Medicare denies national coverage for gender reassignment surgery: No evidence of therapeutic outcome
August 31, 2016
On June 2, 2016 the Centers for Medicare & Medicaid Services (CMS) denied national coverage for gender reassignment surgery after the agency conducted a year long review which determined that there is no medical evidence of a therapeutic outcome for patients who have undergone these procedures.
Excerpts from their report:
On December 3, 2015, CMS accepted a formal complete request from a beneficiary to initiate a national coverage analysis (NCA) for gender reassignment surgery.
CMS opened this National Coverage Analysis (NCA) to thoroughly review the evidence to determine whether or not gender reassignment surgery may be covered nationally under the Medicare program.
In general, when making national coverage determinations, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding that an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (§ 1862 (a)(1)(A)). The evidence may consist of external technology assessments, internal review of published and unpublished studies, recommendations from the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), evidence-based guidelines, professional society position statements, expert opinion, and public comments.
The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical question relevant to the coverage request can be answered conclusively; and 2) the extent to which we are confident that the intervention will improve health outcomes for patients.
CMS staff extensively searched for primary studies evaluating therapeutic interventions for gender dysphoria. There was particular emphasis on the various surgical interventions, but other treatments including hormone therapy, psychotherapy, psychiatric treatment, ancillary reproductive and gender modifying services, and post-operative surveillance services for natal sex organs were also included because of their serial and sometimes overlapping roles in patient management. The emphasis focused less on specific surgical techniques and more on functional outcomes unless specific techniques altered those types of outcomes.
The reviewed evidence included articles obtained by searching literature databases and technology review databases from PubMed (1965 to current date), EMBASE, the Agency for Healthcare Research and Quality (AHRQ), the Blue Cross/Blue Shield Technology Evaluation Center, the Cochrane Collection, the Institute of Medicine, and the National Institute for Health and Care Excellence (NICE) as well as the source material for commentary, guidelines, and formal evidence-based documents published by professional societies. Systematic reviews were used to help locate some of the more obscure publications and abstracts.
CMS reviewed and considered potential objective measures of function including mortality, psychiatric treatment, and attempted suicide. None of the longitudinal studies in which patients served as their own control, however, comprehensively tracked changes in these events as objective measures of function before and after surgery. Events such as suicide and institutionalization were mentioned incidentally when describing patients excluded from a follow-up study or during the study (Heylens et al., 2014; Ruppin, Pfafflin, 2015). Other times investigators tracked these functional outcomes (e.g., psychiatric out-patient treatment, psychiatric in-patient treatment, and substance abuse) for the most current prior year (Ruppin, Pfafflin, 2015).
The most comprehensive study with functional endpoints, the Swedish study that followed all patients who had undergone reassignment surgery (at mean age 35.1 years) over a 30 year interval and compared them to 6480 matched controls, identified increased mortality and increased psychiatric hospitalization (Dhejne et al., 2011). The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well. The divergence in mortality from the Swedish population did not become apparent until after 10 years. The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18%). The risk for attempted suicide was greater in male-to-female patients regardless of the gender of the control. Unfortunately, the study was not constructed to assess the impact of gender reassignment per se. The finding of this study, again, demonstrated that reassignment surgery does not return patients to a normal level of morbidity risk and that the morbidity risk is significant, because of its clinical importance, its persistence over the interval of data collection and the increase in risk over time for the individual.
The currently available evidence has limitations:
- There were design deficiencies. All but one of the studies were observational in nature. All but two were non-blinded. The accompanying loss to follow-up suggests that there is selection bias and that the population that seeks treatment for gender dysphoria is not the same population that undergoes reassignment surgery without hesitation or regret.
- The psychometric and psychosocial function endpoints are not well validated.
- There were limitations of the psychosocial endpoints and of the data collection of other hard functional outcomes. Evidence on mortality and especially suicide was stronger. The mortality and psychiatric hospitalization rates even after vetting in highly structured programs are of concern.
- There are insufficient data to select optimal candidates for surgery.
- The results were inconsistent, but negative in the best studies, i.e., those that reduced confounding by testing patients prior to and after surgery and which used psychometric tests with some established validation in other large populations. (Atkins et al., 2004; Balshem et al., 2011; Chan, Altman, 2005; Deeks et al., 2003; Guyatt et al., 2008a-c; 2011a-e; Kunz, Oxman,1998; Kunz et al., 2007 and 2011; Odgaard-Jensen et al., 2011).
Data on reassignment surgery performed on geriatric patients or follow-up data in geriatric patients who had reassignment surgery in the distant past is anecdotal (Orel, 2014).
Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results – of the best designed studies, some reported benefits while others reported harms.
The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up. Due in part to the generally younger and healthier study participants, the generalizability of the studies to the Medicare population is also unclear. Additional research is needed. This proposed conclusion is consistent with the West Midlands Health Technology Assessment Collaboration (2009) that reported “[f]urther research is needed but must use more sophisticated designs with comparison groups.” WPATH also noted the need for further research: “More studies are needed that focus on the outcomes of current assessment and treatment approaches for gender dysphoria.” Further, as mentioned earlier, patient preference is an important aspect of any treatment. With that in mind, CMS is interested in knowing from the patients with gender dysphoria what is important to them as a result of a successful gender reassignment surgery.
Knowledge on gender reassignment surgery for individuals with gender dysphoria is evolving. The specific role for various surgical procedures is less well understood than the role of hormonal intervention. Much of the available research has been conducted in highly vetted patients at select care programs integrating psychotherapy, endocrinology, and various surgical disciplines and operating under European medical management and regulatory structures. Standard psychometric tools need to be developed and tested in the patients with gender dysphoria to validly assess long term outcomes. As such, further evidence in this area would contribute to the question of whether gender reassignment surgery improves health outcomes in adults with gender dysphoria.
Because CMS is mindful of the unique and complex needs of this patient population and because CMS seeks sound data to guide proper care of the Medicare subset of this patient population, CMS strongly encourages robust clinical studies with adequate patient protections that will fill the evidence gaps delineated in this decision memorandum.
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria. Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.
Read the complete evidence review and text of Medicare’s denial of a national coverage determination for ‘Gender Reasignment Surgery” here:
Police have issued an arrest warrant for a suspect in the arson attack on Dr. Pierre Brassard’s cosmetic surgery clinic. Brassard is the only surgeon in Canada who will perform the radical genital surgeries desired by some transgender people who believe the procedures will ease their dysphoria caused by wishing they had reproductive systems of the opposite sex. The men who keep Brassard in business call themselves “Brassard Beauties”. These complex surgeries have a high rate of complications, both acute and chronic, even in the best case scenario. For example, the majority of males who undergo “gender affirming” genital surgery will go on to experience chronic urinary tract infections for the rest of their lives.
On May 2nd a man carrying a machete, an ax, and a gas can entered the side door of the clinic after hours. He was witnessed by a worker who assumed he was a fellow employee who’d gotten locked out by the back dumpsters. The man rushed past him into the operating theatre and ignited the incendiary, which set off the sprinkler system, damaging clinic equipment and supplies. He left the premises before the fire department arrived. Personnel who remained in the building evacuated and no one was harmed. Over $700,000. in damage was caused, and surgeries were cancelled for two days until an alternate temporary facility was arranged. 
The transgender community described the incident as an “act of terror” against transgenders , likened to attacks by men on women’s reproductive health providers , and called for hate crime charges to be brought against the perpetrator. Egale, the Canadian Human Rights Trust, stated:
“On May 2nd, 2016, a man armed with a machete, axe, and gas can, stormed Canada’s only sex reassignment clinic in Montréal, and set it on fire.
This act of arson is a symbolic affront to Canada’s trans community, and nothing short of hate crime. The attack underlines the threat of violence that is endured by Canadian trans people on a daily basis, and affirms the continued need for positive change in our country’s public perception of trans people.” 
The suspect sought by police is Jayne Hellen Heideck, 42, of British Columbia, a transwoman and apparent  ex-patient of Brassard’s. He is charged with breaking and entering, arson by negligence, arson with disregard for human life, among other charges.
While the transgender community decried the lack of outrage that the “hate crime” received in the mainstream press and blogosphere, common sense led most sites, including this one, to suspect the perpetrator may be a member of the transgender community itself.
In 2012 transgender activists attempted to fire bomb a Wells Fargo bank in Portland. 
In 2012 transgender activists shut down the University of Pittsburgh repeatedly via bomb threats scrawled on bathroom walls and sent over the internet. 
In 2012 a transgender activist threatened to firebomb the feminist London Radfem 2012 conference. 
In 2015 a transwoman was convicted in an arson attack on the San Francisco home of facial feminization surgeon Doug Ousterhout. 
In 2015 Stacie Laughton, first elected openly transgender state representative, was arrested for threatening to firebomb a hospital. 
Last month, a transwoman confessed to an arson attack on the Gay Pride flag at the University of British Columbia. 
June 22, 2015
What is a “true transsexual”?
Sex roles, or “gender” assigns the cultural behaviors and traits of supremacy and domination to males, and assigns the behavior and traits of inferiority and subjugation to females. Gender is a political hierarchy, a social caste system of males on the top, ruling, and females on the bottom, serving them. Those of us who’ve been educated in such matters have been informed by the transgender movement that “transgender” is an umbrella term for anyone whose social behavior or whose personality traits deviate from the stereotypes imposed on all of us based on our reproductive sex for the purpose of codifying and perpetuating male supremacy over the bodies of females.
Except for gay people, whose deviation from sex-stereotypical social norms is due to sexual orientation (unless we are also non-conforming in ways indirectly related to sexuality: butch dykes or gay queens, or perform in drag shows, and then maybe…)
And except for crossdressers, who are men dedicated to the fetish hobby of performing their own idealized, objectified version of the female sex-stereotype, an activity which sexually arouses them as men. Unless such men are socially persecuted for their hobby, in which case they are transgender. And unless such men form an attachment to their ritualized “female other” persona, and decide to expand the practice into a full-time lifestyle, like Bruce Jenner, who wanted to become “her”, in which case they are transgender.
And except for women who passed as male in order to escape the female role, to avoid male rape and violence, persecution for homosexuality or to engage in activities and careers forbidden to women. Unless they are now dead, in which case they posthumously are transgender.
Men who believe their personalities are aligned with any characteristics they assign via sexism to women based on our reproductive biology are transgender, even if they sport full beards, cock and balls, and answer to “Bubba”. Donna Perry is transgender, even though he brutally murdered five women as a sexual sociopath and serial killer on the path to discovering his true authentic self.
Genderqueers are women who don’t want to be thought of as female because the female sex-role is oppressive. Their pronouns are “anything but female” but that doesn’t stop them from being raped and assaulted by men. They are transgender.
Coy Mathis and Jazz Jennings are boys whose parents with Munchausen By Proxy pimp them out to the media as pediatric transgender Honey-boo-boos for fame and profit. They are transgender.
Chaz Bono is Cher’s self-hating lesbian daughter who complained that the Ellen Degeneres Show was “too gay” and “moving too fast for society” before she began injecting testosterone. She is transgender.
Morgan Page, Julia Serano, Dana Beyer are autogynephiles that are very upset that lesbian people exist because they believe female homosexuality discriminates against males by rejecting males as sexual partners. They are transgender.
So it seems that “transgender” is an umbrella term for anyone whose social behavior or whose personality traits deviate from the stereotypes imposed on all of us based on our reproductive sex for the purpose of upholding a caste system which benefits males and disadvantages females, but only if such a person supports these sex stereotypes and believes that sex roles are innate and define sexual reproduction instead of actual reproductive biology. Or something.
Of course, females who transgender can’t “identify” their way out of the subordinate caste and the requisite male rape and male violence which enforces it, unless their biology is completely disguised and their origins unknown. Female “Transmen” aren’t exactly fighting for their right to be housed in men’s prisons when they get arrested. They aren’t demanding “male” abortion services and pap smears at the local urology clinic. The transgender community itself is notoriously sex-segregated and misogynist towards females who transgender because there really is no benefit to the males (“Transwomen”) even attempting to undo their socialization as the dominant and superior members of the sex caste. That’s about as likely to occur as men deciding to stop raping us because we ask them to. What’s in it for them?
Transgender is a Men’s Rights Movement. It seeks to expand both the dominance of males and the subjugation of females, and all with a tidy profit made by what one commenter here called the “Gender Industrial Complex”. Transgender also acts as a release valve to siphon off and neutralize female rebellion against the sex caste system of gender by allowing women to access some superficial privileges of maleness (such as avoiding a measure of public surveillance by men on the street, etc) in exchange for pledging fealty to the hierarchical premise of the caste system and voluntarily submitting oneself to monitoring by the medical authorities.
So. Now that we know what “transgender” means: what is a “True Transsexual”? I’ve been hearing so much about the “truly transsexual” these days, and from the most unlikely of places! It seems a cohort of heterosexual women and men calling themselves “gender critical” are now forwarding the idea of the “true” vs. “false” transsexual. These folks have taken to defanging the work of Radical Feminists and Lesbian Feminists by re-writing (or just downright plagiarizing) with a few significant changes, or perhaps “corrections” in their view: namely they remove the lesbian and women-centered analysis and instead center the concerns of their men friends who would like to transgender. The straight women and “transwomen” (who are “gender critical” male femulators in the same way that Rachel Dolezal is a white “race-critical transblack”) seem to be trying to create a liberal feminist version of gender critique the sole purpose of which is to center men who impersonate women and to replicate the heterosexual dynamic.
“The “radical” in radical feminism means getting to the root of the problem. The root of the problem is gender, meaning the idea of male (masculine/dominant) and female (feminine/subordinate) personalities,” says one of these women.
Huh? The tribal legacy of violent male control over the means of human reproduction (Females!) is not the root? Wow. Learn something new every day. The root of female oppression is not violent sex-based exploitation but rooted in the barriers to full expression of male personalities. Huh. Well, we’ve nearly got this all sorted, then. Male liberation now! The sooner the better! This whole global history thing really was a big misunderstanding! Ritualized cultural sex-caste traditions are the problem, not the violent control of those bodies capable of creating offspring, which is at the root of such traditions.
This is Trans-feminism. This is Mans-feminism. The author goes on to lecture women that we should “offer safety” in the male-occupied land of women to male “refugees” from the ruling caste –(weary is the head that holds the crown!)- men who want to call themselves Meredith, take estrogen, wear yoga pants and try to pass themselves off as “transwomen”. Like we don’t have enough problems, we should perform as unpaid femulator academies for the male lesbians.
These heterosexual transfeminist women propagating a rootless mansfeminism stripped of sex-based analysis so that they can better serve the needs of their TBF* (*Transwoman Best Friends- the straight woman’s “gay best friend” is like, so five minutes ago, apparently) would be laughable if they weren’t so damn harmful to the women and girls who actually have a dog in the transgender race, so to speak. It’s no coincidence that all of the new radlib transfeminists parsing out the “true transsexuals” from the nasty bad false ones are straight. It’s not a coincidence that they de-lesbian their analysis. The fact that they also dis-include “Transmen” (who are actual females! hello?) from their MansFeminist Tranifestos is no coincidence.
I’m going to tell you now what a “True Transsexual” really is.
This is what enters my mind every. single. time. one of these straight women makes the distinction between the “True” transsexual with “Real Sex Dysphoria!” and the “False” bad kind. I don’t think about their TranswomanBestFriend and whatever shit he does to himself. I really don’t care what men do to themselves.
From the WPATH World Professional Transgender Health Symposium, Bangkok, 2014:
Gennaro Selvaggi, MD, PhD, MSc, FRCS, Rickard Branemark, MD, PhD, MSc, Anna
Elander, Joacim Stalfors, MD, PhD.
Preoperative planning and titanium implant fixation for “boneanchored penile epithesis”.
The principle of osseointegration is accepted and used in reconstructive surgery: different
types of epithesis (ear, nose, etc.) can be fixed via titanium screws to the recipient bone.
We present the first series of patients where titanium implants have been implanted onto the
pubic bones of femaletomale (FTM) transsexual patients, in order to attach a “bone anchored” penile epithesis.
Following patients’ selection based on patients’ wishes, pubic bones of five FTM transsexuals
were analysed with CTscan.
CTscan images were uploaded on Surgiguide 5.0 software and a virtual planning was made,
simulating various implant (“fixtures” and “abutments”) sizes and locations.
A surgical plan composed of a two separate stages was developed.
To the date of the submission of this abstract, six FTM transsexuals underwent stage1 surgery, and 3 underwent stage2 surgery.
During the stage1 surgery, two titanium implants (“fixtures”) were implanted onto the pubic boneof each patient,
lateral to the pubic symphisis. Four weeks postop, a new CT scan was performed to analyze osteointegration and the final implant position.
During the stage2 surgery, the soft tissue of the pubic have been reduced; abutments have been inserted and passed through the skin.
After few weeks, a penile epithesis is connected via a “retention” system to the titanium implants.
Preoperative virtual planning is crucial for the selection of the appropriate implants size and the
anatomical location where to set the implants.
Both stage1 and stage2 surgeries occurred uneventfully in all patients.
Postoperative CT scan is demonstrating implant osteointegration in all 6 cases.
Functional results of the use of the epithesis will be provided as soon as available.
This experimental clinical study demonstrates that titanium osteointegration onto the pubic bone is feasible.
This new approach for penile reconstruction in FTM transsexuals constitutes another alternative for these patients.
Further technical development is needed to validate the stage2 surgery and the penile epithesis.
There are six women out there, somewhere in the world, please God bless them and keep them, with titanium rods screwed into their pelvic bones and expressed (sticking out through perpetually broken, lymph oozing skin) through their groin in the hopes that one day a dildo might after “further technical development” be affixed to the metal. Who knows what else these surgeons are doing to female “True Transsexuals” that isn’t being presented to the public at WPATH. I say a prayer for these women every time I think of them, and I think of them every single time I hear a “feminist” say the words “True Transsexual”. I hope you do now too. With a prayer.
January 8, 2015
A transwoman being described as a “disgruntled ex-patient” was arrested yesterday for the attempted murder by arson of Dr. Douglas Ousterhout, a long-time specialist in transgender facial feminization surgery. On Monday the suspect allegedly doused the front and back of the surgeon’s home with gasoline, then ignited it, after a reported “physical confrontation” earlier in the day. The doctor was home cooking dinner at the time and the fire was extinguished without injury. Dr. Ousterhout lives in the San Francisco landmark home used as the movie set for the Robin William’s crossdressing film “Mrs. Doubtfire”.
The suspect, Tyqwon Eugenen Welch, 25, was located by police on Wednesday and detained and booked on charges of attempted murder, arson, possession of an incendiary device, criminal threats, and trespassing. Police kept Ousterhout’s residence under police watch until the suspect was apprehended.
Transgender facial feminization is a small and notoriously acrimonious and competitive specialty. Physicians have been accused of running smear campaigns against one another, lawsuits have been filed, and disgruntled ex-patients have been arrested.
Ousterhout, 79, has reportedly announced, then retracted, his retirement at least twice in the last four years. He continues to practice.
Insurers struggle to justify the sex discrimination of legally mandated “transgender care” while surgical providers continue to decline
October 30, 2014
Less than 50 physicians worldwide are willing to provide transgender surgical “sex reassignment” or “sex change” procedures, and as the few existing practitioners retire, no one is replacing them. Modern cosmetic and reconstructive surgeons at large are opting not to do these procedures, even when they are state mandated and funded.
Now, insurers are struggling to fulfill state mandates covering transgender surgical procedures for men that are excluded for women based on sex discrimination. Transgender state medical mandates pushed by lobbyists insist that procedures such as breast implants and “face lifts” are medically necessary for men who wish to look more like women, while denying coverage for those same procedures to actual women. Transgender advocates have successfully lobbied for such government provided “care” on the grounds that without such procedures men may become depressed or abuse alcohol or other substances, and that such men have a state-protected right to avoid being mocked or socially ostracized for their appearance. Males must declare a “transgender identity” to receive coverage.
From the Boston Herald:
Four months after the state Division of Insurance put health plans on notice that denying medically necessary treatment to transgender people is prohibited sex discrimination, insurers are still grappling with what constitutes medical necessity, and patients are struggling to find doctors who’ll treat them.
“We were concerned people were having to go all over the country for this surgery,” Dr. Joel Rubenstein of Harvard Pilgrim Health Care said yesterday at a Division of Insurance informational session. “We’re hopeful somebody would step up to put together the surgical piece so it could all be in one place.”
On the other hand, he said, Harvard Pilgrim does not want to approve procedures such as facial feminization for transgender people if those procedures would be considered merely cosmetic for other people.
But Ruben Hopwood of Fenway Health said facial feminization is not about wanting a “cuter nose.” A transgender person’s appearance is more likely to be the difference between getting a job or not getting one, and walking down the street unafraid or being attacked, Hopwood said.
Getting the proper treatment also can save money that might otherwise be spent on treatment for alcohol or substance abuse or depression, said Pam Klein, a nurse at Boston Health Care for the Homeless.
[bolding by me-GM]