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View Public Comments for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N)

Chaudhry, Aneeka
Senior Health Program Planner
San Francisco Department of Public Health

December 31, 2015

Linda Gousis, J.D.
James Rollins, MD
The Centers for Medicare & Medicaid Services (CMS)

RE: CAG-00446N National Coverage Analysis for Gender Dysphoria and Gender Reassignment Surgery

Dear Ms. Gousis and Dr. Rollins,

Thank you for the opportunity to submit comments on the development of a National Coverage Determination (NCD) for Gender Reassignment Surgery. The San Francisco Department of Public Health (SFDPH) strongly supports this NDC endeavor and offers the information below based on our extensive experience providing transition-related surgeries and services.

Having long cared for persons across the Trans spectrum in our system of care, San Francisco became the first city in the United States to provide gender confirming surgery, at a time when Medicare did not deem the procedure medically necessary. Through our Transgender Health Services, we facilitate access to gender confirming surgeries and education and preparation services for transgender, transsexual, and gender non-conforming public health patients in San Francisco. We have three years of experience administering gender confirmation programs for Medicaid beneficiaries and people who do not have health insurance at the time of their surgery.

Our Transgender Health Services program has successfully completed ninety-seven surgeries since September 2013. Our experience mirrors the available peer-reviewed empirical research, which suggests that access to gender confirming surgery decreases gender dysphoria and may improve quality of life. Among the patients in our program, access to gender confirming surgery and other medically necessary care results in health improvement and other positive outcomes. Gender dysphoria, which is the clinical and emotional distress experienced when an individual's gender identity is different from their sex reported at birth, negatively impacts social and vocational functioning and self-esteem.

SFDPH Transgender Health Services offers transgender women access to breast feminization/augmentation and genital surgeries. Masculine spectrum surgeries include chest reconstruction and revisions, metiodioplasty and phalloplasty. All genital surgeries require hair removal from the graft sites prior to surgery, and we have also been able to help patients receive facial hair removal through our local public health plan.

The necessity of providing gender confirmation surgeries is evident in the gratitude expressed by our clients. Routinely, clients report a sense of happiness, empowerment, and completion. Some examples include:

"Thank you for my penis. Before chest surgery/double mastectomy and phalloplasty, daily activities like urinating and bathing would provoke an anxiety that infected every other facet of my life. Surgery access has allowed me to plan, and long for, a future." "I'm ten times happier with my life." "After surgery I felt more beautiful, more womanly, more complete, more positive." "I experienced freedom and empowerment" "I feel complete." "Emotional turmoil and pain of being in the wrong body subsided which is amazing and awesome." "Ifm so lucky to live in San Francisco where we have these surgeries."

When developing the Medicare National Coverage Determination on Gender Reassignment Surgery, we recommend that CMS consider the points enumerated below. These recommendations are grounded in our years of administering the Transgender Health Services program and lessons learned along the way.

  1. Transgender people need to have access to medical and surgical interventions that decrease their gender dysphoria and assist them in functioning as their identified gender in all areas of life. The paradigm of providing transgender people with surgeries that were available for cisgender people is not clinically based, rather it is a civil rights strategy. Clinically, transgender women may need to have facial feminization surgeries or breast feminization procedures that have not historically been available to cisgender women. It is important for CMS to cover surgeries and treatments that permit transgender women to participate fully in life as women and that permit transgender men to participate fully as men. People who are genderqueer may also require surgical interventions to decrease their dysphoria.
  2. All of the following medically necessary procedures should be covered:
    • Facial Feminization Surgeries
    • Vaginoplasty, labiaplasty, vulvoplasty
    • Breast feminization/augmentation
    • Orchiectomy
    • Revision surgeries when needed
    • Hair removal from the face, neck, breasts, and genital region prior to gender confirmation surgeries.
    • Chest reconstruction
    • Metoidioplasty and scrotoplasty
    • Phalloplasty, testicular implants, and erectile devices
    • Hysterectomy/salpingo-oophorectomy
    • Urethral reconstruction including lengthening where indicated
  3. Patient and provider education is critical. Transition can sometimes be a multi-year process, and both the clients and providers need adequate preparation. Each client is a unique individual and must be sufficiently supported to decide for themselves the personal cost and potential benefits of various surgical interventions.
  4. Programs need to be comprehensive and multidisciplinary, and ongoing clinical case management pre- and post-surgery is vital. Successful surgeries are based on solid partnerships between the patient, the provider, and the care management team. SFDPH Transgender Health Services makes a significant effort to train provider teams to ensure a continuum of care for the client pre- and post-surgery.
  5. Transgender people accessing public health care services are disproportionately affected by stigma and discrimination and are less well-resourced. Many patients cannot afford to pay for non-covered medical supplies or travel related to aftercare, and may need extra support due to isolation, poverty and medical/mental health issues. Patients may not have a home to go to, may not have family or friends to assist in their recovery, may lack the financial resources to purchase medical supplies that are not covered, and may need transportation assistance. These issues should be mitigated by care coordination and social programs. Clinical case management and follow-up are critically important.
  6. Some surgeries require revisions and these revisions must also be covered by Medicare. The peer-reviewed literature suggests that unaddressed complications result in increased psychological distress. Barriers to revision surgery essentially prevent transgender persons from moving on with healthy, productive lives.
  7. Patients and providers need assistance navigating the healthcare system and the insurance requirements. The administrative process for successful coverage approvals is cumbersome and confusing for both patients and providers. Billing and coding guidelines must be clearer and easy to follow. The uniform treatment of claims may decrease the need for appeals and reduce or even eliminate the distress caused by denials. Providers need additional support to properly and efficiently navigate the administrative challenges, which often add unnecessary barriers to care. When providers do not have clear paths forward for medically necessary treatments, patients experience unnecessary stress and an undue burden is placed on the system of care.
  8. Gender reassignment eligibility requirements should mirror clinical treatment goals. The World Professional Association of Transgender Health (WPATH) Standards of Care outline the eligibility requirements for transgender-related medical and mental health services, and these Standards are central to the care operations in San Francisco. Genital surgery, for example, requires two letters from mental health professionals; and one letter is required for chest and breast surgery. One of the areas we are currently working to improve are the eligibility requirements for gender non-conforming and genderqueer people. These individuals may also need access to surgical interventions; however, the service eligibility requirements for people identified outside of a gender binary structure are often not as clear to providers as they are for transgender men and women.

In sum, the goals of medically necessary surgical interventions for transgender, transsexual, gender non-conforming, and genderqueer people are to decrease gender dysphoria and to increase the likelihood that the person can more fully participate in society. An NCD on Gender Reassignment Surgery must cover all related medically necessary procedures; surgical eligibility requirements should mirror clinical treatment goals; patients should be well-prepared for surgery and educated about the risks and potential benefits; and patients should also receive ongoing clinical case management before surgery and throughout the recovery period.

The San Francisco Department of Public Health appreciates the opportunity to share our experiences and to offer the comments above. As CMS develops this highly important NCD, which has the capacity to change many peoplefs lives for the better, we are happy to offer further assistance. If you have any questions or need clarifications, please contact Julie Graham, Interim Director of SFDPH Transgender Health Services, at or (415) 642-4519.


Barbara A. Garcia
Director of Health
San Francisco Department of Public Health