National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery.

Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% (n = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures (p = 0.043), whereas those in restrictive states offered less overall coverage (p = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.

A Review of Insurance Coverage of Gender-Affirming Genital Surgery.

BACKGROUND: Despite the multiple benefits of gender-affirming surgery for treatment of gender dysphoria, research shows that barriers to care still exist. Third-party payers play a pivotal role in enabling access to transition-related care. The authors assessed insurance coverage of genital reconstructive ("bottom") surgery and evaluated the differences between policy criteria and international standards of care. METHODS: A cross-sectional analysis of insurance policies for coverage of bottom surgery was conducted. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and telephone interviews were performed to identify the policies and coverage status. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Fifty-seven insurers met inclusion criteria. Almost one in 10 providers did not hold a favorable policy for bottom surgery. Of the 52 insurers who provided coverage, 17 percent held criteria that matched international recommendations. No single criterion was universally required by insurers. Minimum age and definition of gender dysphoria were the requirements with most variation across policies. Almost one in five insurers used proof of legal name change as a coverage requirement. Ten percent would provide coverage for fertility preservation, while 17 percent would cover reversal of the procedure. CONCLUSIONS: Despite the medical necessity, legislative mandates, and economic benefits, global provision of gender-affirming genital surgery is not in place. Furthermore, there is variable adherence to international standards of care. Use of surplus criteria, such as legal name change, may act as an additional barrier to care even when insurance coverage is provided.

Increasing normality-persisting barriers: Current socio-demographic characteristics of 350 individuals diagnosed with gender dysphoria.

INTRODUCTION: The number of individuals requesting medical treatment for gender dysphoria has increased significantly within the past years. Our purpose was to examine current biographic and socio-demographic characteristics and aspects of legal gender reassignment. DESIGN: Medical files from n = 350 individuals of a German Endocrine outpatient clinic were collected from 2009 to 2017 and analysed retrospectively. RESULTS: Ratio of transwomen to transmen equates to 1:1.89 with a remarkable increase of transmen by the year 2013, showing a reversal of gender distribution compared with previous studies for the first time. Use of illegal substances or self-initiated hormone therapy was rare (4.6 and 2.1%). Satisfaction with gender-affirming hormone therapy was significantly higher in transmen than in transwomen (100% vs 96.2%, P = .005). Use of antidepressants declined significantly after onset of hormone treatment in transmen (13% vs 7%; P = .007). The number of individuals with a graduation diploma was only about half as high as in the general population (14.3% vs 27.3%), whereas unemployment rate was more than twice as high (14% vs 6.9%). Median latency between application for legal gender reassignment and definitive court decision was 9 months. CONCLUSIONS: Our data provide possible indications for a decline of psychosocial burden in individuals diagnosed with gender dysphoria over the last years. However, affected individuals are still limited in their occupational and financial opportunities as well as by a complex and expensive procedure of legal gender reassignment in Germany.