Trans woman wins appeal to have Manitoba cover cost of gender-affirming surgery

A transgender woman in Manitoba has won an appeal in a case her lawyer says will mark the first time the province will cover the cost of facial feminization surgery.

"This has been a long road for my client," said Allison Fenske, a staff attorney with the Public Interest Law Centre who represented the woman in her latest appeal.

The Aug. 11 decision from the Manitoba Health Appeal Board came following the woman's second appeal of the province's refusal to pay for the procedure.

The woman, who is not identified in the decision, made her first request with Manitoba Health's insurance division in late 2019. At the time, she had already been diagnosed with gender dysphoria and was taking feminizing hormone therapy, the decision said.

The woman testified that her dysphoria, which is focused mainly on what her face looks like, causes her great anxiety and makes her fear for her physical safety. 

As a result, she "does not participate in society and is overly guarded in her relationships to the extent of not having much of a life outside her home and cannot plan for her future," the decision said.

Fenske said the woman feels "that her face is the first thing people see and the first thing people read when trying to understand her gender identity."

"Having, for her, a face that she felt was male-appearing really impacted her mental health."

The woman saw medical and psychological professionals who recommended she get surgery to make her facial features more feminine — 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.

Years-long process

The woman's first appeal of that decision was dismissed, but the judgment noted that if the woman got "further medical evidence that supports her position, she may wish to submit a further request with that evidence" to Manitoba Health.

After a year of continued treatment with specialists, that's what the woman did. But her request was again denied.

That's when she reached out to Fenske, who said she helped the woman strengthen her case. 

"That meant getting more expansive referral letters and putting together a … broader package for Manitoba Health, for them to hopefully understand and appreciate why this was so necessary for my client. And they, again, just refused to even consider it," Fenske said.

They appealed again, arguing the province's agreement to pay for genital surgery but not the facial surgery the woman said would actually address her gender dysphoria made "no sense" under a health-insurance system set up to address individual medical needs, the decision said.

The province argued facial feminization surgeries "are essentially elective plastic surgery, for which there is no coverage."

This time, the appeal board unanimously agreed with the woman. 

The testimony she and others gave at the second hearing showed that in this situation, the surgery is "the key to tackling her gender dysphoria," making it medically necessary, the decision said.

While the decision doesn't extend beyond this one woman's case, it noted the rules and policies in Manitoba for treating trans patients "may be getting somewhat dated."

A spokesperson for Manitoba Health said the department is analyzing the appeal board's decision and comments "for the appropriate administration of the payment for medically required insured benefits."

Changing clinical considerations, system planning and sustainability are important factors considered in policies governing health care in Manitoba, the spokesperson said.

Fenske said she hopes the ruling encourages the province to update the way it deals with gender-affirming procedures.

"Otherwise, they are likely to see many more appeals of this nature come forward and they're going to continue to have to deal with this on a case-by-case basis," she said.

"And that's just not fair to the broader trans community, to have to keep fighting the same battles over and over again."

'Life-preserving care'

Dr. Robert Obara said those battles are something he sees first-hand.

While facial surgery isn't right for everyone, for many of his clients at Winnipeg's Trans Health Klinic, that type of gender-affirming procedure can make "a world of difference," he said.

Obara said research suggests suicide rates among trans people are disproportionately high, but decrease significantly after they receive gender-affirming care.

Meanwhile, the number who report regret after getting gender-affirming procedures is extremely low.

"Gender-affirming care is life-preserving care," he said.

"And we know that providing proper and timely medical and surgical care to trans people is huge for their mental health, their physical health, their social health."

Obara said the appeal decision that will see the province cover one woman's facial surgery costs is "a huge, positive step forward" — and he hopes it will have a ripple effect across the country.