Should sex reassignment surgery be covered by the government? By Matt Turnbull

By Matt Turnbull

In an ideal world, it would be possible to provide sex reassignment surgeries to anyone who wanted them.  However, in our current situation there are already ludicrously long wait times for surgeries pertaining to life-threatening illnesses and other necessary procedures, as well as shortages of surgeons and hospital beds, especially in certain areas of the country.  It is crucial that these issues are dealt with before we can even consider adding less directly life threatening surgeries to the healthcare umbrella.

The OHIP Schedule of Benefits, which essentially details what is covered by OHIP, specifically states that insured procedures must be “medically necessary”.  It gives as an example of an uninsured procedure “... a service that is solely for the purpose of altering or restoring appearance.” [1]  So it must be shown that sexual reassignment surgery is a medical necessity, and not merely a cosmetic change.  There must be some kind of mental stress or life impairment caused that would be fixed by surgery.   

Interestingly, the Schedule also states that for reconstructive surgeries, “Although surgery solely to restore appearance may be included in this definition under certain limited conditions, emotional, psychological or psychiatric grounds normally are not considered sufficient additional reason for coverage of that surgery.” [2]  So even if there’s significant psychological stress due to being transgendered, for most appearance-altering surgeries that’s not enough to get coverage.  Currently, the only procedures covered relating to psychiatric difficulties are electroconvulsive therapy and some neurological assessment tests.  Psychological assessment is excluded, even though some psychiatric consultations are included in the Schedule. [3]

This isn’t at all to say that there is something psychologically “wrong” with transgendered persons.  It is merely to highlight that stress issues and other life-impairing problems which are not physical in nature are not necessarily covered by government health care.  There is a much stronger focus on physiological problems which directly affect physical livelihood. 

It would be foolish to assume that all the surgeries covered by OHIP are absolutely necessary to stay alive.  It is true that some relate to improving a standard of living caused by an ongoing difficulty, and in some cases reversing the effects of a voluntary behaviour.  However, just because certain surgeries don’t fall within the purview of this article doesn’t mean they shouldn’t also be reviewed based on their medical necessity when there are other more directly life-threatening surgeries being delayed.   

Of 15 types of major surgery, two have actually had a significantly increased wait time, and two have shown no significant change, despite programs in place to decrease Ontario’s famously poor wait times.  As of September 2009 figures, general surgery still has a wait time of 107 days, ophthalmic (eye) surgery has a 115 day wait, and it can take 112 days to get an MRI.  Even cancer surgery has a 65 day wait period according to the most recent figures – and that’s decreased from 81. [4][5] Why add another surgery to our overtaxed medical system when wait times are already long, hospitals are overcrowded, and surgeons are in short supply?  Is this really an equivalent medical concern to heart bypass or eye surgery, where wait times have significantly increased despite our efforts?  Medical time and resources should be going towards essential and life-threatening treatments, especially if the money is being supplied by taxpayers and donors.  

It’s always possible to undertake the surgery voluntarily.  This may be expensive, but if the cognitive dissonance caused by being transgendered is so high, wouldn’t it be worth the cost?  In order for the surgery to be paid for by the government, it would have to be shown that it caused such a high degree of stress and disruption that it strongly impacted an individual’s personal life, likely to the extent that they couldn’t function properly in their daily life and workplace and thereby gain the means to pay for it themselves.

Some public and private insurance companies, as well as some employment benefits insurance plans, are now including sex reassignment surgeries as part of their coverage.  Examples include the City and County of San Francisco, and IBM, and insurance carriers like Aetna and Cigna. [6] There have also been significant steps towards reforming the view of transgender issues and ensuring that equal and fair insurance deals and surgical treatments are given to transgendered persons. [2] This is fortunate not only because it represents a more inclusive and knowledgeable approach towards transgender issues, but also because it provides an opportunity for these surgeries to be offered without overtaxing the public medical system.  These private means of securing sex reassignment surgeries, or at least subsidies for them, should be encouraged and broadened across more socioeconomic strata and employment types to provide wider and more equitable access without detracting from our limited public health resources.

Not committing taxpayer dollars transgendered surgeries when it is intended for patients in medical need isn’t a form of condemnation so much as a lack of facilitation – and they are different.  Even when not covered by the government the means are costly, but available.  It would be nice to be able to provide the surgeries and the services but in the current state of Canadian medicare resources are better spent taking care of patients with health-threatening issues, reducing wait times for necessary surgeries, and building infrastructure, especially in underserviced areas.  And maybe one day we will have the surgeons and resources to provide sexual reassignment surgeries under OHIP but until then, more directly threatening medical needs must come first.