FAQ on Access to Transition-Related Care
MY STORY: Roman Rimer
A struggle, a step forward and then insurance says “no”

“I have memories as a child of wanting to be male-bodied, but I assumed I was meant to be the way I was. I struggled a lot.

“I never enjoyed having breasts. I remember once in college I went to be fitted for a bra in a store and I couldn’t stop crying. I couldn’t really figure out why; I just assumed there was something wrong with me or I was too emotional.

“I bound my chest for a while and then I had surgery. My insurance company said they would cover 70 percent of a double mastectomy if there was a history of breast cancer—which was the case—but not for sex reassignment. I got a letter in the mail, saying, ‘We don’t cover this.”

FAQ on Access to Transition-Related Care

What exactly is Gender Dysphoria?

Gender Dysphoria is a medical diagnosis recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the American Psychiatric Association’s (APA) encyclopedia of official diagnoses, as "[T]he distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender." The World Health Organization’s International Classification of Diseases (ICD) recognizes that Gender Dysphoria (formerly called Gender Identity Disorder, or GID) is “characterized by a persistent and intense distress about assigned sex, together with a desire to be, or insistence that one is, of the other sex.”

The American Medical Association (AMA) established in a 2008 resolution that Gender Dysphoria (then GID) is a “serious medical condition” with symptoms including “distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death.”

In 2013, Gender Dysphoria replaced the diagnosis of Gender Identity Disorder in the DSM. The APA explained that "Replacing 'disorder' with 'dysphoria' in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is 'disordered.'" The APA said it was concerned that completely 'removing the condition as a psychiatric diagnosis--as some had suggested--would jeopardize access to care... Many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. To get insurance coverage for the medical treatments, individuals need a diagnosis."

Does every transgender person have Gender Dysphoria?

No they do not, because not every transgender person experiences the distress associated with Gender Dysphoria or requires medical transition.

What is the treatment for Gender Dysphoria?

The treatment for Gender Dysphoria involves some combination of “triadic therapy”: hormone therapy, sex reassignment surgery and/or Real Life Experience (living for a period of time in accordance with your gender identity). Each patient must be evaluated on a case-by-case basis, with expert medical judgment required for both reaching a diagnosis and determining a course of treatment. There is no set formula for gender transition.

These treatment protocols are outlined in the Standards of Care published by the World Professional Association for Transgender Health (WPATH), which keeps the public up to date on the “professional consensus about the psychiatric, psychological, medical, and surgical management of Gender Dysphoria.”

Can sex reassignment surgery (SRS) and/or hormone therapy be considered “medically necessary” by doctors for people with Gender Dysphoria?

Yes, doctors have found such treatments to be medically necessary for many people. The AMA passed a resolution in 2008 recognizing “an established body of medical research” that “demonstrates the effectiveness and medical necessity of mental health care, hormone therapy, and sex reassignment surgery as forms of therapeutic treatment for many patients diagnosed with [Gender Dysphoria].” Similar policy statements have been issued by a range of medical organizations, including the American Psychological Association, the American Academy of Family Physicians, the National Association of Social Workers and WPATH (see www.lambdalegal.org/trans-insurance for full text).

Courts have repeatedly ruled that these treatments may be medically necessary and have recognized Gender Dysphoria as a legitimate medical condition constituting a “serious medical need” (see Lambda Legal’s victory in Fields v. Smith, next page). Courts have also found that psychotherapy alone is insufficient treatment for Gender Dysphoria, and that for some people, SRS may be the only effective treatment.

Health insurance plans that exclude services related to gender transition often say they are “cosmetic” or “experimental.” Is this true?

No. The myth that transition-related care is “cosmetic” or “experimental” is discriminatory and out of touch with current medical thinking. The AMA and WPATH have specifically rejected these arguments, and courts have affirmed their conclusion. In a case brought by Gay and Lesbian Advocates and Defenders (GLAD), O’Donnabhain v. Commissioner, for instance, the Internal Revenue Service lost its claim that such treatments were cosmetic and experimental when a transgender woman deducted her SRS procedures as a medical expense.

Is it true that some health plans won’t cover Gender Dysphoria but will pay for the same treatments, as long as they are not related to gender transition?

Yes: Psychotherapy, hormone therapy, breast augmentation or removal, hysterectomy, and a range of other procedures are frequently covered for non-Gender-Dysphoria-related medical conditions, but are often denied if related to gender transition.

Such exclusions leave no room for individual medical assessments of the kind recommended by the AMA and other professional medical organizations. They also may be unconstitutional because they deny care to a group of people based on who they are. For people who are incarcerated, courts have called these sorts of blanket policies “deliberate indifference” and ruled that they violate the Eighth Amendment prohibition against cruel and unusual punishment.

Wouldn’t it be expensive for insurance companies to cover transition-related health care?

Some employers worry that covering transition-related health care will raise the cost of insurance premiums, but there are data showing that is not the case. While the cost is prohibitive for many individuals, it’s negligible when an insurance plan takes it on—because Gender Dysphoria is so rare.

For example, San Francisco, which became the first U.S. city to provide insurance coverage for Gender Dysphoria-related care in 2001, quickly learned that the change would not cost municipal employees anything at all. After four years, during which time the city paid out only 11 Gender Dysphoria-related claims, the surcharge that employees had been paying to cover the policy change was reduced to zero. There simply was no need to take in the extra money, because the cost of covering these claims was so negligible.

Not treating Gender Dysphoria, on the other hand, can be quite a strain on the health care system. According to the AMA, “Delaying treatment for [Gender Dysphoria] can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illness, depression, and substance abuse problems.”

Do some employers and insurance companies cover Gender Dysphoria?

Yes, a growing number of employers—including major firms such as Nike, Microsoft and Google—are leading the way in this area by removing outmoded and discriminatory exclusions of transition-related health care and offering trans-inclusive coverage as part of diversity initiatives. Aetna, Cigna and Blue Cross/Blue Shield are among providers now including coverage of transition-related health care, although it is up to each employer to make sure that a plan is inclusive. For more information, go to www.hrc.org/issues/workplace/benefits/transgender_inclusive_benefits.htm.

What should I do if I am denied coverage for transition-related health care?
Is there any progress being made toward getting transgender prisoners access to care?

Yes. People who need transition-related care while in prison are often at the mercy of outmoded treatment policies, on top of being vulnerable to harassment by prisons officials or fellow inmates. Under these extreme conditions, many inmates injure themselves, some going so far as to “self-treat” by attempting to perform surgery to remove their own genitals, which can be life-threatening.

But many transgender prisoners have been successful in demonstrating their need for health care behind bars by arguing that this lack of care violates the Eighth Amendment’s prohibition of cruel and unusual punishment. In Fields v. Smith, for instance, Lambda Legal represented transgender women incarcerated in Wisconsin who had been on hormone therapy for years before the state legislature passed a law in 2006 banning transition-related care for inmates in state prisons. No other state has such a law. The withdrawal symptoms and horrible physical and mental effects that inevitably followed this change in policy were devastating to these women.

A U.S. District Court found in the inmates’ favor in a 2010 ruling that the law violated the Eighth Amendment because “[t]he decision of whether or not certain treatment or a particular type of surgery is ‘medically necessary’ rests with the individual recipient’s physician.” The court also ruled that the Wisconsin law violated the equal protection clause of the Fourteenth Amendment because prisoners with GID were denied many of the exact same medical treatments permitted prisoners with other diagnoses. The court said transgender people should have the same access as similarly situated non-transgender people to an individual assessment of their medical and psychological needs, as well as to the appropriate treatment options. Lambda Legal is working to uphold this ruling in the 7th Circuit Court of Appeals.

FOR MORE INFORMATION: Contact Lambda Legal at 212-809-8585, 120 Wall Street, Suite 1900, New York, NY 10005-3904. If you feel you have experienced discrimination, call our Help Desk toll-free at 866-542-8336 or go to www.lambdalegal.org/help.