MA: M.7 Gender Reassignment Surgery

Description

This document addresses sex reassignment surgery (also known as gender reassignment surgery and gender confirmation surgery), which is one treatment option for extreme cases of gender dysphoria, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in their own gender. People with gender dysphoria often report a feeling of being born the wrong sex. Sex reassignment surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. Before undertaking sex reassignment surgery, important medical and psychological evaluations, medical therapies and behavioral trials should be undertaken to confirm that surgery is the most appropriate treatment choice for the individual.
 
Definitions

Gender identity: A person’s intrinsic sense of being male, female. 

Gender-nonconforming: Individual whose gender identity, role, or expression differs from what is normative for their biology in a given culture and historical period.

Transgender: Individuals who cross or transcend culturally defined categories of gender. The gender identity of transgender people differs to varying degrees from their biologic sex. 

Transsexual: Individuals who seek to change or who have changed their primary and/or secondary sex characteristics through feminizing or masculinizing medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.

Screening

Preventive health screening guidelines developed for the general population are appropriate for transgender persons for organ systems that are unlikely to be affected by feminizing or masculinizing hormone therapy.

Gender-specific preventive services are also necessary for transgender persons appropriate to their anatomy. Examples include the following:

*Routine Pap smears should be performed as recommended if cervical tissue is present in female-to-male transgender persons.
*If mastectomy is not performed, mammograms should be performed as recommended.
*Male-to-female transgender persons treated with estrogen should follow the same screening guidelines for breast cancer as those for all women.
*Screening for prostate cancer should be performed as recommended for those persons who have retained their prostate.

Fertility or Other

Preservation of fertility is subject to the members contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.
 

Policy

1. For individuals undergoing sex reassignment surgery, consisting of any combination of the following; hysterectomy, salpingo-oophorectomy, oophorectomy, or orchiectomy, it is considered medically necessary when all of the following criteria are met:
   
   1. The individual is at least 19 years of age; AND
   2. The individual has capacity to make fully informed decisions and consent for treatment; AND
   3. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
      1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and treatment; AND
      2. The transgender identity has been present persistently for at least two years; AND
      3. The disorder is not a symptom of another mental disorder; AND
      4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
   4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; AND
   5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
   6. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
2. For individuals undergoing sex reassignment surgery, consisting of any combination of the following, metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses, it is considered medically necessary when all of the following criteria are met:
   
   1. The individual is at least 19 years of age; AND
   2. The individual has capacity to make fully informed decisions and consent for treatment; AND
   3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
      1. The desire to live and be accepted as a member of the opposite sex, usually 
      accompanied by the wish to make his or her body as congruent as possible with the preferred 
      sex through surgery and hormone treatment; AND
      2. The transgender identity has been present persistently for at least two years; AND
      3. The disorder is not a symptom of another mental disorder; AND
      4. The disorder causes clinically significant distress or impairment in social, 
      occupational, or other important areas of functioning; AND
   4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; AND
   5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
   6. Regular participation in psychotherapy throughout the real life experience when recommended by a treating medical or behavioral health practitioner; AND
   7. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
   8. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
      
      Verification via communication with individuals who have related to the individual in an identity congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases.
3. The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.
4. Mastectomy or breast reduction for transmasculine may be considered medically necessary when ALL of the following criteria are met:
   
   1. For individuals undergoing sex reassignment surgery, bilateral mastectomy or breast reduction is considered medically necessary when ALL of the following criteria have been met:
      1. 1. The individual is at least 19 years of age; AND
      2. The individual has capacity to make fully informed decisions and consent for treatment; AND
      3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
         
         1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; AND
         2. The transgender identity has been present persistently for at least two years; AND
         3. The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so; AND
         4. The disorder is not a symptom of another mental disorder; AND
         5. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
      4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
      5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
      6. Regular participation in psychotherapy throughout the real life experience when recommended by a treating medical or behavioral health practitioner; AND
      7. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
   2. Breast augmentation for transfeminine members may be considered medically necessary when ALL of the following candidate criteria are met: 
      
      1. The individual is at least 19 years of age; AND
      2. The individual has capacity to make fully informed decisions and consent for treatment; AND
      3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
         
         1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; AND
         2. The transgender identity has been present persistently for at least two years; AND
         3.  The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so: AND
         4.  The disorder is not a symptom of another mental disorder; AND
         5.  The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
      4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
      5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
      6. Regular participation in psychotherapy throughout the real life experience when recommended by a treating medical or behavioral health practitioner; AND
      7. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
      8. For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician without an adequate result for comfort in the social role.

NOTE: Future breast reconstruction surgeries for asymmetry would need to meet medical necessity criteria for reconstruction.

*At least one of the professionals submitting a letter must have a doctoral degree (for example, Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) or a master's level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse Practitioner [N.P.], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Councilor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) and be capable of adequately evaluating comorbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the specifications set forth above.** The medical documentation should include the start date of living full time in the new gender.

Not Medically Necessary: 

Sex reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.

Cosmetic:

The following procedures are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo sex reassignment surgery, including, but not limited to, the following:

• Abdominoplasty
• Blepharoplasty
• Brow lift
• Calf implants
• Electrolysis
• Face lift
• Facial bone reconstruction
• Facial implants
• Gluteal augmentation
• Hair removal/hairplasty, when the criteria above have not been met
• Jaw reduction (jaw contouring)
• Lip reduction/enhancement
• Lipofilling/collagen injections
• Liposuction
• Nose implants
• Pectoral implants
• Rhinoplasty
• Thyroid cartilage reduction (chondroplasty)
• Voice modification surgery
• Voice therapy

Background

Gender dysphoria commonly referred to as transgender, is a condition wherein an individual's psychological gender is the opposite of his or her anatomic sex. This results in the persistent feeling of being "trapped in the wrong body." This diagnosis should not be confused with cross dressing (transvestitism), refusal to accept homosexual orientation, psychotic delusions or personality disorders. In May 2013, the American Psychiatric Association published an update to their Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM5). This update included a significant change to the nomenclature of conditions related to gender psychology. Specifically, the term "Gender Identity Disorder (GID)" was replaced with "Gender Dysphoria." Additionally, the DSM5 provided updated diagnostic criteria for gender dysphoria for both children and adults. The new criteria are as follows:

Gender dysphoria in Children*

A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender, different from one's assigned gender).
2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to wearing of typical feminine clothing. 
3. A strong preference for cross gender roles in make believe play of fantasy play.
4. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
7. A strong dislike of one's sexual anatomy.

A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.
 
The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)\

Coding note: Code the disorder of sex development as well as gender dysphoria.

Gender dysphoria in Adolescents and Adults*

A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (on in young adolescents, the anticipated secondary sex characteristics). 
2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (on in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and /or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).

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

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)

Coding note: Code the disorder of sex development as well as gender dysphoria.

Specify if:

Post transition: The individual has transitioned to fulltime living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one crosssex medical procedure or treatment regimen namely regular crosssex treatment or gender reassignment surgery confirming the desired gender (e.g., appendectomy, vaginoplasty in the natal male; mastectomy or phalloplasty in the natal female).

*From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM5.

American Psychiatric

Association. Washington, DC. May 2013. Page 451-459.

Surgical treatment for gender dysphoria differs depending upon the natal gender of the individual. For male-to-female individuals, also known as "transwomen," surgery involves removal of the testicles and penis and the creation of pseudo vagina, clitoris, and labia. For female-to-male individuals, known as "transmen," surgery involves removal of the uterus, ovaries, and vagina, and creation of a neophallus, and scrotum with scrotal prostheses. At this time, the creation of a neophallus for transmen is a multistage reconstructive procedure. The medical necessity criteria above are based upon the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version, published by the World Professional Association for Transgender Health (WPATH) (2013). This document is widely accepted as the definitive document in the area of gender dysphoria treatment, and it has cited in numerous articles by other respected authors and organizations. The WPATH criteria have been adopted in several countries as the standard of care for the treatment of gender dysphoria, including hormone therapy and sex reassignment surgery.

The criteria in the SOC are supported by evidence based peer reviewed journal publications. Several studies have shown that extensive long-term trials of hormonal therapy and real-life experience living as the other gender, as well as social support and acceptance by peer and family groups, greatly improve psychological outcomes in individuals undergoing sex reassignment surgery (Eldh, 1997; Landen, 1998). A study reported by Monstrey and colleagues (2001) described the importance of close cooperation between the many medical and behavioral specialties required for proper treatment of individuals with gender dysphoria who wish to undergo sex reassignment surgery. Similar findings were reported earlier by Schlatterer et al. in 1996. One study of 188 subjects undergoing sex reassignment surgery found that dissatisfaction with surgery was highly associated with sexual preference, psychological comorbidity, and poor preoperative body image and satisfaction (Smith, 2005).

Sex reassignment surgery presents significant medical and psychological risks, and the results are difficult to reverse (Djordjevic, 2016). Some procedures are irreversible, such as removal of gonad tissue. A stepwise approach to therapy for gender dysphoria, including accurate diagnosis and long-term treatment by a multidisciplinary team including behavioral, medical and surgical specialists, has been shown to provide the best results. As with any treatment involving psychiatric disorders, a thorough behavioral analysis by a qualified practitioner is needed. Once a diagnosis of gender dysphoria is established, treatment with hormone therapy and establishment of real-life transgender experience may be warranted. Sex reassignment surgery should be considered only after such trials have been undertaken, evaluated and confirmed. Hormone therapy, when indicated, should be administered under ongoing medical supervision and is important in beginning the gender transition process by altering body hair, breast size, skin appearance and texture, body fat distribution, and the size and function of sex organs. Hormone therapy is consistent with the development of secondary sexual characteristics vital to gender transition, and should be administered unless contraindicated. Additionally, real-life experience living as the desired gender is important to validate the individual's desire and ability to incorporate into their desired gender role within their social network and daily environment. This generally involves gender specific appearance (garments, hairstyle, etc.), involvement in various activities in the desired gender role including work or academic settings, legal acquisition of a gender appropriate first name, and acknowledgment by others of their new gender role. With regard real-life experience, to the 2013 WPATH document specifically states:

The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience pro vides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one's gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008). The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season specific work or school experiences). During this time, patients should present consistently, on a day to day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings). Health professionals should clearly document a patient's experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable. Once these treatment steps have been established, and have been stable for at least 12 months, an individual may be considered for sex reassignment surgery. In many instances, the creation of a neovagina or a urethra for a neopenis requires an autologous skin graft from the forearm or thigh. Such skin may be excessively hairy, which will impair the function of the newly constructed organ if not permanently removed. Preoperative permanent hair removal treatments to these areas may be warranted to prevent postoperative complications. For both transmen and transwomen, additional surgeries have been proposed to improve the gender appropriate appearance of the individual. Procedures such as breast augmentation, liposuction, Adam's apple reduction, rhinoplasty, facial reconstruction, and others have no medically necessary role in gender identification and are considered cosmetic in nature. The clinical evidence addressing the satisfaction and quality of life following sex reassignment surgery is limited, and the reported findings are mixed (Cardoso da Silva, 2016; Castellano, 2015). It is important that proper and thorough preoperative workup and preparation be conducted in individuals considering such life altering procedures. 

Codes

11970	17380	17999	19303	19304
19318	19325	19357	54125	54520
54660	54690	55175	55180	55970
55980	56620	56625	56800	56805
57110	57292	57295	57296	57335
57426	58150	58262	58552	58554
58570	58571	58572	58573