BC Is No Longer Sending Trans Patients to Montreal for Surgery

[Editor’s note: This article includes references to self-harm and violence against transgender people.]

B.C. will soon stop referring patients to a clinic in Montreal for gender-affirming genital reconstructive surgery.

Starting April 1, Two-Spirit, transgender and non-binary British Columbians will be referred to Vancouver’s Gender Surgery Program instead of being able to choose between having genital reconstructive surgery in Vancouver and having it at the GrS Montreal clinic, according to the Trans Care BC website.

Patients will still be able to pay out of pocket for care in Montreal if they choose.

GrS Montreal has been offering gender-affirming surgery for 30 years. For most of that time it was the only clinic in Canada offering this specialized care.

In 2019, B.C. moved to build its in-house capacity and opened its own surgical clinic, GSPBC.

After GSPBC opened, doctors and their patients could choose whether to have the surgery closer to home or fly to Montreal. Both options were fully covered by B.C.’s Medical Services Plan.

Now, the GrS Montreal pathway is closing. The last day doctors will be able to refer patients to GrS Montreal is March 31.

Patients who have completed a referral to the Montreal clinic by March 31 will still be able to get surgery there.

The GSPBC program provides the same procedures as GrS Montreal and will provide “high-quality gender affirming medical care throughout a patient’s entire surgical journey, including pre- and post-operative care, and until the patient is discharged to their primary care provider,” the Ministry of Health said in an emailed statement.

This change follows provincial guidelines that prioritize in-province care, the ministry added.

Two-Spirit, transgender and non-binary health-care experts and advocates have mixed feelings about this change.

Kai Jacobsen, who is completing their PhD in interdisciplinary studies at the University of British Columbia, said they’re worried ending the agreement with GrS Montreal will increase wait times and reduce surgical options for patients.

Wait times could be increased because the same number of patients are now trying to access a single clinic and single provincial health system rather than two, they said.

This could put people’s lives at risk because the highest suicide risk time for transgender people is when someone decides to access gender-affirming care and then isn’t able to, they said.

Jacobsen pointed to a 2015 study by Trans PULSE Ontario that found the rates of suicide attempts increased for transgender people while they were in the process of transitioning, compared with those who were planning on transitioning but had not yet started, or those who had completed their transition.

“The waiting period for accessing surgery can be really challenging because these surgeries are transforming, life-saving and life-changing for a lot of people,” they said. “The uncertainty of not knowing when you’ll be able to get surgery and the years-long wait-list can be really challenging for people’s mental health.”

Mara Carrier, a Two-Spirit transgender woman who was a patient with GSPBC before ultimately deciding to access surgery at GrS Montreal, said she’s worried B.C. will have a “cascade” of additional referrals as the surgical pathway to Montreal ends.

Carrier is a community transgender activist and medical support contact for her community.

“This suite of services is being overloaded in a system that is not receiving new surgeons, that is not receiving new surgical space and that is not receiving new resources to accommodate the impending influx of new patients,” she said.

Carrier continued, “I cannot see this any other way than a cost-cutting measure that will directly impact a lot of transgender people and lead to a lot of deaths that were unnecessary.”

However, it seems like wait times at GrS Montreal are set to increase as well. On Wednesday GrS Montreal said in a social media post that the budget for gender-affirming surgery in Quebec has been reduced, which “directly impacts wait times for Quebec patients.”

Reduced surgical options

Sources who spoke to The Tyee expressed concern that ending the partnership with GrS Montreal will mean fewer surgical options for patients.

Clio Lake, a director of the Society for Advocacy for Gender-Affirming Healthcare and a master of public health student at Simon Fraser University, says the society has been advocating for B.C. to add more surgical pathways, more surgical coverage and more surgical capacity in-province to bring B.C. up to the standards of the World Professional Association for Transgender Health.

It’s distressing to see the province remove a surgical pathway instead, they said.

Trans Care BC says GSPBC offers the same procedures as GrS Montreal and that doctors can still refer patients for out-of-province care “when medically necessary care cannot be provided in B.C.”

But these procedures are limited compared with what surgeries are available worldwide, or what outcome a patient is seeking.

There are many types of gender-affirming surgical care and many ways to approach genital reconstruction. Each patient’s medical needs will vary widely on what, if any, surgery or surgical technique is right for them.

For example, here in B.C. a transgender woman has filed a BC Human Rights Tribunal complaint because she wasn’t able to access the surgery she sought out and that was medically recommended in Canada.

In two separate Ontario cases, non-binary patients successfully argued they should be allowed to have a vaginoplasty, a surgery to build a vagina without having a penectomy, a surgery to remove their penis, or to have a phalloplasty, a surgical construction of a penis, without vaginectomy, which removes the vagina.

And in Manitoba a transgender woman helped change the rules so patients could apply for facial feminization surgery as part of their gender-affirming care.

Provinces and territories could improve trans health care by removing policies that prevent patients from pursuing the surgery that is right for them, Lake said.

When patients can’t access the surgery they need through public health care, they will try to pay out of pocket to have the surgery elsewhere, they added.

But that puts surgeries out of reach for many people, as they can cost tens of thousands of dollars. Statistics show transgender and non-binary people earn up to 20 per cent less than their cisgender counterparts.

Data shows that public access to comprehensive gender-affirming health care is cost-effective and can reduce overall health-care costs by improving quality of life for Two-Spirit, transgender and non-binary people.

Emma Meredith-Black, a transgender woman living in B.C. who has been navigating transgender health care for a decade, says wait times at the Vancouver clinic can be upwards of five years, while the Montreal clinic has a two-year wait-list for surgery.

The Tyee asked GrS Montreal how long its wait times are but did not hear back by press time. Trans Care BC’s website says, “It's not possible to provide an estimate for wait times because wait times change frequently and depend on many factors.”

“Surgery is thought of as cosmetic when really it’s life-saving,” Meredith-Black told The Tyee. “That’s what a lot of people don’t get.”

GrS Montreal can offer slightly different care because it’s a private organization funded by the province, Carrier said.

“They’ve been doing this for 30-plus years. They have multiple surgeons… their own private recovery suite and a private hospital wing where you are able to recover amongst your own people with nurses well-informed about your circumstances,” she said.

Meredith-Black was critical of B.C. for not recognizing facial or vocal cord feminization, or hair removal as gender-affirming surgery, which means that to access these procedures patients have to pay out of pocket.

“It’s seen as cosmetic, but someone with a strong brow can get harassed on the street because they’re visibly trans,” she said. “It becomes an issue of safety.”

Carrier, who is partnered with Meredith-Black, has experienced this harassment.

She is Mi’kmaw and mixed Acadian which she says gives her a stronger brow.

“Out here it’s seen as a clear sign that I’m a trans person. I’m visibly trans and as such I have been harassed on the streets, beaten in the streets and sexually assaulted. All for the crime of appearing trans,” she said. “I’m not doing anything other than existing in public and this is the treatment I receive.”

In a recent report, the Society for Advocacy for Gender-Affirming Healthcare noted how there are surgeons who can provide gender-affirming facial surgery and body contouring in B.C., but MSP doesn’t cover those procedures.

“It’s rather misogynistic of the province to say, ‘you as a woman should have a vagina and potentially boobs, but we will not do anything to help you be seen as a woman in ways that would keep you safe in institution, in the streets and in public,” Carrier said.

MSP also covers estrogen only in pill form for hormone replacement therapy, rather than regular injections, Meredith-Black said. Many trans people who take hormones prefer injections because they offer a more stable hormone level, rather than the daily dip and spike that can happen when taking pills, she said.

Estradiol may be prescribed in patch or gel form and covered by MSP in special circumstances.

The Tyee asked to speak with B.C.’s health minister, Josie Osborne, for this article but she was not made available.

Instead the ministry sent an emailed statement that said the government was “committed to providing B.C. residents with comprehensive and compassionate health care — including safe and evidence informed gender-affirming care.”

It’s “laudable” that B.C. is investing in its in-province gender-affirming care capacity, said Fae Johnstone, executive director of Queer Momentum, a non-profit political advocacy organization.

At the same time, it’s “critical” that the province doesn’t interrupt care or increase wait times as it shifts to focusing on in-province care, she added.

Overall there’s a growing impetus — with the exception of Alberta and Saskatchewan — to expand coverage of and access to gender-affirming care across Canada, she said.

It’s great to see that “overall positive” trend, but it’s also important to remember that the baseline it’s expanding from is a “patchwork, disorganized and chronically underfunded context,” she said.

“It’s exciting to see B.C. building in-province surgical capacity for gender-affirming health care and I would encourage the province to lean into that space as an opportunity to be an innovator and a global leader on trans and gender-diverse health care,” Johnstone said.

*Story updated on Feb. 26 at 3:15 p.m. to include further information on the potential effects of ending access to surgical pathways at the GrS Montreal clinic.