A Comprehensive Guide to Top Surgery

If you have a private insurance plan, such as through an employer or Healthcare.gov, your plan documents should include in-network providers who can perform the surgery, and one may offer partial coverage for an out-of-network provider. If you go this route, you might be billed directly and will then need to seek reimbursement through your insurance company.If you have Medicaid, it’s possible your surgery will be covered, but it depends on where you live. (You can see if Medicaid in your state covers transition-related care here.) As of 2014, Medicare covers medical transition-related surgery.What if I don’t have health insurance?Not everyone seeking top surgery has insurance or can get their carrier to cover their surgery. According to a recent report from the Centers for Disease Control and Prevention (CDC), 31.6 million—that’s almost 10%—of people in the US were uninsured in 2020. Additionally, transgender people face higher unemployment and poverty rates compared to cisgender people which makes them more likely to be un- or underinsured. If you fall into that category, one option is to seek out community funding to cover the cost of the procedure, as well as related costs like transportation and meals while you recover. There are grants you can apply for, such as Point of Pride’s Annual Trans Surgery Fund, the Jim Collins Foundation grant, and others. Another option, though no one should have to do this, is raising money for your surgery using crowdfunding. For help with insurance, check out the legal resources compiled by T4T Caregiving, which includes services that help people get their gender-affirming treatments covered.Does my top surgery need to be “approved” in some way?Between barriers to gender-affirming care (caused by stigma, lack of provider awareness, and other systemic issues) and the administrative process of getting any medical care covered by insurance, pursuing top surgery can seem frustratingly complex. The gatekeeping around who should be allowed to receive gender-affirming care is detrimental and actively prevents people from getting the treatments they need. With that in mind, familiarizing yourself with what’s ahead and knowing how to access resources and required paperwork will demystify the process and make it more accessible. Let’s get into it. First, you should know a few things about WPATH: The World Professional Association for Transgender Health is a professional organization made up of clinicians and researchers working in medicine, psychology, law, social work, counseling, psychotherapy, nursing, and other disciplines dedicated to understanding and treating gender dysphoria. They publish a comprehensive document called the Standards of Care (SOC) that contains clinical guidance for health care professionals who treat transgender and gender-diverse people. Loren Schechter, MD, medical director of the Gender Affirmation Surgery Program at Rush University Medical Center serves on WPATH’s executive committee. He tells SELF that the SOC are intended to be used to “help provide a framework” for how health care providers should offer gender-affirming treatment. One thing the SOC do is make recommendations for what criteria a person should meet before being approved for gender-affirming care, like hormone therapy or surgery. Over the years, WPATH criteria have been criticized by trans and gender-diverse people because of the barriers it can pose to getting treatment. And even though, as Dr. Schechter explains, health care providers and insurance companies are not required to follow the SOC, many do use them for guidance. As a result, your surgeon’s office may require you to meet some (or all) of the criteria for surgery established by the SOC. Unfortunately, many surgeons will not move forward without documentation that certain criteria have been met (typically in the form of a letter from another doctor or a therapist or other mental or behavioral health provider). So what are the criteria? According to the latest update to the SOC (SOC 8, which was released in September 2022), criteria include “marked and sustained” gender incongruence, an understanding of the effects of gender-affirming surgery, identifying and ruling out other possible causes of “apparent gender incongruence,” the ability to consent to surgery, and more. You can see the full list here, but keep in mind that the most important thing to determine is what, specifically, from these guidelines your doctor and insurance company (if applicable) will require in order to have your surgery approved. How can I go about getting the approvals I need for surgery?Some folks have affirming primary care providers and/or therapists who will happily write a letter to a surgeon and/or insurance company as needed stating that a person meets all the criteria for gender-affirming surgery. Others may not have access to health care providers at all, let alone affirming ones. And other providers require you receive specific treatment (like therapy, for example), before they’ll write the letter, and that might not be something you can afford. The good news is that there are some resources that can help fill this gap. The Gender-Affirming Letter Access Project (GALAP) is a group of transgender, nonbinary, and allied mental health providers working to increase access to free letters for trans and gender-diverse people who need them. GALAP’s directory can help you find a provider who has signed GALAP’s pledge that they’ll provide free, accessible documentation and don’t believe in institutional gatekeeping for trans and gender-diverse people. How do I find a good surgeon?First, make sure that any prospective surgeons are board certified in plastic surgery and meet the rest of the criteria listed by the American Society of Plastic Surgeons. Dr. Liebman also recommends choosing a surgeon who has experience not just as a plastic surgeon but with top surgery specifically, who he says “have the best toolbox for multiple different types of procedures to accomplish top surgery.” 

If you have a private insurance plan, such as through an employer or Healthcare.gov, your plan documents should include in-network providers who can perform the surgery, and one may offer partial coverage for an out-of-network provider. If you go this route, you might be billed directly and will then need to seek reimbursement through your insurance company.

If you have Medicaid, it’s possible your surgery will be covered, but it depends on where you live. (You can see if Medicaid in your state covers transition-related care here.) As of 2014, Medicare covers medical transition-related surgery.

What if I don’t have health insurance?

Not everyone seeking top surgery has insurance or can get their carrier to cover their surgery. According to a recent report from the Centers for Disease Control and Prevention (CDC), 31.6 million—that’s almost 10%—of people in the US were uninsured in 2020. Additionally, transgender people face higher unemployment and poverty rates compared to cisgender people which makes them more likely to be un- or underinsured. 

If you fall into that category, one option is to seek out community funding to cover the cost of the procedure, as well as related costs like transportation and meals while you recover. There are grants you can apply for, such as Point of Pride’s Annual Trans Surgery Fund, the Jim Collins Foundation grant, and others. Another option, though no one should have to do this, is raising money for your surgery using crowdfunding. 

For help with insurance, check out the legal resources compiled by T4T Caregiving, which includes services that help people get their gender-affirming treatments covered.

Does my top surgery need to be “approved” in some way?

Between barriers to gender-affirming care (caused by stigma, lack of provider awareness, and other systemic issues) and the administrative process of getting any medical care covered by insurance, pursuing top surgery can seem frustratingly complex. The gatekeeping around who should be allowed to receive gender-affirming care is detrimental and actively prevents people from getting the treatments they need. With that in mind, familiarizing yourself with what’s ahead and knowing how to access resources and required paperwork will demystify the process and make it more accessible. Let’s get into it. 

First, you should know a few things about WPATH: The World Professional Association for Transgender Health is a professional organization made up of clinicians and researchers working in medicine, psychology, law, social work, counseling, psychotherapy, nursing, and other disciplines dedicated to understanding and treating gender dysphoria. They publish a comprehensive document called the Standards of Care (SOC) that contains clinical guidance for health care professionals who treat transgender and gender-diverse people. Loren Schechter, MD, medical director of the Gender Affirmation Surgery Program at Rush University Medical Center serves on WPATH’s executive committee. He tells SELF that the SOC are intended to be used to “help provide a framework” for how health care providers should offer gender-affirming treatment. 

One thing the SOC do is make recommendations for what criteria a person should meet before being approved for gender-affirming care, like hormone therapy or surgery. Over the years, WPATH criteria have been criticized by trans and gender-diverse people because of the barriers it can pose to getting treatment. And even though, as Dr. Schechter explains, health care providers and insurance companies are not required to follow the SOC, many do use them for guidance. As a result, your surgeon’s office may require you to meet some (or all) of the criteria for surgery established by the SOC. Unfortunately, many surgeons will not move forward without documentation that certain criteria have been met (typically in the form of a letter from another doctor or a therapist or other mental or behavioral health provider). 

So what are the criteria? 

According to the latest update to the SOC (SOC 8, which was released in September 2022), criteria include “marked and sustained” gender incongruence, an understanding of the effects of gender-affirming surgery, identifying and ruling out other possible causes of “apparent gender incongruence,” the ability to consent to surgery, and more. You can see the full list here, but keep in mind that the most important thing to determine is what, specifically, from these guidelines your doctor and insurance company (if applicable) will require in order to have your surgery approved. 

How can I go about getting the approvals I need for surgery?

Some folks have affirming primary care providers and/or therapists who will happily write a letter to a surgeon and/or insurance company as needed stating that a person meets all the criteria for gender-affirming surgery. Others may not have access to health care providers at all, let alone affirming ones. And other providers require you receive specific treatment (like therapy, for example), before they’ll write the letter, and that might not be something you can afford. The good news is that there are some resources that can help fill this gap. The Gender-Affirming Letter Access Project (GALAP) is a group of transgender, nonbinary, and allied mental health providers working to increase access to free letters for trans and gender-diverse people who need them. GALAP’s directory can help you find a provider who has signed GALAP’s pledge that they’ll provide free, accessible documentation and don’t believe in institutional gatekeeping for trans and gender-diverse people. 

How do I find a good surgeon?

First, make sure that any prospective surgeons are board certified in plastic surgery and meet the rest of the criteria listed by the American Society of Plastic Surgeons. Dr. Liebman also recommends choosing a surgeon who has experience not just as a plastic surgeon but with top surgery specifically, who he says “have the best toolbox for multiple different types of procedures to accomplish top surgery.” 

This article was originally published on this site

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