gender reassignment surgery cost canada

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Gender confirming surgery

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

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

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Affirming gender identity.

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

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

How to qualify

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

To qualify for funding, you must:

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

Approval for genital surgery

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

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

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

Approval for chest surgery

To be approved for chest surgery you’ll need:

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

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

Apply for surgery

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

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

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

Additional resources

You can find useful information from organizations, such as:

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

Information for healthcare providers

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

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Funding for Transition Surgeries

Medical transition.

There are several options available for medical transition including hormone therapy and feminizing or masculinizing surgery. Treatment is individualized. Based on your specific health care requirements, your health care provider may prescribe medication (e.g. hormones) or refer you to a Psychiatrist or another expert in transgender care who is registered with the College of Physicians and Surgeons of Alberta. You don’t always need to be assessed by a Psychiatrist (see below). If you decide that surgery may be needed to relieve your symptoms of gender dysphoria, your health care provider may also refer you to specific specialists to match the surgical approach with your needs.

When considering a surgical option, discuss your needs with your health care provider as they are the best pathway to care.

Phalloplasty, Metoidioplasty, & Vaginoplasty Procedures

This Alberta Health funding program was established under a Ministerial Order with specific program criteria and is not funded under the Alberta Health Care Insurance Plan (AHCIP).

Alberta Health provides once per lifetime funding for eligible Alberta residents diagnosed with gender dysphoria who meet the established program criteria to receive Phalloplasty, metoidioplasty or Vaginoplasty. Patients must undergo two independent assessments by Psychiatrists or other physicians with extensive training or clinical experience in assessing and managing the mental health needs of the transgender population, and be diagnosed with gender dysphoria.

Though the program requires two diagnoses of gender dysphoria from Alberta practitioners with extensive training or clinical experience in assessing and managing the needs of the transgender population, any physician licensed in Alberta (psychiatrist, family physician, or others) can submit the application documents to Alberta Health. This means that the patient can be referred to other clinicians with expertise by their family physician, and the family physician may then submit the documents received from other physicians as part of the patient’s application package.  Only complete applications will be processed. Alberta Health will return incomplete applications to the applying physician. Download application forms .

Surgeries for Phalloplasty, metoidioplasty or Vaginoplasty are provided at the Centre Metropolitain de Chirurgie in Montreal.

Not Funded by Alberta Health

• Procedures such as facial feminization, tracheal shave and voice pitch surgery
• Non-medical interventions such as massage therapy and laser hair removal or electrolysis
• Take-home medications and equipment
• Personal expenses, meals and accommodation

Breast Augmentation & Mastectomy

As of January 21, 2019, patients undergoing surgical transition, breast augmentation and mastectomy must have pre-approval from Alberta Health. A surgeon or primary care provider (PCP) must validate a patient’s eligibility using the Request for Breast Surgery form. Patients must undergo one independent assessment by a Psychiatrist or other physician with extensive training or clinical experience in assessing and managing the mental health needs of the transgender population, and be diagnosed with gender dysphoria.

To meet eligibility criteria for payment, the applying surgeon must submit the pre-approval form to Alberta Health. Note - to qualify for breast augmentation for cis and transgender women as an insured service, the patient must have little to no breast growth as clinically determined by the surgeon.

Please Note: To avoid errors, the following Government of Alberta forms must be downloaded to your computer and opened with Adobe Acrobat Reader instead of being viewed via the web browser. Right click on the URL and click "Save Link As" to save the file to your desktop. Download the approved form Request for Breast Surgery . For more information regarding insured services, see Health Care Services Covered in Alberta , update to breast augmentation bulletin and billing codes bulletin.

• TOPS Guidelines

Advisory - Changes due to COVID-19

Note: to minimize the spread of COVID-19, Alberta Health staff may be working remotely. All funding applications and urgent questions only should be emailed to [email protected] .

COVID-19 Update for GRS Montréal: Open for All Surgeries

Patients must provide proof of vaccination. Patients must also provide a negative COVID-19 test taken within 3 days of admission to GRS Montréal.

Upon arrival in Montreal, patients will stay 24 to 48 hrs at the clinic’s partner hotel before admission to GRS Montréal, the morning of the surgery. This accommodation is provided by the clinic.

A 2-week confinement may be mandatory under public health recommendations if patients are suspected to have COVID-19 symptoms. The patient is required to pay for the extra costs of the isolation period before or after surgery.

Otherwise, after convalescence, there is no contraindication to travel.

Contact GRS Montréal at 514-288-2097 for questions about costs during potential isolation periods.

Patients should contact GRS Montréal at 514-288-2097 to discuss concerns about delayed surgery due to COVID-19. GRS Montreal is responsible for scheduling and facility operation .

For further details please see the GRS Montreal COVID-19 Preparedness Strategy .

For more information:

• Consult the postoperative documents you received during your stay at GRS Montreal
• Consult your treating physician if you note any changes in your health status

Contact GRS Montreal at 514-333-1572, ext. 200 or email [email protected] . Note: This line is for physicians only

COVID-19 Travel Disruptions

Return travel may be disrupted due to the pandemic. Patients may be required to remain outside of Alberta longer than expected.

If your medically necessary travel has been approved by Alberta Health and booked, contact Alberta Health at [email protected] to confirm or change travel arrangements.

Read more COVID-19 travel advice .

Find more information at Coronavirus disease (COVID-19) Travel advice - Canada.ca

Our work takes place on historical and contemporary Indigenous lands, including the territories of Treaty 6, Treaty 7 & Treaty 8 and the homeland of the Métis Nation of Alberta and 8 Métis Settlements. We also acknowledge the many Indigenous communities that have been forged in urban centres across Alberta.

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much more than surgery

The quality and safety in our care and services; Your peace of mind. Excellence is a core value that drives the decisions and actions of every member of our staff.

EXPERIENCED SURGEONS

Our surgeons have performed more than 10 000 gender-affirming surgeries over the past 12 years.

PERSONALIZED FOLLOW-UP

Care is provided in the spirit of patient support and in consideration of the uniqueness of your own experience. From the preoperative period to your postoperative follow-ups, we will be right beside you.

QUALITY FACILITIES

Surgeries are performed at the Centre Métropolitain de Chirurgie, our private hospital centre accredited with exemplary standing. For some surgeries, a stay at the Asclépiade convalescent home is necessary.

A WORRY-FREE STAY

No matter where you come from, we will help you plan your stay.

Dr Pierre Brassard, FRCSC

Dre Maud Bélanger, FRCSC

Dre Valérie J. Brousseau, FRCSC

Dr Alex Laungani, FRCSC

Dr Chen Lee, FRCSC

Dr Dru Perkins

Dr Mar Aristeo Poncio

Male to Female / MTF / MTX

Vaginoplasty, Vaginoplasty without vaginal cavity, Breast Augmentation, Adam's Apple Reduction, Voice Surgery, Facial and Body Feminization, Corrective surgeries: Secondary Vaginoplasty, Genital Scar Revision, Vulvar Reconstruction, Labioplasty, Correction of the Clitoris

Female to Male / FTM / FTX

Masculinization of the Torso or Mastectomy, Metoidioplasty, Phalloplasty, Insertion of Testicular Implant(s), Insertion of Penile Implants , Masculinization of the Face and Body surgeries, Corrective surgeries: Torso Scar Removal, Nipple Correction, Secondary Phalloplasty, Phallus Revision

Transition Related Surgery

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

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

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

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

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

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

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

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

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

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

Surgeries Available

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

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

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

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

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

Plastic Surgery

John semple md, msc, frcs(c), facs .

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

Mitchell Brown MD, MEd, FRCS(C) 

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

Dr. Kathleen Armstrong

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

Urologic surgery

Ethan grober md, med, frcs(c) .

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

Yonah Krakowsky, MD FRCS(C)

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

Lisa Allen, MD, FRCS(C)

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

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

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

Making a Referral

To make a referral please submit.

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

Before making your referral ensure

The patient meets OHIP eligibility for surgery (unless contraindicated)

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

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

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

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

For OHIP Funding

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

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

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

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

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

Criteria for Surgery

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

Surgery Planned Visits

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

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

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

Gender History

Discuss the patients current gender identity and process of transition.

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

Goals for surgery

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

Detailed surgery discussion/capacity for informed consent

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

Readiness (medical and psychosocial)

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

Criteria for Transition Related Surgery

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

Provider Resources

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

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

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

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

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

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

Referral Process for Patients

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

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

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

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

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

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

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

Post Surgical Resources – Vaginoplasty

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

Post-Surgical Resources – Chest Surgery

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

The Financial Cost of Being Transgender in Canada

Part 2: we focus on some of the financial challenges faced by the transgender community, both hidden and open.

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

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

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

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

Facial Gender-Affirming Surgery

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

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

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

Gender-Affirming Chest Surgery

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

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

Genital Gender-Affirming Surgery

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

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

Gender-Affirming Body Contouring

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

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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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How gender-affirming health care for kids works in Canada

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

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

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

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

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

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

• CBC Kids News Explaining gender-affirming care to kids

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

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

How does it work?

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

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

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

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

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

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

Do kids get medical treatment before puberty?

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

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

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

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

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

Can minors get surgery?

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

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

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

Are kids rushed into treatment?

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

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

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

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

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

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

What are the effects of puberty blockers?

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

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

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

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

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

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

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

What are the effects of hormone therapy?

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

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

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

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

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

How involved are parents?

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

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

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

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

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

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

Ultimately, she says, it's worth it.

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

ABOUT THE AUTHOR

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

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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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Ontario resident who wants both a vagina and penis wins public funding for unique surgery

A court has ruled Ontario must pay for a penis-sparing vaginoplasty for a person who identifies as neither fully female nor fully male

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Ontario has been ordered to pay for surgery for a resident who is seeking to have a vagina constructed while leaving their penis intact.

Denying the procedure would infringe on the person’s Charter-protected right to security of the person, an Ontario court said in its ruling.

The unanimous decision by a three-member panel of judges of Ontario’s Divisional Court could expand access to a novel “bottom surgery” for people who identify as non-binary, meaning neither fully male nor fully female.

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The Ontario resident, identified in court documents as K.S., has been locked in a legal battle with the Ontario Health Insurance Plan since 2022, when OHIP denied a funding request to have a penile preserving vaginoplasty performed at a clinic in Austin, Texas.

The surgery, which is not available anywhere in Canada, involves creating a vaginal canal, or opening, without removing the penis.

K.S., 33, was born male but identifies as female dominant and uses a feminine name.

OHIP denied her request for funding, arguing that the procedure is not included on its list of sex-reassignment procedures, and is therefore not an insured service.

K.S. appealed OHIP’s decision to Ontario’s Health Services Appeal and Review Board, arguing that forcing her to have her penis removed would invalidate her identity and be akin to an illegal act of conversion therapy.

She also worried about the risk of complications and urinary incontinence from the urological rerouting, and the risk of orgasm dysfunction. She argued the procedure she is seeking abroad is like standard vaginoplasties performed in Ontario, but without the additional procedure, namely, the penectomy.

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The appeal board overturned OHIP’s decision, ruling that a vaginoplasty is among the genital surgeries listed for public coverage and need not inherently include removal of the penis. The board therefore ruled the procedure eligible for public funding.

OHIP appealed the board’s decision to the Divisional Court, arguing the review board erred in finding a penis-sparing vaginoplasty is specifically listed as an insured service, and that it failed to consider that the unorthodox procedure is considered an experimental procedure in Ontario, and, therefore, not eligible for funding.

Just because vaginoplasty is listed as an insured service doesn’t mean any type of vaginoplasty qualifies, OHIP argued in court.

The court disagreed. Vaginoplasty and penectomy are listed as discrete, separate services on Ontario’s list of surgeries eligible for funding, the court said. “The fact that most people who have a vaginoplasty have it done in a way that also involves a penectomy” doesn’t change the provision. If the province had intended for only one type of vaginoplasty to be insured (vaginoplasty with penis removal) it should have drafted the list differently, the court said.

The court said the appeal board’s conclusion was also consistent with standards of care developed by the World Professional Association for Transgender Health (WPATH) — an influential group whose guidelines for gender-affirming care for children and youth were found to lack “developmental rigour”  in a sweeping review released this week.

The WPATH standards “expressly refer to vaginoplasty without penectomy as a surgical option for some non-binary people,” Justice Breese Davies wrote in the court ruling.

While the court said it didn’t need to address Charter arguments, if there was any ambiguity concerning what should or should not be covered, the review board’s interpretation was also consistent with Charter values of equality and security of the person, the court added.

“The Charter-protected right to security of the person safeguards individual dignity and autonomy,” Davies wrote. Requiring a transgender or non-binary person born male “to remove their penis to receive state funding for a vaginoplasty would be inconsistent with the values of equality and security of the person.”

“Such an interpretation would force transgender, non-binary people like K.S. to choose between having a surgery (penectomy) they do not want, and which does not align with their gender expression to get state funding, on the one hand, and not having gender affirming surgery at all, on the other,” Davies wrote.

“Such a choice would reinforce their disadvantaged position and would not promote their dignity and autonomy.”

OHIP’s appeal was dismissed, and the province ordered to pay K.S. $20,000 to cover legal costs.

“This is a significant win for the transgender and non-binary communities,” K.S.’s lawyer, John McIntyre, told CTV News Toronto.

“We hope that OHIP decides to accept the decision of the court rather than seeking leave to appeal so that K.S. can move forward with her surgery she has been trying to get for years now.”

“K.S. is very happy with this unanimous decision,” McIntyre said in an email to the National Post. “The Divisional Court determined the existing language of the Health Insurance Act and the Schedule of Benefits clearly provided coverage for the procedure she sought.”

In earlier reports, National Post was told that gender-affirming surgeries at the Texas clinic range from US$10,000 to $70,000, depending on what is done.

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Four Takeaways From the Vatican’s Document on Human Dignity

The document restated the Roman Catholic Church’s rejection of abortion, gender fluidity and transition surgery.

By Jason Horowitz and Elisabetta Povoledo

Jason Horowitz reported from Rome, and Elisabetta Povoledo from Verbania, Italy.

The document issued on Monday by the Vatican puts human dignity at the center of Catholic life , but in doing so, it broaches some of the most difficult and sensitive social issues, those that Pope Francis has spent his papacy avoiding.

On Monday, though, his church leaned hard into them in the document, called “Infinite Dignity.” It argued that the exploitation of the poor, the outcast and the vulnerable amounted to an erosion of human dignity. But it was the restating of the church’s rejection of abortion, the death penalty and euthanasia, and especially gender fluidity, transition surgery and surrogacy, that church liberals worried would be used as ammunition by the right.

Here are four takeaways.

The pope’s inclusivity has limits.

Pope Francis’ inclusive message, which has included allowing L.G.B.T.Q. Catholics to receive blessings from priests and transgender people to be baptized and act as godparents , has a limit: Catholic doctrine.

The pope’s conservative critics have for a decade argued that his tendency to speak off the cuff and in overly welcoming ways toward L.G.B.T.Q. people, the divorced and remarried, along with others who sin in the church’s eyes, had sent the wrong signal.

But the document released on Monday, and remarks by Cardinal Víctor Manuel Fernández, the prefect of the Vatican department with oversight over doctrine, underlined that the pope’s message was just that — a signal that the church was more open to the world, but that the substance, what it considers immutable “truth,” remained the same.

That dissonance, though, between Francis’ style and his defense of Catholic doctrine was highlighted by the document, and for many supporters of great change within the church, it amounted to a declaration that they would not get what they want.

As if to highlight that tension, Cardinal Fernández responded to a question on Monday about the church’s teaching that homosexual acts are “intrinsically disordered” — what many supporters of L.G.B.T.Q. faithful consider the insurmountable obstacle to true acceptance — by saying that the problem may be the terminology, not the meaning.

It was, he said, a “very strong expression” and that perhaps “more suitable words” could be found to express the thought that homosexual sex could not produce the “mystery” of childbirth.

Gender fluidity erodes human dignity, the document says.

The Vatican argues that gender fluidity, or the idea that people can decide their own sex, erodes human dignity because it blurs the difference between men and women, which it considers a gift from God.

Francis, while personally welcoming to transgender people — he has met many throughout his papacy — is convinced that powerful lobbies are pushing what the Vatican calls “gender theory” as a form of “cultural colonization” on more traditionalist societies.

This ideology, the Vatican said in the document issued on Monday, “envisages a society without sexual differences, thereby eliminating the anthropological basis of the family.” It was unacceptable, the Vatican said, that such ideologies managed to “assert themselves as absolute and unquestionable, even dictating how children should be raised.”

The Vatican ties surrogacy to commercialization.

The Vatican document reiterates its opposition to surrogacy, arguing that even though the process may fulfill the wishes of couples longing to have children, it does so at the cost of a wider human dignity because it reduces women, in the Vatican’s view, to simply carriers and children to what Francis has called products of “commercialization.”

The church’s opposition to surrogacy and in vitro fertilization stems from its ethical and theological teachings on the issue of life. Though Francis has made it clear that while the church opposes surrogacy, children born from surrogacy can be baptized.

“First and foremost, the practice of surrogacy violates the dignity of the child,” who “has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver,” the document states.

“Surrogacy also violates the dignity of the woman, whether she is coerced into it or chooses to subject herself to it freely,” as it detaches the women “from the child growing in her and becomes a mere means subservient to the arbitrary gain or desire of others.”

The sex a person is born with is seen as a gift from God.

The Vatican document is adamant in its rejection of transition surgeries, what it calls “Sex Change.” It argues that the physical sex a person is born with — male or female — is an equal gift from God, who has made the human in his image. It is not a gift you can give back, the Vatican says.

Changing sex, the church argues, is to put individualism before “the need to respect the natural order of the human person,” and “any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.”

The church, however, made an exception for people with “genital abnormalities that are already evident at birth or that develop later,” which could be resolved through “health care professionals” because it would “not constitute a sex change in the sense intended here.”

Jason Horowitz is the Rome bureau chief for The Times, covering Italy, the Vatican, Greece and other parts of Southern Europe. More about Jason Horowitz

Elisabetta Povoledo is a reporter based in Rome, covering Italy, the Vatican and the culture of the region. She has been a journalist for 35 years. More about Elisabetta Povoledo

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The 10 Buzziest Releases Coming to Cannes in 2024—From a Selena Gomez Musical to Sebastian Stan’s Take on Donald Trump

By Radhika Seth

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The line-up at last year’s Cannes Film Festival —which included a staggering eight films that went on to be nominated for Oscars, among them best-picture contenders Anatomy of a Fall , The Zone of Interest , and Killers of the Flower Moon —was one of the strongest in years, cementing the festival’s reputation as the ultimate awards season launchpad. So, naturally, the illustrious French showcase has put together an even starrier shortlist for its 77th edition, due to run from May 14 to 25. Greta Gerwig will serve as jury president, George Lucas is due to receive the honorary Palme d’Or for lifetime achievement, and the releases on the roster range from mind-blowing action epics to surreal musical comedies and one particularly breathlessly anticipated (and expertly timed) political biopic. These are the 10 films you need to look out for.

Furiosa: A Mad Max Saga

Almost a decade after George Miller’s high-octane, nerve-jangling, running-on-fumes blockbuster Mad Max: Fury Road thundered into theaters, the visionary is back with an equally ambitious prequel, casting Anya Taylor-Joy as the titular road warrior previously embodied by a steely Charlize Theron. Snatched from the mythical “green place” as a child, she journeys across the wasteland to the citadel ruled by Immortan Joe, but once she comes of age, she vows to escape by any means necessary. Add Chris Hemsworth as a mustache-twirling warlord, Tom Burke as a warpaint-covered love interest, gasp-inducing stunts, eye-popping explosions, and an appropriately booming soundtrack, and you have a big-screen spectacle like no other.

Kinds of Kindness

Yorgos Lanthimos’s madcap follow-up to Poor Things zips us from a mind-bending Victorian London to the present—or, at least, a (characteristically bonkers) version of it—in which double Oscar winner Emma Stone dances with reckless abandon as cars are nearly crashed and bodies are dragged down hallways . A three-part sci-fi anthology which also stars Hunter Schafer, Joe Alwyn, Margaret Qualley, Hong Chau, Willem Dafoe, Jesse Plemons, and Mamoudou Athie, it looks set to be a surreal romp from an auteur who is, undeniably, at the peak of his powers.

The Apprentice

After making a splash at Cannes in 2018 with the Swedish fantasy Border , and then again in 2022 with the Persian-language thriller Holy Spider , Ali Abbasi returns to the Croisette with something far more conventional, though no less exciting: an account of Donald Trump’s rise in ’70s and ’80s New York, with Pam & Tommy ’s Sebastian Stan donning prosthetics and a blonde wig to play a younger iteration of the former president. Meanwhile, a still-very-much-Kendall-Roy-adjacent Jeremy Strong takes the role of Roy Cohn, the prosecutor and fixer who acted as Trump’s mentor, while Borat Subsequent Moviefilm ’s Maria Bakalova becomes the aspiring real estate tycoon’s first wife, Ivana, and Martin Donovan his father, businessman Fred Trump. With the next presidential election looming and the film’s real-life subject still neck and neck with Joe Biden in the polls , this examination of corruption and deceit couldn’t feel more timely.

Megalopolis

A passion project that’s been over two decades in the making, Francis Ford Coppola’s first big-screen release since 2011 is easily the festival’s most-talked-about Palme d’Or contender: a debauched and decadent cautionary tale about America’s future, with a star-packed cast featuring everyone from Adam Driver and Aubrey Plaza to Giancarlo Esposito, Chloe Fineman, and Nathalie Emmanuel. Early viewers’ responses have ranged from shock and bafflement to euphoria, though all agree that the 135-minute epic—which has, tellingly, still not secured a distribution deal—is an audacious piece of work. Cannes will be crucial to determining its fate: there’s a chance it could dazzle audiences and scoop the top prize (as another long-gestating and once seemingly cursed Coppola project, Apocalypse Now , did back in 1979), or it could be a major misfire. Either way, the entire industry will be watching with bated breath.

Emilia Perez

By Hannah Coates

By Christian Allaire

By Hannah Jackson

Selena Gomez, Zoe Saldaña, Édgar Ramírez, and Karla Sofía Gascón lead this musical crime caper from Palme d’Or winner Jacques Audiard, which centers on a lawyer who receives an unexpected request: to aid a formidable Mexican cartel boss who wishes to retire from the business and undergo sex reassignment surgery—the latter, both to evade authorities and to finally affirm her gender. With original songs penned by French singer Camille, and Saint Laurent’s Anthony Vaccarello creating the costumes and serving as a co-producer, it’s guaranteed to be a wild and stylish ride.

A pitch-black political comedy helmed by Guy Maddin, Evan Johnson, and Galen Johnson, this satire follows the seven leaders of the world’s wealthiest liberal democracies at the annual G7 summit as they become lost in the woods and face ever-increasing peril while attempting to draft a provisional statement regarding a global crisis. Dressed in a pastel pink suit and wispy wig in the first released footage , its star, Cate Blanchett, looks like an amalgamation of Margaret Thatcher and Hillary Clinton, though Cannes’s festival director, Thierry Frémaux, has said that she’s something closer to the president of the European Commission, Ursula von der Leyen. Joining her are fellow power players Alicia Vikander and Charles Dance, with the cast rounded out by the likes of Persuasio n’s Nikki Amuka-Bird, Inglourious Basterds ’s Denis Ménochet, Giri/Haji ’s Takehiro Hira, and Triangle of Sadness ’s Zlatko Burić. Prepare for mayhem.

Paul Schrader—best known for penning Taxi Driver and Raging Bull , as well as directing American Gigolo and First Reformed —has secured a stellar ensemble for his latest portrait of male anguish, an adaptation of the searing Russell Banks novel Foregone : Uma Thurman, Michael Imperioli, Kristine Froseth, Richard Gere, and Jacob Elordi. The latter pair play older and younger incarnations of the protagonist, an enigmatic American documentarian who fled to Canada during the Vietnam War and now, decades later, finds himself on the brink of death. As he looks back on his youth, he’s forced to confront the foundational lies of his past and come to terms with his own mortality.

Horizon: An American Saga

Yellowstone fans, assemble: Kevin Costner is helming and starring in this sweeping new drama chronicling the true cost of the settlement of the American West, the first film in what the industry stalwart hopes will ultimately be a barnstorming four-part saga. Lending support in and amongst the gun fights and nocturnal ambushes are Sienna Miller, Jena Malone, Sam Worthington, Luke Wilson, Owen Crow Shoe, Tatanka Means, Danny Huston, Abbey Lee, Jamie Campbell Bower, Glynn Turman, and Giovanni Ribisi.

Barry Keoghan trades Oliver’s antlers and embroidered blazer in Saltburn for tattoos, gold jewelry, and a flat cap for Andrea Arnold’s first scripted film since 2016’s American Honey , another account of renegades living on the fringes of society. Opposite him is Passages ’s Franz Rogowski, as well as Top Boy ’s Jasmine Jobson, Industry ’s James Nelson-Joyce, and newcomer Nykiya Adams. Plot details are still shrouded in mystery, but given the director’s impressive track record (the BAFTA-winning Red Road and Fish Tank , the Oscar-winning short Wasp ), not to mention Keoghan’s habit of choosing challenging, provocative, and awards-worthy projects, expectations are sky-high.

The Substance

In this blood-soaked feminist body horror, Demi Moore, Margaret Qualley, and Dennis Quaid are under the direction of Coralie Fargeat, who proved her capacity to thrill (and her stomach for gore) with her breathless, candy-colored 2017 action movie Revenge . It promises to be a pulpy delight, with Thierry Frémaux likening it to Julia Ducournau’s recent Palme d’Or winner Titane —a good omen for its competition chances, if there ever was one.

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