does ohip cover gender reassignment surgery

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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.

Transition Related Surgery

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

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

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

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

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

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

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

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

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

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

Surgeries Available

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

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

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

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

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

Plastic Surgery

John semple md, msc, frcs(c), facs .

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

Mitchell Brown MD, MEd, FRCS(C) 

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

Dr. Kathleen Armstrong

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

Urologic surgery

Ethan grober md, med, frcs(c) .

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

Yonah Krakowsky, MD FRCS(C)

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

Lisa Allen, MD, FRCS(C)

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

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

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

Making a Referral

To make a referral please submit.

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

Before making your referral ensure

The patient meets OHIP eligibility for surgery (unless contraindicated)

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

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

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

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

For OHIP Funding

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

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

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

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

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

Criteria for Surgery

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

Surgery Planned Visits

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

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

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

Gender History

Discuss the patients current gender identity and process of transition.

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

Goals for surgery

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

Detailed surgery discussion/capacity for informed consent

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

Readiness (medical and psychosocial)

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

Criteria for Transition Related Surgery

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

Provider Resources

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

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

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

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

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

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

Referral Process for Patients

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

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

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

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

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

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

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

Post Surgical Resources – Vaginoplasty

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

Post-Surgical Resources – Chest Surgery

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

Transition-Related Surgery

Transition-related surgery (TRS) refers to a range of surgical options that can help people feel that their physical characteristics more closely reflect their gender identity or expression. These options can support one in feeling more comfortable in their body and may help to improve your mental wellness.

In order to receive provincially-funded transition-related surgeries, you will need a surgery assessment from one or two health providers, depending on the surgery, one of which being a qualified primary care provider like a Physician or Nurse Practitioner. 

If you have a primary care provider and would like to start a discussion with them about transition-related surgery, you can click here for tips on how to start that conversation. 

If you do not have a primary care provider and would like to access transition-related surgery, you can reach out to Centretown Community Health Centre’s Trans Health Program to get connected with surgery referral support.

Provincially Funded Transition-Related Surgeries

Disclaimer: this section uses medical terminology.

Upper Surgery (Chest or Breast Augmentation) needs one assessment by a qualified Physician or Nurse Practitioner. Lower Surgery (Genital Surgery) needs an additional assessment from any qualified Physician, Nurse Practitioner, Psychologist, or Registered Social Worker (Master’s Degree).

Under the Ministry of Health and Long-Term Care (MOHLTC), the following surgical procedures are provincially-funded:

For “Assigned Male at Birth” individuals:

• Vaginoplasty 
• Orchiectomy
• Augmentation Mammoplasty a (breast enlargement)*

*Patient must have completed twelve continuous months of hormone therapy with no breast enlargement unless hormones are contraindicated

For “Assigned Female at Birth” individuals:

• Hysterectomy
• Clitoral release with vaginectomy
• Metoidioplasty
• Phalloplasty
• Testicular implants with scrotoplasty
• Penile implant

Eligibility

Prior to beginning the referral process for transition-related surgeries, the following eligibility criteria must be met: 

• Has a diagnosis of persistent gender dysphoria 
• For breast augmentation surgery: Has completed 12 continuous months of hormone therapy with no breast enlargement (unless hormones are not appropriate for the person)
• For External Genital Surgery Only: Has completed 12 continuous months living as gender(s)

Not Covered

As of right now, OHIP does not cover the following procedures identified as medically necessary by the World Professional Association for Transgender Health:

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

*OHIP does not cover travel costs involved in obtaining surgery. If you are in financial need and must travel to obtain an OHIP approved procedure, Hope Air can provide free air travel and accommodation. You can learn more about this option here.

For an overview of transition-related surgeries, risks, benefits and additional information, review Rainbow Health Ontario’s TRS Summary Sheets here .

The Referral Process

Step 1: Connect with Qualified Providers. 

The MOHLTC requires 2 qualified providers submit a “Request for Prior Approval for Funding of Sex Reassignment Surgery” form (can be found on the “Clinical Resources” section of our resource library ).

Who is a qualified provider? 

The MOHLTC criteria for a qualified provider includes Physicians, Nurse Practitioners, Registered Nurses, Psychologists and Registered Social Workers. Eligible providers are expected to self-assess if providing transition-related surgical referrals is within the scope of their practice. There is no single training course that “qualifies” a provider, but providers are encouraged to undertake professional development and training activities to build their capacity on trans health services.

If your primary care provider is not able to submit a Prior Approval form on your behalf, Centretown Community Health Centre can help.

Step 2: Participate in a Transition-Related Surgery (TRS) Planning Visit

A TRS planning visit is a collaborative visit between a patient and a qualified provider to discuss TRS and how to optimize the patient’s experience and outcome. Topics discussed include reviewing World Professional Association for Transgender Health (WPATH) and MOHLTC criteria, confirming the diagnosis of gender dysphoria, reviewing the stability of medical and mental health conditions, confirming surgery-specific informed consent and planning aftercare.

Step 3:  Complete the Prior Approval Form

Following your Transition-Related Surgery Planning Visit, your provider can complete, sign, and submit the “Request for Prior Approval for Funding of Sex-Reassignment Surgery” (also known as the “Prior Approval” form) to the MOHLTC.

The number of qualified providers who must complete independent TRS surgery planning visits and sign a Prior Approval form is based on the type of surgery requested. 

Upper body surgery requires a TRS planning visit(s) by one qualified provider (either a P hysician or Nurse Practitioner). 

Gonadal or external genital surgery requires independent TRS planning visits with two qualified providers, one of whom must be a Physician or Nurse Practitioner, while the second can be a Physician, Nurse Practitioner, Registered Nurse, Psychologist, or a Registered Social Worker with a Masters of Social Work. 

Once the application is submitted, the MOHLTC will then send a response letter with the outcome of the funding application. 

If approval is not received, your qualified provider can contact the MOHLTC to provide additional information, the application can be resubmitted, and/or an internal review of the initial application can be requested by your provider.

Step 4: TRS Referral Letter Sent to TRS Surgeon 

Once an approval letter is received from the MOHLTC, your provider can send a referral letter to the transition-related surgery surgeon. TRS referral letters are often more in-depth than typical referral notes and often include details about your TRS planning visits. Surgeons will often request additional documentation, including medication lists, lab results and other information.

Step 5: Complete TRS and After Care 

Once referred to a TRS surgeon, you will be contacted by the surgeon or clinic to sort out additional details, and will receive more information as your surgery date nears.

In partnership with:

Point-of-Care Guides

Quick reference guide for primary care providers.

This quick reference guide was derived from Sherbourne Health Center’s Guidelines and Protocols for Hormone Replacement Therapy and Primary Health Care for Trans Clients and is designed to be used in conjunction with the full Protocols.

Quick Reference Guide: Protocols for Hormone Therapy for Trans Clients

Hormone monitoring summaries, feminizing hormone monitoring summary, masculinizing hormone monitoring summary, effects and expected time course of hormone therapy regimens, effects and expected time course of feminizing hormone therapy, effects and expected time course of masculinizing hormone therapy, consent forms, consent form for feminizing hormone therapy, consent form for masculinizing hormone therapy, referrals & advocacy.

As a primary care provider it is important to be an advocate for you client and support them to actualizing their gender in all walks of life. Below are resources that help you and your client in navigating systemic barriers in health and legal and policy.

Changing sex designation

Template letter in support of an application for change of sex designation on an ontario birth registration, template letter in support of an application for change of sex designation on an ontario driver’s license, support letters, sample support letter for trans clients applying for ei through the just cause mechanism, exceptional access program (eap) for clients on ontario drug benefit (odb).

For clients covered by the Ontario Drug Benefit (ODB) program, oral estrogen (Estrace, Premarin) and intramuscular (IM) testosterone are covered with the submission of an Exceptional Access Form (EAP).

Sample Request for an Unlisted Drug Product: Oral Estradiol

Sample request for an unlisted drug product: im testosterone, referral to transition-related surgery.

Some trans clients may consider transition-related surgery.

Since transition-related/gender-confirming surgeries were relisted under OHIP coverage in 2008, surgical referral was relegated to the CAMH Gender Identity Clinic. However in March 2016, the ministry of health and long term care announced a regulatory change that allowed primary care providers (physicians or nurse practitioners) to coordinate surgical referrals. This was a great change that is already increasing access to trans Ontarians, and doing tremendous work to move the conversation of trans health care completely into primary care.

Benefits of surgical referral being coordinated in primary care

• depathologizing of gender identity
• recognition of the relationships that are built in primary care over the lifetime
• decentralization of access points that can have the most dramatic benefit for remote and rural trans folks with limited access to travel

Two-step referral process:

Step 1: referral to the ministry of health and long term care for prior approval for "sex reassignment surgery", request for prior approval for funding of sex-reassignment surgery.

The referral to the ministry includes either one (in the case of top surgeries) or two (in the case of gonadal and/or genital surgeries) referral letters. The content for the letters are outlined in the prior approval forms. The ministry does not require you to submit any additional information, but expects that you have also documented in practice:

• your training and/or experience in the area of "gender dysphoria and trans/gender-diverse health
• your process with the client to ensure that they have consented to treatment and, by their and your account, meet the criteria for eligibility according to WPATH (diagnosis of gender dysphoria, can consent to treatment, significant medical/mental health conditions "reasonably well controlled", and for some surgeries, having been on hormones continuously for one year)
• how long you have been seeing the client
• some relevant gender history and context around transition
• any medical or mental health information that would benefit the client and surgeon to know to optimize supports for the client
• information about smoking and any substance use that would interfere with surgery and recovery
• risks and benefits of surgery broadly discussed
• expectations around surgical outcomes, healing, and post-op care discussed
• your recommendation for surgery

STEP 2: Referral to the surgeon or surgical facility of choice

The additional information outlined above may also be necessary to present in the referral to the surgical facility that is performing the surgery.

OHIP covered surgeries are:

Masculinizing surgeries.

• chest reconstruction
• hysterectomy with/without bilateral salpingoophorectomy
• metoidioplasty
• phalloplasty

Feminizing surgeries

• orchiectomy
• vaginoplasty

Additional links

The following is a compilation of resources for primary care providers as well as suggestions for keeping up to date on topics in the health care of trans clients. Additionally, opportunities for peer discussion and obtaining input regarding specific clinical scenarios are listed.

• Trans Health Connection - Training, Rainbow Health Ontario
• Trans Care BC's Trans Health Information Program
• Canadian Professional Association for Transgender Health
• World Professional Association for Transgender Health
• UCSF Center of Excellence for Transgender Health
• The Fenway Institute's National LGBT Health Education Center: Learning modules
• TransLine – Free online medical consultation offering healthcare providers clinical information and individualized case consultation service

• Before & After Aesthetics
• Out of Town Patients

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Book a Consultation

Don’t hesitate to contact McLean Clinic today to learn more about double incision top surgery and other types of FTM top surgery. A member of our staff will be more than happy to assist you.

Does OHIP Cover FTM Surgery?

Share article.

Unfortunately OHIP does not cover female-to-male sex reassignment surgery for Ontarians. However, this was not always the case.

From 1970 to 1998, OHIP had covered sex reassignment surgery for female-to-male and male-to-female procedures as long as they had been approved by the Clarke Institute of Psychiatry.Many of the procedures that are part of the transition were covered, including ones that weren’t regularly insured in other cases. Breast enlargement, breast augmentation, mammoplasty, and breast reconstruction were insurable only if the necessary authorization from the Ministry of Health was acquired in advance. Ontario Cuts Funding for FTM Surgery In October of 1998, the government of Ontario delisted gender reassignment surgery as an insurable benefit under OHIP, and ever since there has been objections from various groups against the decision.One such group is the Ontario Human Rights Commission who has taken a position of scrutiny on the decision making process, as well as the fairness of the change in insurance policy.It was reported in a local newspaper that the money saved from not paying for gender reassignment surgery would be reallocated to cardiac surgery, but the OHRC has long since requested a deeper explanation for the sudden elimination of funding. Recent Changes to OHIP Are Too Restrictive In 2008, some of the procedures were re-enlisted as insurable under OHIP, and $200,000 was earmarked on the health care budget which exceeds billions in Ontario. A handful of participants were chosen to undergo rigorous psychological evaluation, a policy that resembles the authorization process through the Clark Institute of Psychiatry in previous decades.Bulletin 4480 seems to imply that the Gender Identity Clinic at the Centre for Addiction and Mental Health is the only recommendation that OHIP will accept when considering coverage of sex reassignment surgery. The bulletin also seems to suggest that only mastectomy would be covered, but it’s vague about specific details. Generally speaking, the government of Ontario will not cover gender reassignment surgery procedures.Future developments in this area of policy are unclear, especially as many Ontarians are entering old age and will incur increased medical costs. There are various other medical concerns competing for funds in the healthcare budget, but without further advocacy for the transsexual and transgender communities, progress may not occur.At this time, the only feasible route to having top surgery in a timely manner is to self-finance the surgery without compensation from OHIP.

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13. preventing and responding to discrimination, page controls, page content, 13.1 organizational reviews, policies and education.

Corporate liability involves more than individual instances of discrimination and harassment. Organizations also risk violating the  Code  if they do not address underlying problems such as systemic barriers, a poisoned environment or an organizational culture that condones discrimination.

There are several steps organizations can take to make sure they are following the  Code  and human rights principles related to gender identity and expression. Strategies can include developing and implementing:

• A barrier prevention, review and removal plan
• Anti-harassment and anti-discrimination policies
• An accommodation policy and procedure
• An internal complaints procedure
• An education and training program [104]
• Ongoing monitoring and evaluation.

Under the  Occupational Health and Safety Act , all workplaces in Ontario are expected to develop harassment policies and review these at least once a year. Harassment policies should specifically recognize protection for gender identity and expression among other  Code  grounds. [105]

For more information about these types of strategies, see the OHRC’s  Policy primer: guide to developing human rights policies and procedures . [106]

Organizations should also consider developing policies and procedures to deal with the specific needs of trans people related to transitioning, identity documents, washrooms and change facilities, privacy and confidentiality, etc. These issues were raised during the OHRC’s public consultation [107]  and are covered in more detail in the next sections of this policy. Addressing them will help remove significant barriers for trans people in their daily lives.

Also see Appendix C: Best practices checklist on these issues and on dress codes, collecting data on sex and gender as well as workplace gender transition guidelines and individual plans.

13.2 Transitioning

Transitioning refers to the activities and process that people may follow to help them live their felt gender identity. This can be very different for each person and some may always be in a state of transition (also see Appendix C: Glossary).

People who are transitioning may need distinct forms and degrees of accommodation along the way. They may ask for recognition of their preferred gender and name while waiting for formal changes to official identity documents. Some may need temporary access to private single-user washrooms and change rooms or housing facilities. They may also need time away for medical procedures or other activities to support their transition. Generally, these will be temporary until the person is ready to access regular services and facilities according to their lived gender identity.

Transitioning can be a very difficult and stressful time for trans people. They are “coming out” to live their felt gender identity making them particularly vulnerable to discrimination and harassment. Issues like name and gender recognition and access to washrooms go to the core of people’s human dignity.

Respect, understanding and confidentiality is everyone’s responsibility during transition and the accommodation process. Organizations should be alert to preventing and addressing any harassment that may happen. Developing policies and training staff will also help prevent problems during transition.

13.3 Identity documents

13.3.1 barriers.

Many identity documents such as birth certificates, health cards, passports, drivers’ licences, school and medical records, etc., show a person’s sex or gender. For trans people, these documents may not match their lived gender identity.

Discrepancies on official documents can create significant barriers, disadvantage and even health and safety risks for trans people.

Example:  In  XY v. Ontario (Government and Consumer Services) , the HRTO said: “A non-transgendered woman can confidently produce a birth certificate when she is required to do so (or when it would be convenient to do so) without having to contend with a sex designation that is incongruent with her lived experience. Her gender identity accords with the sex assigned at birth and is not open to question or challenge. For a transgendered woman, however, this simple act is fraught with risk. Will she be perceived differently as a result of producing a birth certificate that shows that ‘officially’ she is a different gender from the one that she presents? Will her gender identity be questioned or challenged by the person viewing her birth certificate? Will she even perhaps be subject to ridicule or humiliation as a result of producing a government issued document that states that she is a different gender than the one in which she presents herself?”  [108]

Trans people may face invasive questions from schools, shelters, hospitals, potential employers or even police about why their gender expression doesn’t “match” the gender designation on a document. An organization might be unwilling to recognize the person’s chosen name and gender. The person may be placed in the “wrong” sex segregated setting such as dorms or hospital rooms that don’t match their lived gender.

An organization should have a valid reason for collecting and using personal information that identifies a person’s gender. They should keep this information confidential.

13.3.2 Changing a name or sex designation

International human rights standards [109]  and Ontario case law confirm that a trans person cannot be expected to go through sex reassignment surgery, or any other medical procedure, as a condition to change the gender designation on their identity documents.

Example:  In  XY v. Ontario (Government and Consumer Services) , the HRTO found the requirement under the  Vital Statistics Act  that a person must certify they had sex-reassignment surgery before being able to change the sex designation on their birth certificate was discriminatory because it resulted in disadvantageous treatment or impact and perpetuated stereotypes about trans people. [110]  The Tribunal said: The message conveyed is that a transgendered person’s gender identity only becomes valid and deserving of recognition if she surgically alters her body through “transsexual surgery.” This reinforces the prejudicial view in society that, unless and until a transgendered person has “transsexual surgery,” we as a society are entitled to disregard their felt and expressed gender identity and treat them as if they are “really” the sex assigned at birth. [111]

While the Ontario Government has not amended the  Vital Statistics Act , it has made changes to the criteria for changing sex designation on an Ontario birth registration. Sex reassignment surgery is no longer required. A practicing physician or psychologist need only certify that a change in sex designation is appropriate given the person’s lived gender identity. [112]

Criteria for changing the name and or sex designation on identity documents should be respectful, non-intrusive, and need not necessarily be medically based.

Example:  Many types of professionals – social workers, nurses, school or college or university officials, therapists, employers, members of one’s family, faith community or others – could confirm a person is trans and living publicly in the gender matching the change they are requesting. [113]

Other requirements related to changing a name or sex designation, such as public disclosure, should not negatively affect trans people.

Example:  In 2006, the OHRC raised concerns that public disclosure requirements under the  Change of Name Act  were having a discriminatory impact on trans people, effectively “outing” them in public records. To address this, the Government of Ontario amended the legislation and changed the related regulations, accommodating trans people by allowing for a non-publication option. [114]

13.3.3 Recognizing lived gender identity

Sometimes, a person may choose not to change their name and gender on their identity documents. In other instances, different documents may indicate different names and/or gender designations. Regardless of what is recorded on a person’s identity documents, a trans person should be addressed in person by their chosen name and gender.

Organizations should accommodate if a trans person asks them to have documents recognize a name that differs from their legal name.

Example:  A trans student requests that class lists reflect their lived gender identity and chosen name. This would help make sure teachers and other staff and students address them appropriately.

Depending on the circumstances, the  Code  may allow for limits on the duty to accommodate, especially if a person chooses not to change their legal name. An organization would have to show their criteria for recognizing a person’s gender identity is legitimate and they were unable to accommodate short of undue hardship (see sections 9 and 10 of this policy on reasonable  bona fide  requirements and the duty to accommodate). A person’s chosen name and gender might still be used alongside their legal name, again, if appropriate in the circumstances.

Example:  A trans client requests that electronic health records at their local walk-in clinic reflect their lived gender identity and chosen name alongside current health card information that shows a different name and gender. This would help make sure healthcare professionals and other staff address them appropriately in person. For prescriptions and other documents, ordering medical procedures and referrals to other health care practitioners, the clinic believes the name and gender shown on the person’s health card is also necessary to avoid any health and safety risk from mistakes that might happen.

In many cases, organizations will not need corroboration or proof of a person’s lived gender identity to recognize a person’s chosen name and gender in their administrative system. A person’s request should usually be enough.

Example:  The University of Toronto has a policy that allows students to change their name and gender on academic records, class lists and online student databases by writing a letter to their college registrar, requesting this change. The university will require the student to establish and authenticate their identity. [115]

A person’s self-identified gender should be accepted genuinely in good faith even if identity documents do not match their lived gender. An organization would need a serious reason to doubt someone’s self-identified gender. [116]

13.4 Washrooms and change rooms

13.4.1 access based on lived gender identity.

Access to washrooms is a basic physical need at the core of human dignity for everyone. Yet washrooms cause significant barriers for trans people and are one of the public spaces they avoid most. [117]

The  Code  allows for restriction of services or facilities to persons of the same sex for reason of “public decency.” [118]  Facilities such as washrooms, change rooms and locker rooms are typically segregated based on sex. Trans people have the right to access these facilities based on their lived gender identity.

An organization’s washroom facilities and any related policy should not negatively affect trans people. A trans person who identifies and lives as a man should have access to the men’s washrooms and change rooms. A trans person who identifies and lives as a woman should have access to the women’s washrooms and change rooms.

Example:  In a case that went to the British Columbia Human Rights Tribunal, a trans person living as a woman entered a lounge and used the women’s washroom. When she came out, a bouncer told her not to do so again or she would be asked to leave. Later, the manager made a policy that patrons must use the washroom matching their anatomy. The Tribunal found that the policy discriminated against the trans woman and the lounge had a duty to accommodate her needs to the point of undue hardship. The Tribunal said that “transsexuals in transition who are living as members of the desired sex should be considered to be members of that sex for the purposes of human rights legislation” and that “Taking this view, the Complainant was a woman and, therefore, her choice of the women’s washroom was appropriate.” [119]

A trans person should not be required to use a separate washroom or change room because others express discomfort or transphobic attitudes, such as, “trans women are a threat to other women.” Trans people themselves are at risk of harassment and violence when using these facilities. [120]  Education and awareness will help dispel these kinds of stereotypes.

Example:  In the case of  Ferris v. O.T.E.U., Local 15 (1999) , the British Columbia Human Rights Tribunal said: “I accept that transgendered people are particularly vulnerable to discrimination. They often bear the brunt of our society's misunderstanding and ignorance about gender identity. In the context of the workplace, washroom use issues are often contentious and, in the absence of knowledge, sensitivity and respect for all concerned, can inflict a great deal of emotional harm on the transgendered person.” [121]

13.4.2 Accommodation and inclusive design

A trans person does not need to “ask” to use the washroom. They have the right to use the one that matches their lived gender identity. Some people, however, may need accommodation, temporary or otherwise, to access washrooms, change-rooms or other type of sex-segregated facility.

Example:  While going through a transition process, and because of concerns about harassment from others, a trans employee requests access to the single-user gender-neutral accessibility washroom normally reserved for use by persons with disabilities.

An employer or service provider has a duty to accommodate such requests unless there is proof it would cause undue hardship. [122]

The Ontario Building Code Regulation [123]  already recognizes standards for single-user gender-neutral washrooms (a washroom with one toilet that can be used by either sex) as well as “universal” washrooms (a washroom accessible for people with disabilities with a wash basin and one toilet). The standards only apply to new buildings and major renovations.

Changes to the Building Code Regulation, effective January 1, 2015, will require at least one universal washroom in all new buildings or major renovations, and, for multi-storey buildings, at least one for every three floors. The Building Code Regulation also permits single-user gender-neutral washrooms for everyone instead of separate male and female washrooms. [124]  These changes will help meet the needs of trans people and others. [125]

More and more organizations are taking the initiative up front to design, add or convert facilities to be more inclusive with a range of options for everyone. Putting the Building Code standards and other best practices in place sooner will reduce the need for individual accommodation requests and benefit a wide range of people. [126]  Examples include:

• More privacy options in traditional men-only and women-only washrooms and change rooms such as individual shower and changing stalls with curtains or doors, that are also accessible and available to everyone
• Gender-neutral single-user washroom or gender-neutral multi-stall washrooms that anyone can use: these options also improve access for people whose gender identity or expression does not fit into “man” or “woman.” They also allow parents with children of opposite genders to enter the washroom together
• “Universal” washrooms: this single-user option also provides accessibility for people with disabilities as well as families and privacy for anyone who needs it regardless of gender identity

Washrooms and change rooms need to be inclusive, accessible and safe spaces for everyone, including trans people and other gender non-conforming individuals.

13.5 Dress codes

Some employers, educational institutions, service providers like swimming pools, or residential facilities like hospitals or even jails may have rules about what people wear. These requirements can be legitimate depending on the circumstances but they should not negatively affect trans people and others protected under the  Code . Any specific dress codes, such as uniforms or protective gear, must be genuine and reasonably necessary and should not be based solely on gender stereotypes. [127]

Dress code policies need to be inclusive of everyone, including trans people. Organizations must allow trans people and other gender non-conforming individuals to dress according to their expressed gender. Dress codes must also accommodate women who have a masculine gender expression and men who have a feminine gender expression. Others may identify as gender non-conforming, and should not be required to dress in clothing either stereotypical of men, such as a tie, or women, such as a skirt. Dress codes that are gender-inclusive and flexible are the best approach.

13.6 Shelter services

Trans people sometimes face barriers and discriminatory treatment when accessing shelter services. Trans males, for example, have reported that they are unsafe in men’s shelters and unwelcome in women’s. [128]  Some shelters ask invasive questions about a trans person’s transition status. Shelter staff may have little training about transgender-related issues, needs and terminology. [129]   Some youth report being required or feeling compelled to conform to their birth-assigned sex to access shelter services. [130]

The  Code  has exceptions that might permit organizations like homeless, transitional and youth shelters or shelters for abused women to restrict their residential accommodation or other services to persons of the same sex. A trans person should have access to the shelter that matches their lived gender identity. [131]  A shelter might even limit its service to just helping trans people. [132]  A shelter cannot otherwise discriminate based on a person’s gender identity or expression.

Example:  A young person seeks services at a youth shelter that has a “male” and ”female” floor. Her birth assigned sex is male but she identifies as female. She requests to stay on the female floor, and the shelter agrees. The shelter also takes steps to educate clients and staff in the shelter about gender identity and human rights.

Safety from harassment and violence inside shelters is also a pressing concern for people who use them. Trans people are particularly vulnerable. [133]

Example:  A trans man may not feel safe in a men’s shelter and may ask for access to a women’s shelter, or to a separate space within a men’s or a women’s shelter.

Shelter rules and requirements should be inclusive as possible to avoid negatively affecting trans clients. Organizations also have a duty to accommodate any needs trans clients may have unless it would cause undue hardship. Accommodation needs might involve changes to policy requirements, practices or systems and facilities such as washrooms, change rooms, sleeping quarters, or security procedures, as well as identity records or other matters.

Shelters should look for barriers, develop or change policies and procedures and undertake training to deal effectively with access and safety needs of all clients, including trans people and other gender non-conforming individuals. [134]

Example:  Section 4.7 of the City of Toronto’s Shelter Standards addresses the needs of trans clients and reads in part: “It is expected that all shelters be accessible to the transgendered / transsexual/two-spirited (TS/TG/2-S) residents in their self-defined gender, and that shelters will work toward improving access to this group. Shelters will support the choices of TG/TS/2-S residents to gain access to services in the gender they identify will best preserve their safety.” Shelters will be required to identify how they will respond to people who are TS/TG/2-S seeking service including developing a process, that may include a policy, staff training, designated beds, referrals, etc. done in consultation with TS/TG/2-S communities. [135]

13.7 Health care services

Trans people have a wide range of health care needs like anyone else. But they face barriers in accessing health care services on many levels.

Trans people report that family doctors and hospital emergency services often do not understand or respect their lived gender identity. It can be common for trans people to avoid seeking medical assistance, even in dire circumstances, for fear of a degrading experience in the health care setting. [136]

Research points to systemic social exclusion of trans people within the healthcare system. Services are often designed as if trans people do not exist. Little to no information is collected on their health care needs. This often results in policies and practices that may be discriminatory and create barriers for trans people to access care. [137]

Example:  Hospital staff refuse to recognize a trans person’s chosen name and lived gender during a visit to emergency with a broken arm. Staff assign the trans patient to the “wrong” sex-segregated room and ask invasive and unnecessary questions about her body.

Trans people and other gender non-conforming individuals have a right to access health care services free of discrimination and harassment. Hospitals and other healthcare providers have an obligation not to discriminate or condone discrimination, including harassment, because of someone’s gender identity or gender expression. They also have a duty to accommodate any needs trans patients may have unless it would cause undue hardship.

Health care providers should take steps to identify and remove barriers as well as develop policies and procedures to prevent discrimination faced by trans people.

Example:  Toronto’s Mount Sinai Hospital has an anti-discrimination policy that provides guidelines on the treatment of all trans, intersex and two-spirit patients (see Appendix B: Glossary for an explanation of these terms) to make sure they are treated with equality, dignity, and respect, in accordance with the  Code . The policy provides guidance in several areas, including:

All patients have the right to be identified and addressed by their lived gender Patients who are trans, intersex or two-spirit are to be given a range of bed accommodation options (e.g. private or semi-private room) according to their lived gender identity All patients have the right to use washrooms or change rooms based on their lived gender. Information is provided on the location of universal (single-user gender-neutral) washrooms Health care practitioners only request and disclose a patient’s birth-sex and/or other related information when directly related to their health care Admitting services provide options for identification that include trans, intersex and two-spirit. [138]

Trans people also face barriers in accessing specialized health care services unique to their health care needs as a trans person.

The Ontario Health Insurance Plan (OHIP) covers sex reassignment surgery (SRS). Trans people can only access SRS if they complete a designated program, available at only one institution in Ontario, the Centre for Addiction and Mental Health. [139]  There is currently a wait list of several months to access this program. [140]

Trans people may seek other body-changing procedures that are not covered by OHIP. [141]  A few cases have come to the Human Rights Tribunal of Ontario alleging the lack of OHIP coverage for medical procedures related to transitioning gender identity is discriminatory. [142]

Example:  The HRTO dismissed two claims alleging the government’s failure to fund breast augmentation, voice therapy and facial laser hair removal for male-to-female transsexuals was discriminatory. The HRTO found no evidence these procedures were medical needs that fell within the purpose of OHIP. [143]

All health care providers, including those offering elective procedures not covered by OHIP, should be aware of the health care needs of trans people and adapt their services where appropriate. Health care providers must not exclude trans people unless they can show they do not have the competency (skills or experience) needed to safely provide the services. [144]

Example:  In a case that went to the HRTO, two women alleged a doctor, who performs elective cosmetic plastic surgery including on the genitals of both women and men, refused them services because they were trans. One woman was inquiring about plastic surgery on her labia and the other was interested in breast augmentation. The HRTO found the trans women did experience  prima facie  discrimination as the doctor denied the surgeries because they were trans. However, the HRTO accepted the doctor’s justification that he was not qualified to safely perform the surgeries the trans women were seeking and found there is no expectation that he go get the necessary skills. [145]

The international Yogyakarta Principles recognize that access to specialized health care services for trans people is part of the right to the highest standard of health. This includes governments helping to facilitate access to body modifications related to gender reassignment. [146]

13.8 Education system

Trans youth can face a wide range of prejudice and discriminatory treatment at a very challenging time in their life. This can include educators and fellow students not addressing them by their chosen name and pronoun, and a lack of access to appropriate and safe washrooms and change room facilities. Trans youth are especially vulnerable to harassment and bullying from peers.

A 2011 Canadian survey found:

• 78% of trans students feel unsafe in their schools
• 74% of trans youth had been verbally harassed because of their  gender identity
• 49% had experienced sexual harassment in school because of their  gender identity
• 37% had been physically harassed or assaulted because of their gender  identity or expression. [147]

Trans youth want but don’t always have the support of their teachers and school administration to help them during transition to their felt gender. Sometimes they may not have the support of their family either, making a welcoming school environment all the more important.

Ontario’s  Accepting Schools Act  [148]  amended the  Education Act  to provide explicit protection for students from bullying because of gender identity and gender expression among other grounds. The legislation requires school boards to develop and implement equity and inclusive education policies that address all forms of discrimination and harassment based on  Code  protected grounds, including gender identity and gender expression. [149]

All youth have a right to self-identify and express their lived gender identity while accessing education services. Under the  Code , school boards, colleges and universities as well as other educational institutions have a responsibility to take steps to prevent and respond to discrimination and harassment of students because of their gender identity or gender expression. They also have a duty to accommodate any trans students’ needs related to gender identity and expression.

Educational institutions should develop policies and procedures to recognize, among other things, that: [150]

• Trans students have the right to be addressed by their chosen name and pronoun
• Official records should reflect a student’s lived gender, chosen name and pronoun as much as possible
• Trans students have the right to access washrooms and other facilities and  take part in physical education and other classes in accordance with their lived gender identity
• If they wish, trans students can also request accommodations such as access  to gender inclusive washrooms, or private spaces within change rooms
• More privacy options such as individual changing stalls and showers with curtains or doors would benefit all students
• Students have a right to privacy, and schools must keep a student’s transgender status confidential. It should not be communicated to others unless they have a “need to know” to fulfill a specific accommodation need, or if the student requests it
• School dress codes and uniforms should be flexible and inclusive of all students regardless of their sex, gender identity or gender expression
• Where educational institutions have student residents, trans students should be able to choose housing based on their lived gender identity. It is also beneficial to have gender inclusive housing options where students share a facility regardless of their sex or gender identity.

13.9 Law enforcement and justice services

Trans people are especially disadvantaged and vulnerable when dealing with police, correctional institutions and other service providers in positions of power. [151]

It is vital that law enforcement services develop policies as well as education and training for police and correctional service staff, to address the discrimination, harassment and violence that trans people report facing in law enforcement situations. [152]

To effectively promote and protect the rights of trans people, justice institutions and other legal services also need to learn about their needs.

13.9.1 Strip searches

In law enforcement situations requiring strip searches, police and correctional institution officers need to offer trans persons a choice of the sex of the officer(s) who searches them. This should include the option of only male officer(s), only female officer(s), or a “split search” with both male and female officers. A split search might involve, for example, male officers examining a detainee’s “male” lower body and female officers examining the person’s “female” upper and/or lower body. The HRTO confirmed this approach to conducting searches with trans individuals.

Example:  The HRTO found that a detainee, who self-identified as a trans woman, experienced discrimination when police refused her requests for strip-searches to be conducted by female officers. [153]  The HRTO said that in these types of situations detainees must be offered a choice of the sex of the officer who searches them. [154] The HRTO set out appropriate criteria for verifying identity and conducting strip searches. It also identified some exceptions for dealing with high security risk situations and for rare circumstances where an officer might opt out because they have a valid competing right. [155]

13.9.2 Correctional institutions

In correctional settings, trans people are at higher risk of experiencing harassment and violence both from other inmates as well as from institutional staff. [156]  Sometimes, trans people may be held in segregation units for their own protection. However, this can often isolate them and prevent them from having the same privileges or access to services available to others within the general prison population. [157]

Inmates whose gender identity is different from their birth-assigned sex should be assessed and accommodated on an individual basis. To the greatest extent possible, institutions should provide trans inmates with housing that is appropriate for their lived gender identity. Accommodation options should consider both their safety as well as the safety of all inmates. Assessment of safety risk should be based on evidence and not speculation or stereotypes. 

Prison authorities should also make sure that forms of protective segregation are not unjustly used to deny trans inmates the rights and privileges that other prisoners have.

The importance of accommodating trans inmates is supported by the case law.

Example:  A case that went to the Canadian Human Rights Tribunal (CHRT) dealt with a trans inmate who identified and lived as a woman, but was placed in a men’s prison. The CHRT found that Correctional Service Canada had a duty to accommodate trans inmates, especially because of their vulnerability to violence. The CHRT said: Any policy dealing with this uniquely vulnerable group must recognize the differential effect that housing inmates in accordance with their anatomy has on transsexual inmates. The policy also needs to acknowledge their susceptibility to victimization within the prison system. Finally, it must require the individualized assessment of each transsexual inmate by corrections officials, in consultation with qualified medical professionals, as to the appropriate placement of the individual within the various types of facilities available in the male prison system, and the steps that are necessary to ensure their safety. [158]

Trans inmates should also have access to health care services related to transitioning while incarcerated.

Example (continued):  The CHRT also found that Correctional Service Canada's blanket prohibition on sex reassignment surgery had a discriminatory effect on trans-identified inmates, and that it was unable to justify such a policy. As a result, the CHRT ordered Correctional Service Canada to develop a health care services policy that ensures that the needs of transsexual inmates are identified and accommodated.

13.10 Other services

The  Code  also protects trans people and other gender non-conforming individuals from discrimination in other areas involving services, goods and facilities [159]  including retail stores.

Example:  In a complaint that went to the Saskatchewan Human Rights Commission, a trans woman alleged a bridal shop refused to let her try on dresses as she planned her wedding. The complaint was successfully resolved once the business owner better understood the human rights issues. [160]

Retailers and other service providers must not discriminate because of gender identity or expression when providing their services. They too have a duty to accommodate needs that customers or clients may have related to their gender identity and expression, unless it would cause undue hardship.

13.11 Housing

Trans people are vulnerable to discrimination from landlords because of their gender identity or gender expression when applying for housing, exercising their rights as a tenant, [161]  or when trying to access other housing-related services (see also section 13.6 of this policy: Shelter services).

While discrimination may not always be direct or overt, prejudicial attitudes and related treatment can make it hard for trans people and other gender non-conforming individuals to access and maintain housing. This in turn can have a harmful cascading effect on other aspects of their lives, including health, education and employment.

The  Code  says that every person has a right to equal treatment in housing without discrimination because of gender identity and gender expression. [162]  Landlords, their agents and other housing providers must not deny housing to people because of their gender identity or gender expression.

Example:  A trans woman calls a landlord and makes an appointment to see an apartment for rent. During the appointment, the landlord asks what her real name is and says he only rents to women. When the trans woman follows up the next day, he abruptly tells her the apartment was now rented to someone who supposedly came to see it sooner.

As well, landlords must not discriminate in how they treat tenants, including decisions about renewing leases or evictions. They must also address any discrimination or harassment related to gender identity and gender expression that may happen within the housing environment. This could include dealing with the behaviour of other tenants, agents of the landlord such as building supervisors, or others such as maintenance workers.

Example:  A worker doing repairs in the apartment of a trans woman makes ongoing comments about her body and sexual practices. Shortly after, the tenant discovers transphobic graffiti on the wall of the parking garage. She complains to the landlord that she is being harassed, but the landlord says there isn’t much he can do about it.

If landlords become aware of discrimination or harassment through complaints or other means, they must respond appropriately. Landlords who fail to take steps to address problems may be found liable by a tribunal or court. [163]

13.12 Employment

Trans people report facing discriminatory treatment in employment. The Ontario-based Trans PULSE survey found:

• 18% of survey respondents said they were turned down for a job because of their trans identity
• 13% said they were fired from their job or constructively dismissed because they were trans [164]

Discrimination is often based on unfounded stereotypes or negative assumptions such as: trans people will make other co-workers and clients uncomfortable; they will not be a good “fit” for the workplace; or, they have accommodation needs that will be difficult and expensive.

The  Code  says that every person has a right to equal treatment in employment without discrimination and harassment because of gender identity and gender expression. [165]  This includes any accommodation that may be necessary and applies at all stages of employment from hiring, to retention, pay and benefits and dress codes, to training and promotion, performance management and termination.

13.12.1 Hiring

Employers must make sure that overt and subtle or hidden discrimination against trans people or other gender non-conforming individuals does not happen during hiring or they can be held liable.

Example:  In a case that went to the Canadian Human Rights Tribunal, a trans woman had applied for a job as a customer service representative in a bank. She underwent a three-step interview process and was led to believe she would be hired. Later when she found out she did not get the job, the bank did not explain why. Meanwhile, they had not filled the position and continued to look at applicants who had the same qualifications as the trans woman. During the hearing, the bank said it did not hire the trans woman because she was supposedly over qualified, had an attitude during the final interview that “was not that of a person who wishes to serve the public” and wanted to “use the position to promote the rights of transgendered persons.” [166] The CHRT said these reasons were disingenuous and an excuse for bias and prejudice because she was trans. [167]  The CHRT found that discrimination had happened. It said that where a trans person is qualified and someone else, no better qualified, is selected (or where the organization rejects the trans person but continues to seek applicants with the same qualifications), the organization will need to provide a non-discriminatory explanation for not hiring the trans person.

13.12.2 Transitioning employees

Trans employees are particularly vulnerable to discrimination when their identity becomes known to employers or when they begin to transition to their felt gender identity.

Employees who are transitioning publicly can experience a great deal of stress during this time, including at work. This is due in part to their experience and fear of discrimination and harassment. Employers may find an excuse to fire or demote transitioning employees instead of providing accommodation. They sometimes discriminate in other ways, such as assigning less lucrative or prestigious files and clients, or denying training and promotion opportunities. It may be difficult for a trans employee to prove that this type of subtle discrimination happened, [168]  but the negative impact is real.

Example:  In an HRTO case, an employee was taking steps to transition to identifying and presenting as a woman. During this time, she experienced ridicule and harassing comments and conduct from co-workers in the change room and the workplace at large. She complained to her employer about the harassment and the need for separate change facilities. Her employer refused to address the harassment and later fired her. [169] The HRTO found the employer had discriminated and contributed to the harassment and a poisoned work environment by insisting the employee use the men’s change room, even though she was living as a woman and faced ongoing harassment from co-workers. The HRTO also found the employer failed to investigate and respond reasonably to the employee’s complaints of harassment. [170] Example:  An employee intends to transition and speaks to their manager to inform them and discuss what types of accommodation they may need during the transition period. The employee asks for time off so that they may return to work presenting in their new gender. The employer accommodates the employee by working cooperatively to develop a transition plan to address different issues that may arise in the workplace, such as changing the employee’s name in electronic directories, washroom use, and to provide education and training for other employees.

13.13 Vocational associations

The  Code  says that every person has a right to equal treatment with respect to membership in any trade union, trade or occupational association or self-governing profession without discrimination because of gender identity or gender expression. [171]

Example:  In a case that went to the British Columbia Human Rights Tribunal, a trans employee was involved in a dispute with her employer (that initially related to a complaint that was made about her use of the women’s washroom). The person did not feel that her union's actions on her behalf regarding this dispute were adequate. She alleged that the union discriminated against her in its response to the incident, both initially and with respect to the events that followed the initial dispute, and in the way it responded to the employer's handling of the complaint made against her. The Tribunal found that the union had treated her worse than it would have treated other union members in similar circumstances, and that her status as a trans person was a factor in her treatment. The Tribunal ordered the union to stop contravening the human rights law and to pay her damages for lost wages and the injury it had done to her dignity, feelings and self-respect. [172]

[104]  This should include training and education that specifically focuses on the stereotypes and discrimination that trans people face [see  Forrester v. Regional Municipality of Peel (Police Services Board ),  supra , note 23, at paras. 473 and 476]. Also see the  Yogyakarta Principles ,  supra  note 20, at Principle 17, which calls for implementing education and training programs to enable all health care practitioners to deliver the highest attainable standard of health care, with full respect for each person’s gender identity.

[105]  Also see  Occupational Health and Safety Act , supra, note 60.

[106]  See the OHRC’s  Policy primer: guide  to developing human rights policies and procedures  online: OHRC www.ohrc.on.ca/en/guidelines-developing-human-rights-policies-and-proced...

[107]  See OHRC Consultation backgrounder,  supra , note 11.

[108]   XY v. Ontario (Government and Consumer Services), supra , note 2, at paras. 147-48.

[109]  See  Yogyakarta Principles , supra note 20, at Principle 3. See also, Report of the United Nations High Commissioner for Human Rights, supra note 22, at p.22, 25.

[110]   XY v. Ontario (Government and Consumer Services), supra , note 2, at paras. 14-15.

[111]   Ibid. at   para. 172.

[112]  As of the publication date of this policy, the Government of Ontario has not yet amended the discriminatory section 36 provision of the  Vital Statistics Act,  R.S.O. 1990, c. V.4. To learn more about the Government of Ontario’s revised requirements for changing the sex designation on a birth certificate see: Service Ontario ,   Changing your sex designation on your birth registration and birth certificate  online: Service Ontario  www.ontario.ca/government/changing-your-sex-designation-your-birth-registration-and-birth-certificate  (retrieved February 19, 2014).

[113]  See the OHRC’s response to the Ministry of Government Services’ consultation document on revised criteria for change of sex designation on an Ontario birth registration, online: OHRC

  www.ohrc.on.ca/en/re-consultation-document-%E2%80%93-revised-criteria-change-sex-designation-ontario-birth-registration .

[114]  Bill 152,  Ministry of Government Services Consumer Protection and Service Modernization Act, 2006  amended ss. 8(1)(a) and 13 of the  Change of Name Act , R.S.O. 1990, c. C.7 as well as the regulations (R.R.O. 1990, Reg. 68, s. 6).

[115]   University of Toronto’s Statement Concerning Changes of Student Personal Information in Official Academic Records (Approved April 16, 2009) , online: University of Toronto  http://sgdo.utoronto.ca/resources/resources-for-trans-people-u-of-t/

[116]  See for example  Forrester ,  supra , note 23.

[117]  See Scheim  et al .,  supra , note 7.

[118]  See section 20(1) of the  Code : Restriction of facilities by sex

[119]  See  Sheridan ,  supra , note 30, at paras. 102 and 107 (B.C.Trib.). But see  obiter  comments in  Vanderputten ,  supra , note 30, at para. 68.

[120]  See Jody L. Herman “Gendered Restrooms and Minority Stress: The Public Regulation of Gender and its Impact on Transgender People’s Lives” (2013) 19(1)  Journal of Public Management and Social Policy  65 online: Journal of Public Management and Social Policy  www.jpmsp.com/volume-19/vol19-iss1

[121]   Ferris v. O.T.E.U., Local 15  (1999), 36 C.H.R.R. D/329 at para.16 (B.C.H.R.T.).

[122]  See  Sheridan ,  supra , note 30, at para. 102.

[123]   Building Code Act ,  1992 , S.O. 1992, c. 23, O.Reg. 332/12.

[124]   Ibid , ss. 3.7.4.2.(8), (9) & (10) online: e-laws  www.e-laws.gov.on.ca/html/regs/english/elaws_regs_120332_e.htm

[125]  See the section on “Washrooms” in the OHRC’s 2012 Submission to the Ministry of Municipal Affairs and Housing on proposed changes to the Ontario Building Code, online: OHRC  www.ohrc.on.ca/en/ohrc-submission-mmah-proposed-changes-ontario-building-code

[126]  See the 519 Church Street Community Centre  Washroom Signage Policy  online: The 519 Church Street Community Centre  www.the519.org/resources .  See University of Western Ontario Equity & Human Rights Services  Gender-Neutral Washrooms at Western  online: University of Western Ontario  www.uwo.ca/equity/ .

[127]  Cases have recognized that requiring an employee to dress in a sexualized, gender-specific way can be a form of sexual harassment or discrimination. See for example:  Mottu v. MacLeod and others , 2004 B.C.H.R.T. 67;  Doherty and Meehan v. Lodger's International Ltd.  (1981),  3 C.H.R.R. D/628  (N. B.);  Giouvanoudis v. Golden Fleece Restaurant & Tavern Ltd.  (1984,  5 C.H.R.R. D/1967 ; and  Ballentyne v. Molly 'N' Me Tavern  (1982)  4 C.H.R.R. D/1191 .

[128]  The FTM Safer Shelter Project Research Team,  Invisible Men: FTMs and Homelessness in Toronto  (2008) , online: The Wellesley Institute  www.wellesleyinstitute.com/publication/ftms_and_homelessness_in_the_city_of_toronto_-_research_report/ .

[129]  Ilona Alex Abramovich, “No Safe Place to Go LGBTQ Youth Homelessness in Canada: Reviewing the Literature” (2012) 4(1)  Canadian Journal of Family and Youth  29.

[130]  See I. Alex Abramovich, “Teal’s Story”, online: ilona6  www.ilona6.com/artsinformed.php  (retrieved February 18, 2014).

[131]  If a competing rights situation comes up, the shelter would have to show any restriction on a group is legitimate (reasonable and  bona fide ) in the circumstances and how else they might accommodate (also see sections 9 and 10 of this policy).

[132]  See sections 14, 18 and 21 of the  Code

[133]  See Abramovich, supra, note 129.

[134]  Ibid.

[135]  Toronto Community and Neighbourhood Services,  Toronto Shelter Standards  online: City of Toronto  www1.toronto.ca/city_of_toronto/shelter_support__housing_administration/files/pdf/shelter_standards.pdf at 14 .

[136]  See Bauer  et al. , supra, note 16, at 357.

[137]   Ibid.

[138]  For more information see Mt. Sinai Hospital,  Gender Identity Policy , online: Mt. Sinai Hospital  www.mountsinai.on.ca/about_us/corporate-information/policies/Gender%20Identity%20Policy%20-%20I-e-30-36.pdf/view

[139]  See Ministry of Health and Long Term Care,  Bulletin 4480 Relisting of Sex Reassignment Surgery under OHIP  (20 June 2008) online: Ministry of Health and Long Term Care  www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4000/bulletin_4000_mn.aspx .

[140]   Centre for Addiction and Mental Health,  Gender Identity Clinic  online: Centre for Addiction and Mental Health  www.camh.ca/en/hospital/care_program_and_services/hospital_services/Pages/gid_guide_to_camh.aspx  (retrieved February 10, 2014).

[141]  See SRS and Trans Health Policy Group,  Information on Sex Reassignment Surgery (SRS) and Trans Health Care in Ontario  (2009) online: Rainbow Health Ontario  www.rainbowhealthontario.ca/resources/searchResults.cfm?mode=3&resourceID=85313d1e-3048-8bc6-e8bd-be8677d01c3a

[142]  For example, see  Brodeur v. Ontario (Health and Long-Term Care) , 2013 HRTO 1229 (CanLII) and  Hogan v. Ontario (Health and Long-Term Care) , 2006 HRTO 32 (CanLII).

[143]   Brodeur ,  ibid . a t paras 24, 27  and 41.

[144]  For example, the Clinic Head of the Gender Identity Clinic at the Centre for Addiction and Mental Health wrote an open letter to family doctors requesting they start prescribing hormone therapy so patients can begin the process without seeking specialty care. Dr. Christopher McIntosh & Dr. Nicola Brown,  Open Letter to Family Doctors regarding Hormone Therapy  online: Centre for Addiction in Mental Health,  www.camh.ca/en/hospital/care_program_and_services/hospital_services/Pages/Open-Letter-to-Family-Doctors-regarding-Hormone-Therapy.aspx  (retrieved February 18, 2014).

[145]  See  Finan v. Cosmetic Surgicentre (Toronto) , 2008 HRTO 47 paras 42-50 (CanLII).

[146]   Yogyakarta Principles supra,  note 20, Principle 17(g).  

[147]  C. Taylor,  et al ., Every Class in Every School: The First National Climate Survey on Homophobia, Biphobia, and Transphobia in Canadian Schools. Final Report  (2011) online: Egale Canada Human Rights Trust   http://egale.ca/category/youth-and-safer-schools/national-survey/

[148]   Accepting Schools Act,  2012, S.O. 2012 C.5, online: Legislative Assembly of Ontario  http://ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=2549

[149]  For more information see the Ministry of Education,  Policy and Program Memorandum No. 119, Developing and Implementing Equity and Inclusive Education Policies in Ontario Schools  online: Ministry of Education  www.edu.gov.on.ca/extra/eng/ppm/ppm.html . Also see the OHRC’s remarks to the Ontario Legislative Standing Committee on Social Policy regarding Bill 13 and Bill 14 on bullying online: OHRC  www.ohrc.on.ca/en/ohrc-remarks-ontario-legislative-standing-committee-social-policy-regarding-bill-13-and-bill-14

[150]  See Toronto District School Board (TDSB),  Guidelines for the Accommodation of Transgender and Gender Non-Conforming Students and Staff: An Administrative Guideline of the Toronto District School Board  online: TDSB www.tdsb.on.ca/AboutUs/Innovation/GenderBasedViolencePrevention/Accommod... . See also Genny Beemyn,  Transgender Checklist for Colleges and Universities  online: Campus Pride. http://www.campuspride.org/tools/transgender-checklist-for-colleges-univ... (retrieved on February 19, 2014).

[151]  A. Scheim  et al .,  Joint Effort: Prison Experiences of Trans PULSE Participants and Recommendations for Change.  Trans PULSE e-Bulletin, 22 April, 2013. 3 (3) Online: Trans PULSE  www.transpulseproject.ca .

[152]  In  Forrester ,  supra , note 23, the HRTO noted the importance of training all police officers on trans issues at paras. 468 and 473.

[153]  See  Forrester ,  ibid . at para. 416.

[154]   Ibid . at para. 476.

[155]   Ibid . at paras. 467 and 476.

[156]  As Human Rights Watch has found, “empirical data on prison sexual violence suggest that it is not a random activity, but arises from the choosing of particular victims who…are believed to be more vulnerable.” Human Rights Watch,  No Escape: Male Rape in United States Prisons  (2001) as cited in Human Rights Watch,  Transgender Prisoners, Identity, and Detention: Policy Recommendations  (2006) online: www.outcast-films.com/films/cu/transgender_prisoners.pdf; A. Scheim et al., supra note 151.

[157]  Kara Sandor von Dresner  et al ., “Providing Counseling for Transgendered Inmates: A Survey of Correctional Services” (2013) 7(4)  International Journal of Behavioural Consultation and Therapy  38.

[158]  See  Kavanagh v. Canada (Attorney General) , 2001 CanLII 8496 (CHRT) at para 166.

[159]  See section 1 of the  Code .  

[160]  Saskatchewan Human Rights Commission,  Mediation Achieves Resolution For Transgender Woman’s Complaint  (11 September 2013) online: Saskatchewan Human Rights Commission    http://saskatchewanhumanrights.ca/+pub/documents/news/2013/20130911_MediationAnnouncement_MediaRelease.pdf .

[161]  See Grant  et al .,  supra , note 33.

[162]  See section 2 of the  Code :  www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h19_e.htm

[163]  For more information see OHRC’s  Policy on human rights and rental housing  online: OHRC  www.ohrc.on.ca/en/policy-human-rights-and-rental-housing

[164]  G. Bauer  et al ., supra note 6

[165]  See section 5 of the  Code .

[166]   Montreuil v. National Bank of Canada , 2004 CHRT 7 at para. 56 (CanLII).

[167]   Ibid.  at paras. 57-73.

[168]  See  Québec (Comm. des droits de la personne et des droits de la jeunesse) c. Maison des jeunes À-Ma-Baie Inc.  (No 2), supra , note 85. In this case, the employee was fired after she told her employer about her transition.

[169]   Vanderputten, supra , note 30 .

[170]   Ibid.

[171]  See section 6 of the  Code.

[172]   Ferris v. O.T.E.U., Local 15 ,  supra , note 121.

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Transgender Health Program: Insurance Information

OHSU clinics accept many kinds of insurance, including the Oregon Health Plan and many Medicare plans. Some services require prior authorization and referrals.

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Many insurance plans cover some transition-related services. Oregon requires health insurers to cover medically necessary treatments related to gender dysphoria if those treatments are covered for other conditions.

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Terms to look for: Gender dysphoria, gender identity disorder, sexual/gender reassignment or transgender health.

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Individual marketplace: HealthCare.gov , run by the federal government, helps you shop for and enroll in affordable health insurance. What you pay is based mostly on your income. You can enroll early November through mid-December or after certain life-changing events, such as losing your previous health insurance.

Medicare: This federal program is for people 65 and older and certain younger people with disabilities. Medicare.gov can help you find a plan.

Senior Health Insurance Benefits Assistance Program: This Oregon network of trained volunteers helps Medicare patients of all ages get coverage.

Seniors and People with Physical Disabilities Offices: This Oregon agency , a branch of the Department of Human Services, can help you find services.

Find an agent or application assistant: Visit the Oregon.gov help page to find someone near you to help you find the right coverage.

Help from health insurance agents and Medicare agents is free, but some insurance agents get a commission for recommending an insurer’s plan. For free unbiased help, look for Medicare volunteers and community partners on the Oregon.gov help page.

Recommended community partners: These organizations have expertise in transgender and gender-nonconforming health:

• Cascade AIDS Project offers help to anyone.
• Outside In , which helps homeless and marginalized youths, has a trans services coordinator: 503-535-3828 .
• Project Access Now helps vulnerable communities access health care.

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These questions can help you decide on an insurance plan, according to the Strong Families Network:

What is covered? When talking to customer service representatives, ask for the “Evidence of Coverage” or “Certificate of Coverage,” a full list of covered benefits for the plan.

What’s not covered? Pay attention to services or treatments specified as exclusions or limitations.

What’s covered for non-trans patients? If hormone therapy, chest surgery and hysterectomies are covered for anyone on the plan, they should be covered for transgender and gender-nonbinary members. In Oregon, it is illegal for insurers to cover services for some people and deny them to others.

Are there hormone therapy co-pays? If so, how much are they? Is there a limit on hormones or hormone injections? If so, what is it?

Is my health care provider covered by the plan ? Check whether your doctor is in the plan’s network.

Is there a network of trans-friendly doctors with training in gender-diverse care? If you want to find a gender-affirming provider,  GLMA: Health Professionals Advancing LGBT Equality  can help. Once you identify someone, ask which plans work with the provider.

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Ontarian wins legal battle for public funding of gender-affirming surgery argued as 'experimental'

An Ontario resident has successfully secured public funding for a specialized gender-affirming surgery argued to be "experimental" by the provincial health insurer following a years-long legal battle.

The prospective patient, identified only as K.S. in documents filed with the provincial Health Services Appeal and Review Board (HSARB), was seeking coverage under the Ontario Health Insurance Plan (OHIP) for a penile-preserving vaginoplasty, a procedure in which a vaginal cavity is surgically created while keeping the penis intact.

Since 2023, K.S. has been engaged in a series of appeals to the review board following an initial denial by OHIP to cover the surgery. On April 10, a final appeal launched by OHIP was dismissed by the Divisional Court of the Ontario Superior Court of Justice.

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K.S., whose identity is protected under a publication ban, identifies as non-binary. She presents as predominantly female and uses she/her pronouns, but does not align with the gender binary. The reason why K.S. is seeking this particular procedure is because it aligns with her identity – and having the provincial insurer previously deny her request made her feel “less than.”

“There have been so many times that I have had to justify myself to just be,” K.S. previously told CTV News Toronto. “People who aren’t trans or nonbinary don’t have to get that permission to exist.”

• READ MORE: Ontarian takes OHIP to court for gender-affirming surgery funding

Following Wednesday’s decision, K.S. said that she is "ecstatic" over the decision.

"I have been waiting for this day for years!!," she said in a statement given through her lawyer. "Though I know there is still time for OHIP to keep attempting to appeal this, I am relishing this day as it's an extraordinarily huge milestone."

For two years, K.S. has sought coverage for the operation. At this time, the procedure is only offered by a small number of private clinics, none of which are in Canada, and there is no peer-reviewed research on the outcomes of the technique.

K.S.' surgery, to be carried out at the Crane Center for Transgender Surgery in Austin, Texas, would align her body with her identity and put an end to the years of suffering through gender dysphoria, she said.

CTV News Toronto reached out to the Ontario Ministry of Health for comment but did not hear in time for publication.

A series of appeals

K.S. was first denied coverage for the procedure in 2022, with OHIP claiming it wasn't an insurable service.

She successfully overturned that decision in an appeal to the HSARB arguing, in part, her reason for wanting a vaginoplasty without a penectomy would validate her non-binary identity, putting an end to her gender dysphoria that she’s felt since her teenage years.

At that hearing, OHIP called Dr. Yonah Krakowsky, a sexual medicine surgeon at Women's College Hospital, who, although supporting patient autonomy, testified vaginoplasty without penectomy is considered experimental by most surgeons.

Still, K.S.' submissions that the procedure she seeks is identical to the process used with some vaginoplasties in the province were sufficient to see the panel rule in her favour.

But the legal battle didn't end there – OHIP launched its own appeal, and the matter went back to the Divisional Court. In this most recent hearing, held in February, the insurer argued that HSARB erred in deeming the surgery insurable and asked it to reconsider, once again describing the procedure as experimental and, therefore, not eligible for coverage.

On Wednesday, the panel of three judges of the Divisional Court unanimously found HSARB had not erred in its ruling, dismissing OHIP's appeal and ordering the insurer to pay K.S. $20,000 for legal costs. The board was correct with its interpretation, Justice Breese Davies wrote in the decision, adding it is consistent with the country's Charter values of equality and security of the person, and OHIP was being the opposite.

"Such an interpretation would force transgender, non-binary people like K.S. to choose between having a surgery (penectomy) they do not want and which does not align with their gender expression to get state funding, on the one hand, and not having gender-affirming surgery at all, on the other. Such a choice would reinforce their disadvantaged position and would not promote their dignity and autonomy," Justice Breese Davies wrote in the decision, commenting on OHIP's "inconsistent" interpretation of the schedule of benefits.

If OHIP funding for vaginoplasties were supposed to be limited, the decision says that the list of insured services would have been drafted differently.

Further, the court decided that HSARB's conclusion that the term vaginoplasty includes this procedure is consistent with the World Professional Association for Transgender Health (WPATH) Standards of Care, the leading authority on gender-affirming medical and surgical care, especially as it recommends individualized treatment plans, which was in place at the time K.S. made her request for funding.

"This is a significant win for the transgender and non-binary communities. Gender-affirming care is medically necessary and ought to be funded by OHIP," John McIntyre, K.S.' legal representation in February's hearing, told CTV News Toronto in a written statement following the decision.

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

K.S. and McIntyre said they hope the decision encourages Canadian clinics to start offering such procedures, which would, in turn, allow for more data collection and patient feedback. For those looking to access funding for gender-affirming care, McIntyre adds his firm, McIntyre Szabo, is partnering with the 519 to pilot a Gender Affirming Care Legal Support Clinic starting this June.

"With the vast push rightward stemming from the recent strong anti-equality ideology, it's been a second dark ages for us in the 2SLGBTQIA+ community of late, so this very appropriate and correct verdict is a breath of fresh air," K.S. said.

"The fight for healthcare, rights, and equality is far from over, but to all the other trans, non-binary or gender nonconforming people out there, I want to tell them that there is hope," she continued. "Just keep going and never give up on who you are."

With files from CTV News Toronto's Abby O'Brien 

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Ontario Resident Wins Public Funding of Gender Transition Surgery Deemed ‘Experimental’

Friends Read Free

An Ontario resident has been granted public funding for specialized gender-transition surgery outside of Canada, despite the provincial health insurer’s stance against funding procedures abroad and concerns about the surgery’s “experimental” nature.

OHIP raised three arguments in its appeal, including stating that the appeal board erred in claiming that vaginoplasty without a penectomy is “specifically listed” as an insured service under OHIP’s Schedule of Benefits.

‘Experimental’ Procedure

OHIP referenced Dr. Yonah Krakowsky, the medical lead for gender surgery at Women’s College Hospital in Toronto, who is among the few surgeons performing vaginoplasties in Ontario.

As cited in the court document, Dr. Krakowsky outlined three methods for performing vaginoplasty. The most common technique is penile inversion vaginoplasty, where the penile tissue is used to create the vaginal cavity, labia, and clitoris after removing the penis. However, Dr. Krakowsky noted that alternative approaches may be necessary in certain cases, according to the court document.

He described two other techniques, peritoneal pull-through vaginoplasty and rectosigmoid vaginoplasty, which involve using non-penile tissue to construct the vagina and labia when penile inversion is not feasible.

“Dr. Krakowsky testified that he has never performed a vaginoplasty without penectomy. Dr. Krakowsky opined that vaginoplasty without penectomy is considered experimental by most surgeons. Dr. Krakowsky explained that there is not enough current data to determine the efficacy of vaginoplasty without penectomy,” the Divisional Court document stated.

Expanding on its decision that vaginoplasty without penectomy qualifies for funding under OHIP’s Schedule of Benefits, the appeal board determined that it was not necessary to further assess whether the treatment was experimental. The exclusion for experimental treatments does not apply to specifically listed services, the board argued.

Out-of-Country Coverage

The provincial insurer noted that even if the surgery that K.S. seeks is listed as a service, it would still be ineligible for funding, because services conducted outside Canada are only covered if they are considered “generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person.”

OHIP presented this third argument for the first time before the Divisional Court, which it had not raised before the appeal board. Although the Divisional Court has the discretion to consider an issue raised for the first time on appeal, it chose not to do so. The court cited several reasons that render the argument as not in the interests of the justice, including that OHIP did not raise it before the board earlier.

The Epoch Times reached out to OHIP for comment regarding the Divisional Court ruling, but didn’t hear back by publication time.

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Transgender veterans file second lawsuit against VA over gender-affirming surgery coverage

A n advocacy group for transgender veterans filed a second lawsuit against the U.S. government Monday for excluding gender-affirming surgery from former service members’ health benefits. 

In a federal complaint filed Monday, the Transgender American Veterans Association (TAVA) challenged the Department of Veterans Affairs’s (VA) denial of a 2016 petition asking the VA to begin the process of expanding its health benefits to cover gender-affirming surgery for transgender veterans. 

While other gender-affirming treatments — including hormone therapy, fertility preservation and hair removal — are covered by the VA, the department has effectively banned transgender veterans from accessing surgery since 2013, when a department directive stated that the VA “does not provide sex reassignment surgery.” 

VA Secretary Denis McDonough at a 2021 Pride Month event in Orlando said the department planned to expand care for transgender veterans to include surgery but cautioned that implementing the change would take time. 

TAVA’s lawsuit, filed Monday in the U.S. Court of Appeals for the Federal Circuit in Washington, D.C., claims the VA’s refusal to provide gender-affirming surgery “defies clear medical consensus” and discriminates based on sex and transgender status. It asks the court to review the VA’s denial of the group’s 2016 rulemaking petition and to direct the VA to provide gender-affirming surgery. 

“TAVA will not stand idly by as VA continues to discriminate against and breaks its promises to transgender veterans,” said Josie Caballero, the group’s vice president. “VA’s refusal to provide gender-affirming surgery is an affront to the dignity and well-being of transgender veterans.” 

“Gender-affirming surgery is not a choice for many transgender individuals — it’s often a critical part of our care that healthcare professionals consider medically necessary. Denying us access to these puts our lives at risk,” Caballero said. 

A VA spokesperson said the department is unable to comment on potential or pending litigation. 

TAVA in a January lawsuit asked the court to compel the VA to respond to its 2016 petition, which McDonough denied the following month. 

“Because VA is not ready at this time to initiate a rulemaking addressing the specific regulatory changes proposed in the petition, VA hereby denies the petition for rulemaking,” McDonough wrote in his letter rejecting the petition. 

In a statement, TAVA President Bekky Eshler called the VA’s continued denial of care an “insult to transgender veterans.” 

“It is well past time for the VA to ensure that all veterans have access to the complete slate of healthcare services they need and deserve,” Eshler said. “TAVA is not giving up this fight, and VA is not off the hook.”

For the latest news, weather, sports, and streaming video, head to The Hill.

Court rules Ontario health plan must pay for gender-affirming surgery in Texas

Ontario’s publicly funded health insurance plan must pay for a special procedure in Texas for a non-binary person seeking gender-affirming care, the province’s Divisional Court has ruled.

The procedure, not available in Ontario, involves receiving a vagina while still keeping a penis.

The 3-0 ruling by Ontario’s Divisional Court this week is the first from a court in that province on gender-affirming care, and in particular, on treatment for non-binary people, said lawyer John McIntyre, who was involved in the case. He said he was not aware of a similar ruling elsewhere in Canada.

Two years ago, an adult known in court documents as K.S. requested Ontario Health Insurance Plan funding for the surgery in Texas, saying they did not want to invalidate their non-binary identity, or increase the risk of urinary incontinence and orgasm dysfunction, by having their penis removed.

But OHIP rejected the request, asserting that a vaginoplasty without a penectomy, as the surgery is known, is not a listed procedure in the Health Insurance Act’s schedule of benefits. K.S. appealed that decision to the Health Services Appeal and Review Board, which overturned OHIP’s ruling, saying the procedure is in fact listed. OHIP appealed to Divisional Court (the Superior Court sitting in panels of three for appeals from administrative tribunal decisions).

Key to the Divisional Court ruling was its finding that Ontario had incorporated an international standard of medical care for transgender people into its health insurance law. That standard of care is set out by the World Professional Association for Transgendered Health, and recommends individualized treatment plans for non-binary people that “affirm their experience of gender,” the court said. And the association expressly refers to the vaginoplasty without penectomy as an option for some.

The ruling was not, for the most part, about the Charter of Rights and Freedoms. It was a matter of interpreting the health insurance law. That law mentions vaginoplasty in its list of benefits. If legislators had wished to exclude the surgery sought by K.S., they would have written that exclusion into the law, Justice Breese Davies wrote. Her ruling was endorsed by Justice Mark Edwards and Justice Harriet Sachs.

OHIP argued that the specific treatment of vaginoplasty without penectomy is not mentioned in the listed benefits, and is experimental, and therefore not covered. But the court said specifically listed benefits are not restricted if they are experimental. Only benefits not listed may be restricted for this reason.

The court said that while the law’s meaning was clear on a plain reading of it, the judges would have relied on “Charter values” to settle the dispute, had different interpretations been plausible.

It said the Charter of Rights protects the right to equality and security of the person, which includes autonomy and bodily integrity.

Interpreting the health insurance law to require transgender or non-binary people assigned male at birth “to remove their penis to receive state funding for a vaginoplasty would be inconsistent with the values of equality and security of the person,” Justice Davies wrote.

“Such an interpretation would force transgender, non-binary people like K.S. to choose between having a surgery [penectomy] they do not want and which does not align with their gender expression to get state funding, on the one hand, and not having gender affirming surgery at all, on the other. Such a choice would reinforce their disadvantaged position and would not promote their dignity and autonomy.”

While Divisional Court rulings apply only in Ontario, the judgment could be influential in other parts of the country, depending on the wording of provincial health-insurance laws.

Mr. McIntyre, one of K.S.’s lawyers, said the ruling has broad importance. “The unanimous panel of three judges of the Divisional Court set out important principles that will be instrumental in continuing the fight to expand access to health care for the trans and non-binary communities.”

He said he is hopeful that Canadian clinics will start offering this procedure and others, now that they are funded.

K.S., who is described in the court ruling as non-binary though female-dominant, and uses the pronouns “she” and “they,” declined to be interviewed. But she issued a statement saying she was “ecstatic.” (The Globe is using “she” because her lawyers used it in written materials.)

“I hope this decision helps set a foundation of inclusivity in non-binary and trans health care, where no one is left on the sidelines burdened by a life of health care costs that are already insured for others,” K.S., who is in her early thirties, said.

She said no cost estimate for the surgery has been provided yet. Ontario required K.S. to obtain prior approval, and so no advanced consultation has been done with doctors in Texas.

Ontario’s Health Ministry did not respond to requests for comment.

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Maine Lawmakers Approve Liability Shield for Abortion and Gender Care Providers

The Democratic-controlled Maine Legislature gave final approval Friday to a bill that would protect health care workers who provide abortion and gender-affirming care from legal action brought in other states.

If signed by Democratic Gov. Janet Mills, Maine would join more than a dozen states that shield medical providers and others from out-of-state investigations regarding abortions. Republicans were firmly against the bill to shield against out-of-state lawsuits.

The Maine Senate voted 21-13 on Friday, a day after a 76-67 vote in the House.

The votes came after attorneys general in 16 states, including Tennessee, threatened legal action if Maine proceeded with a shield law preventing out-of-state repercussions for those who provide abortions and what they called “gender transition surgeries for children.”

Maine Attorney General Aaron Frey called those accusations “meritless” and said shield laws were necessary due to other states’ efforts “to punish beyond their borders lawful behavior that occurs in Maine and other states.”

“Harmony between our states would be best preserved and promoted by the exercise of restraint by all parties seeking to control health care related policy choices in other states,” Frey said previously in a statement.

There was spirited debate over the measure in Maine.

On Thursday, the Maine House censured two lawmakers after one of them accused legislative colleagues of bringing the wrath of God in the form of a mass shooting and recent storms by enacting such laws. The lawmaker, and another who agreed with him, were required to provide a formal apology on the House floor to be allowed to speak and to vote.

“We are grateful and proud of all of the lawmakers in the legislature who endured threats of violence, abhorrent political rhetoric and rampant disinformation to stand and vote to protect safe, legal, medical care in Maine,” said Lisa Margulies, from Planned Parenthood Maine Action Fund.

Gender Care

Abortion is legal in Maine at all stages of pregnancy with a doctor’s approval. And lawmakers last year approved a bill to allow 16- and 17-year-olds to receive limited gender-affirming care, which does not include surgery, in some cases without parental consent. However, Maine law does not permit gender-reassignment surgery without parental consent for minors.

Since the U.S. Supreme Court overturned Roe v. Wade in 2022 and ended a nationwide right to abortion, states have moved in opposing directions. Most of those under Republican control now have bans or other restrictions in place. Fourteen states now ban abortion in all stages of pregnancy, with limited exceptions. Most Democrat-dominated states have moved to protect access.

At least 13 states have shield laws protecting medical providers and others from out-of-state investigations regarding abortions — and at least nine, including Maine, have executive orders laying out similar policies.

It’s a similar situation with gender-affirming care for minors.

At least 24 states have adopted laws in the past three years banning or limiting treatments including puberty blockers, hormone therapy and gender-affirming surgery — which is rare for younger patients — for minors. At least 12 states have shield laws that apply to gender-affirming care and two have executive orders.

Associated Press writer Geoff Mulvihill in Cherry Hill, New Jersey, contributed to this report.

Topics Legislation Maine

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