OHPTaskForce:DraftpolicyguidelinesforOHP

ByBasicRightsOregonOHPTaskForce

June2015

Introduction
This best practice documenthasbeencreatedincoalitionwithhealthcareadvocates,community
members, health care professionals, and other partners. The goal of this document is to provide
CCOs and health plans with guidelines and best practice policies to help them adopt and
standardize affirming and culturally competent transgender health care services throughout
Oregon.
BackgroundonOHPTransHealthPolicy
The Health Evidence Review Commission (HERC) voted to update and modernize coverage of
treatment for gender dysphoria in August of 2014 to meet current standards of care as
recommended by the American Medical Association and every other leading medical
association.

Effective January 1, 2015, the Oregon Health Plan (OHP) is required to cover
lifesaving treatments for transgender Oregonians that are deemed medically necessary for the
patient. The HERC in 2014 modifiedandupdatedtheprioritylistofhealthservicesthataddress
gender dysphoria. These updates can be found in this document. Treatments for gender
dysphoria include gender affirming counseling, gender affirming hormones (also referred to as
hormone replacement therapy or crosssex hormone therapy) and gender affirming surgeries
(also known as gender reassignment or sex reassignment surgeries). The HERC policy was
developed using the World Professional Association for Transgender Health (WPATH)
standardsofcareandtheEndocrineSocietyasmodelsforcare.
The new HERC OHP health care policy makes it possible for transgender people to obtain
medicallynecessarytranshealthcaretreatmentsbeginningJanuary 1, 2015. However,therehave
been implementation challenges with ensuring that this policycanfullymeetthehealthneedsof
all transgender individuals on Medicaid in Oregon. We hope this document will help address
implementation challenges and help all transgender peoplewithOHPtoaccesstheirtransgender
healthbenefitsandreceiveculturallycompetentandaffirmingservices.

TransgenderTerminology
(NCTE)
Transgender
:Someonewhosegenderidentitydeviatesorisdifferentfromtheirmedically
assignedsexatbirthandthebehaviorsandgenderexpressionassociatedwiththatassignedsex.

Alsoreferredtoastranssexualinmedicalliterature."Trans"isshorthandfor"transgender."
(Note:Transgenderiscorrectlyusedasanadjective,notanoun.)
GenderDysphoria
:Genderdysphoriaisaconditionofdistresscausedbythediscrepancy
betweenapatientsassignedsexatbirthandtheirgenderidentityandthewaysotherpeople
perceivetheirbodies.
TransgenderMan
:Amanwhowasassignedfemaleatbirthandidentifiesandlivesasaman.
Transitioningforatransgendermanoftenincludesmasculinizinghormonereplacementtherapy
andsurgeriesspecificallyaddressingtheirgenderdysphoria(surgeriesoutlinedinthis
document).Alsoreferredtoas
FTM
(femaletomale)inmedicalliterature.
TransgenderWoman
:Awomanwhowasassignedmaleatbirthandidentifiesandlivesasa
woman.Transitioningforatransgenderwomanoftenincludesfeminizinghormonereplacement
therapyandsurgeriesspecificallyaddressingtheirgenderdysphoria(surgeriesoutlinedinthis
document).Alsoreferredtoas
MTF
(maletofemale)inmedicalliterature.
GenderIdentity
:Apersonsinternalsenseofbeingaman,awoman,oranothergender.Since
genderidentityisinternal,onesgenderidentityisnotnecessarilyvisibletoothers.Everyonehas
agenderidentity.
SexReassignmentSurgery
:Surgicalproceduresthatreconstructandreshapethegenitalsand
otherfeaturesofatransgenderpatientsbodytobetterreflectapersonsgenderidentityandto
addresstheirgenderdysphoria.Alsoknownasgenderreassignmentorgenderaffirming
surgery.
Genderqueer
:Atermusedbysomeindividualswhoidentifyasneithermanorwoman.
GenderNonconforming
:Atermforindividualswhosegenderexpressionisdifferentfrom
societalexpectationsrelatedtotheirgender.Transgenderpeoplecanbeeithergender
conformingorgendernonconformingfortheirgenderidentity,butarenotinherentlygender
nonconformingforbeingtransgender.Beinggendernonconformingalsodoesnotmeanyou
aretransgenderandaretwoseparateaspectsofanindividualsidentity.
Discriminationfacedbytransgenderpeople
Transgender people face high rates of discrimination, violence andhealthdisparities.According
to the
2011 National Trans Discrimination Survey
, 41% of respondents reported attempting
suicidecomparedto1.6%of thegeneralpopulation,withratesrisingforthosewholostajobdue
to discrimination (55%), were harassed/bullied in school (51%), had low household income,
have been the victims of physical assault (61%) or sexual assault (64%). Transgender people
face discrimination is every aspect of daily life including when accessing health care. Health
outcomes for all transgender respondents demonstrate the appalling effects of social and
economic marginalization, including much higher rates of HIV infection, smoking, drug and
alcoholuseandsuicideattemptsthanthegeneralpopulation.

Refusal of care: 19% of our sample reported being refused medical care due to their
transgender orgender nonconformingstatus,withevenhighernumbersamongpeopleof
colorinthesurvey.
Uninformed doctors: 50% of the sample reported having to educate their medical
providersabouttransgendercare.
High HIV rates: Respondents reported over four times the national average of HIV
infection,withrateshigheramongtransgenderpeopleofcolor.
Postponed care: Survey participants reported that when they were sick or injured, many
postponedmedicalcareduetodiscrimination(28%)orinabilitytoaffordit(48%).(2011
NationalTransDiscriminationSurvey)

TransgenderOregoniansfaceappallingeconomicinstability:17%oftransgenderOregonians
hadahouseholdincomeof$10,000orless,comparedtoonly4%ofthegeneralnational
population.Thisisalmostfourtimestherateofpoverty.(
NationalTransDiscriminationSurvey:
Oregon
)
Duetodiscrimination,violenceandhealthdisparities,transgenderpeoplefacehighmortalityand
morbidityrates.However,ametaanalysisof28studiesshowsthataftersurgicaltransition,80%
oftransgenderindividualsreportedasignificantimprovementintheirpsychologicalsymptoms
and80%reportedanincreaseintheirqualityoflife(Muradetal.2010).Thereportalsorevealed
thatafterreceivingtransitionrelatedcare,suicideratesamongtranspeopledroppedfromarange
of2919%beforetransitionto6%0.8%afterreceivingcare.(Muradetal.2010).Accessto
transitionrelatedhealthservicesislifesavingandessentialtoreducinghealthdisparitiesand
mortality/morbidityratesfortransgenderpeople.

WPATHandBestPracticesofTreatingGenderDysphoria
ThebestpracticespresentedinthisdocumentarebasedonWPATHstandardsofcareandare
compliantwiththeHERCpolicyfortreatingofgenderdysphoria(withanemphasisonprovider
discretionandinformedconsent).Thegoalofthesebestpracticesaretostandardizelowbarrier
accesstolifesavingcarefortransgenderpeoplethatcanbeadoptedacrossOregon.TheWPATH
recommendsthatpatients,engagein12continuousmonthsoflivinginagenderrolethatis
congruentwiththeirgenderidentity...priortogenderreassignmentsurgerysothatpatientsmay
sociallyadjusttotheirdesiredgenderrole.[7]WPATHnotesthatchangingagenderrolemay
havepersonalandsocialconsequenceswhichshouldbeadequatelyexploredpriortoundergoing
anirreversiblesurgery.Itisimportanttonotehoweverthatthereareprovisionsinthepolicy
allowingproviderdiscretionregardingtheamountoftimeonhormonesand/orlivedexperience
beforesurgery,etc.thatarenecessarybecausedelaycanbeunsafeorevenlifethreateningfor
manytransgenderindividuals.Providerdiscretiononthesestandardsisveryimportanttoensure
patientsanddoctorshavetheabilitytoproceedwithlifesavingmedicallynecessarytreatment.
BelowaretheofficialHERCpolicyguidelines,whicharefollowedbyourbestpractices
recommendationsforpolicyimplementation.

HERC POLICY: Treatment for Gender Dysphoria 2014

To qualify for cross-sex hormone therapy, the patient must:
1. have persistent, well-documented gender dysphoria
2. have the capacity to make a fully informed decision and to give consent for
treatment under Oregon law
3. have any significant medical or mental health concerns reasonably well controlled
4. have a thorough psychosocial assessment by a qualified mental health
professional with experience in working with patients with gender dysphoria

What are the requirements to qualify for sex reassignment surgery?

Sex reassignment surgery is included for patients who meet eligibility criteria. To qualify
for surgery, the patient must:
1. have persistent, well documented gender dysphoria
2. have completed twelve months of continuous hormone therapy as appropriate to
the members gender goals unless hormones are not clinically indicated for the
individual
3. have completed twelve months of living in a gender role that is congruent with
their gender identity unless both a medical and a mental health professional
determine that this requirement is not safe for the patient
4. have the capacity to make a fully informed decision and to give consent for
treatment under Oregon law
5. have any significant medical or mental health concerns reasonably well controlled
6. have two referrals from qualified mental health professionals with experience in
working with patients with gender dysphoria who have independently assessed
the patient. Such an assessment should include the clinical rationale supporting
the patients request for surgery.

BestPracticestoAccessingTransgenderHealthBenefitswithOHP
Step1)Assessments
AssessmentofgenderdysphoriabyaQualifiedMentalHealthPractitioner(QMHP).
Firstassessment:
TheHERCpolicyrequiresadiagnosisofgenderdysphoriainordertobegin
treatment.Thediagnosisofgenderdysphoriacanbediagnosedbyathoroughpsychological
assessmentbyaQualifiedMentalHealthPractitioner.Therearemanymedicalandmental
healthprofessionalsthatqualifyasQMHPsincludingoccupationaltherapistsandnurses.Ideally,
primarycareproviders(PCPs)canalsodiagnosegenderdysphoriausingICD9codesrelatedto
genderidentitydisorder.AuthorizingPCPstoassesstransgenderpeoplebydiagnosiscodes
willalsolowerbarrierstocareandthiscanbebilledasanassessmentvisit.
Bestpracticeswiththeassessmentofgenderdysphoria

TheassessmentofgenderdysphoriaisperformedbyaQMHPthatcantodothefollowing:
1. Diagnosepersistentandongoinggenderdysphoria.
2. Evaluateanddocumenthistoryofgenderdysphoria.
3. Determinetheindividualscapacitytomakeafullyinformeddecisionandtogive
consentfortreatment.
4. Determineiftheindividualhasanyhealthconditionsthatneedtobestabilizedbefore
treatmentscanbegin.Iftheydohavehealthconditionsthatneedtobestabilized,this
shouldbenotedinthetreatmentplan.Theythenshouldbereferredtomedicalandmental
healthservicesinadditiontotransgenderhealthservices.
5. Developatreatmentplanwiththepatienttoidentifywhatpossibletreatmentsmaybe
medicallynecessaryforthepatienttobegintoreducegenderdysphoria.
6. Providethemwithresourcesandreferralstomedicalprofessionals.
7. Issueastandardlettertothepatientthatthepersonshealthplanwillrecognizeas
documentationofthediagnosisofgenderdysphoria.
IftheQMHPisnotabletoprovideagenderdysphoriatreatmentplanfortheindividual,
theindividualshouldbereferredtoaPCPorotherproviderwhocandevelopthe
treatmentplan.
Theassessmentofgenderdysphoriaanddevelopmentofatreatmentplanmayinvolveoneto
threesessions.
WhoisaQMHP?
AccordingtoOAR3090321505:(105),a"QualifiedMentalHealthProfessional(QMHP)"
meansaLMPoranyotherpersonmeetingoneormoreofthefollowingminimumqualifications
asauthorizedbytheLMHAordesignee:
(a)BachelorsdegreeinnursingandlicensedbytheStateofOregon
(b)BachelorsdegreeinoccupationaltherapyandlicensedbytheStateofOregon
(c)Graduatedegreeinpsychology
(d)Graduatedegreeinsocialwork
(e)Graduatedegreeinrecreational,art,ormusictherapyor
(f)Graduatedegreeinabehavioralsciencefield.

Additionally,OAR3090321520(2)(f)definesminimumcompetenciesforQMHPs:"QMHPs
mustdemonstratetheabilitytoconductanassessment,includingidentifyingprecipitatingevents,
gatheringhistoriesofmentalandphysicalhealth,alcoholandotherdruguse,pastmentalhealth
servicesandcriminaljusticecontacts,assessingfamily,culturalsocialandworkrelationships,
andconductingamentalstatusexamination,completeafiveaxisDSMdiagnosis,writeand
supervisetheimplementationofaISSPandprovideindividual,familyorgrouptherapywithin
thescopeoftheirtraining.

Secondassessment:
Ifsurgeriesaredeemedmedicallynecessary,theindividualwillneedan
additionalassessmentcompletedbyasecondQMHP.Inadditiontothesecondassessment,there

maybeothersurgerypreparationrequirementsneededsuchasamedicalphysicalexamand
othermedicaltestsdependingonthesurgeryandsurgeon.
Resources
https://transgenderhealthservices.wordpress.com/assessments/

FiveMainAreasofTransgenderHealthcare
Onceanindividualhasanassessmentofgenderdysphoriatherearefivemainareasofcarethat
theycanaccessifdeemedmedicallynecessary.Thesefiveareasofcaremayincludebehavioral
healthcare,primaryhealthcare,hormonetherapy,genderaffirmingsurgeries,and,ifaminor,
pubertysuppression.Psychotherapy,hormonetherapyandprimaryhealthcareareoftenfirst
accessedafteraninitialassessmentanddiagnosis.(Althoughitisimportanttonotethatnotall
transgenderindividualschoosetomedicallytransitionwithhormonetherapyorgenderaffirming
surgery.)

[i]https://transgenderequality.wordpress.com/category/driverslicenses/
[ii]http://www.transequality.org/Resources/ntds_state_or.pdf
[iii]NYCDepartmentofHomelessServices,DivisionofAdultServices,Transgender/IntersexClients,Procedure
06131(2006)<http://coalhome.3cdn.net/c7a840f68c28233a37_8qm6bngdv.pdf>(providingthattransgender
clientsshouldhaveappropriateaccesstobathroomsandshowers,andthatresidentsmaydressinaccordancewith
theirgenderidentity,regardlessofwhatsexislistedontheirID).

Primarycare
Mostofthehealthcareneedsoftransgenderpeoplearenotspecifictogenderissues.Thegoal
ofcareforindividualpatientsistoassistthemtoliveingoodhealth.Thereisnoreasonto
believethatgivenaccessibleandsensitivecarethattransgenderpeoplecannothavegoodhealth
outcomescomparabletonontransgenderpeople.(
SFDPH
)

BestPracticesforprimarycare
(
SFDPH
)
Delivermedicalcareandpreventativeservicesthatarerelevanttothepatientsanatomy
andriskfactors.
Providehealthmaintenanceandpreventioninterventionsaccordingtoestablished
standardsbasedonpatientage,anatomy,andriskfactors.
Useharmreductionprinciplesinaddressingsubstanceuse,sexualpractices,occupational
sexworkandtoxicinterpersonalrelationships.
Obtainarelevantmedicalhistorythatincludeshistoryofgenderexperience,prior
hormoneuse,priorsurgicalhistory,sexualhistory,individualsgoalsrelatedtohealth
andgendertransition.
Obtainpsychosocialneedsassessmentincludingmentalhealthhistory,informationabout
familyandothersocialsupportorestrangement,alcoholanddrugusehistory,criminal
justiceinvolvement,historyofpastandcurrentsuicidality,andsupportfromand
knowledgeaboutthetransgendercommunity.
Performrelevantandacuteexamsappropriatetoindividualshealthconditionsandwhich
areinformedbyanindividualshistorywithprevioustraumaandabuse.

Avoidbreast,rectalandgenitalexamoninitialvisitsunlessthereisanurgentcondition
thatmustbeaddresseduntiltrusthasbeenestablishedbetweentheproviderandthe
individual.
Createspaceforthepatienttodisclosethewordstheyusetorefertotheirbodypartsand
usetheirtermsratherthanthemedicaltermsinreferencetotheirbodywhenpossible.

Resources
Logicmodel,
Healthpromotion

HormoneReplacementTherapy
Hormonereplacementtherapy(HRT)isundertakeninordertofeminizeormasculinize
individualsbodies.Fortransgenderindividuals,HRTcanresultinthedevelopmentofmany
secondarysexualcharacteristicsofthesextheyidentifyas.Thehormonesprescribedforan
individualwilldifferdependingupontheirsexassignedatbirth.ForMTFindividuals,trans
womenorgendernonconformingpeoplewhowishtofeminizetheirbodies,hormonetreatment
mayincludeestradiol,progesterone,andspironolactone.ForFTMindividuals,transmen,or
gendernonconformingpeoplewhowishtomasculinizetheirbodies,hormonetreatmentmay
includetestosterone.
BestPracticesforHormoneReplacementTherapy
Onceanindividualisdiagnosedwithgenderdysphoria,theclientsPCPorothermedical
providershouldbeabletoinitiatehormonetherapyifdeemedappropriate.Pleasenoteitis
possibleforaPCPtodiagnosegenderdysphoriaiftheyareaQMHP.
InitiationofHormoneTherapyUponDiagnosisbyQMHP
Adiagnosisofgender
dysphoriabyaQMHPshouldbedeemedsufficienttoinitiatehormonetherapy.There
shouldnotbeanyadditionaldocumentationrequired,suchasaletterfromatherapist.
Utilizationofaninformedconsentmodel
Oncediagnosedwithgenderdysphoria,an
individualshouldbeabletoaccesshormoneswithoutdelay.Itisimportantthatinformed
consentdocumentsdetailthemedicaleffects,includinghealthrisks,ofhormonesontheir
overallhealth.Sampleformsareprovidedinthisdocument.
Psychotherapyrecommendedbutnotrequired
Individualsarestronglyencouraged
tobutshouldnotberequiredtoseeatherapisttoinitiatehormonesunlesstheyhavea
cooccurringmentalhealthconditionthatrequirestreatment.Psychotherapyshouldbe
authorizedforgenderdysphoriawiththehighestamountofvisitspermitted,butitshould
notbeforcedonanindividualiftheydonotwantPsychotherapyandtheydonothavea
cooccurringconditionrequiringtreatment.
Modelformulary
AmodelformularywascreatedbyJazzMcginnis,NeolaYoungand
membersoftheBROOHPtaskforce.Thisformularylistsallpossiblehormonesandhormone
blockersthatmaybeprescribedincludingtypicalcostpoints.
Resources:

Hormonetherapytable,
PubertysuppressionforAdolescents
Hormonetreatmentisusedtodelaytheonsetofpubertyand/orcontinuedpubertaldevelopment
withGnRHanaloguesfortransgenderchildrenandadolescents.Pubertysuppressionis

recommendedtobeginassoonassignsofpubertyareexhibited(TannerStageIIIII)andtobe
endedatage16whenhormonereplacementtherapycouldbeadministeredifnotearlierbasedon
theneedsofthepatient[i].Thistherapyisofteninitiatedatthefirstphysicalchangesofpuberty,
confirmedbypubertallevelsofestradiolortestosterone,butnoearlierthanTannerstages23.
Priortoinitiationofpubertysuppressiontherapy,adolescentsmustfulfilleligibilityand
readinesscriteria,andmusthaveacomprehensivementalhealthevaluation.Ongoing
psychologicalcareisstronglyencouragedforcontinuedpubertysuppressiontherapy.

Pubertydelayingmedicationsareaprescriptionmedication,whichcanbeusedforanumberof
medicalconditionsoneofwhichisfordelayingpubertyforsomeonewhoisexperiencing
genderdysphoria.Themedicationactsasapausebuttononayoungpersonspubertal
development,providingthatpersonanopportunitytoexploretheirgenderidentitywithoutthe
distressofdevelopingthepermanent,unwantedphysicalcharacteristicsoftheirassignedsexat
birth.Duringthistime,theyoungpersonwillworkwiththeirfamilyandhealthcareprovidersto
developatreatmentplantoaddresstheyouthsGenderDysphoriathatistailoredtoindividual
needs.Fortransgenderyouth,thatmayeventuallyincludehormonetherapytoinduceapuberty
thatiscongruentwiththeirgenderidentity.Andwhileweallagreethatateenexperiencing
genderdysphoriawouldmostideallybeinasituationwhereasupportivefamilycouldbefully
engagedinevaluation,diagnosisandtreatment,therearecircumstanceswherethatcanbe
challengingorimpossibletoachieve.Fortunately,Oregonlawprovidessomeflexibilityforteens
toconsentontheirownaccord:
AgeofconsentforminorsOregonLawspecifiestheageofconsentfor
mentalhealth
careis14yearsofage
andtheageof
medicalconsent(includingsurgicalprocedures)
is15yearsofage
.ThisisoutlinedinORS109.640and109.675(seeappendix3for
completetextonminorsaccesstohealthcareinOregonRevisedStatutes).
Pubertysuppressants,unlikehormonereplacementforadults,areaproactivemedicalapproach
insteadofreactive.Reactivemedicalapproachestogenderdysphoria(e.g.hormonereplacement
therapyinadults)aremeanttocorrectalreadyexistingandunwantedbodilychangeswhereas
proactiveapproaches,suchaspubertysuppressants,minimizeandpreventunwantedbodily
changescausedbypubertyfromoccurringtobeginwith.Proactivemedicalapproachestogender
dysphoriacaneliminatetheneedformorecostlymedicalservicesandoperationslaterinlifeand
increasesthepatientsoverallqualityoflife[ii].Thebenefitsofpubertysuppressantson
transgenderyouthleadtodecreasedgenderdysphoriaandanimprovementinpsychological
wellbeingonparwiththeircisgenderpeers[iii].

[i]SuppressionofPubertyinTransgenderChildren.JasonLambrese,MD.
AmericanMedicalAssociation
Journal
ofEthicsAugust2010,Volume12,Number8:645649.
[ii]HealthOutcomesSubcommittee:PubertyBlocking&HormoneTherapyforTransgenderAdolescents.
[iii]YoungAdultPsychologicalOutcomeAfterPubertySuppressionandGenderReassignment.AnnelouL.C.de
Vries,JeniferK.McGuire,ThomasD.Steensma,EvaC.F.Wagenaar,TheoA.H.DoreleijersandPeggyT.
CohenKettenis.
Pediatrics
originallypublishedonlineSeptember8,2014.

Psychotherapy

Psychotherapyprovidedbyamentalhealthprofessionalisoftenrecommendedthoughnot
requiredinatreatmentplantoreducethesymptomsofgenderdysphoria.

SurgicalTreatment
Surgicaltreatmentforgenderdysphoriadependsuponanindividualssexassignedatbirth.
Therearesurgeriesthataredesignedtomakebodiesassignedmaleatbirthmorefeminineand
surgeriesdesignedtomakebodiesassignedfemaleatbirthmoremasculine.
TheWorldProfessionalAssociationforTransgenderHealth(WPATH)indicatesthat,
physicianswhoperformsurgicaltreatmentsforgenderdysphoriashouldbeurologists,
gynecologists,plasticsurgeons,orgeneralsurgeons,andboardcertifiedassuchbytherelevant
nationaland/orregionalassociation.Surgeonsshouldhavespecializedcompetenceingenital
reconstructivetechniquesasindicatedbydocumentedsupervisedtrainingwithamore
experiencedsurgeon.[7]
LettersforSurgery
TheHERCpolicyrequirestwolettersfromQMHPstoaccessbenefit
approval.Lettersforsurgeryarenotstandardized,however,standardformscanbeused.
Dependingonthesurgery,surgeonsmayalsorequestlettersattheirdiscretion.Asample
templateisincludedwiththispolicy.
Twelvemonthsofhormonetherapyandtwelvemonthslivedexperiencerequirements

TheHERCpolicymandatesthatbeforesurgicalprocedurescanbeaccessed,individualsmust
undergotwelvemonthsofHRTunlessHRTisnotclinicallyindicatedfortheindividual(e.g.
experiencingillnessesthataresensitivetohormones,orhormonetherapyisnotclinically
necessarytoaddressthepatientsgenderdysphoria).Additionally,12monthsoflived
experiencearerequiredunlessthiscompromisesthesafetyoftheindividual.CCOsandhealth
planadministratorsmustensurethattherearesufficientandpromptinterventionsforproviders
towaivetheserequirementswhenwarrantedforhealthorsafetyreasons.
Surgeryresourcesandforms

Criteriaforsurgeries
,

Surgeryeligibilityform

WPATHStandardsofCareandSurgery
Theessentialpurposeoftransitionrelatedtreatment,whetheritisgenitalreconstruction,
hormonereplacementtherapyoranyothergenderconfirmingprocedure,istotherapeutically
treatGenderDysphoria,nottoimproveapersonsappearance.Theevaluationofmedical
necessitymustbeindividualizedandtakeintoaccountthetotalityofthepatientstotal
appearanceandtransitionrelatedneeds.Transgenderpeoplehaveuniqueclinicalneedsthatare
distinctfromthoseofnontransgenderpeople,andindividualizedassessmentsshouldbebased
ontheirsymptoms,functionality,andthetotalityoftheirappearance.
(Reference:TransLaw
CenterMedicarePaper)

Thecategoryoftransitionrelatedsurgeryalsoknownasgenderreassignmentsurgeryincludes:
1. Breast/chestsurgeries
2. Genitalsurgeries

3. Othersurgeries.

TransgendersurgeriestofeminizebodiesFortransgenderwomenorotherindividualswhoseek
tofeminizetheirbodies,Patient,SurgicalProceduresMayIncludetheFollowing:
1. Breast/chestsurgery:mammaplasty
2. Genitalsurgery:orchiectomy,penectomy,vaginoplasty,clitoroplasty,vulvoplasty.
Labiaplasty,urethroplasty,prostatectomy
3. Othersurgeries:facialreconstructionsurgery,liposuction,lipofilling,voicesurgery,
thyroidcartilagereduction,electrolysisorlaserhairremoval,andhairreconstruction.

TransgenderSurgeriestoMasculinizeBodiesFortransgendermenorotherindividualswho
wishtomasculinizetheirbodiesSurgicalProceduresMayIncludetheFollowing:
1. Breast/chestsurgery:subcutaneousmastectomy,nipplegrafts,chestreconstruction
2. Genitalsurgery:hysterectomy/salpingooophorectomy,metoidioplasty,phalloplasty
(employingapedicledorfreevascularizedflap),reconstructionofthefixedpartofthe
urethra,vaginectomy,vulvectomy,scrotoplasty,andimplantationoferectionand/or
testicularprostheses
3. Other:voicesurgery(rare),liposuction,lipofilling,

OHPandCoveredSurgeries
Thehealthevidencereviewcommitteespolicylistthebelowexcludedproceduresascosmetic,
eventhoughthelateststandardsofcarearguethemostoftheseproceduresmaybeconsidered
medicallynecessaryonacasebycasebases.Itisimportanttonotethattheexclusionsdonot
includebreast/chestreconstruction,speechtherapy.Additionally,clarityneedstobemade
regardingifthispolicycoverselectrolysisforsurgicalsitesandcoverageformedicallynecessary
noncosmetictreatmentslistedbelow.
ExcludedproceduresbyHERCduetobeingseenascosmetic
Rhinoplasty,facelifting,lip
enhancement,facialbonereduction,blepharoplasty,breastaugmentation,liposuctionofthe
waist(bodycontouring),reductionthyroidchondroplasty,hairremoval,voicemodification
surgery(laryngoplastyorshorteningofthevocalcords),andskinresurfacing,whichhavebeen
usedinfeminization,areconsideredcosmetic.Similarly,chinimplants,noseimplants,andlip
reduction,whichhavebeenusedtoassistmasculinization,areconsideredcosmetic.

HERCCPTCodes
CPT code

Code description

19301-19304

Mastectomy

53430

Urethroplasty, reconstruction of female urethra

54125

removal of penis; complete

54400-54417

Insertion/repair/removal of penile prosthesis

54520

Orchiectomy, simple (including subcapsular), with or

without testicular prosthesis, scrotal or inguinal
approach

54660

Insertion of testicular prosthesis (separate

procedure)

54690

Laparoscopy, surgical; orchiectomy

55175-55180

Scrotoplasty

55970

Intersex surgery; male to female

55980

Intersex surgery; female to male

56625

Vulvectomy simple; complete

56800

Plastic repair of introitus

56805

Clitoroplasty for intersex state

56810

Perineoplasty, repair of perineum, nonobstetrical

57106-57107

Vaginectomy, partial removal of vaginal wall;

57110-57111

Vaginectomy, complete removal of vaginal wall

57291-57292

Construction of artificial vagina

57335

Vaginoplasty for intersex state

58150, 58180, 58260-58262,

58275-58291, 58541-58544,
58550-58554, 58570-58573

Hysterectomy

58661

Laparoscopy, surgical; with removal of adnexal

structures

58720

Salpingo-oophorectomy, complete or partial,

unilateral or bilateral

Condition:GENDERDYSPHORIA
Treatment:MEDICAL/PSYCHOTHERAPYMEDICALANDSURGICALTREATMENT
PSYCHOTHERAPY
ICD9:302.85(Genderidentitydisorderinadolescentsoradults)
ICD10:F64.1F64.9(Genderidentitydisorder)
CPT:1930119304,53430,54125,5440054417,54520,54660,54690,5517555180,
55970,55980,56625,56800,56805,56810,5710657107,5711057111,
5729157292,57335,58150,58180,5826058262,5827558291,58541
58544,5855058554,5857058573,58661,58720,90785,9083290840,
9084690853,90882,90887,96101,9896698969,99051,99060,99070,
99078,9920199215,9928199285,9934199355,9935899378,99381
99404,9940899412,9942999449,9948799496,9960599607
HCPCS:G0176,G0177,G0396,G0397,G0459,G0463,H0004,H0023,H0032,H0034,
H0035,H2010,H2011,H2014,H2027,H2032,H2033,S9484,T1016

Appendix-

SCIENTIFICEVIDENCE
Inordertoevaluatethespecifictherapeuticeffectsoftreatmentforgenderdysphoriain
transgenderindividualsandadequatelycontrolforconfoundingfactors,evaluateadverseeffects,
andindividualpatientdifferences(age,assignedsexatbirth,symptoms,severityofillness),
welldesignedrandomizedclinicaltrials(RCTs)comparinggenderdysphoriatreatmentswiththe
nontreatmentareideal.TheRCTisthemostrigorousandreliablestudydesignfor
demonstratingacausalrelationshipbetweenthetherapyunderinvestigationandthehealth
outcomesofinterest.
Specifically,questionsregardingappropriatepatientselection,treatmentstandardizationand
complicationeffectivenessrates,forpatientsofvaryingsexeswouldbeaddressed.However,
therearechallengesinconductingRCTstoevaluatetreatmentsofgenderdysphoriadueto
severalfactors,suchassmallpatientpopulationsandethicalconcernsregardingthehigh
morbidityandmortalityratesassociatedwithnontreatment.Giventheseconfoundingfactors,
datafromlargerandomizedcontrolledtrialsarenotexpectedinthenearfuture.Therefore,
evidencefromnonrandomizedtrialsmaybeconsideredwhentreatmentsofgenderdysphoria
resultinasignificantimprovementofsymptomsandhealthwhichissosizablethatthehealth
improvementrulesoutthecombinedeffectsofallotherpossibleconcurrenttreatmentsornatural
progressionofthedisease.Currently,thereislimitedevidenceofthismagnituderegarding
patientselection,timingandtherapeuticstrategiesintransgenderindividualswithgender
dysphoria.Therefore,largestudieswithadequatefollowupareneededinordertoevaluatethese

andotherconfoundingfactorsrelatedtothetreatmentofgenderdysphoriaintransgender
individuals.
LiteratureAppraisal
Evidenceregardingthetreatmentofgenderdysphoriaintransgenderindividualsiscomprised
mainlyoftwosystematicreviewsconsistingofsmallcohortstudieswithmethodological
limitations.Norandomizedcontrolledtrialswereidentified.Severalkeycohortstudiesare
describedbelowinadditiontothesystematicreviews.
SystematicReviews
Onlyoneoftwosystematicreviewsisconsideredgoodquality
[13]
(Muradetal.)andreportedon
theresolutionofgenderdysphoriapsychiatriccomorbidities,qualityoflife,andsexual
satisfactionoutcomesforindividualstreatedwithbothhormonalandsurgicaltreatmentsfor
genderidentitydisorder(GIDnowreferredtoasGenderDysphoriaintheDSMV).
In2009,Muradandcolleaguesassessedqualityoflifeandotherpsychosocialoutcomesof
transgenderindividualswithGID,receivinghormonaltherapyaspartofgenderaffirming
[13]
surgeries.Twentyeightcohortstudieswereincludedinthereviewwhichincludedpooleddata
from1,833patientswithGID(1,093transwomenand801transmen).Significantimprovements
werereportedaftergenderaffirmingsurgeriescomparedtopretreatmentstatus:80%ofpatients
reportedimprovementingenderdysphoria(95%CI=6889%8studies)78%reported
significantimprovementinpsychologicalsymptoms(95%CI=5694%7studies)80%reported
significantimprovementinqualityoflife(95%CI=7288%16studies)and72%reported
significantimprovementinsexualfunction(95%CI=6081%15studies).Significantstudy
heterogeneitywasreportedforalloutcomes.Althoughtheauthorsacknowledgethelowquality
ofevidenceusedintheanalysis,genderaffirmingsurgeriesthatincludedhormonalinterventions
inpatientwithGIDwasthoughttolikelyimprovesymptomsofgenderdysphoriaandoverall
qualityoflife.

In2009,Elaminandcolleaguesevaluatedtheuseofhormonereplacementtherapyon
cardiovascularriskintransgenderindividuals.
[14]
Atotalof16studieswereincludedinthe
reviewwithatotalof1,471transgenderwomenand651transgendermen.Steroidusewas
associatedwithincreasedserumtriglyceridesinbothtransgenderwomenandtransgendermen
andanonsignificanteffectonHDLcholesterolandsystolicbloodpressureintransmen.Authors
notedthatthequalityofevidencewaslowduetomethodologicallimitationsofincludedstudies,
includingbutnotlimitedto,heterogeneityofpatientpopulationandvariablefollowupperiods
anduncontrolledstudydesign.
RandomizedControlledTrials(RCTs)
Norandomizedcontrolledtrialsregardingthetreatmentofgenderdysphoriaintransgender
individualswereidentified.

NonrandomizedStudies
Primaryevidenceislimitedtocohortstudieswithavarietyofmethodologicallimitations,
includingbutnotlimitedtosmallsamplesize,shorttermfollowup,lackofcomparisongroup,
andvariedtreatmentmethods.Despitetheselimitations,significantimprovementsinqualityof

life,psychologicalcomorbidities,andsexualfunctioningwereconsistentlyreportedinpatients
whoreceivedgenderconfirmingmedicaltreatments.
Imbimboetal.,evaluatedtheclinicalandpsychosocialprofileoftransgenderwomenwhohad
undergonereconstructivesurgery.
[10]
Theaverageageofpatientswas31yearsold,72%hadhigh
educationallevels,halfofpatientscontemplatedsuicideatsomepointpriortosurgeryand4%
hadattemptedsuicide.Improvedsexlifesatisfactionwasreportedin75%ofpatients,with
almostallpatientsreportingsatisfactionwiththeirnewsexualstatus.Additionalstudiessought
toevaluatethesociodemographicprofileoftransgenderindividualswithGIDinaneffortto
bettercharacterizeandprovidetreatmentforthispopulation.
[15]
Heylensandcolleaguesassessedcomorbiditiesandpsychosocialfactorsatvariousphasesof
thegenderaffirmingsurgeryprocessin57patientswithGID.
[16]
TheSymptomChecklist90
(SCL90)wasadministeredatthreetimepoints:baseline,afterthestartofhormonetherapy,and
aftergenderaffirmingsurgeries.Psychopathologicalparametersincludeoverallpsychoneurotic
distress,anxiety,agoraphobia,depression,somatization,paranoidideation/psychoticism,
interpersonalsensitivity,hostility,andsleepingproblemsandthepsychosocialparameters
consistofrelationship,livingsituation,employment,sexualcontacts,socialcontacts,substance
abuse,andsuicideattempt.Thegreatestimprovementinpsychoneuroticdistresswasobserved
aftertheinitiationofhormonetherapy(p<0.001).Inaddition,significantdecreasesinanxiety,
depression,interpersonalsensitivityandhostilitywerereportedafterhormonetherapy.No
significantdifferenceswereobservedinpreandpostoperativeassessments.

Fisheretal.describedclinicalandsociodemographicfeaturesof140transmen(n=48)and
transwomen(n=92)withGIDandwithoutgenderaffirmingsurgeries.
[17]
Thefollowing
assessmenttestswereadministered:theBodyUneasinessTest(aselfratingscaleexploring
differentareasofbodyrelatedpsychopathology),SymptomChecklist90Revised(aselfrating
scaletomeasurepsychologicalstate),andtheBemSexRoleInventory(aselfratingscaleto
evaluategenderrole).Authorsreportedthattransmendisplayedsignificantlybettersocial
functioningthantranswoman.
GorinLazardetal.reportedacaseserieswhichassessedavarietyofgenderdysphoria
symptomswithhormonaltreatmentprecedinggenderaffirmingsurgeries.Preandpost
hormonetreatmentselfesteem(SocialSelfEsteemInventory),mood(BeckDepression
Inventory),QoL(SubjectiveQualityofLifeAnalysis),andglobalfunctioning(Global
AssessmentofFunctioning)scoreswerecomparedin49patients.
[18]
Hormonetherapywas
reportedtobeanindependentfactoringreaterselfesteem,areductionindepression,and
improvedQoLscores.
GomezGilandcolleaguesevaluatedsymptomsofsocialdistress,anxietyanddepressionin
187transgenderindividuals.
[19]
Ofthoseincludedinthestudy,120hadundergonegender
affirminghormonetreatmentand67hadnot.SocialanxietywasassessedwiththeSocial
AnxietyandDistressScale(SADS)anddepressionandanxietywereassessedwiththeHospital
AnxietyandDepressionScale(HADS).Thenonhormonegroupwasreportedtobesignificantly
youngerthanthetreatmentgroup(meanage25.9vs.33.6years,p=0.001)andwaslesslikelyto
haveundergonesurgicalinterventions(p<0.001).Afteradjustingforconfoundingfactors,the

authorsreportedthatpatientswhowerereceivinghormonetreatmenthadsignificantlylower
prevalenceofdepression,anxiety,andsocialanxietythanthosenotreceivinghormones.
Johanssonetal.,reportedlongterm(5year)outcomesoftransgenderindividuals(n=42)with
GIDwhohadcompletelytransitioned(n=32),wereinprogress(n=5)orwhowereonhormone
therapy(n=5).
[20]
Authorsreportedthatnopatientregrettedreassignmentandcliniciansratedthe
globaloutcomeasfavorablein62%ofthecases,comparedto95%accordingtothepatients
themselves,withnodifferencesbetweenthesubgroups.Atfollowup,morethan90%ofpatients
reportedstableorimprovedworksituations,partnerrelationsandsexlife.However515%of
patientsreporteddissatisfactionwithhormonaltreatment,resultsofsurgery,genderaffirming
surgeries,ortheirpresentgeneralhealth.
Asschemanandcolleaguesevaluatedthelongterm(1year)effectsofhormonereplacement
therapyin966transwomenand365transmentransgenderindividuals.
[21]
Transwomanpatients
receiveddifferentdosesofestrogenandcyproteroneacetateandtransmanpatientsreceived
parenteral/oraltestosteroneestersortestosteronegel.Hormonetreatmentlevelsvariedatpreand
postsurgicalreassignmenttimepoints.Highmortalityrateswerereportedinthetranswoman
groupwhencomparedtothegeneralpopulation(51%)however,thisincreasedratewasdueto
nonhormonerelatedcausessuchassuicide,acquiredimmunodeficiencysyndrome(AIDS),
cardiovasculardisease,drugabuseandotherunknowncauses.Nosignificantincreasein
mortalitywasobservedintransmanpatientscomparedtothegeneralpopulation.
ClinicalPracticeGuidelines
TheEndocrineSociety

In2009,theEndocrineSocietyinconjunctionwithEuropeanSocietyofEndocrinology,
EuropeanSocietyforPediatricEndocrinology,LawsonWilkinsPediatricEndocrineSociety,and
WorldProfessionalAssociation,publishedtheonlyevidencebasedguidelinesregardingthe
treatmentoftransgenderindividuals.
[22]
Theguidelineemployedtransparentmethodsfor
evidencereviewandforratingthequalityofevidence.Allrecommendationswerebasedupon
evidencewhichwasratedtobelowquality.Theconsortiummadethefollowing
recommendations:

DiagnosticProcedure
1.Werecommendthatthediagnosisofgenderidentitydisorder(GID)bemadebyamental
healthprofessional(MHP).Forchildrenandadolescents,theMHPshouldalsohavetrainingin
childandadolescentdevelopmentalpsychopathology.
2.GiventhehighrateofremissionofGIDaftertheonsetofpuberty,werecommendagainsta
completesocialrolechangeandhormonetreatmentinprepubertalchildrenwithGID.
3.Werecommendthatphysiciansevaluateandensurethatapplicantsunderstandthereversible
andirreversibleeffectsofhormonesuppression(e.g.GnRHanalogtreatment)andcrosssex
hormonetreatmentbeforetheystarthormonetreatment.
4.Werecommendthatalltranssexualindividualsbeinformedandcounseledregardingoptions
forfertilitypriortoinitiationofpubertysuppressioninadolescentsandpriortotreatmentwith
sexhormonesofthedesiredsexinbothadolescentsandadults.
TreatmentofAdolescents

1.Werecommendthatadolescentswhofulfilleligibilityandreadinesscriteriaforgender
reassignmentinitiallyundergotreatmenttosuppresspubertaldevelopment.
2.Werecommendthatsuppressionofpubertalhormonesstartwhengirlsandboysfirstexhibit
physicalchangesofpuberty(confirmedbypubertallevelsofestradiolandtestosterone,
respectively),butnoearlierthanTannerstages23.
3.WerecommendthatGnRHanalogsbeusedtoachievesuppressionofpubertalhormones.
4.Wesuggestthatpubertaldevelopmentofthedesiredoppositesexbeinitiatedatabouttheage
of16year,usingagraduallyincreasingdosescheduleofcrosssexsteroids.
5.Werecommendreferringhormonetreatedadolescentsforsurgerywhen:a.thereallife
experience(RLE)hasresultedinasatisfactorysocialrolechange
b.theindividualissatisfiedaboutthehormonaleffectsand
c.theindividualdesiresdefinitivesurgicalchanges.
6.Wesuggestdeferringsurgeryuntiltheindividualisatleast18yearold.
HormonalTherapyforTransgenderAdults
1.WerecommendthattreatingendocrinologistsconfirmthediagnosticcriteriaofGIDor
transsexualismandtheeligibilityandreadinesscriteriafortheendocrinephaseofgender
transition.
2.Werecommendthatmedicalconditionsthatcanbeexacerbatedbyhormonedepletionand
crosssexhormonetreatmentbeevaluatedandaddressedpriortoinitiationoftreatment.
3.Wesuggestthatcrosssexhormonelevelsbemaintainedinthenormalphysiologicalrangefor
thedesiredgender.
4.Wesuggestthatendocrinologistsreviewtheonsetandtimecourseofphysicalchanges
inducedbycrosssexhormonetreatment.
AdverseOutcomePreventionandLongtermCare
1.Wesuggestregularclinicalandlaboratorymonitoringevery3monthsduringthefirstyearand
thenonceortwiceyearly.
2.Wesuggestmonitoringprolactinlevelsinmaletofemale(MTF)transsexualpersonstreated
withestrogens.
3.Wesuggestthattranssexualpersonstreatedwithhormonesbeevaluatedforcardiovascular
riskfactors.
4.Wesuggestthatbonemineraldensity(BMD)measurementsbeobtainedifriskfactorsfor
osteoporosisexist,specificallyinthosewhostophormonetherapyaftergonadectomy.
5.WesuggestthatMTFtranssexualpersonswhohavenoknownincreasedriskofbreastcancer
followbreastscreeningguidelinesrecommendedforbiologicalwomen.
6.WesuggestthatMTFtranssexualpersonstreatedwithestrogensfollowscreeningguidelines
forprostaticdiseaseandprostatecancerrecommendedforbiologicalmen.
7.Wesuggestthatfemaletomale(FTM)transsexualpersonsevaluatetherisksandbenefitsof
includingtotalhysterectomyandoophorectomyaspartofsexreassignmentsurgery.
SurgeryforSexReassignment
1.Werecommendthattranssexualpersonsconsidergenitalsexreassignmentsurgeryonlyafter
boththephysicianresponsibleforendocrinetransitiontherapyandtheMHPfindsurgery
advisable.
2.Werecommendthatgenitalsexreassignmentsurgeryberecommendedonlyaftercompletion
ofatleast1yearofconsistentandcomplianthormonetreatment.

3.Werecommendthatthephysicianresponsibleforendocrinetreatmentmedicallyclear
transsexualindividualsforsexreassignmentsurgeryandcollaboratewiththesurgeonregarding
hormoneuseduringandaftersurgery.
AmericanCollegeofObstetriciansandGynecology(ACOG)
In2011,ACOGpublishedacommitteeopinionregardinghealthcareservicesfortransgender
individuals.
[8]
Althoughthisguidelineisnotbasedinevidence,ACOGdoesmakethefollowing
recommendations,Obstetriciangynecologistsshouldbepreparedtoassistorrefertransgender
individualsforroutinetreatmentandscreeningaswellashormonalandsurgicaltherapies.
Hormonalandsurgicaltherapiesfortransgenderpatientsmayberequested,butshouldbe
managedinconsultationwithhealthcareproviderswithexpertiseinspecializedcareand
treatmentoftransgenderpatients.
Inaddition,ACOGguidelinesmadespecificrecommendationsregardinghormonetherapy,
surgeryandscreeningforbothfemaletomaleandmaletofemalepatients:

FemaletoMaleTransgenderIndividuals
Hormones
Methyltestosteroneinjectionsevery2weeksareusuallysufficienttosuppressmensesandinduce
masculinesecondarysexcharacteristics.Beforereceivingandrogentherapy,patientsshouldbe
screenedformedicalcontraindicationsandhaveperiodiclaboratorytesting,including
hemoglobinandhematocrittoevaluateforpolycythemia,liverfunctiontests,andserum
testosteronelevelassessments(goalisamidnormalmalerangeof500microgram/dL),while
receivingthetreatment.
Surgery
Hysterectomy,withorwithoutsalpingooophorectomy,iscommonlypartofthesurgicalprocess.
Anobstetriciangynecologistwhohasnospecializedexpertiseintransgendercaremaybeasked
toperformthissurgery,andalsomaybeconsultedforroutinereasonssuchasdysfunctional
bleeding
orpelvicpain.Reconstructivesurgeryshouldbeperformedbyaurologist,gynecologist,plastic
surgeon,orgeneralsurgeonwhohasspecializedcompetenceandtraininginthisfield.
Screening
Ageappropriatescreeningforbreastcancerandcervicalcancershouldbecontinuedunless
mastectomyorremovalofthecervixhasoccurred.Forpatientsusingandrogentherapywho
havenothadacompletehysterectomy,theremaybeanincreasedriskofendometrialcancerand
ovariancancer.

MaletoFemaleTransgenderIndividuals
Hormones
Estrogentherapyresultsingynecomastia,reducedhairgrowth,redistributionoffat,andreduced
testicularvolume.Allpatientsconsideringtherapyshouldbescreenedformedical
contraindications.Aftersurgery,dosesofestradiol,24mg/d,orconjugatedequineestrogen,2.5
mg/d,areoftensufficienttokeeptotaltestosteronelevelstonormalfemalelevelsoflessthan25
ng/dL.Nonoraltherapyalsocanbeoffered.Itisrecommendedthatmaletofemaletransgender

patientsreceivingestrogentherapyhaveanannualprolactinlevelassessmentandvisualfield
examinationtoscreenforprolactinoma.
Surgery
Surgeryusuallyinvolvespenileandtesticularexcisionandthecreationofaneovagina.Reported
complicationsofsurgeryincludevaginalandurethralstenosis,fistulaformation,problemswith
remnantsoferectiletissue,andpain.Vaginaldilationoftheneovaginaisrequiredtomaintain
patency.Othersurgicalproceduresthatmaybeperformedincludebreastimplantsand
nongenitalsurgery,suchasfacialfeminizationsurgery.
Screening
Ageappropriatescreeningforbreastandprostatecancerisappropriateformaletofemale
transgenderpatients.OpinionvariesregardingtheneedforPaptestinginthispopulation.In
patientswhohaveaneocervixcreatedfromtheglanspenis,routinecytologicexaminationofthe
neocervixmaybeindicated.Theglandsaremorepronetocancerouschangesthantheskinofthe
penileshaft,andintraepithelialneoplasiaoftheglansismorelikelytoprogresstoinvasive
carcinomathanisintraepithelialneoplasiaofotherpenileskin.

TheWorldProfessionalAssociationforTransgenderHealth(WPATH)
WPATHisamultidisciplinaryprofessionalsocietyrepresentingthespecialtiesofmedicine,
psychology,socialsciencesandlawthathaspublishedclinicalguidelinesregardinghealth
servicesforpatientswithgenderdisorders.In2012,WPATHupdatedtheirevidenceand
consensusbasedguidelineregarding,the
StandardsofCare(SOC)fortheHealthof
Transsexual,Transgender,andGenderNonconformingPeoples
.[
7]
WPATHlistedthefollowing
optionsforindividualsseekingtreatmentforgenderdysphoria:
Changesingenderexpressionandrole(whichmayinvolvelivingparttimeorfulltimein
anothergenderrole,consistentwithonesgenderidentity)

Hormonetherapytofeminizeormasculinizethebody
Surgerytochangeprimaryand/orsecondarysexcharacteristics
Psychotherapy(individual,couple,family,orgroup)forpurposessuchasexploringgender
identity,role,andexpressionaddressingthenegativeimpactofgenderdysphoriaandstigmaon
mentalhealthalleviatinginternalizedtransphobiaenhancingsocialandpeersupportimproving
bodyimageorpromotingresilience.
Inaddition,WPATHmadespecificrecommendationsregardingbreastaugmentationprocedures:

Breastreconstruction
TheWPATHguidelinerecommendsMTFpatientsundergofeminizinghormonetherapyfora
minimumof12monthspriortoaugmentationsurgeryandlistsspecificcriteriaforbreast
augmentation(implants/lipofilling).
However,theclassificationofbreastaugmentationasacosmeticversusreconstructiveprocedure
hasremainedcontroversial.WPATHguidelinesnoted,(w)hilemostprofessionalsagreethat
genitalsurgeryandmastectomycannotbeconsideredpurelycosmetic,opinionsdivergeasto
whatdegreeothersurgicalprocedures(e.g.,breastaugmentation,facialfeminizationsurgery)
canbeconsideredpurelyreconstructive.Inaddition,WPATHindicatedthatalthoughbreast
appearancemaybeconsideredanimportantsecondarysexcharacteristic,breastpresenceor
sizeisnotinvolvedinthelegaldefinitionsofsexandgenderandisnotnecessaryfor
reproduction.

Summary
Thereisalackofwelldesignedrandomizedclinicaltrials(RCTs)comparingthesafetyand
effectivenessofnontreatmentforgenderdysphoriaintransgenderindividualswithtreatment,
includingbutnotlimitedtohormonetherapyandsexreassignmentsurgery.However,thereare
challengesinconductingRCTstoevaluatetreatmentsofgenderdysphoriaduetoseveralfactors,
suchassmallpatientpopulationsandethicalconcernsregardingthehighmorbidityand
mortalityratesassociatedwithnontreatment.Giventheseconfoundingfactors,datafromlarge
randomizedcontrolledtrialsarenotexpectedinthenearfuture.Althoughadditionalevidenceis
neededtovalidatepatientselectioncriteriaandtreatmentstrategies,datafromnumerouscohort
studiesconsistentlysuggestsignificantimprovementsingenderdysphoriasymptomsandquality
oflifemeasuresafterreceivingtreatments.Therefore,treatmentofgenderdysphoriain
transgenderindividualsmaybeconsideredmedicallynecessarywhenspecifiedpolicycriteria
aremet.
APPENDIX2
GenderDysphoria[23]
GenderdysphoriaisdefinedbytheDiagnostic&StatisticalManualofMentalDisordersDSMV
as:
GenderDysphoriainChildren:
A.Amarkedincongruencebetweenone'sexperienced/expressedgenderandassignedgender,of
atleast6monthsduration,asmanifestedbyatleastsixofthefollowing(oneofwhichmustbe
CriterionA1):
1.Astrongdesiretobeoftheothergenderoraninsistencethatoneistheothergender(orsome
alternativegender,differentfromone'sassignedgender)
2.Inboys(assignedgender),astrongpreferenceforcrossdressingorsimulatingfemaleattireor
ingirls(assignedgender),astrongpreferenceforwearingonlytypicalmasculineclothinganda
strongresistancetowearingoftypicalfeminineclothing.
3.Astrongpreferenceforcrossgenderrolesinmakebelieveplayoffantasyplay.
4.Astrongpreferencefortoys,games,oractivitiesstereotypicallyusedorengagedinbythe
othergender.
5.Astrongpreferenceforplaymatesoftheothergender.
6.Inboys(assignedgender),astrongrejectionoftypicallymasculinetoys,gamesandactivities
andastrongavoidanceofroughandtumbleplayoringirls(assignedgender),astrongrejection
oftypicallyfemininetoys,gamesandactivities.
7.Astrongdislikeofone'ssexualanatomy.
8.Astrongdesirefortheprimaryand/orsecondarysexcharacteristicsthatmatchone's
experiencedgender.
B.Theconditionisassociatedwithclinicallysignificantdistressorimpairmentinsocial,school,
orotherimportantareasoffunctioning.
Specifyif:
Withadisorderofsexdevelopment(e.g.,acongenitaladrenogenitaldisordersuchas2.55.2
[E25.0]congenitaladrenalhyperplasiaor259.0[E34.50]androgeninsensitivitysyndrome)
Codingnote:Codethedisorderofsexdevelopmentaswellasgenderdysphoria.
GenderDysphoriainAdolescentsandAdults:
A.Amarkedincongruencebetweenone'sexperienced/expressedgenderandassignedgender,of
atleast6monthsduration,asmanifestedbyatleasttwoofthefollowing:

1.Amarkedincongruencebetweenone'sexperienced/expressedgenderandprimaryand/or
secondarysexcharacteristics(oninyoungadolescents,theanticipatedsecondarysex
characteristics).
2.Astrongdesiretoberidofone'sprimaryand/orsecondarysexcharacteristicsbecauseofa
markedincongruencewithone'sexperienced/expressedgender(oninyoungadolescents,adesire
topreventthedevelopmentoftheanticipatedsecondarysexcharacteristics.)
3.Astrongdesirefortheprimaryand/orsecondarysexcharacteristicsoftheothergender.
4.Astrongdesiretobeoftheothergender)orsomealternativegenderdifferentfromone's
assignedgender).
5.Astrongdesiretobetreatedastheothergender(orsomealternativegenderdifferentfrom
one'sassignedgender).
6.Astrongconvictionthatonehasthetypicalfeelingsandreactionsoftheothergender(orsome
alternativegenderdifferentfromone'sassignedgender).
B.Theconditionisassociatedwithclinicallysignificantdistressorimpairmentinsocial,
occupational,orotherimportantareasoffunctioning.
Specifyif:
Withadisorderofsexdevelopment(e.g.,acongenitaladrenogenitaldisordersuchas2.55.2
[E25.0]congenitaladrenalhyperplasiaor259.0[E34.50]androgeninsensitivitysyndrome)
Codingnote:Codethedisorderofsexdevelopmentaswellasgenderdysphoria.
Specifyif:
Posttransition:Theindividualhastransitionedtofulltimelivinginthedesiredgender(withor
withoutlegalizationofgenderchange)andhasundergone(orispreparingtohave)atleastone
crosssexmedicalprocedureortreatmentregimennamelyregularcrosssextreatmentorgender
reassignmentsurgeryconfirmingthedesiredgender(e.g.,appendectomy,vaginoplastyinthe
natalmalemastectomyorphalloplastyinthenatalfemale).
APPENDIX3
RIGHTSOFMINORSTOCONSENTTOHEALTHCARE
109.640Righttomedicalordentaltreatmentwithoutparentalconsentprovisionofbirth
controlinformationandservicestoanyperson.(1)Anyphysicianornursepractitionermay
providebirthcontrolinformationandservicestoanypersonwithoutregardtotheageofthe
person.
(2)Aminor15yearsofageoroldermaygiveconsent,withouttheconsentofaparentor
guardianoftheminor,to:
(a)Hospitalcare,medicalorsurgicaldiagnosisortreatmentbyaphysicianlicensedbythe
OregonMedicalBoard,anddentalorsurgicaldiagnosisortreatmentbyadentistlicensedbythe
OregonBoardofDentistry,exceptasprovidedbyORS109.660.
(b)DiagnosisandtreatmentbyanursepractitionerwhoislicensedbytheOregonStateBoard
ofNursingunderORS678.375andwhoisactingwithinthescopeofpracticeforanurse
practitioner.
109.650Disclosurewithoutminorsconsentandwithoutliability.Ahospitalorany
physician,nursepractitioner,dentistoroptometristdescribedinORS109.640mayadvisea

parentorlegalguardianofaminorofthecare,diagnosisortreatmentoftheminorortheneed
foranytreatmentoftheminor,withouttheconsentoftheminor,andisnotliableforadvisingthe
parentorlegalguardianwithouttheconsentoftheminor.[1971c.38122005c.47182010
c.912]
109.672Certainpersonsimmunefromliabilityforprovidingcaretominor.(1)Noperson
licensed,certifiedorregisteredtopracticeahealthcareprofessionorhealthcarefacilityshallbe
liablefordamagesinanycivilactionarisingoutofthefailureofthepersonorfacilitytoobtain
theconsentofaparenttothegivingofmedicalcareortreatmenttoaminorchildoftheparentif
consenttothecarehasbeengivenbytheotherparentofthechild.
(2)Theimmunityprovidedbysubsection(1)ofthissectionshallapplyregardlessofwhether:
(a)Theparentsaremarried,unmarriedorseparatedatthetimeofconsentortreatment.
(b)Theconsentingparentis,orisnot,acustodialparentoftheminor.
(c)Thegivingofconsentbyonlyoneparentis,orisnot,inconformancewiththetermsof
anyagreementbetweentheparents,anycustodyorderoranyjudgmentofdissolutionor
separation.
(3)Theimmunitycreatedbysubsection(1)ofthissectionshallnotapplyiftheparentalrights
oftheparentwhogivesconsenthavebeenterminatedpursuanttoORS419B.500to419B.524.
(4)Forthepurposesofthissection,healthcarefacilitymeansafacilityasdefinedinORS
442.015oranyotherentityprovidingmedicalservice.[Formerly109.1331993c.332962003
c.576158]
109.675Righttodiagnosisortreatmentformentaloremotionaldisorderorchemical
dependencywithoutparentalconsent.(1)Aminor14yearsofageoroldermayobtain,without
parentalknowledgeorconsent,outpatientdiagnosisortreatmentofamentaloremotional
disorderorachemicaldependency,excludingmethadonemaintenance,byaphysicianlicensed
bytheOregonMedicalBoard,apsychologistlicensedbytheStateBoardofPsychologist
Examiners,anursepractitionerregisteredbytheOregonStateBoardofNursing,aclinicalsocial
workerlicensedbytheStateBoardofLicensedSocialWorkers,aprofessionalcounseloror
marriageandfamilytherapistlicensedbytheOregonBoardofLicensedProfessionalCounselors
andTherapistsoracommunitymentalhealthprogramestablishedandoperatedpursuanttoORS
430.620whenapprovedtodosobytheOregonHealthAuthoritypursuanttorule.
(2)However,thepersonprovidingtreatmentshallhavetheparentsoftheminorinvolved
beforetheendoftreatmentunlesstheparentsrefuseorunlessthereareclearclinicalindications
tothecontrary,whichshallbedocumentedinthetreatmentrecord.Theprovisionsofthis
subsectiondonotapplyto:
(a)Aminorwhohasbeensexuallyabusedbyaparentor

(b)Anemancipatedminor,whetheremancipatedundertheprovisionsofORS109.510and
109.520or419B.550to419B.558or,forthepurposeofthissectiononly,emancipatedbyvirtue
ofhavinglivedapartfromtheparentsorlegalguardianwhilebeingselfsustainingforaperiod
of90dayspriortoobtainingtreatmentasprovidedbythissection.[1985c.52511989c.721
471993c.5461371997c.249382009c.442302009c.595712013c.1781]
109.680Disclosurewithoutminorsconsentcivilimmunity.Aphysician,psychologist,
nursepractitioner,clinicalsocialworkerlicensedunderORS675.530,professionalcounseloror
marriageandfamilytherapistlicensedbytheOregonBoardofLicensedProfessionalCounselors
andTherapistsorcommunitymentalhealthprogramdescribedinORS109.675mayadvisethe
parentorparentsorlegalguardianofanyminordescribedinORS109.675ofthediagnosisor
treatmentwheneverthedisclosureisclinicallyappropriateandwillservethebestinterestsofthe
minorstreatmentbecausetheminorsconditionhasdeterioratedortheriskofasuicideattempt
hasbecomesuchthatinpatienttreatmentisnecessary,ortheminorsconditionrequires
detoxificationinaresidentialoracutecarefacility.Ifsuchdisclosureismade,thephysician,
psychologist,nursepractitioner,clinicalsocialworkerlicensedunderORS675.530,professional
counselorormarriageandfamilytherapistlicensedbytheOregonBoardofLicensed
ProfessionalCounselorsandTherapistsorcommunitymentalhealthprogramshallnotbesubject
toanycivilliabilityforadvisingtheparent,parentsorlegalguardianwithouttheconsentofthe
minor.[1985c.52521989c.721482009c.442312009c.595722013c.1782]
109.685Immunityfromcivilliabilityforpersonprovidingtreatmentordiagnosis.A
physician,psychologist,nursepractitioner,clinicalsocialworkerlicensedunderORS675.530,
professionalcounselorormarriageandfamilytherapistlicensedbytheOregonBoardof
LicensedProfessionalCounselorsandTherapistsorcommunitymentalhealthprogramdescribed
inORS109.675whoingoodfaithprovidesdiagnosisortreatmenttoaminorasauthorizedby
ORS109.675shallnotbesubjecttoanycivilliabilityforprovidingsuchdiagnosisortreatment
withoutconsentoftheparentorlegalguardianoftheminor.[1985c.52531989c.72149
2009c.442322009c.595732013c.1783]
109.690ParentorguardiannotliableforpaymentunderORS109.675.Ifdiagnosisor
treatmentservicesareprovidedtoaminorpursuanttoORS109.675withoutconsentofthe
minorsparentorlegalguardian,theparent,parentsorlegalguardianoftheminorshallnotbe
liableforpaymentforanysuchservicesrendered.[1985c.5254]
109.695RulesforimplementationofORS109.675to109.695.Forthepurposeofcarrying
outthepolicyandintentofORS109.675to109.695whiletakingintoaccounttherespective
rightsofminorsatriskofchemicaldependencyormentaloremotionaldisorderandtherights
andinterestsofparentsorlegalguardiansofsuchminors,theOregonHealthAuthorityshall
adoptrulesfortheimplementationofORS109.675to109.695bycommunitymentalhealth
programsapprovedtodoso.Suchrulesshallprovidefortheearliestfeasibleinvolvementofthe
parentsorguardiansinthetreatmentplanconsistentwithclinicalrequirementsoftheminor.
[1985c.52552009c.59574]
REFERENCES

1. WashingtonStateOfficeoftheInsuranceCommissioner.FAQaboutcoverageof
transgenderenrollees.[cited09/09/2014]Availablefrom:
http://www.insurance.wa.gov/forinsurers/filinginstructions/filehealthcaredisability/tra
nsgendersubscribersfaq/index.html
2. AmericanPsychologicalAssociation.Answerstoyourquestionsabouttransgender
people,genderidentity,andgenderexpression:Whatdoestransgendermean?[cited
09/09/2014]Availablefrom:http://www.apa.org/topics/lgbt/transgender.aspx
3. WorldProfessionalAssociationforTransgenderHealth(WPATH).MedicalNecessity
Statement:WPATHClarificationonMedicalNecessityofTreatment,SexReassignment,
andInsuranceCoverageforTransgenderandTranssexualPeopleWorldwide.[cited
09/11/2014]Availablefrom:
4.
1. http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_associat
ion_webpage=3947
1. AmericanPsychologicalAssociation.Answerstoyourquestionsabouttransgender
people,genderidentity,andgenderexpression:Howprevalentaretransgenderpeople?
[cited09/09/2014]Availablefrom:
http://www.apa.org/topics/lgbt/transgender.aspx?item=6
2. DeCuypere,G,VanHemelrijck,M,Michel,A,etal.Prevalenceanddemographyof
transsexualisminBelgium.
EurPsychiatry
.200722:13741.PMID:17188846
3. Blosnich,JR,Brown,GR,ShipherdPhd,JC,Kauth,M,Piegari,RI,Bossarte,RM.
Prevalenceofgenderidentitydisorderandsuicideriskamongtransgenderveterans
utilizingveteranshealthadministrationcare.
AmJPublicHealth
.2013
Oct103(10):e2732.PMID:23947310
4. WorldProfessionalAssociationforTransgenderHealth(WPATH).StandardsofCarefor
thehealthoftranssexual,transgender,andgenernonconformingpeople.[cited
09/09/2014]Availablefrom:
http://admin.associationsonline.com/uploaded_files/140/files/Standards%20of%20Care,
%20V7%20Full%20Book.pdf
5. CommitteeOpinionno.512:healthcarefortransgenderindividuals.
ObstetGynecol
.
2011118:14548.PMID:22105293
6. Terada,S,Matsumoto,Y,Sato,T,Okabe,N,Kishimoto,Y,Uchitomi,Y.Suicidal
ideationamongpatientswithgenderidentitydisorder.
PsychiatryRes
.2011190:15962.
PMID:21612827
7. Imbimbo,C,Verze,P,Palmieri,A,etal.Areportfromasingleinstitute's14year
experienceintreatmentofmaletofemaletranssexuals.
JSexMed
.20096:273645.
PMID:19619147
8. Spack,NP,EdwardsLeeper,L,Feldman,HA,etal.Childrenandadolescentswith
genderidentitydisorderreferredtoapediatricmedicalcenter.
Pediatrics
.
2012129:41825.PMID:22351896
9. Selvaggi,G,Dhejne,C,Landen,M,Elander,A.The2011WPATHStandardsofCare
andPenileReconstructioninFemaletoMaleTranssexualIndividuals.
AdvUrol
.
20122012:581712.PMID:22654902

10. Murad,MH,Elamin,MB,Garcia,MZ,etal.Hormonaltherapyandsexreassignment:a
systematicreviewandmetaanalysisofqualityoflifeandpsychosocialoutcomes.
Clinicalendocrinology
.201072:21431.PMID:19473181
11. Elamin,MB,Garcia,MZ,Murad,MH,Erwin,PJ,Montori,VM.Effectofsexsteroiduse
oncardiovascularriskintranssexualindividuals:asystematicreviewandmetaanalyses.
Clinicalendocrinology
.201072:110.PMID:19473174
12. Duisin,D,NikolicBalkoski,G,Batinic,B.Sociodemographicprofileoftranssexual
patients.
PsychiatriaDanubina
.2009Jun21(2):2203.PMID:19556952
13. Heylens,G,Verroken,C,DeCock,S,T'Sjoen,G,DeCuypere,G.Effectsofdifferent
stepsingenderreassignmenttherapyonpsychopathology:aprospectivestudyofpersons
withagenderidentitydisorder.
JSexMed
.2014Jan11(1):11926.PMID:24344788
14. Fisher,AD,Bandini,E,Casale,H,etal.Sociodemographicandclinicalfeaturesof
genderidentitydisorder:anItalianmulticentricevaluation.
JSexMed
.2013
Feb10(2):40819.PMID:23171237
15. GorinLazard,A,Baumstarck,K,Boyer,L,etal.Hormonaltherapyisassociatedwith
betterselfesteem,mood,andqualityoflifeintranssexuals.
TheJournalofnervousand
mentaldisease
.2013201:9961000.PMID:24177489
16. GomezGil,E,ZubiaurreElorza,L,Esteva,I,etal.Hormonetreatedtranssexualsreport
lesssocialdistress,anxietyanddepression.
Psychoneuroendocrinology
.201237:66270.
PMID:21937168
17.
18. 20.Johansson,A,Sundbom,E,Hojerback,T,Bodlund,O.Afiveyearfollowupstudyof
Swedishadultswithgenderidentitydisorder.
Archivesofsexualbehavior
.2010
Dec39(6):142937.PMID:19816764
19. 21.Asscheman,H,Giltay,EJ,Megens,JA,deRonde,WP,vanTrotsenburg,MA,
Gooren,LJ.Alongtermfollowupstudyofmortalityintranssexualsreceivingtreatment
withcrosssexhormones.
EurJEndocrinol
.2011164:63542.PMID:21266549
20. 22.Hembree,WC,CohenKettenis,P,DelemarrevandeWaal,HA,etal.Endocrine
treatmentoftranssexualpersons:anEndocrineSocietyclinicalpracticeguideline.
JClin
EndocrinolMetab
.200994:313254.PMID:19509099
21. 23.AmericanPsychiatricAssociation(2013):DiagnosticandStatisticalManualof
MentalDisorders,5thed.Arlington,VA:AmericanPsychiatricPress.
22. CosmeticandReconstructiveSurgery,Surgery,PolicyNo.12
23. ReductionMammaplasty,Surgery,PolicyNo.60

OREGONHEALTHPLANFORMULARY(link)

DRAFT Therapist Documentation Form for Evaluation for Transgender Surgery

Client's name:
Click here to enter text.
Legal name:
Click here to enter text.
DOB:
Click here to enter text.

Clinician Name:
Click here to enter text.
Office location or clinic:
Click here to enter text.
Please describe your experience completing assessments for gender related surgeries.
Click here to enter text.
For which surgery or surgeries are you referring your client?
Orchiectomy
Penectomy
Vaginoplasty
Hysterectomy/Oophorectomy
Phalloplasty
Metoidioplasty
Vulvoplasty/Labiaplasty
Subcutaneous mastectomy with male chest reconstruction
A surgery not listed here. Please describe:
Click here to enter text.
Please list the dates that you evaluated this client for readiness and appropriateness for surgical
intervention?
Click here to enter text.
Which current or previous medical and/or mental health providers did you speak with in your
evaluation?
Click here to enter text.
Please give a description of this client, identifying characteristics, their history of gender dysphoria
and emphasize their attempts to address their gender dysphoria.
Click here to enter text.
Please indicate the length of time your client has taken hormones and their response to hormones?
Surgical requests require 12 months of hormone therapy unless not clinically indicated.
Click here to enter text.
The Standards of Care state that the client must have "12 continuous months of living in a gender role
that is congruent with their gender identity unless it is determined this is not safe for the client.
Please describe how the client has met this standard or how the standard is waived.
Click here to enter text.
Does this client have the capacity to give informed consent for genital surgery? If no, please explain.
Click here to enter text.
Are there issues the surgeons need to know about regarding communication? These could include
English fluency, hearing impairments, an autism spectrum disorder, literacy level, learning differences,
etc.
Click here to enter text.
How will surgery improve your client's functioning? How will it make their life better? Please use the
client's words.
Click here to enter text.

Do you have any hesitation or concern that the client may regret or not benefit from a surgical
intervention?
Click here to enter text.
Please give a brief description of your client's mental health history, including suicidality, homicidality,
a history of violence towards healthcare workers, any psychiatric hospitalizations, and residential
treatment for mental health or substance use.
Click here to enter text.
Please list all current and past DSM Diagnoses.
Click here to enter text.
Please list all medications that the client is currently taking related to psychological concerns, sleep, or
emotional problems (this should include supplements, like St. John's Wort and medical marijuana).
Please list the prescribers name next to the medication.
Click here to enter text.
Does your client have a mental health problem that the stress of surgery, anesthesia, or recovery may
cause your client to decompensate? For instance, PTSD, anxiety disorders, schizophrenia, substance
abuse, etc.
Click here to enter text.
Please describe how you have prepared your client for this possibility and how this will be addressed.
Click here to enter text.
Please list the result of the CAGE or other substance abuse screening tool.
Click here to enter text.
Please describe current and past substance use including nicotine. Please list any concerns the client
has regarding their substance use or their sobriety and pain medication.
Click here to enter text.
Please describe medical problems your client may have.
Click here to enter text.
What is your assessment of your client's function, including their ability to satisfactorily complete
ADL's and IDL's? (Activities of Daily Living and Instrumental Activities of Daily Living.)
Click here to enter text.
Describe your client's support system, relationships, family support and work.
Click here to enter text.
Do you believe your client is capable of carrying out their aftercare plan? (including providing for their
own self-care following surgery (e.g. dilation 3x per day, hygiene issues, monitoring for infection,
getting adequate nutrition, staying housed, etc.)
Yes No
What additional care will your client need and how will that be arranged? Who will provide needed
case management?

Click here to enter text.

Your rationale for the referral for surgery.
Click here to enter text.
Please indicate that you discussed these issues to your client's satisfaction:
Potential alterations in sexual functioning.
Risks and benefits, alternatives to surgery.
The impact of drugs and /or alcohol on surgery and outcomes.
The importance of aftercare related to post-operative complications and aesthetic outcomes.
The mandatory education/preparation program. (Vaginoplasty, metoidioplasty, and phalloplasty
only)
Sterilization and reproductive choices. (Genital surgeries only)

Is your client's gender identity stable and consolidated? Yes No

Do you believe your client has realistic expectations about what the surgery can and cannot do?
Yes No
Is there anything you would like to add:
Click here to enter text.
Your name, title and license:
Click here to enter text.
Your signature: _______________________________________
Date: Click here to enter text.
Your phone number for follow up:
Click here to enter text.
PRINT AND SEND TO CCO? (NEEDS EDITS)

HealthcareTraining
Trans101objectives+appropriatemodule
Modules:
Insurance/CCOs(dividedbydepartment)
Providers
Agencies

Trans101Objectives:

Participantshavelearnedandhavebasicuseofidentityterminology

Participantsexplorestatisticalevidenceandanecdotalevidenceofsystemicexclusion
anddiscriminationoftranspeople.

Participantshavealsoexploredprotectiveandresiliencyfactorsthatimprovethelivesof
transpeople

Participantsunderstandhowtosupporttranspeoplethroughinterpersonalactions,
structuralchanges,andsystemicintervention.

Grouphasbasicunderstandingofhowthisinformationmaybeusedwithintheir
structures

Grouphashadanopportunitytopracticeapplyingthisinformation

Additional101goals:

Participantsexploregenderexpectationsandgenderbinarysystemactivityhelps
participantsunderstandhowgenderaffectseveryoneandthedepthofsystems

Participantsexplorehowmediaconstructsideasofgender,transidentities,and
transphobiaandrecognizingcurrentexamples

Participantsreceivebasicunderstandingoftransmisogynyandhistoricalsignificanceof
transwomen

Medicalgoals:

Participantsunderstand,byprofession,appropriateinteractionswithpatients/clients

Providersunderstandandcanfulfillresponsiveintakeprocesses(e.g.form,EHR,
interviewspostregistration)

Providersunderstandandcanfulfillrequestsfortransitionrelatedcareassessments
(e.g.forhormonetherapy,forsurgicalrequests)

Providershaveaccesstomultiplestandardsofcare(e.g.WPATH,ICATH,Endocrine
Society)

Orderoftraining:
Introduction&establishinggroupagreement
Introducetheculturaliceberg(individualdiscriminationvssystemicvsstructural)
Establishterminologyandappropriateuse
Definetransitionthroughstorytelling
Presentgenderbinaryandanalyzeitsuseandeffectsoneveryone

promoteunderstandingofmultipleidentities

Introducespectrumofgenderidentities(e.g.usingGenderGumby,Genderbreadperson,etc.)

Introducehowsystemsadverselyaffecttranspeople(e.g.healthcare,employment,housing,
education,incarceration,etc)

Statisticalinformationaboutaccesstohealthcare,educationforproviders,specific
effectsonmentalhealthandphysicalhealth

Introductiontoworkingwithtransgenderyouth

Introductiontoworkingwithtransgenderpeopleofcolorandtheimportanceto
acknowledgeintersectingidentities

*
INSERTSPECIFICAUDIENCECONTENT
*Medical,behavioral,administrative,pharmacy
Scenarioworkbasedonworkshopaudience
a. Seemodules
2. Howcanyouapplythisinformation?
a. Whatareyourindividualroles?Responsibilitiesofthoseroles?Ifyoureadoctor,
yourenotjustadoctor.Yourealsoacoworker,employee,student,etc.
b. Whatcanyouaffectinthesystemyourein?E.g.Ifyouarepartofregistration
staff,youcanchangetheintakeprocessincludingpatientinterviewing.
c. Whatdoyouneedtomakethischange?
d. Isthisafeasiblegoal?Whoelseneedstobeinvolvedtomakethischange?
e. Consultationprotocol
3. Ending
a. Reflections
b. Q&a
c. Evaluation