Gender Affirmation Surgery - Medical Clinical Guideline Bulletins (2023)

Number: 0615

table of Contents

Policy
Anwendbare CPT / HCPCS / ICD-10-Codes
bottom
references

Policy

Policy Scope

This Clinical Policy Bulletin addresses gender affirming surgery.

use: Some plans may cover gender affirmation procedures in addition to the following policies. Please see the specific pension documents.

1. medical necessity

   Aetna considers gender-affirming surgery medically necessary if criteria are metfor each of the following proceduresmeeting:

   1. Requirements for breast removal

      1. Signed letter from a licensed psychologist (cf.Adjunct) assess the willingness of the transgender/gender diverse person to receive physical treatment;Y
      2. Documentation of pronounced and persistent gender dysphoria (cf.Adjunct);Y
      3. Other possible causes of apparent gender incongruity were excluded;Y
      4. Mental and physical health conditions that could negatively affect the outcome of gender-affirming medical treatments are evaluated, and risks and benefits are discussed;Y
      5. ability to consent to specific physical treatment;Y
      6. For members under the age of 18, complete one year of testosterone treatment unless hormone therapy is undesirable or medically contraindicated;Y
      7. Risk factors associated with breast cancer were evaluated.

   2. Requirements for breast augmentation (implants/lipofilling)

      1. Signed letter from a licensed psychologist (cf.Adjunct) Assess the willingness of the transgender/gender diverse person to receive physical treatments;Y
      2. Documentation of pronounced and persistent gender dysphoria (cf.Adjunct);Y
      3. Other possible causes of apparent gender incongruity were excluded;Y
      4. Mental and physical health conditions that could negatively affect the outcome of gender-affirming medical treatments are evaluated, and risks and benefits are discussed;Y
      5. ability to consent to specific physical treatment;Y
      6. Complete six months of feminizing hormone therapy (12 months for youth under 18) prior to breast augmentation surgery, unless hormone therapy is undesirable or medically contraindicated);Y
      7. Risk factors associated with breast cancer were evaluated.

   3. Prerequisites for gonadectomy (hysterectomy and oophorectomy or orchiectomy)

      1. Signed letter from a licensed psychologist (cf.Adjunct) Assess the willingness of the transgender/gender diverse person to receive physical treatments;Y
      2. Documentation of pronounced and persistent gender dysphoria (cf.Adjunct);Y
      3. Other possible causes of apparent gender incongruity were excluded;Y
      4. Mental and physical health conditions that could negatively affect the outcome of gender-affirming medical treatments are evaluated, and risks and benefits are discussed;Y
      5. ability to consent to specific physical treatment;Y
      6. Six months of continuous hormone therapy based on the member's gender goals (12 months for youth under age 18), unless hormone therapy is undesirable or medically contraindicated.

   4. Requirements for reconstructive genital surgery(i.e. vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, insertion of testicular and erectile prostheses, penectomy, vaginoplasty, labiaplasty, clitorisplasty, and electrolysis or laser hair removal sessions in preparation for skin grafts for genital surgery)

      1. Signed letter from a licensed psychologist (cf.Adjunct) Assess the willingness of the transgender/gender diverse person to receive physical treatments;Y
      2. Documentation of pronounced and persistent gender dysphoria (cf.Adjunct);Y
      3. Other possible causes of apparent gender incongruity were excluded;Y
      4. Mental and physical health conditions that could negatively affect the outcome of gender-affirming medical treatments are evaluated, and risks and benefits are discussed;Y
      5. ability to consent to specific physical treatment;Y
      6. Six months of continuous hormone therapy based on the member's gender goals (12 months for youth under age 18), unless hormone therapy is undesirable or medically contraindicated.

   Note on gender services for the transgender community:Gender-specific services may be medically necessary for transgender people based on their anatomy. Examples include:

   1. Breast cancer screening may be medically necessary for transmasculine individuals who have not had masculinization breast surgery;
   2. Prostate cancer screening may be medically necessary for transgender people who have retained their prostate.

   Aetna considers gender-affirming surgery reversal (performing surgery to restore anatomy to the sex assigned at birth) to be medically necessary for people who regret their gender-affirming surgery, provided the applicable requirements for gender-affirming surgery are met. gender affirming surgery listed above.

   (Video) Gender Affirmation Surgeries and Care | Cecile Ferrando, MD

   Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans-identified adolescents who meet the World Professional Association for Transgender Health (WPATH) criteria (seeCPB 0501 - Gonadotropin Releasing Hormone Analogs and Antagonists).

2. not medically necessary

   Aetna believes that more than one breast augmentation is not medically necessary. Excluded from this is the medically necessary replacement of breast implants (cf.CPB 0142 - Removal of Breast Implants).

   See Also

   Clinical Medical Policy Bulletins - Health Professionals | EtnaTumor Markers - Medical Clinical Policy BulletinsBreast Pumps - Clinical Medical Policy Bulletins

   The following procedures that may be performed as part of a sex reassignment operation are considered by Aetna to be non-medically necessary and cosmetic (non-exhaustive list) (see alsoCPB 0031 - Aesthetic Surgery):

   • Hair removal (eg, electrolysis, laser hair removal) (Exception: a limited number of laser hair removal or electrolysis sessions are considered medically necessary to prepare the skin graft for genital surgery)
   • Tracheal shaving (thyroid reduction chondroplasty)
   • Facial gender confirmation procedures including:
     • Eyebrows (reduce, increase, lift)
     • Hair lengthening and/or hair transplantation
     • Facelift/mid-facelift (after changing the underlying skeletal structures) (platysmaplasty)
     • Blepharoplasty (Lipofilling)
     • Rhinoplasty (+/- fillers)
     • Wange (Implantat, Lipofilling)
     • Lip (upper lip shortening, lip augmentation)
     • Lower jaw (lower jaw angle reduction, augmentation)
     • Chin Reshaping (Osteoplasty, Alloplastic (Implant-Based))
     • Chondrolaryngoplasty (vocal cord surgery)

   • Body contouring gender affirming surgery including (not an exhaustive list):

     • Liposuction/lipofilling/implants (breast, hip, buttocks, calf).

3. Related Policies

   • CPB 0031 - Aesthetic Surgery
   • CPB 0097 – External Breast Prosthesis
   • CPB 0501 - Gonadotropin Releasing Hormone Analogs and Antagonists
   • CPB 0646 - Voice Therapy

bottom

The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States. . However, the 8th Edition of the World Professional Association's Standard of Transgender Health Care (WPATH SOC8) states: "Although gender dysphoria (GD) is found in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5-TR) Gender incongruence is no longer considered a pathological or mental disorder in the global healthcare community Gender incongruence is recognized as a disease in the International Classification of Diseases and Health Problems Related from World Health Organization version 11 (ICD-11).Due to historical and current stigma, people with PDD may experience distress or dysphoria that can be addressed with various gender-affirming treatment options.Although the nomenclature may change and different health care organizations or administrative agencies may adopt new terminologies and classifications, there is a clear recognition ment of the medical need for treatment and care for many people who experience dissonance between their sex assigned at birth and their gender. identity "

Gender dysphoria refers to discomfort or distress caused by a discrepancy between a person's gender identity and the sex assigned at birth (and associated gender roles and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a clear difference between the person's expressed/experienced gender and the gender others would assign, and this difference must persist for at least six months. This condition can cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender affirmation surgery is performed to change primary and/or secondary sexual characteristics. For transfemale sex change (assigned at birth), surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoral correction), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, tummy tuck, thyroid chondroplasty (larynx shaving), voice change surgery (vocal cord shortening), hair transplant) (Day, 2002). For transmale (assigned at birth) sex change, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance masculine characteristics, such as breast implants and wall reshaping. thoracic (Day, 2002).

The above criteria for some types of genital surgery are based on the consensus of clinical experts that this experience provides ample opportunity for patients to experience their desired gender role and adjust socially before undergoing irreversible surgery (Coleman, et al. ., 2022) .

It is recommended that transfeminine individuals undergo feminizing hormone therapy (at least 6 months) prior to breast augmentation surgery. The goal is to maximize breast growth for better surgical (cosmetic) results.

In addition to hormone therapy and gender affirming surgeries, psychological adjustments are required for gender affirmation. Treatment should focus on psychological adjustment, with hormone therapy and gender-affirming surgery seen as confirmatory procedures dependent on proper psychological adjustment. Continued psychiatric care may be necessary after gender-affirming surgery. The overall success of treatment depends in part on the technical success of the surgery, but more critically on the psychological adjustment of the trans person and the support of family, friends, employers, and the medical community.

Nakatsuka (2012) noted that the third version of the Japan Society of Psychiatry and Neurology guideline on the treatment of persons with gender dysphoria (GD) recommends that feminizing/masculinizing hormone therapy and genital surgery should not be performed before the age of 18 and 20 years. years, respectively On the other hand, the sixth (2001) and seventh (2011) versions of the World Professional Association for Transgender Health (WPATH) Standards of Care for Transgender, Transsexual, and Gender Nonconforming People recommend young (Tanner stage 2, [mainly 12 to 13 years]) are treated by endocrinologists with gonadotropin-releasing hormone (GnRH) agonists to suppress puberty until the age of 16, after which hormones may be given. sexual affirmation. A questionnaire of 181 people with GID diagnosed at Okayama University Hospital (Japan) showed that female-to-male (FTM) transgender people of 15.6 +/- 4.0 (mean +/- standard deviation) with a desire to start masculinizing hormone therapy while men Did people who transidentify as female (MTF) choose to start feminizing hormone therapy at 12.5 +/- 4.0 years of age, before they exhibited secondary sexual characteristics? After confirmation of strong and persistent transgender identification, adolescents with GD should be treated with a sex-affirming hormone or a puberty-delaying hormone to prevent the development of undesirable sexual characteristics. These treatments can prevent transgender teens from attempting suicide, suffering from depression, and refusing to attend school.

Spack (2013) noted that DG is not well understood from both mechanistic and clinical perspectives. Awareness of the condition appears to be increasing, likely due to greater social acceptance and available hormonal treatments. Therapeutic options include hormonal and surgical treatments, but these may be limited by insurance coverage due to high cost. For patients seeking confirmation of MTF, hormonal therapy includes estrogens, finasteride, spironolactone, and GnRH analogues. Surgical options include feminizing facial and genital surgery, breast augmentation, and various fat grafting. For patients seeking FTM gender affirmation, medical therapy includes testosterone and GnRH analogues, and surgical therapy includes mammoplasty and phalloplasty.Medical therapyboth FTM and MTF can be started at early puberty, although the long-term effects are unknown. All patients considering treatment require medical advice and supervision.

Leinung and colleagues (2013) noted that the recently published Endocrine Society Clinical Practice Guidelines for the Treatment of Transgender People recognize the need for more information about the health of transgender people. These researchers reported on one provider's experience of providing endocrine treatment to transgender people over the past 2 decades. Data were collected on the demographics, clinical response to treatment, and psychosocial status of all transgender individuals who received gender-affirming hormone therapy since 1991 at the Albany Medical Center Endocrinology Clinic, a tertiary care referral center in upstate New York. As of 2009, a total of 192 MTF and 50 FTM transgender people have been seen. These patients had a high prevalence of mental and psychiatric problems (more than 50%), low activity rates, and high levels of disability. Mental health and psychiatric problems were inversely related to age of presentation. The prevalence of gender affirming surgery was low (31% for MTF). The number of people seeking treatment has increased considerably in recent years. Gender-affirming hormone therapy has very good results in FTM people and is more successful in MTF people when started at a younger age. The authors concluded that transgender people seeking hormone therapy are being seen more frequently. The dysphoria present in many transgender people is associated with significant mood disorders that hinder a successful career. They indicated that starting therapy at a younger age may reduce negative mental health effects and lead to better social outcomes.

Meyer-Bahlburg (2013) has summarized the current literature on the developmental psychobiology of gender identity and its variants in people with developmental gender disorders or transgenderism for the benefit of the practicing endocrinologist. Gender reassignment remains the treatment of choice for severe and persistent gender dysphoria in both categories, but more research is needed on the short- and long-term effects of puberty-suppressing drugs and cross-sex hormones in the brain and behavior.

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

Mastectomy CPT codes (CPT codes 19303) are related to breast cancer and are not eligible to charge for breast reduction surgery for female-to-male (trans-male) gender confirmation surgeries. CPT 2020 states that "mastectomy procedures (excluding gynecomastia [19300]) are performed for the treatment or prevention of breast cancer." / or nipples (eg, nipple preservation) to treat or prevent breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for sex reassignment. The former requires the careful removal of all breast tissue to reduce the risk of cancer. In contrast, careful removal of all breast tissue is not essential in a sex reassignment mastectomy. In sex reassignment mastectomy, the areola complex can usually be preserved.

Some have attempted to justify the routine billing of CPT code 19350 for nipple reconstruction at the time of gender reassignment mastectomy based on the frequent need to reduce the size of the areola to give it a masculine appearance. However, nipple reconstruction within the meaning of CPT code 19350 describes a much more complex procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in a standing position to ensure that the nipple reconstruction is in a balanced position for a nipple and areola graft position in the right breast. Under local anesthesia, a skid flap is raised and constructed at the site chosen for nipple reconstruction. A full thickness skin graft is taken from the right groin to reconstruct the areola. The right groin donor site is mostly closed in layers.”

The AMA bullet for CPT code 19318 (Breast Reduction Surgery) clarifies that this CPT code includes work required to reposition and reshape the nipple to achieve an aesthetically pleasing result, such as is required in female breast reduction surgery for men. . “The doctor reduces the size of the breasts by removing wedges of skin and breast tissue from a patient. The doctor makes a circular incision in the skin over the nipple, at the position where the nipple will be lifted. Another incision is made in the skin around the perimeter of the nipple. Two incisions are made from the circular incision over the nipple to the crease under the breast, one on each side of the nipple, creating an incision in the skin and breast in the shape of a keyhole. Skin and breast tissue are removed until the desired size is reached. Bleeding vessels can be ligated or cauterized. The physician lifts the nipple and its pedicle from subcutaneous tissue to its new position and sutures the pedicle of the nipple with a layered closure. The remaining incision is repaired with a layered closure” (EncoderPro, 2019). CPT code 19350 does not describe the work being performed, as this code describes the actual construction of a new nipple under code 19318 and, consequently, code 19350 services are included in code 19318. Similarly, transplant codes like , graft code services like 15200 are included in code 19318.

Vulvoplasty versus vaginoplasty as gender-affirming genital surgery for transgender women

Jiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire or can safely undergo a vaginal canal procedure. These investigators described the factors influencing the patient's choice or surgeon's recommendation for vulvoplasty (creating the external appearance of the female genitalia without creating a neovaginal canal) and assessed patient satisfaction with that choice. From March 2015 to December 2017, gender-affirming genital surgery clinics were reviewed and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. In addition to patient reports, these investigators reported satisfaction with the choice of surgery, satisfaction with the surgery itself, and post-surgery sexual activity, demographics, and reasons for choosing vulvoplasty as a gender-affirming surgery for patients. who completed or underwent surgery. I had planned . A total of 486 patients were seen in the gender affirmation transfemale genital surgery consultation: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 patients have completed vulvoplasty or are scheduled for vulvoplasty. The vulvoplasty patients were older and had a higher body mass index (BMI) than those who wanted vaginoplasty. The majority (63%) of the patients who sought vulvoplasty opted for this surgery despite the fact that there were no contraindications for vaginoplasty. The remaining patients had risk factors that led the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision to have vulvoplasty. The authors concluded that this was the first study of factors influencing a patient's choice or surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it was also the first reported series of patients who only underwent vulvoplasty.

Disadvantages of this study included its retrospective nature, unvalidated questions, short-term follow-up, and selection bias in the way vulvoplasty was offered. Vulvoplasty is a form of gender-affirming feminization surgery that does not create a neovagina and is associated with high satisfaction and low decision regret.

Amnion populated with autologous fibroblasts for reconstruction of the neovagina in transfemale reassignment surgery

Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used various methods for neovaginal construction, including the use of penile skin, free skin grafts, small bowel or rectosigmoid grafts, an amniotic graft, and cultured cells. . These investigators compared the results of amnion transplants with amnion seeded with autograft fibroblasts. Over an 8-year period, these researchers retrospectively compared the outcomes of 24 male-to-female transgender patients based on their complications and level of satisfaction; Sixteen patients in group A received amniotic grafts with fibroblasts, and patients in group B received only amniotic grafts without additional cell lining. Vaginal depths, sizes, discharges, and sensations were assessed. Patients were monitored for complications including hypersecretion, stricture, stricture, fistula formation, infection, and bleeding. The mean age of group A was 28 ± 4 years and of group B 32 ± 3 years. Patients were followed from 30 months to 8 years (mean 36 ± 4) after surgery. The depth of the vaginas was 14 to 16 cm in group A and 13 to 16 cm in group B. There was no stenosis in either group. The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B. These investigators had only 2 cases of neovaginal stenosis in group B, but no stenosis was recorded in group A. All patients had good and acceptable neovaginal sensation; 75% of the patients had sexual experiences and of these, 93.7% of group A and 87.5% of group B expressed satisfaction. The authors concluded that creating a neovaginal canal and lining it with amnion allograft and seeded autologous fibroblasts is an effective method of simulating a normal vagina. Neovaginal size, discharge, sensation and orgasm were good and correct. More than 93.7% of the patients were satisfied with intercourse. They stated that amnion seeded with fibroblasts extracted from the patient's own cells results in a properly sized, moist vagina that may eliminate the need for long-term dilation. The designed vagina has a 2-layer structure and is much more resistant to trauma and lacerations. No cases of stenosis or stenosis were recorded. Level of Evidence = IV These preliminary results need to be validated by well-designed studies.

Tone elevation surgery in transfeminine people

Van Damme and colleagues (2017) reviewed the evidence for the effectiveness of tone augmentation surgery performed on male-to-female transsexuals. These investigators searched PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and retrieved manuscript references for studies using "transsexual" or "transgender" as keywords in combination with terms related to voice surgery. They included 8 studies using the cricothyroidism approach, 6 studies using anterior glottic mesh formation, and 6 studies using other surgical types or a combination of surgical techniques, resulting in a total of 20 studies. Objectively, a clear increase in the basic postoperative frequency was determined. Above all, laryngeal web formation appeared to be significantly risky for declining speech quality. Most of the patients were satisfied with the result. However, none of the studies used a control group and randomisation process. The authors concluded that future research needs to investigate the long-term effects of tone-elevation surgery with a more robust study design.

Azul et al. (2017) reviewed the currently available empirical and discursive data on the primarily non-gender aspects of the voice status of transmasculine people and identified limitations in voice function observed in this population and made suggestions. for future research and clinical practice on the voice. . These researchers conducted a comprehensive review of the linguistic literature. Publications were identified by searching 6 electronic databases and bibliographies of relevant articles. A total of 22 publications met the inclusion criteria. Discourse and empirical data were analyzed for factors and practices that affect voice function and for evidence of problems related to voice function in transmasculine people. The quality of the evidence was assessed. Studies examining the vocal function of transmasculine people have been shown to be limited in scope and quality. There was mixed evidence that transmasculine people may experience limitations in several areas of vocal function, including vocal power, vocal control/stability, glottic function, pitch range/variability, vocal endurance, and voice quality. . The authors concluded that further research is needed on the various factors and practices that affect voice function in transmasculine people, taking into account a variety of voice function parameters and taking into account self-assessment by participants, to determine how functional is voice production in this population. can be better supported.

Facial Feminization Surgery

Raffaini and colleagues (2016) stated that gender dysphoria refers to discomfort and distress resulting from a discrepancy between a person's gender identity and the gender assigned at birth. The treatment plan for gender dysphoria varies and may include psychotherapy, hormonal treatment, and gender-confirming surgery, which is partly an irreversible change in sexual identity. Female transformation procedures include facial feminization, vaginoplasty, clitoral correction, and breast augmentation. Facial feminization surgery can include forehead reshaping, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice modification procedures. These investigators reported patient satisfaction after facial feminization surgery, including outcome measures after brow reskinning and chin reshaping. A total of 33 patients between the ages of 19 and 40 were referred between January 2003 and December 2013 for a total of 180 facial feminization procedures. Surgical outcome was analyzed both subjectively using patient questionnaires and objectively using serial photographs. Most facial feminization surgical procedures could be safely completed within 6 months, barring complications. All patients showed excellent cosmetic results and were satisfied with their procedures. Both frontal and profile views achieved a loss of masculine features. The authors concluded that patient satisfaction was high after facial feminization surgery; They indicated that reducing gender dysphoria had psychological and social benefits and had a significant impact on patient outcomes. The level of evidence of this study was IV.

Morrison and colleagues (2018) noted that facial feminization surgery encompasses a wide range of craniomaxillofacial surgical procedures intended to transform masculine facial features into feminine ones. The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone who desires facial feminization. Although the prevalence of these procedures is difficult to quantify, the increasing prevalence of transgenderism (approximately 1 in 14,000 men) along with better insurance coverage for gender confirmation surgeries require surgeons familiar with the techniques, results, and challenges. of facial feminization. These investigators reviewed the current literature on facial feminization surgery. They conducted an extensive literature search of the Medline, PubMed, and Embase databases for studies published up to October 2014 using multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. Of the 24 articles identified, a total of 15 articles were selected and reviewed, all of them retrospective or series/case reports. The articles covered a variety of facial feminization procedures. A total of 1,121 patients underwent facial feminization surgery and 7 complications were reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to measure satisfaction. The authors concluded that facial feminization surgery appears to be safe and satisfactory for patients. These investigators stated that further studies are needed to better compare different techniques and establish best practice more robustly; Prospective studies and patient-reported outcomes are needed to determine patient quality of life (QOL) outcomes.

In a systematic review, Gorbea et al. (2021) A portrait of insurance coverage for gender confirmation surgery (GAS) in the United States, with a particular focus on head and neck surgeries. State transgender care policies were compiled for Medicaid insurance providers in all 50 states. Each state's policy on GAS and facial gender confirmation surgeries (FGAS) was examined. The largest health insurance companies in the United States were identified using the National Association of Insurance Commissioners' market share report. The policies of the 49 major commercial health insurance companies were examined. Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%); 13 states ban Medicaid coverage for all transgender surgeries and 19 states have not issued a gender-affirming health care policy; 92% of commercial health insurance providers had a published policy for GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of commercial policies reviewed; 93% discussed FGAS coverage, but 51% thought these procedures were cosmetic. Thyroid chondroplasty (20%) was the most frequently covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial facelift were each covered by 13% of the reviewed medical guidelines. The authors concluded that while certain surgical aspects of gender-affirming healthcare are almost universally covered by commercial insurance providers, most Medicaid and commercial insurance providers consider FGAS to be cosmetic. Level of evidence = V

Hohman and Teixeira (2022) stated that regarding facial gender affirmation procedures, most of the procedures are performed on patients transitioning from male to female, i. h in transgender women. While there are slightly more transgender women than transgender men in the population (33% transgender women, 29% transgender men, 35% non-binary, 3% transvestites, according to the USTS), this is due to that there are more women than men. that testosterone therapy usually produces enough changes in secondary facial sexual characteristics (facial hair growth, thickening of the skin, increased frontal bossing, decreased voice, etc.) that surgery is not necessary. In some cases, implant placement or fat transfer can increase volume in the lower third of the face and contribute to masculinization. Still, the main focus area for facial feminization is generally the upper third. Feminization of the upper 1/3 of the face often requires the combination of several techniques: hairline advancement, hair transplantation, brow lift, and forehead hump reduction or "frontal cranioplasty." While scalp flap advancement, hair transplantation, and pretricial brow lift are common cosmetic procedures, frontal cranioplasty deserves special attention. Various methods of reducing the prominence of the brows are often referred to as type 1, type 2, and type 3 frontal cranioplasty. Type 1 cranioplasty reduces the prominence of the supraorbital rim, usually with a drill, including a reduction in the thickness of the sinus table former. This technique is the simplest, but it is only effective in patients with a very thick anterior sinus table or an absent pneumatized sinus. Type 2 cranioplasty involves augmentation of the frontal convexity with bone cement or methyl methacrylate, in addition to reduction of the supraorbital ridge with a drill. Championed by many leading surgeons for facial feminization, type 3 cranioplasty involves removing the anterior sinus plate, thinning the bone flap, and replacing that bone in the frontal sinus, but in a more depressed position, plus a reduction of the rest of the sinus. supraorbital ridge. An alternative to the removal and recession of the anterior border of the frontal sinus is to thin the bone with a bur and then fracture it in a controlled manner to produce the desired contour, which some authors do routinely.

Forehead feminization cranioplasty

Eggerstedt and colleagues (2020) noted that feminized frontal cranioplasty (FFC) is an important part of gender-affirming surgery and has become increasingly popular in recent years. However, there is little objective evidence of the safety and clinical impact of the procedure through patient-reported outcome measures (PROMs). In a systematic review, these investigators determined what complications are seen after FFC, the relative incidence of complications after the surgical technique, and the impact of the procedure on the patient's quality of life. They searched databases in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO. Search terms included receding variations of the forehead/FFC. Searches were performed on both controlled vocabularies (ie MeSH and CINAHL suggested terms) and keywords in the title or abstract fields. Two independent reviewers reviewed the titles and abstracts of all articles; and 2 independent surgical reviewers reviewed the full text of all included articles and extracted relevant data points. Key outcomes and measures included complications and the complication rate observed after FFC. Additional outcome parameters were the approach used, procedures performed concurrently, and the use and results of a PROM. A total of 10 articles with 673 patients describing FFC were included. The overall pooled complication rate was 1.3%; PROMs were used in 50% of the studies, without standardization between studies. The authors concluded that complications after FFC were rare and seldom required reoperation. Furthermore, these investigators indicated that further studies on standardized and validated PROMs in patients undergoing facial feminization are needed. Level of evidence = III.

Feminization and masculinization of hands.

Lee and colleagues (2021) found that anatomical features that are inconsistent with a person's gender identity can cause significant gender dysphoria. The hands exhibit conspicuous dimorphic sexual characteristics, but despite their visibility, there are limited studies examining gender-affirmation procedures for the hands. These investigators examined the anatomical features that define female and male hands, surgical and non-surgical approaches to feminizing and masculinizing the hand; and adapted established aesthetic manual techniques for gender affirming nursing. They conducted an exhaustive search of the PubMed, Embase OVID, and SCOPUS databases to identify articles on the characterization of female or male hands, hand treatments related to gender affirmation, and articles on feminization and masculinization techniques of hands in the non-native population. transgender. Of 656 potentially relevant articles, 42 met the inclusion criteria for the current literature review. There is currently no medical literature that specifically examines surgical or non-surgical options for confirmation of the gender in hand. The techniques available for gender affirmation procedures discussed in this article have been adapted from those most commonly used for hand rejuvenation. The authors concluded that there is very little evidence on the possibilities for transgender people to seek available gender affirmation procedures. These investigators noted that although established procedures for hand rejuvenation can be used in gender-affirming care, further study is needed to determine the relative importance of different hand features for gender dysphoria in transgender patients of different identities. and develop novel techniques to help meet those needs Level of Evidence = III.

Vaginoplasty with peritoneal extraction technique for the construction of a neovagina in gender affirmation surgery

Tay and Lo (2022) reviewed the use, efficacy, and results of a new surgical technique, the peritoneal removal vaginoplasty technique, in gender-affirming surgery. Specific outcome parameters included healing time, socket depth achieved, dysphoric relief, and surgical morbidity. These investigators performed a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement and the PROSPERO registry obtained prior to baseline. A search was performed in OVID Medline, Embase, Willey Online Library, and PubMed. We handsearched journals, gray literature, and reference lists of relevant articles. Of 476 potentially relevant articles, 12 articles were analyzed; and all publications were level 4 or level 5 evidence. Healing times were poorly reported or often not mentioned. A total of 8 authors reported a neovaginal cavity depth of at least 13 cm and good patient satisfaction. Dysphoria relief was not discussed in any of the publications and only 6 reported complications. The mean follow-up time ranged from 6 weeks to 14.8 months. The authors concluded that the application of peritoneal removal vaginoplasty in gender-affirming surgery is promising and novel; however, there is a lack of data. These investigators stated that further research and longer-term data are needed to investigate the safety and efficacy of this technique, including stabilization of vaginal depth, subsequent morbidity, and complications. Patients seeking this surgery abroad should be informed of the potential difficulties they may face.

Urethral complications and outcomes in transgender men

Hu et al. (2022) found that urologic problems such as urethral fistulas and strictures are among the most common complications after phalloplasty. Although many studies have reported successful phalloplasty and urethral reconstruction with reliable results in transgender men; So far, no method has been standardized. These investigators examined reports of urological complications and outcomes in transgender men in relation to different types of urethral reconstruction. They conducted a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies on phalloplasty in transgender people. Data on different phallic urethral techniques, urethral complications and outcomes were collected and analyzed using the random effects model. A total of 21 studies (1566 patients) were included: 8 studies (1061 patients) on tube-in-tube, 9 studies (273 patients) on prelaminated flap, and 6 studies (221 patients) on second flap compared to tube-tube. tube technique, the pre-laminated flap was associated with a significantly higher rate of urethral strictures/strictures, however, there was no difference between the pre-laminated flap and the second flap technique, the combined rate of urethral fistulas or strictures was 48.9 %. , ability to urinate while standing rate 91.5%, frequency of occurrence of tactile or erogenous sensations 88%, prosthesis complication rate 27.9%, and patient-reported satisfaction rate result was 90.5%. The authors concluded that urethral reconstruction with a prelaminated flap was associated with a significantly higher rate of urethral strictures and a greater need for revision surgery than when a skin flap was used. In general, most patients were able to urinate standing up and were satisfied with the results.

Adjunct

DSM 5 criteria for gender dysphoria in adults and adolescents

1. A significant mismatch between experienced/expressed gender and assigned gender of at least 6 months' duration, manifested by two or more of the following:

   1. A marked incongruity between experienced/expressed sex and primary and/or secondary sexual characteristics (or, in the case of young adolescents, expected secondary sexual characteristics)
   2. A strong desire to get rid of primary and/or secondary sexual characteristics due to a marked mismatch with the experienced/expressed sex (or, in young adolescents, a desire to prevent the development of expected secondary sexual characteristics)
   3. A strong desire for the primary and/or secondary sexual characteristics of the opposite sex
   4. A strong desire to be the opposite gender (or an alternate gender other than the assigned gender)
   5. A strong desire to be treated as the opposite gender (or as an alternate gender other than the assigned gender)
   6. A strong belief that one has the typical feelings and reactions of the opposite sex (or of an opposite sex other than the assigned sex).

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

No minimum length of relationship with a psychologist is required. It is up to the professional to determine how long it takes to properly write a letter of recommendation. A common period is three months, but there is significant variation in both directions.

Evaluation of candidacy for gender affirming surgery by a psychiatrist is covered under the member's medical benefit, except when the services of a psychiatrist are required to evaluate and treat a mental health problem. In this case, the psychiatrist's services are covered under the member's behavioral health benefits. Review benefit plan descriptions.

Characteristics of a Qualified Health Professional (from SOC-8)

Qualifications of Mental Health Professionals Evaluating Transgender and Gender-Specific Adults for Physical Treatment (from WPATH SOC-8):

1. Be accredited by their statutory body and have at least a master's degree or equivalent training in a clinical area relevant to this role, awarded by a nationally accredited statutory body.
2. They are able to recognize coexisting mental health or other psychosocial problems and distinguish them from dysphoria, incongruity, and gender diversity.
3. They are able to assess the ability to consent to treatment.
4. Have experience or be trained to assess clinical aspects of gender dysphoria, incongruity, and diversity.
5. Complete higher education in healthcare related to gender dysphoria, incongruity, and diversity.
6. Reach professionals in all disciplines of transgender health for advice and referral on behalf of gender-balanced adults seeking gender-affirming treatment when needed.

Ratings of Surgeons Performing Gender Affirming Surgical Procedures (from WPATH SOC-8):

1. Documented training and supervision in gender affirmation procedures;
2. maintain an active practice in gender-affirming surgical procedures;
3. Knowledge of gender identities and forms of expression;
4. Continuing education in the field of gender affirming surgery;
5. Follow-up of surgical results.

Characteristics of health professionals who work with mixed-gender youth:

1. They are accredited by their statutory body and have a postgraduate degree or equivalent in a clinical area relevant to this role, awarded by a nationally accredited statutory body.
2. Receive theoretical and evidence-based training and build expertise in general mental health for children, adolescents, and families across the developmental spectrum.
3. Receive training and experience in gender identity development, gender diversity in children and adolescents, ability to assess capacity for consent/agreement, and general knowledge of gender diversity throughout life.
4. Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or partner with a developmental disability expert when working with gender mismatched autistic/neurodivergent adolescents.
5. Continue to engage in professional development in all areas relevant to gender-biased children, youth, and families.

references