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Surgical Referrals in Ontario
How does someone get transition-related surgery? Learn about the assessment and approval process in Ontario.
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For some trans, non-binary and gender-diverse people, surgeries are a part of gender-affirming care. Before getting surgery, though, you need to go through some assessments and paperwork. Navigating this process can be quite overwhelming – but we’re here to help! This article will explain the assessment process and how to get surgeries covered by OHIP, Ontario’s public health plan.
Transition-related surgeries (TRS)
Surgeries are an option for anyone who wants to align their body with their gender, including non-binary people. There’s no one way to be trans, and you can choose whatever journey feels authentic to you. This might include hormone therapy and transition-related surgeries (TRS), or it might include surgeries without hormones. It might not include medical treatments at all. Not every trans, non-binary or gender diverse person has surgery – it’s a decision that’s yours to make.
Surgery in Ontario
There are two steps to getting TRS in Ontario. The first is one or two assessments, depending on the surgery you choose. These confirm you’re ready for the procedure. If you’re paying out of pocket, your clinician can write a referral to your surgeon when this is complete.
If you’d like your surgery to be funded by OHIP, there’s a second step. This is where you apply for an approval from the province, which means your costs are covered. To be eligible for funding you must already be covered by OHIP. Your clinician can then apply for you, and if you are approved they can write a referral to your surgeon.
Unfortunately, OHIP doesn’t cover all TRS. We’ve got a full list of surgeries that are and aren’t covered by provincial insurance further down.
To get surgery, you’ll need to have an assessment. Sometimes you’ll need two. These can feel like a frustrating step, but it’s an important one! They let you and your clinician talk through the risks, recovery and outcomes of surgery. They also make sure you’re able to consent, which is important because some TRS are irreversible.
What happens during my assessment?
During your assessment, you’ll be asked about your gender history, your health history and your medication history. For most TRS, you’ll need a diagnosis of gender dysphoria. Even though some people don’t identify with this label, it’s still required by surgeons and the Ministry of Health (if you’re applying for coverage).
You’ll also be asked how the surgery will impact your life, where you’d get surgery and what your recovery plan is. Because of this, it’s a good idea to do some research in advance. For example, some OHIP-covered surgeons are out of province so you’d need to make some travel plans. Most out of province OHIP surgeries are at GRS Montreal.
Who does my assessments?
For bottom (genital) surgery, you’ll need two assessments.* For top (breast or chest) surgery, you’ll only need one.
Your first assessment can be done by a doctor or nurse practitioner. Your second can be done by a doctor, nurse practitioner, registered nurse, psychologist or registered social worker (MSW). Your assessor must be experienced in and/or knowledgeable about gender-affirming care. They must also be registered with their regulatory college in Ontario.
For minor surgeries that aren’t covered by OHIP, like hair transplants, your surgeon may do the assessment themselves. For these procedures, you can reach out to your surgeon and ask what their protocol is.
* The World Professional Association for Transgender Health (WPATH) released new guidelines in September 2022, which recommend only one assessment for all gender-affirming surgeries. At the time of writing, Ontario’s Ministry of Health hasn’t updated their guidelines to reflect this.
To get surgeries covered by OHIP, you’ll need to have your assessments first. Your clinician then puts in a request for funding to the Ministry of Health. A decision could come up to eight months after submission. Unfortunately it’s hard to predict.
If you’re approved, the clinician who assessed you will receive a letter (if you had two assessments this will be sent to the first clinician who assessed you). This letter won’t be sent to you, but we will let you know when we receive it. After this, your assessor can then write a referral to your surgeon, which will let you book a surgery under the public system. Approvals are valid for 3 years.
What’s covered by OHIP?
OHIP will cover some but not all TRS. Based on information from the Rainbow Health Guide, these are:
Vaginoplasty (includes penectomy, orchidectomy, clitoroplasty and labiaplasty)
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 (removal of the testicles)
Mastectomy* (includes removal of breast tissue, excess skin, and proper positioning of nipple and areola)
Breast augmentation (after 12 months of hormone therapy with no breast growth)
* OHIP will only cover the mastectomy part of chest surgery. Any masculinization must be paid separately, and varies depending on surgeon and province. If you are getting surgery at GRS Montreal this cost is covered by the clinic.
What isn’t covered by OHIP?
There are some TRS that OHIP doesn’t cover. There are also some costs related to surgery that you’ll have to pay yourself. Based on information from the Rainbow Health Guide, these are:
Breast augmentation for people with breast growth after 12 months of hormone therapy
Laser hair removal
Voice modification surgery
Body contouring (e.g. liposuction, BBL)
Chin, nose, cheek, or buttock implants
Travel and accommodation costs related to surgery**
Supplies related to post-surgery care
* OHIP will only cover the mastectomy part of chest surgery. You’ll have to pay for any masculinization, which varies depending on surgeon and province. If you are getting surgery at GRS Montreal this cost is covered by the clinic.
** If you are getting surgery at GRS Montreal, the clinic will cover your hotel and food costs for three days.
How do I get approved?
If you’re applying for OHIP approval for TRS, you’ll need to meet these criteria:
You have a diagnosis of gender dysphoria. This can be a previous diagnosis or the clinician can make the diagnosis in your appointment, based on your history.
Other health conditions (like diabetes or depression) are treated and/or under good control.
You’ve considered the alternatives to surgery, like binding for chest surgery.
Surgery could help you achieve the goals you have.
You understand the risks and benefits of surgery and can give consent.
You’ve been on hormones for at least a year (for everything except chest surgery).
You’re over the age of 18.
If your clinician can verify all of these, they fill out the Ministry of Health form (called Prior Approval Form) to request funding. For all TRS except chest or breast surgery, two different clinicians must verify this information and fill out the form. These are separate parts of the same form.
How can Foria help?
Foria can provide one or both of your assessments. These are separate from hormone therapy appointments (so we can't do both at the same time). After your assessment(s), we can then write a referral letter to your surgeon confirming you’re ready for surgery.
Foria can also submit paperwork for OHIP funding. We’ll track your approval status with the Ministry and update you through the process. After your surgery is approved, our team can send your approval letter to your surgeon. For more information, see our surgical assessment page.
Surgical assessments with Foria cost $199. If you need two assessments and would like both to be with Foria, a second assessment is required.
This content has been reviewed by Foria’s Medical Director, Dr. Kate Greenaway and our community advisory team. Medical sources include Rainbow Health Ontario’s Transition-Related Surgery FAQ.