Table of ContentsView AllTable of ContentsType of SurgeriesBarriers to AccessWPATH StandardsRestrictions to CoverageGetting StartedWhat You Can Do
Table of ContentsView All
View All
Table of Contents
Type of Surgeries
Barriers to Access
WPATH Standards
Restrictions to Coverage
Getting Started
What You Can Do
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DefinitionGender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like “sex reassignment” or “sex change” should not be used.Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.Medical or surgical procedures are only one facet of gender affirmation.
Definition
Gender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like “sex reassignment” or “sex change” should not be used.Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.Medical or surgical procedures are only one facet of gender affirmation.
Gender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like “sex reassignment” or “sex change” should not be used.
Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.
Medical or surgical procedures are only one facet of gender affirmation.
What Is Transphobia?
Types of Gender-Affirmation Surgery
Not all transgender,non-binary, andgenderqueerindividuals want surgery to align their bodies to their gender identity. Some people are content with social or other medicaltransition options.
Others want one or more surgeries, including those referred to as “top surgery” (occurring above the waist) and “bottom surgery” (occurring below the waist).
An extensive national survey of transgender people found that:
Common Barriers to Gender-Affirmation Surgery
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.
Surgeon Availability
Another major factor limiting access to surgery is the small number of surgeons trained to perform them. These surgeons, particularly very experienced ones, are often booked months or years in advance.
In addition, many don’t take insurance. Fortunately, as insurance coverage for gender-affirmation surgeries has increased, so too has physician interest in training. Today, there are many hospitals across the country that routinely perform vaginoplasty and accept insurance to pay for them.
“Gatekeeping”
It is a process that attracted considerable debate given that this level of scrutiny is not required for other major surgeries. It ultimately places the decision in the hands of a psychiatrist who can determine if a person is mentally “fit” to pursue treatment.
Discrimination and StigmaIn addition to barriers like cost and surgeon availability/competency, there is also a long history of discrimination and stigma limiting transgender patients’ access to care.
Discrimination and Stigma
In addition to barriers like cost and surgeon availability/competency, there is also a long history of discrimination and stigma limiting transgender patients’ access to care.
Insurance and the WPATH Standards
When determining eligibility for gender-affirming surgery coverage, many insurers turn to the WPATH Standards of Care to inform their eligibility guidelines. 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.
The standards of care are broadly described as follows:
Standards for Top Surgery
“Top surgery” refers to gender-affirmation surgery of the breast or chest. For transmasculine people, this surgery is called chest reconstruction. For transfeminine people, it is breast augmentation.
The WPATH criteria for top surgery include:
Standards for Hormone Therapy
It is important to note that hormone therapy is not required for these surgeries. However, a year ofhormone therapyisrecommendedfor transgender women because it allows them to get the maximum possible breast growth without surgery, which improves surgical outcomes.
For transgender men, there is no hormone requirement or recommendation. That’s 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. That said, people who aretaking testosteroneand are very active may wish to wait a year for surgery because testosterone and exercise can significantly reshape the chest. Therefore, waiting a year may result in a more aesthetic outcome.
Standards for Orchiectomy, Hysterectomy, and Ovariectomy
These surgeries involve the removal of the testicles (orchiectomy), uterus (hysterectomy), or ovaries (ovariectomy).
WPATH criteria for these surgeries include:
Surgeries to remove the gonads (testes, ovaries) and the uterus may be performed independently. 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. That’s important because those screening exams can cause dysphoria and discomfort in many transgender men.
Standards for Vaginoplasty, Phalloplasty, and Metoidioplasty
This group of surgeries constructs a vagina (vaginoplasty) or penis (phalloplasty, metoidioplasty). These procedures make a person’s genitalia more in line with their gender identity.
The requirement for a year of living in a gender role is because it gives people time to adjust to their desired gender. In addition, doctors widely believe that a year is a sufficient time for that adjustment before undergoing a complicated, expensive, and irreversible surgery.
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.
Aftercare RecommendationsDue to these surgeries’ physical and emotional intensity, experts recommend that those considering them have regular visits with a mental or medical health professional.
Aftercare Recommendations
Due to these surgeries’ physical and emotional intensity, experts recommend that those considering them have regular visits with a mental or medical health professional.
Standards for Facial Feminization Surgery
Standards for Children and Adolescents
WPATH guidelines for children and adolescents include criteria for fully reversible interventions (puberty blockers that pause puberty, for example) or partially reversible ones (hormones, for example). However, they do not recommend irreversible (surgical) interventions until the age of majority in their given country.
One exception is chest surgery for transmasculine adolescents. WPATH criteria suggest this could be carried out before adulthood, after ample time of living in their gender role, and after being on testosterone treatment for one year.
Generally speaking, private insurance companies are more likely to offer coverage for some or all procedures than government agencies like Medicaid and Medicare. Even so, eligibility requirements can vary as cancopayment and coinsurancecosts.
Medicaid
Many state Medicaid programs cover aspects of gender-affirming health services. But only two states—Maine and Illinois—cover all five WPATH standards of care as of October 2022 (hormone therapy, surgery, fertility assistance, voice and communication therapy, primary care, and behavioral intervention).
Current Medicaid Coverage StatusIn terms of gender-affirming surgery, 23 states provide coverage for adults, while nine states (Alabama, Arizona, Florida, Hawaii, Iowa, Kansas, Missouri, Texas, and Wyoming) currently deny coverage. The remaining states either have no policies in place or offer no reporting of coverage.
Current Medicaid Coverage Status
In terms of gender-affirming surgery, 23 states provide coverage for adults, while nine states (Alabama, Arizona, Florida, Hawaii, Iowa, Kansas, Missouri, Texas, and Wyoming) currently deny coverage. The remaining states either have no policies in place or offer no reporting of coverage.
Medicare
Medicareis federal health insurance for people 65 or older and some younger people with disabilities.Original Medicare(Part A and Part B) will cover gender-affirmation surgery when it is considered medically necessary. Prior to 2014, no coverage was offered.
As a general guideline, the CMS states that the following is needed for you to be an eligible candidate for gender-affirmation surgery:
If coverage is denied, there is an appeal process you can undergo to overturn the denial.
Private Insurance
Most private insurance companies in the United States will offer coverage for some—but not necessarily all—gender-affirming surgeries.
According to the Transgender Legal Defense & Education Fund (TLDEF), many of the larger insurers offer coverage for a comprehensive array of surgeries, including providers like:
Others have different standards in different states (such as AmeriHealth) or only offer coverage for specific surgeries like facial feminization surgery (Prestige and AmeriHealth New Hampshire).
Though coverage of gender-affirmation surgery is increasing, many private insurers still require you to meet extensive criteria before approval is granted. By way of example, to get approval for breast augmentation, a transgender woman would need to provide a company like Aetna:
Even if approval is granted, copayment, coinsurance, and out-of-pocket costs can vary, often considerably.
Out-of-Pocket CostsAccording to a 2022 study from Oregon Health & Science University, a transgender person who underwent “bottom” surgery from 2007 to 2019 paid an average of $1,781 out of pocket.With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.
Out-of-Pocket Costs
According to a 2022 study from Oregon Health & Science University, a transgender person who underwent “bottom” surgery from 2007 to 2019 paid an average of $1,781 out of pocket.With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.
According to a 2022 study from Oregon Health & Science University, a transgender person who underwent “bottom” surgery from 2007 to 2019 paid an average of $1,781 out of pocket.
With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.
Showing that a person has “persistent, well-documented gender dysphoria” usually requires a letter from a mental health provider. This letter usually states that the person meets the criteria for gender dysphoria, including the length of time that has been true.
This letter often also contains a narrative of the person’s gender history in detail. In addition, the letter should state how long the provider has been working with the person.
Well or Reasonably Controlled
It is important to note that some standards require that medical and mental health problems be well controlled, while others only require them to bereasonablywell controlled. Documentation of this is also usually in a letter from the relevant healthcare provider.
This letter should contain information about the history of the condition, how it is controlled, and the length of the clinician’s relationship with the person. Ideally, the phrases “well controlled” or “reasonably well controlled” are used in the letter as appropriate.
Using terminology referenced in the WPTH criteria 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. Symptom relief is true not just for anxiety and depression but for more severe conditions such as psychosis.
Getting insurance coverage for gender confirmation surgery can be a frustrating process. However, it can help to prepare 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 those listed above.
In addition, it may be a good idea to reach out to your local LGBT health center 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.
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.
9 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al.Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study.Plast Reconstr Surg. 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837National Center for Transgender Equality.The report of the 2015 U.S. transgender survey.World Professional Association for Transgender Health.Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.Kaiser Family Foundation.Update on Medicaid coverage of gender-affirming health services.CMS.gov.Gender dysphoria and gender reassignment surgery.Transgender Legal Defense & Education Fund.Health insurance medical policies: gender dysphoria / gender reassignment.Aetna.Gender-affirming surgery.Downing J, Holt SK, Cunetta M, Gore JL, Dy GW.Spending and out-of-pocket costs for genital gender-affirming surgery in the US.JAMA Surg.2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606Meijer 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;4(2):106-114. doi:10.1089/lgbt.2016.0133
9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al.Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study.Plast Reconstr Surg. 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837National Center for Transgender Equality.The report of the 2015 U.S. transgender survey.World Professional Association for Transgender Health.Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.Kaiser Family Foundation.Update on Medicaid coverage of gender-affirming health services.CMS.gov.Gender dysphoria and gender reassignment surgery.Transgender Legal Defense & Education Fund.Health insurance medical policies: gender dysphoria / gender reassignment.Aetna.Gender-affirming surgery.Downing J, Holt SK, Cunetta M, Gore JL, Dy GW.Spending and out-of-pocket costs for genital gender-affirming surgery in the US.JAMA Surg.2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606Meijer 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;4(2):106-114. doi:10.1089/lgbt.2016.0133
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al.Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study.Plast Reconstr Surg. 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837National Center for Transgender Equality.The report of the 2015 U.S. transgender survey.World Professional Association for Transgender Health.Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.Kaiser Family Foundation.Update on Medicaid coverage of gender-affirming health services.CMS.gov.Gender dysphoria and gender reassignment surgery.Transgender Legal Defense & Education Fund.Health insurance medical policies: gender dysphoria / gender reassignment.Aetna.Gender-affirming surgery.Downing J, Holt SK, Cunetta M, Gore JL, Dy GW.Spending and out-of-pocket costs for genital gender-affirming surgery in the US.JAMA Surg.2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606Meijer 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;4(2):106-114. doi:10.1089/lgbt.2016.0133
Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al.Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study.Plast Reconstr Surg. 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837
National Center for Transgender Equality.The report of the 2015 U.S. transgender survey.
World Professional Association for Transgender Health.Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.
Kaiser Family Foundation.Update on Medicaid coverage of gender-affirming health services.
CMS.gov.Gender dysphoria and gender reassignment surgery.
Transgender Legal Defense & Education Fund.Health insurance medical policies: gender dysphoria / gender reassignment.
Aetna.Gender-affirming surgery.
Downing J, Holt SK, Cunetta M, Gore JL, Dy GW.Spending and out-of-pocket costs for genital gender-affirming surgery in the US.JAMA Surg.2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606
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;4(2):106-114. doi:10.1089/lgbt.2016.0133
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