Part 1: Ontario taxpayers are flying a man to Texas for penile-preserving vaginoplasty. But who is he?
A man asked the Ontario Health Insurance Plan (OHIP) to cover an experimental cosmetic genital surgery known as "penile-preserving vaginoplasty." This surgery involves burrowing a tunnel through a man’s pelvic floor from an opening cut into his perineum and lining it with tissue harvested from the abdominal cavity, while leaving the penis (and sometimes the scrotum) intact.1
No doctors in Canada perform this procedure, there is no peer-reviewed literature to support its indications or the surgical techniques used in the process, and there is no long term data reporting psychological or physical outcomes.
The province refused. The man appealed his case, and the Health Services Appeal and Review Board decided that this procedure should be covered. Now, Ontarian taxpayers are paying to fly the man to Austin, Texas to get the surgery.
I’m honestly too bewildered by this whole case to provide much commentary, so instead I’m going to focus on sharing the facts of the case and the personal details we know about the individual who will be receiving it.
Part 1 of this article consists of excerpts from the official documentation. It’ll give you the overall facts of the case while cutting down on superfluous legalese.
Part 2 of this article is something that the mainstream media has missed — namely that the man in question has a significant (and salacious) social media presence and that he has been bragging about his appeal online.
Part 1: The Ontario Health Services Appeal and Review Board Decision
Here is the official documentation of the decision, and here is an archive of it. I’ll summarize it through excerpts, which have been edited both to improve readability and to reflect reality.
Basic Facts
The Appellant was born in 1989 and at the time of the appeal hearing was 33 years of age. The Appellant’s sex is male.
The Appellant identifies as nonbinary. He does not identify as exclusively female, or exclusively male. While the Appellant considers himself “female dominant” and uses a feminine name and pronouns, he identifies as nonbinary and is therefore not completely aligned with either the male or female genders.
KS’ Original Request
KS wishes to pursue genital surgery to continue to assert himself in his preferred gender. He will be pursuing orchiectomy separately (application in process) so that he is able to come off androgen blockers. It is very important for KS to have a pseudo-vagina for his personal interpretation of his gender expression but he also wishes to maintain his penis. KS identifies as transfeminine but not completely on the “feminine” end of the spectrum end for this reason it’s important for him to have a pseudo-vagina while maintaining his penis. This surgery is not available anywhere in Canada and for this reason KS is applying for funding to have this procedure done at the Crane Centre in Texas which has an excellent reputation for GrS and especially with these more complicated procedures.
OHIP’s Denial
In a letter to KS’ doctor, Dr. Druce, dated June 27, 2022, OHIP denied the funding request. OHIP wrote that because Penile Preserving Vaginoplasty is not listed as a procedure in Appendix D of the Schedule, it is not an insured service under OHIP. In the letter, they stated the following:
Vaginoplasty (including penectomy, orchidectomy, clitoroplasty and labiaplasty) is an insured OHIP service when the criteria for payment is met, as set out in Appendix D of the Schedule of Benefits for Physician Services (the Schedule). Penile Preserving Vaginoplasty or Vaginoplasty (without penectomy) is not listed as a procedure in Appendix D of the Schedule. Therefore, this is not an insured service under OHIP. There are no provisions under the Health Insurance Act or its Regulations that permit OHIP to pay for an uninsured service or part of an uninsured service. For this reason the ministry cannot approve this request at this time.
KS’ Appeal
The Appellant submitted that he applied for a vaginoplasty without penectomy because he identifies as nonbinary. He explained that he does not identify as exclusively female, nor exclusively male but considers himself "female dominant" and uses a feminine name. He added that to ignore “the other third” of him and how he presents, would be invalidating; he is “both”, not exclusively one or the other but literally a mix.
The Appellant argued it is appropriate that he seek a surgery that validates his identity and how he regularly presents and identifies.
The Appellant submitted that Canada is “behind the curve” and does not offer surgical options that align with the needs of nonbinary people. He added, there are surgeons in the United States and Asia who offer vaginoplasty without penectomy in a similar process to a standard “binary” vaginoplasty. The Appellant submitted that he investigated various options and chose a surgeon in the United States who could offer a surgery that is identical to “binary” surgeries that are funded under OHIP, with the only exception being that the surgery is one that retains the penis (i.e., the surgery would not include the additional procedure of a penectomy).
The Appellant explained there are two additional medical reasons he chose to request approval for a vaginoplasty without penectomy:
Through his endocrinologist, the Appellant learned that unless he receives supplementary topical testosterone, he is unable to have an orgasm. This condition is referred to as “orgasm dysfunction”. Currently, the low-dose testosterone he receives is applied directly to his penis, in order to provide a tiny amount to keep the nearby prostate functional. The Appellant explained that since he cannot apply the gel inside a perineal cavity or rectally, and because it is an alcohol based irritant, he needs to keep his penis in order to continue the testosterone therapy, and retain the ability to have an orgasm. The Appellant submitted that it is unjust to deny him the ability to have an orgasm for the rest of his life.
The Appellant indicated that another complication of hormone therapy is that it has created urinary incontinence issues. He is concerned that a vaginoplasty with a penectomy will create additional urological rerouting complications and intensify his incontinence problems. By retaining his penis the Appellant believes he can avoid those additional complications.
The Appellant argued that despite the position taken by the Respondent in denying his prior application there is no requirement in the legislation, regulations or Schedule of Benefits that when one applies for prior approval for vaginoplasty surgery that the surgery “must” include penectomy, orchidectomy, clitoroplasty, and labiaplasty.
OHIP’s Response & Expert Testimony
OHIP submitted that the Appellant’s request is for public funding of a medical service that is not an “insured service” and is therefore not eligible to be received by the Appellant as a publicly funded insured benefit of OHIP. For these reasons, the Respondent submitted the Appellant’s appeal should be dismissed.
Respondent provided another submission on January 12, 2023, accompanied by the expert report of Dr. Yonah Krakowsky, in support of its additional position in this appeal:
“Current expert opinion would widely agree that the penile preservation vaginoplasty is experimental. There is no peer-reviewed literature to support its indications, or the surgical techniques used in the process. Further, there is no longer term data reporting psychological or physical outcomes. When discussed at the international conference of the World Professional Association for Transgender Health the non-official consensus among high volume surgeons was that this technique is poorly understood and is experimental. This is also my personal opinion on penile preservation vaginoplasty.”
KS’ Additional Submissions2
KS claims that OHIP has sought to “invent separate terminology for medically identical procedures” in order to classify the Appellant’s prior approval application for surgery as experimental.
The surgical procedure that KS has requested is a vaginoplasty. A “vaginoplasty, regardless of the technique employed,” is a vaginoplasty.
Vaginoplasty without using penile material (i.e., vaginoplasty without penectomy) has been studied in “cisgender” patients alongside trans-identified patients. KS maintained that vaginoplasty without penectomy does not meet the threshold for “experimental treatment.”
Relevant Ontario Law
Section 11.2 of the Act defines “Insured services” as:
1. Prescribed services of hospitals and health facilities rendered under such conditions and limitations as may be prescribed.
2. Prescribed medically necessary services rendered by physicians under such conditions and limitations as may be prescribed.
Paragraph 17 of Appendix D, page AD7, of the Schedule of Benefits states that:
Sex-reassignment surgical procedures listed in this section are insured services when prior authorization has been obtained from the MOH.
A prior authorization request must include supporting assessment(s) that recommend surgery; the assessment must be completed by a provider trained in the assessment, diagnosis, and treatment of gender dysphoria in accordance with the World Professional Association for Transgendered Health (WPATH) Standards of Care3 that are in place at the time of the recommendation (“appropriately trained provider”).
Section 24.1 of the Act states that treatments for a medical condition that are generally accepted within Ontario as experimental are not insured services.
Issues Being Decided
Q1: Does “vaginoplasty” (included in the list of eligible External Genital Surgeries), include “penectomy”? If the answer to this question is yes, then a vaginoplasty without penectomy is not included in the list of eligible External Genital Surgeries.
Q2: Is a penile-preserving vaginoplasty generally accepted within Ontario as experimental?
The Hearing
KS’ Testimony
OHIP is seeking to exclude people who identify as nonbinary from eligibility for OHIP-funded cosmetic genital surgery.
Dr. Krakowsky, OHIP’s expert witness, has a bias towards “binary” surgical outcomes.
To “force” a person who identifies as nonbinary like the Appellant to undergo “binary” surgery would only exacerbate their gender dysphoria and would be akin to conversion therapy, which is now illegal under Bill 77, Affirming Sexual Orientation and Gender Identity Act, 2015 and the Criminal Code.
Dr. Druce’s Evidence
Dr. Druce is an endocrinologist who identifies as an expert in “gender diversity.”
Dr. Druce explained that she requested funding for a vaginoplasty without penectomy on behalf of the Appellant because of her belief that “gender is not linear/binary” and that genital surgery should “affirm one’s gender in their own individual way.”
Dr. Druce believes that heading for paragraph 17 of Appendix D, “Sex-Reassignment Surgery,” is antiquated and flawed language, and should instead be retitled “Gender Affirming Surgery” in accordance with her belief in the concept of gender identity.
Under cross-examination, Dr. Druce confirmed that she is not a surgeon and does not have training in surgery. She confirmed that she would defer to the opinion of a surgeon, such as Dr. Krakowsky, with respect to surgical related questions.
Dr. Krakowsky’s Evidence
Dr. Krakowsky is the medical lead for “gender affirming” surgery at WCH. He is one of three surgeons performing genital surgeries on people who claim to have gender identities at the only hospital in Ontario that performs them.
Dr. Krakowsky confirmed his opinion that the creation of a perineal canal meant to mimic the aesthetics of a vagina without the removal of the penis is currently considered experimental by most surgeons.
He maintained that it is experimental despite the fact that it is performed by foreign surgeons because not enough current data gathered through randomized controlled trials has been presented to support its efficacy.
The Findings
Q1: Does “vaginoplasty” (in the list of eligible External Genital Surgery) include “penectomy”?
In determining the meaning of vaginoplasty, the Appeal Board considered WPATH’s self-styled “Standards of Care” Version 8 (SOC-8).
While SOC-8 does not provide a definition of vaginoplasty, it claims that “gender identities may present along a spectrum” and that “gender diverse presentations may lead to individually-customized surgical requests some may consider non-standard.”
The Appeal Board notes that in the Appendix D definition of External Genital Surgery,4 the words “vaginoplasty” and “penectomy” are listed separately, which suggests that “vaginoplasty” does not necessarily include “penectomy.”
The Appeal Board finds that “vaginoplasty” does not include “penectomy” and therefore, a “vaginoplasty without penectomy” as requested by the Appellant in his application for “gender reassignment surgery” is eligible for prior approval.
Q2: Is vaginoplasty without penectomy surgery generally accepted within Ontario as experimental?
Having found that vaginoplasty without penectomy is specifically listed as an insured service in the list eligible External Genital Surgeries, the services cannot be excluded from coverage due to being experimental.
The Verdict
The Appeal Board finds that the Appellant’s proposed vaginoplasty without penectomy surgery, to be performed at the Crane Center for Transgender Surgery in Austin Texas, USA, is an insured service and is eligible for payment.
The appeal is allowed.
Part 2: Ontario taxpayers are flying a man to Texas for penile-preserving vaginoplasty. But who is he?
A man asked the Ontario Health Insurance Plan (OHIP) to cover an experimental cosmetic genital surgery, and the province refused. The man appealed, and won. Now, Ontarian taxpayers are paying to fly the man to Austin, Texas to get the surgery. In Part 1
I’ve (unfortunately) seen photos of the results. It looks like a second anus without the sphincter muscles.
The official documentation states that he “filed extensive submissions in response to [OHIP’s] submissions” and that they could only be summarized.
It should be noted that WPATH’s self-described “standards of care” have not been recognized as evidence-based health and social service standards by any Standards Development Organization recognized by the Standards Council of Canada. How and why an activist organization’s pamphlets came to be referenced in Ontario Health Insurance Plan’s Schedule of Benefits should be highly concerning.
which lists: clitoral release, glansplasty, metoidioplasty, penile implant, phalloplasty, scrotoplasty, testicular implants, urethroplasty, vaginectomy, penectomy, vaginoplasty