Gender Confirmation Surgery: Cosmetic or Reconstructive Procedure?

Sir:

With new reports indicating a higher incidence than previously published, transgender individuals see their medical needs increasing proportionally. Similarly to many other subspecialties, transgender medicine and surgery include a wide variety of providers working together in a multidisciplinary environment. Plastic surgeons play a key role in providing diverse surgical procedures contributing to helping relieve the significant distress encountered by transgender individuals.[1]

The line between the cosmetic or reconstructive nature of these procedures can somewhat appear difficult to draw. Overall, it is not uncommon in our specialty to get the excitement of being able to restore a function while achieving beauty and vice versa, but it can also be misinterpreted by third party payers and cause of frustration to our patients. It becomes even more complex when the function is conserved, making all procedures virtually “non-medically needed.”

It is commonly accepted to consider the surgical treatment of a defect as reconstructive, whereas more elective surgeries might be considered cosmetic and imputable to the patient. This dichotomy might not be as clearly defined in the reality of various situations that the plastic surgeon deals with. Patient factors and clinical context may influence widely the nature of a procedure and the qualification of cosmetic versus reconstructive. For example, shall we consider reconstructive or cosmetic the extreme case of a facial allotransplantation procedure that gives a blind patient a better chance to interact with peers, especially if his oral function was conserved but his appearance was discriminated against? In this specific situation, one acknowledges that the patient’s life is impacted only by the peer pressure and accepts to proceed with a corrective reconstruction to provide the patient with a more balanced life.[2]

Even though appearing physically intact, the gender dysphoric patient wears the mask of a gendered body he/she/they do(es) not assimilate to, which provides a mismatch between society expectation and self-feeling. For the sole purpose of dichotomy, the transgender patient could be considered as having a birth defect by not having a body envelope corresponding to their true gender. Gender confirmation (also called sex reassignment) with hormones, mental therapy, and surgical transition, has been shown to relieve symptoms of gender dysphoria and to provide patients with a regained socialization in their true gender, as opposed to their gender assigned at birth.[3,4]

As a society and more specifically as a scientific community, it is our role to provide guidelines for interpretation and to publish appropriately in the “cosmetic” versus “reconstructive” sections of peer-reviewed journals, based on our knowledge and expertise. We do believe that it is crucial to recognize gender confirmation surgical procedures as reconstructive and classify/publish them accordingly. The alternative would consider a life-changing operation as purely cosmetic and could threaten the insurance coverage for our patients in the long term. Furthermore, it perpetrates the wrong idea that being gender dysphoric is a choice and that undergoing medical, psychiatric, and surgical therapy is a chosen way to enhance one’s physical appearance.