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Transgender Health Care and Insurance

Posted on the 27 March 2015 by Pacificprime @ThePacificPrime

Across international news, we’ve been hearing the word ‘transgender’ a lot more. Some states in America are passing transgender bathroom bills to make public facilities more (or less) inclusive. The Amazon series Transparent picked up its first Golden Globe, and in March even Pope Francis set aside some time to meet with Diego Neria Lejárraga, a Catholic man rejected from his local church after sex reassignment surgery.

Transgender means a person’s gender expression doesn’t match their biological sex. Diego Neria Lejárraga (who, by the way, was welcomed into the Catholic church with open arms by Pope Francis) was born a woman. People who are transgender usually say that while growing up, they never identified with their sex, often experiencing a feeling of having been born into the wrong body. When the choice becomes available, many opt to take hormones or undergo sexual reassignment surgery in order to change their sex.

Transgender health insurance issues

The health care concerns facing transgender people are the same as the health care concerns facing everyone: From viruses to cancer to lifestyle diseases like diabetes. However, transgender people will at many points interact with health care providers and insurers in a fundamentally different way, especially if they have an interest in taking medical measures to live as a different sex.

Many health insurers do offer coverage for sexual reassignment surgery. The procedure is covered because the policyholder is ‘ill’ with gender dysmorphia (a psychiatric diagnosis to describe a person not content with their gender or sex from birth) and, therefore, needs treatment. Although transgender people would hesitate to call themselves diseased, from an insurer’s perspective, it makes sense to categorize gender dysmorphia as an illness of the mind. A number of well known international insurers do offer sex reassignment coverage, including Aetna, some Blue Cross Blue Shield plans, and Cigna.

A policyholder will generally have to prove that a sex reassignment surgery is medically necessary. To do this, they must meet a number of criteria. Aetna states that in order to access sex reassignment benefits, a policyholder must be 18 years or older, have two referrals from mental health professionals, and have been diagnosed with gender dysmorphia. As part of that diagnosis, Aetna (like most health insurers and doctors) requires that the patient has spent at least two years living as a member of the opposite sex, and has undergone 12 months of hormonal therapy.


There are a few reasons why a transgender person might be denied sex reassignment coverage by their insurer. Firstly, many insurers simply don’t cover the procedure – transgender people should read their policy’s coverage exclusions carefully to find out if theirs does. Insurers may also exclude cosmetic surgery or any procedure that fits into the general category of gender issues. Some insurance companies also define being transgender as a pre-existing condition, and on that basis may refuse to cover reassignment surgery.

Without insurance or socialized health care options, sex reassignment surgery can be very expensive. For a biological male who wishes to surgically become female, the surgery involves removing the penis and testes, and using the excess skin to create an exterior vagina. The female to male surgery will remove the uterus and ovaries, then use genital reconstructive techniques to create a prosthetic penis from the clitoris (which can be enlarged with hormones) and other tissue grafts. Breasts would be surgically altered as well. Both of these procedures rely on the post-surgical and long-term use of hormones: Estrogen to raise voice pitch, stimulate breast development and inhibit facial hair; or male androgen hormones to deepen the voice and stimulate hair growth on the chest and face. Male to female reassignment surgery is likely to cost around US$20,000, and female to male reassignment surgery will likely cost around US$50,000 – a higher price to account for the more difficult breast augmentation and ovary removal.

Thanks to the Affordable Care Act, most insurers in the U.S. are not allowed to deny coverage based on pre-existing conditions. That’s good news for transgender people who previously could not get surgery or hormone therapy based on this exclusion. However, insurers in other parts of the world may still classify transgenderism as a pre-existing condition – and if the policyholder doesn’t report it upfront and then later proceeds to seeks treatment, there’s a chance the insurance company could accuse the client of fraud.

It’s also important to remember that not every transgender person wants full sex reassignment surgery. Many are happy to simply ‘present’ as one gender while having different sexual organs, and many choose long-term hormonal therapy only – at the cost of around US$30 per month. Some insurance policies will cover this medication, while others only pay for hormonal therapy associated with sex reassignment surgery.

Getting treated and treated well

Some of the health issues a transgender person faces can be treated – and paid for by insurance – without necessarily referring to the term ‘transgender’ on coverage claims. Many transgender people come to terms with their identity by visiting a trans-positive psychologist. As long as their counselor is also qualified in general psychological care, those sessions should be covered by any insurance policy offering mental health treatment. Some people can also receive hormone therapy by claiming a general hormone imbalance. In countries where transgender people may be viewed with suspicion or discrimination, patients seeking gender dysmorphia related services will often make use of these insurance loopholes.

In much of the world, progressive views on transgender people are becoming more and more prevalent. In terms of health care, many countries with a national health system include transgender needs within the public medical sphere. The National Health Service (NHS) in the UK, for example, advises transgender people on medical options and legal health care rights. The NHS offers therapy, hormone programs and sexual reassignment surgery, although some British patients choose to undergo their transition in private clinics and hospitals to cut down on wait time and select a trusted physician. In that circumstance, holding private insurance that covers transgender medical care is essential.

What about in Asia?

There is a common view among many western countries that South East Asian countries – especially Thailand – are the most accepting of transgender individuals. Indeed in Thailand there is a third gender in the language, however, the government does not officially recognize transgender individuals as transgendered – automatically labeling them as male. Beyond that, the public healthcare system in Thailand will not normally cover surgeries related to gender re-assignment or hormone treatment, forcing many to pursue expensive private health care.

That being said, Gender Reassignment Surgery at the private hospitals in Thailand is among the best in the world, with many traveling there just for the surgery – especially if their health insurance covers it.

In other cities and countries in Asia individuals who identify as transgendered face a varying level of acceptance. For example in Malaysia, which follows Sharia Law, view transgender as being illegal, with many reports of transgender individuals being harassed, discriminated against, and even arrested.

On the other hand, in Hong Kong and Singapore you can legally change your gender on most forms of ID, e.g, passport, but not on your birth certificate. Also, an individual who has undergone reassignment surgery and legally changed their sex, can get married to someone of the opposite sex.

Despite the progress in health care options for transgender needs, some say there is still a “one size fits all” health and insurance mentality toward transgender people – a mentality that transgender activists are working to change. For example, some physicians may require that a transitioning individual dress in a very feminine way for two years before sexual reassignment surgery, to prove that she is living the lifestyle of a female. No woman wears dresses every day and a male-to-female patient may actually be somewhat of a tomboy – but still identify as a woman, and still feel the surgery is medically necessary. Transgender people who also identify as gay may come across similar problems and have a tough time providing evidence to their insurer that they are “presenting” as a member of the opposite sex.

Transgender people on a workplace insurance policy may likewise have a hard time getting coverage for surgery or counseling. Employees don’t usually have the ability to choose their employer-sponsored health policy, leaving them with just a few choices: talk to their boss about the workplace insurance policy’s potential discrimination toward transgender people, or purchase supplemental insurance that will cover sexual reassignment surgery.

If you have any additional questions about the specifics related to insurance and transgender people, please feel free to contact Pacific Prime today. Our helpful agents can find health insurance plans that fit anyone’s needs, and provide free advice and quotations.

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Transgender Health Care and Insurance

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