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Avid cyclist Gavin Wyer, a former prison guard in Regina, had female-to-male genital reconstructive surgery in Serbia in 2012.

CHAD HIPOLITO/The Globe and Mail

The human rights, health issues and social challenges experienced by people with changed or changing gender identities stepped beyond the activism of a few to become mainstream policy debates of governments, schools and health institutions in 2015. James Goldie, a winner of Langara's Read-Mercer scholarship, examined the personal journeys of three people at different points along the path.

At a private hospital in Serbia, where the nurses had long painted fingernails and wore high-heeled shoes, Gavin Wyer wondered if he was going to die.

"God, do I trust these people?" he had been asking himself before his operation. "What if they do some huge screw-up? What if they knock me out and take my organs?"

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It was December, 2012, and Gavin was at the Belgrade Center for Genital Reconstructive Surgery, about to take the next step in his female-to-male transition. He had been living as a man for almost two years and knew this operation was what he needed to finally feel he was living in the right body.

It was, to his surprise, when he returned to British Columbia that Gavin's life-and-death ordeal would begin. He developed serious complications. Thousands of miles from the surgeon, bleeding uncontrollably, he found there was nowhere to go for help.

"The lack of aftercare was really a nightmare," he says. "There was no one."

Sex-reassignment surgery in Canada is now publicly funded in every jurisdiction except New Brunswick, Nunavut and the Northwest Territories, though coverage varies. But a private Montreal clinic is the only place that offers "bottom" surgery – genital reconstruction – and hormone therapies can be difficult to come by without co-operative doctors.

In addition, simply getting into the clinic involves a long wait.

In May, the Provincial Health Services Authority's steering committee on transgender health announced a series of recommendations for the B.C. Ministry of Health to improve services for transgender people across the province. Among these recommendations: a call to fund aftercare costs following surgery in Montreal, which can run anywhere from $500 to more than $2,000, depending on the operation.

The authority is also recommending that the ministry cover surgeries at clinics outside of Canada and produce a feasibility study for a gender-affirming surgical program in B.C., eliminating the need to send patients to Montreal or abroad for lower surgeries.

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Last month in Ontario, for example, the provincial government announced that people needing a medical referral for sex-reassignment surgery could obtain one from any qualified health-care provider, changing a policy that allowed only doctors at the Gender Identity Clinic at the Centre for Addiction and Mental Health in Toronto to make referrals. As of last month, there were more than 1,150 people on the waiting list for referrals.

Gavin first began his transition in 2010. At the time, he was still "Kari," a 52-year-old woman who identified as lesbian, working as a corrections officer at the Regina Provincial Correctional Centre.

One day, he happened to watch interviews with Chaz Bono, the transgender son of Cher and Sonny Bono.

"That was the first trans man I had ever seen in my life," he says. "I knew trans women existed. I knew that you could do that. But I had never heard of trans men."

It was a light-bulb moment. A lifetime of struggling to understand who he was and why he'd always felt so incongruous with his female body suddenly made sense.

"When I came out as lesbian, I knew it didn't fit. But I didn't know what else did fit," he says.

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Gavin realized that all his life, he hadn't been a lesbian struggling to fit into heterosexual society, but a transgender man trying to fit into an identity he was assigned at birth.

Even his choice of profession made sense to him now.

"When you put on a corrections uniform, you put on the persona that goes with it," he says, describing it as a career in which masks are a part of the job. "You become who you need to be."

Over the next two years, Gavin legally changed his name, began taking testosterone and underwent a hysterectomy and chest surgery to remove his breasts.

Gavin's co-workers were supportive. He believes the bond between them as guards trumped any prejudice or preconceived notions about trans people.

He anticipated harassment from the inmates, but it never happened. "Beard's coming in great," some said. Others commented positively on his new "man voice."

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"A real factor is that I was transitioning female to male. Had it been the other way, it would have been a whole different story," he says. "Male privilege is very real. … As soon as I looked like a man and sounded like a man, I [was] treated differently, even by prisoners."

Although his work life didn't suffer because of his transition, by 2012 Gavin was still looking for a change. He longed to return to B.C., where he grew up.

He also planned to undergo genital reassignment surgery. In his case, he wanted a metoidioplasty, a procedure in which the clitoris is made into a penis through a complicated series of ligament cuts, skin grafts and the lengthening of the urethra.

At the time, this procedure was not covered in B.C. or Saskatchewan. He would have to pay out of pocket. At the GRS Clinic in Montreal – the only option in Canada – the surgery alone would cost about $45,000. Costs were even higher in the United States.

So he chose the clinic in Serbia run by Dr. Miroslav "Miro" Djordjevic.

"I liked the work that I saw Miro doing," Gavin says. He found him through online research. "It wasn't just the price."

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Receiving patients from abroad is normal for Dr. Djordjevic.

"From 2006 to now, we've performed more than 500 cases from abroad," he says, adding that more than 30 of those patients have been Canadian. "We really have patients from all parts of the world. From Japan to Canada. From South Africa to Norway and Sweden."

Gavin had done his research and knew there would be risks. He stayed in Belgrade for a month, close to the hospital in case he had any problems. Still, he was in rough shape when he arrived back in Canada.

"I was really unhappy that they sent him home," says his sister, Sandra. "When I picked him up at the airport, he could barely stand up. My husband practically had to carry him."

Dr. Djordjevic says that some "minor complications" such as swelling, prolonged bleeding or difficulty healing may occur after surgery, but "it's possible to follow up by myself using … e-mail or by general practitioner in their country."

Gavin was experiencing all of these conditions, which only worsened.

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Sandra, who had no medical training, spent every night taking care of Gavin's wounds with sterile bandages and equipment she purchased at a local rehab supply shop. Within the first week, a number of complications arose, but Gavin resisted going to a doctor.

"Gavin was convinced that no one would help him because he's transgender," Sandra says.

This fear is not unique.

In 2013, the Trans Pulse Project in Ontario released a study that found 12 per cent of transgender emergency department users reported an emergency health provider refused to examine parts of their body because they were transgender. Twenty-one per cent of the study's participants reported avoiding going to an emergency room out of fear their status as transgender would be negatively received.

However, when Gavin's stitches began dissolving prematurely, causing the recently grafted tissues to separate, there was no other choice but to seek emergency medical attention.

Sandra took him to Abbotsford Regional Hospital. The ER doctor who examined Gavin was kind and wanted to help, but he had never seen, let alone repaired, a metoidioplasty. He admitted he had no idea what to do.

The only person in B.C. trained to perform (or repair) sex-reassignment surgeries is Dr. Cameron Bowman, a plastic surgeon in Vancouver who says the province's lack of a centre for transgender surgery is why people find themselves in situations like Gavin did.

"The current model is poor," he says, pointing out that whether transgender people go to the GRS Clinic in Montreal (where lower surgery is covered by B.C.'s medical services plan) or leave Canada and pay themselves, the procedures are inherently complex and require proper aftercare.

"[Patients] come home and they have no follow-up. I just don't think that's smart. It's not safe, it's not ethical."

If patients return to B.C. and experience non-life-threatening complications, they must go back to the original surgeon for any corrections.

Despite his painful ordeal, Gavin doesn't regret his decision to pursue sex-reassignment surgery. He only wishes there had been options closer to home and that the health-care system in B.C. had been properly equipped to help him afterward.

But Gavin has also come to realize that surgery, for those who need it, is just one part of being transgender.

"I really believed going in that transition was going to be entirely about medical, physical transition," he says. "Yeah, way wrong."

Gavin now works as a security guard in Victoria. He's an active member of a local synagogue, he enjoys cycling and dinners with friends. He's healthy and happy, but his journey isn't over yet.

Two years after surgery, Gavin says he is still learning new things about himself every day. He compares it to being a teenager all over again, figuring out who he is – sexually, spiritually, socially.

"When you do such a massive change, particularly when it's about self-authenticity, anything else that is buried is going to come up," he says. "Anything you haven't dealt with already, it's coming."

Editor's note: A previous version of this story included an incorrect spelling of Gavin Wyer's last name. The story also said he was 50 years old when he began his transition. In fact, he was 52.

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