Facial Gender Confirming Surgery
I am writing regarding your initial determination to deny Ms. Patricia Patient's Facial Gender Confirming Surgery (FGCS). I have no doubt that in Ms. Patient's case, medical necessity can be demonstrated as required by California’s Insurance Gender Non-Discrimination Act (AB1586)¹.
Ms. Patient is a transgender woman, diagnosed with Gender Dysphoria of Adulthood (ICD-10 F64.0). She notes she first knew her gender identity differed from her assigned sex at 23, has been living in a gender role that aligns with her gender identity since 2017, and began estrogen-based hormone therapy 8/01/2017. She has consistently been in my care since that time. Despite these interventions, Ms. Patient continues to experience gender dysphoria. Her symptoms have manifested as anxiety, depression, agoraphobia, and overall distress. She has expressed a persistent desire for the procedures collectively referred to as FGCS. Ms. Patient experiences significant specific dysphoria caused by the appearance of the bone structure and soft tissue of her face. These features are a secondary sex characteristic, and if she had not experienced a testosterone-induced puberty, the visible appearance of these features would be different. Unfortunately, estrogen and spironolactone do not alter bone structure.
Ms. Patient experiences assumptions about her transgender status from the general public as a result of this secondary sex characteristic. She states when she interacts with the world, she is constantly misgendered, harassed, and threatened. This has led her to be quite agoraphobic and isolated. Transgender women face the highest rates of suicidality of any other group. Moreover, not being perceived as female leaves her vulnerable to transphobic violence. The 2017 NCAVP Hate Violence Report² also shows that transgender women represent the group most highly impacted by hate violence homicides in the US. I believe she would benefit greatly both medically and psychologically from FGCS.
Because your plan would cover this surgery for the purpose of correcting “accidental injury, disease, trauma, treatment of a disease or congenital defect,” but does not consider Gender Dysphoria to be a qualifying indication, this denial is discriminatory. Title XIX of the 1965 Social Security Act states that Medicaid Agencies “may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§440.210 and 440.220 to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition.³” Moreover, California’s Insurance Gender Non-Discrimination Act has been interpreted by the Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) to mean that exclusions of procedures that aid in gender transition are prohibited. We have consulted with the DMHC, the DOI, and the Transgender Law Center (TLC), all of whom have stated this denial is unlawful given the clear medical necessity of this procedure for this client.
Of note, we have submitted Independent Medical Reviews to the DMHC for FGCS denials previously, all of which were overturned and approved by DMHC. They have clearly stated in each of these cases that FGCS for the treatment of gender dysphoria is reconstructive, not cosmetic. It is frustrating that we continue to see denials and exclusions for this service when the DMHC has clearly stated that it is not a cosmetic surgery. This denial is unlawful under California law. We encourage you to proactively change your policy and to overturn this denial so that further action need not be taken with DMHC and the TLC to address this illegal exclusion.
Ms. Patient is medically and psychosocially stable for surgery, and I have no concern for housing instability, substance use, or other disruptions to her recovery. I hereby recommend and refer her for these surgeries. Her treating mental health providers agree that it is medically necessary step in the treatment plan for her gender dysphoria. This is appropriate treatment in accordance with the guidelines from the World Professional Association of Transgender Health (WPATH) Standards of Care ver 7, and she has met all criteria for surgery⁴. It is not a cosmetic procedure because the purpose is not solely to improve her physical appearance, but instead to surgically alter a secondary sex characteristic, promote her safety and psychological wellbeing, and treat her well-documented gender dysphoria.
I have enclosed numerous citations of publications that clearly demonstrate the reconstructive nature of FGCS for transgender women, as well as it’s efficacy for the treatment of gender dysphoria. It is much safer than the alternative that patients can afford without health funding, free silicone injection⁵. I have also included WPATH’s statement that FGCS may also be considered one of the most impactful medically necessary interventions⁶.
Thank you,
Physician, MD
1. California State Legislature. "AB 1586 Anti-Discrimination Law for Transgendered Persons." (September 29, 2005): 1283-1297.
2. National Coalition of Anti-Violence Programs (NCAVP). (2016). Lesbian, Gay, Bisexual, Transgender, Queer, and HIV-Affected Hate Violence in 2016. New York, NY: Emily Waters.
3. Pub.L 89-97, 79 Stat. 1432, Social Security Amendments of 1965
4. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232. https://doi.org/10.1080/15532739.2011.700873
5. Hage, J. J., Kanhai, R. C. J., Oen, A. L., van Diest, P. J., & Karim, R. B. (2001). The Devastating Outcome of Massive Subcutaneous Injection of Highly Viscous Fluids in Male-to-Female Transsexuals. Plastic and Reconstructive Surgery, 107(3), 734–741.
6. Gail, K. Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the USA. World Professional Association for Transgender Health (WPATH), (Dec. 21, 2016).
Demonstrating Efficacy of Facial Gender Confirming Surgery:
Raffaini, M., Magri, A. S., & Agostini, T. (2016). Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients. Plastic and Reconstructive Surgery, 137(2), 438. https://doi.org/10.1097/01.prs.0000475754.71333.f6
Ainsworth, T. A., & Spiegel, J. H. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research, 19(7), 1019– 1024. https://doi.org/10.1007/s11136-010-9668-7
Berli, J. U., Capitán, L., Simon, D., Bluebond-Langner, R., Plemons, E., & Morrison, S. D. (2017). Facial gender confirmation surgery—review of the literature and recommendations for Version 8 of the WPATH Standards of Care. International Journal of Transgenderism, 18(3), 264– 270. https://doi.org/10.1080/15532739.2017.1302862
Morrison, S. D., Vyas, K. S., Motakef, S., Gast, K. M., Chung, M. T., Rashidi, V., ... Cederna, P. S. (2016). Facial Feminization: Systematic Review of the Literature. Plastic and Reconstructive Surgery, 137(6), 1759. https://doi.org/10.1097/PRS.0000000000002171