Why the long wait for sex reassignment surgery isn’t about to get better

By Erica Lenti - Published on March 10, 2016
a bed in a medical exam room
As of March 1, the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery.

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If bodies were Airbnbs, Marcel’s would be a one-star stay. The bed sheets would feel too staticky, the light in the bathroom unflattering, the carpet a little too rough. Like renting an uncomfortable room from a stranger, such is how Marcel describes his dysphoria. But while shoddy rooms for rent can be left, Marcel can’t escape this. A transgender man in the throes of transition: he can’t feel at home in his body.

Marcel, whose name has been changed to protect his identity, started his transition four years ago. The first step was hormone replacement therapy, a ritual of two-millimetre needles of testosterone that he will give himself every day for the rest of his life. For the first few months of the therapy, Marcel rode his bike from downtown Toronto to suburban Mississauga to receive his shots from a transgender-friendly doctor.

By 2012, Marcel was ready for top surgery – a bilateral mastectomy. At Toronto’s Centre for Addiction and Mental Health, the only institution in the province at which reassignment surgeries are covered by health insurance, a queue had formed. Faced with a minimum wait of two years, he scrounged up as much money as he could—a loan from his sister, funds raised by friends, paycheques from a nine-to-five job—and had the surgery at a private clinic. The procedure set him back $6,000. Today, Marcel awaits one last surgical procedure: lower reassignment surgery.

Marcel is among a large group of transgender Canadians seeking this procedure to reconstruct the genitals. Not all people who identify as transgender seek to transition medically or physically, but prospects remain grim for those who do. Several years have passed, but Marcel still doesn’t have the body he says he needs.

Even in a country as accepting and progressive as Canada, Marcel’s transition from female to male has been difficult. The situation has improved only slightly: As of March 1, the Ontario government allowed more health-care providers to be trained to give referrals for sex reassignment surgery. The Ontario government has also set aside $2 million to reduce the backlog from CAMH. But while the province’s efforts are intended to relieve the referral wait, such a move also threatens to create an even larger bottleneck at the only institution near Ontario that offers the surgeries.

Since 2008, when provincial funding for the procedures began, transgender Ontarians have had to work through a seemingly interminable process to fulfill their surgical requirements for transition. Top and lower surgery can cost upwards of $8,000 and $100,000 respectively (though the costs fluctuate depending on the surgeon). Typically, OHIP will cover these fees, provided that the person transitioning passes psychological and psychiatric assessments and is referred to a surgeon by a designated doctor or clinic.

Each province has its own policies and procedures, but a pattern has emerged: the number of institutions at which transgender people can be assessed in each province is paltry, so there’s almost always a queue. Alberta boasts two qualified doctors. In B.C., there’s one. Prior to the province’s announcement, in Ontario the wait list for assessments at CAMH had swelled to more than 1,500.

“Certainly the demand has increased over the past five to 10 years, as people have found a word to describe their circumstances,” says Dr. Amy Bourns, a physician who specializes in transgender care at Toronto’s Sherbourne Health Centre.

Under new legislation, health-care providers who want to make assessments and referrals for transgender patients must undergo training that complies with standards set by the World Professional Association for Transgender Health, an Illinois-based organization. Currently, there is no word on whether this training will be mandatory.

Meanwhile, as the Globe and Mail has reported, doctors are urging transgender Ontarians to stay on the CAMH waitlist until “things get sorted out.”

On a Sunday in 2014 Marcel gave up waiting. No point in trying to get cozy in his body, he told himself. At that point, his wait for an appointment at CAMH could have taken as long as five years. He was just 26; he would be into his 30s before getting a referral. With no easy fix in sight, he says he hid under the covers and sobbed, his brain flooded with negative images. In his bedroom that night, he attempted suicide. His last thought before unconsciousness: I can’t believe I’m going to be another statistic.

Hours later, Marcel’s best friend found him passed out in bed. “I did not expect to wake up,” Marcel says. “That was hellish in its own right.” Even worse, he feared the idea of going to the hospital and being misgendered by doctors. His loved ones were able to convince him to visit his family doctor, who assessed the situation.

“The [prolonged] wait is something I couldn’t mentally last,” Marcel tells me a year and a half after his suicide attempt. While the long wait for assessment can perpetuate mental health issues in transgender Ontarians, acknowledging these issues can create setbacks for them; psychologists will often deem suicidal patients unfit for referral.

Even if assessments become more widely available, yet another bottleneck will occur: a queue for the actual surgeries. Just one clinic in the country performs lower surgery, and it’s in Montreal, headed by Dr. Pierre Brassard and Dr. Maud Bélanger; as a result, many are already choosing to have the surgery elsewhere, in the U.S. or Europe. The current wait list at Brassard and Bélanger’s clinic is six months.  According to Bourns, the two surgeons could increase their output, but not enough to prevent an even longer queue from forming.

Bourns says some surgeons have shown an interest in learning the ins and outs of reassignment surgery, but many aren’t committed to perfecting the craft. “There have been inquiries from surgeons who want to come for a week to train with Dr. Brassard, but it would require something more like a six-month residency for them to learn to do the surgery,” she says. In recent years, medical schools have begun to incorporate training specific to LGBTQ patients, with organizations such as Rainbow Health Ontario spearheading the cause. But only those with a specific interest in performing reassignment surgery are likely to learn about and train to execute the procedure.

As a result, patients are searching for alternatives. Marcel considered heading to Thailand for the procedure, but his doctor advised against it. (Many Canadians go anyway, because of the low cost. Vaginoplasty, for instance, starts at just $12,000, in comparison to about $50,000 in Canada.) Instead, he ponied up as much cash as he could and found a private gender therapist with the qualifications to assess and refer him to an OHIP-approved surgeon in San Francisco; so long as a transgender Ontarian has letters of assessment (from a CAMH therapist or a much more costly private therapist), OHIP will cover the cost of surgery out-of-province. Patients who go this route have to pay for their own travel and accommodations. After a half-year wait, Marcel has a consultation with the San Francisco surgeon this month, but what comes after that is still unknown.

Bourns suggests travelling for reassignment surgery could raise other issues. For one, she says, Canadian doctors could be unwilling to work with patients who experience complications from surgeries abroad. “That means they'll have to hop back on a flight to correct something like issues with urination,” she says. Until more surgeons practise in Canada, small corrections to these major surgeries could be incredibly costly.

“I realize I’m privileged,” Marcel says. He has a career, a modest but homey apartment, a puppy. These are not common comforts: Many transgender Ontarians live below the poverty line and private therapists are not an option.

Marcel says he thinks about time often. It is the barrier that keeps him from his true self. It’s what stops him from using public washrooms. There is no fast-forward button.

“I’ve always yearned for transition to end,” he says. “I feel stagnant right now. I don’t know where I’m moving.”  But, the way Marcel puts it, he does know where he’d like to be at: the sensation of coming home, of leaving a strange abode. Here, the sheets are crisp and the light natural. Here, there is comfort.

Erica Lenti is a Toronto-based freelance journalist who covers mental health, LGTBQ and women’s issues.

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