Minimally invasive procedures in gender-affirming care: the case for public funding across Canada
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* Katie Ross
* Sarah Fraser

KEY POINTS
*   Although access to gender-affirming care has increased in Canada in recent years, substantial wait times and care gaps remain.

*   Minimally invasive procedures including facial injectables and hair removal are relatively safe and may support gender transition in a timely fashion.

*   Public funding for such procedures, which are currently funded in only 2 jurisdictions in Canada, warrants serious consideration in all provinces and territories.

The 2022 World Professional Association for Transgender Health Standards of Care Version 8 (WPATH SOC8) states that along with hormonal therapy for people wishing to transition, hair removal and facial surgeries are appropriate interventions for gender-affirming care.1 In the 2021 Canadian National Census, more than 100 800 people living in Canada reported identifying as transgender or nonbinary.2 Although access to gender-affirming care has increased in Canada in recent years, substantial wait times and care gaps remain.3 A recent Trans PULSE Report reviewed specific health concerns for nonbinary people; 59% of survey respondents reported being misgendered daily4 (e.g., being referred to as he/him after explicitly stating that their preferred pronouns are they/them1).

In light of the new standards and the continued barriers faced, it is important to consider how to optimize the care of patients who are transgender and gender diverse (TGD) safely and responsively. Given the WPATH support for facial surgeries and hair removal as complementary treatments for TGD people, we argue that facial injectables, which have been used with success in TGD individuals, could also be used to help achieve desired facial aesthetic benefits.5 Minimally invasive procedures such as facial injectables and hair removal warrant consideration for public health care funding across Canadian jurisdictions.

Transgender and gender-diverse people may seek transition in 3 domains: legal (e.g., changing one’s name), social (e.g., using different pronouns, changing style) and medical (e.g., using medical treatments to alter appearance).1 The most common medical treatments to facilitate transition are hormone replacement therapy and surgical procedures, including chest surgeries and genital reconstruction.1 However, for many TGD people, facial transformation and hair removal are also key elements for attaining social gender congruence.5 Minimally invasive procedures — including injectable fillers, neuromodulators like botulinum toxin, and hair removal such as laser and electrolysis — are growing in popularity,6 as they may help compensate for delays in accessing surgical and medical gender-affirming care.

According to the WPATH SOC8, a TGD person’s gender incongruence must be “marked and sustained” for them to qualify to access medical care, but little guidance is given regarding the duration of incongruity required.1 Moreover, even with access to hormone therapy, the desired aesthetic effects often take months to years to manifest.7 Whether delays in achieving the desired benefits are due to barriers to accessing care or to slow medical treatment effects, minimally invasive procedures could be considered to support patients’ gender affirmation. Minimally invasive procedures have the added benefit of being relatively low risk and reversible when compared with surgical and hormonal approaches; they can also be performed by a variety of practitioners, which increases their potential for wide availability. 8 Minimally invasive procedures are therefore a suitable option for people not considered to qualify for surgeries, or in whom the risks associated with hormone therapy are increased because of medical comorbidities.

The findings of a 2021 survey of TGD individuals showed that people who received nonsurgical facial injectables reported greater self-esteem, a more positive body image, greater gender congruence and less anticipated discrimination from others than people who did not.9 A large 2021 cross-sectional study found that transgender women who received gender-affirming hair removal had better mental health status than those who did not.10 Public health care payers may argue that appearance-enhancing procedures should be covered privately. However, public coverage for otoplasty surgery — which alters the shape, position or proportion of the ear — for people younger than 18 years has been publicly funded in most Canadian jurisdictions for years,11 and children and teens who have undergone this procedure have been shown to have significant associated improvements in self-esteem and relief of appearance-related anxiety.11

Our scan of Canadian health care systems showed that Manitoba and Yukon were the only 2 jurisdictions to cover hair removal for gender-affirming care.3 Because hair removal can help to achieve a desired aesthetic, and may be helpful for patients in whom avoiding the systemic adverse effects of oral therapies is desirable, why is this intervention covered in some jurisdictions in Canada and not others? Yukon, known as a leader in gender-affirming care in North America, also covers facial feminization surgery (and additional interventions that other provinces and territories do not fund).3 We did not identify any provinces or territories that covered neuromodulator or filler therapies for facial masculinization or feminization.

In a review of systems in the United States and Europe, we found that no jurisdiction offered public coverage for minimally invasive facial injections, as these were deemed cosmetic procedures. 12,13 England and the Czech Republic appear to be the only countries to provide public insurance for hair removal on a national level, but coverage requires patients to undergo stringent assessments.13 We did not explore coverage offered under private health care plans in any jurisdiction.

Estimating the cost of funding minimally invasive procedures in Canada may be challenging, as the degree of feminization or masculinization that a person pursues is an individual choice. Moreover, not all TGD people seek out medical transition. If implemented, government support for the provision of minimally invasive gender-affirming procedures could be accomplished through the funding of billing codes for such procedures, or through coverage of the products used for these purposes under provincial and territorial pharmacare programs.

Operationalizing this may present challenges. For example, the Government of Yukon had to change legislation that permitted private clinics to provide hair-removal services (which are then reimbursed by the government).14 It is also important to consider that hair removal may be less applicable to TGD individuals assigned female at birth (hair growth is often desired by members of this group).

Minimally invasive procedures such as hair removal and facial injectables may support the process of transition in a timely fashion; evidence supports their therapeutic benefits in the field of gender-affirming care. Such procedures warrant serious consideration for public funding across Canada, for a population that continues to face systemic discrimination and barriers to access in care.

## Acknowledgement

*The authors recognize that they are cis-gendered women, but both provide care for transgender and gender-diverse people.

## Footnotes

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** Both authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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