Clinical Policy Bulletins

Number: 0615

Subject:		Sex Reassignment Surgery
Reviewed:		October 15, 2004

Important Note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. CMS's Coverage Issues Manual can be found on the following website: http://www.aetna.com/sharedsvcs/Redirect?d=std&t=/exit_disclaimer/external_link.html&u=http://cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.



Policy

Note: Most Aetna plans exclude coverage of sex change surgery (gender reassignment surgery, transgender surgery) or any treatment of gender identity disorders. Please check benefit plan descriptions.

Aetna considers sex reassignment surgery medically necessary when all of the following criteria are met:

1. Member is at least 18 years old; and
2. Member has criteria for the diagnosis of “true” transsexualism, including:

   • Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and
   • A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and
   • Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
   • A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress; and
   • Does not gain sexual arousal from cross-dressing; and
   • Absence of physical inter-sex of genetic abnormality; and
   • Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and

3. Member has completed a recognized program at a specialized gender identity treatment center as evidenced by all of the following:

   • The member has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and
   • Unless medically contraindicated, member has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a mental health professional and carried out by an endocrinologist (which can be simultaneous with the real-life experience); and
   • A qualified mental health professional* who has been acquainted with the member for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and
   • A second concurring recommendation by another qualified mental health professional * must be documented in the form of a written expert opinion**; and
   • Psychotherapy is not an absolute requirement for surgery unless the mental health professional's initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimate its frequency and duration throughout the real life experience (usually a minimum of 3 months); and
   • Member has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of, and the alteration of, the genitourinary tract; and
   • Member has a recent negative HIV test; and
   • Member has signed a consent of understanding the proposed Male to Female or Female to Male sex reassignment surgery with its attendant costs, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements prior to the planned surgery. If the member is married, the physician may not require divorce but may also require the spouse to sign a waiver of liability form.

* At least one of the two clinical behavioral scientists making the favorable recommendation for surgical (genital and breast) sex reassignment must possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy. D., or M.D.)

** Either two separate letters or one letter with two signatures is acceptable.

Background

Transsexualism is “a gender identity disorder in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively take steps to live in the opposite sex role full-time.” People 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).

Transsexuals usually present to the medical profession with a diagnosis of transsexualism, a sophisticated understanding of their condition, and a desired course of treatment, that is, hormone therapy and sex-reassignment surgery. Due to the far-reaching and irreversible results of hormonal and/or surgical transformational measures, a careful diagnosis and differential diagnosis is absolutely vital to the patient's best interest. In and of themselves, a patient's self-diagnosis and the intensity of his desire for sex reassignment cannot be viewed as reliable indicators of transsexuality. A vital part of the long-term diagnostic therapy is the so-called real-life experience, in which the patient lives as a member of the desired sex continually and in all social spheres in order to accumulate necessary experience. Experience in specialist Gender Identity Units has shown that only about 15% of male transsexuals and 90% of female transsexuals are considered suitable for surgery or still desire it after specialist psychiatric care and a prolonged period of observation used to identify the relatively rare “true” transsexual from the more common “secondary” transsexual.

Hormone therapy and sex-reassignment surgery are superficial changes in comparison to the major psychological adjustments necessary in changing sex. Treatment should concentrate on the psychological adjustment, with hormone therapy and sex-reassignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Psychiatric care may need to be continued for many years after sex-reassignment surgery. The technical success of sex-reassignment surgery is greater for male-to-female transsexuals than female-to-male transsexuals, and continues to improve as new techniques are developed. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the transsexual, and the support from family, friends, employers and the medical profession.

The above policy is based on the following references:

1. Becker S, Bosinski HA, Clement U, et al. Standards for treatment and expert opinion on transsexuals. The German Society for Sexual Research, The Academy of Sexual medicine and the Society for Sexual Science. Fortschr Neurol Psychiatr. 1998;66(4):164-169.
2. Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Harry Benjamin International Gender Dysphoria Association. Arch Sex Behav. 1985;14(1):79-90 and (Fifth Version) June 15, 1998.
3. Landen M, Walinder J, Lundstrom B. Clinical characteristics of a total cohort of female and male applicants for sex reassignment: A descriptive study. Acta Psychiatr Scand. 1998;97(3):189-194.
4. Schlatterer K, Yassouridis A, von Werder K, et al. A follow-up study for estimating the effectiveness of a cross-gender hormone substitution therapy on transsexual patients. Arch Sex Behav. 1998;27(5):475-492.
5. Midence K, Hargreaves I. Psychosocial adjustment in male-to-female transsexuals: An overview of the research evidence. J Psychol. 1997;131(6):602-614.
6. van Kesteren PJ, Asscheman H, Megens JA, et al. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol (Oxf). 1997;47(3):337-342.
7. Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997;31(1):39-45.
8. Bradley SJ, Zucker KJ. Gender identity disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36(7):872-880.
9. Luton JP, Bremont C. The place of endocrinology in the management of transsexualism. Bull Acad Natl Med. 1996;180(6):1403-1407.
10. Beemer BR. Gender dysphoria update. J Psychosoc Nurs Ment Health Serv. 1996;34(4):12-19.
11. Schlatterer K, von Werder K, Stalla GK. Multistep treatment concept of transsexual patients. Exp Clin Endocrinol Diabetes. 1996;104(6):413-419.
12. Breton J, Cordier B. Psychiatric aspects of transsexualism. Bull Acad Natl Med. 1996;180(6):1389-1393; discussion 1393-1394.
13. Hage JJ. Medical requirements and consequences of sex reassignment surgery. Med Sci Law. 1995;35(1):17-24.
14. Cole CM, Emory LE, Huang T, et al. Treatment of gender dysphoria (transsexualism). Tex Med. 1994;90(5):68-72.
15. Snaith RP, Hohberger AD. Transsexualism and gender reassignment. Br J Psychiatry. 1994;165(3):418-419.
16. Cohen-Kettenis PT, Kuiper AJ, Zwaan WA, et al. Transsexualism. II. Diagnosis: The initial, tentative phase. Ned Tijdschr Geneeskd. 1992;136(39):1895-1897.
17. Brown GR. A review of clinical approaches to gender dysphoria. J Clin Psychiatry. 1990;51(2):57-64.
18. Mate-Kole C. Sex reassignment surgery. Br J Hosp Med. 1989;42(4):340.
19. Gooren LJ. Transsexualism. I. Description, etiology, management. Ned Tijdschr Geneeskd. 1992;136(39):1893-1895.
20. Alberta Heritage Foundation for Medical Research (AHFMR). Phalloplasty in female-male transsexuals. Edmonton, AB: AHFMR; 1996.
21. Alberta Heritage Foundation for Medical Research (AHFMR). Vaginoplasty in male-female transsexuals and criteria for sex reassignment surgery. Edmonton, AB: AHFMR; 1997.
22. Best L, Stein K. Surgical gender reassignment for male to female transsexual people. Southampton, UK: Wessex Institute for Health Research and Development; 1998.
23. Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261.
24. Day P. Trans-gender reassignment surgery. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002.

Property of Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.