Non-binary person says OHIP discriminated against him, denying coverage for phalloplasty surgery

Open this photo in gallery:

A non-binary person is accusing OHIP of discrimination after the Ontario government-run insurance plan denied him coverage for the gender affirming surgery he sought.

Nathaniel Le May, a 41-year-old Ottawa public servant, identifies as transmasculine non-binary. He is seeking a phalloplasty, which is the surgical construction of a phallus. The procedure was set to be performed at GRS Montreal, one of a handful of clinics in the country providing publicly funded gender affirming surgery. Mr. Le May was seeking out-of-province coverage for the procedure.

But the surgery was held up since last summer, when Ontario’s ministry of health told Mr. Le May that OHIP does not fund phalloplasty unless it is performed alongside several other procedures, including vaginectomy, which removes the vagina. For safety reasons and cervical cancer risks, vaginectomy procedures require a prior hysterectomy. Mr. Le May does not want to undergo these additional surgeries, or be rendered permanently sterile.

In January, the ministry reiterated its position that vaginectomy must accompany phalloplasty to qualify for OHIP coverage. On Feb 20, OHIP’s general manager, represented by the health ministry’s legal counsel, wrote Mr. Le May to say his application for only one procedure without the other “is not a valid request for funding approval of sex reassignment surgery.”

Mr. Le May is appealing OHIP’s denial, arguing it violates his human rights.

“All individuals should have the choice to decline unnecessary and irreversible surgeries,” he wrote in his appeal last month. OHIP’s decision, Mr. Le May continued, is “discriminatory and a violation of the human rights of transgender individuals, given it removes choice, control and bodily autonomy from what is supposed to be a gender-affirming surgical process.”

An e-mailed statement sent Feb. 2 from Ontario’s ministry of health said it does not comment on matters that are under appeal. The ministry also did not respond to The Globe and Mail’s specific questions about its policies on phalloplasty coverage, or the medical reasoning behind OHIP’s requirement that vaginectomy be performed alongside phalloplasty.

Mr. Le May said the ministry of health is being inconsistent, and that his situation captures the province’s lack of transparency. The Globe spoke to two other Ontarians who received OHIP approval and then subsequently underwent surgeries for stand-alone phalloplasty, without vaginectomy, following consultations with their surgeons.

“Why would you be forced to be sterilized in order to have phalloplasty funded by OHIP?” Mr. Le May said in an interview. “There’s been no clarity.”

Devin O’Brien-Coon, an associate surgeon specializing in gender affirming surgery at Boston’s Brigham and Women’s Hospital, has been performing stand-alone phalloplasty since 2017.

There is no medical reason that would necessitate pairing all phalloplasty procedures with vaginectomy, according to the surgeon. He added that the medical risks of vaginectomy – “a big surgery” – actually outweigh those of stand-alone phalloplasty.

“If someone is saying, ‘I don’t want an organ removed,’ from an ethical standpoint, you really have to give that some weight,” said Dr. O’Brien-Coon, an associate professor at Harvard Medical School.

“If you don’t have a surgical reason why you need to remove a vagina … I don’t see any ethical rationale for pushing that on somebody just because, ‘This is the full package.’”

Ontario’s health ministry lumps phalloplasty together with vaginectomy, urethroplasty and glansplasty on its funding application forms for sex reassignment surgery.

Contradictory information appears in the “Schedule of Benefits,” a 982-page document that lists all physician services covered under Ontario’s Health Insurance Act. Under “external genital surgery,” 11 individual procedures are listed, with no requirement stated that phalloplasty be performed alongside vaginectomy to qualify for coverage.

It’s an inconsistency Mr. Le May wants addressed.

Other Ontarians have had stand-alone phalloplasty, this while securing OHIP funding. One trans man from Welland, Ont., underwent phalloplasty in November, 2019, at Baltimore’s Johns Hopkins Center for Transgender Health with out-of-country funding. The following year, a Toronto transgender man had his phalloplasty with GRS Montreal. Both checked off “phalloplasty (includes vaginectomy, urethroplasty, glansplasty)” on their OHIP forms but did not plan for or undergo vaginectomy during the course of their procedures.

“That was not a problem,” said the Toronto man, Julian Soloveichik, who secured out-of-province funding for surgery in Montreal. Mr. Soloveichik, 28, consulted in person with his surgeon about a stand-alone phalloplasty, ahead of the procedure.

“You should be able to make a decision for your own self,” Mr. Soloveichik said. “This is your body and you’re going under for a surgery.”

Medical transition still remains loaded with binary expectations, with packages of male-to-female and female-to-male procedures bundled together, according to Yael Sela, a social worker and psychotherapist with the trans health team at Ottawa’s Centretown Community Health Centre.

“There’s such a wide range of transition goals and identities that we haven’t caught up to,” Ms. Sela said.

Delays and rejections of gender affirming care can lead to distrust toward the medical system and hopelessness, Ms. Sela said. “Undergoing a medical procedure that you don’t need or want, I don’t know anybody who would support that,” she added, referring to Mr. Le May’s case.

Experts and advocates argue that medical guidelines are slowly advancing to recognize a broader range of gender diverse patients. They point to the newly revised Standards of Care for the Health of Transgender and Gender Diverse People, viewed as a gold standard by health care providers working with this population.

“Gender identities may present along a spectrum and the expression of a person’s identity may vary quite widely amongst individuals. … The patient and their surgeon need to work together to ensure the patient’s expectations are realistic and achievable, and the proposed interventions are safe and technically feasible,” the guidelines read.

“Best practices are evolving toward ultimately recognizing that this is a surgery which is meant to improve psychological well-being,” Dr. O’Brien-Coon said. “We’re more broad-minded about that than we were 10 years ago, with the continuing constraint being what is safe to do, from a medical and surgical standpoint.”

Mr. Le May has asked the appeal board to ensure OHIP makes its application forms more inclusive toward non-binary people, and to reopen any recent decisions in which others may have been denied coverage for stand-alone phalloplasty.

“We need to know very specifically, what’s covered, what’s not covered, and why,” said Elgin Pecjak, a PhD candidate at the University of Ottawa’s Institute of Feminist and Gender Studies.

Pointing to Mr. Le May, who wants fewer surgeries than OHIP has prescribed through its funding model, Mr. Pecjak argued, “When you think about dollars and cents, it doesn’t make sense. … This would cost less money and require less surgeries for an individual person.”

Overall, Mr. Pecjak believes skepticism and “a need for correction” persist toward the bodies of those who are transgender or gender diverse.

“When people seek out affirming surgery or care, there’s either very little information, or there’s high-ranking forms of regulation,” he said. “There’s still this governance that’s happening through OHIP: ‘If you’re going to get funding to have this procedure, you have to do it the way we want.’”