Finally Dana

One of the many wonderful things about being transgender in 2019 is the myriad medical interventions available to me, many of which are covered by insurance. One operation in particular is not due to its apparent lack of “medical necessity.”

Gender dysphoria is a complicated and difficult to describe condition. The DSM-V defines it as “a marked incongruence between one’s experienced/expressed gender and assigned gender” (DSM-V, n.a, 2013). While useful, this definition does not adequately describe the myriad factors involved in a persons individual experience of gender dysphoria. 

The incongruence experienced by transgender individuals may be centered around particular physical aspects, and the treatment of them may require surgical intervention. Traditionally, the basis of most surgical care has been centered around the gender dysphoria associated with the genitalia (Benjamin, 1954). However, many aspects related to the masculinization or feminization of a persons body through puberty may be a basis for significant dysphoria and mental distress.

The World Professional Association for Transgender Health (WPATH) publishes a document titled the Standards of Care (SOC) in order to provide guidance for the medical care and treatment of transgender individuals. The current edition (v.7) published in 2012 recommends Hormone Replacement Therapy (HRT) as well as the surgical interventions of gender reassignment surgery and chest feminization and masculinization. It neglects to explicitly recommend facial gender confirmation surgery (formally facial feminization surgery) however.

“While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive…for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is more medically necessary than for somebody without gender dysphoria” (WPATH, V.7, p. 58).

The document goes on to recommend surgical intervention for chest and genitals but leaves facial gender confirmation surgery delegated to “other surgeries.” It does contain a small nod to the  possible medical necessity of the operation by stating “Although most of these procedures are generally labeled “purely aesthetic,” these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient’s conditions and life situation” (WPATH soc, V.7, p.64). 

While I am grateful the document guiding all trans care deigned to acknowledge the possible medical necessity of facial gender confirmation surgery, I am stunned at its ambiguity. My personal struggle with gender dysphoria is far more centered around my face than anything else. I refuse to look in the mirror if I can help it and when I need to shave, I do it in the shower. I can be in a good mood and catch my reflection in a window and immediately spiral into despondency. A person’s face is what they present to the world. It is the most important feature involved in the presentation of a transgender persons true identity. I am stunned that the organization devoted to transgender care would compare the pain of gender dysphoria associated with secondary sex characteristics in a persons face with someone desiring a nose reduction. 

Tiffany Ainsworth and Jeffery Spiegel published a study comparing the quality of life of individuals with and without facial feminization surgery. This first of its kind research showed that trans women who underwent surgical intervention showed a statistically significant positive impact in their mental health-related quality of life stating that “perhaps the most significant finding of this survey has been to demonstrate the potential benefits of facial feminization to transgender patients. Indeed the individuals perception of success in achieving a more feminine face is more important than any objective evaluation of acceptable cosmesis” ( Ainsworth and Spiegel, 2010 p. 1023).

Fortunately, there is hope on the horizon for the long awaited SOC V.8. In their article, titled “Facial gender confirmation surgery-review of the literature and recommendations for Version 8 of the WPATH Standards of Care” Jens Berli and colleagues synthesize the research and state “FGCS can no longer be deemed as an aesthetic component of gender confirming care” (p.4). If this recommendation is followed, then perhaps the damage wrought by the current version may be somewhat undone. 

I am sharing this with you because on Thursday I was denied authorization to proceed with Facial Gender Confirmation Surgery. My insurance states that they comply with the WPATH standards of care and would not cover what to me, is a medically necessary and life changing procedure. “This request has been denied for the following reasons: Secondary procedures done for cosmetic reasons to enhance the physical appearance or to more closely meet the desired physical characteristics of the reassigned gender…are nor covered per policy” (denial letter, p. 1).

Cosmetic reasons. My need for this surgery is so far beyond “cosmetic” but the WPATH SOC allows insurance companies to deny life saving medical procedures such as this. I do not want to look like a movie star. All I want is for the damage done to my face by years of testosterone exposure to be removed. 

I am fighting this decision. I am using various avenues and I will prevail. This surgery is more important to me then genital reassignment or chest feminization. I will reach a point that the person in the mirror matches who I am inside and I will not allow backwards assumption of what is and isn’t cosmetic to stop me. In the meantime, I am continuing to avoid mirrors and windows and only shaving in the shower because the procedure most important to my quality of life has been deemed not medically necessary.