Understanding Insurance Requirements for Gender Confirmation Surgery

Gender confirmation surgery is an umbrella term used for any surgery that transgender or gender-nonconforming people use to align their bodies to their gender identity.

Gender confirmation surgery is also called gender alignment surgery and gender affirmation surgery.

"Sex change operation" or "sex reassignment surgery" are outdated terms that people should no longer use. Instead, phrases that refer to aligning a person's body to their gender are more appropriate.

Transgender rally outside with flags and signs
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This article explains the World Professional Association for Transgender Health (WPATH) standards of care for each type of gender confirmation surgery and how insurance companies use them to determine eligibility. It also explains the documentation you may need for surgery and how to obtain it.

Access and Interest in Gender Confirmation Surgery

Not all transgender, non-binary, and genderqueer individuals want surgery to align their bodies to their gender identity. Some people are content with social or other medical transition options.

Others want one or more surgeries but may or may not have access to them. An extensive national survey of transgender individuals found that:

  • 66% of transgender women either had or wanted vaginoplasty or labiaplasty.
  • 51% of transgender women either had or wanted breast augmentation.
  • 50% of transgender women either had or wanted facial feminization (surgery to make a face appear more feminine).
  • 38% of transgender women either had or wanted a tracheal shave (removal of the Adam's apple).
  • 58% of transgender women either had or wanted orchiectomy (removal of the testes).
  • 22% of transgender men either had or wanted phalloplasty (creation of a penis).
  • 27% of transgender men either had or wanted metoidioplasty (surgery that uses existing genitalia to create a penis).
  • 97% of transgender men either had or wanted chest reconstruction or mastectomy (also called "top surgery").
  • 71% of transgender men either had or wanted a hysterectomy (removal of the uterus).

Cost

Cost is one of the primary reasons people have limited access to gender confirmation surgeries. Historically, most public or private insurance companies have not covered these procedures. Fortunately, that is changing.

Some public and private insurance companies cover some or all gender confirmation surgery options. But unfortunately, that coverage often comes with many hoops that people need to jump through. It is also not available to all people in all states.

Qualified Doctors

Another major factor limiting access to surgery is the small number of doctors trained to perform them. These doctors, particularly the very experienced ones, are often booked out for months or years in advance.

In addition, many of them don't take insurance. Fortunately, as insurance coverage for gender confirmation surgeries has increased, so has physician interest in training. For example, there are now many hospitals across the country that perform vaginoplasty. Even better, many accept insurance to pay for the procedure.

Prejudice and Stigma

In addition to barriers like cost and finding a competent physician, there is also a long history of prejudice and stigma limiting transgender patients' access to care.

Insurance and the WPATH Standards

There are several different surgeries that people may be interested in for gender alignment or confirmation. In addition, there are often specific guidelines for coverage for each surgery.

As a general rule, many insurers are turning to the WPATH Standards of Care as guidelines to establish eligibility for surgery coverage; these are also known as the WPATH criteria or WPATH requirements.

WPATH is the acronym for the World Professional Association for Transgender Health. Formally known as the Harry Benjamin Society, WPATH is not without controversy.

Gatekeeping

Historically, WPATH standards have encouraged what many transgender community members call "gatekeeping." Gatekeeping refers to the requirement that transgender people undergo a significant amount of therapy or psychiatric assessment before they are permitted to transition by the medical establishment.

Requiring therapy or psychiatric assessments positions behavioral health providers as gatekeepers who are needed to unlock access to care.

Activists, researchers, and community members have accurately pointed out that this level of scrutiny is not required for other major surgeries.

For example, people do not need to seek counseling before getting access to other plastic surgery. As such, there are legitimate questions about whether these guidelines reflect stigma against transgender people instead of clinically appropriate measures.

Insurance Coverage

Regardless of whether or not the WPATH standards of care are ideal, they are the guidelines that most large organizations follow. In fact, they are the only formal care guidelines that medical practices and insurance companies widely accept.

Fortunately, WPATH updates its surgery and treatment guidelines every five to 10 years. In general, these standards of care have become less restrictive over time, reflecting the growing recognition of gender diversity in society.

The information below is based on version 7 of the standards of care, published in 2011.

"Note: Some insurers may have different coverage requirements. For those willing to provide coverage but do not have a policy in place, recommending that the company review the WPATH standards of care can be a good place to start.

Remember that the standards of care are guidelines—which explicitly state that it is appropriate to alter criteria depending on the circumstance."

Standards for Top Surgery

"Top surgery" refers to gender confirmation 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:

  1. Persistent, well-documented gender dysphoria (distress caused by the incongruence between a person's gender and the gender they were assigned at birth)
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions that are "reasonably well controlled"

Hormones

It is important to note that hormone therapy is not required for these surgeries. However, a year of hormone therapy is recommended for transgender women because it allows them to get the maximum possible breast growth without surgery, which improves surgery 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 are taking testosterone and 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.

Orchiectomy, Hysterectomy, and Ovariectomy

These surgeries involve the removal of the testicles (orchiectomy), uterus (hysterectomy), or ovaries (ovariectomy).

WPATH criteria for these surgeries include:

  1. Persistent, well-documented gender dysphoria
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions that are "well controlled"
  4. At least 12 continuous months of appropriate hormone therapy, unless there are reasons someone can't or won't take hormones. The purpose of this guideline is so that people can experience reversible hormone changes before they undergo irreversible ones.

Surgeries to remove the gonads (testes, ovaries) and the uterus may be performed independently. They may also be performed alongside other gender confirmation 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.

Vaginoplasty, Phalloplasty, 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.

WPATH criteria for these surgeries include:

  1. Persistent, well-documented gender dysphoria
  2. The ability to make an informed decision and consent to treatment
  3. Any significant medical or mental health conditions that are "well controlled"
  4. Appropriate hormone therapy for 12 continuous months, unless there are reasons why someone can't or won't take hormones
  5. Living in a gender role that is consistent with their gender identity for 12 continuous months

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.

Due to these surgeries' physical and emotional intensity, experts recommend that those considering them have regular visits with a mental or medical health professional.

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.

Facial Feminization Surgery

There are no formal guidelines for facial feminization surgery. In addition, it has historically been tough to get this procedure covered by insurance due to a lack of research on the benefits.

However, some individuals have been able to have it successfully covered by arguing that it is as medically necessary as genital surgery and has equally positive effects on quality of life.

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.

Required Documentation

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 be reasonably well 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.

Summary

Gender confirmation 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 confirmation surgery.

Not all insurance offers coverage for gender confirmation surgery, but some do. First, however, you need to provide the proper documentation to show that you meet specific surgery criteria. This documentation is usually in a letter written by your physician or mental health clinician.

A Word From Verywell

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.

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  1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version. East Dundee, IL: The World Professional Association for Transgender Health; 2011.

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