Transition Related Surgery

Required Documents

To refer a patient for surgery, please fax the following documents to (416)32306310

1. Transition Related Surgery Referral COVER SHEET
2. Prior Approval Funding Confirmation Letter.
   • Prior Approval for Funding of Sex-Reassignment Surgery Form
   • Please do not send the funding application to the TRS Program.
3. Comprehensive referral
   • Should include medical, gender, surgical and social history
   • Must document clear surgical goals
   • A Referral template (.docx) is available for guidance

Before submitting a referral, please ensure…

• The patient meets OHIP eligibility for surgery (unless contraindicated)
• The patient has received comprehensive surgery planning visit(s)
• Surgery information has been reviewed with the patient
  • Resources available at https://www.rainbowhealthontario.ca/news-publications/rho-publications-resources/
• OHIP Funding has been applied for, and the confirmation letter has been received

After submitting the referral…

• Once received, referrals are assessed by the TRS team
• If incomplete, it will be returned via fax requesting the missing information
• If complete, the referral will be processed and a consultation will be scheduled when available

OHIP Funding Process

For details on OHIP funding for gender affirming surgery, see:

• The TRS Frequently Asked Questions (.pdf) – A guide for patients and providers.
• The Ministry of Health’s website outlines OHIP funding criteria. There is a specific form, the Request for Prior Approval for Funding of Sex-Reassignment Surgery Form, you must complete in the current referral system to gain access to OHIP coverage. This form can be found

How to apply for OHIP Funding

Once your patient…

• Meets eligibility criteria for surgery
• Completes TRS planning visits discussing surgery, risks and benefits
• Decides to proceed with surgery

You must…

1. Complete the Prior Approval Funding Form
2. Fax the form to the Ministry of Health at (613) 536-3188 (DO NOT send it to WCH’s TRS Program).
3. Wait for approval (typically one to four weeks) where the Ministry will fax a Prior Approval Funding Confirmation Letter to the referring provider.
4. The form is to be completed and faxed to the MOHLTC at (613) 536-3188

Additional Funding Options

• UHIP (for international students)
• Federal funding (for individuals who are incarcerated or military personnel).

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.

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. 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 template to guide you through the key topics. The documentation should confirm that these topics have been reviewed.

Providers should document that these topics were reviewed:

1. Gender History

• Current gender identity and transition process
• Confirmation of persistent gender dysphoria
• Steps taken or considered (e.g., medical, social transition)
• WPATH and OHIP eligibility (e.g., hormone therapy, gender role experience)

2. Surgical Goals

• Why does the patient want surgery?
• How will surgery help achieve gender goals/reduce dysphoria/incongruence?
• Are expectations realistic?
• Awareness of alternative surgical/non-surgical options
• Fertility considerations (if applicable)

3. Surgery Details & Consent

• Description of desired surgery, risks, and alternatives
• Discussion of irreversible effects
• The surgeon will provide further detailed discussion during consultation

4. Readiness for Surgery (Medical & Psychosocial)

• Medical & mental health conditions (stability and management)
• Smoking, alcohol, and substance use history
• Post-surgery support system and financial resource

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.

Criteria for surgery are set by the World Professional Association of Transgender Health’s (WPATH) Standards of care (SOC). The SOC ‘s criteria for surgery include:

• Gender incongruence is marked and sustained.
• Meets diagnostic criteria for gender incongruence & other possible causes have been identified and excluded.
• Mental and physical health conditions that could negatively impact outcome have been assessed with risk-benefit discussion.
• Demonstrates the capacity to consent to the specific treatment.

For genital surgeries:

• Understands the effect of gender-affirming surgical intervention on fertility & options have been discussed.

Minimum 6 months of hormone therapy, unless not desired or medically contraindicated.

1. 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.
2. For information on the referral process for surgery in Ontario see Rainbow Health Ontario’s Frequently Asked Questions.
3. For information about specific transition related surgeries, please see these surgical info summary sheets.
4. RHO provides a weekly mentorship call on Wednesdays 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.
5. If you are looking for a primary or secondary provider to support trans pre-surgical planning visits you can make a referral to CAMH.
6. Visit the RHO Newsroomto be kept up-to-date as our program and website expands to include helpful resources and ensure access to care.
7. The WCH TRS Program has numerous resources regarding surgery including patient handouts and recorded videos. Please see “Patient Resources” for more information.

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.

For your first appointment, depending on the type of surgery, you will either meet with your surgeon, or with nursing. During this visit, we will take a comprehensive history and there will be a detailed discussion about surgery. If the appointment is with the surgeon, a physical exam will take place or previously sent photos will be reviewed. If the initial appointment is with the nursing team, no physical exam will take place at this visit.  An in person follow up appointment with the surgeon will be made and an exam will take place at this time. A social support person is welcome to join during this part of the visit if that may be helpful to you

After the initial consultations, the next steps may look as follows:

1. Option 1: No issues identified. Surgery planning continues, including booking a surgery date once one becomes available.
2. Option 2: An issue(s) has been identified that may increase the risk of putting you to sleep for surgery. A preoperative anesthesia consult (PAC) will be required to determine if you can safely proceed to surgery at WCH. If anesthesia gives approval, and no other issues identified, surgery planning continues, including booking a surgery date once one becomes available.
3. Option 3: An issue(s) has been identified that may not allow for surgery to safely proceed at WCH. We will follow up with you and your referring health care provider to determine if this issue can be addressed sufficiently to proceed forward with surgery planning. If we are not able to safely address the issue- surgery will not be possible at WCH and this will be communicated to you and your referring provider.

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 a minimum of 24 hours, and up to 96 hours depending on the surgery. If you do not have such a person, we will discuss options available to you including the Acute Respite Care (ARC) program at Sherbourne Health Center (SHC). If you require ARC, your surgery date will need to be coordinated with the availability of this service.

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* (waitlist currently on hold)
• Breast Augmentation** (waitlist currently on hold)
• Hysterectomy
• Bilateral salpingo-oopherectomy
• Orchiectomy
• Scrotectomy
• Vaginoplasty
• Vulvaplasty
• Metoidioplasty (coming soon)

*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

Please note: The waitlist for top surgeries (mastectomy with chest contouring and breast augmentation) are currently on hold. We are not currently accepting new referrals for surgery. Please check back here for updates on our waitlist.

• Consent for vaginoplasty
• Vaginoplasty Guidebook
• Vulvaplasty Guidebook
• Orchiectomy Guidebook 
• 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
• Douching
• 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

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

Join us for an anonymous virtual seminar to learn about and discuss gender affirming surgeries with our team of medical experts. This event is open to trans and gender diverse people, their loved ones and providers living in Ontario.

The series is an informational event for those who are making decisions regarding gender affirming surgery and provides an accessible pathway for education on the surgery, surgical techniques, surgical outcomes and the patient experience. These events hope to provide prospective patients an anonymous opportunity to engage with medical experts to discuss this important milestone in their lives and will include an anonymous Q&A period at the end of each seminar.

Individuals considering or receiving surgery at other surgical centers are welcome.

To see the most up to date schedule and to register, click here.

 What TRS does OHIP cover?

OHIP only covers pre-approved surgeries. The Ministry will not reimburse you if you pay out of pocket. Multiple procedures can be applied for on the same form if they are performed in the same location. This does not mean that both surgeries can occur at the same time.

OHIP-Funded Procedures (note, some of these procedures are not offered at WCH)

• Vaginoplasty (includes penile desconstruction, orchidectomy, clitoroplasty, labiaplasty, with and without the creation of a vaginal canal)
  • Phalloplasty (includes vaginectomy, urethroplasty, glansplasty, and penile and
  testicular implants)
  • Metoidioplasty (includes vaginectomy and urethroplasty)
  • Clitoral release with vaginectomy
  • Testicular implants with scrotoplasty
  • Hysterectomy (removal of the uterus)
  • Salpingo-oophorectomy (removal of the tubes and ovaries)
  • Orchidectomy
  • Mastectomy* (includes removal of breast tissue, excess skin, and proper positioning of
  nipple and areola)
  • Breast Augmentation**

*Mastectomy with Chest contouring is currently not covered by OHIP. There is a $1500 +HST cost for this procedure.

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

Please note, some of these procedures are not offered at WCH

• Chest contouring/masculinization**
  • Breast augmentation for people with breast growth past Tanner Stage I after 12 months
  of hormone therapy
  • Facial masculinization
  • Facial feminization
  • Electrolysis
  • Laser hair removal
  • Hair transplants
  • Tracheal shave
  • Voice modification surgery
  • Liposuction
  • Chin, nose, cheek, or buttock implants
  • Travel and accommodation costs related to obtaining surgery
  • Supplies related to post-surgery care

** OHIP will only cover the Mastectomy part of chest surgery. Any masculinization must be paid by the patient and will vary from surgeon to surgeon.

As a surgical program, we are not involved in all aspects of gender affirming medical care provision. We do not provide consultations for hormone provision or deliver primary care. Initial surgery discussions are required with a qualified health care provider and funding approval must be in place prior to referral to our program.

Wait times for surgery can be highly variable. Once you have completed your consultation and begin surgical planning, please ask someone from the TRS Program for the estimated wait times.

To inquire about the status of your referral, please first reach out to your referring health care provider. Upon receipt of any referral, a member of our team will send a response to your referring provider indicating that the referral has either been accepted, declined or is incomplete (requires further information). If your referring provider has not received such a response letter, please have them re-send the referral.