A transgender-health specialist believes that although the government says all 56 applications it received for gender-confirming surgeries were approved, access to the procedure isn't as straightforward as the stats suggest. Dr. Adrian Edgar, director of Clinic 554 in Fredericton, said many people don't get far enough into the process for their application to land on a government official's desk. "The biggest barrier is cost," he wrote in an email. "A great number of my patients are working class." Since June 2016, the government has  covered the cost of medically necessary gender-confirming surgeries. While the move was praised within gender minority circles,  some still believe the coverage could improve. For example, liposuction, a $3,000 procedure, to remove some of the extra fat left over on the breasts for men and laser-hair removal for transitioning women aren't covered because they're considered cosmetic.

'Not everyone who wants to have surgery is able to have it.'- Dr. Adrian Edgar

In general, Edgar said patients with gender dysphoria are under-employed because of stigma and discrimination in the workplace. They're some of the people least likely to be able to afford these costs, he said. But the barriers don't stop there. An age limit, rigorous mental and physical health checks, lack of experienced surgeons and some operations not being covered all either delay or prevent access to the surgeries. "No, not everyone who wants to have surgery is able to have it," he wrote.

Overall health a priority

However, it may be some of the barriers serve some purpose. Edgar said patients are expected to follow through on treatment recommendations, like counselling or prescription drugs, to make sure their overall health is optimized prior to surgery. "This can take time and patients are sometimes required to wait for surgery while addressing other aspects of their health." According to the doctor, individuals must have had clinically significant distress from experiencing their gender as different than the one they were designated at birth in order to be diagnosed with gender dysphoria in the first place. But other blocks aren't as science-based, the specialist said. "In New Brunswick, there is an additional minimum age requirement of 18 that is not based on scientific evidence, so youth who require surgery are made to postpone their treatment longer than medically advisable," Edgar wrote.

Focus on genitalia surgery

Likewise, he said while the government does cover "bottom" surgeries, operations that don't focus on genitalia aren't always insured by medicare. Many male-to-female patients are distressed by their masculine facial features. "Having an angular jawline or a pronounced brow ridge can mark these ladies as unfeminine and lead to everything from lower employment rates to suicidal thoughts," said Edgar. In other provinces, there are movements towards funding facial feminization surgery, "to help patients fully treat their dysphoria and fully integrate into society," he wrote. The reason applications the government receives are approved, Edgar said, is because the clinicians making referrals are trained to assess other diagnoses better treated by non-surgical methods. "By the time the application has been vetted and sent to Medicare, the clinician should have done their due diligence to ensure the patient requires the surgery," he said.