Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape

Abstract

Background Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. Objective The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. Methods The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. Results Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. Conclusions There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.

Coverage for Gender‐Affirming Voice Surgery and Therapy for Transgender Individuals

“…Although preceding literature suggests interstate variation in the extent of coverage for ancillary gender‐affirming surgeries, 22 coverage status for voice‐related care was not correlated with laws driving transgender equality in the present study. Anecdotally, many states successful in securing greater coverage were those with nondiscrimination laws for private insurance companies, reflected in their high state tallies.…”

“…The present study extends this literature by establishing a similar trend in coverage for voice therapy and surgery. Derived from over twice the number of insurance companies, these data also demonstrate a lower incidence in overall coverage for transgender voice interventions than previously described 22 …”

“…Although considered medically necessary by international standards of care, 18 universal coverage is not provided for transition‐related genital and chest surgeries 19,20 . Less than a third of commercial insurers offer coverage for facial gender‐affirming surgery, chondrolaryngoplasty (i.e., tracheal shave), and body contouring; furthermore, coverage for these auxiliary gender‐affirming surgeries varies by state legal advocacy, such that companies in states without nondiscrimination laws 21 for transgender‐related healthcare offer less favorable policies 22 …”

“…Such interventions have not only been shown to effectively increase patient satisfaction and promote gains in externally rated characteristics important to listeners' perception of gender, 26,27 but also improve voice‐related quality of life and mental health while reducing gender dysphoria 29–34 . However, gender‐affirming vocal fold surgeries are rarely covered by insurance, 22 and the extent of coverage for voice therapy is unknown. Previous literature points to the potential reasons for lack of coverage, including discrimination and harassment in a medical setting 35,36 .…”

Transition Coverage and Clarity in Self-Insured Corporate Health Insurance Benefit Plans

“…Much research in this area has focused on insurance market segments where publication is required such as those on the ACA marketplaces, Medicare, and Medicaid, and surveys of other insurance offerings do not analyze the actual insurance contract (the consumer-facing document), { and rely on phone calls to insurers and web searches to gather insurance company information. 7,[20][21][22] Advocacy organizations such as the Human Rights Campaign (HRC) have been very important in filling the gap of knowledge for LGBT people with their Healthcare Equality and Workplace Equality ratings, 23 but these are self-reported surveys without scrutiny of documents.…”