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Transgender health care

A transgender person’s assigned sex at birth doesn’t match their gender identity, expression, or behavior.

Refer to glossary for more details.

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Sex-specific preventive services.

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

Plans with transgender exclusions

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

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Know Your Rights

Health care.

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

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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.

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Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population

Kellan baker.

1: WHITMAN-WALKER INSTITUTE, WASHINGTON, DC, USA

2: JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH, BALTIMORE, MD, USA

Arjee Restar

3: CENTER FOR APPLIED TRANSGENDER STUDIES, CHICAGO, IL, USA

4: UNIVERSITY OF WASHINGTON, SEATTLE, WA, USA.

Associated Data

For supplementary material accompanying this paper visit https://doi.org/10.1017/jme.2022.87.

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services.

Introduction

Transgender people have a gender identity that is different from the sex they were assigned at birth, and many seek multiple ways to access and attain gender affirmation across their lifetime. 1 Gender affirmation refers to the multifaceted ways in which one may attain recognition of their gender socially (by publicly expressing their gender), psychologically (by rejecting internalized transphobia), legally (by correcting their gender marker and name on identification documents and records), and medically (by pursuing medical interventions like hormones or surgery). 2 Gender affirmation is a non-linear, non-prescriptive pathway that is tailored to individual goals and affirmation needs, and it has been linked to multiple positive health outcomes such as better quality of life; 3 lower rates of mental health conditions such as depression, anxiety, and psychological distress; 4 decrease in or elimination of distress associated with gender dysphoria; and mitigation of stigma. 5

In the context of medical interventions, the Standards of Care for Transgender and Gender Diverse People maintained by the World Professional Association for Transgender Health (WPATH) have established categories of health services and procedures that are recognized as gender-affirming medical care. These services include psychological support, hormone therapy, and reconstructive surgeries. 6 Hormone therapy typically involves estrogens and anti-androgens for transgender women and other transfeminine people and testosterone for transgender men and other transmasculine people. Surgeries that may be part of gender affirmation for transgender people include genital surgeries, such as phalloplasty or vaginoplasty; gonadectomy; chest surgeries, including mastectomy or mammoplasty; and facial surgeries, particularly for transgender women.

There are multiple structural and economic barriers that transgender people face when seeking gender-affirming medical services and procedures. Compared to the general US population, transgender people are more likely to be uninsured (14% vs. 11%), unemployed (15% vs. 5%), and living in poverty (29% vs. 12%). 7 Even for people with insurance, reports of insurance denials are common, 8 and many people report that deductibles and other out-of-pocket costs like copays and coinsurance for hormones and surgeries are a major economic barrier to pursuing gender-affirmation care. 9 One study using Centers for Medicare and Medicaid Services prescription drug plan formulary files found that out-of-pocket costs for gender-affirming hormone therapy can be substantial, ranging between $84 to $2,716 in 2010 and from $72 to $3,792 in 2018. 10 Moreover, insurers often require proof of referral letters for hormone initiation as well as surgical procedures from mental health professionals, which can also serve as a limiting factor given the inadequate workforce capacity of gender-affirming therapists, counselors, social workers, primary care providers, and surgeons, particularly in geographical areas that are prone to insurance network inadequacy issues and policy restrictions in the US. 11

The objective of the present study was to investigate temporal trends in coding, utilization, and costs of gender-affirming hormone therapy and surgeries using a proprietary commercial insurance claims database that captures all encounters for enrolled beneficiaries.

As a step to providing coverage of gender-affirming care, one imperfect approach has been to characterize a need for gender-affirming care using diagnoses such as gender dysphoria, which replaced gender identity disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 12 This change, like the revision to the International Classification of Diseases , 11th Revision (ICD-11) to create a new diagnosis of gender incongruence (codes: HA60, HA61, HA6Z), clarifies that the target of gender-affirming medical interventions is not the person’s gender identity itself but rather the clinically significant distress that can accompany a lack of alignment between gender identity and sex assigned at birth. 13

Over the last decade, interest among insurance carriers, regulators, and medical coders about trends in gender-affirming care has grown as nondiscrimination laws and private employer practices have evolved toward ensuring coverage for and broadening the availability of these services. 14 Because no national health survey consistently asks questions about gender identity, efforts to track trends and measure the effects of coverage changes have focused on alternative sources of data, such as insurance claims. 15 The objective of the present study was to investigate temporal trends in coding, utilization, and costs of gender-affirming hormone therapy and surgeries using a proprietary commercial insurance claims database that captures all encounters for enrolled beneficiaries. We anticipated that transgender people in this database would be identified in all geographic regions and that claims for hormone therapy and gender-affirming surgeries would come from diverse clinical specialties and would increase over time, particularly in the period after 2010, when the Affordable Care Act (ACA) made private health insurance broadly more accessible and both public and private payers began to remove coverage exclusions of gender-affirming care. 16 We also expected that the age at which transgender people were first identified in the database would drop over time in parallel with general U.S. population trends, which have shown increasing numbers of people identifying as transgender at younger ages. 17 Finally, we anticipated that the system-wide costs of gender-affirming care would increase over time as insurance coverage of these services became more common, but that the impact of covering gender-affirming care on payers’ budgets would be small.

We accessed the OptumLabs Data Warehouse (OLDW), which contains insurance claims data for more than 200 million people covered by commercial and Medicare Advantage plans. The OLDW Unified View provides nationwide de-identified physician, facility, and pharmacy claims, as well as person-level enrollment and demographic information. Claims include ICD-9 and ICD-10 diagnostic codes (up to five codes for physician claims and up to nine codes plus any admitting diagnosis, if present, for facility claims), Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, health plan and patient paid amounts, type of facility, provider type, and an internal provider identification number. OLDW is a closed system that captures complete records of health service utilization during periods of enrollment. Claims data are refreshed monthly and are accessible for research after a six-month lag. The demographic information in the Unified View is year of birth, recorded sex, census region, and race/ethnicity. Race/ethnicity is imputed through a proprietary process by a third party and provided to OLDW for use in analyses. Most fields are 100 percent populated, with the exception of imputed race/ethnicity, which is approximately 70 percent complete. Individuals receive a unique identifier and can be followed over time whenever they are enrolled in coverage.

Study Population

Using an approach developed by researchers at the Veterans Administration (VA) and elsewhere, 18 we identified transgender people by searching OLDW for transgender-specific diagnostic codes in all physician and facility claims of people with simultaneous commercial medical and pharmacy coverage. Medicare Advantage enrollees were not included. Before the U.S. conversion to ICD-10 in mid-2015, we searched for the following ICD-9 codes in any diagnosis position: transsexualism (302.5x), gender identity disorder in children (302.6), and gender identity disorder in adolescents and adults (302.85). In 2015 and later, we added the following ICD-10 codes in any position: transsexualism (F64.0); gender identity disorder in adolescence or adulthood (F64.1); gender identity disorder in childhood (F64.2); other gender identity disorders (F64.8); gender identity disorder, unspecified (F64.9); and personal history of sex reassignment (Z87.890). 19 To improve specificity, we required two instances of at least one code separated by 30 days in the claims history. 20 The first appearance of any transgender-specific diagnosis code in a person’s claims history was designated as their index date of diagnosis, which was used to assess trends in the age at which people received their first transgender-specific code in the OLDW database. Research indicates that a child’s sense of gender identity typically develops around the age of three, so we excluded children who were younger than three on their index date. 21

To assess trends in prescribing patterns, we extracted the transgender-specific diagnostic codes assigned on each person’s index date, along with the demographic variables of year of birth, race/ethnicity, region, and recorded sex. We categorized age in 2021 as 4-17, 18-29, 30-39, 40-49, 50-59, 60-69, and 70+; race/ethnicity as white, Black, Asian, Hispanic, or unknown; and location by census region (Northeast, South, Midwest, West). Recorded sex was either male or female; OLDW contains very few instances of sex being recorded as “unknown,” so we dropped those rare cases. It was impossible to know whether this variable referred to gender identity or to sex assigned at birth, so while it was included as a covariate, it should not be interpreted as a true estimate of the proportions of transmasculine and transfeminine people in the database. To assess patterns in use of transgender-specific diagnostic codes by specialty, we also extracted the internal OLDW identification number and specialty of clinicians who assigned these codes in any encounter, regardless of whether it was the index diagnosis.

Outcome Measures

Following published guidelines for hormone therapy in transgender people, 22 we characterized gender-affirming testosterone therapy as at least one pharmacy claim for any formulation of testosterone without any claim for an estrogen formulation; for transgender women and other transfeminine people, gender-affirming hormone therapy was at least one claim for an estrogen formulation with at least one claim for an anti-androgen such as spironolactone or bicalutamide. Dutasteride and finasteride, which may be used by transfeminine people for purposes of gender affirmation but also by transmasculine people to prevent hair loss associated with testosterone use, were not included. 23 We classified people with claims for both testosterone and estrogen formulations as transmasculine because of the potential use of estrogen formulations for birth control among people assigned female at birth, regardless of gender identity. We did not use recorded sex data to classify hormone therapy because it was impossible to determine whether the sex variable in the database referred to current gender identity or to assigned sex at birth. Gonadotropin-releasing hormone (GnRH) analogs, which may be prescribed to transgender adolescents of any gender to delay the onset of puberty as a precursor to eventual hormone replacement therapy with testosterone or estrogens, were included as a separate category. For each gender-affirming hormone therapy claim, we extracted the generic and brand names, dosage, out-of-pocket and health plan paid amounts, and the prescribing provider’s specialty and internal OLDW identification number (Appendix A, Table A.1).

To identify gender-affirming surgeries, we first extracted all physician and facility claims that included a transgender-specific ICD-9 or ICD-10 diagnostic code in any position. We then used published coverage protocols 24 to identify claims with ICD-9 or ICD-10 procedure codes or CPT codes that can be used to bill for the following categories of gender-affirming surgical procedures: phalloplasty or metoidioplasty, hysterectomy, and mastectomy for transgender men and other transmasculine people and vaginoplasty, orchiectomy, mammoplasty, and facial feminization for transgender women and other transfeminine people (Appendix A, Table A.2). Codes that could not be readily associated with a specific gender were grouped as “unspecified top surgery” (i.e., mastectomy or mammoplasty) or “unspecified genital surgery” (i.e., phalloplasty/metoidioplasty or vaginoplasty). We confirmed the composition of this code list with a surgeon who performs high volumes of these procedures (Loren Schecter, personal communication, August 20, 2019).

Descriptive Analyses

We calculated the incidence by year of transgender people newly identified in OLDW using their index date. The denominator for both annual incidence and the total number of transgender people with coverage by year was the count of all people with commercial coverage in OLDW in that year. We explored trends in coding by calculating the mean age at index diagnosis for people with index dates between 1993 to 2000, 2001 to 2010, and 2011 to 2020, as well as by assessing the relative proportions of transgender-specific diagnostic codes assigned by each clinical specialty. We used χ 2 tests to compare index codes by demographics.

The assessment of gender-affirming health services utilization consisted of annual counts of individual hormone therapy prescriptions in each category (testosterone, estrogens plus anti-androgens, and GnRH analogs), annual counts of the number of people receiving any gender-affirming hormone therapy prescription, counts of episodes of individual surgical procedures in each category of surgeries by year, and annual counts of transgender people who underwent any gender-affirming surgical procedure. Procedures that occurred within 14 days of each other were counted as a single episode. We calculated the percentage of people who received hormone therapy or a surgical procedure among all individuals identified as transgender in the database who were enrolled in coverage for any part of each year. We used multivariable logistic regression models to identify demographic characteristics associated with receipt of hormone therapy or gender-affirming surgery. Statistical significance was set at α = 0.05, and analyses were conducted in R (version 4.0.2).

Annual costs for each category of hormone therapy were calculated from a payer perspective by summing the health plan paid costs; we also calculated average annual health plan paid costs per person for each category. Average and annual costs for each type of surgery were similarly calculated from a payer perspective, and all costs incurred during the 14-day window after each procedure were included. We calculated the annual budget impact of the overall cost of gender-affirming care, including all types of hormone therapy and surgical procedures, using the total OLDW population with commercial coverage in each year as the denominator. All costs were estimated in 2019 dollars.

We identified 16,619 people who had physician or facility claims and met our inclusion criteria between 1993 and 2019. Of this group, 15,790 also had pharmacy claims. The annual incidence of index codes, meaning the appearance of an individual’s first transgender-specific code in the database, rose from 4 per million enrollees in 1993 to 149 per million in 2019, with more than 80 percent of that growth occurring between 2011 and 2019. Between 1993 and 2000 and between 2001 and 2010, an average of 18 and 166 people, respectively, received a transgender-specific code for the first time each year; between 2011 and 2019, an average of 1,646 people were newly identified as transgender in OLDW each year. The number of people in OLDW with transgender codes in each year similarly increased slowly through the first two decades before beginning an exponential rise around 2011 ( Figure 2.1 ). In 1993, the number of transgender people with coverage in OLDW was 71 per million enrollees; this number rose slowly to 178 per million in 2010 before climbing rapidly to 411 per million by 2019. The mean age at index diagnosis declined from 33.9 years in 1993 to 26.3 years in 2019 ( Figure 2.2 ). The transgender population was young, with the largest proportion (46%) in the age group between 18 and 29 as of 2019. The majority were identified in the database as female (53%) and white (67%), and most (35%) lived in the South, where OLDW has large representation ( Table 2.1 ).

Annual New Identifications and Total Count of Transgender People in the OptumLabs Data Warehouse, 1993-2019

Age Distribution of Newly Identified Transgender People by Index Year, 1993-2019

Demographics of Transgender People Identified in the OptumLabs Data Warehouse, 1993-2019

The most common index code during the ICD-9 period was the non-specific code 302.85 (Gender Identity Disorder in Adolescents or Adults). Codes with sexual orientation subclassification (e.g., 302.53; Transsexualism, Heterosexual Sexual History) became less common throughout the ICD-9 period; these codes were phased out in the conversion to ICD-10 in mid-2015 (Appendix A, Figure A.1 ). Immediately following the conversion, there was a temporary spike in the use of F64.1 (Dual-Role Transvestism). There was no increase over time in the use of codes specific to children (e.g., F64.2, Gender Identity Disorder in Childhood). While transgender-specific diagnostic codes typically appeared in claims for services that could be part of gender affirmation, including mental health counseling as well as hormone therapy and surgeries, the use of these codes was not confined to gender-affirming care: these codes were also identified in claims for encounters such as arthroscopic knee surgeries and influenza vaccines. The provider specialties that used these codes most often were social work, family practice, and psychology (Appendix A, Figure A.2 ).

Seventy-two percent of transgender people had at least one encounter for gender-affirming hormone therapy. The clinical specialties most likely to write prescriptions for hormone therapy were family practice (28%) and endocrinology (18%) (Appendix A, Table A.3 ). Many individual providers were represented, and no single provider wrote more than 1.6 percent of all the prescriptions in the claims database. Hormone therapy by gender was roughly even between transmasculine and transfeminine regimens: 46 and 54 percent of people on hormone therapy were classified as transmasculine or transfeminine, respectively. Only 0.4 percent of those on hormone therapy were observed to have received GnRH treatment, and 78 percent of those who had been on GnRH treatment subsequently received prescriptions for estrogens or testosterone. While the number of people on GnRH treatment remained consistently low, the number of people receiving hormone therapy with estrogen or testosterone increased rapidly beginning around 2011 ( Figures 2.3 and 2.4 ). In 2011, 17 percent of transgender people identified in this database were receiving gender-affirming hormone therapy, and by 2019 this proportion had increased almost 4-fold, to 65 percent. The average payer costs of gender-affirming hormones were consistently low for both testosterone and estrogen therapy, at $121 and $153 per year; GnRH therapy cost an average of $2,410 per person per year ( Table 2.2 ). As a proportion of total costs, out-of-pocket spending per year was 38 percent for estrogens, 25 percent for testosterone, and 8 percent for GnRH.

Number of People with Claims for Gender-Affirming Hormone Therapy by Year and Medication Type, 1993-2019

Annual Health Plan Paid Cost by Gender-Affirming Hormone Therapy Type, 1993-2019

Frequency and Costs of Claims for Gender-Affirming Hormone Therapy, 1993-2019

GnRH = gonadotropin-releasing hormone

* Average weighted by proportion of people with prescriptions for each type of therapy; denominator is the total number of transgender people identified in OLDW (N = 16,619)

Temporal trends in the frequency of gender-affirming surgeries paralleled those of hormone therapy. Throughout the first two decades of claims, gender-affirming surgeries were performed infrequently, if at all, but the annual number of procedures performed began to increase around 2011: in 2011, 21 people (0.5% of all transgender people with coverage that year) underwent a gender-affirming surgery, and by 2019, that number had risen to 794 (8%) ( Figures 2.5 and 2.6 ). Overall, 14 percent of the transgender people identified for this analysis had ever undergone a gender-affirming surgery while enrolled in OLDW, of which mastectomy was the most common procedure. The per-episode payer costs of gender-affirming surgeries ranged from $6,927 for orchiectomy to $45,080 for vaginoplasty and $63,432 for phalloplasty ( Table 2.3 ). As vaginoplasty and phalloplasty were frequently multi-episode procedures, the total average cost of these procedures per person was $53,645 and $133,911, respectively. There were substantially lower odds of having undergone surgery among people living in the South (adjusted odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.63, 0.88), although there were no differences by imputed race (Appendix A, Table A.4 ). No single provider was responsible for more than 6.6 percent of surgeries.

Number of Gender-Affirming Surgical Procedures by Year, 2010-2019

Annual Health Plan Paid Cost by Gender-Affirming Procedure Type, 2010-2019

Frequency and Costs of Claims for Gender-Affirming Surgeries, 1993-2019

Over the time period covered by this study, the annual frequency of gender-affirming hormone therapy and surgeries increased both in absolute terms and as a proportion of the number of transgender people identified in the database, and costs changed accordingly. In 2019, each covered transgender person incurred an average of $1,776 in costs for gender-affirming hormone therapy and surgeries combined. Considered on a per-member basis across the entire commercially insured population in OLDW, the budget impact of gender-affirming care in 2019 was $0.73 per year, or $0.06 per member per month (PMPM).

To our knowledge, this is the first study to evaluate temporal trends in coding, utilization, and costs for both gender-affirming hormone therapy and surgeries. We found that the number of people receiving transgender-specific diagnostic codes and accessing gender-affirming care in this privately insured population has increased rapidly over the decade between 2011 and 2019. Even as coverage of gender-affirming care has expanded, its budget impact remains small: the PMPM estimate of providing gender-affirming care in 2019 was $0.06 when distributed across all people with commercial coverage in OLDW. This is in line with estimates from a cost-effectiveness study that estimated the costs of coverage for gender-affirming care at $0.016 when spread across the entire U.S. population. 25

These trends in utilization of gender-affirming health services align with broader societal trends in the visibility of transgender people. The time frame of this increase coincides with policy reforms over the last decade lifting several barriers that previously limited both the use of transgender-specific codes and the provision of gender-affirming care. In 2010, the ACA introduced new guaranteed-issue protections in private insurance that were interpreted by the U.S. Department of Health and Human Services (HHS) to prohibit the designation of a transgender identity as a pre-existing condition for which insurance coverage could be restricted or denied. 34 Between 2010 and 2014, HHS promulgated several regulations that codified nondiscrimination protections on the basis of gender identity in insurance marketing, benefit design, and coverage determinations. 26 Around the same time, individual states began to adopt or strengthen similar protections by interpreting existing law to prohibit unfair discrimination against transgender people in both state-regulated health insurance markets and state Medicaid programs. 27 These reforms included the 2014 rescission of Medicare’s ban on coverage for gender-affirming surgeries and a 2016 HHS regulation that prohibited blanket exclusions of gender-affirming care in both public and private coverage. 28 Though the Trump administration revised that regulation in 2020 and future activity by the Biden administration remains unknown, state and federal courts have consistently found that discrimination against transgender people on the basis of gender identity is a form of sex discrimination. 29 As of early 2021, 24 states and territories prohibited blanket transgender coverage exclusions in state-regulated private coverage, up from one in the pre-2010 period. 30 The biggest increase in the number of people being identified as transgender in OLDW in the decade between 2010 and 2020 occurred in the South, where no states apart from Virginia, Maryland, and Delaware have state-specific protections. This pattern is consistent with the hypothesis that the 2016 national regulation played a substantial role in removing barriers to private coverage for transgender people, though more research is needed to explore this possibility.

The findings of this study indicate that the impact of gender-affirming care on payer budgets has remained nominal even as national trends in coverage policies have made this care more accessible to transgender people. Future directions for research include assessing the health outcomes associated with access to gender-affirming care, improving methods for identifying transgender people in insurance claims databases, and investigating opportunities to link different data sources to provide a more complete picture of the health needs and experiences of transgender people.

As restrictions on coverage for gender-affirming care have receded, other studies using data sources such as the National Inpatient Sample have identified increases in the number of gender-affirming surgeries performed in the U.S. 31 The present study expands this evidence base by analyzing the frequency of individual procedures and assessing trends in hormone therapy use as well; a better understanding of the availability and uptake of both gender-affirming surgeries and hormone therapy is important for insurance carriers seeking to ensure the adequacy of their coverage and provider networks for these services and for hospitals and other health service organizations identifying trends in patient care needs. These data may also help federal and state insurance regulators establish baseline estimates of service availability and utilization, which can be used to monitor market conduct and identify potential concerns related to inadequacy of benefit designs or inappropriate use of utilization management tools. For instance, this study found that utilization of GnRH treatment remained low, even as the number of people identified in the 4-17 age group increased. This pattern is consistent with reports that barriers in insurance coverage of GnRH treatment for transgender adolescents remain high. 32 Some regulators are beginning to explore the degree to which restrictions on coverage of GnRH treatment for this population may violate nondiscrimination requirements on the basis of gender identity and age. 33

Limitations

This study has several limitations, many of which relate to the difficulty of using diagnoses in insurance claims as proxies for gender identity, which is a complex aspect of personal identity that has social, legal, and medical components. Because this insurance claims database does not currently include any self-reported data on gender identity, it was not possible to determine how many people in the database would self-identify as transgender but are not captured by the algorithm based on transgender-specific diagnostic codes. The proportion of the population in this database that was identified as transgender was 411 per million in 2019 (0.04%), which is comparable to other estimates from clinical records but much less than estimates from more representative population surveys that use self-report, which range between 0.1 percent and 2.0 percent. 34 It was also impossible to definitively identify claims for gender-affirming care, as the assessment of coding practices indicated that these codes may be applied to services provided to transgender people that do not have any relation to gender affirmation. We thus may have incorrectly categorized unrelated services as gender-affirming care; this was a particular concern with services that may be more commonly needed for other indications, such as hysterectomy and estrogen therapy.

At the same time, we may have missed services and procedures that were provided for purposes of gender affirmation but were not submitted with transgender-specific diagnostic codes. The number of claims with procedure codes that might indicate a gender-affirming service but that were not coded with relevant diagnostic codes was very small among the group of people identified as transgender, but it was not possible to know how many such procedures for purposes of gender affirmation were performed for people who were not included in the transgender group. The routine capture of self-reported gender identity data in clinical records, including both medical records and claims, would aid in assessments of transgender population size and health services costs and use. Similarly, more consistent coding standards guiding the application of both diagnostic codes related to a need for gender-affirming care and procedure codes describing the provision of this care would improve estimates of the frequency and costs of these procedures.

The number of people with transgender-specific diagnostic codes in this commercial insurance claims database has increased sharply over the last decade, in tandem with law and policy changes that seek to remove barriers to coverage for this population. In 2019, almost 10,000 people were identified as transgender in this database, representing 0.04 percent of people with commercial coverage in OLDW. In the same year, 65 percent of people identified as transgender were receiving gender-affirming hormone therapy, and 8 percent had some gender-affirming surgical procedure. The annual cost of providing gender-affirming care for this population was $1,776 per person, or $0.06 per member per month. The findings of this study indicate that the impact of gender-affirming care on payer budgets has remained nominal even as national trends in coverage policies have made this care more accessible to transgender people. Future directions for research include assessing the health outcomes associated with access to gender-affirming care, improving methods for identifying transgender people in insurance claims databases, and investigating opportunities to link different data sources to provide a more complete picture of the health needs and experiences of transgender people.

The authors have no conflicts to disclose.

Acknowledgments

Our gratitude goes out to Jodi B. Segal, M.D., M.P.H. of the Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, and Helene Hedian, M.D. of the Johns Hopkins School of Medicine. We would also like to thank Optum Labs and the Robert Wood Johnson Foundation Health Policy Research Scholar Program.

Biographies

Kellan Baker, Ph.D., M.P.H., M.A., is affiliated with the Whitman-Walker Institute, Washington, DC, USA and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Arjee Restar, Ph.D., M.P.H., is affiliated with the Center for Applied Transgender Studies, Chicago, IL, USA and the Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.

Appendix A: Supplementary Material

Hormone Therapy Prescriptions by Provider Specialty

Associations Between Demographic Characteristics and Gender-Affirming Medical Services

OR = odds ratio, CI = confidence interval, Ref = reference category

Index Codes by Year, 1993-2019

Use of Transgender-Specific Codes by Provider Specialty

Supplementary material

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Supreme Court Clears Way, for Now, for Idaho to Ban Transgender Treatment for Minors

The Idaho attorney general had asked the justices to move swiftly to let the state law, which would ban gender-affirming medical care for minors, go into effect.

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By Abbie VanSickle

Reporting from Washington

The Supreme Court temporarily allowed Idaho on Monday to enforce a ban on gender-affirming treatment for minors, effectively suggesting that some justices appear comfortable with wading into another front in the culture wars.

In siding with state officials who had asked the court to lift a block on the law as an appeal moves forward, the justices were sharply split, with a majority of the conservatives voting to allow the ban to take effect over the objections of the three liberals.

The court said the ban would apply to everyone except for the plaintiffs who brought the challenge.

Notably, the opinions focused not on transgender care, a hot-button political issue that has prompted several Republican-led legislatures to approve bills to restrict puberty-blocking drugs and hormone treatments, but on a broader legal question: universal injunctions.

Universal injunctions are when a single judge issues a sweeping decision that applies beyond those directly involved in the dispute. Some justices have signaled an interest in looking at the tactic.

Although orders in response to emergency applications often include no reasoning, the justices in this case divided into several factions.

The decision included concurrences by Justice Neil M. Gorsuch, who was joined by Justices Samuel A. Alito Jr. and Clarence Thomas, and Justice Brett M. Kavanaugh, who was joined by Justice Amy Coney Barrett. Chief Justice John G. Roberts Jr. did not note a position.

Justice Ketanji Brown Jackson dissented and was joined by Justice Sonia Sotomayor. Justice Elena Kagan noted a dissent.

The Idaho law, passed by the state’s Republican-controlled Legislature, makes it a felony for doctors to provide transgender medical care for minors, including hormone treatment.

States around the country have pushed to curtail transgender rights. At least 20 Republican-led states, including Idaho, have enacted legislation that limits access for gender transition care for minors.

In his concurrence, Justice Gorsuch said the use of a universal injunction “meant Idaho could not enforce its prohibition against surgeries to remove or alter children’s genitals, even though no party before the court had sought access to those surgeries or demonstrated that Idaho’s prohibition of them offended federal law.”

He wrote that the case broached the use of such injunctions, “a question of great significance that has been in need of the court’s attention for some time.” In recent years, he added, lower courts had overstepped their bounds by seeking “to govern an entire state or even the whole nation from their courtrooms.”

In her dissent, Justice Jackson also honed in on similar questions. But she wrote that the case, particularly given that it was brought on the emergency docket, was “not be the place to address the open and challenging questions that that issue raises.”

If there was any point of agreement in the case, it seemed to be a growing frustration with the number and scope of cases brought on the court’s emergency docket.

Justice Jackson noted that she saw “some common ground” with her conservative colleagues by agreeing that “our emergency docket seems to have become increasingly unworkable.”

The American Civil Liberties Union, which represents the plaintiffs in the case, denounced the outcome, saying it was “an awful result for transgender youth and their families across the state.”

“Today’s ruling allows the state to shut down the care that thousands of families rely on while sowing further confusion and disruption,” it said in a statement.

The Idaho attorney general, Raúl Labrador, a Republican and former member of Congress who helped found the conservative House Freedom Caucus, celebrated the decision.

“Denying the basic truth that boys and girls are biologically different hurts our kids,” Mr. Labrador said. “No one has the right to harm children, and I’m grateful that we, as the state, have the power — and duty — to protect them.”

Idaho officials had appealed to the Supreme Court after the U.S. Court of Appeals for the Ninth Circuit, in San Francisco, upheld a temporary block on the law as litigation continues in lower courts.

The law, the Vulnerable Child Protection Act, makes it a crime for medical providers to offer medical care to transgender teenagers.

Mr. Labrador, in his emergency application, said that the case raised a recurring question that a majority of the justices had expressed interest in: whether a court can enact a universal injunction.

Mr. Labrador contended that a federal court erred in applying the freeze so expansively. “The plaintiffs are two minors and their parents, and the injunction covers two million,” he wrote.

Temporarily barring the law meant “leaving vulnerable children subject to procedures that even plaintiffs’ experts agree are inappropriate for some of them,” he added.

Mr. Labrador continued, “These procedures have lifelong, irreversible consequences, with more and more minors voicing their regret for taking this path.”

The plaintiffs had asserted that the case was not the right vehicle for addressing concerns about universal injunctions.

That is because the four plaintiffs are anonymous, referred to only by pseudonyms. If the court narrowed the temporary pause on the Idaho law to apply only to those directly involved in the lawsuit, the plaintiffs, including minors, would be forced to “disclose their identities as the transgender plaintiffs in this litigation to staff at doctors’ offices and pharmacies every time they visited a doctor or sought to fill their prescriptions.”

Abbie VanSickle covers the United States Supreme Court for The Times. She is a lawyer and has an extensive background in investigative reporting. More about Abbie VanSickle

Ohio judge temporarily blocks ban on gender-affirming care for transgender minors

A Franklin County judge on Tuesday temporarily blocked an impending law that would restrict medical care for transgender minors in Ohio.

The decision came weeks after the American Civil Liberties Union filed a lawsuit challenging House Bill 68 on behalf of two transgender girls and their families. The measure prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery before patients turn 18.

Attorneys contend the law violates the state Constitution , which gives Ohioans the right to choose their health care.

"Today's ruling is a victory for transgender Ohioans and their families," said Harper Seldin, staff attorney for the ACLU. "Ohio's ban is an openly discriminatory breach of the rights of transgender youth and their parents alike and presents a real danger to the same young people it claims to protect."

House Bill 68 was set to take effect April 24 after House and Senate Republicans  voted to override  Gov. Mike DeWine's veto. Proponents of the bill contend it will protect children, but critics say decisions about transition care should be left to families and their medical providers.

The suit in Ohio mirrors efforts in other states to challenge laws that restrict gender-affirming care for minors. A federal judge struck down a  similar policy in Arkansas , arguing it violates the constitutional rights of transgender youth and their families. The state is appealing that decision.

“This is just the first page of the book,” Attorney General Dave Yost said Monday. “We will fight vigorously to defend this properly enacted statute, which protects our children from irrevocable adult decisions. I am confident that this law will be upheld.”

What does House Bill 68 do?

House Bill 68 allows Ohioans younger than 18 who already receiving hormones or puberty blockers to continue, as long as doctors determine stopping the prescription would cause harm. Critics say that's not enough to protect current patients because health care providers could be wary of legal consequences.

The legislation does not ban talk therapy, but it requires mental health providers to get permission from at least one parent or guardian to diagnose and treat gender dysphoria.

The bill also bans transgender girls and women from playing on female sports teams in high school and college. It doesn't specify how schools would verify an athlete's gender if it's called into question. Players and their families can sue if they believe they lost an opportunity because of a transgender athlete.

The lawsuit doesn't specifically challenge the athlete ban. But it argues that House Bill 68 flouts the constitution's single-subject rule, which requires legislation to address only one topic. House Republicans introduced separate bills on gender-affirming care and transgender athletes before  combining them into one .

In Tuesday's decision, Franklin County Judge Michael Holbrook indicated that the law could be tossed out because of a single-subject violation.

"It is not lost upon this Court that the General Assembly was unable to pass the (Saving Ohio Adolescents from Experimentation) portion of the Act separately, and it was only upon logrolling in the Saving Women’s Sports provisions that it was able to pass," Holbrook wrote.

Panel clears ban on gender reassignment surgery for minors

Tuesday's decision came one day after a legislative panel cleared the way for an administrative rule that will ban gender reassignment surgery for minors. Ohio health care providers say they do not perform that procedure on patients under 18.

The rule will take effect May 3.

The measure was among several that DeWine proposed to regulate gender-affirming care after he vetoed House Bill 68. In testimony for Monday's meeting, opponents argued that the rules overstep the administration's authority and conflict with federal law.

"The proposed administrative rule changes are based on biased definitions, ignore well-established best practices and restrict countless patients’ access to gender-affirming care," said Mallory Golski, civic engagement and advocacy manager for Kaleidoscope Youth Center.

DeWine's other proposals are still working their way through the rulemaking process. That includes a requirement for transgender minors to undergo at least six months of counseling before further treatment occurs. Another rule would require providers to report non-identifying data on gender dysphoria diagnoses and treatment.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

Ohio judge blocks ban on gender-affirming care for transgender minors—for now

A n Ohio judge on Tuesday temporarily blocked an impending law that would restrict medical care for transgender minors in the Buckeye State.

The decision came weeks after the American Civil Liberties Union filed a lawsuit challenging the state on behalf of two transgender girls and their families. The measure prevents doctors from prescribing hormones, puberty blockers, or gender reassignment surgery before patients turn 18.

Attorneys contend the law violates the state Constitution , which gives Ohioans the right to choose their health care.

“Today’s ruling is a victory for transgender Ohioans and their families,” said Harper Seldin, staff attorney for the ACLU. “Ohio’s ban is an openly discriminatory breach of the rights of transgender youth and their parents alike and presents a real danger to the same young people it claims to protect.”

The legislation was set to take effect on April 24 after House and Senate Republicans  voted to override  Gov. Mike DeWine’s veto. Proponents of the bill contend it will protect children, but critics say decisions about transition care should be left to families and their medical providers.

The suit in Ohio mirrors efforts in other states to challenge laws that restrict gender-affirming care for minors. A federal judge struck down a  similar policy in Arkansas , arguing it violates the constitutional rights of transgender youth and their families. The state is appealing that decision.

“We protect children with various restrictions that do not apply to adults − from signing legal contracts to buying alcohol and tobacco and more,” Attorney General Dave Yost posted on X , formerly known as Twitter, after the lawsuit was filed. “As I promised during the veto override, my office will defend this constitutional statute.”

What does the Ohio bill do?

The bill allows Ohioans younger than 18 who are already receiving hormones or puberty blockers to continue as long as doctors determine stopping the prescription would cause harm. Critics say that’s not enough to protect current patients because health care providers could be wary of legal consequences.

The legislation does not ban talk therapy, but it requires mental health providers to get permission from at least one parent or guardian to diagnose and treat gender dysphoria.

More: 6 jurors selected to serve in Donald Trump's hush money trial: Latest Trump trial news

The bill also bans transgender girls and women from playing on female sports teams in high school and college. It doesn’t specify how schools would verify an athlete’s gender if it’s called into question. Players and their families can sue if they believe they lost an opportunity because of a transgender athlete.

The lawsuit doesn’t specifically challenge the athlete ban. But it argues the legislation flouts the constitution’s single-subject rule, which requires legislation to address only one topic. House Republicans introduced separate bills on gender-affirming care and transgender athletes before  combining them into one .

In Tuesday’s decision, Franklin County Judge Michael Holbrook indicated that the law could be tossed out because of a single-subject violation.

“It is not lost upon this Court that the General Assembly was unable to pass the (Saving Ohio Adolescents from Experimentation) portion of the Act separately, and it was only upon logrolling in the Saving Women’s Sports provisions that it was able to pass,” Holbrook wrote.

Panel clears ban on gender reassignment surgery for minors

Tuesday’s decision came one day after a legislative panel cleared the way for an administrative rule that will ban gender reassignment surgery for minors. Ohio health care providers say they do not perform that procedure on patients under 18.

The rule will take effect May 3.

More: Supreme Court, in an emergency order, lets Idaho enforce ban on transgender care

The measure was among several that DeWine proposed to regulate gender-affirming care after he vetoed the legislation. In testimony for Monday’s meeting, opponents argued that the rules overstep the administration’s authority and conflict with federal law.

“The proposed administrative rule changes are based on biased definitions, ignore well-established best practices, and restrict countless patients’ access to gender-affirming care,” said Mallory Golski, civic engagement and advocacy manager for Kaleidoscope Youth Center.

DeWine’s other proposals are still working their way through the rulemaking process. That includes a requirement for transgender minors to undergo at least six months of counseling before further treatment occurs. Another rule would require providers to report non-identifying data on gender dysphoria diagnoses and treatment.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

This article originally appeared on The Columbus Dispatch: Ohio judge blocks ban on gender-affirming care for transgender minors—for now

Sweden passes law to make it easier to change legal gender

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Seattle hospital won’t turn over gender-affirming care records in lawsuit settlement with Texas

DALLAS —  Texas Attorney General Ken Paxton  is dropping a request for a Seattle hospital to hand over records regarding  gender-affirming treatment  potentially given to children from Texas as part of a lawsuit settlement announced Monday.

Seattle Children’s Hospital  filed the lawsuit  against Paxton’s office in December in response to the Republican appearing to go beyond state borders to investigate transgender health care. Paxton, a staunch conservative who has helped drive GOP efforts that target the rights of trans people, sent  similar letters to Texas hospitals  last year.

The Seattle hospital said in a statement that it had “successfully fought” the “overreaching demands to obtain confidential patient information.” A judge in Austin dismissed the lawsuit Friday, saying the parties had settled their dispute.

Texas is among states that have  enacted laws restricting or banning  gender-affirming medical care for transgender minors.

The hospital’s lawsuit included a copy of the letter from Paxton’s office, which among other requests asked the hospital to produce records identifying medication given to children who live in Texas; the number of Texas children who received treatment; and documents that identified the “standard protocol or guidance” used for treatment.

As part of the settlement, according to court records, the parties agreed that Seattle Children’s Hospital would withdraw its registration to transact business in Texas. But a hospital spokesperson said in a statement that they don’t operate health care facilities or provide gender-affirming care in Texas.

In court records, the hospital had previously stated that it had a “limited number” of people who work remotely and live in Texas but that none were involved in gender-affirming care. It also said it did not advertise its services in Texas.

“When we merely began asking questions, they decided to leave the State of Texas and forfeit the opportunity to do business here,” Paxton said in a news release Monday. He said Texas will “vigorously protect” children from gender-affirming treatment that he called “damaging.”

The Texas law prevents transgender minors from accessing hormone therapies, puberty blockers and transition surgeries, even though medical experts say such surgical procedures are rarely performed on children.

In Washington,  Democratic Gov. Jay Inslee  has signed  a law  that aims to protects minors seeking gender-affirming care there, part of  a wave of legislation in Democratic-led states  intended to give refuge to those seeking gender-affirming treatment.

The Associated Press

Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

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A review into how children with gender dysphoria are treated in england has been released. here's what it means for australia.

Former AFL star Danielle Laidley tells her story — 'nothing more, nothing less'

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Seattle Hospital Won't Turn Over Gender-Affirming Care Records in Lawsuit Settlement With Texas

Texas Attorney General Ken Paxton is dropping a request for a Seattle hospital to hand over records regarding gender-affirming treatment potentially given to children from Texas as part of a lawsuit settlement announced Monday

Seattle Hospital Won't Turn Over Gender-Affirming Care Records in Lawsuit Settlement With Texas

FILE - Texas Attorney General Ken Paxton makes a statement at his office, May 26, 2023, in Austin, Texas. Paxton is dropping a request for a Seattle hospital to hand over records regarding gender-affirming treatment potentially given to children from Texas as part of a lawsuit settlement announced Monday, April 22, 2024. (AP Photo/Eric Gay, File)

DALLAS (AP) — Texas Attorney General Ken Paxton is dropping a request for a Seattle hospital to hand over records regarding gender-affirming treatment potentially given to children from Texas as part of a lawsuit settlement announced Monday.

Seattle Children's Hospital filed the lawsuit against Paxton's office in December in response to the Republican appearing to go beyond state borders to investigate transgender health care. Paxton, a staunch conservative who has helped drive GOP efforts that target the rights of trans people, sent similar letters to Texas hospitals last year.

The Seattle hospital said in a statement that it had “successfully fought” the “overreaching demands to obtain confidential patient information.” A judge in Austin dismissed the lawsuit Friday, saying the parties had settled their dispute.

Texas is among states that have enacted laws restricting or banning gender-affirming medical care for transgender minors.

The hospital's lawsuit included a copy of the letter from Paxton’s office, which among other requests asked the hospital to produce records identifying medication given to children who live in Texas; the number of Texas children who received treatment; and documents that identified the “standard protocol or guidance” used for treatment.

As part of the settlement, according to court records, the parties agreed that Seattle Children’s Hospital would withdraw its registration to transact business in Texas. But a hospital spokesperson said in a statement that they don't operate health care facilities or provide gender-affirming care in Texas.

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In court records, the hospital had previously stated that it had a “limited number” of people who work remotely and live in Texas but that none were involved in gender-affirming care. It also said it did not advertise its services in Texas.

“When we merely began asking questions, they decided to leave the State of Texas and forfeit the opportunity to do business here," Paxton said in a news release Monday. He said Texas will “vigorously protect” children from gender-affirming treatment that he called “damaging.”

The Texas law prevents transgender minors from accessing hormone therapies, puberty blockers and transition surgeries, even though medical experts say such surgical procedures are rarely performed on children.

In Washington, Democratic Gov. Jay Inslee has signed a law that aims to protects minors seeking gender-affirming care there, part of a wave of legislation in Democratic-led states intended to give refuge to those seeking gender-affirming treatment.

Copyright 2024 The  Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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New federal rule bars transgender school bathroom bans, but it likely isn’t the final word

FILE - A protester outside the Kansas Statehouse holds a sign after a rally for transgender rights on the Transgender Day of Visibility, March 31, 2023, in Topeka, Kan. A new rule from President Joe Biden’s administration assuring transgender students be allowed to use the school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states that seek to make sure they can’t. (AP Photo/John Hanna, File)

FILE - Oklahoma Gov. Kevin Stitt, center, signs a bill that prevents transgender girls and women from competing on female sports teams, March 30, 2022, in Oklahoma City. A new rule from President Joe Biden’s administration assuring transgender students be allowed to use the school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states that seek to make sure they can’t. (AP Photo/Sean Murphy, File)

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A new rule from President Joe Biden’s administration blocking blanket policies to keep transgender students from using school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states.

The clash over bathroom policy and other elements of a federal regulation finalized last week could set the stage for another wave of legal battles over how transgender kids should be treated in the U.S.

In recent years, transgender people have gained visibility and acceptance in the U.S. — and some conservative officials have pushed back.

Most GOP-controlled states now have laws reining in their rights. Measures include laws to keep transgender girls out of girls school sports, limiting which school bathrooms transgender people can use, requiring school staff to notify parents if their student identifies in school as transgender, and barring school staff from being required to use the pronouns a transgender student uses.

Most of those policies have been challenged in court.

Here’s a look at the new regulation, the states’ laws and what could happen next.

WHAT’S THE HEART OF THE REGULATION?

The 1,577-page regulation finalized last week seeks to clarify Title IX, the 1972 sex discrimination law originally passed to address women’s rights and applies to schools and colleges that receive federal money.

The regulations, which are to take effect in August, spell out that Title IX bars discrimination based on sexual orientation and gender identity, too.

Many Republicans say this wasn’t the intent of the law.

The new rules also provide more protections to students who make accusations of sexual misconduct.

RULE CONTRADICTS BATHROOM LAWS

At least 11 states have adopted laws barring transgender girls and women from using girls’ and women’s bathrooms at public schools.

The new regulation opposes those sweeping policies.

It states that sex separation at schools isn’t always unlawful. However, the separation becomes a violation of Title IX’s nondiscrimination rule when it causes more than a very minor harm on a protected individual, “such as when it denies a transgender student access to a sex-separate facility or activity consistent with that student’s gender identity.”

The laws are in effect in Alabama, Arkansas, Florida, Iowa, Kansas, Kentucky, North Dakota, Oklahoma and Tennessee. A judge’s order putting enforcement on hold is in place in Idaho. A prohibition in Utah is scheduled to take effect July 1.

RULE ALLOWS PARENTAL NOTIFICATION REQUIREMENTS

At least seven states have laws or other policies calling for schools to notify parents if their children are transgender.

The regulation seems to authorize those requirements, stating that “nothing in these final regulations prevents a recipient from disclosing information about a minor child to their parent who has the legal right to receive disclosures on behalf of their child.”

The requirements are already law in Alabama, Arizona, Arkansas, Idaho, Indiana and North Carolina. The Arizona law requires schools to provide information to parents but does not specifically include details about students’ gender expression or sexuality. Virginia asked schools to provide guidance to the state’s school districts to adopt similar policies, though they’re not written into state law.

ARE PRONOUN RESTRICTIONS LEGAL? IT DEPENDS

At least four states — Florida, Kentucky, Montana and North Dakota — have laws intended to protect from discipline teachers and/or students who won’t use the pronouns transgender or nonbinary students use.

The regulations wrestle with this, finding that “harassing a student — including acts of verbal, nonverbal, or physical aggression, intimidation, or hostility based on the student’s nonconformity with stereotypical notions of masculinity and femininity or gender identity — can constitute discrimination on the basis of sex under Title IX in certain circumstances.”

But they also spell out that “a stray remark” does not constitute harassment and seek to protect the right of free speech.

THE BIG DEBATE: SPORTS PARTICIPATION

The new rules don’t specifically mention whether states can ban transgender girls from girls sports competitions. The Biden administration has put on hold a policy that would forbid schools from having outright bans.

State laws that contain such bans have been adopted in at least two dozen states in the name of preserving girls sports. But judges have paused enforcement of some of them, including in a ruling last week that applies only to one teenage athlete in West Virginia.

While the new rules are not specific to sports participation, advocates on both sides believe they could apply.

“They may be saying that this doesn’t address it, but through the broad language they’re using, the ultimate result is you have to allow a boy on a girls team,” said Matt Sharp, a lawyer with Alliance Defending Freedom, falsely identifying transgender girls as boys. Alliance Defending Freedom is a conservative group that has represented female athletes challenging sports participation by transgender women and girls.

“This document gives a good sense that says you can’t have a rule that says, ‘If you’re transgender, you can’t participate,’” said Harper Seldin, an American Civil Liberties Union lawyer.

WHAT HAPPENS NOW?

Lawsuits, probably.

After the rules were unveiled last week, Tennessee Attorney General Jonathan Skrmetti posted on X that “TN is prepared to defend Title IX & protect against unlawful regulations that redefine what sex really means.”

“We absolutely plan to challenge this betrayal of women in court,” Florida Attorney General Ashley Moody said in a statement Monday.

Oklahoma Attorney General Gentner Drummond submitted comments critical of the rule before it was finalized.

Over the last two decades, attorneys general have frequently sued the opposing party’s president over rules and executive orders.

Sharp of Alliance Defending Freedom said his group is still dissecting the federal rules but does represent groups that could be affected, including female athletes and religious schools and could sue over aspects of the rules. He expects states to do the same thing.

“I don’t think a lot of states want to wait until the federal government enforces this,” he said.

The ACLU’s Seldin said his organization will watch carefully how the rules play out.

“What do theses laws and regulations mean in terms of transgender youth and transgender students who find themselves attacked in every aspect of their lives?” he asked.

___ Associated Press reporter Brendan Farrington in Tallahassee, Florida; Jonathan Mattise in Nashville, Tennessee; and Sean Murphy in Oklahoma City contributed to this article.

Sweden votes on controversial gender reassignment law

Sweden was the first country to introduce legal gender reassignment in 1972, but a proposal to lower the minimum age from 18 to 16 to be voted on by parliament Wednesday has sparked controversy.

Issued on: 17/04/2024 - 04:31

The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

Beyond lowering the age, the proposals also aim to make it simpler for a person to change their legal gender. 

"The process today is very long, it can take up to seven years to change your legal gender in Sweden ," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Under the proposal, two new laws would replace the current legislation: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

If parliament adopts the bill as expected on Wednesday, people will be able to change their legal gender starting at the age of 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes would however only be allowed from the age of 23, unchanged from today. 

Gender dysphoria surging 

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it. 

Some critics have expressed concerns about biological males in women's locker rooms and prisons, and fear the legal change will encourage confused youths to embark down the path toward surgical transitions.

Others have insisted that more study is needed given the lack of explanation for the sharp rise in gender dysphoria.

Deep divisions 

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT. 

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

RFSL's Ponkala disagreed, saying the simplified process was important for transgender people, a "vulnerable" group.

"They face a lot of risks... We see that the political climate has hardened," he said. 

Kristersson, the prime minister, has defended the proposal as "balanced and responsible".

But he has also admitted he wanted to keep the age at 18 but gave in to strong forces in his party.

His own government has been split on the issue, with the Moderates and the Liberals largely in favour and the Christian Democrats and Sweden Democrats against. 

He has had to seek support from the left-wing opposition to get the proposal through parliament.

If adopted, the new law would come into force on July 1, 2025.

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• Gender identity
• LGBT rights

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