A surgeon says “chest masculinization” or breast removal surgery is a growing part of her medical practice.
Insurance coverage has made it possible for her breast care clinic to perform nearly 350 of these procedures since 2017, according to Amie M. Hop, M.D., a breast surgeon from the Corewell Health West Comprehensive Breast and Gender Affirmation Clinic in Grand Rapids, Michigan, and a clinical assistant professor at Michigan State University College of Human Medicine.
Corewell Health markets the surgery by posting success stories online.
Insurance Required
In a “Diversity, Equity and Inclusion Grand Rounds” webinar on “chest masculinization” surgery for continuing medical education credit, Hop says she has been in surgical practice for seven years but gravitated to “chest masculinization” surgery four years ago.
“We have a unique perspective in our office as a vast majority of gender affirming surgeries are performed by plastic surgeons,” said Hop.
In 2019, Michigan began covering sex change surgery under the state’s Medicaid program. Private health plans followed suit, and insurance coverage is a must, says Hop.
“We don’t do a self-pay option because we’re operating in the hospital where things can be quite expensive,” said Hop.
Customized Appearance
Hop explained “chest masculinization” involves removal of mammary tissue and excess skin, and repositioning the nipples and areolae.
Some patients want a “male-female” look where not all excess skin is removed or a “blank canvas” appearance. Hop shared images of two types of surgeries.
Most insurance carriers, as well as Hop’s clinic, require a letter of support from a qualified mental health professional, and there must be a diagnosis of “persistent and well-documented gender dysphoria; typically, at least six months in duration,” said Hop. Patients must have the letter before a consultation, said Hop, “because finding a therapist is not easy.”
Hop says mental health issues must be under control because “stressors” may come post-surgery.
Transgender, Non-binary Patients
Most of the women who seek breast removal describe themselves as “transgender/non-binary,” but occasionally a patient will describe “themself” as having body dysmorphic disorder, an intense dislike of their appearance.
The clinic does not treat minors but will offer informational visits, with a parent. The median age of the clinic’s patients is 25 years old, and 90 percent have had a history of mental health problems, with 11 percent who attempted suicide.
Hop says the clinic has gone to great lengths to be “inclusive.” Intake forms require patients, including women seeking a mastectomy for cancer, to state their pronouns. The color pink and the use of the word “breast” has been mostly eliminated because Hop said it can “trigger” some trans patients. Hop showed the Webinar participants how she wears a prominent rainbow on her badge.
Outcomes and Complications
Removing breasts does not eliminate the need for breast cancer screens in the future as some breast tissue may be left behind, and the patient will require imaging that might not be covered by insurance, according to Hop.
Because the clinic has only been performing the surgeries for seven years, there is limited long-term data. Over the seven years, 20 percent of patients suffered hematomas, seromas, surgical site infections, or nipple necrosis. Internal surveys have found that 59 percent “strongly agree” they were satisfied with the outcome while 97 percent “strongly disagreed” that they regretted the surgery.
Hop said “detransition” is rare but data is limited.
A Sanitized View?
In her presentation, Hop shared two photos of biological females who underwent “chest masculinization” surgery. Both photos showed a chest wall undistinguishable from a biological adult male.
The photos were a marked contrast to a photo shared recently in a Substack post by Peter McCullough, M.D. The patient bears a huge, visible scar across the entire chest wall and unnatural nipples.
The photos accompany a post that McCullough wrote which discussed a Finish study that found more than 40 percent of female-to-male transgender patients undergoing chest surgery had another psychiatric diagnosis other than gender dysphoria. The study also found one-third of patients had complications, which McCullough calls “astounding.”
Informed Consent ‘a Joke’
There is not enough valid data on the long-term outcomes of such surgeries to allow patients to give informed consent, says Marilyn Singleton, M.D., J.D., a board-certified anesthesiologist and visiting fellow at Do No Harm, an advocacy group.
“This is uncharted territory,” said Singleton. “Sex change operations have been going on sub rosa for decades, but likely not in the numbers needed to have concrete data. Informed consent is a cruel joke.”
Medicaid likely considers breast removal medically necessary, but it is difficult for enrollees to obtain psychological treatment for dysphoria, says Singleton.
“I’d like to know the extent of Medicaid coverage for mental health counseling,” said Singleton. “Finding a mental health professional who accepts Medicaid patients is difficult because of the low reimbursement. From a financial standpoint, mental therapy is time-consuming and can last years. By contrast, the surgery is presumably ‘’one and done.’ Of course, this does not contemplate the complications.”
Cost No Longer a Guardrail
Insurance has often been a guardrail against risky procedures that aren’t medically necessary, because of the out-of-pocket cost to the patient, says Singleton.
“It is an equity issue now,” said Singleton. “In the past, only the rich could afford to be transgender.”
Medicaid may also now look at breast removal surgery as a discrimination issue under the Affordable Care Act (ACA), after the Biden administration reversed a Trump administration rule, on June 15, says Singleton.
“The announcement from the Department of Health and Human Services concerns one of the most notable parts of the ACA—the provision in Section 1557 that prevents health care providers and insurance companies from discriminating on the basis ‘race, color, national origin, sex, age or disability in certain health programs and activities.’ Effective immediately, the agency says it will interpret that provision to encompass discrimination against someone based on their sexual orientation or gender identity in health care,” said Singleton.
Medicaid and insurance could cover cosmetic breast enhancement surgery for non-transitioning women as medically necessary, says Singleton.
“I would argue that a person seeking bigger breasts is also suffering from a self-image disorder,” said Singleton. “So perhaps we should petition insurance to pay for that, too.”
AnneMarie Schieber (amschieber@heartland.org) is the managing editor of Health Care News.
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This article was updated on July 12, 2023, to include information about the McCullough Substack post.