Surgical Management of FtM

Highlights

  • The three main categories of surgery include: chest surgery (“top surgery”), genital surgery (“bottom surgery”) and non-genital/non-chest surgery.
  • Chest surgery does not require that a patient has taken cross-sex hormones and requires only one referral from a mental health professional.
  • Genital surgery requires that a patient has been on cross-sex hormone therapy for a minimum of one year and requires two referral letters from mental heath professionals.
  • New Brunswick Medicare covers the cost of medically necessary gender-affirming surgery.
  • External genital surgery in not available in New Brunswick; most patients are referred to Montreal.

Overview

Surgical alterations can be made to primary or secondary sex characteristics (internal/external genitalia, breasts/chest, facial features, body contouring) . There is no recommendation as to the number or sequence of surgical procedures.

Surgical Options

  • Breast/chest surgery; “top surgery”: Subcutaneous mastectomy, creation of a male chest;
  • Genital surgery; “bottom surgery”: Hysterectomy/ovariectomy, reconstruction of the fixed part of the urethra, which can be combined with a metoidioplasty (use of the clitoris to fashion a penis) or with a phalloplasty (creation a neopenis), vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses;
  • Non-genital, non-breast surgical interventions: Voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures.

Chest Surgery

Criteria for mastectomy and creation of a male chest (WPATH):
  • Persistent, well-documented gender dysphoria;
  • Capacity to make a fully informed decision and to consent for treatment;
  • Age of majority in a given country;
    • The Endocrine Society guidelines state there is not sufficient evidence to recommend a minimum age for FtM chest surgery and that readiness should be based on the physical and mental health of the individual.
  • If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a pre-requisite.

 

Genital Surgery

Criteria for hysterectomy and ovariectomy:
  •  Persistent, well documented gender dysphoria;
  • Capacity to make a fully informed decision and to consent for treatment;
  • Age of majority in a given country;
  • If significant medical or mental health concerns are present, they must be well controlled;
  • 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).
Criteria for metoidioplasty or phalloplasty (WPATH):
  • Persistent, well documented gender dysphoria;
  • Capacity to make a fully informed decision and to consent for treatment;
  • Age of majority in a given country;
  • If significant medical or mental health concerns are present, they must be well controlled;
  • 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);
  • 12 continuous months of living in a gender role that is congruent with their gender identity.

*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.

From: Gender-affirming Care for Trans, Two-Spirit, and Gender Diverse Patients in BC: A Primary Care Toolkit

Phalloplasty (construction of a neopenis) is a multistage surgery most often using a radial forearm flap. Inconsistent results have been achieved with neopenile erections but erections are also possible with the implantation of a mechanical or inflatable device. Given these limitations, outcomes are often less than satisfactory and most FtM patients do not undergo external genital surgery. However, some may choose a metoidioplasty that brings forward the clitoris, thereby allowing them to successfully void in a standing position. A scrotum can also be created from the labia majora with good cosmetic effects and testicular prostheses can be implanted.

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

Referring for Gender-Affirming Surgery 

New Brunswick Medicare covers medically necessary gender-affirming surgeries for transgender persons living in New Brunswick. Gender-affirming surgery is a medically recognized treatment for gender dysphoria.

  • The following FtM procedures are covered by Medicare: Vaginectomy, hysterectomy, salpingo-oophorectomy, mastectomy (with chest masculinization), metoidioplasty, phalloplasty, erectile and testicular implants.
    • Patients must be at least 18 years of age to receive funding from the province for the above procedures. However, mastectomy is available at 16 years of age to certain interested patients and there may be the possibility to advocate for coverage on a case by case basis. Speak with a surgeon for more information. 
  • The following FtM procedures are not covered by Medicare: Pectoral implants

Patients interested in pursuing surgery that is covered by Medicare must have the Gender Confirming Surgery Prior Approval Request form completed by a qualified mental health professional.  Accompanying this application must also be one or two referral letters (see below). This information must be sent to either the involved local surgeon or for genital surgery not offered in New Brunswick, to the Gender Reassignment Surgery Centre in Montreal.

Centre Métropolitain de Chirurgie
999 Salaberry, Montréal, QC, H3L 1L2
Fax: (514) 288-3547
Tel: 514 288‑2097

The surgeon will then assess the patient and, if satisfied, will send the satisfactory and completed form and formal request indicating the proposed surgery to the New-Brunswick Medicare Medical Consultant for approval of funding. There is no retroactive funding available for surgeries performed prior to funding being made available.

When the patient has received a positive recommendation from their physician, and approval by New Brunswick Medicare, they can then work with the surgical team to develop a surgical plan.

Non-chest/non-gential surgeries do not require a specific referral from a mental health professional. One referral from a mental health professional is required for breast/chest surgery, and two referrals from mental health professionals are required for genital surgery. Remember, family physicians can act as the mental health professional if they met the criteria set out by the WPATH.

The recommended content for a referral letter recommending surgery is as follows (WPATH):

  •  The client’s general identifying characteristics;
  • Results of the client’s psychosocial assessment, including any diagnoses;
  • The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling 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 mental health professional is available for coordination of care and welcomes a phone call to establish this.
Where is surgery available?
  • FtM surgeries available in New Brunswick: Mastectomy (with chest masculinization), pectoral implants, hysterectomy, saplingo-oophorectomy.
  • FtM surgeries available out-of-Province: Vaginectomy,  metoidioplasty, phalloplasty, erectile and testicular implants.
    • Out of province surgeries are only covered by Medicare if they are provided by a Canadian facility approved by New Brunswick Medicare (e.g. the Gender Reassignment Surgery Centre).
    • Patients travelling out of province can receive coverage for accommodations during the approved time frame. Coverage is not available for accompanying friends or family.