Max Evans* has spent the last six years on various wait-lists for gender-affirming care, a process he describes as “frustrating and exhausting.”
This year, the second-year master’s student at the University of British Columbia (UBC) is on the final wait-list of his transition: the one for accessing bottom surgery at Vancouver’s Gender Surgery Clinic. But for months, Evans, who requested a pseudonym because he’s not out as trans in his professional life, was dogged by one question: how would he pay for his care?
While B.C.’s provincial healthcare covers phalloplasty, Evans’s chosen procedure, it doesn’t always cover the full cost of the electrolysis or laser hair removal required to get the surgery. Phalloplasty requires the grafting of tissue from another part of one’s body—such as the forearm—and removing hair from this tissue is both cosmetic and essential for avoiding infection post-surgery. Evans was recommended weekly electrolysis sessions for a year to remove the necessary hair from his forearm. At $100 per session, he knew the cost would quickly add up.
“I was under a lot of stress trying to figure out, ‘How am I going to get this money? Will I still be able to remain on this wait-list?’” Evans says.
If he didn’t complete the electrolysis in time, Evans risked losing his spot at the Gender Surgery Clinic. Thankfully, last summer he learned that his university healthcare program would start covering the cost.
“When I found out that my electrolysis was going to be covered, I literally just broke down and cried because it was such a relief.”
Thanks to the advocacy of some of his fellow UBC students, Evans is one of more than 200,000 university students across 20 Canadian universities who gained access to coverage of gender-affirming procedures through their student union’s extended benefit plans as of September.
The gender-affirmation care benefit, developed by the not-for-profit insurance provider GreenShield and made available through university insurance broker Studentcare, provides lifetime coverage of up to $10,000 for gender-affirming procedures not covered by provincial health insurance. Designed to fill gaps in existing provincial coverage, the procedures covered vary by province and territory but can include fees for chest and bottom surgeries, as well as procedures that are not typically publicly funded, like vocal surgery and facial feminization surgery (FFS).
GreenShield first launched the gender-affirmation care benefit in 2021 and automatically included it in its extended group benefits. Student groups who already had their primary insurance through GreenShield gained immediate access, but it wasn’t until this year that the benefit became more widely available as an insurance product for schools to opt into through Studentcare—which brokers insurance for over a million students across Canada—regardless of primary insurance provider.
In September, 27 student unions across 20 universities opted into the benefit through Studentcare, nearly doubling the benefit’s student enrollment. In addition to UBC, the University of Victoria, McGill University, Concordia University, Queen’s University and Western University also added the benefit to their student health plans.
Long wait times and gaps in public coverage can make accessing essential gender-affirming care especially challenging for students, a group already under financial strain and likely further economically disadvantaged if they’re trans. Sophia Haque, director of partnerships and development at Studentcare, admits that before the introduction of the gender-affirmation benefit, coverage of gender-affirming care in student health plans was “fairly limited.” Prescription drug coverage provided access to certain hormone replacement therapies (HRT) but extended procedural coverage was rare outside of plans through GreenShield.
Haque says that while expanding the scope of coverage had been on Studentcare’s radar, it was advocacy from the UBC Trans Coalition, a student-led initiative, that pushed them to launch the benefit this year. “I see the UBC Trans Co folks as being really key,” Haque says. “I like to believe that this service would have made its way to students anyway [but] I’m not sure it would have been Sept. 1, 2023, if it wasn’t for their effort.”
Part of UBC’s Pride Collective, the Trans Coalition focuses on expanding the gender-affirming coverage available to students and making existing coverage more accessible. The group’s five lead organizers understand first-hand the struggle of accessing gender-affirming care as students.
“I think a lot of us come to B.C. and we expect a gold standard of healthcare coverage or supports for trans folks in Canada. But it’s not the case,” Sage Bishop*, a UBC Trans Coalition organizer, explains. (All UBC Trans Coalition organizers have been given pseudonyms and gender-neutral pronouns at their request to protect their identities as they have previously experienced doxxing.)
Hair removal, FFS and vocal surgery are still not covered under B.C.’s provincial plan while breast construction surgery and HRT that isn’t in pill format are only covered under certain circumstances. This leaves many trans students on the hook for thousands of dollars should they want to access a range of gender-affirming care.
The UBC Trans Coalition looked to fill gaps in their student and provincial coverage through private insurance, meeting with UBC’s student union, the Alma Mater Society (AMS), and Studentcare in the summer of 2022. The AMS health and dental plan was already operating at a deficit after an influx in claims over the pandemic, so adding the gender-affirming benefit required increasing every student’s health plan fee by $8 per year. In February, adding the gender-affirmation care benefit in exchange for the fee increase was put to a student-wide vote. The benefit passed with 65.5 per cent of voters’ approval.
“It felt like a relief when we won. It felt like a glimmer, but there’s so much ahead of us,” says Bishop. In addition to inspiring Studentcare to offer the new gender-affirmation benefit, UBC was the only university where its inclusion was put to a student vote—a process they don’t recommend other schools repeat.
“We had to fight tooth and nail in the process, putting our community of trans students in the spotlight,” says Tatum Greene*, another organizer with the UBC Trans Coalition. For Greene, watching their fellow trans students have to openly campaign for their own healthcare was “terrifying and difficult.”
Concordia University in Montreal, another early adopter of the benefit, did so through a vote of the Concordia Student Union’s (CSU) eight-person student executive. To Hannah Jackson, the CSU’s external and mobilization coordinator, adding the benefit was “a pretty obvious choice.”
“We thought it would complement the already-existing gender-affirming coverage within the student plan and it wasn’t an incredibly large cost,” Jackson says. At Concordia, adding the benefit also didn’t require any increase to student fees.
While its addition is an important victory, the UBC Trans Coalition and the CSU acknowledge that the new benefit isn’t without its drawbacks. One major barrier flagged by both Jackson and the UBC Trans Coalition is the requirement that claimants receive a diagnosis of gender dysphoria in order to access coverage. Despite recommendations from the World Professional Association for Transgender Health to move away from a diagnostic model and toward an informed consent model of trans healthcare, insurance providers usually still require patients to obtain a diagnosis from a doctor in order to receive coverage.
“The diagnostic requirement is to ensure the safety of the student [and] that they are under the proper care,” JP Girard, executive vice president and head of health insurance at GreenShield, says. “And for us as well, to ensure that we are being responsible in providing a benefit that is not being misused or mistreated.”
Bishop acknowledges that insurers may want to prevent gender-affirming benefits from being used by cis folks for cosmetic purposes, but points out that a diagnosis of gender dysphoria can be difficult to access. Many students don’t have a primary care provider and if they do, not all doctors are properly trained in gender-affirming care. UBC’s Student Health Service provides on-campus primary care to students, but has only one nurse practitioner trained in gender-affirming care.
Another shortcoming of the benefit is the $10,000 lifetime limit, which is further divided into a $5,000 maximum per procedure. For procedures like FFS, which can cost tens of thousands of dollars, the existing benefit barely makes a dent. The fact that students have to foot the bill before being reimbursed by their insurance is another likely barrier.
Jackson points out that in cases like FFS, the benefit functions more as a subsidy. “If somebody gave a $5,000 donation to your FFS GoFundMe, that’s pretty significant, but it’s not going to enable you to book the appointment tomorrow,” she says.
For less costly and minimally invasive procedures like electrolysis and laser hair removal, which aren’t covered by public insurance anywhere in Canada other than in the Yukon, the benefit’s impact is significant. “It’s definitely not a perfect solution. But I think that it brings some of these really important life-saving procedures into the realm of possibility for some folks where they wouldn’t have been before,” says Kit Bailey*, another UBC Trans Coalition organizer.
While some major student groups that work with Studentcare, like the University of Toronto Students’ Union, have yet to opt in, Haque points out that for a brand-new benefit, the enrollment so far has been significant. She adds that while student unions are hesitating to increase the cost of their health plans with rising inflation, many have expressed interest in the benefit and enrollment will likely increase in the coming years.
The UBC Trans Coalition and the CSU continue to push to expand the scope of gender-affirming care available to students, advocating for extended coverage of HRT and other procedures not reflected in the GreenShield benefit. While private insurance has been a successful strategy in expanding the coverage available to students, they both emphasize provincial coverage as the ultimate solution.
“In an ideal world, we wouldn’t even need something like this … because it would be covered by the province,” Bailey says. “But again, that’s a slower process. The bigger the institution, the longer it takes to change things. So starting here makes a difference.”