• Elijah Castle

hair removal in preparation for bottom surgery

I wrote the following for someone whose health insurance company covers phalloplasty but not electrolysis. The following is meant to be sent as supplemental information to the insurance company in order to appeal a denial of electrolysis coverage. Many insurance companies do not cover hair-removal, pre-op or otherwise. I am of the belief that all gender-affirming procedures, including hair removal of any kind, should be covered 100% at no cost to the patient - just for context and my own perspective.

Medical Necessity of Hair Removal for Gender-Affirming Genital Surgeries

In preparation for phalloplasty and vaginoplasty, hair removal on the donor site/surgical site is essential. If surgery is performed with hair still present, hair growth inside the neourethra and/or vaginal canal can cause long-term complications. This includes debris formation as well as recurrent infection that may require surgical intervention.

To prevent this, hair removal should be supported and covered by insurance, not only to ensure the health of the patient, but also to lower the long-term costs to the health insurance company. If the presence of hair causes postoperative complications that require surgical intervention, the insurance company must undertake further financial responsibility.

The only FDA-approved form of permanent hair removal is electrolysis. It is imperative that health insurance companies which cover medically necessary gender-affirming surgeries also cover the patient’s electrolysis.

Further research-backed support specific to phalloplasty and vaginoplasty surgeries:

  • “To prevent unwanted hair growth and associated complications, genital GAS has become a recognized indication for hair removal” (Zhang et al., 381)

  • “...electrolysis and LHR are the preferred treatments for permanent removal because of their higher efficacy. Surgeons performing genital GAS require preoperative permanent hair removal from any skin that will either be brought into contact with urine (e.g., used to construct a neourethra)...” (Zhang et al., 381)

  • “Hair within a neourethra will obstruct urine outflow, promote urine retention within the urethra, and often become encrusted with stone and sebaceous debris - all of which increase the risk of urinary infections and post-void dribbling of urine” (Zhang et al., 381)

  • “Electrolysis is the process of electric epilation, in use since 1875 and approved by the FDA for permanent hair removal” (Zhang et al., 382)

  • “...electrolysis has been commonly used for this indication, as it had been the sole solution for long-term hair removal…” (Zhang et al., 382)

  • “...transgender men undergoing phalloplasty with urethral lengthening (construction of a neourethra) require preoperative hair removal. The skin-flap area that will be used to construct the neourethra must be rendered free of hair-growth to avoid hair-related complications” (Zhang et al, 384)

  • “The use of hair-bearing skin for the phalloplasty carries extra complications because of the introduction of skin epithelial elements into a previously urothelium-exclusive environment” (Viviano et al., 55)

  • “A tricholithobezoar, or the formation of a stone over a hairball, is an unusual complication and has been seen when a hair-bearing skin flap is used for urethral reconstruction” (Singh et al., 346)

  • “Elective epilation can be a prophylactic measure to prevent tricholithobezoar formation” (Singh e al., 346)

  • “This case highlights the need for prophylactic removal of hairs along with long-term follow-up” (Singh e al., 346)

Due to the above medical research and more, there is a precedent set for health insurance companies to cover hair removal for gender-affirming surgeries. Amida Care (, a Medicaid plan that serves people living with HIV/AIDS and transgender people in New York City, covers hair removal in preparation for surgery as well as hair removal to reduce gender dysphoria. The prerequisite for coverage with Amida Care is a letter of medical necessity from the patient’s medical provider. Additionally, many other health insurance companies providing group plans with transgender-inclusive coverage also provide coverage for hair removal in preparation for surgery. To deny coverage of hair removal for a transgender person preparing for surgery is intentional denial of necessary medical care in the face of supporting evidence.


Singh, V., Nagathan, D. S., Singa, R. J., Gupta, D. K. (2012) Tricholithobezoar: An Unusual Late Complication of Neourethral Reconstruction in Aphallia.

Viviano, R., Morganstern, B. A., & O’Tool, A. (2014) Urethral Stone Disease Leading to Retention After Hair-bearing Neophalloplasty.

Zhang, W. R., Garrett, G. L., Arron, S. T., Garcia, M. M. (2016) Laser hair removal for genital gender affirming surgery.

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