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Facial Feminization Surgery and the WPATH Standards of Care

UPDATE, January 2023: The World Professional Association for Transgender Health’s “Standards of Care, 8th version,” (SOC8) published in September 2022, makes an important declaration: that facial gender-affirming surgery is a medical necessity. Prior to SOC8, Facial Feminization Surgery was largely considered cosmetic and was therefore less likely to be covered by medical insurance policies. This critical shift was backed by findings from numerous peer-reviewed studies that found a high satisfaction rate among patients who had undergone FFS and improvements in both mid- and long-term quality of life. More specifically, the benefits of FFS include reduced anxiety and depression related to gender dysphoria and improvements in self-confidence and well-being. Ultimately, the revised SOC is helping to improve greater access to gender-affirming care by clarifying the medical necessity of FFS for insurance providers.

The current version of the WPATH Standards of Care (7th version) has not devoted enough attention to Facial Feminization Surgery and its place within the field of transgender health care. This is a concern because of new developments in insurance coverage for transgender surgeries.

Insurance companies look to the Standards of Care to determine what surgical procedures are medically required for the treatment of gender dysphoria, and the current lack of discussion of FFS in the Standards of Care may lead insurance companies to deny coverage for FFS surgeries, claiming that they are cosmetic and not medically required procedures. (As of 2020, California, New York, Connecticut, the District of Columbia, Massachusetts, and Washington are the only states whose public Medicaid programs cover FFS.)

FFS must be considered part of the treatment of people with gender dysphoria, because the feminization of facial features allows them to adapt more easily to the workplace and social and family environments. FFS is often of greater practical significance in daily life than genital reconstruction.

"The trans women would say over and over again, 'Yes, maybe one day I'd like to have genital surgery, but what will change my life today is the way I look on the street." says Eric Plemons author of The Look of a Woman: Facial Feminization Surgery and the Aims of Trans-Medicine.

Dr. Jens Berli agrees. "If you think about it, not getting a job or having trouble going to [one's preferred] bathroom is largely because of how people see your face."

Opinions diverge as to what degree surgical procedures such as FFS can be considered purely reconstructive and not cosmetic. This ambiguity makes it easier for insurance companies to deny coverage for FFS. And yet for some patients, a surgery like a reduction Rhinoplasty can have a marked and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Indeed, studies have shown that FFS procedures are associated with improved mental health-related quality of life.

"This demarcation between 'necessity' and 'cosmetic' in transgender health care based on specific body parts is in direct opposition to the scientific community's understanding of gender dysphoria and professional guidelines for transgender health. GRS affects one's ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one's quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs." — Alex Dubov & Liana Fraenkel

Dr. Berli and his co-authors of the 2017 article, "Facial gender confirmation surgery—review of the literature and recommendations for Version 8 of the WPATH Standards of Care", cite several studies suggesting that psychosocial well-being is much higher in trans women who have undergone Facial Feminization Surgery, and they argue that these procedures should be considered "medically necessary" in the next edition of the Stands of Care.

The current Standards of Care do not state criteria for Facial Feminization and these surgeries do not require referral by mental health professionals. WPATH is now in the process of editing the 8th version of the Standards of Care publication.

References

World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Conforming People [7th Version].

The Case For Facial Feminization Surgery
To make something like FFS truly accessible — and to give trans people true agency over it — requires completely reimagining the capitalist medical system.
Alex V Green, BuzzFeed News Posted on July 28, 2020.

Facial gender confirmation surgery—review of the literature and recommendations for Version 8 of the WPATH Standards of Care
Jens U. Berli, Luis Capitán, Daniel Simon, Rachel Bluebond-Langner, Eric Plemons & Shane D. Morrison. International Journal of Transgenderism, Volume 18, 2017 - Issue 3, Pages 264-270.

 

Last updated: 01/26/23