German Trans Surgery Bureaucracy 101

Every now and then English speaking people ask about the way to get surgeries (especially SRS) paid by German public health insurance. So here is my 101. I will amend it when new questions or difficulties come up.

Basically you need to write an Antrag (application) to your public health insurance, and they need to decide about it within five weeks. The difficulty is in the documents that you need to send with your Antrag, because they are meant to prove that you fulfill all the requirements for SRS. These are especially:

  • 18 Months of psychotherapy
  • 18 Months of real life experience
  • 6 Months of HRT
  • Your genital configuration (in case of srs) needs to be „normal“ and surgery possible and with good prognosis

So the first thing is to fulfill those requirements.

To get psychotherapy you need to make an appointment for a Vorgespräch (preliminary appointment) with a therapist. It’s good to go to a therapist with trans experience (ask in the community for recommendations) so they don’t try to „heal the trans“ or are reluctant to give you the necessary papers. For payment you only need the Gesundheitskarte, it’s good for the first four appointments, in that time the therapist will apply for the therapy at your Krankenkasse, you don’t have to do anything for it.

The real life experience needs to be described in the report of the therapist. So it is good to discuss right away what would be the requirements that they write it in the report. If you are already full time, then that should be enough (the 18 months of real life experience are then just the 18 months of your therapy where you go about your normal life), it is jut important that they write it in the report.

In case you are not in HRT yet, after some time the therapist should write you an Indikation (recommendation letter) that you can then take to an endocrinologist who can then prescribe you hormones. For the first appointment at the endocrinologist there is usually a long waiting time, and usually they first want to make some tests before they write the prescription, so it is good to start the process early.

Then you need to look for a surgeon. There are a good handful in Germany, with different methods and different outcomes, so it is good to ask around in the community for recommendations. It is important to not care about geographical distance, because the good ones are seldom close by. Then you should make appointments for Vorgespräch for a few ones that you consider fitting for your needs. There often is a large waiting time for those appointments, so it is also good to start early. At the Vorgespräch you can ask your questions (it is good to write a list of questions beforehand, to not forget anything important) and they usually will also do a medical examination to assess whether surgery is possible and how and also to be able to write the necessary documentation.

You should get the following elements in the documentation from them:

  • Description of your medical condition (descended testes for example)
  • Confirmation that you have been informed about risks and limits of the procedure
  • Confirmation that surgery is possible and that there is a good prognosis for the outcome
  • Usually also date for surgery (kind of fictional, but necessary for the application)

If you don’t get that documentation, call them. Some also only give it to you if you provide a recommendation for surgery from your therapist. Best ask about that beforehand when you make the appointment. Then you need to decide for a surgeon.

For the Antrag best is to ask the insurance about the necessary documents and ask them to send you a list of them. This paper is very helpful in collecting the documents. The doctors can read what they need to write and also have a contact (in the letterhead) to ask if something is unclear and also to regulate the payment for their reports. Usually you need the following documents:

  • Verlaufsbericht of your psychotherapy, confirming the 18 months of therapy and 18 months of real life experience and detailing that surgery is necessary.
  • Current hormonal status from the endocrinologist, also mentioning the time when HRT has been started.
  • The documentation of the surgeon as described above.
  • Usually they will also ask for the letters from your name change. If you have them and they are positive, send them, but the insurance is not allowed to require them.
  • Sometimes an additional psychiatric evaluation is necessary, especially if your psychotherapist is not a doctor. Usually that should be doable in one or two sessions, ask around in the community or ask your psychotherapist for recommendations.
  • Then a „Persönliche Stellungnahme“ (personal statement) is asked for. There you should write personally why you want the surgery and also describe what other medical interventions you plan and why. If you have a „transssexueller Lebenslauf“, for example from your name change, you can send that as well.

When you have all the documents, you can send your Antrag to the Krankenkasse. Make sure you get a written confirmation of the reception of the Antrag, either by handing it personally and having it confirmed by signature on a copy, or by sending it via „Einschreiben mit Rückschein“.

Within three weeks the Krankenkasse needs to send a reply. Usually they will send something that they have send it to the MDK for evaluation.

Within five weeks after reception of the Antrag, the Krankenkasse needs to decide on it and send the answer to you.

If you haven’t received anything within six weeks (allowing some time for post), the Antrag is legally approved (§ 13 Patientenrechtegesetz). Then you write a letter to the Krankenkasse informing them about that fact and giving them notice to send you a Kostenübernahmeerklärung.

Otherwise they will either send you a Kostenübernahmeerklärung or will require some additional documents. Then you need to collect those and send them in.

If you have the Kostenübernahmeerklärung, you send a copy to your surgeon and ask them for a surgery date. Sometimes they will also put you on a „quick waiting list“ in case someone cancels and then you can jump in and get the surgery earlier. They will also give you the information when to show up where for surgery and what to bring. They might ask for the original copy of the Kostenübernahmeerklärung when you show up.


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