Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Andrology. 2021 Nov;9(6):1765-1772. doi: 10.1111/andr.13028. Epub 2021 Sep 14.
The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines.
This study investigates insurance requirements for referral letters and their negative impact on care.
We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed.
Nearly all reviewed U.S. health insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH.
Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.
世界跨性别健康专业协会（WPATH）建议在进行性别肯定型生殖器手术（gGAS）前一年，由两名心理健康提供者出具转诊信，以确保患者在接受主要手术前已做好准备。许多美国健康保险公司在没有两份转诊信的情况下，不会授权进行第二阶段和第三阶段手术或修正手术。WPATH 指南并未支持此类要求。
本研究旨在调查转诊信的保险要求及其对护理的负面影响。
我们回顾性地审查了在我们的三级保健医疗中心进行的为期 4 年的所有 gGAS 病例。记录了保险授权所需的转诊信要求。我们联系了全国最大的保险公司，包括商业、州和联邦资助的计划，以确认要求。我们前瞻性地记录了为患者亚组完成保险授权所需的时间。回顾了 WPATH 的出版物。
几乎所有审查的美国健康保险计划都要求对每一次 gGAS 手术（包括分期和修正手术）的转诊信进行年度更新。没有更新的信件改变了临床管理。转诊信要求延迟了护理。WPATH 表示，分期手术不需要转诊信。一些计划甚至要求对初始手术咨询也需要转诊信，而 WPATH 并不支持这种做法。
保险公司对转诊信的要求阻碍了护理，并与 WPATH 指南相矛盾。我们主张，至少不应要求在患者已接受第一阶段主要 gGAS 后，进行手术咨询或分期或修正手术时提供转诊信。普遍的转诊信要求提供的临床价值极小，会延迟护理，增加成本，并通过否定性别转换而加剧性别焦虑。与所有手术一样，外科医生本身应负责评估患者的手术准备情况。心理健康状况或社会状况的重大变化应促使外科医生寻求重新评估。应澄清并将 WPATH 关于转诊信的建议整合到一份文件中。
