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to physically alter sexual characteristics to simulate
the other sex) or belief that he or she was born the
wrong sex.
3. The disturbance is not concurrent with a physical
intersex condition.
4. The disturbance causes clinically significant distress or
impairment in social, occupational or other important
areas of functioning.
D. The diagnosis has been made and documented by a professional who is appropriately trained in transgender medicine. (See glossary for definition of “appropriately trained
in transgender medicine.”)
E.
Member desires to live and be accepted as a person of the
opposite sex, usually accompanied by the wish to make his/
her body conform as much as possible with the preferred
sex through surgery and hormone treatment.
F. GD has been present persistently for at least two years.
G. GD is not a symptom of another mental disorder.
II. Hormone therapy:
A. Member has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental
health professional and provided under the supervision of
a physician with documentation of member’s compliance
and the type, frequency and route of administration.
Note: Hormonal gender reassignment does not refer to the administration of hormones for the purpose of medical care or research
conducted for the treatment or study of non–gender dysphoric
medical conditions (i.e., aplastic anemia, impotence, cancer).
III. Real-life experience: documentation that the member has completed a minimum of 12 months of successful continuous full time
real-life experience in the new gender:
personality disorder), documentation must indicate that
an effort has been made to improve these conditions with
psychotropic medications and/or psychotherapy before
GRS is considered.
V. Referrals:
A. Three referrals are necessary:
1. One referral must be from the member’s medical
provider.
2. Two referrals must be from qualified mental health
professionals who have independently assessed the
individual.
3. If the first mental health referral is from the member’s
psychotherapist, the second referral should be from
an independent evaluator.,
4. Two separate letters from the mental health providers,
or one signed by both (e.g., if practicing within the
same clinic) are required. One letter is sufficient if
signed by two providers if one of them has met the
doctoral degree specifications (see below).
5. At least one of the mental health professionals submitting a letter must be appropriately trained in transgender medicine. (See glossary).
B. The referral letters must include:
1. Agreement to the proposed GRS within three months
of the prior authorization request.
2. Documentation that there are no contraindications
to the planned surgery.
C. Format for referral letters/letters of qualification should
include:
•
Member’s general identifying characteristics.
•
A. Across a wide range of settings, experiences, and events
that occur in the course of normal life (e.g., family events,
holidays and vacations).
Results of the member’s psychosocial assessment,
including any diagnoses.
•
B. Coming out to partners, family, friends and community
members.
Duration of the mental health professional’s relationship with the member, including the type of evaluation
and therapy or counseling to date.
•
Explanation that the criteria for surgery have been
met, and a brief description of the clinical rationale
for supporting the member’s request for surgery.
•
A statement about the fact that informed consent has
been obtained from the member.
•
A statement that the mental health professional is
available for coordination of care and welcomes a
phone call to establish this.
C. Medical do