What is medically necessary treatment for gender-affirming health care?


Story highlights

Treatment for gender dysphoria can include hormone therapy or genital surgery

Insurance companies may use their own criteria for medically necessary treatment

CNN —  

For some, being transgender is an identity. For others, it’s a label. At its core, it’s the state of knowing that your gender is different from the one you were assigned at birth.

There’s no one way to be transgender, no set of boxes to check that make it so. And while the medical community is working to figure out what causes people to be transgender, the consensus is clear on this: Being transgender is not a mental illness, though as late as 2012 the American mental health community classified it that way.

But for a transgender person to access medical care to align their body with their gender, they often must be diagnosed with a mental disorder called gender dysphoria – especially if they plan to seek reimbursement from an insurance company.  

And they must convince their insurer that the treatment is medically necessary and not cosmetic. That’s where things can get even more complicated.

First, you must have a mental disorder

Gender dysphoria is defined by the distress caused by the discrepancy between a person’s body and their gender identity. The American Psychiatric Association added the term to its diagnostic manual in 2013 to distinguish between the condition of being transgender and symptoms that arise from distress over being transgender.

Technically speaking, being transgender has never been considered a mental illness because the word was never adopted as diagnostic nomenclature, said Jamison Green, past president of the World Professional Association for Transgender Health (WPATH). But the medical community used other terms in its Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, to pathologize gender nonconformity, including transsexualism and gender identity disorder.

For years, advocates and clinicians fought to remove those terms from the DSM. They argued that they contributed to the stigmatization of the trans community, just as the inclusion of “homosexuality” in the DSM until 1973 fostered misperceptions that being gay was a mental disorder – one that could be treated and cured.

The DSM-5, published in 2013, replaced gender identity disorder with gender dysphoria to make clear that the diagnosis pertains to distress and not identity, per se. The World Health Organization has signaled its intention to move transgender identity from its chapter on mental illness to a new one on sexual health.

The new diagnosis was intended to clear hurdles to gender-affirming treatment, including surgical procedures. But some contend that it inappropriately pathologizes transgender identity by requiring a mental health diagnosis to access care.

Others argue that the diagnosis is essential to ensure access to care. For many seeking treatment in the American health care system – especially those without the means to pay out of pocket – it can be the only option available.

Everyone is different

But not all transgender individuals want or need surgical interventions to transition. The process of transitioning is different for each person. Some resist the term altogether because they don’t buy into the idea that gender is binary and that there are only two options: man or woman. And not all people who identify as transgender have gender dysphoria at the level of distress that requires diagnostic treatment.

For some, transitioning may not involve any kind of surgical intervention; it might be enough to change their name or gender designation on identity documents and come out to friends and family, known as social transitions. Some people take hormones to change features they developed in puberty. Hormone replacement therapy may aid in redistributing body fat to different parts of the body and accelerate or slow body hair growth. The hormone estrogen can produce breast tissue and halt sperm production, and testosterone tends to stop me