The road to gender-affirming care is complex and expensive: ‘Even if something is big-C covered, it’s not little-C covered’

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When Magan Carty got their date for top surgery in August, 2022, they had roughly four months to pull together about $4,000.

Mx. Carty, a 31-year-old radio producer in Toronto, had been seeking top surgery since March, 2020. It took a year and a half to get a referral letter from a qualified doctor. Then came the nine-month wait for approval from the Ontario Health Insurance Plan. Even though there was no reason to think they wouldn’t be approved for coverage, Mx. Carty was nervous. “Because without it, it’s about $10,000.”

The approval came through in June. But while OHIP covers the surgery to remove breast tissue, costing $6,500, it doesn’t cover the $3,500 chest masculinization procedure. Mx. Carty, who also paid $300 for a chest compression vest and $500 in taxes on the surgery, had to pay the full amount before the procedure.

At the suggestion of their roommate, they started a GoFundMe campaign, setting the goal at $2,000 and paying a little more than $2,000 from their own savings. Though they knew there would be expenses, Mx. Carty said they were “adamant” the surgery had to be done “for my well-being.”

And the crowdfunding campaign was a success: “I was overwhelmed with people who wanted to help me.”

Trans and non-binary Canadians seeking gender-affirming care often need to not only navigate a complex path to approval and wait times for provincially covered surgeries but also potentially plan for out-of-pocket health care costs, which can run from hundreds to tens of thousands of dollars, prompting them to dig into their own savings, launch crowdfunding campaigns or take out medical loans – or to put off care indefinitely.

“It can get very expensive very quickly,” said Laura Whiteland, a certified financial planner and founder of Inclusive Financial Planning in Truro, N.S. “With provincial health insurance, it’s a very specific category of things that they’ll cover.”

Accessing publicly funded gender-affirming health care depends largely on where a person lives. All provinces and territories cover transition-related surgeries, but most require approval and referral from one or two medical professionals.

There are also exceptions: While all provinces cover surgeries to remove breast tissue, many do not cover the contouring procedures that make a chest look more masculine. Most public plans don’t fund breast augmentation or only cover it under certain conditions.

But there can be more to someone’s transition than just those surgeries, including facial feminization surgeries, vocal surgeries or voice training, liposuction and other body contouring, or hair transplants or removal.

Facial feminization procedures run from between $10,000 to more than $15,000. Laser hair removal or electrolysis can costs hundreds of dollars. Voice training specialists typically charge $60 to $150 an hour. According to 2021 figures from the Aesthetic Society, a California-based association of plastic surgery and cosmetic medicine professionals from the United States and Canada, body contouring procedures such as liposuction cost more than US$2,000 each. Yukon pays for all of these (its coverage is considered the best in North America) but most public plans cover only some or none.

Riley Nielson-Baker, executive director of Gender Affirming Care Nova Scotia, an advocacy and policy organization, said a transition is often highly dependent on “who you can afford to see and the quality of care you can afford.”

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The Canada Health Act entitles Canadians to medically necessary health care. Procedures seen as cosmetic are excluded, though provinces have leeway to decide what medically necessary means. Advocates argue that gender-affirming care that isn’t currently publicly funded should fall under medicare, as research has demonstrated an ability to access to such care improves mental health and reduces suicide risk.

Mx. Nielson-Baker said better provincial coverage would also contribute to trans and non-binary Canadians’ economic security “because people are no longer trying to privately fund their own procedures” and could instead focus on other financial goals.

Even for surgeries covered by the public system, other expenses crop up, Ms. Whiteland said. There are only three clinics that perform surgeries such as vaginoplasties and phalloplasties – in Montreal, Toronto and British Columbia – and travel and accommodation costs are rarely covered. Most surgeries require days or weeks off work to recover.

As well, not all provinces fund the cost of mental-health professionals or hormone therapy, despite some requiring an assessment from a psychiatrist or a certain amount of months on hormone therapy to be approved for surgeries.

“Even if something is big-C covered, it’s not little-C covered,” Ms. Whiteland said. “I travel an hour to see a specialist for hormones, and it’s not uncommon to travel 100 to 300 kilometres to get to a doctor who will even prescribe those.”

Canadian employers have started adding financial support for gender-affirming care as part of organizational diversity, equity and inclusion initiatives and to attract top talent. Twenty-one per cent of Canadian employers cover gender-affirmation benefits and a further 33 per cent are interested in covering them, according to a 2022 survey of more than 500 employers and other benefits-plan sponsors by trade publication Benefits Canada.

In the past few years employers including most of the big five banks, the University of Toronto, KPMG Canada, Molson Coors and Toyota Motor Manufacturing Canada have added coverage to their plans. Toronto Dominion Bank and Accenture were among the first to offer such coverage, dating back more than a decade ago.

The public service health care plan, which covers federal employees, has one of the most generous plans, covering gender-affirming procedures up to a lifetime maximum of $75,000.

The benefits generally fill in the gaps of provincial or territorial health plans, said Stephanie Lue-Kim, principal of total health management at employee benefits consulting firm Mercer Canada.

Ms. Lue-Kim has seen more companies show interest in such benefits. “Employers understand they need to match benefits to the current population’s needs, one of which is gender affirming care,” she said.

Mx. Carty said they have known they wanted top surgery since they were 19. But if they had actually tried to pursue it at that time, the cost would have been an insurmountable barrier.

“If you don’t have the money or a way to pay for it, it stops you before you can even start.”

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