Can SRS be considered medically necessary without dysphoria?

[suzifrommd]

The WPATH guidelines require "Persistent, well documented gender dysphoria" as a requirement for SRS.

Suppose someone were happy with life as it was, but wanted genital surgery. Someone who met all the other criteria, living as a woman, competent to make decisions, no overriding health concerns, etc. They want SRS because they want their gender and their body sex to match, or because they've always thought it would be cool to have a vag, or maybe they're intensely curious. Or maybe it's all of these, but there's no documented dysphoria present.

Should someone who meets the all the other criteria but does not suffer dysphoria be eligible for SRS referral?

[Sephirah]

Speaking personally, I think that's something that's too general to have any sort of view on, and is something that should be worked out between the person themselves and the folks they're dealing with, on a case-by-case basis. I wouldn't feel comfortable expressing any sort of opinion having no background information on the people in question. Maybe yes, maybe no. It's not really for me to say. I know there are a lot of people who don't suffer dysphoria in the physical sense, but that doesn't mean they shouldn't be eligible for SRS. Gender dysphoria comes in many flavours - not all of them involve wanting to re-arrange yourself by means of assorted power tools and a few hundred bandages. Sometimes it's more subtle, but no less real.

[Jill F]

I personally think that it's your body and you should be able to modify it in any way you please.  As long as you sign a bulletproof waiver saying that you are of sound mind, know damned well what you're getting into and won't sue if you regret it later, then I don't see a problem.

You can get a Mike Tyson tattoo, pierce anything/everything and get your tongue split in two without a letter.  Why not SRS?

I once read an article in the LA Times about an underground SRS surgeon who would do it for cash and no questions asked, but he was pretty much a complete hack and fraud.  It's sad that this is how it's done outside the current system.

[mrs izzy]

As anything in this world one can buy anything if it's what you want.

But for someone in the system and under medical care and not getting a letter I will say No.

Safe guards over the years in clinic guidelines for personal protection of those in the system for reasons. If one wishes sometime that does not fit there personal feelings then go find it or skirt the system.

That's my personal feelings.

[Missy~rmdlm]

That I cannot get on board with. The thread the other day was a bit different asking if a person who wanted to live as a male could have the SRS. I in fact know a person who did just that. Therapy and bodily modification fixed their dysphoria. Social transition has huge costs...I never advocate it.

In this newer example post you state: an individual "happily living as a woman." I assume this individual is MtF, which you don't specify. It's would generally be considered dysphoria that motivates a MtF individual to live happily as a woman. I would expect a typical woman to have typical woman parts, and therefore get SRS. Though if dysphoria isn't present for either bodily or social reasons than no SRS doesn't have a necessity. Don't fix what isn't broken.

[stephaniec]

I don't know , but I'm incredibly interested if there is anything after death, but I don't consider it a valid reason to commit suicide just because I'm intensely curious. 

[Jill F]

As anything in this world one can buy anything if it's what you want.

But for someone in the system and under medical care and not getting a letter I will say No.

Safe guards over the years in clinic guidelines for personal protection of those in the system for reasons. If one wishes sometime that does not fit there personal feelings then go find it or skirt the system.

That's my personal feelings.

Full disclosure- I have my letters.  I just think I've already had to jump through a bunch of unnecessary hoops, and when I am ready for full SRS, I apparently have to jump through even more if I want it done by any other surgeon than the one who did my orchi (more $$ out the window).  I was Dx'd with severe gender dysphoria by a therapist and psychiatrist on my respective first visits and immediately referred to an endo for a therapeutic dose of E.  For the transitioning dose, I had to have the required 12 sessions and further visits to the psych.  Do you know what we mostly talked about after the third sessions?  Music.  The therapist and psych knew damned well all along that I am a transsexual (they apparently knew me better than I did), but they had to follow the WPATH, which is IMHO a ham-fisted, one-size-fits-all approach.  After I started taking the estrogen, there were no further doubts by any of us about what I am- FEMALE.  When I wanted the orchi, I still had to go through more unnecessary therapy and another checkup from the neck up just to get it done by a respected SRS surgeon, which cost extra.  I'm glad I was treated for dysphoria, but what I had to go through was quite frankly expensive overkill. 

I believe that SRS should be available via informed consent and the letter should be simply recommended for your own protection.   

[Tessa James]

Hmmm, dysphoria can come in many forms and flavors.  I was once challenged about my level of dysphoria and transitioning because i apparently had "coped so well for so long."  Like we should wait until we are suicidal or ?  Now I am being denied an orchiectomy because an insurance company review finds it to be unnecessary and cosmetic.

Medical necessity for me is determined by my interaction with therapists and physicians.  IMO we don't need a dysphoria meter or gauge.  It is highly subjective and documenting it is simply acknowledging what we have previously said about our lives.  I don't need to hate my genitals to know they don't fit on me.  Does coping with what reality offers us imply we don't need medical care? 

Claiming our medical necessity is simply a cosmetic service is how insurance companies are currently keeping many of us from the treatment we need.  It is belittling, demeaning, invalidating and untrue.   Health care for transgender people in the USA is, for the most part, based on business models that do little for equity, respect, compassion and care. 

[Myarkstir]

I heard of only one case where a man's genitals were so badly mangled in an accident yhat they offered him srs as the only sollution. But otherwise a man with no dysphoria woul not even need srs.

[suzifrommd]

I assume this individual is MtF, which you don't specify.

Well it's kind of subsumed in the fact that they meet all other WPATH criteria. I.e. they're clearly trans, and have been living as their identified gender. They're just not experiencing dysphoria.

It's not merely a rhetorical question. At some point there's going to be a question raised of when insurance will cover SRS and when it won't. How dysphoric does someone have to be? Should it be enough simply to be living as one's identified gender, or should one have to pretend to be dysphoric before they're allowed insurance coverage?

[mrs izzy]

Full disclosure- I have my letters.  I just think I've already had to jump through a bunch of unnecessary hoops, and when I am ready for full SRS, I apparently have to jump through even more if I want it done by any other surgeon than the one who did my orchi (more $$ out the window).  I was Dx'd with severe gender dysphoria by a therapist and psychiatrist on my respective first visits and immediately referred to an endo for a therapeutic dose of E.  For the transitioning dose, I had to have the required 12 sessions and further visits to the psych.  Do you know what we mostly talked about after the third sessions?  Music.  The therapist and psych knew damned well all along that I am a transsexual (they apparently knew me better than I did), but they had to follow the WPATH, which is IMHO a ham-fisted, one-size-fits-all approach.  Aster I started taking the estrogen, there were no further doubts by any of us about what I am- FEMALE.  When I wanted the orchi, I still had to go through more unnecessary therapy and another checkup from the neck up just to get it done by a respected SRS surgeon, which cost extra.  I'm glad I was treated for dysphoria, but what I had to go through was quite frankly expensive overkill. 

I believe that SRS should be available via informed consent and the letter should be simply recommended for your own protection.

Sorry you had these issues.

Me I never had gate keeping.

All my doctors where profession and my needs where always number 1

I just had to wait many many tears fir the $$ to come or other means to afford my GCG

Again personally informed consent is a very dangerous slippery slope.

So sorry you felt my post was a direct attack on you, was not even on my mind. I am me and have my opinion and it's mine period.

I feel so many want to make transition a pay for service. It is serious and I stand behind WPATH SOC 100000000%. If anyone has a per $ over a patient's health then they should he reported and seek more confident therapy.

But what do I know.

[mrs izzy]

Well it's kind of subsumed in the fact that they meet all other WPATH criteria. I.e. they're clearly trans, and have been living as their identified gender. They're just not experiencing dysphoria.

It's not merely a rhetorical question. At some point there's going to be a question raised of when insurance will cover SRS and when it won't. How dysphoric does someone have to be? Should it be enough simply to be living as one's identified gender, or should one have to pretend to be dysphoric before they're allowed insurance coverage?

Everyone has to watch, we have been fighting for years to get it not classed as plastic surgery. If to many push because they want it not for dysphoria then the whole thing will revert back to a cosmetic surgery and again be out if pocket.

Slippery slope effect. Sometime you have to watch what you wish for.

Anyway a forum setting has no clout on the outside world. People need to be active there then here.

[Zumbagirl]

Here's where I have the problem. SRS surgery fundamentally stops a human being from performing the biological function of reproduction permanently and forever. FFS, hormones, all that stuff can alter a person, and from what I understand if one were to remove the estrogen, the changes would eventually revert. But Srs is a one and done kind of thing. There is no going back and there won't be any gonads so there would be no sex specific hormones. I can't help but to keep coming down on the side of doctors who would always want the real life experience as a way of determining a person who is wrongly sexed, if you know what I mean.

I think from a medical perspective a doctor will always want to fall on the side of least harm from a risk perspective, therefor it's better to deny the 5 people who may benefit from the 500 who would commit suicide immediately after such an operation. Even if the ratio was lower, I don't think any doctor would be willing to take such a chance. They would rather have 95% satisfied patients than potentially 50% satisfied. It may even affect their ability to practice medicine with enough bad outcomes.

This issue is always 2 sides, what we may want or desire or think may be good for us, and the people on the other side who are saddled with the risks of medical malpractice should it all go sour. So to me in the end, you can wish for anything you want (meaning modify your body at will), but what you can really convince someone to do is something different.

[Jessica Merriman]

I agree someone has the right to modify their bodies any way they want to. Most body modification is reversible though such as tattoo's and piercings. SRS is not reversible so it should not be acquired as easy as other forms of modification. Transition is done at stages and stopped when Dysphoria has relieved itself enough for the patient for the most part. Izzy is also right about something in her reply. If everyone could get SRS at will and not for Dysphoria it would be reclassed as cosmetic and insurance would go back to denying care for those of us who truly need it to survive. I say no to SRS for cosmetic or non Dysphoric reasons.

[Jill F]

Well, it looks like SRS is in my future.  Do I really need to go through all this crap all over again if I want a different surgeon?  I think I've paid my dues and jumped through enough hoops.  I think the one size fits all thing can bite me.  I am frankly exhausted already.

[Jessica Merriman]

Didn't mean to offend, just giving my opinion. 

[mrs izzy]

Well, it looks like SRS is in my future.  Do I really need to go through all this crap all over again if I want a different surgeon?  I think I've paid my dues and jumped through enough hoops.  I think the one size fits all thing can bite me.  I am frankly exhausted already.

I am confused, letters are letters and if for some reason a professional GCS doctors will not take letters originally written for one doctor and they have been later choose then it's a sad world.

[Jill F]

I am confused, letters are letters and if for some reason a professional GCS doctors will not take letters originally written for one doctor and they have been later choose then it's a sad world.

Some will, some won't.  If I went to Thailand or back to my orchi surgeon ($40K, no insurance taken in Beverly Hills!!!), I'd probably be OK, but the ones on my short list seem to want fresh ones in order to cover their asses just in case I get a case of the regrets and end up getting litigious.  It's the same with my therapist, endo and psych, who are all basically sticklers for the standards of care, just in case someone ends up suing.  They are all well-respected and interconnected, and I'm sure it's not so much intentional gatekeeping as it is advice by their attorneys and malprcatice insurers.  I am one to pull up my big girl panties and sign whatever release I'd need to, but the fact remains that somewhere along the line, some people must have had regrets, got all lawyer-happy and *BAM!* I have to deal with what is effectively yet more gatekeeping hell by no fault of my own.  I tried the orchi on for size, just in case it would be enough, and found it to be a drastic improvement but I still find myself thinking about needing the whole shebang all day long. 

At any rate, my case involves severe dysphoria and is IMHO medically necessary, but it SUCKS that I probably have to jump through even more hoops just because some individuals apparently with not-so-severe dysphoria essentially ruined it for the ones who really need it by bringing on the lawsuits.

THIS is why I think it sucks that we can't just go the informed consent and waiver route.   I also find it ironic that all transfolk have slightly different needs, yet a one-size-fits-all approach is generally applied.

Now where do I sign?

[Jill F]

I agree someone has the right to modify their bodies any way they want to. Most body modification is reversible though such as tattoo's and piercings. SRS is not reversible so it should not be acquired as easy as other forms of modification. Transition is done at stages and stopped when Dysphoria has relieved itself enough for the patient for the most part. Izzy is also right about something in her reply. If everyone could get SRS at will and not for Dysphoria it would be reclassed as cosmetic and insurance would go back to denying care for those of us who truly need it to survive. I say no to SRS for cosmetic or non Dysphoric reasons.

I have thought about this one all day, and I see the potential for it making us take a step backward in our care if the greedy insurance companies successfully argued that.  I agree that if a person is not dysphoric, then it would be an elective cosmetic procedure.  The way I see it, they must pay for it out of pocket 100%, just like a nose job.  But if you were born without a nose, this would no longer be classified as an elective cosmetic procedure; it is the correction of a birth defect.  Insurance totally pays for this.

[Jessica Merriman]

I'm sorry Jill, I should have been more clear.

What I meant to say was if everyone got SRS on INSURANCE at will and not for Dysphoria That could get it reclassed as cosmetic and we would go back to square one. If it was available on a whim with no diagnosis of gender issue's they (insurance companies) would literally go bankrupt. I was very tired when I posted that. So private pay if you have no gender issue's fine. Have it covered by insurance no