Medical Affirmation
Medical affirmation may involve the suppression of monthly bleeding, puberty blockers, electrolysis for hair removal, surgery, and gender-affirming hormone therapy. For those who seek them, medical interventions can be a critically important part of how 2STIGD individuals affirm their gender. Medical forms of affirmation are not only medically necessary, but life saving.
It is important to note that some 2STIGD individuals may choose to socially and medically transition, but not surgically transition. Alternatively, individuals may socially and surgically transition, but not desire to medically transition. Each individual will have different goals and expectations, all of which are valid.
On This Page
Where To Get Care
Paediatrics – Child/Youth
Dr. Marc Nicholson
Mailing Address: 600 Main St., Suite 160, Saint John, N.B. E3K 1J5
Telephone: 506-648-7579
Dr. Kelly Milton
Mailing Address:
Telephone:
Dr. Rachel Ouellette
Mailing Address: 403-1015 Regent St., Fredericton, N.B, E3B 3Y9
Telephone: 506-206-5999
Accepts patients under 18 but would likely not be able to triage and see a 17y 11mo before their 18th birthday.
Hormone Readiness Assessment
A hormone readiness assessment is an evaluation conducted by a health care professional to determine if a patient is ready to begin gender-affirming hormone therapy (GAHT). The decision to initiate GAHT should be a collaborative, patient-centered process that focuses on both psychosocial preparation and informed consent.
The World Professional Association for Transgender Health Standards of Care requires an assessment before GAHT is started. Gender-affirming care in N.B. is guided by Version 7 of the Standards, which were published in 2011. In N.B., a WPATH letter of recommendation for the initiation of hormones is not required. However, it should be noted that version 8 of the standards of care have recently been published and will soon replace SoC-7 on all NB forms.
While there is no required waiting period required prior to initiating GAHT, there are a number of steps that a primary care provider is required to follow to ensure GAHT is provided in the safest manner possible. The role of your primary care provider (with or without the support of a multidisciplinary team) is to facilitate a decision-making process that informs, educates, and supports you and your goals. Assessment by a psychologist or psychiatrist is not required for most people, however your primary care provider is required to assess both your mental and physical health as part of a hormone readiness assessment and may refer to appropriate specialists as needed.
Hormone readiness assessments often take place over a number of visits, depending on the length of time available per visit, the clinical situation, and the experience of the clinician. More visits may be required for individuals with complex physical or mental health issues, or for folks who are socially isolated. Fewer visits may be appropriate for a “straightforward” situation, for more experienced clinicians, if appointments are longer, or if you have a referral from a WPATH mental health provider. Fewer visits may also be recommended in situations where harm reduction is the priority (e.g., extreme distress, is currently taking hormones unprescribed, etc.).
Below we outline the steps of a hormone readiness assessment and cover some of the basic questions that a primary care provider may ask you when getting ready to initiate GAHT.
Patient History
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Discuss the rationale for assessment period: Establish rapport
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Ensure optimal readiness
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Ensure patient has all information they need to start GAHT
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General medical intake & medical history
Effects of Testosterone-Based Hormones
Effects of Estrogen-Based Hormones
Surgery
New Brunswick Medicare now covers certain gender-affirming surgeries for Two-Spirit, trans, Indigiqueer, and gender-diverse folks living in New Brunswick. Folks considering gender-affirming surgery that is covered by Medicare are required to approach their family physician, nurse practitioner, and/or mental health professional to undergo a surgical readiness assessment.
A surgical assessment ensures that an individual is prepared for the surgery and will have the best possible post-surgical outcome. In NB, a surgical readiness assessment involves the following steps:
Gather Basic Surgery Information
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Gather the following information:
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Patient’s anticipated timeline for having surgery
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Surgery type
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Who the desired surgeon is
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Pre-op requirements
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If applicable, insurance coverage and requirements
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Verify that the patient is physically fit and has no significant physical health problems that would contraindicate or complicate the proposed surgery:
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Health screening commensurate to age & risk profile
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Focused physical exam
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Vitals (incl. BP, T, HR, Ht, Wt, Waist & Abdo circ.)
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Surgical readiness assessments should use criteria established by WPATH. The WPATH assessment involves a comprehensive psychiatric assessment and prolonged medical management before surgery is considered an option. Please note: It should be noted that version 8 of the standards of care have recently been published and will soon replace SoC-7 on all NB forms.
In NB the follow is required:
Criteria for chest masculinization surgery (one referral)
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Persistent, well-documented gender dysphoria (will change with version 8);
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Capacity to make a fully informed decision and to consent for treatment;
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Age of majority in a given country (within NB, must be at least 18)
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If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.
Criteria for breast augmentation (not covered in NB):
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Persistent, well-documented gender dysphoria (will change with version 8);
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Capacity to make a fully informed decision and to consent for treatment;
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Age of majority in a given country (within NB, must be at least 18)
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If significant medical or mental health concerns are present, they must be reasonably well controlled.
Although not an explicit criterion, it is recommended that that folks undergo estrogen-based GAHT (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
Criteria for genital surgery (two referrals)
Criteria for hysterectomy and ovariectomy and for orchiectomy:
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Persistent, well documented gender dysphoria (will change with version 8);
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Capacity to make a fully informed decision and to consent for treatment;
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Age of majority in a given country (within NB, must be at least 18);
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If significant medical or mental health concerns are present, they must be well controlled;
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12 continuous months of hormone therapy as appropriate to your gender goals (unless the individual has a medical contraindication or is otherwise unable or unwilling to take hormones).
The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the individual undergoes irreversible surgical intervention.
Criteria for metoidioplasty or phalloplasty and for vaginoplasty:
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Persistent, well documented gender dysphoria (will change with version 8);
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Capacity to make a fully informed decision and to consent for treatment;
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Age of majority in a given country (within NB, must be at least 18);
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If significant medical or mental health concerns are present, they must be well controlled;
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12 continuous months of hormone therapy as appropriate to your gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);
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12 continuous months of living in a gender role that is congruent with their gender identity.
Following the completion of a surgical readiness assessment a PCP and/or psychologist determines that someone is clinically eligible for surgery and completes the Gender Confirming Surgery Prior Approval Request form. Once prepared the request form is sent to the Executive Director of Addictions and Mental Health, who in turn forwards it to New Brunswick Medicare for consideration. Upon approval, a surgical plan is put in place by the patient's medical team.
In addition to completing the Prior Approval Request form the following are required to access Medicare covered gender-affirming surgery:
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Must be at least 18 years of age;
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Must hold a valid NB Medicare card;
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One or two referral letters;
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For all genital surgery: 12 continuous months of GAHT for all bottom surgeries unless there is medical contraindication, or inability / unwillingness to undergo hormone replacement therapy;
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For genital reconstruction: 12 continuous months of living in a gender role congruent with their identity unless a specific reason has been stated in a referral letter.
According WPATH, a referral letter recommending surgery should include the following information:
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Your general identifying characteristics;
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Results of your psychosocial assessment, including any diagnoses;
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The duration your primary care provider and/or mental health professional has known you, including the type of evaluation and therapy or counselling to date;
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An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting your request for surgery;
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A statement about the fact that informed consent has been obtained;
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A statement that your primary care provider and/or mental health professional is available for coordination of care and welcomes a phone call to establish this.
In New Brunswick, two letters are required for genital surgery. If two referral letters are required and the first referral letter is from a Physician or Mental Health Professional who mainly had a clinical relationship with you, the second referral letter must be from a different Physician or Mental Health Professional who had an evaluative role with you.
Gender-Affirming Surgeries Covered By NB Medicare
Subcutaneous mastectomy & chest contouring
Removal of breast tissue and creation of a flatter and/or more sculpted chest
Requirements:
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Only Partial Coverage
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One WPATH/ CPATH Supporting Letter
Hysterectomy with bilateral salpingo- oophorectomy
Removal of uterus, ovaries, and fallopian tubes
Requirements:
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Two WPATH/ CPATH Supporting Letters
Orchidectomy
Removal of testes
Eliminates need for testosterone blocker
Requirements:
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Two WPATH/ CPATH Supporting Letters
Vaginoplasty (including Vulvoplasty)
Creation of vagina and vulva (including mons, labia, clitoris, and urethral opening)
Requirements:
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Two WPATH/CPATH Supporting Letters
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Orchidectomy previously performed in a public hospital in Canada.
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Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Clitoral release
Ligaments around clitoris are cut releasing clitoris from the pubis and allowing creation of penis 4-6cm long
Requirements:
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Two WPATH/CPATH Supporting Letters
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Hysterectomy with bilateral salpingo- oophorectomy previously performed in a public hospital in Canada, the cervix must be completely removed, and a pathology report confirming this must be provided to the Centre Métropolitain de chirurgie in Montreal.
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Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Metoidioplasty
Clitoral release plus urethral lengthening and incorporation into penis, increased girth of penis using skin from labia. Creation of scrotum from labia, +/- vaginectomy and scrotal implants
Requirements:
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Two WPATH/CPATH Supporting Letters
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Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Phalloplasty
3 phase surgery to create penis, scrotal sac, and testes using genital and tissue grafted from forearm, thigh or back
Requirements:
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Two WPATH/CPATH Supporting Letters
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Hysterectomy with bilateral salpingo- oophorectomy previously performed.
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Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Construction of the urethra
Performed either simultaneously with a phalloplasty or during second intervention after phalloplasty. This procedure will allow urine to flow through the tip of the phallus.
Requirements:
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Two WPATH/CPATH Supporting Letters
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Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Insertion of testicular implants
Insertion of 1 or 2 gel-filled testicular implants into the scrotum.
Requirements:
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Two WPATH/CPATH Supporting Letters
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Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Insertion of penile implant
Insertion of an implant into the phallus that was formed during the phalloplasty.
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Gender-Affirming Surgeries Covered By NB Medicare
Subcutaneous mastectomy & chest contouring
Removal of breast tissue and creation of a flatter and/or more sculpted chest. Only Partial Coverage.
Requirements:
-
One WPATH/ CPATH Supporting Letter
Hysterectomy with bilateral salpingo- oophorectomy
Removal of uterus, ovaries, and fallopian tubes
Requirements:
-
Two WPATH/ CPATH Supporting Letters
Orchidectomy
Removal of testes
Eliminates need for testosterone blocker
Requirements:
-
Two WPATH/ CPATH Supporting Letters
Vaginoplasty (including Vulvoplasty)
Creation of vagina and vulva (including mons, labia, clitoris, and urethral opening)
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Orchidectomy previously performed in a public hospital in Canada.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Clitoral release
Ligaments around clitoris are cut releasing clitoris from the pubis and allowing creation of penis 4-6cm long
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed in a public hospital in Canada, the cervix must be completely removed, and a pathology report confirming this must be provided to the Centre Métropolitain de chirurgie in Montreal.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Metoidioplasty
Clitoral release plus urethral lengthening and incorporation into penis, increased girth of penis using skin from labia. Creation of scrotum from labia, +/- vaginectomy and scrotal implants
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Phalloplasty
3 phase surgery to create penis, scrotal sac, and testes using genital and tissue grafted from forearm, thigh or back
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Construction of the urethra
Performed either simultaneously with a phalloplasty or during second intervention after phalloplasty. This procedure will allow urine to flow through the tip of the phallus.
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Insertion of testicular implants
Insertion of 1 or 2 gel-filled testicular implants into the scrotum.
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Insertion of penile implant
Insertion of an implant into the phallus that was formed during the phalloplasty.
Requirements:
-
Two WPATH/CPATH Supporting Letters
-
Hysterectomy with bilateral salpingo- oophorectomy previously performed.
-
Travel to the Centre Métropolitain de Chirurgie, Montréal, Québec
Gender-Affirming Surgeries Not Covered By NB Medicare
Breast construction
Implantation of prosthesis to enhance size and shape of breasts
Facial surgery
May include alterations to the facial bones, cheeks, forehead, nose, hairline and areas surrounding the eyes, ears, or lips
Tracheal shave
Reduction and reshaping of Private Variable BC thyroid cartilage
Voice surgery
Alteration of vocal fold mass and/or tension to elevate pitch
Pectoral augmentation
Implants placed beneath pectoral muscles to increase size and projection of muscles
Liposuction or lipofilling
Removal or transfer of body fat to achieve desired body contour