Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

BACKGROUND: The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. OBJECTIVES: This study investigates insurance requirements for referral letters and their negative impact on care. MATERIALS AND METHODS: We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. RESULTS: Nearly all reviewed U.S. health insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. DISCUSSION AND CONCLUSION: Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.

Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance.

OBJECTIVE: To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. STUDY DESIGN: Systematic review. SETTING: Policy review of US medical insurance companies. METHODS: State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. RESULTS: Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. CONCLUSION: While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. LEVEL OF EVIDENCE: Level V.

Oncologic Considerations for Safe Gender-Affirming Mastectomy: Preoperative Imaging, Pathologic Evaluation, Counseling, and Long-Term Screening.

SUMMARY: There remain significant gaps in the evidence-based care of patients undergoing gender-affirming mastectomy with regard to implications for breast cancer development and screening. The current clinical evidence does not demonstrate an increased risk of breast cancer secondary to testosterone therapy in transgender patients. Gender-affirmation mastectomy techniques vary significantly with regard to the amount of residual breast tissue left behind, which has unknown implications for the incidence of postoperative breast cancer and need for screening. Subcutaneous mastectomy should aim to remove all gross breast parenchyma, although this is limited in certain techniques. Tissue specimens should also be routinely sent for pathologic analysis. Several cases of incidental breast cancer after subcutaneous mastectomy have been described. There is little evidence on the need for or types of postoperative cancer screening. Chest awareness is an important concept for patients that have undergone subcutaneous mastectomies, as clinical examination remains the most common reported method of postmastectomy malignancy detection. In patients with greater known retained breast tissue, such as those with circumareolar or pedicled techniques, consideration may be given to alternative imaging modalities, although the efficacy and cost-utility of these techniques must still be proven. Preoperative patient counseling on the risk of breast cancer after gender-affirming mastectomy in addition to the unknown implications of residual breast tissue and long-term androgen exposure is critical. Patient awareness and education play an important role in shared decision-making, as further research is needed to define standards of medical and oncologic care in this population.

Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management.

During the past 10 years, academic publications that address facial feminization surgery have largely examined the technical aspects of the different surgical procedures involved and clinical evaluations of postoperative results. This Special Topic article focuses on aspects that are underdeveloped to date but useful with regard to taking the correct therapeutic approach to transgender patients who are candidates for facial gender confirmation surgery. The authors propose a protocolized sequence, from the clinical evaluation to the postoperative period, based on a sample size of more than 1300 trans feminine patients, offering facial gender confirmation surgery specialists standardized guidelines to handle their patients' needs in a way that is both objective and reproducible.

A Review of Insurance Coverage of Gender-Affirming Genital Surgery.

BACKGROUND: Despite the multiple benefits of gender-affirming surgery for treatment of gender dysphoria, research shows that barriers to care still exist. Third-party payers play a pivotal role in enabling access to transition-related care. The authors assessed insurance coverage of genital reconstructive ("bottom") surgery and evaluated the differences between policy criteria and international standards of care. METHODS: A cross-sectional analysis of insurance policies for coverage of bottom surgery was conducted. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and telephone interviews were performed to identify the policies and coverage status. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Fifty-seven insurers met inclusion criteria. Almost one in 10 providers did not hold a favorable policy for bottom surgery. Of the 52 insurers who provided coverage, 17 percent held criteria that matched international recommendations. No single criterion was universally required by insurers. Minimum age and definition of gender dysphoria were the requirements with most variation across policies. Almost one in five insurers used proof of legal name change as a coverage requirement. Ten percent would provide coverage for fertility preservation, while 17 percent would cover reversal of the procedure. CONCLUSIONS: Despite the medical necessity, legislative mandates, and economic benefits, global provision of gender-affirming genital surgery is not in place. Furthermore, there is variable adherence to international standards of care. Use of surplus criteria, such as legal name change, may act as an additional barrier to care even when insurance coverage is provided.

Systematic review of studies reporting perioperative and functional outcomes following male-to-female gender assignment surgery (MtoF GAS): a call for standardization in data reporting.

INTRODUCTION: The aim of this study is to accomplish a systematic review on the surgical techniques available for male-to-female gender assignment surgery (MtoF GAS) published in the last 15 years, from January 2002 to May 2017, assessing advantages and disadvantages. EVIDENCE ACQUISITION: A specific search on MEDLINE, Scopus and Web of Science databases included vaginoplasty for gender exchange. Preoperative (age, gender, body mass index, prior surgery), intraoperative (mean operating time, intraoperative complications, transfusion rate, conversion rate), postoperative (hospital stays, readmission rate, early and late complication rate), postoperative sexual activity, subjective satisfaction, vaginal depth, and long-term outcomes (vaginal stenosis, prolapse, dyspareunia and labial abscess) data of vaginoplasty for sexual exchange were collected. 29 articles were included (2.402 patients). EVIDENCE SYNTHESIS: Out of the 29 papers, 19 studies assessed penile skin inversion and 10 evaluated intestinal vaginoplasty. No comparative studies were found. Penile skin inversion vaginoplasty reported slightly shorter operative time compared to intestinal vaginoplasty (109-420 vs 145-420 minutes). Intraoperative complications for penile skin inversion vaginoplasty not exceeded an incidence of 10%. No significant differences in terms of postoperative complications or hospitalization time were reported. Intestinal vaginoplasty provides a deeper neovagina. Female Sexual Function Index score was significantly higher in patients undergoing intestinal vaginoplasty. CONCLUSIONS: A standardized data collection may allow a better understanding of effectiveness and outcomes of different techniques.

Preparing for Facial Feminization Surgery: Timing.

Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

Current Concepts in Feminizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

Identifying policies, financial support and professional regulations for medically necessary hair removal

Hair removal is a necessary pre-surgical procedure prior to performing genital gender-affirming surgeries such as vaginoplasty and phalloplasty. For example, a recent literature review on the topic notes that the use of hairbearing skin in gender-affirming surgical procedures can result in post-operative intra-vaginal and intra-urethral hair growth, which can lead to complications and lower satisfaction with the surgery.

Gynecologic care for transgender youth.

PURPOSE OF REVIEW: To provide an overview of the care of the adolescent transgender patient with regard to the guidelines and recommendations that currently exist, and to review the role of the clinician caring for transgender youth. RECENT FINDINGS: The World Professional Association for Transgender Health and the Endocrine Society continue to provide comprehensive guidelines for the care of adolescent transgender patients. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach should be taken with important ethical principles in mind. Cross-sex steroid use places transgender adolescents at risk for metabolic disorders, and careful surveillance is necessary. In addition, transgender teens are at high risk for depression, anxiety and suicidality and have been shown to engage in more high-risk behaviors compared with their nontransgender heterosexual counterparts. SUMMARY: Clinicians who care for adolescents can play an important role in the counseling, screening, health maintenance and support of their patients through the transition process.

[Genital reassignment surgery in male-to-female transsexuals: do we have guidelines or standards?]. / Operative Genitalangleichung bei Mann-zu-Frau-Transsexualität: Gibt es Leitlinien oder Standards?

BACKGROUND: In 2011 the WPATH (World Professional Association for Transgender Health) published the 7th version of their "Standards of Care" for diagnosis and treatment of transsexual people. In face of further recent peer-reviewed reports of experienced centres on surgical sex reassignment it should be examined whether or not genital sex reassignment in male-to-female transsexuals actually can be based on evidence-based guidelines or standards. RESULTS: The indication for surgery is widely standardised and evidence-based. Most critical steps of the operation are also founded on grade B recommendations. Most experienced authors rely on penoscrotal pedicled flaps for neovaginal lining. The topic of ideal reconstruction of the vulva, especially the clitoro-labial complex is still a field of debate. Due to the high frequency of further corrective surgeries which exceeds 50% in most experienced centres, some authors prefer a primary 2-step procedure for genital reassignment. CONCLUSIONS: The indication and principal operative steps in surgical genital reassignment in male-to-female patients rely on evidence-based recommendations. By respecting these recommendations subjective success rates of over 80% can be expected.

Propuesta de plan de cuidados para pacientes con cirugía de reasignación sexual / Proposal of a care plan for patients with sex reassignment surgery

Introducción: independientemente del nivel científicotécnico del médico que realiza la cirugía, de los recursos materiales de que se dispongan y de la tecnología de punta utilizada, no es posible una intervención quirúrgica exitosa sin la actuación de profesionales del cuidado competentes, con un profundo contenido humano y ético.Objetivo: proponer un plan de cuidados para pacientes con cirugía de reasignación sexual, integrando la teoría de las 14 necesidades básicas de Virginia Henderson y el Modelo de la adaptación de Sor Callista Roy.Métodos: se realizó un estudio descriptivo de corte transversal en una institución de salud del tercer nivel de atención durante el año 2011. El universo de estudio quedó constituido por personas de ambos sexos a las que se les realizó cirugía de reasignación sexual durante los años 2008 al 2011. Se utilizó el método observacional documental de historias clínicas, de donde se obtuvo la información necesaria. Las variables de estudio fueron necesidades humanas afectadas las que se evaluaron según la teoría de las 14 necesidades básicas de Virginia Henderson. El plan de cuidados se diseñó por la taxonomía diagnóstica de la North American Nursing Diagnosis Association (NANDA) y el Modelo de la adaptación de Sor Callista Roy. Resultados: las 14 necesidades básicas se encontraron afectadas en todas las personas estudiadas la valoración global y focalizada realizada generaron los 10 diagnósticos de enfermería precisos, igual número de objetivos y 64 acciones de enfermería con los que se cuidaron los pacientes durante el perioperatorio. Conclusiones: se concluyó que la aplicación en la práctica clínica de las teorías de Virginia Henderson y Sor Callista Roy orientó los cuidados y sustentaron la calidad de la atención de enfermería brindada a los pacientes con tratamiento quirúrgico de reasignación sexual(AU)

Background: regardless the scientific and technological level of the doctor that performs surgery, the material resources they have and the technology used, a successful surgical intervention is not possible without the performance of competent care professionals, with a deep human and ethical content. Objective: to propose a care plan for patients with sex reassignment surgery, integrating the theory of Virginia Henderson's 14 fundamental needs and Callista Roy's Adaptation Model. Methods: a descriptive cross-sectional study was conducted in a tertiary health institution during the year 2011. The study universe was composed of persons of both sexes to whom sex reassignment surgery was performed during the years 2008 and 2011. The documentary observational method of clinical histories was used, from which the necessary information was obtained. The study variables were affected human needs, which were evaluated according to Virginia Henderson's 14 fundamental needs. The care plan was designed by the diagnostic taxonomy of the North American Nursing Diagnosis Association (NANDA) and the Callista Roy's Adaptation Model. Results: the 14 fundamental needs were affected in all the persons under study; the global focused assessment conducted reported the 10 accurate nursing diagnosis, the same number of objectives and 64 nursing actions carried out for the care of the patients during the perioperative period. Conclusions: it was concluded that the application of Virginia Henderson's 14 fundamental needs and Callista Roy's Adaptation Model in clinical practice, oriented the care and sustained the quality of nursing attention given to patients with sex reassignment surgical treatment(AU)

Coordination of healthcare for transsexual persons: a multidisciplinary approach.

PURPOSE OF REVIEW: To describe the experience in Spain concerning the public healthcare for transsexual persons using a multidisciplinary approach and to review the relevant literature. Treatment includes social and psychological support, cross-hormone treatment, and sex reassignment surgeries. Although the recommendations of The World Professional Association for Transgender Health are used as guidelines, the application of these standards of care varies considerably, probably because of specific clinical and country factors. RECENT FINDINGS: The sex reassignment process is complex and requires not only coordination of multiple procedures, but also lifetime follow-up of transsexual individuals. Gender units must provide high-quality services, been essential the principle of accessibility to resources together with a protocolized follow-up and anticipation of secondary effects from the clinical surgical treatment. Two recent challenges are juvenile gender dysphoria and gender variants, which increasingly consult professionals. SUMMARY: Transsexualism affects all adaptive physical and psychosocial aspects of a person. As diagnosis is based only on the history and personal perceptions, a broad social debate exists about the need for treatment financed by the public health systems. Some countries restrict the care to transsexuals with private medical policies. Thus, coordination of care also requires participation of the family and associations, with continuous information to the health authorities, the judiciary, and the media of each country.

Gender monitoring and gender reassignment of children and adolescents with a somatic disorder of sex development.

Individuals born with a somatic disorder of sex development (DSD) have high rates of gender-atypical behavior, gender uncertainty, gender dysphoria, and patient-initiated gender change in childhood, adolescence,and adulthood. This article addresses the issues a mental health services provider has to consider in evaluating and assisting such patients and provides examples of assessment-method batteries. To date, the World Professional Association for Transgender Health's Standards of Care, 6th version, for non-DSD patients with gender dysphoria, may be cautiously used for guidance, taking into account the considerable differences in presentation and medical context between gender dysphoric patients with and without a DSD.

Guidelines for pubertal suspension and gender reassignment for transgender adolescents.

Pubertal suppression at Tanner stage 2 should be considered in adolescents with persistent gender identity disorder (GID). Issues related to achievement of adult height, timing of initiating sex steroid treatment, future fertility options, preventing uterine bleeding, and required modifications of genital surgery remain concerns. Concerns have been raised about altering neuropsychological development during cessation of puberty and reinitiation of puberty by the sex steroid opposite those determined by genetic sex. Collaborative assessment and treatment of dysphoric adolescents with persistent GID resolves these concerns and deepens our understanding of gender development.