Nipple areolar complex reconstruction is an integral component of chest reconstruction in the treatment of transgender and gender diverse people

There has been a growing trend for insurance companies in the United States to deny coverage of nipple areolar reconstruction for transgender patients undergoing chest masculinization. We, the undersigned, representing the national leaders in gender affirming surgical treatment are writing to state our joint and expert opinion that nipple and areolar reconstruction in trans masculine chest surgery is an inherent and irrefutable part of treatment for transgender and gender diverse individuals undergoing mastectomy for gender dysphoria. We cite our concerns regarding insurance denials for this medically necessary procedure.

The nipple areolar complex (NAC) is considered a humanizing and foundational subunit of the chest (Beckenstein, Windle, & Stroup, 1996; Djohan et al., 2010; Kasai et al., 2015). There are numerous conditions in which the absence of a NAC is considered pathologic and surgical interventions exist to correct these abnormalities. A symmetric and natural NAC helps to regain balance and chest appearance, and reconstruction of the NAC has been correlated with a significant and positive impact on patient wellbeing (Wellisch, Schain, & Noone, 1987).

It is well established that patients with gender dysphoria are more likely to suffer from depression, anxiety, have a lower socioeconomic status, and be more likely to self-harm, and attempt and commit suicide (Bouman et al., 2017; Dhejne, Van Vlerken, Heylens, & Arcelus, 2016; Drescher, 2010; Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016; Witcomb et al., 2018). In the transgender population, nipple size and shape contribute to an individual’s feeling of gender congruence and plays a role in a diagnosis of gender dysphoria. The goal of this reconstruction is not only for patients to feel whole in their bodies, but also comfortable and safe enough to remove their clothing in situations such as locker rooms and outdoor summer activities. Without NAC reconstruction patients are immediately recognizable as being different.

It is also well established that gender affirming medical treatments (i.e. hormonal and/or surgical therapies) have been found to relieve distress and improve psychological wellbeing (Costa & Colizzi, 2016; Hembree et al., 2017; Murad et al., 2010). Chest reconstruction or “top surgery” is a key component in gender affirming treatments and significantly improves mental health and quality of life outcomes for patients with gender dysphoria (Owen-Smith et al., 2018; van de Grift et al., 2016, 2018; Weigert, Frison, Sessiecq, Al Mutairi, & Casoli, 2013).

We believe that insurance denials are inappropriate and continue to show prejudice toward an already marginalized population. Many transgender individuals are reticent to seek medical care due to mistrust and maltreatment by the medical system. Denial of a standard component of breast reconstruction in transgender and gender diverse individuals highlights barriers faced in accessing the basic standards of care in place for the remainder of the population.

For the reasons described above, and based on our expert opinion, NAC during chest masculinization is of paramount importance for the adequate treatment of gender dysphoria. The act of withholding NAC reconstruction for transgender and gender nonconforming mastectomy procedures restricts access to the standard of care (Coleman et al., 2012). NAC reconstruction is an inherent and inalienable component to chest reconstruction as it applies towards the diagnosis of gender dysphoria. We urge our fellow plastic and reconstructive surgeons to object vigorously to insurance companies’ limits on access to care via denials of coverage for NAC in any covered patient.

Scott W. Mosser, MD, FACS
Director of the Gender Institute, Saint Francis
Memorial Hospital Founder, The Gender Confirmation Center of San Francisco
San Francisco, CA, USA

Loren S. Schechter, MD, FACS
Clinical Professor of Surgery, The University of Illinois at Chicago
Director, The Center for Gender Confirmation Surgery, Weiss Memorial Hospital
Chicago, IL, USA

Alexander R. Facque, MD
The Center for Gender Confirmation Surgery, Weiss Memorial Hospital
Chicago, IL, USA

Jens Urs Berli, MD
Assistant Professor
Oregon Health and Science University
Portland, OR, USA

Cori Agarwal, MD
Associate Professor
University of Utah
Salt Lake City, UT, USA

Thomas Satterwhite, MD
Align Surgical Associates
San Francisco, CA, USA

Rachel Bluebond Langner, MD
Associate professor of plastic surgery
NYU Langone health
New York, NY, USA

William M. Kuzon, Jr., MD, PhD
Reed O. Dingman Collegiate Professor of Surgery Section of Plastic Surgery University of Michigan Chief of Surgery, VA Ann Arbor Healthcare
Ann Arbor, MI, USA

Oren Ganor, MD
Center for Gender Surgery – Co-Director
Boston Children's Hospital
Harvard Medical School
Boston, MA, USA

Joshua D. Safer, MD, FACP, on behalf of the Board of Directors of the United States Professional Association for Transgender Health (USPATH)
Gail Knudson, MD, MEd, FRCPC on behalf of the Board of Directors of the World Professional Association for Transgender Health (WPATH)