Decide which Qualified Provider(s)will conduct the TRS planning visit(s) and hence complete the MOHLTC Prior Approval from.

The MOHLTC requires the Prior Approval form to be completed by “a provider trained in the assessment, diagnosis and treatment of gender dysphoria in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care…”, and it is expected that the Qualified Provider who signs the Prior Approval form has conducted a complete TRS planning visit. Patients and their providers may choose what works best given individual patient needs and local resources.

Who is a Qualified Provider?

• The MOHLTC has maintained that providers should determine for themselves if TRS planning visits and referrals fall within their scope of practice, as providers would generally self-determine in other areas of care. There is no single training course that ‘qualifies’ a provider; rather a provider can become ‘qualified’ by any number of activities, including but not limited to: attending continuing medical education (CME) on trans surgical care through RHO, CPATH or WPATH; working at a health facility that practices trans primary care in accordance to WPATH guidelines; obtaining mentorship from an experienced colleague, through participation in the RHO trans mentorship call, or ECHO Ontario on Trans and Gender Diverse Healthcare. A provider who is new to this area of practice may want to combine a number of these activities to gain the necessary expertise.

Providers can gain TRS knowledge and access mentorship through:

• WPATH SOC
• RHO Workshops on Transition-related Surgeries
• RHO trans care mentorship call
• Sherbourne Health TRS Summary sheets (valuable resource to facilitate discussion between provider and patient)
• UofT/CAMH Trans ECHO^R
• Trans E-consult, Champlain LHIN
• Mentorship with an experienced provider

A TRS planning visit is a collaborative visit between patient and a qualified provider to discuss TRS and how to optimize the patient’s experience and outcome. Topics discussed include WPATH and MOHLTC criteria, confirming the diagnosis of gender dysphoria, reviewing the stability of medical and mental health conditions, a surgery-specific informed consent discussion and aftercare planning.

All primary care providers can support patients during the TRS process, whether or not they conduct the TRS planning visit(s)

Whether a patient has TRS planning visits in Primary Care or with CAMH or another Qualified Provider, there are many ways that a primary care provider can support a patient throughout the TRS process. Providers can help prepare patients for surgery by assisting in the optimization of medical and mental health conditions, supporting smoking cessation, discussing the aftercare plan, preparing for travel, finances and supplies, and providing emotional support. Some patients may benefit from peer support and information such as that provided by Sherbourne Health’s Surgical Support Groups for Community Members.

Complete, sign, and submit the “Request for Prior Approval for Funding of Sex-Reassignment Surgery” (also known as the “Prior Approval” form) to the MOHLTC.

The number of qualified providers who must complete independent TRS surgery planning visits and sign a Prior Approval from is based on the type of surgery requested. Upper body surgery requires a TRS planning visit(s) by one qualified provider (either a physician or NP). Gonadal or external genital surgery requires independent TRS planning visits with two qualified providers, one of whom must be a physician or NP, while the second can be a physician, NP, registered nurse, psychologist, or a registered social worker with a Masters of Social Work. Only the Prior Approval form should be sent to the MOHLTC; TRS clinical notes and referral letters should not be sent. The MOHLTC will then send a response letter with the outcome of the funding application.

Once an Approved Funding Letter is received, the qualified provider(s) can then send TRS referral letters to the TRS surgeon. TRS referral letters are different from typical referral letters; they include a large amount of information regarding the topics covered in the TRS planning visits. Providers should be familiar with the WPATH recommendations for TRS referral letters. Most surgeons will require complete documentation of thorough TRS planning visit(s). Additional materials such as medication lists, lab results, ECG, and/or photographs may be required by some surgeons before an appointment is booked.