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Transgender health care

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Does Insurance Cover Gender-Affirming Care?

Determining what your plan covers.

  • Gender-Affirming Surgery Costs
  • Gender-Affirming Medication Costs

Other Ways to Pay for Gender-Affirming Care and Surgery

Tips for financing gender-affirming care and surgery, the bottom line.

  • Health Insurance

In many cases, health insurance in the U.S. covers gender-affirming care. However, whether or not your insurance plan will cover a specific gender-affirming treatment can depend on your state, your employer, and your plan's benefits.

Key Takeaways

  • Health insurance generally covers gender-affirming care.
  • Not all plans cover all procedures, however, and the process can be murky and require preauthorization.
  • Gender-affirming care can cost tens of thousands of dollars without insurance coverage.

Major insurance companies today generally recognize transgender-related care as being medically necessary. However, at least 24 states have passed new laws or enacted new policies limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage for certain procedures by their insurers.

1.6 million

The estimated number of Americans age 13 or older who identify as transgender, according to a 2022 study.

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association, which reaffirmed its advocacy for such care in 2023. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the one they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care can include hormones, surgery, or counseling. The care aligns a person's gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act (ACA) banned health insurance discrimination based on sexual orientation and gender identity. Before the law's passage, medically necessary gender-affirming surgeries and hormones often weren't covered by insurers.

A 2024 rule from the Department of Health and Human Services stated that covered entities (a term that includes both insurance plans and providers such as doctors) could not "deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition or other gender-affirming care if such denial, limitation, or restriction results in discrimination on the basis of sex."

However, insurance is also regulated at the state level and rules can vary based on whether it is an ACA, public, or employer plan, so they don't apply evenly to all insurers.

Investopedia / Candra Huff

Policyholders and plan members can generally find out what's available to them in their member booklet. This should have been given to you when you got the policy or, if it's an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer's clinical evidence criteria to qualify for claim coverage. For example, to begin hormone therapy, the requirements might include a diagnosis of gender dysphoria from a licensed mental health professional.

Some plans may list exclusions for certain procedures. Even if an exclusion exists in the documentation, it can still be worthwhile to apply for pre-authorization or pre-approval for the procedure to obtain an official decision. For one thing, as the Transgender Legal Defense & Education Fund, notes, "the plan booklet may simply be out of date."

Even if you're turned down, that is not necessarily the final word. If a preauthorization request or a claim is denied, an attorney, healthcare advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service's medical necessity and appropriateness.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving half the states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer buys its coverage from an insurance company or is funding the plan itself. If the employer's plan is self-funded, it is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer can decide what health care is or is not covered.

In the Human Rights Campaign's 2023-2024 Corporate Equality Index, a record 94% of the companies it evaluated offered at least one transgender-inclusive plan option.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov Marketplace. Most insurers have eliminated transgender-specific exclusions, which ACA regulations explicitly ban.

Still, policies vary by state and in what they cover. As the Healthcare.gov website notes, "Many health plans are still using exclusions such as 'services related to sex change' or 'sex reassignment surgery' to deny coverage to transgender people for certain health care services."

It suggests that before enrolling in a plan, consumers should carefully review its terms: "Plans might use different language to describe these kinds of exclusions. Look for language like 'All procedures related to being transgender are not covered.' Other terms to look for include 'gender change,' 'transsexualism,' 'gender identity disorder,' and 'gender identity dysphoria.'"

Fortunately, according to Out2Enroll, an organization connecting the LGBT+ community with healthcare coverage, when it recently reviewed silver Marketplace options in 32 states it found that "the vast majority of insurers did not use transgender-specific exclusions" and that "40% of plans had language indicating that all or some medically necessary gender-affirming care would be covered by the plan." (ACA coverage is broken down into bronze, silver, gold, and platinum plans, with silver being a moderately priced level.)

Out2Enroll also has state-specific Transgender Health Insurance Guides on its website for help in choosing a plan.

Medicare and Medicaid Coverage

About 6% of transgender adults receive their health coverage from Medicare, the federal insurance program primarily for Americans over age 65. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Private Medicare Advantage plans should abide by the same rules as traditional Medicare, but patients on such plans should try to get preauthorization before accessing transition-related services, the National Center for Transgender Equality advises.

Some 21% of transgender adults receive Medicaid, the joint federal and state health insurance plan for low-income Americans. On a state-by-state basis, Medicaid coverage is uneven. Medicaid programs explicitly cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in 10 states bar coverage of transgender-related care for people of all ages, and programs in three states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access some types of gender-affirming care. TRICARE, the health benefits provider for military members, says it "covers hormone therapy and psychological counseling for gender dysphoria. TRICARE generally doesn't cover surgery for the treatment of gender dysphoria. However, active duty service members may request a waiver for medically necessary, gender affirming surgery."

The Veterans Health Administration offers gender-affirming healthcare, including hormones and prosthetics, mental health care, and other healthcare. Coverage for gender-affirming surgery has traditionally been denied but is currently undergoing a review.

How Much Does Gender-Affirming Surgery Cost?

The cost of gender-affirming care might range from $25,000 to $75,000, according to an estimate from the Human Rights Campaign.

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam's apple removal, and forehead reduction.

Bottom surgery may include:

  • Phalloplasty : Creation of penis 
  • Metoidioplasty : Phallus created from existing genital region tissue. 
  • Hysterectomy : Uterus and cervix removal  
  • Nullification surgery : Creating a gender-neutral look in the groin
  • Oophorectomy : Removal of one or both ovaries
  • Vaginoplasty and vulvoplasty : Creation of vagina and vulva 
  • Orchiectomy : Testicle removal 

Research published in 2022 by JAMA Surgery found that while gender-affirming surgery can be costly, insurance (for patients who have it) will often cover most of the cost. Looking at phalloplasty and vaginoplasty procedures specifically, it reported:

However, not all transgender people desire surgery. According to 2019 research statistics, only 28% of transgender women get any type of surgery, and only 4% to 13% receive genital surgery. Surgery is more common among transgender men, with 42% to 54% getting some type of surgery; up to 50% get genital surgery.

How Much Does Gender-Affirming Medication Cost?

Gender-affirming medication is far more common than surgery. As many as 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to the Journal of Law, Medicine & Ethics .

The costs of gender-affirming medications can vary widely. While they are often at least partially covered by insurance, they also come with out-of-pocket costs, which may continue through the patient's lifetime.

For example, a study in the Journal of General Internal Medicine reported that, "in 2019, median prices for feminizing and masculinizing hormone therapy ranged from $6.76 to $91.15 and $31.82 to $398.99, respectively." At the same time, patients' "median out-of-pocket costs ranged from $5.00 to $10.71 and $10.00 to $12.86 for feminizing and masculinizing hormone therapy, respectively." Those prices refer to a 30-day supply.

Other costs can be involved as well. For example, patients who are taking hormones may need periodic blood tests to monitor their health.

A 2020 study in Annals of Family Medicine found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those who are uninsured) were more likely to take nonprescription hormones from unlicensed sources, which may not be monitored for quality and potentially carry serious health risks.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are some options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards cab be another avenue for covering the costs of gender-affirming care or surgery, although they tend to have very high interest rates if you run a balance.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations, such as the Jim Collins Foundation, offer grants for people seeking gender-affirming care or surgery.

Health Accounts 

If you have a flexible spending account (FSA) or health savings account (HSA) , consider allocating some account money for gendering-affirming care or surgery if you are anticipating it.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Loan or Line of Credit (HELOC) 

You could take out a home equity loan or line of credit to cover the costs of gender-affirming care or surgery. With these types of loans, you can typically borrow up to a certain percentage of your home's equity. Interest rates are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can't repay the loan, your could lose your home. 

Friends and Family Loans 

If you've got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. To avoid misunderstandings, it's usually best to have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues, or even strangers.

When you're financing gender-affirming care or surgery, you may be able to save some money if you follow these tips.

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. Doing this homework could save you a lot of money.

Check the Interest Rate Before You Borrow 

Be sure to investigate how much you'll pay to borrow money if you decide to go the credit card or loan route. 

Try Negotiating or Set up a Payment Plan

You can sometimes negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn't willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that will cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-Affirming Care Cost in the U.S.?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. A common range is anywhere from $25,000 to $75,000, according to the Human Rights Campaign. Health insurance may cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one 2019 study, about 31% of the plans it looked at online claimed to cover puberty blockers. That makes it all the more important for patients and their families to shop around for insurance.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress, some people still encounter problems obtaining health insurance to cover such care or paying the out-of-pocket costs involved. People who expect to need gender-affirming care will want to read their insurance plan's coverage details carefully and ask questions if they're unsure about what's covered.

Human Rights Campaign. " Map: Attacks on Gender-Affirming Care by State ."

KFF. " Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions ."

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

UCSF Transgender Care. " Initiating Hormone Therapy ."

American Medical Association. " Transgender Coverage Issue Brief ."

U.S. Department of Health and Human Services. " Section 1557 of the Patient Protection and Affordable Care Act ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan ."

Federal Register. " Vol. 89, No. 88 / Monday, May 6, 2024 / Rules and Regulations ," Page 37701.

Movement Advance Protect. " Healthcare Laws and Policies ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan: Differences Between Self-Funded and Insured Plans. "

Human Rights Campaign. " Corporate Equality Index 2023-2024 ."

HealthCare.gov. " Transgender Health Care ."  

Out2Enroll. " Plan Information for 2024 ."

Healthcare.gov. " How to Pick a Health Insurance Plan ."

KFF. " Trans People in the U.S.: Identities, Demographics, Wellbeing. "

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

TRICARE. " Gender Dysphoria Services ."

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Annals of Family Medicine, November 2020. " Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ," See Abstract: Results.

Translational Andrology and Urology. " Demographic and Temporal Trends in Transgender Identities and Gender Confirming Surgery ."

JAMA Surgery. " Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the U.S. "

The Journal of Law, Medicine, and Ethics. " Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population ."

Journal of General Internal Medicine. " Gender Affirming Hormone Therapy Spending and Use in the USA, 2013-2019 ."

Transgender Health. April 11, 2019. " Health Care Insurance of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information ," See Table 1.

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Insurance Coverage for Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on March 13, 2024.

Navigating insurance coverage for gender affirmation surgery can be complex, but many insurance providers now recognize these forms of healthcare for transgender individuals as medically necessary and thereby deserving of coverage. This guide aims to simplify the process of finding and applying for insurance coverage for gender-affirmative surgery, also known as gender confirmation surgery.

The GCC’s list of insurance providers that cover gender-affirming surgeries

Below you can find a list of insurance providers for which our team has successfully obtained approval for top surgery procedures from here. If you don’t see your insurance listed here or are unsure, you can schedule a free, virtual consultation so our team can verify this information for you. Unfortunately, Medicare does not cover any of our procedures at this time.

*  This list does not guarantee insurance coverage for top surgery and successful approvals may vary on a number of factors, such as the type of plan for each insurance company.

How to Get Coverage: An Overview

The following information is meant to give you an overview of all the components you will need to take into consideration in finding an insurance plan that will cover your gender-affirming surgery.

  • Contact your insurance provider directly to inquire about coverage for gender reassignment surgery. You can start by calling the phone number on your insurance card.
  • Review your insurance policy or member handbook carefully for any exclusions or limitations related to transgender healthcare.
  • Consult the Transgender Legal Defense & Education Fund (TLDEF) for a list of insurance companies known to offer coverage for gender affirmation procedures.
  • Get enrollment help from Out2Enroll once you are ready to sign up for health coverage to understand your options.
  • Coverage Exclusions: Federal and state laws prohibit discrimination against transgender individuals by most public and private insurance health plans. This means insurance companies must cover transition-related care that’s medically necessary and it is illegal for them to deny coverage, in most cases. Some plans may still have exclusions in their policies, but you can ask for an exception or request the removal of the exclusion.
  • Medical Necessity: Virtually all major insurance companies now recognize that gender-affirming medical care for transgender patients is medically necessary. However, the specifics of what procedures or treatments are covered will depend on each insurance plan. Most of them will require letters from healthcare providers to support medical necessity. You can find a list of therapists that can provide support letters for insurance coverage through GALAP .
  • Referral Letters: To secure insurance coverage, patients will need 1-2 letters from healthcare providers. Besides a therapist support letter,  if GCC surgeons are not in-network providers, you will need a referral letter from your Primary Care Physician.
  • Financial Options: If your insurance provider does not cover gender-affirming surgery, other options include paying out-of-pocket, taking out a personal loan, or seeking financial help from charities and organizations.

Identifying Insurance Providers That Cover Gender Affirming Surgery

If you live in the United States, here’s a list of resources to help you identify insurance providers offering coverage for gender-affirming surgery:

  • Transgender Legal Defense & Education Fund (TLDEF) provides a list of insurance companies that have coverage for gender-affirming care.
  • Campus Pride provides a list of colleges and universities by state that cover gender-affirming surgery or hormone therapy under student health insurance.
  • Our Insurance Advocacy Team here at the Gender Confirmation Center has successfully secured coverage for surgery from the insurance companies mentioned above.

Navigating Insurance Policies for Gender Affirming Surgery

The National Center for Transgender Equality created a guide to help navigate getting your insurance to cover gender-affirming care. This process can be summarized in 3 steps below:

  • Learn what your insurance plan covers for gender-affirming care by calling your insurance company and ask what medical policies on gender dysphoria treatment are applicable to your plan. You may also find this information in the Member Handbook provided by your insurance.
  • Determine the type of insurance you have (self-funded vs fully insured) to see if there are exclusions or limitations on healthcare coverage for transition-related care. Self-funded plans (e.g. insurance through work, school, or government employment) typically have exclusions or limitations to coverage that may be exempt from state protection laws. You may need to request your employer or school to remove the exclusion before insurance can cover surgery.
  • Gather necessary documentation , such as letters from healthcare providers (i.e. mental health provider). Some insurance companies require at least 2 letters.
  • Submit a pre-authorization request to your insurance provider by writing a letter to explain why the procedure is necessary and why refusing to provide coverage may be illegal.
  • Follow up with your insurance to ensure the request is being processed or check on its status. Your insurance will send you a notification if your request has been approved or denied.

Navigating this process can be challenging but our Insurance Advocacy team works directly with your insurance for each step of this process until the insurance company reaches a decision for the preauthorization request. This service is provided free of charge for our patients to ensure the best chance of success in getting their surgery covered.

Overcoming Challenges in Insurance Coverage for Gender Affirming Surgery

  • Denial of preauthorization request or claim for reimbursement: Understanding the reason for denial can help determine your options for appealing this decision. Seeking legal assistance from a lawyer may help facilitate this process.
  • Dealing with out-of-network coverage: Insurance companies usually have a list of “in-network” healthcare providers that are covered by a particular plan. While some patients are restricted to these in-network providers (i.e. HMO plans), others may have the option to see out-of-network providers if the in-network options are not qualified (i.e., PPO plans). For example, your insurance may restrict you to seek care from a surgeon who can perform mastectomies but may not have training in gender-affirming techniques. In such cases, you have the right to seek out an out-of-network provider who is qualified in gender-affirming surgery, as the in-network provider cannot fulfill your specific needs. It’s essential to understand that the insurance may initially refuse coverage for out-of-network surgeons or facilities, but this decision can be challenged through the appeals process.
  • Consider an independent review for denials : If the insurance company continues to deny coverage, you may have the option to request an independent review by a third-party organization. This review can provide an unbiased evaluation of your case and potentially overturn the denial.

Exploring Financial Aid Options for Gender Affirming Surgery

  • Surgery Grants: Organizations and programs may offer grants or financial aid to help cover the costs of surgery. The GCC works with various organizations to help with costs of surgery. Learn more about them here.
  • CareCredit: GCC has partnered with CareCredit to help patients finance the costs of surgery. Patients can apply for this credit card to see if they qualify and figure out what payment plan options are available.

Advocating for Comprehensive Insurance Coverage

The Affordable Care Act prohibits discrimination based on gender identity, which can be leveraged when seeking coverage for gender-affirming surgery. Despite this, many still face challenges with access or coverage of medically necessary transition related care. Recently, these states have limited protections for transgender youth after passing laws banning their access to gender-affirming care.

Navigating insurance coverage for gender-affirming surgery can be challenging, but our Insurance Advocacy team is dedicated to ensuring access to care for our patients. The National Center for Transgender Equality and Transgender Legal Defense and Education Fund also provides a comprehensive list of resources to help patients find and get insurance coverage for gender-affirming care.

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Aetna Agrees to Expand Coverage for Gender-Affirming Surgeries

One of the nation’s largest health insurers is agreeing to pay for breast augmentation for some trans women.

gender reassignment surgery and insurance

By Reed Abelson

Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.

“I knew from my case, it wasn’t cosmetic,” said Ms. Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.

Ms. Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights , and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they can show it to be medically necessary.

To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.

The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals . While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.

“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.

Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah E. Lewis, the director of the Trans Health Project at the fund.

In addition, he said, it is illegal for a health insurer to deny coverage of medical care because of someone’s gender identity. “It’s a really simple matter of discrimination,” he said.

Aetna, which is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had talked to numerous doctors who provide the surgery.

“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the L.G.B.T.Q. community,” Dr. Pritzker said in a statement.

Aetna said it would also reimburse some trans women who were denied coverage but had the surgery. The company said it was actively reaching out to individuals who had sought authorization for their surgeries and were denied.

Cora Brna was denied coverage for breast augmentation surgery two years ago, when she tried to schedule it at the same time that she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she said.

“I felt like a group of people were deciding whether I was or was not a woman,” said Mrs. Brna, 32, who works as a health care worker in Pittsburgh and was one of the women who petitioned Aetna. She went ahead with the genital surgery but had the procedure to augment her breasts only after it was covered by a different health plan.

Aetna’s new policy also comes at a time when the federal government is re-examining whether denying some types of care to transgender individuals is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services the insurers would cover, said Katie Keith, who teaches law at Georgetown University and closely follows this area of the law.

“It’s almost like a parity issue,” she said.

While the Trump administration sought to undo protections for transgender individuals with a rule last June , the issue is still being sorted out in the courts, said Ms. Keith, who also pointed to the recent Supreme Court decision that said gay and transgender workers are protected from workplace discrimination under civil rights law.

The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.

Major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines established by the World Professional Association for Transgender Health, a nonprofit.

But other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic, since they do not generally cover the procedures for women without the gender dysphoria diagnosis. They say they are not discriminating against trans women.

Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.”

And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery to address gender dysphoria.” It added that it uses “evidence-based medicine to make coverage policy decisions,” which are regularly updated.

But lawyers for the women involved in the Aetna agreement say they are looking closely at the policies of other insurers to see if they can make the same case that their refusal to offer coverage is discriminatory. “This is something that needs to be changed across the industry,” said Ms. Kotagal of Cohen Milstein.

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. More about Reed Abelson

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Preparing for Transgender Surgery

We understand that the decision to have gender-affirming surgery is life changing. Our transgender healthcare team provides support and education to help you and your loved ones know what to expect throughout the gender-affirming surgery process.

As your surgical date approaches, we schedule one-on-one preoperative education visits with our nursing team. For those seeking genital surgery, we host classes with former patients who can share their experiences and introduce you to nurses and other staff who provide care in the hospital. Preoperative and postoperative photographs of procedure outcomes are available at the time of your surgical consultation. Referrals to mental health professionals who can support your emotional and physical wellbeing are also available.

Presurgical Requirements

There are certain requirements that need to be fulfilled before surgery, including surgical referral letters from mental health professionals and clinicians who provide hormone therapy; insurance authorization, which is done by our office; and hair removal for people having vaginoplasty or phalloplasty.

Surgical Referral Letters

Our surgeons follow the standards of care guidelines provided by the World Professional Association for Transgender Health (WPATH). This requires obtaining letters from your mental health professional and the clinician who managed your hormone therapy. We provide referrals to mental health professionals who can assist with letter writing and support your emotional wellbeing during this process. Here are suggestions for what to include in your surgery recommendation letter .

Insurance Authorization

Our office makes every effort to obtain insurance authorization after surgery has been scheduled. Please confirm that your insurance plan includes gender-affirming benefits before consultation. We offer a guide to verifying your health insurance benefits .

Occasionally, our efforts to authorize procedures are not successful even for those with gender-affirming surgery benefits, and in these instances we may refer patients to options for no- or low-cost legal assistance.

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If your surgical plan includes vaginoplasty or phalloplasty, permanent hair removal by either electrolysis or laser treatment is required before surgery. Please message us through your NYU Langone Health MyChart account for details on hair removal requirements.

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Does Medicare cover gender reassignment surgery?

gender reassignment surgery and insurance

Medicare provides coverage for gender reassignment surgery, although it needs to be deemed as medically necessary. A person can appeal the decision if surgery is denied.

While Medicare coverage is nationwide, there may be state variations in policies and guidelines.

In this article, we discuss gender reassignment surgeries, Medicare coverage, enrollment, and costs.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan: Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments. Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%. Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

What is gender reassignment surgery?

Shot of two surgeons analyzing a patient’s medical scans during gender reassignment surgery

Gender reassignment surgery is usually the last step in the process of changing from one sex to the other. The surgery can help a person with gender dysphoria transition to their desired gender.

The process usually begins with talk therapy to determine if a person is ready to go through a permanent physical change. Following that decision, the next phase involves hormone therapy . Biological men take estrogen and biological females take androgens (male hormones).

The purpose of hormone therapy is to change a person’s physical appearance. For example, females who take androgens may develop facial hair, while males who take estrogen may experience female traits such as weight redistribution and changes in the skin.

There can be complications from therapy:

Estrogen therapy may increases the risk of heart disease and diabetes , or blood clots or breast cancer .

Androgen therapy may increases blood pressure , insulin resistance, and cholesterol levels.

Doctors may ask a person to take on the role of the desired sex, socially and professionally, for up to a year before surgery.

Surgery is the final step in gender reassignment. It may take several surgeries to complete the change from a male to female or from a female to male.

Medicare resources

For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub .

What is involved in the surgery?

The goal of the surgery is to give the person the appearance and function of the desired gender. To achieve that goal, a person may need to go through several surgeries. As such, the surgical team often includes a plastic surgeon, urologist, gynecologist , and an ear, nose, and throat specialist.

Surgeries may include several steps , depending on the desired gender changes.

Biological female to male

  • mastectomy or breast reduction
  • nipple graft
  • removal of the uterus and ovaries
  • closure of the vagina
  • creation of a penis and scrotum
  • extension of the urethra through the penis, via a tube from the bladder to the outside of the body
  • penile implant
  • synthetic testicles
  • voice surgery
  • liposuction

Biological male to female

  • facial feminization
  • nose surgery
  • eyebrow lift
  • jaw surgery
  • chin reduction
  • enhancement of cheekbones
  • female hairline
  • laser hair removal
  • hair reconstruction
  • voice change
  • reduction of the Adam’s apple
  • breast augmentation
  • removal of penis and scrotum
  • creation of vagina, clitoris, and labia

Are there possible complications from the surgery?

There may be complications from surgery , including bleeding, infection, and side effects from anesthesia.

Medicare coverage

Medicare does not cover what they rule as cosmetic surgery, and until 2014 , did not cover surgeries to change gender. The rule was changed to include surgeries for medical reasons, which includes gender reassignment.

However, the Centers for Medicare & Medicaid Services (CMS) has not created a national policy, which means a person’s plans will decide if the surgery is medically necessary. This online tool will help a person find more information about their local state policies.

Medicare Advantage

Medicare Advantage (Part C) plans are sold by private companies. They combine the benefits of original Medicare parts A and B. Some plans also pay for medications.

In general, Advantage plans provide the same coverage as original Medicare, parts A and B.

However, because there is no nationwide policy on access to gender reassignment surgery, a person’s Medicare Advantage plan can decide if surgery is necessary and reasonable.

To find out if coverage is available, a person can check with their plan, use the Medicare online tool .

Medicare Part D pays for hormone therapy. However, if a person does not have Medicare Part D or Medicare Advantage, they may have to pay for prescription medications themselves.

People who are aged 65 and older can enroll in Medicare . Some younger people with disabilities or end stage renal disease also can get Medicare. People can enroll online through Social Security or at their local Social Security office.

There are various times during the year when a person can enroll in Medicare:

  • The Initial Enrollment Period (IEP) starts 3 months before the month of a person’s 65 birthday, includes the birth month, and ends 3 months later. There is a total of 7 months in the IEP, including the birth month.
  • If a person does not enroll during the IEP, they can sign up during the General Enrollment Period, from January 1 to March 31 every year.
  • During the period of October 15 to December 7, a person can drop, join, switch, or change a Medicare drug plan or Advantage plan.
  • In some circumstances, called a Special Enrollment Period , a person can make changes to the Medicare drug plans or Advantage plans.

When a person does not sign up for Medicare during the IEP, they may pay a late penalty.

Most people do not pay a premium for Part A. However, if a person does not qualify for premium-free Part A, they may have to buy Part A, which can cost up to $458 per month.

The standard premium for Medicare Part B in 2020 is $144.60 each month, and there is a $198 annual deductible cost. After a person pays the deductible, Medicare pays 80% of the allowable costs. The coinsurance is 20% of the charges.

If a person goes into hospital, there is a $1,408 deductible for every benefit period. There is no coinsurance if a person is discharged within 60 days.

Premiums for Medicare Advantage plans or Part D plans vary depending on the company providing the plans. An online tool can help people find and compare plan costs.

The cost of gender reassignment while on medicare will depend on which surgeries you will need performed and what medications you will be on after surgery. You will likely pay the $1408 Medicare Part A deductible for the some of the major surgeries, but will also pay the Part B deductible and 20% coinsurance on any outpatient procedures.

Medicare pays for gender reassignment surgeries and hormone replacement therapy , as long as the surgery is deemed medically necessary. There are several surgeries a person needs to finish the process.

Medicare Advantage plans may apply different rules when considering approval for surgeries.

A person must pay the same premiums and deductibles as they would for other surgeries or medical treatments.

Last medically reviewed on August 5, 2020

  • Cosmetic Medicine / Plastic Surgery
  • Health Insurance / Medical Insurance
  • Medicare / Medicaid / SCHIP

How we reviewed this article:

  • Advanced search. (n.d.). https://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx
  • After surgery: Discomforts and complications. (2020). https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/after-surgery-discomforts-and-complications
  • Decision memo for gender dysphoria and gender reassignment surgery (CAG-00446N). (2016). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=282&CoverageSelection=National&KeyWord=gender+reassignment+surgery&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAACAAAAA%3D%3D&
  • Gender confirmation surgeries. (n.d.). https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries
  • Gender reassignment surgery model NCD. (n.d.). https://www.cms.gov/medicare/coverage/determinationProcess/downloads/Kalra_comment_01022016.pdf
  • How do I get parts A and B? (n.d.). https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b
  • How do I file an appeal? (n.d.). https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal
  • Is my test, item, or service covered? (n.d.). https://www.medicare.gov/coverage
  • Medicare Advantage Plans. (n.d.). https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans
  • Medicare costs at a glance. (n.d.). https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
  • Part A and B sign up periods. (n.d.). https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods
  • Part A late enrollment penalty. (n.d.). https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-late-enrollment-penalty
  • Special circumstances (Special enrollment periods). (n.d.). https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances-special-enrollment-periods
  • Transwomen. (n.d.). https://thetranscenter.com/transwomen/
  • Unger, C.A. (2016). Hormone therapy for transgender patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182227/
  • What does Medicare cover for transgender people? (n.d.). https://transequality.org/know-your-rights/medicare
  • What is gender reassignment surgery? (n.d.). https://www.issm.info/sexual-health-qa/what-is-gender-reassignment-surgery/
  • Your health insurance coverage. (n.d.). https://www.ssa.gov/benefits/medicare/

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Does Health Insurance Cover Transgender Health Care?

For transgender Americans, access to necessary health care can be fraught with challenges. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination on a wide variety of grounds for any "health program or activity" that receives any sort of federal financial assistance.  

But the specifics of how that section is interpreted and enforced are left up to the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Not surprisingly, the Obama and Trump administrations took very different approaches to ACA Section 1557. But the Biden administration has reverted to the Obama-era rules.

In 2020, the Trump administration finalized new rules that rolled back the Obama administration's rules. This came just days before the Supreme Court ruled that employers could not discriminate against employees based on sexual orientation or gender identity. The Trump administration's rule was subsequently challenged in various court cases.

And in May 2021, the Biden administration issued a notice clarifying that the Office of Civil Rights would once again prohibit discrimination by health care entities based on sexual orientation or gender identity.

The Biden administration subsequently issued a proposed rule in 2022 to update the implementation of Section 1557 and strengthen nondiscrimination rules for health care. The proposed rule " restores and strengthens civil rights protections for patients and consumers in certain federally funded health programs and HHS programs after the 2020 version of the rule limited its scope and power to cover fewer programs and services. "

Section 1557 of the ACA

ACA Section 1557 has been in effect since 2010, but it's only a couple of paragraphs long and very general in nature. It prohibits discrimination in health care based on existing guidelines—the Civil Rights Act, Title IX, the Age Act, and Section 504 of the Rehabilitation Act—that were already very familiar to most Americans (i.e., age, disability, race, color, national origin, and sex).

Section 1557 of the ACA applies those same non-discrimination rules to health plans and activities that receive federal funding.

Section 1557 applies to any organization that provides healthcare services or health insurance (including organizations that have self-insured health plans for their employees) if they receive any sort of federal financial assistance for the health insurance or health activities.

That includes hospitals and other medical facilities, Medicaid , Medicare (with the exception of Medicare Part B ), student health plans, Children's Health Insurance Program, and private insurers that receive federal funding.

For private insurers, federal funding includes subsidies for their individual market enrollees who purchase coverage in the exchange (marketplace). In that case, all of the insurer's plans must be compliant with Section 1557, not just their individual exchange plans.

(Note that self-insured employer-sponsored plans are not subject to Section 1557 unless they receive some type of federal funding related to health care activities. The majority of people with employer-sponsored health coverage are enrolled in self-insured plans.)

To clarify the nondiscrimination requirements, the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR) published a 362-page final rule for implementation of Section 1557 in May 2016.

At that point, HHS and OCR clarified that gender identity "may be male, female, neither, or a combination of male and female." The rule explicitly prohibited health plans and activities receiving federal funding from discrimination against individuals based on gender identity or sex stereotypes.

But the rule was subject to ongoing litigation, and the nondiscrimination protections for transgender people were vacated by a federal judge in late 2019.

And in 2020, the Trump administration finalized new rules which reversed much of the Obama administration's rule. The new rule was issued in June 2020, and took effect in August 2020. It eliminated the ban on discrimination based on gender identity, sexual orientation, and sex stereotyping, and reverted to a binary definition of sex as being either male or female.

Just a few days later, however, the Supreme Court ruled that it was illegal for a workplace to discriminate based on a person's gender identity or sexual orientation. The case hinged on the court's interpretation of what it means to discriminate on the basis of sex, which has long been prohibited under US law. The majority of the justices agreed that "it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex."

The Biden administration announced in May 2020 that Section 1557's ban on sex discrimination by health care entities would once again include discrimination based on gender identity and sexual orientation.

And in 2022, the Biden administration published a new proposed rule for the implementation of Section 1557, rolling back the Trump-era rule changes and including a new focus on gender-affirming care (as opposed to just gender transition care).

Are Health Plans Required to Cover Gender Affirming Care?

Even before the Obama administration's rule was blocked by a judge and then rolled back by the Trump administration, it did not require health insurance policies to " cover any particular procedure or treatment for transition-related care ."

The rule also did not prevent a covered entity from " applying neutral standards that govern the circumstances in which it will offer coverage to all its enrollees in a nondiscriminatory manner ." In other words, medical and surgical procedures had to be offered in a non-discriminatory manner, but there was no specific requirement that insurers cover any specific transgender-related healthcare procedures, even when they're considered medically necessary.

Under the Obama administration's rule, OCR explained that if a covered entity performed or paid for a particular procedure for some of its members, it could not use gender identity or sex stereotyping to avoid providing that procedure to a transgender individual. So for example, if an insurer covers hysterectomies to prevent or treat cancer in cisgender women, it would have to use neutral, non-discriminatory criteria to determine whether it would cover hysterectomies to treat gender dysphoria.

And gender identity could not be used to deny medically necessary procedures, regardless of whether it affirmed the individual's gender. For example, a transgender man could not be denied treatment for ovarian cancer based on the fact that he identifies as a man.

But the issue remained complicated, and it's still complicated even with the Biden administration's proposed rule to strengthen Section 1557's nondiscrimination rules.

Under the 2016 rule, covered entities in every state were prohibited from using blanket exclusions to deny care for gender dysphoria and had to utilize non-discriminatory methods when determining whether a procedure will be covered. But that was vacated by a federal judge in 2019.

However, the new rules proposed in 2022 by the Biden administration " prohibit a covered entity from having or implementing a categorical coverage exclusion or limitation for all health services related to gender transition or other gender-affirming care. "

As of 2023, HealthCare.gov's page about transgender health care still states that " many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services. Coverage varies by state. "

The page goes on to note that " transgender health insurance exclusions may be unlawful sex discrimination. The healthcare law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities ."

The page advises that " if you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to  [email protected] ." (note that this language existed on that page in 2020 as well.)

State Rules for Health Coverage of Gender Affirming Care

Prior to the 2016 guidance issued in the Section 1557 final rule, there were 17 states that specifically prevented state-regulated health insurers from including blanket exclusions for transgender-specific care and 10 states that prevented such blanket exclusions in their Medicaid programs. And as of 2023, the list of states that ban specific transgender exclusions in state-regulated private health plans has grown to 24, plus the District of Columbia.

Starting in 2023, Colorado became the first state to explicitly include gender-affirming care in its benchmark plan (used to define essential health benefits ), ensuring that all individual and small-group health plans in the state must provide that coverage.

While Section 1557 was initially a big step towards equality in health care for transgender Americans, it does not explicitly require coverage for sex reassignment surgery and related medical care. And the implementation of Section 1557 has been a convoluted process with various changes along the way. Most recently, the Biden administration has restored nondiscrimination protections based on gender identity.

Do Health Insurance Plans Cover Sex Reassignment?

It depends on the health insurance plan. This description from Aetna  and this one from Blue Cross Blue Shield of Tennessee are good examples of how private health insurers might cover some—but not all—aspects of the gender transition process, and how medical necessity is considered in the context of gender-affirming care.

Since 2014,  Medicare has covered medically necessary sex reassignment surgery , with coverage decisions made on a case-by-case basis depending on medical need. And the Department of Veterans Affairs (VA) has announced in June 2021 that it has eliminated its long-standing ban on paying for sex reassignment surgery for America's veterans.

But Medicaid programs differ from one state to another, and there are pending lawsuits over some states' refusals to cover gender transition services for Medicaid enrollees.

Over the last several years, many health plans and self-insured employers have opted to expand their coverage in order to cover sex reassignment surgery and other gender-affirming care. But although health coverage for transgender-specific services has become more available, it is still far from universal.

This issue is likely to face protracted legal debate over the coming years, and coverage will likely continue to vary from one state to another and from one employer or private health plan to another.

Many health plans in the U.S. are subject to ACA Section 1557, which prohibits discrimination based on gender. But this section is implemented via HHS rules, which have changed over time: The Obama administration issued rules to protect people from gender-related discrimination in health care, the Trump administration relaxed those rules, and the Biden administration has proposed changes to strengthen them once again.

A Word from Verywell

If you're in need of gender-affirming medical care, you'll want to carefully consider the specifics of the health policy you have or any that you may be considering. If you think that you're experiencing discrimination based on your gender identity, you can file a complaint with the Office of Civil Rights . But you may find that a different health plan simply covers your needs more comprehensively.

US Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act .

Keith, Katie. Health Affairs. HHS Will Enforce Section 1557 To Protect LGBTQ People From Discrimination . May 11, 2021.

U.S. Department of Health and Human Services. HHS Announces Proposed Rule to Strengthen Nondiscrimination in Health Care . July 25, 2022.

United States DoJ. Overview of Title IX of the education amendments of 1972 . Updated August, 2015.

DHS.  Nondiscrimination in health programs and activities . Effective July 18, 2016.

Keith, Katie. Health Affairs. Court Vacates Parts Of ACA Nondiscrimination Rule . October 16, 2019.

Department of Health and Human Services. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority . June 12, 2020.

SCOTUS Blog. R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission . Argued October 2019; Decision issued June 15, 2020.

U.S. Department of Health and Human Services. HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity . May 10, 2021.

National Center for Transgender Equality. Know your rights: medicare .

HealthCare.gov. Transgender Health Care .

Health Affairs. LGBT protections in affordable care act section 1557 . June 2016.

LGBT Map. Health Care Laws and Policies .

U.S. Department of Health and Human Services. Biden-Harris Administration Greenlights Coverage of LGBTQ+ Care as an Essential Health Benefit in Colorado . October 12, 2021.

Military Times. VA to Offer Gender Surgery to Transgender Vets for the First Time . June 19, 2021.

Fleig, Shelby. Des Moines Register. ACLU of Iowa Renews Effort to Overturn Law Restricting Public Funds for Trans Iowans' Transition-Related Care . April 22, 2021.

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

Aetna

Gender Affirming Surgery

  • Clinical Policy Bulletins
  • Medical Clinical Policy Bulletins

Number: 0615

Table Of Contents

The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States.  Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.”

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  

Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).

The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022). 

It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively.  On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given.  A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters.  After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters.  These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school. 

Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints.  Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment.  Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high.  For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs.  Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations.  For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty.  Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known.  All patients considering treatment need counseling and medical monitoring.

Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health.  These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.  Through 2009, a total 192 MTF and 50 FTM transgender persons were seen.  These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability.  Mental health and psychiatric problems were inversely correlated with age at presentation.  The prevalence of gender affirming surgery was low (31 % for MTF).  The number of persons seeking treatment has increased substantially in recent years.  Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.  The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency.  The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers.  They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.

Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism.  Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved. 

Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast.  Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed.  A full-thickness skin graft is taken from the right groin to reconstruct the areola.  The right groin donor site is closed primarily in layers.”  

The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple.  Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, are included in code 19318. 

Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women

Jiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation.  These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice.  Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone.  These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery.  A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty.  Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty.  The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty.  The remaining patients had risk factors leading the surgeon to recommend vulvoplasty.  Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty.  The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only. 

Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered.  Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery

Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells.  These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts.  Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining.  The depths, sizes, secretions, and sensations of the vaginas were evaluated.  The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding.  The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years.  Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery.  The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B.  There was no stenosis in neither group.  The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B.  These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A.  All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5%  in group B expressed satisfaction.  The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina.  The size of neo-vagina, secretion, sensation, and orgasm was good and proper.  More than 93.7 % of patients had satisfaction with sexual intercourse.  They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation.  The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration.  No cases of stenosis or stricture were recorded.  Level of Evidence = IV.  These preliminary findings need to be validated by well-designed studies.

Pitch-Raising Surgery in Transfeminine Persons

Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals.  These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery.  They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total.  Objectively, a substantial rise in post-operative fundamental frequency was identified.  Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality.  The majority of patients appeared satisfied with the outcome.  However, none of the studies used a control group and randomization process.  The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design. 

Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice.  These researchers conducted a comprehensive review of the voice literature.  Publications were identified by searching 6 electronic databases and bibliographies of relevant articles.  A total of 22 publications met inclusion criteria.  Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people.  The quality of the evidence was appraised.  The extent and quality of studies investigating trans-masculine people's voice function was found to be limited.  There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.  The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Facial Feminization Surgery

Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth.  The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity.  Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation.  Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures.  These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling.  A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures.  Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs.  Most facial feminization surgery procedures could be safely completed in 6 months, barring complications.  All patients showed excellent cosmetic results and were satisfied with their procedures.  Both frontal and profile views achieved a loss of masculine features.  The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome.  The level of evidence of this study was IV.

Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features.  The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face.  Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed.  These researchers appraised the current facial feminization surgery literature.  They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization.  Data on techniques, outcomes, complications, and patient satisfaction were collected.  A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports.  Articles covered a variety of facial feminization procedures.  A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications.  Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.  The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients.  These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.  

In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck.  State policies on transgender care for Medicaid insurance providers were collected for all 50 states.  Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined.  The largest medical insurance companies in the U.S. were identified using the National Association of Insurance Commissioners Market Share report.  Policies of the top 49 primary commercial medical insurance companies were examined.  Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % of commercial medical insurance providers had a published policy on GAS coverage.  Genital reconstruction was described as a medically necessary aspect of transgender care in 100 % of the commercial policies reviewed; 93 % discussed coverage of FGAS, but 51 % considered these procedures cosmetic.  Thyroid chondroplasty (20 %) was the most commonly covered FGAS procedure.  Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13 % of the medical policies reviewed.  The authors concluded that while certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers.  Level of Evidence = V.

Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women.  While there are slightly more transgender women than transgender men in the population (33 % transgender women, 29 % transgender men, 35 % non-binary, 3 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization.  Still, the primary area of focus for facial feminization is generally the upper 1/3.  Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty".  While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration.  Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties.  Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus.  This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus.  Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill.  Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge.  An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors.

Forehead Feminization Cranioplasty

Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years.  However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs).  In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL.  They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO.  The search terms included variations of forehead setback/FFC.  Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched.  Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted.  Main outcomes and measures included complications and complication rate observed following FFC.  Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM.  A total of 10 articles describing FFC were included, entailing 673 patients.  The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies.  The authors concluded that complications following FFC were rare and infrequently required reoperation.  Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed.  Level of Evidence = III.

Hand Feminization and Masculinization

Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria.  Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands.  These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care.  They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population.  From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search.  There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation.  The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation.  The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand.  These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs.  Level of Evidence = III.

Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery

Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery.  Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery.  These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement.  A search was performed in OVID Medline, Embase, Willey Online Library and PubMed.  Specialty-related journals, grey literature and reference lists of relevant articles were manually searched.  From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence.  Healing times were poorly reported or often not mentioned.  A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction.  Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications.  Average follow-up ranged from 6 weeks to 14.8 months.  The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data.  These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications.  Patients seeking this surgery overseas should be informed of the potential difficulties they may face.

Urethral Complications and Outcomes in Transgender Men

Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty.  Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized.  These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction.  They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals.  Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model.  A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap,  and 6 studies (221 patients) on "second flap".  Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques.  For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %.  The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap.  Overall, most patients were able to void while standing and were satisfied with the outcomes.

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
  • 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 (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • 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).

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.

Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Characteristics of a Qualified Health Professionals (From SOC-8)

Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):

  • Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
  • Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
  • Are able to assess capacity to consent for treatment.
  • Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
  • Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
  • Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required.

Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8):

  • Training and documented supervision in gender-affirming procedures;
  • Maintenance of an active practice in gender-affirming surgical procedures;
  • Knowledge about gender diverse identities and expressions;
  • Continuing education in the field of gender-affirmation surgery;
  • Tracking of surgical outcomes.

Characteristics of health care professionals working with gender diverse adolescents:

  • Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
  • Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
  • Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
  • Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
  • Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

The above policy is based on the following references:

  • Almazan AN, Boskey ER, Labow B, Ganor O. Insurance policy trends for breast surgery in cisgender women, cisgender men, and transgender men. Plast Reconstr Surg. 2019;144(2):334e-336e. 
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  • Azul D, Nygren U, Södersten M, Neuschaefer-Rube C. Transmasculine people's voice function: A review of the currently available evidence. J Voice. 2017;31(2):261.e9-261.e23.
  • Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: A systematic review. Ann Transl Med. 2021;9(7):607.
  • Bowman C, Goldberg J. Care of the Patient Undergoing Sex Reassignment Surgery. Vancouver, BC: Vancouver Coastal Health, Transcend Transgender Support & Education Society, and the Canadian Rainbow Health Coalition; January 2006. 
  • Buncamper ME, Honselaar JS, Bouman MB, et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12(7):1626-1634.
  • Byne W, Bradley SJ, Coleman E, et al.; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796.
  • Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45(3):369-380. 
  • Colebunders B, Brondeel S, D'Arpa S, et al. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5(1):103-109.
  • Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.  Int J Transgend. 2022; 23 sup1:S1-S259.
  • Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011.
  • Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232.
  • Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1). 
  • Djordjevic ML, Bizic MR, Duisin D, et al. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J Sex Med. 2016;13(6):1000-1007.
  • Eggerstedt M, Hong YS, Wakefield CJ, et al. Setbacks in forehead feminization cranioplasty: A systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749.
  • Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: Single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745.
  • Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.
  • Gorbea E, Gidumal S, Kozato A, et al. Insurance coverage of facial gender affirmation surgery: A review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. 2021;165(6):791-797.
  • Guan X, Bardawil E, Liu J, Kho R. Transvaginal natural orifice transluminal endoscopic surgery as a rescue for total vaginal hysterectomy. J Minim Invasive Gynecol. 2018;25(7):1135-1136.
  • Hembree et al. Endocrine Treatment of Transsexual Persons:  An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154.
  • Hohman MH, Teixeira J. Transgender surgery of the head and neck. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; February 27, 2022.
  • Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12(6):1499-1512.
  • Hu C-H, Chang C-J, Wang S-W, Chang K-V. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24.
  • Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med. 2018;15(6):902-906.
  • Jolly D, Wu CA, Boskey ER, et al. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294.
  • Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2016;106 (1):74-79.
  • Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145.
  • Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315.
  • Lee J, Nolan IT, Swanson M, et al. A review of hand feminization and masculinization techniques in gender affirming therapy. Aesthetic Plast Surg. 2021;45(2):589-601.
  • Lee YL, Hsu TF, Jiang LY, et al. Transvaginal natural orifice transluminal endoscopic surgery for female-to-male transgender men. J Minim Invasive Gynecol. 2019;26(1):135-142.
  • Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: Extensive personal experience. Endocr Pract. 2013;19(4):644-650.
  • Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833.
  • Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42(3):435-452.
  • Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open. 2019;21:63-74. 
  • Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: Systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770. 
  • Nakatsuka M. [Adolescents with gender identity disorder: Reconsideration of the age limits for endocrine treatment and surgery]. Seishin Shinkeigaku Zasshi. 2012;114(6):647-653.
  • Ngaage LM, Knighton BJ, McGlone KL, et al. Health insurance coverage of gender-affirming top surgery in the United States. Plast Reconstr Surg. 2019;144(4):824-833. 
  • Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 1: Breast/chest, face, and voice). Ann Surg. 2022;275(1):e52-e66.
  • Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 2: Genital reconstruction). Ann Surg. 2022;275(1):e67-e74.
  • Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431-436.
  • Patel H, Arruarana V, Yao L, et al. Effects of hormones and hormone therapy on breast tissue in transgender patients: A concise review. Endocrine. 2020;68(1):6-15.
  • Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: Patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448..
  • Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4).
  • Salgado CJ, Fein LA. Breast augmentation in transgender women and the lack of adherence amongst plastic surgeons to professional standards of care. J Plast Reconstr Aesthet Surg. 2015;68(10):1471-1472.
  • Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: A systematic review. Turk J Urol. 2017;43(3):229-236.
  • Schechter LS. Gender confirmation surgery: An update for the primary care provider. Transgender Health. 2016;1.1:32-40.
  • Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery. Aesthetic Plast Surg. 2018;42(2):491-497.
  • Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261.
  • Spack NP. Management of transgenderism. JAMA. 2013;309(5):478-484.
  • Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009;62(3):294-306; discussion 306-308.
  • Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg. 2022;92(3):373-378.
  • Tonseth KA, Bjark T, Kratz G, et al. Sex reassignment surgery in transsexuals. Tidsskr Nor Laegeforen. 2010;130(4):376-379.
  • Tugnet N, Goddard JC, Vickery RM, et al.  Current management of male-to-female gender identity disorder in the UK. Postgrad Med J. 2007;83(984):638-642.
  • UK National Health Service (NHS), Oxfordshire Primary Care Trust, South Central Priorities Committee. Treatments for gender dysphoria. Policy Statement 18c. Ref TV63. Oxford, UK: NHS; updated September 2009.
  • Van Damme S, Cosyns M, Deman S, et al. The effectiveness of pitch-raising surgery in male-to-female transsexuals: A systematic review. J Voice. 2017;31(2):244.e1-244.e5.
  • Wesp LM, Deutsch MB. Hormonal and surgical treatment options for transgender women and transfeminine spectrum persons. Psychiatr Clin North Am. 2017;40(1):99-111. 

Policy History

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Know Your Rights

Health care.

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Read Our Covid-19 Guides

See these resources for more information about your rights during COVID-19:

  • A Know Your Rights Guide for Transgender People Navigating COVID-19   (PDF)
  • Una guía para que las personas transgénero navegando la COVID-19 conozcan sus derechos   (PDF)

Know Your Rights in Health Care

Federal and state laws - and, in many cases, the U.S. Constitution - prohibit discrimination in health care and insurance because you're transgender. That means that health plans aren’t allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.

Updated October 2021 

What are my rights in insurance coverage?

Federal and state law prohibits most public and private health plans from discriminating against you because you are transgender. This means, with few exceptions, that it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.

Here are some examples of illegal discrimination in insurance:

  • Health plans can’t have automatic or categorical exclusions of transition-related care . For example, a health plan that says that all care related to gender transition is excluded violates the law.
  • Health plans can’t have a categorical exclusion of a specific transition-related procedure. Excluding from coverage specific medically necessary procedures that some transgender people need is discrimination. For example, a health plan should not categorically exclude all coverage for facial feminization surgery or impose arbitrary age limits that contradict medical standards of care.
  • An insurance company can’t place limits on coverage for transition-related care if those limits are discriminatory . For example, an insurance company can’t automatically exclude a specific type of procedure if it covers that procedure for non-transgender people. For example, if a plan covers breast reconstruction for cancer treatment, or hormones to treat post-menopause symptoms, it cannot exclude these procedures to treat gender dysphoria.
  • Refusing to enroll you in a plan, cancelling your coverage, or charging higher rates because of your transgender status : An insurance company can’t treat you differently, refuse to enroll you, or limit coverage for any services because you are transgender.
  • Denying coverage for care typically associated with one gender : It’s illegal for an insurance company to deny you coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth. For example, if a transgender woman’s health care provider decides she needs a prostate exam, an insurance company can’t deny it because she is listed as female in her records. If her provider recommends gynecological care, coverage can’t be denied simply because she was identified as male at birth.

What should I do to get coverage for transition-related care?

Check out NCTE’s Health Coverage Guide for more information on getting the care that you need covered by your health plan.

If you do not yet have health insurance, you can visit our friends at Out2Enroll to understand your options.

Does private health insurance cover transition-related care?

It is illegal for most private insurance plans to deny coverage for medically necessary transition-related care. Your private insurance plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. 

To understand how to get access to the care that you need under your private insurance plan, check out NCTE’s Health Coverage Guide .

Does Medicaid cover transition-related care?

It is illegal for Medicaid plans to deny coverage for medically necessary transition-related care. Your state Medicaid plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. Some states have specific guidelines on the steps you have to take to access care. You can check if your state has specific guidelines here .

To understand how to get access to the care that you need under your Medicaid plan, check out NCTE’s Navigating Insurance page.

My plan has an exclusion for transition-related care. What should I do?

There are many reasons why your plan might still have an exclusion for transition-related care in general or for a specific procedure. This does not mean that your plan will not cover your care. Sometimes plan documents are out of date, or you can ask for an exception by showing that this care is medically necessary for you.

If you get insurance through work or school, you can advocate with your employer to have the exclusion removed.

NCTE’s Health Coverage Guide has more information on how to access care and remove exclusions.

Does Medicare cover transition-related care?

It is illegal for Medicare to deny coverage for medically necessary transition-related care.

For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. Some local Medicare contractors have specific policies spelling out their coverage for transition-related care, as do some private Medicare Advantage plans.

To learn more about your rights on Medicare, check out NCTE’s Medicare page.

Does the Veterans Health Administration (VHA) provide transition-related care?

The Veterans Health Administration (VHA) provides coverage for some transition-related care for eligible veterans. However, VHA still has an arbitrary and medically baseless exclusion for coverage of transition-related surgery.  On June 19th, The US Department of Veterans Affairs announced that they will begin the process to expand health care services available to transgender veterans to include gender confirmation surgery. Currently, the Veterans Health Administration (VHA) provides care for thousands of transgender veterans, including some transition-related medical care. We expect the rule will finalize in approximately two years.

For more information FAQs by VHA are found here.

For more information about VHA and transition-related care, check out NCTE’s VAH Veterans Health Care page.

Does TRICARE cover transition-related care?

TRICARE provides coverage for some transition-related care for family members and dependents of military personnel. However, TRICARE still has an exclusion for coverage of transition-related surgery.

What are my rights in receiving health care?

Which health providers are prohibited from discriminating against me?

Under the Affordable Care Act, it is illegal for most health providers and organizations to discriminate against you because you are transgender. The following are examples of places and programs that may be covered by the law:

  • Physicians’ offices
  • Community health clinics
  • Drug rehabilitation programs
  • Rape crisis centers
  • Nursing homes and assisted living facilities
  • Health clinics in schools and universities
  • Medical residency programs
  • Home health providers
  • Veterans health centers
  • Health services in prison or detention facilities

What types of discrimination by health care providers are prohibited by law?

Examples of discriminatory treatment prohibited by federal law include (but are not limited to):

  • Refusing to admit or treat you because you are transgender
  • Forcing you to have intrusive and unnecessary examinations because you are transgender
  • Refusing to provide you services that they provide to other patients because you are transgender
  • Refuse to treat you according to your gender identity, including by providing you access to restrooms consistent with your gender
  • Refusing to respect your gender identity in making room assignments
  • Harassing you or refusing to respond to harassment by staff or other patients
  • Refusing to provide counseling, medical advocacy or referrals, or other support services because you are transgender
  • Isolating you or depriving you of human contact in a residential treatment facility, or limiting your participation in social or recreational activities offered to others
  • Requiring you to participate in “conversion therapy” for the purpose of changing your gender identity
  • Attempting to harass, coerce, intimidate, or interfere with your ability to exercise your health care rights

What are my rights related to privacy of my health information?

The Health Insurance Portability and Accountability Act (HIPAA) requires most health care providers and health insurance plans to protect your privacy when it comes to certain information about your health or medical history. Information about your transgender status, including your diagnosis, medical history, sex assigned at birth, or anatomy, may be protected health information. Such information should not be disclosed to anyone—including family, friends, and other patients—without your consent. This information should also not be disclosed to medical staff unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA.

What Can I Do If I Face Discrimination?

Seek preauthorization for care and appeal insurance denials

You shouldn’t be denied the care that you need just because you’re transgender. That's illegal.

To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.

Check our NCTE’s Health Coverage Guide for more information on how to get the care that you need covered.

Contact an attorney or legal organization

If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.

While NCTE does not take clients or provide legal services or referrals, there are many other groups that may give you referrals or maintain lists of local attorneys. You can try your local legal aid or legal services organization, or national or regional organizations such as the National Center for Lesbian Rights, Lambda Legal, the Transgender Law Center, the ACLU, and others listed  on our   Additional Resources page  and in the  Trans Legal Services Network .

File discrimination complaints with state and federal agencies

Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The U.S. Department of Health and Human Services has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint.  If you face any of ther kind of discrimination or denial of care based on your gender, disability, age, race, or national origin, or if your health care privacy was violated, you can still file a complaint with the   U.S. Department of Health and Human Services, Office for Civil Rights .

Here are some other places you can file health care complaints:

  • Private insurance: File a complaint with your state insurance department. You can find information about your state department here:  https://www.naic.org/state_web_map.htm .
  • Hospitals: File a complaint with the Joint Commission, which accredits most hospitals. You can find more information or submit a complaint online at  http://www.jointcommission.org .
  • Nursing home, board and care home, or assisted living facility: Contact your local long-term care ombudsman. You can locate an ombudsman here:  http://www.ltcombudsman.org/ombudsman .
  • HIPPA violations: file a complaint with the U.S. Department of Health and Human Services (HHS): https://www.hhs.gov/hipaa/filing-a-complaint/index.html
  • Federal Health Employee Benefits Program: File a complaint with the Office of Personnel Management ( [email protected] ) or the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
  • Veterans Health Administration: File a complaint with the Veterans Administration’s External Discrimination Complaints Program or contact a Patient Advocate at your VA Medical Center. Find out more here:  http://www.va.gov/orm/  and  http://www.va.gov/health/patientadvocate .
  • Employee health plan: File a complaint with the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
  • TRICARE (military health care): File a complaint with TRICARE ( http://tricare.mil/ContactUs/FileComplaint.aspx ).

Other state and local agencies: If you face discrimination, you may be able to file a complaint with your state’s human rights agency. You can find a list of state human rights agencies here:  http://www.justice.gov/crt/legalinfo/stateandlocal.php .

What Laws Protect Me?

Federal protections

  • The Health Care Rights Law, as part of the Affordable Care Act (ACA)  prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IX’s prohibitions on discrimination based on sex to include: 
  • Discrimination on the basis of sexual orientation.
  • Discrimination on the basis of gender identity.

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities.  The update was made in light of the U.S. Supreme Court’s decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at: https://www.hhs.gov/ocr/complaints

  • The Health Insurance Portability and Accountability Act (HIPAA)  protects patients’ privacy when it comes to certain health information, including information related to a person’s transgender status and transition. It also gives patients the right to access, inspect, and copy their protected health information held by hospitals, clinics, and health plans.
  • The Americans with Disabilities Act  prohibits discrimination in health care and other settings based on a disability, which may include a diagnosis of gender dyshoria.
  • Medicare and Medicaid regulations  protect the right of hospital patients to choose their own visitors and medical decision-makers regardless of their legal relationship to the patient. This means that hospitals cannot discriminate against LGBT people or their families in visitation and in recognizing a patient’s designated decision-maker.
  • The Joint Commission hospital accreditation standards  require hospitals to have internal policies prohibiting discrimination based on gender identity and sexual orientation.
  • The Nursing Home Reform Act  establishes a set of nursing home residents’ rights that include the right to privacy, including in visits from friends or loved ones; the right to be free from abuse, mistreatment, and neglect; the right to choose your physician; the right to dignity and self-determination; and the right to file grievances without retaliation.

State and local nondiscrimination laws  prohibit health care discrimination against transgender people in many circumstances.

A large number of states also have explicit policies that prohibit anti-transgender discrimination in private insurance and Medicaid, like exclusions of transition-related care.

  • California  private insurance ( PPO regulation ,  HMO general guidelines  and  HMO guidelines on surgery coverage ) and  Medicaid
  • Colorado   private insurance  and  Medicaid
  • Connecticut   private insurance  and  Medicaid
  • Delaware   private insurance
  • District of Columbia   private insurance  and  Medicaid
  • Hawaii   private insurance and Medicaid
  • Illinois  private insurance ( regulations and bulletin ) and Medicaid
  • Maine  private insurance and  Medicaid
  • Maryland   private insurance  and  Medicaid
  • Massachusetts   private insurance  and  Medicaid
  • Michigan   Medicaid
  • Minnesota   private insurance  and  Medicaid
  • Montana  private insurance  and  Medicaid
  • Nevada  private insurance  and  Medicaid
  • New Hampshire  private insurance  and  Medicaid
  • New   Jersey  private insurance and Medicaid
  • New Mexico  private insurance 
  • New York  private insurance ( coverage ,  code mismatches ,  updated policy ) and Medicaid ( general Medicaid policy ,  criteria for authorization of procedures )
  • Oregon  private insurance  and Medicaid ( general policy --refer to Guideline Note 127--and  facial feminization policy )
  • Pennsylvania  private insurance  and  Medicaid
  • Rhode   Island  private insurance  and  Medicaid
  • Vermont  private insurance  and  Medicaid
  • Virginia   private insurance
  • Washington   State  private insurance  and  Medicaid
  • Wisconsin   Medicaid
  • Puerto Rico   private insurance

Remember: Just because your state isn’t listed here doesn’t mean you’re not protected. Check out NCTE’s Health Coverage Guide for more information about getting coverage for the care that you need. 

How Can I Help?

  • Head to NCTE’s Health Action Center to see the latest on health care and how you can help fight for transgender people’s right to get the health care they need
  • Share your story. If you are facing discriminatory treatment, consider  sharing your story  with NCTE so we can use it in advocacy efforts to advance public understanding and policy change for transgender people. If you successfully resolved a health care situation, we want to hear about that as well.

Additional Resources

Government agencies.

Department of Health and Human Services Office for Civil Rights: http://www.hhs.gov/ocr/office/index.html

Links to State and Local Human Rights Agencies: http://www.justice.gov/crt/legalinfo/stateandlocal.php

HealthCare.Gov: https://www.healthcare.gov/transgender-health-care/

Partner resources, best practices and standards of care

Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, Lambda Legal, HRC, & New York Bar: http://www.lambdalegal.org/publications/fs_transgender-affirming-hospital-policies

Healthcare Equality Index, Human Rights Campaign http://www.hrc.org/campaigns/healthcare-equality-index

National Center for LGBT Health Education: http://www.lgbthealtheducation.org/

  • National LGBT Health Education Center’s  guide to best practices for front-line health care staff
  • National LGBT Health Education Center’s  guide to providing health care to non-binary people
  • National LGBT Health Education Center’s  guide to making health care forms LGBT-inclusive

National Resource Center on LGBT Aging: http://www.lgbtagingcenter.org

RAD Remedy’s  guide to providing competent care for trans people

Transgender Law Center’s  guide to organizing community clinics

Clinical standards of care for transgender people

  • WPATH Standards of Care
  • Endocrine Society Clinical Guideline
  • Center for Excellence for Transgender Health

Mental Health Resources

Trans LifeLine

National suicide prevention hotline

US: 877-565-8860Canada: 877-330-6366

https://www.translifeline.org/

National Alliance on Mental Illness (NAMI)

National network of mental health care providers, as well as a provider database

http://www.nami.org/Find­-Support/LGBTQ Help Line   800­-950-­6264

National Council for Behavioral Health

National network of community behavioral health centers, as well as a provider database

http://www.thenationalcouncil.org/

SAMHSA (Substance Abuse and Mental Health Services Administration)

A national database for local professionals and agencies that provide addiction recovery services and mental health care.

https://findtreatment.samhsa.gov/

800-662-HELP (4357)

Health provider resources

National Association of Free and Charitable Clinics (NAFC) Clinics around the United States that offer basic health care for those without insurance or experiencing homelessness. http://www.nafcclinics.org/

RAD Remedy Community­-sourced list of trans-­affirming healthcare providers https://www.radremedy.org/

Insurance resources

Resources to help transgender people select and enroll in insurance 

https://out2enroll.org

TransHealth Health and guidance for healthcare providers, as well as a list of trans­affirming health clinics in Canada, the United States, and England. http://www.trans-­health.com/

Transcend Legal Transcend Legal helps people get transgender-related health care covered under insurance. https://transcendlegal.org/

TransChance Health Helps transgender people navigate health care and insurance to receive respectful, high-quality care, and get transition-related care covered  

https://www.transchancehealth.org/

JustUs Health Leads the work to achieve health equity for diverse gender, sexual, and cultural communities in Minnesota, including the  Trans Aging Project  and a  Trans Health Insurance guide https://www.justushealth.mn

Transition-related financial support

Jim Collins Foundation Financial support for transition-related expenses for people without insurance or who have been excluded by insurance http://jimcollinsfoundation.org/apply/

Point of Pride Annual Transgender Surgery Fund Provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery https://pointofpride.org/annual-transgender-surgery-fund/

Community Kinship Life Surgery Scholarship Provides the trans community with assistance while having a sense of community and kinship http://cklife.org/scholarship/

Transformative Freedom Fund (Colorado) Supports the authentic selves of transgender Coloradans by removing financial barriers to transition related healthcare https://transformativefreedomfund.org/

Kentucky Health Justice Network Trans Health Advocacy Works to help Trans Kentuckians access the healthcare they need, as well as reaffirm our autonomy and community http://www.kentuckyhealthjusticenetwork.org/trans-health.html

Join Our Mailing List

The National Center for Transgender Equality and Transgender Legal Defense and Education Fund are merging. Learn more.

TLDEF's Trans Health Project

Gender affirmation surgery.

Policy: Gender Affirmation Surgery Policy Number: HUM-0518-020 Last Update: 2023-09-28

Please ctrl + F to find the correct document titled "gender affirmation surgery" and download the pdf.

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Updated on Nov 27, 2023

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Health Care

Colorado now requires gender-affirming care to be covered by private health insurance.

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Colorado now requires private health insurance plans to cover gender-affirming care for trans people like facial bone remodeling and hormone therapy. Health advocates say it's a very big deal.

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gender reassignment surgery and insurance

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Denying gender-affirming care coverage violates federal law, says appeals court

A federal appeals court has upheld a lower court’s ruling that the Houston County, Ga. , Sheriff’s Office violated antidiscrimination law by denying transition-related health care to a deputy.

Anna Lange sued in 2019 because she had been repeatedly denied insurance coverage for gender-affirming care under the county’s employee health plan. A U.S. district court in Georgia ruled in 2022 that the denial violated federal civil rights law, and Monday a three-judge panel of the U.S. Court of Appeals for the 11 Circuit affirmed that ruling.

It is only the second decision by a federal appellate court affirming that it is unlawful for an employer to discriminate against transgender people in an employee health plan, the first being a recent decision on North Carolina's plan for state employees. It is immediately binding on employers in Georgia, Florida, and Alabama, the states covered by the 11th Circuit, notes a press release from the Transgender Legal Defense and Education Fund, which is representing Lange along with a private law firm.

In his ruling for the 2-1 majority, Judge Charles Wilson cited the Supreme Court’s 2020 decision in Bostock v. Clayton County, in which the high court ruled that job discrimination based on sexual orientation and gender identity constitutes sex discrimination, banned by Title VII of the Civil Rights Act of 1964.

“Applying Bostock ’s reasoning to the facts in this case, we conclude that the district court was correct in finding that the Exclusion violated Title VII,” he wrote. “There is no genuine dispute of fact or law as to whether the Exclusion unlawfully discriminates against Lange and other transgender persons. The Exclusion is a blanket denial of coverage for gender-affirming surgery. Health Plan participants who are transgender are the only participants who would seek gender-affirming surgery. Because transgender persons are the only plan participants who qualify for gender-affirming surgery, the plan denies health care coverage based on transgender status.”

“Today’s victory is a win not just for me, but for all transgender Southerners who deserve equal access to life-saving transition-related care,” Lange said in the TLDEF press release. “I have proudly served my community for decades and it has been deeply painful to have the county fight tooth and nail, redirecting valuable resources toward denying me basic health care — health care that the courts and a jury of my peers have already agreed I deserve. I’m pleased to see that yet another court has deemed those efforts to be unfair and illegal.”

Lange has spent 26 years in law enforcement, 17 of them with Houston County. She came out as trans in 2017.

“Today, the 11th Circuit upheld the well-reasoned ruling of the U.S. District Court that treating Sgt. Anna Lange differently because she is transgender is discriminatory,” TLDEF Co-Interim Legal Director Gabriel Arkles said in the release “Houston County and Sheriff [Cullen] Talton have once again lost in court, after spending some $2 million on lawyers to try to deprive Sgt. Lange of medically necessary care that costs orders of magnitude less solely to discriminate against transgender people.”

“We are pleased that the 11th Circuit Court came to the same conclusion as the lower courts that denying health care coverage to transgender individuals is wrong and illegal, and affirmed the lower court ruling in Sgt. Lange’s favor,” added Wesley Powell, partner at Willkie Farr & Gallagher LLP, who serves as co-counsel.

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Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

gender reassignment surgery and insurance

The 14th Amendment to the Constitution is truly a magical amendment. It was used to justify attempts to kick Donald Trump off the 2024 ballot. Through the decades, judges who want to play at social engineering have used it frequently to justify questionable law. 

It's even been invoked to bypass Congress to raise the debt limit.

Now, the Fourth Circuit Court of Appeals has decided that the amendment's "equal protection" clause means that state Medicaid programs have to cover gender reassignment surgeries.

The appeals court ruled that West Virginia's Medicaid rules on mastectomies are unconstitutional because they violate the "equal protection standard" by not covering mastectomies for gender dysphoria.

Yes, really.

The ruling also includes a North Carolina Medicaid case that the state government won't cover "sex changes." The Fourth Circuit nullified the state ban on gender change surgeries, citing the 14th Amendment’s guarantee of “equal protection of the laws.”

This was a court looking for an excuse to make law.

Judge Roger Gregory who wrote the majority opinion in Kadel v. Folwell (8-6) asked, “Is removing a patient’s breasts to treat cancer the same procedure as removing a patient’s breasts to treat gender dysphoria?” He continued, “There is no case law to ground this discussion nor obvious first principles.”

Wall Street Journal:

He is undeterred, and he concludes that gender dysphoria and transgender status are intertwined, so that such insurance exclusions are nothing more than a proxy for discriminating against gender identity. Then he goes further, finding that West Virginia’s and North Carolina’s policies also unconstitutionally discriminate based on sex. How so? Imagine, Judge Gregory says, an unidentified patient seeking a vaginoplasty. Is this a biological female with a rare birth defect? Is it a transgender patient? “By virtue of the fact that they are seeking a vaginoplasty, we know that they were born without a vagina,” he writes. “But we do not know what sex they were assigned at birth. Without that information, we cannot say whether the Plan or Program will cover the surgery.” Ergo, sex discrimination.

Gregory gets even nuttier.

The differences in coverage "is rooted in a gender stereotype: the assumption that people who have been assigned female at birth are supposed to have breasts, and that people assigned male at birth are not."

It's not a "gender stereotype." It's a biological fact. 

"No doubt, the majority of those assigned female at birth have breasts, and the majority of those assigned male at birth do not. But we cannot mistake what is for what must be.”

Not just a "majority." It's a universal biological fact with a tiny number of exceptions.

Treating different things differently doesn’t violate the 14th Amendment’s Equal Protection Clause, and jurists aren’t supposed to ignore the obvious. Writing in dissent at the Fourth Circuit, Judge Julius Richardson struggles to contain his exasperation. “The states,” he says, “have chosen to cover alterations of a person’s breasts or genitalia only if the person experiences physical injury, disease, or (in West Virginia) congenital absence of genitalia.” That determination does not turn on the patient’s sex or gender. “Christopher Fain—one of the plaintiffs below—received coverage for a hysterectomy based on a diagnosis unrelated to Fain’s transgender status,” the dissent says. Likewise, males with gynecomastia qualify for surgery coverage in West Virginia only “if they have physical symptoms, like breast pain,” meaning that isn’t a procedure done merely “to affirm a patient’s biological sex.”

The ruling that opened this can of worms was Bostock v. Clayton County, a case that "held that Title VII of the Civil Rights Act of 1964 protects employees against discrimination because of  sexuality or gender identity." Now, as a dissenting judge in Kadel v. Folwell,  Judge J. Harvie Wilkinson III is saying that this ruling could be a Roe v Wade  ruling for the transgender community.

“This is imperial judging at its least defensible,” he says, “What plaintiffs propose is nothing less than to use the Constitution to establish a nationwide mandate that States pay for emerging gender dysphoria treatments.”

He's not wrong. But getting the ruling past this Supreme Court would be a stretch. 

Rick Moran

Rick Moran has been writing for PJ Media for 18 years. His work has appeared in dozens of media outlets including the Washington Times  and ABC News. He was an editor at American Thinker for 14 years. His own blog is Right Wing Nut House . For media inquiries, please contact [email protected] .

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Federal appeals court finds Houston County Sheriff's Office discriminated against transgender employee

In 2022, a court found the sheriff's office policy denying coverage for gender-affirming care was discriminatory.

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ATLANTA — A panel of appeals court judges have found the Houston County Sheriff's Office discriminated against a transgender employee in its health insurance plan, the 11th Circuit Court of Appeals ruled on Monday .

They found that Anna Lange, a transgender employee for the sheriff's office, was discriminated against since they denied her coverage for "medically necessary" gender affirmation surgery solely because she was transgender. 

"By drawing a line between gender-affirming surgery and other operations, the plan intentionally carves out an exclusion based on one's transgender status," the federal appeals court found. "Lange's sex is inextricably tied to the denial of coverage for gender-affirming coverage."

Lange had previously  been awarded $60,000 in damages by the U.S. Middle District of Georgia in 2022 , but the sheriff's office then appealed to the 11th Circuit Court of Appeals. 

Lange has worked for the sheriff's office since 2006. However, when Lange transitioned in 2017, she encountered problems with the county's insurance.

Her doctors recommended "medically necessary" gender reassignment surgery, but the sheriff's office health insurance policy stated that "services and supplies for a sex change and/or reversal of a sex change" and "drugs for sex change surgery" were not covered.

According to the U.S. Department of Justice, Lange had previously paid out of pocket for hormone replacement therapy and chest surgery because she knew it wouldn't be covered under the county's insurance policy.

While Lange put off gender reassignment surgery — which would have cost $20,000 — her endocrinologist, two psychologists and a surgeon recommended the procedure. So, she sought out the surgery and requested the county's health insurance cover it.

The county's health insurance provider, BlueCross BlueShield, originally approved the surgery since it was "medically necessary" under the insurance company's guidance, according to the DOJ. But, once the county pointed out the provision in their policy, they denied coverage for Lange. 

In the federal appeals court's decision, they found the Houston County Sheriff's Office policy was "facially discriminatory" since it treated coverage for transgender issues differently from other medically necessary treatment. 

In the DOJ's filing in the 11th Circuit Court of Appeals, they note the county's health care provider, Anthem Blue Cross Blue Shield, had previously recommended the county remove the exclusion, but that the county rejected their recommendation.

The Department of Justice  joined the case against the Houston County Sheriff's Office as an "amicus curiae," or friend of the court, since they had a vested interest in the proper enforcement of federal anti-discrimination laws. 

In the DOJ's filings, they say many procedures used as part of gender-affirming care are covered in other medically necessary contexts, like hormone replacement therapy for menopause. 

"Thus, given the 'undisputed' fact that the challenged provisions of the plan deny coverage 'only for transgender members,' the court held that the plan facially discriminates based on sex," the DOJ wrote.

The 11th Circuit Court of Appeals agreed, upholding the previous court's decision and finding Houston County cannot enforce its ban on covering gender-affirming care.

"Because transgender persons are the only plan participants who qualify for gender-affirming surgery, the plan denies health care coverage based on transgender status," the federal appeals court ruled.

Lange's lawyer has previously said that the county has spend over a million dollars fighting this case. Right now, it is unclear whether or not the county will appeal the 11th Circuit Court of Appeal's decision to the U.S. Supreme Court — or whether the high court would hear the case. 

Related Articles

  • 'It is life affirming surgery and treatment': Houston County activists protest $1.25 million lawsuit appeal
  • U.S. Justice Department asks to join case against Houston County Sheriff over covering transgender deputy surgery
  • Houston County is appealing a ruling requiring it to pay for a transgender deputy's surgery

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Appeals court upholds ruling: Georgia county must cover deputy's gender-affirming surgery

by The Associated Press

Anna Lange, a sheriff's sergeant in Houston County, Ga., poses for a picture, Nov. 14, 2023. (AP Photo/Jeff Amy, file)

ATLANTA (AP) — A federal appeals court has upheld a lower court's ruling that a Georgia county illegally discriminated against a sheriff's deputy by failing to pay for her gender-affirming surgery .

In its ruling Monday, the 11th U.S. Circuit Court of Appeals said it was tasked with determining whether a health insurance provider can be held liable under the Civil Rights Act of 1964 for denying coverage for a procedure because an employee is transgender. The three-judge panel decided in a 2-1 vote that it can and that the lower court had ruled correctly.

Houston County Sgt. Anna Lange, an investigator for the Houston County sheriff's office, had sued Sheriff Cullen Talton and the county in 2019 after she was denied coverage.

“I have proudly served my community for decades and it has been deeply painful to have the county fight tooth and nail, redirecting valuable resources toward denying me basic health care – health care that the courts and a jury of my peers have already agreed I deserve," Lange said in a news release from the Transgender Legal Defense and Education Fund, which represented her.

A woman who answered the phone at the sheriff’s office Tuesday said she would pass along a message seeking comment.

U.S. District Court Judge Marc Treadwell ruled in 2022 that the county’s refusal to cover Lange’s prescribed gender-affirmation surgery amounted to illegal sex discrimination under the Civil Rights Act of 1964. Treadwell’s order cited the U.S. Supreme Court’s 2020 decision finding that a Michigan funeral home could not fire an employee for being transgender.

The judge ordered the county’s insurance plan to pay for the surgery and Lange eventually underwent the procedure. A jury awarded Lange $60,000 in damages in 2022.

The county sought to undo Treadwell's order and the damage award.

Title VII of the Civil Rights Act of 1964 says an employer cannot "discriminate against any individual with respect to his (or her) compensation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin.”

The 11th Circuit opinion says the Supreme Court clarified in another Georgia case that discrimination based on the fact that someone is transgender “necessarily entails discrimination based on sex.”

gender reassignment surgery and insurance

gender reassignment surgery and insurance

South Carolina wraps up 2024 legislative session. Here are six key takeaways

T he South Carolina legislature concluded the 2024 session last week. Some widely discussed bills passed through both chambers by the May 9 deadline while several others failed. At least one is in limbo before it can reach Gov. Henry McMaster’s desk.  

McMaster signed the permitless “constitutional” firearm carry bill into law on March 7, and the “Help Not Harm” bill banning medical care for transgender youth is headed to the governor’s desk after the House approved Senate amendments to the bill.   

Senate Bill 1046, the “judicial reform” measure could become law if a joint conference committee approves it in the coming months, while medical marijuana and an insurance bill related to liquor liability failed to make it that far.  

Here are six takeaways from the state General Assembly’s 2024 session.  

Permitless “constitutional” firearm carry  

McMaster signed H.3594, making permitless firearm carry legal for those 18 and older legally allowed to carry a gun. The new law, dubbed “constitutional carry,” bounced between both chambers of the General Assembly before the finalized version was signed into law. 

Days earlier, a joint committee of the House and Senate ultimately decided on the final version of the bill on the morning of March 5. The House approved the committee’s report later that afternoon, and the Senate approved the bill the next day.  

The law allows anyone 18 and older, legally eligible to carry a firearm, to do so, openly or concealed, without the need for a permit or registration. It further loosened firearm restrictions after the 2021  Open Carry law  allowed a concealed weapons permit (CWP) holder to openly carry handguns.  

While CWPs are no longer required under the new permitless carry law, they can still have reciprocity for concealed carry in other states .  

With the new law, South Carolina became the 29 th state to legalize permitless carry.  

Medical care for transgender youth banned  

A House bill outlawing medical care for transgender youth is headed to McMaster to sign into law. On Thursday, the last day of the legislative session, the House agreed to accept the Senate’s amendments to the law.  

The bill eliminates puberty-blocking drugs, hormone therapy, and gender-reassignment surgery for those under 18. The bill does make exceptions for people being treated with hormone therapy or puberty blockers that have conditions like precocious puberty or endometriosis. 

The Senate's most significant change was an amendment requiring public school principals and vice principals to inform parents if a student reported identifying as a different gender from their assigned sex or using different pronouns.  

Opponents of the provision said it was a forced outing and could be dangerous for a child. 

Supporters of the bill argued that parents have a right to know if their child is identifying as transgender and said the bill’s goal is to protect children.  

If signed into law by the governor, South Carolina would join 25 other states outlawing medical care for transgender youth, according to Human Rights Campaign.  

'Judicial reform' bill could become law 

The future of S.1046, a bill that would revise the commission that selects judges in the state, remains in limbo as it was referred to a joint conference committee before the legislative session adjourned.  

South Carolina and Virginia are the only two states where the legislature appoints judges. Once a judicial merit selection commission screens and approves candidates, they are voted on by the legislature.   

However, the two chambers were not able to reconcile their respective versions of the bill, so it is headed to a joint conference committee consisting of three members of the House and three members of the Senate. 

Judges appointed by the commission serve six-year terms, except for Supreme Court appointees who serve 10-year terms. The bill looks to establish non-successive terms for commission members. This would, in theory, limit judges from repeatedly appearing before the same lawyer-legislators on the commission. 

Currently, the 10-member panel has five Senate appointees and five House appointees. Of those appointees, three are from the Senate and three are from the House. All are practicing attorneys. Each chamber also appoints two members of the general public.

In the conference committee, if two of the three legislators from each body approve a version of the bill, there will still be an opportunity for the Senate and House to agree on the conference report. If they do agree, it will proceed to the governor’s desk. 

Rep. Leon Stavrinakis, D-Charleston, is one of the three House members appointed to the committee. Although the legislature adjourned this year’s session “sine die” at 5 p.m. Thursday, Stavrinakis told the Greenville News that if the conference committee comes to an agreed-upon version, both chambers have several opportunities to approve the bill before the end of June. 

Insurance bill related to liquor liability fails

House Bill 5066, which would regulate insurance companies and premiums, was one measure that did not reach the conference committee stage. It passed the House in late March but died in committee in the Senate.  

Stavrinakis, a co-sponsor of the bill, said it was intended to prevent “blatant” price gouging by insurance companies, especially among bars and restaurants that serve alcohol. He said that some insurance companies charge the businesses “exorbitant” premiums. Some entertainment venues have spoken out against the rising costs of coverage, which has caused some Upstate drinking establishments to shutter.  

“The essence of the bill was to create a system that rates risk like we do for automobiles, homes, every other kind of insurance,” Stavrinakis said. “If you think about your automobile policy, people who get in accidents and get tickets pay more money than people that don't. Homeowners claim the same thing, people who make claims pay more money than people who don't.” 

Rep. Jason Elliot, R-Greenville, the lead sponsor of the bill, said he hopes the bill can "start over" next legislative session.

"It's a real issue. It's one that's affecting the economic viability of businesses, and it affects jobs," Elliott said.

Medical marijuana killed for a second year in a row  

In February, South Carolina’s Senate passed a bill to allow marijuana for medical use 24-19. However, the bill died in a House committee. 

Last year, the bill was killed due to a technicality over where the measure must start because it would generate revenue.

Sen. Tom Davis, a Republican representing Beaufort County, has pushed the bill for almost a decade, adamant that it would not be for recreational use.

 ‘Health czar’ bill squashed

A bill that would have dissolved several departments and combined them into one agency was killed by the South Carolina’s Freedom Caucus in the last minutes of the legislative session.  

The bill, introduced in the Senate earlier this year, would have created an Executive Office of Health and Policy by combining the newly created Department of Public Health with five departments.  

Last year, South Carolina passed a bill dividing the South Carolina Department of Health and Environment Control (DHEC) into two separate agencies. Effective in July, the two new agencies will be the South Carolina Department of Environmental Services (SCDES) and South Carolina Public Health (DPH.)  

The Executive Office of Health Policy bill would have eliminated the Department of Alcohol and Other Drug Abuse Services, Department of Disabilities and Special Needs, Department of Health and Human Services, Department of Mental Health, and Department of Aging and combined them in the Department of Health.  

It passed the Senate and made its way out of a House committee but did not pass the House at the last minute. Critics of the bill dubbed the bill the “Health Czar bill.” 

“We need medical freedom bills, not more Fauci’s,” said Rep. Adam Morgan, the Republican chairman of the South Carolina Freedom Caucus, on X, formerly Twitter, Thursday night. Morgan, also a candidate for the 4th District Congressional seat, was referring to Anthony Fauci, the nation's former chief medical advisor to the president.  

This article originally appeared on Herald-Journal: South Carolina wraps up 2024 legislative session. Here are six key takeaways

The South Carolina statehouse, where Gov Henry McMaster delivered his "last call" executive order speech during a COVID press conference at the State House in Columbia, S.C. Friday, July 10, 2020. Beginning Saturday, July 11, 2020, South Carolina's 8,000 restaurants, bars, breweries and other establishments will be ordered to stop serving alcohol nightly at 11 p.m., Gov. Henry McMaster said at the press conference.

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Court upholds ruling in Georgia transgender health care case

The 11th U.S. Circuit Court of Appeals has upheld a ruling that a Georgia county illegally discriminated against a sheriff's deputy by not covering her gender-affirming surgery, the Associated Press reports. The court decided that a health insurance provider can be held liable under the Civil Rights Act of 1964 for denying coverage due to an employee's transgender status. The deputy, Sgt. Anna Lange, was awarded $60,000 in damages in 2022, and the county's insurance plan was ordered to pay for her surgery.

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  5. Things that you need to Know about gender reassignment surgery

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  6. Understanding Medicare Coverage for Gender Reassignment Surgery

    gender reassignment surgery and insurance

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  1. Insurance companies that cover gender affirmation surgery

    Scenario 1: The insurance plan covers the surgery. If people have a health insurance plan that covers gender affirmation surgery, people will need to take steps to ensure they meet certain ...

  2. Insurance for Gender Affirmation or Confirmation Surgery

    Medicare. Medicare is federal health insurance for people 65 or older and some younger people with disabilities. Original Medicare (Part A and Part B) will cover gender-affirmation surgery when it is considered medically necessary. Prior to 2014, no coverage was offered.

  3. Transgender health care coverage

    Plans with transgender exclusions. Many health plans are still using exclusions such as "services related to sex change" or "sex reassignment surgery" to deny coverage to transgender people for certain health care services. Coverage varies by state. Before you enroll in a plan, you should always look at the complete terms of coverage ...

  4. Does Insurance Cover Gender-Affirming Care?

    Key Takeaways. Health insurance generally covers gender-affirming care. Not all plans cover all procedures, or the process can be murky and require preauthorization and appeals. Gender-affirming ...

  5. Health insurance Medical Policies

    Gender Dysphoria / Gender Reassignment. Virtually all major insurance companies recognize that transgender-related medical care is medically necessary and have a written policy describing their criteria for when plans they administer will cover it. Below is a list of such policies. The fact that an insurance company is listed below does not ...

  6. Gender-Affirming Surgery

    Insurance Coverage for Gender-Affirming Surgery Medically reviewed by Paul Gonzales on March 13, 2024. Navigating insurance coverage for gender affirmation surgery can be complex, but many insurance providers now recognize these forms of healthcare for transgender individuals as medically necessary and thereby deserving of coverage. This guide aims to simplify the process of finding and ...

  7. Gender Confirmation Surgery

    The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed. A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019. Insurance Coverage for Sex Reassignment Surgery.

  8. Find a Surgeon for Gender-Affirming Care

    Dr. Jens Berli. Dr. Jens Berli is a board-certified plastic and reconstructive surgeon in Portland, Oregon who specializes in Gender Affirming Surgery. He joined the Transgender Health Program at Oregon Health & Science University (OHSU) in 2016. Dr. Berli is an Assistant Professor of Surgery in the Division of Plastic and Reconstructive ...

  9. Navigating Insurance Policies in the United States for Gende ...

    Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Most insurance companies, 122 of 124 (98%), covered chest masculinization, but only 25 of 124 (20%) of insurance companies covered nipple-areola complex reconstruction. ... Weiss P, Schechter L. Coding for sex-reassignment surgery is evolving. Plast Surg ...

  10. Aetna Agrees to Expand Coverage for Gender-Affirming Surgeries

    Sarah Huny Young for The New York Times. Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance ...

  11. Preparing for Transgender Surgery

    Preparing for Transgender Surgery. We understand that the decision to have gender-affirming surgery is life changing. Our transgender healthcare team provides support and education to help you and your loved ones know what to expect throughout the gender-affirming surgery process. As your surgical date approaches, we schedule one-on-one ...

  12. Find a Surgeon for Gender Affirming Surgery

    The Crane Center for Transgender Surgery has announced the launch of a gender-affirming hormone clinic at their transgender wellness center in Austin, Texas. The new clinic offers hormone replacement therapy for transgender and non-binary adults through an informed consent model. Both in-office and telemedicine appointments are available.

  13. Does Medicare cover gender reassignment surgery?

    Medicare pays for gender reassignment surgeries and hormone replacement therapy, as long as the surgery is deemed medically necessary. There are several surgeries a person needs to finish the process.

  14. How To Afford Transgender Surgery Expenses

    Bottom surgeries, such as vaginoplasty or phalloplasty, can cost $25,600 and $24,900, respectively, according to estimates from The Philadelphia Center for Transgender Surgery. Additional ...

  15. Does Health Insurance Cover Transgender Health Care?

    While Section 1557 was initially a big step towards equality in health care for transgender Americans, it does not explicitly require coverage for sex reassignment surgery and related medical care. And the implementation of Section 1557 has been a convoluted process with various changes along the way. Most recently, the Biden administration has ...

  16. Gender Affirming Surgery

    In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck. State policies on transgender care for Medicaid insurance providers were collected for all 50 states. ... Tonseth KA, Bjark T, Kratz G, et al. Sex reassignment ...

  17. Health Care

    Federal protections. The Health Care Rights Law, as part of the Affordable Care Act (ACA) prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability.Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care ...

  18. Humana

    Trans Health Insurance Tutorial. Choosing a Plan; Understanding Your Plan; Applying for Coverage; ... Prev Index Gender Dysphoria/Reassignment [100 of 163] Next. Humana Gender Affirmation Surgery. Policy: Gender Affirmation Surgery Policy Number: HUM-0518-020 Last Update: 2023-09-28 ...

  19. Gender-affirming surgery

    Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals.

  20. Colorado now requires gender-affirming care to be covered by ...

    Colorado now requires private health insurance plans to cover gender-affirming care for trans people like facial bone remodeling and hormone therapy. Health advocates say it's a very big deal.

  21. Denying gender-affirming care coverage violates federal law, says

    Anna Lange sued in 2019 because she had been repeatedly denied insurance coverage for gender-affirming care under the county's employee health plan. A U.S. district court in Georgia ruled in ...

  22. Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

    Now, the Fourth Circuit Court of Appeals has decided that the amendment's "equal protection" clause means that state Medicaid programs have to cover gender reassignment surgeries. The appeals ...

  23. Appeals court upholds ruling requiring Georgia county to pay for a

    The judge ordered the county's insurance plan to pay for the surgery and Lange eventually underwent the procedure. A jury awarded Lange $60,000 in damages in 2022. The county sought to undo ...

  24. Houston Co. insurance plan discriminates against trans employee

    Her doctors recommended "medically necessary" gender reassignment surgery, but the sheriff's office health insurance policy stated that "services and supplies for a sex change and/or reversal of a ...

  25. Section 3701-59-06

    Section 3701-59-06 - Hospital quality standards for gender reassignment surgery and genital gender reassigment surgery for minors (A) As used in this rule: (1) "Biological sex," "Birth sex," and "sex" mean the biological indication of male and female, including sex chromosomes, naturally occurring sex hormones, gonads, and nonambiguous internal and external genitalia present at birth, without ...

  26. Gender Doctor Calls Genital Surgery An 'Adventure' For Young People

    The sex reassignment surgical industry is projected by some financial analysts to become a $5 billion industry by 2030. This rapid growth of the sex change surgery industry hinges upon insurance coverage, a topic Laungani addressed during his talk. "So something that alters the appearance just for cosmetic purposes versus having a function.

  27. Appeals court upholds ruling: Georgia county must cover deputy's gender

    The judge ordered the county's insurance plan to pay for the surgery and Lange eventually underwent the procedure. A jury awarded Lange $60,000 in damages in 2022. The county sought to undo ...

  28. South Carolina wraps up 2024 legislative session. Here are six key

    The bill eliminates puberty-blocking drugs, hormone therapy, and gender-reassignment surgery for those under 18. The bill does make exceptions for people being treated with hormone therapy or ...

  29. Section 3701-83-60

    Section 3701-83-60 - Health care facility quality standards for gender reassignment surgery and genital gender reassignment surgery for minors (A) As used in this rule: (1) "Biological sex," "birth sex," and "sex" mean the biological indication of male and female, including sex chromosomes, naturally occurring sex hormones, gonads, and nonambiguous internal and external genitalia present at ...

  30. Court upholds ruling in Georgia transgender health care case

    The deputy, Sgt. Anna Lange, was awarded $60,000 in damages in 2022, and the county's insurance plan was ordered to pay for her surgery. Login Subscribe For Free