gender reassignment surgery codes

Gender Affirming Surgery

Clinical Policy Bulletins
Medical Clinical Policy Bulletins

Number: 0615

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. Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.”

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).

The criterion noted above for some types of genital surgeries 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 (Coleman, et al., 2022).

It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively. On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given. A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school.

Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.

Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health. These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York. Through 2009, a total 192 MTF and 50 FTM transgender persons were seen. These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability. Mental health and psychiatric problems were inversely correlated with age at presentation. The prevalence of gender affirming surgery was low (31 % for MTF). The number of persons seeking treatment has increased substantially in recent years. Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages. The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency. The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers. They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.

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

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved.

Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast. Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed. A full-thickness skin graft is taken from the right groin to reconstruct the areola. The right groin donor site is closed primarily in layers.”

The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple. Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, 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 nor can safely undergo vaginal canal creation. These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice. Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty. The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty. The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only.

Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery

Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts. Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery. The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B. These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5% in group B expressed satisfaction. The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7 % of patients had satisfaction with sexual intercourse. They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. Level of Evidence = IV. These preliminary findings need to be validated by well-designed studies.

Pitch-Raising Surgery in Transfeminine Persons

Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals. These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery. They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total. Objectively, a substantial rise in post-operative fundamental frequency was identified. Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality. The majority of patients appeared satisfied with the outcome. However, none of the studies used a control group and randomization process. The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design.

Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice. These researchers conducted a comprehensive review of the voice literature. Publications were identified by searching 6 electronic databases and bibliographies of relevant articles. A total of 22 publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people. The quality of the evidence was appraised. The extent and quality of studies investigating trans-masculine people's voice function was found to be limited. There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality. The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Facial Feminization Surgery

Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth. The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity. Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation. Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling. A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures. Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs. Most facial feminization surgery procedures could be safely completed in 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 following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome. The level of evidence of this study was IV.

Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. These researchers appraised the current facial feminization surgery literature. They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients. These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.

In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck. 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 U.S. were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical 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 prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % 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; 93 % 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. The authors concluded that 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. Level of Evidence = V.

Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., 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 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization. Still, the primary area of focus for facial feminization is generally the upper 1/3. Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty". While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration. Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties. Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus. This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus. Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill. Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge. An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors.

Forehead Feminization Cranioplasty

Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years. However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs). In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL. They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO. The search terms included variations of forehead setback/FFC. Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched. Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted. Main outcomes and measures included complications and complication rate observed following FFC. Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM. A total of 10 articles describing FFC were included, entailing 673 patients. The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies. The authors concluded that complications following FFC were rare and infrequently required reoperation. Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed. Level of Evidence = III.

Hand Feminization and Masculinization

Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care. They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population. From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation. The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand. These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. Level of Evidence = III.

Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery

Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery. Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery. These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement. A search was performed in OVID Medline, Embase, Willey Online Library and PubMed. Specialty-related journals, grey literature and reference lists of relevant articles were manually searched. From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence. Healing times were poorly reported or often not mentioned. A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction. Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications. Average follow-up ranged from 6 weeks to 14.8 months. The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data. These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications. Patients seeking this surgery overseas should be informed of the potential difficulties they may face.

Urethral Complications and Outcomes in Transgender Men

Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty. Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized. These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction. They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals. Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model. A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap, and 6 studies (221 patients) on "second flap". Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques. For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %. The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap. Overall, most patients were able to void while standing and were satisfied with the outcomes.

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

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

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
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)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

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

There is no minimum duration of relationship required with mental health professional. It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written. A common period of time is three months, but there is significant variation in both directions.

Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Characteristics of a Qualified Health Professionals (From SOC-8)

Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):

Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
Are able to assess capacity to consent for treatment.
Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required.

Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8):

Training and documented supervision in gender-affirming procedures;
Maintenance of an active practice in gender-affirming surgical procedures;
Knowledge about gender diverse identities and expressions;
Continuing education in the field of gender-affirmation surgery;
Tracking of surgical outcomes.

Characteristics of health care professionals working with gender diverse adolescents:

Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

The above policy is based on the following references:

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Colebunders B, Brondeel S, D'Arpa S, et al. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5(1):103-109.
Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend. 2022; 23 sup1:S1-S259.
Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011.
Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232.
Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1).
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.
Eggerstedt M, Hong YS, Wakefield CJ, et al. Setbacks in forehead feminization cranioplasty: A systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749.
Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: Single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745.
Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.
Gorbea E, Gidumal S, Kozato A, et al. Insurance coverage of facial gender affirmation surgery: A review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. 2021;165(6):791-797.
Guan X, Bardawil E, Liu J, Kho R. Transvaginal natural orifice transluminal endoscopic surgery as a rescue for total vaginal hysterectomy. J Minim Invasive Gynecol. 2018;25(7):1135-1136.
Hembree et al. Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154.
Hohman MH, Teixeira J. Transgender surgery of the head and neck. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; February 27, 2022.
Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12(6):1499-1512.
Hu C-H, Chang C-J, Wang S-W, Chang K-V. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24.
Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med. 2018;15(6):902-906.
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Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2016;106 (1):74-79.
Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145.
Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315.
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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.
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Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: Patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448..
Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4).
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Gender Dysphoria and Gender Reassignment Procedures

Consistently stating he is really a girl when he has the physical characteristics of a boy or that she is really a boy with the physical characteristics of a girl
Strong preference for friends of the same sex that he/she identifies with
Having an aversion to clothes, toys, and games typical for boys or girls
Refusing to urinate in the position that other boys or girls do
Stating he/she wants the genitals of the other sex instead of the genitals that he/she has
Believing he/she will grow up to be a person of the sex he/she identifies with even though currently he/she has the physical characteristics of the other gender
Experiencing substantial distress about the changes his/her body goes through during puberty
Believing that his/her gender is not in line with his/her body
Loathing of his/her genitals, which may cause an avoidance to taking showers, changing clothes, or having intercourse so that he/she won't have to look at or touch his/her genitals
Extreme desire to have the genitals gone
F64.0 - Gender dysphoria in adolescents and adults
F64.1 - Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery)
F64.2 - Gender dysphoria in children
F64.8 - Other specified gender dysphoria
F64.9 - Gender dysphoria, unspecified
Written psychological assessment from one or more qualified behavioral health providers experienced in gender dysphoria treatment who has assessed the patient and documented all of the following:
The same requirements as listed above for breast surgery
Completed 12 months or more of successful, ongoing full-time, real-life experience in the desired gender
Completed 12 months of ongoing cross-sex hormone therapy appropriate for the desired gender, unless medically contraindicated
Treatment plan, including ongoing followup and care by a qualified behavioral health provider experienced in treating gender dysphoria
Penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
Urethral opening is moved to a position similar to that of a female.
Vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split-thickness grafts.
Labia are created out of skin from the scrotum and adjacent tissue.
Stent or obturator is usually left in place in the newly created vagina for three weeks or longer.
Portions of the clitoris and adjacent skin are used.
Prostheses are often placed in the penis to make a sexually functional organ.
Prosthetic testicles are implanted in the scrotum.
Vagina is closed or removed.
Liposuction (fat removal)
Rhinoplasty (nose reshaping)
Rhytidectomy (face lift)
Blepharoplasty (removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat)
Hair removal or hair transplantation
Facial feminizing (such as facial bone reduction)
Chin augmentation (chin reshaping or chin enhancing)
Collagen injections
Lip reduction/enhancement (lip size decrease or enlargement)
Cricothyroid approximation (voice modification)
Trachea shave/reduction thyroid chondroplasty (thyroid cartilage reduction)
Laryngoplasty (laryngeal reshaping framework - voice modification surgery)
Mastopexy (breast lift)

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Gender Dysphoria and Gender Reassignment Surgery

Tracking information, description information.

Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

A. General

Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity.

B. Nationally Covered Indications

C. Nationally Non-Covered Indications

D. Other

The Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

(This policy last reviewed August 2016.)

Transmittal Information

03/2017 - Effective Date: 08/30/2016. Implementation Date: 04/04/2017. ( TN 194 ) (CR9981)

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Original Consideration for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N)

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

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This page displays your requested National Coverage Determination (NCD). The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. National Coverage Determinations (NCDs) are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service.

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NCDs are developed and published by CMS and apply to all states. NCDs are made through an evidence-based process, with opportunities for public participation. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare Administrative Contractors (MACs) are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, an item or service may be covered at the discretion of the MAC based on a Local Coverage Determination (LCD). LCDs cannot contradict NCDs, but exist to clarify an NCD or address common coverage issues. Prior to implementation of an NCD, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to claims-processing contractors. That issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. An NCD becomes effective as of the date of the decision memorandum.

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Hong Kong Amends Its Surgery Requirements to Change Gender Markers on IDs

View of Immigration Tower in Wan Chai. 12OCT17 SCMP/ Roy Issa

H ong Kong no longer requires transgender people to undergo full gender-affirming surgery to change their legal gender markers in their IDs, more than a year after the Chinese enclave’s top court called the requirement unconstitutional.

The government announced the change on Wednesday, “having prudently considered the objective of the policy, relevant legal and medical advice, as well as drawing reference from the relevant practices overseas.”

Under the new rules, Hong Kong residents who have not undergone full sex reassignment surgery [SRS] who want to have their gender marker on their ID changed still must have completed select surgical treatment to modify their sexual characteristics—removal of the breasts for transgender men, removal of the penis and testes for transgender women—along with medical documentation. Previous guidelines required the removal of the uterus and ovaries or the construction of a penis or “some form” of it for female-to-male transition, and the removal of the penis and testes and the construction of a vagina for male-to-female transition.

“We are still concerned about the heavy emphasis on sex reassignment surgeries being a requirement,” Wong Hiu-chong, the lawyer for transgender activist Henry Tse , whose case led to the policy change, told TIME. “SRS can be life threatening.”

Those who wish to change their gender markers must also statutorily declare that they have gender dysphoria—the medical term for the psychological distress a person feels when their gender identity does not match with their assigned sex at birth—and have lived as the opposite sex for at least two years before their application. They must also show proof of receiving hormonal treatment throughout the previous two years, and will be subjected to random blood tests to check their hormonal profile.

“Our clients have waited a very long time for such an unconstitutional policy to be revised, and for them, the wait has been painful,” Wong said in a statement. She also questioned the need for blood tests, calling this requirement, among others that remain for gender marker changes, “potentially discriminatory” as it does not apply to other Hong Kong ID card holders.

A government spokesperson clarified in the announcement that the gender marker change will only apply to the Hong Kong Identity Card and that “the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law. It does not affect any other policies of the Government or the handling of any other gender-related matters under the law in Hong Kong or relevant legal procedures.”

The policy change comes years after Tse filed a case in 2017 to question the full gender-affirming surgery requirement. Despite the city’s Court of Final Appeal issuing a ruling deeming the requirement unconstitutional in February 2023, implementation of the ruling was long-delayed, which Tse also challenged . The ruling said “such surgical procedures are at the most invasive end of the treatment spectrum” and that “full SRS is not medically required by many transgender persons whose gender dysphoria has been effectively treated.”

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Critics blast NY’s proposed ‘Equal Rights Amendment’ they say strips parents of their rights over kids’ transgender surgery

C ritics are raging against New York’s proposed “Equal Rights Amendment,” claiming the Nov. 5 ballot measure could curb the rights of parents when it comes to allowing minors to undergo gender reassignment surgery.

New York voters don’t yet know much about the particulars of the ERA, which could codify abortion rights in the state constitution — advanced by Gov. Kathy Hochul and Democrats who run the state legislature.

The broad language of the proposal — dubbed Proposition One — has sparked a fierce debate over what could happen if it gets passed, with opponents claiming it’ll lead to kids possibly being able to get serious medical procedures without their parents’ OK and allow transgender females to compete in women’s sports.

“Proposition One would strip the legal rights of parents with school age children to know about crucially important things happening with their kids, including controversial gender transformation procedures” the Coalition to Protect Kids said in a statement.

“Schools would be required to permit biological males to compete on girls’ sports teams if voters approve this amendment.”

The proposal asks voters whether they support or oppose adding language to the constitution that people cannot be denied rights based on their “ethnicity, national origin, age, and disability” or “sex, including sexual orientation, gender identity, gender expression, pregnancy, pregnancy outcomes, and reproductive healthcare and autonomy.”

Coalition to Protect Kids NY Executive Director Greg Garvey said the ERA should instead be called “The Parent Replacement Act,” because it “opens the floodgates” for the government wielding more authority over children than their parents on some of the most important decisions of their lives.

“Any decent lawyer will take one look at the Proposition One language and say, ‘you’ve got to be kidding me,’” said Garvey.

“This ballot initiative is written so broadly and so poorly that it could cause irreparable harm to children and families,” he added.

“Governor Hochul and her woke Albany colleagues have a lot of explaining to do.”

The group’s website includes a video saying a school could help a 7-year-old girl “try life as a boy” and help her transition without her mother “ever knowing” under the amendment, adding, “Do you think that’s OK?”

The Coalition to Protect Kids also claims that laws that determine the legal age to purchase and/or consume alcohol or cannabis, elder abuse and statutory rape could all be weakened because they might arguably “‘discriminate’ based on age.”

The group New Yorkers for Equal Rights denied that the amendment strips parents of their rights.

“These claims simply aren’t true. This amendment is about making sure our fundamental rights and reproductive freedoms are protected and never at risk of becoming a political football,” said Sasha Ahuja, campaign director of New Yorkers for Equal Rights.

The pro-amendment group, in a statement Monday, also said, “If passed, the NY ERA would provide the most comprehensive list of protected categories of any state in the country — safeguarding New Yorkers’ rights, as well as serving as a model for other states.”

Members of the pro-ERA group include 1199SEIU United Healthcare Workers East, Planned Parenthood, North Star, New York Immigration Coalition, the Civil Liberties Union, NEW Pride Agenda, National Institute for Reproductive Health Action Fund, NAACP, Make the Road New York and New York State United Teachers.

New York already has among the strongest abortion laws in the country and long been a pro-choice, with critics questioning whether such a controversial issue belongs in the constitution.

“It’s an ‘anything goes’ amendment,” said state Conservative Party chairman Gerard Kassar, whose party will campaign against the ERA.

He also said Democrats are looking to “change the conversation” away from problems they own — such as the migrant crisis and crime.

A lawsuit has been filed in Livingston County Supreme Court claiming that the legislature approved the proposed amendment going to the voters before getting a legal opinion from state Attorney General Letitia James’ Office.

There’s also been a recent public backlash in New York against permitting trans females from competing in women’s sports, leading to a controversial ban in some sporting venues in Nassau County.

Even one of the world’s most famous transgender females — Caitlyn Jenner — the former 1976 Olympic decathlon champion as Bruce Jenner — is opposed.

Additional reporting by Vaughn Golden

Critics blast NY’s proposed ‘Equal Rights Amendment’ they say strips parents of their rights over kids’ transgender surgery

Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery: Study

Attempted suicide rates among people who identified as transgender more than doubled after receiving a vaginoplasty, according to a peer-reviewed study published in The Journal of Urology.

Researchers found the rates of psychiatric emergencies were high both before and after gender-altering surgery, with similar overall rates in both groups. However, suicide attempts were markedly higher in those who received vaginoplasties.

“In fact, our observed rate of suicide attempts in the phalloplasty group is actually similar to the general population, while the vaginoplasty group’s rate is more than double that of the general population,” the study authors wrote.

Among the 869 patients who underwent vaginoplasty, 38 patients attempted suicide—with nine attempts before surgery, 25 after surgery, and four attempts before and after surgery. Researchers found a 1.5 percent overall risk of suicide before vaginoplasty and a 3.3 percent risk of suicide after the procedure. Almost 3 percent of those who attempted suicide after undergoing vaginoplasty did not present with a risk of suicide prior to surgery.

Among the 357 biologically female patients who underwent phalloplasty, there were six suicide attempts with a 0.8 percent risk of suicide before and after surgery.

‘Affirmation at All Costs’: What Internal Files Reveal About Transgender Care

Overall, the proportion of those who experienced an emergency room and inpatient psychiatric encounter outside of suicide attempts was similar between the vaginoplasty and phalloplasty groups. Approximately 22.2 percent and 20.7 percent of patients, respectively, experienced at least one psychiatric encounter.

Suicide Rate 19-Fold Higher

“It’s hard to refute this paper because it’s a longitudinal study,” Dr. Oliva said. “In Sweden, everyone is in a database, and through diagnosis codes, they’re able to follow what happens to every citizen in terms of their medical history. They waited more than 10 years after people had surgery and found that death by suicide had an adjusted hazard ratio of 19.1.”

Surgical Procedures

A penial inversion is the most commonly performed procedure where the skin is removed from the penis and inverted to form a pouch that is inserted into the vaginal cavity created between the urethra and the rectum. Surgeons then partially remove, shorten, and reposition the urethra and create a labia majora, labia minora, and clitoris.

Another surgical method involves using a robotic system that enables surgeons to reach into the body through a small incision in the belly button to create a vaginal canal. The type of vaginoplasty performed varies among patients. For example, younger patients who have never experienced puberty may have insufficient penile skin to do a standard penile inversion.

Vaginoplasty Associated With Serious Risks

“For cosmetic surgery, if the complication rate was more than 2 percent to 3 percent, you wouldn’t have any patients,” Dr. Oliva told The Epoch Times. “These are very high percentage rates that we just accept.”

Dr. Oliva said complications with these surgical procedures are very high and he thinks this is why suicide rates are so high.

“People think this is going to solve the problem and it doesn’t,” he said.

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IMAGES

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Transgender Surgery Cost Infographic: Female To Male Sex Change Operation
Transgender Surgery Cost Infographic: Male To Female Sex Change Operation
Surgical Reconstruction for Male-to-Female Sex Reassignment
Document Your Gender Reassignment Surgery
Gender Dysphoria and Gender Reassignment Procedures

VIDEO

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COMMENTS

Billing and Coding: Gender Reassignment Services for Gender Dysphoria
The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social ...
Clear Up Misconceptions About Transgender Coding
Use code Z87.890 Personal history of sex reassignment for sex reassignment surgery (SRS) status. Procedural Coding. Although there is no specific procedure code for people diagnosed with gender dysphoria who are choosing to transition, there are two CPT® codes that pertain to intersex surgery: 55970 Intersex surgery; male to female
PDF Clinical Review Criteria Related to Gender Reassignment Surgery
Gender reassignment surgery may also be referred to as gender-affirming or gender-confirmation ... CPT®* Codes Description 55970† Intersex surgery; male to female † Includes only the following procedures: 17380 Electrolysis epilation, each 30 minutes 19316 Mastopexy 19325 ...
PDF GENDER REASSIGNMENT SURGERY MODEL NCD
GENDER REASSIGNMENT SURGERY MODEL NCD I. Indications, Limitations of Coverage and/or Medical Necessity 1 II. Documentation Requirements 4 III. Providers of Gender Reassignment Surgery 5 IV. Common CPT Codes 5 V. ICD-9 and ICD-10 Codes 8 VI. References 9 Written by Transgender Medicine Model NCD Working Group. Contact: Anand Kalra, Transgender ...
Gender Affirming Surgery
In mastectomy for gender reassignment, the nipple areola complex typically can be preserved. Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance.
PDF Gender Dysphoria and Gender Reassignment Surgery (NCD 140.9)
Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity. Guidelines NCD 140.9 Gender Dysphoria and Gender Reassignment Surgery states, the Centers for Medicare & Medicaid Services (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery.
PDF Gender Dysphoria Treatment
details. In addition, coverage for treatment of gender dysphoria, including gender reassignment surgery and related services may be governed by state and/or federal mandates. 1. 2. Some states require coverage of health services specific to treatment of gender ... to CPT 19318. Thus, these two codes cannot be billed together for "mastectomy ...
From Registration to Claims Billing, Overcome Gender Identity ...
Use additional code to identify sex reassignment status (Z87.890) Excludes1: gender identity disorder in childhood (F64.2) ... Gender reassignment surgery is intended to be a permanent change between an individual's gender identity and physical appearance — it is not easily reversible. A careful and accurate diagnosis is essential for ...
Gender Dysphoria and Gender Reassignment Procedures
ICD-10-CM Diagnosis Codes. Once the above criteria are met, codes from F64.0-F64.9 may be used to describe the type of gender dysphoria diagnosed. F64.0 - Gender dysphoria in adolescents and adults. F64.1 - Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery)
PDF Gender Reassignment Surgery for Gender Dysphoria
The term gender affirming surgery, also known as gender reassignment surgery, may be used to mean either the reconstruction of male or female genitals, specifically, or the reshaping, by ... (AAPC) gives guidance on coding reduction mammaplasty for gender affirmation. Per AMA, CPT code 19303 (mastectomy) is to be used for the treatment or ...
National Estimates of Gender-Affirming Surgery in the US
ICD-10 and CPT Codes of Gender-Affirming Surgery. eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS. ... 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 ...
PDF Gender Reassignment Surgery
Description of Procedure or Service. Gender reassignment surgery (also known as genital reconstruction surgery, sex affirmation surgery, or sex-change operation) is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex.
NCD
In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862 (a) (1) (A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis. (This policy last reviewed August 2016.)
PDF Gender Assignment Surgery and Gender Reassignment Surgery with Related
Gender Assignment Surgery and Gender Reassignment Surgery with Related Services /SUR717.001 Page 1 Policy Number SUR717.001 Policy Effective Date 05/01/2023 ... surgery. A more appropriate code to report this service is 19318, as it includes the work that is necessary to create a more aesthetically pleasing result.
PDF Gender Dysphoria Treatment
experienced in treating Gender Dysphoria who has independentlyassessed the individual o Documentation the member has completed at least 12 months of successful continuous full-time real-life experience in identified gender *For code descriptions, refer to the . Applicable Codes. section. Definitions . Gender Dysphoria in Adolescents and Adults
Coding Question: Coding for the Transgender Process Services
Answer. You might consider using diagnosis code F64.0, Transsexualism, in addition to an appropriately leveled Evaluation and Management (E/M) code. Please note that per ICD-10-CM inclusive notes for F64.0, code F64.0 covers both "gender identity disorder in adolescence and adulthood" and "gender dysphoria in adolescents and adults.".
Reimbursement of Voice Therapy for Gender Affirmation Services
Specific diagnosis codes related to gender dysphoria are found in the F64 series for gender identity disorders. There is also a code used to report a personal history of sex reassignment (Z87.890). SLPs should always consult the medical record or referring physician to confirm the appropriate medical diagnosis code for gender dysphoria.
PDF POLICY AND PROCEDURE MANUAL
Referral letters for gender-affirming services must follow format outlined in 89 III Adm. Code 140.413(a)(16). Limitations 1. Gender reassignment surgery is covered only once per lifetime. Transitioning back to the natal gender is not a covered benefit. 2. Revisions after gender reassignment surgery are not covered unless there is a
PDF Medical Policy Transgender Services
Gender Reassignment Surgery (GRS) may be MEDICALLY NECESSARY when ALL of the following candidate criteria are met and supporting provider documentation is provided: The candidate is at least 18 years of age, AND. The candidate has been diagnosed with gender dysphoria (ICD-9 Code 302.85 gender identity disorder), including meeting ALL of the ...
Hong Kong Amends Surgery Requirements to Change ID Gender Markers
April 3, 2024 7:15 AM EDT. H ong Kong no longer requires transgender people to undergo full gender-affirming surgery to change their legal gender markers in their IDs, more than a year after the ...
Hong Kong LGBTQ activists upset at revised ID card gender rules
HONG KONG, April 3 (Reuters) - Hong Kong will allow transgender people who have not completed full sex reassignment surgery to change gender on their ID cards, the government said on Wednesday ...
Arkansas Code Title 20. Public Health and Welfare
(4) " Gender reassignment surgery " means any medical or surgical service that seeks to surgically alter or remove healthy physical or anatomical characteristics or features that are typical for the individual's biological sex, in order to instill or create physiological or anatomical characteristics that resemble a sex different from the individual's biological sex, including without ...
Help Transgender Patients Understand Their Coverage and Rights
All medically necessary services for gender reassignment surgery should be covered if documentation can prove that the procedure for treatment of gender dysphoria is warranted (See part 2 of this series for the requirements and documentation to prove medical necessity). ... Report condition code 45 Ambiguous gender category when submitting ...
PDF 189 Gender Affirming Services (Transgender Services)
• The member has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender ... as possible with the identified gender through surgery and hormone treatment. o The new gender identity should be present for at least 12 months. o The member has a consistent, stable gender identity that is well documented by their ...
Wyoming governor signs bill banning gender reassignment surgery, care
March 23 (UPI) --Wyoming's Republican governor has signed a bill into law banning doctors in that state from performing gender transitioning and gender reassignment procedures for children.Wyoming ...
Sex reassignment in minors may be medical history's 'greatest ethical
Senators want to table a Bill banning gender transition treatments for under-18s. French Senators want to ban gender transition treatments for under-18s, after a report described sex reassignment ...
Critics rage against NY's proposed 'Equal Rights Amendment ...
Critics are raging against New York's proposed "Equal Rights Amendment," claiming the Nov. 5 ballot measure could curb the rights of parents when it comes to allowing minors to undergo ...
PDF Cigna Medical Coverage Policy
Genital surgical procedures often performed as part of gender reassignment surgery of MTF transsexuals include orchiectomy, vaginoplasty, penectomy, labiaplasty, clitoroplasty and vulvoplasty (WPATH, 2012). Surgical techniques vary but may include penile inversion to create a vagina and clitoris or creation of a vagina from the sigmoid colon (i ...
Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery
Vaginoplasty is the most commonly performed gender-reassignment surgery for those with gender dysphoria, with more than 3,000 procedures performed annually. According to Johns Hopkins Medicine ...
Identify Transgender Coding Mishaps
Code Updates Ensure Claims Payment. ICD-10 notes that new code F64.0 covers both "Gender identity disorder in adolescence and adulthood" and "Gender dysphoria in adolescents and adults.". And for revised code F64.1, ICD-10 instructs you to "Use additional code to identify sex reassignment status (Z87.890).".

Gender Affirming Surgery

Table Of Contents

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery

Pitch-Raising Surgery in Transfeminine Persons

Facial Feminization Surgery

Forehead Feminization Cranioplasty

Hand Feminization and Masculinization

Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery

Urethral Complications and Outcomes in Transgender Men

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

Characteristics of a Qualified Health Professionals (From SOC-8)

Policy History

Additional Information

State Information

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National Estimates of Gender-Affirming Surgery in the US

Gender Dysphoria and Gender Reassignment Surgery

Transmittal Information

National Coverage Analyses (NCAs)

Coding Analyses for Labs (CALs)

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Hong Kong Amends Its Surgery Requirements to Change Gender Markers on IDs

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