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Transition-Related Surgeries*

 

* also known as/including but limited to: gender affirmation/confirmation surgery; sex reassignment/realignment surgery

Overview

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 publically 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.

Current Available Surgeries

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
  • Chest contouring*
  • Breast Augmentation**
  • Oophorectomy
  • Orchiectomy
  • Scrotoplasty
  • Penile implant post phalloplasty
  • Testicular implant
  • Select surgical revisions
  • Hysterectomy (partner institution)

*currently not covered by OHIP, there is a $1500 inclusive 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
Contact:  Emery.Potter@wchospital.ca, phone: (416)323-6400 ext 4339

Plastic Surgery

Mitchell Brown MD, MEd, FRCS(C)
Brett Beber, MD, FRSC(C)
John Semple MD, MSc, FRCS(C), FACS

Urologic surgery

Yonah Krakowsky, MD FRCS(C)
Ethan Grober MD, MEd, FRCS(C)

Gynecology

Lisa Allen, MD, FRCS(C)

 

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 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 Providers

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 Masters degree. If you are one of the aforementioned professionals interested in becoming a qualified provider, please see our Community Resource page for more information.

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, 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

  1. The patient is confirmed to meet the criteria for surgery
  2. TRS planning visits have been completed and the patient wishes to move forward with surgery
  3. 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, the referring provider and the surgeon/program.

Referrals for pre-operative consultation without first submitting the Request for Prior Approval for Funding of Sex-Reassignment Surgery Form can occur but ONLY if discussed with the WCH TRS Nurse Practitioner. Please contact the Nurse Practitioner (416)323-6400 ext 4339.

The TRS Frequently Asked Questions 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.

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 1st letter (MD/NP) 2nd letter
(NP/MD/RN
/MSW/
psychologist)
Hormones Medical and
Mental Health
Conditions
Gender Role Experience
Mastectomy (contouring cost not OHIP covered) x   Not a pre-requisite “controlled”  
Augmentation mammoplasty x   12 continuous months with no breast development “controlled”  
Gonad: Hysterectomy, salpingo-oophorectomy or orchiectomy x x 12 continuous months “well controlled”  
Vaginoplasty (penectomy, orchiectomy, clitoroplasty, labiaplasty) x x 12 continuous months “well controlled” 12 continuous months of living in a gender role congruent with gender identity
Phalloplasty/Metoidioplasty including scrotoplasty, vaginectomy, urethroplasty, glansplasty x x 12 continuous months “well controlled” 12 continuous months of living in a gender role congruent with gender identity

Surgery planning 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. 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 list of key topics to discuss and include during these appointments. Documentation should confirm that these topics have been reviewed.

Surgical planning visits

  1. Gender History
    1. Discuss the patients current gender identity and process of transition
    2. Confirm persistent Gender Dysphoria, the patients experience with transition so far, medical and social steps taken or considered
    3. 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)
  2. Goals for surgery
    1. Why does the patient want surgery? How will surgery help the patient achieve their gender goals/reduce dysphoria?
    2. Are their expectations for surgery realistic?
    3. Aware of alternative non-surgical and surgical options
    4. If relevant, discussion around fertility and options for preservation reviewed
  3. Detailed surgery discussion/capacity for informed consent
    1. 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)
  4. Readiness (medical and psychosocial)
    1. How well controlled are medical and mental health conditions
    2. Smoking, alcohol, substance use
    3. Supports in place (including financial), and aftercare planning

Making a Referral

Before making your referral ensure

  1. The patient meets OHIP eligibility for surgery (unless contraindicated)
  2. You have provided the patient with comprehensive TRS planning visit(s)

And that you have completed and are including the following

  1. WCH TRS Referral form
  2. Comprehensive referral or brief referral with TRS planning visit notes
  3. Prior Approval Funding Confirmation Letter or indicate that you have submitted the Prior Approval for Funding of Sex-Reassignment Surgery Form (unless previously discussed with TRS Program NP)

To refer to the TRS program, complete the above and 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.

Once the referral is received, it will be assessed first by the TRS medical secretary to ensure it is complete. If incomplete, it will be returned by fax requesting the identified required information.

If the referral is complete, it will then be assessed by the TRS Nurse Practitioner for review of clinical information and identification of any areas requiring further clarification. The Nurse Practitioner will follow-up directly with the referring health care provider. The Nurse Practitioner will meet with the surgeon(s) to review the referral and identify the next available appointment for a surgical consultation.

Your referring Health Care Provider will be notified via fax once the appointment has been booked. Your referring Health Care provider will notify you of the appointment time, date and location. Should the date and time provided require re-scheduling you will be given the contact information.

During the surgical consultation, you will meet with your surgeon and Nurse Practitioner. During this visit, there will be a detailed discussion about surgery, a physical exam, photos may or may not be taken, consent to communicate with your primary care team will be sought. A pre-op medical questionnaire will be completed. A medical form will also be given for you to follow up with your primary care provider for completion. A pre-admission clinic visit will be arranged and you will bring the completed medical form to this visit.

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.

After this visit you will be scheduled for surgery.

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.

Referral Letter

When the TRS planning visits are completed, the Request for Prior Approval for Funding of Sex-Reassignment Surgery Form is completed and submitted, Prior Approval Funding Confirmation Letter has been received and the client is ready for surgery, a referral is ready to be sent. A referral should incluce the following information:

  1. The patients general identifying characteristics
  2. Medication and Allergies
  3. Past medical and mental health history
  4. The duration and nature of the relationship of the referring provider with the patient
  5. An explanation confirming criteria for surgery has been met and a brief description of the rational for supporting patients request for surgery
  6. Indication that the following has been discussed with the patient in pre-surgical planning visits(s):
    • Gender History
    • Goals for surgery
    • Detailed surgery discussion/capacity for informed consent
    • Readiness (medical and psychosocial)

You are welcome to attach your pre-surgical planning visit notes, however if the referral is complete this is not necessary.

Community 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. 

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