Policy: Gender Affirming Surgery
Policy Number: CG-SURG-27
Last Update: 2021-05-20
Issued in: New York

Breast Reconstruction:

Gender affirming chest surgery (augmentation, mastectomy, or reduction) is considered reconstructive 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 (see Discussion section for diagnostic criteria); 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. For gender affirming breast augmentation procedures only: for individuals without a medical contraindication or intolerance, 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 insufficient breast development has occurred; and
6. Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
7. 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.

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been 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 (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, 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. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. 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.

†See Discussion section for a list of procedures included in this group of procedures

Permanent Hair Removal:

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.

Voice Therapy and Surgery:

Gender affirming voice modification surgery is considered reconstructive when all of the following criteria have been 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 (see Discussion section for diagnostic criteria); and
4. For gender masculinization only: for individuals without a medical contraindication or intolerance, 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. Existing vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Youth Services:

Further Considerations:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure 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 Affirming Surgery in Individuals Under the Age of 18’).

Gender Affirming Chest Surgery in Individuals Under the Age of 18 (Return to Clinical Indications)

Further consideration of a gender affirming chest procedure in select individuals under 18 years of age may be appropriate; there may exist extenuating circumstances, such as the level of maturity of the individual, duration of dysphoric symptoms, medical and mental health, and other factors, that should be considered in consultation with a provider with experience treating adolescents with gender dysphoria. The WPATH SOC provides the following guidance for individuals under the age of 18:

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.