Transgender Healthcare in the US

General Health Care

Transgender healthcare in the U.S. falls into two categories: general healthcare services for transgender individuals and transgender-related services. 

Prior to the Affordable Care Act (ACA), many transgender individuals had limited access to both general healthcare services and transgender-related services. Being transgender was considered a pre-existing condition, which meant that health insurance companies could legally charge a transgender patient higher premiums or deny them coverage. The ACA made that practice illegal in 2014. Two years later, the federal government provided another layer of legal protection by adding gender identity to Section 1557 of the law, which already prohibited discrimination based on race, color, national origin, sex, age, or disability. 

As a result, transgender individuals in the US now have the right to purchase insurance and receive general health servces equal to cisgender people. However, that does not necessarily mean that gender affirmation services are guaranteed to be covered.

What are Gender Affirmation Services?

Transgender is an umbrella term used to refer to individuals whose gender identity does not align with the sex they were assigned at birth. Many members of this population experience discomfort in their body as a result, potentially leading to psychological distress. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) calls this gender dysphoria. 

While previous versions of the DSM instead listed “Gender Identity Disorder”, the authors of the DSM-5 concluded that there is nothing inherently wrong with varied gender identities and classifying them as a disorder was, like the inclusion of “homosexuality” in the DSM until 1973, unneccessarily stigmatizing. The DSM-5 clarifies that having a non-traditional gender identity is not an issue. However, if a person experiences persistent distress as a result of the conflict between their body and their identity, that “gender dysphoria” is a disorder in need of treatment. Effective treatment involves altering the person’s gender expression and body to better align with their identity. Gender affirmation services are medical services that achieve this purpose. Types of gender affirmation services include:

• Gender-Affirming Hormone Therapy
  • Feminizing hormone therapy: Medications will a) block the production of testosterone, and b) introduce more estrogen into the system in order to induce feminine secondary sex characteristics such as breast development and facial/body hair reduction. 
  • Masculinizing hormone therapy: Medications will a) block the production of estrogen, and b) introduce more testosterone into the system in order to induce masculine characteristics such as a change in muscle mass as well as the production of facial/body hair. 
• Pubertal blockers: Medications that young gender divergent individuals can take to temporarily suppress the release of sex hormones and therefore the effects of puberty. If someone stops taking the medication, the release of hormones and normal development of secondary sex characteristics will resume.
• Surgery
  • Removal of breasts, ovaries, uterus, penis, testicals, and prostate gland; and genital reconstruction.
  • Facial contouring or hair transplants (often considered cosmetic and therefore commonly excluded even in plans that have broader coverage).

Types of Insurance

Whether a person experiencing gender dysphoria is able to access treatment depends largely on what type of insurance they have. 

• Uninsured: If someone is uninsured, they pay for the entirety of the service out of pocket. Transgender adults are more likely to be uninsured than cisgender adults as well as to report barriers due to cost. Hormone therapy typically costs $100/month and gender affirmation surgery usually ranges from $7,000 to $50,000.
• Employer Insurance: Nearly half of Americans receive health insurance through their employer. Employers (including 67% of Fortune 500 companies), increasingly offer health plans that include coverage for gender affirmation services, yet there is still variation in coverage. Employers can be as generous as they wish. When it comes to determining whether an employer is meeting minimum coverage requirements, however, it is far more complex. Self-insured and level-funded group health plans are only subject to federal nondiscrimination laws. Fully insured group health plans must also comply with non-discrimination laws of the state they are written out of. 
• Medicaid: Medicaid is a government-provided health insurance option for low-income Americans. While the program receives federal funding, it is run and administered by the state. As a result, the 152,000 transgender adults on Medicaid experience different coverage depending on their location. However, evaluating coverage is not easy, as most states do not include information about gender affirmation services in their Medicaid handbooks/webpages. An analysis published in 2021 found that 67% of states cover hormone therapy and 49% cover surgery.
  • Hormone Therapy:
    • Covered: 34 of 51 states 
    • Not covered: 9 of 51 states and 2 of 5 territories 
    • Could not confirm: 8 of 51 states and 3 of 5 territories
  • Surgery
    • Covered: 25 of 51 states 
    • Not covered: 22 of 51 states and 3 of 5 territories 
    • Could not confirm: 4 of 51 states and 2 of 5 territories
• Medicare: Medicare is a federal government health insurance program available to persons over the age of 65 and persons with disabilities. For decades, Medicare excluded transgender surgery and related procedures because procedures were deemed experimental. In 2014, the Centers for Medicare and Medicaid Services issued a new determination. Now Medicare determines coverage of transgender-related procedures on a case-by-case basis. As with other health services, it outlines requirements for diagnosis and proof of need. So long as that burden is met, Medicare now covers hormone therapy as well as most surgical procedures (with the exception of those deemed cosmetic, such as facial contouring and hair transplants). As of 2018, 10,200 individuals were accessing transgender services through Medicare. An analysis showed that 77% of transgender individuals on Medicare were under the age of 65, meaning they had access to this insurance option because of a disability. 
• Non-Group Insurance: Individuals who do not qualify for Medicare or Medicaid and who do not receive insurance through their employer can purchase health insurance on the government-run Marketplace. Like with employer-sponsored insurance, there is extensive variation in clarity, coverage specification, and types of exclusions.
  • 9% of contracts excluded all trans-related services.
  • 25% of companies offered an exclusionary contract.

According to Healthcare.gov, transgender individuals should look in contracts for:

• “All procedures related to being transgender are not covered.”
• Other sections using language: “gender change,” “transsexualism,”  “gender identity disorder,” and “gender identity dysphoria.”