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Hormone Therapy and Surgery

A good place to start when looking for  more information about gender confirming surgery and other medical interventions is to review the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), Version VIII. This edition is freely available for viewing online as a PDF. The WPATH SOC guidelines are an important reference for both individuals who desire gender affirming medical care, as well as anyone else interested in the topic or wanting to support trans loved ones.  Many US-based health insurance companies base their coverage of gender affirming medical interventions on the WPATH SOCs, so it can be helpful to be familiar with them. 

Clinical research and social science studies have advanced the understanding of trans  identity, and there have been many positive changes regarding social acceptance and access to treatment. The intention of the SOC is to recommend standards of diagnosis, care, and treatment to help individuals achieve quality of life and satisfaction  specific to their gender.  The SOC allows for variations in treatment to suit the many varieties and degrees of Gender Dysphoria, which is the current “diagnosis” used in the medical treatment of trans patients.

What are the guidelines for HRT and gender-affirming surgery?

At the Gender Confirmation Center we strive to make gender-affirming surgeries accessible to patients who have traditionally been marginalized within transgender healthcare: non-binary patients, patients with high BMIs, patients with disabilities and senior patients. We strive to make the highest quality gender-affirming surgical care available and affordable to patients who do not conform with the gender binary. Below are our guidelines and recommendations around surgical eligibility and HRT usage:

• Top surgery:
  • Undergoing HRT is not a requirement for chest reconstruction, breast reduction or breast augmentation procedures.
  • Some patients try to develop their pectoral muscles through weight training so that their surgeon can contour their top surgery incisions/scars to their muscle border. Testosterone can help with this process, though it is not necessary.
• Breast Augmentation:
  • While not an explicit criterion, it is recommended that patients interested in breast augmentation undergo a full-dosage treatment of feminizing hormone therapy for a minimum 12 months prior to breast augmentation surgery. Doing so can help maximize breast tissue growth to obtain better surgical (aesthetic) results. That said, our surgeons are experienced in operating on patients who microdose or do not take HRT.
• Body contouring:
  • Though hormone replacement therapy (HRT) is not a requirement for surgery, it can have a positive effect on fat redistribution and changing someone’s gluteal shape. For patients whose transition process involves HRT on regular or full doses, it is recommended to wait until hormones have taken effect for at least a year before undergoing a body contouring procedure. Still, many patients experience difficulty with reducing or increasing fat reserves around the hips, legs and buttocks with HRT, exercise and diet alone. This is why even with hormone usage, some find it necessary to undergo a body contouring procedure to feel aligned with the shape of their bodies.
• Facial surgery:
  • HRT is not a requirement to undergo facial surgery. HRT can only alter soft tissue such as fat redistribution–most commonly, the amount of fat in the cheeks and jaw to soften the appearance of these areas. That said, the effects of HRT cannot change bone structure, which is why many patients seek out facial surgery to change the overall structure of their face. Though not a requirement, if you are considering or currently taking HRT, talk to one of our surgeons about how that might figure into your gender affirming facial surgery plan.
• Bottom surgery:
  • Dr. Ley does not require patients to undergo HRT to be eligible for bottom surgery. However, some insurance plans do. This is in part due to the fact that the WPATH Soc 8 guidelines recommend that patients undergo HRT for at least 6 months before undergoing a gonadectomy (removal of the testicles or both ovaries) unless hormones are not clinically indicated for the patient.
  • For patients who are on HRT and would like to undergo an orchiectomy or removal of the testicles, your dosages will likely change post-op. For this reason, we recommend that you speak with your endocrinologist or hormone provider about bottom surgery. Likewise, since an orchiectomy is technically a sterilization procedure, we recommend that our patients look into their options around fertility preservation first.
  • Some patients who microdose testosterone might still experience menstruation. Undergoing a hysterectomy can allow a patient to stop monthly bleeding without having to increase their testosterone dosage. That said, a hysterectomy is a sterilization procedure, which is why we recommend our patients look into their options around fertility preservation first.

Insurance Requirements: HRT and Coverage

For chest reconstruction and breast reduction top surgery, most insurance providers do not require that patients be on HRT to cover surgery.

For breast augmentation, facial surgery, body contouring, and bottom surgery, most insurance providers require that patients be on HRT for a minimum of 12 months, continuously, to qualify for coverage. These clinical guidelines are based on the fact that hormone therapy can change the soft tissue of the face, redistribute body fat and/or develop breast tissue, which may alter the patient’s appearance and therefore the assessment of which procedures are necessary to resolve their gender dysphoria.

If a patient is able to document a medical contradiction that does not allow them to continuously take hormone therapy, this requirement will be waived, Please note that insurance approvals differ on a case-by-case basis; there are occasions where patients may not fulfill all clinical guidelines perfectly (e.g., only being on hormone therapy for 6 months) and still get pre-approval for their procedure.

We recognize that these mandates can be a form of gatekeeping medically necessary, gender-affirming care. This is why we do not hold them as candidacy requirements for our own surgical practice. If you need help navigating this insurance requirement and others, our insurance advocacy team can offer you free support after you request a free consultation with the GCC.