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Submitting Appropriately for Breast Surgery in Transmasculine Patients

Ganor, Oren M.D.; Boskey, Elizabeth R. Ph.D.

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Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 254e
doi: 10.1097/PRS.0000000000005159
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Sir:

Studies estimate that there are more than 1 million transgender and gender dysphoric individuals living in the United States alone.1 Individuals with gender dysphoria experience intense discomfort because of identifying as a gender that is different from how they are perceived by society and/or the gender commonly associated with their physiologic sex. Medical treatment for gender dysphoria focuses on addressing sources of somatic discomfort. This is done through whatever combination of surgical and medical options are necessary and appropriate to address an individual’s dysphoria. In most but not all cases, the initial medical treatment involves cross-sex hormone therapy and/or medications that block the effects of endogenous hormones. This may be followed by one or more gender-affirming operations.

Transmasculine individuals are individuals who were assigned female at birth but have a masculine gender identity. According to a large national survey of transgender individuals, almost three-quarters (72 percent) of transgender men have had or want chest reconstruction surgery, as do approximately half of transmasculine nonbinary patients.2 Chest reconstruction and breast reduction are both procedures to reduce the size of the breast in natal girls, but they have fundamentally different indications and require different documentation.

Patients are considered to be appropriate for breast reduction surgery when they experience somatic symptoms caused by breast hypertrophy. Documentation of these symptoms, and the volume of tissue to be removed, is required for the procedure to be approved by insurance companies.3 In contrast, gender dysphoria is the sole indicator for chest reconstruction, and documentation of that dysphoria is critical to providing appropriate care for the transmasculine patient. According to the standards of care published by the World Professional Association of Transgender Health, to access chest reconstruction, patients must be referred by a behavioral health provider and primary care provider who are able to document persistent gender dysphoria. Patients also are required to present with documentation that any significant medical and mental health conditions are well controlled and that they have the capacity to make a fully informed decision and give consent for treatment.4 Reviewing this required documentation can help the surgeon to feel more confident in the appropriateness of this gender-affirming surgery and address concerns about psychosocial issues transgender patients may face during recovery.

Plastic surgeons unfamiliar with transgender patients may be unaware of the different clinical indications for breast reduction and chest reconstruction, which has the potential to lead both to difficulty receiving authorizations and to inappropriate clinical care. When gender dysphoric patients present for breast or chest surgery, it is imperative that surgeons assess their goals and intentions for surgery and determine whether they are seeking breast reduction or chest reconstruction to submit the appropriate information with the insurance authorization. Such assessment also has the potential to reduce the risk that a gender dysphoric patient might need additional surgery to create a masculine chest contour when a reduction has been performed where a chest reconstruction would have been more appropriate. Performing a chest reconstruction secondary to a breast reduction both complicates the surgical plan and provides less favorable outcomes for patients.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Oren Ganor, M.D.
Elizabeth R. Boskey, Ph.D.
Department of Plastic and Oral Surgery
Boston Children’s Hospital
Boston, Mass.

REFERENCES

1. Meerwijk EL, Sevelius JM. Transgender population size in the United States: A meta-regression of population-based probability samples. Am J Public Health 2017;107:e1e8.
2. James SE, Herman JL, Rankin S, Keisling M, Mottet M, Anafi M. The Report of the 2015 U.S. Transgender Survey. Available at: http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf. Accessed October 2, 2017.
3. American Society of Plastic Surgeons. ASPS recommended insurance coverage criteria for third-party payers: Reduction mammaplasty. Available at: https://www.plasticsurgery.org/Documents/Health-Policy/Reimbursement/insurance-2017-reduction-mammaplasty.pdf. Accessed March 13, 2018.
4. World Professional Association of Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011. 7th Version. East Dundee, Ill: World Professional Association of Transgender Health; Available at: https://www.wpath.org/publications/soc. Accessed September 3, 2017.

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