With the increasing visibility of trans people in the media recently there has been a renewed focus on the status of health care for those seeking a medical transition in Ontario. Specifically, the focus is on the process one has to go through in Ontario to access the various surgeries that one may need when medically transitioning. Under the current benefits schedule requires one to be assessed and gain the approval from the Center for Addiction and Mental Health (CAMH) Adult Gender Identity Clinic in Toronto. There are no other providers in the province who are allowed to perform this assessment and make the appropriate referrals and funding requests. What does this mean for trans people? A very long wait for needed surgeries. What does this wait look like, and how long is it really?
This is the process in Ontario:
- Referral: The first step is to have a referral to CAMH from your doctor. For most people who seek this referral they have already begun a process of medical transition through local providers. Others, however do not have access to care in their local community and have to travel for this. CAMH recommends that one receive hormone referrals, prescriptions, and follow up elsewhere. (See: Information for Family Doctors and Nurse Practitioners regarding Hormone Therapy ) Once the referral is received the clinic at CAMH sends the person a questionnaire with questions about their experiences with gender dysphoria.
- Questionnaire: After receiving the questionnaire, the person seeking service through the clinic must fill it out and send it back in order to be put on the waiting list for an initial assessment appointment. The current estimated wait time for this initial assessment is more than two years. Often when this is discussed in media there is an implication that this initial assessment is then enough to get approval for surgery. Not true.
- Initial Assessment: The initial assessment appointment takes place, usually in Toronto, sometimes by video link if it is available in the person’s region. This is a one or two hour appointment where one is given a psychological evaluation. It is also important that the person seeking genital surgery be able to prove to the satisfaction of the clinic that one has one year of gender role experience. Having the documentation at this appointment speeds up the process slightly as one won’t have to provide the documentation at the surgery readiness appointment. A description of the initial assessment appointment is on the CAMH web site. Once this appointment is complete the waiting then continues
- Case meeting: After the initial assessment the clinic staff meet for a case meeting to determine if one is ready for the surgical readiness appointment or if more follow up is required. If one is seeking a hormone referral from the clinic the process would be different. This meeting may be up to eight weeks after the initial assessment. Once this meeting has happened, and if one is approved for the surgical readiness appointment, one is then put on the wait list for this appointment. It can be two or more months before the surgical readiness appointment.
- Surgical Readiness Appointments: This is where the fun really begins. These are two appointments, or possibly one appointment with two people if using telepsychiatry services. Each appointment is one hour. One way that these appointments have been described is that they are like a university level oral examination. The amount of information that the person seeking surgery is required to know is quite extensive, and it is up to the individual to do their own learning. The document, which has been posted by various people online through social and other media, provided by CAMH when this appointment has been set states:
As part of your approval, you will be asked and expected to verbally describe to us: (1) the surgical procedures involved in the surgery you are pursuing (e.g., How would you describe what happens in this surgery?), (2) your awareness of the medical risks involved (e.g., What are the common risks associated with major surgery generally, and with this surgery specifically?), and (3) a clear and reasonable aftercare plan regarding your recovery (e.g., How will you get home? Who will be looking after you when you get home?).
This is a lot of information to have to know going in to an appointment. If one is not able to answer these questions to the satisfaction of those performing the assessment, one may be denied approval for surgery until a later date. Once these appointments are over the wait continues.
- Another case meeting: After the surgery readiness appointments the staff have another case meeting, which can take another eight weeks to happen. During this case meeting they decide whether or not to recommend surgery. For genital surgeries two referral letters are then sent to the surgeon’s office, at this time Dr. Brassard’s office in Montreal. A letter is also sent to the Ministry of Health requesting that funding for surgery be approved. The approval and subsequent funding letter from the ministry takes about a month or so from the time they receive the funding request from CAMH. The ministry sends copies of the funding letter to CAMH, the person seeking surgery, and to the clinic where the surgery will take place.
- Surgery date is set: Once the funding letter is in hand, the date for surgery can be set. For those seeking vaginoplasty the wait time from this point is approximately four months. For those seeking metaidoioplasty or phalloplasty can face a wait time of up to eighteen months from this point. Once the surgery date is set, there is no further need to deal with the CAMH clinic.
From the time CAMH receives the questionnaire to the surgery date: 35 to 59 months depending on the type of surgery, 31 months of which is time waiting for CAMH.
Hopefully this post helps put things in perspective when it comes to health care access for trans people. It is important to note that the length of time one has to wait to complete medical transition increases the risk of suicide. (Intervenable Factors Associated with Suicide Risk in Transgender Persons) There are many services that are not adequately funded or provided for in Ontario, this is a case where a regulatory hurdle is in place that unnecessarily limits access to health care for trans people.