Medical Ethics: Pay For Transitional Services For Transgender Clients

Should medical insurance companies be required to pay for transitional services for their transgender clients? Public and private health insurances cover most things related to medical treatment, dental services, vision care, and preventative medicine for individuals that identify with their natal sex, regardless of the need, only sometimes requiring special considerations. Transgender consumers make up a small percentage of insurance consumers, d should these insurances be required to cover transitional services such as psychotherapy, hormone therapy, and surgical intervention or should those costs be put directly onto the consumer? According to some states, transitional services for transgender individuals do not qualify as a medical need, therefor are not covered under insurances.

Transgender are described as “people whose gender identity, gender expression, or behavior is different from what typically associated with their natal sex or the sex they were assigned at birth.” (Burke, et al G-16) Transitional services for transgender consumers are vital to their mental and physical health and wellbeing. Proper medical care, proper mental health services, and corrective surgical interventions (if requested) should be completed and covered by consumer insurance companies, regardless of the funding source. These services should be considered to be medically necessary, mentally necessary, and should not require special consideration or be allowed to be denied and left to the consumer to cover.

I have the pleasure of being friends with two people who have utilized transitional services both paying cash and through insurances. Allison was born as an assigned male at birth. Dallen was born assigned female at birth. Dallen lives in the state of Maine and recently underwent breast augmentation surgery, a double mastectomy with masculine reconstruction and nipple grafting. Dallen has participated in hormonal (testosterone) therapy for several years. He has also undergone a hysterectomy and oophorectomy and cervical removal. Dallen lives with his son, he birthed, and his husband- Sam.

Allison has had hormonal therapy and surgery and has been living comfortably as a female for a while now. She recently relocated from Maryland to California, where she feels more accepted by the community around her. She has two children and is divorced. She was married to a female, when she was in her birth assigned gender. She talks openly about not being happy with who she was and that being a cause of her divorce. (G. Allison, 2020)

For some, transitional services mean nothing. However, to many, that are being denied the right to them, they could mean their life. Dallen spoke candidly about his mental health struggles before he was granted access to transitional services. “I suffered severe suicidal ideation and engaged in self-mutilation until I began my transition. After about a year a huge number of my mental health issues either went away or were much easier to manage.” (Delgado, 2020) Dallen suffered from gender dysphoria. “A condition in which there is a conflict in the gender a person is assigned at birth and the gender the person identifies with.” (Burke, et al 436) Gender dysphoria is the main reason why transitional services are needed. The suicide and self-harm rates amongst transgender individuals are the highest in the country according to a 2015 survey. (UCLA, 2019) Transgender individuals also face ridicule, bullying, violence. It was also determined in the same survey that a lower risk for suicide was assigned to individuals who had support from others, such as family and friends, who lived in a state with a gender identity nondiscrimination statute, and who wanted and received transitional services (such as hormone therapy, mental health care, and surgical interventions) (UCLA, 2019) I believe this one study is essential in proving why these services are so important.

Transitional services are the services transgender individuals rely on in order to be the gender they identify. These services include mental health counseling and sometimes medications, hormonal therapy, and possible surgical intervention. Mental health therapy aides in the identification of gender dysphoria, it gives an individual professional help to identify and work through the feelings of not being happy in their own body. It also gives the option to try medications to help aide with any depression or anxiety that is felt. A mental health evaluation is something that is generally required by insurance companies that do cover transitional surgeries before a candidate is approved for the procedure. Hormonal therapy aides in transitioning the body from the inside to one’s identified gender. Female to male transitional candidates take testosterone, which helps to stop the menses. Male to female transitional candidates take estrogen, which helps to stop sperm production and aids the growth of breast tissue. Neither of these hormones, however, can change the genitiia that one is born with. This is where the surgical intervention comes in. According to “The Trans Center” a leading surgical office for transgender reassignment surgeries, some of the options available for Male to Female transitional services can include breast augmentation, adding breasts and creating a more female form, gender confirmation surgery – which includes penial inversion. A female to male surgical candidate might undergo a full mastectomy or urogenital reconstruction. (The Trans Center, 2019)

The cost of transitional services can be astronomical. In a study performed in 2018, it was found that the cost of transitional services can be upwards of $35,000. This does not include all of the services necessary, such as repeated therapy sessions for depression. It was also found that changing one’s gender on their insurance could cause them to lose vital care designated only for their birth assigned gender. For instance, if a male who identifies as female changes their gender status on their insurance, the insurance may no longer cover prostate exams. (Psychology today, 2019)

Recently Maine changed their rulings to cover transitional services for transgender individuals under their Medicaid program. They did so after Medicare decided to cover these services as well. In Maine one can now have a gender reassignment surgery and if they have a state funded insurance, it will be covered. Medicare recently changed their guidelines and they will also cover gender transition services. States like Ohio, Wyoming, and Iowa have specific wording in their legislation to prohibit these services. Although states such as Maine, California, Wisconsin, and DC have moved to make these coverages part of their plans. The denial of these services seems to vary with the current administration in the White House. Obama pressed to include these coverages as part of the ACA, while Trump has put measures in to place to give states the ability to consider not covering these services as a right. The Trump administration granted the right to refuse to perform these surgeries based on a provider’s personal belief’s giving them permission to cite religious reasoning for not wishing to participate in transitional services. (Washington Post, 2019). Some providers deem the surgical interventions needed for transitioning as cosmetic procedures instead of viewing them as a medically necessary intervention as a treatment for gender dysphoria.

Given that the population of transgender individuals has the highest suicide rate out of a controlled study group in the United States, it would be assumed that preventing as many of these deaths as possible, would be a major argument for states covering these services. If an insurance company can cover a bariatric surgery to help someone who has gained an excessive amount of weight, lose weight to become healthier and less of a financial burden, to have a longer life, to prevent medical issues, and to help that person become happier with themselves; they should be able to cover transitional services for transgender individuals. Transgender individuals that seek transitional services are seeking these services because they have gender dysphoria. This leads to depression, depression leads to higher instances of attempted suicide, ongoing medical issues, ongoing therapy appointments. All of these things cause a financial burden on the insurance company and the individual themselves. Repeated hospitalizations, doctors’ appointments, tests, etc. If insurance companies covered the transitional services such as the mental health therapy, hormone replacement therapy, and surgical interventions; this would allow for the individual to be happier with themselves. This leads to a better quality of life. A better quality of life can lead to fewer hospitalizations, fewer doctors’ visits, a more active lifestyle, and a healthier human all the way around. While the cost might be a huge consideration up front, these costs (with the exception of hormone therapy) are one-time costs that do not need to continue for years. Unlike one who is unhealthy, depressed, and visiting doctors frequently. If a provider sees it morally irresponsible to perform a gender transitioning surgery due to religious a religious belief, that is up to the provider- though I do not agree with that, however ethically, insurance companies should be required to cover transitional services in order to help to prevent the unnecessary mental anguish and suicide that denying these services can cause. 

Not all transgender individuals struggle with gender dysphoria or are wanting to go through these things in order to feel like comfortable in their own skin. This is another reason why insurance companies should be able to cover these things without being an issue. Services like these are not wanted by everyone, but they should be available if the need should arise. An individual should have the right to be comfortable in their own skin. If they have insurance, whether it be a private, employer based, or state funded insurance. Insurances should be required to cover them for the individuals who need them. Insurance companies have an ethical responsibility to ensure the services deemed mentally and medically necessity by providers that they contract with are covered and carried out for the individual who pays for their services.