Gender Confirmation Surgery ... FFS

[LeaP]

Another active thread asks about member's preferences concerning the order of surgeries they may undertake.  That evolved (or devolved, take your pick) into a discussion of the merits and meaning of several different surgeries.  Rather then take that topic off-track, I thought I would spin off the FFS portion of the topic for separate consideration.  This was triggered by a post that was intended to support the primacy of SRS. It cited Lynn Conway, though it's not clear that particular member knew that Lynn had not only undergone FFS, but has commented on its importance. 

Lynn writes about her FFS here:  http://ai.eecs.umich.edu/~mirror/FFS/LynnsFFS.html

Some relevant excerpts that support my contention that FFS is as gender confirming as SRS include:

The aim of FFS surgery is to eliminate or reduce many of the cross-gender-related deformities of the facial bones caused by late-pubertal testosterone masculinization in MtF transsexuals.

Back in the late 80's, Dr. Douglas Ousterhout came to understand that facial masculinization effects in male-to-female (MtF) transsexuals can be every bit as disfiguring and socially damaging to them as are the effects of severe facial disfigurement in accident victims and genetic facial deformities in children.

One does not undergo such extreme surgical ordeals for "cosmetic reasons".

... in some TS cases where the browridge is very large and the jawbone is very large, Doug's surgery can mean almost the difference between a decent life and a living death, i.e., between finding easy acceptance as a normal female vs being subjected to ongoing massive public ridicule for one's appearance.

In many ways, the innovation of FFS is having as profound an impact on transsexual women's lives, and their chances for happiness in life, as did the innovation of SRS. The woman who can reverse her facial masculinization this way experiences something much deeper than an exercise in vanity and the beautification of appearance. Instead, these extremely aggressive surgeries are about healing, self-acceptance, and ultimately comfort in finding one's true place in society.

So – what do you think? Is FFS gender confirming or not? As important as SRS or not? Something else?

[suzifrommd]

Wow, Lea. Great question.

First, I think we can't use the level of dysphoria as a measure of whether we consider it medically necessary, since you can't measure dysphoria. Likewise, we can't use the extent to which someone has trouble passing, since that also is not easily measured. If we see it as necessary in those cases, we need to decide it's medically necessary if the patient says it is.

I'm of the opinion that every, cis or trans, has a right to be whole. But is facial surgery making us whole? If a cis woman looks too much like a man (in her estimation), would we consider her medically necessary as well? After all, if walking around as a woman who looks like a man causes dysphoria, wouldn't that equally be true for cis women? Do we classify any kind of facial surgery as medically necessary? Nose jobs, e.g.? A large nose is said by some to make one look more masculine, right?

I think the difference between GRS and FFS is that GRS is an absolute. It's easy to say, "yes that person doesn't have a vagina". It's not something the patient reports. It's medically verifiable.

Whereas you can't say, "clearly that person doesn't pass". Even if there are cases where the answer is obvious, there are cases where it isn't. Where do you draw the line?

[charlotte15]

Wow Suzi I think the exact opposite.

Here's what I wrote in the other thread:

If the tree falls in a forest where there is no one to hear it, does it makes a sound?

Just having SRS (say not even laser or electrolysis) won't make someone a woman. She'll still get sired all the time, and none would be the wiser of what's in her panties if the doesn't wear dresses or makeup.

For me, being a woman means not being able to be confused with a man, or pass as a man - a permanent male fail if you want. It means being unable to claim male privilege ever again. Maybe this is a feminist view of what a woman is, but that's my view.

About SRS, I'm not sure. I don't really hate these parts to the point of throwing up. I'm indifferent. I'm considering an orchy as it would be less expansive, but if SRS was paid for and gave a good functional results, I could wear bathsuits and bikinis - so why not?

So I see FFS as a necessity, SRS as something that could be nice. I say SRS, not GRS because I know my gender. SRS is just to fix the dangly bits to wear a bikini.

[LeaP]

Patients don't determine medical necessity - providers do. Determinations are evidence based, not subjective. That assessment criteria may not exist for FFS doesn't mean they cannot be developed. The extremes of cissexual experience needn't prevent this any more than the presence in the population of extremely large-breasted women prevents medically necessary reductions for those less endowed.

[mmmmm]

Who is there to say that a woman with a penis isn't really a woman? And that in order to have a gender confirmation any kind of surgery should be a necessity? Therefore SRS/GRS isn't necessity and FFS isn't either. If anyone feels she/he needs to undergone a certain surgical treatment in order to live and function normally, than this is a necessity for them. Not for transgender (really more transsexual) community.

Should FFS be covered by an insurance to all who suffer dysphoric feelings because of facial deformity of any kind, not just testosterone inflicted post-puberty deformity such as upper face masculine traits, or square chin, or big manly nose. In a case of covering facial feminization procedures for trans women, should be also covered surgical procedures for afab women, in a cases where one would suffer from psychological discomfort (dysphoria) because of their facial feature deformity, in order to help improve their quality of life and their overall well-being (like self-image, social interactions, etc...). And should we exclude men, both trans and cis, from this benefitiary surgery discussion? What if a cis-man suffers from discomfort because of having too small..... you know what.... lets say it's a "chin"... shouldn't we say that he also deserves to have a gender confirmation surgery, of course covered by a private health insurance, or public healthcare system? In order to make him feel as a whole, to feel more as a real man?
Why would be SRS/GRS any more gender conforming surgery than BA or FFS, even to a point as being called "an absolute"? While it is absolutely necessary for me, it isn't for (I don't know how many tens of) thousands and thousands of other transsexual women who feel differently about it than me. And even I need it for myself, not to prove for anyone that I'm being a real woman.

[charlotte15]

Patients don't determine medical necessity - providers do. Determinations are evidence based, not subjective. That assessment criteria may not exist for FFS doesn't mean they cannot be developed.

Woa!!! Are you like from Europe or the UK??

Because I'm sorry, but I'm in the total opposite directions: patients determine necessity. Medical providers only know how to add 2+2 and read guidelines and try to hammer a square peg in a round hole

Maybe I don't react to authority very well, but nobody has the right to tell me anything about my necessities and my bodies. And that's the kind of freedom there is on this side of the atlantic.

[suzifrommd]

That assessment criteria may not exist for FFS doesn't mean they cannot be developed. The extremes of cissexual experience needn't prevent this any more than the presence in the population of extremely large-breasted women prevents medically necessary reductions for those less endowed.

But how? How would you say Jane has enough dysphoria for FFS, whereas Jenny doesn't have quite enough? How do they know Jane is telling the truth?

And, the biggest question, do you really want a doctor who is not you deciding whether you're dysphoric enough for surgery you know you need?

The extremes of cissexual experience needn't prevent this any more than the presence in the population of extremely large-breasted women prevents medically necessary reductions for those less endowed.

Oh yes, I totally agree. But they should be allowed the same services we ask for, shouldn't they?

And who's to say where those extremes end? When one person is extreme enough but another isn't quite that extreme?

Wow Suzi I think the exact opposite.

Here's what I wrote in the other thread:

So I see FFS as a necessity, SRS as something that could be nice. I say SRS, not GRS because I know my gender. SRS is just to fix the dangly bits to wear a bikini.

I'm not saying FFS isn't a necessity. I'm saying that there are a lot of unanswered questions relating to the decision of when it is and when it isn't, questions that are really hard to resolve.

I disagree that SRS is just to wear a bikini. Many people require SRS who never plan to wear a bathing suit. They do it because they literally cannot stand a body that is the wrong shape.

[charlotte15]

I disagree that SRS is just to wear a bikini. Many people require SRS who never plan to wear a bathing suit. They do it because they literally cannot stand a body that is the wrong shape.

I should have been more precise as in the other thread: this bikini thing, it's only for me, because I do not feel disgusted to the point of throwing up of what's between my legs. I mean, it's there, ok, I'd rather not have it there but it is. I can totally understand how other girls could feel differently.

[LeaP]

First, I'm from the US. Second, my wife was a surgical practice administrator. Third, I have done both internal and consulting work for insurance companies. I am very well versed in medical necessity. 

Patients do not determine medical necessity. Patients make pleas to their doctors, who then will or will not make the case for medical necessity to an insurance provider.  The insurance provider is going to rely on one of three things, primarily.  The first is whether there is a standard of care that provides objective standards.  The second is in consideration of an emergency.  The third is medical judgment, and with that they will look to both an in-house opinion as well as considering the doctor's opinion and will often also require a second outside opinion as well. 

My views are libertarian. I'm inclined to let people do whatever they want to do, medical necessity or not.   Having someone else pay for it, however, is something else entirely. Ask someone else to pay and they have a perfect right to ask why they should.

I don't think the questions are as hard to resolve as you think. They seem that way because of the discussions around considerations of passing, beauty,  and even dysphoria. As far as I am concerned, pass whatever bars are needed for establishing your transsexuality and whether or not certain FFS procedures are covered can be as simple as establishing some statistical guidelines. (E.g., so many standard deviations off the top of the normal cisfemale curve - something like that). 

Should ciswomen be allowed the same services (meaning on the same basis)?  No! Different conditions. Different treatments. 

[Dee Marshall]

Why does everyone say "getting someone else to pay" in regards to insurance? My insurance premium was partially paid by my employer and partially paid from my salary. The part paid by my employer was part of my negotiated compensation. I certainly was taxed by enough because of them. The same goes for social security and unemployment compensation. None of this is an entitlement, it's things we pay good money for. Yes, it's pooled money. This year you had cancer surgery, next year I have SRS, sad for John Doe, he never got sick, but the money was there if he did. I know this is a slight derailment, but "it's not your money" is the argument used to justify "medical necessity" and "existing condition" for that matter. No insurance company loses money, they just use any argument to keep as much as possible. You in conjunction with your doctor should determine medical necessity. The insurance company should not. They don't have your best interests at heart.

And yes, my views are libertarian, too. If I pay for a service I expect to be able to use that service.

[Emily E]

For some people it is a necessity for gender confirmation for others its helpful and yet for others its not necessary... fortunately FFS is considered a cosmetic procedure otherwise some doctor or insurance company would turn into a true gatekeeper and prevent a lot of people who really need it and others who just want it from getting this potentially necessary or helpful procedure. 

I read some comments in the other thread where it was discussed that people should be prevented from getting FFS until after they had been on HRT for a year or had SRS which I found a little surprising but understandable seeing their reasons but I don't agree with it I believe that I should have control over what my face looks like and if I think it would make me happy and feel better about myself that I should be able to do it.

I would love it if I could get my insurance to pay for at least part of it as I (and my company) pay a lot for it every month and I don't really use it that much but I'm not going to hold my breath.

[LeaP]

Why does everyone say "getting someone else to pay" in regards to insurance?

Because insurance isn't a service.  It's also not pooled funds.  It is pooled risk, but that's not the same.  It's true that most insurance companies make money - but not on their insurance operations.  Many lose money or break even there and make the difference (and profit) from their investment portfolio.  That portfolio (their general fund) is also commingled.  There will be some asset segregation and segmentation for a variety of reasons, but the entire portfolio effectively backs their entire insurance book.  Beyond that, they pool risk via reinsurance. 

Large companies almost universally self-insure.  The insurance company primarily functions in a servicing role, dealing with everything from enrollments to handling billings to handing regulatory issues and oversight, providing systems services, and yes, making medical determinations.  Payment to medical providers on behalf of employees is billed back to the contracting company.  Not only is your company (assuming you work for a self-insured company) doing the paying, you are getting the benefits at a subsidized costs in a variety of ways, including lower premiums and lower payouts to providers at contracted rates.  Insurance contracts are just that - contracts.  You are entitled to exactly what the contract provides for, no more, no less.  Participation in the contracted PLAN is part of your comp, not any medical payments.  It's value is the combination of your premium plus the company premium.  The cost, on a level benefits provided basis, is virtually always lower than market. 

Finally, subject to some specific statutory and regulatory exceptions as well as regs involving considerations like discrimination, insurance plans may exclude all kinds of things that are medically necessary.  You are not covered for any medical service you may need.  You are covered by what the plan provides by contract.  Period. 

Should you be thinking of going the discrimination route as it relates to trans services, it's of limited value.  First, insurance law recognizes that some legitimate sex differences exist.  But the most basic test, assuming that it's something that *could* be extended to you, is whether a denial of coverage was arbitrary, discriminatory on its face, subject to a permitted exclusion, or justifiable based on differences in condition.  You can't argue for cross-sex hormones, for example, on the basis that contraceptives are covered.  (Not the best example, as contraceptives are now required coverage, but it illustrates the idea.)  Moreover, contracts can and do exclude all kinds of things to all plan participants.  No-one gets it, no discrimination claim.

Sorry, but I've been in financial services in executive positions, including insurance companies, for over 35 years.  I would like to see some of the same things you would, but it ain't gonna happen with the current financial structures. 

The evil insurance company meme is a myth.  If you want to point a finger and you work for a self-insured firm, point it at your company - they are the ones who specified the plan's coverage.  My firm is very large, self-insured and my plan has all the typical trans exclusions.  The insurance company didn't do that - my employer did.  The insurance company offers all kinds of variations on their standarized plan structures and, in fact, the insurance company itself provides trans coverage to its own employees!  My company didn't want to provide the coverage.  I've been working behind the scenes for the last year to get that changed, and expect coverage to start with the next plan year, based on recent updates.

[Erica_Y]

Lea I tend to agree with the position that FFS is just as gender confirming as SRS. They are both addressing issues physically and psychologically from different ends of the same stick so to speak. If you are young and T did not damage your face yet great if it has then FFS in my experience has been very confirming and has done so much to facilitate my very positive experience so far. I suspect that this type of conversation can not be totally objective as $$$ seems to play a confirmation bias role in the opinions and availability of options to pursue and prioritize.

[LeaP]

...I suspect that this type of conversation can not be totally objective as $$$ seems to play a confirmation bias role in the opinions and availability of options to pursue and prioritize.

I agree and it's a good observation.  It is, of course, also applicable to SRS.

[iKate]

There is a very simple reason why SRS is considered to be a gender reassignment/confirming surgery and FFS is not.

Nearly all cis women have vaginas and none of them have penises.
Not all cis women have fully feminine faces.

Remember as well that the purpose of gender reassignment is to alleviate your gender dysphoria, not make you look beautiful or "pass" beyond a normal degree.

Insurance coverage's purpose is to make you whole, and recover from a loss. It is not an unlimited pool of funds to give you everything you want. If it were used as an unlimited pool of funds it would go bankrupt pretty quickly. This applies even to Government insurance programs. Tax dollars are not unlimited. When your Government runs out of money they have to take it from someone else or borrow it. They can do this through devaluation of the dollar (aka "printing money") or simply raising taxes. Borrowing is not without cost. Governments issue bonds to borrow or take loans. These attract interest, determined by a Government's credit rating.

That said, FFS should be covered on a case-by-case basis. BTW, so should GRS/SRS/GCS. Case-by-case meaning that it is needed to make you whole, and not just a desire or want because you want to enhance yourself.

[mmmmm]

Genitals do not define or confirm whether you are a man or a woman (except for some retarded parts of the world where is SRS required for legal gender recognition).

I personally am not interested in your genitals. Having a penis or vagina is not what makes me see you as a woman. Looking like a woman does. And having natural feminine expression, not forced and obviously learned mannerisms, walking or way of speaking. But it is mostly about how you look. I honestly can't see someone as a woman, if she looks like a man with make-up who is trying to pass as a woman. I will be nice and use all the right pronous and try to percieve you as another woman, and you would never know I don't. But in reality I will still see you as a man, as long as your facial features and facial expression are telling me so. FFS is much more gender confirming than many of people here are trying to make it seem, as kind of cosmetic procedure those not authentic transwomen get to look more pretty.

[suzifrommd]

That said, FFS should be covered on a case-by-case basis. BTW, so should GRS/SRS/GCS. Case-by-case meaning that it is needed to make you whole, and not just a desire or want because you want to enhance yourself.

But how do you decide? How do you know if your patient is really experiencing dysphoria or simply wants to enhance herself?

[iKate]

But how do you decide? How do you know if your patient is really experiencing dysphoria or simply wants to enhance herself?

How do you currently determine it for SRS?

I don't know exactly why but consider this - due to equal access, you'll have cis women complaining that trans women are getting insurance covered cosmetic surgery and they are not. How do you deal with this? You can't simply say everyone who wants it gets it.

[suzifrommd]

How do you currently determine it for SRS?

Well, you convince a psychologist you are dysphoric.

This works really well for the well-to-do and well-insured who can shop around and find therapists who aren't into gatekeeping.

For the poorer folk, it doesn't work as well, but unless they have a really good insurance plan they're not going to afford SRS anyway.

Having been through the process, I think it's awful, patronizing, and ultimately useless. In my mind, the only system that makes sense is that all transfolk have the right to be whole in their gender and that SRS should be available for all of us. If a cis man gets his junk blown off in war or burned off in a motorcycle accident, he'd be entitled to reconstruction. He wouldn't have to prove dysphoria. We deserve no less.

I don't know exactly why but consider this - due to equal access, you'll have cis women complaining that trans women are getting insurance covered cosmetic surgery and they are not. How do you deal with this? You can't simply say everyone who wants it gets it.

I think this really is an issue. That's why I'm hemming and hawing about considering facial surgery as medically necessary.

[iKate]

Well, you convince a psychologist you are dysphoric.

This works really well for the well-to-do and well-insured who can shop around and find therapists who aren't into gatekeeping.

For the poorer folk, it doesn't work as well, but unless they have a really good insurance plan they're not going to afford SRS anyway.

Well, that's a completely different issue. I certainly don't support an entity such as the Government or an insurance company paying for FFS without some sort of evaluation.

But maybe the therapist and psych should be covered as well.

Having been through the process, I think it's awful, patronizing, and ultimately useless. In my mind, the only system that makes sense is that all transfolk have the right to be whole in their gender and that SRS should be available for all of us.

I think it is important because even with this process we have some people who regret getting surgery.

Also, initially I never really thought I'd do SRS but now I'm leaning more into the direction of getting it. An important component of this is my gender therapist.

And again, we are not medical professionals. We cannot and should not decide what is necessary, even for ourselves. We are talking about permanent changes that can even kill us if not done properly. It can't just be done on a whim, or because we feel that we must have it. Even so, I don't think we should be paying for people's whims and desires. The purpose of insurance is to make you whole. The guy who had his junk burned off in an accident has very obviously suffered a loss.  But someone claiming they are really a woman when they were born with a penis and masculine looking face isn't very obvious. That is why we are evaluated by psychologists, psychiatrists and therapists. This is why the WPATH SOC exists. This is why Harry Benjamin's work is so critical.

Put another way - I have diabetes. I test my blood using a meter and test strips which cost $1 apiece. I use about 400 over a 3 month period. I can't just go to my insurance company and say "here, pay for this" and hand them the receipt for test strips. I had to have my physician prescribe it, and justify it as being medically necessary, namely that I am undergoing treatment and lifestyle management for type 2 diabetes. Once they determine that there is a loss and a means to monitor my condition which is covered, they cover it (without a copay even.)

I think this really is an issue. That's why I'm hemming and hawing about considering facial surgery as medically necessary.

We can use the model for covering breast surgery. Women who have had breast cancer and a mastectomy can get reconstruction covered by insurance. Those who simply have small breasts and want to make them bigger will not.

Someone who has serious dysphoria about their face and is evaluated by a professional to determine that their face is a major problem for their everyday life should get facial feminization surgery covered. Meanwhile, someone who doesn't like their face but passes anyway should not get it.