Why is SRS "medically necessary," and not "cosmetic?"

[katiew88]

I think one of the issues as to why facial feminization, electrolysis aren't covered is because, for those aspects, there is no standard as to what is feminine or masculine enough.  We can't argue that cis women don't have facial hair, because some do. Same with adams apples, or masculine noses, etc. 

[jeni]

Actually, with FFS, yes you are. Unlike boobs or hips, the face's bone structure isn't feminine because it's been affected by estrogen, it's feminine because it hasn't been affected by testosterone. Testosterone causes the brow ridge, causes the bigger chin, causes the angularity and the Adam's Apple, while estrogen really doesn't do anything to the face's bone structure. So in a way, FFS actually is reconstructive surgery. It's taking your face and trying to revert it to the state it was previously in before testosterone un-feminized it.

While that's all true, I think it's quite a bit different from ordinary reconstructive surgery. Assuming a normal adolescence, there was never a mature female facial structure to reconstruct. Not that I don't like your reasoning! FFS *should* be covered if it's needed.

[ImagineKate]

Respectfully, I disagree.
I know of a few trans living full time, great jobs, great life, but never started HRT. One, because of a bad liver, the other because her doctor suggested she might have a few extra pounds. I also know of another who's been an airline stewardess for years with a major airline, never been on hormones.
I am also of the belief, from someone who's been on hormones six full years, hormones do not make me a woman. They did not mold me into who I am. They didn't define my character or magically make me more sensitive. Hormones were a nice addition to my transition, but had i for some reason been denied access to them, I still would have transitioned.
Hormones, In opinion are not the magic ingredient to transition, but they don't hurt for some.

That's why I said, "of those who medically transition."

Among all transitioners, it's RLE.

[ainsley]

BA/FFS = vanity

GRS/SRS/GCS = sanity

WPATH disagrees with a BA being vanity (emphasis mine):

WPATH's  Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide:
http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947


Medically necessary sex reassignment procedures also include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient (including breast prostheses if necessary), genital reconstruction (by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, penile and testicular prostheses, as necessary), facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.

"Non-genital surgical procedures are routinely performed... notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals." [3]

[3] Monstrey S, De Cuypere G, Ettner R,.(2007) . Surgery: General Principles. In Ettner R et al (eds) Principles of Transgender Medicine and Surgery. New York:Haworth Press:2007.p.90.

However, the insurance companies have not caught up to the standard.  Take Aetna, for example:

Clinical Policy Bulletin:
Gender Reassignment Surgery
http://www.aetna.com/cpb/medical/data/600_699/0615.html

"Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic."

[Muffinheart]

Ainsley, Yep I agree.

Fyi, for those living in Ontario:


What kinds of surgical body changing procedures does OHIP cover for approved sex reassignment surgery?
Male to Female Sex Reassignment Surgery
• Vaginoplasty - removal of male genitals, construction of vagina, labia, clitoris
Female to Male Sex Reassignment Surgery
• Mastectomy - removal of breasts and chest reconstruction
• Metoidioplasty/Phallopasty – (two different options) freeing of the clitoris and construction of
testes, or removal of female genitals, construction of male genitals
• Hysterectomy - removal of uterus and ovaries upon recommendation by GIC at CAMH as
part of transition.

Are there body changing procedures that are not covered by OHIP?
OHIP does not provide coverage for the following procedures:
• Breast implants
• Facial surgeries such as lip augmentation, lip reduction, jaw shortening, rhinoplasty (nose
reshaping)
• Neck or vocal chord surgery
• Hair transplants
• Electrolysis (removal of beard or body hair)
• Male chest contouring unless part of a mastectomy procedure
• Liposuction

[lovelessheart]

Well thats only because a lot of trans women cant afford srs. Not because they dont want it. Its obvious due to the fact that for safety reasons as well. If you get rape with male genitalia by a man who isnt aware, that could end a lit worse than if you had srs. Imo

I disagree.



SRS is at the very bottom of my list, and a lot of trans women do not have SRS.

In my opinion, HRT is the most important to most that medically transition.

[jeni]

Fyi, for those living in Ontario:

It is the same (or extremely similar) in Nova Scotia, too.

[Muffinheart]

It is the same (or extremely similar) in Nova Scotia, too.

Nova Scotia too? Nice, I used to live in Halifax


So GRS is now offered in BC, Alberta, Ontario, Quebec, PEI and NS - kewl

[jeni]

Yep, I think NS just added it within the last year. Convenient because we'll hopefully be moving there soonish. ("Free" GRS isn't the reason we're going there, but it did kinda put an end to wondering if it was the right place to go...)

[Damara]

I'm so moving to Canada someday! Sounds awesome.

[mrs izzy]

I just want to cry when I see someone post something like this.

Why is SRS "medically necessary," and not "cosmetic?"

All the years I mean years we been fighting to get GCS declared to be medically necessary.

Sigh!

Not many under stand that it could take just one person who presses the cosmetic issue back to insurance companies and they will turn right back to the Not covered.

Sigh!


Watch what you wish for. Might be standing outside looking in again.

5 years of having a medically necessary prescription for GCS i sent in to my insurance company every year. Just to get the letter saying it is cosmetic and not covered under our exclusion for cosmetic surgery every single year.


Sigh!

[bxcellent2eo]

I just want to cry when I see someone post something like this.

Why is SRS "medically necessary," and not "cosmetic?"

All the years I mean years we been fighting to get GCS declared to be medically necessary.

Sigh!

Not many under stand that it could take just one person who presses the cosmetic issue back to insurance companies and they will turn right back to the Not covered.

Sigh!


Watch what you wish for. Might be standing outside looking in again.

5 years of having a medically necessary prescription for GCS i sent in to my insurance company every year. Just to get the letter saying it is cosmetic and not covered under our exclusion for cosmetic surgery every single year.


Sigh!

I'm not saying SRS shouldn't be medically necessary, I'm only trying to find out why insurance companies consider it as such, so those arguments can be applied toward other procedures, not currently covered.

[calicarly]

It is highly unlikely that you will be successful at this task you've set yourself as a goal. If I am not mistaken I remember you posting in the FFS section about you living in the Bay Area and having medi-cal. I almost commented then but I didn't want to because I didn't want to burst your bubble and be a Debbie downer. I am originally from Cali and worked in a specialist medical provider's office in so cal for years before moving to the UK. And medi-cal had a very bad reputation for coverage of procedures. We did sometimes take medical patients but truly just to fill in an empty bed if there was any. Medical is well known for underpaying providers the amounts they request. This may have all changed by now as it has been maybe 6- 7 years since I managed that office. So do investigate first but if things are anything like back then my advice would be above all to try and figure out a way to switch insurance provider or accept a switch if your employer is offerinig it. In the amazing case that you were able to jump through all the hoops, and had the great luck of finding a psychiatrist to back all your arguments in paper and signed saying that it is absolutely necessary for your mental health to have these procedures done.and your insurance accepted. The only FFS surgeon I have ever heard of accepting an insurance funded patient, is Zukowsky in Chicago area, so don't plan to stay within the Bay Area for this if you were able to make it happen.
Asking the question of why is SRS medically necessary and not cosmetic? Is, in my opinion. A confusing way of asking people for what you want to know. Because it sounds like you're questioning the validity of GRS as a necessary surgery. I do however, understand what you're asking.

There is several studies backing up the validity of GRS as an effective surgery to alleviate gender dysphoria. So another reason why the question you are asking is wrong, is because nobody has to prove the medical necessity of GRS anymore. It has already been proven, by statistics and different studies.

What you WOULD need is yes, some serious and probably extensive evidence that FFS and BA are absolutely necessary to your everyday life and for your mental health. Have in mind the person I read about having had FFS paid for by her insurance, was. Very masculine pre Ffs, this could be a requirement and I am sure one that many would not meet (as uncomfortable as they might be with certain features) I am assuming continued assessment by a psychiatrist/ psychologist/therapist with considerable and lengthy (maybe a year or 2) evidence in regards to this issue and how it affects your daily life etc etc would be likely necessary steps to hand to a lenient and flexible insurance provider to consider you seriously, obviously, you would need the full backing of said psych. And they would have to do so in paper. You might have to fight back and forth and eventually as I said. If successful, you go to a provider who is willing to bill your insurance. Don't take my comments and possible scenarios word by word, I am only going by what knowledge I have in the subject.

So all in all, the question you wanted to ask is: how can I convince my health insurance that what they consider cosmetic procedures are actually medically necessary for me? ...  We have to ask the right questions to get the right answers!

Being in the UK, and appreciating that there will be differences between countries, I have known of cis and trans females being covered for a BA , after a 2 year process of continuous therapy in which they communicate to their therapist how negatively their look is affecting their mental health and daily lives. In these cases, it has to be obvious to all of the medical professionals involved that there is under-development apart from the above stated unhappiness.

I hope that there might be any info I've given you that might be of use to yourself for the future and that you don't consider this a negative post. It isn't meant to be. It is meant to be helpful and not detrimental.
Best of luck

[bxcellent2eo]

It is highly unlikely that you will be successful at this task you've set yourself as a goal. If I am not mistaken I remember you posting in the FFS section about you living in the Bay Area and having medi-cal. I almost commented then but I didn't want to because I didn't want to burst your bubble and be a Debbie downer. I am originally from Cali and worked in a specialist medical provider's office in so cal for years before moving to the UK. And medi-cal had a very bad reputation for coverage of procedures. We did sometimes take medical patients but truly just to fill in an empty bed if there was any. Medical is well known for underpaying providers the amounts they request. This may have all changed by now as it has been maybe 6- 7 years since I managed that office. So do investigate first but if things are anything like back then my advice would be above all to try and figure out a way to switch insurance provider or accept a switch if your employer is offerinig it. In the amazing case that you were able to jump through all the hoops, and had the great luck of finding a psychiatrist to back all your arguments in paper and signed saying that it is absolutely necessary for your mental health to have these procedures done.and your insurance accepted. The only FFS surgeon I have ever heard of accepting an insurance funded patient, is Zukowsky in Chicago area, so don't plan to stay within the Bay Area for this if you were able to make it happen.

This is what I've been told before. But with research, writing lots of papers on this, getting psychs to back me, and many appeals, I'm hoping to not only get FFS and Electrolysis, but set a precedent so others can get it as well.

Asking the question of why is SRS medically necessary and not cosmetic? Is, in my opinion. A confusing way of asking people for what you want to know. Because it sounds like you're questioning the validity of GRS as a necessary surgery. I do however, understand what you're asking.

There are several studies backing up the validity of GRS as an effective surgery to alleviate gender dysphoria. So another reason why the question you are asking is wrong, is because nobody has to prove the medical necessity of GRS anymore. It has already been proven, by statistics and different studies.

Actually, these studies are what I need. I need to see why GRS is necessary, because almost all of the reasons for GRS can be applied to every other medical procedure generally required by transgender patients.

So all in all, the question you wanted to ask is: how can I convince my health insurance that what they consider cosmetic procedures are actually medically necessary for me? ...  We have to ask the right questions to get the right answers!

If I asked that, I'd more than likely get an answer saying that it's impossible, or "good luck with that."

I hope that there might be any info I've given you that might be of use to yourself for the future and that you don't consider this a negative post. It isn't meant to be. It is meant to be helpful and not detrimental.
Best of luck

Thank you much, your post has been helpful.

[jojo702]

I think it really depends how you live your life as a trans woman. Some freely and openly exposes themselves about their identity therefore would not have the same views of seeing srs as a sanity but vanity but for those who was and is always seen or known to be a female for always hiding what they are, they would call srs a surgery for purposes of sanity and to match up with how they're living their life.

As for breast augmentation and facial reconstruction, it could go both sanity or vanity. If you got into a car accident and your face was messed up then it would be medically necessary to have FFS same for breast, if you have breast cancer and got mastectomy, it would be your choice to get breast implants to reshape both breast.

You could choose to refuse to have ffs, ba, or srs if you're sacrificing finding a certain type of love and relationship but you can choose to get it if you plan to live stealth all your life.

At least that's the way I see it.

[Aazhie]

I feel like there is argument for "harm done" in the case of major surgeries:  a cis woman whose chest is mangled by some horrible accident is considered well within her rights to get plastic surgery to repair the damage.  If she also happens to chose to request a different size and appearance, well she is already requiring surgery so who would really see much issue with this?  (Aside from religious views on how God wants her to live horridly mangled or not survive and accident which I feel are obviously exempt.) A transwoman in the case of breast augmentation can also be considered, in my view and many companies, as equally harmed by being denied this kind of surgery, whereas a cis-woman seeking to augment her chest is cosmetic.  Her breasts exist and have not been damaged, even if in her mind she has always seen herself as a larger cup size. 

A women, whether trans or cis can be suffering from facial hair.  I can see how in many traswomen's cases, they have much more difficult facial hair than even the hairiest bearded cis-woman.  But I think in either case it can be said that shaving removes the hair 'effectively' even if it truly does not. Personally I haven't heard of any cis-woman being able to write off electroylosis as a necessary procedure, but I still think in severe cases, whether cis or trans it is humane to assist a women with hair removal in a place that is fairly unusual for a woman to be excessively hairy.  I suspect there's a lot of concern for abuse as many people have unwanted hair in our societies and they don't want to pay up for a total vanity procedure.  It's a case of bad apples spoiling the bunch, or rather some people trying to abuse the system and get something for reduced cost that they may not actually need, or decide soon after they did not need?  This is a lot of conjecture on my part... :C

[LizMarie]

WPATH has the right of it, that each situation should be clinically evaluated and assessed from there and that FFS or BA can be medically necessary in certain circumstances.

The problem is that we are a small group and the insurance companies would rather screw us over for a few more bucks than take proper care of us. This is yet one more example of the failure of private health care in the United States, versus having a national health care system.

So unless/until the insurance companies in the United States catch up to current medical standards, we're stuck with what we have. You may win the argument that FFS or BA or electrolysis is medically necessary, for yourself, but it will be a one-of sort of decision and won't really help anyone else. Basically, they may look at it and decide legal costs of fighting you are higher than just giving you the coverage - a cruel and sadistic way to make such decisions, but that's what happens when you build an entire country around profit motive.

[mmmmm]

In the end, bxcellent2eo (and everyone else) has all the options and opportunities to go to the court with insurance company and prove her point.

Do I think it would be nice to have FFS covered by insurance as a necessary treatment? Yes. Definitely. Do I think it is a medical necessity? No, because it isn't. Some biological women also have very masculine face, and ugly big noses, and prominent brow ridges.... (some even get misgendered constantly) shouldn't they also be allowed to have their surgical treatment covered by an insurance? Because, you know, they also deserve to look more beautiful, and more feminine, and more close to the idealistic perfection by modern day aesthetic standards... Where do you draw the line, who should have it for free, and who should not? Why would someone who has more prominent masculine features be allowed to have it covered, compared to those who don't have to do it because of "passing" reasons, and only want to have it because they want to improve their self-image and relationship with a mirror reflection. Isn't that a LOT more important to how others percieve you, and if they gender you correctly? And most people who would need it the most (heck, I would pay for them if I would be a millionare...), say that they don't need it and don't want it, because they are passing most perfectly in their opinion... hairstyle/wigstyle and correct make-up skills is enough for them to feel comfortable in everyday situations. Shouldn't that then apply to everyone else? If you know how do master level facial contouring, even the biggest ugliest nose isn't a problem anymore (apart from side profile)... and who need a brow lift, if you can just pluck your eyebrows from under, and you're good to go. 5 minute work eyebrow lift, which can save you 5000$ + hospital fees, + hotel for 10 days, + flight costs .... If that kind of silly things work for some people, than why it wouldn't for other? Despite all the amazing benefits of facial feminization surgery, it obviously isn't necessary, and because of that it can't be expected to be treated as such by an insurance companies.
Is electrolysis really necessary, when a LOT of people happily shave everyday, and apply a ton of foundation and concealers ond other silly tricks with lipstics, etc to hide a beard shadow? It doesn't seem to bother them, as they have no problem doing so, and if they can live full-time while doing so, why couldn't you? It did bother me, and I did 90% of laser hair removal BEFORE I started "living full-time", because I didn't want any of that sticky ->-bleeped-<- on my face, and I shurely didn't want to shave everyday.

I hope anyone who is trying, manages to get a FFS covered, and I hope it comes along with an opportunity to have it with a capable surgeon. Good Luck!

[ImagineKate]

My understanding, and I try to break it down logically, the goal is to be accepted as a female by one's self and society. The goal is to be as close to a cis woman as possible.

Not all cis women have large breasts and some have faces that aren't 100% feminine (according to societal perception and natural instinct). A significant number of cis women have flat chests. However nearly all of them have vaginas. Almost none of them have penises. For a cis woman with a flat chest to get a BA or a "manly" face to get a facelift it is classified as cosmetic surgery.

This seems to be the rationale (as it seems to me anyway) behind the guidelines of covering GRS/SRS as medically necessary whereas FFS/BA/VFS/lipo etc is not.

[Tessa James]

I just want to cry when I see someone post something like this.

Why is SRS "medically necessary," and not "cosmetic?"

All the years I mean years we been fighting to get GCS declared to be medically necessary.

Sigh!

Not many under stand that it could take just one person who presses the cosmetic issue back to insurance companies and they will turn right back to the Not covered.

Sigh!


Watch what you wish for. Might be standing outside looking in again.

5 years of having a medically necessary prescription for GCS i sent in to my insurance company every year. Just to get the letter saying it is cosmetic and not covered under our exclusion for cosmetic surgery every single year.


Sigh!

Thank you Izzy,

I am still there and in a frustrating appeal process to get an orchiectomy that Kaiser has stated is "cosmetic" based on their trans exclusionary rider.   While individual practitioners and providers may support the WPATH standards the insurance industry is a powerful and $$ oriented dinosaur that needs the real makeover.   And then extinction sounds like a fitting end too.....;-)