Background: Transgender people continue to experience elevated rates of interpersonal violence and other negative sequelae associated with gender dysphoria, and gender-affirming surgery confers demonstrated quality-of-life benefits. As testosterone treatment often fails to adequately masculinize facial features, transmasculine individuals can continue to experience gender dysphoria. The purpose of this study is to assess the landscape of FMS and recommend strategies to make FMS more accessible to those who would benefit.
Methods: Insurance company websites were queried for their policies regarding FMS. In tandem, a review of the existing literature on gender-affirming care was undertaken to identify the frequency of gender-affirming care training in national Plastic Surgery programs, research outputs pertaining to FMS, and the number of FMS-trained surgeons.
Results: Medicaid offers coverage of gender-affirming services in 18 states, but only 10 states explicitly refer to facial gender-affirming surgery in their policies. Only 18% of the surgeons in the transhealthcare.org database accept Medicaid. One private insurance carrier covers FMS in 18 states. 79 surgeons are offering FMS in 24 states. Nationwide, only 96 plastic surgery residency programs offered gender-affirming surgery as part of their curriculum, of which only 7 centers have 1-year transgender fellowships. In terms of research output, 9 research articles pertained to FMS. By contrast,143 manuscripts were dedicated to facial feminization surgery (FFS).
Conclusion: The present lack of insurance coverage precludes access to FMS for many individuals who would be candidates for surgery. Moreover, there is a lack of parity in coverage between individuals desiring FMS and FFS which is more readily accessible. Additionally, the small number of surgeons formally trained in FMS techniques exacerbates barriers to access. This review of the landscape of FMS highlights pressing inequities in transmasculine care and makes the case that FMS should be considered a medically necessary intervention eligible for coverage.
