Casper Slack received a major surgery at the Ottawa Hospital on March 25 — a double mastectomy with chest contouring, also known as masculinizing top surgery.
Before they could get on the operating table, Slack needed to run through a laundry list of obstacles: obtaining a community organization referral, waiting months for appointments with the Ottawa Hospital’s family health team, answering OHIP screening questions and launching a fundraising campaign to cover uninsured parts of the surgery.
“Once I got to see [the surgeon], it was amazing,” said Slack, a local freelance artist. “The many years of time leading up to that, I could’ve done without.”
Receiving critical health care anywhere in Canada is tricky enough for most people, but transgender and gender-diverse people in Ottawa seeking gender-affirming care find even more barriers in their path.
Gender-affirming care is an umbrella term for processes that “support and affirm an individual’s gender identity,” according to the World Health Organization. This includes practices such as voice training, hormone replacement therapy and surgical procedures like double mastectomies and vaginoplasties.
In Ontario, a family doctor can prescribe gender-affirming hormone replacement therapy (HRT) if they have chosen to complete training on gender-affirming care practices, HRT treatment and responsible prescription practices. However, training takes years to complete — something not all family doctors have time to do.
This presents inconsistent barriers, where some transgender and gender-diverse people can access gender-affirming care directly through their family doctor, while others must seek out specialists.
As for surgical procedures, surgeons at many hospitals can perform gender-affirming surgeries such as hysterectomies. In September 2023, the Ottawa Hospital opened a specialized gender-affirming surgery clinic, offering masculinizing top surgery (double mastectomy), feminizing top surgery (enhancing breast size), facial surgery and bottom surgery to transform genitalia.
People in Ottawa seeking gender-affirming surgeries may also travel to the Women’s College Hospital in Toronto or Montreal’s GrS Montréal clinic.
Sydney Renaud, a master’s student in feminism and gender studies at the University of Ottawa, said doctors typically follow an informed consent model when prescribing gender-affirming health care. She said this contrasts the former approach that required a full psychological diagnosis before treatment.
The informed consent model involves doctors disclosing information to patients so that they can “make an informed decision about their own health care,” according to Healthline.
When assessing a request for gender-affirming care, Renaud said local doctors use a “weak” informed consent model, as they ask patients informal screening questions to gauge whether they match “general conventions.” These conventions include assessing the patient’s reasons for transitioning and if they experience gender dysphoria — a legacy of the strict psychiatric and pathologizing model used by many organizations until the 2010s.
Slack said they went through mandatory OHIP screening questions before they could get in touch with a surgeon. They said the questionnaire asked if they considered the impact their surgery could have on their family or employers.
This information-gathering process felt like cisgender people deciding whether they were “trans enough to get top surgery,” they said.
“These are definitely cis people asking questions that, in my mind, make no sense,” Slack said.
The sequence of events for receiving gender-affirming care generally includes the individual receiving a doctor’s referral, completing OHIP screening and then accessing care.
A prescription won’t always suffice to get someone the gender-affirming care they need. When Ottawa resident Zandy Pothier received a referral from a specialized Centretown Community Health Centre endocrinologist to start feminizing HRT, she had her prescription filled at a local pharmacy and started taking one pill a day, as instructed by the pharmacy — until she saw her endocrinologist again and learned she was meant to be taking two pills all along.
“I can’t prove that it’s malice, but it did feel very negligent of this pharmacy,” Pothier said.
After re-visiting her endocrinologist to ensure her two-pill-a-day treatment could become a well-established routine, Pothier was able to consult with her family doctor for quicker access to medication refills.
Based in a downtown Ottawa clinic, the CCHC’s interdisciplinary team includes counselors, social workers, a registered nurse and medical receptionists, as well as a medical doctor and nurse practitioner who can prescribe treatments.
Slack also went through the CCHC’s self-referral program to access top surgery. After hearing back from the clinic, they waited eight months for an appointment.
“Outside of how long it took, it was wonderful,” they said.
Holly Brown, the CCHC’s trans health clinic and program lead, said she’s frustrated by these wait times.
“Sometimes I wonder if people are thinking, ‘What are they doing back there?’” she said, explaining these issues persist despite improvements to the system. She said the CCHC actively connects with local health-care providers to improve access to gender-affirming care.
However, the trans health clinic only operates two days a week, according to Brown. Its waitlists have been closed for the better part of the last two years, meaning no new patients can join the clinic.
“We’ll open for maybe 10 weeks and then close again and stay closed,” Brown said.
CCHC’s patients aren’t the only ones dealing with long wait times.
Based on the automated response for his office, Ottawa Hospital plastic surgeon Dr. Nicholas Cormier currently has a wait time of 12-24 months for routine gender-affirming surgeries.
Still, Slack chose the Ottawa Hospital for their surgery. This led to an extra complication, since having the procedure done at the Ottawa Hospital wasn’t entirely covered by their provincial health insurance.
Slack said they were discouraged by GrS Montréal’s weight requirements, as the clinic prefers to operate on patients within the body mass index (BMI) range of 18.5-25.
“Even though I technically was under the maximum BMI requirement, I was within what they consider a risk zone,” Slack said. “I just don’t trust people who use BMI. To me that says you don’t know how to do the surgery on fat people, and I don’t want to go to you.”
Slack chose the Ottawa Hospital, rather than GrS Montréal, so they could work with Dr. Mario Jarmuske, a uOttawa professor and chair of the hospital’s plastic surgery division. Jarmuske was part of a 2021 study which concluded it was entirely possible to offer masculinizing top surgery to patients with a BMI range between 30 and 40.
While OHIP can cover the cost of the chest contouring component of top surgery at GrS Montréal, Slack had to pay $4,000 out of pocket for this portion of their surgery at the Ottawa Hospital.
Insurance coverage can be a deciding factor in these situations, as Pothier said her HRT would be “prohibitively expensive” if not paid for by her insurance.
In an anonymous survey conducted by the Charlatan, 15 people who sought gender-affirming care in Ottawa shared their experiences, and several respondents attested to paying for part or all of their HRT costs.
Taking time off work to recover from surgeries also has a cost.
“I have basically had to do six months’ worth of work in the last three months so that I can afford my rent while I’m healing,” Slack said.
Money is also tight for service providers such as the CCHC, according to Brown.
“We’re severely underfunded given the true need in the region,” she said. “We have applied for very substantial proposals, pots of money, for bridging some of these gaps and we’ve been unsuccessful with all of them.”
More than half of survey respondents expressed worry about the future of gender-affirming health care, citing issues like diminishing access and funding, long wait times and increased public pushback.
One Ontario doctor who provides gender-affirming care, who asked not to be identified for professional reasons, said she is worried recent media coverage around transgender people might discourage medical providers from prescribing gender-affirming care out of concern that the patient will regret the procedures.
According to an article published in the Plastic and Reconstructive Surgery Global Open journal, regret rates after gender-affirming surgery average to one per cent. By contrast, an article published in the BMC Musculoskeletal Disorders journal indicated that the regret rate after knee replacement surgery averages between six and 30 per cent.
The political framing of regret rates can either empower transgender people or lead to a distortion of the rates.
“The future does depend on who our elected representatives are over the next few years,” Pothier said.
To Slack, the situation feels precarious, even if recently re-elected Progressive Conservative Premier Doug Ford “doesn’t particularly target trans people.”
“He hasn’t done anything so far and you just hope he won’t again for the next couple years,” they said.
“Either it’s going to stay the same or get worse,” Pothier said. “I don’t want to be too bleak about this, but I don’t see it getting better anytime soon.”
Nonetheless, Ottawa’s trans community — and the broader medical community — are ready to respond to these pressures.
“Pretty much everything we’ve accomplished has been done on a shoestring,” Brown said, adding that while the CCHC might not be able to grow and provide new services, it will continue its permanent operations.
The doctor said she was optimistic about the slow-going process of training more medical providers in Ottawa to practise gender-affirming care. She said many family doctors are interested in providing gender-affirming care and are receiving as much training in the field as their workload allows.
Another recent health-care development might change the game for access to gender-affirming care: nurse practitioners will soon be able to fund their services with OHIP. The new rules come into effect on April 1, 2026.
Unlike registered nurses, nurse practitioners can prescribe some treatments. Without their services being reassigned under OHIP coverage, they could only work out of private practices or other doctors’ offices — until now.
“Those nurses are generally some of the first that are willing to support medical transition needs,” Brown said. “To have nurse practitioners with that new ability is great.”
Featured image by Jaya Budhia/the Charlatan archives.
