Clinical UM Guideline

This document addresses gender affirming surgery (also known as sex affirmation surgery, gender or sex reassignment surgery, gender or sex confirmation surgery). Gender affirming surgery is a treatment option for gender dysphoria, a condition in which a person experiences persistent incongruence between gender identity and sexual anatomy at birth. Gender affirming surgery is not an isolated intervention; it is part of a complex process involving multiple medical, psychiatric and psychologic, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. Before undertaking gender affirming surgery, medical and psychological evaluations, medical therapies and behavioral trials are undertaken to help ensure that surgery is an appropriate treatment choice for the individual.

Note: Please refer to the following documents for additional information, including the use of these and other procedures for individuals with gender dysphoria that are not related to gender affirming surgery:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
• CG-SURG-12 Penile Prosthesis Implantation
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: Voice therapy is not addressed in this document, as it is not a surgical procedure.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

NOTE: Procedures to address postoperative complications of gender affirming surgery procedures (for example, stenosis, scarring, chronic infection, or pain) are not considered separate gender affirming surgery procedures.

NOTE: Reversal of a prior gender affirming surgery procedure is considered gender affirming surgery and the medical necessity criteria below apply.

Medically Necessary:

Gender affirming pelvic or gonadal surgery (which may consist of a combination of the following: hysterectomy, orchiectomy, ovariectomy, or salpingo-oophorectomy), is considered medically necessary when all of the following criteria are met:

1. The individual is at least 18 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 (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, 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.

Gender affirming genital surgery (which may consist of a combination of the following: clitoroplasty, labiaplasty, metoidioplasty, penectomy, phalloplasty, scrotoplasty, urethroplasty, vaginectomy, vaginoplasty, or placement of penile or testicular prostheses), is considered medically necessary when all of the following criteria are met:

1. The individual is at least 18 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 (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, 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 the 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.

*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 Counselor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) and be capable of adequately evaluating co-morbid 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. 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.

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Reconstructive

Gender affirming chest surgery (augmentation, mastectomy, or reduction) is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age (see Further Considerations section below for individuals under 18 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 (see Discussion section for diagnostic criteria); 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. For gender affirming breast augmentation procedures only: for individuals without a medical contraindication or intolerance, 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 insufficient breast development has occurred; and
6. Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
7. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Nipple reconstruction, including tattooing, following a gender affirming mastectomy that meets the reconstructive criteria above is considered reconstructive.

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 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 (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, 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. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

^†See Discussion section for a list of procedures included in this group of procedures

Gender affirming voice modification surgery is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 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 (see Discussion section for diagnostic criteria); and
4. For gender masculinization only: for individuals without a medical contraindication or intolerance, 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. Existing vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Not Medically Necessary:

The following gender affirming surgical procedures are considered not medically necessary when one or more of the medical necessary or reconstructive criteria above have not been met:

1. Clitoroplasty
2. Hysterectomy
3. Labiaplasty
4. Metoidioplasty
5. Orchiectomy
6. Ovariectomy
7. Penectomy
8. Phalloplasty
9. Salpingo-Oophorectomy
10. Scrotoplasty
11. Urethroplasty
12. Vaginectomy
13. Vaginoplasty

Cosmetic and Not Medically Necessary:

The following procedures, when requested alone or in combination with other procedures, are considered cosmetic and not medically necessary when applicable reconstructive criteria above have not been met, or when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender affirming surgery, including, but not limited to, the following:

1. Abdominoplasty
2. Bilateral mastectomy
3. Blepharoplasty
4. Breast augmentation
5. Brow lift
6. Calf implants
7. Face lift
8. Facial bone reconstruction
9. Facial implants
10. Gluteal augmentation
11. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
12. Jaw reduction (jaw contouring)
13. Lip reduction/enhancement
14. Lipofilling/collagen injections
15. Liposuction
16. Nose implants
17. Pectoral implants
18. Rhinoplasty
19. Thyroid cartilage reduction (chondroplasty)
20. Voice modification surgery

Further Considerations:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure criteria above (including prior mental health evaluation) by contacting a Medical Director. (Further information is available in the Discussion/General Information section of this document titled ‘Gender Affirming Surgery in Individuals Under the Age of 18’).

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

When services may be Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when reconstructive criteria are not met or when the code describes a procedure designated in the Clinical Indications section as cosmetic and not medically necessary.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) provides criteria for the diagnosis of gender dysphoria. The DSM-5 criteria are widely recognized as the community standard by which individuals suspected of gender dysphoria are evaluated and diagnoses are confirmed. The DSM-5 criteria for gender dysphoria are as follows:

Gender dysphoria in Children*

1. 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 or 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.
   8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
2. 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*

1. 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 (or 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).
2. 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 full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen- namely regular cross-sex 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. DSM-5. American Psychiatric Association. Washington, DC. May 2013. Page 451-459.

The World Professional Association for Transgender Health’s (WPATH) Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version (2012) provides recommendations for care of individuals with gender dysphoria. The SOC states,

The SOC are intended to be flexible in order to meet the diverse health care needs of transsexual, transgender, and gender-nonconforming people. While flexible, they offer standards for promoting optimal health care and guiding the treatment of people experiencing gender dysphoria.

and

Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm-reduction strategies.

Any variations from recommendations by WPATH within this guideline may reflect where SOC standards are, for example, not based on published medical evidence.

Procedures for the chest, also known as “top surgery”, and those for the groin and reproductive organs, also known as “bottom surgery”, do not need to be done in conjunction. Additionally, individuals undergoing top surgery do not need to subsequently undergo bottom surgery, or vice versa. The selection of appropriate procedures should be based on the needs of the individual in relation to the treatment of their diagnosis of gender dysphoria. The WPATH SOC addresses this issue, “The SOC do not specify an order in which different surgeries should occur. The number and sequence of surgical procedures may vary from patient to patient, according to their clinical needs.”

Gender Affirming Pelvic and Gonadal Procedures

Procedures addressing pelvic and gonadal anatomy in individuals with gender dysphoria are conducted to achieve the desired physical anatomy and function aligning with the individual’s experienced gender. Gender affirming pelvic and gonadal procedures have been shown in many studies to provide significant functional improvement in multiple areas (Becker, 2018; Butler, 2019; Cardoso da Silva, 2016; Castellano, 2015; De Cuypere, 2005; de Vries, 2014; Djordjevic, 2009; Guss, 2015; Hage, 2006; Jellestad, 2018; Lawrence, 2006; Miller, 2019; Murad, 2010; Olson-Kennedy, 2018; Owen-Smith, 2018; Papadopulos, 2015; Simbar, 2018; Terrier, 2014; Tucker, 2018; van de Grift, 2017; Weigert, 2013; Wernick, 2019; Wierckx, 2011). These improvements include gender dysphoria-related symptoms such as psychological distress, depression, anxiety, and acceptance of the individual’s body. Additionally, the available literature also demonstrates significant benefits related to quality of life and overall well-being.           

The medical necessity criteria above for pelvic and gonadal procedures are based on several sources including the WPATH SOC, published peer-reviewed studies and expert opinion. In addition to having an established gender dysphoria diagnosis, individuals seeking gender affirmation surgery must be of the age of legal majority in the country in which they are seeking care (in the United states: 18 years of age). Individuals seeking irreversible surgical procedures should have the capacity to make fully informed decisions, and any significant medical or mental health issues should be reasonably well controlled. Gender affirming surgical procedures present significant medical and psychological risks, and the results are difficult to reverse (Djordjevic, 2016).

Published peer-reviewed studies have shown that hormonal therapy and real-life experience living as the other gender, as well as social support and acceptance by peer and family groups, improve psychological outcomes in individuals undergoing gender affirming surgery (Eldh, 1997; Landen, 1998). Monstrey (2001) described the importance of close cooperation between the medical and behavioral specialties required for proper treatment of individuals with gender dysphoria who wish to undergo gender affirming surgery. Similar findings were reported earlier by Schlatterer (1996). One study of 188 subjects undergoing gender affirming surgery found that dissatisfaction with surgery was highly associated with sexual preference, psychological co-morbidity, and poor pre-operative body image and satisfaction (Smith, 2005).                                                                                    

While this document does not address the medical necessity of hormone therapy, when indicated, it is administered under medical supervision and begins the gender transition process by altering body hair, breast size or development, skin appearance and texture, body fat distribution, the size and function of sex organs, and other characteristics, including voice deepening. The WPATH guidelines support using hormonal therapy prior to pelvic and gonadal procedures.

For individuals undergoing gender affirming genital procedures, 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 acknowledgement by others of the new gender role. With regard to real-life experience, the WPATH 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 provides 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.

Gender Affirming Chest Surgery:

Gender affirming chest surgery in individuals with gender dysphoria is reconstructive, in that the procedure is intended to address the significant variation from normal appearance for the experienced gender. The evidence addressing gender affirming chest surgery for the treatment of gender dysphoria supports a consistent association between surgery and satisfaction with breast appearance, psychological and sexual well-being, and body image and attractiveness; however, evidence supporting improvements in functional outcomes (for example, quality of life, gender dysphoria symptoms, or sequelae of severe illness, including crisis visits, suicide attempts, etc.) is less clear  (Becker, 2018; Miller, 2019; Olson-Kennedy, 2018; Weigert, 2013). Criteria for chest surgery are generally consistent with genital/gonadal surgery including requirements related to age, capacity to consent, diagnosis of gender dysphoria, and reasonably well controlled concomitant physical and mental health conditions.

For individuals born with male anatomy and considering gender affirming breast surgery, hormone therapy results in the development of at least some breast tissue in most cases. Breast development generally occurs within the first 12 months (although development may continue through 2-3 years of therapy) (De Blok, 2020a). Published studies have reported that final breast size varies significantly, anywhere from no growth to a C-cup, although the average individual achieves an A-cup in size. WPATH notes “Although not an explicit criterion, it is recommended that patients undergo feminizing hormone therapy (minimum 12 months) prior to gender affirming breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.” To establish a reconstructive intent, it is important that an individual has undergone a minimum of 12 months of continuous hormonal therapy (when recommended by a mental health professional), and insufficient breast development has occurred.

Gender Affirming Chest Surgery in Individuals Under the Age of 18 (Return to Clinical Indications)

Further consideration of a gender affirming chest procedure in select individuals under 18 years of age may be appropriate; there may exist extenuating circumstances, such as the level of maturity of the individual, duration of dysphoric symptoms, medical and mental health, and other factors, that should be considered in consultation with a provider with experience treating adolescents with gender dysphoria. The WPATH SOC provides the following guidance for individuals under the age of 18:

Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.

Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.

Gender Affirming Facial Surgery (Return to Clinical Indations)

In some cases, an individual’s facial features may be outside of what is perceived as normal for their experienced gender. Gender affirming facial surgery in individuals with gender dysphoria is considered reconstructive, in that the procedure is intended to address as a significant variation from normal appearance for the experienced gender.

The published data regarding gender affirming facial surgery generally support associations between surgery and  the likelihood of being properly identified by the experienced gender by observers; however, evidence supporting improvements in functional outcomes (for example, quality of life, gender dysphoria symptoms, or sequelae of severe illness, including crisis visits, suicide attempts, etc.) is less clear (Ainsworth, 2010; Cohen, 2018; Fisher, 2020; Morrison, 2020). There is some data to demonstrate that the long-term use of hormone therapy does quantifiably femininize or masculinize facial features, thus extended use of hormone therapy prior to facial feminization may be warranted in some circumstances (Tebbens, 2019).

The WPATH does not recommend specific criteria for the use of facial feminization procedures. Instead, they note the following:

Unfortunately, in the field of plastic and reconstructive surgery (both in general and specifically for gender-related surgeries), there is no clear distinction between what is purely reconstructive and what is purely cosmetic. Most plastic surgery procedures actually are a mixture of both reconstructive and cosmetic components.

While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive. Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria.

Individuals with gender dysphoria who undergo gender affirming procedures may seek additional procedures to further alter their facial appearance when existing facial appearance demonstrates significant variation from normal appearance for the experienced gender. Such procedures may include the following:

• Facial bone reconstruction
• Facial implants
• Jaw reduction (jaw contouring)
• Lip reduction/enhancement
• Lipofilling/collagen injections
• Liposuction
• Nose implants
• Rhinoplasty
• Thyroid cartilage reduction (chondroplasty)

Gender Affirming Voice Modification Surgery

Gender affirming voice modification surgery is considered reconstructive for individuals when existing vocal presentation demonstrates significant variation from normal for the experienced gender. WPATH notes:

Some transsexual, transgender, and gender-nonconforming people will undergo voice feminization surgery. (Voice deepening can be achieved through masculinizing hormone therapy, but feminizing hormones do not have an impact on the adult MtF (sic: male-to-female) voice.) There are varying degrees of satisfaction, safety, and long-term improvement in patients who have had such surgery. It is recommended that individuals undergoing voice feminization surgery also consult a voice and communication specialist to maximize the surgical outcome, help protect vocal health, and learn nonpitch related aspects of communication. Voice surgery procedures should include follow-up sessions with a voice and communication specialist who is licensed and/or credentialed by the board responsible for speech therapists/speech-language pathologists in that country.

WPATH notes that voice surgery to obtain a deeper voice in individuals desiring body masculinization is rare but may be recommended in some cases, such as when hormone therapy has been ineffective.

Published data evaluating gender affirming voice modification surgery is limited to postoperative satisfaction and vocal outcomes; functional outcomes (for example, quality of life, gender dysphoria symptoms, or sequelae of severe illness, including crisis visits, suicide attempts, etc.) have not been specifically assessed (Kim, 2020).

Referral Letters (Return to Clinical Indications)

An independent assessment of an individual by a qualified mental health professional is considered standard of care before an individual undergoes a gender affirming surgical procedure.

The SOC states the following regarding referral letters in support of gender affirming surgery:

The recommended content of the referral letters for surgery is as follows:

1. The client’s general identifying characteristics;
2. Results of the client’s psychosocial assessment, including any diagnoses;
3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
5. A statement about the fact that informed consent has been obtained from the patient;
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

While the SOC also states:

For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.

Additionally, the SOC provides the following recommendations regarding the credentials for mental health professionals who work with adults presenting with gender dysphoria:

1. A master’s degree or its equivalent in a clinical behavioral science field. This degree, or a more advanced one, should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country.
2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes.
3. Ability to recognize and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria.
4. Documented supervised training and competence in psychotherapy or counseling.
5. Knowledgeable about gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

This statement from the SOC does not govern CG-SURG-27. A letter including all of the recommended items should be included in surgical requests.

Other Guidelines

In late 2017, the Endocrine Society released a clinical practice guideline for the endocrine treatment of gender-dysphoric/gender-incongruent persons (Hembree, 2017). This publication was co-sponsored by the American Association of Clinical Endocrinologists, the American Society of Andrology, the European Society for Pediatric Endocrinology, the European Society of Endocrinology, the Pediatric Endocrine Society, and WPATH. Among other recommendations this document includes the following:

2.1. We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development. (2 |⊕⊕○○)
2.2. We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty. (2 |⊕⊕○○)
2.3. We recommend that, where indicated, GnRH analogues are used to suppress pubertal hormones. (1 |⊕⊕○○)™™
2.4. In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.  (1 |⊕⊕○○)™™
2.5. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years. As with the care of adolescents ≥16 years of age, we recommend that an expert multidisciplinary team of medical and MHPs manage this treatment. (1 |⊕○○○)™™
5.1. We recommend that a patient pursue genital gender-affirming surgery only after the MHP and the clinician responsible for endocrine transition therapy both agree that surgery is medically necessary and would benefit the patient’s overall health and/or well-being. (1 |⊕⊕○○)™™
5.2. We advise that clinicians approve genital gender affirming surgery only after completion of at least 1 year of consistent and compliant hormone treatment, unless hormone therapy is not desired or medically contraindicated. (Ungraded Good Practice Statement)
5.3. We advise that the clinician responsible for endocrine treatment and the primary care provider ensure appropriate medical clearance of transgender individuals for genital gender-affirming surgery and collaborate with the surgeon regarding hormone use during and after surgery. (Ungraded Good Practice Statement)
5.4. We recommend that clinicians refer hormone treated transgender individuals for genital surgery when: (1) the individual has had a satisfactory social role change, (2) the individual is satisfied about the hormonal effects, and (3) the individual desires definitive surgical changes.  (1 |⊕⊕○○○)™™
5.5. We suggest that clinicians delay gender-affirming genital surgery involving gonadectomy and/or hysterectomy until the patient is at least 18 years old or legal age of majority in his or her country.  (2 |⊕⊕○○).

Note: “MHP” is the Endocrine Society’s abbreviation for “mental health professional”.

Hair removal Procedures

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. Pre-operative permanent hair removal treatments to these areas may be warranted to prevent post-operative complications.

Procedures to Address Postoperative Complications of Gender Affirming Surgery and Reversal Surgery (Return to Clinical Indications)

Procedures to address postoperative complications of a prior gender affirming surgery (for example, scarring, stenosis, infection, etc.) are not considered a separate gender affirming surgery procedure and are not addressed in this document.

Reversal of a prior gender affirming surgery procedure is rare and is considered gender affirming surgery. According to the literature on this issue, the predominant factor in requests for reversals are regret, which has been further associated with age greater than 30 at first surgery, personality disorders, early loss of both parents, social instability, preoperative sexual orientation for heterosexual male-to-female (MtF) individuals, degree of social support, secondary transsexualism, early decision to undergo surgery and dissatisfaction with surgical results (Blanchard, 1989; Landén, 1998; Lawrence, 2003; Lindemalm, 1986 and 1987; Olsson, 2006).

Djordjevic (2016) reported on the outcomes of surgical reversal surgery in MtF individuals wishing to transition back to male. While the main focus of this paper is related to surgical outcomes, the authors reported on characteristics of the participating subjects and contributing factors to the reversal decisions. The seven subjects had an absence of “real-life experience” prior to surgery, absence or inappropriate hormonal treatment, recommendations by inexperienced professionals, and insufficient hormonal therapy and medical follow-up. Furthermore, they failed to fulfill the complete diagnostic criteria for GID. The authors concluded that the main factor contributing to regret was absence of proper pretreatment assessment. In their reversal protocol, each subject was required to have recommendations from three well-known WPATH psychiatrists prior to reversal procedures.

The available evidence indicates the importance of thorough preoperative physical and psychological evaluation and treatment as being a critical factor in postoperative success. As noted above, these aspects of the treatment process are critical to sufficiently prepare an individual for the social, physical, and mental ramifications of the decision to undergo gender affirming surgery.

The clinical evidence addressing the satisfaction and quality of life following gender affirming surgery is limited, and the reported findings are mixed (Cardoso da Silva, 2016; Castellano, 2015). It is important that proper and thorough pre-operative work-up and preparation be conducted in individuals considering such life-altering procedures. Additionally, long-term post-operative follow-up, including availability of mental health services, may also contribute to satisfaction with surgical results.

Other Procedures

Additional surgeries have been proposed to improve the gender appropriate appearance of the individual. Such procedures may be considered cosmetic and are not reconstructive when intended to change a physical appearance that would be considered within normal human anatomic variation or are primarily intended to preserve or improve appearance irrespective of gender-defining features.

Such procedures may include the following when one or more of the medical necessary or reconstructive criteria above have not been met:

1. Abdominoplasty
2. Bilateral mastectomy
3. Blepharoplasty
4. Breast augmentation
5. Brow lift
6. Face lift
7. Facial bone reconstruction
8. Facial implants
9. Gluteal implants
10. Hair removal (for example, electrolysis or laser) and hairplasty
11. Jaw reduction (jaw contouring)
12. Lip reduction/enhancement
13. Lipofilling/collagen injections
14. Liposuction
15. Nose implants
16. Pectoral implants
17. Rhinoplasty
18. Thyroid cartilage reduction (chondroplasty)
19. Voice modification surgery

WPATH notes that other surgeries for assisting in body feminization or masculinization may include suction-assisted lipoplasty (contour modeling) of the waist, face-lift, blepharoplasty (rejuvenation of the eyelid), gluteal augmentation (implants/lipofilling), liposuction, lipofilling, pectoral implants, and “various aesthetic procedures.” Such procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation or are primarily intended to preserve or improve appearance.

Review Considerations:

Reconstructive procedures address features that are distinctly and directly related to gender appearance (or in the case of gender affirming voice modification surgery, vocal presentation), when documentation sufficiently demonstrates significant variation from what is considered normal for the experienced gender. When multiple procedures are requested, each procedure should be considered separately as some procedures may be cosmetic and others may be reconstructive. Procedures primarily intended to preserve or improve appearance (that is: independent of any gender-defining feature or overall gender appearance) are considered cosmetic.

Peer Reviewed Publications:

1. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010; 19(7):1019-24.
2. Becker I, Auer M, Barkmann C, Fuss J, et al. A cross-sectional multicenter study of multidimensional body image in adolescents and adults with gender dysphoria before and after transition-related medical interventions. Arch Sex Behav. 2018; 47(8):2335-2347.
3. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Facial corrections in male to female transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg. 1996; 54(4):413-418.
4. Blanchard R, Steiner BW, Clemmensen LH, Dickey R. Prediction of regrets in postoperative transsexuals. Can J Psychiatry. 1989; 34(1):43-45.
5. Bradley SJ, Zucker KJ. Gender identity disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997; 36(7):872-880.
6. Butler RM, Horenstein A, Gitlin M, Testa RJ, et al. Social anxiety among transgender and gender nonconforming individuals: The role of gender-affirming medical interventions. J Abnorm Psychol. 2019; 128(1):25-31.
7. Capitán L, Simon D, Kaye K, Tenorio T. Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg. 2014; 134(4):609-619.
8. Cardoso da Silva D, Schwarz K, Fontanari AM, et al. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. J Sex Med. 2016; 13(6):988-993.
9. Castellano E, Crespi C, Dell’Aquila C, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest. 2015; 38(12):1373-1381.
10. Cohen MB, Insalaco LF, Tonn CR, Spiegel JH. Patient satisfaction after aesthetic chondrolaryngoplasty. Plast Reconstr Surg Glob Open. 2018; 6(10):e1877.
11. Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. 1999; 46(4):315-333.
12. Cristofari S, Bertrand B, Leuzzi S, et al Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study. Ann Chir Plast Esthet. 2018. Pii: S0294-1260(18)30142-0.
13. de Blok CJM, Dijkman BAM, Wiepjes CM, et al. Sustained breast development and breast anthropometric changes in three years gender-affirming hormone treatment. J Clin Endocrinol Metab. 2020a 18:dgaa841. Epub ahead of print.
14. de Blok CJM, Klaver M, Wiepjes CM, et al. Breast development in transwomen after 1 year of cross-sex hormone therapy: results of a prospective multicenter study. J Clin Endocrinol Metab. 2018; 103(2):532-538.
15. De Cuypere G, T'Sjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005; 34(6):679-690.
16. de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014; 134(4):696-704.
17. Djordjevic ML, Bizic MR, Duisin D, et al. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J Sex Med. 2016; 13(6):1000-1007.
18. Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009; 6(5):1306-1313.
19. Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997; 31(1):39-45.
20. Fisher M, Lu SM, Chen K, et al. Facial feminization surgery changes perception of patient gender. Aesthet Surg J. 2020; 40(7):703-709.
21. Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Curr Opin Pediatr. 2015; 27(4):421-426.
22. Hage JJ, van Turnhout AA. Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals. Ann Plast Surg. 2006; 57(3):312-316
23. Hepp U, Kraemer B, Schnyder U, et al. Psychiatric comorbidity in gender identity disorder. J Psychosom Res. 2005; 58(3):259-261.
24. Jellestad L, Jäggi T, Corbisiero S, et al. Quality of life in transitioned trans persons: a retrospective cross-sectional cohort study. Biomed Res Int. 2018; 2018:8684625.
25. Landén M, Wålinder J, Hambert G, Lundström B. Factors predictive of regret in sex reassignment. Acta Psychiatry Scand. 1998; 7(4):284-289.
26. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003; 32(4):299-315.
27. Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch Sex Behav. 2006; 35(6):717-727.
28. Lindemalm G, Körlin D, Uddenberg N. Long-term follow-up of “sex change" in 13 male-to-female transsexuals. Arch Sex Behav. 1986; 15(3):187-210.
29. Lindemalm G, Körlin D, Uddenberg N. Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases. Acta Psychiatr Scand. 1987; 75(3):268-274.
30. Mate-Kole C, Freschi M, Robin A. A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals. Br J Psychiatry. 1990; 157:261-264.
31. Midence K, Hargreaves I. Psychosocial adjustment in male-to-female transsexuals: an overview of the research evidence. J Psychol. 1997; 131(6):602-614.
32. Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open. 2019; 21:63-74.
33. Monstrey S, Hoebeke P, Dhont M, et al. Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg. 2001; 101(5):200-209.
34. Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study. Plast Reconstr Surg. 2020; 145(6):1499-1509.
35. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010; 72(2):214-231.
36. Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018; 172(5):431-436.
37. Olsson SE, Möller A. Regret after sex reassignment surgery in a male-to-female transsexual: a long-term follow-up. Arch Sex Behav. 2006; 35(4):501-506.
38. Owen-Smith AA, Gerth J, Sineath RC, et al. association between gender confirmation treatments and perceived gender congruence, body image satisfaction, and mental health in a cohort of transgender individuals. J Sex Med. 2018; 15(4):591-600.
39. Papadopulos NA, Zavlin D, Lellé JD, et al. Male-to-female sex reassignment surgery using the combined technique leads to increased quality of life in a prospective study. Plast Reconstr Surg. 2017; 140(2):286-294.
40. Ruppin U, Pfäfflin F. Long-term follow-up of adults with gender identity disorder. Arch Sex Behav. 2015; 44(5):1321-1329.
41. Schlatterer K, von Werder K, Stalla GK. Multistep treatment concept of transsexual patients. Exp Clin Endocrinol Diabetes. 1996; 104(6):413-419.
42. Selvaggi G, Ceulemans P, De Cuypere G, et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg. 2005; 116(6):135e-145e.
43. Simbar M, Nazarpour S, Mirzababaie M, et al. quality of life and body image of individuals with gender dysphoria. J Sex Marital Ther. 2018; 44(6):523-532.
44. Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005; 35(1):89-99.
45. Tebbens M, Nota NM, Liberton NPTJ, et al. Gender-affirming hormone treatment induces facial feminization in transwomen and masculinization in transmen: quantification by 3D scanning and patient-reported outcome measures. J Sex Med. 2019; 16(5):746-754.
46. Terrier JÉ, Courtois F, Ruffion A, Morel Journel N. Surgical outcomes and patients' satisfaction with suprapubic phalloplasty. J Sex Med. 2014; 11(1):288-298.
47. Tucker RP, Testa RJ, Simpson TL, et al. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans. Psychol Med. 2018; 48(14):2329-2336.
48. van de Grift TC, Elaut E, Cerwenka SC, et al. Effects of medical interventions on gender dysphoria and body image: a follow-up study. Psychosom Med. 2017; 79(7):815-823.
49. Weigert R, Frison E, Sessiecq Q, et al. Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plast Reconstr Surg. 2013; 132(6):1421-1429.
50. Wernick JA, Busa S, Matouk K, Nicholson J, Janssen A. A systematic review of the psychological benefits of gender-affirming surgery. Urol Clin North Am. 2019; 46(4):475-486.
51. Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011; 8(12):3379-3388.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. Washington, DC. Pages 451-459.
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. Endocr Pract. 2017; 23(12):1437.
3. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7^th version. 2012. Available at: https://www.wpath.org/publications/soc. Accessed on May 5, 2021.
4. World Professional Association for Transgender Health (WPATH) (formerly The Harry Benjamin International Gender Dysphoria Association). Standards of Care for Gender Identity Disorders. 6^th version. 2001 Feb.

Gender affirmation
Gender confirmation
Sex affirmation
Sex change
Sex confirmation
Sex reassignment

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