UW–Madison SHIP sexual reassignment surgery benefit

Female-to-Male Gender Reassignment

Requirements for mastectomy or breast reduction

• Single letter of referral or recommendation from a qualified mental health professional*
• Persistent, well-documented gender dysphoria
• Capacity to make a fully informed decision and to consent for treatment
• Age of majority (18 years of age or older)
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

Note: A trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy/breast reduction surgery.

Requirements for hysterectomy and salpingo-oophorectomy:

• Two referral letters or recommendations for sex reassignment surgery (SRS) from two qualified mental health professionals* with written documentation submitted to the physician performing the surgery;
• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority (18 years of age or older);
• If significant medical or mental health concerns are present, they must be reasonably well controlled;
• Documentation of at least twelve (12) months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication).

Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, urethromeatoplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis):

• Two referral letters or recommendations for sex reassignment surgery (SRS) from two qualified mental health professionals* with written documentation submitted to the physician performing the surgery;
• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority (age 18 years of age and older);
• If significant medical or mental health concerns are present, they must be reasonably well controlled;
• Documentation of at least twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication);
• Documentation of twelve (12) months of living in a gender role that is congruent with their gender identity (real life experience).

Male-to-Female Gender Reassignment

Requirements for gonadectomy or orchiectomy:

• Two referral letters or recommendations for sex reassignment surgery (SRS) from two qualified mental health professionals* with written documentation submitted to the physician performing the surgery;
• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority (18 years or older);
• If significant medical or mental health concerns are present, they must be reasonably well controlled;
• Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones.

Requirements for genital reconstructive surgery vaginoplasty (including penectomy, colovaginoplasty, labiaplasty, clitoroplasty, vulvoplasty, penile skin inversion, repair of introitus, construction of vagina with graft, coloproctostomy):

• Two referral letters or recommendations for sex reassignment surgery (SRS) from two qualified mental health professionals* with written documentation submitted to the physician performing the surgery;
• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority (age 18 years of age and older);
• If significant medical or mental health concerns are present, they must be reasonably well controlled;
• Documentation of at least twelve (12) months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication);
• Twelve (12) months of living in a gender role that is congruent with their gender identity

Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

Note: As established by the World Professional Association for Transgender Health (WPATH)†, The following are recommended minimum credentials for mental health professionals who work with adults presenting with gender dysphoria:

• A master’s degree or its equivalent in a clinical behavioral science field. This degree, or a more advanced one, should be granted by an institution accredited by the appropriate national or regional accrediting board.
• Documented credentials from a relevant state licensing board or equivalent for that country.
• Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes.
• Ability to recognize and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria.
• Documented supervised training and competence in psychotherapy or counseling.
• Continuing education in the assessment and treatment of gender dysphoria.

Some Gender-specific services are excluded and some may be medically necessary for transgender persons

• Procedures for preservation of fertility (e.g.: procurement, cryopreservation, and storage of sperm, oocytes and/or embryos) performed prior to gender reassignment surgery are considered not medically necessary.
• Uterine transplants are considered not medically necessary.
• Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
• Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.

Cosmetic Procedures: Note: The following procedures are considered cosmetic in nature and not medically necessary when performed as a component of gender reassignment process. 

(This list is not all-inclusive)

The following is a partial list of CPT Codes that may be covered as medically necessary if the selection criteria are met.

Process Overview:

Finding a comfortable gender role is, first and foremost, a psychosocial process. Transsexual, transgender, and gender nonconforming people might seek the assistance of a mental health professional for any number of reasons.

Mental health professionals can provide support and promote interpersonal skills and resilience in individuals and their families as they navigate a world that often is ill prepared to accommodate and respect transgender, transsexual, and gender nonconforming people. Psychotherapy can also aid in alleviating any co-existing mental health concerns (e.g., anxiety, depression) identified during screening and assessment. For transsexual, transgender, and gender nonconforming individuals who plan to change gender roles permanently and make a social gender role transition, mental health professionals can facilitate the development of an individualized plan with specific goals and timelines. While the experience of changing one’s gender role differs from person to person, the social aspects of the experience are usually challenging – often more so than the physical aspects. Because changing gender role can have profound personal and social consequences, 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.

Hormone Therapy

Mental health professionals can help clients who are considering hormone therapy to be both psychologically prepared (for example, has made a fully informed decision with clear and realistic expectations; is ready to receive the service in line with the overall treatment plan; has included family and community as appropriate) and practically prepared (for example, has been evaluated by a physician to rule out or address medical contraindications to hormone use; has considered the psychosocial implications).

Hormone therapy must be individualized based on a patient’s goals, the risk/benefit ratio of medications, the presence of other medical conditions, and consideration of social and economic issues.

The criteria for hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI);
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

Note: the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones; rather, these concerns need to be managed prior to or concurrent with treatment of gender dysphoria.

All medical interventions carry risks. The likelihood of a serious adverse event is dependent on numerous factors: the medication itself, dose, route of administration, and a patient’s clinical characteristics (age, comorbidities, family history, health habits). It is thus impossible to predict whether a given adverse effect will happen in an individual patient.

It is important for mental health professionals to recognize that decisions about hormones are first and foremost the client’s decisions – as are all decisions regarding healthcare. However, mental health professionals have a responsibility to encourage, guide, and assist clients with making fully informed decisions and becoming adequately prepared. To best support their clients’ decisions, mental health professionals need to have functioning working relationships with their clients and sufficient information about them. Clients should receive prompt and attentive evaluation, with the goal of alleviating their gender dysphoria and providing them with appropriate medical services.

Surgery

Surgery – particularly genital surgery – is often the last and the most considered step in the treatment process for gender dysphoria. It is important that health professionals caring for patients with gender dysphoria feel comfortable about altering anatomically normal structures. In order to understand how surgery can alleviate the psychological discomfort and distress of individuals with gender dysphoria, professionals need to listen to these patients discuss their symptoms, dilemmas, and life histories. The resistance against performing surgery on the ethical basis of “above all do no harm” should be respected, discussed, and met with the opportunity to learn from patients themselves about the psychological distress of having gender dysphoria and the potential for harm caused by denying access to appropriate treatments.

BASIC TERMS (as provided by WPATH SOC v7):

Gender identity disorder: Formal diagnosis set forth by the Diagnostic Statistical Manual of Mental Disorders, 4th Edition, Text Rev (DSM IV-TR) (American Psychiatric Association, 2000). Gender identity disorder is characterized by a strong and persistent cross-gender identification and a persistent discomfort with one’s sex or sense of inappropriateness in the gender role of that sex, causing clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Sex reassignment surgery (gender affirmation surgery): Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity. Sex reassignment surgery can be an important part of medically necessary treatment to alleviate gender dysphoria.

World Professional Association for Transgender Health, Standards of Care, 7th Version.

UW–Madison SHIP sexual reassignment surgery benefit (PDF version)