In May 2021, the Biden administration prohibited discrimination against transgender people in healthcare. The order will help enforce the June 2020 decision by the Supreme Court that ruled that the provisions against sexual discrimination in the 2010 Affordable Care Act do apply to transgender people. And it reverses the HHS policy adopted under former President Trump which held that the anti-discrimination provisions did not apply to transgender people.
While the executive order protects transgender people from discrimination in routine medical care, it is not clear how it will affect gender reassignment treatments that are sought by many of the 1.4 million US adults and 150,000 youth aged 13 to 17 who identify as transgender.
- Gender dysphoria is the high level of distress and discomfort that affects some people whose gender identity differs from the sex they were assigned at birth or their sex-related physical traits.
- A diagnosis of “gender dysphoria” is required by health insurers before they will cover gender altering treatments.
- Gender reassignment surgeries are expensive. Bottom surgeries can cost about $25,000 and top (breast surgeries) from $7,800 to 10,000. Facial and body contouring are also costly.
- More employer insurance policies, and those sold under the Affordable Care Act, now cover at least some gender reassignment surgeries.
- Pay-as-you-go options include negotiating directly for price with providers and hospitals, paying through a personal loan or credit card, or seeking a medical grant or crowdfunding from family and acquaintances.
A medical diagnosis of “gender dysphoria” is required by health insurers before they will cover gender-altering treatments. Gender dysphoria is the high level of distress and discomfort that affects some people whose gender identity differs from the sex they were assigned at birth or their sex-related physical traits. Every major US medical association has called for insurance coverage of treatment for gender dysphoria, which has been shown to improve physical and mental health.
Gender-affirming care includes social and medical processes that allow the person to live authentically. The individual chooses among measures ranging from counseling to the choice of pronouns and dress, to the use of hormones and gender-altering surgery. Not all transgender people wish to pursue medical interventions.5
The costs of treatment, especially multiple surgeries, can be significant. Here is a sampling of the costs for the usual treatments and surgeries for male-to-female and female-to-male gender alteration, as well as a rundown of strategies for covering the costs, ranging from finding the right health insurance to various loans, grants, and fundraising ideas.
Recent Events Affecting Transgender Surgeries
Fast-moving currents of both positive and negative change are affecting individuals’ access to gender reassignment treatments. Health insurance companies and large employers are to a growing extent covering gender altering surgeries. A Willis Towers Watson industry survey found that an increasing number of employers are taking action to add transgender medical benefits.6 In December 2020, a federal prisoner in Wisconsin won his lawsuit demanding sexual reassignment surgery.7 And in May 2021, the Utah Supreme Court affirmed the right of transgender people to change their sex designation on their birth certificate.
On the other hand, based on reporting by the New York Times, hundreds of bills restricting the rights of transgender people have been introduced in the US. Treating gender dysphoria in younger people (teenagers or younger) is particularly controversial.
For example, in May 2021, Karolinska hospital in Stockholm, the first in Sweden to offer gender identity assessments for children, stopped giving hormone treatment. This happened after the hospital found the treatments were causing serious, sometimes irreversible, side effects, such as cardiovascular disease, osteoporosis, infertility, cancer, and thrombosis.
Breaking Down the Costs
Candidates for gender reassignment surgeries are often required to live a year in their identified gender role and to undergo at least a year of hormone treatments and perhaps permanent hair removal.
Hormone treatments for male-to-female patients involve estrogen and female-to-male patients receive testosterone. Most patients (75% to 78% of those seeking gender dysphoria care) will pursue hormone treatments, which are generally continued for the duration of the patient’s life.
While these drugs are not usually especially expensive, they can add up to more than $2,000 a year.
Bottom surgery, or changing the genitalia, costs an estimated $25,600 for male-to-female patients and about $24,900 for female-to-male, according to The Philadelphia Center for Transgender Surgery. The Center publishes a detailed price list of surgery and hospital anesthesia costs for common procedures, though costs may vary widely.
Top (breast) surgery involving breast augmentation for male-to-female transitions costs about $9,000. For female-to-male, top surgery involving mastectomy and ranges from $7,800 to $10,900 depending on the amount of skin reduction. Masculinizing ($53,700) or feminizing (up to $70,100) facial surgery and body sculpting surgeries add to the costs.
Paying for Gender Reassignment Surgeries
Given the high costs, paying for gender reassignment surgeries is no easy task.
Employer-provided insurance may cover at least some of the expenses of gender reassignment treatment. In January 2021, for example, Aetna agreed to expand coverage for patients with gender dysphoria to include breast augmentation. It will also reimburse patients who have been denied coverage in recent years.
While coverage is changing quickly, large insurers provide a detailed list of what is and is not covered by their policies. For example, BlueCross BlueShield of Tennessee’s Medical Policy Manual covers surgeries it deems “medically necessary,” but excludes a long list of procedures as not covered because they’re considered cosmetic. These include brow lift, cheek, chin, and nose implants, jaw shortening and sculpting, removal of redundant skin, and voice modification surgery.
Tricare, the civilian health care provider for the military, generally doesn’t cover surgery for gender dysphoria, according to fact-check website, Snopes. However, conforming to the latest Biden administration orders, Tricare and active military healthcare may have to catch up its coverage.
Some treatments for transgender youths may be covered by their parents’ health insurance policies. Puberty blockers, hormones, masculinizing chest surgery, and counseling were the most commonly covered, according an analysis of 36 plans used by patients at a pediatric gender clinic. No plans covered all four categories of recommended services, and fewer than half covered any service. Nearly half of the plans had transgender-specific exclusions.
Affordable Care Act policies
Individuals can purchase their own health insurance policies, often with significant government subsidies, at healthcare.gov. Subsidies on policy premiums have been boosted as part of COVID-19 relief.
Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. Still, policies vary by state and in what they cover, and many health plans still exclude services related to sex change or sex reassignment surgery. Check a policy’s complete terms of coverage for the full explanation of which procedures and services are covered or excluded under each plan. Many plans deny coverage to transgender people for certain healthcare services.
For the approximately 10,000 transgender people who are enrolled in Medicare or Medicare Advantage, medically necessary care, including some gender confirmation procedures, are covered. Medicare Advantage plans may vary in coverage; an insurance broker can help you find the right plan.
A patchwork of policies across the U.S. leave some Medicaid beneficiaries who are transgender without access to coverage for gender-affirming care. Eighteen states and D.C. specifically include coverage for gender-affirming care under their Medicaid programs or are in the process of extending coverage. Twelve states exclude coverage for such care and 20 states have not expressly addressed coverage.
Personal loans. A loan from a family member, credit union, or bank is one way to manage expenses. Another is an online personal loan from places such as Lending Club, Lightstream, and Prosper. These may be quicker and easier to compare than those from traditional banks.
Credit cards. Paying surgical bills using a low interest credit card or medical credit card is another strategy. As with loans, it’s important to compare interest rates, which can significantly increase the total expense. Keep in mind that, in many cases, a missed payment can greatly increase your interest rate and fees.
Cash. Patients paying providers and hospitals directly without using insurance may find that they can get cash prices for services that are lower than those that providers charge insurers. It’s important to obtain a clear list of all charges in advance so there are no surprises once the procedure is done. When negotiating directly with hospitals or providers, keep in mind that online pricing estimates are cash prices and often lower than the hospital will bill your insurance. Enlist your doctor’s help with any pricing or billing disputes. Keeping staff surgeons happy is in the hospital’s interest, so billing representatives may be more responsive to doctors than patients.
Crowdfunding. Sites like GoFundMe and YouCare may work best for those who have friends or relatives willing to contribute, since they, not strangers, are likely to be the best contributors. In a study by the Pew Foundation, a large majority of crowdfunders’ money went to family, close friends, and acquaintances.21 Using social media to publicize the fundraising can help individuals meet their goals.
Medical Grants. Some organizations, such as The Jim Collins Foundation and Point of Pride, offer grants to help transgender people afford surgery. Some are quite specialized. For example, blacktransmen offers grants of up to $1,000 to help Black and African American men afford gender-affirming top surgery. While many of these organizations can fund only a small number of applicants, they are certainly worth investigating.
The Bottom Line
Finding a provider or a medical center that has experience treating transgender patients is a good first step. Transhealthcare offers a Go-To Guide to Gender Surgeons. And the National Center for Transgender Equality offers a guide for analyzing your coverage, composing preauthorization patient and doctor letters, and dealing with coverage denials.