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A long road for publicly funded gender-affirmation surgeries

James Gardner is a much happier man after undergoing the first of three gender-affirmation surgeries paid for by the province. His procedure was one of an estimated 20 phalloplasty surgeries funded through the B.C. Medical Services Plan since 2015.
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James Gardner is a transgender man who has just had the first of three surgeries in Montreal, funded through B.C.'s Medical Services Plan.

James Gardner is a much happier man after undergoing the first of three gender-affirmation surgeries paid for by the province.

His procedure was one of an estimated 20 phalloplasty surgeries funded through the B.C. Medical Services Plan since 2015. The complex surgery, which creates a functioning penis out of tissue from other parts of the body for people transitioning from female to male, was deemed “experimental” by the ministry between 2003 and 2012.

“Most of us didn’t think we’d ever get it or have to wait up to 10 years,” said Gardner, a 58-year-old Victoria broadcaster. He underwent a radial forearm phalloplasty that involved extensive grafting of skin, arteries and nerves from his left forearm and expects to undergo the second part of the three-phase process this spring.

Gardner has yet to regain feeling in his arm, but said it has been worth it because he feels so much lighter, so much better.

“Not all trans men want these surgeries for various reasons and don’t feel they need them to be a man,” he said. “Others like me require these surgeries to feel ‘more congruent with our bodies.’”

He got MSP approval for the phalloplasty in early 2015, and that May travelled to the Montreal clinic where most surgery for B.C. residents is performed. On Sept. 26, 2016, he underwent six hours of surgery.

“It is very invasive,” he acknowledged, adding he needed three months off work to recuperate. “You have to have a lot of courage going into it, because it’s not a lot of fun.”

Not every transgender person — whose biological sex does not match their gender identity — chooses to have surgery. B.C. covers gender reassignment surgeries for those who want to alter their anatomy to match their gender identity.

• • •

The province reversed its ban on funding phalloplasty in 2012, but it was four years before anyone received the surgery. In 2014, health officials maintained that no one had come forward — a view at odds with a waiting list estimated at 100 people desperate for the life-changing surgery.

At the time, funded female-to-male surgeries were limited to five a year, even though male-to-female gender surgery has long been funded by MSP in substantial numbers.

The most recent figures show there were 115 lower-body surgeries for all transgender patients in 2015-16: 105 to create female genitalia and 10 to create male genitalia. From April 1 to Sept. 30, 2016, the most recent period for which figures are available, there were 30 lower surgeries, 22 for female genitalia, eight to create male genitalia.

It is not possible to confirm how many three-phase phalloplasties have taken place since MSP coverage was reinstated, but fewer than five people have had more than one procedure, said Brett Mineer of the Provincial Health Services Authority. The authority co-ordinates services for transgender people, working with the Ministry of Health, regional health authorities and trans representatives on a provincial model of care.

On top of gender surgery, the province pays for thousands of dollars worth of post-operative care in Montreal, which patients formerly had to fund on their own. Gardner’s first go-round required 12 days of recovery time in Montreal; he estimated the province paid about $5,000 for that.

Patient feedback made it clear that having to come up with such sums was “a barrier to care,” said Lorraine Grieves of Trans Care B.C., which works to improve co-ordination of transgender health services.

Since December 2014, B.C. residents no longer need to apply for MSP coverage for gender surgery but have been automatically covered if it was recommended by a qualified assessor. Candidates still must complete one or two surgical-readiness assessments to ensure they are prepared and have the best possible result, but a psychiatrist no longer has to sign off on gender-affirming surgery. “It’s more of a straightforward surgical referral,” Grieves said.

As well, more B.C. doctors and nurses are being trained in follow-up care for transgender patients in case of complications that can occur once patients have returned from Montreal, she said.

Gardner said complications can include anything from urological issues to graft sites on forearms, deep wounds that take months to heal.

He expects to go back to Montreal by May for construction of a urethra to allow urination while standing up. Stage three will be the insertion of testicle implants and a penile implant, an inflatable erection device, he explained. “That’s it.”

• • •

Almost all gender-affirming genital surgeries for B.C. residents are performed by three Montreal specialty surgeons in a private clinic, although Trans Care B.C. and MSP are working to provide services at several American centres.

“In the meantime, we need more access to surgeons in the U.S.,” Gardner said, noting, “Some B.C. trans men are being given this option on a case-by-case basis.” Different surgeons have different techniques, including using the thigh or abdomen as the donor site for phalloplasty.

Grieves said transgender people need health-care options closer to home.

“We would love to see this care happen in B.C.,” something she said would be “quite do-able in five years’ time” with the right resources, planning and surgical recruitment.

Gardner is happy that gender surgery now comes under the auspices of Trans Care B.C.

“Since they’ve taken over this specialized program from MSP, they have been a lot more respectful and inclusive in their consultations with the transgender community,” he said. “We are getting there.”

He felt he was “treated like a child” when contacting MSP; now he can call up Grieves when he needs to talk about something. “She keeps us in the loop.”

Transgender patients are still responsible for their own travel expenses for surgery.

“Those who have financial difficulty can get their airfares covered through Hope Air,” said Gardner, adding for him it’s tax-deductible as a medical expense. (Hope Air arranges free flights for financially disadvantaged people who need health care.)

“We are the first to go for these surgeries, and they don’t yet know what we need,” he said in an email to the Times Colonist. “They are starting to get a better idea. There is no blueprint for this; we are all pioneers.”

kdedyna@timescolonist.com