Ontario boosts access for trans people seeking gender confirmation surgery

There are potentially more than 800 health-care professionals across the province who can now assess patients for sex-reassignment surgery, a change Ontario adopted March 1 to trim the more than two-year wait list for referral.

• Ontario expands referrals for sex-reassignment surgery
• Why transgender people can't get surgery approval in Thunder Bay

Until last week, transgender people hoping to undergo sex-reassignment  — also known as gender confirmation surgery — could only get a referral through the adult Gender Identity Clinic at Toronto's Centre for Addiction and Mental Health.

And that wait list for referral has stretched to more than 1,500, the psychiatrist who heads up the clinic said.

"The model of having only one clinic for all of Ontario might have worked when only a small number of seeking these services, but now there are far more," Dr. Chris McIntosh said. "We really feel like this is a great step forward in terms of increasing access."

The province announced the change to the referral process in November, which will see a wide range of health-care practitioners able to refer patients once they are trained in the assessment criteria created by World Professional Association for Transgender Health.

No surgical options in Ontario

Rainbow Health Ontario has already taken more than 800 health professionals through the training, which includes information about surgical and hormone options, how to help someone prepare for a procedure and the necessary support a patient will need after an operation. The majority of those trained so far have been mental health professionals, according to a spokesperson for Rainbow Health.

Donna Turner said the group is still waiting to learn exactly how clinicians who have taken that training can ensure their patients are included in the pipeline for insured candidates receiving gender confirmation surgery in Montreal.

Right now there are no surgical options in Ontario, although Health Minister Eric Hoskins said the expansion of the referral program includes a promise of $2 million, some of which will go toward supporting a program for chest surgery that could run out of Women's College Hospital. A spokesman for the ministry could not say when such a program might begin.

Dr. McIntosh acknowledged that the expansion of the referral service could mean "the bottleneck stops being at CAMH and starts happening in Montreal," but both he and Turner said the Quebec clinic has indicated it can take on more patients.

Rainbow Health and CAMH both expect to help with continued training for surgical referral, McIntosh and Turner said. Some of the provincial funding has already been earmarked to hire more staff at CAMH to clear the backlog of those waiting — and so practitioners there can begin training others, according to a statement from the health ministry.

In an announcing plans to expand the referral system, the health minister said last fall that an increasing number of Ontarians are experiencing gender dysphoria, defined as the distress caused by a conflict between a person's gender identity and their assigned sex at birth.

"One of the most vulnerable times for trans people is when they are ready for surgery, but face a prolonged wait," Hoskins said in November. "This change would reduce wait times by allowing many trans clients to get surgical approvals from their own local primary care teams.

Getting family doctors involved

McIntosh said that's a huge advantage to the expansion. A patient's own doctor — who understands their history — can now be part of a critical medical decision, the psychiatrist said.

Those on the waiting list, however, should not cancel their appointments at CAMH, McIntosh said, until they are certain they can see another physician or nurse practitioner who has the appropriate training to make a referral.

Two referrals are still needed for people seeking genital surgery, while only one is necessary for chest surgery. 

If two referrals are needed, one can be performed by a nurse, a social worker with a masters degree or a psychologist. But a physician or a nurse practitioner must be always involved in at least one referral for surgery, according to the guidelines.

"This provides flexibility that the person's own care provider — that's known the person for a long time … can contribute to the decision of assessing someone's readiness for surgery," McIntosh said.