Surgical Management of MtF

Highlights

• The three main categories of surgery include: chest surgery (“top surgery”), genital surgery (“bottom surgery”) and non-genital/non-chest surgery.
• It is recommended (but not required) that MtF patients take cross-sex hormones prior to chest surgery; only one referral is required 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 for 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”: Augmentation mammoplasty (implants/lipofilling);
• Genital surgery; “bottom surgery”: Penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty;
• Non-genital, non-breast surgical interventions: Facial feminization surgery, liposuction, lipofilling, feminizing voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures.

Chest Surgery

• 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 reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy for a minimum of 24 months prior to breast augmentation surgery in order to maximize breast growth and obtain better surgical (aesthetic) results.

Surgeons in the Moncton area will perform breast augmentation for eligible patients at 16 years of age.

Genital Surgery

•  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).

• 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 induce 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

Neovaginas are often constructed by inverting the skin of the penis to form the wall of the vagina.  However, when there is inadequate tissue (i.e. in patients that never fully developed their natal secondary sex characteristics because of their use of hormone blockers followed by cross-sex hormones) the use of part of the intestine is another option. Increased and/or malodorous discharge post-vaginoplasty should be managed with intravaginal metronidazole gel twice daily and plain water douching until symptoms resolve.

The scrotum can become the labia majora and reconstructive surgery can create a clitoris and its hood, preserving the neurovascular bundle at the tip of the penis as the neurosensory supply to the clitoris. Some surgeons are also creating a sensate pedicled-spot adding a G spot to the neovagina to increase sensation. Recently, some plastic surgeons have developed techniques to fashion labia minora.

During genital surgery, genital sexual responsivity and other aspects of sexual function are usually preserved however neovaginal prolapse, rectovaginal fistula, delayed healing, vaginal stenosis, and other complications do sometimes occur. The consistent use of dilators for neovaginas is of the utmost importance.

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 MtF procedures are covered by Medicare: Vaginoplasty including: penectomy, orchidectomy, construction of a vaginal cavity and the vulva.
• The following FtM procedures are not covered by Medicare: Breast augmentation, facial feminization, tracheal shaving, hair removal.

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 then 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.

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. However, 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.

• MtF surgeries available in New Brunswick: Breast augmentation, solo-orchiectomy (not pursuing further genital surgery), facial feminization, tracheal shaving.
• MtF surgeries available out-of-Province: Vaginoplasty including: penectomy, orchidectomy, construction of a vaginal cavity and the vulva.
  • 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.