Understanding Insurance Requirements for Gender Confirmation Surgery

NEW YORK, NY - FEBRUARY 23: Hundreds protest a Trump administration announcement this week that rescinds an Obama-era order allowing transgender students to use school bathrooms matching their gender identities, at the Stonewall Inn on February 23, 2017 in New York City. Activists and members of the transgender community gathered outside the historic LGTB bar to denounce the new policy.
Spencer Platt/Getty Images News/Getty Images

Gender confirmation surgery is an umbrella term for any surgery that transgender or gender nonconforming people use to align their bodies to their gender identity. Gender confirmation surgery is also known by a number of other names including gender alignment surgery, gender reassignment surgery, and sex change surgery.

Although gender reassignment surgery and sex change surgery are better known terms, they are not the terms preferred by many community members.

Why? Gender reassignment surgery implies that the surgery is changing someone's gender, when it is actually aligning the body to the person's gender. Sex change surgery is somewhat antiquated as a term, and comes with a problematic history. However, all of these terms are used in various contexts.

Access and Interest in Gender Confirmation Surgery

Not all transgender, non-binary, and gender queer individuals want surgery to align their bodies to their gender identity. Some individuals are content with social or medical transition options. Others want one or more surgeries, but may or may not have access to them. A large national survey of transgender individuals found that:

  • 55 percent of transgender women either had or wanted neovaginoplasty (creation of a vagina)
  • 44 percent of transgender women either had or wanted breast augmentation
  • 45 percent of transgender women either had or wanted facial feminization
  • 33 percent of transgender women either had or wanted a tracheal shave
  • 49 percent of transgender women either had or wanted orchiectomy (removal of the testes)
  • 22 percent of transgender men either had or wanted phalloplasty (creation of a penis)
  • 27 percent of transgender men either had or wanted metoidoplasty (surgery to change the positioning of the clitoris to one that mimics the position of a penis)
  • 97 percent of transgender men either had or wanted chest reconstruction or mastectomy
  • 71 percent of transgender men either had or wanted a hysterectomy

Cost is one of the major reasons that people have limited access to gender confirmation surgeries. Historically, these procedures have not been covered by most public or private insurance companies. Fortunately, that is changing. There are now a number of public and private insurance companies that cover some, or all, gender confirmation surgery options. Unfortunately, that coverage often comes with a lot of hoops to jump through for interested patients. It is also not available to all people in all states.

Another major factor limiting access to surgery is the small number of doctors who are trained to perform these surgeries. These doctors, particularly the very experienced ones, are often booked out for months or years in advance. In addition, many of them don't take insurance. Fortunately, as insurance coverage for gender confirmation surgeries has increased, so has physician interest in training. There is now at least one teaching hospital training residents in performing neovaginoplasty. Even better, they are accepting insurance to pay for the procedure.

Finally, there is a long history of prejudice and stigma limiting transgender patients' access to care.

Insurance Companies and the WPATH Standards of Care

There are a number of different surgeries that individuals may be interested in for gender alignment or confirmation. There are specific guidelines for coverage for each surgery. However, as a general rule, many insurers are turning to the WPATH Standards of Care as guidelines to establish eligibility for surgery coverage.

WPATH is the acronym for the World Professional Association for Transgender Health. Formally known as the Harry Benjamin Society, WPATH is not without controversy.

Historically, WPATH standards have encouraged what many members of the community refer to as gatekeeping. Gatekeeping refers to the requirement that transgender individuals undergo a significant amount of therapy and/or psychiatric assessment before they are permitted to transition by the medical establishment. This positions behavioral health providers as gate keepers who are needed to unlock access to care.

Activists, researchers, and community members have accurately pointed out that this level of scrutiny is not required for other major surgeries. For example, people are not required to seek counseling before getting access to other plastic surgery. As such, there are legitimate questions about whether these guidelines reflect stigma against transgender people instead of clinically appropriate measures.

Regardless of whether or not the WPATH standards of care are ideal, they are the guidelines that most large organizations follow. In fact, they are the only formal care guidelines that are widely accepted by the medical and insurance communities. Fortunately, WPATH updates their surgery and treatment guidelines every five to ten years. In general, these standards of care have become less restrictive over time. This reflects the growing recognition of gender diversity in society. The information below is based on version 7 of the standards of care, published in 2011.

Note: Some insurers may have different coverage requirements. For those that are willing to provide coverage but do not have a policy in place, recommending that the company review the WPATH standards of care can be a good place to start. Remember that the standards of care are guidelines—which explicitly state that it is appropriate to alter criteria depending on the circumstance.

Standards of Care for Chest Reconstruction (Transmasculine) or Breast Augmentation (Transfeminine)

  1. Persistent, well documented gender dysphoria
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions must be "reasonably well controlled." 

It is important to note that hormone therapy is NOT required for these surgeries, which are colloquially referred to as "top surgery." A year of hormone is recommended for transgender women, as this allows them to get the maximum possible breast growth without surgery. This, in turn, improves surgery outcomes.

For transgender men, there is no hormone requirement or recommendation. This is because there are a number of transmasculine people who are only dysphoric about their chests. It is also because there are a number of reasons, both physical and psychological, why people choose to undergo top surgery without hormone use.

Standards of Care for Orchiectomy, Hysterectomy, and Ovariectomy

  1. Persistent, well documented gender dysphoria
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions must be "well controlled."
  4. At least 12 continuous months of appropriate hormone therapy, unless there are reasons why the patient can't or won't take hormones. The purpose of this guideline is so that patients can experience reversible hormone changes before they undergo irreversible ones.

Surgeries to remove the gonads (testes, ovaries) and the uterus may be performed on their own, as well as alongside other gender confirmation surgeries. Removing the gonads alone has the advantage of lowering the amount of cross-sex hormone therapy required to get results.

Removing the uterus and/or cervix removes the need for screening of those organs. Those screening exams can cause dysphoria and discomfort in many transgender men.

Standards of Care for Neovaginoplasty, Phalloplasty, or Metoidoplasty

  1. Persistent, well documented gender dysphoria
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions must be "well controlled."
  4. 12 continuous months of appropriate hormone therapy, unless there are reasons why the patient can't or won't take hormones
  5. 12 continuous months of living in a gender role that is consistent with their gender identity

This group of surgeries is used to construct genitalia concordant with a patient's gender identity. The requirement for a year of living in gender role is because doctors widely believe that that is sufficient time for people to adjust to their desired gender role before undergoing a surgery that is difficult, expensive, and irreversible.

Due to the physical and emotional intensity of these surgeries, it is highly recommended that patients considering them have regular visits with a mental or medical health professional. Aftercare for these surgeries can be emotionally intense and difficult. That is particularly a concern for transgender women with a history of sexual trauma, for whom dilation can require significant support. Regular dilation is required after the creation of the neovagina to avoid complications.

Standards of Care for Facial Feminization Surgery

There are no formal guidelines for facial feminization surgery. It has historically been very difficult to get this procedure covered by insurance, due to a lack of research on the benefits. However, some individuals have been able to have it successfully covered by arguing that it is as medically necessary as genital surgery and has equally positive effects on quality of life.

Understanding Documentation Required by the Standards of Care

Showing that a person has "persistent, well documented gender dysphoria" usually requires a letter from a mental health provider stating that the person meets the criteria for gender dysphoria and the length of time for which that has been true. This letter often also contains a narrative of the patient's gender history—in varying degrees of detail. In addition, the letter should state how long the provider has been working with the patient.

It is important to note that some standards require medical and mental health problems to be well controlled, while others only require them to be reasonably well controlled. Documentation of this is usually in the form of a letter from the relevant provider. This letter should contain information about the history of the condition, how the condition is being controlled, and how long the doctor has been working with the patient. Ideally, the phrases "well controlled" or "reasonably well controlled" should be used in the letter, as appropriate. That makes it easier for providers and insurance companies to determine that the conditions of the standards of care have been met.

Of note, mental health conditions are NOT a contraindication for gender affirmation surgeries. In fact, these procedures can help resolve symptoms in many transgender people and others with gender dysphoria. This is true not just for anxiety and depression but for more serious conditions such as psychosis.

A Word From Verywell

Getting insurance coverage for gender confirmation surgery can be a frustrating process. It can help to be prepared with a copy of the WPATH guidelines and any relevant research papers to support your goals. That's particularly true if they include surgeries other than the ones listed above.

In addition, it may be a good idea to reach out to your local LGBT health center, if you have one, for assistance. Many health centers are now hiring transgender patient navigators who have extensive experience with the insurance process. They can be a great resource, as can the support personnel in your surgeon's office—if she has them. Finally, local and national LGBTQ-focused legal organizations often half help lines or access hours where people can seek information.

Sources:

Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010 Sep;19(7):1019-24. doi: 10.1007/s11136-010-9668-7.

James, SE, Herman, JL, Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

Meijer JH, Eeckhout GM, van Vlerken RH, de Vries AL. Gender Dysphoria and Co-Existing Psychosis: Review and Four Case Examples of Successful Gender Affirmative Treatment. LGBT Health. 2017 Apr;4(2):106-114. doi: 10.1089/lgbt.2016.0133.

The World Professional Assocation for Transgender Health (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version. www.wpath.org

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