This is the text version of the comic. The images are not particularly good as they are primarily stick figures. Where the images are explanatory, I have written those explanations into this text. Therefore, there are slight differences between the two versions. Where images are not explanatory, I omit them. To make this version more accessible, I didn’t put end notes in as links but the references are a the bottom. If you want the version with endnotes in the text, click here.

Hi there. Welcome to my guide to navigating the sex reassignment surgery approval process in Ontario. This is a map or, institutional analysis, of the process.

Here are some acronyms that get used (if you forget what one is, just come back to this page):
CAMH – Center for Addiction and Mental Health
DSM – Diagnostic and Statistical Manual
GD – Gender Dysphoria
GIC – Gender Identity Clinic
GID – Gender Identity Disorder
FtM – Female to Male (transsexual or transgender)
MtF – Male to Female (transsexual or transgender)
SRS – Sex Reassignment Surgery

There are a lot of different things that come into play in the process. I talk a lot about the primary governing texts (the written stuff that dictates the process) because, in this system, they set the criteria for who gets surgery. There is a lot of overlap between them, but also some important differences.

Of course, society dictates the ways that CAMH operates. In a society without as fixed or stringent gender system, the Gender Identity Clinic would look very different. Actually, there are lots of cultures that not only have space for different kinds of trans people but also celebrate them. Because it has to do with gender, patriarchy and heteronormativity play really key roles here but so do racism, disablism and classism because gender is interpreted through different lenses and because trans people are often racialized, disabled and/or working class.

There are other important factors, however, that determine who gets surgery and who doesn’t. One of the key ones is power. There is a hierarchy at CAMH, like all hospitals, and patients have the least amount of power.

CAMH has over 3,000 staff and 25,000 patients.

The organization is a pyramid with the CEO at the top, followed by trustees, senior management, doctors, then nurses, non-professional staff and at the very bottom, patients or clients.

Ok, let’s go!

This is CAMH (Center for Addiction and Mental Health), a massive mental health facility in Toronto that some people still call “The Clarke.” It was opened in 1966 as the Clarke Institute of Psychiatry.

It was named after C.K. Clarke, one of the most prominent psychiatrists in the early 20th century.
He fought to have immigrants with psychiatric diagnoses deported.

The GIC at CAMH follows 3 sets of rules: OHIP, WPATH & DSM.

CAMH is a massive psych institution that treats people who choose to go there but also incarcerates people against their will.

The GIC at CAMH will also assess people for hormones but they encourage people to get those through other doctors and mostly assess people for surgeries.

The clinic will see anyone who “wishes to explore issues related to their gender identity.” But, in order to qualify for hormones or surgery, you have to meet the DSM criteria. There are only two acceptable ways to gender identify in order to access surgery – male or female.

There’s gonna be a lot of hoops to jump through if you want provincial funding and the rules can change depending on who is in government…
To get funding, you have to have OHIP. This means that people without immigration status can’t access SRS funded.

Mike Harris cut funding for trans surgeries as part of the neo-liberal policies he implemented as Premier. Housing, social assistance and many more things were cut in this era.

Dalton McGuinty was elected Premier in 2003 and his government relisted SRS in 2008. He also implemented austerity measures and cut social assistance. He resigned in 2012, replaced by Kathleen Wynne.
OHIPs rules to get sex reassignment surgery paid for are:
1. Be approved by the CAMH Gender Identity Clinic
2. OHIP only funds surgeries, not hormones
3. Generally, the surgeries are done in Montreal. And, not everything is offered, the most significant likely being the refusal to give trans women breast augmentation. Some less common procedures aren’t covered either.

The World Professional Association for Transgender Health (WPATH) is the organization that dictates the standards of care for trans surgeries and hormone use. It Issued its first version of the Standards of Care in 1979 back when it was called the Harry Benjamin International Gender Dysphoria Association. 16 It was named after Harry Benjamin who says: “their minds and their souls are ‘trapped’ in the wrong body.”

Of course, the “wrong body” hypothesis doesn’t fit everybody.

I think that I know it is the dominant narrative and all, but this whole wrong body shit doesn’t work for me. I mean, this is the only body I have. There are parts I might want to change or that might make me uncomfortable but don’t call it wrong.

Anyone can join WPATH but only “professionals working in disciplines such as medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology, speech and voice therapy and sexology” can vote.

WPATH perpetuates a lot of problematic notions about trans people. They pathologize the experiences of oppression as
“minority stress.”

These are the WPATH criteria for surgeries (but it says there can sometimes be exceptions to this):
1. “Persistent, well-documented gender dysphoria”
2. “Capacity to make a fully informed decision and to consent for treatment”
3. “Age of majority”
4. “If significant medical or mental health concerns are present, they must be reasonably well controlled.”

#4 can have some major implications for psychiztrized people.
There is a guy standing in an auditorium whit a bunch of people in it. He is wearing a bow-tie and glasses (the two stick figure tropes for stuffy smart guy). He says:

I am a WPATH expert. Today I will be talking about how “mental health concerns…. can complicate the process of gender identity exploration and resolution of gender dysphoria.”

“No surgery should be performed while a patient is actively psychotic.”

“an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.”

A random trans person thinks this probably isn’t a big deal… right?

Wrong. In order to get access to surgeries (or hormones) trans people can be coerced into taking psychiatric drugs or getting psychotherapy that they don’t otherwise want.

There is also a requirement that you get a “referral from a qualified mental health professional” (1 for top, 2 for bottom) and “a mental health screening and/or assessment.” This requirement ensures that there will be a psychiatric/psychological examination at some point in the process.

There are some surgery specific criteria as well… For removal of a uterus, ovaries or testicles: “12 continuous months of hormone therapy” is required.

For vaginoplasty, phalloplasty or metoidioplasty, you have to meet all of the other requirements plus “12 continuous months of living in a gender role that is congruent with [your] gender identity.” This is often called the ‘real life test.’

WPATH also says that professionals can ask people to provide proof of legal gender and/or name change. However, CAMH GIC doesn’t require this anymore.

Ok, Here’s the deal with the DSM (Diagnostic and Statistical Manual)… Essentially, it’s the Psy-ble (the Psychiatric Bible). It is the big book of diagnoses that psychiatrists use. The DSM 5 just came out in May, 2013. There were a lot of changes to the DSM in this issue, including changing Gender Identity Disorder to Gender Dysphoria.

One of the ‘experts’ on the committee for the DSM 5 was Kenneth Zucker. He also works at CAMH trying to make trans and queer kids normal. This outraged a lot of trans activists. (More on him later.)
Gender Dysphoria has several components in the DSM:

A) It lasts at least 6 months and has 2 of the following:
1. “marked incongruence between one’s experienced/expressed gender and… sex characteristics;”
2. “strong desire to be rid of one’s… sex characteristics;”
3. “strong desire for sex characteristics of the other gender;”
4. “strong desire to be of the other gender;”
5. “strong desire to be treated as the other gender;”
6. strong conviction that one has the typical feelings and reactions of the other gender

B) The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Ok, so once all of that is done and you meet all these criteria, have all the documentation and recommendations, etc. you can go to CAMH.

1. You can’t go directly to CAMH. You have to get a referral from a doctor; this is probably your GP but could be a psychiatrist or another doctor.
2. The application asks why you are going to the clinic, where you are in your transition, what your family thinks, who all your doctors are and for who to contact in an emergency. They also ask you to supply a “written life story regarding your gender identity history and goals.” (Image of a made up letter from CAMH: Dear Transsexual: We have been informed that you want to have surgery. Please come to our clinic so we can decide if you are a real transsexual or just a freak.
3. Mail in your application and wait …and wait. (Trans person mailing package that says: “CAMH: You have too much power CAMH but OK”)
4. Eventually, you’ll get an appointment. You will have two interviews that are up to 90 minutes each and you could be asked to go for multiple follow up appointments.
5. CAMH assesses people to see if they meet its criteria: a) you are at least 18 years old; b) you have a GID diagnoses; c) you’ve thought about it sufficiently; d) you are ‘out’ to people close to you; e) “mental health or substance use issues are well-controlled”; f) you understand the risks and have a surgery recovery plan. For people trying to access bottom surgery: there is an additional requirement of what CAMH calls “a continuous Gender Role Experience” which they say, most of the time “will continue to be found in employment, school studies and voluntarism, or any combination of these.” While they say this real life test can be “an individually-tailored plan” some trans activists claim that CAMH requires people to have 40 hours a week of paid employment, automatically something that disqualifies many disabled people. They also report that sex workers are disqualified.
6. The clinic will send their findings to your doctor- not to you. This could take two months or more.

Make it through all of these steps and the CAMH GIC may approve you for surgery.

However, OHIP mandates that people have to go the GRS clinic in Montreal. This clinic ensures that the vaginal “cavity [is] definitely closed” for all FtM bottom surgeries. This procedure is not medically required to perform the surgeries and is clearly about creating normative bodies, not pleasure or, necessarily, the desire of trans men.

CAMH acts as a gatekeeper for trans people in order to access surgeries. This happens in a lot of different ways: making people wait to get an appointment, taking a long time to send referring doctors the results, making some people do follow-up appointments, requiring people to do the real life test to get bottom surgery and making people meet rigid criteria. It slows people down and cuts people out.

The entire process can take a really long time.

The Gender Identity Clinic at CAMH: The Facts

Who’s In Charge?

Chris McIntosh: Clinic Head. He is a psychiatrist and a member of the Southern Ontario Gay And Lesbian Association Of Doctors.

I happened to see him for a consultation many years ago and I liked him. However, I have never met a trans person who has been through the CAMH system with him who has liked him. But, that doesn’t mean they don’t exist. And, being gay doesn’t mean he is cool – just look at Kathleen Wynne and that guy from ‘N SYNC.

Nicola Brown: GIC Coordinator. She is a psychologist who also has a private practice. She also researches how transitioning affects partners of trans people.

How Long Are We Talking?

It takes about a year from when your doctor refers you to the time of your first appointment. After your first appointment, you can be given a surgery approval appointment or a follow-up appointment. If you are given a follow-up appointment, it will usually take 6 months and you can have many of these appointments. A surgery approval appointment takes a few months to get. If and when you have a surgery approval, it takes a few months for the Ministry of Health to approve the funding. Then, you can get into see a surgeon which may also have a waiting list.

By the Numbers

In 2010, 52 people were approved for surgery. In 2011, this climbed to 72 people and in 2012 it rose again, to 101 (These numbers exclude hysterectomies because, in 2012, the clinic put in a system to approve hysterectomies at the same time as top or bottom surgery so a number of people would be included twice if hysterectomies were included. There could, however, be some people who only accessed hysterectomies and were not included in these numbers. The 2010-2011 increase was partly caused by a policy change shortening the real life test length).43

Alternatively, if you have class privilege:
Hop in your car, head on over to a private clinic. There, the nice doctor will ask things like:
“How do you gender identity?”
“What kind of support do you have?”
“How long have you been trans?”
“How do you feel about your [insert body part here]?”
“You understand the surgery is permanent?”

Then, maybe he’ll say “I can go over some of the fine print and then we can book you for surgery.”

Then… SURGERY!

I don’t want to suggest that these clinics aren’t sometimes problematic. But trans people with money don’t have the same constraints on them and when they come across a clinic they don’t like, they have the choice to switch.

Meet Ray Blanchard:
Another person who is embedded in the GID in the DSM system is Ray Blanchard. He became been part of CAMH’s GIC since 1980 and is currently in charge of CAMH’s Clinical Sexology Services in the Law and Mental Health Program.

Blanchard argues that pretty much all trans women are either extreme homosexuals or autogynephilic (they are sexually aroused by the idea of themselves as women). Autogynephilia is now in the DSM as a diagnostic category. This, according to Mulé and Daley “theorizes reducing [trans women’s] motives to fetishistic sexual gratification rather than their attempts at achieving a harmonious gender identity.”

Blanchard was a part of the APA committee that decides how the new DSM classifies ‘gender disorders.’

He has said: “This is not waving a magic wand and a man becomes a woman and vice versa… It’s something that has to be taken very seriously. A man without a penis has certain disadvantages in this world, and this is in reality what you’re creating.”

There are obviously, then, some big problems with the fact the Blanchard has so much power over trans people, their access to health care and the way that the medical establishment constructs their identities.

Who Decides?
Which one is not like the other?
C.K. Clark, Dalton McGuinty, Harry Benjamin, Ray Blanchard, Kenneth Zucker, Chris McIntosh, Mike Harris, Nicola Brown.

Answer: D – None of the above.

Most of the people with power in this process are not trans. They are all white, straight, rich, nondisabled and almost all men. Their lives are very different than most trans people’s lives; for instance, Dalton McGuinty made $208,974 and Kennith Zucker made $123,950 in 2012 while half of all trans people live on less than $15,000 a year. The World Professional Association for Transgender Health is mostly non-trans people. These are the people who get to decide how trans people are categorized and treated.

The problem, however, is not just who decides what gender presentations are acceptable. What gets decided about gender presentations (and gender as a whole) and how it gets decided are also problematic. Mulé and Daley assert the decision making that psychiatrists make at places like the CAMH GIC “constitutes a social process of ‘gate keeping’ that contributes to rigid binary, heteronormative categories of sex, gender and sexuality.” People who do not have normative gender identities cannot access the surgeries that they may want or need because they do not fit into the gender binary. The doctors at CAMH are engaged in upholding that binary and trans people are trapped in a system that demands normative (read middle-class, white, straight and stereotypical) gender identities. This is why C. Jacob Hale argues “we must either insert ourselves into these regimes or forego adequate medical care.” Gender Identity Clinics construct trans identities within a problematic gender binary that is a self-replicating cycle: trans people articulate particular stories about how they experience their bodies and identities in order to access surgeries. Doctors then use that data to enforce those same experiences and identities back on people. Of course, this system works fine for some folks but there are others who find it oppressive. This isn’t only a concern for trans people, however. Places like CAMH aren’t only working to construct trans identities as normative, they are working to uphold the gender binary itself.

Me, I’m made of sticks and all I need is a pencil and an eraser if I want or need to change parts of my body. For most trans people, it is a lot more complex than that. Only individual trans people can decide to what extent, if any, they want to go through systems like the CAMH GIC; and, those decisions need to be supported. At the same time, however, it is up to all of us, trans or not, to work to ensure that, regardless of class privilege, people can have access to SRS and that, ultimately, the systems of patriarchy, heterosexism, capitalism and cissexism that allow places like the GIC to have so much power over trans people be dismantled.

How do You Get Through or Around CAMH?
Lots of folks have a hard time with the CAMH system while others don’t. This section includes some of the ways that people got through/around the system. Some of them might work for you and some might not. But, here are some real stories… (Just to be clear, I’m am not saying you should do any of these things, some of them, you really shouldn’t do.)

“The people at my church raised the money for me.”
“I moved to B.C. where the clinic is way more progressive and got it done no problem.”
“CAMH was a great experience for me.”
“It sucked for me. But, I jumped through their hoops and made it through”
“I started hormones before going to CAMH which, I think, made it easier for me to get approved in the long run.”
“I got hit by a car (that was horrible). I used my insurance settlement to pay for surgery.”
“I gave a lot of blow jobs to get the money for surgery.”
“I could explain why I didn’t play football through my disability so they considered me to be a normal man who would have played football if I could.”

Here’s what I (A.J.) did. First, I got into a unionized job. I know lots of people can’t do this because of the right wing attack on unions is making them harder and harder to come by and not everyone can work, etc. My union job is through my grad school job – again, something most folks don’t have access to. In the long-term you could organize your workplace.

My union does lots of stuff, like: fight for social justice and support other political organizing. Also, when my boss tried to change my job from working fall and winter to winter and summer without asking, they helped me fight it. My union has a trans fund in order to help trans folks cover the costs they have for surgeries, hormones, clothes or whatever. This is pretty great and a good part of why I went to grad school and why I went to York. You can get up to $15,000 in your life but only $5,000 except in special circumstances.

But, if lots of people apply, you might not get the $5,000. I needed $2,000 to cover the difference between the usual maximum and my surgery but maybe way more. So I invented a ‘cis tax’ and asked cis people to pay. I raised the money I needed and then the trans fund came through for the full amount!

I had surgery, some people got paid back and the extra money is going to someone else for surgery who can’t wait a year for CAMH to return her calls.

Here’s the e-mail I sent to folks: Hi friends who have good jobs/money:

I am writing because I am planning on getting top-surgery in December. (which I am keeping under wraps). I applied to the Trans-fund at York which I could possibly get $5000 this year for (but often it isn’t that much – it depends on how many people apply). My surgery is $6,780.

I haven’t heard from them and I have to pay the surgeon right away. I was going to try and cover the $1,780 (or raise it through what I have cleverly named the “cis tax”). Unfortunately, however, I now have to pay the full amount (some of which I may get back).

I have saved enough to cover $1000-2000 comfortably but I am making very little right now. Originally (for the $1,780) I was going to ask each of you for a bit of money as this is an expense you won’t have pending some major life changes anyways). I thought it would be cool to collectivize the expense of trans surgeries a bit more but I can’t imagine ever doing a fundraiser the way so many folks do (I just can’t deal with being public about it in that way). Now, however, because I am still waiting on the fund and the surgeon’s deadlines, I have to come up with the money in the next week or cancel my surgery.

If you have some money you want to donate to me for this, please get in touch and let me know how much. There is the real potential that I can get money from the trans fund down the road and pay some of it back (or pay it forward to other trans folks if that is what you like) but I can’t make that promise.

Please, however, don’t put money into this if it would otherwise go to political organizing or helping a friend/family with their basic needs. Please, also, don’t feel guilty if you can’t give me any money. My idea of rich is the poverty line and while y’all are “rich” you aren’t actually rich. I know folks have lots of different financial constraints and I know folks have some I don’t know about. Don’t feel like I will hold any resentment if you don’t/can’t give money and please don’t feel pressured.

Thanks for your time,
AJ

Here I am post-surgery. [Image of s stick figure person] What do you think? I think the doctor did a great job.

One of the things about gender identity clinics is that you are more likely to be successful in them and, at the same time, more likely to be successful going around them if you have privilege. And that is really shitty. But, the more communities come together to support each other in the immediate AND fight for systemic change, the more people will get what they need. I definitely struggled with doing something privately that should be done publicly. At the same time, the idea of going to CAMH, especially because I am not gender normative, gave me so much anxiety. Because of a bunch of health issues, I have been waiting so much longer for everything than a lot of trans people have to (it took me 9 years to get hormones) and I really didn’t feel like I could keep waiting. In the end, I decided I would do what I had to do but would also work to try and get access to surgeries for people.

Some people dress up in gender stereotypical clothing. Just remember, the people at CAMH don’t live in the real world. If you want to pass the test, don’t do anything that isn’t normal (for them – i.e. boring). Skirts and long hair are okay for women, bow-ties and pants are okay for men but don’t mix it up. The longhair, bow-tie, skirt combo is a guaranteed fail.

Because psychiatrists have such difficulty with gender, a lot of trans people wrap their stories in clean, easy to define, ‘typical’ boxes for the doctors at gender identity clinics.

That means that trans people end up having to reinforce a lot of the problematic ideas about trans people in order to get what we need.

The Catch 22 of the Trans Narrative
Step 1: Some old white cissies listen to a few (middle-class, straight white) trans women patients (trans men were largely ignored by medicine until the 1980s).
Step 2: Then they decide that the stories of being born in the wrong body, knowing from childhood, etc. apply to all trans people.
Step 3: So, trans folks started telling other trans folks what works and what doesn’t.
Step 4: Studies conclusively proved that there is only one trans story. [Official Report: Trans people all have the same experiences of being trans.]
Step 5: So, if people deviate from this story, they aren’t really trans.
Step 6: But, because of ‘coaching’ doctors say they can’t trust trans people, no matter what story you tell. That is why they know best and they have to do a lot of tests – so they can catch the people who are actually gay or trying to get free surgery.

And, it all comes back to non-trans doctors knowing what’s best for us.

Zucker’s Pants
I have a pair of Kenneth Zucker’s pants. The important part of this story isn’t that I got them from his son so that I could represent someone he was helping fight eviction at the Housing Tribunal.

The story isn’t about how his kid hangs out with a bunch of queers, genderqueers and trans folks and how outrageous that might be for his dad.

It’s not about how Zucker’s clinic at CAMH is believed to diagnose more kids with GID than anywhere else on the planet.

Nor is the story about how this jerk, Zucker Senior, believes trans kids are “saying each and every day by [their] behaviour that they are, in fact, not feeling good about who they are. Because they are constantly trying to be someone else.”

And, this story isn’t about how Zucker encourages parents to force gender non-conforming kids to give up the activities they love, their clothes, their friends, etc.

This story is really just about the pants. You see, these pants are not particularly masculine. I might even say that they are kind of unisex. They are cream coloured 34” waist Ralph Lauren pants. I was pretty underwhelmed when I got them.

I have to be careful about what I wear because I am trans. Once I wore a dress and vampire blood on my face for Halloween. Halloween! And for several months people had changed my pronoun from they to she. If I want my gender identity to be respected, I have to wear a certain kind of pant (which, btw is totally bullshit). Kennith Zucker is the boss of the gender identities of gender freaks across the country but his pants were not really gender suitable for someone like me who dresses fairly masculine.

But, should we really fault anyone for being a bit blurry on gender appropriate pants? It used to be that everyone wore dresses (call them togas or kilts or loin cloths or whatever) but then that changed. Pink and blue are only recent gendered constructions in the Western world, with American producers only definitively making the determination in the 1940s. So, the binary that guys like Zucker uphold has never been fixed the way that it is so frequently portrayed.

Nevertheless, think of the children. Even if it is tough to figure out a gender appropriate outfit given all the changes in fashion over the past few thousand years, it is important to set an example. How can the kids that are subjected to Zucker’s treatment know that they are being gender appropriate when their own psychiatrist is wearing confusing pants?

Of course, another option would be to stop forcing the gender binary onto people and to let people have access to the medical care they desire if they desire it in order to transition (and for whatever else). The way that the gender clinic system is set up right now, fully half of all cis women would not pass their tests to be considered real women – would not be able to get ‘women’s bodies’ if they didn’t already have them. HALF! There clearly isn’t a lot of room for gender diversity, flexibility or variance if normative women aren’t passing these tests.

Ok, back to the pants. Those pants are really only femmy or masculine based on the way they are socially interpreted. So, while they are really quite girly, at the same time, they are the most masculine pants I have ever owned because they came from the arbiter of masculinity – Kenneth Zucker himself. Those pants can also be other things in addition to just those two. While Zucker and his colleagues are working to uphold the gender binary, it isn’t like the world is going to implode into a black hole if kids and adults play with gender or live in diverse ways. What undoing the gender binary could help do is weaken cissexism, patriarchy and heterosexism – things that those who work at gender clinics are deeply invested in.
Regardless of Zucker’s hold on the gender binary, I can tell you one thing for sure: I am a better man than him – cunt and all.

PS: Ok, I really wanted to say that I am a better man than Zucker, and it is true. But, I also want to be clear that Just because I say that it doesn’t also mean that I am not genderqueer. I can identify as sometimes a man and not be a man.

PSS: If you are trying to think of a good word for your bits that doesn’t gender them (lady parts) or isn’t nasty (twat, etc.) don’t google synonyms and cunt because it is just going to make you mad at the world in general and patriarchy in particular.

Special thanks to Laura Mac for drawing the car and help with the title, to Lenny O. for giving me feedback and to Rachel Gorman for letting me make a comic instead of a paper for class.

Written and illustrated by A.J. Withers
still.my.revolution[at]gmail.com

Its Over!