Sex Reassignment Surgery (SRS) Backgrounder

In the late 1960s Gender Identity Clinics (GICs) emerged as a response to the growing demand by transsexual people for hormones and sex change surgery. GICs assessed patients for gender identity disorder and upon this diagnosis, provided referrals for hormone therapy and sex change surgery (sex reassignment surgery). In Ontario, the Gender Identity Clinic began in 1969 at the Clarke Institute of Psychiatry in Toronto as a pilot program within the University of Toronto. Patients referred by this clinic had their surgery funded by the Ontario government until October 1, 1998 when sex reassignment surgery (SRS) funding was removed by the Provincial government.

Individuals presenting with a persistent and compulsive desire to become a member of the opposite sex are diagnosed with gender identity disorder (GID). Originally, transsexualism was the diagnosis for those presenting with these desires, however this term was replaced with the term gender identity disorder in 1994.

GID is internationally recognised as a medical condition by the Harry Benjamin International Gender Dysphoria Association and this condition is documented in their universally accepted Standards of Care of Gender Identity Disorders. Transsexualism is recognised as a psychiatric disorder by the American Psychiatric Association and the World Health Organisation. SRS is the recommended treatment for transsexuals who cannot live in their original sex and gender role.

“As an effective treatment for a specific mental disorder, sex reassignment surgery is as deserving of public funding as any other psychiatric treatment.” states Dr. Ray Blanchard, head of the Clinical Sexology Program at the Centre for Addiction and Mental Health.

According to the International Journal of Transgenderism, estimates for those presenting with GID are approximately 1 in 11,900 males and 1 in 30,000 females. Unfortunately, these numbers are based upon research that reports those presenting for assessment at GICs. Other sources indicate higher numbers of transsexual people upwards of 1 in 10,000. It is impossible, though, to determine the total population of transsexual people because this population is hidden – either remaining undisclosed in the closet or successfully being accepted in their new sex/gender role without detection.

Who are transsexuals?

Transsexual persons work in a variety of fields and professions much like the general Canadian population. In Canada transsexual people work as university professors, graduate and undergraduate students, clinical psychologists, managers in corporate and non-profit organisations, artists, musicians, mechanics, caretakers, health care workers, housing workers, truck drivers, telemarketers, bartenders, cooks, sex workers, lawyers, police officers, and in the armed forces. Some transsexual persons are underemployed and unemployed.

Transsexual persons live in urban and rural regions across Canada. Migration towards urban centres, particularly Toronto, Vancouver, and Ottawa, occurs as transsexual people attempt to access valuable social and health services critical to their health and wellbeing.

Transsexual persons both rent and own houses and condominiums, rent apartments and live in subsidised housing. Some transsexual people are homeless and live on the street or in shelters.

Transsexual people experience a high level of harassment and discrimination based upon their appearance and identification. This population experiences transphobia, which is a fear and hatred of transsexual people. Harassment, discrimination, and transphobia cause barriers to access to education, housing, and employment for transsexual people. Consequently, many transsexual persons encounter financial hardship in accessing SRS.

What are “SRS” and “related medical procedures”?

Defined within the transsexual communities, sex reassignment surgery includes a spectrum of medical surgeries which transform the sex characteristics of physical body to fit the desired opposite sex body. Simplified for audience reading, these surgeries include: vaginoplasty, phalloplasty, metaidioplasty, chest reconstruction, breast augmentation, hysterectomy, penectomy, orchiectomy, vaginectomy, salpingo-oopherectomy and electrolysis. Defined by GICs and some provincial health insurance programs, SRS is limited to sex change surgery, which includes vaginoplasty, metaidioplasty and possibly phalloplasty. Consequently, this backgrounder employs the term, “SRS and related medical procedures” to indicate the need for a comprehensive health care package for transsexual persons in Ontario.

Vaginoplasty – male to female sex change surgery where the penis is converted into a neo-vagina. Other methods include skin grafts and sigmoid colon resection, which allow the penile and scrotal skin to be used to form the labia. This is a routine procedure which often results in a high rate of sexual satisfaction once the region has healed.

Phalloplasty – female to male sex change surgery where skin grafts are used to construct and attach a penis. This procedure is expensive and intrusive, and is usually desired by individuals experiencing a high level of discomfort resulting from GID.

Metaidioplasty – female to male sex surgery where the enlarged clitoris (resulting from male hormone therapy) is partially cut loose so that it can function more like a penis. This less expensive and intrusive procedure is more often desired due to its high success rate for sexual function afterwards.

Chest reconstruction – female to male surgery where the breast tissue is reconstructed to produce a male chest. This procedure has become routine, however caution must be exercised that the surgeon understands the difference between a mastectomy and sex change chest reconstruction.

Breast augmentation – male to female surgery more commonly known as breast implants. This procedure is sometimes necessary for individuals to enhance their female presentation, particularly when hormone therapy does not fully provide sufficient breast growth.

Hysterectomy – female to male sex surgery where the uterus is surgically removed.

Penectomy – removal of the penis

Orchiectomy – removal of the testicles

Vaginectomy – removal and/or closure of the vagina

Salpingo-oopherectomy – removal of ovaries and fallopian tubes

Electrolysis/Laser hair removal – male to female procedure where the facial hair (beard) is removed. This is a routine procedure which is necessary for a transsexual woman to achieve a female physical appearance so that she is accepted as a woman.

Why are SRS and related medical procedures important?

For a person suffering from gender identity disorder, SRS and other medical procedures can significantly reduce the feelings of discomfort caused by one’s birth sex and social rearing in that sex. SRS can alleviate the discomfort or dysphoria caused by GID and shift the feeling of being ‘out of order’ (gender identity disorder) to a sense of being ‘in order’ with one’s body.

Failure to remedy feelings of dysphoria can cause significant health care concerns. Health issues transsexual persons face include; depression, anxiety, anger, stress, drug and alcohol use, eating disorders, childhood trauma, self-harm and suicide. Supportive counselling and medical care for transsexual persons can greatly alleviate these concerns, and reduce resulting health care costs.
Legally, a certificate verifying the completion of SRS by a practising doctor in Canada is required to obtain a change of sex on a birth certificate. When the sex record on the birth certificate does not match an individual’s gender presentation, harassment and discrimination is possible with legal documentation (banking, employment, health coverage, insurance, marriage, drivers licence, etc.). When using legal documents transsexual persons must decide whether to be honest about their birth sex and face possible discrimination or lie and face the possibility of being caught.

Several participants interviewed in the Trans Health Project, a recent study into health care access for transsexual persons in Ontario reported that SRS was a priority in their lives, and the lack of funding was a barrier to accessing this important health procedure.

SRS Health Coverage in Ontario
The Health Insurance Act covered gender (sex) reassignment surgery and related medical procedures until it was delisted on October 1, 1998.

The Ministry of Health Schedule of Benefits covered electrolysis for facial hair until November 14, 1991 when it was delisted as an insured service.

In April 1999, Michelle Josef initiated a Charter Application to challenge the delisting of SRS. It was stalled for a number of years for a variety of reasons, including insufficient funds to put the expert evidence together The case is moving forward now, with the cooperation of many experts. The evidence will be filed at the end of October 2004, then the government will respond with its evidence. The hearing will likely take place in spring 2005. Legal arguments include: (1) that the Charter protects trans people from discrimination based on gender identity; (2) that the delisting violates the equality rights of transsexuals; and (3) that the Regulation which imposed the delisting is outside the powers of the provincial government because it was enacted in bad faith and with an improper purpose that is contrary to the purposes of the Health Care Act.

In 2000, Martine Stonehouse and others launched a Human Rights complaint against the Provincial government to re-list SRS and protect the health care system from further erosion of critical services. In December 2002, the Ontario Human Rights Commission referred the complaint to the Human Rights Tribunal and on September 23, 2003 the four complainants and the Commission began a Tribunal hearing against the Ministry of Health.

Upon election of a new Provincial government on October 2, 2003 the newly appointed Minister of Health and the Attorney General began negotiations with the complainants. Prior to an agreed upon settlement which included the re-listing of SRS, the Premier’s office announced that SRS was not a priority and would not be re-listed. Consequently, the Tribunal hearings restart on Monday, October 4, 2004 and will continue until the New Year.

SRS Health Coverage across Canada

British Columbia
In British Columbia, the Hospital Insurance Act covered gender (sex) reassignment surgery until July 1988 when this procedure was delisted from coverage. On June 30, 1993 this exclusion was repealed because gender reassignment surgery was considered a medically necessary service.

A 2003 British Columbia Human Rights Tribunal ruled that female to male sex change surgery performed in the United States should be covered by provincial health insurance (Waters v. BC Medical Services Plan, 2003).

Alberta

The Alberta Health Care Insurance Plan (AHCIP) covers SRS and a variety of related procedures including chest reconstruction and breast augmentation.

SRS is performed in a Montreal clinic while Alberta physicians perform the other procedures.

Saskatchewan

The Saskatchewan Physician’s Payment Schedule Manual covers in-province procedures such as chest reconstruction, hysterectomy, and breast augmentation. There is no coverage for electrolysis.
SRS is not completed in-province and requires special approval by a departmental committee of Saskatchewan Health. Coverage for male to female SRS is completed in Montreal at Saskatchewan rates, which are approximately 1/3 of Montreal clinic’s fees.
To qualify for SRS and related procedures, patients must be recommended by the GIC program in Toronto.

Manitoba

Manitoba Health insures SRS and a variety of related medical procedures including chest reconstruction, hysterectomy, and electrolysis. No coverage exists for breast augmentation.

Male to female SRS is covered at the Montreal clinic. There is no coverage for the facility portion of fees because it is a private clinic. There may be a transportation subsidy for out-of-province travel.
Patients must be recommended by the Gender Identity Clinic in Toronto.

Quebec

Régie de l’assurance maladie du Québec (RAMQ) theoretically provides coverage for SRS and related procedures including chest reconstruction, breast augmentation, hysterectomy and electrolysis.

However, Quebec only reimburses for the surgery if it is performed in a recognized hospital in Quebec, and the only place it is actually performed is in a private clinic in Montreal. Thus, in practice, no surgeries are paid for in Quebec.
To be eligible for coverage, patients must be recommended by the Hôtel-Dieu de Montréal or at the Montreal General Hospital, and by a psychiatrist practising at one of those two hospital centres.

Newfoundland and Labrador

Provincial health insurance coverage information regarding SRS is not available. Egale is advised that in most Atlantic provinces, there is no formal policy recognizing the coverage, but in practice SRS is paid for on a case-by-case basis.

New Brunswick

Nova Scotia

Prince Edward Island

Yukon

Provincial health insurance coverage information regarding SRS is not available.

Nunavut

Provincial health insurance coverage information regarding SRS is not available.

Northwest Territories

Provincial health insurance coverage information regarding SRS is not available.
International SRS Health Coverage
In surveys conducted by the Gender Identity Clinic, most countries with socialized health care plans cover SRS. This is the case

AROUND THE WORLD.
Support
In addition to Egale, the following organisations support public funding for SRS:
Canadian Federation of Students – Ontario (CFS-O)
Canadian Union of Public Employees – Ontario (CUPE-Ontario)
Centre for Addiction and Mental Health
Rainbow Health Network, a Reference Group of the Coalition for Lesbian and Gay Rights in Ontario (CLGRO)
Ontario Public Health Association (OPHA)
Salaam Toronto Queer Muslim Community
Political Support:
Marilyn Churley, deputy leader of the Ontario New Democratic Party (NDP)
supports re-listing of SRS and electrolysis and will be taking the lead for the NDP on this issue
Counsellor Kyle Rae, City of Toronto
Some Liberal Members of Provincial Parliament have indicated their support for funding of SRS.
Links for Further Information
Trans Alliance Society
http://www.transalliancesociety.org/index.html
Educational Resources
http://www.transalliancesociety.org/education/publications.html
Trans Health Project Position Paper – Ontario Public Health Association
http://www.opha.on.ca/ppres/2003-06_pp.pdf
Trans Legislative Needs Assessment – Egale Canada
https://egale.ca/index.asp?lang=E&menu=34&item=998
Trans Programmes – 519 Church Street Community Centre
http://www.the519.org/programs/trans/index.shtml
Sources
Benjamin, Harry. The Transsexual Phenomenon. New York: Warner Books, 1966.
Blanchard, Ray, and J. Paul Fedoroff. “The Case For and Against Publicly Funded Transsexual Surgery” in Psychiatry Rounds, Department of Psychiatry, University of Toronto and Centre for Addiction and Mental Health, April 2000: v 2. 2.
The International Journal of Transgenderism, v. 5, 1, January – March 2001, Harry Benjamin International Gender Dysphoria Association’s – The Standards of Care for Gender Identity Disorders – Sixth Version, I. Introductory Concepts.
Namaste, Vivianne. Invisible Lives: The Erasure of Transsexual and Transgendered People. Chicago: University of Chicago Press, 2000.
Ontario Legislature, Bill 13, An Act to amend the Vital Statistics Act. 1983.
Ontario Legislative Library, Bulletin Number 4243.
Ontario Legislative Library, Bulletin Number 4330.
Policy on Discrimination and Harassment because of Gender Identity. Ontario Human Rights Commission, http://www.ohrc.on.ca/english/publications/gender-identity-policy.pdf.
Stryker, Susan, “Transsexuality: The Postmodern Body and/as Technology” in
The Cyber Cultures Reader, 1st ed. Eds. Bell, David and Barbara Kennedy. Routledge: 2000: 588-97.
Gapka, Susan and Rupert Raj. Trans Health Project Position Paper. Ontario Public Health Association. November 2003. http://www.opha.on.ca/ppres/2003-06_pp.pdf.
Goldberg, Joshua. Coverage of Sex Reassignment Surgery (SRS) Across Canada as of January 23, 2004. Unpublished.
Waters v. BC Medical Services Plan,
http://www.bchrt.bc.ca/down/decisions_2003/ waters_v_bc_medical_services_plan_2003_bchrt_13.pdf.