The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

Dave Gwun^#¹, Brennan Snow^#², Emery Potter^{2

3}, Rachel Loewen Walker⁴, Alexandra L Millman^{5

6}, Yonah Krakowsky^{5

6}, Gianni R Lorello^{2

7

8

9}, Janice Du Mont^{2

10}, Lucy C Barker^{2

11}, Percy Lezard¹², Marudan Sivagurunathan², David R Urbach^{6

13}, Kathleen Armstrong^{14

15

16}

Affiliations

¹ Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. dave.gwun@mail.utoronto.ca.
² Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
³ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
⁴ Department of Women's and Gender Studies and Political Studies, University of Saskatchewan, Saskatoon, SK, Canada.
⁵ Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
⁶ Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada.
⁷ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁸ Department of Anesthesiology and Pain Management, University Health Network - Toronto Western Hospital, Toronto, ON, Canada.
⁹ The Wilson Centre, Toronto General Hospital, Toronto, ON, Canada.
¹⁰ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
¹² Department of Indigenous Studies, Law and Social Justice, Wilfrid Laurier University, Waterloo, ON, Canada.
¹³ Department of Surgery, Women's College Hospital, Toronto, ON, Canada.
¹⁴ Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. kathleen.armstrong@wchospital.ca.
¹⁵ Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada. kathleen.armstrong@wchospital.ca.
¹⁶ Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. kathleen.armstrong@wchospital.ca.

^# Contributed equally.

PMID: 39123233
PMCID: PMC11316376
DOI: 10.1186/s12913-024-11361-w

The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

Dave Gwun et al. BMC Health Serv Res. 2024.

. 2024 Aug 10;24(1):916.

doi: 10.1186/s12913-024-11361-w.

Authors

Affiliations

¹ Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. dave.gwun@mail.utoronto.ca.
² Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
³ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
⁴ Department of Women's and Gender Studies and Political Studies, University of Saskatchewan, Saskatoon, SK, Canada.
⁵ Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
⁶ Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada.
⁷ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁸ Department of Anesthesiology and Pain Management, University Health Network - Toronto Western Hospital, Toronto, ON, Canada.
⁹ The Wilson Centre, Toronto General Hospital, Toronto, ON, Canada.
¹⁰ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
¹² Department of Indigenous Studies, Law and Social Justice, Wilfrid Laurier University, Waterloo, ON, Canada.
¹³ Department of Surgery, Women's College Hospital, Toronto, ON, Canada.
¹⁴ Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. kathleen.armstrong@wchospital.ca.
¹⁵ Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada. kathleen.armstrong@wchospital.ca.
¹⁶ Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. kathleen.armstrong@wchospital.ca.

^# Contributed equally.

PMID: 39123233
PMCID: PMC11316376
DOI: 10.1186/s12913-024-11361-w

Abstract

Background: Many studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time.

Methods: We conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada. RESULTS: Eight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years. CONCLUSIONS : We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers.

Keywords: 2S-LGBTQ + health; Access to care; Insurance policy; Resource.

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Conflict of interest statement

The authors declare no competing interests.

Figures

**Fig. 1**
Flow chart of the environmental scan and screening results. This flow chart depicts the combined raw search results from 23 government (gov.) websites, the Google search engine (google.com), an online legal database (canlii.org), and the manual search. The online search produced 5424 results. After applying the inclusion criteria, 257 results were obtained. Twelve additional documents and webpages were gathered from the manual search, which consisted of citation searching, access to Information and Privacy (ATIP) requests, and contacting representatives from the regional government. In total, 269 documents were included in the environmental scan

**Fig. 2**
Geographic heat map showing the number of GAS covered by each province and territory. Map pins specify the locations where GAS are performed in Canada. From left to right: The Gender Surgery Program in Vancouver, British Columbia; Women’s College Hospital in Toronto, Ontario; and Centre Metropolitain de Chirurgie in Montreal, Quebec. The asterisk (*) specifies provinces without publicly available GAS Medicare policy documents or web pages. Provinces offering travel-related costs coverage (Alberta, British Columbia, Newfoundland and Labrador, Nova Scotia, and Nunavut) are indicated with an airplane symbol

**Fig. 3**
Summary of Medicare coverage for gender-affirming surgeries (GAS) for each province and territory in Canada. Provinces and territories are organized according to the most to least types of GAS covered. References to policy documents where the information is sourced are written in square brackets. The green circles indicate procedures covered by Medicare. Pink triangles identify procedures excluded from Medicare. Yellow diamonds indicate procedures that are covered under specific criteria. The gray squares denote unknown coverage. Abbreviations: AB = Alberta; BC = British Columbia; MB = Manitoba; NB = New Brunswick; NL = Newfoundland and Labrador; NS = Nova Scotia; NU = Nunavut; NWT = Northwest Territories; ON = Ontario; PEI = Prince Edward Island; QB = Quebec; SK = Saskatchewan; Yk = Yukon

**Fig. 4**
Timeline of gender-affirming surgery Medicare policy changes from 1970 to 2024. Abbreviations: AB = Alberta; Apr = April; Aug = August; BC = British Columbia; CAMH = Centre of Addiction and Mental Health; CBC = Canadian Broadcasting Channel; Feb = February; FFS = facial feminization surgery; GAS = gender-affirming surgery; Jan = January; Jul = July; Jun = June; Mar = March; masc. = masculinization; MB = Manitoba; NB = New Brunswick; NL = Newfoundland and Labrador; Nov = November; NS = Nova Scotia; NU = Nunavut; Oct = October; OHIP = Ontario Health Insurance Plan; ON = Ontario; PEI = Prince Edward Island; psych = psychologist; re. = regarding; req. = requirement; v. = versus; YK = Yukon

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References

1. Statistics Canada Government of Canada. The Daily. 2022. Canada is the first country to provide census data on transgender and non-binary people. Available from: https://www150.statcan.gc.ca/n1/daily-quotidien/220427/dq220427b-eng.htm. Cited 2022 Jul 18.
1. Bauer GR, Pyne J, Francino MC, et al. Suicidality among trans people in Ontario: Implications for social work and social justice. Serv Soc. 2013;59(1):35–62.10.7202/1017478ar - DOI
1. Bauer GR, Scheim AI, Deutsch MB, et al. Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey. Ann Emerg Med. 2014;63(6):713-720.e1. 10.1016/j.annemergmed.2013.09.027 - DOI - PubMed
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5-TR. 5th edition, text revision. Washington, DC: American Psychiatric Association Publishing; 2022.
1. Wright JD, Chen L, Suzuki Y, et al. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. 10.1001/jamanetworkopen.2023.30348 - DOI - PMC - PubMed

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The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

Affiliations

The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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