gender reassignment surgery cost in canada

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Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

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Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

• be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
• have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
• have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

• one of the assessments must be from a doctor or nurse practitioner
• you have a diagnosis of persistent gender dysphoria
• have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
• you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

• have a diagnosis of persistent gender dysphoria
• have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

• find out about their ongoing project, Trans Health Connection
• consult their service directory
• find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

Everything you need to know about getting top surgery in Canada

It can cost thousands of dollars more out of pocket to get top surgery in Ontario compared to B.C.

Credit: Getty Images, Brian Wong/Xtra

Top surgery. Chest construction. The tit eviction. The ol’ nip-nop chip-chop. The teet yeet. Whatever you call it, it can be a life-changing and affirming procedure for trans folks of all stripes. 

While it’s not necessarily important for everyone’s gender journey, the gender-affirming procedure colloquially known as “top surgery” is a big part of some trans folks’ medical transition . The COVID-19 pandemic gave many trans people the space to explore their identities and come out , and now they may be considering surgeries. 

But a number of first-person accounts and guides for getting top surgery in English-speaking countries focus on the United States, which has a vastly different medical system from Canada. South of the border, the procedure can run up huge medical bills—well into the tens of thousands of dollars. And doctors like Florida’s Charles Garramone can garner thousands of online followers and celebrity-level name recognition amongst trans social media users. 

@drgarramone The official TikTok channel for Dr. Charles Garramone #ftmtopsurgery #mansculpture #mansculpting #transgender #nonbinary #lgbtq #gendersurgery ♬ original sound – Dr. Charles Garramone

But here in Canada, it’s (mostly) free if you need it. Gender-affirming top surgery is covered in most provinces under our public health care system. And while that’s great news for trans folks, it doesn’t mean the process is totally easy. Not every province and territory currently has surgeons who perform the procedure, and the exact process of getting referred and paying for it ranges from jurisdiction to jurisdiction. Some provinces like British Columbia have centralized trans health care networks, while it’s the wild west in others. 

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Here’s everything you need to know if you’re considering top surgery in Canada.

What is top surgery? 

Top surgery is a procedure some trans and non-binary folks assigned female at birth choose to undergo in order to achieve a flatter and more traditionally “masculine” chest. It is technically different from a straight-up mastectomy, in that it usually involves some level contouring or intentional scar placement to create that “masculine” chest. 

There are several techniques used to achieve this, and they vary based on patient preference and chest size. Smaller chested individuals may be able to have tissue removed without damaging or moving the nipple and areola, while larger chested folks usually require the nipple to be removed and reattached (or they may choose to go nipple-less). 

A subcutaneous or periareolar mastectomy involves small incisions at the base of the nipples from which the tissue, fat and extra skin is removed. A double-incision mastectomy involves multiple incisions made on the chest in order for excess tissue and skin to be removed. The incisions are then closed together and the nipples can be reattached. 

You can talk about which technique is best for you with your surgeon. 

How do I get a referral for top surgery in Canada?

In most provinces, it starts with speaking with your family doctor or nurse practitioner. If you don’t have access to either, you can reach out to a local LGBTQ2S+ health group to discuss options for finding affirming medical professionals, or even to be directly connected to someone who can refer you. Rainbow Health Ontario or T hree Bridges Community Health Centre can connect you to top surgery referrals in Toronto and Vancouver, respectively. 

Gil Goletski, who lives in Metro Vancouver, didn’t have a family doctor when they started their top surgery process, so they went through Three Bridges. They say it was helpful to have all of their transition-related medical care filtered through the same place—and it be an affirming place at that. 

“Originally when I wanted to start hormones and they set me up with a doctor, I went to a couple of appointments with her and she started me on that process, doing the referral for surgery,” Goletski says.

During your referral appointment, you can expect to be asked questions around your feelings about your body, gender identity, dysphoria and goals for surgery or other aspects of medical transition. You’ll also talk about whether you’re able to take time off of work for the surgery and what sort of support networks you have in your life—it’s important to have a close friend, partner or family member who can pick you up from the hospital and help you out with tasks like bathing in the weeks post-op. 

You’ll also be asked about your health habits, particularly smoking. Some research has shown that smoking cigarettes can increase your risk of surgical complications, including nipple necrosis (the horror situation of your nipple falling off). 

While the process varies from province to province, your assessor will usually provide a determination either for or against surgery after your referral appointment, and then you move on to a surgeon.

What requirements must I meet to get top surgery in Canada?  

Barriers to accessing top surgery mostly come at the level of individual surgeons. You do not have to be on HRT (hormone replacement therapy) to get top surgery, though some surgeons recommend it in order to achieve a certain look. Similarly, weight or BMI (body mass index) should not technically prevent you from getting the surgery, but internalized fatphobia in the medical system can lead to certain surgeons rejecting you.

Many surgeons will perform top surgery on anyone, regardless of size, though they may warn you about some risks and possible complications. 

Some surgeons also recommend chest-related strength-building in the months ahead of surgery in order to give some muscle definition to guide the incisions. 

It’s important to remember that if a certain surgeon isn’t a fit for you, there is usually an option to see another. Goletski was initially matched with one Vancouver-area surgeon, who said they couldn’t do the procedure due to their history with marijuana smoking.

“My referral was rejected because I said that I smoked cannabis, and they rejected me outright not because I wouldn’t stop before surgery but just because I smoked cannabis at all,” they say. 

However, when matched with another surgeon, Goletski was told that wouldn’t be an issue as they stopped around the surgery date.

“When I eventually got surgery, it wasn’t a problem,” they say. “I was just told to stop smoking when I was healing and to do edibles or vaping instead of smoking. And that was all fine.”

Goletski also recommends that folks not be afraid to switch surgeons if a particular waitlist seems to be taking a long time, particularly in a province like B.C. where everything is centralized through an authority like TransCare B.C. They were matched to a second surgeon and languished on their waitlist for months, before getting on a third waitlist and getting in right away.

Nico Mara-McKay got top surgery in Ontario during the pandemic, and they say that the variance between medical professions means that you should be prepared to advocate for yourself. 

“Do your research beforehand to know what you want because they won’t tell you what you need,” they say. “Even if you think they might, do your research.” 

They said they ended up in a situation where they had to essentially dictate their referral to their doctor because the practitioner wasn’t well-versed in trans issues. They also point out that even knowledgeable doctors may not be up-to-date on the latest requirements. 

“I’m not on hormones, that’s not part of my journey,” they say. “But doctors might have that old information. Make sure that you know what the rules and regulations are, or whatever health care options you have within your specific sphere, because they do change.”

How much does top surgery in Canada cost?

Ostensibly, it’s free across Canada, just like other medically necessary surgeries. But there can be unexpected fees in certain regions. 

Mara-McKay got top surgery from a popular Ontario surgeon earlier this year, but say they were hit with a “contouring fee” part way through the consultation process that caught them by surprise. 

“For the removal of breast tissue, there’s no fee,” they say. “But if you want contouring to get rid of ‘dog tags’ that are on the side of the chest or, you know, shape the chest, then you have to pay for it. For me, it was about $3,000.”

It turns out that’s very common in Ontario. When reached by Xtra , Rainbow Health Ontario confirmed that, unlike in other provinces, the entire top surgery procedure is not covered by the provincial health plan; most Ontario surgeons will charge the contouring fee to the patient, in addition to the top surgery cost they bill to the province. 

Provincial funding from the government of Ontario only covers the basic mastectomy. However, it is usually not an option for a patient to get “just the free part,” which means Ontario patients like Mara-MacKay end up footing some couple thousands of dollars worth of surprise bills. According to Rainbow Health Ontario, this “contouring” fee is a result of public health policy in the province, and a decision to only fund part of the procedure at the provincial level. 

It’s good to ask your referrer or surgeon about any fees early in the process, so you can understand your options. For example, some Ontario patients actually choose to see surgeons elsewhere, such as in Montreal, in order to get publicly-funded surgery while avoiding the contouring fee. 

You should also be prepared to budget for the time off of work, which will vary depending on your job, as well as for any bandages, pain medications or other healing process needs recommended by your surgeon. 

Where can you get top surgery in Canada?

In most Canadian provinces, the procedure is covered, at least partially, by public health care, since it is a medically necessary procedure for some people to alleviate gender dysphoria. Most provinces also have surgeons who will do top surgeries, though their availability can vary. 

The process of accessing the surgery can vary based on provincial public health policy, funding and the number of forms you need to fill out. Here’s where you can learn more about getting top surgery in each province and territory. 

British Columbia: TransCare BC 

Ontario: Rainbow Health Ontario

Quebec: GRS Montreal  

Alberta: Alberta’s Gender Reaffirming Program

Saskatchewan: Saskatchewan Trans Health Coalition 

Manitoba: Sexuality Education Resource Centre MB

Nova Scotia: Nova Scotia Health

New Brunswick: New Brunswick Health

Prince Edward Island: PEI Health

Newfoundland and Labrador: Trans Support NL

Yukon: TransCare BC

Northwest Territories and Nunavut: NWT Health

Senior editor Mel Woods is an English-speaking Vancouver-based writer and audio producer and a former associate editor with HuffPost Canada . A proud prairie queer and ranch dressing expert, their work has also appeared in Vice , Slate , the Tyee , the CBC , the Globe and Mail and the Walrus .

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New gender-affirming surgery clinic now accepting patients

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Plastic Surgeon Dr. Nicholas Cormier has dedicated nearly his entire career to caring for trans and non-binary patients.

The Ottawa Hospital understands that trans and non-binary people often face barriers accessing gender-affirming care. Faced with long wait times or even lack of access in the communities where they live, they may struggle to achieve their gender-affirming goals.

We are very pleased to announce that The Ottawa Hospital’s new gender-affirming surgery clinic is here to help. Launched in September 2023, it is the only clinic in Ontario and the second in Canada to offer all three of the following gender-affirming procedures:

• Facial surgery to make facial features more masculine or feminine
• Top surgery to remove breast tissue for a more masculine appearance or enhance breast size for a more feminine appearance
• Bottom surgery to transform the genitalia

The clinic’s lead and co-founder, Plastic Surgeon Dr. Nicholas Cormier, has some more wonderful news to share: “We’re currently accepting patient referrals from physicians,” he announces with a smile. “We’re ready to service Ottawa and the surrounding communities.” 

A truly collaborative effort

Before our clinic, patients seeking gender-affirming surgery in Ottawa could only access top surgery but not bottom or facial. Previously, a clinic in Montreal was the only location in Canada offering all three procedures.

“There’s just a massive gap in our health-care system for the treatment of the transgender population and people seeking gender-affirming care,” says Dr. Cormier. “What’s so groundbreaking about this new clinic is that everyone is coming together to address this shortcoming in our system.”

These partners include different surgical divisions at the hospital—plastic surgery, urology, obstetrics and gynecology—as well as trans health programs out in the community, such as the Centretown Community Health Centre’s Trans Health Program , which provides patients with a referral to our clinic, and CHEO’s Gender Diversity Clinic , which provided Dr. Cormier and his team with advice on setting up the clinic and also refers patients who have reached the age of 18.

These community programs are also important for the overall health and wellbeing of Ottawa’s trans and non-binary population. “Accessing gender-affirming surgery is just one small component of gender-affirming care,” says Dr. Cormier. “That’s where these community partners really come into play.”

Years in the making

For Dr. Cormier, the clinic is the culmination of many years of caring for the gender-diverse community.

“In my residency, I was always interested in gender-affirming care, and that led me to seek out a fellowship in San Francisco, where I was able to train with world-renowned experts in gender-affirming care,” he recalls. “And I’m really excited about bringing that to my hometown of Ottawa.”

And Ottawa’s gender-diverse community is (literally) in good hands, says Dr. Daniel Peters, Division Head of Plastic Surgery at The Ottawa Hospital. “Dr. Cormier has dedicated nearly his entire career to caring for this often underserved patient population. He has learned from the best of the best in this field and has the compassion to match his expertise. He joined The Ottawa Hospital’s Division of Plastic Surgery not long ago, and yet he has already shown tremendous leadership by getting this clinic up and running. That’s really a testament to his passion for helping people on their gender-affirmation journeys.”

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This website gives you common facts, advice and tips. Some of it may not apply to you. Please talk to your doctor, nurse or other health-care team member to see if this information will work for you. They can also answer your questions and concerns.

Frequently asked questions

• Do I have to have genital reconstructive surgery before changing my gender status on my legal documents?
• Will my surgery be reimbursed by my province’s health insurance?
• From what age can I have gender affirming surgery?
• What documents do I need to provide if I want to have surgery?
• I am intersexed and would like to undergo gender reassignment surgery. What documents do I need to provide?
• My file is complete; I am following WPATH’s Standards of Care and I have provided all of the documents requested by my surgeon. How long will I have to wait to be given a surgery date?
• How long before surgery do I have to provide my lab results?
• What are the possible complications involved with my surgical procedure?
• Will I lose the ability to achieve orgasm after surgery?
• I don’t speak French. Do the physicians and staff at GrS Montréal speak English?
• Will I have an opportunity to speak with the GrS Montréal team before my surgery?
• My blood is infected with HIV. Can I still have surgery?
• If I have an STI, can I still have surgery?
• Can I contract or transmit an STI even if I have undergone genital reconstructive surgery?
• Can I be operated on if I am overweight?
• Can I undergo surgery if I take drugs?
• How long before and after surgery do I have to stop consuming alcohol and stop smoking?
• Should I stop taking my hormones before surgery?
• Will the dosage of my hormones need to be adjusted after surgery?
• How do I prepare for surgery?
• How do I plan my transportation to and from my procedure?
• I am afraid to experience pain after my surgery. Will I be given medication?
• Why do I need to stay for a few days at the Asclépiade convalescent home after my surgery?
• If my recovery is difficult, can I get psychological support at your hospital?
• I would like to undergo surgery at GrS Montréal. Should I be accompanied during my stay?
• What are the rules regarding visitors?
• Will I have access to entertainment during my stay?
• Will I require the aid of a nurse after my surgery?
• Once I am back home after surgery, what should I do if I need help?
• Can I drive my car after surgery?
• How long will my convalescence last after surgery and when can I return to work?
• When can I start to swim again after my surgical procedure?

No, if you are a resident of Quebec, it is no longer mandatory to have genital reconstruction surgery in order to change your gender status in legal documents.

For more information, visit the Directeur de l’état civil’s website: https://www.etatcivil.gouv.qc.ca/en/change-sexe.html

If you are not a Quebec resident, you can find information in the Being Trans section of our website or from your provincial or state government.

*If necessary, we will provide you with the official documents (affidavit) required to support your efforts.

Most Canadian provinces cover the cost of gender reassignment surgery. However, feminizing surgeries considered cosmetic, such as breast augmentation , voice surgery , Adam’s Apple reduction , and facial feminization , are not currently covered by all health insurance programs. Each Canadian province has its own reimbursement program. You can find information specific to your province in the Being Trans section of our website or of your provincial government.   

If you are a U.S. citizen or from elsewhere in the world, check with the health department of your state or provincial government and/or your own insurance company.

*Some health insurance programs cover certain fees associated with your surgery while others do not.

According to WPATH 's Standards of Care, an individual must be of the age of majority in the country of reference (Canada) to be allowed to undergo gender reassignment surgery. Therefore, the required age for genital reconstructive surgery is 18 years of age and 16 for masculinization of the torso surgery (mastectomy).  

The documents required are linked to the type of surgery you are interested in undergoing. The basic required documents are those that allow surgeons to confirm that you have met WPATH’s Standards of Care. Additional documents, like proof of good health from your doctor, will be requested to ensure safe surgical proceedings.

Consult the WPATH document  for more information.

The documents required are the same set out by WPATH’s Standards of Care . GrS Montréal surgeons may ask you for additional documentation and/or test results in order to ensure safe surgical proceedings. 

Once your preoperative medical file has been confirmed, a GrS Montréal staff member will contact you to provide you with a preliminary surgery date, taking into account your own availability and that of the operating room.

Although you will have been assigned a date, you must send us the required lab results by the deadline you will be provided with. Once the results of these tests have been validated, your surgery date will be confirmed.   

GrS Montreal must have received these results at least 2 months before the surgery otherwise it could be postponed.

It is important to keep in mind that complications rarely occur. Generally, minor problems are the most common. Complications may make recovery time longer, but they do not necessarily affect final results.

While risk is involved in all surgeries, GrS Montréal physicians work continually to prevent them through the development and maintenance of safe surgical practices. Additionally, pre and postoperative treatment and follow-up plans allow for early detection and management of complications that may arise. In the case of complications, our doctors will provide you with all of the necessary information to help you eliminate all problems as quickly as possible. 

Risks and complications are not directly related to the scale of the surgical procedure involved and are sometimes difficult to prevent despite precautions taken. Severe allergic reactions to medication, cardiac arrhythmia, hypertension, hemorrhage, embolism, the reopening of wounds or slow healing, injuries to other parts of the body, loss of feeling, bruising and swelling, wide and thick scars, and unsatisfactory outcomes are common complications in all surgeries. You will be provided with all details related to the complications specific to your surgery.      

The majority of patients retain their ability to achieve orgasm after surgery, but there is still a risk that sexual function or the ability to have an orgasm will be affected. GrS Montréal surgeons are very experienced and use techniques that allow the patient to retain her or his sensations of sexual pleasure. Your health history (smoking, diet, alcohol, etc.) can also affect healing and, in this way, alter the sensitivity of your genitals.

Our staff speaks French and English. We are also able to provide you with documents concerning your surgical procedure in these two languages.

If you do not speak French or English, it is still possible to have surgery at the CMC. In the past, we have accompanied deaf and mute patients, as well as patients whose mother tongue is neither French nor English. From the beginning of the preoperative period, we will accompany you in the process to obtain an interpreter or translator.  

You can contact us at any time in order to communicate confidentially with a member of the GrS Montréal team. Once your file is complete, a member of the nursing staff in the preoperative clinic will contact you. 

Yes, it is possible to have surgery as HIV is not a contraindication to surgery. However, it is important to mention your infection to us and to provide us with the results of your viral load when you want to plan your surgery. Your viral load lab results must be labelled “undetectable”. Antivirals are the only way to achieve this label.   

Yes, surgery is possible even if you have contracted an STI in the past. However, if you currently have an STI, it is recommended you be healed before having surgery. Your symptoms must be treated. if a fever is present, surgery will be postponed.  

After surgery, you remain at risk of contracting or transmitting infections transmitted sexually and by blood. Consult your family doctor for information about available protection.

Resources:  https://www.sexandu.ca/

Your weight and diet can significantly influence your healing, the results of your surgery, your ability to take care of yourself. It is preferable to have attained a healthy weight by the time of your surgery (a BMI between 18.5 and 25). If your BMI is below or above the normal range, your situation will be assessed and you will be informed of your possibilities for surgery. GrS Montréal can direct you to resources that can help you achieve your weight loss or weight gain goals.

  Calculate your BMI

Access to our establishment is forbidden to anyone with drugs or alcohol in their possession, or are under the influence of these substances.

Drug use can affect patient safety during surgery. All drug use should be reported to us during the planning stages of your surgery. Your surgeon and anesthesiologist must have this information to ensure the surgery is safe for you.

Alcohol: You must avoid drinking alcohol during the 2 weeks before surgery. Mixing alcohol and medications can cause unpredictable and undesired reactions.

Tobacco and nicotine substitutes:  We highly recommend you stop smoking or using nicotine substitutes during the 6 weeks before and after the procedure, with the exception of phalloplasty surgery, for which you must stop smoking 6 months before and after the procedure in order to optimize the vascularization of the graft of the phallus as well as nerve regeneration. Toxic substances found in tobacco can:

• Tighten small blood vessels and thus negatively affect the results of your surgery and the healing of your wounds;
• Cause nausea upon waking up, vomiting, and excessive coughing, which increase the risk of bleeding after surgery;
• Resource https://defitabac.qc.ca/en

According to the law to provide a healthy environment, it is strictly prohibited to smoke on the premises, with the exception of specifically designated smoking areas. These areas are located at least nine (9) meters from all of the facility’s doors. Violating this rule can make you subject to fines ranging from $250 to $750 for a first infraction and from $500 to $1500 for a recurrence. Cigarette butts must be disposed of in designated metal containers.

Three (3) weeks before surgery, you should stop taking feminizing hormones such as estrogen, progesterone, as well as cyproterone acetate (Androcur®). You can continue taking your anti-androgens (Finasteride®, Spironolactone®).

Masculinizing hormones such as testosterone: you will need to continue taking these according to your usual schedule.

If you are taking feminizing hormones and antiandrogen drugs , make an appointment with your prescribing physician 2 months after a genital reconstructive surgery such as vaginoplasty , vaginoplasty without vaginal cavity , and orchiectomy .

If you are taking masculinizing hormones , you do not need to make a follow-up appointment.

Once your surgery date has been confirmed, we will provide you with documentation containing all the details required to be well-prepares for your surgical procedure and your stay. 

If you are traveling by train or airplane, a transportation service is available at no additional cost. If you are not hospitalized (day surgery), you must be accompanied at the time of departure.

*If it is impossible for you to be accompanied, please let us know as early as possible so that we may put necessary resources in place.

If you are hospitalized, you must leave your room by 8:00 am on the day of your departure so that we can make it available to the next patient. For this reason, we ask that you plan your flight or train departure for the morning. If you are not hospitalized (day surgery), the nurse will tell you when you can leave the facility.

The majority of patients experience pain after surgery. Its intensity varies from one person to another and the experience of pain is unique to each person. To relieve pain, surgeons prescribe a daily medication such as an anti-inflammatory and a non-opioid analgesic. If your pain persists, take a narcotic analgesic in addition to your regular medication. We cannot predict how long the pain will last, but it should decrease in intensity as your healing progresses.

Depending on the type of surgery, your surgeon will, when needed, renew your narcotic analgesic prescription during your medical leave. Should you require more medication, make an appointment with your family doctor.  

Your stay at Asclépiade is necessary because you will receive the majority of your care and postoperative treatments there. Your convalescence allows you to recover under 24-hour a day surveillance by the nursing staff. If complications arise, your surgeon will immediately take charge of you. Finally, the nursing staff will also teach you all that you will need to know to continue your care yourself when you return home. 

The nurses at the CMC and Asclépiade can provide frontline psychological support and decide with you if additional support is necessary. We do not have any mental health professionals in place in our facility. It is therefore important to maintain contact with health professionals involved with your care and bring their contact information with you.

We highly recommend that you be accompanied by a family member or friend during your stay to support and comfort you during this unique event. Our staff will work with you and your companion to create the most positive experience possible. In addition, the presence of a companion during teaching periods can facilitate the understanding and integration of care into your daily routine. 

At the CMC:

Visiting hours are Monday to Friday from 9 :00 am to 8 :00 pm;

In order to ensure the rest, comfort, and tranquility of all of our clients, we ask you to limit your visitors to 2, 1 visitor at a time in the room. Young children are not allowed to visit;

Visitors are not authorized to enter the operating or recovery rooms;

In order to prevent infections, visitors are not allowed to sit on patients’ beds;

In order to avoid interference with medical equipment, cellphone use is prohibited between 6:00 am and 5:00 pm. Outside of these hours, we ask that you put your device on vibrate, speak quietly, and avoid long conversations.

At Asclépiade:

• Visiting hours are Monday to Sunday from 2:00 pm to 8:00 pm;
• In order to respect the privacy of patients and to prevent infections, visitors are prohibited from entering the rooms;
• Cellphones are permitted at all times but we ask that you put your device on vibrate, speak quietly, and avoid long conversations.

Yes, each room has its own television, and wireless internet service is offered for free. In order to respect the other patients in convalescence, we ask that you bring a pair of earphones with you for your own personal use.

If you wish, you may bring music, your laptop, books, or other forms of entertainment.

Usually, no. All patients who undergo surgery receive a personalized follow-up service by email or telephone to ensure that their recovery, as well as the management of their health, is going well. You will also receive educational guides for your reference at home.

If nursing care at home is required, the Nurse Navigator can make the request for you or communicate with your treating physician about how to ensure the continuity of your care. The GrS Montreal team is always available to work with the health professionals involved in order to facilitate the management of your care.

Once you are back at home, you can communicate with your surgeons through the nurse at Asclépiade.

In case of medical emergency, you must go to the emergency room of your nearest hospital or call the emergency telephone number in your area. The emergency doctor can communicate with your surgeon through Asclépiade so that you can be cared for properly and effectively. The GrS Montreal team is ready to work in tandem with other health professionals involved in your medical care.

For genital surgeries and surgeries of the torso, we recommend that you wait 2 weeks before driving a motor vehicle. After surgery of the torso, you must be able to perform unpredictable arm movements in an unconstrained manner. For genital surgeries, you must avoid placing too much pressure on your genitals, which may cause pain. Once you resume driving, begin with short distances. If you must drive a long distance, make frequent stops to walk a little and to urinate. Walking and emptying your bladder reduces pressure on the genitals.

It is prohibited to drive a motor vehicle after surgery if you are taking narcotic analgesics. 

For more information about the recovery time involved in each surgery, visit the Surgeries section of our website. Your surgeon can provide you with a sick leave letter for your employer and your insurance company.

*Please note that recovery time depends on the progress of your healing and the type of work that you do. Estimated convalescence times are for informational purposes only. 

You can resume swimming when your wounds related to your procedure are completely healed. Normally, it is necessary to plan for a complete healing time of about 4 to 6 weeks.

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

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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.

Breast Reconstruction Awareness Day - BRA-Day

BRA Day is an initiative designed to promote education, awareness and access for women who may wish to consider post-mastectomy breast reconstruction.

Only physicians who are certified in Plastic Surgery are Plastic Surgeons. There is no foolproof way to choose a Plastic Surgeon or to guarantee your results. However, there are a few basics, which can help you to decide.

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

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Transmasculine Transition

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Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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How Long It Takes to Get Gender-Affirming Surgery Across Canada

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In the recent years, transgender health care in Canada has seen dramatic improvements. More provinces have expanded their public healthcare packages to accommodate gender-affirming surgeries, including FTM/N top surgery or genital reconstruction procedures, for gender dysphoria treatment. However, access and availability of transition-related treatments are still far from reach for most members of the LGBTQ+ community because of the long wait times. 

What's the average waiting time to get a gender-affirming surgery in Canada? The country's first study on transgender patients' experiences published in 2017 by researchers from the University of British Columbia revealed it's anywhere from one month to nine years. The results of the study showed frustrating inconsistencies in trans patients' experience across the country.

In this article, we break down the study's key findings to pinpoint where the bottleneck is coming from and what's causing the delay in delivering life-saving surgical procedures for the Canadian LGBTQ+ population .

1. Surgery Readiness Assessment

The application process towards a gender-affirming surgery in Canada is divided into several steps. The first one is a surgery readiness assessment. Whether you are getting a transition-related operation done from a publicly funded or private clinic , a surgical readiness assessment is required by most surgeons to ensure that a potential patient is prepared and will get the best results post-surgery.

According to Trans Care BC , the primary criteria for most types of gender-affirming surgery in British Columbia are:

• Persistent gender dysphoria 
• Capacity to consent to the procedure  
• Medical and mental health conditions are reasonably well-controlled
• Being of the age of majority (In BC, the age of majority is 19. If you're under 19, your surgeon may recommend additional surgery readiness assessment steps).

The Assessment Process

Before even receiving a readiness assessment, the individual needs to follow several processes to qualify for one. This can range from:

Getting referred to an assessor through your primary care provider: 

• They can send a referral for a surgical readiness assessment directly to a qualified assessor, or
• Can send a request to your province's health care office who can refer you to a qualified assessor in your community, or
• They are a qualified assessor who can carry out the assessment themselves.

Depending on the type of gender-reaffirming surgery, one or two assessments carried out by different assessors may be required. Surgical readiness assessments can be covered if they are qualified assessors working in the publicly-funded health care system. You can also have them conducted by qualified private assessors, such as psychologists or clinical counsellors.

Getting assessed:

Once you've been referred, you have to wait for a schedule for your surgical readiness assessment. The actual appointment lasts between one to two hours, where you'll discuss your gender identity , medical history, and surgical aftercare plan . In some cases, you may be asked to come back to provide additional information.

Get a recommendation:

The qualified assessor may or may not recommend you for surgery or recommend you return for further assessment. They would send their recommendation directly to your primary care physician, who will send you a referral for surgery.

Waiting Time for Surgery Readiness Assessment

In British Columbia, most people (60%) easily or very easily got referred to an assessor, and half of these trans people (50%) did not have to spend any money on their assessment appointment(s). 

Half (50%) of the respondents in BC waited 150 days or less between the referral and their most recent surgery readiness assessment appointment. This is in contrast to the average of 180 days other patients in the country reported. However, BC's wait time also had unusual fluctuations, with some people waiting for a single day to as long as 1,825 days or more than five years.

On the other hand, the average wait time between referral and assessment in BC also differed according to the types of gender-affirming surgery planned.

• Vaginoplasty - 212 days
• Labiaplasty - 255 days
• Chest surgery - 318 days
• Orchiectomy - 322 days
• Hysterectomy-336 days
• Tracheal shave* - 364 days
• Phalloplasty- 383 days
• Breast augmentation -572 days
• Facial feminization - 607 days

2. Funding Approval

Data suggests that for all types of gender-affirming surgery in Canada, 71% had their surgery paid for, at least partially, through a government health care plan . The vast majority (93%) only had one source of funding. Almost seven out of 10 Canadians had their transition-related surgery funded with a public health plan, and one in three people said they used their own money as their sole source for surgery funding.

Unfortunately, not everyone receives approval for the life-changing surgery they had in mind. Aside from having an existing medical condition that increases the risk of being on general anesthesia, many hopefuls are deemed ineligible due to two primary reasons:

• Breast augmentation criteria  MSP criteria specifies that the patient should have been on hormone replacement therapy for at least 18 months (unless not clinically indicated) and that there's been less than an AA cup of breast growth or significant asymmetric breast growth greater than one and a half cup size difference. Most respondents feel that these are not enough to make them feel good or feminine enough about their bodies
• BMI (body mass index) Many gender-affirming surgeons have BMI eligibility criteria of 35 and below. They say they will not operate on an individual above this BMI due to hospital or clinical restrictions, clinical safety, and patient results.

3. Waiting for Surgery

After getting approved for funding, the vast majority of participants (84%) said they did not have any problem getting a referral to a surgeon for gender-affirming surgery. More than half (57%) also said they were able to choose the surgeon they wanted.

The average wait time between getting an approval and surgery date was less than 12 months or less for half of the surgeries in BC. In other parts of Canada, the wait time was eight months or less for half the surgeries.

The researchers said each patient's experiences were so diverse, with waiting times ranging from a month up to 108 months or nine years. The longest wait times were reported in the following gender-reaffirming surgeries in Canada:

• Orchiectomy
• Breast augmentation
• Phalloplasty
• Chest surgery

Interestingly, the researchers also noted that 50% of the people taking the survey were currently waiting for their surgery and/or had a scheduled surgery date, and had already been waiting for at least 17 months. Half of the people who were now waiting for surgery but did not have a scheduled surgery date had been waiting 11 months or more when they took the survey.

What's Taking So Long?

Elizabeth Saewyc, one of the lead authors on the study, gave VICE a few valid points regarding what her thoughts were on the potential causes of the long waiting process for accessing gender-affirming surgery in Canada .

• Different training in general physicians and frontline medical staff  
• Saewyc says the wait time during the pre-approval stage could be due to doctors who are clueless about where to begin, contributing to the "lack of clarity in the pathway" and impeding the transition process for trans patients.  
• Capacity issue  
• There's a lack of surgeons and specialists in the field, which is why it takes time before one can get an appointment with, say, a top surgeon. 
• Lack of specialty clinics
• For "bottom" surgeries, like vaginoplasty and phalloplasty, Canadians are limited in choice to only one clinic located in Montreal.

Wait Times Worsened by the COVID-19 Pandemic

The long wait times for gender-affirming surgery in Canada have been exacerbated exponentially by the unexpected arrival of the COVID-19 pandemic. Both public and private hospitals and clinics had to cancel scheduled surgeries and other transition-related procedures to adhere to stringent lockdown restrictions placed in different countries worldwide. Currently, we see many health care providers tackling their backlogs with surgeries booked up to 2022.

The Negative Impact of Long Wait Times

One of the biggest concerns caused by the long wait times in gender-affirming surgery in Canada would be its detrimental effects on the mental health of the LGBTQ+ population , who are already at an increased risk for:

• Depression  
• Obsessive-compulsive and phobic disorders
• Substance use
• Post-traumatic stress disorder
• Suicide and self-harm

This is cemented in a quote by N. Nicole Nussbaum, former president of Canadian Professional Association for Transgender Health and staff lawyer at Legal Aid Ontario, "Trans people are at the highest risk of suicide and self-harm between the period that they've mentally decided to transition and when they complete their medical transition ."

For inquiries about gender-affirming surgery in Canada or to learn more about what an FTM top surgery at McLean Clinic is like , don’t hesitate to reach out to us. A member of our team will be more than happy to answer your questions.

Contact McLean Clinic today!

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Work and Money Under Canada’s Federal Employment Act , employers “shall implement employment equity by identifying and eliminating employment barriers against persons in designated groups”. The four designated groups are women, aboriginal peoples, persons with disabilities, and members of visible minorities. Neither sexual orientation nor gender identity are protected classes. However, transgender Canadians are not without anti-discrimination protections. Gender and sexual minority people are named in and protected by Section 3(1) of the Canadian Human Rights Act . Still, there’s a gap between theory and practice. Egale , a Canadian advocacy group and a leader in research on the nation’s LGBTIQ2S issues, has perhaps the most up-to-date and comprehensive data on this matter. In their 2020 report on workplace discrimination , Egale notes that LGBTIQ2S Canadians continue to face widespread inequity, particularly in terms of access to safe work, and inequity is more pronounced for transgender, Two Spirit, and gender non-conforming people. This is borne out by the Trans PULSE 2011 report on workplace discrimination , which found that just 37% of transgender Ontarians were working full-time, while 20% were unemployed or on disability. The higher rates of un- or under-employment in these populations “are despite having an overall higher rate of qualifications.” A reported 71% have some college or university but approximately half earn $15,000 or less per year. As with the broader community, the effects of workplace discrimination go far beyond wage loss. Employment can provide access to good housing and educational opportunities, as well as benefits like medical, mental health care, and dental coverage, bonuses, paid leave and vacations, and investment power in the form of RRSP contribution room and matching employer contributions. Health Care Canadians enjoy universal healthcare—but just how universal is it? Among the services not covered are prescription drugs, dentistry, and mental health care. For those without employer plans, these expenses can be out of reach, particularly for low income Canadians. The Standing Committee on Health released a report in 2019 on the health of LGBTIQ2S Canadians and found that between 20% and 30% of transgender people who needed emergency services did not go to the ER, and of those who did, 52% had negative experiences. Refusal of service, inappropriate or invasive questions, misgendering, and other forms of discrimination all contribute to a health care system that can be hostile to transgender people. In this context, it’s not surprising that transgender Canadians underuse available health care services. For a more comprehensive discussion of the costs of health care refer to part one  of this series. Specific to the transgender community, there are two aspects of health care worth a closer look: fertility and adoption, and gender affirmation. Fertility and Adoption In addition to adoption and reproductive technologies like intra-uterine insemination (IUI), surrogacy, or in vitro fertilization (IVF), there are fertility preservation strategies for transgender people who have eggs or sperm. For those who have eggs , in addition to IUI or IVF, embryo or egg freezing and storage, prior to hormone therapy (if applicable) may be an option. The costs of this procedure varies by clinic but are estimated to be about $10,000 to extract and $300 per year to store. If and when the time comes to transfer, there is an addition fee of around $2,000. For those who have sperm , banking for future use may a good option. As always, costs vary but the sperm extraction is usually in the neighbourhood of $2,000 with an additional $450 to freeze and around $400 per year to store. There may also be extra handling fees. Gender Affirmation Although medical interventions are only one aspect of the transition process, and not necessary to claim a transgender identity, many trans folks opt for one or all of the following: counselling, hormone therapy, or surgery. Visits with psychologists or clinical counsellors are not covered by basic health care but may be within some employer or extended plans. That said, there some programs across the country, such as Gender Journeys through Sherbourne Health Centre in Toronto, that offer free group sessions for transgender or questioning Canadians. For those without local resources or who want to go the private route, fees for psychologists or counsellors run anywhere between $100 and $300 per hour. Hormone therapies include the administration of testosterone, estrogen, and hormone blockers, all of which are designed to alter secondary sex characteristics such as body hair, voice, and fat distribution. Some Canadians with employer benefits or extended health care plans, or those on disability or social assistance, may be eligible for funding towards their hormone therapies but these are generally an out-of-pocket expense. Gender affirming surgeries include “top surgeries” such as a mastectomy or breast implants and “bottom surgeries” like a hysterectomy, vaginectomy, vulvoplasty, orchiectomy, metoidioplasty, scrotoplasty, and phalloplasty. Coverage for these procedures varies but many are available under provincial health care plans. Extended insurance might broaden the coverage. Other costs to consider that are not typically covered are facial feminization or masculinization procedures, vocal coaching, prosthetics, hair removal, and body contouring. Identity Documentation Should a transgender person want to change their name, it will cost between $100 and $137, depending on province of residence. Afterwards, or in the case of changing a gender marker, they’ll need to update their identification. Again, the fees differ according to location but in Ontario, the cost for a replacement birth certificate is $35. A replacement driver’s license is $35.75. Note: *LGBTIQ2S is an acronym for lesbian, gay, bisexual, transgender, intersex, queer, and Two Spirit. It is uniquely Canadian, and may be understood in place of LGBT+. **In this piece, transgender is used to identify people within the “trans umbrella”. That is, people who identify as transgender, transsexual, genderqueer, non-binary, agender, bigender, and Two Spirit, among other identities of transgender experience. Importantly, a person may claim these identities independent of medical interventions like surgery or hormones, or of legal documentation such as name or sex designation markers.

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Hundreds of trans teens under 18 have had breasts removed in Canada, new data show

Concerns have been raised about mastectomies in teens when uncertainties exist about long-term health effects and the possibility of regret

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As tensions rise over the medical care of trans children, a new analysis shows hundreds of adolescents in Canada have undergone female-to-male “top surgery” — double mastectomies  — over the past five years.

Hospitalizations and day surgery visits for bilateral mastectomies for gender reassignment surgery have risen sharply, from 536 in 2018-19, to 985 in fiscal 2022-23, according to data compiled for National Post by the Canadian Institute for Health Information.

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Of the 4,071 visits in total involving gender-affirming mastectomies or breast reductions reported since 2018, 602 involved youth 18 and under.

Of those, 303 involved teens 17 and younger. The youngest age was 14.

The numbers tell only part of the story. The CIHI data exclude Quebec hospitals as well as surgeries performed in private clinics like the McLean Clinic in Mississauga, which describes its surgeons as “industry pioneers” for top surgery — mastectomies and breast reductions in those assigned female at birth, and breast augmentation for those born male transitioning to female.

One specialist in transgender health issues said that, when applying for OHIP funding for people seeking top surgery, “50 to 70 per cent will go to McLean.”

Female-to-male chest surgery involves removing the breasts to achieve a flatter, more masculinized torso, to better align the person’s physical body with their gender identity and reduce gender dysphoria, defined as the persistent distress that can accompany the incongruence between the gender one identifies with and one’s gender at birth.

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If this was just about ... kids being allowed to wear what they want and say what they want and be called whatever name they want and it stopped there, who would care?

But concerns have been raised about intervening with permanent, body-altering surgeries in adolescents when uncertainties exist about the long-term health effects, the possibility of regret and whether their trans identity will be lifelong.

Last week thousands gathered in cities across the country for duelling protests over gender policies in schools. Earlier this month delegates to the federal Conservative party’s policy convention voted 69 per cent in favour of prohibiting “life altering medicinal or surgical interventions” on minors under 18 to treat gender confusion or dysphoria.

Sweden, the world’s first country to authorize legal gender transitions in 1972, last year began limiting mastectomies for teenage girls to research settings. “The uncertain state of knowledge calls for caution,” the head of Sweden’s National Board of Health and Welfare said in a statement reported by AFP.

Public coverage for the surgeries varies from province to province. Most cover the cost of the mastectomy itself, but not several thousand dollars or more in extra add on fees for “chest contouring,” liposuction procedures to give the body a more sculpted, masculine look.

The rise in surgeries reflects a dramatic shift in the sex ratio of children and teens being referred to specialized gender identity clinics across the country, from once predominantly young boys to children born female.

One study involving 174 trans and non-binary children and teens referred to 10 gender identity clinics in Canada found 34 per cent of those assigned female at birth were referred for top surgery. Most were 15 or 16 at the time of referral.

Ontario’s Health Ministry declined to respond when asked the number of OHIP approvals for gender-affirming mastectomies in the most recent year available, including the proportion in youth. The McLean Clinic said its surgeons were unable to accommodate a request for an interview.

According to CIHI, of the 536 hospital visits for transgender reassignment mastectomies in 2018-19, 76, or 14 per cent, involved 18-year-olds and younger.

That age group accounted for 18 per cent of visits for mastectomies (174 out of 991) reported in fiscal 2021-22, and 14 per cent of visits (135 out of 985) in 2022-23.

The percentage dipped last year as hospitals grappled with pandemic-driven surgical backlogs. “But the private clinics just kept churning them through,” said one doctor familiar with trans medicine who requested anonymity fearing professional repercussions.

“The fact that you can’t get the numbers from private clinics…. It’s very cloak-and-dagger,” the doctor said. “They’re still billing OHIP. That’s tax dollars. That should be publicly accessible information. We need to see these numbers and ask questions,” the doctor said.

“If this was just about the schools, and just about kids being allowed to wear what they want and say what they want and be called whatever name they want and it stopped there, who would care? But medicine got involved.”

For a double mastectomy, typically two incisions are made on the bottom border of the pectoral muscle or chest area, according to the McLean Clinic’s website. “The skin is then lifted to surgically remove the breast tissue underneath.” The nipples are removed, re-sized and repositioned by grafting “to suit the new masculine appearance of the chest.”

It’s a day-surgery procedure performed under general anesthesia that takes approximately two hours. Complications can include bruising, wound infections and scarring. People lose nipple sensation as well as the ability to breastfeed should they become pregnant.

The uncertain state of knowledge calls for caution

Major medical groups like the American Academy of Pediatrics have strongly endorsed a gender-affirming approach to care to promote “optimal physical, mental and social wellbeing.” Eligibility for gender-affirmative surgeries in teens should be determined on a case-by-case basis, the AAP said in a 2018 policy statement the organization recently reaffirmed, while at the same time calling for a review of the evidence to develop an “expanded set of guidance.”

The growth in referrals to specialized clinics could be due to greater awareness and social acceptance, and the teaching of gender identity in school, experts said. But it’s not clear why it’s concentrated in children and teens born female.

Denying or holding back access to gender-affirming care “can have negative consequences for some youth,” SickKids in Toronto said in a statement. “Decisions for care should be made by youth, their families and their health-care providers, who are best-positioned to support them.”

Trans teens are known to be at higher risk of harassment and cyberbullying, wrote the authors of a recent review on the surgical and ethical considerations of gender affirming surgery in teens. Early access to surgery may reduce the bullying, they said, or help facilitate “age-appropriate romantic and sexual development in adolescents who may otherwise be prevented from engaging in these activities due to gender dysphoria.”

But the evidence is largely anecdotal, they said. The handful of published studies on surgery in minors involved relatively short follow-up periods.

“What we do know is that regret does take place, and it does take place later on in life,” said one trans medicine specialist, who also agreed to speak on the condition of anonymity for fear of being labelled “transphobic.”

“If we know that people can come to this realization that maybe this may have not been the best decision for them, if that takes place after five years or 10 years, we don’t have all the information to allow patients to make an informed decision.”

For such a permanent decision as the removal of healthy breasts, “I’m always looking at the why, and because that hasn’t been answered yet, that’s what leads to my ambivalence,” the specialist said.

“What all this says to me is that we need to be much more thoughtful in our approach and in our assessments.”

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How gender-affirming health care for kids works in Canada

Transgender youth and their health-care providers say the field is widely misunderstood.

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Robyn Hodgson says she's watched struggling young people heal, grow and ultimately thrive because of gender-affirming health care. 

"It genuinely is profound," Hodgson, a registered nurse and co-ordinator for the transgender and non-binary program at the InterCommunity Health Centre in London, Ont., said. 

"I'm in my 27th year, and I've worked in a lot of areas — and this has been the most rewarding area that I've ever worked in."

Gender-affirming health care — an approach that affirms a trans person's gender identity instead of trying to change it — is endorsed by medical associations in Canada and around the world, including the Canadian Psychological Association and the Canadian Pediatric Society.

But it's also a type of health care that's widely misunderstood, especially as it pertains to the treatment of young people, say the medical professionals who provide it and the patients who receive it. 

• CBC Kids News Explaining gender-affirming care to kids

"So many people make uninformed opinions," said Silas Cain, a 16-year-old transgender boy receiving gender-affirming care in Saskatoon. "They see a headline or they hear one person talking about it and they take it as fact, which is harmful in so many different contexts."

Here's what transgender youth, their caregivers and their health-care providers want you to know about what affirming care actually looks like for young people in Canada. 

How does it work?

Affirming care ranges from social and psychological support, like using someone's chosen pronouns; to transition-related medical treatments, such as puberty blockers and hormones, or gender-affirming surgeries.

Hodgson likens it to how society accommodates people who are left-handed.

"We've tried changing handedness in the school system, and people were struck in the knuckles with rulers," she said. "Trying to force people to live in a shell that is absolutely foreign to their experience is equally difficult."

What it’s like to fight for health care as a trans teen

Forcing kids into genders they don't identify with can have negative impacts on their well-being, says Rhea Mossman Sims, a nurse practitioner at Trans Health Klinic in Winnipeg.

"They can have a significant decrease in their self-esteem and they can also have a significant decrease in their general mental health, and there is a potential for suicidality," she said.

Do kids get medical treatment before puberty?

Canadian health-care providers broadly follow the World Professional Association for Transgender Health (WPATH) standards of care, which has guidelines for patients at different stages of their development.

For kids who haven't hit puberty, affirming care means letting them explore their gender in a supportive environment. That can mean using different pronouns, trying out a new name, or letting them pick different clothes or try a new haircut. 

"There is nothing medically that is done in a child [before signs of puberty]," Hodgson said.

For Cain, that started not at a health clinic, but at school when he found teachers who supported him as he explored different labels. 

"Trying out different pronouns and different names was affirming care for me at that time," he said. "Having a space to experiment is so important and so vital."

Can minors get surgery?

Surgical options, Hodgson says, aren't considered until "very, very late in care" — and almost never for patients under 18. 

"I can tell you, internationally, I do not know anybody that will perform any type of genital surgery on anyone under 18 years of age."

In some very rare cases, she says, older teenagers may be eligible for chest surgery — also known as top surgery — but only if they've already had "a significant duration of care," she said.

Are kids rushed into treatment?

Before puberty blockers or hormone therapy can be considered, WPATH guidelines recommend that all youth be assessed by a qualified health-care professional who has studied psycho-neurodevelopment in adolescence.

"I think that there is this assumption that people are rushing into medical care and there's no thoughtful contemplation or support," Hodgson said.

"It certainly hasn't been the experience of any of the providers that I know that are doing this care, nor of the trans population that's accessing care."

• Trans teens and youth say gender-affirming care is 'life-changing.' So why is it so hard to find in Canada?

Since 17-year-old Seelie Romard of Sydney, N.S., first started seeking gender-affirming treatment in 2021, he says he's visited a pediatrician, a physician who specializes in gender care, and a psychologist — all before being put on a waitlist for testosterone. 

"It took a really long time … just to make sure that I was, like, OK mentally, that I was in the right place, that I was informed," Seelie said. 

What are the effects of puberty blockers?

Patients in the early stages of puberty may be prescribed puberty blockers, which slow the pituitary gland from stimulating secondary sex hormones, putting puberty on pause.

"One of the nice things about blockers is that they can give you some time to continue to explore, rather than having to go through the puberty changes that would happen otherwise," Dr. Tania Culham, a physician with Trans Care B.C., said. 

Some countries have placed restrictions on puberty blockers until their long-term effects can be better studied.  England has restricted their use to minors enrolled in clinical trials , and the Norwegian Healthcare Investigation Board has recommended they be considered "exploratory" and "experimental."

Culham says they are widely considered safe, noting they have been used for more than 40 years to treat precocious puberty — puberty that starts too early — and about 20 years for transition-related care.

Some research has linked them to decreased bone density over time , so providers may limit how long a patient takes them, Sims said. Doctors also supplement treatment with vitamins and dietary guidance for bone health, Hodgson and Culham said.

Patients can pull the plug any time, Culham said, and their regular puberty will resume.

"The whole point of the puberty blocker is that they are reversible," Culham said.

What are the effects of hormone therapy?

Adolescents further along in puberty may consider taking estrogen or testosterone to help develop sex characteristics that better align with their identities. 

Cain started testosterone in July and says it's already having enormous benefits for his health and well-being. 

"Pretty much everyone that I've talked to — my teachers, my therapist, doctors — they all say that I look so much happier now than I did before," he said. "And I definitely feel much happier than I was before."

Because hormones can have long-term effects on fertility , Sims says health-care providers don't prescribe them until a patient has shown a persistent desire to transition, been fully informed about the side effects and been offered a chance to have their sperm or eggs preserved for future use.

"These decisions, in general, are not taken very lightly," she said.

How involved are parents?

According to WPATH, parents should be involved in decisions to pursue medical treatments whenever possible. In fact, Culham says a "family-centred care" leads to better outcomes in all pediatric care.

"As hard as it is sometimes for people to come out to their parents or caregivers or have these conversations, I know a lot of youth take a lot of great care bringing their families, parents, caregivers along," she said.

But that's not always possible. In Canada, under the Convention on the Rights of the Child and Children's Participatory Rights , some people under 18 may be designated "mature minors," capable of making their own health-care decisions.

That's how Tristen Roscoe, 17, of Halifax was able to access testosterone.

"I did tell her about it, but my mom wasn't happy," he said. "She didn't have to, like, sign anything or give the OK, which was good because I don't think she would have."

Roberta Cain, mother to 16-year-old Silas, says helping her son navigate the health-care system has been a "a real balancing act" between respecting his privacy and making sure she has the information she needs to support him. 

Ultimately, she says, it's worth it.

"My feeling is that the staff involved want the best for the kid," she said. "There's no other agenda than that."

ABOUT THE AUTHOR

Sheena Goodyear is a web journalist with CBC Radio's As It Happens in Toronto. She is equally comfortable tackling complex and emotionally difficult stories that hold truth to power, or spinning quirky yarns about the weird and wonderful things people get up to all over the world. She has a particular passion for highlighting stories from LGBTQ communities. Originally from Newfoundland and Labrador, her work has appeared on CBC News, Sun Media, the Globe & Mail, the Toronto Star, VICE News and more. You can reach her at [email protected]

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 Location:  University of Alberta Hospital

The service is an innovative program which offers a multidisciplinary approach to the diagnosis and management of Gender Dysphoria. It provides comprehensive assessments and facilitates gender-affirming interventions to help individuals lead full comfortable lives.

This service offers:

• psychiatry, endocrinology, pediatric and adolescent medicine, and nursing support
• referrals to surgery and other specialties
• information about supports available in the community

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Monday 8:00 am - 4:30 pm

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Wednesday 8:00 am - 4:30 pm

Thursday 8:00 am - 4:30 pm

Friday 8:00 am - 4:30 pm

The program helps persons across the age spectrum who feel that their assigned sex at birth is misaligned with their lived gender (transgender and nonbinary individuals).

Referral forms are available by email [email protected] .

Return the completed form by email or fax.

Healthcare providers should consult the Alberta Referral Directory for service referral information.

Pediatric wait time 12 - 24 months as of September 2022

Adult wait time 4 - 8 months as of September 2022

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Dr. Krista Genoway, MD, FRCSC is a board-certified plastic and reconstructive surgeon in Vancouver, Canada. After completing medical school and a plastic surgery residency at the University of British Columbia, Dr. Genoway completed fellowship training in microsurgery with a focus on gender-affirming surgery at the world-renowned Buncke Clinic in San Francisco , California.

Dr. Genoway started performing gender-affirming Breast Augmentation and Top Surgery in Vancouver in 2016, followed by Vaginoplasty and Phalloplasty when the Gender Surgery Program B.C. launched in September, 2019. She also serves as a clinical instructor in the Department of Surgery at the University of B.C. and is on staff within the Vancouver Coastal Health system.

Detailed information about this provider is not yet available.

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Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

The 14th Amendment to the Constitution is truly a magical amendment. It was used to justify attempts to kick Donald Trump off the 2024 ballot. Through the decades, judges who want to play at social engineering have used it frequently to justify questionable law. 

It's even been invoked to bypass Congress to raise the debt limit.

Now, the Fourth Circuit Court of Appeals has decided that the amendment's "equal protection" clause means that state Medicaid programs have to cover gender reassignment surgeries.

The appeals court ruled that West Virginia's Medicaid rules on mastectomies are unconstitutional because they violate the "equal protection standard" by not covering mastectomies for gender dysphoria.

Yes, really.

The ruling also includes a North Carolina Medicaid case that the state government won't cover "sex changes." The Fourth Circuit nullified the state ban on gender change surgeries, citing the 14th Amendment’s guarantee of “equal protection of the laws.”

This was a court looking for an excuse to make law.

Judge Roger Gregory who wrote the majority opinion in Kadel v. Folwell (8-6) asked, “Is removing a patient’s breasts to treat cancer the same procedure as removing a patient’s breasts to treat gender dysphoria?” He continued, “There is no case law to ground this discussion nor obvious first principles.”

Wall Street Journal:

He is undeterred, and he concludes that gender dysphoria and transgender status are intertwined, so that such insurance exclusions are nothing more than a proxy for discriminating against gender identity. Then he goes further, finding that West Virginia’s and North Carolina’s policies also unconstitutionally discriminate based on sex. How so? Imagine, Judge Gregory says, an unidentified patient seeking a vaginoplasty. Is this a biological female with a rare birth defect? Is it a transgender patient? “By virtue of the fact that they are seeking a vaginoplasty, we know that they were born without a vagina,” he writes. “But we do not know what sex they were assigned at birth. Without that information, we cannot say whether the Plan or Program will cover the surgery.” Ergo, sex discrimination.

Gregory gets even nuttier.

The differences in coverage "is rooted in a gender stereotype: the assumption that people who have been assigned female at birth are supposed to have breasts, and that people assigned male at birth are not."

It's not a "gender stereotype." It's a biological fact. 

"No doubt, the majority of those assigned female at birth have breasts, and the majority of those assigned male at birth do not. But we cannot mistake what is for what must be.”

Not just a "majority." It's a universal biological fact with a tiny number of exceptions.

Treating different things differently doesn’t violate the 14th Amendment’s Equal Protection Clause, and jurists aren’t supposed to ignore the obvious. Writing in dissent at the Fourth Circuit, Judge Julius Richardson struggles to contain his exasperation. “The states,” he says, “have chosen to cover alterations of a person’s breasts or genitalia only if the person experiences physical injury, disease, or (in West Virginia) congenital absence of genitalia.” That determination does not turn on the patient’s sex or gender. “Christopher Fain—one of the plaintiffs below—received coverage for a hysterectomy based on a diagnosis unrelated to Fain’s transgender status,” the dissent says. Likewise, males with gynecomastia qualify for surgery coverage in West Virginia only “if they have physical symptoms, like breast pain,” meaning that isn’t a procedure done merely “to affirm a patient’s biological sex.”

The ruling that opened this can of worms was Bostock v. Clayton County, a case that "held that Title VII of the Civil Rights Act of 1964 protects employees against discrimination because of  sexuality or gender identity." Now, as a dissenting judge in Kadel v. Folwell,  Judge J. Harvie Wilkinson III is saying that this ruling could be a Roe v Wade  ruling for the transgender community.

“This is imperial judging at its least defensible,” he says, “What plaintiffs propose is nothing less than to use the Constitution to establish a nationwide mandate that States pay for emerging gender dysphoria treatments.”

He's not wrong. But getting the ruling past this Supreme Court would be a stretch. 

Rick Moran has been writing for PJ Media for 18 years. His work has appeared in dozens of media outlets including the Washington Times  and ABC News. He was an editor at American Thinker for 14 years. His own blog is Right Wing Nut House . For media inquiries, please contact [email protected] .

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