The Impact of Limiting Bottom Surgery Readiness Assessments in BC

Introduction: The Lengthening Wait for Gender-Affirming Care

Access to timely, compassionate healthcare is a fundamental right, yet for trans+, nonbinary, and gender expansive individuals in British Columbia, this right is increasingly compromised. For years, bottom surgery readiness assessments in BC were conducted by qualified, WPATH SOC8 Certified mental health professionals, providing essential support that helped reduce wait times and ensure that assessments were trauma-informed and sensitive to the unique needs of trans+ individuals.

However, recent policy changes have drastically altered this landscape. In March 2023, the BC Gender Surgery Program (BCGSP) restricted bottom-surgery readiness assessments to doctors, nurse practitioners, and registered nurses only. This shift, intended to streamline care, has instead created significant barriers, delays, and confusion, ultimately impacting the mental and physical well-being of those who rely on these services.

Contrary to common belief, this decision was not made by Transcare BC; it was established by the surgeons at the BCGSP based on their clinical experience. While Transcare BC can help inform and guide individuals through this process, they do not have authority over these clinical practices. As a result, a policy intended to improve care has, in practice, led to serious access issues, placing additional strain on an already overwhelmed healthcare system and directly impacting the health and dignity of trans+ individuals in BC.

The Issue: New Restrictions to Accessing Timely Bottom Surgery Assessments

Since March 2023, the BCGSP has required that bottom-surgery readiness assessments be performed solely by doctors, nurse practitioners, and registered nurses. Intended to streamline care, this policy has instead created significant barriers, causing delays, confusion, and adverse mental health effects for those seeking gender-affirming surgery. Although Transcare BC is often thought to be responsible, the BCGSP’s surgeons developed this requirement based on their professional experiences. Transcare BC can provide guidance but cannot enforce clinical practice decisions.

Prior to this policy change, trained, WPATH SOC8 Certified therapists like myself could conduct these assessments, alleviating some strain on the healthcare system by reducing wait times and providing informed, trauma-sensitive evaluations. Now, trans+ individuals in BC face lengthy delays, with some unable to even reach the waitlist due to misunderstandings among providers or unfamiliarity with the new requirements.

The Reality on the Ground

The policy shift has had profound impacts, felt daily by trans+ individuals navigating a strained healthcare system. Intended to streamline care, the restriction of bottom surgery readiness assessments to a narrow group of medical providers has instead led to widespread confusion, knowledge gaps, and treatment delays. Many doctors, nurse practitioners, and registered nurses—though well-intentioned—lack specialized training in trans+ healthcare, which requires nuanced understanding, trauma-informed approaches, and familiarity with the specific needs of those undergoing gender-affirming procedures.

As a result, the system has become fragmented, with the quality of care varying widely from provider to provider. Patients often find themselves without clear pathways to care. Without standardized training programs for medical professionals in this area, many providers are unaware of the new policy requirements or uncertain about how to proceed.

Recently, without a necessary update from BCGSP or Transcare BC, clients were referred back to me by medical providers who mistakenly believed I’m still able to complete bottom surgery assessments, only for the completed assessments to be rejected. For example, a readiness assessment, which I conducted under my WPATH SOC8 Certification, was returned to the referring doctor with the message: “Clayre is not a qualified bottom surgery assessor.” This message came without further instructions or guidance, leaving both the doctor, the patient, and myself confused and unsure of the next steps. This lack of communication creates unnecessary stress, delays in accessing critical care, and places undue pressure on individuals already navigating complex challenges.

This confusion reveals a critical issue: limiting assessments to select medical professionals without investing in adequate training has created bottlenecks that exacerbate wait times, amplify patient distress, and put individuals at risk. Many clients find themselves in limbo, waiting months for reassessment or clear guidance, all while struggling with dysphoria, anxiety, and other mental health impacts of delayed care.

Impact on Access and Mental Health

Delays in gender-affirming surgeries extend far beyond mere inconvenience; for many trans+ individuals, these delays are life-altering, with profound consequences for mental health and well-being. Access to timely surgery is not just a medical necessity but a pathway to feeling whole, affirmed, and comfortable in one’s body. When these procedures are stalled by policy barriers and provider knowledge gaps, feelings of dysphoria, anxiety, and hopelessness can compound over time, taking a toll on mental health.

Research links delays in gender-affirming care to mental health risks. For example, Jacqueline’s Medical Gaslighting (2024) highlights how systemic healthcare barriers can lead to feelings of dismissal and invisibility among marginalized groups, with adverse effects on mental health. In the case of delayed surgery, individuals are left in a harmful cycle where access to care feels perpetually out of reach, leading to a heightened sense of vulnerability and isolation. When the healthcare system does not respond in a timely, supportive manner, patients may internalize messages of unworthiness, which further erodes mental well-being and self-worth.

The current BC policies have, as Dusenbery (2018) notes, “put the cart before the horse.” They assume that restricting assessments to certain medical providers will streamline care, yet without corresponding investments in training and infrastructure, patients are left to navigate an unsupported system. Providers are often ill-prepared to meet the needs of trans+ individuals, forcing patients—already managing the emotional toll of dysphoria—to become their own advocates. This self-advocacy burden, combined with inconsistent information and provider knowledge gaps, places undue strain on patients’ mental health.

Systemic issues force many individuals to advocate repeatedly, even when they encounter dead ends. Navigating these barriers can deepen feelings of alienation and lead to growing distrust in the healthcare system—an experience well-documented among marginalized populations facing health inequities (Frohard-Dourlent et al., 2017). This distrust can discourage individuals from seeking care, compromising health outcomes and exacerbating the psychological distress caused by these delays.

BC’s current approach does not address the urgency of these needs. Harvard T.H. Chan School of Public Health (2021) found that timely access to gender-affirming care is associated with significant reductions in psychological distress and suicidality. However, as waitlists grow and confusion around policies deepens, trans+ individuals are left waiting for months, sometimes years, for life-affirming care. Each delay becomes a barrier to healing, safety, and well-being, underscoring an urgent need for policy and infrastructure reform.

In sum, restricting access to timely assessments is not a mere logistical misstep but a profound systemic failure with far-reaching impacts. Without meaningful improvements in training, communication, and resource allocation, BC’s healthcare system will continue to fall short of providing the compassionate, competent care trans+ individuals need.

What Needs to Change?

To address the barriers impacting trans+ individuals’ access to life-affirming care, BC’s healthcare system must commit to thoughtful reform. The current approach does not adequately support the timely, compassionate, and effective care fundamental to equitable health services. Addressing these shortcomings requires both immediate changes and a long-term commitment to systemic change:

1. Provincial Accountability and Training Investment

BC’s provincial health authorities need to recognize their responsibility to provide equitable, accessible gender-affirming care. This requires investing in specialized training for the medical providers now responsible for bottom surgery assessments—namely doctors, nurse practitioners, and registered nurses—who often lack specific expertise in trans+ healthcare (Jacqueline, 2024). This training should include the principles of trauma-informed care and adherence to WPATH SOC8 guidelines to ensure that assessments are sensitive, supportive, and clinically sound. Without these foundational competencies, assessments can fail to address the full scope of a patient’s needs, inadvertently deepening the harm these policies aim to reduce (Dusenbery, 2018).

2. Commitment to Clear, Transparent Communication

Effective care relies on clarity at every level, especially when policies and procedures directly impact patient access to essential services. Consistent and transparent communication from BC’s healthcare system is crucial. This includes clear, accessible information for both providers and patients on assessment requirements and pathways to care. Without clear communication, individuals are often left in the dark, navigating an opaque system without direction. As Frohard-Dourlent et al. (2017) underscore, the lack of systemic clarity disproportionately affects marginalized groups, compounding delays, confusion, and the psychological burden on those already vulnerable.

3. Broadening the Scope of Qualified Assessors

Expanding the pool of qualified assessors to include trained mental health clinicians would significantly alleviate bottlenecks and reduce wait times for bottom surgery readiness assessments. This inclusive approach not only mitigates the strain on medical providers but also reintroduces access to assessments by professionals who often have deeper expertise in gender-affirming care. Mental health clinicians—many of whom are trans+ themselves—bring a trauma-sensitive, culturally competent lens to these assessments, offering patients a level of understanding and care that medical professionals without this background may lack (WPATH, 2022). Reinstituting the role of WPATH-certified clinicians in assessments would align with best practices in accessible, affirming care and offer a broader range of support to those in need.

4. Leveraging Available Resources and Support Systems

Resources such as the RACE line and Transcare BC’s Health Navigators are valuable supports that can help medical providers navigate the complexities of gender-affirming care. However, providers may be unaware of these resources or hesitant to use them. Actively promoting these support systems as integral parts of the assessment process can help providers gain confidence in delivering competent care and ensure patients are not caught in gaps created by uncertainty or lack of guidance (Harvard T.H. Chan School of Public Health, 2021). Medical providers need encouragement to leverage these tools to bridge their knowledge gaps and offer informed, timely care.

Ultimately, BC’s healthcare system must build a foundation of inclusive, accessible care. Systemic change goes beyond policy compliance; it means addressing the real, human impacts of healthcare policies on marginalized communities. By investing in training, prioritizing clear communication, broadening assessment roles, and utilizing available resources, BC can create a system that truly respects the well-being, dignity, and rights of every individual seeking gender-affirming care.

FAQs: Navigating Bottom Surgery Readiness and Hormone Therapy in BC

Bottom-Surgery Readiness Assessments

How do referrals for gender-affirming treatment work in BC?

In BC, a primary care provider (doctor, nurse practitioner, or registered nurse) can refer you to specialists for gender-affirming medical care, including bottom surgeries. The process begins with a conversation with your primary provider, who assesses your needs and makes the appropriate referral. For more information, refer to Transcare BC’s referral guide here.

How do I get on the bottom surgery waitlist in BC?

To be placed on the bottom surgery waitlist, you first need to complete a bottom surgery readiness assessment with your primary medical provider (doctor, nurse practitioner, or registered nurse). After this assessment, your provider will refer you to a qualified surgeon. If you’re unsure where to start, contact a Health Navigator at Transcare BC for guidance.

What if I don’t have a primary medical provider, such as a doctor, nurse practitioner, or registered nurse?

If you don’t have a primary medical provider, it’s essential to find one. A Health Navigator at Transcare BC can help connect you with a gender-affirming primary care provider. Additionally, I have written a blog post on how to find a doctor in BC that may be useful. Don’t hesitate to seek assistance from these resources—they are there to support you.

How many types of bottom surgery are available in BC?

Transcare BC highlights four types of bottom surgeries: removal of the uterus and ovaries (hysterectomy), removal of the testes (orchiectomy), construction of a penis (phalloplasty), and construction of a vulva and vagina (vaginoplasty). For more details on these procedures, visit Transcare BC’s page here.

Can Clayre Sessoms, RP, RCT, RCC, RCAT, CCC, ATR-BC, or Audrey Wolfe, RCC provide a bottom surgery readiness assessment in BC?

No. Due to policy changes from the BC Gender Surgery Program (BCGSP), only your primary care provider (MD, NP, or RN) can conduct bottom surgery readiness assessments in BC. This policy applies to all licensed mental health professionals, regardless of WPATH SOC8 certification.

Can a registered clinical counsellor (RCC), psychologist (R.Psych.), registered social worker (RSW), or registered clinical social worker (RCSW) provide a surgical readiness assessment in BC?

No. Due to BC regulations set by the BCGSP, only doctors, nurse practitioners, and registered nurses can provide bottom surgery readiness assessments. This policy excludes registered clinical counsellors, psychologists, and social workers.

Can Clayre Sessoms, RP, RCT, RCC, RCAT, CCC, ATR-BC, or Audrey Wolfe, RCC provide hormone therapy assessments in BC?

Yes, I and Audrey Wolfe, RCC, can still provide hormone therapy assessments in BC for clients. Once you have a hormone therapy assessment from us, your primary care provider can refer you to an endocrinologist, such as Dr. Marshall Dahl or another endocrinologist who accepts assessments from WPATH SOC8 Certified mental health clinicians.

Can Clayre Sessoms, RP, RCT, RCC, RCAT, CCC, ATR-BC or Audrey Wolfe, RCC provide a surgical readiness assessment in other provinces?

Yes, in some provinces, we can provide various types of surgical readiness assessments. We will, however, need to verify your province’s regulations and policies to ensure the assessment will be accepted.

Can Clayre Sessoms, RP, RCT, RCC, RCAT, CCC, ATR-BC or Audrey Wolfe, RCC provide a bottom surgery readiness assessment for surgeries in the US, Thailand, or other parts of the world?

Yes, I often can. However, we will need to check the jurisdiction’s regulations and policies to ensure the readiness assessment will be accepted in that region.

What if my primary care provider keeps referring me back to Audrey and Clayre for a bottom surgery readiness assessment in BC?

This is a significant issue due to the current lack of system clarity. If your primary care provider isn’t familiar with the updated assessment process, it may help to suggest that they consult the RACE line or eCASE to speak with an experienced clinician who can guide them. Encourage them to visit the Transcare BC web page on surgery readiness assessments, where a Health Navigator can offer support, education, and guidance to providers unfamiliar with the new requirements.

What if my doctor, nurse practitioner, or registered nurse doesn’t know how to help me?

This is a common issue with the current policy. If your primary care provider is unsure how to proceed, recommend they consult the RACE line or eCASE for direct guidance from experienced clinicians. Transcare BC’s Health Navigators are also available to support and educate providers on these processes, ensuring patients can access the care they need without unnecessary delays.

What if I need to find a more gender affirming doctor, nurse practitioner, or registered nurse to support me?

Transcare BC’s Health Navigators are an excellent resource to support you in finding the right MD, NP, or RN, and they can be contacted here. Also, I’ve written a blog post about how to find a primary care provider in BC.

What if my doctor refuses to provide a bottom surgery readiness assessment?

If your doctor refuses or is unsure how to provide a readiness assessment, they should reach out to Transcare BC for support. You can also ask them to consult the RACE line or eCASE to speak with a more experienced physician. If needed, you can request a referral to a different primary care provider who is more familiar with trans* healthcare.

How long does it take to get a bottom surgery readiness assessment completed?

Wait times for readiness assessments vary, but most people can complete them within six months to a year. The wait time largely depends on your primary care provider’s familiarity with the process and the availability of assessors. If wait times are a concern, reach out to Transcare BC for advice on expediting the process or finding an alternative assessor.

What should I expect during my bottom surgery readiness assessment?

The assessment focuses on supporting you through your surgery journey and ensuring you meet the criteria for surgery. It usually lasts 1–2 hours, and the assessor will ask about your gender identity, health history, expectations for the surgery, understanding of the risks and procedure, and your aftercare plan. The goal is to ensure you are fully informed and supported before proceeding with surgery.

What can I do if I’m experiencing mental health distress while waiting for surgery?

Waiting for surgery can be extremely stressful, and it’s important to seek support. You can connect with a counsellor or therapist who specializes in trans* care, or join a support group with others going through similar experiences. Transcare BC and other community organizations, such as Qmunity and CWHWC, often have resources and support groups to help you cope with the emotional challenges of the wait.

What should I do if my referral seems to be delayed or lost?

It’s important to follow up regularly with your primary care provider and the BC Gender Surgery Program (BCGSP) to which you’ve been referred. If you believe your referral has been delayed or lost, contact your provider’s office to inquire. They can help ensure your referral is moving through the system and advocate on your behalf if there are unnecessary delays.

What if I change my mind about surgery after being assessed?

It’s okay to change your mind at any point during the process. If you feel uncertain, reach out to your assessor or a trusted healthcare provider to discuss your concerns. Gender-affirming surgery is a personal and significant decision, and you deserve to take the time you need to make the right choice for yourself. Talk with your therapist about choices, reach out to your primary care provider for support and to update BC Gender Surgery Program, if needed.

Hormone Readiness Assessments

Can Clayre Sessoms, RP, RCT, RCC, RCAT, CCC, ATR-BC or Audrey Wolfe, RCC provide hormone readiness assessments in BC or abroad?

Yes—although BC is “leaving it up to endocrinologists to decide what assessment they’ll accept” to restrict our ability to help, sometimes—we can provide hormone readiness assessments for most endocrinologists in BC and abroad, depending on the regulations, policies, and endocrinologist’s comfort level of the jurisdiction where you reside.

What if I can’t afford a private hormone readiness assessment in BC …because rent is too damn high?

Not to worry. If your primary care provider (MD, NP, or RN) provides the hormone readiness assessment, it’s covered under BC’s Medical Services Plan (MSP). For those who can’t afford private assessments, there are several low-cost or free options, including BC’s new network of clinics, and you can find more info in my blog post on hormone readiness assessments in BC.

For any other questions related to lower surgery assessments in BC, I encourage you to visit the Trans Care BC website.

Conclusion: A Call for True Equity in Healthcare

Conclusion: A Call for True Equity in Healthcare

The current policy limiting bottom surgery readiness assessments in BC reflects more than an administrative oversight—it reveals a fundamental gap in the province’s commitment to equitable, compassionate healthcare for trans+, nonbinary, and gender expansive individuals. This is not about simple delays or bureaucratic red tape; it is about the right to timely, affirming care that respects the dignity and well-being of every individual. For those awaiting surgery, the stakes are high, and the impact on mental and physical health is severe. These policies affect survival, and no one should have to wait indefinitely for the care they need to live authentically and healthily.

As a province, BC must reframe gender-affirming care not as a luxury or elective service but as an essential right. This reframing must involve a healthcare system that acknowledges the expertise of trans+ professionals and recognizes the specific needs of the communities it serves. The current policy falls short of providing timely, competent, and compassionate care—but change is possible. History shows that lasting reform happens when communities and allies speak out against systemic barriers, driving collective demand for meaningful action.

Now is the time to advocate for a healthcare system that not only meets minimum standards but affirms the dignity, humanity, and inherent worth of every trans+ person. This is about more than healthcare; it is about justice, equity, and the basic right to be seen, supported, and respected. BC has the opportunity to set a new standard: a system that meets trans+ people with clear, accessible medical care rather than indifference; with urgency rather than delays; with respect rather than disregard. Together, we can—and must—demand the compassionate, inclusive healthcare that every resident of British Columbia deserves.

Continue the Convo

If the ideas in this blog resonate with you, I warmly invite you to connect with us. Whether you’re a therapist seeking guidance on navigating these policy changes or someone looking for gender-affirming support, I’m one of a handful of BC-based WPATH SOC8 Certified members here to help. You may book individual therapy sessions, peer consultations, or even hormone readiness assessments with Audrey Wolfe, RCC or myself online. Be sure to bookmark this blog for future insights, reflections, and updates.

References

Dalwood, C. (2023, August 16). Wait times for bottom surgery in Canada can be as long as eight years. The impact on individuals can be deadly. Xtra. https://xtramagazine.com/health/wait-times-trans-bottom-surgery-canada-255804

Erickson-Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource for the transgender community. Oxford University Press.

Frohard-Dourlent, H., Strayed, N., & Saewyc, E. (2017). The agency to choose what’s right for their body: Experiences with gender-affirming surgery in British Columbia. Stigma and Resilience Among Vulnerable Youth Centre, School of Nursing, University of British Columbia. https://www.saravyc.ubc.ca

Harvard T.H. Chan School of Public Health. (2021). Mental health benefits associated with gender-affirming surgery. https://www.hsph.harvard.edu

Jacqueline, I. (2024). Medical gaslighting: How doctors dismiss symptoms and deny care. HarperOne.

Martinez, D. B., & Fleck-Henderson, A. (2014). Social justice in clinical practice: A liberation health framework for social work. Routledge.

Vancouver Foundation. (2022). Paving the way for the future of gender-affirming care. https://www.vancouverfoundation.ca/featured-funded-projects/ochi_gender_affirming_care

World Professional Association for Transgender Health (WPATH). (2022). Standards of care for the health of transgender and gender diverse people, Version 8. International Journal of Transgender Health, 23(S1), S1–S258. https://doi.org/10.1080/26895269.2022.2100644