OHP Task Force: Draft policy guidelines for OHP By Basic Rights Oregon OHP Task Force

June 2015

Introduction

This best practice document has been created in coalition with health care advocates, community members, health care professionals, and other partners. The goal of this document is to provide CCOs and health plans with guidelines and best practice policies to help them adopt and standardize affirming and culturally competent transgender health care services throughout Oregon.

Background on OHP Trans Health Policy

The Health Evidence Review Commission (HERC) voted to update and modernize coverage of treatment for gender dysphoria in August of 2014 to meet current standards of care as recommended by the American Medical Association and every other leading medical association. Effective January 1, 2015, the Oregon Health Plan (OHP) is required to cover lifesaving treatments for transgender Oregonians that are deemed medically necessary for the patient. The HERC in 2014 modified and updated the priority list of health services that address gender dysphoria. These updates can be found in this document. Treatments for gender dysphoria include gender affirming counseling, gender affirming hormones (also referred to as hormone replacement therapy or cross­sex hormone therapy) and gender affirming surgeries (also known as gender reassignment or sex reassignment surgeries). The HERC policy was developed using the World Professional Association for Transgender Health (WPATH) standards of care and the Endocrine Society as models for care.

The new HERC OHP health care policy makes it possible for transgender people to obtain medically necessary trans health care treatments beginning January 1, 2015. However, there have been implementation challenges with ensuring that this policy can fully meet the health needs of all transgender individuals on Medicaid in Oregon. We hope this document will help address implementation challenges and help all transgender people with OHP to access their transgender health benefits and receive culturally competent and affirming services.

Transgender Terminology (NCTE)

Transgender: Someone whose gender identity deviates or is different from their medically assigned sex at birth and the behaviors and gender expression associated with that assigned sex.

Also referred to as “transsexual” in medical literature."Trans" is shorthand for "transgender." (Note: Transgender is correctly used as an adjective, not a noun.)

Gender Dysphoria: Gender dysphoria is a condition of distress caused by the discrepancy between a patient’s assigned sex at birth and their gender identity and the ways other people perceive their bodies.

Transgender Man: A man who was assigned female at birth and identifies and lives as a man. Transitioning for a transgender man often includes masculinizing hormone replacement therapy and surgeries specifically addressing their gender dysphoria (surgeries outlined in this document). Also referred to as “FTM” (female to male) in medical literature.

Transgender Woman: A woman who was assigned male at birth and identifies and lives as a woman. Transitioning for a transgender woman often includes feminizing hormone replacement therapy and surgeries specifically addressing their gender dysphoria (surgeries outlined in this document). Also referred to as “MTF” (male to female) in medical literature.

Gender Identity: A person’s internal sense of being a man, a woman, or another gender. Since gender identity is internal, one’s gender identity is not necessarily visible to others. Everyone has a gender identity.

Sex Reassignment Surgery: Surgical procedures that reconstruct and reshape the genitals and other features of a transgender patient’s body to better reflect a person’s gender identity and to address their gender dysphoria. Also known as “gender reassignment” or “gender affirming surgery.”

Genderqueer: A term used by some individuals who identify as neither man or woman.

Gender Non­conforming: A term for individuals whose gender expression is different from societal expectations related to their gender. Transgender people can be either gender conforming or gender non­conforming for their gender identity, but are not inherently gender non­conforming for being transgender. Being gender non­conforming also does not mean you are transgender and are two separate aspects of an individual’s identity.

Discrimination faced by transgender people

Transgender people face high rates of discrimination, violence and health disparities. According to the 2011 National Trans Discrimination Survey, 41% of respondents reported attempting suicide compared to 1.6% of the general population, with rates rising for those who lost a job due to discrimination (55%), were harassed/bullied in school (51%), had low household income, have been the victims of physical assault (61%) or sexual assault (64%). Transgender people face discrimination is every aspect of daily life including when accessing health care. Health outcomes for all transgender respondents demonstrate the appalling effects of social and economic marginalization, including much higher rates of HIV infection, smoking, drug and alcohol use and suicide attempts than the general population.

Refusal of care: 19% of our sample reported being refused medical care due to their transgender or gender non­conforming status, with even higher numbers among people of color in the survey.

Uninformed doctors: 50% of the sample reported having to educate their medical providers about transgender care.

High HIV rates: Respondents reported over four times the national average of HIV infection, with rates higher among transgender people of color.

Postponed care: Survey participants reported that when they were sick or injured, many postponed medical care due to discrimination (28%) or inability to afford it (48%). (2011 National Trans Discrimination Survey)

Transgender Oregonians face appalling economic instability: 17% of transgender Oregonians had a household income of $10,000 or less, compared to only 4% of the general national population. This is almost four times the rate of poverty. (National Trans Discrimination Survey: Oregon)

Due to discrimination, violence and health disparities, transgender people face high mortality and morbidity rates. However, a meta­analysis of 28 studies shows that after surgical transition, 80% of transgender individuals reported a significant improvement in their psychological symptoms and 80% reported an increase in their quality of life (Murad et al. 2010). The report also revealed that after receiving transition­related care, suicide rates among trans people dropped from a range of 29­19% before transition to 6% ­ 0.8% after receiving care. (Murad et al. 2010). Access to transition related health services is life saving and essential to reducing health disparities and mortality/morbidity rates for transgender people.

WPATH and Best Practices of Treating Gender Dysphoria

The best practices presented in this document are based on WPATH standards of care and are compliant with the HERC policy for treating of gender dysphoria (with an emphasis on provider discretion and informed consent). The goal of these best practices are to standardize low­barrier access to lifesaving care for transgender people that can be adopted across Oregon. The WPATH recommends that patients, “engage in 12 continuous months of living in a gender role that is congruent with their gender identity...” prior to gender reassignment surgery so that patients may socially adjust to their desired gender role.[7] WPATH notes that changing a gender role may have personal and social consequences which should be adequately explored prior to undergoing an irreversible surgery. It is important to note however that there are provisions in the policy allowing provider discretion regarding the amount of time on hormones and/or lived experience before surgery, etc. that are necessary because delay can be unsafe or even life threatening for many transgender individuals. Provider discretion on these standards is very important to ensure patients and doctors have the ability to proceed with lifesaving medically necessary treatment.

Below are the official HERC policy guidelines, which are followed by our best practices recommendations for policy implementation.

HERC POLICY: Treatment for Gender Dysphoria 2014 To qualify for cross-sex hormone therapy, the patient must:

1. have persistent, well-documented gender dysphoria 2. have the capacity to make a fully informed decision and to give consent for

treatment under Oregon law 3. have any significant medical or mental health concerns reasonably well controlled 4. have a thorough psychosocial assessment by a qualified mental health

professional with experience in working with patients with gender dysphoria What are the requirements to qualify for sex reassignment surgery? Sex reassignment surgery is included for patients who meet eligibility criteria. To qualify for surgery, the patient must:

1. have persistent, well documented gender dysphoria 2. have completed twelve months of continuous hormone therapy as appropriate to

the member’s gender goals unless hormones are not clinically indicated for the individual

3. have completed twelve months of living in a gender role that is congruent with their gender identity unless both a medical and a mental health professional determine that this requirement is not safe for the patient

4. have the capacity to make a fully informed decision and to give consent for treatment under Oregon law

5. have any significant medical or mental health concerns reasonably well controlled 6. have two referrals from qualified mental health professionals with experience in

working with patients with gender dysphoria who have independently assessed the patient. Such an assessment should include the clinical rationale supporting the patient’s request for surgery.

Best Practices to Accessing Transgender Health Benefits with OHP

Step 1) Assessments

Assessment of gender dysphoria by a Qualified Mental Health Practitioner (QMHP).

First assessment: The HERC policy requires a diagnosis of gender dysphoria in order to begin treatment. The diagnosis of gender dysphoria can be diagnosed by a thorough psychological assessment by a Qualified Mental Health Practitioner. There are many medical and mental health professionals that qualify as QMHPs including occupational therapists and nurses. Ideally, primary care providers (PCPs) can also diagnose gender dysphoria using ICD­9 codes related to “gender identity disorder.” Authorizing PCPs to assess transgender people by diagnosis codes will also lower barriers to care and this can be billed as an assessment visit.

Best practices with the assessment of gender dysphoria

The assessment of gender dysphoria is performed by a QMHP that can to do the following:

1. Diagnose persistent and ongoing gender dysphoria. 2. Evaluate and document history of gender dysphoria. 3. Determine the individual’s capacity to make a fully informed decision and to give

consent for treatment. 4. Determine if the individual has any health conditions that need to be stabilized before

treatments can begin. If they do have health conditions that need to be stabilized, this should be noted in the treatment plan. They then should be referred to medical and mental health services in addition to transgender health services.

5. Develop a treatment plan with the patient to identify what possible treatments may be medically necessary for the patient to begin to reduce gender dysphoria.

6. Provide them with resources and referrals to medical professionals. 7. Issue a standard letter to the patient that the person’s health plan will recognize as

documentation of the diagnosis of gender dysphoria.

If the QMHP is not able to provide a gender dysphoria treatment plan for the individual, the individual should be referred to a PCP or other provider who can develop the treatment plan.

The assessment of gender dysphoria and development of a treatment plan may involve one to three sessions.

Who is a QMHP?

According to OAR 309­032­1505:(105), a "Qualified Mental Health Professional (QMHP)" means a LMP or any other person meeting one or more of the following minimum qualifications as authorized by the LMHA or designee:

(a) Bachelor’s degree in nursing and licensed by the State of Oregon; (b) Bachelor’s degree in occupational therapy and licensed by the State of Oregon; (c) Graduate degree in psychology; (d) Graduate degree in social work; (e) Graduate degree in recreational, art, or music therapy; or (f) Graduate degree in a behavioral science field. Additionally, OAR 309­032­1520 (2)(f) defines minimum competencies for QMHPs: "QMHPs must demonstrate the ability to conduct an assessment, including identifying precipitating events, gathering histories of mental and physical health, alcohol and other drug use, past mental health services and criminal justice contacts, assessing family, cultural social and work relationships, and conducting a mental status examination, complete a five­axis DSM diagnosis, write and supervise the implementation of a ISSP and provide individual, family or group therapy within the scope of their training.” Second assessment: If surgeries are deemed medically necessary, the individual will need an additional assessment completed by a second QMHP. In addition to the second assessment, there

may be other surgery preparation requirements needed such as a medical physical exam and other medical tests depending on the surgery and surgeon. Resources­ https://transgenderhealthservices.wordpress.com/assessments/

Five Main Areas of Transgender Healthcare

Once an individual has an assessment of gender dysphoria there are five main areas of care that they can access if deemed medically necessary. These five areas of care may include behavioral health care, primary health care, hormone therapy, gender affirming surgeries, and, if a minor, puberty suppression. Psychotherapy, hormone therapy and primary health care are often first accessed after an initial assessment and diagnosis. (Although it is important to note that not all transgender individuals choose to medically transition with hormone therapy or gender­affirming surgery.)

[i] https://transgenderequality.wordpress.com/category/drivers­licenses/ [ii] http://www.transequality.org/Resources/ntds_state_or.pdf [iii] NYC Department of Homeless Services, Division of Adult Services, Transgender/Intersex Clients, Procedure 06­1­31 (2006) <http://coalhome.3cdn.net/c7a840f68c28233a37_8qm6bngdv.pdf> (providing that transgender clients should have appropriate access to bathrooms and showers, and that residents may dress in accordance with their gender identity, regardless of what sex is listed on their ID). Primary care “Most of the health care needs of transgender people are not specific to gender issues. The goal of care for individual patients is to assist them to live in good health. There is no reason to believe that given accessible and sensitive care that transgender people cannot have good health outcomes comparable to non­transgender people.” (SFDPH) Best Practices for primary care (SFDPH)

Deliver medical care and preventative services that are relevant to the patient’s anatomy and risk factors.

Provide health maintenance and prevention interventions according to established standards based on patient age, anatomy, and risk factors.

Use harm reduction principles in addressing substance use, sexual practices, occupational sex work and toxic interpersonal relationships.

Obtain a relevant medical history that includes history of gender experience, prior hormone use, prior surgical history, sexual history, individual’s goals related to health and gender transition.

Obtain psychosocial needs assessment including mental health history, information about family and other social support or estrangement, alcohol and drug use history, criminal justice involvement, history of past and current suicidality, and support from and knowledge about the transgender community.

Perform relevant and acute exams appropriate to individual’s health conditions and which are informed by an individual’s history with previous trauma and abuse.

Avoid breast, rectal and genital exam on initial visits unless there is an urgent condition that must be addressed until trust has been established between the provider and the individual.

Create space for the patient to disclose the words they use to refer to their body parts and use their terms rather than the medical terms in reference to their body when possible.

Resources ­ Logic model, Health promotion Hormone Replacement Therapy Hormone replacement therapy (HRT) is undertaken in order to feminize or masculinize individuals’ bodies. For transgender individuals, HRT can result in the development of many secondary sexual characteristics of the sex they identify as. The hormones prescribed for an individual will differ depending upon their sex assigned at birth. For MTF individuals, trans women or gender nonconforming people who wish to feminize their bodies, hormone treatment may include estradiol, progesterone, and spironolactone. For FTM individuals, trans men, or gender nonconforming people who wish to masculinize their bodies, hormone treatment may include testosterone.

Best Practices for Hormone Replacement Therapy Once an individual is diagnosed with gender dysphoria, the clients’ PCP or other medical provider should be able to initiate hormone therapy if deemed appropriate. Please note it is possible for a PCP to diagnose gender dysphoria if they are a QMHP.

Initiation of Hormone Therapy Upon Diagnosis by QMHP ­ A diagnosis of gender dysphoria by a QMHP should be deemed sufficient to initiate hormone therapy. There should not be any additional documentation required, such as a letter from a therapist.

Utilization of an informed consent model ­ Once diagnosed with gender dysphoria, an individual should be able to access hormones without delay. It is important that informed consent documents detail the medical effects, including health risks, of hormones on their overall health. Sample forms are provided in this document.

Psychotherapy recommended but not required ­ Individuals are strongly encouraged to but should not be required to see a therapist to initiate hormones unless they have a co­occurring mental health condition that requires treatment. Psychotherapy should be authorized for gender dysphoria with the highest amount of visits permitted, but it should not be forced on an individual if they do not want Psychotherapy and they do not have a co­occurring condition requiring treatment.

Model formulary ­ A model formulary was created by Jazz Mcginnis, Neola Young and members of the BRO OHP task force. This formulary lists all possible hormones and hormone blockers that may be prescribed including typical cost points.

Resources: Hormone therapy table,

Puberty suppression for Adolescents Hormone treatment is used to delay the onset of puberty and/or continued pubertal development with GnRH analogues for transgender children and adolescents. Puberty suppression is

recommended to begin as soon as signs of puberty are exhibited (Tanner Stage II­III) and to be ended at age 16 when hormone replacement therapy could be administered if not earlier based on the needs of the patient [i].This therapy is often initiated at the first physical changes of puberty, confirmed by pubertal levels of estradiol or testosterone, but no earlier than Tanner stages 2­3. Prior to initiation of puberty suppression therapy, adolescents must fulfill eligibility and readiness criteria, and must have a comprehensive mental health evaluation. Ongoing psychological care is strongly encouraged for continued puberty suppression therapy. Puberty delaying medications are a prescription medication, which can be used for a number of medical conditions­­one of which is for delaying puberty for someone who is experiencing gender dysphoria. The medication acts as a “pause button” on a young person’s pubertal development, providing that person an opportunity to explore their gender identity without the distress of developing the permanent, unwanted physical characteristics of their assigned sex at birth. During this time, the young person will work with their family and health care providers to develop a treatment plan to address the youth’s Gender Dysphoria that is tailored to individual needs. For transgender youth, that may eventually include hormone therapy to induce a puberty that is congruent with their gender identity. And while we all agree that a teen experiencing gender dysphoria would most ideally be in a situation where a supportive family could be fully engaged in evaluation, diagnosis and treatment, there are circumstances where that can be challenging or impossible to achieve. Fortunately, Oregon law provides some flexibility for teens to consent on their own accord:

Age of consent for minors­ Oregon Law specifies the age of consent for mental health care is 14 years of age and the age of medical consent (including surgical procedures) is 15 years of age. This is outlined in ORS 109.640 and 109.675 (see appendix 3 for complete text on minor’s access to health care in Oregon Revised Statutes).

Puberty suppressants, unlike hormone replacement for adults, are a proactive medical approach instead of reactive. Reactive medical approaches to gender dysphoria (e.g. hormone replacement therapy in adults) are meant to correct already existing and unwanted bodily changes whereas proactive approaches, such as puberty suppressants, minimize and prevent unwanted bodily changes caused by puberty from occurring to begin with. Proactive medical approaches to gender dysphoria can eliminate the need for more costly medical services and operations later in life and increases the patient’s overall quality of life [ii]. The benefits of puberty suppressants on transgender youth lead to decreased gender dysphoria and an improvement in psychological well­being on par with their cisgender peers [iii].

[i] Suppression of Puberty in Transgender Children. Jason Lambrese, MD. American Medical Association Journal of Ethics August 2010, Volume 12, Number 8: 645­649. [ii] Health Outcomes Subcommittee: Puberty Blocking & Hormone Therapy for Transgender Adolescents. [iii] Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Annelou L.C. de Vries, Jenifer K. McGuire, Thomas D. Steensma, Eva C.F. Wagenaar, Theo A.H. Doreleijers and Peggy T. Cohen­Kettenis. Pediatrics; originally published online September 8, 2014. Psychotherapy

Psychotherapy provided by a mental health professional is often recommended though not required in a treatment plan to reduce the symptoms of gender dysphoria. Surgical Treatment Surgical treatment for gender dysphoria depends upon an individual’s sex assigned at birth. There are surgeries that are designed to make bodies assigned male at birth more feminine and surgeries designed to make bodies assigned female at birth more masculine.

The World Professional Association for Transgender Health (WPATH) indicates that, “physicians who perform surgical treatments for gender dysphoria should be urologists, gynecologists, plastic surgeons, or general surgeons, and board­certified as such by the relevant national and/or regional association. Surgeons should have specialized competence in genital reconstructive techniques as indicated by documented supervised training with a more experienced surgeon.”[7]

Letters for Surgery ­ The HERC policy requires two letters from QMHPs to access benefit approval. Letters for surgery are not standardized, however, standard forms can be used. Depending on the surgery, surgeons may also request letters at their discretion. A sample template is included with this policy.

Twelve months of hormone therapy and twelve months “lived experience” requirements ­ The HERC policy mandates that before surgical procedures can be accessed, individuals must undergo twelve months of HRT unless HRT is not clinically indicated for the individual (e.g. experiencing illnesses that are sensitive to hormones, or hormone therapy is not clinically necessary to address the patient’s gender dysphoria). Additionally, 12 months of ‘lived experience’ are required unless this compromises the safety of the individual. CCOs and health plan administrators must ensure that there are sufficient and prompt interventions for providers to waive these requirements when warranted for health or safety reasons. Surgery resources and forms­ Criteria for surgeries, Surgery eligibility form

WPATH Standards of Care and Surgery The essential purpose of transition­related treatment, whether it is genital reconstruction, hormone replacement therapy or any other gender­confirming procedure, is to therapeutically treat Gender Dysphoria, not to improve a person’s appearance. The evaluation of medical necessity must be individualized and take into account the totality of the patient’s total appearance and transition­related needs. Transgender people have unique clinical needs that are distinct from those of non­transgender people, and individualized assessments should be based on their symptoms, functionality, and the totality of their appearance. (Reference: Trans Law Center Medicare Paper) The category of transition related surgery also known as gender reassignment surgery includes:

1. Breast/chest surgeries; 2. Genital surgeries;

3. Other surgeries. Transgender surgeries to feminize bodies ­ For transgender women or other individuals who seek to feminize their bodies, Patient, Surgical Procedures May Include the Following:

1. Breast/chest surgery: mammaplasty; 2. Genital surgery: orchiectomy, penectomy, vaginoplasty, clitoroplasty, vulvoplasty.

Labiaplasty, urethroplasty, prostatectomy; 3. Other surgeries: facial reconstruction surgery, liposuction, lipofilling, voice surgery,

thyroid cartilage reduction, electrolysis or laser hair removal, and hair reconstruction. Transgender Surgeries to Masculinize Bodies ­ For transgender men or other individuals who wish to masculinize their bodies Surgical Procedures May Include the Following:

1. Breast/chest surgery: subcutaneous mastectomy, nipple grafts, chest reconstruction; 2. Genital surgery: hysterectomy/salpingo­oophorectomy, metoidioplasty, phalloplasty

(employing a pedicled or free vascularized flap), reconstruction of the fixed part of the urethra, vaginectomy, vulvectomy, scrotoplasty, and implantation of erection and/or testicular prostheses;

3. Other: voice surgery (rare), liposuction, lipofilling,

OHP and Covered Surgeries

The health evidence review committee’s policy list the below excluded procedures as cosmetic, even though the latest standards of care argue the most of these procedures may be considered medically necessary on a case by case bases. It is important to note that the exclusions do not include breast/chest reconstruction, speech therapy. Additionally, clarity needs to be made regarding if this policy covers electrolysis for surgical sites and coverage for medically necessary non­cosmetic treatments listed below.

Excluded procedures by HERC due to being seen as cosmetic­ Rhinoplasty, face­lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic.

HERC CPT Codes

CPT code Code description

19301-19304 Mastectomy

53430 Urethroplasty, reconstruction of female urethra

54125 removal of penis; complete

54400-54417 Insertion/repair/removal of penile prosthesis

54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach

54660 Insertion of testicular prosthesis (separate procedure)

54690 Laparoscopy, surgical; orchiectomy

55175-55180 Scrotoplasty

55970 Intersex surgery; male to female

55980 Intersex surgery; female to male

56625 Vulvectomy simple; complete

56800 Plastic repair of introitus

56805 Clitoroplasty for intersex state

56810 Perineoplasty, repair of perineum, nonobstetrical

57106-57107 Vaginectomy, partial removal of vaginal wall;

57110-57111 Vaginectomy, complete removal of vaginal wall

57291-57292 Construction of artificial vagina

57335 Vaginoplasty for intersex state

58150, 58180, 58260-58262, 58275-58291, 58541-58544, 58550-58554, 58570-58573

Hysterectomy

58661 Laparoscopy, surgical; with removal of adnexal structures

58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral

Condition: GENDER DYSPHORIA Treatment: MEDICAL/PSYCHOTHERAPY MEDICAL AND SURGICAL TREATMENT; PSYCHOTHERAPY ICD­9: 302.85 (Gender identity disorder in adolescents or adults) ICD10: F64.1­F64.9 (Gender identity disorder) CPT: 19301­19304, 53430, 54125, 54400­54417, 54520, 54660, 54690, 55175­55180, 55970, 55980, 56625, 56800, 56805, 56810, 57106­57107, 57110­57111, 57291­57292, 57335, 58150, 58180, 58260­58262, 58275­58291, 58541­ 58544, 58550­58554, 58570­58573, 58661, 58720, 90785,90832­90840, 90846­90853,90882,90887,96101,98966­98969,99051,99060,99070, 99078,99201­99215,99281­99285,99341­99355,99358­99378,99381­ 99404,99408­99412,99429­99449,99487­99496,99605­99607 HCPCS:G0176,G0177,G0396,G0397,G0459,G0463,H0004,H0023,H0032,H0034, H0035,H2010,H2011,H2014,H2027,H2032,H2033,S9484,T1016

Appendix- SCIENTIFIC EVIDENCE In order to evaluate the specific therapeutic effects of treatment for gender dysphoria in transgender individuals and adequately control for confounding factors, evaluate adverse effects, and individual patient differences (age, assigned sex at birth, symptoms, severity of illness), well­designed randomized clinical trials (RCTs) comparing gender dysphoria treatments with the non­treatment are ideal. The RCT is the most rigorous and reliable study design for demonstrating a causal relationship between the therapy under investigation and the health outcomes of interest. Specifically, questions regarding appropriate patient selection, treatment standardization and complication effectiveness rates, for patients of varying sexes would be addressed. However, there are challenges in conducting RCTs to evaluate treatments of gender dysphoria due to several factors, such as small patient populations and ethical concerns regarding the high morbidity and mortality rates associated with non­treatment. Given these confounding factors, data from large randomized controlled trials are not expected in the near future. Therefore, evidence from nonrandomized trials may be considered when treatments of gender dysphoria result in a significant improvement of symptoms and health which is so sizable that the health improvement rules out the combined effects of all other possible concurrent treatments or natural progression of the disease. Currently, there is limited evidence of this magnitude regarding patient selection, timing and therapeutic strategies in transgender individuals with gender dysphoria. Therefore, large studies with adequate follow­up are needed in order to evaluate these

and other confounding factors related to the treatment of gender dysphoria in transgender individuals. Literature Appraisal Evidence regarding the treatment of gender dysphoria in transgender individuals is comprised mainly of two systematic reviews consisting of small cohort studies with methodological limitations. No randomized controlled trials were identified. Several key cohort studies are described below in addition to the systematic reviews.

Systematic Reviews Only one of two systematic reviews is considered good quality[13] (Murad et al.) and reported on the resolution of gender dysphoria psychiatric comorbidities, quality of life, and sexual satisfaction outcomes for individuals treated with both hormonal and surgical treatments for gender identity disorder (GID ­ now referred to as Gender Dysphoria in the DSM­V).

• In 2009, Murad and colleagues assessed quality of life and other psychosocial outcomes of transgender individuals with GID, receiving hormonal therapy as part of gender affirming[13] surgeries. Twenty­eight cohort studies were included in the review which included pooled data from 1,833 patients with GID (1,093 trans women and 801 trans men). Significant improvements were reported after gender affirming surgeries compared to pre­treatment status: 80% of patients reported improvement in gender dysphoria (95% CI = 68­89%; 8 studies) 78% reported significant improvement in psychological symptoms (95% CI = 56­94%; 7 studies) 80% reported significant improvement in quality of life (95% CI = 72­88%; 16 studies); and 72% reported significant improvement in sexual function (95% CI = 60­81%; 15 studies). Significant study heterogeneity was reported for all outcomes. Although the authors acknowledge the low quality of evidence used in the analysis, gender affirming surgeries that included hormonal interventions in patient with GID was thought to likely improve symptoms of gender dysphoria and overall quality of life. • In 2009, Elamin and colleagues evaluated the use of hormone replacement therapy on cardiovascular risk in transgender individuals.[14] A total of 16 studies were included in the review with a total of 1,471 transgender women and 651 transgender men. Steroid use was associated with increased serum triglycerides in both transgender women and transgender men and a nonsignificant effect on HDL­cholesterol and systolic blood pressure in trans men. Authors noted that the quality of evidence was low due to methodological limitations of included studies, including but not limited to, heterogeneity of patient population and variable follow­up periods and uncontrolled study design. Randomized Controlled Trials (RCTs) No randomized controlled trials regarding the treatment of gender dysphoria in transgender individuals were identified. Nonrandomized Studies Primary evidence is limited to cohort studies with a variety of methodological limitations, including but not limited to small sample size, short­term follow­up, lack of comparison group, and varied treatment methods. Despite these limitations, significant improvements in quality of

life, psychological comorbidities, and sexual functioning were consistently reported in patients who received gender­confirming medical treatments.

• Imbimbo et al., evaluated the clinical and psychosocial profile of transgender women who had undergone reconstructive surgery.[10] The average age of patients was 31 years old, 72% had high educational levels, half of patients’ contemplated suicide at some point prior to surgery and 4% had attempted suicide. Improved sex life satisfaction was reported in 75% of patients, with almost all patients’ reporting satisfaction with their new sexual status. Additional studies sought to evaluate the sociodemographic profile of transgender individuals with GID in an effort to better characterize and provide treatment for this population.[15]

• Heylens and colleagues assessed comorbidities and psychosocial factors at various phases of the gender affirming surgery process in 57 patients with GID.[16] The Symptom Checklist­90 (SCL­90) was administered at three time points: baseline, after the start of hormone therapy, and after gender affirming surgeries. Psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems and the psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. The greatest improvement in psychoneurotic distress was observed after the initiation of hormone therapy (p<0.001). In addition, significant decreases in anxiety, depression, interpersonal sensitivity and hostility were reported after hormone therapy. No significant differences were observed in pre­ and postoperative assessments.

• Fisher et al. described clinical and sociodemographic features of 140 trans men (n=48) and trans women (n=92) with GID and without gender affirming surgeries.[17] The following assessment tests were administered: the Body Uneasiness Test (a self­rating scale exploring different areas of body­related psychopathology), Symptom Checklist­90 Revised (a self­rating scale to measure psychological state), and the Bem Sex Role Inventory (a self­rating scale to evaluate gender role). Authors reported that trans men displayed significantly better social functioning than trans woman.

• Gorin­Lazard et al. reported a case series which assessed a variety of gender dysphoria symptoms with hormonal treatment preceding gender affirming surgeries. Pre­ and post­ hormone treatment self­esteem (Social Self­Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning) scores were compared in 49 patients.[18] Hormone therapy was reported to be an independent factor in greater self­esteem, a reduction in depression, and improved QoL scores.

• Gomez­Gil and colleagues evaluated symptoms of social distress, anxiety and depression in 187 transgender individuals.[19] Of those included in the study, 120 had undergone gender affirming hormone treatment and 67 had not. Social anxiety was assessed with the Social Anxiety and Distress Scale (SADS) and depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS). The non­hormone group was reported to be significantly younger than the treatment group (mean age 25.9 vs. 33.6 years, p=0.001) and was less likely to have undergone surgical interventions (p<0.001). After adjusting for confounding factors, the

authors reported that patients who were receiving hormone treatment had significantly lower prevalence of depression, anxiety, and social anxiety than those not receiving hormones.

• Johansson et al., reported long­term (5­year) outcomes of transgender individuals (n=42) with GID who had completely transitioned (n=32), were in progress (n=5) or who were on hormone therapy (n=5).[20] Authors reported that no patient regretted reassignment and clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. At follow­up, more than 90% of patients reported stable or improved work situations, partner relations and sex­life. However 5­15% of patients reported dissatisfaction with hormonal treatment, results of surgery, gender affirming surgeries, or their present general health.

• Asscheman and colleagues evaluated the long­term (1­year) effects of hormone replacement therapy in 966 trans women and 365 trans men transgender individuals.[21] Trans woman patients received different doses of estrogen and cyproterone acetate and trans man patients received parenteral/oral testosterone esters or testosterone gel. Hormone treatment levels varied at pre­and post­surgical reassignment time points. High mortality rates were reported in the trans woman group when compared to the general population (51%); however, this increased rate was due to non­hormone­related causes such as suicide, acquired immunodeficiency syndrome (AIDS), cardiovascular disease, drug abuse and other unknown causes. No significant increase in mortality was observed in trans man patients compared to the general population. Clinical Practice Guidelines The Endocrine Society In 2009, the Endocrine Society in conjunction with European Society of Endocrinology, European Society for Pediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association, published the only evidence­based guidelines regarding the treatment of transgender individuals.[22] The guideline employed transparent methods for evidence review and for rating the quality of evidence. All recommendations were based upon evidence which was rated to be low quality. The consortium made the following recommendations: Diagnostic Procedure 1. We recommend that the diagnosis of gender identity disorder (GID) be made by a mental health professional (MHP). For children and adolescents, the MHP should also have training in child and adolescent developmental psychopathology. 2. Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in prepubertal children with GID. 3. We recommend that physicians evaluate and ensure that applicants understand the reversible and irreversible effects of hormone suppression (e.g. GnRH analog treatment) and cross­sex hormone treatment before they start hormone treatment. 4. We recommend that all transsexual individuals be informed and counseled regarding options for fertility prior to initiation of puberty suppression in adolescents and prior to treatment with sex hormones of the desired sex in both adolescents and adults. Treatment of Adolescents

1. We recommend that adolescents who fulfill eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development. 2. We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of estradiol and testosterone, respectively), but no earlier than Tanner stages 2–3. 3. We recommend that GnRH analogs be used to achieve suppression of pubertal hormones. 4. We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 year, using a gradually increasing dose schedule of cross­sex steroids. 5. We recommend referring hormone­treated adolescents for surgery when: a. the real­life experience (RLE) has resulted in a satisfactory social role change; b. the individual is satisfied about the hormonal effects; and c. the individual desires definitive surgical changes. 6. We suggest deferring surgery until the individual is at least 18 year old. Hormonal Therapy for Transgender Adults 1. We recommend that treating endocrinologists confirm the diagnostic criteria of GID or transsexualism and the eligibility and readiness criteria for the endocrine phase of gender transition. 2. We recommend that medical conditions that can be exacerbated by hormone depletion and cross­sex hormone treatment be evaluated and addressed prior to initiation of treatment. 3. We suggest that cross­sex hormone levels be maintained in the normal physiological range for the desired gender. 4. We suggest that endocrinologists review the onset and time course of physical changes induced by cross­sex hormone treatment. Adverse Outcome Prevention and Long­term Care 1. We suggest regular clinical and laboratory monitoring every 3 months during the first year and then once or twice yearly. 2. We suggest monitoring prolactin levels in male­to­female (MTF) transsexual persons treated with estrogens. 3. We suggest that transsexual persons treated with hormones be evaluated for cardiovascular risk factors. 4. We suggest that bone mineral density (BMD) measurements be obtained if risk factors for osteoporosis exist, specifically in those who stop hormone therapy after gonadectomy. 5. We suggest that MTF transsexual persons who have no known increased risk of breast cancer follow breast screening guidelines recommended for biological women. 6. We suggest that MTF transsexual persons treated with estrogens follow screening guidelines for prostatic disease and prostate cancer recommended for biological men. 7. We suggest that female­to­male (FTM) transsexual persons evaluate the risks and benefits of including total hysterectomy and oophorectomy as part of sex reassignment surgery. Surgery for Sex Reassignment 1. We recommend that transsexual persons consider genital sex reassignment surgery only after both the physician responsible for endocrine transition therapy and the MHP find surgery advisable. 2. We recommend that genital sex reassignment surgery be recommended only after completion of at least 1 year of consistent and compliant hormone treatment.

3. We recommend that the physician responsible for endocrine treatment medically clear transsexual individuals for sex reassignment surgery and collaborate with the surgeon regarding hormone use during and after surgery. American College of Obstetricians and Gynecology (ACOG) In 2011, ACOG published a committee opinion regarding health care services for transgender individuals.[8] Although this guideline is not based in evidence, ACOG does make the following recommendations, “Obstetrician–gynecologists should be prepared to assist or refer transgender individuals for routine treatment and screening as well as hormonal and surgical therapies. Hormonal and surgical therapies for transgender patients may be requested, but should be managed in consultation with health care providers with expertise in specialized care and treatment of transgender patients.” In addition, ACOG guidelines made specific recommendations regarding hormone therapy, surgery and screening for both female­to­male and male­to­female patients: Female­to­Male Transgender Individuals

• Hormones Methyltestosterone injections every 2 weeks are usually sufficient to suppress menses and induce masculine secondary sex characteristics. Before receiving androgen therapy, patients should be screened for medical contraindications and have periodic laboratory testing, including hemoglobin and hematocrit to evaluate for polycythemia, liver function tests, and serum testosterone level assessments (goal is a mid­normal male range of 500 microgram/dL), while receiving the treatment.

• Surgery Hysterectomy, with or without salpingo­oophorectomy, is commonly part of the surgical process. An obstetrician–gynecologist who has no specialized expertise in transgender care may be asked to perform this surgery, and also may be consulted for routine reasons such as dysfunctional bleeding or pelvic pain. Reconstructive surgery should be performed by a urologist, gynecologist, plastic surgeon, or general surgeon who has specialized competence and training in this field.

• Screening Age­appropriate screening for breast cancer and cervical cancer should be continued unless mastectomy or removal of the cervix has occurred. For patients using androgen therapy who have not had a complete hysterectomy, there may be an increased risk of endometrial cancer and ovarian cancer. Male­to­Female Transgender Individuals

• Hormones Estrogen therapy results in gynecomastia, reduced hair growth, redistribution of fat, and reduced testicular volume. All patients considering therapy should be screened for medical contraindications. After surgery, doses of estradiol, 2–4 mg/d, or conjugated equine estrogen, 2.5 mg/d, are often sufficient to keep total testosterone levels to normal female levels of less than 25 ng/dL. Nonoral therapy also can be offered. It is recommended that male­to­female transgender

patients receiving estrogen therapy have an annual prolactin level assessment and visual field examination to screen for prolactinoma. • Surgery Surgery usually involves penile and testicular excision and the creation of a neovagina. Reported complications of surgery include vaginal and urethral stenosis, fistula formation, problems with remnants of erectile tissue, and pain. Vaginal dilation of the neovagina is required to maintain patency. Other surgical procedures that may be performed include breast implants and non­genital surgery, such as facial feminization surgery. • Screening Age­appropriate screening for breast and prostate cancer is appropriate for male­to­female transgender patients. Opinion varies regarding the need for Pap testing in this population. In patients who have a neocervix created from the glans penis, routine cytologic examination of the neocervix may be indicated. The glands are more prone to cancerous changes than the skin of the penile shaft, and intraepithelial neoplasia of the glans is more likely to progress to invasive carcinoma than is intraepithelial neoplasia of other penile skin. The World Professional Association for Transgender Health (WPATH) WPATH is a multidisciplinary professional society representing the specialties of medicine, psychology, social sciences and law that has published clinical guidelines regarding health services for patients with gender disorders. In 2012, WPATH updated their evidence and consensus­based guideline regarding, the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming Peoples.[7] WPATH listed the following options for individuals seeking treatment for gender dysphoria: • Changes in gender expression and role (which may involve living part time or full time in another gender role, consistent with one’s gender identity); • Hormone therapy to feminize or masculinize the body; • Surgery to change primary and/or secondary sex characteristics; • Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience. In addition, WPATH made specific recommendations regarding breast augmentation procedures: Breast reconstruction The WPATH guideline recommends MTF patients undergo feminizing hormone therapy for a minimum of 12 months prior to augmentation surgery and lists specific criteria for breast augmentation (implants/lipofilling). However, the classification of breast augmentation as a cosmetic versus reconstructive procedure has remained controversial. WPATH guidelines noted, “(w)hile most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive.” In addition, WPATH indicated that although breast appearance may be considered an important secondary sex characteristic, “breast presence or size is not involved in the legal definitions of sex and gender and is not necessary for reproduction.”

Summary There is a lack of well­designed randomized clinical trials (RCTs) comparing the safety and effectiveness of non­treatment for gender dysphoria in transgender individuals with treatment, including but not limited to hormone therapy and sex reassignment surgery. However, there are challenges in conducting RCTs to evaluate treatments of gender dysphoria due to several factors, such as small patient populations and ethical concerns regarding the high morbidity and mortality rates associated with non­treatment. Given these confounding factors, data from large randomized controlled trials are not expected in the near future. Although additional evidence is needed to validate patient selection criteria and treatment strategies, data from numerous cohort studies consistently suggest significant improvements in gender dysphoria symptoms and quality of life measures after receiving treatments. Therefore, treatment of gender dysphoria in transgender individuals may be considered medically necessary when specified policy criteria are met. APPENDIX 2 Gender Dysphoria[23] Gender dysphoria is defined by the Diagnostic & Statistical Manual of Mental Disorders DSM­V as: Gender Dysphoria in Children: A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender, different from one's assigned gender) 2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to wearing of typical feminine clothing. 3. A strong preference for cross­gender roles in make­believe play of fantasy play. 4. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities. 7. A strong dislike of one's sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender. B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome) Coding note: Code the disorder of sex development as well as gender dysphoria. Gender Dysphoria in Adolescents and Adults: A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (on in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (on in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics.) 3. A strong desire for the primary and /or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender) or some alternative gender different from one's assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender). B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome) Coding note: Code the disorder of sex development as well as gender dysphoria. Specify if: Post transition: The individual has transitioned to full­time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross­sex medical procedure or treatment regimen­ namely regular cross­sex treatment or gender reassignment surgery confirming the desired gender (e.g., appendectomy, vaginoplasty in the natal male; mastectomy or phalloplasty in the natal female).” APPENDIX 3 RIGHTS OF MINORS TO CONSENT TO HEALTH CARE

109.640 Right to medical or dental treatment without parental consent; provision of birth control information and services to any person. (1) Any physician or nurse practitioner may provide birth control information and services to any person without regard to the age of the person.

(2) A minor 15 years of age or older may give consent, without the consent of a parent or guardian of the minor, to:

(a) Hospital care, medical or surgical diagnosis or treatment by a physician licensed by the Oregon Medical Board, and dental or surgical diagnosis or treatment by a dentist licensed by the Oregon Board of Dentistry, except as provided by ORS 109.660.

(b) Diagnosis and treatment by a nurse practitioner who is licensed by the Oregon State Board of Nursing under ORS 678.375 and who is acting within the scope of practice for a nurse practitioner.

109.650 Disclosure without minor’s consent and without liability. A hospital or any physician, nurse practitioner, dentist or optometrist described in ORS 109.640 may advise a

parent or legal guardian of a minor of the care, diagnosis or treatment of the minor or the need for any treatment of the minor, without the consent of the minor, and is not liable for advising the parent or legal guardian without the consent of the minor. [1971 c.381 §2; 2005 c.471 §8; 2010 c.91 §2]

109.672 Certain persons immune from liability for providing care to minor. (1) No person licensed, certified or registered to practice a health care profession or health care facility shall be liable for damages in any civil action arising out of the failure of the person or facility to obtain the consent of a parent to the giving of medical care or treatment to a minor child of the parent if consent to the care has been given by the other parent of the child.

(2) The immunity provided by subsection (1) of this section shall apply regardless of whether:

(a) The parents are married, unmarried or separated at the time of consent or treatment.

(b) The consenting parent is, or is not, a custodial parent of the minor.

(c) The giving of consent by only one parent is, or is not, in conformance with the terms of any agreement between the parents, any custody order or any judgment of dissolution or separation.

(3) The immunity created by subsection (1) of this section shall not apply if the parental rights of the parent who gives consent have been terminated pursuant to ORS 419B.500 to 419B.524.

(4) For the purposes of this section, “health care facility” means a facility as defined in ORS 442.015 or any other entity providing medical service. [Formerly 109.133; 1993 c.33 §296; 2003 c.576 §158]

109.675 Right to diagnosis or treatment for mental or emotional disorder or chemical dependency without parental consent. (1) A minor 14 years of age or older may obtain, without parental knowledge or consent, outpatient diagnosis or treatment of a mental or emotional disorder or a chemical dependency, excluding methadone maintenance, by a physician licensed by the Oregon Medical Board, a psychologist licensed by the State Board of Psychologist Examiners, a nurse practitioner registered by the Oregon State Board of Nursing, a clinical social worker licensed by the State Board of Licensed Social Workers, a professional counselor or marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists or a community mental health program established and operated pursuant to ORS 430.620 when approved to do so by the Oregon Health Authority pursuant to rule.

(2) However, the person providing treatment shall have the parents of the minor involved before the end of treatment unless the parents refuse or unless there are clear clinical indications to the contrary, which shall be documented in the treatment record. The provisions of this subsection do not apply to:

(a) A minor who has been sexually abused by a parent; or

(b) An emancipated minor, whether emancipated under the provisions of ORS 109.510 and 109.520 or 419B.550 to 419B.558 or, for the purpose of this section only, emancipated by virtue of having lived apart from the parents or legal guardian while being self­sustaining for a period of 90 days prior to obtaining treatment as provided by this section. [1985 c.525 §1; 1989 c.721 §47; 1993 c.546 §137; 1997 c.249 §38; 2009 c.442 §30; 2009 c.595 §71; 2013 c.178 §1]

109.680 Disclosure without minor’s consent; civil immunity. A physician, psychologist, nurse practitioner, clinical social worker licensed under ORS 675.530, professional counselor or marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists or community mental health program described in ORS 109.675 may advise the parent or parents or legal guardian of any minor described in ORS 109.675 of the diagnosis or treatment whenever the disclosure is clinically appropriate and will serve the best interests of the minor’s treatment because the minor’s condition has deteriorated or the risk of a suicide attempt has become such that inpatient treatment is necessary, or the minor’s condition requires detoxification in a residential or acute care facility. If such disclosure is made, the physician, psychologist, nurse practitioner, clinical social worker licensed under ORS 675.530, professional counselor or marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists or community mental health program shall not be subject to any civil liability for advising the parent, parents or legal guardian without the consent of the minor. [1985 c.525 §2; 1989 c.721 §48; 2009 c.442 §31; 2009 c.595 §72; 2013 c.178 §2]

109.685 Immunity from civil liability for person providing treatment or diagnosis. A physician, psychologist, nurse practitioner, clinical social worker licensed under ORS 675.530, professional counselor or marriage and family therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists or community mental health program described in ORS 109.675 who in good faith provides diagnosis or treatment to a minor as authorized by ORS 109.675 shall not be subject to any civil liability for providing such diagnosis or treatment without consent of the parent or legal guardian of the minor. [1985 c.525 §3; 1989 c.721 §49; 2009 c.442 §32; 2009 c.595 §73; 2013 c.178 §3]

109.690 Parent or guardian not liable for payment under ORS 109.675. If diagnosis or treatment services are provided to a minor pursuant to ORS 109.675 without consent of the minor’s parent or legal guardian, the parent, parents or legal guardian of the minor shall not be liable for payment for any such services rendered. [1985 c.525 §4]

109.695 Rules for implementation of ORS 109.675 to 109.695. For the purpose of carrying out the policy and intent of ORS 109.675 to 109.695 while taking into account the respective rights of minors at risk of chemical dependency or mental or emotional disorder and the rights and interests of parents or legal guardians of such minors, the Oregon Health Authority shall adopt rules for the implementation of ORS 109.675 to 109.695 by community mental health programs approved to do so. Such rules shall provide for the earliest feasible involvement of the parents or guardians in the treatment plan consistent with clinical requirements of the minor. [1985 c.525 §5; 2009 c.595 §74]

REFERENCES

1. Washington State Office of the Insurance Commissioner. FAQ about coverage of transgender enrollees. [cited 09/09/2014]; Available from: http://www.insurance.wa.gov/for­insurers/filing­instructions/file­health­care­disability/transgender­subscribers­faq/index.html

2. American Psychological Association. Answers to your questions about transgender people, gender identity, and gender expression: What does transgender mean? [cited 09/09/2014]; Available from: http://www.apa.org/topics/lgbt/transgender.aspx

3. World Professional Association for Transgender Health (WPATH). Medical Necessity Statement: WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide. [cited 09/11/2014]; Available from:

4. 1. http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_associat

ion_webpage=3947 1. American Psychological Association. Answers to your questions about transgender

people, gender identity, and gender expression: How prevalent are transgender people? [cited 09/09/2014]; Available from: http://www.apa.org/topics/lgbt/transgender.aspx?item=6

2. De Cuypere, G, Van Hemelrijck, M, Michel, A, et al. Prevalence and demography of transsexualism in Belgium. Eur Psychiatry. 2007;22:137­41. PMID: 17188846

3. Blosnich, JR, Brown, GR, Shipherd Phd, JC, Kauth, M, Piegari, RI, Bossarte, RM. Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing veterans health administration care. Am J Public Health. 2013 Oct;103(10):e27­32. PMID: 23947310

4. World Professional Association for Transgender Health (WPATH). Standards of Care for the health of transsexual, transgender, and gener­nonconforming people. [cited 09/09/2014]; Available from: http://admin.associationsonline.com/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf

5. Committee Opinion no. 512: health care for transgender individuals. Obstet Gynecol. 2011;118:1454­8. PMID: 22105293

6. Terada, S, Matsumoto, Y, Sato, T, Okabe, N, Kishimoto, Y, Uchitomi, Y. Suicidal ideation among patients with gender identity disorder. Psychiatry Res. 2011;190:159­62. PMID: 21612827

7. Imbimbo, C, Verze, P, Palmieri, A, et al. A report from a single institute's 14­year experience in treatment of male­to­female transsexuals. J Sex Med. 2009;6:2736­45. PMID: 19619147

8. Spack, NP, Edwards­Leeper, L, Feldman, HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129:418­25. PMID: 22351896

9. Selvaggi, G, Dhejne, C, Landen, M, Elander, A. The 2011 WPATH Standards of Care and Penile Reconstruction in Female­to­Male Transsexual Individuals. Adv Urol. 2012;2012:581712. PMID: 22654902

10. Murad, MH, Elamin, MB, Garcia, MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta­analysis of quality of life and psychosocial outcomes. Clinical endocrinology. 2010;72:214­31. PMID: 19473181

11. Elamin, MB, Garcia, MZ, Murad, MH, Erwin, PJ, Montori, VM. Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta­analyses. Clinical endocrinology. 2010;72:1­10. PMID: 19473174

12. Duisin, D, Nikolic­Balkoski, G, Batinic, B. Sociodemographic profile of transsexual patients. Psychiatria Danubina. 2009 Jun;21(2):220­3. PMID: 19556952

13. Heylens, G, Verroken, C, De Cock, S, T'Sjoen, G, De Cuypere, G. Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. J Sex Med. 2014 Jan;11(1):119­26. PMID: 24344788

14. Fisher, AD, Bandini, E, Casale, H, et al. Sociodemographic and clinical features of gender identity disorder: an Italian multicentric evaluation. J Sex Med. 2013 Feb;10(2):408­19. PMID: 23171237

15. Gorin­Lazard, A, Baumstarck, K, Boyer, L, et al. Hormonal therapy is associated with better self­esteem, mood, and quality of life in transsexuals. The Journal of nervous and mental disease. 2013;201:996­1000. PMID: 24177489

16. Gomez­Gil, E, Zubiaurre­Elorza, L, Esteva, I, et al. Hormone­treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology. 2012;37:662­70. PMID: 21937168

17. 18. 20.Johansson, A, Sundbom, E, Hojerback, T, Bodlund, O. A five­year follow­up study of

Swedishadults with gender identity disorder. Archives of sexual behavior. 2010 Dec;39(6):1429­37.PMID: 19816764

19. 21.Asscheman, H, Giltay, EJ, Megens, JA, de Ronde, WP, van Trotsenburg, MA, Gooren, LJ. Along­term follow­up study of mortality in transsexuals receiving treatment with cross­sexhormones. Eur J Endocrinol. 2011;164:635­42. PMID: 21266549

20. 22.Hembree, WC, Cohen­Kettenis, P, Delemarre­van de Waal, HA, et al. Endocrine treatment oftranssexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab.2009;94:3132­54. PMID: 19509099

21. 23.American Psychiatric Association (2013): Diagnostic and Statistical Manual of MentalDisorders, 5th ed. Arlington, VA: American Psychiatric Press.

22. Cosmetic and Reconstructive Surgery, Surgery, Policy No. 12 23. Reduction Mammaplasty, Surgery, Policy No. 60

OREGON HEALTH PLAN FORMULARY (link)

DRAFT Therapist Documentation Form for Evaluation for Transgender Surgery Client's name: Click here to enter text. Legal name: Click here to enter text. DOB: Click here to enter text.

Clinician Name: Click here to enter text. Office location or clinic: Click here to enter text. Please describe your experience completing assessments for gender related surgeries. Click here to enter text. For which surgery or surgeries are you referring your client? Orchiectomy Penectomy Vaginoplasty Hysterectomy/Oophorectomy Phalloplasty Metoidioplasty Vulvoplasty/Labiaplasty Subcutaneous mastectomy with male chest reconstruction A surgery not listed here. Please describe: Click here to enter text. Please list the dates that you evaluated this client for readiness and appropriateness for surgical intervention? Click here to enter text.

Which current or previous medical and/or mental health providers did you speak with in your evaluation? Click here to enter text. Please give a description of this client, identifying characteristics, their history of gender dysphoria and emphasize their attempts to address their gender dysphoria. Click here to enter text. Please indicate the length of time your client has taken hormones and their response to hormones? Surgical requests require 12 months of hormone therapy unless not clinically indicated. Click here to enter text. The Standards of Care state that the client must have "12 continuous months of living in a gender role that is congruent with their gender identity” unless it is determined this is not safe for the client. Please describe how the client has met this standard or how the standard is waived. Click here to enter text. Does this client have the capacity to give informed consent for genital surgery? If no, please explain. Click here to enter text. Are there issues the surgeons need to know about regarding communication? These could include English fluency, hearing impairments, an autism spectrum disorder, literacy level, learning differences, etc. Click here to enter text. How will surgery improve your client's functioning? How will it make their life better? Please use the client's words. Click here to enter text.

Do you have any hesitation or concern that the client may regret or not benefit from a surgical intervention? Click here to enter text. Please give a brief description of your client's mental health history, including suicidality, homicidality, a history of violence towards healthcare workers, any psychiatric hospitalizations, and residential treatment for mental health or substance use. Click here to enter text. Please list all current and past DSM Diagnoses. Click here to enter text. Please list all medications that the client is currently taking related to psychological concerns, sleep, or emotional problems (this should include supplements, like St. John's Wort and medical marijuana). Please list the prescriber’s name next to the medication. Click here to enter text. Does your client have a mental health problem that the stress of surgery, anesthesia, or recovery may cause your client to decompensate? For instance, PTSD, anxiety disorders, schizophrenia, substance abuse, etc. Click here to enter text. Please describe how you have prepared your client for this possibility and how this will be addressed. Click here to enter text. Please list the result of the CAGE or other substance abuse screening tool. Click here to enter text. Please describe current and past substance use including nicotine. Please list any concerns the client has regarding their substance use or their sobriety and pain medication. Click here to enter text. Please describe medical problems your client may have. Click here to enter text. What is your assessment of your client's function, including their ability to satisfactorily complete ADL's and IDL's? (Activities of Daily Living and Instrumental Activities of Daily Living.) Click here to enter text. Describe your client's support system, relationships, family support and work. Click here to enter text. Do you believe your client is capable of carrying out their aftercare plan? (including providing for their own self-care following surgery (e.g. dilation 3x per day, hygiene issues, monitoring for infection, getting adequate nutrition, staying housed, etc.) Yes No What additional care will your client need and how will that be arranged? Who will provide needed case management?

Click here to enter text. Your rationale for the referral for surgery. Click here to enter text. Please indicate that you discussed these issues to your client's satisfaction: Potential alterations in sexual functioning. Risks and benefits, alternatives to surgery. The impact of drugs and /or alcohol on surgery and outcomes. The importance of aftercare related to post-operative complications and aesthetic outcomes. The mandatory education/preparation program. (Vaginoplasty, metoidioplasty, and phalloplasty only) Sterilization and reproductive choices. (Genital surgeries only) Is your client's gender identity stable and consolidated? Yes No Do you believe your client has realistic expectations about what the surgery can and cannot do? Yes No Is there anything you would like to add: Click here to enter text. Your name, title and license: Click here to enter text. Your signature: _______________________________________ Date: Click here to enter text. Your phone number for follow up: Click here to enter text.

PRINT AND SEND TO CCO? (NEEDS EDITS)

Healthcare Training Trans 101 objectives + appropriate module Modules: Insurance/CCOs (divided by department) Providers Agencies

Trans 101 Objectives: Participants have learned and have basic use of identity terminology Participants explore statistical evidence and anecdotal evidence of systemic exclusion

and discrimination of trans people. Participants have also explored protective and resiliency factors that improve the lives of

trans people Participants understand how to support trans people through interpersonal actions,

structural changes, and systemic intervention. Group has basic understanding of how this information may be used within their

structures Group has had an opportunity to practice applying this information

Additional 101 goals:

Participants explore gender expectations and gender binary system; activity helps participants understand how gender affects everyone and the depth of systems

Participants explore how media constructs ideas of gender, trans identities, and transphobia and recognizing current examples

Participants receive basic understanding of transmisogyny and historical significance of trans women

Medical goals: Participants understand, by profession, appropriate interactions with patients/clients Providers understand and can fulfill responsive intake processes (e.g. form, EHR,

interviews post registration) Providers understand and can fulfill requests for transition related care assessments

(e.g. for hormone therapy, for surgical requests) Providers have access to multiple standards of care (e.g. WPATH, ICATH, Endocrine

Society) Order of training: Introduction & establishing group agreement Introduce the cultural iceberg (individual discrimination vs systemic vs structural) Establish terminology and appropriate use Define transition through storytelling Present gender binary and analyze its use and effects on everyone

promote understanding of multiple identities Introduce spectrum of gender identities (e.g. using Gender Gumby, Genderbread person, etc.)

Introduce how systems adversely affect trans people (e.g. health care, employment, housing, education, incarceration, etc)

Statistical information about access to healthcare, education for providers, specific effects on mental health and physical health

Introduction to working with transgender youth Introduction to working with transgender people of color and the importance to

acknowledge intersecting identities *INSERT SPECIFIC AUDIENCE CONTENT* Medical, behavioral, administrative, pharmacy Scenario work based on workshop audience

a. See modules 2. How can you apply this information?

a. What are your individual roles? Responsibilities of those roles? If you’re a doctor, you’re not just a doctor. You’re also a co­worker, employee, student, etc.

b. What can you affect in the system you’re in? E.g. If you are part of registration staff, you can change the intake process including patient interviewing.

c. What do you need to make this change? d. Is this a feasible goal? Who else needs to be involved to make this change? e. Consultation protocol

3. Ending a. Reflections b. Q & a c. Evaluation