Navigating Trans and Gender-diverse Health Care

Guidance from prideHealth about how to connect with the information, support, and health services that are right for you.

Gender-affirming Surgery (GAS) is a broad term. It covers any surgical procedure that changes or makes one's body align more closely with their gender identity.

What do I need to know?

  • Many trans and gender-diverse people are happy with their bodies, or find comfort with their bodies through non-surgical means. Only you can decide if surgery is right for you.
  • Nova Scotia's health insurance program, MSI, covers some gender-affirming surgeries (see below). Some surgeries are done in Nova Scotia. For other surgeries you will need to travel to GrS Montréal in Quebec. GrS Montreal is a division of the Complexe Chirurgical (CMC) that exclusively performs gender-affirming surgery.
  • The location where the procedure is performed will be determined on a case-by-case basis. The decision depends on the nature and extent of the surgery and the availability of staff with surgical expertise.
  • You will have to pay for surgeries or additional procedures not insured by MSI at your own expense.
  • MSI will not retroactively cover procedures that you already paid for out of pocket.

GAS Procedures Covered by MSI

Surgery Description
Breast Augmentation 
  • Creating larger breast size with the insertion of breast implants
Breast / Chest Reduction
  • Reducing breast size by removing fat, glandular tissue, and skin
Chest Masculinization / Mastectomy
  • Removing breast tissue, mammary glands and excess skin in order to create a masculine torso
Hysterectomy
  • Removing the uterus. A total hysterectomy removes the uterus and cervix, and possibly fallopian tubes. There is also the option of a partial hysterectomy, which removes the uterus but leaves the ovaries. Hysterectomy including removal of the cervix must be performed at least 6 months before phalloplasty surgery
Metoidioplasty
  • Creating a penis through the lengthening of the clitoris. Options for this procedure also may include lengthening of the urethra so you can stand to pee, vaginectomy (closure of the vaginal cavity), the creation of a scrotum and insertion of testicular implants. Testicular implants may require a follow-up surgery. Vaginectomy requires a hysterectomy at least 6 months before
Oophorectomy
  • Removing the ovaries. May be done with a hysterectomy
Orchiectomy
  • Removing the testicles. May considerably lower production of testosterone, when there is a contraindication to feminizing hormonotherapy
Penectomy
  • Removing the penis. CMC performs this surgery as part of vaginoplasty and not as a standalone surgery
Phalloplasty
  • Creating a phallus from body tissue (commonly taken from the forearm, stomach, or upper thigh) through a three-step surgery
Vaginoplasty
  • Creating female genitals including a vagina, a clitoris and a vulva

Learn more about GAS:

MSI Surgical Criteria

CHEST SURGERY

Chest Masculinization / Mastectomy / Breast Reduction

  • GAS application signed by a Nova Scotia Physician, Nurse Practitioner or Specialist
  • One psychosocial assessment letter (required by WPATH and GrS clinic) signed by a health care provider with clinical competencies as outlined in the WPATH SoC
    (it can be the Physician/Nurse Practitioner/Specialist who signs the application)
  • Letter from your Family Physician or Nurse Practitioner, confirming post-operative care
    (for surgeries done out of province)
  • Hormone therapy is not a prerequisite

Breast Augmentation

  • GAS application signed by a Nova Scotia Physician, Nurse Practitioner or Specialist
  • One psychosocial assessment letter (required by WPATH and GrS clinic) signed by a health care provider with clinical competencies as outlined in the WPATH SoC
    (it can be the Physician/Nurse Practitioner/Specialist who signs the application)
  • Letter from your Family Physician or Nurse Practitioner, confirming post-operative care
    (for surgeries done out of province)
  • Minimum 12 months of hormone therapy (recommended by WPATH) with breast growth less than or equal to Tanner stage 2 (unless there is medical contraindication, or inability / unwillingness to undergo hormone therapy)

GENITAL SURGERY

Removal (ectomy): Oophorectomy, Hysterectomy, Penectomy, Orchiectomy or Reconstruction (plasty): Phalloplasty, Metoidioplasty, Vaginoplasty

  • GAS application signed by a Nova Scotia Physician, Nurse Practitioner or Specialist
  • One psychosocial assessment letter (required by WPATH and GrS clinic), signed by a healthcare professional who has the required WPATH credentials and training in culturally competent trans care (it can be the same signatory as for the application itself).
  • Letter from your Family Physician or Nurse Practitioner, confirming post-operative care
    (for surgeries done out of province)
  • A letter from the Physician, Nurse Practitioner, or Specialist monitoring hormone therapy
    (if not covered by one of the above letters)
  • 12 continuous months of hormone therapy as appropriate to the patient`s gender goals (unless there is medical contraindication, or inability / unwillingness to undergo hormone therapy)
  • Been living 12 continuous months in a gender role that is congruent with their gender identity
    (WPATH recommendation for reconstruction procedures)

List of MSI insured GAS (when performed in approved locations):

Available in NS and Centre Metropolitain de Chirurgie in Montreal Available Only in Centre Metropolitain de Chirurgie in Montreal
Orchiectomy Phalloplasty
Penectomy Metoidioplasty
Breast Augmentation Vaginoplasty
Breast / Chest Reduction  
Chest Masculinization / Mastectomy  
Hysterectomy  
Oophorectomy  

How to Get Surgery

Click through the tabs for more information.

There are several criteria to meet in order to qualify for gender-affirming surgery/surgeries:

  • Persistent, well-documented gender dysphoria*
  • Capacity to make a fully informed decision and to give consent for treatment
  • Age of majority (18 years in Nova Scotia) or older at the time of surgery
    (An exception to the age requirement can be requested for chest surgeries by individuals at 16 years of age through their health care provider The rationale for this exception must be provided in a letter attached to the gender affirming surgery application and must be provided to the Nova Scotia Department of Health and Wellness for approval).
  • Reasonably well-controlled significant medical or mental health concerns if they are present and would not contraindicate GAS

What do I need for surgery to be covered?

*Distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b).

You will need a licensed Nova Scotia doctor (family doctor or specialist), Nurse Practitioner or Health Care Provider to complete the GAS application form and apply to MSI on your behalf. You will also need a doctor or Nurse Practitioner who is able to provide post-operative care. This could be the surgeon if the procedure is done locally.


If you don’t have a family doctor you can register for one at the Nova Scotia Health's Family Practice Registry.


You can also book an appointment with the doctors at Halifax Sexual Health Centre. They can support you with your GAS application and post-operative care but they will not be your family doctor.

There are a few ways you can get the WPATH assessment(s) needed for surgery:

Self-refer to the Community Mental Health Team

You can access WPATH clinicians by self-referring to Community Mental Health by calling (toll-free) 1-888-429-8167. Explain you are requesting a WPATH assessment for gender-affirming surgery. The person on the phone will do an initial screening and make decisions on where to refer you based on where you live and wait times. You will then be placed on a waitlist and given the first appointment at the closest mental health clinic.

  • If you express mental health concerns such as anxiety, depression, etc. you will be referred to someone specifically for that treatment while being placed on the waitlist for surgeries.
  • You will receive a letter from CMH Team welcoming you to the waitlist.

What to expect from your appointment for WPATH surgical or hormone assessment
You may be asked if a learner (medical student, resident, other health care student) can be present for teaching purposes. This is typical with all appointments in these clinics.

  1. Your first appointment will be with a clinical therapist who is trained in WPATH SoC.
    • You may have one or more appointments to review your diagnosis and mental health stability.
  2. After your appointment(s) with the clinical therapist, you'll have a joint appointment with your clinical therapist and the specialist (psychiatrist).
    • They need to make sure that any mental health concerns are under control.
    • They need to make sure you have the capacity to consent to surgery and understand the changes/effects, etc.
    • They need to confirm and document your diagnosis
    • The purpose of the appointment is to complete your mental health assessment to confirm that you meet the WPATH criteria for readiness for the surgery you are requesting. This involves a standard interview covering many aspects of how you are doing now and your past history. This may take one session or more depending on the individual.
  3. After that appointment, if you were found to meet WPATH criteria for surgical readiness, then you will have the necessary psychosocial assessment as per the WPATH SoC.
    • If the psychiatrist and clinical therapist do a joint WPATH assessment and find you are ready for surgery, they will provide a joint letter that will satisfy the need for two WPATH assessment letters for your application package. These letters will be forwarded to your family doctor or nurse practitioner to be added to the MSI funding application and later sent to the surgeon with the family doctor’s or nurse practitioner's referral.

Doctor or Nurse Practitioner Referral to Endocrinology Clinic Social Worker

You can access a WPATH trained social worker by referral from your doctor or nurse practitioner. The fax number for these referrals is 902-473-3770. Please note: If you have serious mental health concerns your referral may be more appropriate for community mental health.

What to expect from the appointment
Your appointment will be with a social worker trained in WPATH SoC. Appointments are typically a single three hour session. Letters are typically provided within the week to patient and referring doctor or nurse practitioner.

Private Assessments

There are many private practitioners available to do WPATH assessments. They usually charge between $100-$160 an hour and can require up to three appointments. For information about private practitioners, contact::

Medical Appointments

Surgery in Nova Scotia

If the surgery will be done in Nova Scotia, then the referral will go directly to the surgeon (e.g Urology or Gynecology). Please see the MSI Surgical Criteria chart above for surgery(s) that can be done in Nova Scotia.

Once approved, your surgeon will be in touch to book your surgery. Please note that the surgeons wait for MSI approval before booking your surgery. Wait times for orchiectomy is around 3-6 months, 6-9 months for hysterectomy.

Surgery in Montreal

If the surgery will be done in Montreal at Complexe Chirurgical CMC, you can be referred to a physician specialist (typically an Endocrinologist, Psychiatrist or Plastic Surgeon) to get a letter of support. Most specialists prefer you to have your WPATH assessment(s) complete before they will see you.

Once your doctor or nurse practitioner has the necessary letters for your surgery, you will complete and sign the application and they will send your letters and the GAS application to MSI. The approval process through MSI usually takes several weeks.

Your doctor or nurse practitioner needs to write a letter stating you require an escort to travel with you to Montreal if you want their costs covered by MSI.

MSI requires for all surgeries that people have a letter from their doctor or nurse practitioner saying they will provide post-operative care. If you do not have this, your doctor or nurse practitioner can include this in their letter of support for you.

Once MSI has approved your surgery, they will send your referring doctor or nurse practitioner and you a copy of the approval, which is valid for 24 months (2 years). They will also include a copy of the Out-of-Province Travel and Accommodation Expense Claim Form (which you have to submit within 30 days of returning from Montreal).

Once approved, your doctor or nurse practitioner will send a copy of your assessment(s) and MSI approval to Montreal. Complexe Chirurgical CMC will send you back a package that needs to be completed.

  1. Two of the documents require a doctor’s or nurse practitioner's signature/assistance. Please book an appointment with your doctor or nurse practitioner to complete these forms.
  2. Once your doctor or nurse practitioner has completed the forms you will send all the information to Montreal.
  3. Wait times for surgery vary by procedure. Complexe Chirurgical CMC will notify you of your surgery date by mail. You will also receive information about clinic location, airport pick-up and accommodations.

Preparing for Surgery

  • It is important that you plan emotionally, physically, and financially for surgery.
  • It is important to note that smoking can affect your ability to recover from surgery. Your doctor can talk to you about options for quitting.
  • It's important to know that Montreal GRS won't do mastectomy surgery if your BMI is over 40. If this applies to you, talk to your doctor about healthy weight loss options.

For more information on GAS, including considerations, types of GAS procedures, and pre and post-care, check out the resources in the After Surgery section below.

Travelling to Montreal

If you've been approved for surgery in Montreal, MSI provides out-of-province travel accommodation and assistance.

Out-of-Province Travel Forms and Accommodation Assistance Policies:

After Surgery

NOTE Some information on these external sites may not be applicable for Nova Scotia; always ask your health care provider first for information around processes, preparation and aftercare for GAS procedures.