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Gender-Affirming Surgery

NB Medicare now covers certain gender-affirming surgeries for Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) folks living in New Brunswick. This section provides an overview of the NB system for surgery planning, referral, and coverage. This section is comprised of both visual and written material, and should be completed in the following order: 

Watch the Community Based Research Centre’s Gender-Affirming Care: Surgical Readiness and Aftercare.

1

Read and review the written information outlined below. 

2

We would like to recognize that there may be some unconscious negative undertones in the video for this section toward those engage in sex work. This is an important intersection to understand, as those who engage in sex work are valid and deserving of no less respect than anyone else. For more information to better understand this intersection, please see Sex work, as well as the resource Stigma and Sex Work, put together by Peers Victoria, “an organization of sex workers for sex workers.”

 

Please note as well that surgery is another area where Gatekeeping and Bias can easily negatively impact patient care. For more information, please refer to that section.

Surgical Readiness Assessment

Patients 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 a patient 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

  • Gather the following information:

    • Patient’s anticipated timeline for having surgery

    • Surgery type

    • Who the desired surgeon is

    • Pre-op requirements

    • If applicable, insurance coverage and requirements

  • Verify that the patient is physically fit and has no significant physical health problems that would contraindicate or complicate the proposed surgery: 

    • Health screening commensurate to age & risk profile

    • Focused physical exam

    • Vitals (incl. BP, T, HR, Ht, Wt, Waist & Abdo circ.)

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. However, it should be noted that version 8 of the standards of care (SoC-8) has recently been published and will soon replace SoC-7 on all NB forms. 

Criteria for chest masculinization surgery (one referral)

  1. Persistent, well-documented gender dysphoria;

  2. Capacity to make a fully informed decision and to consent for treatment (see Informed Consent Model);

  3. Age of majority in a given country (within NB, must be at least 18 - if younger, follow the SOC for children and adolescents; see Part 8: 2STIGD Youth);

  4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

 

Hormone therapy is not a prerequisite.

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Criteria for breast augmentation in MtF patients (not covered in NB):

  1. Persistent, well-documented gender dysphoria;

  2. Capacity to make a fully informed decision and to consent for treatment (see Informed Consent Model);

  3. Age of majority in a given country (within NB, must be at least 18 - if younger, follow the SOC for children and adolescents; see Part 8: 2STIGD Youth);

  4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

 

Although not an explicit criterion, it is recommended that patients 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. 

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Criteria for genital surgery (two referrals)

The criteria for genital surgery are specific to the type of surgery being requested (see Gender-Affirming Surgeries Covered By Medicare table below).

 

Criteria for hysterectomy and ovariectomy and for orchiectomy:

  1. Persistent, well documented gender dysphoria;

  2. Capacity to make a fully informed decision and to consent for treatment (see Informed Consent Model);

  3. Age of majority in a given country (within NB, must be at least 18);

  4. If significant medical or mental health concerns are present, they must be well controlled;

  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient 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 patient undergoes irreversible surgical intervention.

 

These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria.

 

Criteria for metoidioplasty or phalloplasty and for vaginoplasty:

  1. Persistent, well documented gender dysphoria;

  2. Capacity to make a fully informed decision and to consent for treatment (see Informed Consent Model);

  3. Age of majority in a given country (within NB, must be at least 18);

  4. If significant medical or mental health concerns are present, they must be well controlled;

  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);

  6. 12 continuous months of living in a gender role that is congruent with their gender identity.

 

Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. 

Beyond the specific criteria set forth by the WPATH Standards of Care, there are two other important areas for assessment of anyone undergoing major surgery for any reason, including hip replacements, organ transplants, open heart surgery, etc:

 

1) Insuring realistic expectations of what surgery can and cannot do, being emotionally prepared for the realities of potential complications or less-than-satisfactory outcomes.

 

2) Insuring adequate support during the pre- and post-surgery period. This includes having someone to take them to and from surgery, and be with them after surgery to assist with recovery needs. This could include anything from obtaining supplies at the pharmacy to preparing meals and assisting with domestic needs. For those who do not have someone to fill these roles, PCP’s should work with patients to make arrangements for home health assistance.

 

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:

  • Patients must be at least 18 years of age;

  • Patients must hold a valid NB Medicare card;

  • One or two referral letters;

  • 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;

  • For gential 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.

Referral Letters

According WPATH, a referral letter recommending surgery should include the following information:

  • The client’s general identifying characteristics;

  • Results of the client’s psychosocial assessment, including any diagnoses;

  • The duration of the PCP and/or mental health professional’s relationship with the client, including the type of evaluation and therapy or counselling to date;

  • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;

  • A statement about the fact that informed consent has been obtained from the patient;

  • A statement that the PCP 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 gential 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 the patient, the second referral letter must be from a different physician or Mental Health Professional who had an evaluative role with the patient).


To access referral letter templates, please click here.

Possible Questions to Explore Patient Expectations and Goals

* All questions listed below are intended to be guiding questions. When establishing a rapport with a patient it is important that you make these questions your own, personalize them, or come up with questions that better suit your patient.  

    

  • Who would you like to be your surgeon and where would you like to have surgery if possible? 

  • Which surgery are you planning to have? 

  • How do you foresee surgery helping to affirm your gender?

  • Can you tell me what you know so far about the surgery itself and what to expect?

  • Do you know anything about the pre-op requirements and expectations? If so, what do you know?

Possible Questions to Explore Patient Supports

* All questions listed below are intended to be guiding questions. When establishing a rapport with a patient it is important that you make these questions your own, personalize them, or come up with questions that better suit your patient.  

    

  • Have you identified a support person(s) to help you with your pre- and post-surgical care?

  • What is your post-operative care plan? How can I assist you in this plan?

  • What kinds of support and advocacy do you need at this time?

  • Will you be able to access medication after surgery?

  • Do you have adequate financial support for the procedure (if necessary), transportation and/or accommodation, and for aftercare?

Gender-Affirming Surgeries Covered By Medicare

Subcutaneous mastectomy & chest contouring

Description 

  • Removal of breast tissue and creation of a flatter and/or more sculpted chest

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Requirements

  • Only Partial Coverage

  • One WPATH/ CPATH Supporting Letter

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Location: NB

Gender-Affirming Surgeries Not Covered By Medicare

Breast Construction

Description 

  • Implantation of prosthesis to enhance size and shape of breasts

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Location: New Brunswick and outside of province

For information about NIHB coverage for eligible Indigenous patients, see NIHB Program.

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