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Chrystofer Maillet pose for a portrait at his home April 14, 2015 in Ottawa.

Dave Chan/The Globe and Mail

It took years of suffering and soul searching, but when Chrystofer Maillet decided to make the transition out of the female body in which he had never felt comfortable, he knew he was ready for the change.

One thing stood in his way. Mr. Maillet, now 35, was told he would have to wait one to two years for an initial assessment at the Centre for Addiction and Mental Health's (CAMH) Adult Gender Identity Clinic in Toronto, the lone site for sex-reassignment approvals not just for Ontario, but for Newfoundland and Labrador and, until last year, Saskatchewan, too. Unable to endure the wait, Mr. Maillet put nearly $7,500 on a line of credit and paid for a double mastectomy, a procedure the Ontario Health Insurance Plan (OHIP) would have covered if he had managed to secure CAMH's blessing first.

Mr. Maillet is not alone. As the demand for sex-change operations has grown, so too has the line at CAMH. The psychiatrist who leads the small Adult Gender Identity Clinic says the Ontario government's decision to make one facility the sole gatekeeper for these procedures "really isn't working," especially considering that trans people who want to switch genders but have yet to begin the process are at an elevated risk for suicide.

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The bottleneck at CAMH is just one example of the barriers to medical care that Canadian trans people still face, despite the fact that every jurisdiction except New Brunswick, Nunavut and the Northwest Territories now publicly funds at least some gender reassignment surgeries. Coverage varies from place to place, and it remains difficult to obtain surgeries and the hormone treatments that should precede them. A private Montreal clinic is the only place in Canada that offers "bottom" surgery – genital reconstruction – while trans people who need estrogen or testosterone to begin their transitions often struggle to find co-operative doctors.

"We're not quite hitting the mark as a country," said Adrian Edgar, a New Brunswick doctor who opened that province's first trans-friendly health clinic earlier this year inside Fredericton's former Morgentaler clinic. "I don't think there's a province that is providing the full gamut of surgeries that would truly decrease the discrimination that people feel on a daily basis."

Waiting for gender reassignment surgery can have serious consequences, said Greta Bauer, an associate professor of epidemiology and biostatistics at the University of Western Ontario in London.

"People's lives are actually at risk," she said.

Dr. Bauer is one of the lead researchers on the Trans PULSE project, which studied 433 Ontario trans people who responded to an 87-page questionnaire in 2009-2010. It found that people who had decided to transition but had not begun to do so were often suicidal – 55 per cent had considered suicide in the past year and 27 per cent had tried to take their own lives. Those figures plunged after people transitioned to their desired gender.

Mr. Maillet found himself in that high-risk category when he decided to pay out of pocket for his double mastectomy on March 3, 2013.

In a Jan. 28 decision dismissing his $7,401.50 OHIP claim, the quasi-judicial board that hears appeals of OHIP rejections acknowledged that Mr. Maillet was suffering as he awaited surgery. "He explained the difficulties he experienced and the delays in obtaining an appointment at CAMH," the decision reads. "He explained that he made the decision to undergo surgery to 'save his own life.'"

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Despite the fact that Mr. Maillet received CAMH's retroactive blessing when he finally secured an appointment – on Dec. 3, 2013, nine months after his surgery – the Health Services Appeal and Review Board ruled against him, writing that although his case was "very compelling," the rules are clear. No CAMH pre-approval, no public funding.

By the time he made his plea to the board, Mr. Maillet had spent nearly a lifetime wrestling with gender dysphoria. He grew up in Riverview, N.B., where, as he put it in an interview, "there weren't even gay people there."

His parents still love him, he said, but they are baffled by his decision to become a man. His father insists on calling him Christine.

"Really, what was I going to do? I always wanted to be a boy. You can see pictures that my family took of me from the age of three until forever. They're all, like, building forts in the backyard or playing Dukes of Hazzard or playing with Transformers. Not typical feminine or female things. I never went for that. I never was interested – at all."

About a decade ago, Mr. Maillet moved to Ottawa to make a fresh start. Identifying as a lesbian, he fell into an abusive relationship from which he eventually escaped. Then he landed a federal government job, made a small circle of friends and gained confidence as a singer performing now and then at pubs in the capital. Meanwhile, he dressed as a man and introduced himself simply as "Chrys."

It was during a month-long solo hike on Spain's Camino de Santiago trail in 2010 that Mr. Maillet finally decided to make the medical transition to become a man. When he returned to Ottawa, he started testosterone treatments, which prompted his voice to drop, his leg hair to thicken and his muscles to bulge. He was sad to lose his female singing voice, but otherwise he "felt amazing."

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"It was like, this is exactly how I want to feel," he said.

Unfortunately, his bulked-up chest muscles made his breasts larger; before long he was hunching his shoulders and suffocating under chest binders designed to camouflage his breasts. When he learned about the waiting times at CAMH, Mr. Maillet found an Ottawa plastic surgeon who agreed to perform the mastectomy after spending more than three hours assessing him to ensure he met the criteria for approval set by the World Professional Association for Transgender Health (WPATH) – the same standard of care used by CAMH. (The WPATH standards vary depending on the surgery, but they include a persistent, well-documented diagnosis of gender dysphoria, that the patient be in good mental and physical health and, in some cases, that he or she take hormones and live as the desired gender for a year.)

The surgery was a success, but losing his OHIP appeal made him feel hopeless. "I want to get married. I want to have kids. I don't know if I'm ever going to be able to move into a house with the debt that I'm sitting on," he said.

Dr. McIntosh of CAMH said the Ontario government needs to rethink the approval process as demand continues to surge. The clinic approved 177 surgeries last year, he said, up from 59 in 2010, but staff can't keep pace with the need. The Ministry of Health and Long-Term Care, meanwhile, said it doled out nearly $2.2-million on gender reassignment surgeries in 2014-15, up from just more than $22,000 in 2008-09, the year the procedures were relisted under OHIP after a 10-year hiatus.

"We certainly support people being able to access these services closer to their own communities," Dr. McIntosh said. "We're not tied to this model of us being the only game in town."

For its part, Saskatchewan added a second site – out of province in Edmonton – for surgery approvals last year to increase access. Newfoundland still lists CAMH as its lone approval site. Some other provinces, including Nova Scotia, which only began covering gender reassignment surgeries last year, allow family doctors to grant approvals using the WPATH standards.

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David Jensen, a spokesperson for Ontario's Ministry of Health and Long-Term Care, said by e-mail that "the ministry is aware of concerns related to wait times at CAMH and is exploring options to improve wait times."

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