gender reassignment canada cost

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Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

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Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

• be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
• have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
• have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

• one of the assessments must be from a doctor or nurse practitioner
• you have a diagnosis of persistent gender dysphoria
• have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
• you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

• have a diagnosis of persistent gender dysphoria
• have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

• find out about their ongoing project, Trans Health Connection
• consult their service directory
• find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

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Canada Finally Has Nation-Wide Funding For Gender-Affirming Surgeries

With last week’s announcement from the Government of Nunavut confirming that the territory will pay for mental health services and transition treatments for transgender and non-binary residents, Canada will now have nation-wide funding available for gender-affirming surgeries. Nunavut’s Health Department is partnering with GrS Montréal to provide the surgeries.

Health care in Canada is delivered by the provinces and territories and funding for gender-affirming surgeries varies depending on where a person lives. This patchwork of coverage has resulted in barriers to accessing care that have disproportionately affected people living in Canada’s territories in the North, which includes Yukon, Northwest Territories and Nunavut. While expansion of surgery funding in Canadian provinces has continually progressed over the last decade, comprehensive coverage has only been established in the territories over the past three years.

Nation-wide coverage is obviously a very positive development but advocacy is still needed to continue the work of dismantling barriers for Canadians to access surgical care. Current challenges include:

Getting coverage across the country for Facial Feminization , Breast Augmentation and Male Chest Contouring , procedures that are excluded from funding policies in some jurisdictions.

Surgeons who practice gender-affirming genital surgery are only located in Montreal, Toronto and Vancouver. This means that many transgender and non-binary Canadians need to travel great distances to access surgeons for primary surgeries, follow-ups and specialized care for complications, incurring significant expenses that aren’t universally covered or subsidized.

Wait times are a problem that is not unique to gender-affirming surgical care in Canada but with few experts performing these surgeries patients can wait up to three years just for a consultation with a surgeon.

With the Government of Nunavut’s funding commitment, the goal of nation-wide coverage for gender-affirming surgery in Canada has been achieved. Improvements to provincial and territorial funding policies are still needed but this is a milestone to be celebrated.

Review Funding Policies by Province and Territory:

• British Columbia
• New Brunswick
• Newfoundland and Labrador
• Nova Scotia
• Ontario – PDF
• Prince Edward Island
• Saskatchewan – PDF
• Northwest Territories – PDF
• Nunavut – News article: GN transgender, non-binary health services a positive step
• Yukon – News article: Yukon’s new gender-affirming care policy is most comprehensive in Canada

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How much does male to female (MTF) surgery cost in 2024?

Explore the interactive cost guide below for detailed pricing information on a range of MTF surgeries and compare costs in different countries.

• Transgender Surgery

Did you know? 

In 2024 , there is a high demand for gender-affirming surgeries. Recent data shows a 25% increase in interest in MTF surgery, highlighting the changing landscape of accessible and affordable care.

Sex reassignment surgery is a procedure enabling individuals to transition to their self-identified gender, typically involving hormone therapy. Male-to-female (MTF) reassignment surgery includes 'top' and 'bottom' surgeries, as well as facial feminization. In some places, like India, it's on the rise due to affordable costs, with an average MTF surgery cost of $2438 to $6095 .

Looking to gather information about the costs associated with personalized treatments from a t op plastic surgeon ? Don't hesitate.

You might be wondering why hormone therapy is necessary in male-to-female surgery. Read on to discover all the details.

In hormone therapy, female hormones like estrogen and progesterone are injected into male bodies to foster a more feminine appearance. Anti-androgens are incorporated due to higher male androgen production. Male-to-female transgender hormone therapy costs approximately $30 per month, with therapist visits averaging around $100 .

Let's read ahead to what male-to-female gender reassignment surgery costs.  

What does MTF top surgery cost?

Breast augmentation and implant surgery are the initial steps in the male-to-female gender reassignment process. Through this transformative procedure, one can effortlessly obtain the desired breast size. This method encompasses both the insertion and placement of implants, ensuring a comprehensive augmentation. The cost for this procedure may fluctuate depending on the chosen hospital and surgeon.

The MTF Breast augmentation surgery cost is given below:  

What is the male-to-female (MtF) bottom surgery cost?

The cost of male-to-female (MtF) bottom surgery, a vital step in the journey of gender affirmation, can vary depending on several factors. These factors may include the specific type of surgery chosen, the geographic location of the surgical facility, and individual healthcare providers' fees. 

Here, we provide an overview of the estimated costs for common MtF bottom surgeries:

What is included in facial feminization surgery, and what is its cost?

Facial Feminization Surgery (FFS) is a transformative cosmetic procedure that aims to soften and reshape male facial characteristics into more feminine features. This comprehensive surgery involves a series of procedures, including lip and cheekbone augmentation, hairline adjustment to reduce forehead size, and sculpting of the jaw and chin. The goal is to harmonize and enhance facial traits for a more feminine appearance.

The total Male to male-to-female feminization surgery cost may go up from $9,000 to $12,000. 

Do you know Robotic surgery is an effective alternative to traditional penile inversion and Vaginoplasty in transgender cases. It utilizes small tools on a robotic arm, marking a revolutionary advancement in surgery.

Take charge of your health and your life.  Contact us today!

If you're curious about the expenses of male-to-female sex reassignment surgery across various countries, let's explore further. Keep reading to find out more.

Factors affecting the cost of male-to-female surgery

The number of surgical procedures performed for gender reassignment is on the rise. With the surge in cases, the male-to-female surgery cost is also becoming more affordable and nominal in Asian countries compared to other nations. However, a few factors still affect the total cost of surgery.

• Lack of insurance coverage from major companies
• Pre and post-operative charges
• Pre-operative counselling charges (if required)
• Hormonal Therapy charges
• Hospital charges
• Doctor’s fee for all the different treatments
• Higher costs or prices for cosmetic surgery procedures such as facial feminization surgery.

Your well-being is our priority -   call us to book your appointment today

Insurance and Financing for MTF Surgeries 

Insurance and Financing for MTF Surgeries Gender-affirming surgeries, such as those involved in male-to-female (MTF) transitions, often come with associated costs. Understanding your insurance coverage and financing options can greatly aid in managing these expenses.

• Insurance Coverage: Review your policy for coverage of gender-affirming surgeries.
• Medicaid and Medicare: Some states offer coverage through these programs.
• Out-of-Pocket Costs: Plan for co-payments, deductibles, and uncovered services.
• Financing Options: Explore personal loans, medical financing, and crowdfunding.
• Consultation with Experts: Seek guidance from experienced healthcare providers.

1.) How long does a male-to-female transition take? Some transitions may take less than a month, and some can even take years. It mostly depends on the mental and physical health of the person and what kind of treatment you are involved in.

2.) How long does it take to grow breasts on estrogen?

The estimated time to grow breasts through estrogen is 2 to 6 months. It also depends on factors like fatty tissue levels, body genetics, etc.

3.) How long does it take to recover from male-to-female surgery?

It takes an average of 2 to 8 weeks to recover from male-to-female transition surgery. However, penectomy and vaginoplasty are major surgeries that need more care and usually take longer to recover.

4.) Can I undergo MTF transition without surgery?

Yes, many individuals choose to undergo MTF hormone therapy and other non-surgical procedures to achieve their desired gender expression without surgery. It's essential to discuss your options with a healthcare provider.

5.) What is the typical duration of hormone therapy for MTF transition?

The duration of hormone therapy varies from person to person. Typically, individuals undergo hormone therapy for an extended period, often lifelong, to maintain their desired physical and emotional changes. Your healthcare provider can provide more personalized guidance.

Health Tips, Health Care and Fitness Tips, Health News | TheHealthSite.com

National Center for Biotechnology Information (nih.gov)

https://my.clevelandclinic.org/health/treatments/21526-gender-affirmation-confirmation-or-sex-reassignment-surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994261/

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Question and Answers

48 yaşında bir erkeğim trans birey olarak kadın olmak istiyorum hormon tedavisi istiyorum. hangi ilaçlardan başlamalıyım.

For someone who is 48 years old and seeking to transition from male to female, it's important to consult with an endocrinologist before starting any hormone therapy. They will guide you on the appropriate medications and dosages based on your specific needs. 

Answered on 2nd Aug '24

Dr. Vinod Vij

if I have top surgery without T can I develop pecs if I hit the gym a lot?

If you don't take testosterone or undergo top surgery, you can still build your pecs by lifting weights. Pecs, short for pectoral muscles, can grow with exercises like chest presses and push-ups, which target these muscles. Pace yourself, use the correct form, and be consistent with your workouts. Your pecs can still develop even without testosterone.

Answered on 29th July '24

I'm male and would like to know how to grow breasts without HRT?

Hormones and surgery are the only ways of growing breasts safely. The appearance of women's breasts in some regions is partly dependent on hormones during puberty and pregnancy. Trying to get a larger breast by force can cause some serious medical issues. If you are worried about your body, it's important to talk to a plastic surgeon for safe and honest guidance.

Answered on 22nd Aug '24

I am a 32 years old male who has got into cross dressing some 8 years back, now my urge of being like this has grown, last two years I have been I’m eating dian35 prescribed by a doctor in Malaysia, but now I believe I shall be needing more strong dose since the transformation is already 2 years and can see few changes

It seems like you may be going through some changes about turning into the opposite sex. Understand that these changes are complicated and might need some medical interventions. You might require different amounts of hormones to help you through the process. Talk about what is bothering you and your symptoms with a doctor who can help you figure out the best way forward.

Answered on 18th July '24

Namaste , I am a transgender and I am feeling desperate about my facial hair and tried many ways to reduce facial hair but my hairs are growing continuously. I want to know solution

For transgender individuals, hormone therapy can often help reduce facial hair growth. It's important to consult with an endocrinologist , who specializes in hormone-related conditions, for personalized advice and treatment options. They can guide you on the best course of action tailored to your needs.

Answered on 10th July '24

Transgender Surgery Hospitals In Other Cities

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New gender-affirming surgery clinic now accepting patients

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Plastic Surgeon Dr. Nicholas Cormier has dedicated nearly his entire career to caring for trans and non-binary patients.

The Ottawa Hospital understands that trans and non-binary people often face barriers accessing gender-affirming care. Faced with long wait times or even lack of access in the communities where they live, they may struggle to achieve their gender-affirming goals.

We are very pleased to announce that The Ottawa Hospital’s new gender-affirming surgery clinic is here to help. Launched in September 2023, it is the only clinic in Ontario and the second in Canada to offer all three of the following gender-affirming procedures:

• Facial surgery to make facial features more masculine or feminine
• Top surgery to remove breast tissue for a more masculine appearance or enhance breast size for a more feminine appearance
• Bottom surgery to transform the genitalia

The clinic’s lead and co-founder, Plastic Surgeon Dr. Nicholas Cormier, has some more wonderful news to share: “We’re currently accepting patient referrals from physicians,” he announces with a smile. “We’re ready to service Ottawa and the surrounding communities.” 

A truly collaborative effort

Before our clinic, patients seeking gender-affirming surgery in Ottawa could only access top surgery but not bottom or facial. Previously, a clinic in Montreal was the only location in Canada offering all three procedures.

“There’s just a massive gap in our health-care system for the treatment of the transgender population and people seeking gender-affirming care,” says Dr. Cormier. “What’s so groundbreaking about this new clinic is that everyone is coming together to address this shortcoming in our system.”

These partners include different surgical divisions at the hospital—plastic surgery, urology, obstetrics and gynecology—as well as trans health programs out in the community, such as the Centretown Community Health Centre’s Trans Health Program , which provides patients with a referral to our clinic, and CHEO’s Gender Diversity Clinic , which provided Dr. Cormier and his team with advice on setting up the clinic and also refers patients who have reached the age of 18.

These community programs are also important for the overall health and wellbeing of Ottawa’s trans and non-binary population. “Accessing gender-affirming surgery is just one small component of gender-affirming care,” says Dr. Cormier. “That’s where these community partners really come into play.”

Years in the making

For Dr. Cormier, the clinic is the culmination of many years of caring for the gender-diverse community.

“In my residency, I was always interested in gender-affirming care, and that led me to seek out a fellowship in San Francisco, where I was able to train with world-renowned experts in gender-affirming care,” he recalls. “And I’m really excited about bringing that to my hometown of Ottawa.”

And Ottawa’s gender-diverse community is (literally) in good hands, says Dr. Daniel Peters, Division Head of Plastic Surgery at The Ottawa Hospital. “Dr. Cormier has dedicated nearly his entire career to caring for this often underserved patient population. He has learned from the best of the best in this field and has the compassion to match his expertise. He joined The Ottawa Hospital’s Division of Plastic Surgery not long ago, and yet he has already shown tremendous leadership by getting this clinic up and running. That’s really a testament to his passion for helping people on their gender-affirmation journeys.”

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This website gives you common facts, advice and tips. Some of it may not apply to you. Please talk to your doctor, nurse or other health-care team member to see if this information will work for you. They can also answer your questions and concerns.

Frequently asked questions

• Do I have to have genital reconstructive surgery before changing my gender status on my legal documents?
• Will my surgery be reimbursed by my province’s health insurance?
• From what age can I have gender affirming surgery?
• What documents do I need to provide if I want to have surgery?
• I am intersexed and would like to undergo gender reassignment surgery. What documents do I need to provide?
• My file is complete; I am following WPATH’s Standards of Care and I have provided all of the documents requested by my surgeon. How long will I have to wait to be given a surgery date?
• How long before surgery do I have to provide my lab results?
• What are the possible complications involved with my surgical procedure?
• Will I lose the ability to achieve orgasm after surgery?
• I don’t speak French. Do the physicians and staff at GrS Montréal speak English?
• Will I have an opportunity to speak with the GrS Montréal team before my surgery?
• My blood is infected with HIV. Can I still have surgery?
• If I have an STI, can I still have surgery?
• Can I contract or transmit an STI even if I have undergone genital reconstructive surgery?
• Can I be operated on if I am overweight?
• Can I undergo surgery if I take drugs?
• How long before and after surgery do I have to stop consuming alcohol and stop smoking?
• Should I stop taking my hormones before surgery?
• Will the dosage of my hormones need to be adjusted after surgery?
• How do I prepare for surgery?
• How do I plan my transportation to and from my procedure?
• I am afraid to experience pain after my surgery. Will I be given medication?
• Why do I need to stay for a few days at the Asclépiade convalescent home after my surgery?
• If my recovery is difficult, can I get psychological support at your hospital?
• I would like to undergo surgery at GrS Montréal. Should I be accompanied during my stay?
• What are the rules regarding visitors?
• Will I have access to entertainment during my stay?
• Will I require the aid of a nurse after my surgery?
• Once I am back home after surgery, what should I do if I need help?
• Can I drive my car after surgery?
• How long will my convalescence last after surgery and when can I return to work?
• When can I start to swim again after my surgical procedure?

No, if you are a resident of Quebec, it is no longer mandatory to have genital reconstruction surgery in order to change your gender status in legal documents.

For more information, visit the Directeur de l’état civil’s website: https://www.etatcivil.gouv.qc.ca/en/change-sexe.html

If you are not a Quebec resident, you can find information in the Being Trans section of our website or from your provincial or state government.

*If necessary, we will provide you with the official documents (affidavit) required to support your efforts.

Most Canadian provinces cover the cost of gender reassignment surgery. However, feminizing surgeries considered cosmetic, such as breast augmentation , voice surgery , Adam’s Apple reduction , and facial feminization , are not currently covered by all health insurance programs. Each Canadian province has its own reimbursement program. You can find information specific to your province in the Being Trans section of our website or of your provincial government.   

If you are a U.S. citizen or from elsewhere in the world, check with the health department of your state or provincial government and/or your own insurance company.

*Some health insurance programs cover certain fees associated with your surgery while others do not.

According to WPATH 's Standards of Care, an individual must be of the age of majority in the country of reference (Canada) to be allowed to undergo gender reassignment surgery. Therefore, the required age for genital reconstructive surgery is 18 years of age and 16 for masculinization of the torso surgery (mastectomy).  

The documents required are linked to the type of surgery you are interested in undergoing. The basic required documents are those that allow surgeons to confirm that you have met WPATH’s Standards of Care. Additional documents, like proof of good health from your doctor, will be requested to ensure safe surgical proceedings.

Consult the WPATH document  for more information.

The documents required are the same set out by WPATH’s Standards of Care . GrS Montréal surgeons may ask you for additional documentation and/or test results in order to ensure safe surgical proceedings. 

Once your preoperative medical file has been confirmed, a GrS Montréal staff member will contact you to provide you with a preliminary surgery date, taking into account your own availability and that of the operating room.

Although you will have been assigned a date, you must send us the required lab results by the deadline you will be provided with. Once the results of these tests have been validated, your surgery date will be confirmed.   

GrS Montreal must have received these results at least 2 months before the surgery otherwise it could be postponed.

It is important to keep in mind that complications rarely occur. Generally, minor problems are the most common. Complications may make recovery time longer, but they do not necessarily affect final results.

While risk is involved in all surgeries, GrS Montréal physicians work continually to prevent them through the development and maintenance of safe surgical practices. Additionally, pre and postoperative treatment and follow-up plans allow for early detection and management of complications that may arise. In the case of complications, our doctors will provide you with all of the necessary information to help you eliminate all problems as quickly as possible. 

Risks and complications are not directly related to the scale of the surgical procedure involved and are sometimes difficult to prevent despite precautions taken. Severe allergic reactions to medication, cardiac arrhythmia, hypertension, hemorrhage, embolism, the reopening of wounds or slow healing, injuries to other parts of the body, loss of feeling, bruising and swelling, wide and thick scars, and unsatisfactory outcomes are common complications in all surgeries. You will be provided with all details related to the complications specific to your surgery.      

The majority of patients retain their ability to achieve orgasm after surgery, but there is still a risk that sexual function or the ability to have an orgasm will be affected. GrS Montréal surgeons are very experienced and use techniques that allow the patient to retain her or his sensations of sexual pleasure. Your health history (smoking, diet, alcohol, etc.) can also affect healing and, in this way, alter the sensitivity of your genitals.

Our staff speaks French and English. We are also able to provide you with documents concerning your surgical procedure in these two languages.

If you do not speak French or English, it is still possible to have surgery at the CMC. In the past, we have accompanied deaf and mute patients, as well as patients whose mother tongue is neither French nor English. From the beginning of the preoperative period, we will accompany you in the process to obtain an interpreter or translator.  

You can contact us at any time in order to communicate confidentially with a member of the GrS Montréal team. Once your file is complete, a member of the nursing staff in the preoperative clinic will contact you. 

Yes, it is possible to have surgery as HIV is not a contraindication to surgery. However, it is important to mention your infection to us and to provide us with the results of your viral load when you want to plan your surgery. Your viral load lab results must be labelled “undetectable”. Antivirals are the only way to achieve this label.   

Yes, surgery is possible even if you have contracted an STI in the past. However, if you currently have an STI, it is recommended you be healed before having surgery. Your symptoms must be treated. if a fever is present, surgery will be postponed.  

After surgery, you remain at risk of contracting or transmitting infections transmitted sexually and by blood. Consult your family doctor for information about available protection.

Resources:  https://www.sexandu.ca/

Your weight and diet can significantly influence your healing, the results of your surgery, your ability to take care of yourself. It is preferable to have attained a healthy weight by the time of your surgery (a BMI between 18.5 and 25). If your BMI is below or above the normal range, your situation will be assessed and you will be informed of your possibilities for surgery. GrS Montréal can direct you to resources that can help you achieve your weight loss or weight gain goals.

  Calculate your BMI

Access to our establishment is forbidden to anyone with drugs or alcohol in their possession, or are under the influence of these substances.

Drug use can affect patient safety during surgery. All drug use should be reported to us during the planning stages of your surgery. Your surgeon and anesthesiologist must have this information to ensure the surgery is safe for you.

Alcohol: You must avoid drinking alcohol during the 2 weeks before surgery. Mixing alcohol and medications can cause unpredictable and undesired reactions.

Tobacco and nicotine substitutes:  We highly recommend you stop smoking or using nicotine substitutes during the 6 weeks before and after the procedure, with the exception of phalloplasty surgery, for which you must stop smoking 6 months before and after the procedure in order to optimize the vascularization of the graft of the phallus as well as nerve regeneration. Toxic substances found in tobacco can:

• Tighten small blood vessels and thus negatively affect the results of your surgery and the healing of your wounds;
• Cause nausea upon waking up, vomiting, and excessive coughing, which increase the risk of bleeding after surgery;
• Resource https://defitabac.qc.ca/en

According to the law to provide a healthy environment, it is strictly prohibited to smoke on the premises, with the exception of specifically designated smoking areas. These areas are located at least nine (9) meters from all of the facility’s doors. Violating this rule can make you subject to fines ranging from $250 to $750 for a first infraction and from $500 to $1500 for a recurrence. Cigarette butts must be disposed of in designated metal containers.

Three (3) weeks before surgery, you should stop taking feminizing hormones such as estrogen, progesterone, as well as cyproterone acetate (Androcur®). You can continue taking your anti-androgens (Finasteride®, Spironolactone®).

Masculinizing hormones such as testosterone: you will need to continue taking these according to your usual schedule.

If you are taking feminizing hormones and antiandrogen drugs , make an appointment with your prescribing physician 2 months after a genital reconstructive surgery such as vaginoplasty , vaginoplasty without vaginal cavity , and orchiectomy .

If you are taking masculinizing hormones , you do not need to make a follow-up appointment.

Once your surgery date has been confirmed, we will provide you with documentation containing all the details required to be well-prepares for your surgical procedure and your stay. 

If you are traveling by train or airplane, a transportation service is available at no additional cost. If you are not hospitalized (day surgery), you must be accompanied at the time of departure.

*If it is impossible for you to be accompanied, please let us know as early as possible so that we may put necessary resources in place.

If you are hospitalized, you must leave your room by 8:00 am on the day of your departure so that we can make it available to the next patient. For this reason, we ask that you plan your flight or train departure for the morning. If you are not hospitalized (day surgery), the nurse will tell you when you can leave the facility.

The majority of patients experience pain after surgery. Its intensity varies from one person to another and the experience of pain is unique to each person. To relieve pain, surgeons prescribe a daily medication such as an anti-inflammatory and a non-opioid analgesic. If your pain persists, take a narcotic analgesic in addition to your regular medication. We cannot predict how long the pain will last, but it should decrease in intensity as your healing progresses.

Depending on the type of surgery, your surgeon will, when needed, renew your narcotic analgesic prescription during your medical leave. Should you require more medication, make an appointment with your family doctor.  

Your stay at Asclépiade is necessary because you will receive the majority of your care and postoperative treatments there. Your convalescence allows you to recover under 24-hour a day surveillance by the nursing staff. If complications arise, your surgeon will immediately take charge of you. Finally, the nursing staff will also teach you all that you will need to know to continue your care yourself when you return home. 

The nurses at the CMC and Asclépiade can provide frontline psychological support and decide with you if additional support is necessary. We do not have any mental health professionals in place in our facility. It is therefore important to maintain contact with health professionals involved with your care and bring their contact information with you.

We highly recommend that you be accompanied by a family member or friend during your stay to support and comfort you during this unique event. Our staff will work with you and your companion to create the most positive experience possible. In addition, the presence of a companion during teaching periods can facilitate the understanding and integration of care into your daily routine. 

At the CMC:

Visiting hours are Monday to Friday from 9 :00 am to 8 :00 pm;

In order to ensure the rest, comfort, and tranquility of all of our clients, we ask you to limit your visitors to 2, 1 visitor at a time in the room. Young children are not allowed to visit;

Visitors are not authorized to enter the operating or recovery rooms;

In order to prevent infections, visitors are not allowed to sit on patients’ beds;

In order to avoid interference with medical equipment, cellphone use is prohibited between 6:00 am and 5:00 pm. Outside of these hours, we ask that you put your device on vibrate, speak quietly, and avoid long conversations.

At Asclépiade:

• Visiting hours are Monday to Sunday from 2:00 pm to 8:00 pm;
• In order to respect the privacy of patients and to prevent infections, visitors are prohibited from entering the rooms;
• Cellphones are permitted at all times but we ask that you put your device on vibrate, speak quietly, and avoid long conversations.

Yes, each room has its own television, and wireless internet service is offered for free. In order to respect the other patients in convalescence, we ask that you bring a pair of earphones with you for your own personal use.

If you wish, you may bring music, your laptop, books, or other forms of entertainment.

Usually, no. All patients who undergo surgery receive a personalized follow-up service by email or telephone to ensure that their recovery, as well as the management of their health, is going well. You will also receive educational guides for your reference at home.

If nursing care at home is required, the Nurse Navigator can make the request for you or communicate with your treating physician about how to ensure the continuity of your care. The GrS Montreal team is always available to work with the health professionals involved in order to facilitate the management of your care.

Once you are back at home, you can communicate with your surgeons through the nurse at Asclépiade.

In case of medical emergency, you must go to the emergency room of your nearest hospital or call the emergency telephone number in your area. The emergency doctor can communicate with your surgeon through Asclépiade so that you can be cared for properly and effectively. The GrS Montreal team is ready to work in tandem with other health professionals involved in your medical care.

For genital surgeries and surgeries of the torso, we recommend that you wait 2 weeks before driving a motor vehicle. After surgery of the torso, you must be able to perform unpredictable arm movements in an unconstrained manner. For genital surgeries, you must avoid placing too much pressure on your genitals, which may cause pain. Once you resume driving, begin with short distances. If you must drive a long distance, make frequent stops to walk a little and to urinate. Walking and emptying your bladder reduces pressure on the genitals.

It is prohibited to drive a motor vehicle after surgery if you are taking narcotic analgesics. 

For more information about the recovery time involved in each surgery, visit the Surgeries section of our website. Your surgeon can provide you with a sick leave letter for your employer and your insurance company.

*Please note that recovery time depends on the progress of your healing and the type of work that you do. Estimated convalescence times are for informational purposes only. 

You can resume swimming when your wounds related to your procedure are completely healed. Normally, it is necessary to plan for a complete healing time of about 4 to 6 weeks.

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

Ontario boosts access for trans people seeking gender confirmation surgery

People left waiting 2 years to get surgical referral from camh gender identity clinic.

Social Sharing

There are potentially more than 800 health-care professionals across the province who can now assess patients for sex-reassignment surgery, a change Ontario adopted March 1 to trim the more than two-year wait list for referral.

• Ontario expands referrals for sex-reassignment surgery
• Why transgender people can't get surgery approval in Thunder Bay

Until last week, transgender people hoping to undergo sex-reassignment  — also known as gender confirmation surgery — could only get a referral through the adult Gender Identity Clinic at Toronto's Centre for Addiction and Mental Health.

And that wait list for referral has stretched to more than 1,500, the psychiatrist who heads up the clinic said.

"The model of having only one clinic for all of Ontario might have worked when only a small number of seeking these services, but now there are far more," Dr. Chris McIntosh said. "We really feel like this is a great step forward in terms of increasing access."

The province announced the change to the referral process in November, which will see a wide range of health-care practitioners able to refer patients once they are trained in the assessment criteria created by World Professional Association for Transgender Health.

No surgical options in Ontario

Rainbow Health Ontario has already taken more than 800 health professionals through the training, which includes information about surgical and hormone options, how to help someone prepare for a procedure and the necessary support a patient will need after an operation. The majority of those trained so far have been mental health professionals, according to a spokesperson for Rainbow Health.

Donna Turner said the group is still waiting to learn exactly how clinicians who have taken that training can ensure their patients are included in the pipeline for insured candidates receiving gender confirmation surgery in Montreal.

Right now there are no surgical options in Ontario, although Health Minister Eric Hoskins said the expansion of the referral program includes a promise of $2 million, some of which will go toward supporting a program for chest surgery that could run out of Women's College Hospital. A spokesman for the ministry could not say when such a program might begin.

Dr. McIntosh acknowledged that the expansion of the referral service could mean "the bottleneck stops being at CAMH and starts happening in Montreal," but both he and Turner said the Quebec clinic has indicated it can take on more patients.

Rainbow Health and CAMH both expect to help with continued training for surgical referral, McIntosh and Turner said. Some of the provincial funding has already been earmarked to hire more staff at CAMH to clear the backlog of those waiting — and so practitioners there can begin training others, according to a statement from the health ministry.

In an announcing plans to expand the referral system, the health minister said last fall that an increasing number of Ontarians are experiencing gender dysphoria, defined as the distress caused by a conflict between a person's gender identity and their assigned sex at birth.

"One of the most vulnerable times for trans people is when they are ready for surgery, but face a prolonged wait," Hoskins said in November. "This change would reduce wait times by allowing many trans clients to get surgical approvals from their own local primary care teams.

Getting family doctors involved

McIntosh said that's a huge advantage to the expansion. A patient's own doctor — who understands their history — can now be part of a critical medical decision, the psychiatrist said.

Those on the waiting list, however, should not cancel their appointments at CAMH, McIntosh said, until they are certain they can see another physician or nurse practitioner who has the appropriate training to make a referral.

Two referrals are still needed for people seeking genital surgery, while only one is necessary for chest surgery. 

If two referrals are needed, one can be performed by a nurse, a social worker with a masters degree or a psychologist. But a physician or a nurse practitioner must be always involved in at least one referral for surgery, according to the guidelines.

"This provides flexibility that the person's own care provider — that's known the person for a long time … can contribute to the decision of assessing someone's readiness for surgery," McIntosh said. 

Clarifications

• A previous version of the story indicated that nurses, social workers, and psychologists could provide a referral for chest surgery. In fact, only a physician or a nurse practitioner can, while qualified mental health professionals can provide a second referral for genital surgery. Mar 07, 2016 12:24 AM ET

Related Stories

• Ontario expands referrals for gender reassignment surgery
• Audio Why transgender people can't get surgery approval in Thunder Bay

Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

Home » GET INFORMED » Talk Rights » Frequently Asked Questions Regarding Change of Sex Designation For Trans Persons

May 19, 2015

Like all content on this website, this document is not legal advice and is provided solely for the purpose of public information and education. If you are facing a legal issue or have a question about your specific situation, you should consider seeking independent legal advice. You can find a list of legal clinics and other resources to help you here.

The CCLA is a national organization that works to protect and promote fundamental human rights and civil liberties. To fulfill this mandate, the CCLA focuses on litigation, law reform, advocacy and public education. Our organization is not a legal clinic. As such, we are typically not in a position to provide members of the public with legal advice or direct legal representation. However, we do try to provide general legal information and appropriate referrals where possible. For questions about this document, email publicenquiries [at] ccla [dot] org.

How can Trans Persons Change the Sex Designation on their Birth Certificate?

This guide is focused on issues relating to how trans persons can change the sex designation on their birth certificates. For information on how trans persons can legally change the name used on their identification documents,  see this guide .

This page is intended to help trans persons with issues related to changing the sex designation on their birth certificates. As such, some of this information may not be helpful to those seeking to change their birth certificates for another reason.

Note: Every effort has been made to ensure comprehensiveness and accuracy (as of May 2015). However, this FAQ may not fully reflect the current state of the law.

We use the term “trans” to include anyone who does not identify with the sex designation they were assigned at birth.

Questions addressed in this FAQ:

Why might I want to change the sex designation on my birth certificate?

Should i have to have surgery in order to change the sex designation on my birth certificate, are sex designations on birth certificates even necessary, how can i change the sex designation on my birth certificate, where do i apply to change the sex designation on my birth certificate, what proof do i need to show in order to change the sex designation on my birth certificate do i need to show proof of surgery, can i apply if i am younger than 18 or 19, can i apply even if i was born outside of my current province/territory.

You can download a PDF of this document here:  CCLA Change of Sex Designation FAQ .

Many trans persons consider the sex they were assigned at birth to be inaccurate. If this is you, changing the sex designation on your birth certificate may be important for your well-being. It is also important for legal reasons as well.

In order to enjoy a greater degree of safety and freedom from discrimination, you may want to have identification documents that match the gender with which you identify and present yourself. The information on most identification documents is drawn from birth certificates, so changing your birth certificate is often a necessary first step. “Sex” is a category on most driver’s licenses, passports and health cards, and so you may find yourself being forced to discuss your gender identity – sometimes even your genitals – with a stranger. This is even worse when that stranger is empowered to make decisions that greatly affect you, such as whether to write you a traffic ticket, offer you a job, refer you for medical treatment, or let you enter the country.

Trans persons face widespread discrimination and high rates of violence. Of trans Ontarians  surveyed  by the Trans PULSE Project, 26% reported being hit or beaten up because they were trans, 73% reported being made fun of, and 39% reported being turned down for a job. In 2010, Trans PULSE  estimated  that 50% of trans Ontarians had seriously considered suicide at some point in their lives because of the discrimination they faced. Involuntary outing on a regular basis, such as by having an inaccurate gender specified on your identification documents, eliminates one of the few mechanisms you may have to protect yourself from transphobia.

In 2014, a judge in Alberta considered the constitutionality of the provincial law that regulated gender markers on birth certificates. The judge  struck down  that law, because it was contrary to the  Canadian Charter of Rights and Freedoms . In doing so, the judge cited a  prior decision  of the Ontario Human Rights Tribunal. That decision detailed some of the discrimination faced by trans persons (referred to here as “transgendered” [sic]):

“[T]ransgendered persons as a group tend to face very high rates of verbal harassment and physical assault and are sometimes even murdered because of their transgendered status. […] [I]t is very difficult for a transgendered person to find employment, […] there are very high rates of unemployment among transgendered people generally, and […] many transgendered people are fired once they are exposed in the workplace as being transgendered.”

These concerns also extend to young trans persons, who may be forced to endure bullying by their peers if the sex designation on school records does not match their gender identity.

Many trans persons want the benefits of official documents that correspond to their identity but may not want to undergo surgery. They may be content with the use of hormones or simply by presenting themselves consistently with their gender identity.

Gender reassignment surgery can be expensive, difficult to access, and carries the risks associated with any surgery. In addition, it has been reported to  typically cause sterility . Gabrielle Bouchard of the Montreal-based Centre for Gender Advocacy has said the surgical requirement in order for official documents to be changed  amounts to mandatory sterilization.  The surgery requirement also emphasizes biological sex characteristics rather than gender identity. Even after surgery has been performed, a second doctor must sometimes “confirm” the surgery. C.F., the plaintiff in the  Alberta  court case mentioned earlier,  told the  Edmonton Journal :

“What this legislation requires is that you not only submit to dangerous, risky surgery, but then actually attend for a humiliating genital inspection before two separate physicians, both of whom will make a value judgment about whether your genitals are sufficiently female[.] It’s like something from ages gone by. It’s very disturbing stuff.”

Due to these types of concerns, there have been and continue to be legal challenges to the various provincial legislation that require reassignment surgery in order to change sex designation. In the  Ontario  and  Alberta   decisions discussed earlier, the requirement for gender reassignment surgery was found to be discriminatory. As a result of these rulings, several provinces, including Alberta, British Columbia, Manitoba, Ontario, and Quebec, have taken steps to amend their laws to remove reassignment surgery from the requirements necessary in order for you to change your sex designation. Nova Scotia has also indicated that it plans to amend its legislation to remove the surgery requirement.

Some activists have argued for the removal of sex designations from identification documents altogether, on the basis that gender identity is not a binary classification. The binary does not accommodate people who do not identify with a binary gender classification.

Ongoing cases challenging legislation in  British Columbia ,  Saskatchewan  and  Quebec  are seeking the removal of sex designations from birth certificates. So far, although several provinces have removed the surgery requirement, no province has taken the step of removing sex designations altogether or providing for a third non-binary option.

In contrast, several countries, including  Australia and Germany , now allow persons to designate their sex on their passport with an “X”. However, some trans rights advocates argue that the “X” continues to out trans persons, and is used as an excuse for not eliminating the surgery requirement. An  Australian  court has ordered the government to register a third category of sex designations on birth certificates and name change certificates.

For more on the possibility of non-binary gender designations, see the BC Law Institute’s  report , where the Institute highlights the implications and consequences of different solutions to providing a non-binary sex designation in Canada.

All provinces and territories except Nunavut have procedures for changing sex designations when a person has undergone gender reassignment surgery.

The rules for changing the sex designation on a birth certificate vary from province to province. They are also changing rapidly. In all provinces except Quebec, where the  Civil Code  governs these issues, the law concerning birth registration is found in the provincial  Vital Statistics Act  and associated regulations. These laws and regulations can be consulted for free on  http://canlii.org . Note that a province may have policies that are not in the legislation. For more information about requirements, check with the government agency responsible for birth certificates in your province or territory (listed below), or with a trans advocacy organization, such as  Egale Canada .

Many provinces require letters from a mental health professional in order to change a person’s gender marker or name. Such a letter may also be required to access sex reassignment surgery.

Online government information is limited outside British Columbia, Manitoba and Ontario. Where specific information regarding change of sex designation is unavailable on a province’s website, the links below provide contact information for the appropriate agency.

Until recently, all provinces and territories required you to have gender reassignment surgery if you wanted to change the sex designation on your birth certificate. Ontario became the first province to drop this requirement in 2012 when, as mentioned previously, its human rights tribunal  ruled  the requirement was discriminatory. The Alberta Court of Queen’s Bench handed down a similar  ruling  in April 2014. Ontario has not officially amended their legislation, but are now registering changes without proof of surgery as a matter of policy. British Columbia, Alberta and Manitoba are the only provinces that have formally amended their legislation to eliminate the surgery requirement. In Alberta, the new requirements are set out in  regulations .

New Brunswick, Newfoundland and Labrador, PEI and Saskatchewan   all require applicants to document that they have undergone gender reassignment surgery, usually by having at least two physicians – the surgeon who performed the surgery and another who did not – certify that fact. Quebec and Nova Scotia also currently require proof of surgery, but changes to the law are on their way (see below). In Quebec, the second physician must practice medicine in Quebec. In New Brunswick and the Northwest Territories, the second physician must be licensed in any Canadian jurisdiction.

The law in this area is changing rapidly as legislation is amended and court challenges are brought regarding surgery requirements. Consulting the relevant statutes will not always give a full picture of the current requirements or upcoming amendments. For current information, contact a trans advocacy organization, such as  Egale Canada .

You must provide:

A declaration, which provides your date of birth, and states that you identify with and maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a licensed doctor or psychologist licensed in Alberta or another jurisdiction that the sex designation on your birth certificate does not correspond with your gender identityBritish ColumbiaNo proof of surgery required;

A declaration, which states you have assumed, identify with and intend to maintain the gender identity that corresponds with your desired sex designation; and

Confirmation from a doctor or psychologist licensed in BC or the province or territory where you live that the sex designation on your birth certificate does not correspond with your gender identityManitobaNo proof of surgery required;

A declaration, which states you identify with the requested sex designation, you are currently living full-time in a manner consistent with the requested sex designation and you intend to continue doing so; and

A supporting letter from a health care professional licensed in Canada or where you live that your gender identity corresponds with the requested sex designationNew BrunswickProof of surgery requiredNewfoundland and LabradorProof of surgery requiredNova ScotiaProof of surgery still required, but a bill to eliminate the requirement has received royal assent. Under the new law, which is not yet in force, you will written statements from themselves and a member of a profession to be prescribed in the regulations that confirm your gender identity.OntarioNo proof of surgery required;

A declaration, which states your gender identity); and

A note from a doctor or psychologist licensed to practice in Canada that confirms your gender identityPrince Edward IslandProof of surgery requiredQuebecProof of surgery required, but change is pending;

The requirements under the new law have not been set yet.SaskatchewanProof of surgery requiredNorthwest TerritoriesProof of surgery requiredYukonProof of surgery requiredNunavutThere is no provision in the  Vital Statistics Act  for changing sex designation, even with surgery

Sex reassignment surgery is generally not performed on those under the provincial age of majority, as all clinics in Canada that currently perform reassignment surgery conform to the recognized  Standards of Care . These Standards, which are regarding health care for trans persons, forbid irreversible interventions (such as surgery) on patients before they reach the age of majority. As a result, if you are a minor in Canada, you generally cannot change your sex designation in provinces or territories where proof of surgery is required.

In provinces that do not require surgery, the age requirements vary:

Note that legal challenges to the minimum age requirements are currently proceeding in several provinces, including  Quebec  and  Saskatchewan . Click  here  to listen to an interesting radio interview with a 10 year old who would like to change the sex designation on her birth certificate.

Under new law (not yet in force) : No age minimum, but if you are under 16, you must have parental/guardian permission or apply to the Supreme Court of Nova Scotia for an order dispensing with the requirement of parental consent.OntarioNo age minimum, but if you are under 16, you must have parental/guardian permissionPrince Edward IslandNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionQuebecAge minimum is 18.SaskatchewanNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (18), you must have parental/guardian permissionNorthwest TerritoriesNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permissionNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonNo age minimum, but surgery is required and will not be performed if you are under 18; in addition, if you are under the age of majority (19), you must have parental/guardian permission

British Columbia, Ontario and Northwest Territories will change sex designations only for births registered in their respective provinces. Some provinces will register a change of sex and then transmit it to the jurisdiction where the birth was registered.

Under new law (not yet in force) : Legislation requires that the applicant was born in Nova Scotia.OntarioLegislation requires that the applicant was born in OntarioPrince Edward IslandApplicants born outside of Prince Edward Island may apply, and the province will transmit their request to the jurisdiction where their birth was registered.SaskatchewanNo explicit requirement that the applicant was born in SaskatchewanQuebec Under the new law (not yet in force) : Legislation requires that the applicant was born in Canada and resides in Quebec, or that the applicant was born in Quebec and resides in a place where change of sex designation is unavailable or impossibleNorthwest TerritoriesLegislation requires that the applicant was born in Northwest TerritoriesNunavutThere is no provision in the  Vital Statistics Act  for changing sex designationYukonApplicants born outside of Yukon may apply, and the province will transmit their request to the jurisdiction where their birth was registered

For more information:

The Trans PULSE Project prepared a report for the Canadian Human Rights Commission on sex designation in federal and provincial IDs in 2012. The report was prepared for hearings on Bill C-279, a proposal to add gender identity and expression to the  Canadian Human Rights Act  and to hate crime provisions of the  Criminal Code . The report can be found  here .

In 2014, the British Columbia Law Institute prepared a report for the Uniform Law Conference of Canada on the state of the Canadian law regarding change of sex designation, and regarding options for reform in 2014. The report can be found  here .

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The Financial Cost of Being Transgender in Canada

Part 2: we focus on some of the financial challenges faced by the transgender community, both hidden and open.

Work and Money Under Canada’s Federal Employment Act , employers “shall implement employment equity by identifying and eliminating employment barriers against persons in designated groups”. The four designated groups are women, aboriginal peoples, persons with disabilities, and members of visible minorities. Neither sexual orientation nor gender identity are protected classes. However, transgender Canadians are not without anti-discrimination protections. Gender and sexual minority people are named in and protected by Section 3(1) of the Canadian Human Rights Act . Still, there’s a gap between theory and practice. Egale , a Canadian advocacy group and a leader in research on the nation’s LGBTIQ2S issues, has perhaps the most up-to-date and comprehensive data on this matter. In their 2020 report on workplace discrimination , Egale notes that LGBTIQ2S Canadians continue to face widespread inequity, particularly in terms of access to safe work, and inequity is more pronounced for transgender, Two Spirit, and gender non-conforming people. This is borne out by the Trans PULSE 2011 report on workplace discrimination , which found that just 37% of transgender Ontarians were working full-time, while 20% were unemployed or on disability. The higher rates of un- or under-employment in these populations “are despite having an overall higher rate of qualifications.” A reported 71% have some college or university but approximately half earn $15,000 or less per year. As with the broader community, the effects of workplace discrimination go far beyond wage loss. Employment can provide access to good housing and educational opportunities, as well as benefits like medical, mental health care, and dental coverage, bonuses, paid leave and vacations, and investment power in the form of RRSP contribution room and matching employer contributions. Health Care Canadians enjoy universal healthcare—but just how universal is it? Among the services not covered are prescription drugs, dentistry, and mental health care. For those without employer plans, these expenses can be out of reach, particularly for low income Canadians. The Standing Committee on Health released a report in 2019 on the health of LGBTIQ2S Canadians and found that between 20% and 30% of transgender people who needed emergency services did not go to the ER, and of those who did, 52% had negative experiences. Refusal of service, inappropriate or invasive questions, misgendering, and other forms of discrimination all contribute to a health care system that can be hostile to transgender people. In this context, it’s not surprising that transgender Canadians underuse available health care services. For a more comprehensive discussion of the costs of health care refer to part one  of this series. Specific to the transgender community, there are two aspects of health care worth a closer look: fertility and adoption, and gender affirmation. Fertility and Adoption In addition to adoption and reproductive technologies like intra-uterine insemination (IUI), surrogacy, or in vitro fertilization (IVF), there are fertility preservation strategies for transgender people who have eggs or sperm. For those who have eggs , in addition to IUI or IVF, embryo or egg freezing and storage, prior to hormone therapy (if applicable) may be an option. The costs of this procedure varies by clinic but are estimated to be about $10,000 to extract and $300 per year to store. If and when the time comes to transfer, there is an addition fee of around $2,000. For those who have sperm , banking for future use may a good option. As always, costs vary but the sperm extraction is usually in the neighbourhood of $2,000 with an additional $450 to freeze and around $400 per year to store. There may also be extra handling fees. Gender Affirmation Although medical interventions are only one aspect of the transition process, and not necessary to claim a transgender identity, many trans folks opt for one or all of the following: counselling, hormone therapy, or surgery. Visits with psychologists or clinical counsellors are not covered by basic health care but may be within some employer or extended plans. That said, there some programs across the country, such as Gender Journeys through Sherbourne Health Centre in Toronto, that offer free group sessions for transgender or questioning Canadians. For those without local resources or who want to go the private route, fees for psychologists or counsellors run anywhere between $100 and $300 per hour. Hormone therapies include the administration of testosterone, estrogen, and hormone blockers, all of which are designed to alter secondary sex characteristics such as body hair, voice, and fat distribution. Some Canadians with employer benefits or extended health care plans, or those on disability or social assistance, may be eligible for funding towards their hormone therapies but these are generally an out-of-pocket expense. Gender affirming surgeries include “top surgeries” such as a mastectomy or breast implants and “bottom surgeries” like a hysterectomy, vaginectomy, vulvoplasty, orchiectomy, metoidioplasty, scrotoplasty, and phalloplasty. Coverage for these procedures varies but many are available under provincial health care plans. Extended insurance might broaden the coverage. Other costs to consider that are not typically covered are facial feminization or masculinization procedures, vocal coaching, prosthetics, hair removal, and body contouring. Identity Documentation Should a transgender person want to change their name, it will cost between $100 and $137, depending on province of residence. Afterwards, or in the case of changing a gender marker, they’ll need to update their identification. Again, the fees differ according to location but in Ontario, the cost for a replacement birth certificate is $35. A replacement driver’s license is $35.75. Note: *LGBTIQ2S is an acronym for lesbian, gay, bisexual, transgender, intersex, queer, and Two Spirit. It is uniquely Canadian, and may be understood in place of LGBT+. **In this piece, transgender is used to identify people within the “trans umbrella”. That is, people who identify as transgender, transsexual, genderqueer, non-binary, agender, bigender, and Two Spirit, among other identities of transgender experience. Importantly, a person may claim these identities independent of medical interventions like surgery or hormones, or of legal documentation such as name or sex designation markers.

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How to afford transgender surgery expenses.

Updated: Nov 11, 2022, 2:00pm

Transgender surgeries—also called gender affirmation or gender confirmation surgeries—are medical procedures you can undergo to affirm your gender identity.

The cost of these kinds of surgeries are often steep, and health insurance coverage for them can vary by policy. “Even if a procedure is covered by insurance, there are still deductibles and out-of-pocket maximums,” said Wynne Nowland, CEO of Bradley & Parker, who transitioned at 56. Surgeries that are solely cosmetic might not be covered by insurance at all.

The good news is that several financing options are available to help you pay for procedures. Some organizations even offer grants and scholarships that can help you afford surgery costs.

How Much Does Transgender Surgery Cost?

The cost of transgender surgery can vary by provider and the type of surgery you choose to get. For a female-to-male transition, masculinization chest surgery (also known as top surgery) might cost $3,000 to $10,000 while chest surgery for a male-to-female transition could cost $5,000 to $10,000, according to Longwood Plastic Surgery.

Bottom surgeries, such as vaginoplasty or phalloplasty, can cost $25,600 and $24,900, respectively, according to estimates from The Philadelphia Center for Transgender Surgery. Additional procedures can increase the transition expenses from there. Aside from the actual surgery cost, other hidden expenses can arise as well.

For example, you could need help at home while in recovery if you don’t have a good support system, according to Nowland. There may also be travel and hotel expenses, which are typically not covered by insurance. Nowland says the best way to prepare for surgery is to reach out to insurance to discuss coverage and plan on saving the funds you’ll need to proceed.

If you’re considering borrowing money to pay for surgery and recovery costs, here are four options to consider.

Related: Does Being Transgender Affect Life Insurance?

4 Ways to Finance Transgender Surgery Costs

Personal loans, credit cards, medical credit cards and home equity loans are products you could use to pay for transgender surgery costs over time. Here’s what you need to know about each:

Personal loans are typically unsecured installment loans that provide a lump sum you can use for almost any legal personal expense, including medical bills. Lenders may offer loans of $1,000 to $100,000. However, your credit and income can affect how much you can borrow and your interest rate.

The average annual percentage rate (APR) for a five-year personal loan is 15.93% as of Sept. 19, 2022, but rates can go up to 36% APR. The good news is that many lenders let you prequalify for personal loans online without a hard credit check , allowing you to shop around for rates and compare costs before borrowing.

Credit Cards

Credit cards give you access to a credit line you can use to cover medical bills. You’ll then pay off the balance over time. While certain credit cards have annual fees, many don’t. Some credit cards even offer an introductory 0% APR for a number of months when you open a new account.

Standard interest applies after the interest-free period, but charging and paying off procedures during the interest-free period could be an affordable way to finance bills. That said, credit cards are usually best for expenses you can repay relatively quickly since interest rates can be higher than personal loans, so maintaining a high balance over several years can get costly.

Medical Credit Cards

Medical credit cards are designed specifically for medical bills and could be a financing option recommended by your doctor’s office.

CareCredit is a popular medical credit card that offers no-interest financing plans of six, 12, 18 or 24 months on transactions over $200. There’s a catch, though: If you don’t pay off the balance during the financing period, interest is charged retroactively from the time of your purchase.

For purchases of at least $1,000, CareCredit offers extended financing terms of 24, 36, 48 or 60 months. The APR for payment plans is fixed and ranges from 14.90% to 17.90%, depending on how much you borrow and the loan term you choose.

Home Equity Loans or Lines of Credit

If you own a house, home equity loans and home equity lines of credit (HELOCs) are ways to borrow from the equity you’ve built up. Here’s how both of these options work:

• Home equity loans: A home equity loan is an installment loan that lets you borrow money in a lump sum, which you could use to cover transgender surgery costs. Homeowners are typically able to borrow up to 85% of home equity, and loan terms can range from five to 30 years.
• HELOCs: These are lines of credit you can draw from and pay down with a variable interest rate. A HELOC could be a better alternative to a home equity loan if you have ongoing costs as it will give you the flexibility to borrow only what you need and pay it back as you go.

The advantage of home equity products for medical expenses is that interest rates may be lower than unsecured personal loans since the collateral (your home) backing minimizes risk for the lender.

However, since your home secures the transaction, you could lose your house if you can’t keep up with loan payments. If the value of your home decreases, there’s also a chance you could go underwater on the house if you end up owing more on your mortgage and loan than the home is worth.

Can You Get Transgender Surgery Grants?

Several organizations offer grants to help cover transition costs, including gender-affirming surgery, which is money you don’t have to pay back. Requirements for grant funding can vary, but in some cases, you need to show that you’ve saved up some money on your own for the surgery to be awarded money. Here are a few examples of organizations offering grants:

• Jim Collins Foundation : The Jim Collins Foundation offers two grants. General Fund grants can cover all gender-affirming surgery costs while Krysallis Anne Hembrough Legacy Fund grants can cover 50% of surgery costs for recipients who match the grant funds awarded.
• Point of Pride : Point of Pride offers an annual scholarship-like program that provides financial assistance for gender-affirming surgery.
• The Loft LGBTQ+ Community Center : TransMission grant funds through the Loft LGBTQ+ Community Center aren’t enough to cover the full cost of surgery. However, grants may be used to help pay for therapy, hormones and other transition expenses.

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Tips to Pay For Transgender Surgery Expenses

As you come up with a plan and explore ways to pay for surgeries, here are a few tips to consider:

• Double-check your insurance policy. Read policy terms carefully and reach out to your insurer to ask about what surgeries are covered. “Like all covered insurance procedures, expect to deal with some red tape, but your patience in doing so will be worth it,” said Nowland.
• Use a health savings account (HSA) or flexible spending account (FSA). HSAs and FSAs are both tax-advantaged accounts designed to help you stash money for medical expenses, which could include gender-affirming surgeries. You can make pre-tax contributions to both accounts from your salary if you set them up with your employer. If you set up an HSA on your own, you can deduct contributions from your tax return.
• Consider crowdfunding. Crowdfunding is when you set up a campaign to raise funds. If you prefer to keep medical procedures private, creating a campaign and asking for donations may not be the right route to take. But if you feel comfortable sharing your story, setting up a GoFundMe or Fundly fundraising page could be a way to cover the cost of your surgeries. Bonfire is another site you can use to fundraise by selling customized t-shirts.
• Get support from family and peers. If you have friends or family able to gift or loan you money, it can be more affordable than taking out a loan from a bank, online lender or credit union.

How to Save Up for Gender Affirming Surgery

Using a combination of funding sources is a strategy that could help you rely less heavily on loans.

Different surgeons charge different fees, so compare prices to project costs. From there, you can determine how much you’ll need to save and by when. If you don’t use an FSA or HSA to save, consider stashing your savings for surgery in a high-yield savings account so your savings earn more interest than it would in a traditional savings account.

Certain savings tools can make setting aside money easier. For example, banks often have recurring transfer features you can set up to automatically move money from a checking account to your savings on a schedule. Plus, savings apps like Digit exist, which can connect to your bank account, use an algorithm to review your cash flow and put spare money away for you automatically. Your savings can grow over time, so you can pay for treatment and surgery as you go.

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Gender Identity Clinic

The Gender Identity Clinic offers services to individuals and their primary care practitioners in regard to gender identity and expression.

Individuals over 17 who wish to explore issues related to their gender identity, which may include any degree of transgender expression.

Community professionals looking for support and consultation to help their clients reach their goals related to gender identity and expression.

Ask your health care provider to fill out the CAMH adult referral form. Here is a link to the online referral form . Forms should be faxed to Access CAMH at 416 979-6815. If you have any questions about the referral process, call Access CAMH at 416 535-8501 and press 2.

Types of Treatment and Services Offered

For individuals, consultation and support may include:

• diagnostic assessments in support of affirming a diagnosis of Gender Dysphoria in support of transition related surgeries. 
• individual support and treatment *Please note that our clinic does not offer long-term therapy
• surgical and hormone eligibility assessments *Please note that our clinic does not prescribe hormones
• group-based services

If you are interested in accessing LGBTQ2S affirmative psychotherapy, please check the service provider listing at Rainbow Health Ontario to find out options for psychotherapy in your region. 

For community professionals, consultations may include:

• completing a mental health assessment
• consultation with regard to completing a surgery referral assessment
• being a second assessor for surgery referrals

Program Overview

The Gender Identity Clinic at CAMH offers specialty services to both individuals and their primary care practitioners in Ontario with regard to issues related to gender identity and expression, including gender expansive, trans and non-binary identities. The program offers a comprehensive response to the variety of clinical issues experienced by clients. The clinical team is interdisciplinary and includes social work, psychiatry and psychology staff with specialized expertise in trauma-informed mental health and addiction care.

Our Services

For community professionals.

Primary care providers can diagnose for gender dysphoria, prescribe transition-related hormones, and refer for transition-related surgeries. If you are new to the field of trans care, Rainbow Health Ontario provides education, clinical support, and mentorship to primary care providers across Ontario. All courses provided by Rainbow Health Ontario are Mainpro+ certified. Please visit learn.rainbowhealthontario.ca for more information on courses offered at this time.

Rainbow Health Ontario also hosts a free bi-monthly Trans Health Mentorship Call to support clinicians in their practices. To register for this call, please visit learn.rainbowhealthontario.ca

IMPORTANT: Rainbow Health Ontario does not accept referrals or provide direct services of any kind.

Hormone Therapy

We would encourage referring physicians and/or nurse practitioners to consider prescribing hormone therapy (HT) for their trans clients.

If you are unsure about prescribing HRT:

• We recommend that you review the published Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients available through Sherbourne Health Centre , and review the WPATH Standards of Care
• If, after reading this document, you feel confident in your knowledge of HT, then you can prescribe in advance of the client’s initial assessment. If HT is your client’s sole gender goal, then there is no need to access the clinic once hormones have been prescribed. 
• If you are aware of complicating medical concerns and these medical concerns have prevented the initiation of hormone therapy, please consider making a referral to endocrinology on the client’s behalf.
• If you are interested in training to develop further competency in health care for trans clients, please contact Rainbow Health Ontario, which will take you to various training opportunities offered by that organization throughout the province of Ontario.

*If hormone replacement therapy is the primary reason for referral, we would ask that you consider these above-mentioned recommendations, as it will help to reduce unnecessary waiting for your client in terms of further medical transition.*

The clinic plays a significant role in training health professionals in culturally competent delivery of mental health assessment and treatment services to trans and gender expansive communities. We train and provide practicum and residency opportunities for social work students, psychologists and people from other health disciplines, including more than 10 PhD-level clinical psychologists over the past five years.

Consultation

Additionally, we provide support and consultations to primary care practitioners and other health care providers to help their clients reach their goals related to gender identity and expression. This may include consultations in regard to completing a mental health assessment, consultation in regard to completing a surgery readiness assessment, or being a second assessor for surgery readiness. The clinic will work collaboratively with you and your organization/practice to help you meet your client’s goals. Clinicians and organizations wanting consultation by the clinic for clients currently on our waitlist can contact our clinic at 416 535-8501 ext. 30985.

We have also launched an ECHO (Extension for Community Healthcare Outcomes) for trans and gender diverse health care . Please consider joining us for free CME-accredited training and consultation.

For Individuals

The clinic offers consultations and support to individuals over 17 years of age who wish to explore issues related to their gender identity, which may include any degree of transgender expression. Clients are seen for an assessment with one of our team members to determine the client’s transition goals, as well as to provide any diagnostic impressions regarding mental health and substance use. Recommendations about how to assist clients in meeting their transition goals are then made. This may include individual support and treatment, group-based support and treatment, as well as recommendations for surgery funding and referrals for clients seeking transition-related surgeries. The clinic follows the World Professional Association for Transgender Health Standards of Care (WPATH),V7 for transition-related surgery (TRS) .

Rainbow Health Ontario has an Ontario Service Provider Directory where you can search for a provider by region. Please go here to find a provider in your area.

If you cannot find anyone in your area after searching the provider directory, you can contact [email protected] . Please note that Rainbow Health Ontario cannot guarantee there will be a provider in your area to prescribe hormones or refer for surgeries.

Additionally, Rainbow Health Ontario’s Trans Health Knowledge Base can provide you with answers to general questions related to navigating the Ontario health care system. Go here for more information . 

For clients living outside the GTA

Given the context of the Covid-19 pandemic, our clinic provides virtual appointments via the Webex platform.

Given our referrals come from across the province, our clinic is equipped to see clients via telemedicine when possible. Typically, the first assessment in our clinic is in person in Toronto, and subsequent appointments for clients who live outside of the GTA may be made using telemedicine.

If you live in the north, you may be eligible for a Northern Travel Grant to cover basic travel costs to and from your appointments with CAMH. If you are an ODSP recipient, you may similarly be eligible to have basic travel costs reimbursed. Please ask your local provider for further details.

Transition-Related Surgery (TRS) - Frequently Asked Questions

T hese FAQ's are designed to provide a brief overview of the assessment and referral process in Ontario for persons considering gender-affirming surgeries funded by the Ministry of Health and Long-Term Care (MOHLTC). For more information on types of surgery, see the TRS Surgical Summary Sheets update .

For specific questions or more detailed information pertaining to gender-affirming surgeries, please don't hesitate to contact our office at 416 535-8501 ext. 30985.

Significant improvement in wait times for assessment

From 2008–2016 the Ministry of Health and Long Term Care (MOHLTC) regulation stipulated that CAMH was the sole assessment site for OHIP-funded transition-related surgery (TRS) (from 1998-2008 TRS was not funded by OHIP). In March 2016, the MOHLTC introduced a regulation change that improves and expands access to assessment for TRS for Ontarians, empowering primary care providers to provide surgery referrals and assessments. CAMH and its community partners championed this expansion of access to assessments for gender-affirming surgery. In anticipation of this important system change, CAMH partnered with Sherbourne Health Centre (including Rainbow Health Ontario) and Women’s College Hospital on a proposal to expand access to surgery-related care. Thanks to funding from the MOHLTC, the Trans Health Expansion (THEx) partnership is working on several key priorities including improving access to assessment, building capacity of primary care providers, and enhancing access to surgery and post-surgical recovery and support.

The funding helped our clinic to hire new staff members and in doing so, we were able to significantly decrease wait times for assessment. Prior to March 2016 the wait for assessment was over 30 months, and to date it is less than one-third of that. We continue to work to see more clients and reduce the current wait times.

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Gender-affirming care encompasses a broad range of psychological, behavioral and medical treatments for transgender, nonbinary and gender-nonconforming people.

The care is designed to “support and affirm an individual’s gender identity” when it is at odds with the sex they were assigned at birth, as defined by the World Health Organization.

What is gender-affirming surgery?

Gender-affirming surgery refers to the surgical and cosmetic procedures that give transgender and nonbinary people “the physical appearance and functional abilities of the gender they know themselves to be,” according to the American Society of Plastic Surgeons. It is sometimes called gender reassignment surgery.

There are three main types of gender-affirming surgeries, per the Cleveland Clinic:

Top surgery , in which a surgeon either removes a person’s breast tissue for a more traditionally masculine appearance or shapes a person’s breast tissue for a more traditionally feminine appearance. 

Bottom surgery , or the reconstruction of the genitals to better align with a person’s gender identity.

Facial feminization or masculinization surgery , in which the bones and soft tissue of a person’s face are transformed for either a more traditionally masculine or feminine appearance.   

Some people who undergo gender-affirming surgeries also use specific hormone therapies. A trans woman or nonbinary person on feminizing hormone therapy, for example, takes estrogen that’s paired with a substance that blocks testosterone. And a trans man or nonbinary person on masculinizing hormone therapy takes testosterone.

Gender-affirming surgeries and treatments are the recommended course of treatment for gender dysphoria by the American Medical Association. Gender dysphoria is defined as “clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics,” according to the American Psychiatric Association.

Some LGBTQ+ advocates and medical professionals feel that gender dysphoria shouldn't be treated as a mental disorder, and worry that gender dysphoria’s inclusion in the DSM-5 — the authoritative source on recognized mental health disorders for the psychiatric industry — stigmatizes trans and nonbinary people.

How much does gender-affirming surgery cost?

Gender-affirming surgery can cost between $6,900 and $63,400 depending on the precise procedure, according to a 2022 study published in The Journal of Law, Medicine and Ethics.

Out-of-pocket costs can vary dramatically, though, depending on whether you have insurance and whether your insurance company covers gender-affirming surgeries.

There are also costs associated with the surgery that may not be represented in these estimates. Additional costs may include:

Surgeons fees

Hospital fees

Consultation fees

Insurance copays

The cost of psychiatric care or therapy, as most insurance companies and surgeons require at least one referral letter prior to the surgery. An hour of therapy can cost between $65 and $250, according to Good Therapy, an online platform for therapists and counselors. 

Time off work. After bottom surgery, you can expect to miss six weeks of work while recovering. Most people miss around two weeks of work after top surgery. 

Miscellaneous goods that’ll help you recover. For example, after bottom surgery, you might need to invest in a shower stool, waterproof bed sheets, cheap underwear and sanitary towels. Top surgery patients may need, depending on the procedure, a mastectomy pillow, chest binder and baggy clothes.

Is gender-affirming surgery covered by insurance?

It’s illegal for any federally funded health insurance program to deny coverage on the basis of gender identity, sexual orientation or sexual characteristics, per Section 1557, a section of the Affordable Care Act. Section 1557 doesn’t apply to private insurance companies, though, and several U.S. states have passed laws banning gender-affirming care.

The following states have banned gender-affirming surgery for people under 18 years old, according to the Human Rights Campaign: Alabama, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah, West Virginia. In four of these states — Alabama, Arkansas, Florida and Indiana — court injunctions are currently ensuring access to care.

And these states have either passed laws — or have governors who issued executive orders — protecting access to gender-affirming surgery, according to the Movement Advancement Project, a public policy nonprofit: California, Colorado, Connecticut, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New Mexico, New York, Oregon, Vermont and Washington, D.C.

But even if your state has enshrined protections for gender-affirming care, some private insurance companies may consider surgeries “cosmetic” and therefore “not medically necessary,” according to the Transgender Legal Defense and Education Fund. If you have private insurance or are insured through your employer, contact your insurance company and see if they cover gender-affirming care. Also, ask about any documentation the insurance company requires for coverage.

The Williams Institute estimates that 14% of trans Americans currently enrolled in Medicaid live in states where such coverage is banned, while another 27% of trans Americans live in states where coverage is “uncertain,” because their state laws are “silent or unclear on coverage for gender-affirming care.”

Because of Section 1557, Medicaid is federally banned from denying coverage on the basis of sex or gender; among the roughly 1.3 million transgender Americans, around 276,000 have Medicaid coverage, according to a 2022 report from the Williams Institute.

How to pay for gender-affirming surgery

If your private insurance company won’t cover gender-affirming care, and you’re unable to obtain coverage through the federal marketplace, consider these sources:

Online personal loan.

Credit union personal loan.

Credit card.

CareCredit.

Home equity line of credit.

Family loan.

There are also several nonprofits that offer financial assistance for gender-affirmation surgeries. Those organizations include:

Point of Pride , which offers grants and scholarships to trans and nonbinary people seeking gender-affirming surgery and care.

The Jim Collins Foundation , which raises money to fund gender-affirming surgeries. 

Genderbands , which offers grants for gender-affirming surgeries and care. 

Black Transmen Inc. , which funds gender-affirming surgeries for Black trans men. 

On a similar note...

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Health Reporting in the States

Bill of the month: a plan for affordable gender-confirmation surgery goes awry.

Emmarie Huetteman

Wren Vetens was promised a significant discount on the cost of her gender-confirmation surgery if she paid in cash upfront, without using her health insurance. Yet afterward, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000. Lauren Justice for KHN hide caption

Wren Vetens was promised a significant discount on the cost of her gender-confirmation surgery if she paid in cash upfront, without using her health insurance. Yet afterward, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000.

Wren Vetens thought she'd done everything possible to prepare for her surgery.

She chose a doctoral program in physics at the University of Wisconsin-Madison, a school that not only embraced transgender students like her, but also granted insurance coverage for her gender-confirmation surgery when she enrolled in 2016. When uncertainty over the fate of an Obama-era anti-discrimination rule allowed the state to discontinue such coverage, Vetens and her mother, Kimberly Moreland, an OB-GYN, shopped for another plan.

Deducing the procedure would run from $19,000 to $25,000, based on prices posted online, they purchased insurance from Consolidated Health Plans. It would pay a maximum of $25,000 for the operation.

With that information in hand, Vetens planned ahead: She got her insurer's preapproval and scheduled surgery during winter break of her second year, allowing time for recovery before returning to her studies.

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So, she was shocked when a hospital representative called her a couple of months before the long-awaited surgery estimating the bill would be $100,000. That meant she would be on the hook for as much as $75,000 after her insurer's $25,000 payout.

With preparations for the surgery well underway, Vetens was feeling overwhelmed with stress. "There were days when I just couldn't get out of bed for a whole day," she said, describing two weeks of panic attacks.

After mother and daughter complained about the last-minute surprise, a hospital representative offered a solution: If they paid out of pocket and in full before Vetens' surgery — forgoing their use of insurance — the hospital would accept just $20,080, assuring them the hospital would charge nothing to Vetens' insurer. But if they did not decide and pay up right away, the surgery would be canceled.

"I certainly felt that I had no choice," Vetens said.

After Moreland gave the hospital her credit card number for payment, they thought the financial roller coaster was over and Vetens could focus on recovery.

Then the bill came.

Patient: Wren Vetens, then 23, a Ph.D. student at the University of Wisconsin-Madison

Total bill: $91,850.20

Insurance payment: $25,427.91

Vetens owed: $13,191.95 (after $20,080 that was counted as a deposit)

Service provider: University of Wisconsin Hospital in Madison

Medical treatment: Vetens underwent a procedure known as penile inversion vaginoplasty to address her diagnosis of gender dysphoria, a condition resulting from one's sex identified at birth being in conflict with one's gender identity.

The procedure, in which the patient's penile and scrotal tissue is used to create a vagina, generally takes about two to four hours and requires a short inpatient stay, according to Dr. Madeline Deutsch, the medical director for transgender care at the University of California, San Francisco.

Candidates for the procedure must live for at least one year in their identified gender role and undergo at least one year of hormone therapy, Deutsch said. Preparation also includes permanent hair removal.

What gives: Though gender dysphoria is relatively uncommon, many of the billing and insurance issues Vetens encountered are typical for patients planning major surgery. Much of her stress and frustration arose from the vast difference between online price estimates ($19,000-$25,000), the hospital's billed price to the insurer ($91,850) and what it was willing to accept as an upfront cash payment ($20,080).

Hospitals set list prices high because insurers with whom they have contracts typically negotiate them down. In exchange for charging an insurer's members a lower price, doctors and hospitals gain access to those customers, who have incentives to use these in-network providers. Hospitals may offer package deals for procedures to patients, if they pay cash upfront, in part because the hospital avoids the hassle of negotiation.

Officials at University of Wisconsin Hospital said they offered Vetens the option to pay $20,080 for these reasons: to secure extra experience and exposure for the hospital's programs for transgender patients, and to shield Vetens from an even bigger bill. "We were trying to protect the patient," said Dr. Katherine Gast, Vetens' surgeon.

Dr. Kimberly Moreland (left) helped her daughter shop for an insurance plan that would cover Vetens' gender-confirmation surgery. Yet mother and daughter still found themselves caught between the hospital and the insurer. Courtesy of Richard Malatesta/Kimberly Moreland hide caption

Dr. Kimberly Moreland (left) helped her daughter shop for an insurance plan that would cover Vetens' gender-confirmation surgery. Yet mother and daughter still found themselves caught between the hospital and the insurer.

As both parties hedged their bets in trying to determine what a penile inversion vaginoplasty was worth, Vetens was stuck in the middle with the prospect of hugely varying payments.

Lisa Brunette, a hospital spokeswoman, said that, despite having provided Vetens an estimate of $100,000, the hospital really did not know how much it would charge for the procedure because it did not know how much it would be reimbursed by the insurance company. Vetens was the second person to have the procedure at the hospital.

The spokeswoman for the hospital said its contract with Vetens' insurer "relies on a complex formula."

And in an apparent chicken-and-egg quandary, Drew DiGiorgio, president and chief executive of Consolidated Health Plans, said the insurer did not know how much it would reimburse because it did not know how much the hospital would charge.

When Moreland called the hospital to pay the $20,080 price — an option she acknowledged many simply could not afford — she asked for an itemized bill.

The next day, she received a brief letter outlining some of the general services included for the price, such as "physician's fee" and "post surgery labs." Then it simply said: "Penile Inversion Vaginoplasty — $20,080.00."

"How in the world did you come up with a number if you have no idea what it covers?" she asked.

Had Vetens chosen a hospital that did not contract with her insurer, the family could have been reimbursed 60 percent, or about $12,000 of the money paid, since her insurance pays a portion of out-of-network care.

But since Consolidated Health Plans has a contract with the University of Wisconsin Hospital, it said it would not reimburse anything at all. Contracts between insurers and providers discourage such sideline cash transactions, since hospitals can make more money when patients use insurance, as evidenced by Vetens' bill.

Vetens and Moreland appealed to Consolidated Health Plans, feeling that they had been "the victims of a bait-and-switch scam."

The surprises didn't end there. Though multiple hospital representatives reassured Vetens that they wouldn't charge her insurance after her cash payment, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000.

A hospital bill followed, identifying their $20,080 as "pre-payment," treating it like a partial deposit. Vetens owed more than $13,000, it said.

Studies have shown that more than half of hospital bills contain errors , a problem made worse by the fact that medical bills — with codes and jargon — can be nearly impossible for even savvy patients to understand.

"That was not supposed to happen. That was an error," said Abby Abongwa, a hospital billing official. "That was absolutely an error on our part."

Resolution: After the bill for $91,850 arrived, an alarmed Vetens showed it to her surgeon. The hospital quickly apologized and repaid her insurance company.

Within a few weeks of receiving the appeal — which noted that Vetens and Moreland had contacted a national media outlet — Consolidated Health Plans reimbursed Vetens nearly $18,000, offering her no explanation for why the company had ultimately decided to reverse its earlier judgement that it would not pay anything toward her care.

With their reimbursement, Vetens and Moreland paid about $2,100 for the surgery, all told.

The Takeaway: Be mindful that online pricing estimates frequently represent cash prices, which are often far lower than the price hospitals will bill your insurance.

Ask about a cash price — you may get a better deal. But if you forgo insurance, you're on your own. Your insurer is under no obligation to pay you back for any part of the bill or help you troubleshoot billing, and any payment you make likely will not count toward your deductible.

Enlist your doctor's help. Gast, Vetens' surgeon, proved a powerful advocate for her patient when disputes arose about billing and pricing. Billing representatives might not always be responsive to patients, but it's in the hospital executives' interest to keep staff surgeons happy.

Some of these issues can be settled only through legislation. Right now, there is no legal requirement for hospitals to provide itemized bills to patients. Hospital bills are fraught with errors, and there is little accountability for providers who bill erroneously.

In the meantime, don't be afraid to ask questions and fight back.

Bram Sable-Smith, who contributed to the audio story, is part of NPR's reporting partnership with Side Effects Public Media, member station KBIA and Kaiser Health News.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

You can follow Emmarie Huetteman on Twitter: @emmarieDC .

• transgender
• bill of the month
• gender dysphoria
• gender identity
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• Plastic surgery