Paying for Transition-Related Surgeries: Double-Edged Sword

On May 30, 2014, the Department Appeals Board at the Department of Health and Human Services issued a ruling that will end the discriminatory Medicare policy excluding transition-related surgeries from Medicare coverage. Transgender people receiving Medicare will no longer be automatically denied coverage for sex reassignment surgeries. The ruling recognizes the procedures as medically necessary for individuals who do not identify with their biological sex.

Like most other medical services under Medicare, patients must still be approved for any procedure by their provider(s). Decisions about coverage for transition-related care will be made on an individual basis. This ruling only affects Medicare. It will not affect private insurance, Medicaid, or Veterans insurance.

Although this change in Medicare will hopefully allow numerous people to finally transition, this ruling brings another issue to light. To qualify for transition-related surgery through private insurance or Medicare, a provider must diagnose a person with Gender Identity Disorder or Gender Dysphoria. These disorders are found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Providers use these codes to document a diagnosis, which in turn is used by insurance companies to determine reimbursement for care.

These diagnosis codes denote a disease or condition (a pathology). Thus, a Gender Identity Disorder / Gender Dysphoria diagnosis is double-edged. It is not only required for insurance companies to pay for transition-related health services, but it also shows that the person has a disease/disorder/condition. It pathologizes the individual.

In the meantime, it seems that this ruling will produce the most immediate results. Transgender people who qualify for Medicare will be able to seek transition-related health services. But more advocacy work needs to be done to de-pathologize transgender people, but still provide pathways for insurance companies to pay for their care.


Here are a few related web links:


National Center for Transgender Equality

Fact Sheet on Medicare Coverage of Transition-Related Care

American Psychiatric Association

Gender Dysphoria Fact Sheet


A call for the removal of gender identity variance from the psychiatric diagnostic manuals

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3 Responses to Paying for Transition-Related Surgeries: Double-Edged Sword

  1. Mickey says:

    I seem to remember that a similar issue was raised when the discussions about removing homosexuality from the DSM were happening. Some said there needed to be a diagnosis for those who wanted to have therapy related to problems in their lives stemming from sexuality. The solution was to have a disorder “ego-dystonic” homosexuality. That did not last for long. But the surgery issue for transgender folks is a bit different. Perhaps there needs to be a category in the ICD, not the DSM? In this healthcare climate, is a diagnosis a necessary evil?

  2. Mickey, I tried finding a web link that I stumbled across a while back that listed ICD codes that were not “pathological” but can’t find it. One of the examples was pregnancy.

    As a psychiatric clinical instructor, I’ve come across a few patients who were diagnosed with Gender Identity Disorder. In one case, the MTF patient (admitted for something unrelated to gender) was very upset that the psychiatrist diagnosed her with GID on admission. She had never sought surgery, but was living as a female. She had never seen a psychiatrist in the past and was extremely angry that she was labeled with this disorder upon admission. That incident reminded me of the history behind the homosexuality diagnosis.

    I agree with you though. Undergoing surgery is a unique situation. At least the current system provides a pathway for transition surgery. But hopefully changes occur that won’t restrict surgery to those who have a DSM diagnosis, but instead be based solely on ICD codes.

  3. Erin says:

    Great bllog you have here

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