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.”

Accessing Coverage for Transition-Related Health Care

The kinds of health care associated with gender transition have too often been misunderstood as cosmetic, experimental or simply unnecessary. Yet there is medical consensus that hormone therapy and gender-affirming surgery are medically necessary for many transgender people. It’s quite clear now that a person’s gender identity—one’s inner sense of being male or female—is deep-seated and cannot be changed. Therefore, this transition-related health care can be crucial.

To read our FAQ about health care access, click here.

The courts have come a long way on this issue in recent years, citing decades of medical data to find in more and more cases that not providing transition-related health care as readily as other medically necessary treatment is discrimination.

The problem is that most public and private insurance companies are still behind the times. Many cite cost, even though that hasn’t turned out to be an issue at all for the growing number of employers now providing coverage. Often the real hesitation is a mixture of anti-transgender prejudice and ideas about such care that are out of sync with modern medical thinking.

The language used by doctors and the courts in this area can be frustrating, because it generally relies on technical terms such as gender dysphoria, a mental health diagnosis that describes the extreme distress some people experience when their bodies don’t match their gender identity. Some people feel that this diagnosis unnecessarily stigmatizes transgender people and encourages mistreatment of them. Whatever term is used, however, it is not fair for health care policies to have different standards for treating transgender people who have medical needs associated with transition than for treating someone with diabetes who needs vital care. In both cases, a doctor makes an individualized assessment to determine if treatment is warranted—if it is, both patients should get the recommended care.

Our FAQ about health care access explains the medical community’s current framework for understanding transition-related care as medically necessary and how Lambda Legal and other advocates are applying this in the legal domain to challenge denial of such care as discrimination. Also highlighted are ways that private industry and municipal government have begun to follow the medical mainstream by dropping barriers to health care for transgender people and setting standards for a more equitable future.

DIAGNOSIS?

“GID” IS NOW OFFICIALLY “GENDER DYSPHORIA”

In 2013, gender dysphoria replaced the diagnosis of gender identity disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) manual used by clinicians and researchers to diagnose and classify mental conditions. 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.”

TIPS

ADVOCATING FOR INSURANCE COVERAGE OF YOUR MEDICAL NEEDS

If you are denied insurance coverage for transition-related health care, consider taking these steps:

  1. Get a copy of your health insurance policy to see if there is any discriminatory exclusion language. If so, find out what the process is to appeal a denial of coverage. You will likely need to provide written documentation from your doctor that this treatment is deemed medically necessary for you.
  2. Use official statements from any of the following five medical organizations (links to them online are available at www.lambdalegal.org/publications/trans-insurance) as backup for your argument that transition-related care is not cosmetic or elective and should be covered:

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.