Archived Policies - Surgery
Gender Reassignment Surgery
Number:SUR717.001
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.
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).
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, although 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 medicolegal 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
Transsexual surgery for sex reassignment of transsexuals is controversial. Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental. Moreover, there is a high rate of serious complications for these surgical procedures. For these reasons, transsexual surgery is not covered.
The information contained in this section is for informational purposes only. HCSC makes no representation to its accuracy. This information is not to be used for claims adjudication for HCSC plans.
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