gender reassignment surgery cost canada

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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• Inside Pride homepage

Gender-affirming health coverage by Canadian province, territory

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Gender and gender expression is incredibly individual and the healthcare needs of folks along this spectrum are just as varied and diverse.

There are generally three areas of transition: social (which may include coming out, using a different name, a different pronoun, changing style of dress, or using gender-affirming products like binders or pads), medical (which may include hormone therapies, hormone blockers and/or gender-affirming surgeries) and legal transition (which may include legally changing name, changing gender marker listed on legal documents and changing legal documents to reflect appropriate titles).

For instance, some transgender, intersex or gender diverse Canadians may require surgery to feel as though their true gender matches their external body. Others may need hormones or hormone blockers. Others may need laser hair removal or binders.

The World Professional Association of Transgender Health ( WPATH ) has standards of care but there is not a standard for coverage and prerequisites across Canada.

FULL COVERAGE:  Inside Pride

The ability for Canadians to access gender-affirming healthcare — including coverage, requirements and wait times — is different depending on what province/territory they live in and also whether they reside in urban or rural areas.

Yukon is considered the “gold standard” by advocates; the territory reduces the number of specialists required to sign off on procedures, removes the pathologizing term and requirement of a “gender dysphoria diagnosis,” and offers public health coverage for residents requiring rarely covered gender-affirming procedures like facial feminization, laser hair removal or tracheal shaves.

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All provinces and territories, for instance, provide health coverage for genital sex re-assignment surgery but most health departments require a psychiatrist and another “expert” to approve and refer for the procedure. Wait times for psychiatrists can be years-long in some communities.

Most provinces and territories require documented “gender dysphoria” for gender-affirming treatment, including access to hormones and any type of gender-affirming procedure. The International Classification of Diseases removed gender diversity from its list of psychiatric diagnoses, and it is no longer considered a psychiatric disorder.

Most provinces and territories do not offer coverage for mental health supports, including appointments with the required psychiatrists or experts.

While gender-affirming genital surgery is covered by most provinces/territories, there are only three clinics in which these procedures can be done: a private clinic in Montreal, Centre Metropolitain de Chirurgie , a small public clinic that’s part of the Women’s College Hospital in Toronto , and the Gender Surgery Program B.C. , a public clinic in B.C. (which only treats B.C. and Yukon residents).

British Columbia

Patients must work with primary care provider to have one or more surgical readiness assessment(s) completed with a qualified surgical assessor. Depending on the surgery, their primary care provider sends a referral, including completed readiness assessment (to urologist for orchiectomy; to obstetrician or gynecologist for hysterectomy and bilateral salpingo-oophorectomy), consultation with surgeon, and funding must be approved prior to surgery. 

• Chest construction (including reduction)
• Orchiectomy
• Hysterectomy with bilateral salpingo-oophorectomy
• Vaginoplasty
• Vulvoplasty
• Clitoral release
• Metoidioplasty
• Phalloplasty
• Travel Assistance Program for provincial travel assistance for services not available in own community
• Expenses for out-of-province surgical aftercare if medically required
• Psychiatry services
• Vocal feminization program (via free Changing Keys program)

CONDITONALLY/PARTIALLY COVERED:

• Breast construction/augmentation (reviewed on case-by-case basis and funded in some circumstances)
• Hormone therapy (coverage under Fair Pharmacare or other PharmaCare plans such as Plan C, which covers drug costs for those receiving income assistance; or coverage can be requested through Special Authority; or through an employer benefit plan)
• Those with PWD coverage can get binders, packers, breast forms with prescription/letter from MD or NP

NOT COVERED:

• Facial procedures like reduction of Adam’s apple, nose feminization, facial bone reduction, face lifts, rejuvenation of eyelid
• Pectoral implants
• Hair removal; hair reconstruction or restoration
• Liposuction or lipofilling
• Voice surgery
• Psychologists, social workers and registered clinical counsellors (work benefits, private insurance, some community organizations offer limited free counselling)
• Travel and accommodation costs to and from surgical centres (BC or MTL)
• Supportive garments and wound care supplies
• Other travel related costs like insurance or accommodation

Alberta Health provides funding for eligible Albertans diagnosed with gender dysphoria who meet program criteria for phalloplasty, metoidioplasty and vaginoplasty (provided at Centre Metropolitain de Chirurgie in Montreal). This program is available to Albertans who are diagnosed with gender dysphoria by two physicians (including psychiatrists) licensed in Alberta and who meet program criteria, which are based on World Professional Association of Transgender Health standards of care. Two licensed Alberta physicians (including psychiatrists) must apply for this funding on behalf of a patient and funding applications are reviewed upon receipt. “Top surgery” is an insured service under Alberta’s Schedule of Medical Benefits. Patients are referred by their primary care provider to an Alberta surgeon.

• Hysterectomy and ovary removal
• Breast augmentation and mastectomy (patient must get pre-approval from Alberta Health, must get surgeon or primary care provider to validate eligibility, patients must have one independent assessment by a psychiatrist or other physician with expertise, and be diagnosed with gender dysphoria.)
• Voice therapy

CONDITIONALLY/PARTIALLY COVERED:

• To qualify for breast augmentation as an insured service, patient must have “little to no breast growth as directly determined by the surgeon.”
• There are multiple hormone replacement therapy products available for transgender health on the Alberta Drug Benefit List (ADBL) for patients on government sponsored drug plans (Medroxyprogesterone, progesterone, conjugated estrogens, estradiol 17 B and testosterone). Endocrine therapies, such as gonadotropin releasing hormone therapy (GnRH), are available on the ADBL (leuprolide, goserelin and buserelin).
• Alternatives to GnRH therapy, such as spironolactone, are listed as an open benefit on the ADBL and available to transgender Albertans. Many of these products are an open benefit; however, some testosterone products and GnRH medications require a special authorization form to be completed by a prescriber, and special authorization criteria to be met, in order to be considered for coverage.
• Facial feminization
• Tracheal shave
• Voice pitch surgery
• Non-medical interventions like laser hair removal or electrolysis
• Take-home medications and equipment
• Personal expenses, meals and accommodation

Yukon Insured Health Services expanded coverage in 2021 to include “comprehensive list of surgeries and other procedures” for the trans and gender diverse community, in accordance with WPATH standards.

“Last year, we expanded Yukon’s healthcare to cover surgeries and other procedures essential to gender transition. The new policy was recognized at that time as the most comprehensive health coverage for gender-affirming care in North America,” a government spokesperson told Global News.

To receive coverage, patients must have gender dysphoria and a referral from a mental health provider. A medical practitioner (including a nurse practitioner) can prescribe hormone therapy.

• Hormone therapy (medical practitioner must apply to benefits program on behalf of patient)
• Hysterectomy
• Salpingo-oophorectomy
• Chest contouring
• Body contouring
• Hair removal
• Medical and travel costs
• Facial feminization surgery ($30K-$50K)
• Vocal surgery
• Mental wellness services (through All Genders Yukon Society)
• Training for healthcare professionals (at no cost) to provide compassionate and culturally sensitive WPATH gender-inclusive care

PARTIALLY/CONDITIONALLY COVERED:

• Counselling services

Northwest Territories

In order to have gender-affirming procedures covered, patients must have well-documented gender dysphoria, assessment(s) by a clinical expert(s) and have 12 continuous months on hormone therapy (to qualify for coverage for genital surgeries). The diagnosis of gender dysphoria can be made by a primary care practitioner with “extensive experience or formal training in gender care.” A primary care practitioner who does not have extensive experience or formal training in gender care may refer the patient to a clinical expert to confirm the diagnosis.

• Breast surgery (augmentation) only covered when deemed medically necessary (when there failure to respond to hormone therapy or a congenital breast abnormality. Only few patients will fulfil these eligibility criteria)
• Outpatient medications, equipment/supplies (i.e. dressings, dilators)
• Meals, accommodations, and personal expenses
• Psychotherapy
• Fertility preservation techniques
• Liposuction/lipofilling
• Electrolysis/laser hair removal
• Cosmetic procedures arising from the original surgery to improve appearance

To be eligible for transition-related services, Nunavut residents must have well-documented gender dysphoria, diagnosed and confirmed by a clinical expert, be assessed and referred by a clinical expert, and a surgical readiness assessment must be completed by a clinical expert. Some procedures have additional eligibility criteria. 

• Mental health services
• Chest surgery/contouring (requires surgical readiness assessment and referral from clinical expert)
• Breast augmentation (requires surgical readiness assessment, referral from clinical expert, and patient must be on feminizing hormone therapy for continuous 12 months)
• hysterectomy
• vaginoplasty
• phalloplasty
• Genital reconstruction (requires two surgical readiness assessments by clinical experts, patient must be on hormone therapy for continuous 12 months, and patient must be living in gender role congruent with gender identity for 12 continuous months)
• Hormone therapy (covered and can be prescribed by a physician or a nurse practitioner).
• Liposuction/body contouring
• Hair transplantation
• Voice training
• “Cosmetic” surgical revisions

Saskatchewan

Prior approval is required for coverage of gender-affirmation surgeries. Saskatchewan Health may cover up to 100 per cent of physician costs associated with some out-of-province procedures. Surgical interventions may be considered at the determination of the treating psychiatrist. The psychiatrist must contact one of the recognized authorities (list of eight Saskatchewan and Alberta doctors or Ontario Centre for Addiction and Mental Health). Saskatchewan residents can be referred to an in-province specialist for most common surgeries, such as a hysterectomy or mastectomy. Any physician or nurse practitioner can prescribe hormone therapy.

• Oophorectomy
• Vaginoplasty (with or without vaginal canal)
• Some hormones (those listed on Saskatchewan Formulary are eligible for co-pay for those with active provincial health card)
• Breast augmentation
• Body sculpting surgeries (implants, liposuction and other procedures)
• Facial feminization surgery
• Facial hair removal
• Laryngeal Chondroplasty
• Travel and accommodation costs
• Certain hormone therapy drugs
• Voice training/Voice pitch surgery

Manitoba requires a medical diagnosis of gender dysphoria for gender-affirming procedures, including hormone therapy. Covered surgeries require references from both medical and psychiatric experts. There are currently 14 mental health professionals (11 for adults and three for youth) of providers approved by to submit gender-reassignment surgery cases. If available, gender-affirming procedures are done in Manitoba. If not, they’re referred to another jurisdiction. For hormones, medical regulatory bodies determine who can prescribe hormone therapy and it may require consultation with a specialist.

• Chest masculinization
• Hysterectomy and oophorectomy
• Feminizing voice therapy
• Laser hair removal
• Breast augmentation (on a case-by-case basis)
• Hormone therapy (may be applicable for support as a non-insured benefit subject to the person’s eligibility for the Manitoba Pharmacare Program, or through a personal third-party insurance coverage.)

If a clinician is seeking services that are excluded by legislation and or regulation and/or do not meet the current standard of practice for the medical condition, the department, on a case-by-case basis, will seek independent medical advice in determining if such is an insured service. If a person feels that such a decision is not aligned to Manitoba’s legislation or regulations, they are permitted to bring forth a case through the Manitoba Appeals Board., which is independent of the department of Health.

• Electrolysis

Primary care providers can diagnose for gender dysphoria, prescribe hormones (nurse practitioners can also prescribe hormone therapy), refer for transition-related surgeries. Since 2016, any qualified provider can refer for transition-related surgery. Physicians, psychiatrists and endocrinologists can self-identify as a qualified provider.

• Assessment for hormone therapy
• Counselling
• Augmentation mammoplasty or mastectomy
• Private clinic stay and/or ministry-approved services outside Canada
• Clitoroplasty
• Labiaplasty
• Vaginectomy
• Testicular implants with scrotoplasty
• Penile implant
• Hormones (patients covered by Ontario Drug Benefit program can get injectable testosterone covered with submission of Exceptional Access Form)
• Anti-androgen and estradiol covered without EAP approval
• Chest contouring/masculinization
• Liposuction
• Hair transplants
• Voice modification surgery
• Chin, nose, cheek or buttock implants
• Facial feminization/masculinization
• Travel involved in obtaining surgery

Quebec residents with public health insurance plan RAMQ are covered for gender reassignment surgery and treatments if a doctor determines surgeries/treatments are necessary, at least one evaluation by a psychiatrist or clinical psychologist, two letters of reference from a psychiatrist, psychologist, sexologist, endocrinologist or family doctor.

• Double mastectomy with reconstruction
• Hormone therapy

An endocrinologist determines the hormone therapy regiment for the patient and a family physician may oversee ongoing treatment. For gender-affirmation surgeries , an assessment must be done by WPATH-trained staff and then a prior approval is obtained from Medicare for coverage. Patients must receive a diagnosis of gender dysphoria and receive signed letters from one to three psychiatrists. Any psychiatrists with WPATH training can do this. Once the request is approved, a surgical plan is put in place by the attending professionals.

• Mastectomy with chest masculinization (for trans-masculine patients)
• Vaginoplasty (including: penectomy, orchidectomy, construction of a vaginal cavity and the vulva)
• Vaginectomy, hysterectomy, salpingo-oophorectomy
• Mastectomy (with chest masculinization)
• Phalloplasty, erectile and testicular implants.
• Breast augmentation (for trans-feminine patients)
• Tracheal shaving
• Travel, accommodation or medications prescribed outside of hospital
• Voice and communication training
• Cosmetic surgical revisions

Nova Scotia

Gender-affirmation surgery (sex-reassignment surgery) is an insured benefit in Nova Scotia . An assessment by a physician, specialist, nurse practitioner, or healthcare professional with required competencies to assess, refer and treat gender dysphoric patients is required for coverage.

• Oophorectomy (only available in NS)
• Breast reduction
• Chest masculinization/mastectomy (in NS or Montreal Centre)
• Metoidplasty
• Vaginoplasty (only available at Centre Metropolitain de Chirurgie in Montreal)
• Counselling and psychotherapy is funded when provided in public institutions
• Hormone therapy is funded when provided in public institutions

Prince Edward Island

Any family doctor or nurse practitioner can prescribe hormone therapy. Patients can also be referred to the Gender Affirming Care clinic for hormone therapy. Access to gender-affirming care in PEI does not require a diagnosis of gender dysphoria. For surgery to be covered, patients must have a referral from a healthcare provider and must get pre-approval from Health PEI .  As of June 2021, Health PEI’s Gender Confirming Surgery Policy is under review. 

• Mastectomy with chest masculinization
• Erectile/testicular implant
• Scrotoplasty

PARTIAL/CONDITIONALLY COVERED:

• Hormone therapy (per the provincial drug formulary or as per a patients’ private insurance policy)

Newfoundland and Labrador

As of November 2019, health care providers who meet WPATH credentials can provide patients with surgical readiness assessments. Physicians and nurse practitioners with or without WPATH credentials can request transition-related surgery prior approval for funding. A psychiatric diagnosis of gender dysphoria is not required. Physicians and nurse practitioners can prescribe hormone therapy.

• Breast augmentation (when no breast development for 18 months of hormone therapy)
• Mastectomy with chest masculinization (excluding implants and liposuction)
• Vaginoplasty (includes orchiectomy, penectomy, labiaplasty, clitoroplasty; with or without construction of vaginal cavity)
• Phalloplasty (includes urethroplasty, scrotoplasty, vaginectomy, and insertion of testicular and approved penile implants)
• Insured out-of-province procedures not available in NFLD, at publicly funded facility, with prior approval
• Travel to access out-of-province procedures (airfare, accommodation, meals and local transportation. Some restrictions may apply)
• Hormone therapy may be covered through the Newfoundland and Labrador Prescription Drug Program. NLPDP covers eligible prescription medications for those who are an eligible Medical Care Plan (MCP) beneficiary.
• If the prescription is on the special authorization listing, a physician would have to apply for the product through the NLPDP special authorization process.

GENDER-AFFIRMATION SURGICAL PROCEDURES:

Phalloplasty: Creates penis (using grafting of tissue), scrotal sac and testes. It involves neophallus, urethroplasty (creation of urethra), vaginectomy (removal of the vagina or closure of vagina), glansplasty (creation of glans penis), scrotoplasty (creation of scrotum and insertion of testicular implants), and insertion of erectile device, if desired.

Vaginoplasty: surgery to create a vagina and vulva (including mons, labia, clitoris and urethral opening) and remove the penis, scrotal sac and testes.

Clitoral Release: a penis is created with the enlarged clitoral tissue.

Hysterectomy: removal of the uterus

Bilateral Salpingo-Oophorectomy (BSO): r emoval of both fallopian tubes and removal of both ovaries

Bilateral Salpingectomy: removal of both fallopian tubes

Bilateral Oophorectomy: removal of both ovaries

Metoidioplasty: a penis is created with the enlarged clitoral tissue. The urethra is extended to the tip of the penis.

Orchiectomy: removal of the testes (testicles) and spermatic cord.

In the month of June, Global News is exploring deeper issues related to the 2SLGBTQQIA+ community in our series,  Inside Pride , which looks at the importance of the acronym and the labels it represents.

Gender-affirmation surgeries: Summary and definition by Emily Mertz on Scribd

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Transition-Related Surgery

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

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

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

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

Provincially Funded Transition-Related Surgeries

Disclaimer: this section uses medical terminology.

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

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

For “Assigned Male at Birth” individuals:

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

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

For “Assigned Female at Birth” individuals:

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

Eligibility

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

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

Not Covered

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

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

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

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

The Referral Process

Step 1: Connect with Qualified Providers. 

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

Who is a qualified provider? 

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

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

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

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

Step 3:  Complete the Prior Approval Form

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

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

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

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

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

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

Step 4: TRS Referral Letter Sent to TRS Surgeon 

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

Step 5: Complete TRS and After Care 

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

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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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Find Healthcare

Programs & services, gender program, the.

 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

University of Alberta Hospital

Parking and Public transportation available

Parking map

Monday 8:00 am - 4:30 pm

Tuesday 8:00 am - 4:30 pm

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

Contact Details

Related info.

More female doctors in the operating room could improve patient outcomes: study

Female doctor focus for better care, not just equity and justice.

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Ontario hospitals with more than 35 per cent female surgeons and anesthesiologists had better patient outcomes, including fewer deaths, in the following three months after their surgery, according to a new study in Wednesday's British Journal of Surgery .

"It's not only about equity and justice," Dr. Julie Hallet, one of the researchers, said in an interview. "It's really about increasing performance and providing better care, which is really what we should all strive towards." 

Overall, female surgeons performed 47,874 (seven per cent) of all surgeries in Ontario from 2009 to 2019. Female anesthesiologists treated patients in 192,144 (27 per cent) of operations.

Reaching critical mass in the OR

In industries ranging from finance to technology to law, gender diversity is considered a way to improve team output, thanks to the range of experiences and viewpoints each person brings. But less is known about the operating room.

To find out more, Hallet, an associate professor of surgery at the University of Toronto, and her team from Vancouver, Ottawa, Montreal and Laval, Que., looked back at a decade of administrative health-care data from more than 709,000 surgeries at hospitals across Ontario for adults having major elective surgeries including cardiac, orthopedic and gastrointestinal.

More women doctors in ORs could lead to better patient outcomes, new study suggests

The researchers said the new study builds on past work  in 2023 from another team, which looked at individual doctors and patients, by now considering entire hospitals.

Hospitals that reached the 35 per cent critical mass saw a three per cent reduction in patients' post-operative major complications, including death and admission to intensive care, after 90 days.

The association was even stronger when patients were treated with both female surgeons and anesthesiologists, they said.

Researchers from the United States, Italy, Australia and Japan have also observed better outcomes in other industries once teams had 35 per cent female members.

The number of female anesthesiologists and surgeons in Ontario rose by only five per cent over 10 years, according to the study. Half the hospitals included in the study didn't reach the 35 per cent threshold or critical mass of women in 2019. 

Hallet said the small increase shows there's a lot of work to do.

The study's authors said they were only able to consider assigned sex at birth. 

Free to share perspectives 

Dr. Saroo Sharda, associate dean of equity and inclusion at McMaster University's Faculty of Health Sciences, called the study's focus on patient outcomes compelling. Sharda was not involved with the study.

Sharda, an anesthesiologist, said the study builds on research she did over a decade ago in her graduate studies on the composition of surgical teams, and raises important questions about hierarchy and power.

"Why do we have underrepresentation of women in the OR?" Sharda said. "I think this idea that they talk about in terms of a critical-mass concept where minority team members can actually share their perspectives is exceedingly important."

Sharda said in her own career, she's experienced the ways perception of gender can play out  in the OR, such as a surgeon or another staff member raising their voice at her in front of the team and patient, questioning her judgment, until a white male colleague backed up her treatment plan.

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Pay gaps also need to close, Hallet said. A June 2023 study found that doctors in eight provinces who performed genitourinary (reproductive and urologic) procedures on female patients were paid 28 per cent less on an average than those who do similar surgeries on male patients.

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Experiences of operating room staff also differ based on other ways including race and sexuality, Sharda said, which also depends on the culture of the organization.

Hallet said recruiting more female doctors into surgical streams also matters.

Team mix benefits 

"A team of only male physicians will probably perform the same way as a team of only female physicians and both will be outperformed by balanced teams," Hallet said. "So as you increase the proportion of female physicians, eventually you're going to hit a wall where you don't have any more benefits."

Dr. Jana Dengler, a staff surgeon at Sunnybrook who was not part of the study, said having role models and mentors matters for recruitment and retention in the operating room. Dengler came from an engineering background and now performs hand surgeries.

"I am an introvert and I am quieter, and so I had to learn how take charge in the operating room," Dengler recalled. "That was something that I struggled with earlier on in residency and had to be mentored through."

Dengler said it is hard to glean from the study why the sex mix in the operating room makes a difference, but she thinks communication styles could be part of it. 

ABOUT THE AUTHOR

Amina Zafar covers medical sciences and health topics, including infectious diseases, for CBC News. She holds an undergraduate degree in environmental science and a master's in journalism.

With files from CBC's Tashauna Reid

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