discuss variation in scar placement techniques.

Genital Gender-Affirming Surgery

For individuals assigned male at birth, options for orchiectomy (testicle removal) in isolation or in combination with vulvar procedures can be done for gender affirmation. Vulvar procedures include either a vulvoplasty or a vaginoplasty. Vulvoplasty refers to creation of an external vulva without a vaginal canal while vaginoplasty similarly creates the external genitalia in addition to a vaginal canal capable of receptive penetrative intercourse. The preoperative preparation for these surgeries varies and may influence your choice of treatment. Vaginoplasty typically requires extensive pre-operative hair removal and a post-operative dilation regimen.

Genital gender-affirming surgery for individual’s with assigned female at birth anatomy falls into two main categories: metoidioplasty and phalloplasty. In both categories the main differentiating factor between the various surgical options is the desire to stand to urinate. While metoidioplasty is done using only pre-existing genital tissue, phalloplasty requires tissue to be transferred from somewhere else on the body to construct the penis. Phalloplasty surgery is often done over multiple stages meaning more than one surgery is required to obtain a functioning phallus capable of standing urination. Many variations of phalloplasty exist. The traditional phalloplasty includes urethral lengthening with the goal of standing urination. Other variations of phalloplasty, referred to as “shaft-only” phalloplasty are increasingly performed. Shaft-only phalloplasty refers to the creation of a phallus without lengthening the uretha. Options in addition to a shaft only phalloplasty include vaginectomy, perineal urostomy, clitoral burial and scrotoplasty, depending on patient goals and individual preference.

Gender-Affirming Body Contouring

Gender-affirming body contouring includes liposuction or fat grating to change the distribution of adipose tissue in the body. Liposuction is done to help narrow the hips and alter the shape of the body. Conversely fat grafting can help augment the buttock and hips to accentuate curves.

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Are fertility treatments and reproductive technology covered by OHIP?

The journey to parenthood looks different for every family and can include fertility services and reproductive technology, as well as other avenues discussed in this article later.

Since 2015, the Ontario Fertility Program has been available to eligible patients in helping them grow their families. You may be able to access funded fertility services regardless of your gender, sexual orientation, and/or family status.

What are fertility treatments?

Fertility treatments are the medical interventions used to help people have children. They often include medications that help with hormones and are sometimes combined with minor surgical procedures.

The first place to start is with your health care provider . They can help you start the process by ordering tests, if necessary, or making referrals to specialists if that is the next step.

Who is eligible?

To be eligible for the Ontario Fertility Program, patients must be a resident and have a valid Ontario Health Insurance (OHIP) card . Depending on the type of fertility services you require there may be limits and conditions. You can learn more about the treatment types and coverage limits on the program page.

What is not covered?

Even if you are covered by OHIP and eligible for the Ontario Fertility Program, there will be costs that you are responsible for:

• Prescribed medications; some private health plans may limit what they will cover during fertility treatments, so be sure to check with your provider
• Storage or shipping of eggs/sperm/embryos; if required
• Counselling sessions are often required by clinics; fertility treatments can be a long, emotional and stressful process
• Genetic testing may be recommended depending on your situation.

Is there a waitlist?

Be prepared to wait for funded fertility services. Each clinic keeps its own waitlist but they must report to the Ministry of Health and Long-Term Care about wait times, and other clinic information during regular monitoring and reporting.

What other options do I have?

If you are not eligible for the Ontario Fertility Program you have the option to pay for treatments yourself. This can be expensive with the average costs of fertility treatments and technology averaging between $2,000-$25,000 depending on your situation.

You may wish to explore options outside of Canada . Be sure to do your research on the rules, regulations and costs for fertility treatments and surrogacy in that country before you make a final decision.

Sometimes people are not able to have children the way they had initially envisioned. There are many ways to build your family, such as the things listed above, and adoption and/or fostering children .

If adoption or foster care does not feel right for you, you may be interested in volunteering with community organizations that offer mentoring and group programs that provide children with role models and friends to talk to and share in the experiences of growing up.

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• Participating Clinics in the Fertility Program - This is a list of government-funded fertility clinics that are participating in the Fertility Program. From the Ministry of Health Ministry of Long-Term Care.
• Fertility - Facts on fertility, including treatment options and risks, counselling, and genetic testing and screening. From the Public Health Agency of Canada.
• Planting the Seed - A Fertility and Reproductive Support Group for 2SLGBTQIA Communities. Hosted by Seed & Sprout Community.
• Queer Family Planning - Explore the practical, emotional, social, and legal issues surrounding queer parenthood and navigating queer family life. From the 519.
• Cancer and Fertility - Learn about how cancer can affect fertility. From the Public Health Agency of Canada.
• Parenting with a Disability Network (PDN) - A cross-disability network for parents and prospective parents with disabilities in Toronto and the GTA.
• Accessible Care Pregnancy Clinic - Sunnybrook’s accessible care pregnancy clinic is a specialized clinic that provides care for people with physical disabilities who are pregnant or are contemplating pregnancy.
• Disabled Parenting Project (DPP) - Is part of the US-based National Research Center for Parents with Disabilities, is an online space for sharing experiences, advice, and conversations among disabled parents as well as those considering parenthood.
• LGBTQIA+ Parenting Mount Sinai - Ensures a safe, welcoming and inclusive environment for all lesbian, gay, bisexual, transgender and other (LGBTQIA+) patients, visitors and staff.

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Transgender Health Program: Insurance Information

OHSU clinics accept many kinds of insurance, including the Oregon Health Plan and many Medicare plans. Some services require prior authorization and referrals.

If you have insurance

Many insurance plans cover some transition-related services. Oregon requires health insurers to cover medically necessary treatments related to gender dysphoria if those treatments are covered for other conditions.

Private insurance

Check your member handbook or call the member services number on your insurance card to find out what may be covered.

Terms to look for: Gender dysphoria, gender identity disorder, sexual/gender reassignment or transgender health.

Oregon Health Plan

The Oregon Health Plan covers hormone therapy and some surgical services for transgender and gender-nonbinary patients. Talk to your health care provider and coordinated care organization to find out what services they may provide.

Learn more:

• The Oregon Health Authority has information about Oregon Health Plan benefits .

For patients

• For providers

Employer-provided benefits

If you get health insurance through your job, you should have a summary of benefits. Talk with your company’s benefits specialist or human resources manager about what’s covered.

If you don’t have insurance

Choosing a plan.

Oregon Health Plan: The Oregon Health Plan is the state’s Medicaid program for low-income people. You can apply online if you haven’t already been denied coverage.

Individual marketplace: HealthCare.gov , run by the federal government, helps you shop for and enroll in affordable health insurance. What you pay is based mostly on your income. You can enroll early November through mid-December or after certain life-changing events, such as losing your previous health insurance.

Medicare: This federal program is for people 65 and older and certain younger people with disabilities. Medicare.gov can help you find a plan.

Senior Health Insurance Benefits Assistance Program: This Oregon network of trained volunteers helps Medicare patients of all ages get coverage.

Seniors and People with Physical Disabilities Offices: This Oregon agency , a branch of the Department of Human Services, can help you find services.

Find an agent or application assistant: Visit the Oregon.gov help page to find someone near you to help you find the right coverage.

Help from health insurance agents and Medicare agents is free, but some insurance agents get a commission for recommending an insurer’s plan. For free unbiased help, look for Medicare volunteers and community partners on the Oregon.gov help page.

Recommended community partners: These organizations have expertise in transgender and gender-nonconforming health:

• Cascade AIDS Project offers help to anyone.
• Outside In , which helps homeless and marginalized youths, has a trans services coordinator: 503-535-3828 .
• Project Access Now helps vulnerable communities access health care.

What to ask

These questions can help you decide on an insurance plan, according to the Strong Families Network:

What is covered? When talking to customer service representatives, ask for the “Evidence of Coverage” or “Certificate of Coverage,” a full list of covered benefits for the plan.

What’s not covered? Pay attention to services or treatments specified as exclusions or limitations.

What’s covered for non-trans patients? If hormone therapy, chest surgery and hysterectomies are covered for anyone on the plan, they should be covered for transgender and gender-nonbinary members. In Oregon, it is illegal for insurers to cover services for some people and deny them to others.

Are there hormone therapy co-pays? If so, how much are they? Is there a limit on hormones or hormone injections? If so, what is it?

Is my health care provider covered by the plan ? Check whether your doctor is in the plan’s network.

Is there a network of trans-friendly doctors with training in gender-diverse care? If you want to find a gender-affirming provider,  GLMA: Health Professionals Advancing LGBT Equality  can help. Once you identify someone, ask which plans work with the provider.

Other questions to ask:

• Are there doctors within 30 miles who can serve trans and gender-nonbinary patients?
• Are mental health services available for gender-diverse people and their families, and are visits for gender-related needs covered?
• What kinds of documents are needed to receive services?
• Do I need to change my legal ID to get coverage as a person who is trans-identified?
• Are procedures such as facial gender-confirmation surgery covered?

Dealing with claims

These tips can help you navigate the claims process with your insurer:

• If your insurance is through your employer, contact your company’s benefits specialist or human resources manager.
• Have an advocate nearby or on call, ready to help you handle the stress.
• Be prepared to be misgendered. Many insurance companies don’t train their call-center staff on etiquette for transgender and gender-nonbinary patients.
• Have your group number, plan number and, if you have an online account with your insurer, your username and password.
• Research your plan and be prepared to explain your benefits package. Know what’s included and excluded. Call-center staffers don’t always distinguish well among the insurer’s various plans.
• You may need to ask for a supervisor. Be patient and polite, and remember they’re humans on the other end of the line.
• If you’re told you need a certain form, ask to have a blank copy emailed to you. Use the company’s name for any form, which can help representatives work faster.

These tips can help:

• Don’t despair. You can appeal.
• If you get an operator who can’t help, calmly ask for someone else.
• Don’t accept partial payment. A partial payment can be appealed.
• If you’re insured through work, ask your human resources manager or benefits specialist for help.
• If your employer has a policy on nondiscrimination, inclusion and diversity, you can use it to appeal.
• Find out if your plan has an explicit policy on parity.
• Some claims are denied more than once, even when a procedure is covered.
• If your doctor or benefits specialist finds a successful appeal for the same procedure, remove identifying information and include it with your appeal. This can help you avoid multiple denials.

OHSU resources

Visit our Billing and Insurance page to find:

• Information about our billing process
• Hospital costs
• Numbers to call if you need help
• Answers to frequent questions
• Information about financial assistance

Oregon resources

The Oregon Department of Consumer and Business Affairs has information about finding insurance, getting help paying for it, and your rights.

Request services

Please fill out an online form:

• I am seeking services for myself.
• I am seeking services for someone else.

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

• Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
• Learn more on our  For Health Care Professionals  page.

The Cass Review into medical care provided to children with gender dysphoria has been released. Here’s what it found

There's been a lot of discussion this week about the adequacy of medical care provided to children with gender dysphoria and whether change is needed.

It's been sparked by a landmark investigation into gender-affirming care offered via the National Health Service [NHS] in England, conducted by well-known paediatrician Hilary Cass.

The outcomes of the report are designed to reshape how publicly-funded care is provided to young people in England.

Her report, known as the Cass Review, spans hundreds of pages and calls for sweeping changes to how the NHS provides treatment to young people through its gender clinics.

In a nutshell, it recommends the service significantly limit the prescribing of medications — colloquially known as puberty blockers — for people aged under 18 and for patient care to be multi-disciplinary and centred around mental health support rather than medical interventions.

It's a recommendation the NHS England adopted last month, in anticipation of the findings.

"We have concluded that there is not enough evidence to support the safety or clinical effectiveness of [puberty blockers] to make the treatment routinely available at this time," the NHS England wrote in March.

"NHS England recommends that access to [puberty blockers] for children and young people with gender incongruence/dysphoria should only be available as part of research."

Prior to the change, the drugs had been prescribed to patients with gender dysphoria in England. Though, according to UK media, it was estimated fewer than 100 people were on the drugs via the NHS. Those patients would be allowed to continue to take them.

The review also recommends "extreme caution" in prescribing masculinising and feminising hormones under the age of 18.

In her report, Dr Cass said she made the recommendations because of a lack of scientific evidence into the long-term use of the medications in children.

"You must have the same standards of care as everyone else in the NHS, and that means basing treatments on good evidence," Dr Cass wrote, directly addressing gender dysphoric children.

"I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you."

Dr Cass' findings were based on a series of systematic reviews of the medical evidence and international treatment guidelines undertaken by University of York.

"This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint," she wrote.

As part of the work, researchers identified 23 guidelines published between 1998 and 2022 that contained recommendations about children and young people with gender dysphoria, four of those were international, three were regional and 16 were national.  

Dr Cass went on to call for both the scientific community and patients who are taking puberty blockers to come together to study their use.

As a result, questions are being asked about whether those findings should have implications in other countries, like Australia, where gender affirming care is available.

Will things change in Australia?

It's not out of the question, but there is deep resistance.

In Australia the review has been acknowledged but most doctors and institutions, and even the government, have cautioned against applying the findings here, arguing the settings are very different.

Here, puberty blockers are only subsidised for patients who have certain cancers or those experiencing early puberty. Though, patients can access them without subsidy.

Health Minister, Mark Butler, described the Cass Review as "significant" but said the clinical pathways in Australia were different to those offered in the UK.

"Clinical treatment of transgender children and adolescents is a complex and evolving area in which longer term evidence to inform treatment protocols is still developing," he said.

"Everyone, including the states and territories who are responsible for these services in Australia, will take the time to consider this review which has just been released."

In 2020, the Australian government rejected calls for a national inquiry into gender affirming care for young people, saying it was concerned it would negatively impact their wellbeing.

That followed the advice provided by the Royal Australian College of GPs, which warned such an inquiry would not increase scientific evidence but would further harm vulnerable patients.

Who is sceptical of the review's findings?

A recurring bone of contention is around the quality of existing research. Some advocates and doctors argue the data available is strong enough despite the Cass Review suggesting otherwise.

Head of the Trans Health Research group at The University of Melbourne, Associate Professor Ada Cheung, said she did not see any merit in carrying out a similar review here.

"The Cass report goes against the consensus of professional medical associations around the world, and I don't think is relevant to practice in Australia," she said.,

"It downplays the risk of denying treatment to young people with gender dysphoria and limits their options by placing restrictions on their access to care."

Associate Professor Cheung said, unlike the UK, Australia already had a coordinated multidisciplinary approach to care, where puberty blockers were provided as part of specialist hospital-based teams, as recommended by Australian guidelines.

"The way that gender affirming care is accessed and provided in Australia is substantially different to the NHS."

The Royal Children's Hospital Melbourne, which penned the guidelines, declined to comment for this story.

The head of Transcend Australia, the national body for trans, gender diverse, and non-binary young people, suggested the review excluded good research.

"Families deserve to be provided with all the available evidence about medical treatment, which the Cass Review has failed to do by excluding a significant amount of global research," Transcend Australia CEO Jeremy Wiggins said.

Dr Portia Predny, from the Australian Professional Association for Trans Health agreed, adding that applying the findings here would be "flawed" because the review specifically looked at the NHS in England.

"In Australia, our guidelines for gender affirming care for young people already prioritise holistic, individualised and person-centred care with the involvement of multidisciplinary teams of clinicians with all kinds of areas of expertise, to help and support young people to navigate their gender journey," Dr Predny said.

Who is supportive of the findings?

In the UK, the review has been widely welcomed by senior academics and the medical profession. Though, some doctors and advocates are worried that patients will be blocked from receiving the care they need.

The findings were cautiously welcomed by Ashley Grossman, an Emeritus Professor of Endocrinology with the University of Oxford.

"It may be that a small number of these children should in the long-term transition to a different sex, but routine puberty blocking treatment for this use has not yet been adequately studied, and many of these children may have other problems for which they need help," Prof Grossman said.

"More carefully run clinical trials are needed so that we can understand how and when such agents are justified and of benefit."

There is also some divide in Australia.

Dr Jillian Spencer is a child and adolescent psychiatrist who has long advocated against gender affirming medical interventions and has welcomed the review's findings.

"I think it signals a return to careful and evidence-based treatment approaches rather than treatment approaches driven by activists," she said.

She also remained critical of the services provided by specialist gender clinics here.

"There has been failure to acknowledge the risks and harms of transitioning children," she said.

Dr Spencer was stood down from clinical duties at the Queensland Children's Hospital last year and is awaiting the outcome of an investigation over a complaint from a young transgender patient.

She's contesting the action with a case to be heard by the Queensland Industrial Relations Commission.

Speaking to the ABC, Dr Spencer cited FOI documentation showing there were 172 prescriptions initiated for puberty blockers last year at Queensland's Gender Service and said she was worried by that rate.

"The lesson for Australia is that we must find a way to freely discuss health care issues regardless of their sensitivity. In this case, children have been harmed by the mainstream media and the government being unwilling to examine concerns that were repeatedly raised by health professionals and parents over many years."

The Australian Medical Association declined to comment, but provided a statement from earlier this year which said, "people who are LGBTQIASB+ thrive in health care environments where they feel safe, affirmed, respected and understood".

It also called for greater access to gender-affirming treatment.,

The ABC has also approached the RACGP for comment.

Editor’s note: This story was amended to clarify the way in which Dr Jillian Spencer’s position had been paraphrased and to note the Cass Review’s recommendation on cross-sex hormones.

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Sweden passes law lowering age to legally change gender from 18 to 16

Proposal sparked intense debate in country but passed with 234 votes in favour and 94 against

Sweden’s parliament has passed a law lowering the minimum age to legally change gender from 18 to 16 and making it easier to get access to surgical interventions.

The law passed with 234 votes in favour and 94 against in Sweden’s 349-seat parliament.

While the Nordic country was the first to introduce legal gender reassignment in 1972, the new proposal, aimed at allowing self-identification and simplifying the procedure, sparked an intense debate in the country.

The center-right coalition of the conservative prime minister, Ulf Kristersson, has been split on the issue, with his own Moderates and the Liberals largely supporting the law while the smaller Christian Democrats were against it.

The Sweden Democrats, the populist party with far-right roots that support the government in parliament but are not part of the government, also opposed it.

“The great majority of Swedes will never notice that the law has changed, but for a number of transgender people the new law makes a large and important difference,” Johan Hultberg, an MP representing the ruling conservative Moderate party, told parliament.

Beyond lowering the age, the new legislation is aimed at making it simpler for a person to change their legal gender.

“The process today is very long, it can take up to seven years to change your legal gender in Sweden,” Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender , Queer and Intersex Rights (RFSL), told AFP.

Two new laws will go into force on 1 July 2025: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

People will be able to change their legal gender at 16, though those under 18 will need the approval of their parents, a doctor and the National Board of Health and Welfare.

A diagnosis of “gender dysphoria” – where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as – will no longer be required.

Surgical procedures to transition would be allowed from the age of 18, but would no longer require the board’s approval. The removal of ovaries or testes will only be allowed from the age of 23, unchanged from today.

Denmark, Norway, Finland and Spain are among countries that already have similar laws.

Last Friday German lawmakers approved similar legislation, making it easier for transgender, intersex and non-binary people to change their name and gender in official records directly at register offices.

In the UK, the Scottish parliament in 2022 passed a bill allowing people aged 16 or older to change their gender designation on identity documents by self-declaration. It was blocked by the British government , a decision that Scotland’s highest civil court upheld in December.

The legislation set Scotland apart from the rest of the UK, where the minimum age is 18 and a medical diagnosis is required.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases. This is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500% since 2008, according to the Board of Health and Welfare.

While tolerance for gender transition has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal.

A poll published this week suggested almost 60% of Swedes oppose the proposal, while only 22% back it.

In a sign of the strong feelings it stirred, members of parliament spent six hours debating the proposal.

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OHIP reverses course, will fund gender-affirming surgery for Ottawa public servant

This article was published more than 6 months ago. Some information may no longer be current.

Nathaniel Le May at the National Arts Centre in Ottawa on Jan. 27. OHIP has decided to fund a gender affirming surgery for Mr. Le May after he was denied coverage for a procedure for nearly a year. Blair Gable/Blair Gable Photography

OHIP has reversed its stance and decided to fund a gender-affirming surgery for Nathaniel Le May , an Ottawa public servant who accused staff at Ontario’s government-run insurance plan of discrimination after he was denied coverage for a procedure for nearly a year.

Mr. Le May, who identifies as transmasculine non-binary, is seeking a phalloplasty, the surgical construction of a phallus. Originally, OHIP repeatedly denied funding the surgery unless it was performed in tandem with a vaginectomy, which removes the vagina, and which in turn necessitates a hysterectomy, owing to cervical cancer risks. Mr. Le May did not want these additional surgeries, arguing they would amount to forced sterilization.

Last week, OHIP reversed course and approved funding for a phalloplasty, without a vaginectomy.

“I’m happy that it’s funded. Now there’s a precedent: People can refer back to my case,” Mr. Le May said.

While the funding approval was a personal win, it arrived mere days before Mr. Le May was scheduled to appear at an appeal hearing he’d lodged against OHIP. Here, he was seeking broader remedies that would ensure other non-binary and transgender people wouldn’t be denied similar health coverage in future. With Mr. Le May’s surgery approved on June 7 after months of denials, his June 12 appeal at the Health Services Appeal and Review Board was abruptly cancelled.

The move concerns advocates calling for more accountability in transgender health care , which remains a largely misunderstood field in medicine.

“With no interpretive guidance from the board, other transgender patients may find themselves in the same situation,” said Frank Nasca, a recent law graduate who helped Mr. Le May prepare for his appeal.

“The board’s decision reflects a lack of commitment to systemic change for the trans community,” said Mx. Nasca, who is transgender.

Ontario’s Ministry of Health did not respond to The Globe and Mail’s questions about why OHIP changed its stance to fund Mr. Le May’s surgery, or whether it would fund similar surgeries in future. An e-mailed statement sent June 14 from the ministry said it does not comment on matters under the jurisdiction of a court, appeal board or tribunal. (There is no active legal proceeding in Mr. Le May’s case.)

Through his appeal submissions, Mr. Le May had been pushing for OHIP to remove any “interpretive ambiguity” from its funding approval forms and to bring the language in line with the physician services clearly listed under Ontario’s Health Insurance Act . Here, gender-affirming surgeries such as phalloplasty are listed individually – not bundled together with other surgeries, the way they’ve been on OHIP’s documentation forms.

Today, the standard of care in transgender health care revolves around considering medically safe surgeries on a case-by-case basis, to alleviate gender dysphoria. Forcing people to check a box for a male-to-female or female-to-male package of surgeries under the banner of “sex reassignment” is outmoded, experts say.

“I would recommend to OHIP’s gender-affirming surgery program that when there are issues and trans people are saying, ‘This is breaching my rights; this is not aligned with the standard of care,’ that they get proper medical advice from someone who is certified in the standard of care,” Mr. Le May said.

His appeal submissions had included testimony from Devin O’Brien-Coon, an associate professor at Harvard Medical School and a doctor who specializes in gender-affirming surgery at Boston’s Brigham and Women’s Hospital.

Contradicting OHIP’s original letters to Mr. Le May – which stated that in order to get funding, his phalloplasty needed to be accompanied by a vaginectomy – Dr. O’Brien-Coon stressed there was no medical reason to perform those surgeries together in Mr. Le May’s case. Asking any patient to submit to the unnecessary removal of a uterus and vagina in order to secure public funding amounts to “coercive conduct that violates medical ethical obligations,” Dr. O’Brien-Coon wrote.

In the now called-off appeal, Mr. Le May argued that OHIP’s repeated denials for health coverage infringed on his human rights and created undue delay in his access to gender-affirming care. He’s now considering legal action through the Human Rights Tribunal of Ontario.

“The less barriers we put in front of somebody who’s already struggling with dysphoria and other forms of distress, the better,” said Yael Sela, a social worker and psychotherapist with the trans health team at Ottawa’s Centretown Community Health Centre.

“Surgery can be life changing,” Ms. Sela said. “I see that in the clients that I talk to. After they have surgery, things can really change in a significant way.”

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