The Gender Identity Clinic subscribes to many of the core criteria for transition-related surgeries (TRS) outlined in the World Professional Association for Transgender Health (WPATH), Standards of Care, 2011. The International Standards of Care specify that these represent minimum standards and how they are applied can vary by professionals and by setting. Other aspects of our criteria, for example, reflect requirements to access OHIP funding.
There are a number of relevant factors for surgical approval, all of which are necessary components in an approval, and none of which are alone sufficient for an approval. Some of the factors are related to eligibility, and other factors are related to readiness criteria.
Below is not an exhaustive list, but gives some idea of both aspects of the criteria:
- You are 18.
- You have received a diagnosis of Gender Dysphoria.
- You have given this due thought and made appropriate disclosures and arrangements. This can include things like having considered implications for fertility (where relevant), and having “come out” to important people in your life.
- Any mental health or substance abuse issues are well-controlled.
- You are knowledgeable about the intervention(s) and their risks, and have a good aftercare plan in place.
- Clients become eligible for genital surgery after one year of continuous (medically supervised) hormone therapy and completion of a continuous Gender Role Experience (or GRE). This is a WPATH standard. The GRE is multidimensional and includes documented activity of your community living in a role congruent with your identity. This activity should be commensurate with your abilities, and also demonstrate a social experience of good breadth and quality. A good GRE provides a reasonable set of social experiences necessary as part of informed consent, as well as time to adjust and adapt to the challenges within it in order to function well. For most people, this will continue to be found in employment, school studies and voluntarism, or any combination of these. For others, we may take the approach of an individually-tailored plan as to the nature and quality of the GRE.
If there are issues of concern, we’ll let you know and may offer guidance or community resources in order to help increase your readiness.
Although individuals seeking gender affirming surgeries once had to come through CAMH to be approved for surgery, this is no longer true as of March 2016, when the government of Ontario changed legislation. Now, any qualified health care provider throughout Ontario may perform supporting assessments for gender-affirming surgeries. Many people still opt to come to CAMH to have supporting assessments done. However, individuals have the option of having supporting assessments for surgery done by qualitied health care providers in their community.
Qualified health care providers include:
- Nurse Practitioner
- Registered Nurse
- Registered Social Worker with a Master’s Degree
(See the Transition Related Surgery FAQ for details on how qualifications are received)
The following website provides helpful Information about medical interventions http://transhealth.vch.ca/medical-options/surgeries#.VYHaO6PD8dU.
The clinic does not make determinations of medical eligibility, only psychiatric eligibility and readiness. Medical eligibility determination is made by the endocrinologist and/or surgeon. It is possible that you are eligible from a psychiatric perspective, but not a medical perspective.
For example, smoking significantly increases medical risk of serious surgical complications-- most surgeons will not operate on you unless you are smoke-free. If you would like support to quit smoking, please visit the CAMH Nicotine Dependence Clinic or speak to us at one of your appointments.
The approval process:
Your first appointment in our clinic will be booked as an initial consultation and assessment. During this appointment you will be asked questions about your goals and experiences. You also have the opportunity to ask us any questions you might have. This will be your first experience with our clinic after a lengthy wait and we understand that you may have a number of things to share with us. We recognize this is a highly personal experience and one that you may have been anticipating for some time. We very much look forward to working with you and helping to facilitate the process for you.
What happens following your first appointment depends very much on the reason you have come and where you are in a transition process, if you are. For those who are seeking surgery, your next appointment could be an appointment to discuss and assess possible surgery approval, or it may be a follow-up appointment with another purpose.
Follow-up appointments are offered to those who we have determined do not yet meet all of the diagnostic, eligibility and readiness criteria required to proceed. We generally provide specific feedback and recommendations as part of working with you towards an approval and will see you back in six months for reassessment.
Possible surgery approval appointments are offered to those who we have determined are ready to meet all of the diagnostic, eligibility and readiness criteria required to proceed. Possible surgery approval appointments are booked in our next available appointments- we are typically booked a few months in advance.
Once approved for surgery:
Following approval, an application is submitted to the Ministry of Health and Long Term Care. When the application has been processed by the Ministry, they send a funding decision letter to the client. The letter will clearly outline what service(s) have been approved, the facility where the service(s) are to be provided, the approved cost of the service(s), and a time limit by which the service(s) are to be provided. The process of getting this letter from the time of your approval appointment with us is approximately two months.
Surgeons maintain their own waiting lists and wait times that vary.
Options regarding surgeons:
We also get a number of questions from people about their options for surgeons. Hysterectomy clients can attend an Ontario provider of their choice, which may be someone you choose with your primary care provider, or from the small list of gynecologists who have provided surgery to our clinic clients in the past. Clients must first be approved by the clinic for the surgery itself and we will make the referral on your behalf.
FTM chest surgery clients typically see Drs. Brassard and Belanger in Montreal as they accept reimbursement from OHIP. Clients seeking genital surgery may request to go to a provider of their choice for their surgery, whether it is to Drs. Brassard and Belanger in Montreal (the only surgeons in Canada currently performing these surgeries), or a provider outside of Canada.
We encourage prospective surgery clients to do their research on prospective providers. It should be noted that the Ministry may decline certain providers due to their high complication rates, and some providers may choose to decline the Ministry’s reimbursement. If you select a surgeon that the Ministry does not yet have a relationship with, there will be some extra time needed to determine if an agreement between the two parties can be reached. If not, you will need to make another selection, which requires a new application (applications are surgeon and surgery-specific). There are some additional considerations with having surgery out-of-country (e.g., financial planning, planning for possible complications, a shorter funding window), which we will be happy to discuss further with clients who are interested.
The Ministry currently has working relationships with: Drs. Brassard and Belanger in Montreal, Dr. Meltzer in Arizona, Dr. Crane in San Francisco, Dr. Bowers in Burlingame, Dr. Leis in Philadelphia, Dr. Monstrey in Ghent (Belgium), and Mr. Nim Christopher in London (England). This list may be subject to change, but we hope this information is helpful in building client awareness about surgeon choice for future decision-making.