minimum age for gender reassignment surgery canada

Trans kids' treatment can start younger, new guidelines say

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group's previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn't match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group's standards of care and director of the University of Minnesota Medical School's human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents' consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

"Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision," he said. "That is why we recommend a careful multidisciplinary assessment."

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment, along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about "sloppy" treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn't always happen.

"They tell me horror stories. They tell me, `Our child had 20 minutes with the doctor"' before being offered hormones, she said. "The parents leave with their hair on fire."

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association's new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8 per cent in kids.

Anderson said she's heard recent estimates suggesting the rate in kids is as high as 1 in 5 -- which she strongly disputes. That number likely reflects gender-questioning kids who aren't good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

"That's just absolutely cruel," she said.

Dr. Marci Bowers, the transgender health group's president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been "forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis."

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he's glad he was able to get treatment at a young age.

"Transitioning under the roof with your parents so they can go through it with you, that's really beneficial," he said. "I'm so much happier now."

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

"Those decisions are best made by patients and patient families and medical professionals," they said. "It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together."

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn't strong evidence in favor of transgender medical treatment for kids.

"In medicine ... the treatment has to be proven safe and effective before we can start recommending it," Mason said.

Experts say the most rigorous research -- studies comparing treated kids with outcomes in untreated kids -- would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That's no change from the group's previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones -- estrogen or testosterone -- starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.
• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn't listed.
• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don't offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago's Lurie Children's Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they're prone to risk-taking and they take into account long-term consequences of their actions only when they're much older.

Coleen Williams, a psychologist at Boston Children's Hospital's Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

"Medical intervention in any realm is not a one-size-fits-all option," Williams said.

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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.

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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.

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• News Release

Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

Media Information

• Release Date: September 16, 2022

Media Contacts

Kristin Samuelson

• (847) 491-4888
• Email Kristin
• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

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Home » Surgeon News

Canada Finally Has Nation-Wide Funding For Gender-Affirming Surgeries

With last week’s announcement from the Government of Nunavut confirming that the territory will pay for mental health services and transition treatments for transgender and non-binary residents, Canada will now have nation-wide funding available for gender-affirming surgeries. Nunavut’s Health Department is partnering with GrS Montréal to provide the surgeries.

Health care in Canada is delivered by the provinces and territories and funding for gender-affirming surgeries varies depending on where a person lives. This patchwork of coverage has resulted in barriers to accessing care that have disproportionately affected people living in Canada’s territories in the North, which includes Yukon, Northwest Territories and Nunavut. While expansion of surgery funding in Canadian provinces has continually progressed over the last decade, comprehensive coverage has only been established in the territories over the past three years.

Nation-wide coverage is obviously a very positive development but advocacy is still needed to continue the work of dismantling barriers for Canadians to access surgical care. Current challenges include:

Getting coverage across the country for Facial Feminization , Breast Augmentation and Male Chest Contouring , procedures that are excluded from funding policies in some jurisdictions.

Surgeons who practice gender-affirming genital surgery are only located in Montreal, Toronto and Vancouver. This means that many transgender and non-binary Canadians need to travel great distances to access surgeons for primary surgeries, follow-ups and specialized care for complications, incurring significant expenses that aren’t universally covered or subsidized.

Wait times are a problem that is not unique to gender-affirming surgical care in Canada but with few experts performing these surgeries patients can wait up to three years just for a consultation with a surgeon.

With the Government of Nunavut’s funding commitment, the goal of nation-wide coverage for gender-affirming surgery in Canada has been achieved. Improvements to provincial and territorial funding policies are still needed but this is a milestone to be celebrated.

Review Funding Policies by Province and Territory:

• British Columbia
• New Brunswick
• Newfoundland and Labrador
• Nova Scotia
• Ontario – PDF
• Prince Edward Island
• Saskatchewan – PDF
• Northwest Territories – PDF
• Nunavut – News article: GN transgender, non-binary health services a positive step
• Yukon – News article: Yukon’s new gender-affirming care policy is most comprehensive in Canada

Canada's teen transgender treatment boom: Life-saving services or dangerous experimentation?

As a rising number of young people seek help, some parents, mental health professionals and others are raising concerns about how they’re being treated

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Article content

Mary has always known her daughter was a little different and never had an issue with that. The teenager was in elementary school when she came out first as bisexual, then as lesbian.

But what happened when the girl entered Grade 9 at an Ontario high school was unexpected. The young woman gravitated naturally toward other LGBTQ students, including a transgender boy. The school leapt into action to accommodate him, making sure a gender-neutral bathroom was available.

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Then, by the time the class reached Grade 10 this fall, the boy was no longer alone: At least half a dozen other biological girls in the same loose friend group, including Mary’s daughter, had also come out as transgender .

“It became much more of a thing within one year,” said the mother, who asked that her full name and that of the school be withheld to protect the family’s privacy. “It does seem not statistically possible.”

Yet an elementary school in Eastern Ontario experienced the same phenomenon four years ago. Within months of an outside group’s presentation on gender identity to a Grade 7 class, at least five of the 32 pupils declared they were transgender, said Carolyn, a parent at the school. Her 11-year-old son was among them, announcing he was a “demi-girl.”

“It was kind of presented (at school) that if you are uncomfortable with your body you can be transgender,” said the mother, who is also a social worker and counsels troubled youth. “Lightbulbs went on, with multiple children in this class.”

Even I was thinking it was too fast, and I wanted it

The surprising clusters of gender dysphoria — the feeling of having a gender identity different than one’s birth sex — arose amid another striking trend. The number of Canadian adolescents reporting to gender-identity clinics with dysphoria has soared in recent years , a large majority of them being teenagers born female.

Trans-care experts say this simply reflects demand for potentially life-saving services that went unmet in the past amid stigma around a long-persecuted minority. Others cite more contentious factors like peer group “social contagion.”

Regardless, as an exponentially rising number of young people seek out such help, some parents, mental health professionals and others are raising concerns about how they’re being treated.

Many of these young patients suffer a range of other mental-health troubles. But the standard approach is what’s called “affirmation” — a ready acceptance of a patient’s belief that their gender is different than their biological sex. That’s followed by a move often to medical transition: puberty-blocking drugs, then cross-sexual hormones like testosterone and surgical modifications.

Get a dash of perspective along with the trending news of the day in a very readable format.

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Critics do not question that transition is necessary and beneficial for some young people with gender dysphoria, and acknowledge such individuals have historically met resistance or abuse from parents and even health-care providers.

But they worry that well-intentioned therapists are giving short shrift to complex, multi-faceted psychological issues, while accentuating medical treatment that can be irreversible.

Sadie, who asked that her full name not be published, said the B.C. Children’s Hospital offered her a testosterone prescription when she was 17, after just two hour-long sessions with psychologists. She thought then she was a trans boy.

“Even I was thinking it was too fast, and I wanted it,” Sadie said. “I remember one (therapist), I talked about anxiety, depression and she said, ‘Oh yeah, that will go away once you go on T.’ And I thought, ‘Oh, not helpful, but thank you, I guess.’ ”

Now 21, she said she identifies as gender fluid or non-binary, and is grateful she never did medically alter her body.

A professional at a mental health clinic for youth in Western Canada, transgender himself, said he tries to approach gender dysphoria clients in a balanced way, explaining both the risks and benefits of medical transition. But he said he’s been harshly criticized by superiors, accused of not caring about the patients.

“I don’t feel good about transitioning someone and giving someone permanent changes to their body when they’re actually a gay woman — that doesn’t feel like ethical practice,” said the counselor, who’s not authorized to speak for his employer and asked for anonymity.

“But all these fears about conversion therapy, or the narrative of never questioning anyone’s identity, has made it impossible for us to talk about this … We’ve created this very dangerous situation for kids.”

Similar concerns are echoed by so-called detransitioners, people who have changed to another gender and come to rethink their decision. A new Canadian detrans group is part of what may be a growing cohort.

Schools also sometimes actively support gender transition, even accepting name changes without informing parents.

Ottawa resident Pam Buffone says her six-year-old came home upset after a lesson on gender identity in which her teacher said “boys are not real and girls are not real.” The Ontario Human Rights Tribunal is planning a hearing on the mother’s complaint about the matter.

“What’s happening in Canada is an uncontrolled medical experiment on children without any independent oversight or requirement to track health outcomes,” said Buffone, who runs the Canada Gender Report , a group raising questions about such issues. “We’re going into this totally blind.”

There has been some pushback. At a mother’s request, a B.C. judge this month imposed an injunction temporarily delaying a mastectomy for a female-born, 17-year-old transgender boy.

But rather than pause and re-assess current approaches, legislation now being considered by Parliament could further entrench the affirmation model. Bill C-6 outlaws “conversion therapy,” treatments designed to correct someone’s sexual orientation or gender identity, but critics worry that it could effectively criminalize non-medical options, like psychotherapy, for treating gender dysphoria.

Meanwhile, some other countries that have seen similar trends are taking a step back.

The U.K.’s High Court ruled earlier this month that it’s highly unlikely children under 16 can properly consent to taking puberty blockers, and suggested a court order would be appropriate to authorize the “experimental” treatment.

Sweden’s left-of-centre government shelved its plan to lower the minimum age for sex-reassignment surgery, launching a review of gender dysphoria treatment instead.

In Canada, the number of pediatric clients at 10 gender clinics across the country climbed steadily from barely any in 2004, to more than 1,000 in 2016, according to Trans Youth Can! , a study on hormone treatment of dysphoria.

More than eight in 10 of them were children born as girls who came out as trans boys, and two-thirds showed up at the clinics at age 14 or 15, the project’s data suggests .

There is now a significant sense of anxiety and concern among people for whom gender diversity is a new and unfamiliar issue

In Ontario, provincial health insurance approved 1,460 people for gender-reassignment surgery in 2018, up from 59 in 2010, reports the Canadian Professional Association for Transgender Health . It’s unclear how many of those were minors.

Many professionals who care for and study people with gender dysphoria in Canada say none of this is alarming.

“The increase may look steep, but we have to remember that these are still very small numbers in the context of the number of youth who know they’re trans and will need gender-affirming medical care,” said epidemiologist Greta Bauer, who holds the CIHR chair in sex and gender science at Western University.

She said research by the Trans Pulse project she headed suggests that about one in every 278 14-year-olds is trans and requires gender-affirming hormones — far more than even the elevated numbers seen now.

Concern about the trend is akin to the “moral panic” when homosexuality first started gaining social acceptance and many people came out as gay, TransCare B.C. said in a statement.

“There is now a significant sense of anxiety and concern among people for whom gender diversity is a new and unfamiliar issue,” said the government agency.

Treatment with hormones and surgery only occurs after considerable assessment that involves families, said the B.C. Children’s Hospital in a statement about its gender clinic. Still, minors deemed able to consent do not legally need their parents’ agreement, it noted.

“We understand these decisions can be difficult for families, but as health-care providers, patient-centered care is our top priority,” said the hospital.

Regardless of the pros and cons, the gender dysphoria boom and how it’s treated has received little public airing in Canada. As media and government embrace a community that’s long had to contend with discrimination, poverty and violence, the details of what’s happening in clinics and schools have gone largely unnoticed.

To shine a light on more critical perspectives, the National Post spoke to seven parents of children who came out as transgender, young people who abandoned or reversed their transition, and scientists skeptical of the prevailing treatment approach.

The non-experts asked that their full names not be published, afraid of exacerbating family tensions or exposing children to harassment.

The parents claimed to have open-minded and accepting views about sexual orientation and gender identity, but felt their own children were being pushed too fast toward transition.

They described offspring who had been suffering emotional or psychological problems — depression, anxiety, eating disorders, self-harm, ADHD, bullying — then declared abruptly in the midst of puberty or early adolescence that they were transgender.

Some eventually abandoned their transgender identity, turning out to be gay, lesbian or bi-sexual.

Chris, who lives in the greater Toronto area, said his daughter suffered from depression and anxiety but otherwise seemed like a “typical” girl, until declaring in the summer after Grade 9 that he was a boy. It turned out he had already adopted a male-sounding name and male pronouns at school; the school staff later explained they do not inform families of such changes in case the parents are unsupportive.

Chris said staff at the transgender clinic at Toronto’s Hospital for Sick Children recommended after the second of two relatively brief sessions that the child start puberty blockers.

Technically called ”gonatropin-releasing hormone agonists,” the drugs essentially buy time, allowing a young person to decide if they want to transition before more masculine or feminine characteristics set in.

It’s unknown if the experimental drugs could have long-term negative effects on issues like bone and brain development, that British court ruling concluded. Some preliminary research, on the other hand, has suggested they make it less likely transgender people will commit suicide.

Chris, convinced it was too early to take such a step and worried about the drugs’ side effects, never took his teenager back to the clinic.

But Sick Kids says it does not rush into prescription of puberty blockers or cross-sexual hormones.

In fact, it’s often a year from the time a child identifies as trans before their first appointment, and medical treatment starts only after considerable assessment and a “period of reflection,” the hospital said in a response to a letter of complaint from Buffone’s parents group.

M., a mother in a mid-size Ontario city, said her daughter declared at age 15 — “out of the blue,” while suffering severe anxiety — that she was transgender, and made it clear she wanted to move quickly to testosterone treatment and gender-reassignment surgery.

At her high school, there were “nine or ten” other natal girls who had come out as trans boys, including a buddy who was already medically transitioning.

“It broke my heart to hear one of her friends go on hormones, hear her voice start to change,” said M. “I was terrified about my daughter, because you don’t come back from that.”

In the end, she didn’t medically transition, seems happier and considers herself bi-sexual or lesbian, according to the mother.

The childrens’ age and birth sex seem to reflect the statistics here and in other countries. James Cantor has a provocative theory to explain the sudden flood of girls identifying as trans boys in adolescence.

A former sexual behaviour scientist at Ontario’s Centre for Addiction and Mental Health (CAMH), Cantor is critical of the current treatment paradigm. He believes those girls are simply being misdiagnosed, much like a previous generation’s mental health troubles were often blamed on suppressed memories of childhood sexual abuse, a practice that has been largely discredited.

Cantor suspects many are suffering from borderline personality disorder, a condition marked in part by confused self-identity and suicidal thoughts.

“As a clinician-scientist, one should be curious,” said Ken Zucker, who headed the CAMH gender clinic until it was shut down in 2015 under contentious circumstances. “We’re seeing a whole group of kids we never saw before. What is this about? … Anybody who sees adolescents with gender dysphoria needs to think about it.”

A hotly debated paper published in 2018 by Brown University public health professor Dr. Lisa Littman even coined a term for the possible phenomenon — rapid onset gender dysphoria (ROGD) — and theorized that social contagion could be one explanation for it.

Critics say her study was undermined by bias — it was based largely on interviews with parents who belonged to organizations critical of transgender treatment.

Bauer said there is another explanation for the preponderance of natal females appearing at clinics. They are likely coming out as transgender earlier in their lives, partly because they reach puberty sooner. And, she said, birth males who become trans girls face more societal pressure to conceal their feminine identity.

As for those two kids who came out as transgender alongside clusters of friends at school, neither transitioned medically.

Carolyn said her son had his revelation at a time when he was emotionally fragile, socially rejected by other boys in his class, depressed and anxious.

Four years later, he now identifies as a heterosexual boy, and even has a girlfriend.

But the episode made it clear to Carolyn that the health-care, social-service and education systems are determined to be affirmative. She notes that her husband, a child-protection worker, must ask every young person he deals with, unsolicited, about his or her gender identity.

Mary’s child is in a “holding pattern,” not having moved forward with any kind of medical treatment.

The mother is relieved, and worried that others are choosing transition before they know for sure.

“If you make a mistake about being gay, there’s no harm, no foul, really in the end.” Mary said. “But If you think you’re transgender at 15 and have a mastectomy, and then at 25 you go, ‘Oh, my God, what did I do?’ — that’s why parents are terrified.”

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Transgender children in Canada to get more support, expert says

Clinics offer range of therapies to transgender children, youth at 5 canadian locations.

Services for Canadian transgender children to expand, expert says

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A network of support for transgender children is growing in Canada, at clinics working to help youth transition from one gender to another.​

But critics say it raises ethical questions about when children are able to make medical decisions.

In Winnipeg, the Gender Dysphoria Assessment and Action for Youth (GDAAY) clinic helps young people who feel they were born in the wrong body.

The clinic helps people such as 18-year-old Xavier Raddysh, who says he knew from a young age he was a man.

Raddysh was identified as a girl at birth and named Kenzie, but says he doesn’t remember ever feeling female.

If young people are saying they want to transition, the question is, is that truly an autonomous, independent wish that’s reflective of their values, or are they internalizing a lot of very negative messages and stereotypes in society? -— University of Toronto bioethicist Kerry Bowman

“I've definitely always been more of a male person. When I was little, I wouldn't play with the Barbies my parents got me. People would call me by my birth name, but I never did feel female, no,” said the Winnipeg teen.

Later, those feelings intensified.

“I was very uncomfortable when I hit puberty as a female. I would feel very sad and upset when I would get my period or when I started to get a higher voice,” he said. “When I started growing breasts, I was just so upset and I didn't know why.”

Raddysh didn’t hear the term transgender until he was 15, but when he finally did, he said he instantly identified with it.

Coming out as a male presented its own set of problems, though. He suffered immense bullying, which led to depression.

Suicide rates higher among transgender youth

“I’ve tried to commit suicide at least three times. I’ve self-harmed,” said Raddysh.

His experience isn’t unique, according to the Public Health Agency of Canada, which says 20 to 30 per cent of transgender youth have attempted suicide.

Younger children should know they have the option if they don’t feel like the gender they are — they can change that. — Xavier Raddysh

An Ontario study found 47 per cent of transgender youth reported seriously considering suicide.

Statistics such as those are part of what convinced psychiatrist Simon Trepel to start the GDAAY clinic in Winnipeg, to help children and young people diagnosed with gender dysphoria.

Raddysh credits the clinic with changing his life and helping him find the resources he needed.

“Once I figured out I could get more hormone replacement therapy and get surgeries to feel more like me, I changed as fast as I could,” explained Raddysh. “I would’ve been way depressed if they hadn’t helped me, and I’m very glad they have clinics like that.”

Limited access to youth and child-focused care

But access to the clinics is limited, as there are only five in Canada so far.

As we’re going to see in the next five to 10 years, as this population becomes larger, there will be more options in Canada. — Psychiatrist Simon Trepel of the Gender Dysphoria Assessment and Action for Youth in Winnipeg

“This is still a fairly new issue in our world and North American society,” said Trepel. “Right now, the data shows, as a child expressing transgender identity, a majority won't go on to have transgender issues in adolescent and adult years, whereas teens presenting with transgender ideation often will.”

Trepel’s clinic currently treats children as young as four years old, and the therapies available to them depend on their age.

Currently, children as young as seven or eight years old can take hormones to block the physical changes of puberty, a therapy that is completely reversible.

By their early teens, they can opt for cross-hormone therapy, which is more difficult to reverse.

As for sex reassignment surgery, most will have to be at least 18 to obtain it.

Trepel said that options for youth are limited right now, but he expects that to change.

“It’s definitely not offered everywhere,” said Trepel. “It hasn’t attracted a lot of surgical specialists doing this kind of work, but as we’re going to see in the next five to 10 years, as this population becomes larger, there will be more options in Canada.”

Issue 'triggers powerful taboos,' says bioethicist

University of Toronto bioethicist Kerry Bowman worries that some children are being asked to “pick a side” too early.

“I actually do think in many situations, young people have the right to make more medical choice than they’re given in society,” he said.

Bowman said he does believe children can understand and appreciate the implications of their decisions, “but it’s different in this domain. If young people are saying they want to transition, the question is, is that truly an autonomous, independent wish that’s reflective of their values, or are they internalizing a lot of very negative messages and stereotypes in society?”

Bowman added the issue has become highly charged “because it’s linked with sexuality and sex roles. It triggers powerful taboos in Western culture.”

Reassignment surgery

Plastic surgeons in most Canadian cities will perform “top body surgeries,” which include removing breasts.

As for "bottom surgeries," which involve altering the genitals, the Gender Variance Program at the Montreal Children’s Hospital refers adult patients to a gender surgery clinic that is run by Dr. Pierre Brassard  —  one of the only places in Canada where gender reassignment surgery occurs.

Now 18, Raddysh is hoping to have that surgery. He started testosterone treatments eight months ago and plans to have a double mastectomy next month.

“I really just want to get surgery over with, and I know I’ll feel a thousand times better after surgery,” he said. “Younger children should know they have the option if they don’t feel like the gender they are — they can change that.”

Corrections

• An earlier version of this story incorrectly stated that the Gender Variance Program at the Montreal Children’s Hospital performs “bottom surgeries,” which include altering the genitals of patients. The hospital does not perform such surgeries, but refers adult patients to the gender surgery clinic run by Dr. Pierre Brassard, one of the only places in Canada where gender reassignment surgery occurs. Dec 09, 2013 4:52 PM CT

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Trans kids’ treatment can start younger, new guidelines say

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Assn. for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association, known as WPATH, provided an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

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A transgender psychologist has helped hundreds of teens transition. But rising numbers have her concerned

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Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of WPATH last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number probably reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,” she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.”

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Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, N.C., resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,” they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.”

Science & Medicine

Early transgender identity in kids tends to endure, study suggests

Children who begin identifying as transgender at a young age tend to retain that identity for several years at least, a new study suggests.

May 4, 2022

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn’t listed.

• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Assn. support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader , a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams , a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

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The Gender Surgery Program B.C.

What we offer

Frequently asked questions, the referral and surgical journey, preparing for surgery, wait times and waitlist, hair removal, the clinic team, vch partners in care.

• Find this service near you

The Gender Surgery Program B.C., including the Gender Surgery Clinic, opened at Vancouver General Hospital (VGH) in September 2019, making the Gender Surgery Program B.C. Western Canada's only program performing lower gender-affirming surgeries for transgender and gender-diverse people.

The Gender Surgery Program is comprised of a multidisciplinary team of health care providers and surgical specialists devoted to providing high-quality gender-affirming treatment and surgical care. Patients will receive care through the Gender Surgery Clinic throughout their entire surgical journey, including pre- and post-operative care, until discharged to their primary care provider. 

The Gender Surgery Program offers both feminizing and masculinizing procedures consistent with the guidelines established by the World Professional Association of Transgender Health (WPATH). 

Feminizing Procedures

• vaginoplasty 
• vulvoplasty 
• revision surgery 

Masculinizing Procedures

• metoidioplasty 
• clitoral release 
• phalloplasty
• penile and testicular implant surgery 

All procedures will be performed at surgical sites in Vancouver.

For breast construction and mastectomy questions, referrals, and waitlist visit Surgery Referral

What is the minimum age for the Gender Surgery Program BC?

The age for access to lower gender-affirming surgery is the age of the majority, which in British Columbia is 19 years of age.

Can peers/family members attend gender surgery consultations?

Yes, family, friends and peers are encouraged to attend. However, please be mindful of how many people you bring with you as the clinic rooms can only accommodate 1-2 extra support people.

Why was I discharged from the program and told I must start again?

We hold a three-call policy when needing to reach patients at any point during the GSPBC process. After attempting to contact both you and your referring Primary Care Provider (PCP), we will begin a 4 week waiting period before you are formally discharged from the program. In the event of discharge, a letter will be sent to you and your PCP. Should you be interested in joining the program once more, a full re-referral is needed, and you will be placed at the start of the GSPBC process.

To avoid being discharged, please ensure to respond to communication from the GSPBC in a timely manner. Please also inform the clinic should your contact information change.

How can I change the type of surgery I’m getting?

A change in the type of surgery may require a patient to undergo surgical readiness assessments specific to their newly requested surgery. Patients may start at the beginning of the GSPBC process. Occasionally, an alternate surgery may be recommended after a surgical consult. In these cases, no new surgical readiness assessments will be required.

Can I see photos of surgical results?

As our program is currently still relatively new, we are unable to provide photos of past results. This ensures the complete confidentiality of our patients who have already had surgery. Without high volumes of completed surgeries, there is too great of a risk that a photo could be identified as a specific patient. We hope to re-evaluate this policy in the future as our program grows.

What makes BC the best option for gender-affirming surgery?

Gender-affirming surgery is a complex procedure, and it is not uncommon to experience postoperative complications. These can vary from mild to more significant complications. If complications do arise, having surgery closer to home ensures that you have access to your surgical team for both routine follow-up and if you experience any issues in your post-op healing. Reducing the stress and strain of travel will also help improve surgical outcomes and the overall surgical experience while reducing the uncertainties and expenses involved with long-distance travel out of province.

Why are revisions listed as a surgery option? Are they inevitable?

Revisions are not inevitable. Many people are happy with the outcomes of their initial surgery and require no further surgery outside of planned surgical stages. However, there are times when the surgical team might recommend a revision surgery if there is an unexpected outcome or complication that can be surgically addressed. This is best discussed with your surgical team during your consult and at your post-op follow-up appointments. In other cases, surgical intervention is intentionally staged for prosthetic implants or urethral continuity.

Can I access the GSPBC clinic if I had surgery elsewhere and need revisions?

Patients who have received surgery elsewhere should return to their original surgical center for all follow-up and revision requirements. Out-of-country surgeries provided on a recommendation from a GSPBC surgeon may receive post-operative care and revisions in further consultation with GSPBC. 

Can I access the GSPBC program if I had surgery at the GSPBC and need revisions?

Yes, revisions for those who have received surgery through the GSPBC program will be prioritized. If you require a revision or care after an extended period since your GSPBC surgery, please complete a re-referral back to our program through your primary care provider. We will flag the re-referral and have this prioritized.

What complications are common after a vaginoplasty?

Possible complications vary with each case and depend on the individual. At the initial consultation, your surgeons and clinic staff will explain the surgery and associated complications, including:

• tissue loss or necrosis
• urinary retention
• urinary infection
• urethral meatal stenosis
• neovaginal prolapse
• rectovaginal fistula
• urethroneovaginal fistula
• loss of depth and width of the vaginal cavity
• hyper granulation tissue
• anesthetic and other medical/general surgical complications

What complications are common after a phalloplasty?

• urethral stricture
• urethral fistula
• retained vaginal remnant

Where am I on the waitlist?

Unfortunately, we cannot provide your standing number as you wait for surgery. The waitlist changes are dependent on the complexity of surgeries, OR availability, differences in patient hair removal times, etc. We can, if needed, provide a general sense of where you fall in each stage of the process on request.

• ERAS workbooks
• Recovery and care

Lower surgery referral form (Print)

Lower surgery referral form (fillable), faq vaginoplasty hair removal template change, vaginoplasty and vulvoplasty workbook.

TransCare B.C.

Phalloplasty, Metoidioplasty, ET Release Workbook

Metoidioplasty.

Enhanced Recovery After Surgery (ERAS) workbook

Phalloplasty

Vaginoplasty, vulvoplasty, vaginoplasty: dilation handout, vaginoplasty: rinsing handout, if you need emergency care post phalloplasty.

• Obtain a referral - Your primary care provider sends a referral, including your completed surgical readiness assessment, to the Gender Surgery Program’s clinic at VGH.
• After completed referral  -  After the GSPBC receives a fully completed referral, patients are placed on an extensive, first come first serve waitlist dependent on their surgical type.
• Intake and surgical consult -   Patients will be booked for an intake appointment over the phone with one of the GSPBC Nurses. The purpose of this session is to confirm your medical history, and get a full sense of how best we can support you. At a later date, you will then meet with a surgeon either in person, or via zoom. They help provide more information about your surgery, answer questions, and help determine steps to move towards surgical readiness. For many, this includes starting on the process of hair removal.
• Hair removal  -  The process of hair removal takes different amounts of time for each person, dependent on the type of surgery and your individual body (this can take up to 18 months). GSPBC is working with Trans Care BC to track hair removal progress.  Trans Care BC will connect with patients and inform GSPBC once hair removal is near completion. Patients are then scheduled for a second surgical consult. *Please note that if Trans Care BC and GSPBC cannot reach you this may result in a discharge from the surgical program. To avoid this, please keep your contact information up to date and check your voicemail and email regularly.
• Second surgical consult  -  This consultation is a check-in on your surgical readiness and helps to determine if any additional steps are needed. If all steps are completed, you are deemed surgically ready and added to a wait list for surgery. Please note the second surgical consult is often completed in person and may require a physical examination that can include one of the surgeons looking at your current genitals to help plan for your surgery.
• Preparing for surgery  -  This stage involves multiple Allied Health professionals depending on your needs. You will meet with the GSPBC Social Worker for an assessment, and to help prepare multiple kinds of supports, travel, accommodation, and a post-surgery support plan. You will also check-in with the GSPBC Pelvic Floor Physiotherapist for an assessment and ongoing support as needed. When a surgical date is offered to you, you will receive further education on your surgery. An Enhanced Recovery After Surgery (ERAS) booklet will be reviewed with the clinic nurse.
• Surgery  -  Our aim is to provide patients 2 - 3 months’ notice prior to an available OR date for your surgery. We may offer an OR date sooner than this should there be cancellations. Surgery typically requires a few days of hospital stay, with the length of stay dependent on the type of surgery and follow-up requirements.
• Post-op follow-up -  Follow-up is provided by our team of surgeons, nurses, social worker, and physical therapist. This will look different for each person but requires multiple check-ins and support sessions for the first six weeks, followed by ongoing support as needed. Depending on your type of surgery you will be asked to stay local in Vancouver for a given length of time after you leave the hospital.
• Discharge  -  When your post-operative care is complete, you will be discharged from the Gender Surgery Clinic to your primary care provider for any required ongoing care.

Gender-affirming surgery does involve additional planning, and we encourage you to think ahead in your surgical journey. To learn more about how you can prepare for your upcoming surgery, read our guide to preparing for gender-affirming surgery .

Unfortunately, we cannot provide a clear timeframe for when to expect surgery. Multiple factors influence movement through each program stage, making wait time extremely hard to predict. The first wait for an intake and consult varies based on the volume of referrals and amount of surgeries being completed. The second wait is found within the process of hair removal. Depending on the type of surgery, hair removal may be required and can take a variable amount of time for each person.

Once hair removal has been completed (if necessary), and you’re deemed ready by a surgeon, the provincial goal is to limit the wait for surgery to 6 months. Unfortunately, this timeline often changes based on staffing and OR availability and can be longer. We aim to give you 2 - 3 months' notice before an available OR space for your surgery. We may offer an OR date sooner should there be cancellations. 

Those electing to undergo vaginoplasty or phalloplasty may need to complete permanent hair removal. This is to limit or prevent post-operative hair regrowth in places where hair removal would be difficult or impossible, such as deep inside the vagina or inside the urethra. Electrolysis or laser hair removal is utilized as these are the two types of hair removal deemed to be permanent. Your hair removal provider will determine the type of hair removal you receive in partnership with your surgeon’s assessment.

After you meet with a surgeon, you will receive information on if you are required to undergo hair removal and which areas you may need hair removal. If you are deemed to need hair removal, the clinic will provide you with a template as well as a list of hair removal providers that Trans Care BC has approved. All medically necessary hair removal will be covered and funded.

As the hair removal process can be long (12-18 months on average), we recognize that some individuals may wish to begin their hair removal before their surgical consult. Hair removal can be self-initiated, but please note hair removal completed before surgical consultation will be paid out of pocket and not reimbursed or covered. If you do wish to self-fund hair removal before your surgical consult, please contact the GSPBC clinic, and a hair removal template will be provided.

The GSPBC consists of a multidisciplinary team of nurses, surgeons, and allied health providers, such as a physiotherapist and a social worker, who will work together to support you through the various stages of your surgical journey. All our clinicians are experienced in working with transgender and gender-diverse individuals.

Our team strives to provide you with high quality care. Quality care is best achieved when you, the patient, along with your friends and family, become “partners in care” with us, your health care providers. Please review what you can expect from us, and what we expect from you in the VCH Partners in Care document found here. Please note, deviating from this may result in reduced care and discharge from the program.

Partners in Care - Expectations and responsibilities

Gender Surgery Clinic at Gordon and Leslie Diamond Health Care Centre

• (604) 875-5060

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• Inside Pride homepage

Gender-affirming health coverage by Canadian province, territory

If you get Global News from Instagram or Facebook - that will be changing. Find out how you can still connect with us .

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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Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

Home » GET INFORMED » Talk Rights » Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

May 19, 2015

Like all content on this website, this document is not legal advice and is provided solely for the purpose of public information and education. If you are facing a legal issue or have a question about your specific situation, you should consider seeking independent legal advice. You can find a list of legal clinics and other resources to help you here.

The CCLA is a national organization that works to protect and promote fundamental human rights and civil liberties. To fulfill this mandate, the CCLA focuses on litigation, law reform, advocacy and public education. Our organization is not a legal clinic. As such, we are typically not in a position to provide members of the public with legal advice or direct legal representation. However, we do try to provide general legal information and appropriate referrals where possible. For questions about this document, email publicenquiries [at] ccla [dot] org.

How can Trans Persons Change the Sex Designation on their Birth Certificate?

This guide is focused on issues relating to how trans persons can change the sex designation on their birth certificates. For information on how trans persons can legally change the name used on their identification documents,  see this guide .

This page is intended to help trans persons with issues related to changing the sex designation on their birth certificates. As such, some of this information may not be helpful to those seeking to change their birth certificates for another reason.

Note: Every effort has been made to ensure comprehensiveness and accuracy (as of May 2015). However, this FAQ may not fully reflect the current state of the law.

We use the term “trans” to include anyone who does not identify with the sex designation they were assigned at birth.

Questions addressed in this FAQ:

Why might I want to change the sex designation on my birth certificate?

Should i have to have surgery in order to change the sex designation on my birth certificate, are sex designations on birth certificates even necessary, how can i change the sex designation on my birth certificate, where do i apply to change the sex designation on my birth certificate, what proof do i need to show in order to change the sex designation on my birth certificate do i need to show proof of surgery, can i apply if i am younger than 18 or 19, can i apply even if i was born outside of my current province/territory.

You can download a PDF of this document here:  CCLA Change of Sex Designation FAQ .

Many trans persons consider the sex they were assigned at birth to be inaccurate. If this is you, changing the sex designation on your birth certificate may be important for your well-being. It is also important for legal reasons as well.

In order to enjoy a greater degree of safety and freedom from discrimination, you may want to have identification documents that match the gender with which you identify and present yourself. The information on most identification documents is drawn from birth certificates, so changing your birth certificate is often a necessary first step. “Sex” is a category on most driver’s licenses, passports and health cards, and so you may find yourself being forced to discuss your gender identity – sometimes even your genitals – with a stranger. This is even worse when that stranger is empowered to make decisions that greatly affect you, such as whether to write you a traffic ticket, offer you a job, refer you for medical treatment, or let you enter the country.

Trans persons face widespread discrimination and high rates of violence. Of trans Ontarians  surveyed  by the Trans PULSE Project, 26% reported being hit or beaten up because they were trans, 73% reported being made fun of, and 39% reported being turned down for a job. In 2010, Trans PULSE  estimated  that 50% of trans Ontarians had seriously considered suicide at some point in their lives because of the discrimination they faced. Involuntary outing on a regular basis, such as by having an inaccurate gender specified on your identification documents, eliminates one of the few mechanisms you may have to protect yourself from transphobia.

In 2014, a judge in Alberta considered the constitutionality of the provincial law that regulated gender markers on birth certificates. The judge  struck down  that law, because it was contrary to the  Canadian Charter of Rights and Freedoms . In doing so, the judge cited a  prior decision  of the Ontario Human Rights Tribunal. That decision detailed some of the discrimination faced by trans persons (referred to here as “transgendered” [sic]):

“[T]ransgendered persons as a group tend to face very high rates of verbal harassment and physical assault and are sometimes even murdered because of their transgendered status. […] [I]t is very difficult for a transgendered person to find employment, […] there are very high rates of unemployment among transgendered people generally, and […] many transgendered people are fired once they are exposed in the workplace as being transgendered.”

These concerns also extend to young trans persons, who may be forced to endure bullying by their peers if the sex designation on school records does not match their gender identity.

Many trans persons want the benefits of official documents that correspond to their identity but may not want to undergo surgery. They may be content with the use of hormones or simply by presenting themselves consistently with their gender identity.

Gender reassignment surgery can be expensive, difficult to access, and carries the risks associated with any surgery. In addition, it has been reported to  typically cause sterility . Gabrielle Bouchard of the Montreal-based Centre for Gender Advocacy has said the surgical requirement in order for official documents to be changed  amounts to mandatory sterilization.  The surgery requirement also emphasizes biological sex characteristics rather than gender identity. Even after surgery has been performed, a second doctor must sometimes “confirm” the surgery. C.F., the plaintiff in the  Alberta  court case mentioned earlier,  told the  Edmonton Journal :

“What this legislation requires is that you not only submit to dangerous, risky surgery, but then actually attend for a humiliating genital inspection before two separate physicians, both of whom will make a value judgment about whether your genitals are sufficiently female[.] It’s like something from ages gone by. It’s very disturbing stuff.”

Due to these types of concerns, there have been and continue to be legal challenges to the various provincial legislation that require reassignment surgery in order to change sex designation. In the  Ontario  and  Alberta   decisions discussed earlier, the requirement for gender reassignment surgery was found to be discriminatory. As a result of these rulings, several provinces, including Alberta, British Columbia, Manitoba, Ontario, and Quebec, have taken steps to amend their laws to remove reassignment surgery from the requirements necessary in order for you to change your sex designation. Nova Scotia has also indicated that it plans to amend its legislation to remove the surgery requirement.

Some activists have argued for the removal of sex designations from identification documents altogether, on the basis that gender identity is not a binary classification. The binary does not accommodate people who do not identify with a binary gender classification.

Ongoing cases challenging legislation in  British Columbia ,  Saskatchewan  and  Quebec  are seeking the removal of sex designations from birth certificates. So far, although several provinces have removed the surgery requirement, no province has taken the step of removing sex designations altogether or providing for a third non-binary option.

In contrast, several countries, including  Australia and Germany , now allow persons to designate their sex on their passport with an “X”. However, some trans rights advocates argue that the “X” continues to out trans persons, and is used as an excuse for not eliminating the surgery requirement. An  Australian  court has ordered the government to register a third category of sex designations on birth certificates and name change certificates.

For more on the possibility of non-binary gender designations, see the BC Law Institute’s  report , where the Institute highlights the implications and consequences of different solutions to providing a non-binary sex designation in Canada.

All provinces and territories except Nunavut have procedures for changing sex designations when a person has undergone gender reassignment surgery.

The rules for changing the sex designation on a birth certificate vary from province to province. They are also changing rapidly. In all provinces except Quebec, where the  Civil Code  governs these issues, the law concerning birth registration is found in the provincial  Vital Statistics Act  and associated regulations. These laws and regulations can be consulted for free on  http://canlii.org . Note that a province may have policies that are not in the legislation. For more information about requirements, check with the government agency responsible for birth certificates in your province or territory (listed below), or with a trans advocacy organization, such as  Egale Canada .

Many provinces require letters from a mental health professional in order to change a person’s gender marker or name. Such a letter may also be required to access sex reassignment surgery.

Online government information is limited outside British Columbia, Manitoba and Ontario. Where specific information regarding change of sex designation is unavailable on a province’s website, the links below provide contact information for the appropriate agency.

Until recently, all provinces and territories required you to have gender reassignment surgery if you wanted to change the sex designation on your birth certificate. Ontario became the first province to drop this requirement in 2012 when, as mentioned previously, its human rights tribunal  ruled  the requirement was discriminatory. The Alberta Court of Queen’s Bench handed down a similar  ruling  in April 2014. Ontario has not officially amended their legislation, but are now registering changes without proof of surgery as a matter of policy. British Columbia, Alberta and Manitoba are the only provinces that have formally amended their legislation to eliminate the surgery requirement. In Alberta, the new requirements are set out in  regulations .

New Brunswick, Newfoundland and Labrador, PEI and Saskatchewan   all require applicants to document that they have undergone gender reassignment surgery, usually by having at least two physicians – the surgeon who performed the surgery and another who did not – certify that fact. Quebec and Nova Scotia also currently require proof of surgery, but changes to the law are on their way (see below). In Quebec, the second physician must practice medicine in Quebec. In New Brunswick and the Northwest Territories, the second physician must be licensed in any Canadian jurisdiction.

The law in this area is changing rapidly as legislation is amended and court challenges are brought regarding surgery requirements. Consulting the relevant statutes will not always give a full picture of the current requirements or upcoming amendments. For current information, contact a trans advocacy organization, such as  Egale Canada .

You must provide:

A declaration, which provides your date of birth, and states that you identify with and maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a licensed doctor or psychologist licensed in Alberta or another jurisdiction that the sex designation on your birth certificate does not correspond with your gender identityBritish ColumbiaNo proof of surgery required;

A declaration, which states you have assumed, identify with and intend to maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a doctor or psychologist licensed in BC or the province or territory where you live that the sex designation on your birth certificate does not correspond with your gender identityManitobaNo proof of surgery required;

A declaration, which states you identify with the requested sex designation, you are currently living full-time in a manner consistent with the requested sex designation and you intend to continue doing so; and

A supporting letter from a health care professional licensed in Canada or where you live that your gender identity corresponds with the requested sex designationNew BrunswickProof of surgery requiredNewfoundland and LabradorProof of surgery requiredNova ScotiaProof of surgery still required, but a bill to eliminate the requirement has received royal assent. Under the new law, which is not yet in force, you will written statements from themselves and a member of a profession to be prescribed in the regulations that confirm your gender identity.OntarioNo proof of surgery required;

A declaration, which states your gender identity); and

A note from a doctor or psychologist licensed to practice in Canada that confirms your gender identityPrince Edward IslandProof of surgery requiredQuebecProof of surgery required, but change is pending;

The requirements under the new law have not been set yet.SaskatchewanProof of surgery requiredNorthwest TerritoriesProof of surgery requiredYukonProof of surgery requiredNunavutThere is no provision in the  Vital Statistics Act  for changing sex designation, even with surgery

Sex reassignment surgery is generally not performed on those under the provincial age of majority, as all clinics in Canada that currently perform reassignment surgery conform to the recognized  Standards of Care . These Standards, which are regarding health care for trans persons, forbid irreversible interventions (such as surgery) on patients before they reach the age of majority. As a result, if you are a minor in Canada, you generally cannot change your sex designation in provinces or territories where proof of surgery is required.

In provinces that do not require surgery, the age requirements vary:

Note that legal challenges to the minimum age requirements are currently proceeding in several provinces, including  Quebec  and  Saskatchewan . Click  here  to listen to an interesting radio interview with a 10 year old who would like to change the sex designation on her birth certificate.

Under new law (not yet in force) : No age minimum, but if you are under 16, you must have parental/guardian permission or apply to the Supreme Court of Nova Scotia for an order dispensing with the requirement of parental consent.OntarioNo age minimum, but if you are under 16, you must have parental/guardian permissionPrince Edward IslandNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionQuebecAge minimum is 18.SaskatchewanNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionNorthwest TerritoriesNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permissionNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permission

British Columbia, Ontario and Northwest Territories will change sex designations only for births registered in their respective provinces. Some provinces will register a change of sex and then transmit it to the jurisdiction where the birth was registered.

Under new law (not yet in force) : Legislation requires that the applicant was born in Nova Scotia.OntarioLegislation requires that the applicant was born in OntarioPrince Edward IslandApplicants born outside of Prince Edward Island may apply, and the province will transmit their request to the jurisdiction where their birth was registered.SaskatchewanNo explicit requirement that the applicant was born in SaskatchewanQuebec Under the new law (not yet in force) : Legislation requires that the applicant was born in Canada and resides in Quebec, or that the applicant was born in Quebec and resides in a place where change of sex designation is unavailable or impossibleNorthwest TerritoriesLegislation requires that the applicant was born in Northwest TerritoriesNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonApplicants born outside of Yukon may apply, and the province will transmit their request to the jurisdiction where their birth was registered

For more information:

The Trans PULSE Project prepared a report for the Canadian Human Rights Commission on sex designation in federal and provincial IDs in 2012. The report was prepared for hearings on Bill C-279, a proposal to add gender identity and expression to the  Canadian Human Rights Act  and to hate crime provisions of the  Criminal Code . The report can be found  here .

In 2014, the British Columbia Law Institute prepared a report for the Uniform Law Conference of Canada on the state of the Canadian law regarding change of sex designation, and regarding options for reform in 2014. The report can be found  here .

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Information on Sex Reassignment Surgery (SRS) and Trans Health Care in Ontario

This resource is currently only available in English. Visit our English resources for 2SLGBTQ health information in English.

Questions? Get in touch with us at [email protected]

Answers to Frequently Answered Questions about SRS and Trans Health Care in Ontario.

The document offers information on the current status of SRS in Ontario and related health care for trans patients under the Ontario’s Health Insurance Plan (OHIP) which has not been readily accessible. We have produced this Frequently Asked Questions document to address these issues.

Wait times for bottom surgery in Canada can be as long as eight years. The impact on individuals can be deadly

The story of a 30-something Albertan shows how broken the Canadian system is. It may also be a gross violation of their human rights

Credit: Getty Images; Elham Numan/Xtra

“It’s harrowing.” 

That’s how Ash describes the process of trying to access gender-confirming bottom surgery in their home province of Alberta. (Ash is not their real name. In order to protect them from possible retaliation by Alberta Health, Xtra has agreed to use a pseudonym.)

Almost three years after Ash, who is now in their 30s, got a referral from their family doctor to one of the province’s gender clinics, they still haven’t received provincial approval for this medically necessary operation—and it will likely be another nine months before they hear from the province. Even then, they’re not guaranteed to get approved at all. All it takes is one bureaucrat at Alberta Health to say no and they’re back to square one.

If Ash is approved for surgery, they’re still facing a wait of up to four years at the one clinic in all of Canada that performs bottom surgeries for trans Albertans. All told, even if Ash is approved soon, they’ll be facing a wait of about eight years total to receive care.

“It’s awful waking up every day and just feeling this weight, this misfortune of … having the wrong body parts that could be fixed,” Ash says. “Some days you wake up, and the only way to continue moving forward with your day is just to completely dissociate from yourself, which, of course, impacts how you go about interacting with other people. People do notice.”

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Often, dissociating is the only way they can keep functioning. “The dissociation isn’t something that can be helped; it’s either that, or I let in the full emotion, discomfort, tangible pain of my existence.” 

Ash received no mental health supports from Alberta Health Services during the years they were waiting for the gender clinic to process their referral. The waiting game they are currently playing with Alberta Health has caused them major depression, which they have had to hide for fear that their application for bottom surgery funding will be denied—a legitimate concern given that Alberta Health criteria prevents people with symptomatic depression from receiving funding.

The relational cost of that depression has been severe. “The depression, dysphoria and the dissociation I use as a defence mechanism have completely destroyed my marriage,” they say. “A relationship in which one individual is physically in limbo for such a long period of time simply can’t be maintained in a healthy way.” 

All the while, they feel they’ve been “watching their life go by,” and worry constantly about whether they will receive bottom surgery at all.

 “Is one person along the way with more power than me going to decide that, actually no, this person doesn’t deserve this surgery?” they ask. 

Ash’s story is one told many times over across the country. The story of trans healthcare in Canada is one of lack of access, gatekeeping and provincial inaction. Many argue that these systemic problems may also be a gross violation of human rights.

A bureaucratic nightmare just to start access

Getting vaginoplasty and phalloplasty—more commonly known as “bottom surgery” or gender confirmation surgery—is an intensively bureaucratic process in Canada, one that involves a complicated interplay between public and private health agencies. A recent improvement in the bureaucratic tangle in Alberta reveals just how complicated it is to navigate the system in Canada.

In 2022, Alberta Health quietly revised its criteria for approving trans patients for gender confirmation surgery. Previously, approval required a psychiatrist’s diagnosis and referral, a slow process given the few qualified psychiatrists in the province. Now, any physician can make the required diagnosis of gender dysphoria, and any “ practitioner with extensive training or clinical experience in assessing and managing the needs of the transgender population ” may make a valid referral. 

It would be difficult to overstate the sea change in trans health policy this revision represents. 

Alberta Health Services operates a gender clinic in each of Alberta’s major cities: The Gender Program in Edmonton and the Adult Gender Clinic in Calgary . Both offer comprehensive medical, psychological and social support for people experiencing gender dysphoria. Until this year, both were also the only places in the province where trans people could reliably obtain referrals for gender-affirming bottom surgery. 

The problem with the gender clinic model is, of course, facilitating access to the gender clinics themselves. At Edmonton’s Gender Program, the wait time for adults was between four and eight months in September 2022. At Calgary’s Adult Gender Clinic, wait times are currently closer to two years. And those are just the wait times to begin the process of securing the necessary documentation and referral for bottom surgery approval. 

Xtra reached out to Alberta minister of health Adriana LaGrange to ask what the province was doing to reduce wait times at the gender clinics and received no response from the minister’s office as of press time. 

However, by allowing any qualified physician to refer trans patients for bottom surgery—not just those psychiatrists who work at a gender clinic—Alberta is allowing patients to bypass the backlogged gender clinics, throwing open the door to vaginoplasty and phalloplasty access. Not a small thing in what is arguably Canada’s most conservative province. Indeed, this puts Alberta ahead of neighbouring Saskatchewan , which only accepts funding applications that include a referral from one of four provincially recognized physicians; and, in this respect, even British Columbia , which still requires trans people seeking bottom surgery to obtain a surgical recommendation from a pre-approved list of clinicians.

This doesn’t mean, however, that the fight for trans healthcare in Alberta has been easy, or that it’s over. By removing one bottleneck, the policy change in Alberta smacks hard against an even bigger bottleneck: there are only three clinics in the whole country that offer bottom surgery and two of them are off-limits to out-of-province residents. That means most Canadians, including those from Alberta, are funnelled into one clinic in Montreal where wait times can be up to four years long. 

Accessing funding is one thing, accessing surgery is something very different

Like most provinces, Alberta outsources gender confirmation surgeries to a private hospital in Montreal: the Centre Métropolitain de Chirurgie (CMC).

Founded in 1973 , the CMC is the only private hospital in Quebec and one of only a handful of such hospitals in Canada. (Though privately run, the hospital accepts provincial health coverage, meaning patients access surgery for free.) Currently owned by Dr. Pierre Brassard, the CMC performs upward of 1,000 gender confirmation surgeries every year. It has been the exclusive provider of bottom surgery for Albertans since 1990, as well as, until recently, for most trans Canadians. The latest available data , published in 2019, indicates that in the three previous years, 90 percent of the patients who came to the CMC for gender-affirming surgery hailed from Canada with: 26 percent coming from Quebec, 35 percent from Ontario, 26 percent from the Western provinces and six percent from the Maritimes. 

The CMC offers patients everything from a preoperative stay at the hospital’s partner hotel in Laval, Quebec, to a postoperative stay at the Asclépiade , the only hospital-affiliated convalescent home in the world dedicated specifically to the care of trans patients who have received bottom surgery, to the care of five surgeons specializing in some or all aspects of gender confirmation surgery.

But the wait-list to access gender confirmation surgery at the CMC is notoriously long. The hospital did not respond to a request from Xtra to confirm current average wait times for the operation. However, reporting by the CBC in March 2023 found that the current wait time to access surgery is currently more than four years from the time the CMC receives a referral from a provincial funding body, regardless of which province is submitting the referral.

And as Alberta increases the accessibility of public funding for bottom surgery, that wait time is likely to increase. That’s exactly what happened when Ontario similarly opened up the funding gates in 2016. In that province, the loosened referral rules caused a nearly threefold jump in the number of gender confirmation surgeries funded each year, from 158 in 2015 to 414 three years later. 

Long wait times have been an issue for trans Albertans since the province began funding bottom surgery on an ad hoc basis in 1984 . That year, at the urging of trans healthcare advocate Dr. Lorne Warneke , the province sent three trans patients to Belgium for their surgeries. 

In April 2022, the University of Calgary’s Public Interest Law Clinic (PILC) authored a report on the history and state of trans healthcare in Alberta. That report, which is not public, but has been provided to Xtra by the PILC, drew on internal government records obtained from Alberta Health through a 2018 Freedom of Information and Protection of Privacy request. It shows that, from the beginning, gender-confirmation surgery has been underfunded and inaccessible.

For the first decade that funding was available, from 1984 to 1994, there was no official policy or system for facilitating access to this medically necessary procedure. “It is most likely,” the report concludes, “that Dr. Warneke was pushing each application through the system [himself].”

It was only in 1996 , when Warneke founded the Edmonton Gender Program , that the Alberta government launched an official program to fund bottom surgeries out of the CMC. For the first 12 years that the program was in operation, however, funding was strictly limited to 16 surgeries per year—far short of the demand from trans Albertans. Just five months into the province’s 2008–2009 budgetary year, that quota had already been filled and trans patients were being wait-listed for surgeries in the following year. 

Then, in order to save $700,000 a year—or roughly $0.18 per Albertan based on the population at the time—Alberta Health announced in April 2009 that it would be discontinuing funding for gender confirmation surgeries as an austerity measure. As Ron Liepert, minister of health and wellness at the time, put it in a speech to the provincial legislature, the decision to defund the program “was not based on medical decisions.”

The province never truly followed through on its plan to eliminate funding for bottom surgery; funding kept flowing in a limited capacity, and in 2012, Alberta officially reinstated the program with an annual budget of $1.1 million. That would be enough to cover approximately 25 bottom surgeries per year. In 2016 and 2017, that number grew to 38 surgeries; and in 2018 and 2019, the province funded 83 surgeries, a more than fivefold increase from the original 16 surgery cap. 

As the number of surgeries increased, so, too, did wait times. While Edmonton’s Gender Program saw 580 patients in 2019 (the most recent year for which data is available), more than 650 other patients were on the wait-list for an initial consultation. 

In September 2019, the clinic’s director, Dr. Michael Marshall, publicly resigned, citing the clinic’s financial precarity as his reason for leaving. With one exception, he and his entire staff were dependent on University of Alberta grants—not provincial healthcare dollars—for their funding. “Securing grants as a means of providing care is not sustainable,” Dr. Marshall told Global News at the time.

The two other clinics in Canada don’t accept out-of-province patients

The CMC does not have a monopoly on the provision of bottom surgery in Canada. 

In 2019 , the Women’s College Hospital in Toronto —a public healthcare institution—began offering vaginoplasty to trans Ontarians. That came two years after the hospital launched the Trans Health Expansion Partnership, an undertaking in partnership with Sherbourne Health Centre, the Centre for Addiction and Mental Health and community consultants meant to increase the availability of transition-related healthcare across Ontario. 

Also in 2019 , British Columbia began offering its trans residents access to bottom surgeries at the Vancouver General Hospital. This made it the first province in Western Canada to offer gender-confirmation surgeries for both transmasculine and transfeminine people.

Ontario’s gender-affirming surgical clinic “has the capacity to perform 40 vaginoplasty surgeries in an average year,” according to Emery Potter, nurse practitioner and clinical lead of the Women’s College Hospital’s Transition-Related Surgery program. Last year, the program received 75 referrals for vaginoplasty—almost twice as many as the hospital had the capacity to perform, evidencing the high demand for the health services the program offers.

In B.C., patients move toward bottom surgery in stages. “The first phase includes an intake and consult,” Vancouver Coastal Health told Xtra via email. At this stage, “the wait time is typically 12 to 18 months.” Patients then have the choice to pursue pre-surgery hair removal, which takes about 12 to 18 months by itself; or “intra-operative hair removal” (permanent hair removal during bottom surgery), which can reduce their wait time considerably. Either way, “Once patients are deemed ready, the provincial objective is to ensure that patients wait no longer than six months for surgery.” In the most recent fiscal year, 2022–2023, Vancouver Coastal Health performed 44 vaginoplasties under this program.

Perhaps accounting for their shorter wait times, neither clinic accepts out-of-province patients. (British Columbia’s program does accept referrals from patients in the Yukon, however.) This means that trans people in Canada’s other provinces and territories must still brave the much lengthier wait-list at the CMC, or pay out-of-pocket costs of upward of CAD 13,000 to 20,000  to receive their bottom surgery in another country, like Thailand, for example.

The latter speaks to a deeper problem with the state of healthcare for trans people in Canada. The country has, with two major exceptions, effectively privatized vaginoplasty and phalloplasty. Those with the money to do so can access these procedures fast by going elsewhere. Those without must go to the back of a very long line.

For many trans people, delayed access to gender-affirming bottom surgery is more than an inconvenience. It’s a matter of life or death. 

The suicide rate among Canada’s trans population is notoriously high. Compared to the cis lesbian, gay and bisexual population as a whole, trans Canadians are twice as likely to consider or attempt suicide. In 2019 alone, 31 percent of trans Canadians considered suicide and six percent attempted it.

Adequate access to gender-affirming care can help to reduce that risk. Gender-affirming surgeries demonstrably reduce psychological distress and suicidal ideation, according to research undertaken by Harvard University’s T.H. Chan School of Public Health. And a 2020 Dutch study found that, among trans youth, accessing gender-affirming medical care reduced rates of suicidal thoughts compared to those seen in the cis population.

One Alberta trans woman, Donna Battaglia, told CBC News in March that the wait time to access vaginoplasty in Montreal drove her close to suicide twice. She ended up receiving the operation from a local surgeon who agreed to provide it in tandem with cancer-correction surgery. But there is currently no official mechanism for trans people to obtain any gender-affirming bottom surgery at an in-province clinic because neither gender-affirming vaginoplasty nor phalloplasty are listed on Alberta’s Schedule of Medical Benefits —the list of services that Alberta’s public healthcare program will fund with public money. So while there are surgeons in the province capable of performing bottom surgeries, they don’t usually do so.

All of which raises a pointed legal question.

Might it be a violation of trans Canadians’ human rights to deny them ready access to life-saving genital surgeries like vaginoplasty and phalloplasty?

Are the provinces violating trans Canadians’ human rights?

There’s no free-standing right to healthcare in Canada . But there is a right to be free from healthcare discrimination on the basis of one’s gender identity .

Calgary psychiatrist Joe Raiche thinks Alberta Health has violated that right. He helped develop the city’s Adult Gender Clinic and, in February 2017, filed a human rights complaint against Alberta Health alleging discrimination against the province’s trans population.

The quota in place at the time—which limited funding to 25 bottom surgeries per budgetary year—created a “funding bottleneck,” Raiche argued in his complaint, “since there are always more than 25 Albertans perpetually applying for surgery in a given year.” 

“By virtue of being transgender, certain Albertans will be discriminated against as they not only need to wait for medical care/surgery (uniformly seen in healthcare), but also need to wait an additional time specifically for funding (not seen in other areas of healthcare). A medical diagnosis of gender dysphoria is the only condition where an additional barrier exists based solely on waiting for funding. This amounts to discrimination based on gender identity, as only transgender patients will experience this additional burden.”

Government records provided to Xtra by the Calgary lawyer who worked with Raiche, Drew Yewchuk , indicate that Alberta Health chose to eliminate the cap on bottom surgery funding rather than fight Raiche in front of the Alberta Human Rights Commission Tribunal. Indeed, an internal government memo submitted in November 2017 to the assistant deputy minister of health indicated that “in response to public calls to reduce the wait time for [bottom surgery] funding approval from transgender Albertans, the media and some of Alberta’s referring psychiatrists, including [Raiche’s] Human Rights challenge, decreasing and eliminating the wait time for [Final Stage Gender Reassignment Surgery]  FSGRS funding approval is a program priority.”

In other words, the combination of public outcry and human rights litigation was enough to force the province to dramatically restructure its program for providing trans healthcare. That should offer some hope to trans activists and their allies: change is possible.

And change is needed. Alberta Health may have lifted the formal quota on the number of surgeries it will fund each year, but it still only allocates $1.1 million toward bottom surgeries annually. That would be enough to cover approximately 40 vaginoplasties, Raiche tells Xtra . But the money also has to cover phalloplasties, which can cost four to five times as much. In practice, this means funding for bottom surgery continues to be strictly limited in a province whose population is now estimated to be over 4.5 million residents.

That $1.1 million funding cap needs to go, Raiche says, and vaginoplasty and phalloplasty need to be listed in the provincial Schedule of Medical Benefits . Doing so would place both surgeries on par with other publicly funded operations like gallbladder removal or urethral repair and “allow [Albertans] to have a funding system in place that’s scalable and expands or contracts depending on the needs of the population … at the time.” 

Xtra asked Adriana LaGrange why gender-confirming vaginoplasty and phalloplasty are not in the Schedule, as well as when they would be added to it. Spokesperson Andrew Livingstone declined to say when that would happen. 

Ideally, there needs to be surgeons in the province performing bottom surgeries under the Alberta Health Services umbrella. 

Alberta is moving in the right direction by increasing the availability of public funding for gender-confirmation surgeries. But its progress will remain minimal so long as the province continues to send trans patients out of province. It, along with every other province and territory without its own bottom surgery clinic, needs to follow the lead of Ontario and British Columbia and open up a local clinic for the provision of this surgery.

“There are no legal barriers to Alberta providing such a service in the province,” according to University of Calgary law professor and health law expert Lorian Hardcastle . As far as funding goes, “it is extremely easy for the government to make changes and add new insured services to the Schedule of Medical Benefits.” 

The absence of a bottom surgery clinic in the province “seems to be the product of policy choices either by government” or Alberta Health Services (AHS). “These policy choices may be deliberate decisions that the government or AHS has consciously made to send patients out of province, or it may be policy inaction.”

Indeed, “it would be interesting to know,” Hardcastle says, “what AHS has done to try to encourage or facilitate the opening of such a clinic.” 

The answer, it seems, is nothing.

According to Raiche, in 2019 a multidisciplinary group of Alberta physicians—including psychiatrists, surgeons, endocrinologists and primary care providers—put together a proposal for an in-province centre for gender-confirmation surgery. Alberta Health Services rejected that proposal due to “budgetary constraints.”

“It’s not that Alberta doesn’t have the providers or the clinicians necessary,” Raiche says. “I think we have a really strong network of particular surgeons who are very passionate and committed to trans care. It is just a financial funding decision that, right now, Alberta Health would rather choose to pay for people to go to Montreal as opposed to working together with AHS to create a surgical program here.”

Indeed, when Xtra asked LaGrange what Alberta Health is doing to facilitate the opening of a bottom surgery clinic in the province, the minister’s office declined to say.

Inaction from provincial governments ultimately means that trans Canadians will face more suffering.

Canada’s provinces are, with two exceptions, failing their trans residents. By relying on a backlogged clinic in Montreal to provide a medically necessary and life-saving operation, the provinces are putting trans people’s health, safety and well-being at risk. 

• “ Alberta Healthcare Insurance Bulletin ,” Aug. 20, 2012
• “ Funding for Transition Surgeries ,” Alberta Health Services, 2023
• “ The Gender Program ,” Alberta Health Services, 2023
• “ Adult Gender Clinic ,” Alberta Health Services, 2023
• “ Saskatchewan Medical Transition Guide ,” Saskatchewan Trans Health Coalition, Jan. 2019
• “ Surgical Care Planning ,” Trans Care B.C., 2023
• “ CENTRE MÉTROPOLITAIN DE CHIRURGIE—CMC ,” TransAvenue, Nov. 8, 2019
• “ D'où viennent les patients du Centre Métropolitain de Chirurgie? ” TransAvenue, Dec. 16, 2019
• “ La maison de convalescence Asclepiade fête ses 15 ans! ” TransAvenue, Sept. 22, 2022
• “ Advocates push for gender surgery funding within Alberta amid years-long backlog in Montreal ,”  Katarina Szulc, CBC, March 16, 2023
• “ Toronto’s Women’s College Hospital launches new program for gender-reassignment surgery ,” Kelly Grant, Globe and Mail, June 17, 2019
• “ Dr. Lorne Warneke remembered as pivotal LGBTQ pioneer in Alberta ,” CBC News, Sept. 3, 2020
• “ Trans rights trailblazer reflects on 50 years of social change ,” Kristen Bauer, University of Alberta, Sept. 25, 2017
• “ Province of Alberta 27th legislative Session ,” April 14, 2009
• “ Head of program’s resignation raises questions about accessibility to transgender care in Alberta ,” Jill Croteau, Global News, Sept. 16, 2019
• “ The Gender Surgery Program B.C. ” Vancouver Coastal Health, 2023
• “‘ It’s wonderful’: Community reacts to news B.C. will offer gender-affirming lower surgeries ,” Micki Cowan, CBC, Nov. 16, 2018
• “ Price List ,” Transgender Thailand, 2023
• “ Transgender people and suicide fact sheet ,” Mental Health Commission of Canada, May 10, 2019
• “ Mental health benefits associated with gender-affirming surgery ,” Harvard, 2021
• “ Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers ,” Journal of Adolescent Health, June 2020
• “ Alberta Health Care Insurance Plan: schedule of medical benefits as of 01 April 2023 ,” Alberta government, April 1, 2021
• “ Alberta’s population expected to hit 5 million later this decade, possibly as early as 2025 ,” Robson Fletcher, CBC, July 7, 2023

Sources And Methodology

Charlotte Dalwood is an English-speaking freelance journalist and JD student based in Calgary, AB. Her other publications include a monthly column on 2SLGBTQ+ and legal issues for rabble.ca.

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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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CANADIAN GENDER REPORT

Can Kids Consent To Medical Transition?

We’re excited to welcome a new ally and repost their piece on the critical topic of consent. GD Alliance Canada is a grassroots group of people with gender dysphoria, some who have medically transitioned and all of whom believe “the current popular gender narrative doesn’t tell the whole story.” We look forward to a close collaboration with this group. Follow them on Twitter @canada_gender

The Ethical Dilemma of Consent

In January 2021, the research article This Wasn’t a Split-Second Decision: An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy was published in the Journal of Bioethical Inquiry. https://link.springer.com/article/10.1007/s11673-020-10086-9

The stated aims of the authors are “to provide empirical analysis of minor trans youth capacity to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to care.” The authors explain that their research was conducted in British Columbia where mature minor legislation applies to healthcare decision making. It’s also notable that they selected interview participants from gender-affirming organizations and treatment facilities, thus making this a biased sample. The authors admittedly follow “a gender-affirmative clinical orientation” and therefore aren’t applying ethical analysis to that model itself. They concluded that yes, minors are capable of consenting to hormone therapy.

The second line of the ethics abstract reads: “Transgender (trans) youth experience barriers to needed gender-affirming care”

There’s a lot to unpack right there.

Transgender versus gender dysphoria

The authors begin their whole argument with an assumption that we all know and agree upon what a “transgender youth” is. Do we? Is it like a racial group, or a third biological sex? Is it a newly discovered phenotype? Is it a nationality or religious affiliation? I can tell you that, even within the trans-identified population, there is no consensus on what constitutes “trans”. Deep ideological divides exist within the trans community just as much as anywhere else.

Classifying “trans” as a definable group of people has been politically effective and lends itself well to advocacy, especially when piggy-backed onto LGB and intersex issues (which, I might add, has ticked off many LGB and intersex people). The ideas of “human rights” and “access to care” easily roll off of the designation of a marginalized group. We want justice for those who are oppressed, so well-meaning people get on board without question. But, the reality is, “trans” is a mere declaration of identity, not a measurable entity.

Anyone can be “trans”.  Identity is subjective. Sound medical practice on the other hand, requires evidence-based objectivity. What is the diagnosis? How do we reliably determine the diagnosis? Are there biomarkers? How do we determine who will most likely benefit from treatment? Such questions are now considered taboo, even among clinicians.

Let that sink in. Clinicians within the system are not allowed to openly discuss among themselves and debate what this condition is. It’s considered wrong to “pathologize” naturally occurring gender identity. We’re to eliminate all barriers to medical interventions for something we’re not allowed to name as a condition. Any barriers (like taking the time to explore identity development with a client) are considered oppressive (“gatekeeping”). Valid clinical research is being suppressed whenever it doesn’t align with this narrative. (Link 1 and 2)

If there’s no pathology, then why is treatment needed and paid for by the public health system? If treatment is so desperately needed, then there is pathology.

The truth is, there is no such thing as a “trans person” outside of political utility and socially constructed identity.  There is a range of ways in which any person can express their femininity or masculinity, within the bounds of their biological sex. There are tomboys and feminine men. There are gender roles, and many people take up roles which are not traditionally aligned to their sex. Nothing pathological about that. No need for a doctor.

There are people who experience Gender Dysphoria (GD), or what used to be called Gender Identity Disorder (GID). Many gay and lesbian people feel GD. Some intersex people experience it. There are correlations between GD and schizophrenia, autism spectrum disorders and personality disorders. (Links 3-5) In some cases GD goes away, and for others it doesn’t. Some people feel it but still embrace their biological sex. Others dissociate entirely from their sexed body.  There are many reasons why people dissociate from their bodies or hate their sex, like sexual trauma or social inequities. And, I’ve heard many trans-identified people say that they never felt GD at all and lied to their clinicians in order to get hormones. I’ve heard others say they transitioned for “political reasons”. Some heterosexual men are turned on by the idea of having a female body. So there’s our motley crew. I may be missing some. Some of these pathways have been well studied and articulated by psychologists like Dr Ray Blanchard. As far as clinical or social need, does a gay kid have the same needs as someone with autism? Is a woman who’s experienced sexual trauma the same as a man who’s sexually aroused by the thought of having a female body? (Link 6) 

Many people don’t realize that approximately 84% of children with GD resolve it by the time they’re through puberty. (Link 7)  Most of those kids end up being gay or lesbian. So, why is it considered ethical to capture children with GD into a trans identity and present medicalization as the only treatment pathway when we know that most of those kids would desist if left alone? What does the gay and lesbian community think about transitioning kids who most likely would have turned out to be gay or lesbian?

“Trans” is an identity that masks all of these separate and often unrelated pathways. When children experience GD, or are otherwise distressed by their bodies, they are being taught a trans narrative, rather than being helped to find themselves within a complex array of GD presentations and social pressures. No one can provide informed consent if they’re not being truthfully well-informed.

No one can provide informed consent if they’re not being truthfully well-informed.

Gender-affirming care

Gender-affirming healthcare is an extension of the trans ideological narrative. As such, it’s a significant departure from medical conventions. For any other healthcare issue, whether a medical condition like diabetes or a mental health condition like anorexia nervosa, a qualified clinician employs a standardized process for examining and diagnosing the condition. Once reasonably certain of a diagnosis, treatment options are presented to the patient (and family, if applicable), risks and benefits are discussed, and then the patient may either consent to treatment or decline treatment.

This is not the current pathway to gender medicine, where principles of safekeeping and evidence-based discernment by qualified specialists are being reframed as oppressive “barriers”. Patients present to clinics stating that they are “trans”, having made a self-diagnosis by obtaining trans-cultural information from places such as the internet, social media and peer groups, and then tell the clinician that they want hormones and surgeries. Gender-affirming clinicians don’t question that self-diagnosis or conduct careful, exploratory, diagnostic assessments. In a co-operative trans-cultural effort, they presume that “people know who they are and what they need” and initiate treatment, as long as the client seems capable of consenting to the treatment they’ve said they want.

While affirming someone’s identity may be socially polite, it is a grossly irresponsible departure from science-based medical practice, regardless of the age of the patient.

Clinicians are willfully ignoring a wealth of research about the different types, pathways and therapeutic options for GD, choosing instead to collude with gender ideology. This sudden, dramatic shift to affirmation was the result of activism, not new scientific evidence. The “old” science stands, but is rejected.

Finland, Denmark, Australia, Ireland, and the UK have completed or started systematic reviews of gender-affirmative treatment for children. Finland and Denmark concluded that there is insufficient evidence to support this approach. There’s still a great deal unknown about the long-term health outcomes, and it hasn’t yet been determined why gender clinics are seeing sudden, exponential growth in young people (mostly girls) seeking treatment. Finland has released their own guidelines of care, emphasizing psychological interventions and cautious assessment. Gender politics didn’t hold up to clinical scrutiny in the landmark 2020 case in the UK between the Tavistock clinic and Keira Bell. The judge concluded that children are not legally capable of consenting to puberty blockers – the first step in medically transitioning children. The judge’s ruling outlines many key points of debate in detail. (Link 8)

Some highlights include: – The Dutch Protocol, on which this intervention is based, was designed for the use of puberty blockers on children who had severe early childhood onset GD. It was not intended for use on children with later onset GD or other presentations.  – Puberty blockers may generate persistence of GD and prevent desistance, since virtually all kids who start puberty blockers move on to hormone therapy. – There is insufficient data about the long-term health risks. Possible risks include: weakening of bones, incomplete development of sex organs, body shape and height, memory and concentration deficits, and infertility.  – The clinic’s claim that puberty blockers are “fully reversible” is misleading – It was noted that “there was no overall improvement in mood or psychological wellbeing using standardized psychological measures” – This is experimental treatment which should only be used in research settings – Authorization of the court will be required to receive puberty blockers – GD as a condition was not contested

A similar legal challenge or systematic review has not taken place in Canada, but I expect similar outcomes when that happens.

I am not proposing that we roll back civil rights for trans people, nor am I proposing a roll back to coercive and punitive measures to treat it. (Most people aren’t.) I would like to see an approach that is integrative of all that is currently known about these conditions, which requires that we take the lid off the box and look at these issues with honesty as well as compassion. Medicalization should be a last resort, not first-line treatment for such complex psychological, social and political phenomena. Children are not developmentally mature enough to fully understand these complexities, especially when they are also struggling with other mental health symptoms or developmental disabilities.

The lack of mature, balanced, clinical oversight and community leadership places all of the decision-making responsibility onto the shoulders of these misinformed children.

I would like to see the authors of this ethics paper back up, set aside their own political bias, and provide analysis on the glaring ethical problems within the very foundations of gender-affirming care. Our children require this of us, as their parents, teachers, researchers, and clinicians.

• https://www.independent.co.uk/news/uk/home-news/psychotherapist-gender- assignment-surgery-reverse-research-stop-trans-bath-spa-university-james- caspian-a7965281.html
• https://www.nydailynews.com/news/national/ny-news-brown-university-removal- gender-dysphoria-study-reaps-backlash-20180905-story.html
• https://www.hindawi.com/journals/schizort/2014/463757/?fbclid=IwAR28sAg5ilHYpGYjQmOiy7jH1AuEFJYjDViigAoVlL9Qp8agRAYI82gPrQg
• https://www.autism.org/gender-dysphoria-autism/
• https://www.hindawi.com/journals/tswj/2014/809058/
• https://www.researchgate.net/publication/5893630_What_Many_Transgender_Activists_Don’t_Want_You_to_Know_and_why_you_should_know_it_anyway
• https://jaacap.org/article/S0890-8567(13)00187-1/fulltext
• https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock- Judgment.pdf

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Sweden lowers gender reassignment age in controversial new law

People can now legally change gender from the age of 16 under new rules that also make access to surgical interventions easier

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

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

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

The debate has also weakened the prime minister’s standing, after he admitted to caving in to pressure from party members on the issue.

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

Currently, the process of changing a person’s legal gender can take up to seven years.

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

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

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

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

A number of European countries have already passed laws making it easier for people to change their legal gender.

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

Rise in gender dysphoria

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

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

A recent poll suggested almost 60 per cent of Swedes oppose the proposal, while only 22 per cent back it.

Jimmie Akesson, the far-Right Sweden Democrats leader, lamented the result of Wednesday’s vote.

“I think it’s deplorable that a proposal that obviously lacks support among the population is so casually voted through,” Mr Akesson told reporters.

Some critics had expressed concerns about biological males in women’s locker rooms and prisons and fear the simplified procedure to change legal gender will encourage confused youths to embark down the path toward surgical transitions.

Others had insisted that more study is needed given the lack of explanation for the sharp rise in gender dysphoria.

Annika Strandhall, the head of the women’s wing of the Social Democrats (S-kvinnor), told Swedish news agency TT ahead of the vote: “There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism.

“We want to pause this [age change] and wait until there is further research that can explain this increase [in gender dysphoria cases].”

Ulf Kristersson, the prime minister, had defended the proposal as “balanced and responsible”.

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