Facial gender-affirming surgery should be publicly funded: doctors

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A transgender woman has lost her appeal to have Ontario pay for surgery to soften her masculine facial features.

Facial feminization surgery can provide results that can’t be achieved with hormones alone, surgeons have reported, and can allow trans feminine individuals “to be recognizable as women to others.”

But critics say governments must draw the line somewhere.

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“Why should this quickly growing identity group be entitled to services that others are not,” said Pamela Buffone, founder of the Canadian Gender Report.

In the Ontario case, the transgender woman, M.F., who suffers from severe gender dysphoria, and whose identity is protected under a publication ban, sought surgery for a pronounced Adam’s apple and prominent forehead, facial characteristics that don’t align with her self-identified gender.

M.F. received a letter last September from Ontario’s health insurer, denying her request for approval of payment to undergo a tracheal shave and brow reduction at a Montreal clinic specializing in facial feminization surgery, or, alternatively, in Ontario, if need be. Administrators of the Ontario Health Insurance Plan (OHIP) argued that the procedures sought aren’t insured services under the Schedule of Benefits, and therefore not eligible for payment. The patient appealed to Ontario’s Health Services Appeal and Review Board, which upheld OHIP’s decision in a recently published ruling.

In submissions filed in the written hearing, M.F. wrote that her gender dysphoria is getting worse as she gets older, that her facial features “are causing her severe daily distress” and that she “hates being visibly transgender,” according to the board’s written decision. She argued that facial feminization surgery is necessary to cure her gender dysphoria. She has been on hormone therapy for more than a year but has “certain facial characteristics that are associated with males” because she went through male puberty.

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Since OHIP pays for “medically necessary” gender reassignment surgeries, M.F. argued that the province should also agree to cover the requested facial surgeries, which would cost less — roughly $15,000 to $30,000, depending on what’s done — than if she were seeking genital surgery.

She argued that the emphasis on sex reassignment surgery “reinforces outdated beliefs about there being only one way to transition and that many transgender people do not want genital surgery.”

OHIP, however, denied M.F’s request for surgery to reduce her Adam’s apple and reconfigure her brow, arguing the “specific sex reassignment surgery” she is seeking isn’t included among the gender-affirming procedures Ontario does cover, like external genital surgery, hysterectomies or mastectomies.

While acknowledging her argument that the facial feminization surgeries are medically necessary for her, the appeal board denied her appeal. The regulations are clear that a service must be referred to in the Schedule of Benefits in order to be eligible, the three-member panel ruled.

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Last year, an appeal board panel ruled that Ontario should pay for a non-binary resident who identifies as neither fully female nor fully male to have surgery to create a vaginal opening while leaving their penis intact, a “penile sparing vaginoplasty” than can cost upwards of US$70,000.

Yukon and Prince Edward Island are the only jurisdictions in Canada that cover facial feminization surgery, however, in 2021, a Manitoba trans woman successfully appealed Manitoba’s refusal to pay for facial surgeries.

“It is often easier, medically, for trans men to achieve changes that will result in passing,” said Dr. Sarah Fraser, a Halifax family physician who regularly treats trans and gender diverse people.

Pass is a term used more colloquially, Fraser said, “but, basically it means to be able to fit into society recognizable as one’s gender identity, instead of being perceived as the sex assigned at birth.”

“But for trans women, that can be a lot more difficult, especially in the case of this person (in Ontario) who has a prominent Adam’s apple,” said Fraser, who argued for public funding for minimally invasive procedures, like injectable fillers, Botox, and hair removal via lasers and electrolysis in a commentary published in the Canadian Medical Association Journal.

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Even with access to hormone therapy, “the desired aesthetic effects often take months to years to manifest,” Fraser and her co-author, Dr. Katie Ross, wrote.

Facial feminization surgery isn’t a minor procedure. It’s major surgery, Fraser said. Still, “I think it’s absolutely legitimate that this person was applying for public funding and I frankly think that it should be covered across the board,” along with minor cosmetic procedures, she said.

“When you look at the mental health of people who are trans and gender diverse, these surgeries can impact mental health substantially,” Fraser said. One study published in the journal, Annals of Surgery, found trans feminine patients who had undergone facial surgery reported less depression, less anxiety and less social isolation compared to a pre-surgery group.

“There is still a sense out there that these surgeries are considered aesthetic, or superfluous or something extra, and I think the concerns aren’t taken seriously because of the discrimination that exists at its roots,” Fraser said.

Facial feminization surgery “is just as important as genital surgery,” she said. “It’s your face that you’re presenting to the world when you’re getting a job and when you’re out and interacting with the public on a day-to-day basis.”

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Ontario’s ministry of health did not respond to a request for comment before deadline.

“The question for our health-care system is, what is medically necessary and which procedures should be publicly funded,” Buffone, of Canadian Gender Report, said in an email. “There are cancer patients who are left disfigured and distressed but who are not entitled to publicly funded facial surgeries or minor cosmetic procedures to reconstruct their appearance.

“What (M.F.) is requesting is for our health-care system to give special status to people who identify with this amorphous group called ‘trans’ and cater to any and every whim they have. Where do we draw the line?”

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