gender reassignment surgery in canada

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Gender confirming surgery

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

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

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Affirming gender identity.

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

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

How to qualify

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

To qualify for funding, you must:

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

Approval for genital surgery

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

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

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

Approval for chest surgery

To be approved for chest surgery you’ll need:

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

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

Apply for surgery

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

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

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

Additional resources

You can find useful information from organizations, such as:

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

Information for healthcare providers

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

New gender-affirming surgery clinic now accepting patients

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

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

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

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

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

A truly collaborative effort

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

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

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

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

Years in the making

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

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

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

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New Ottawa gender-affirming surgery clinic a first in Ontario

Ottawa hospital clinic accepting referrals for facial, top and bottom surgeries.

Social Sharing

A new clinic at The Ottawa Hospital aims to be a game changer for those seeking gender-affirming care in the nation's capital.

The hospital says it will offer facial, top and bottom surgeries, becoming the first in Ontario to do all three.

Previously, a Montreal-based clinic was the only facility in the country to offer that trifecta, according to the hospital's news release . 

"It was about one of the best headlines I've read in some time," said Holly Brown, who leads the trans health team at Ottawa's Centretown Community Health Centre. 

"I have been doing advocacy dedicated toward the provision and access of this health care for the last two and a half years, and this is about the best news that I have received."

Clinic taking referrals 

Officially launched in September, the clinic is now accepting patient referrals.

According to the hospital, previously patients could only access top surgery in Ottawa, but not facial or bottom surgeries.

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

No one from The Ottawa Hospital was available for an interview on Thursday, but Brown said many in the region would travel to Montreal or Toronto for certain procedures. 

Brown said she's pleased the services will be offered closer to home, and said these supports can offer an array of improvements to the lives of trans and non-binary people. 

Travelling could be a struggle

Brown said previously, getting to Montreal or Toronto could also be a struggle for some patients.

"Many folks in this population are experiencing challenges that would make it difficult for them to travel, such as living by themselves, such as lower income," Brown said.

"These are social demographics of health that are really common for this subset of the population."

What's covered varies between provinces, with  OHIP funding chest and genital surgeries  in Ontario.

• CBC Investigates U.S. conservatives are using Canadian research to justify anti-trans laws

Brown said any extraneous costs associated with transitional surgeries usually fall to the patient.

Fae Johnstone, a local trans activist, said this will change, save and improve lives in the Ottawa region. 

While she knew such a clinic was in the works, she said it would have been difficult to describe her expression when she learned about the launch.

"It is so hard to access this care. Traditionally, it takes years and it takes personal effort from individuals," Johnstone said.

"And to have it made easier and to have not just a new clinic, but one that is working in partnership with our existing services — that is just incredible."

ABOUT THE AUTHOR

Joseph Tunney is a reporter for CBC News in Ottawa. He can be reached at [email protected]

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Female to Male / FTM / FTX / Non-Binary

Several surgical procedures are available to help you achieve your desired physical appearance goals. Your surgeons will listen to your needs and answer all of your questions.

Patients who wish to undergo surgery with a surgeon from GrS Montréal must meet the criteria set by WPATH .

The surgeries

Procedure in which the breast tissues and mammary glands are removed.

Metoidioplasty

Procedure used to obtain a more masculine appearance of the genitals.

Phalloplasty

Procedure considered as the most significant surgical procedure in the masculinization process of the genitals.

Second step phalloplasty - construction of the urethra

Procedure that will allow urine to flow through the tip of the phallus, making it possible for you to urinate standing up.

Insertion of testicular implants

Involves inserting 1 or 2 gel-filled testicular implants into the scrotum.

Insertion of penile implant

Insertion of the implant into the phallus that was formed during your phalloplasty and allows sexual intercourse with penetration.

Masculinization of the face and body surgeries

Several surgical procedures of the face and body for men are offered by the Centre Métropolitain de Chirurgie and are performed on site.

Corrective surgeries

• Masculinization of the torso - Torso scar removal
• Masculinization of the torso - Nipple correction
• Secondary Phalloplasty
• Genital scar revision

First-of-its-kind Ottawa Hospital gender-affirming clinic now accepting patients

The Ottawa Hospital is now accepting referrals to its new state of the art gender affirming care clinic.

The clinic is the first of its kind in Ontario and second in Canada to offer trans and non-binary patients facial, top and bottom procedures.

The clinic will have life-changing implications for trans and non-binary individuals, who often face barriers to seek care with long wait times or lack of access in the communities where they live.

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"There’s just a massive gap in our health-care system for the treatment of the transgender population and people seeking gender-affirming care," said the clinic’s lead and co-founder, Dr. Nicholas Cormier in a news release .

"What’s so groundbreaking about this new clinic is that everyone is coming together to address this shortcoming in our system."

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

The clinic will be partnering with other surgical divisions at the hospital—plastic surgery, urology, obstetrics and gynecology.

The hospital will also be working with trans health programs out in the community, such as the Centretown Community Health Centre’s Trans Health Program , which provides patients with a referral to the clinic and CHEO’s Gender Diversity Clinic .

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

"Accessing gender-affirming surgery is just one small component of gender-affirming care," Cormier said. "That’s where these community partners really come into play."

The Ottawa Hospital also launched the Gender and Diversity Specialty Clinic in January 2022, providing care for medically complex trans and non-binary patients.

some gender-affirming surgeries are available at other Canadian hospitals.

Women’s College Hospital has been increasing its capacity and growing its team in order to provide this life-saving care for its patients requiring gender-affirming surgeries. Its transition related team started out in 2019 with nurse practitioner Emery Potter and medical director. The team has since grown.

Vancouver General Hospital also offers top and bottom surgery.

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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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Increasing demand for gender-affirming surgeries in Canada

Experts say the wait lists for gender-affirming surgeries in Canada is growing, with some procedures requiring patients wait more than five years.

The Women’s College Hospital in Toronto became the first public institution in Canada to offer specialized surgeries in 2019 through its Transition Related Surgical Program. Before that, patients would have to go to a private clinic in Montreal, the United States, or overseas.

“Even now, about a third of transition-related surgeries are occurring outside of the province,” VP of Strategy and Quality at Women’s College Jack Woodman said.

The wait for top surgery - breast augmentation or chest masculinization - can be anywhere from 12 months to two years, experts say. The wait for vaginoplasties can be up to 65 months.

“I always like to emphasize that not all trans people want or require surgery. It’s really important to acknowledge that. But for those that do, it can be life-saving,” Woodman said.

This was the case for 27-year-old Toronto resident Amelia Smith, who has finished recuperating from a gender-affirming surgery performed in May 2021.

“I’d like to see a rise in provincial funding go along with that” she said. “Because that’s really what’s limiting things right now.”

Woodman says a lack of data for the trans and non-binary community is part of the problem in getting funding for transition related surgery.

And beyond that, they’d like to see not just surgery, but a full range of health services for the community.

“What folks need to remember is that one of the biggest issues in health-care for trans and non-binary people is the stigma and discrimination,” he said. “It’s that - walking into your doctors office, you feel welcome and comfortable to share what your situation is, what your health-care issues are. These are things that we really have to work on.”

The Centre for Addiction and Mental Health provides a list of resources for individuals experiencing a crisis.

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

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

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

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

Canada too quick to treat gender dysphoria in minors with hormones, surgery: critics

Other countries have taken a step back and the critics’ concerns are unexpectedly being shared by some leading figures in the transgender medical world itself

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Mary’s troubled daughter had talked about her changing sexual identity before, but when she announced at age 16 that she was a transgender boy, it seemed to come out of the blue.

Even so, a doctor later wrote her a prescription for testosterone after a pair of 15-minute appointments, the mother says. Within months, the teenager had also had a double mastectomy. She was now a trans male.

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But Mary says her child’s long-standing depression and anxiety only worsened. And last year the young woman made a stunning admission to her mother: even as she was being wheeled into the operating room to have her breasts removed, she was having doubts about her decision.

Now the 21-year-old is “detransitioning,” reverting to her original female identity. And Mary is part of a nascent movement calling for brakes to be placed on a health-care system geared to affirming a young person’s transgender feelings with drugs and surgery, allegedly in some instances after little assessment of other psychological issues.

That movement has picked up steam just in the last year. Countries from Finland to Australia have stepped back somewhat from the affirmative approach, while the critics’ concerns are unexpectedly being shared by some of the leading figures in the transgender medical world itself.

But in Canada the thrust is if anything in the other direction, which proponents say is a positive thing.

Alarms are being sounded all over the world, and Canada seems completely deaf to it

A bill now before the Ontario legislature emphasizes speeding up access to medical transition, reducing the need for practitioners’ referrals to get such treatment and defining services like double mastectomies as life-saving.

And on Wednesday the House of Commons passed legislation that would ban the widely condemned practice of conversion therapy, despite concerns that it could also make it a crime to provide any therapy to gender-identity patients that explored broader psychological issues.

“Alarms are being sounded all over the world,” says Aaron Kimberly, a B.C.-based transgender man and registered nurse with qualms about the current approach. “And Canada seems completely deaf to it.”

Parents, detransitioners and other critics say they support improving access to medical transition for those who need it and decry transphobic bigotry and violence. They do not oppose gender-neutral bathrooms or public funding for transition treatment.

But they argue the pendulum has swung too far from the days when people with gender dysphoria – a sense that their birth sex does not match their gender identity – often met resistance and prejudice in the health care system.

“For years and years, people have been homophobic, transphobic,” said Mary, who asked that her full name not be published to safeguard her daughter’s privacy. “We’re now trying to correct that but by doing that we’re putting others at risk. And those others we’re putting at risk are children.”

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

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The Toronto resident said she and her daughter even considered suing the health professionals responsible for her transition. Mary cites the case of Keira Bell, the British woman who won a court ruling that restricted prescription of puberty-blocker drugs to minors, a decision that was overturned on appeal recently.

But the NDP MPP who introduced Ontario’s Bill-17 says its main goal is to address a much louder alarm she’s hearing from doctors and constituents. Far from the pendulum having swung too far, Suze Morrison says, backlogs for gender reassignment surgery are so long, it’s driving patients to suicide.

“People are dying on wait lists so there is clearly a gap in care and a gap in quality of care that needs to be addressed,” said Morrison. “At the end of the day, I don’t think a five-year wait list is acceptable for any form of health care in Ontario.”

A prominent expert in the gender-treatment world here agrees, saying that concerns about a rush to transition simply do not apply to Canada, where hospital-based clinics, at least, are exhaustive in their assessment of young patients.

“No one makes these decisions lightly,” said Dr. Margaret Lawson, medical director of the gender-diversity clinic at the Children’s Hospital of Eastern Ontario. “They are made very slowly, very cautiously, after long discussions with these youth and their parents.”

Regardless, she said the question of patients like Mary’s daughter with psychological issues separate from gender dysphoria is a relatively minor one. Barely one in 10 patients her clinic sees have such conditions, said Lawson.

But some gender treatment now occurs outside of hospitals, and the tentative questioning of the current status quo has come in parallel with a boom in demand and changing patient demographics. Critics see both as red flags.

While those presenting with gender dysphoria were once predominately young boys or middle-aged men, gender-identity clinics are now seeing mostly teenagers who were born girls. The number of pediatric patients at 10 hospital clinics across Canada jumped from almost none in 2004 to more than 1,000 in 2016. About 80% were natal girls, most under 16 when they first came to the clinics, says the Trans Youth Can! research project .

A major, ongoing U.S. college health study found the percentage of students identifying as transgender or gender non-conforming soared from about .05 per cent between 2008 and 2015 to three to four per cent recently.

A 2018 U.S. study of parents skeptical about gender treatment hypothesized that there was a new “rapid-onset gender dysphoria” phenomenon involving young girls who were sometimes swayed by online influencers and social contagion .

But gender-medicine professionals say the explosion simply reflects a growing acceptance of transgenderism after years of stigma and hatred – and may actually underestimate the number of youth in need.

A study published this year by Trans Youth Can! – which generally promotes the current treatment approach – rejected the ROGD hypothesis, finding no evidence  teenagers who had recently come out as transgender were swayed by psychological distress, gender-supportive friends or online influences.

Even so, critics complain that rather than explore the often-complex mental-health issues of young people who present as trans, health-care practitioners are too readily putting children on “puberty blockers” – drugs that “pause” the development of puberty – and then cross-sex hormones, followed often by reassignment surgery.

“We feel the health-care system has been completely taken over by a political agenda at the expense of the actual evidence,” argues Kimberly, who runs the group Gender Dysphoria Alliance .

Another Trans Youth Can! survey found that five of 10 clinics do not have psychologists or psychiatrists assess patients before prescribing puberty blockers or hormones.

But Lawson said those five still have social workers or other professionals do mental-health screening. At CHEO, such assessments are followed by two or more doctor appointments and then a two-hour session with an endocrinologist like her, she said.

Yet the concerns have led to change in some countries in recent months. Finland last year encouraged psychotherapy before transition treatment, while the Australia-New Zealand psychiatry regulator said it was essential. Clinics in Sweden this year stopped prescribing puberty-blocking drugs and cross-sex hormones to patients under 18.

And more strikingly, three top figures in the field have echoed such worries lately.

They include Dr. Marci Bowers, a trans woman and widely-respected gender-reassignment surgeon who is to become president next year of the World Professional Association for Transgender Health (WPATH). She suggested in an interview that children are sometimes being put on puberty blockers too soon, leading to complications in reassignment surgery that can potentially deprive them of sexual pleasure for life.

In a Washington Post op-ed article this month, psychologists Erica Anderson , a transgender woman, and Laura Edwards-Leeper, both senior officers with WPATH, complained about sloppy and dangerous assessment of young people presenting as transgender, with overly hasty prescribing of medical interventions. They also call into question the assumption that delays in getting such treatment – as opposed to general mental distress – increases the risk of suicide.

But critics worry the federal government’s conversion-therapy Bill C-4 , passed by the Commons with unanimous consent Wednesday, could inadvertently outlaw more careful assessment before transition — or at least discourage therapists from providing it.

The legislation has been hailed as a triumph for LGBTQ rights, criminalizing treatment that tries to change someone’s orientation to heterosexual or gender identity to that of their birth sex.

Opponents worry the bill is vaguely enough worded that it could also call into question the legality of therapy that explores other mental-health issues or reasons for gender dysphoria before a decision to medically transition.

The Ontario bill — which passed second reading without opposition from the Conservative government — also reflects none of the other nations’ or WPATH experts’ cautions.

It would set up an advisory committee consisting predominately of LGBTQ people to advise on how to speed up access to transition treatment and implement an “informed-consent” model with less need for referrals from health professionals, making it easier for patients to get hormones and surgery based on their transgender feelings.

Morrison says constituents tell her the process is too cumbersome now, one person describing it as being like a Catch-22.

“She said … “I have to prove I’m both mentally well enough to have surgery, and that I’m mentally unwell enough that I need surgery.”

Michellle Zacchigna says she was among the first people in Ontario to be treated under the sort of model encouraged by the bill, and now has deep regrets.

We feel the health-care system has been completely taken over by a political agenda at the expense of the actual evidence

At the third of three perfunctory appointments with a doctor at age 21 and armed with a short letter from a therapist, she was prescribed testosterone, and later had a double-mastectomy and partial hysterectomy.

But her mental-health issues only got worse and Zacchigna was eventually diagnosed with autism, anxiety, ADHD and depression – problems she says were largely overlooked by professionals before she transitioned medically. Then last year the 33-year-old detransitioned, though she will never be able to get pregnant.

“In trans health care, patients diagnose themselves and prescribe their own treatment,” she charged in a submission on Bill-17. “Medical professionals are encouraged to accept a person’s belief without question under the assumption that it will never change.”

Lawson said Zacchigna’s critique runs counter to her experience in the field and argues that the measures taken by places like Finland and Sweden would only create more damaging delays here.

“It would be incredibly worrisome,” said the University of Ottawa professor. “It would harm so many kids. I would hate to think what would happen to them.”

As for Mary’s daughter, she’s still suffering psychologically as she adapts to her new/old gender identity. But there’s hope, says her mother: the young woman no longer wishes she were dead.

“When I talk to her about how she’s doing … she says ‘I want to live. I’m still alive, I want to live.’ ”

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Trans kids' treatment can start younger, new guidelines say

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The update also recommends:

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

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

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

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

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

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

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Beyond the scale: Bariatric surgery and weight management solutions

During this episode of Making the Rounds, we discuss the bariatric surgery and weight management services offered at Banner Health.

You'll hear from a panel of experts specializing in the treatment of patients in the field of obesity medicine and bariatric surgery, including Dr. Farah Husain, bariatric surgeon at Banner - University Medical Center - Phoenix and division chief of bariatric surgery at University of Arizona College of Medicine - Phoenix, Dr. David Podkameni, bariatric surgeon at the Banner Bariatric Clinic at Banner Gateway Medical Center and Banner Estrella Medical Center, and Dr. Joyce Lee-Iannotti, a neurologist specializing in sleep medicine and stroke at Banner - University Medical Center - Phoenix and Banner Desert Medical Center.

For more information on this topic or other services related to bariatric and weight loss surgical services provided by Banner Health, please visit bannerhealth.com.

Information

• Show Making the Rounds
• Frequency Updated Monthly
• Published August 16, 2024 at 9:58 PM UTC
• Length 47 min
• Rating Clean

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