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Is Gender Reassignment Surgery Covered By Ohip Eligibility

The small number of Ontarians hoping for sex-change operations will soon see the surgery covered by provincial health insurance again.

The decision is expected to cost a total of $200,000 a year because just "eight to 10" people annually are expected to pass the "very rigorous" psychological evaluation required before sex reassignment surgery, Health Minister George Smitherman said yesterday.

"It's a very serious medical condition that affects a very small number of people," he told reporters, noting that other provinces including Alberta pay for the surgery.

Smitherman acknowledged the coverage could be controversial in some circles, given the heavy demands on Ontario's health-care system from people with rare, life-threatening diseases, for example.

"I think that people should be careful not to use what is $200,000 on a $40.2 billion health budget as an excuse to try a bit of a `them and us' conversation," he said.

It was 10 years ago that the previous Progressive Conservative government declared the operations were no longer eligible under the taxpayer-funded Ontario Health Insurance Plan, which had covered the surgery since 1971.

That prompted complaints to the Ontario Human Rights Commission from transsexuals whose progression through the psychological evaluation to gender reassignment surgery was interrupted.

Two years ago, the commission ordered the government to compensate three patients who had begun the sex-change process.

Smitherman's announcement was welcomed by the transsexual community, but one group is hoping the criteria for gender reassignment surgery will be made "less rigorous" than the 1970s standards used before taxpayer funding for the operation was axed.

"A more sensitive model would be appropriate," said Susan Gapka of the Rainbow Health Network.

Gapka said it's hard to say how many people are awaiting the surgery.

"It's a hidden population ... there's a large community in Ontario and in Toronto and southern Ontario."

While details of the policy are still being worked out, Smitherman said patients will likely be sent to a clinic in Montreal that specializes in the surgery, which costs about $20,000.

The Liberals had promised to reinstate the coverage of sex change operations.

More details will be announced in a few weeks, Smitherman said.

By Rob FergusonQueen's Park Bureau

Fri., May 16, 2008

Sex Reassignment Surgery

Ontario is expanding access to referrals for medically necessary sex reassignment surgery (also known as gender confirming surgery). As of March 1, 2016, the Ontario Health Insurance Plan (OHIP) has changed the funding criteria for sex reassignment surgery by allowing qualified providers throughout the province to assess patients for the surgery.

The amended OHIP criteria for sex reassignment surgery align with the internationally-accepted standards of care for gender dysphoria, which are established by the World Professional Association for Transgender Health (WPATH). Gender dysphoria is the medical term that WPATH describes as referring to discomfort or distress that is caused by a difference between a person’s gender identity and their sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).

Prior approval for OHIP-funded surgery

Sex reassignment surgery is only insured when prior approval has been obtained from the Ministry of Health and Long-Term Care.

A physician or nurse practitioner needs to submit a prior approval form on behalf of their patient, which includes supporting assessments recommending surgery from specified qualified health care providers confirming that the OHIP funding criteria have been met.

Recommendations for the surgery
For chest surgery, a patient will need one supporting assessment recommending surgery from a qualified physician or nurse practitioner who has the appropriate training.

For genital surgery, a patient will need two supporting assessments recommending surgery from qualified physicians, nurse practitioners, registered nurses, psychologists or registered social workers who have the appropriate training with the following restrictions:

  • At least one of these assessments must be from a physician or nurse practitioner.
  • A registered social worker refers to a social worker that has a master’s degree in social work and holds a current certificate of registration from the Ontario College of Social Workers and Social Service Workers.

Health care providers recommending surgery must have training in the assessment, diagnosis and treatment of gender dysphoria in accordance with the WPATH Standards of Care that are in place at the time of the recommendation.

The specific requirements for OHIP-insured sex reassignment surgery are listed in Appendix D of the Schedule of Benefits for Physician Services.

Location of the surgery
This prior approval form will also need to include details about the proposed hospital or health facility where the surgery will take place. Currently, there is only one site in Canada that performs genital sex reassignment surgery.

If a patient is requesting that their surgery take place in Ontario or in another province, the prior approval form may be completed by the attending Ontario physician or nurse practitioner. If a patient is requesting that their surgery take place out-of-country, part of this form must be completed by an Ontario physician only.

Confirmation of approval
Patients will be notified about the outcome of their application by the health care provider who submitted the prior approval form. Applicants must receive written confirmation of funding approval before any surgical procedures or services take place.

If a patient receives any surgical procedures without prior approval, these services are not insured under OHIP and will not be reimbursed. Even if the patient later provides supporting documentation that shows they met the requirements for sex reassignment funding, the patient will not be reimbursed.

OHIP insured surgical procedures

The OHIP-insured surgical procedures related to sex reassignment are listed in the Schedule of Benefits for Physician Services.

Procedures that OHIP covers include:

  • Reproductive and external genital surgery, including clitoral release, glansplasty, metoidioplasty, penectomy, penile implant, phalloplasty, scrotoplasty, testicular implants, urethroplasty, vaginectomy, vaginoplasty, salpingo-oophorectomy, hysterectomy, orchidectomy
  • Mastectomy
  • Augmentation mammoplasty for the purpose of sex reassignment surgery is also insured for individuals with no breast enlargement following 12 continuous months of hormone therapy

When prior approval from the ministry has been received, OHIP-insured mastectomy procedures include the removal of breast tissue and reconstruction, including removal of excess skin, reduction and proper positioning of the nipple and areola, and minimization of chest wall scars.

Sex reassignment surgical procedures that are not listed in the Schedule of Benefits for Physician Services are not covered by OHIP.

Post-surgery complications

Additional surgery that is required because of complications causing significant physical symptoms or functional impairment is insured when prior authorization has been obtained from the ministry.

The prior authorization request must be made by the surgeon proposing the surgery.

Age requirements

There is no minimum age requirement for sex reassignment surgery that must be met for OHIP to approve funding. The responsibility for determining whether a patient is capable of consenting to treatment is that of the treating provider.

More information

Primary care providers can seek assistance about health care for transgendered people from Rainbow Health Ontario, the Sherbourne Health Centre, the Centre for Addictions and Mental Health, and other community health centres.