Archived Policies - Surgery


Gender Reassignment Surgery

Number:SUR717.001

Effective Date:04-01-2008

End Date:03-14-2013

Coverage:

This medical document is no longer scheduled for routine literature review and update.

Gender assignment surgery for patients with ambiguous genitalia is considered to be reconstructive surgery and is eligible for coverage.  

Gender reassignment surgery, also known as transsexual surgery, sex reassignment surgery or intersex surgery is considered not medically necessary.

Description:

Gender Identity is the sense of knowing to which sex one belongs—that is the awareness that ‘I am female” or “I am male”.  Gender identity is the private experience of gender role and gender role is the public expression of gender identity.  Gender role can be defined as everything one says and does, including sexual arousal, to indicate to others or to oneself the degree to which one is male or female.

Gender Identity Disorder is characterized by strong persistent cross-gender identification and by continuous discomfort about one’s anatomic sex or, by a sense of inappropriateness in the gender role of that sex.  

Gender reassignment surgery, also known as transsexual surgery, sex reassignment surgery or intersex surgery, is the culmination of a series of procedures designed to change the anatomy to conform to the gender to which a person with a gender identity disorder identifies themselves.  Gender reassignment surgery entails castration, penectomy and vulva-vaginal construction for male to female gender reassignment.  Female to male surgery includes bilateral mammectomy, hysterectomy, salpingo-oophorectomy, followed by phalloplasty and insertion of testicular prosthesis.  

Transsexualism is a gender identifying disorder in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively takes steps to live in the opposite sex role full-time.  Those persons who wish to change their sex may be referred to as “Transsexuals” or as people suffering from “Gender Dysphoria” (meaning unhappiness with one’s gender).

Ambiguous genitalia are those in which it is difficult to classify the infant as male or female.  The extent of the ambiguity varies.  In very rare instances, the physical appearance may be fully developed as the opposite of the genetic sex (e.g., a genetic male may have developed the appearance of a normal female).

Typically, ambiguous genitalia in genetic females (babies with two X chromosomes) include an enlarged clitoris that has the appearance of a small penis.  The urethral opening can be anywhere along, above, or below the surface of the clitoris.  The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles.  Sometimes a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles.

In a genetic male (one X and one Y chromosome), ambiguous genitalia typically include a small penis (less than 2-3 centimeters or 0.8-1.2 inches) that may appear to be an enlarged clitoris (the clitoris of a newborn female is normally somewhat enlarged at birth).  The urethral opening may be anywhere along, above, or below the penis; it can be placed as low as on the peritoneum, further making the infant appear to be female.  There may be a small scrotum with any degree of separation, resembling labia.  Undescended testicles commonly accompany ambiguous genitalia.

Ambiguous genitalia are usually not life threatening, but can create social upheaval for the child and the family.  Making a correct determination of gender is both important for treatment purposes, as well as the emotional well-being of the child.  Some children born with ambiguous genitalia may have normal internal reproductive organs that allow them to live normal lives. However, others may experience health issues from an underlying cause of the disorder.  A list of the most common causes is listed below:

  • Pseudohermaphroditism, the genitalia are of one sex, but some physical characteristics of the other sex are present.
  • True hermaphrodism, a very rare condition in which both ovarian and testicular tissue is present.  The child may have parts of both male and female genitalia.
  • Mixed gonadal dysgenesis (MGD), an intersex condition in which there appears some male structures (gonads, testis), as well as a uterus, vagina, and fallopian tubes.
  • Congenital adrenal hyperplasia (CAH).  This condition has several forms, but the most common form causes the genetic female to appear male.  (CAH is a potentially life threatening condition.).
  • Chromosomal abnormalities, including Klinefelter’s syndrome (XXY) and Turner’s syndrome (XO).
  • Maternal ingestion of certain medications (i.e. androgenic steroids) may cause a genetic female to look more male.
  • Lack of production of specific hormones can cause the embryo to develop with a female body type regardless of genetic sex. (Lack of testosterone cellular receptors).

Rationale:

Gender reassignment surgery is controversial among the available literature and few long term studies can be located.  These controversial differences are most apparent due to the far reaching and irreversible results of hormonal and/or surgical transformation and the high rate of serious complications of these procedures.  

Postoperative complications include infection, hemorrhage, urethral urinary incontinence, rectal fistula, vaginal stenosis, and erectile tissue around the urethral meatus.  Serious postoperative incidents include request for reversal, hospitalization and suicide.  The incidence of the number of events attributed to postoperative complications cannot be ascertained with confidence due to variability between the studies, and the high rates of losses to follow up.  Case series give some indication on the frequency of these events, although there is great variation in the figures presented, and suicide rates range from 0% to 18%.  This data should be interpreted with caution, as figures are derived from small studies in which there are no control groups, incomplete follow up and the possibility of bias in reporting.

Thrombotic risk of estrogen therapy should be considered when estimating potential harms of gender reassignment interventions.

New problems may emerge following reassignment surgery.  Some individuals may need to come to terms with painful loss including jobs, families, partners, children and friends.  Many are forced to move away from their familiar environments despite being confident in their new gender roles.  Many individuals have difficulty with social adaptation and acceptance by other members of society.

The evidence to support gender reassignment surgery is limited in that most studies are non-controlled and have not collected data prospectively.  In addition they are hampered by losses to follow up and a lack of validated assessment measures.  It has been noted that a number of transsexual people experience a successful outcome in terms of subjective well-being, cosmesis and sexual function.  The magnitude of benefit and harm cannot be estimated accurately using current evidence.

The ability to diagnose infants born with intersex conditions has advanced rapidly in recent years. In most cases today, clinicians can promptly make an accurate diagnosis and counsel parents on therapeutic options.  However, the paradigm of early gender assignment has been challenged by the results of clinical and basic science research, which show that gender identity development likely begins in utero.  While the techniques of surgical genital reconstruction have been mastered, the understanding of the psychological and social implications of gender assignment is poor.

Treatment of ambiguous genitalia is controversial.  No one debates the need to treat underlying physiologic problems such as those associated with CAH or tumors in the gonads.  However treatment for ambiguous genitalia depends on the type of disorder, but will usually include corrective surgery to remove or create reproductive organs appropriate for the gender of the child.  Treatment may also include hormone replacement therapy (HRT).  Controversy revolves around issues of gender reassignment by the physician and family which may not correlate with gender preference by the patient in adulthood. 

Reilly and Woodhouse interviewed and examined 20 patients with the primary diagnosis of micropenis in infancy” and concluded that “[A] small penis does not preclude normal male role and a micropenis or microphallus alone should not dictate a female gender reassignment in infancy.”  More particularly, these doctors found that when parents “were well counseled about diagnosis they reflected an attitude of concern but not anxiety about the problem, and they did not convey anxiety to their children.  They were honest and explained problems to the child and encouraged normality in behavior.  We believe that this is the attitude that allows these children to approach their peers with confidence.

From a medico legal standpoint, the best approach to managing these cases is to provide parents with as much information as possible so that they can make informed decisions.  Adequate counseling and support for parents is vital.  The ideal management method is a team approach including neonatologists, geneticists, endocrinologists, surgeons, counselors, and ethicists

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

None


Medicare Coverage:

The information contained in this section is for informational purposes only.  HCSC makes no representation as to the accuracy of this information.  It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been developed or changed since this medical policy document was written.  See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

Medicare Coverage Database.  NCD for Transsexual Surgery.  Centers for Medicare & Medicaid Services. Baltimore, Maryland. Publication Number 13-3, Manual Section Number 140.3, Version 1. <http://www cms hhs gov/med>

Hunt, D.D., and J.L. Hampson.  Follow-up of 17 biologic male transsexuals after sex reassignment surgery.  American Journal of Psychiatry (1980) 137: 432-438.

Pauly, I.B.  Outcome of sex reassignment surgery for transsexuals.  Australia and New Zealand Journal of Psychiatry (1981) 15; 45-51.

Sorensen, T.A.  A follow-up study of operated transsexual males.  Acta Psychiatrica Scandinavica (1981) 63: 486-503.

Dixen, J.M., Maddever, H., et al.  Psychosocial characteristics of applicants evaluated for surgical gender reassignment.  Archives of Sexual Behavior (1984) 13(3): 269-276.

Lindemalm, G., Korlin, D., et al.  Long term follow-up of “sex change” in 13 male-to-female transsexuals.  Archives of Sexual Behavior (1986) 15: 187-210.

Mate-Kole, C., Freschi, M.  Psychiatric aspects of sex reassignment surgery.  British Journal of Hospital Medicine (1988 February) 39(2): 153-5.

Bouman, F.G.  Sex reassignment surgery in male to female transsexuals.  Annals of Plastic Surgery (1988) 21: 526-531.

Reilly, J.M., and Woodhouse, C.R.J.  Small penis and the male sexual role.  Journal of Urology (1989) 142: 569-571.

Mate-Cole, C., Freschi, M., et al.  A controlled study of psychosocial change after surgical gender reassignment in selected male transsexuals.  British Journal of Psychiatry (1990 August) 157: 261-264.

Stein, M., Tiefer, L., et al.  Follow-up observations of operated male to female transsexuals.  Journal of Urology (1990) 143: 1188-1192.

Green, R., and D.T. Fleming.  Transsexual surgery follow-up: Status in Annual Review of Sex Research (1990) 1: 163-174.

Coleman, E., and J. Cesnik.  Skoptic syndrome:  the treatment of an obsessional gender dysphoria with lithium carbonate and psychotherapy.  American Journal of Psychotherapy (1990 April) 44(2): 204-217.

Bakker, A., van Kesteren, P.J., et al.  The Prevalence of transsexualism in the Netherlands.  Acta Psychiatrica Scandinavica (1993 Apr) 87(4); 237-8.

Snaith, P., Tarsh, M.J., et al.  Sex reassignment surgery.  A study of 141 Dutch transsexuals.  British Journal of Psychiatry (1993) 62:681-685.

Olsson, S.E., Jansson, I., et al.  A critical view on male to female reassignment surgical and hormonal treatment:  An analysis of follow-up studies.  Nordisk Sexologi (1995) 13: 14-35.

Landen, M., Walinder, J., et al.  Incidence and sex ratio of transsexualism in Sweden.  Acta Psychiatrica Scandinavica (1996 April) 93(4): 261-3.

Rakic, Z., Starcevic, V., et al.  The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes.  Archives of Sexual Behavior (1996) 25: 515-525.

Alberta Heritage Foundation for Medical Research.  Vaginoplasty in male-female transsexuals and criteria for sex reassignment surgery (1997).

Cohen-Kettenis, P.T., and S.H. van Goozen.  Sex reassignment of adolescent transsexual: a follow-up study.  Journal of the American Academy of Child & Adolescent Psychiatry (1997) 36: 263-271.

Eldh, J., Berg, A., et al.  Long term follow-up after sex reassignment surgery.  Scandinavial Journal of Plastic & Reconstructive Surgery & Hand Surgery (1997) 31:515-525.

Fleming, M., Steinman, C., et al.  Methodological Problems in Assessing Sex-Reassignment Surgery:  A reply to Meyer and Reter.  The International Journal of Transgenderism (1998 April-June) 2(2): 1-7.

Standards of Care.  The Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version.  (2001 February).

Beers, Mark H., and Robert Berkow, eds.  The Merck Manual – 17th edition.  New Jersey: Merck & Co., Inc. (1999) 1559-1560.

Transsexual Surgery: Its Pros and Cons.  Comprehensive Exam Essay.  Transsexual Women’s Resources.  Medical and Other Resources for Transsexual Women (2000) <www.annelawrence com>.

Krege, S., Bex, A., et al.  Male-to female transsexualism: a technique, results, results and long- term follow-up in 66 patients.  Ingentaconnect (2001 September) 88(4): 396-402(7).

Nuttbrock, L., Rosenblum, A., et al.  Transgender Identity Affirmation and Mental Health.  The International Journal of Transgenderism   (2002) 6(4): 1-15.

Wagner, I., Fugain, C., et al.  Pitch-raising surgery in fourteen male-to-female transsexuals.  Laryngoscope (2003 July) 113(7): 1157-1165.

Fang, R.H., Chen, T.J., et al.  Anatomic study of vaginal width in male-to-female transsexual surgery.  Plastic and Reconstructive Surgery (2003 August) 112(2): 511-514.

eMedicine.com – Hutcheson, Joel.  Ambiguous genitalia and intersexuality.  May 26, 2004. eMedicine Pediatric Continuing Education. (19 October 2005) <http://www emedicine com>

Hart, Anita C., and Catherine A. Hopkins.  ICD-9-CM Professional for Physicians Volumes I & 2.  Salt Lake, Utah: Ingenix (2004 October 1).

Rethinking the gender Identity disorder terminology in the Diagnostic and Statistical Manual of Mental Disorders. – Position Paper, Bologna, Italy:  HBIGDA Conference (2005 April 7). <http://www avitale.com>.

Kanagalingam, J., Georgalas, C., et al.  Cricothyroid approximation and subluxation in 21 male-to-female transsexuals.  Laryngoscope (2005 April) 115(4): 611-8.

Sobralske, M.  Primary care needs of patients who have undergone gender reassignment.  Journal of the American Academy of Nurse Practitioners (2005 April) 17(4): 133-138.

Mayer-Bahlburg, H.F.  Introduction:  gender dysphoria and gender change in persons with intersexuality.  Archives of Sexual Behavior (2005 August) 34(4): 371-373.

Policy History:

4/1/2008          Policy reviewed without literature review; new review date only.  This policy is no longer scheduled for routine literature review and update.

5/1/2006          New medical document

Archived Document(s):

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