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. Requirements for mastectomy for female-to-male patients:

   1. Single letter of referral from a qualified mental health professional (see appendix); and
   2. Persistent, well-documented gender identity disorder (see appendix); and
   3. Capacity to make a fully informed decision and to consent for treatment; and
   4. Age of majority (18 years of age or older); and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

   Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

2. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):

   1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
   2. Persistent, well-documented gender identity disorder (see appendix); and
   3. Capacity to make a fully informed decision and to consent for treatment; and
   4. Age of majority (18 years or older); and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
   6. Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones)

3. Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female)

   1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
   2. Persistent, well-documented gender identity disorder (see appendix); and
   3. Capacity to make a fully informed decision and to consent for treatment; and
   4. Age of majority (age 18 years and older); and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
   6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
   7. Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic.

Note on gender specific services for transgender persons:

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

1. Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
2. Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.

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.  The therapeutic approach to gender identity disorder consists of three parts: a real life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics (Day, 2002). The most typical order, if all three elements are undertaken, is hormones followed by real life experience and, finally, surgery.

For male to female transsexuals selected for surgery, procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, laryngeal shaving, vocal cord shortening, hair transplants) (Day, 2002). For female to male transsexuals, surgical procedures may include genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, chest wall contouring and cosmetic surgery (Day, 1992).

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.

Appendix

Table 1: DSM IV-TR criteria for the diagnosis of gender identity disorder in adolescents and adults:

1. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).  In adolescents and adults, the disturbance in manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex; and
2. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.  In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary se characteristics (e.g. request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex; and
3. The disturbance is not concurrent with a physical intersex condition; and
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Table 2: Format for referral letters from Qualified Health Professional: (From SOC-7)

1. Client’s general identifying characteristics; and
2. Results of the client’s psychosocial assessment, including any diagnoses; and
3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; and
4. An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; and
5. A statement about the fact that informed consent has been obtained from the patient; and
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

Note:  There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.  When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.

Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Table 3: Characteristics of a Qualified Mental Health Professional: (From SOC-7):

1. Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board.  The professional should also have documented credentials from the relevant licensing board or equivalent; and
2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and
3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; 
4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
5. Continuing education in the assessment and treatment of gender dysphoria.  This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.