gender reassignment surgery financial assistance

Annual Trans Surgery Fund

About the program, requirements, self-assessment, info sessions, application process, what to expect, meet past recipients.

Point of Pride’s Annual Transgender Surgery Fund is a scholarship-like program that provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery.

We have very few requirements in an effort to be as inclusive as possible:

• You identify as transgender (FTM, MTF, non-binary, genderqueer, gender non-conforming, and all other non-cis identities.)
• You are 18 years of age or older at the time of your surgery.
• You have financial need that prevents you from affording gender-affirming surgery.
• You can demonstrate past attempts at affording care (i.e. saving money, fundraising, attempting to get insurance coverage.)
• You complete your surgery in the United States with a US-based surgeon.
• Your surgery takes place on or after March 1 of the following year.

2017 recipient Gabriel (center) with Point of Pride leadership & volunteers

This program is intended to help trans folks who otherwise can not afford gender-affirming surgery. We ask that you consider your access to healthcare before applying for this grant. Here are some questions to consider:

• Do you have health insurance coverage that is trans-inclusive?
• If not, do you qualify for Medicaid? ( Learn more )
• Do you have access to healthcare providers who are trans competent, and are able to travel to them to receive care?
• Are you employed and able to save some money towards surgery?
• Are you a citizen or documented immigrant?
• Do you consider yourself healthy and able-bodied (i.e., not living with a chronic or long-standing illness)?
• Do you identify as white, or do you experience white/light-skinned privilege?

If you answered YES to most of these questions, you may consider making space for our trans siblings who mostly answered NO. (Even if you answer YES to most or all of these questions, you are still eligible to apply.)

Left: 2018 recipient Cairo following gender-affirming top surgery; Right: 2018 recipient Leah shared she felt “like a whole person” following her facial feminization surgery

Point of Pride staff will host live "Before You Apply" info sessions to walk potential applicants through our requirements and processes, and answer questions. These are completely optional to attend and will not impact your application positively or negatively.

• Watch last year's recording   (YouTube)
• Future info session dates TBD

Your privacy and security are our top priority. Your personal information will be hidden from other participants; your video and microphone will be disabled. You will not be able to see or interact with other participants; you will only be able to interact with staff via a private chat feature.

The sessions have generated captions with Zoom's built-in, real-time translation available.

Applications are open on November 1. The deadline to apply is November 30 by 11:59pm EST. All applications must be submitted online.

• Carefully read this page, especially our Frequently Asked Questions section.
• Review our   Instruction Packet , which walks you through each question of the application form.
• Submit your application via the form below.

Once the application period ends, our Board of Directors and team of Community Grantmaking Fellows (trained volunteers) evaluate each and every application received. This process is necessarily difficult and time-intensive, so thank you for your patience!

• If you are selected as a finalist, or if our reviewers determine they need additional information,   you will be contacted in mid-January via email. You may be invited to submit additional writing samples and/or participate in a brief phone or online interview.
• If you are selected as a recipient,   we will contact you again via email or phone regarding next steps. You will have a window of 18 months to schedule your surgery date (not necessarily complete surgery.) The full details of your award will be explained in your recipient agreement.
• If you are not selected as a finalist or recipient,   we will notify you via email, and you are welcome to apply again for our next application cycle. (Note: Our team stores your application materials for a full year, and we continue to pair candidates with financial assistance as we receive grants, resources, and new opportunities. You may be contacted later in the year via email. Review our   Privacy Policy .)

For even more detail,   this resource  serves to provide complete context and clarity around our financial assistance programs, and why we have certain requirements or parameters in place.

• Privacy and safety:   We know many applicants feel vulnerable in sharing their experiences, and we take this very seriously. Anything you share with us in your written responses will be kept strictly confidential and private. Recipients will have the opportunity to publicly share their stories in the way that feels safest and most affirming for them, as well as hide identifying information if preferred.
• Language:   Our application is not an English test. We will not consider grammar/spelling or writing ability when reviewing your responses. Above all, please give us detailed, thorough responses so we understand your unique situation. We hope to provide full translation support in the future.
• Accessibility:   We understand that some applicants may want or need extra support in completing their application. You may list someone else on the application as your liaison, translator, or support person. This person will be CC'd on all email notifications regarding your application status. (Access can be revoked at any time by the applicant by contacting Point of Pride.)
• Equity:   Our organization prioritizes equity as one of our   guiding principles . Your application will be assessed on the responses you provide and in accordance with this guiding principle. Point of Pride does not discriminate based on age, race, ethnicity, gender, or any other identity.

Applicants must be at least 18 years old by your surgery date. There is no upper limit for age.

We understand the challenges of debt and medical loans that so many of us deal with in order to afford care. Unfortunately, no; at this time, our grants are paid directly to health care providers specifically for the procedure itself, before it takes place. We cannot apply grant awards toward transportation, lodging, general expenses or (for international applicants) getting a visa and other logistical expenses.

Yes; if you have a surgery date scheduled, there is an option to include that in your application. Because of the time it takes our volunteers to review the high number of applications we receive each year, however, we can not fund applicants who are having surgery in the months of November–February of the current cycle. So, when you submit an application in November, your surgery would need to be scheduled on or after March 1 of the following year in order to receive funding.

We strongly encourage you to review our  Instruction Packet , which walks you through each question of the application with tips. Ultimately, our reviewers are looking for thorough responses that answer each question with specific examples and detailed explanations. 

Unfortunately, no. Our team does not have the expertise or ability to provide referrals or recommendations for trans-affirming surgeons. Every person's surgery goals and priorities are unique. So many factors – a given surgeon's specialty or expertise, the procedure type that's right for you, whether or not you're willing/able to travel for surgery – means that finding a surgeon is a highly individualized decision. Therefore, you will ultimately be the best judge of who your provider should be. We recommend that you reach out to local LGBTQ+ centers and trans support groups, as well as your current healthcare providers and/or insurance company (if applicable), for recommendations to help you as you research.

We recognize there may be barriers that prevent someone from submitting an application on their own without help. You may submit an application on behalf of someone else  only  if you are working directly with the applicant and clearly reference their involvement in completing the application. (For example, if you are providing technological support, language translation, or other assistance on behalf of the applicant, please note your role and that the applicant is still the primary author of their responses.) However, you  may not  submit an application without the applicant's involvement. (For example, applying for a loved one without their knowledge.) While we understand the desire to surprise someone with a grant, our process builds on the fundamental idea that trans people are our own best advocates: we want to ensure that this belief is reflected throughout the application process.

Grant awards vary widely. The fund covers a high percentage (70-97%) of your total surgical, anesthesia, and facility fees. You will be responsible for a smaller percentage of your care, with a maximum out-of-pocket expense specified in your recipient agreement. You should expect to cover travel fees, lodging, food expenses, time away from work, postoperative nursing care (when required), and certain postoperative medications. 

Applications are currently closed. The next cycle will open on Nov. 1.

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Over $1,313,500 in financial assistance awarded to 114 recipients.

Gemma (she/they) is a 33-year-old trans femme non-binary person from Australia seeking bottom surgery. 

$20,487 awarded

$1,020 awarded

$33,860 awarded

$9,825 awarded

$10,745 awarded

$14,450 awarded

Reiss (she/they) is a 21-year-old biracial trans woman who is seeking breast augmentation surgery. She is the oldest of five siblings and is a preschool teacher. She enjoys gaming, drawing and anime.

$7,700 awarded

$7,567 awarded

$9,050 awarded

$11,205 awarded

$32,135 awarded

$11,025 awarded

$9,800 awarded

$15,300 awarded

X (they/he/she) is a 41-year-old Black agender and gender non-conforming person from California seeking hysterectomy. 

$10,000 awarded

$5,632 awarded

$7,979 awarded

$26,600 awarded

$7,999 awarded

Traci (she/her) is a 42-year-old Black trans woman from South Carolina seeking bottom surgery. 

$29,375 awarded

Kai (they/them) is a gender neutral, non-binary person of color seeking top surgery. 

Rio (he/him) is a 32-year-old trans man from Guatemala City, Guatemala seeking top surgery. 

$13,910 awarded

Samantha (she/her) is a 32-year-old trans woman of color from Honduras living in Florida seeking facial feminization surgery.

$29,150 awarded

$30,450 awarded

$14,300 awarded

$8,125 awarded

$8,150 awarded

Daniel (he/him) is a trans man from Idaho seeking top surgery.

$8,053 awarded

$10,601 awarded

Dandy (he/him) is a trans masculine person of color from Texas seeking top surgery. 

$13,264 awarded

$8,100 awarded

$10,975 awarded

$10,825 awarded

$36,910 awarded

$31,090 awarded

$10,661 awarded

$12,000 awarded

Dani (he/they) is a 33-year-old trans man seeking top surgery. They are currently dealing with housing insecurity, though Dani hopes once they are post-op and at home in their body, they will be able to find a home in the world.

Pluto (he/him) is a 61-year-old legally blind trans and intersex person. Pluto is of Jewish and Native Arctic descent.

$20,000 awarded

$8,000 awarded

$7,600 awarded

$7,200 awarded

$24,000 awarded

Carlos (they/he) is 37-year-old undocumented, disabled trans person of color. He is seeking to get a masculinizing chest surgery (double mastectomy.)

$5,000 awarded

Aru (she/her) is a 21-year-old asylum-seeking trans woman from Venezuela who is seeking bottom surgery, also known as GRS or SRS.

$6,500 awarded

Zen (he/him) is a 41-year-old demimale trans person of color currently seeking top surgery.

$7,300 awarded

Blake (he/him) is a 20-year-old Latino trans man and immigrant currently seeking top surgery. At this moment, he cannot yet work, apply for healthcare or government aid, or obtain a credit card, which has made obtaining his surgery impossible.

$3,600 awarded

$6,000 awarded

Winter (she/her) is 35-year-old trans woman seeking facial feminization surgery (FFS). She’s currently working on a master’s degree in Mental Health Counseling, specifically so she can serve the LGBTQ+ community.

$4,500 awarded

$9,000 awarded

$6,900 awarded

$6,200 awarded

Jessie (he/him) is a 21-year-old trans man of color from Florida who has faced a number of unique challenges in obtaining the care he needs.

$8,500 awarded

Chamar (he/him) is a 40-year-old trans man of color from Ohio. Like so many of our applicants, Chamar works two jobs to provide for himself, his wife, and their four children.

Alida (she/her) is a 29-year-old trans woman from Massachusetts seeking facial feminization surgery and tracheal shave.

$2,000 awarded

$3,000 awarded

Blake-JordenW

$7,000 awarded

$3,500 awarded

$7,500 awarded

$2,500 awarded

Armaan (he/him) is a trans man from Washington. Armaan’s application was so moving that he received almost unanimous support from the Board to name him as a finalist. 

$2,300 awarded

Gabriel (they/them) is a trans person from New York seeking gender-affirming top surgery. 

$1,250 awarded

We know how challenging it can be to access necessary gender-affirming care. Below are some resources you may find helpful.

Health insurance

• Point of Pride: How to Approach Getting Insurance Coverage for a Trans Surgery
• Point of Pride: Does Medicare Cover Gender-Affirming Surgery?
• Point of Pride: Trans Health Coverage: Deductibles, copays, coinsurance & more
• Point of Pride: My Insurance Has Denied My Gender Affirming Surgery. Now What?
• Magnify Money: What You Should Know Before Using CareCredit to Pay for Medical Expenses

Fundraising

• GoFundMe: Guide to medical crowdfunding
• GoFundMe: Guide to fundraising for gender-affirming surgery
• TransGuys.com: Comprehensive Guide to Surgery Fundraising
• Point of Pride: 6 Creative Ways to Raise Money

Other considerations

• Point of Pride: Tips for Traveling Out-of-State for Gender-Affirming Surgery
• Point of Pride: Traveling for Gender-Affirming Surgery in Another Country: Things to consider

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Financing & Support for Gender Confirmation Surgery

Updated: December 5, 2023

Quality Verified

Featured Experts:

On This Page:

• Options and Average Costs

What Health Insurance Can Cover

• Ways to Navigate Health Insurance

Financing Options and Support

• Organizations Making a Change
• Expert Insight
• Additional Healthcare Resources

Advertising & Editorial Disclosure

Between 1.4 million and 1.65 million adults in the U.S. identify as transgender, according to the Williams Institute at UCLA's School of Law. For many transgender and gender non-conforming individuals, medical transition is a significant and empowering part of their journey. Transition may include hormonal treatment and/or surgery known as gender confirmation surgery or gender affirmation surgery.

Many transgender individuals go through the process of transition — which includes legal, psychological, social and medical experiences — to resolve gender incongruence between their internal sense of self and external anatomy. Gender identity refers to an individual's experienced gender and sense of self.

Not all transgender people want to undergo gender confirmation surgery. But for those who do, the process can help to alleviate gender dysphoria . Gender confirmation surgery also doesn’t change or “reassign” one’s gender or sex. Instead, it allows transgender and gender non-conforming people to change their bodies to reflect their gender identity more accurately.

While hormonal treatment and/or surgery is a deeply important step for many trans and gender non-conforming people, it can also be expensive. Learn more about the average costs of medical transition care options and find resources and ways to help fund procedures.

Medical Transition Care Options and Average Costs

Medical transition care options are diverse in terms of procedures, costs and outcomes. Each transgender person, along with their medical provider, should choose the options that make the most sense in terms of budget and desired results.

The main two medical transition care options are hormonal transition and gender confirmation surgery. Here’s a breakdown of the average costs of each kind of gender-confirming healthcare treatment.

Hormonal Transition

Average Cost: $20–350/month

The majority of transgender individuals who seek out medical transition choose to undergo hormonal transition, also known as hormone therapy. Because of its relative affordability and accessibility, hormone therapy can be a particularly effective option for those experiencing gender dysphoria or looking for an alternative to surgery. Hormone therapy can help trans men and women, as well as nonbinary and gender non-conforming individuals, achieve significant physical changes.

Patients who undergo masculinizing hormone therapy often take testosterone. Testosterone therapy can affect a patient’s fat distribution, facial characteristics, vocal cords, hair growth patterns, libido, menstrual cycles and more. Testosterone typically comes in the form of injections (approximately $80 per month), patches ($300 per month), and gels ($300–350 per month) .

Patients who go through feminizing hormone therapy often take estrogen or testosterone blockers such as spironolactone and/or progesterone. Like testosterone therapy, this can affect a patient’s voice, facial appearance, libido, fertility, emotions and fat distribution. It can also promote breast development. On average, oral estrogen costs about $20 per month, while estrogen injections can cost up to $200 per month and spironolactone up to $20 per month.

Gender Confirmation Surgeries

Average Cost: $5,000–$50,000

Gender confirmation surgery for transgender patients refers to reconstructive surgeries to bring patients' bodies into conformity with their experienced gender. Surgeries might include reconstruction of the chest and/or face. Depending on the type of surgery, patients may have a recovery period from about two weeks to several months after their initial hospitalization.

Like all surgeries, these procedures come with potential risks. But patients who seek out board-certified surgeons and follow all pre- and post-op guidelines are usually satisfied with their results.

Here are some of the most common gender confirmation surgeries that transgender and gender non-conforming patients seek out.

Types of Surgeries for Trans Men

For trans patients, gender confirmation surgery might include removing breast tissue and reconstructing the chest, facial masculinization surgery (FMS) to make their facial features appear more masculine, removing and reconstructing the external genitalia, and removing internal reproductive organs.

Here are the most common forms of gender confirmation surgery for trans men and nonbinary patients.

How much is facial masculinization surgery (FMS)?

Average Cost: $10,000–$50,000

Here is what FMS surgery may include:

• Thyroid cartilage enhancement: An “Adam’s apple” is made using a small incision in the chin area and an implant in the throat region.
• Cheek augmentation: Small incisions inside the mouth allow the surgeon to place implants in the cheek to create a more angular appearance.
• Forehead lengthening or augmentation: Forehead lengthening and augmentation procedures involve lengthening the area between the eyes and scalp, and sometimes placing an implant, to create a more masculine, angular forehead.
• Jaw and chin augmentation: Jaw and chin reshaping and implants can help to widen the face and contour the jawline for more masculine facial proportions.
• Nose reshaping: Rhinoplasty can help to widen the nose and masculinize the facial proportions.

How much does it cost to have surgery procedures for trans men and what are the procedures?

Surgery procedures could include:

• Facial masculinization surgery (FMS): FMS may include thyroid cartilage enhancement, cheek augmentation, forehead lengthening or augmentation, jaw and chin augmentation and nose reshaping.
• Periareolar procedure: The areolas and nipples are resized and repositioned during this surgery. Two circular incisions around the areolas allow the surgeon to remove the “ring” of chest tissue.
• Keyhole procedure: The keyhole procedure involves just one semi-circular incision below each of the nipples. Keyhole top surgery also allows most patients to keep the sensation in their nipple area.
• Double incision: In double incision top surgery, the surgeon makes two incisions at the top and bottom of the pectoral muscles. The nipples and areolas are removed and replaced with nipple grafts.
• Inverted-T top surgery: Inverted-T top surgery involves horizontal and vertical incisions and the removal of chest tissue but not nipples. Sensation is retained for most patients.
• Metoidioplasty: Metoidioplasty involves releasing the clitoris from the ligament attached to it and repositioning it to create a penis. With this procedure, patients can also choose to undergo urethral lengthening and remove vaginal tissue.
• Phalloplasty: Surgeons use skin grafts from other parts of the body (usually the thigh or forearm) to create a penis. A vaginectomy, or the closing of the opening in the front of the pelvis, as well as scrotoplasty, which creates a scrotum, can be included in some phalloplasty procedures. This is the most expensive of bottom surgery options for trans men, with price tags up to $150,000 in some cases.
• Hysterectomy: A hysterectomy includes the removal of the uterus and ovaries.

Types of Surgeries for Trans Women

Around half of trans patients choose to undergo breast augmentation, facial feminization surgery (FFS) (which involves a variety of procedures that make facial features appear more feminine) and the removal or reconstruction of genitalia.

How much is facial feminization surgery (FFS)?

Average Cost: $20,000–$50,000

Facial feminization surgery (FFS) may include:

• Genioplasty: Genioplasty uses surgical incisions inside the mouth to contour the chin for a softer, rounder shape.
• Cheek augmentation: Implants, fat transfers or fillers can soften the face to create a more feminine look.
• Brow lift: A brow lift raises the eyebrows for a shorter forehead, softer look, and enlarged appearance of the eyes.
• Tracheal shave: The neck bump created by thyroid cartilage is reduced in a tracheal shave.
• Lip lift or augmentation: Lip augmentation can be achieved with implants and fillers. A lip lift emphasizes the upper lip.

What are the surgery procedures for trans women and how much do they cost?

Here are some of the most common gender confirmation surgeries for trans women:

• Facial feminization surgery (FFS): This surgery may include genioplasty, cheek augmentation, brow lifts, tracheal shave and lip lift or augmentation.
• Breast augmentation/augmentation mammoplasty: Breast augmentation is one of the most common gender confirmation surgeries for trans women and nonbinary patients. It might involve saline or silicone implants or even fat transfers from other parts of the body.
• Vaginoplasty: In vaginoplasty, a surgeon uses skin grafts from another part of the body (usually the scrotum or abdomen) to create a vaginal canal. The surgeon also uses existing genital tissue to create a clitoris. This allows most patients to have penetrative intercourse.
• Orchiectomy: An orchiectomy is often a transfeminine patient ’s first gender affirmation surgery. It involves the removal of the testicles.
• Vulvoplasty: A vulvoplasty involves the external part of the vagina rather than the vaginal canal. Skin from the patient’s genitalia is used to create a vaginal opening, the inner and outer labia, a clitoris and an opening that allows the patient to urinate.

Additional Alternatives

Some trans women undergo voice feminizing therapy to adapt their voice to their gender identity. In voice feminizing therapy, vocal cords are surgically altered to raise the patient’s vocal pitch.

Some trans patients might also choose to undergo gender confirmation surgery in the form of body contouring procedures. These might include liposuction or abdominoplasty as well as implants in the calves, buttocks or other areas.

In the U.S., it is illegal for most public and private health insurance providers to discriminate against transgender patients or deny them transition-related care. However, trans patients may still face financial and logistical barriers. Here’s what you should know about health insurance coverage and gender confirmation surgery.

Type of Barriers

Transgender patients still sometimes face health disparities and barriers to medical care, including transition-related medical care. These are some of the obstacles that trans and gender non-conforming people might face when trying to access healthcare and insurance coverage.

• Differences in state-by-state health insurance coverage: Each U.S. state has different policies regarding health insurance and trans-related care. Some U.S. states legally require health insurance providers to cover transition-related care while others do not.
• Difficulty accessing up-to-date and accurate insurance information: The language in health insurance plan summaries can be out-of-date or vague. This can lead to discriminatory denials of care.
• Discrimination and stigma: Discrimination against the LGBTQ community remains widespread, and transgender people may face health disparities and stigma in the context of medical care as a result, as well as other financial challenges . A 2015 study by the National Center for Transgender Equality revealed that about one-third of transgender patients said they were denied medical care or harassed by a medical provider.
• Lack of training and cultural competency among health providers: Some healthcare providers haven’t had adequate training in healthcare for transgender patients, which can lead them to make questionable decisions.

Additional Insurance Considerations

Transgender patients might also have questions about Medicaid coverage and Medicare coverage for gender confirmation surgery and other transition-related care. Both Medicare and Medicaid are prohibited from denying coverage of trans-related care if it is medically necessary.

The Veterans Health Administration (VHA) provides some coverage for transition-related medical care to transgender veterans . However, there is still an exclusion when it comes to coverage of gender confirmation surgery.

If you have insurance through your employer, you might be able to save up for your out-of-pocket surgery costs with a non-taxed Flexible Spending Account (FSA).

Ways to Navigate Health Insurance for Gender-Confirming Surgeries

It can be challenging to navigate health insurance coverage for gender confirmation surgery, but it’s not impossible. It’s important to know your rights as a patient when interacting with providers and finding the best health insurance plan for your needs. Here are some tips to keep in mind.

Stay informed

Remember that your health insurance plan should cover your transition-related care. Make sure that you read your insurance provider’s member handbook. Ask for the medical policy and any specific documents about eligibility for trans-related medical care to determine if you qualify.

Find a plan with no exclusions

Look for a health insurance plan that doesn’t have exclusions for either all transition-related care or specific kinds of treatments. You can often find this information in the medical policy.

Ask your current or potential employer about coverage

If you’re in the negotiation phase of a job interview, don’t be afraid to ask your potential employer about transition-related health coverage. If your current company or school doesn’t cover transition-related care, you might want to advocate for coverage.

Understand informed consent vs. WPATH standards

Before choosing a plan and care provider, find out about your potential provider’s ethical approach. An informed consent model of care allows you to make your own transition-related decisions after being informed of the risks by a physician. The WPATH standards of care might require additional steps, such as letters of support from therapists and other providers.

Look into pre-authorization

You'll need to see your primary care physician before requesting pre-authorization for surgery. It is also known as prior authorization. You might need to gather documents such as letters from medical providers before applying. Depending on the plan you selected, your primary care physician can provide you with a referral. Keep in mind that the referral or pre-authorization may not guarantee the surgery or other procedures will be authorized. National Center for Transgender Equality addresses common health coverage questions related to pre-authorization that may be helpful. It may be a good idea to speak with your health coverage provider directly.

Appeal denials

If you are denied coverage for a transition-related procedure, do not be afraid to appeal your insurance provider’s decision. Some exclusions might be prohibited or deemed discriminatory.

Outside of partial or full health insurance coverage, there are several other options for financing gender confirmation surgery, such as loans, lines of credit, grants and scholarships and fundraising.

There are several different personal loans you can use to fund your transition-related care.

• Bank or credit union loans: To qualify for a loan from a bank or credit union, you’ll need a good credit score and history.
• Family loans: If a family member can extend you a personal loan, consider creating a promissory note so that you have a repayment schedule in writing.
• Online loans: If your credit history is less than ideal, an online personal loan could be a good option.

Grants and Scholarships

Several organizations offer grants and scholarships to cover some or all of the costs associated with gender-confirming surgeries. These can help you avoid or offset any potential medical debt .

• The Jim Collins Foundation : The Jim Collins Foundation is dedicated to funding gender-confirming surgeries for trans people who need them. Grants are awarded on an annual basis.
• Genderbands Transition Grants : Genderbands offers transition grants to offset the expense of gender confirmation surgery for trans and nonbinary recipients.
• Rizi Xavier Timane Trans Surgery Grant : Rizi Xavier Timane, DSW, established a grant program to aid in the costs of gender-confirming surgeries for trans and nonbinary individuals.
• TransMission : The Loft LGBTQ+ Community Center’s TransMission is a small scholarship fund that helps trans and nonbinary recipients with medical, surgical and legal expenses.
• Stealth Bros & Co. Surgery Support Fund : The Stealth Bros & Co. Support Fund offers financial aid to trans men and transmasculine people for surgery, hormone therapy and related expenses.
• Black Transmen, Inc. Surgery Scholarship : Black trans men in the U.S. who have already been approved for surgery by a surgeon can apply for up to $1,000 in financial assistance.
• Point of Pride : Point of Pride offers scholarship-like funding for gender-confirming surgeries on an annual basis with a competitive application process each November.

Fundraising

Many people may raise funds for their gender confirmation surgery. For example, some throw parties with suggested donation amounts so friends, family and other supporters come together. Others raise money for their procedures by selling original art and letting would-be buyers know that they’re supporting a good cause.

Line of Credit

A home equity line of credit (HELOC) is one option if you own your home. With a HELOC, you can borrow against your home’s appraised value and repay it over time.

Certain surgeons partner with medical financing companies to help gender confirmation surgery patients make payments over time. You may want to check your credit score with a free report . Other surgeons allow patients to make smaller payments in installments.

Advocacy Organizations Making a Change

Many LGBTQ advocacy organizations are making a difference in the lives of transgender and gender non-conforming people every day. Here are just a few of the LGBTQ charities , nonprofits and other organizations making positive changes.

• The Sylvia Rivera Law Project : In addition to impact litigation advocacy, the Sylvia Rivera Law Project offers legal services and resources to aid people in their journey toward gender self-determination.
• Transgender Legal Defense & Education Fund : The Transgender Legal Defense & Education Fund is a nonprofit that fights for trans rights and against discrimination. The organization’s Trans Health Project helps transgender people access trans-confirming health insurance.
• Transgender Law Center : The Transgender Law Center is a trans-led advocacy organization that offers educational materials and other resources around healthcare, immigration, incarceration and employment.
• National Center for Transgender Equality : The National Center for Transgender Equality offers educational materials, self-help guides and other resources for the trans community.
• SPARTA : SPARTA is a nonprofit organization dedicated to transgender, nonbinary and gender non-conforming people serving in the U.S. military.

Additional Resources for Trans-Related Healthcare and Support

If you are a transgender or gender non-conforming patient seeking funding or support for your gender confirmation surgery, various resources can help. Here are some of the best resources available for trans people, loved ones and allies who want to know more about gender confirmation surgery.

• National Center for Transgender Equality's Know Your Rights : The National Center for Transgender Equality regularly updates its guide to existing and expanding legal protections for trans people in the U.S.
• HealthCare.gov's Transgender Health Care : The website helps explain what to know about applying for Marketplace health insurance coverage as a trans or gender non-conforming patient.
• HRC's Corporate Equality Index : Human Rights Campaign (HRC) publishes an annual guide to workplace policies and benefits for LGBTQ employees, including a list of companies that offer trans-inclusive benefits.
• Transgender Law Center's Transgender Health Benefits Guide : The Transgender Law Center offers a guide to healthcare advocacy for trans and gender non-conforming patients, including advice on what to do if you face discriminatory denials of care.
• Out2Enroll : Out2Enroll helps members of the LGBTQ community find and enroll in health insurance plans.
• Trans-Health.com's Trans Health Clinics : The clinics in this list specialize in transition-related and trans-confirming care and mental health support.

Social Support

• Transbucket : Initially started in 2009, Transbucket is an online resource and peer-to-peer support group exclusively dedicated to trans participants, primarily discussing gender confirming surgeries and medical transition.
• Gender Spectrum : Gender Spectrum hosts online support groups for trans, nonbinary and gender non-conforming youth, as well as parents and educators.
• Sam & Devorah Foundation for Trans Youth : The Sam & Devorah Foundation for Trans Youth connects members of the trans community with mentors who can offer emotional support and advice as well as empowerment and "building the confidence and skills critical for self-agency and leadership."

Mental Health Support

• The Trevor Project : The Trevor Project provides a number of resources, including suicide prevention and crisis intervention services, to LGBTQ people under 25.
• Trans Lifeline : The Trans Lifeline is a hotline offering peer-to-peer support services for trans callers, as well as their family, friends and allies.
• The Tribe, LGBTribe : The LGBTribe offers mental health support and wellness tools to LGBTQ participants.

About Laura Dorwart

Laura Dorwart is a writer living in Oberlin, Ohio, with her family. She has bylines at VICE, The New York Times, The Guardian and many others. She has a Ph.D. from UCSD, an MFA in nonfiction writing from Antioch University Los Angeles and experience in UX writing and copywriting for brands such as KeyBank. Follow her work at www.lauradorwart.com.

• American Psychiatric Association . " What Is Gender Dysphoria ." Accessed May 27, 2021 .
• CostHelper . " How Much Does Sex Reassignment Surgery Cost ." Accessed May 30, 2021 .
• Current Opinion in Endocrinology, Diabetes and Obesity . " Barriers to Health Care for Transgender Individuals ." Accessed May 28, 2021 .
• European Association of Urology . " First accurate data showing that male to female transgender surgery can lead to a better life ." Accessed May 19, 2023 .
• First Report Managed Care . " Transgender Patients: Calculating the Actual Cost ." Accessed May 30, 2021 .
• Gender Confirmation Center . " Techniques, Incisions, & Surgery Options Facial For Feminization Surgery ." Accessed May 30, 2021 .
• Grand View Research . " U.S. Sex Reassignment Surgery Market Size, Share & Trends Analysis Report by Gender Transition ." Accessed May 29, 2021 .
• Jones, Jeffrey M. Gallup . " LGBT Identification Rises to 5.6% in Latest U.S. Estimate ." Accessed June 1, 2021 .
• Mount Sinai Center for Transgender Medicine and Surgery . " Trans-masculine (Female to Male) Surgeries ." Accessed May 30, 2021 .
• National Center for Transgender Equality . " U.S. Trans Survey ." Accessed May 26, 2021 .
• Planned Parenthood . " Sex and Gender Identity ." Accessed May 25, 2021 .
• The International Center for Transgender Care . " Facial Masculinization Surgery ." Accessed May 30, 2021 .
• UCSF Transgender Care . " Information on Estrogen Hormone Therapy ." Accessed May 29, 2021 .
• UCSF Transgender Care . " Information on Testosterone Hormone Therapy ." Accessed May 29, 2021 .
• University of Utah Healthcare . " Transfeminine Bottom Surgery ." Accessed May 30, 2021 .
• Williams Institute at UCLA School of Law . " How Many Adults Identify as Transgender in the United States ." Accessed May 27, 2021 .

Jim Collins Foundation

Support trans health

Jim Collins Foundation Announces 2023 Founders’ Fund Grant Recipients

The Jim Collins Foundation (JCF), a national nonprofit organization with a mission to fund gender-affirming surgeries, is delighted to announce that for the 2023 grant year, 5 surgical grants from our Founders’ Fund have been awarded to a diverse group of grant recipients from across the United States. JCF is grateful to the many individuals […]

Recent Grant Recipients

2023 Jada Ayala (she/her)

Jada Ayala (she/her) of Illinois was selected for a Founders’ grant to receive … [Read More...]

2023 Aspen Ben Azulay (he/him or they/them)

Aspen Ben Azulay (he/him or they/them) of South Carolina was selected for a … [Read More...]

2023 Alexandra Dogwood (she/her)

Alexandra Dogwood (she/her) of Mississippi was selected for a Founders’ grant … [Read More...]

2023 Michelle Harding (she/her)

Michelle Harding (she/her) of Colorado was selected for a Founders’ grant for … [Read More...]

2023 Owen Lartson (he/him or they/them)

Owen Lartson (he/him or they/them) of Texas was selected for a Founders’ grant … [Read More...]

2022 Founders’ Fund Grant Recipient Andrew Marshall (he/him)

Andrew Marshall (he/him) of Georgia was selected for a Founders’ grant for … [Read More...]

The Jim Collins Foundation offers two grant options. The Founders' Grant covers 100% of the surgical costs associated with a gender-affirming surgery. The Krysallis Anne Hembrough Legacy Fund covers 50% of the surgical costs associated with a gender-affirming surgery, the recipient provides the other 50% using their own financial resources. Applicants may only apply once per grant cycle, and in their application, must choose to be considered for either the Founders' Grant or the Krysallis Anne Hembrough Legacy Fund. The mission of the Jim Collins Foundation is to provide financial assistance to transgender people for gender-affirming surgeries. The Jim Collins Foundation recognizes that not every transgender person needs or wants surgery to achieve a healthy transition. But for those who do, gender-affirming surgeries are an important step in their transition to being their true selves. However, access to gender-affirming surgery is impossible for most. Discrimination against transgender people is so prevalent that many transgender people struggle to survive, never mind save for surgery costs.

Surgery Funding Assistance

Us surgery funding assistance programs.

Following is a list of organizations that provide financial assistance for transition-related surgery. You'll find information about the organizations and their requirements for applying for aid. We also maintain a list of employers who offer trans-inclusive health insurance .

If you operate a charity that provides financial assistance and don't see your organization listed here, please contact us with the details!

Note: TransPulse does not administer any of these programs. To get in touch with them, click their names to be taken to their websites.

Jim Collins Foundation

The Jim Collins Foundation offers two grant options. General Fund grants cover 100% of the medical fees associated with the gender-affirming surgery. Alternately, grants from the Krysallis Anne Hembrough Legacy Fund cover half of the associated fees and require each recipient to match funds received from the organization dollar-for-dollar with their own money or money raised through other means. Applicants may apply only once per grant cycle. When applying, you must choose either the General Fund or the Krysallis Anne Hembrough Legacy Fund - you cannot apply for both.

• Secure a letter of support from a licensed medical or mental health professional such as a psychologist, psychiatrist, social worker, or therapist.
• Select a surgeon who is knowledgeable in transition-related surgeries. If applicant is chosen, the organization assumes this named surgeon is final.
• Identify who will care for and provide support post-surgery.
• If applicant has not completed all of these steps, but is planning to do so, please include your plans in your application.
• Note: If you are selected for funding, the payment will be made directly to the doctor or hospital facility. You must comply with any and all requirements according to the Standards of Care of the World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA), as determined by your selected surgeon.
• Applicant must demonstrate a genuine need for financial assistance.
• Applicant must detail the efforts they have made to fund-raise and the amount of cost they will be able to cover on their own, if any.

The Jim Collins Foundation makes selections for grants based on a combination of demonstrated financial need and level of preparedness.

Trans Love Fund

(South Carolina residents only.)

The Trans Love Fund is a program of We Are Family, an organization dedicated to providing resources, support and leadership development to LGBTQ+ youth. The Trans Love Fund is dedicated to helping the transgender community of South Carolina by providing microgrants to trans-identified individuals for medical, legal, and emergency living expenses.

TLDEF's Trans Health Project

Financial aid for transgender surgeries.

We encourage people to challenge insurance denials and exclusions as the best way to fund transgender-related surgeries. Winning insurance coverage also has the added benefit of removing barriers to care for the whole community.

In cases where insurance copays and deductibles are prohibitive or the individual cannot obtain health insurance, there are a number of small transgender surgery grant programs .

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Updated on Apr 12, 2023

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Transgender health care

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Refer to glossary for more details.

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The independent source for health policy research, polling, and news.

Update on Medicaid Coverage of Gender-Affirming Health Services

Ivette Gomez , Usha Ranji , Alina Salganicoff , Lindsey Dawson , Carrie Rosenzweig, Rebecca Kellenberg, and Kathy Gifford Published: Oct 11, 2022

• Issue Brief

Transgender and nonbinary adults often face challenges and barriers to accessing needed health services and face worse health outcomes than their cisgender peers. Transgender adults are mo re likely than cisgender adults to be uninsured, report poor health, have lower household incomes, and face barriers to care due to cost. Given their lower incomes, Medicaid plays an important role in health coverage for transgender people. A 2019 report by the Williams Institute estimated that among the 1.4 million transgender adults living in the United States, approximately 152,000 had Medicaid coverage.

Medicaid is the country’s health coverage program for low-income people and is jointly funded by the federal government and states. Under Medicaid, states must cover certain mandatory benefits , such as inpatient and outpatient services, home health services, and family planning services. While there are no specific federal requirements regarding coverage or exclusion of gender-affirming health care services as a category of Medicaid benefits, there are rules regarding comparability requiring that services must be equal in amount, duration, and scope for all beneficiaries within an eligibility group.

Medicaid benefits are subject to Section 1557 of the Affordable Care Act (ACA), the law’s major non-discrimination provisions, which prohibit discrimination based on sex. The Biden Administration recently proposed a new rule on Section 1557 that explicitly states that it interprets, and will enforce, sex-based protections to include sexual orientation and gender identity. The administration had already asserted this position in guidance stating that under 1557 protections, “categorically refusing to provide treatment to an individual based on their gender identity is prohibited discrimination” and it returns to a position more closely aligned to that under the Obama administration but walked back under the Trump administration.

Despite these protections, some states have recently moved to implement or consider actions aimed at limiting access to gender-affirming health care, particularly for youth. This has included restrictions on coverage of benefits as well as bans on the provision of gender-affirming care by health care providers. A number of lawsuits are pending.

What gender affirming services do states report covering through Medicaid?

The standards of care for gender-affirming health services set by the World Professional Association for Transgender Health include hormone therapy, surgeries, fertility assistance, voice and communication therapy, primary care, and behavioral health interventions. Additionally, the Endocrine Society supports gender-affirming care in their clinical practice guidelines . Together, these guidelines form the standard of care for treatment of gender dysphoria. Gender-affirming care is highly individualized, and while not all transgender and nonbinary individuals will want or seek any or all of these medically necessary services, limiting access to them can lead to negative and life threating outcomes. Major U.S. medical associations, such as the American Medical Association , the American College of Obstetricians and Gynecologists , the American Academy of Nursing , the American Psychiatric Association , among others , have issued statements underscoring the medical necessity of gender-affirming care.

In a survey of states on coverage of sexual and reproductive health services conducted in Summer 2021, KFF and Health Management Associates (HMA) asked states about coverage of five gender-affirming care services: gender-affirming counseling, hormones, surgery, voice and communication therapy, and fertility assistance for transgender enrollees (Questions presented in Appendix Table 1 ). Because the survey focused on adult access, states were not asked about puberty blocking hormones. States were asked if a service was covered, excluded from coverage, or whether coverage was not addressed in state policy or statute for adults over the age of 21, as of July 1, 2021. Services that are not addressed in state policy or statute may or may not be covered by the state, or coverage may vary by case. The survey instrument was distributed via email to state Medicaid directors and where applicable, Medicaid agency staff working on women’s health and reproductive health issues. Forty-one states and the District of Columbia responded to the survey. Tennessee responded to the survey but did not answer questions related to gender-affirming services. Survey findings are summarized in Figure 1 and Table 1 and highlights are presented below.

Overall coverage of gender-affirming care:

As detailed below, many state Medicaid programs cover aspects of gender-affirming health services. However, only two of the 41 states responding to this survey, Maine and Illinois, reported covering all five services. Two states, Alabama and Texas, reported they do not cover any of these services under Medicaid.

Gender-Affirming Hormone Therapy:

Gender-affirming hormone drugs include estrogen, anti-androgens, and progestins (feminizing hormones), as well as testosterone and other agents (masculinizing hormones). Under federal law, and subject to exceptions for a few drugs or drug classes, state Medicaid programs are required to cover all drugs from manufacturers that have entered into a rebate agreement with the Secretary of Health and Human services under the federal Medicaid Drug Rebate program . Twenty-five states reported covering gender-affirming hormones, and 10 of these states require prior authorization. Thirteen states said coverage was not addressed in state statute or policy, and three states— Alabama , Hawaii , and Texas —exclude coverage of gender-affirming hormone therapy.

Gender Affirming Surgery:

Gender-affirming surgery can include chest surgery, genital surgery, facial surgery, and other surgical procedures aimed at helping a transgender or nonbinary person transition to their self-identified gender. Not all transgender or nonbinary individuals seek or want surgical treatments. Twenty-three of the 41 responding states reported covering gender-affirming surgery for adults through their state Medicaid programs. Nine states reported coverage was not addressed in state statute or policy, and nine states reported that they excluded gender-affirming surgery from coverage. This survey did not ask states to specify what surgical procedures they cover, but some states provided additional details, which can be found in Appendix Table 2 .

Ten of 23 covering states require prior authorization. For example, Colorado requires a clinical diagnosis of gender dysphoria and that the patient has lived in their preferred gender for 12 continuous months. Colorado and Wisconsin also require that the patient has completed 12 continuous months of hormone therapy.

Voice and Communication Therapy

Some transgender people have challenges with developing a voice that matches their gender identity. Voice therapy services can encompass a range of treatments that address pitch, intonation, articulation, pragmatic speech and other aspects of communication.

Thirteen of the 41 responding survey states report that they cover gender-affirming speech or voice therapy services, some requiring prior authorization. Ten of the survey states reported that they exclude coverage for gender-affirming voice therapy services, and 18 states responded that they have not addressed this coverage in their state policy.

Fertility Services:

A broad array of diagnostic and treatment services are available to assist with achieving a pregnancy. Diagnostics typically include lab tests, semen analysis and imaging studies, or procedures of the reproductive organs. Treatment services include medications, reproductive system procedures to allow for pregnancy, and an array of other interventions to help an individual achieve pregnancy, such as intrauterine insemination (IUI) and in-vitro fertilization (IVF). While federal rules require states to cover most prescription medications under Medicaid, there is an exception that allows states to exclude coverage for fertility medications.

Fertility services can be unaffordable without insurance coverage but few states (11) cover services for any beneficiaries, regardless of gender identity. In this survey, just three states ( Illinois , Maryland , and Maine ) reported covering fertility services as part of gender-affirming care. Of these three states, Illinois is the only one that reported covering services for beneficiaries without exceptions. More than half of states (29) reported that they exclude coverage for fertility services for transgender individuals, and nine states responded that they have not addressed this coverage in their state policy ( Table 1 ).

Mental Health Counseling:

Transgender and nonbinary individuals may seek mental health services to address issues related to their gender identity and transition but may also seek care to address issues that are not related to their gender transitions. As noted, in some cases a diagnosis of gender dysphoria is required before gender-affirming services can be accessed.

Twenty-seven states reported covering mental health counseling and services specifically related to gender affirming health services, 11 states reported coverage was not addressed in their state statute or policy, and three states, Alabama , Kansas , and Texas , reported that they exclude this benefit.

Some states reported requiring that transgender and non-binary Medicaid enrollees receive mental health assessments prior to receiving hormone therapy or having gender-affirming surgeries. For example, Delaware requires prior authorization for mental health counseling related to gender-affirming care, and Connecticut reported that depending on the type of service, prior authorization may be required.

The need for coverage of and access to medically necessary gender-affirming care has been recognized by leading medical and health professional organizations. However, some states have enacted laws banning the provision of gender-affirming health services to youth, and coverage for gender-affirming health services is uneven in state Medicaid programs. In most states, there is variation in coverage for specific services and some states do not have policies addressing coverage in their state Medicaid programs, potentially leaving many low-income transgender and nonbinary individuals without access to medically necessary health services.

Since this survey was conducted, the Biden Administration has proposed a new rule on Section 1557, which is consistent with their prior guidance, and proposes that excluding coverage for gender-affirming care constitutes sex discrimination. In addition, beyond what is stated in rulemaking by the current or previous administrations, some courts have found that the statue itself (i.e., sex non-discrimination provisions) protects against health care discrimination based on gender identity and sexual orientation. For example, a federal district court permanently enjoined the Wisconsin Medicaid program from categorically excluding gender-affirming services from coverage, relying on the statute. Similarly, in recent months, federal courts have ruled the Georgia and West Virginia must cover gender-affirming care in their Medicaid programs. Most recently, in June 2022, Florida’s Medicaid agency announced it would ban coverage of gender-affirming health services in the state. The policy went into effect in August and was challenged in court a few weeks later (with the case still pending). States that do not cover components of gender-affirming care may be in violation of Sec. 1557 of the ACA. However, there are a number of pending legal challenges to the Sec. 1557 rule as well as over specific Medicaid state policies related to coverage of gender-affirming services which will be important to watch moving forward to fully understand this evolving landscape.

• Women's Health Policy

news release

• Few State Medicaid Programs Report Covering a Broad Range of Gender-Affirming Health Services for Adults

Also of Interest

• Demographics, Insurance Coverage, and Access to Care Among Transgender Adults
• Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S.
• Youth Access to Gender Affirming Care: The Federal and State Policy Landscape
• Recent and Anticipated Actions to Reverse Trump Administration Section 1557 Non-Discrimination Rules

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Does Insurance Cover Gender-Affirming Care?

How much does gender-affirming surgery cost, how much does gender-affirming medication cost, other ways to pay for gender-affirming care and surgery, tips for financing gender-affirming care and surgery, bottom line.

• Health Insurance

In many cases, health insurance in the U.S. covers gender-affirming care. However, whether or not your insurance plan covers a specific gender-affirming treatment depends on your state, employer, and the plan’s benefits.

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, or the process can be murky and require preauthorization and appeals.
• Gender-affirming care can cost tens of thousands of dollars.

Major insurance companies recognize transgender-related care as being medically necessary and have put policies in place outlining coverage criteria. However, at least 20 states have passed legislation limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage of hormone treatments or transition-related surgery by an insurer.

An estimated 1.6 million Americans at least 13 years old identify as transgender, according to a June 2022 estimate.

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the gender they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care includes hormones, surgery, or counseling. The care aligns a person’s gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act banned health insurance discrimination based on sexual orientation and gender identity. Before the law’s passage, medically necessary gender-affirming surgeries and hormones often weren’t covered by insurers.

A 2022 rule from the Biden Administration noted that “categorical coverage exclusions or limitations for all health services related to gender transition are discriminatory” and that a covered entity can’t deny or limit coverage or claims, or charge more in cost-sharing related to gender transition.

However, insurance is regulated at the federal and state level based on whether it is an ACA, public, or employer plan, so the rule doesn’t apply evenly to all insurers. Coverage and requirements vary based on state, employer, plan type, and more.

Investopedia / Candra Huff

Determining What Your Plan Covers

Plan members can generally find out what’s available in their member booklet. This should have been given to you when you got the policy or, if it’s an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer’s clinical evidence criteria to qualify for gender dysphoria treatment claim coverage. Requirements might include:  

• One or two letters from a therapist containing specific information
• Being on hormones for a year
• Being at least 18 years old to have surgery.

Some plans may still list exclusions for certain procedures. Even if an exclusion exists in the documentation, the next step is to apply for pre-authorization or pre-approval. This earns a plan’s approval in advance for claims and may even be successful if an exclusion is evident—as it allows an appeal.

"Many [patients] call their insurance carrier and are told services will not be covered, and on that basis never attempt to file a claim,” says an article on the San Francisco-based UCSF Gender Affirming Health Program’s website. “Transgender individuals and their health providers should be aware that unless a denial is in writing, it is not a denial and cannot be appealed.

Typically, documentation submitted to the health plan shows why the treatment is medically necessary or explains the legal problems with an exclusion. Not getting preauthorization can lead to a claim denial, even if a procedure is covered. For example, many plans routinely require preauthorization for all surgeries of any kind for anyone.

If denied a preauthorization request or a claim, an attorney, health care advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service’s medical necessity and appropriateness, and a comprehensive overview of the transition process of gender transition.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving 26 states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer fully funds the plan. If funded by the employer, the plan is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer decides what health care is or is not covered.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Up to 91% of businesses on the 2022 Human Rights Campaign’s Corporate Equality Index-rated businesses offer at least one transgender-inclusive plan option, up from 0 in 2002.

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov marketplace. Most insurers are getting rid of transgender-specific exclusions, which ACA regulation explicitly banned.

Still, policies vary by state and in what they cover. Health insurance policies may feature exclusions for items such as “services related to sex change” or “sex reassignment surgery” to deny coverage.

Around 6% of Silver Marketplace plans specifically exclude coverage for exclusions for treatment of gender dysphoria, according to a survey by Out2Enroll, an organization connecting the LGBT+ community with health care coverage.

Check a policy’s terms of coverage for a full explanation of which procedures and services are covered or excluded. You can also use a state-based Trans Insurance Guide from Out2Enroll to find a plan with the coverage you want.

Medicare and Medicaid Coverage

Nearly 10,000 transgender Americans 65 and older are enrolled in Medicare or Medicare Advantage. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Coverage by Medicare Advantage plans may vary, so try to get preauthorization before accessing transition-related services, suggests the National Center for Transgender Equality.

On a state-by-state basis, Medicaid coverage is uneven for lower-income people seeking gender-affirming care. Medicaid programs cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in nine states bar coverage of transgender-related care for people of all ages, and programs in two states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access gender-affirming hormonal treatment and therapy for gender dysphoria. Tricare, the health benefits provider for military members, does not usually cover gender-affirming surgeries. However, a waiver may be requested and granted in some cases for medically necessary gender-affirming surgery.  

The Veterans Health Administration offers gender-affirming health care, including hormones and prosthetics, mental health care, and other health care. Coverage for gender-affirming surgery has traditionally been denied but is currently undergoing a review.

For just one person, the cost of gender-affirming care might range from $25,000 to $75,000, according to estimates from the HRC Foundation.

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam’s apple removal, and forehead reduction.

Bottom surgery may include:

• Phalloplasty : Creation of penis 
• Metoidioplasty : Phallus created from existing genital region tissue. 
• Hysterectomy : Uterus and cervix removal  
• Nullification surgery : Creating a gender-neutral look in the groin
• Oophorectomy : Removal of one or both ovaries
• Vaginoplasty and vulvoplasty : Creation of vagina and vulva 
• Orchiectomy : Testicle removal 

Research published in 2022 by The Journal of Law, Medicine & Ethics detailed the costs of gender-affirming surgery from 1993 to 2019. The chart below shows the average costs of five of the most common gender-affirming procedures within a commercially insured population over the span of those years.

However, not all transgender people desire surgery. According to 2019 statistics, only 28% of transgender women get any type of surgery, and only 5%–13% receive genital surgery. Surgery is more common among transgender men, with 42%–54% getting some type of surgery; up to 50% get genital surgery.  

Gender-affirming medication is far more common. Up to 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to The Journal of Law, Medicine & Ethics. The study notes the costs of gender-affirming medication from 1993 to 2019.  

Another 2022 study from Vanderbilt University found that masculinizing hormones run $29.76 to $463.54 per fill while feminizing hormones cost $12.95 to $180.98. Much of the cost depends on the delivery method, such as injection or gel. The authors note that “the most cost-effective hormone therapies were oral estrogen and injectable testosterone esters.”

One 2020 survey found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those uninsured) were more likely to take non-prescription hormones from unlicensed sources, which may not be monitored for quality and potentially lead to health risks.

Other costs are involved as well. For example, at Planned Parenthood of South, East, and North Florida, gender-affirming hormone treatment costs between $95 to $105. Lab monitoring may need to be run to ensure health while taking hormones, which can average $26 to $142 per visit.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are 10 options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards may be another avenue for covering the costs of gender-affirming care or surgery, although these tend to have higher interest rates. You may see promotional materials for the CareCredit credit card in your provider’s office, but other credit cards can pay for the same healthcare costs, often with a better interest rate and without the dangerous deferred interest feature that CareCredit cards have. You’re better off with a regular credit card that has a promotional 0% purchase rate offer.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations offer grants for people seeking gender-affirming care or surgery, such as the Darcy Jeda Crobitt Foundation and the Jim Collins Foundation.

Health Accounts 

If you have a flexible spending account (FSA) or Health Savings Account (HSA) , consider allocating some account money for gendering-affirming care or surgery.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Line of Credit (HELOC) 

You could take out a home equity line of credit to cover the costs of gender-affirming care or surgery. With this type of loan, you typically can borrow up to a specific percentage of your home equity. Interest rates on HELOCs are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can’t repay the loan, your could lose your home. 

Friends-and-Family Loans 

If you’ve got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. Just make sure you have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues or strangers.

When you’re financing gender-affirming care or surgery, follow these tips:

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. This homework could save you a lot of money.

Explore Your Options 

Even if health insurance covers a procedure or treatment, you must cover some out-of-pocket costs. Therefore, consider looking into surgery grants, crowdfunding, friends-and-family loans or other methods to bridge the monetary gap.

Check the Interest Rate 

Be sure to investigate how much you’ll pay to borrow money if you go down that road. With the CareCredit card, for example, the APR may be higher than a regular credit card or a personal loan. 

Try Negotiating or a Payment Plan

You can negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn’t willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-affirming Care Cost in the U.S?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. For one person, gender-affirming care might cost anywhere from $25,000 to $75,000, according to estimates from the Human Rights Campaign Foundation. Health insurance may or may not cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one study, insurance companies cover puberty blockers 72% of the time. The estimated out-of-pocket cost for a 3-month supply ranges between $9,500 and $39,000.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress made, some people still encounter problems securing health insurance coverage for gender-affirming care or covering out-of-pocket costs. Getting coverage for care may require preauthorization, documentation of medical necessity, and an appeal. This may prompt use of alternative financing methods like crowdfunding, credit cards, loans, or grants.

U.S. Department of Health and Human Services. “ HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity .”

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

American Medical Association. “ Transgender Coverage Issue Brief .”

First Report Managed Care. “ Transgender Patients: Calculating the Actual Cost .”

UCSF. " Health Insurance Coverage Issues for Transgender People in the United States .”

Transgender Health Insurance. " Health Insurance - Understanding Your Plan ."

HRC. " Corporate Equality Index 2022. "

Society for Evidence-Based Gender Medicine. “ Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies .”

BlueCross BlueShield of Tennessee. “ BlueCross BlueShield of Tennessee Medical Policy Manual .” 

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

HealthCare.gov. “ Transgender Health Care .”  

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Williams Institute, UCLA School of Law. “ Medicaid Coverage for Gender-Affirming Care ,” Page 1.

National Center for Biotechnology Information. “ Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information .”

British Columbia Nurses’ Union. “ Position Statement: Gender-Affirming Care .”

Journal of General Internal Medicine. " Gender-Affirming Hormone Therapy Spending and Use in the USA, 2013–2019. "

Annals of Family Medicine. "Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ."

Aetna. “ Gender Affirming Surgery .”

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Understanding Insurance Requirements for Gender Affirmation Surgery

• Type of Surgeries
• Barriers to Access
• WPATH Standards

Restrictions to Coverage

Getting started, what you can do.

Insurance coverage for orchiectomy, genitoplasty, and other types of gender-affirmation surgery is largely governed by standards issued by the World Professional Association for Transgender Health (WPATH). Many health insurance providers use these guidelines to direct which procedures are medically necessary. However, not every insurer—or state—does.

Because acceptance of WPATH guidelines can vary, it can sometimes be hard to determine which procedures are covered by your health plan and whether gender affirmation is even affordable.

This article describes the types of surgeries pursued by transgender or gender-nonconforming people as a part of gender affirmation and the barriers they face. It also explains the WPATH standards of care for each type of surgery, how insurance companies use them to determine eligibility, and what restrictions are imposed by providers or states.

Gender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like "sex reassignment" or "sex change" should not be used.

Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.

Medical or surgical procedures are only one facet of gender affirmation.

Types of Gender-Affirmation 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, including those referred to as " top surgery ” (occurring above the waist) and "bottom surgery" (occurring below the waist).

An extensive national survey of transgender people 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).
• 37% 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 testicles).
• 22% of transgender men either had or wanted phalloplasty (the 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 (removal of the breasts).
• 71% of transgender men either had or wanted a hysterectomy (removal of the uterus).

Common Barriers to Gender-Affirmation Surgery

Cost, surgeon availability, and a process referred to "gatekeeping" are three major hurdles commonly faced by people undergoing gender affirmation.

Cost is one of the primary reasons people have limited access to gender-affirmation 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-affirmation surgery options. But that coverage often comes with many hoops that people need to jump through. It is also not available to all people in all states.

Surgeon Availability

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

In addition, many don’t take insurance. Fortunately, as insurance coverage for gender-affirmation surgeries has increased, so too has physician interest in training. Today, there are many hospitals across the country that routinely perform vaginoplasty and accept insurance to pay for them.

"Gatekeeping"

Another barrier is a process called “gatekeeping" currently endorsed by WPATH. Gatekeeping involves undergoing a significant therapy or psychiatric assessment before they are allowed to transition medically.

It is a process that attracted considerable debate given that this level of scrutiny is not required for other major surgeries. It ultimately places the decision in the hands of a psychiatrist who can determine if a person is mentally "fit" to pursue treatment.

Discrimination and Stigma

In addition to barriers like cost and surgeon availability/competency, there is also a long history of discrimination and stigma limiting transgender patients’ access to care.

Insurance and the WPATH Standards

When determining eligibility for gender-affirming surgery coverage, many insurers turn to the WPATH Standards of Care to inform their eligibility guidelines. These are also known as the WPATH criteria or WPATH requirements.

WPATH updates its guidelines every five to 10 years. These standards of care help define which treatments are medically necessary and under which conditions they should be authorized. The standards have become less restrictive over time, reflecting the growing recognition of gender diversity in society.

The standards of care are broadly described as follows:

Standards for Top Surgery

“Top surgery” refers to gender-affirmation 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:

• Persistent, well-documented gender dysphoria (distress caused by the difference between a person’s gender and the gender they were assigned at birth)
• The ability to make an informed decision and consent to treatment
• Any significant medical or mental health conditions are “reasonably well controlled”

Standards for Hormone Therapy

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 surgical 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.

Standards for Orchiectomy, Hysterectomy, and Ovariectomy

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

WPATH criteria for these surgeries include:

• Persistent, well-documented gender dysphoria
• Any significant medical or mental health conditions are “well controlled”
• 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-affirmation 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.

Standards for Vaginoplasty, Phalloplasty, and 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.

• Any significant medical or mental health conditions are “well controlled”
• Appropriate hormone therapy for 12 continuous months, unless there are reasons why someone can’t or won’t take hormones
• 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.

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.

Aftercare Recommendations

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

Standards for 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.

Standards for 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.

Despite the increasing uptake of WPATH guidelines by insurers, not every organization embraces them or applies them in the same way. Even WPATH notes that “the criteria put forth in this document... are clinical guidelines. Individual health professionals and programs may modify them.” And many times, they do.

Generally speaking, private insurance companies are more likely to offer coverage for some or all procedures than government agencies like Medicaid and Medicare. Even so, eligibility requirements can vary as can copayment and coinsurance costs.

Medicaid is the U.S. government health coverage program for low-income people, jointly funded by the federal government and states. Of the estimated 1.4 million transgender adults living in the United States, approximately 152,000 have Medicaid coverage, according to the Kaiser Family Foundation.

Many state Medicaid programs cover aspects of gender-affirming health services. But only two states—Maine and Illinois—cover all five WPATH standards of care as of October 2022 (hormone therapy, surgery, fertility assistance, voice and communication therapy, primary care, and behavioral intervention).

Current Medicaid Coverage Status

In terms of gender-affirming surgery, 23 states provide coverage for adults, while nine states (Alabama, Arizona, Florida, Hawaii, Iowa, Kansas, Missouri, Texas, and Wyoming) currently deny coverage. The remaining states either have no policies in place or offer no reporting of coverage.

Medicare is federal health insurance for people 65 or older and some younger people with disabilities. Original Medicare (Part A and Part B) will cover gender-affirmation surgery when it is considered medically necessary. Prior to 2014, no coverage was offered.

The challenge with accessing surgery is that Medicare has no national precedent for approving or denying coverage. As such, approval or denial is based largely on precedents within your state and is conducted on a case-by-case basis.

This suggests that approval may be more difficult in states that deny coverage to Medicaid recipients given that Medicare is administered by a central agency called the Centers for Medicare & Medicaid Services (CMS).

As a general guideline, the CMS states that the following is needed for you to be an eligible candidate for gender-affirmation surgery:

• Have a diagnosis of gender dysphoria
• Provide proof of counseling
• Provide evidence of hormone therapy (for transgender women)

If coverage is denied, there is an appeal process you can undergo to overturn the denial.

Private Insurance

Most private insurance companies in the United States will offer coverage for some—but not necessarily all—gender-affirming surgeries.

According to the Transgender Legal Defense & Education Fund (TLDEF), many of the larger insurers offer coverage for a comprehensive array of surgeries, including providers like:

• Blue Cross/Blue Shield
• UnitedHealthcare

Others have different standards in different states (such as AmeriHealth) or only offer coverage for specific surgeries like facial feminization surgery (Prestige and AmeriHealth New Hampshire).

Though coverage of gender-affirmation surgery is increasing, many private insurers still require you to meet extensive criteria before approval is granted. By way of example, to get approval for breast augmentation, a transgender woman would need to provide a company like Aetna:

• A signed letter from a qualified mental health professional stating their readiness for physical treatment as well as their capacity to consent to a specific treatment
• Documentation of marked and sustained gender dysphoria
• Documentation that other possible causes of gender dysphoria have been excluded
• The completion of six to 12 months of hormone therapy
• A risk assessment of breast cancer screening by a qualified healthcare provider

Even if approval is granted, copayment, coinsurance, and out-of-pocket costs can vary, often considerably.

Out-of-Pocket Costs

According to a 2022 study from Oregon Health & Science University, a transgender person who underwent "bottom" surgery from 2007 to 2019 paid an average of $1,781 out of pocket.

With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.

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.

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.

Gender-affirmation 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-affirmation surgery.

Not all insurance offers coverage for gender-affirmation 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.

Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study . Plast Reconstr Surg . 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837

National Center for Transgender Equality. The report of the 2015 U.S. transgender survey .

World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version .

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services .

CMS.gov. Gender dysphoria and gender reassignment surgery .

Transgender Legal Defense & Education Fund. Health insurance medical policies: gender dysphoria / gender reassignment .

Aetna. Gender-affirming surgery .

Downing J, Holt SK, Cunetta M, Gore JL, Dy GW. Spending and out-of-pocket costs for genital gender-affirming surgery in the US . JAMA Surg.  2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606

Meijer JH, Eeckhout GM, van Vlerken RH, de Vries AL. Gender dysphoria and co-existing psychosis: review and four case examples of successful gender affirmative treatment . LGBT Health . 2017;4(2):106-114. doi:10.1089/lgbt.2016.0133

By Elizabeth Boskey, PhD Boskey has a doctorate in biophysics and master's degrees in public health and social work, with expertise in transgender and sexual health.

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How to Pay for Gender-Affirming Surgery

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Americans considering gender-affirming surgery can find themselves at the start of an exciting new chapter but the costs to be steep. For many, managing the expenses related to transitioning requires planning and may call for more than one financing solution.

Wolsey Bradley and his wife, Lucky, had to be creative in financing their procedures. The couple used credit cards, medical credit cards, cash and insurance to pay for nearly $50,000 in medical expenses related to their transitions.

"We’ve probably paid for our surgeries in every way you can think of," Wolsey says.

Borrowing money or financing a procedure can also be an option when savings or insurance doesn’t cover all the costs.

How much does gender-affirming surgery cost?

The price tag for individual gender-affirming surgical procedures can range from $8,000 to $64,000, according to 2022 research in the Journal for Law, Medicine and Ethics. The cost generally covers the surgeon’s fee, facility costs, anesthesia fees, medical tests, medication and post-surgery needs, depending on the type of procedure.

For people who need a series of procedures, the combined expenses can reach six figures.

Ways to finance gender-affirming surgery costs

The best-case scenario is for health insurance to cover the costs of gender-affirming surgery, also known as gender-confirmation surgery. If that’s not an option, other ways include personal loans and credit cards. Consider these options to pay for gender-affirming surgery and care:

Online personal loan.

Credit union personal loan.

Credit card.

CareCredit.

Home equity line of credit.

Family loan.

Online personal loan

Online lenders offer unsecured personal loans that can be used for almost any purpose, including medical costs. Loan amounts range from $1,000 to $100,000, and interest rates and monthly payments are fixed over the life of the loan.

Online lenders typically let you pre-qualify and apply for a personal loan online, and some loans have next-day funding. However, online loans can be one of the most expensive ways to cover gender-affirming surgery costs. Compare the annual percentage rates (APRs) of multiple lenders to receive the best rates and monthly payments that fit your budget.

Use our personal loan calculator to see estimated rates and monthly payments.

Whom it’s best for: Borrowers who qualify for a low rate and prefer an online experience.

» MORE: Compare medical loans

Credit union personal loan

Credit unions also offer personal loans, often with lower rates and more flexible terms than those of online lenders. Like online lenders, credit unions set loan terms based on your credit score and history, but some may consider factors outside your credit score, making it easier to qualify for funding. The loan amounts offered may not cover the total cost of surgery, and you must qualify for credit union membership.

Whom it’s best for: Credit union members and those with thin or imperfect credit histories.

Credit card

Credit cards are one way to cover a small procedure or a portion of a costlier surgery, but interest rates can be high.

If you have good or excellent credit (a score of 690 or above), you could be eligible for a credit card with an introductory 0% APR . There is no interest during the card's promotional period, which can usually last 15 to 21 months. You have to pay off the balance within the promotional period to avoid paying interest.

When using a credit card, ensure that your medical costs don't reach the credit limit, which can negatively affect your credit score.

Whom it’s best for: Cardholders with a comfortable amount of credit available and who are looking to pay for minor procedures.

Wolsey says he used CareCredit to help cover $5,000 of his nearly $15,000 chest reconstruction surgery cost. CareCredit is a credit card used specifically for financing health care expenses . If your doctor accepts it, you can apply at their office or online.

CareCredit offers attractive zero-interest promotional financing for a designated term, but unlike most 0% APR credit cards, it defers interest . That means if you don’t pay your balance within the promo period, you must pay all your interest retroactively from the date of purchase. CareCredit’s standard APR is 29.99%, which may be higher than the rates of other credit card issuers.

Whom it’s best for: Individuals who need help covering a small procedure or a portion of a larger procedure and can pay off the debt within the promotional period.

Home equity line of credit

If you own a house, a home equity line of credit allows you to borrow against it, sometimes up to 85% of its appraised value minus any amount you still owe on the mortgage. You can borrow and repay the funds as often as needed during the term, and highly qualified borrowers may get lower APRs.

However, you could lose your home if you can’t repay the HELOC. Interest rates are usually variable, so monthly payments could fluctuate, and some HELOCs have closing costs, an appraisal fee or other fees.

Whom it’s best for: Homeowners with equity in their homes who are unsure of the total cost or number of procedures they’ll have and want flexible credit to draw from.

Family loan

A no-interest or low-interest loan from a relative may be an affordable and lowest-risk option. However, it’s worth weighing the potential impact of this arrangement on your relationship with the family member. Formalizing the process with a promissory note — a document that details factors like interest and repayment terms — and consulting a tax preparer can help make the feeling of borrowing from family easier.

Whom it’s best for: Those looking for a low-cost way to pay for the procedures and who feel comfortable borrowing from family members.

» MORE: Family loans: How to borrow from and lend to family

Other ways to cover gender-affirming care costs

Surgery grants.

Some foundations and organizations offer grants — funds that don’t need to be repaid — for gender-affirming surgery. The Jim Collins Foundation , Point of Pride and Genderbands are examples of organizations that offer funding. Check their websites for eligibility requirements and application deadlines.

Flexible spending accounts

Your employer-provided insurance may allow you to contribute to a flexible spending account, up to $3,050 annually. The money in an FSA isn't taxed and can be used to pay out-of-pocket health expenses like co-pays or prescriptions.

Payment plan

Some health care providers allow you to set up payment plans that break up large medical bills into more affordable monthly payments. The total monthly payment depends on the procedure’s cost and terms you negotiate with your health care provider, and there may be billing charges or fees associated with the plan.

» MORE: How to pay off medical bills: 6 options

Additional tips: Compare and plan

After managing thousands of dollars in medical expenses — and spreadsheets to track them — Wolsey and Lucky have found additional ways to save on costly surgeries.

Don’t always choose the cheapest option

It may be tempting to shop based on price alone, but it benefits you to find a reputable surgeon with experience in the procedures you need. Working with someone unsuitable could mean you’ll have to pay someone else to fix mistakes — something that Lucky has witnessed in her community.

“I had a couple of friends who went with a cheaper surgeon just because it was less money, and they ended up spending a lot more because other surgeons had to fix it," she says.

Compare options

Having multiple options allows you to make the best decision for yourself and your budget.

"You can go into any surgeon’s office and get them to give you a quote. It’s like buying a car," Wolsey says. Through this approach, Wolsey and Lucky found a surgeon who performed the procedures they needed at a more affordable price.

“The surgeon who did my first bottom surgery and Lucky’s final round of facial feminization surgery does time on the table. She does not charge for each individual procedure she does.”

Budget and plan

Before you take out a loan or apply for a credit card, add the monthly payments into your budget to determine whether you can afford them.

“I think financially you really have to check what you have. You have to be really aware of how well you are budgeting and paying off debt,” Wolsey says.

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Know Your Rights

Health care.

Read Our Covid-19 Guides

See these resources for more information about your rights during COVID-19:

• A Know Your Rights Guide for Transgender People Navigating COVID-19   (PDF)
• Una guía para que las personas transgénero navegando la COVID-19 conozcan sus derechos   (PDF)

Know Your Rights in Health Care

Federal and state laws - and, in many cases, the U.S. Constitution - prohibit discrimination in health care and insurance because you're transgender. That means that health plans aren’t allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.

Updated October 2021 

What are my rights in insurance coverage?

Federal and state law prohibits most public and private health plans from discriminating against you because you are transgender. This means, with few exceptions, that it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.

Here are some examples of illegal discrimination in insurance:

• Health plans can’t have automatic or categorical exclusions of transition-related care . For example, a health plan that says that all care related to gender transition is excluded violates the law.
• Health plans can’t have a categorical exclusion of a specific transition-related procedure. Excluding from coverage specific medically necessary procedures that some transgender people need is discrimination. For example, a health plan should not categorically exclude all coverage for facial feminization surgery or impose arbitrary age limits that contradict medical standards of care.
• An insurance company can’t place limits on coverage for transition-related care if those limits are discriminatory . For example, an insurance company can’t automatically exclude a specific type of procedure if it covers that procedure for non-transgender people. For example, if a plan covers breast reconstruction for cancer treatment, or hormones to treat post-menopause symptoms, it cannot exclude these procedures to treat gender dysphoria.
• Refusing to enroll you in a plan, cancelling your coverage, or charging higher rates because of your transgender status : An insurance company can’t treat you differently, refuse to enroll you, or limit coverage for any services because you are transgender.
• Denying coverage for care typically associated with one gender : It’s illegal for an insurance company to deny you coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth. For example, if a transgender woman’s health care provider decides she needs a prostate exam, an insurance company can’t deny it because she is listed as female in her records. If her provider recommends gynecological care, coverage can’t be denied simply because she was identified as male at birth.

What should I do to get coverage for transition-related care?

Check out NCTE’s Health Coverage Guide for more information on getting the care that you need covered by your health plan.

If you do not yet have health insurance, you can visit our friends at Out2Enroll to understand your options.

Does private health insurance cover transition-related care?

It is illegal for most private insurance plans to deny coverage for medically necessary transition-related care. Your private insurance plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. 

To understand how to get access to the care that you need under your private insurance plan, check out NCTE’s Health Coverage Guide .

Does Medicaid cover transition-related care?

It is illegal for Medicaid plans to deny coverage for medically necessary transition-related care. Your state Medicaid plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. Some states have specific guidelines on the steps you have to take to access care. You can check if your state has specific guidelines here .

To understand how to get access to the care that you need under your Medicaid plan, check out NCTE’s Navigating Insurance page.

My plan has an exclusion for transition-related care. What should I do?

There are many reasons why your plan might still have an exclusion for transition-related care in general or for a specific procedure. This does not mean that your plan will not cover your care. Sometimes plan documents are out of date, or you can ask for an exception by showing that this care is medically necessary for you.

If you get insurance through work or school, you can advocate with your employer to have the exclusion removed.

NCTE’s Health Coverage Guide has more information on how to access care and remove exclusions.

Does Medicare cover transition-related care?

It is illegal for Medicare to deny coverage for medically necessary transition-related care.

For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. Some local Medicare contractors have specific policies spelling out their coverage for transition-related care, as do some private Medicare Advantage plans.

To learn more about your rights on Medicare, check out NCTE’s Medicare page.

Does the Veterans Health Administration (VHA) provide transition-related care?

The Veterans Health Administration (VHA) provides coverage for some transition-related care for eligible veterans. However, VHA still has an arbitrary and medically baseless exclusion for coverage of transition-related surgery.  On June 19th, The US Department of Veterans Affairs announced that they will begin the process to expand health care services available to transgender veterans to include gender confirmation surgery. Currently, the Veterans Health Administration (VHA) provides care for thousands of transgender veterans, including some transition-related medical care. We expect the rule will finalize in approximately two years.

For more information FAQs by VHA are found here.

For more information about VHA and transition-related care, check out NCTE’s VAH Veterans Health Care page.

Does TRICARE cover transition-related care?

TRICARE provides coverage for some transition-related care for family members and dependents of military personnel. However, TRICARE still has an exclusion for coverage of transition-related surgery.

What are my rights in receiving health care?

Which health providers are prohibited from discriminating against me?

Under the Affordable Care Act, it is illegal for most health providers and organizations to discriminate against you because you are transgender. The following are examples of places and programs that may be covered by the law:

• Physicians’ offices
• Community health clinics
• Drug rehabilitation programs
• Rape crisis centers
• Nursing homes and assisted living facilities
• Health clinics in schools and universities
• Medical residency programs
• Home health providers
• Veterans health centers
• Health services in prison or detention facilities

What types of discrimination by health care providers are prohibited by law?

Examples of discriminatory treatment prohibited by federal law include (but are not limited to):

• Refusing to admit or treat you because you are transgender
• Forcing you to have intrusive and unnecessary examinations because you are transgender
• Refusing to provide you services that they provide to other patients because you are transgender
• Refuse to treat you according to your gender identity, including by providing you access to restrooms consistent with your gender
• Refusing to respect your gender identity in making room assignments
• Harassing you or refusing to respond to harassment by staff or other patients
• Refusing to provide counseling, medical advocacy or referrals, or other support services because you are transgender
• Isolating you or depriving you of human contact in a residential treatment facility, or limiting your participation in social or recreational activities offered to others
• Requiring you to participate in “conversion therapy” for the purpose of changing your gender identity
• Attempting to harass, coerce, intimidate, or interfere with your ability to exercise your health care rights

What are my rights related to privacy of my health information?

The Health Insurance Portability and Accountability Act (HIPAA) requires most health care providers and health insurance plans to protect your privacy when it comes to certain information about your health or medical history. Information about your transgender status, including your diagnosis, medical history, sex assigned at birth, or anatomy, may be protected health information. Such information should not be disclosed to anyone—including family, friends, and other patients—without your consent. This information should also not be disclosed to medical staff unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA.

What Can I Do If I Face Discrimination?

Seek preauthorization for care and appeal insurance denials

You shouldn’t be denied the care that you need just because you’re transgender. That's illegal.

To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.

Check our NCTE’s Health Coverage Guide for more information on how to get the care that you need covered.

Contact an attorney or legal organization

If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.

While NCTE does not take clients or provide legal services or referrals, there are many other groups that may give you referrals or maintain lists of local attorneys. You can try your local legal aid or legal services organization, or national or regional organizations such as the National Center for Lesbian Rights, Lambda Legal, the Transgender Law Center, the ACLU, and others listed  on our   Additional Resources page  and in the  Trans Legal Services Network .

File discrimination complaints with state and federal agencies

Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The U.S. Department of Health and Human Services has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint.  If you face any of ther kind of discrimination or denial of care based on your gender, disability, age, race, or national origin, or if your health care privacy was violated, you can still file a complaint with the   U.S. Department of Health and Human Services, Office for Civil Rights .

Here are some other places you can file health care complaints:

• Private insurance: File a complaint with your state insurance department. You can find information about your state department here:  https://www.naic.org/state_web_map.htm .
• Hospitals: File a complaint with the Joint Commission, which accredits most hospitals. You can find more information or submit a complaint online at  http://www.jointcommission.org .
• Nursing home, board and care home, or assisted living facility: Contact your local long-term care ombudsman. You can locate an ombudsman here:  http://www.ltcombudsman.org/ombudsman .
• HIPPA violations: file a complaint with the U.S. Department of Health and Human Services (HHS): https://www.hhs.gov/hipaa/filing-a-complaint/index.html
• Federal Health Employee Benefits Program: File a complaint with the Office of Personnel Management ( [email protected] ) or the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• Veterans Health Administration: File a complaint with the Veterans Administration’s External Discrimination Complaints Program or contact a Patient Advocate at your VA Medical Center. Find out more here:  http://www.va.gov/orm/  and  http://www.va.gov/health/patientadvocate .
• Employee health plan: File a complaint with the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• TRICARE (military health care): File a complaint with TRICARE ( http://tricare.mil/ContactUs/FileComplaint.aspx ).

Other state and local agencies: If you face discrimination, you may be able to file a complaint with your state’s human rights agency. You can find a list of state human rights agencies here:  http://www.justice.gov/crt/legalinfo/stateandlocal.php .

What Laws Protect Me?

Federal protections

• The Health Care Rights Law, as part of the Affordable Care Act (ACA)  prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IX’s prohibitions on discrimination based on sex to include: 
• Discrimination on the basis of sexual orientation.
• Discrimination on the basis of gender identity.

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities.  The update was made in light of the U.S. Supreme Court’s decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at: https://www.hhs.gov/ocr/complaints

• The Health Insurance Portability and Accountability Act (HIPAA)  protects patients’ privacy when it comes to certain health information, including information related to a person’s transgender status and transition. It also gives patients the right to access, inspect, and copy their protected health information held by hospitals, clinics, and health plans.
• The Americans with Disabilities Act  prohibits discrimination in health care and other settings based on a disability, which may include a diagnosis of gender dyshoria.
• Medicare and Medicaid regulations  protect the right of hospital patients to choose their own visitors and medical decision-makers regardless of their legal relationship to the patient. This means that hospitals cannot discriminate against LGBT people or their families in visitation and in recognizing a patient’s designated decision-maker.
• The Joint Commission hospital accreditation standards  require hospitals to have internal policies prohibiting discrimination based on gender identity and sexual orientation.
• The Nursing Home Reform Act  establishes a set of nursing home residents’ rights that include the right to privacy, including in visits from friends or loved ones; the right to be free from abuse, mistreatment, and neglect; the right to choose your physician; the right to dignity and self-determination; and the right to file grievances without retaliation.

State and local nondiscrimination laws  prohibit health care discrimination against transgender people in many circumstances.

A large number of states also have explicit policies that prohibit anti-transgender discrimination in private insurance and Medicaid, like exclusions of transition-related care.

• California  private insurance ( PPO regulation ,  HMO general guidelines  and  HMO guidelines on surgery coverage ) and  Medicaid
• Colorado   private insurance  and  Medicaid
• Connecticut   private insurance  and  Medicaid
• Delaware   private insurance
• District of Columbia   private insurance  and  Medicaid
• Hawaii   private insurance and Medicaid
• Illinois  private insurance ( regulations and bulletin ) and Medicaid
• Maine  private insurance and  Medicaid
• Maryland   private insurance  and  Medicaid
• Massachusetts   private insurance  and  Medicaid
• Michigan   Medicaid
• Minnesota   private insurance  and  Medicaid
• Montana  private insurance  and  Medicaid
• Nevada  private insurance  and  Medicaid
• New Hampshire  private insurance  and  Medicaid
• New   Jersey  private insurance and Medicaid
• New Mexico  private insurance 
• New York  private insurance ( coverage ,  code mismatches ,  updated policy ) and Medicaid ( general Medicaid policy ,  criteria for authorization of procedures )
• Oregon  private insurance  and Medicaid ( general policy --refer to Guideline Note 127--and  facial feminization policy )
• Pennsylvania  private insurance  and  Medicaid
• Rhode   Island  private insurance  and  Medicaid
• Vermont  private insurance  and  Medicaid
• Virginia   private insurance
• Washington   State  private insurance  and  Medicaid
• Wisconsin   Medicaid
• Puerto Rico   private insurance

Remember: Just because your state isn’t listed here doesn’t mean you’re not protected. Check out NCTE’s Health Coverage Guide for more information about getting coverage for the care that you need. 

How Can I Help?

• Head to NCTE’s Health Action Center to see the latest on health care and how you can help fight for transgender people’s right to get the health care they need
• Share your story. If you are facing discriminatory treatment, consider  sharing your story  with NCTE so we can use it in advocacy efforts to advance public understanding and policy change for transgender people. If you successfully resolved a health care situation, we want to hear about that as well.

Additional Resources

Government agencies.

Department of Health and Human Services Office for Civil Rights: http://www.hhs.gov/ocr/office/index.html

Links to State and Local Human Rights Agencies: http://www.justice.gov/crt/legalinfo/stateandlocal.php

HealthCare.Gov: https://www.healthcare.gov/transgender-health-care/

Partner resources, best practices and standards of care

Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, Lambda Legal, HRC, & New York Bar: http://www.lambdalegal.org/publications/fs_transgender-affirming-hospital-policies

Healthcare Equality Index, Human Rights Campaign http://www.hrc.org/campaigns/healthcare-equality-index

National Center for LGBT Health Education: http://www.lgbthealtheducation.org/

• National LGBT Health Education Center’s  guide to best practices for front-line health care staff
• National LGBT Health Education Center’s  guide to providing health care to non-binary people
• National LGBT Health Education Center’s  guide to making health care forms LGBT-inclusive

National Resource Center on LGBT Aging: http://www.lgbtagingcenter.org

RAD Remedy’s  guide to providing competent care for trans people

Transgender Law Center’s  guide to organizing community clinics

Clinical standards of care for transgender people

• WPATH Standards of Care
• Endocrine Society Clinical Guideline
• Center for Excellence for Transgender Health

Mental Health Resources

Trans LifeLine

National suicide prevention hotline

US: 877-565-8860Canada: 877-330-6366

https://www.translifeline.org/

National Alliance on Mental Illness (NAMI)

National network of mental health care providers, as well as a provider database

http://www.nami.org/Find­-Support/LGBTQ Help Line   800­-950-­6264

National Council for Behavioral Health

National network of community behavioral health centers, as well as a provider database

http://www.thenationalcouncil.org/

SAMHSA (Substance Abuse and Mental Health Services Administration)

A national database for local professionals and agencies that provide addiction recovery services and mental health care.

https://findtreatment.samhsa.gov/

800-662-HELP (4357)

Health provider resources

National Association of Free and Charitable Clinics (NAFC) Clinics around the United States that offer basic health care for those without insurance or experiencing homelessness. http://www.nafcclinics.org/

RAD Remedy Community­-sourced list of trans-­affirming healthcare providers https://www.radremedy.org/

Insurance resources

Resources to help transgender people select and enroll in insurance 

https://out2enroll.org

TransHealth Health and guidance for healthcare providers, as well as a list of trans­affirming health clinics in Canada, the United States, and England. http://www.trans-­health.com/

Transcend Legal Transcend Legal helps people get transgender-related health care covered under insurance. https://transcendlegal.org/

TransChance Health Helps transgender people navigate health care and insurance to receive respectful, high-quality care, and get transition-related care covered  

https://www.transchancehealth.org/

JustUs Health Leads the work to achieve health equity for diverse gender, sexual, and cultural communities in Minnesota, including the  Trans Aging Project  and a  Trans Health Insurance guide https://www.justushealth.mn

Transition-related financial support

Jim Collins Foundation Financial support for transition-related expenses for people without insurance or who have been excluded by insurance http://jimcollinsfoundation.org/apply/

Point of Pride Annual Transgender Surgery Fund Provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery https://pointofpride.org/annual-transgender-surgery-fund/

Community Kinship Life Surgery Scholarship Provides the trans community with assistance while having a sense of community and kinship http://cklife.org/scholarship/

Transformative Freedom Fund (Colorado) Supports the authentic selves of transgender Coloradans by removing financial barriers to transition related healthcare https://transformativefreedomfund.org/

Kentucky Health Justice Network Trans Health Advocacy Works to help Trans Kentuckians access the healthcare they need, as well as reaffirm our autonomy and community http://www.kentuckyhealthjusticenetwork.org/trans-health.html

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• Plast Reconstr Surg Glob Open
• v.7(12); 2019 Dec

Navigating Insurance Policies in the United States for Gender-affirming Surgery

Wess a. cohen.

From the Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, N.J.

Alexa M. Sangalang

Margaret m. dalena, haripriya s. ayyala, jonathan d. keith, background:.

Patients with gender dysphoria seeking to undergo gender affirmation surgery are often challenged by lack of insurance coverage. The authors aim to review gender affirmation surgery policies and to highlight discrepancies between qualifying criteria across top insurance companies in the United States.

The top 3 insurance companies in each state within the United States were determined by market share. Each insurance policy was analyzed according to coverage for specific “top surgeries” and “bottom surgeries.” Policies were obtained from company-published data and phone calls placed to the insurance provider.

Of the total 150 insurance companies identified, policies related to gender- affirming surgery were found for 124. Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Most insurance companies, 122 of 124 (98%), covered chest masculinization, but only 25 of 124 (20%) of insurance companies covered nipple-areola complex reconstruction. Additionally, 36 of 124 (29%) insurance companies covered chest feminization. Vaginoplasty is covered by 120 of 124 (97%) insurance companies. Despite high rates of vaginoplasty coverage, vulvoplasty is only covered by 26 of 124 (21%) insurance companies. Phalloplasty and metoidioplasty are covered by 118 of 124 (95%) and 115 of 124 (93%) of insurance companies, respectively. Slightly more than half, 75 of 124 (60%) insurance companies covered penile prosthesis.

Conclusions:

As gender-affirming surgery insurance coverage increases, the policies regarding them remain inconsistent. Standardized policies across insurance companies would further increase access to gender-affirming surgery.

INTRODUCTION

Approximately 1.4 million adults and 150,000 teens in the United States identified as transgender as of 2015. 1 Many of these individuals have been diagnosed with gender dysphoria—the distress that is caused by a discrepancy between a person’s gender identity and the gender they were assigned at birth. Transfemales (TFs) are individuals assigned male at birth who identify as female, whereas transmales are individuals assigned female at birth who identify as male. Transgender patients frequently endure lack of acceptance, harassment, and assault, likely contributing to depression rates as high as 62%, as compared to rates of 16% in the general population. 2 Additionally, suicide rates have been cited to be as high as 45% in this population. 3

Gender-affirming surgery can provide life-changing results for transgender patients and has been shown to significantly improve patients’ self-esteem and functioning. 4 These surgeries range from chest wall contouring procedures, such as mastectomy and breast augmentation, to penile and neovaginal reconstruction, and have proven to be effective in treating gender dysphoria. 5 , 6 Despite the profound positive impact gender affirmation surgery provides, insurance coverage has been historically limited. 7 However, in 2014, Medicare and Medicaid lifted the 1981 exclusion of transition-related care, and in 2017 an addendum to the Affordable Care Act banned discrimination on the basis of gender identity. 8 , 9 Since then, some private insurers have increased coverage for gender affirmation surgery. 10 , 11

Historically, most patients undergoing gender-affirming surgery have been self-pay. However, sociopolitical changes and expanding health insurance coverage have led to an increased incidence of gender-affirming surgery. 6 , 12 , 13 Despite this, more than half of patients within the past year were denied insurance coverage for gender-affirming surgeries. 14 The World Professional Association for Transgender Health, a nonprofit, interdisciplinary professional and educational organization devoted to transgender health, has set guidelines for which surgeries should be deemed medically necessary. Nonetheless, insurance coverage remains fragmented, inconsistent, and unclear to navigate.

Uncertainty surrounding insurance coverage for gender-affirming surgery contributes to confusion for providers and patients. It is critical for both plastic surgeons and transgender patients to be aware of the various insurance policies and potential hurdles for gender affirmation surgeries. The ability to navigate insurance policies will dramatically improve access to care for a traditionally underserved community. The authors aim to provide an overview of the current coverage atmosphere in the United States for gender affirmation surgeries and to highlight the challenges when navigating insurance policies. Although surgeons who routinely perform these surgeries may be familiar with the results described, the vast majority of plastic surgeons will not be. Additionally, this is the first manuscript to compile national insurance data on commonly performed gender-affirming surgeries.

The top 3 private insurance companies of each state in the continental United States were determined by market share as published by the Kaiser Family Foundation, a nonprofit, nonpartisan organization. Insurance companies were stratified into large and small group insurance companies by Kaiser. Only large groups were used in this study and were defined as having 101 or more employees. Policies as of December 11, 2018, from each insurance company regarding gender-affirming surgery were then obtained either by company-published online data or via phone call inquiry. Procedures analyzed for top surgery coverage were mastectomy, breast augmentation, and nipple-areola complex (NAC) reconstruction. Bottom surgery analysis included penectomy, clitoroplasty, labiaplasty, vaginoplasty, vulvoplasty, vaginectomy, vulvectomy, phalloplasty, metoidioplasty, penile prosthesis, scrotoplasty, testicular prosthesis, and urethroplasty. Coverage was determined if the medical policy’s stated procedures were considered medically necessary and eligible for coverage. Exclusions were noted when the medical policy explicitly stated such procedures were not covered.

Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Of the total 150 insurance companies identified, policies were found for 124. Three insurance companies had no written policy regarding gender affirmation surgery, and 23 insurance companies did not provide policy information after online and phone call inquiry (Fig. ​ (Fig.1). 1 ). Among the 123 insurance companies where policies were found, 3 of these companies stated that they cover genital surgery but did not specify which specific surgeries are included.

Insurance company inclusions and exclusions.

Top Surgery

Although most insurance companies, 122 of 124 (98%), covered mastectomy, 1 excluded mastectomy as medically necessary in the treatment of gender dysphoria (Fig. ​ (Fig.2). 2 ). Only 25 of 124 (20%) of insurance companies covered NAC reconstruction. 35 of 124 (28%) companies excluded NAC reconstruction coverage specifically. Only 36 of 124 (29%) insurance companies covered breast augmentation, whereas more than half, 84 of 124 (68%), of insurance companies deemed breast augmentation as not medically necessary (Figs. ​ (Figs.3 3 and ​ and4 4 ).

Chest masculinization coverage.

Chest feminization coverage.

Insurance company coverage of top surgery.

Bottom Surgery: Male to Female

Vaginoplasty is covered by 120 of 124 (97%) of insurance companies, and penectomy is covered by 118 of 124 (95%) insurance companies (Fig. ​ (Fig.5). 5 ). Additionally, clitoroplasty is covered by 114 of 124 (92%) companies and labiaplasty is covered by 116 of 124 (95%) of companies. Despite high rates of vaginoplasty coverage, vulvoplasty is only covered by 26 of 124 (21%) insurance companies (Fig. ​ (Fig.6 6 ).

Vaginoplasty coverage.

Bottom surgery: MtF.

Bottom Surgery: Female to Male

Vaginectomy is covered by 110 of 124 (89%) of insurance companies; however vulvectomy is only covered by 47 of 124 (38%). Phalloplasty and metoidioplasty are covered by 118 of 124 (95%) and 115 of 124 (93%) of insurance companies, respectively (Fig. ​ (Fig.7). 7 ). Slightly more than half, 75 of 124 (60%) insurance companies covered penile prosthesis, and 7 (6%) insurance companies specifically excluded its coverage (Fig. ​ (Fig.8). 8 ). Scrotoplasty is covered by 104 of 124 (84%) of insurance companies; however, 7 (6%) insurance companies explicitly state its exclusion of coverage. One hundred two of 124 (82%) insurance companies covered testicular prosthesis, yet 10 of 124 (8%) of insurance companies excluded it. Although a total of 117 insurance companies covered urethroplasty, only 69 of these covered urethroplasty in both female-to-male (FtM) and male-to-female (MtF) gender affirmation surgery. The remaining 48 insurance companies only covered urethroplasty in FtM surgery (Fig. ​ (Fig.9 9 ).

Phalloplasty coverage.

Penile prosthesis coverage.

Bottom surgery: FtM.

Gender-affirming surgeries improve patient well-being, cosmesis, and sexual function. 15 Unfortunately, financial burden is a frequently reported barrier to gender-affirming care. 16 , 17 Transgender patients specifically encounter economic hardship with almost half earning less than $10,000 annually. 17 Not coincidentally, gender-affirming surgery can improve a patient’s income which manifests a public good. 18 Therefore, insurance coverage is critical for transgender patients seeking gender-affirming surgery. Despite these benefits, insurance coverage for gender-affirming surgery, while increasing, remains unreliable and vague. 19 Although we did not observe geographic trends that correlated to a political map, the northeast and midatlantic regions trended toward broader coverage.

Chest Masculinization

An overwhelming number of insurance companies covered FtM mastectomy. Breasts are a strong female-identifying characteristic, 20 and therefore these patients often try to conceal their breasts either by wearing loose clothing or by binding their breasts, which may lead to skin damage, intertriginous infections, and even cellulitis. 21 However, less than 20% of insurance companies covered NAC reconstruction, whereas another 25% implicitly exclude NAC reconstruction coverage (Fig. ​ (Fig.4). 4 ). This is most likely because MtF chest contouring is not done for oncologic reasons, and therefore the NAC does not necessarily need to be removed. However, the male nipple is located laterally and inferiorly as compared to the female nipple and not accounting for this by means of free nipple grafting may lead to unsatisfactory aesthetic results and may add to dysphoria. 22 , 23

Chest Feminization

Chest feminization was not deemed medically necessary by almost 75% of health insurers (Fig. ​ (Fig.4). 4 ). TF patients seek to solidify their feminine gender frequently through breast surgery. Although chest feminization significantly increases patient satisfaction, many insurance companies continue to consider breast augmentation equivalent to a cisgendered female desiring larger breasts and therefore consider it a cosmetic procedure. In fact, the current procedural terminology (CPT) code recognized by insurance companies is for bilateral augmentation mammoplasty with prosthetic implant: a traditional cosmetic code. 10 However, when performing these procedures on TFs, it is reconstructive and should be covered by insurance. Coverage for breast implants may be further complicated by the inherent risks of placing a foreign body into a patient, which may lead to infection, capsular contracture, breast implant-associated anaplastic large cell lymphoma, cosmetic deformity, and need for additional procedures. 24

Bottom Surgery

The majority of insurance companies covered “bottom” surgeries. More than 90% of companies covered penectomies (Fig. ​ (Fig.6). 6 ). This is most likely because most health-care professionals believe that genitalia is what defines an individual’s sex. 25 Moreover, if gender dysphoria is defined as discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth, 26 then bottom surgery can be considered a direct treatment. 17

Bottom Surgery: MtF

The associated procedures with penectomies for vaginal reconstruction, including clitoroplasty, labiaplasty, and vaginoplasty, were also covered by more than 90% of insurance companies (Fig. ​ (Fig.6). 6 ). This supports the idea that most professionals agree that the creation of the corresponding genitalia would inherently treat the dissociation between their gender identity and sex assigned at birth. Although a penectomy is the first step in constructing female genitalia, it is clear that most insurance companies believe that creating a functional vagina that can receive penetrative intercourse and shortening the urethra are important.

Interestingly, less than one-third of insurance companies covered a vulvoplasty, which is the creation of the external appearance of female genitalia without the creation of the vaginal canal (Fig. ​ (Fig.6). 6 ). This may be an option for patients who are older, have higher BMI, or have preexisting conditions such as prostatic radiation as the complication rate and risk profile is significantly lower than a vaginoplasty. Additionally, vulvoplasty was still associated with high levels of satisfaction. 27 It is unclear if insurance companies consider this procedure “cosmetic” and therefore justify not covering it.

Bottom Surgery: FtM

Similar to MtF bottom surgeries, the majority of FtM bottom surgeries were covered by insurance companies. Vaginectomy and related FtM bottom surgeries including phalloplasty and metoidioplasty were covered by more than 85% of companies (Fig. ​ (Fig.9). 9 ). Similar to penectomies, insurance companies agree that the removal of the genitals, ie, vaginectomy, can treat gender dysphoria. However, unlike MtF procedures, FtM procedures can also include procedures that increase function in addition to aesthetics such as penile prosthesis, which was covered by less than half of the insurance companies. Insurance companies may contend that phalloplasties without prosthesis already improve quality of life and sexual function 28 and therefore penile prosthesis is not necessary. However, penile prosthesis with or without inflation could further increase sexual satisfaction by providing penetrative intercourse. 29 , 30 Further studies are needed to delineate patient satisfaction with and without penile prosthesis.

Interestingly, more than 80% of companies cover a scrotoplasty and testicular prosthesis (Fig. ​ (Fig.9). 9 ). It is unclear why such a high proportion of insurance companies cover these nonfunctional procedures, but have chosen to forgo coverage of NAC reconstruction: similarly nonfunctional, but aesthetically native. The high rate of coverage of these procedures further demonstrates medical insurance companies possible opinion that genital surgery is a direct treatment for gender dysphoria, despite their lack of consistency regarding vulvoplasty. Urethroplasty is covered by more than 90% of insurance companies as it is necessary to lengthen the urethra when creating a neophallus to achieve normal micturition (Fig. ​ (Fig.9 9 ).

Criteria for Surgery

We encountered little consistency in which procedures insurance companies would cover, mirroring our own practice frustrations. The World Professional Association for Transgender Health provides standard-of-care guidelines and a list of surgical procedures that may be useful in treating MtF and FtM patients and is often utilized as a guide for insurance companies and health-care providers. 31 However, we found little uniformity in criteria for coverage for any gender-affirming surgery within or between states. At a minimum, documentation of persistent gender dysphoria by a qualified mental health professional and further criteria including capacity, age of majority, no other significant medical or mental health problems, hormone therapy, and real-life experience may should be obtained.

Future Directions

Although we were unable to deduce any geographic or insurance company trends to coverage, we believe this presents an opportunity for those performing gender-affirming surgeries to advocate for their patients. Surgeons will need to continue to communicate with one another, publish their results, and lobby the government as well as the insurance companies to expand coverage and increase transparency. Additionally, as the construct of “gender” continues to morph from binary to nonbinary and gender fluidity, gender-affirming surgeons must continue to understand their patients’ needs.

CONCLUSIONS

As the demand for gender-affirming surgery continues to increase, it is critical for both the patient and physician to understand how to navigate insurance coverage policies. Greater awareness and transparency will improve access to care for a traditionally marginalized group of society. Additionally, more research is needed to delineate best practices for gender-affirming surgeries and their correlated patient-reported outcome measures.

Published online 11 December 2019.

Presented at the American Society for Reconstructive Microsurgeons, Palm Desert, California, February 2019.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Phone: 617-726-3525 Fax: 617-724-7126

Email: [email protected]

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About gender-affirming surgery at mass general.

Specialists in the  Transgender Health Program  and Transgender Surgical Program at Massachusetts General Hospital are dedicated to ensuring a welcoming and affirming environment for all patients. We offer patients a wide spectrum of gender-affirming services to support them throughout their entire care journey, including comprehensive primary care, surgical treatment, hormone management, case management and behavioral health support.

The Transgender Surgical Program is a collaboration with specialists from the Mass General  Division of Plastic and Reconstructive Surgery , the  Department of Urology  and the  Department of Obstetrics and Gynecology . Our multidisciplinary surgical team works closely with providers from the Transgender Health Program and every patient to develop a safe and all-inclusive surgical plan that aligns with the patient’s personal goals.

Gender-Affirming Surgical Procedures

Our expert team performs a variety of highly specialized gender-affirming surgical procedures tailored to meet the needs of transgender and gender-nonconforming patients.

• Vaginoplasty , sometimes referred to as bottom surgery, is a surgery that is used to create a vulva, labia, and vaginal canal
• Orchiectomy , also known as testicle removal surgery and/or bottom surgery, is a procedure in which the testicles are surgically removed
• Hysterectomy and/or oophorectomy is a surgery that involves the removal of the uterus and, in some case, the ovaries
• Phalloplasty , sometimes referred to as bottom surgery, is surgery to create a penis. It can include a variety of different procedures, depending on individual goals
• Mastectomy , sometimes referred to as top surgery, is a surgery to remove breast tissue from the chest
• Breast augmentation is surgery that uses implants made of silicone or saline to enhance the size of a person’s natural breasts
• Facial feminization or masculinization is surgery to alter facial features—the chin, nose, cheeks, forehead, etc.—to create a more feminine or masculine facial structure
• Voice feminization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more feminine sound though surgery that involves lengthening the vocal cords or adjusting the tension of the vocal cords. Before undergoing surgical intervention, patients will work with a speech therapist specializing in voice feminization
• Voice masculinization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more masculine sound though surgery to decrease the tension of the vocal cords. In addition to surgery, some individuals may benefit from speech therapy to further refine their vocal skills and communication. This procedure is not common, as only 75% of people can masculinize their voice with hormone therapy

Frequently Asked Questions About Gender-Affirming Surgery

For genital or “bottom” surgery, the first step is to schedule an initial visit with the Transgender Health Program. To schedule this appointment, call 617-726-3525 or email us . For breast or “top” surgery, you are not required to schedule an intake visit with the Transgender Health Program, unless you need a referral for support services. Instead, please contact the Transgender Surgery Program team at 617-726-3525 to learn how to proceed with a surgical consult. Providers should fax referrals to 617-724-7126.

Following confirmation from the Transgender Health Program that you are ready to move forward with bottom surgery, the Transgender Surgery Program team will contact you to set up a surgical consult.

Fertility preservation offers the opportunity to freeze eggs or sperm to be used for building a family in the future. This can be done prior to initiation of gender affirming hormone therapy or surgery. For some, it can also be used after hormonal therapy has already been started. Resources and care are also available for coordinating use of eggs or sperm from another person (donor) or for another individual to carry a pregnancy (gestational carrier).

Patients who desire fertility preservation or family building through Mass General must:

• Complete a consultation with the Mass General Fertility Center
• Be of reproductive age (requirements vary by family building plan)
• Follow center-specific guidance and protocols for selected treatment

During your surgical consultation, your physician will ask you about your fertility preservation goals and will assist you with setting up a consultation with a fertility specialist. We are committed to supporting you and guiding you through this process.

Required documents prior to gender-affirming surgery vary depending on the type of procedure. Our surgical program coordinator will assist you with questions and provide you with more information during your surgical consult.

Once we’ve scheduled a date for your surgery, we will submit a prior authorization for surgery to your insurance company for approval. Some out-of-network insurances may require you to obtain prior authorization for surgical consultations. Please reach out to your insurance company to determine what is required. Our dedicated surgical coordinator is happy to assist you with this process.

There are medical rates at many of the surrounding local hospitals. Depending on the procedure, you may need to remain local for a few weeks. If you are interested in medical rates, our dedicated surgical coordinator will be happy to provide you with more information.

Patient Stories

Patients who underwent gender-affirming surgery at Mass General share their experiences.

Finally, Herself: Elise’s Journey to Gender-Affirming Surgery

When Elise first heard of gender-affirming surgery, it seemed next to impossible in her situation. After a few years filled with research and conversations about her gender identity, what seemed impossible became achievable. She sought care with the Mass General Transgender Health Program team.

Tanner Chose Mass General for Gender-Affirming Care

"I wouldn’t have been able to do it if I didn’t have my team by my side every step of the way. I went from worrying, to feeling grateful," Tanner Bonanza, gender-affirming surgical patient.

Meet Our Team

The Mass General Transgender Surgical Program and the Transgender Health Program form a multidisciplinary and collaborative team of providers and staff who work together to provide gender-affirming care for all patients.

Jay Austen, MD

• Chief, Plastic and Reconstructive Surgery
• Chief, Division of Burn Surgery
• Interim Chief of the Department of Oral & Maxillofacial Surgery

Branko Bojovic, MD

• Plastic and Reconstructive Surgery
• Department of Surgery

Katherine Carruthers, MD, MS

• Attending Surgeon, Massachusetts General Hospital

Beth Drzewiecki, MD

• Pediatric Urology, MassGeneral Hospital for Children

Rich Ehrlichman, MD

• Assistant Professor of Surgery, Harvard Medical School
• Assistant Surgeon, Massachusetts General Hospital

Ariel Frey-Vogel, MD, MAT

• Primary Care
• Department of Medicine
• Department of Pediatrics

Youngwu Kim, MD

• Urogynecologist
• Urogynecology and Reconstructive Pelvic Surgeon

Jenny Siegel, MD

Eleanor Tomczyk, MD

Milena Weinstein, MD

• Chief of Urogynecology and Reconstructive Pelvic Surgery (URPS)
• Co-chair, Center for Pelvic Floor Disorders
• Director of Research, Urogynecology and Reconstructive Pelvic Surgery Fellowship

Jonathan Winograd, MD

• Associate Visiting Surgeon, Massachusetts General Hospital
• Associate Professor, Harvard Medical School

Telehealth at Mass General

Virtual visits allow you to conveniently meet with your provider from home—either online (over your computer or device) or by phone.

#1 Research Hospital in America

Mass General is recognized as a top hospital on the U.S. News Best Hospitals Honor Roll for 2023-2024.

If you would like to request an appointment with or refer a patient to the Division of Plastic and Reconstructive Surgery, please use the following contact information.

Court to decide if Ontario must pay for surgery to make vagina if patient also wants to keep penis

A non-binary Ontario resident is locked in a legal battle over public funding for surgery to create a vagina while leaving the penis intact

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Article content

In a lengthy legal battle that could lead to more requests for individually customized and unorthodox gender-affirming surgeries, an Ontario resident is seeking publicly funded surgery to construct a vagina while preserving the penis.

The case, now before the courts, reflects a small but growing demand for niche surgeries for people who identify as non-binary, meaning neither exclusively female nor exclusively male.

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To critics, the procedures are risky experiments that illustrate “how far off the rails” gender-affirming medicine has gone and the excesses of “consumer-driven gender embodiment.”

“Our public health-care system is at the breaking point and really needs to focus on procedures that are medically necessary,” Pamela Buffone, founder of the parents’ group Canadian Gender Report, said in an email to the National Post.

“Is this type of surgery health care? The patient will not be physically healthier because of the operation, which is likely to result in complications and the need for corrective surgeries and further demands on the health system.”

LGBTQ rights groups say such surgeries can profoundly improve a person’s quality of life and reduce the distress and deep sense of unease from gender dysphoria. Health-care providers shouldn’t make assumptions about what care may be medically necessary, Egale Canada argued in a written submission to the court.

“Ultimately OHIP’s interpretation (of a vaginoplasty) is exclusionary and discriminates against nonbinary people on the basis of their gender identity,” Egale said. If there is any ambiguity in what should be publicly covered, it should be resolved in favour of the claimant, they said.

As National Post columnist Jamie Sarkonak first reported in September , the case involves 33-year-old K.S., as she is identified in court documents, who was born male but who identifies as female dominant and uses a feminine name.

Ontario’s Health Insurance Plan (OHIP) originally denied K.S.’s request in 2022 for funding for a penile sparing vaginoplasty, a procedure that isn’t available in Canada. The surgery was to be performed at the Crane Center for Transgender Surgery in Austin, Texas.

Is this type of surgery health care?

According to legal documents, K.S. argued that “to ignore ‘the other third’ of her and how she presents would be invalidating; she is ‘both,’ not exclusively one or the other but literally a mix.”

OHIP argued that, while it may be of medical benefit to K.S., a vaginoplasty without penectomy (removal of the penis) is considered an experimental procedure and isn’t listed as an insured service under its schedule of benefits.

K.S. complained to Ontario’s Health Services Appeal and Review Board, which overturned OHIP’s decision, ruling that a vaginoplasty is among the 11 external genital surgeries listed for public coverage, and that it shouldn’t inherently include a penectomy.

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OHIP, in turn, appealed the review board’s decision to Ontario’s Superior Court of Justice. The case was heard in late February. “We do not yet have a decision — it could still be months,” K.S.’s lawyer, John McIntyre, said in an email.

K.S., who has experienced gender dysphoria since a teen, doesn’t completely align with either the male or female genders, the appeal board heard. Her doctor, an Ottawa endocrinologist, supported K.S.’s request for a specific type of bottom surgery.

“It is very important for (K.S.)  to have a vagina for her personal interpretation of her gender expression but she also wishes to maintain her penis,” the doctor wrote in a letter to OHIP supporting the request for prior funding approval. “(K.S.) is transfeminine but not completely on the ‘feminine” end of the spectrum (and) for this reason it’s important for her to have a vagina while maintaining a penis.”

K.S. argued that forcing a non-binary person to undergo binary surgery — male to female, or female to male — would only exacerbate her gender dysphoria and would be akin to an act of conversion therapy, which has been banned in Canada since 2022.

She also wishes to preserve her penis for sexual health reasons and out of concern the “urological rerouting” could create urinary incontinence problems, a recognized complication.

In its decision, the health services appeal tribunal referenced standards of care as set out by the influential World Professional Association for Transgender Health, or WPATH, which considers a penile sparing vaginoplasty a valid treatment option for non-binary people. The board said it adopted the trans care group’s logic that “gender diverse presentations may lead to individually customized surgical requests some may consider ‘non-standard.'”

The Ontario health ministry said it doesn’t comment on matters still before the courts.

K.S. declined to comment when contacted through her lawyer.

In a similar case reported last year by the Globe and Mail, OHIP initially denied coverage to a 41-year-old Ottawa public servant who identifies as transmasculine non-binary and who was seeking the surgical construction of a penis without the removal of the vagina and uterus.

Nathaniel Le May and his lawyers argued that phalloplasty, on its own, is listed as an insured service, and that OHIP was wrong in interpreting that it was only insured if also accompanied by a vaginectomy. The additional procedures, they also argued,  amounted to coerced sterilization.

Two days before the case was set to be heard by the appeal board, OHIP reversed its decision and agreed to fund the surgery.

“My outcome is the same as K.S. We will both have a penis and a vagina,” Le May said in an email to the National Post.

“Why is it considered experimental in her case to have a vagina and a penis, but not in my case? Why did OHIP concede that it is an insured service for me but continue to fight that hers is not? OHIP is being inconsistent,” Le May said.

The Crane Center in Texas offers several non-binary surgical options. “We offer everything you could think of,” Dr. Curtis Crane, a plastic surgeon and reconstructive urologist with fellowship training in transgender surgery, said during a Facebook live Q&A session for patients three years ago. “I can’t think of a time that a patient has come up with a surgical request that I haven’t been able to fulfill.”

Hundreds of messages recently leaked from WPATH’s internal forum included discussions about an anticipated “wave” of requests for non-binary affirming surgeries such as mastectomies without nipples, “nullification” (removal of all external genitalia, just smooth skin) and phallus-preserving vaginoplasty — “non-standard” procedures resulting in bodies that one therapist said “either don’t exist in nature or represent the first of their kind and therefore probably have few examples of best practices.”

Crane argues that vaginoplasty without penectomy surgery is not experimental. “I probably do 10 or so a year; it’s not uncommon,” he said in an interview with National Post. Bodies with mixed genitalia “absolutely do exist in nature,” he added. “There are disorders of differentiation of sexual genitalia that will leave both parts.”

Techniques vary, but with the standard male-to-female vaginoplasty — penile inversion vaginoplasty — a vaginal canal is created and lined using penile tissue. “Next you would move on to surgically dissecting out the phallus, shortening the urethra and making a clitoris,” Crane said.

With penile preservation vaginoplasty, the vagina can be created using scrotal tissue or tissue from other parts of the body, like the abdomen or colon.

Crane said some patients seeking vaginoplasty get sexual gratification from their phallus and don’t want to have to sit to urinate.

“There are all kinds of reasons. I don’t say one reason is not a good enough reason. It’s the patient’s body,” he said. During the Facebook session, Crane said, “It’s kind of assault to make a patient remove an organ that they’re enjoying.”

But Dr. Yonah Krakowsky, a staff urologist at Women’s College Hospital in Toronto and medical lead of the hospital’s transition-related surgeries program, told the review board that phallus-sparing vaginoplasties are considered experimental by most surgeons, published reports on the “functional or psychological outcomes” are lacking and that the surgical technique used in the process is poorly understood.

Crane said he couldn’t recall, “off the top of my head,” the cost of a penile preserving vaginoplasty. When Sarkonak, the Post’s columnist, called the Texas clinic, she was told gender-affirming surgeries can range from US$10,000 to US$70,000, depending on what’s done.

“If someone just has an agenda to say, ‘no,’ (to public funding), you can never compete with that,” Crane said. “And unfortunately, that’s what it is the majority of the time: ‘I’m just gonna say no, because I don’t like this.’”

Others said it’s hard to justify the public coverage when Canadians across the country are facing lengthy wait lists for standard surgeries, and standard diagnostic tests.

“It’s hard to call this actual health care,” said Dr. Roy Eappen, a Montreal endocrinologist and senior fellow at Do No Harm, a medical and policy advocacy group. “There is no evidence that it improves anything physically, and the evidence that it helps mental health is not there either.”

“I can’t see the justification for paying. This is not something that really exists in nature and there is a very high complication rate for these kinds of surgeries,” Eappen said.

“WPATH wants to separate this all from any psychiatric diagnosis and call this ‘consumer driven.’ If that’s the case, then you can pay for it.”

While more people are identifying as non-binary, Crane said there are “plenty” of non-binary people who don’t want any surgery.

Eappen agreed. “I don’t know how many of them will want this kind of surgery. But I think this (case) would encourage them to ask. And I’m not sure we’re actually doing anyone a favour.”

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Hong Kong Amends Its Surgery Requirements to Change Gender Markers on IDs

H ong Kong no longer requires transgender people to undergo full gender-affirming surgery to change their legal gender markers in their IDs, more than a year after the Chinese enclave’s top court called the requirement unconstitutional.

The government announced the change on Wednesday, “having prudently considered the objective of the policy, relevant legal and medical advice, as well as drawing reference from the relevant practices overseas.”

Under the new rules, Hong Kong residents who have not undergone full sex reassignment surgery [SRS] who want to have their gender marker on their ID changed still must have completed select surgical treatment to modify their sexual characteristics—removal of the breasts for transgender men, removal of the penis and testes for transgender women—along with medical documentation. Previous guidelines required the removal of the uterus and ovaries or the construction of a penis or “some form” of it for female-to-male transition, and the removal of the penis and testes and the construction of a vagina for male-to-female transition.

“We are still concerned about the heavy emphasis on sex reassignment surgeries being a requirement,” Wong Hiu-chong, the lawyer for transgender activist Henry Tse , whose case led to the policy change, told TIME. “SRS can be life threatening.”

Those who wish to change their gender markers must also statutorily declare that they have gender dysphoria—the medical term for the psychological distress a person feels when their gender identity does not match with their assigned sex at birth—and have lived as the opposite sex for at least two years before their application. They must also show proof of receiving hormonal treatment throughout the previous two years, and will be subjected to random blood tests to check their hormonal profile.

“Our clients have waited a very long time for such an unconstitutional policy to be revised, and for them, the wait has been painful,” Wong said in a statement. She also questioned the need for blood tests, calling this requirement, among others that remain for gender marker changes, “potentially discriminatory” as it does not apply to other Hong Kong ID card holders.

A government spokesperson clarified in the announcement that the gender marker change will only apply to the Hong Kong Identity Card and that “the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law. It does not affect any other policies of the Government or the handling of any other gender-related matters under the law in Hong Kong or relevant legal procedures.”

The policy change comes years after Tse filed a case in 2017 to question the full gender-affirming surgery requirement. Despite the city’s Court of Final Appeal issuing a ruling deeming the requirement unconstitutional in February 2023, implementation of the ruling was long-delayed, which Tse also challenged . The ruling said “such surgical procedures are at the most invasive end of the treatment spectrum” and that “full SRS is not medically required by many transgender persons whose gender dysphoria has been effectively treated.”

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The Vatican says surrogacy and gender theory are 'grave threats' to human dignity

Updated April 8, 2024 at 5:55 PM ET

The Vatican has released a new document calling poverty, war and the plight of migrants "threats to human dignity." But it also calls abortion, surrogacy and gender theory "grave threats" facing humanity today.

The document, titled " Infinite Dignity " says that each person's dignity comes from the love of the creator "who has imprinted the indelible features of his image on every person." This language is familiar to Christians accustomed to hearing that humans are all made in God's image.

The document goes on to say that this dignity is inalienable, beyond any circumstance or situation the person might encounter. Simply put, because a person exists, a human has intrinsic dignity.

"Infinite Dignity" details a long list of what it calls grave threats to that dignity, some of which might be expected given other Catholic teachings. It talks about the drama of poverty and how the unequal distribution of wealth denies humans their God-given dignity. It also describes war, the abuse of migrants, sexual abuse, violence against women, the marginalizing of people with disabilities, assisted suicide and abortion all as affronts to human dignity.

But then the document turns to other issues that have become more highly politicized in recent years: surrogacy, gender theory, and what it calls "sex change."

The document's framework holds that if a person is made in God's image, gender theory and gender reassignment surgery call into question why God would create a person with the wrong gender.

It says that the understanding of humanity as divided into two sexes — male and female — is biblical and deeply meaningful, especially in terms of procreation. Gender theory argues that a person's gender can be different from the sex that person was assigned at birth.

"Infinite Dignity" says the concept of human dignity can be misused to justify what it calls an "arbitrary proliferation of new rights," describing those, rather, as "individual preference" or "desire." That language is very similar to how conservatives often talk about being transgender as a choice, which is something major medical and psychological groups dispute.

The document makes a clear distinction between the issue of sexual orientation (whether a person is gay, lesbian or bisexual) and the issue of gender identity (whether a person's sex assigned at birth matches what that person understands his or her gender to be).

The document will be seen by some more conservative Catholic as a win after years of feeling embattled during Pope Francis's leadership. Just last year, the Vatican said priests could baptize transgender Catholics and allowed for priests to bless people in same-sex relationships .

But many transgender Catholics and their families as well as more progressive Catholics are displeased with "Infinite Dignity."

Executive director of the LGBTQ Catholic group New Ways Ministry, Francis DeBernardo says of the document, "When it gets to the section on people who are transgender or non-binary, it doesn't apply the principles of human dignity to them."

New Ways Ministry's mission is, in part, to help pastors and religious teachers better understand gender identity and sexuality. It also fosters, "holiness and wholeness within the Catholic LGBTQ+ community."

DeBernardo argues "Infinite Dignity" does not live up to its own name. "In a sense, it's not infinite dignity," he says. "It's a very limited dignity that the church is offering."

He fears this document will be used to further persecute transgender people, and he thinks it will cause transgender Catholics and their families to leave the church.

DeBernardo also worries the sections on gender theory and what it calls "sex change" will eclipse what he describes as the very good parts of the document on war, poverty and migrants.

The group Catholics for Choice, is also disappointed and calls into question how the document was created. "Yet again," said the group's president Jamie Manson in a written statement, "a group of all-male, celibate clergymen are telling women and gender-expansive people that their lived experiences are not real or valid."

Catholics for Choice advocates within the church on a variety of issues regarding sexual and reproductive health, including abortion rights. The group holds – and argues that Catholic teaching supports – people's individual consciences should be their guide in such decisions.

"It is clear to me that the women and trans people who continue to identify as Catholic — despite documents like this completely disregarding our experiences — only do so because of a deep love for our faith and its traditions," continues Manson in her statement. "It is devastating that our leaders do not offer the same respect and love in return."

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Hong Kong LGBTQ activists upset at revised ID card gender rules

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Vatican Condemns Gender-Affirming Surgery, Gender Theory And Surrogacy As Threats To Human ‘Dignity’

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The Vatican on Monday slammed gender theory, surrogacy and gender-affirming surgery as major threats to human dignity in a highly anticipated text , reaffirming the Church’s conservative stance on these and numerous other matters like abortion, euthanasia and assisted suicide amid discontent following a series of more divisive and progressive moves by Pope Francis.

Pope Francis and the Vatican rejected gender-affirming surgery, gender theory and surrogacy as major ... [+] threats in line with Catholic teachings on abortion

The document, titled “Dignitas Inifinita,” or Infinite Dignity, dismissed the idea that gender is mutable and said God created an “ineliminable sexual difference between man and woman.”

This “gender theory” should be rejected and efforts to change gender or sexual characteristics “amounts to a concession to the age-old temptation to make oneself God,” the declaration said.

As a rule, any sex-change intervention like gender-reaffirming surgery ”risks threatening the unique dignity the person has received from the moment of conception,” the Church said, carving out a caveat for “genital abnormalities” evident at birth or developing later in life, which it said were different and can be resolved with the help of medical professionals.

The Church also reaffirmed its opposition to surrogacy, which it deemed “deplorable” and “a grave violation of the dignity of the woman and the child.”

The Vatican said that surrogacy, “first and foremost,” violates the rights of the child, particularly the right to have a “fully human”—and not artificially induced—origin and turns them into a “mere object.”

The document also reiterated longstanding Catholic objections to euthanasia and assisted suicide, warning legalization efforts were quietly but “swiftly gaining ground,” as well as abortion, where increasing popular acceptance represents an “​​extremely dangerous” moral crisis.

Pope Francis’ tenure as the head of the Catholic Church has marked a more liberal turn for the centuries old institution. In part, this document marks his position within the still deeply conservative Catholic tradition and offers a reprieve to the Church’s conservative factions who are battling some of the Pope’s more liberal positions. Pope Francis’ efforts to make the Church more inclusive to groups such as LGBTQ people are still a long way from being liberal in the traditional sense but denote a sharp departure from traditional Catholic doctrine and they are deeply controversial. His more liberal teachings have sharply divided clerics, creating factions in the Church keen to retain the more conservative stance, with particular opposition evident in the U.S. , Europe and parts of Africa . The rejection of gender theory, a flashpoint of partisan “culture wars” across the U.S. and elsewhere around the world, has been hotly anticipated and its inclusion in this document places Catholic objections to gender-affirming surgery on par with its existing objections to abortion and euthanasia.

Further Reading

Vatican Reaffirms Support Of Same-Sex Blessings After Bishop Pushback (Forbes)

The war against Pope Francis (The Guardian)

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The price of pain: Questionable billing by doctors rife in Australia

A major investigation into the chronic pain industry has uncovered how Australia's healthcare system is being left open to financial exploitation by some medical practitioners.

Trudi King is always in pain.

"The only relief you get is when you go to sleep," the 60-year-old says.

In 2021, she had spinal fusion surgery at a private hospital in Sydney after struggling with back pain for four years.

"All I wanted was to live a pain-free life," she says.

When she woke up, she couldn't feel her feet. 

"I was terrified … no one really told me what was going on," she says.

Trudi had a second surgery the next day. There were serious complications and she was in a coma for almost three weeks.

When she finally got home, she had to use a wheelchair.

As for the pain, it's now even worse.

Trudi is one of more than three million Australians grappling with the relentless agony of chronic pain. Back pain is the leading cause of disability and lost productivity in Australia and globally.

It has spawned a multi-billion-dollar industry offering treatments including spinal surgeries and medical devices — the majority done in the private sector.

For the past six months, Four Corners has been investigating the trail of misery it has left behind. For some it's meant more pain, paralysis, and even death.

Spinal fusion costs tens of thousands of dollars. Trudi's experience cost her health fund a fortune.

What she now knows, after the investigation by Four Corners, is that not only did her surgery cause her harm, but some of her medical bills raise concern.

An analysis of Trudi's records by medical billing expert Margaret Faux found questionable billing from anaesthetists involved in her surgery.

Dr Faux, the founder of medical technology company Synapse, did not have access to Trudi's full medical records, but analysed her private health insurance and Medicare bills for the time she was in hospital, including the period she was in a coma.

"There are red flags because during that same period, a number of doctors came into the intensive care unit," she says.

"The services that they billed are services that require the doctor to have a discussion with the patient; not their relatives, not their colleagues — with the patient — because you have to explain treatment to the patient.

"I do not understand how it is possible to have a discussion with an unconscious patient who is in a coma."

It's not an isolated case.

Four Corners has obtained the private health insurance billing records of more than 23,000 patients who underwent spinal surgery in Australia between November 2017 and May 2023.

Across the full data set, the analysis found:

• 77 per cent were billed for more complex services than provided
• 10 per cent were billed for longer services than provided ; and
• 7 per cent were billed for spinal fusions for chronic lower back pain without a diagnosis , in breach of a Medicare rule

The de-identified data was supplied by six private health funds, representing 25 per cent of the private health fund industry.

The records were sent for analysis to Dr Faux and a team at Synapse, as well as a team at Kirontech, a UK-based health fraud investigation company that used its specialist detection software.

They cross-checked the analysis and wrote a report. Together, they found more than 20 per cent of the bills they assessed raised questions.

The experts state in their report there is a strong suggestion of "a serious fraud, waste and abuse problem requiring urgent attention".

The terms "fraud, waste and abuse" are used widely in the industry and can cover conduct ranging from errors, to overservicing, to fraud.

Rachel David, CEO of Private Healthcare Australia, says if the findings were applied to the whole industry for spinal surgery, it would signal a huge draining of the health system by some medical professionals.

"We're talking about half a billion dollars."

The team analysing the data ran complex algorithms to exclude the possibility of other medical explanations, but without each patients' medical records it's impossible to be conclusive.

Most of the questionable billing came from anaesthetists and surgeons.

Here's how it works …

Every time a patient is admitted to hospital in Australia, that admission generates a number of bills across the health system.

Among them are bills from individual medical practitioners, claiming payment from a patient's private health fund and Medicare for the services they say they provided.

Practitioners charge for their services using codes. Each code represents a specific service.

As it's based on an honour system, they are automatically paid without checks that the services took place.

Red flags can emerge when the codes used by different practitioners involved in the same surgery are compared.

For example, each of these surgeries involved a fluoroscopy , an imaging procedure often used in spinal fusions.

The billing code used indicates the surgeries took less than one hour.

But the time billed by the anaesthetists in those same surgeries is much longer.

The analysis applied a buffer to take into account anaesthetic times are always longer than surgical times.

This means the anaesthetists charged the health system more ...

… including one who billed for more than 14 hours of work at an added cost of over $2,500.

The analysis also uncovered questionable billing patterns among surgeons … including charging for advanced procedures in implausibly short times.

In these surgeries, the anaesthetist billed for 2.5 hours or less … but the surgeon charged for procedures that even the quickest practitioner would be unlikely to complete in the available time.

For each additional level of spinal fusion surgery, surgeons claim an extra $1,350 on average.

In this surgery, a patient allegedly underwent three complex procedures in what code 23041 indicates was 20-35 minutes.

An expert who analysed the data said it was highly unlikely even a fast surgeon would be able to complete all three in that time.

Kirontech's chief medical advisor Dr Simon Peck – who is also a former anaesthetist – says the findings are alarming.

"We've looked at data from all around the world, and I would say the indicators of misbilling … is at the top end of the scale," Dr Peck says.

"Medical bills are paid on the basis of trust … After a while, when people realise that they're not being checked up on, they start … to push the boundaries."

The system is hitting the patient twice, Dr Faux says.

"We are exploiting them clinically by offering them treatments and procedures that … can be harmful, and then a second time financially."

Last year, an Independent Review of Medicare Integrity and Compliance, commissioned by Health Minister Mark Butler, found "legislation, governance, systems, processes and tools are currently not fit for purpose and, without significant attention, will result in significant levels of fraud".

The review made several recommendations to be implemented to strengthen the Medicare system.

Trudi says she's now in worse pain than before her surgery.

"It's just a dark place you have to mentally deal with," the grandmother of three says.

"I was very active, and I liked fishing and walking. [Now] I've got three grand babies under five and I can't play with them like I want to.

"It's like, 'Nanny's always sick.'"

The need for surgery

Trudi regrets deciding to have the surgery.

Spinal fusion involves permanently joining two or more vertebrae to prevent movement between them.

Trudi had three bones fused. She says an X-ray had found disk degeneration.

Spinal fusion is an accepted surgery for treating people with congenital spinal disorders, those who have broken their back, and some other conditions.

Sometimes it is recommended as a treatment for chronic back pain but a rising number of health researchers and surgeons say it's not an effective treatment.

Orthopaedic surgeon Ian Harris says there have only been a handful of trials.

"Those trials, when put together, don't show a clear benefit of surgery," he says.

"Some surgeons are very unlikely to recommend the procedure … it tells us that someone's wrong."

Professor Harris says MRI scans pick up abnormalities in most people aged over 40.

"The more things you find, the more likely it is that you'll end up with somebody wanting to treat or correct that abnormality — even though correcting that abnormality might not help the patient because it might not be associated with their pain."

More than 70 per cent of spinal fusions are done in the private sector, the latest figures estimate. The more bones that are fused, the higher the cost of the surgery.

Professor Harris is concerned this financial incentive drives more surgeries.

"The more you get paid for a procedure, the more likely it is that that procedure will be done," he says.

"It's too easy for us to let these other incentives influence our decision making."

Trudi says she's now trapped in the pain industry.

"I'm never not in pain," she says.

"Now I'm on this cycle; pain doctors … neurologists …"

She says she'd like to ask the surgeon who operated on her, "What the hell did you do?"

Watch Four Corners: Pain Factory, tonight from 8.30pm on ABC TV and ABC iview .     

Subscribe to the Four Corners newsletter and follow Four Corners on Facebook .  

Adele Ferguson is a reporter with ABC Investigations

Research: Dunja Karagic

Data visualisation: Mark Doman , Inga Ting  and  Alex Lim

Photos: Chris Gillett

Editing and production: Kate Sullivan

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