Janet Macbeth says "to be trans is to wait."

The 40-year-old waited until her wife was pregnant with their second child in 2017 to come out as transgender. Then she waited for her relatives, friends and professional colleagues at Walpole Island First Nation's Heritage Centre to adjust to her gender identity.

After starting hormone therapy at a trans-health centre in London, about a two-hour drive from her home in Wallaceburg, Ont., Macbeth waited the requisite one year to be approved for gender-affirming surgery under the Ontario Health Insurance Plan (OHIP) in spring 2018. She waited several months to book a date for the procedure, which was several more months away.

But on Monday, Macbeth's wait was finally over as she became one of the first patients to undergo vaginoplasty at a Canadian public hospital, according to medical officials.

"For trans people, not everyone gets surgery ... but for those who decide to get the surgery, it's a life-saving treatment and medically necessary," said Dr. Yonah Krakowsky, a urologist and medical lead of the Transition-Related Surgery Program at Women's College Hospital in Toronto.

"Their ability to live true lives really depends on our ability to do our work."

Krakowsky said Monday marks the first time vaginoplasty, a surgery that constructs a vagina for trans patients, has been performed in Ontario in more than two decades.

Previously, he said, the only options for Canadians seeking trans-related surgical care were a private clinic in Montreal or to look abroad.

While OHIP compensates out-of-province providers for some procedures, patients must cover their own travel costs, said Krakowsky, which often means they have to recover without the support of their loved ones. The distance also makes it harder for patients to receive follow-up care, which is associated with better health outcomes, he said.

In 2016, the Ontario government changed its policies to make it easier for people to qualify for gender-affirming surgery, creating a backlog of patients waiting for care, Krakowsky said.

He said Women's College Hospital launched the Transition-Related Surgery Program in 2018 to help fill that gap, offering services including mastectomies, chest contouring and breast augmentation; the surgical removal of ovaries and testicles; plastic surgery of the scrotum and penile and testicular implants.

But it took more than a year of training involving doctors from several departments, nurses and social workers for the program to prepare for its first three vaginoplasty surgeries this week, said Krakowsky.

This effort speaks to the specialized knowledge required to perform vaginoplasty, which is considered "the jewel" of gender-affirming surgeries, said Dr. Marci Bowers, a world-renowned American gynecologist and surgeon who helped train the team at Women's College Hospital.

"It's a surgery that I've often said takes as much art as it does science," Bowers said while in Toronto to assist with this week's surgeries. "You have to be comfortable crossing disciplines, and you obviously have to have a very thorough knowledge of pelvic anatomy."

Bowers said the surgeries at Women's College Hospital will use a modified penile inversion, in which the surgeon creates a vaginal cavity between the rectum and urethra, which is then lined with skin from the shaft of the penis or scrotum.

The procedure involves elements of urology, gynecology, general surgery and plastic surgery, said Bowers, as well as a dash of "artistry" to construct the clitoris, labia and pubic mound from existing tissues.

While the program is still in its early days, Krakowsky hopes the teaching hospital's multidisciplinary approach will help establish a model that can be adopted by medical institutions across the country.

"I think the long-term goal is for this to be available in every province," he said. "There's a clear need. There are patients waiting for medically necessary surgery that's not available."

While she could have had her surgery at a private clinic months ago, Macbeth said she was willing to wait a little longer to be part of a program with so much potential to better the health of Canada's trans community.

"This is just the beginning," Macbeth said in an interview last week. "Canada now has two (trans-related surgical centres), so we probably need to work on the third one, the fourth one. There's more trans people out there than people realize."

All trans women are women, she emphasized, regardless of whether they decide to pursue gender-affirming treatment. While no medical procedure could change her identity as a mother, a worker or a woman, Macbeth said her surgery will help her feel more at home in her body.

"This is something that's necessary for me," Macbeth said. "It reduces the dysphoria I have, this conflict between myself and my body.

"It will help align myself with who I am, and in general terms, make me a lot healthier."