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trans-health_4.pdf. 8 See, e.g., Glenn v. Brumby, 724 F. Supp. 2d 1284, 1289 n.4 (N.D. Ga. 2010), aff'd, 663 F.3d 1312 (11th Cir. 2011) (recognizing WPATH’s published statements as “accepted in the medical community”); American Medical Association House of Delegates, “Removing Financial Barriers to Care for Transgender Patients,” Resolution 122, A-08 (2008), http://www.tgender.net/taw/ama_resolutions.pdf (characterizing WPATH as “the leading international, interdisciplinary professional organization devoted to the understanding and treatment of gender identity disorders”). 9 “NCD 140.3 Decision” at 22-23. Gender Reassignment Surgery Model NCD | 3 physical sex and their gender identity. While the DSM-V and ICD-10 classify it as a mental health diagnosis, the WHOs draft of ICD-11 removes this diagnosis from the mental health section and provides a new name for the condition (gender incongruence) and classifies it in conditions related to sexual health. Treatment for Gender Dysphoria often includes mental health counseling, medical treatment with cross-gender hormones, and surgeries, but the exact combination must be individualized to each patient. In the U.S., the American Psychiatric Association permits a diagnosis of Gender Dysphoria in adults or adolescents if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) are met. The criteria are: A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following: 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics; OR 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender; OR 3. A strong desire for the primary and/or secondary sex characteristics of the other gender; OR 4. A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR 5. A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR 6. A strong conviction that one has the typical feelings and reactions of the other gender or some alternative gender different from one’s assigned gender; AND B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Categories of Gender Reassignment Surgery The category of Gender Reassignment Surgery (GRS) includes: 1. Breast/chest surgeries; 2. Genital surgeries; 3. Other surgeries. For the Male-to-Female (MTF) patient, surgical procedures may include the following: 1. Breast/chest surgery: mammaplasty 2. Genital surgery: orchiectomy, penectomy, vaginoplasty, clitoroplasty, vulvoplasty, labiaplasty, urethroplasty, prostatectomy 3. Other procedures: facial reconstruction surgery, electrolysis or laser hair removal, thyroid cartilage reduction, hair reconstruction, voice surgery, liposuction and lipofilling (rare) For the Female-to-Male (FTM) patient, surgical procedures may include the following: 1. Breast/chest surgery: subcutaneous mastectomy, nipple grafts, chest reconstruction 2. Genital surgery: hysterectomy/salpingo-oophorectomy, metoidioplasty, phalloplasty (employing a pedicled or free vascularized flap), reconstruction of the fixed part of the Gender Reassignment Surgery Model NCD | 4 urethra, vaginectomy, vulvectomy, scrotoplasty, implantation of erectile and/or testicular prostheses 3. Other procedures (rare): voice surgery, liposuction, lipofilling Indications of Coverage Gender Reassignment Surgery is reasonable and necessary when the patient demonstrates: 1. Persistent, well-documented Gender Dysphoria; 2. Capacity to make a fully informed decision and to consent for treatment; 3. Age of majority in a given country (if younger, follow the Standards of Care for children and adolescents); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled. 5. For genital surgeries only: 12 continuous months of hormone therapy as appropriate to the patient’s gender goals, unless hormones are not clinically indicated for the individual. For breast/chest surgeries: Hormone therapy is not a prerequisite for FTM patients. For MTF patients, it is recommended that MTF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery, unless clinically contraindicated. These criteria do not apply to patients who are having these procedures for medical indications other than Gender Dysphoria. Limitations of Coverage No surgery should be performed while a patient is actively psychotic. Excluded procedures include lipectomy of upper limbs, neck, and head; excision of excessive skin and subcutaneous tissue from abdomen, thigh, leg, hip, buttock, arm, forearm or hand. II. Documentation Requirements One referral from a qualified mental health professional is needed for breast/chest surgery. 10 Two referrals from qualified mental health professionals who have independently assessed the patient are needed for genital surgeries. If the first referral is from the patient’s psychotherapist, the second referral may be from a person who has only had an
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