Many health insurance providers use these guidelines to direct which procedures are medically necessary.
However, not every insureror statedoes.
Outdated terms like sex reassignment or sex change should not be used.
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Medical or surgical procedures are only one facet of gender affirmation.
Some people are content with social or other medicaltransition options.
Cost
Cost is one of the primary reasons people have limited access to gender-affirmation surgeries.
Historically, mostpublic or private insurance companieshave not covered these procedures.
Fortunately, that is changing.
Some public and private insurance companies cover some or all gender-affirmation surgery options.
But that coverage often comes with many hoops that people need to jump through.
It is also not available to all people in all states.
These surgeons, particularly very experienced ones, are often booked months or years in advance.
In addition, many dont take insurance.
Fortunately, as insurance coverage for gender-affirmation surgeries has increased, so too has physician interest in training.
Gatekeeping
Another barrier is a process called gatekeeping currently endorsed by WPATH.
Gatekeeping involves undergoing a significant therapy or psychiatric assessment before they are allowed to transition medically.
These are also known as the WPATH criteria or WPATH requirements.
WPATH updates its guidelines every five to 10 years.
These standards of care help define which treatments are medically necessary and under which conditions they should be authorized.
The standards have become less restrictive over time, reflecting the growing recognition of gender diversity in society.
For transmasculine people, this surgery is called chest reconstruction.
For transfeminine people, it is breast augmentation.
For transgender men, there is no hormone requirement or recommendation.
Thats because some transmasculine people are only dysphoric about their chests.
Therefore, they do not want or need testosterone treatment.
There are also several physical and psychological reasons people choose to undergo top surgery without hormone use.
Therefore, waiting a year may result in a more aesthetic outcome.
They may also be performed alongside other gender-affirmation surgeries.
Removing the gonads alone can lower the amount of cross-sex hormone therapy required to get results.
In addition, removing the uterus or cervix eliminates the need to screen those organs.
Thats important because those screening exams can cause dysphoria and discomfort in many transgender men.
These procedures make a persons genitalia more in line with their gender identity.
Aftercare for these surgeries can be emotionally intense and difficult.
For example,following vaginoplasty, consistent vaginal dilation is required to maintain depth and girth and avoid complications.
These requirements can sometimes be challenging for people with a history of sexual trauma.
Standards for Facial Feminization Surgery
There are no formal guidelines for facial feminization surgery.
One exception is chest surgery for transmasculine adolescents.
Even WPATH notes that the criteria put forth in this document… are clinical guidelines.
Individual health professionals and programs may modify them.And many times, they do.
Even so, eligibility requirements can vary as cancopayment and coinsurancecosts.
Many state Medicaid programs cover aspects of gender-affirming health services.
The remaining states either have no policies in place or offer no reporting of coverage.
Prior to 2014, no coverage was offered.
The challenge with accessing surgery is that Medicare has no national precedent for approving or denying coverage.
This letter often also contains a narrative of the persons gender history in detail.
In addition, the letter should state how long the provider has been working with the person.
Documentation of this is also usually in a letter from the relevant healthcare provider.
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.
Symptom relief is true not just for anxiety and depression but for more severe conditions such as psychosis.
What you might Do
Getting insurance coverage for gender confirmation surgery can be a frustrating process.
Thats particularly true if they include surgeries other than those listed above.
Many health centers are now hiring transgender patient navigators who have extensive experience with the insurance process.
They can be a great resource.
Local and national LGBTQ-focused legal organizations often have helplines or access hours where people can seek information.
Summary
Gender-affirmation surgery refers to various surgeries that allow people to align their bodies with their gender.
WPATH guidelines offer criteria for determining whether someone is a good candidate for gender-affirmation surgery.
Not all insurance offers coverage for gender-affirmation surgery, but some do.
First, however, you gotta provide the proper documentation to show that you meet specific surgery criteria.
This documentation is usually in a letter written by your physician or mental health clinician.
National Center for Transgender Equality.The report of the 2015 U.S. transgender survey.
2022;23(Suppl 1):S1-S259.
2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837
Kaiser Family Foundation.Update on Medicaid coverage of gender-affirming health services.
Centers for Medicare and Medicaid Services.Gender dysphoria and gender reassignment surgery.
Transgender Legal Defense & Education Fund.Health insurance medical policies: gender dysphoria / gender reassignment.
2017;4(2):106-114. doi:10.1089/lgbt.2016.0133
