It was a series of government blunders that led to the funding of gender-confirming surgeries (GCS, also referred to as sex-reassignment surgery) in Nova Scotia this year.

On June 3, 2013, Nova Scotia’s umbrella LGBT group, the Nova Scotia Rainbow Action Project (NSRAP), received a letter from the NDP health minister stating that the government would not fund GCS “due to the lack of high quality scientific evidence to support the efficacy of the long-term outcomes of these procedures and lack of a strong economic argument.”

Community push-back peaked on June 11 when CBC ran the story. The very next day, after a hastily called meeting with NSRAP, the government completely reversed its stance and committed to funding GCS.

“I think [the government was] a little shocked at how big the reaction was when they said no,” says Kate Shewan, who has sat on NSRAP’s board for years and was recently elected chair.

NSRAP celebrated at its annual general meeting with a blue, white and pink trans flag cake, but the funding was quickly jeopardized by an election called for that fall.

On Sept 30, 2013, NSRAP sent Liberal leader Stephen McNeil a letter requesting a signed commitment to fund GCS in a “timely” manner. When the group received no response, Shewan, a mild-mannered parent of three with a finance background, hand delivered the letter to McNeil’s people at a campaign stop. McNeil signed it that night, and on Oct 8 he was elected premier with a majority government.

Though NSRAP wrote Health Minister Leo Glavine in November, it received no update on the file until just two weeks before Christmas, and even then, it came from freelance reporter Maggie Rahr.

Rahr was producing a CBC radio documentary about the challenges faced by trans people waiting for GCS. In an interview with Glavine, Rahr stated that those waiting for GCS were “statistically at a higher risk of suicide than any other known population,” which prompted the minister to commit to a meeting with NSRAP before Christmas.

The meeting did not happen until mid-January, after Rahr’s documentary aired on CBC, but it was a game changer, with Glavine committing to release a list of funded surgeries by April 1.

Many people were still skeptical that the commitment would turn into actual surgeries, Shewan says. “We’re a marginalized community, and people have pretty low expectations when they’re told that good things are going to happen,” she says. “Everybody was kind of in a position of ‘I’ll believe it when I see it.’ I had been in those meetings with the Department of Health, and I was feeling great and feeling very confident that this would happen.”

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Gender-confirming surgeries are just one component of a social and medical transition aimed at alleviating gender dysphoria, the stress people feel when their gender expression doesn’t match how others see them. Transition can also include name and pronoun changes, changing the sex marker on government-issued identity documents (which often requires proof of surgery), wearing clothes that align with a person’s gender identity, and taking hormones.

The wide spectrum of trans identities means that not every trans person wants gender-confirming surgeries; for those who do, the surgeries are considered essential.

Eight provinces, all but New Brunswick and PEI, fund some combination of gender-confirming surgeries. According to unreleased data from the Canadian Professional Association for Transgender Health’s (CPATH) 2013 provincial survey, the seven procedures covered by most provinces are hysterectomy (uterus removal), oophorectomy (ovary removal), metaoidioplasty and phalloplasty (bottom surgery for female-to-male trans people), penectomy (penis removal for male-to-female trans people), orchiectomy (testes removal) and vaginoplasty (the creation of a vagina).

British Columbia, Alberta, Ontario, Quebec and Nova Scotia fund all seven. Alberta relisted GCS in 2012 after cutting it in 2009, and Ontario did the same in 2008 after delisting the surgeries a decade earlier.

On April 1, 2014, the Nova Scotia government released its list of publicly funded surgeries. Community members were shocked to learn that mastectomies with chest contouring did not make the list; only plain mastectomies done in-province would be funded. This meant that trans men would have surgery similar to that obtained by women with breast cancer, but with nipples.

“I kind of hate making the distinction between chest contouring, and not because it’s not really top surgery if you don’t do [contouring],” Shewan says.

Female-to-male (FTM) trans Nova Scotians had previously been self-funding mastectomies with chest contouring and flying to Montreal or Mississauga for the procedure. Many weren’t confident that local surgeons had the necessary experience. The government stated it would not be “covering chest masculinization and/or chest contouring, which typically involve liposuction and implants.”

While top surgery does require some liposuction to take puckering out of the corners, most do not include implants, says Dr Ian Whetter, a physician at Winnipeg’s Transgender Health Program (within The Klinic).

Whetter became involved in trans healthcare after a good friend transitioned. He soon met other trans friends in Montreal who thought he could play an important role in helping people with their transitions. He thinks that the confusion stems from “muddy” language around top surgery for FTM folks but that the benchmark needs to be surgery that “results in a chest that people feel comfortable having their shirt off.”

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Nova Scotia is not the only province to fall into the mastectomy-without-chest-contouring trap. Newfoundland and Labrador doesn’t fund contouring, either, and, according to the 2013 CPATH results, Saskatchewan only sometimes funds mastectomies as part of the transition process.

On paper, Manitoba seems to fund mastectomies with chest contouring, but the doctor currently performing FTM top surgery is billing patients an extra $1,500 for a nipple graft. This entails trimming the existing areola, removing excess breast tissue and then replacing the nipple.

“If you fail to incorporate the free nipple graft as part of that surgery, then people aren’t going to be left with an aesthetically pleasing masculine chest, which is the ultimate goal,” Whetter says. “We’re currently working to figure out a different process for that because it’s not acceptable to have something listed as an insured service but not actually offer [it].”

According to Whetter, metaoidioplasty and phalloplasty are not officially insured in Manitoba but can be accessed through an appeal process.

“I think that people are generally satisfied with access to bottom surgery, and I think people are currently quite frustrated with their access to top surgery in Manitoba,” Whetter says.

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In Newfoundland and Labrador, metaoidioplasty and phalloplasty, the cornerstones of bottom surgery, are not listed as insured services because of their “associated high complication and failure rates,” according to the province’s Department of Health and Community Services. However, scrotoplasty (the creation of testes) is covered, making it the province with the most perplexing coverage.

Newfoundland and Saskatchewan are the only two provinces that still require trans people seeking surgery to travel out of province, to Toronto, to the Centre for Addiction and Mental Health’s (CAMH) Gender Identity Clinic for a referral.

Just getting to CAMH requires a visit to a psychologist or psychiatrist willing to approve the trip, notes Jamie Harnum-Davidson, a member of Memorial’s Trans Needs Committee and a vice-president of St John’s Pride in Newfoundland.

“The wait times here for mental health professionals are about a year, then you have to wait about a year to get into CAMH because all of Ontario also goes to CAMH,” says Harnum-Davidson, who uses the gender-neutral pronoun they.

“And then, after that, you still might have to wait to get in to see the surgeon because I think CAMH usually recommends the clinic in Montreal, [and] they also have about a year [wait time],” they say. “So that ends up being three to four years from when you first decide ‘I really need surgery’ to when you’re actually sitting in a surgeon’s office.”

Harnum-Davison considers the wait “ridiculous.”

Long wait times are not unique to Newfoundland and Labrador. The Alberta government funds only 25 GCS procedures per fiscal year (April 1 to March 31), bumping the remaining patients to a wait list. According to the Trans Equality Society of Alberta (TESA), the 2013/14 cap was reached last fall, the 2014/15 ceiling has already been reached, and a 2015/16 waitlist has been established.

British Columbia finally agreed to fund phalloplasties and metaoidioplasties (a total of five “bottom surgeries” per year) in 2012, but procedures were delayed while the province finalized an agreement with the Brassard & Bélanger clinic in Montreal, the only clinic in Canada performing such genital reconstruction surgeries. Surgeries are now being booked.

“Basically, every step in the process there’s just big delays,” Shewan says.

“Really, it’s the whole process, right from educating your family doctors,” she says. “A lot of times someone will go to their family doctor and [they] will have no clue what to do or who to send somebody to. If they do figure out who to refer you to, that’s when you get into the counselling and the assessment, and that’s where there’s a big shortage and they’re turning people away.”

Nova Scotia has only one endocrinologist (a doctor who specializes in hormones, for both trans and non-trans people), resulting in a six- to nine-month wait, according to Shewan.

Nova Scotia health insurance also requires a specialist’s referral to reimburse top surgeries done out-of-province, a higher benchmark than the originally announced requirement of a referral from a trained professional with a master’s degree. This is incongruent with the latest standards of care from the World Professional Association for Transgender Health and adds an additional barrier for those who do not have an existing relationship with a psychiatrist, endocrinologist or surgeon, for example. NSRAP has asked the government to either remove the regulation or expand its definition of specialist to include anyone trained to assess gender dysphoria.

Meanwhile, trans Newfoundlanders are still paying for their own surgeries, often by fundraising and taking out loans.

“Most trans folks don’t have the money to pay for it out of pocket, but they also don’t have the time to wait five-plus years in order to get these surgeries,” Harnum-Davison says, “especially considering the growing population of people who don’t fit into the normative model of gender identity. I identify as non-binary. I’m probably never going to get through CAMH’s process because they don’t even list gender-nonconforming individuals as [being] eligible for surgery.”

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Trans people are leaving Prince Edward Island because of the lack of trans-specific healthcare and surgery coverage, says Sarah Smith, Pride and communications coordinator for ARCPEI. “To see any type of efforts being made would be an improvement,” she says.

Many trans Islanders go to Halifax (and pay for travel and accommodations) to access the care they need, Smith adds.

Jim Oulton, a social worker and therapist who worked in Nova Scotia for 15 years before moving to Vancouver, used to accept clients from PEI or New Brunswick “under the radar.”

Smith hopes the recent addition of gender identity and expression to PEI’s Human Rights Code will provide leverage for provincially funded GCS, as it did in Nova Scotia.

In New Brunswick, a change.org petition, “New Brunswick Legislature: Provide Coverage for Gender Reassignment Surgery,” also cites Nova Scotia’s move to fund GCS.

Though New Brunswick and PEI are the last Canadian provinces not to cover any gender-confirming surgeries, there are a few surgeries recommended by CPATH that none of the provinces cover, such as tracheal shaving (minimizing the Adam’s apple) and facial feminization. And only BC funds breast augmentation for male-to-female trans people.

Whetter thinks Canadians need to have a frank conversation about “the constellation of surgeries that we consider to be medically necessary and where we draw the line between what is cosmetic.”

“Electrolysis is way more important for a lot of people than genital surgery, but we don’t fund electrolysis and we fund genital surgery,” he notes. As some of Whetter’s trans patients have told him, “More people in the day are going to look at my face than are going to look at my genitals.” Electrolysis is not covered in any province.

Oulton, now past-president of CPATH, puts the emphasis on education and training “so transgender and gender non-binary people are not seen as odd,” he says. “There has to be a level of familiarity and competence, just to include the needs of transgender and gender non-binary people in medical practice across the country.”

In part, this would lead to better access to gender-confirming surgeries. “We want to make it accessible, just like tonsillectomies,” Oulton says.