Clinical UM Guideline

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

Note: Please refer to the following documents for additional information:

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

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

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

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

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

Note: Procedures for the chest, also known as “top surgery”, and those for the groin and reproductive organs, also known as “bottom surgery”, do not need to be done in conjunction. Additionally, individuals undergoing top surgery do not need to subsequently undergo bottom surgery, or vice versa. The selection of appropriate procedures should be based on the needs of the individual in relation to the treatment of their diagnosis of gender dysphoria.

Medically Necessary:

For individuals undergoing gender reassignment surgery, consisting of any combination of the following; hysterectomy, salpingo-oophorectomy, ovariectomy, or orchiectomy, it is considered medically necessary when all of the following criteria are met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
   1. The desire to live and be accepted as a member of the opposite gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment; and
   2. The transgender identity has been present persistently for at least two years; and
   3. The disorder is not a symptom of another mental disorder; and
   4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.

For individuals undergoing gender reassignment surgery, consisting of any combination of the following, metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of penile or testicular prostheses, it is considered medically necessary when all of the following criteria are met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
   1. The desire to live and be accepted as a member of the opposite gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment; and
   2. The transgender identity has been present persistently for at least two years; and
   3. The disorder is not a symptom of another mental disorder; and
   4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real-life experience in the new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season-specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); and
6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and
7. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
8. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.

For individuals undergoing gender reassignment surgery, bilateral mastectomy is considered medically necessary when all of the following criteria have been met:

1. The individual is at least 18 years of age (see Further Considerations section below for individuals under 18 years of age); and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
   1. The desire to live and be accepted as a member of the opposite gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment; and
   2. The transgender identity has been present persistently for at least two years; and
   3. The disorder is not a symptom of another mental disorder; and
   4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
5. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission; and
6. The individual is a female desiring gender transition.

*At least one of the professionals submitting a letter must have a doctoral degree (for example, Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) or a master’s level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse Practitioner [N.P.], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Counselor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the specifications set forth above.

**The medical documentation should include the start date of living full time in the new gender. Verification via communication with individuals who have related to the individual in an identity-congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases.

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

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

Nipple reconstruction, including tattooing, following a mastectomy that meets the medically necessary criteria above is considered medically necessary.

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary when the medical necessity criteria for phalloplasty or vaginoplasty procedures above has been met.

Not Medically Necessary:

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

Cosmetic and Not Medically Necessary:

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

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

Further Considerations:

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

Note: Please refer to the following documents ANC.00007, ANC.00008 and ANC.00009 for more information regarding the use of these and other procedures for individuals with gender dysphoria that are not planning gender reassignment surgery.

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

When services may be Medically Necessary when criteria are met:

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

When services are Cosmetic and Not Medically Necessary:
For the following procedure code, or when the code describes a procedure designated in the Clinical Indications section as cosmetic and not medically necessary.

Gender dysphoria is a condition wherein an individual’s psychological gender identity does not coincide with their anatomic gender. This results in the persistent feeling of being “trapped in the wrong body” or gender incongruence. This diagnosis should not be confused with cross-dressing, refusal to accept homosexual orientation, psychotic delusions, or personality disorders.

In May 2013, the American Psychiatric Association published an update to its Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). This update included a significant change to the nomenclature of conditions related to gender psychology. Specifically, the term “Gender Identity Disorder (GID)” was replaced with “Gender Dysphoria.”  Additionally, the DSM-5 provided updated diagnostic criteria for gender dysphoria for both children and adults. The new criteria are as follows:

Gender dysphoria in Children*

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):
   1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender, different from one’s assigned gender).
   2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to wearing of typical feminine clothing.
   3. A strong preference for cross-gender roles in make-believe play of fantasy play.
   4. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender.
   5. A strong preference for playmates of the other gender.
   6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
   7. A strong dislike of one’s sexual anatomy.
   8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
   Specify if:
   With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
   Coding note: Code the disorder of sex development as well as gender dysphoria.

Gender dysphoria in Adolescents and Adults*

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
   1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (on in young adolescents, the anticipated secondary sex characteristics).
   2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (on in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
   3. A strong desire for the primary and /or secondary sex characteristics of the other gender.
   4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
   5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
   6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
   Specify if:
   With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
   Coding note: Code the disorder of sex development as well as gender dysphoria.
   Specify if:
   Post transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen- namely regular cross-sex treatment or gender reassignment surgery confirming the desired gender (e.g., appendectomy, vaginoplasty in the natal male; mastectomy or phalloplasty in the natal female).

*From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. American Psychiatric Association. Washington, DC. May 2013. Page 451-459.

Surgical treatment for gender dysphoria differs depending upon the natal gender of the individual. For male-to-female (MtF) individuals, also known as “transwomen,” surgery involves removal of the testicles and penis and the creation of neovagina, clitoris, and labia. For female-to-male (FtM) individuals, known as “transmen,” surgery involves removal of the uterus, ovaries, and vagina, and creation of a neophallus, and scrotum with scrotal prostheses. At this time, the creation of a neophallus for transmen is a multistage reconstructive procedure.

The medical necessity criteria above are based upon the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version, published by the World Professional Association for Transgender Health (WPATH) (2013). This document is widely accepted as the definitive document in the area of gender dysphoria treatment, and it has been cited in numerous articles by other respected authors and organizations. The WPATH criteria have been adopted in several countries as the standard of care for the treatment of gender dysphoria, including hormone therapy and gender reassignment surgery.

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

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

The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one’s gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008).

The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).

Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable.

Once these treatment steps have been established, and have been stable for at least 12 months, an individual may be considered for gender reassignment surgery.

Issues Related to Chest Procedures:

For FtM individuals, chest surgery involves subcutaneous mastectomy. The main goals of surgery are removal of breast tissue and excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. In some cases, chest surgery may performed via reduction mammoplasty, when the intention is to preserve the vascular integrity of the nipple areolar complex. Regardless of the technique used, the procedures are considered equivalent when the intended volume of breast tissue removed is comparable, and the goal of chest surgery is to create a normal male thorax.

Gender Reassignment Surgery in Individuals Under the Age of 18

The use of chest surgery, specifically mastectomy, for individuals under the age of 18 is an area of increasing interest, and involves a complex array of issues. The WPATH SOC provides the following guidance on this issue:

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

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

Referral Letters

Regarding the necessity and content of referral letters required with requests for genital and chest surgical procedures, the SOC states the following:

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

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

While the SOC also states:

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

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

Other Authoritative Recommendations

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

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

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

Hair removal Procedures

In many instances, the creation of a neovagina or a urethra for a neopenis requires an autologous skin graft from the forearm or thigh. Such skin may be excessively hairy, which will impair the function of the newly constructed organ if not permanently removed. Pre-operative permanent hair removal treatments to these areas may be warranted to prevent post-operative complications.

Procedures to Address Postoperative Complications of Gender Reassignment Surgery and Reversal Surgery

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

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

In 2003 Lawrence reported the results of a study involving subjects who underwent MtF gender reassignment surgery conducted by a single surgeon. A pool of 727 eligible subjects was sent an anonymized questionnaire, and 232 provided valid responses. Interestingly, 51 subjects (22%) reported that they did not meet one or more of the minimum eligibility requirements prior to surgery, including less than 12 months of hormone therapy, less than 12 months living in their desired gender role, and less than 12 hours of preoperative psychotherapy. No subject reported consistent regret of their decision but 15 reported being occasionally regretful, citing disappointing physical or functional surgical results and/or difficult familial or social issues. The authors reported that postoperative satisfaction was significantly correlated with increased childhood self-assessed femininity, early age at which a transition was desired, incidence of surgical complications and functional status. Importantly, they cited compliance with accepted preoperative treatment regimes, especially real life experience and psychotherapy, as significant correlates to postoperative success. While this study is hampered by significant methodological issues, it is the most rigorous data available on this issue and provides significant information.

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

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

For both transmen and transwomen, additional surgeries have been proposed to improve the gender appropriate appearance of the individual. Procedures such as breast augmentation, liposuction, Adam’s apple reduction, rhinoplasty, facial reconstruction, and others have no medically necessary role in gender identification and are considered cosmetic in nature.

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

Facial Feminization and Masculinization Procedures

Individuals with gender dysphoria who undergo gender reassignment procedures may seek additional procedures to further alter their appearance. Facial feminization and masculinization is one group of such procedures. Surgical augmentation, reduction, or other types of restructuring of the brows, forehead, cheeks, eyes, lips, and/or nose, or some combination of these procedures, may be involved. The literature addressing outcomes of such procedures in subjects with gender dysphoria is limited to small-to-moderate sized case series studies (Becking, 1996 and 2007; Capitán, 2014; Hage, 1997; Noureai, 2007). These studies primarily address the cosmetic results of these surgical procedures, and do not describe the impact of facial feminization procedures on gender dysphoria symptoms or quality of life using a validated or quantifiable methods.. Furthermore, reports on complication rates (for example; rhinoplasty: nasal airway obstruction; botulinum toxin injection: muscle weakness leading to swallowing and breathing difficulties) are also lacking. At this time there are no studies comparing outcomes of facial feminization procedures in cis and gender dysphoric subjects. The values of these types of procedures is not well established in the published literature. A better understanding of their impact on gender dysphoria symptoms or quality of life is also needed. In summary, there is insufficient high quality data that the use of facial feminization and masculization procedures improve net healthcare outcomes in individuals with gender dysphoria, and no data suggesting that use of these procedures leads to differential healthcare outcomes as compared to non-transgender individuals.

Peer Reviewed Publications:

1. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Transgender feminization of the facial skeleton. Clin Plast Surg. 2007; 34(3):557-564.
2. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Facial corrections in male to female transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg. 1996; 54(4):413-418.
3. Blanchard R, Steiner BW, Clemmensen LH, Dickey R. Prediction of regrets in postoperative transsexuals. Can J Psychiatry. 1989; 34(1):43-45.
4. Bradley SJ, Zucker KJ. Gender identity disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997; 36(7):872-880.
5. Capitán L, Simon D, Kaye K, Tenorio T. Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg. 2014; 134(4):609-619.
6. Cardoso da Silva D, Schwarz K, Fontanari AM, et al. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. J Sex Med. 2016; 13(6):988-993.
7. Castellano E, Crespi C, Dell'Aquila C, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest. 2015; 38(12):1373-1381.
8. Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. 1999; 46(4):315-333.
9. Cristofari S, Bertrand B, Leuzzi S, et al Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study. Ann Chir Plast Esthet. 2018. pii: S0294-1260(18)30142-0.
10. de Blok CJM, Klaver M, Wiepjes CM, et al. Breast development in transwomen after 1 year of cross-sex hormone therapy: results of a prospective multicenter study. J Clin Endocrinol Metab. 2018; 103(2):532-538.
11. 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.
12. Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997; 31(1):39-45.
13. Hage JJ, Becking AG, de Graaf FH, Tuinzing DB. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg. 1997; 99(7):1799-1807.
14. Hepp U, Kraemer B, Schnyder U, et al. Psychiatric comorbidity in gender identity disorder. J Psychosom Res. 2005; 58(3):259-261.
15. Landén M, Wålinder J, Hambert G, Lundström B. Factors predictive of regret in sex reassignment. Acta Psychiatry Scand. 1998; 7(4):284-289.
16. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003; 32(4):299-315.
17. Lindemalm G, Körlin D, Uddenberg N. Long-term follow-up of "sex change" in 13 male-to-female transsexuals. Arch Sex Behav. 1986; 15(3):187-210.
18. Lindemalm G, Körlin D, Uddenberg N. Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases. Acta Psychiatr Scand. 1987; 75(3):268-274.
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Government Agency, Medical Society, and Other Authoritative Publications:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. Washington, DC. Pages 451-459.
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. Endocr Pract. 2017; 23(12):1437.
3. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7^th version. 2012. Available at: https://www.wpath.org/publications/soc. Accessed on January 26, 2021.
4. World Professional Association for Transgender Health (WPATH) (formerly The Harry Benjamin International Gender Dysphoria Association). Standards of Care for Gender Identity Disorders. 6^th version. 2001 Feb.

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

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