Gender-affirming health coverage by Canadian province, territory

Inside Pride: Gender-affirming healthcare spotty, hard to navigate across Canada

Wait times for experts and requirements for people to access gender-affirming care vary depending on where they live in Canada. Emily Mertz spoke with gender diverse folks, advocates and providers about what needs to improve and which province or territory is leading the way.

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

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

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

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

FULL COVERAGE: Inside Pride

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

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

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

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

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

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

British Columbia

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

COVERED:

• Chest construction (including reduction)
• Orchiectomy
• Hysterectomy with bilateral salpingo-oophorectomy
• Vaginoplasty
• Vulvoplasty
• Clitoral release
• Metoidioplasty
• Phalloplasty
• Travel Assistance Program for provincial travel assistance for services not available in own community
• Expenses for out-of-province surgical aftercare if medically required
• Psychiatry services
• Vocal feminization program (via free Changing Keys program)

CONDITONALLY/PARTIALLY COVERED:

• Breast construction/augmentation (reviewed on case-by-case basis and funded in some circumstances)
• Hormone therapy (coverage under Fair Pharmacare or other PharmaCare plans such as Plan C, which covers drug costs for those receiving income assistance; or coverage can be requested through Special Authority; or through an employer benefit plan)
• Those with PWD coverage can get binders, packers, breast forms with prescription/letter from MD or NP

NOT COVERED:

• Facial procedures like reduction of Adam’s apple, nose feminization, facial bone reduction, face lifts, rejuvenation of eyelid
• Pectoral implants
• Hair removal; hair reconstruction or restoration
• Liposuction or lipofilling
• Voice surgery
• Psychologists, social workers and registered clinical counsellors (work benefits, private insurance, some community organizations offer limited free counselling)
• Travel and accommodation costs to and from surgical centres (BC or MTL)
• Supportive garments and wound care supplies
• Other travel related costs like insurance or accommodation

Alberta

Alberta HealthAlberta physicians

COVERED:

• Phalloplasty
• Metoidioplasty
• Vaginoplasty
• Hysterectomy and ovary removal
• Breast augmentation and mastectomy (patient must get pre-approval from Alberta Health, must get surgeon or primary care provider to validate eligibility, patients must have one independent assessment by a psychiatrist or other physician with expertise, and be diagnosed with gender dysphoria.)
• Voice therapy

CONDITIONALLY/PARTIALLY COVERED:

• To qualify for breast augmentation as an insured service, patient must have “little to no breast growth as directly determined by the surgeon.”
• There are multiple hormone replacement therapy products available for transgender health on the Alberta Drug Benefit List (ADBL) for patients on government sponsored drug plans (Medroxyprogesterone, progesterone, conjugated estrogens, estradiol 17 B and testosterone). Endocrine therapies, such as gonadotropin releasing hormone therapy (GnRH), are available on the ADBL (leuprolide, goserelin and buserelin).
• Alternatives to GnRH therapy, such as spironolactone, are listed as an open benefit on the ADBL and available to transgender Albertans. Many of these products are an open benefit; however, some testosterone products and GnRH medications require a special authorization form to be completed by a prescriber, and special authorization criteria to be met, in order to be considered for coverage.

NOT COVERED:

• Facial feminization
• Tracheal shave
• Voice pitch surgery
• Non-medical interventions like laser hair removal or electrolysis
• Take-home medications and equipment
• Personal expenses, meals and accommodation

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Yukon

Yukon Insured Health Servicesgender diverse community

“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.

COVERED:

• Hormone therapy (medical practitioner must apply to benefits program on behalf of patient)
• Vaginoplasty
• Phalloplasty
• Metoidioplasty
• Penectomy
• Hysterectomy
• Salpingo-oophorectomy
• Orchiectomy
• Mastectomy
• Chest contouring
• Body contouring
• Hair removal
• Medical and travel costs
• Facial feminization surgery ($30K-$50K)
• Voice therapy
• Vocal surgery
• Mental wellness services (through All Genders Yukon Society)
• Training for healthcare professionals (at no cost) to provide compassionate and culturally sensitive WPATH gender-inclusive care

PARTIALLY/CONDITIONALLY COVERED:

• Counselling services

Northwest Territories

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

COVERED:

• Mastectomy
• Genital surgery (with two independent assessments, referral and prior government approval)
  • Vaginoplasty
  • Metoidioplasty
  • Phalloplasty
  • Clitoral release

PARTIALLY/CONDITIONALLY COVERED:

• Breast surgery (augmentation) only covered when deemed medically necessary (when there failure to respond to hormone therapy or a
  congenital breast abnormality. Only few patients will fulfil these eligibility criteria)

NOT COVERED:

• Outpatient medications, equipment/supplies (i.e. dressings, dilators)
• Meals, accommodations, and personal expenses
• Chest contouring
• Facial feminization
• Tracheal shave
• Voice pitch surgery
• Psychotherapy
• Fertility preservation techniques
• Liposuction/lipofilling
• Electrolysis/laser hair removal
• Cosmetic procedures arising from the original surgery to improve appearance

Nunavut

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.

COVERED:

• Mental health services
• Chest surgery/contouring (requires surgical readiness assessment and referral from clinical expert)
• Breast augmentation (requires surgical readiness assessment, referral from clinical expert, and patient must be on feminizing hormone therapy for continuous 12 months)
• Genital surgery (requires two surgical readiness assessments by clinical experts, patient must be on hormone therapy for continuous 12 months, and patient must be living in gender role congruent with gender identity for 12 continuous months)
  • hysterectomy
  • vaginoplasty
  • phalloplasty
• Genital reconstruction (requires two surgical readiness assessments by clinical experts, patient must be on hormone therapy for continuous 12 months, and patient must be living in gender role congruent with gender identity for 12 continuous months)

PARTIALLY/CONDITIONALLY COVERED:

• Hormone therapy (covered and can be prescribed by a physician or a nurse practitioner).

NOT COVERED:

• Facial feminization
• Liposuction/body contouring
• Tracheal shave
• Hair transplantation
• Voice training
• Voice pitch surgery
• “Cosmetic” surgical revisions

Saskatchewan

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

COVERED:

• Hysterectomy
• Mastectomy
• Oophorectomy
• Metoidioplasty
• Orchiectomy
• Vaginoplasty (with or without vaginal canal)
• Phalloplasty
• Voice therapy

PARTIALLY/CONDITIONALLY COVERED:

• Some hormones (those listed on Saskatchewan Formulary are eligible for co-pay for those with active provincial health card)

NOT COVERED:

• Breast augmentation
• Chest contouring
• Body sculpting surgeries (implants, liposuction and other procedures)
• Facial feminization surgery
• Facial hair removal
• Hair transplantation
• Laryngeal Chondroplasty
• Tracheal shave
• Travel and accommodation costs
• Certain hormone therapy drugs
• Voice training/Voice pitch surgery
• “Cosmetic” surgical revisions

Manitoba

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.

COVERED:

• Chest masculinization
• Hysterectomy and oophorectomy
• Metoidioplasty
• Orchiectomy
• Penectomy
• Vaginoplasty
• Feminizing voice therapy
• Laser hair removal

PARTIALLY/CONDITIONALLY COVERED:

• Breast augmentation (on a case-by-case basis)
• Hormone therapy (may be applicable for support as a non-insured benefit subject to the person’s eligibility for the Manitoba Pharmacare Program, or through a personal third-party insurance coverage.)

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

NOT COVERED:

• Facial feminization surgery
• Tracheal shave
• Electrolysis
• Hair transplantation
• Voice pitch surgery

Ontario

Primary care providershormone therapy

COVERED:

• Assessment for hormone therapy
• Counselling
• Augmentation mammoplasty or mastectomy
• Private clinic stay and/or ministry-approved services outside Canada
• Orchiectomy
• Hysterectomy
• Salpingo-oophorectomy
• Vaginoplasty
• Clitoroplasty
• Clitoral release
• Labiaplasty
• Vaginectomy
• Metoidioplasty
• Phalloplasty
• Testicular implants with scrotoplasty
• Penile implant

PARTIALLY/CONDITIONALLY COVERED:

• Hormones (patients covered by Ontario Drug Benefit program can get injectable testosterone covered with submission of Exceptional Access Form)
• Anti-androgen and estradiol covered without EAP approval

NOT COVERED:

• Chest contouring/masculinization
• Liposuction
• Electrolysis
• Laser hair removal
• Hair transplants
• Tracheal shave
• Voice modification surgery
• Chin, nose, cheek or buttock implants
• Facial feminization/masculinization
• Travel involved in obtaining surgery

Quebec

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.

COVERED:

• Phalloplasty
• Metoidioplasty
• Vaginoplasty
• Double mastectomy with reconstruction
• Hysterectomy

PARTIALLY/CONDITIONALLY COVERED:

• Hormone therapy

NOT COVERED:

• Breast augmentation
• Facial feminization
• Liposuction/body contouring
• Tracheal shave
• Hair transplantation
• Voice training
• Voice pitch surgery
• “Cosmetic” surgical revisions

New Brunswick

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.

COVERED:

• Hormone therapy
• Mastectomy with chest masculinization (for trans-masculine patients)
• Vaginoplasty (including: penectomy, orchidectomy, construction of a vaginal cavity and the vulva)
• Vaginectomy, hysterectomy, salpingo-oophorectomy
• Mastectomy (with chest masculinization)
• Metoidioplasty
• Phalloplasty, erectile and testicular implants.

NOT COVERED:

• Breast augmentation (for trans-feminine patients)
• Facial feminization
• Tracheal shaving
• Hair removal
• Hair transplantation
• Travel, accommodation or medications prescribed outside of hospital
• Voice and communication training
• Voice pitch surgery
• Cosmetic surgical revisions
• Body contouring
• Pectoral implants

Nova Scotia

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

COVERED:

• Hysterectomy
• Oophorectomy (only available in NS)
• Orchiectomy
• Penectomy
• Breast augmentation
• Breast reduction
• Chest masculinization/mastectomy (in NS or Montreal Centre)
• Phalloplasty
• Metoidplasty
• Vaginoplasty (only available at Centre Metropolitain de Chirurgie in Montreal)

PARTIALLY/CONDITIONALLY COVERED:

• Counselling and psychotherapy is funded when provided in public institutions
• Hormone therapy is funded when provided in public institutions

NOT COVERED:

• Facial feminization
• Liposuction/body contouring
• Tracheal shave
• Hair transplantation
• Voice training
• Voice pitch surgery
• “Cosmetic” surgical revisions

Prince Edward Island

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

COVERED:

• Hysterectomy
• Mastectomy with chest masculinization
• Breast augmentation
• Metoidioplasty
• Clitoral release
• Erectile/testicular implant
• Oophorectomy
• Phalloplasty
• Scrotoplasty
• Vaginectomy
• Clitoroplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty

PARTIAL/CONDITIONALLY COVERED:

• Hormone therapy (per the provincial drug formulary or as per a patients’ private insurance policy)

NOT COVERED:

• Facial feminization
• Liposuction/body contouring
• Tracheal shave
• Hair transplantation
• Voice training
• Voice pitch surgery
• “Cosmetic” surgical revisions

Newfoundland and Labrador

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

COVERED:

• Breast augmentation (when no breast development for 18 months of hormone therapy)
• Mastectomy with chest masculinization (excluding implants and liposuction)
• Hysterectomy
• Orchiectomy
• Salpingo-oophorectomy
• Vaginoplasty (includes orchiectomy, penectomy, labiaplasty, clitoroplasty; with or without construction of vaginal cavity)
• Metoidioplasty
• Phalloplasty (includes urethroplasty, scrotoplasty, vaginectomy, and insertion of testicular and approved penile implants)
• Voice therapy

PARTIALLY/CONDITIONALLY COVERED:

• Insured out-of-province procedures not available in NFLD, at publicly funded facility, with prior approval
• Travel to access out-of-province procedures (airfare, accommodation, meals and local transportation. Some restrictions may apply)
• Hormone therapy may be covered through the Newfoundland and Labrador Prescription Drug Program. NLPDP covers eligible prescription medications for those who are an eligible Medical Care Plan (MCP) beneficiary.
• If the prescription is on the special authorization listing, a physician would have to apply for the product through the NLPDP special authorization process.

NOT COVERED:

• Facial feminization
• Liposuction
• Tracheal shave
• Hair transplantation
• Voice pitch surgery
• “Cosmetic” surgical revisions
• Liposuction/body contouring

GENDER-AFFIRMATION SURGICAL PROCEDURES:

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

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

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

Hysterectomy: removal of the uterus

Bilateral Salpingo-Oophorectomy (BSO): 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