cpt codes for gender reassignment surgery

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Gender Dysphoria and Gender Reassignment Procedures

• Consistently stating he is really a girl when he has the physical characteristics of a boy or that she is really a boy with the physical characteristics of a girl 
• Strong preference for friends of the same sex that he/she identifies with
• Having an aversion to clothes, toys, and games typical for boys or girls
• Refusing to urinate in the position that other boys or girls do
• Stating he/she wants the genitals of the other sex instead of the genitals that he/she has
• Believing he/she will grow up to be a person of the sex he/she identifies with even though currently he/she has the physical characteristics of the other gender 
• Experiencing substantial distress about the changes his/her body goes through during puberty 
• Believing that his/her gender is not in line with his/her body
• Loathing of his/her genitals, which may cause an avoidance to taking showers, changing clothes, or having intercourse so that he/she won't have to look at or touch his/her genitals 
• Extreme desire to have the genitals gone
• F64.0 - Gender dysphoria in adolescents and adults
• F64.1 - Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery) 
• F64.2 - Gender dysphoria in children
• F64.8 - Other specified gender dysphoria
• F64.9 - Gender dysphoria, unspecified
• Written psychological assessment from one or more qualified behavioral health providers experienced in gender dysphoria treatment who has assessed the patient and documented all of the following:
• The same requirements as listed above for breast surgery
• Completed 12 months or more of successful, ongoing full-time, real-life experience in the desired gender
• Completed 12 months of ongoing cross-sex hormone therapy appropriate for the desired gender, unless medically contraindicated
• Treatment plan, including ongoing followup and care by a qualified behavioral health provider experienced in treating gender dysphoria
• Penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
• Urethral opening is moved to a position similar to that of a female.
• Vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split-thickness grafts.
• Labia are created out of skin from the scrotum and adjacent tissue.
• Stent or obturator is usually left in place in the newly created vagina for three weeks or longer.
• Portions of the clitoris and adjacent skin are used. 
• Prostheses are often placed in the penis to make a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum. 
• Vagina is closed or removed.
• Liposuction (fat removal)
• Rhinoplasty (nose reshaping) 
• Rhytidectomy (face lift) 
• Blepharoplasty (removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat) 
• Hair removal or hair transplantation 
• Facial feminizing (such as facial bone reduction) 
• Chin augmentation (chin reshaping or chin enhancing) 
• Collagen injections 
• Lip reduction/enhancement (lip size decrease or enlargement)
• Cricothyroid approximation (voice modification)  
• Trachea shave/reduction thyroid chondroplasty (thyroid cartilage reduction)
• Laryngoplasty (laryngeal reshaping framework - voice modification surgery) 
• Mastopexy (breast lift)

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• Coding Question: Coding for the Transgender Process Services

Coding for the Transgender Process Services 

I have a physician who is starting treatment for the transgender process on a patient. she came in to discuss the process and received a prescription for testosterone. how can i code it correctly.

You might consider using diagnosis code F64.0 , Transsexualism, in addition to an appropriately leveled Evaluation and Management (E/M) code. Please note that per ICD-10-CM inclusive notes for F64.0 , code F64.0 covers both “gender identity disorder in adolescence and adulthood” and “gender dysphoria in adolescents and adults.”

Per the CMS Transmittal, condition code 45 , Ambiguous Gender Category, needs to be reported on Part A Medicare claims to identify transgender- or hermaphrodite-related cases. The presence of this condition code on your claim will allow sex-related edits to be bypassed so your claim can be processed like other regular Medicare claims.

Meanwhile, modifier KX , Requirements specified in the medical policy have been met, should be appended to any gender-specific procedure code reported on Part B Medicare claims. This modifier informs Medicare that the procedure is performed on a beneficiary for whom gender-specific editing may apply, but that Medicare should allow the edit to be overridden.

Commercial Payers

Please note that commercial payers may or may not follow Medicare guidelines. It’s advisable to check with your payers first on their specific policy on services furnished to transgender patients. Coding will depend on what services are provided, and it is best practice to obtain from your payers their definitive list of covered and noncovered services. Whatever your patient’s insurance may be, you would use the gender marker indicated in their insurance record when preparing your claim for submission.

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Gender Dysphoria and Gender Reassignment Surgery

Tracking information, description information.

Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

A.     General

Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity.

B.     Nationally Covered Indications

C.    Nationally Non-Covered Indications

D.    Other

The Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

(This policy last reviewed August 2016.)

Transmittal Information

03/2017 - Effective Date: 08/30/2016. Implementation Date: 04/04/2017. ( TN 194 ) (CR9981)

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

• Original Consideration for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N)

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

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Page Help for NCD - Gender Dysphoria and Gender Reassignment Surgery (140.9)

Introduction.

This page displays your requested National Coverage Determination (NCD). The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. National Coverage Determinations (NCDs) are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service.

More information

NCDs are developed and published by CMS and apply to all states. NCDs are made through an evidence-based process, with opportunities for public participation. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare Administrative Contractors (MACs) are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, an item or service may be covered at the discretion of the MAC based on a Local Coverage Determination (LCD). LCDs cannot contradict NCDs, but exist to clarify an NCD or address common coverage issues. Prior to implementation of an NCD, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to claims-processing contractors. That issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. An NCD becomes effective as of the date of the decision memorandum.

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Frequently Asked Questions (FAQs)

Are you a provider and have a question about billing or coding.

Please contact your Medicare Administrative Contractor (MAC). MACs can be found in the MAC Contacts Report .

Do you have questions related to the content of a specific Local Coverage Determination (LCD) or an Article?

Are you a beneficiary and have questions about your coverage, are you looking for codes (e.g., cpt/hcpcs, icd-10), local coverage.

For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

National Coverage

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

How do I find out if a specific CPT code is covered in my state?

Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.

If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).

If you don’t find the Article you are looking for, contact your MAC .

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Payment of Gender-Affirming Voice Therapy

Considerations for speech-language pathologists.

Individuals may seek gender affirmation services to make their voice and/or other aspects of their communication congruent with their gender identity and/or gender expression. Speech-language pathologists (SLPs) provide expertise in safely modifying the voice. According to The Report of the 2015 U.S. Transgender Survey  [PDF] voice therapy is the second most common reported medical intervention, behind hair removal, for transgender individuals assigned male at birth. SLPs who serve this population should be specifically educated and appropriately trained to do so.

The following information focuses on policies related to payment and coding for voice therapy related to gender affirmation services for transgender and gender diverse people. Language is dynamic, and terminology evolves. The terminology on this page reflects terms currently used in health care and education policy. When treating members of the transgender and gender nonconforming community, clinicians are encouraged to ask their client what terminology they (the client) use.

On this page:

Federal and State Laws and Regulations

Private insurance.

• Coding for Reimbursement

Laws related to gender identity are constantly evolving. Title VII of the 1964 Civil Rights Act , a federal regulation, prohibits discrimination in any federally funded program on the basis of race, color, sex, or national origin. This includes any public or private facility, such as a hospital, clinic, nursing home, public school, university, or Head Start program that receives federal financial assistance, such as grants, training, use of equipment, and other assistance.

According to Section 1557 of the Patient Protection and Affordable Care Act  (ACA), which is the primary anti-discrimination provision of the ACA, a health plan or health insurer that receives federal financial assistance from the Department of Health and Human Services (HHS) cannot categorically exclude all services related to gender affirmation and/or make coverage decisions in a manner that results in discrimination against a transgender or gender diverse individual (i.e., deny a claim or impose limitations or restrictions on any health service). 

In addition, the Health Insurance Portability and Accountability Act (HIPAA) protects the disclosure of information about a patient’s sexual orientation and gender identity.

As of 2021, 21 states plus the District of Columbia have affirmative coverage for gender affirmation-related care for Medicaid, and 22 states plus the District of Columbia have coverage requirements for private payers. Although some coverage may be provided for voice therapy related to gender affirmation, there can be barriers to accessing it. Seek legal counsel if you have questions or concerns regarding the impact of federal or state law on the reimbursement of voice therapy for gender affirmation-related care.

Payer Policies

SLPs should keep in mind that there is significant variability in coverage for services related to  gender affirmation . Such services may be covered with the medical diagnosis of "gender dysphoria." According to  The Report of the 2015 U.S. Transgender Survey [PDF], nearly 25% of respondents reported having experienced challenges with insurance regarding services related to gender. Often, current laws only mention specific services, such as gender affirmation surgery or hormone therapy

Always verify payer coverage policies before beginning to provide voice therapy services for transgender; or gender diverse people. Payers may use an evolving variety of terms to describe gender affirmation services, including but not limited to, gender reassignment, transgender voice services and gender dysphoria evaluation and treatment.

Effective August 30, 2016, the Centers for Medicare & Medicaid Services (CMS) determined that no national coverage determination (NCD) [1] is appropriate at this time for gender affirmation surgery   and gender dysphoria. Instead, coverage determinations will continue to be made by the local   Medicare Administrative Contractors   (MACs) on a case-by-case basis. Coverage for voice therapy for transgender   and gender diverse people   may be available under Medicare. Absent specific Medicare guidance regarding   voice therapy   for gender reassignment services (Medicare’s current terminology) ,   SLPs should verify coverage with the local MAC and follow the   Medicare Physician Fee Schedule   (MPFS), generally accepted coding guidelines, and national Medicare policies as outlined in Medicare manuals, such as the   Medicare Benefit Policy Manual .  

As of  2021, 21  state Medicaid agencies, plus the District of Columbia, have affirmative coverage  laws for gender affirmation-related care . The majority of Medicaid agencies that cover  care tend to cover gender affirmation surgery , hormone therapy, and mental health treatment. However, a case could be made for voice therapy based on medical necessity.  

The following state Medicaid agencies cover  gender affirmation-related  care but do not mention whether voice therapy is a covered or non-covered service: California, Colorado, Connecticut, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Washington, and Wisconsin.

The following state Medicaid agencies exclude coverage for voice therapy  for gender affirmation services:  District of Columbia, Maryland, and Vermont.  

SLPs should contact their Medicaid agency for guidance on the following questions:  

• Which services may or may not be covered for  gender affirmation- related care?  
• If voice therapy is not covered, can a provider request that the service be approved for coverage? For example, voice therapy is not a covered service for the state of Washington’s Medicaid agency. However, a provider can  request  that the service be approved for coverage.  
• Which International Classification of Diseases (ICD) and Current Procedural Terminology (CPT ®) codes are eligible for  gender affirmation- related care?  

As of  2021 , the following states have affirmative coverage for medically necessary  gender affirmation-related  care for private insurance: California (vocal training is an example of a covered service), Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois,  Maine,  Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Jersey,  New Mexico,  New York, Oregon, Pennsylvania, Rhode Island, Vermont,  Virginia,  and Washington.  

Like Medicaid, very few state laws mention coverage for voice therapy  for transgender or gender diverse people.  However, many of the state laws prohibit insurers from denying or excluding medically necessary services related to the diagnosis of gender dysphoria. Therefore, a case could be made for voice therapy coverage.   

For example,  BlueCross Blue Shield of North Carolina  covers medically necessary voice therapy as part of the overall treatment for gender dysphoria.  

It is important to check with each private insurer regarding coverage for voice therapy.  

SLPs should contact private insurers for guidance on the following questions:  

• Which services may or may not be covered?  
• If voice therapy is denied, can a provider request that the service be approved for coverage via an appeal?  
• What provider types are eligible to deliver services?  
• Which ICD and CPT® codes are eligible for  billing ?  

Coding for Payment

Each claim that is submitted to a payer for reimbursement of voice therapy should include both International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes to report the patient’s medical and treating diagnosis, and Current Procedural Terminology (CPT® American Medical Association) codes to report the services provided by the SLP.   

The following information follows basic coding principles. SLPs should consult the payer if clarification of coding or coverage is needed regarding a specific case.  

ICD-10-CM 

The R49 series of ICD-10-CM codes is used to report voice and resonance disorders and may be used in conjunction with ICD-10-CM codes related to gender dysphoria when providing voice therapy as part of gender affirmation services.

Specific diagnosis codes related to gender dysphoria are found in the F64 series for gender identity disorders. There is also a code used to report a personal history of sex reassignment (Z87.890). SLPs should always consult the medical record or referring physician to confirm the appropriate medical diagnosis code for gender dysphoria.  

Although payers often refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, American Psychiatric Association) criteria when establishing a medical diagnosis of gender dysphoria, ICD-10-CM codes are used on claims for reimbursement, unless otherwise specified by the payer.  HIPAA  requires use of the ICD-10-CM for health care billing and recordkeeping.  

A detailed list of  ICD-10-CM codes for gender dysphoria and voice disorders  [PDF] is available on ASHA’s website.  

There are no CPT codes specific to  gender affirmation- related voice therapy. Coding for evaluation and treatment is accomplished using the same CPT codes, regardless of the patient’s medical or treating diagnosis. CPT codes typically used by SLPs to report voice services include 92524 (Behavioral and qualitative analysis of voice and resonance) and 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder). A full list of CPT codes related to the evaluation and treatment of voice and communication disorders is available on  ASHA’s CPT coding webpage .   

ASHA Resources

• Gender-Affirming Voice Therapy Advocacy
• Practice Portal: Gender Affirming Voice and Communication
• CPT Codes for SLPs
• ICD-10-CM Codes Related to Speech, Language, and Swallowing Disorders  [PDF]
• Medicare Fee Schedule for SLPs
• Questions? Contact [email protected] . 

Other Resources 

• A Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities, People with Disabilities and Sexual and Gender Minorities  [PDF], by the Centers for Medicare & Medicaid Services
• The Report of the 2015 U.S. Transgender Survey  [PDF], by the National Center for Transgender Equality
• Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th version)  [PDF], by the World Professional Association for Transgender Health
• Finding Insurance for Transgender-Related Healthcare , by the Human Rights Campaign.
• Promoting Cultural Diversity and Cultural and Linguistic Competency: Self-Assessment Checklist for Personnel Providing Services and Supports to LGBTQ Youth and Their Families   [PDF], by the National Center for Cultural Competence at Georgetown University  

[1] In 2014, Medicare updated its National Coverage Determination (NCD) for Gender Dysphoria and Gender Reassignment Surgery  to provide coverage for medically necessary services related to gender transition such as gender reassignment surgery. The categorical exclusion of coverage of transition-related surgery was invalidated, meaning that coverage decisions for transition-related care will be made on an individual basis like all other services under Medicare. 

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Coding Update: Breast Augmentation and Removal for Gender Affirming Surgery

April 29, 2022

The American Medical Association (AMA) recently updated their guidance for the correct Current Procedural Terminology (CPT ® ) codes to use when filing claims for breast removal and breast augmentation as part of gender reassignment surgeries. Blue Cross and Blue Shield of Illinois (BCBSIL) has updated its system to align with AMA and American Academy of Professional Coders (AAPC) billing guidance, as summarized below.

What’s New For gender affirming breast reduction and/or removal for transgender male and non-binary members, the AMA and AAPC guidance is to use CPT code 19318 for breast reduction/reduction mammaplasty. Claims for gender affirming breast reduction and/or removal for transgender male and non-binary members should not be coded with 19303 for complete mastectomy +19350 for nipple/areola reconstruction.

Background The AMA recommends the use of CPT code 19303 for the treatment or prevention of breast cancer . It recommends CPT code 19318 for reduction mammaplasty when breast tissue is removed for breast-size reduction and not for treatment or prevention of breast cancer .

The AAPC does not recommend the use of CPT code 19350 for nipple reconstruction in transmasculine gender reassignment . AAPC advises that CPT code 19318 may be used to reflect reshaping of the nipple for cosmetic purposes.

BCBSIL Resources Refer to BCBSIL Medical Policy SUR717.001 - Gender Assignment Surgery and Gender Reassignment Surgery with Related Services for more information. Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual .  

CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. 

BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.    

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A Consensus No Longer

The American Society of Plastic Surgeons becomes the first major medical association to challenge the consensus of medical groups over “gender-affirming care” for minors.

The main justification for “gender-affirming care” for minors in the United States has been that “all major U.S. medical associations” support it. Critics of this supposed consensus have argued that it is not grounded in high-quality research or decades of honest and robust deliberation among clinicians with different viewpoints and experiences. Instead, it is the result of a small number of ideologically driven doctor-association members in LGBT-focused committees, who exploit their colleagues' trust. Physicians presenting different viewpoints are silenced or kept away from decision-making circles, ensuring the appearance of unanimity.

As the U.K.’s Cass Review pointed out, the World Professional Association for Transgender Health (WPATH) and the U.S. Endocrine Society were especially important in forging this consensus, and they did so by citing each other’s statements, rather than conducting a scientific appraisal of the evidence. The “circularity” of this approach, says Cass in her report to England’s National Health Service , “may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

Perhaps because it has never really depended on evidence, this doctor-group consensus has shown remarkable resilience in the face of major system shocks, including several whistleblowers , revelations from court documents that WPATH manipulated scientific evidence reviews , the Cass Review, a bipartisan commitment in the U.K. to roll back pediatric medical transition, and a growing international call for a developmentally informed approach that prioritizes psychotherapy over hormones and surgeries.

But the U.S. consensus now appears to have its first big fracture. In July, the American Society of Plastic Surgeons, a major medical association representing 11,000 members and over 90 percent of the field in the U.S. and Canada, told me that it “has not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria.” ASPS acknowledged that there is “considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions” and that “the existing evidence base is viewed as low quality/low certainty.”  

Calling the evidence for youth gender transition “low quality” is not, as some gender clinicians say, a “scary buzzword” intended to “confus[e] non-experts.” In evidence-based medicine, “low quality” evidence means something very specific : that the true effect of an intervention is likely to be markedly different from the results reported in studies. As one expert in evidence-based medicine put it , low quality “doesn’t just mean something esoteric about study design, it means there’s uncertainty about whether the long-term benefits outweigh the harms.” As evidence for those harms —which include infertility , sexual dysfunction , and the agony of regret —continues to mount and ethical concerns  get  harder to ignore , European countries are increasingly prioritizing psychotherapy and reclassifying endocrine and surgical approaches as experimental.

Aware that WPATH suppressed systematic reviews of evidence while developing its latest “standards of care,” ASPS says that it “is reviewing and prioritizing several initiatives that best support evidence-based gender surgical care to provide guidance to plastic surgeons.” I also asked ASPS whether plastic surgeons share responsibility for determining the medical necessity of gender surgeries for minors. ASPS responded that surgeons are “members of the multidisciplinary care team” and as such “have a responsibility to provide comprehensive patient education and maintain a robust and evidence-based informed consent process, so patients and their families can set realistic expectations in the shared decision-making process.”

Sheila Nazarian, a plastic surgeon who practices in Beverly Hills, California, told me that colleagues in her field are increasingly expressing concern about the use of hormones and surgeries to help minors who experience distress associated with their sex. Many, however, fear that voicing these concerns will bring professional and social blowback. “It’s a real problem when colleagues are afraid to debate any medical treatment or procedure, and especially when minors are the patients,” Nazarian says. “I have been following the international debate on youth gender medicine for some time now and know we [in the U.S.] are far behind in recognizing the lack of evidence for long-term benefits, something that our European colleagues have done.”

One obstacle to having productive discussions, Nazarian said, is the partisan divide over youth gender medicine, which leads physicians to believe that disagreement with the “gender-affirming” approach is driven by political or ideological considerations. This perception is understandable, given that the debate is in fact polarized along partisan lines, though it has become less so in the last two years as a number of Democrats in state legislatures have voted in favor of (or abstained from voting against) age restriction laws. It’s possible that advocates of “gender-affirming” interventions see benefit in the partisan framing, as it may deter liberal doctors from examining the issue in greater depth and speaking up when they detect problems.

Regardless of why the issue is polarized in the U.S., the growing international consensus against the “gender affirming” approach for minors is anything but partisan. In Finland and Sweden, for instance, left-leaning governments implemented restrictions following systematic reviews of evidence by independent health-care quality agencies. In the U.K., the NHS-commissioned independent review of the Gender Identity Development Service, led by Hilary Cass, prompted the Tory government to ban puberty blockers, a move subsequently endorsed by the new Labour government.

The U.S. is one of the few Western countries where minors can receive gender surgeries, according to a new report . Teens under 18 cannot undergo double mastectomy in Belgium, Finland, Germany, Luxemburg, Sweden, the U.K., and three Canadian provinces. Countries that allow these procedures typically do so only in “rare cases,” after age 16, and with parental consent. In the U.S., WPATH Standards of Care, Version 8 , widely followed and endorsed by the Biden administration , specifies no age minimums for gender surgeries, with the exception of phalloplasty (but even that can be performed if “significant, compelling reasons” exist to do so). In June, unsealed court documents revealed that WPATH eliminated age minimums for political reasons, and under pressure from U.S. Assistant Secretary for Health Rachel Levine, a transgender woman.

An estimate of U.S. “gender-affirming” double mastectomies published in 2023 in the Journal of the American Medical Association reported 3,125 cases of “breast or chest procedures” in patients ages 12 to 18 between 2016 to 2020. The study did not differentiate between 18-year-olds and minors. A new analysis by the Manhattan Institute, using a more up-to-date all-payer national insurance database from 2017 to 2023, found evidence of 5,288 to 6,294 “gender-affirming” double mastectomies for girls under age 18. This includes 50 to 179 girls who were 12.5 or younger at the time of their procedure. (“Top surgery” on 12-year-old girls has been reported in the medical literature.)

Two caveats should be mentioned. First, 2023 data are incomplete, making it premature to conclude that a dip occurred that year, relative to previous years. Second, even the liberal estimates are an undercount, as the data are limited by two constraints: the procedures had to be covered by insurance, and patients had to have a preexisting diagnosis of gender dysphoria. The out-of-pocket costs of “top surgery” can be as low as $3,000 , a sum many middle-class families can afford. Further, if it is true, as is being alleged , that gender clinicians are using false diagnostic and procedural codes for insurance billing, these cases would not show up in our data.

A growing trend in gender medicine is “nonbinary” mastectomies, a procedure that some patients seek in order to appear neither male nor female. According to our data, a minimum of 1,873 such procedures (conservative estimate) were performed on girls under age 18 in the U.S. between 2017 and 2023. The number of procedures grew from 70 in 2017 to 470 in 2023—an almost seven-fold rise. Plastic surgeons who perform these procedures leverage the existing billing code for breast reduction (“19318–Unilateral reduction mammaplasty”), a practice some might argue amounts to insurance fraud.

When speaking to the public, American gender clinicians have a tendency vastly to understate or even deny the existence of gender surgeries on minors. For example, in 2023, Marci Bowers, a plastic surgeon and president of WPATH, told CBS News that “Surgery really is not done under the age of 18, except in severe cases . . . And even that is rare, I think the estimates are something like 57 surgeries under the age of 18 were done for trans individuals.” (Bowers, a genital surgery specialist, may have been thinking about genital surgery on minors, of which at least 56 were performed between 2019 and 2021, according to a Reuters report .)

At an April 2023 hearing before the Texas Senate Committee on Health and Human Services, Cody Miller Pyke, a physician and gender medicine advocate, said that “children under the age of eighteen in this country do not have gender reassignment surgery. There isn’t a single case.” Texas Pediatric Society president Louis Appel testified that “surgeries are not part of the standard of care.” This was seven months after WPATH published its Standards of Care, Version 8 , which includes gender surgeries with no age minimums.

Due to the nature of their work, plastic surgeons are increasingly finding themselves in the hot seat of gender medicine lawsuits. Almost two dozen lawsuits by detransitioners against clinics and clinicians are currently underway, and at least seven of the defendants in these cases are ASPS members. One, Winnie Tong, performed a double mastectomy on Kayla Lovdahl in 2017, when she was only 13. Lovdahl is now suing Kaiser Permanente and Tong, who claim that they were following WPATH’s Standards of Care, Version 7 —a guideline so poor in its quality that it does not meet Kaiser’s own explicitly stated criteria for what makes a clinical guideline trustworthy.

Whether detransitioners like Lovdahl will win in court depends largely on how the courts understand the standard of care—a medical-legal term—at the time defendants performed the surgeries. WPATH calls its recommendations “standards of care,” likely because it recognizes—or hopes—that judges will look to these recommendations when determining what the standard of care was and whether the defendants deviated from it. But the unsealed court documents from the lawsuit challenging Alabama’s age restriction law revealed that WPATH wrote its current standards of care explicitly with a view to eventual litigation, even consulting an ACLU lawyer in the process. The ACLU has regularly cited WPATH’s standards of care in its legal briefings to argue that its legal position is grounded in medical science—a claim that seems, at the least, to represent circular reasoning.

If surgeons who perform double mastectomy or vaginoplasty on teenagers lose in court, the judgment will show up on their board of medicine examiner website and on their license. Malpractice premiums in this area are already rising , and some insurers outright exclude under-18 gender-transition procedures from their coverage policies. California, where Chloe Cole and Kayla Lovdahl are suing Kaiser Permanente, limits punitive damages to nine times the total amount of special and general damages awarded. This could bring the total awarded to each plaintiff to as high as $18 million, according to an attorney familiar with the case. 

Kevin Keller, a lawyer who specializes in health-care-related tort litigation, told me that medical malpractice is actually the lesser worry for clinicians here. Plaintiffs can also allege “intentional acts,” a category of behaviors including fraud that are typically excluded under medical malpractice insurance policies. In her lawsuit against Eric T. Emerson—an ASPS member—and his clinic, Piedmont Plastic Surgery and Dermatology in North Carolina, Prisha Mosley, a former patient, alleges that Emerson “misled and deceived [her] into thinking that surgery on her healthy breasts would benefit her and that she needed this surgery.” Juries can award massive damages for such tort claims, and these will be borne directly by the surgeon and the clinic. “Juries can easily award plaintiffs like Mosley $10 million or more,” Keller said. “And that’s money that doctors and clinics will have to pay out of pocket.”

A key question for these lawsuits is the degree to which surgeons are responsible for determining the medical necessity of the procedures that they are asked to perform. According to Mosley’s complaint, for instance, Emerson, the surgeon, “noted” her “history of anxiety and anorexia nervosa and family history of depression” but did not see any of these issues as red flags and did not “form an evidence-based, independent judgment” about the medical necessity of mastectomy in her case.

Existing guidelines like the ones issued by WPATH and the Endocrine Society envision surgeons as part of a “multidisciplinary” team that includes mental-health professionals. Though WPATH recommends that surgeons have special training in “gender-affirming care,” it is unclear whether surgeons can second-guess the appropriateness of surgery (except if there are physical contraindications) once a patient has been “affirmed” and given the all-clear by a mental-health professional. Doing so would constitute “gatekeeping,” which is seen in the gender medicine community as “non-affirming” and harmful. “Treatment” is oriented around “the child’s sense of reality and feeling of who they are,” says Jason Rafferty , who wrote the American Academy of Pediatrics’ statement on “gender-affirming care” at the very beginning of his medical career and who is now being sued by two former patients .  

Kayla Lovdahl, the young woman currently suing Kaiser Permanente, was approved for surgery after an “affirming” psychologist conducted a single 75-minute evaluation and determined that she was “transgender,” according to her legal complaint . Five weeks later, Lovdahl, still only 12, met with the plastic surgeon, Winnie Tong, who concluded after a 30-minute evaluation that she fulfilled criteria for a double mastectomy. The procedure was performed four months later, just after Lovdahl turned 13.

In July, the Pennsylvania Psychological Association, a branch of the American Psychological Association, forbade any mention of the Cass Review on its professional listserv. Doing so, the leadership suggested, could cause “harm” to colleagues with “very different points of view based on their varied life experiences.” This is but one of many examples of how the mental health profession has abdicated its role in ensuring that young people with mental health challenges are provided evidence-based care. It is likely a matter of time before judges come to appreciate how this area of medicine operates and refuse to let surgeons off the hook when they assert that they were relying on mental health professionals to determine medical necessity.

Gender clinics across the country have adopted letter-of-support and letter-of-medical-necessity templates to ensure that adolescents seeking surgery get approval, with few hiccups. The message these templates implicitly send to therapists, who are the first and arguably most important gatekeepers, is that gender surgery for minors is a standard procedure rather than an extreme departure requiring strong evidence.

The gender clinic at Seattle Children’s Hospital is an example of a major clinic that offers mental-health professionals a template to use for writing letters of support for surgery. The template contains language designed to bypass any concern that the candidate fits the profile of “rapid onset gender dysphoria” (ROGD), the most common adolescent presentation and the one that prompted the course reversal in Europe. The template effectively instructs the referring therapist to attest that the ROGD presentation is really just a teen who has always known he or she was transgender but only disclosed that information to his or her parents during adolescence. This common anti-ROGD refrain is based on highly dubious research .

Nazarian, the Beverly Hills surgeon, told me that surgeons in her professional network who perform gender surgeries typically defer to mental-health professionals and endocrinologists to determine for them whether minors should receive procedures like double mastectomy. That approach, she believes, is misguided, and reduces surgeons to mechanics.

“We are not highly trained technicians,” Nazarian told me. “We are physicians with responsibility for the health and well-being of our patients. We can get input from other clinicians, but ultimately the responsibility for determining medical readiness lies with us. That means that we have to examine all the data and studies available to us. Furthermore, you can’t help people by ignoring the reasons they want to go under the knife. With every patient, I exercise discretion as a professional and determine whether the procedure they are seeking is in their ultimate best interest.” The idea that surgeons should defer heavily to the prior assessments of clinicians struck Nazarian as wrong. “You can’t outsource your professional judgement to other clinicians. It’s your responsibility as the last in a chain of treatment to ensure you are doing what is best for the patient now and in the long term.”

Editor’s note: This article has been corrected to remove reference to a template mistakenly attributed to Caitlin Thornbrugh.

Leor Sapir is a fellow at the Manhattan Institute.

Photo by Jessica Rinaldi/The Boston Globe via Getty Images

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Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

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