Gender-affirming health coverage by Canadian province, territory

23 Jun 2022 | Health | 23 |
Gender-affirming health coverage by Canadian province, territory

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

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

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

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

FULL COVERAGE: Inside Pride

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hysterectomy: removal of the uterus

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

Bilateral Salpingectomy: removal of both fallopian tubes

Bilateral Oophorectomy: removal of both ovaries

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

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

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

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

by Global News