A transgender woman in Manitoba says the province has been ignoring her requests regarding a follow-up facial feminization surgery she needs to live a normal life.
The woman, who has been diagnosed with gender dysphoria, had facial feminization surgeries last April after successfully appealing the province’s refusal to pay for it.
She says her surgeon has recommended follow-up surgery to correct some of the work that did not take, as her original surgeries involved bone and soft tissue work.
She stressed that the follow-up procedures are not cosmetic but are crucial to treating her dysphoria. A referral from her surgeon was sent to Manitoba Health in November 2022.
But nearly a year later, the woman says she’s yet to get an answer from the province regarding coverage despite numerous attempts to get in touch with someone.
The woman, whom CBC is not naming due to concerns for her safety, said this leaves her in limbo.
“So I’m at a standstill waiting for Manitoba Health to respond, and I’m being held hostage by this process.”
While waiting for an answer, the woman says she’s been living with extreme distress due to the impacts of her dysphoria and inability to get the gender affirming care she needs.
“It causes me severe anxiety, depression, and distress. I don’t want to go out,” she said.
“I want to feel normal. I want to be a productive member of society … and without this procedure I’m unable to do that.”
Because these surgeries can cost tens of thousands of dollars, the woman says she can’t afford to pay for them on her own.
Though she lost her first appeal of Manitoba Health’s decision not cover them in 2019, she won her second appeal in 2021.
A copy of the decision from the Manitoba Health Appeal Board says the woman testified that her dysphoria is focused mainly on what her face looks like and causes her great anxiety and makes her fear for her physical safety.
The woman saw medical and psychological professionals who recommended she get facial feminization surgeries, which the decision describes as a highly specialized gender-affirming procedure offered by few clinics and doctors across Canada.
While Manitoba Health said it would cover the cost of surgeries if the woman wanted to change her genitalia, it denied her request for coverage for facial surgery, deeming it not medically required.
The judgment noted while not all facial feminization surgery will qualify as medically necessary, the province “ought to take the time to consider each such proposed surgery on a case by case basis to determine if for that individual, surgery is medically required.”
A letter sent by the woman’s lawyer to Manitoba Health says her surgeon has recommended certain revisions to the initial surgeries for the treatment of her dysphoria.
A provincial spokesperson said Manitoba Health currently covers chest and genital surgeries as well as offering “conditional” coverage for hormonal therapy, psychological support, speech language, nursing and nutritional support.
Asked why facial feminization surgeries aren’t covered, the spokesperson said gender-affirming care has “an evolving list of proposed surgical and other procedures, including facial-feminization.”
When it comes to how long it takes to respond to requests for coverage, the spokesperson said Manitoba Health typically responds within two to four weeks, but may take longer in cases where “established policies do not exist.”
Oftentimes, gender-affirming care is thought of as chest or genital surgery, but for some, the way their face looks is even more important, said Ashley Smith, director of advocacy for the Rainbow Resource Centre, which offers support to the 2SLGBTQ community.
“For many people, the dysphoria that they experience related to their appearance starts every morning when they look at themselves in the mirror,” he said.
“It has nothing to do with their top or their bottom.”
It’s important to understand that not every trans person is going to want facial feminization surgery, but for those who need it, it can be life-saving, he said.
“Facial feminization surgeries add value to people’s lives, yes, but they actually lower the instances of suicide and suicide ideation, and also prevent violence against this community, which often is stigmatized by the appearance of the face.”
Facial feminization surgery is not one procedure but actually encompasses multiple procedures that aim to remove masculine traits in someone’s face, said Dr. Eric Bensimon, a Montreal-based plastic surgeon who specializes in it.
“Every patient is different, every patient needs an assessment and every patient chooses how much and how many procedures they want to do to achieve their goals,” he said.
The issue of coverage and what is deemed medically necessary is complicated because some facial feminization surgeries are specifically for improving masculine features, such as removing an Adam’s apple, while others like rhinoplasty are also performed on cis-females, he said.
Few provinces provide coverage
In their recommended standards of care, the World Professional Association for Transgender Health says that for people suffering from gender dysphoria, facial feminization surgery “can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria.”
However, while most provinces and territories now cover chest and genital surgery, very few provide coverage for facial surgery in Canada as part of their gender-affirming care policies. Those include Yukon and Prince Edward Island, on the condition that the patient is assessed by a licensed health-care provider.
Bensimon said he thinks provinces will have to start providing coverage for these procedures if they are committed to providing gender-affirming care.
He said oftentimes, his patients who are transitioning are more distressed by their face than other parts of their body because their face is visible to the world.
“The face is the first contact with the outside world to get validation, respect, you know, even safety issues at some point, whereas what’s under our clothes, it’s hidden, no one sees it,” he said.
The Manitoba transwoman stressed that for her, facial feminization isn’t cosmetic but medically necessary to live a normal life.
“I’m not doing this to feel better about myself, in the sense, cosmetically. I’m doing this to be able to go out and go to the grocery store, go to work without being misgendered,” she said, adding she wants to feel comfortable in her own skin.
“I want to have a fulfilling life. And without these surgeries I’m unable to do that.”