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Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

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AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update

The AAP Board of Directors voted to reaffirm the 2018 AAP policy statement on gender-affirming care and authorized development of an expanded set of guidance for pediatricians based on a systematic review of the evidence.

An updated policy statement, plus companion clinical and technical reports, will reflect data and research on gender-affirming care since the original policy was released and offer updated guidance. The board recognized  the value of additional detail with five more years of experience since the 2018 policy statement was issued.

The decision to authorize a systematic review reflects the board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 states.

AAP CEO/Executive Vice President Mark Del Monte, J.D., is speaking today at the AAP Leadership Conference in Itasca, Ill.

He emphasizes that policy authors and AAP leadership are confident the principles presented in the original policy, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , remain in the best interest of children.

As part of its mission, the AAP will continue to “ensure young people get the reproductive and gender-affirming care they need and are seen, heard and valued as they are,” Del Monte said.

The board reviews evidence and considers policy renewal on a regular schedule as authorizations expire. Based on the continuing review, the board reaffirmed the current guidance on transgender care until there is an updated version.

To ensure the policy update process is transparent and inclusive, the AAP will invite members and other stakeholders to share input.

The AAP and other major medical organizations — including the American Medical Association, the American College of Obstetricians and Gynecologists and the World Health Organization — support giving transgender adolescents access to the health care they need.

The AAP opposes any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship. Additional Leadership Conference coverage

• Leadership Conference: AAP pledges to address payment issues, support pediatrician wellness
• Leadership Conference: Top resolution calls for federal protections of gender-affirming care for patients, doctors
• Reform humanitarian system for migrant children: Leadership Conference speaker

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FACT SHEET: Biden- ⁠ Harris Administration Advances Equality and Visibility for Transgender Americans

Today, the Biden-Harris Administration recognizes Transgender Day of Visibility, an annual celebration of the resilience, achievements, and joy of transgender people in the United States and around the world. Every American deserves the freedom to be themselves. But far too many transgender Americans still face systemic barriers, discrimination, and acts of violence. Today, the Administration once again condemns the proliferation of dangerous anti-transgender legislative attacks that have been introduced and passed in state legislatures around the country. The evidence is clear that these types of bills stigmatize and worsen the well-being and mental health of transgender kids, and they put loving and supportive families across the country at risk of discrimination and harassment. As the President has said, these bills are government overreach at its worst, they are un-American, and they must stop. Transgender people are some of the bravest people in our nation. But nobody should have to be brave just to be themselves. Today, the Biden Administration announced new actions to support the mental health of transgender children, remove barriers that transgender people face accessing critical government services, and improve the visibility of transgender people in our nation’s data.

Reinforcing federal protections for transgender kids. The Justice Department announced today that it has issued a letter to all state attorneys general reminding them of federal constitutional and statutory provisions that protect transgender youth against discrimination, including when those youth seek gender-affirming care. Advancing dignity, respect, and self-determination for transgender people by improving the traveler experience. For far too long, transgender, non-binary, and gender non-conforming Americans have faced significant barriers to travelling safely and many have not had their gender identity respected as they travel within the United States and around the world. To create a safer and more dignified travel experience, the Biden Administration is announcing the following changes.

• The Department of State is announcing that beginning on April 11, 2022, all U.S. citizens will be able select an “X” as their gender marker on their U.S. passport application. This is a major step in delivering on the President’s commitment to expand access to accurate identification documents for transgender and non-binary Americans. Information on how to apply will be available at travel.state.gov/gender .
• Implementing enhanced screening technology. The Transportation Security Administration (TSA) will soon begin updating its Advanced Imaging Technology (AIT) body scanners with new technology that will increase security and efficiency by reducing false alarm rates and pat-downs for the traveling public. By replacing the current, gender-based system with this more accurate technology, TSA will improve the customer experience of transgender travelers who have previously been required to undergo additional screening due to alarms in sensitive areas.  This new technology will help to improve the experience of travelers, particularly those who are transgender and non-binary travelers. TSA will begin deploying this new technology in airports throughout the country later this year.
• Expanding airline partnerships to enhance the overall travel experience.  TSA is working closely with air carriers across the nation to promote the use and acceptance of the “X” gender marker to ensure more efficient and accurate passenger processing. As of March 31st, two major domestic air carriers already offer a third gender marker option in their travel-reservation systems, with a third air carrier planning to offer this option in the Fall of 2022.
• Streamlining identity validation. TSA has updated its Standard Operating Procedures to remove gender considerations when validating a traveler’s identification at airport security checkpoints. This ensures that TSOs can accurately and efficiently validate each traveler’s identity while avoiding unnecessary delays.
• Updating TSA PreCheck and CBP Trusted Traveler Programs enrollment to include “X” gender markers. The Department of Homeland Security is beginning the process of adding “X” gender markers options in Trusted Traveler programs and the TSA PreCheck program to enhance access for transgender, non-binary, and gender non-conforming travelers to these programs.

Providing resources for transgender kids and their families. Transgender children are put at higher risk of attempted suicide or mental health challenges when they face bullying, rejection, or denial of health care. The Biden Administration is releasing several new resources to help transgender children and their parents thrive:

• Providing mental health resources for transgender youth.  In recent months, multiple states have removed critical information about mental health resources for LGBTQI+ youth from official state websites. Transgender youth often face significant barriers in accessing supportive resources, and are at greater risk of attempted suicide. In response, the Department of Health and Human Services released a new website that offers resources for transgender and LGBTQI+ youth, their parents, and providers. These resources include best practices for affirming an LGBTQI+ child, and information about suicide prevention services.
• Expanding trainings to support transgender and nonbinary students in schools. The Office of Safe and Supportive Schools in the Department of Education will offer new training for schools with experts and school leaders who will discuss the challenges faced by many transgender and nonbinary students and strategies and actions for providing support.
• Confirming the positive impact of gender affirming care on youth mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA) has posted LGBTQI+ Youth – Like All Americans, They Deserve Evidence-Based Care , in which Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA, shares how to engage LGBTQI+ youth, the evidence behind the positive effects of gender affirming care, and available resources for LGBTQI+ youth, their families, providers, community organizations, and government agencies.
• Confirming that gender-affirming care is trauma-informed care. The National Child Traumatic Stress Network (NCTSN), which is administered by the Substance Abuse and Mental Health Services Administration, is releasing new information for providers confirming that providing gender-affirming care is neither child maltreatment nor malpractice.
• Providing resources on the importance of gender affirming care for children and adolescents. The Office of the Assistant Secretary for Health has developed a resource to inform parents and guardians, educators, and other persons supporting children and adolescents with information on what is gender-affirming care and why it is important to transgender, nonbinary, and other gender expansive young people’s well-being.

Improving access to federal services and benefits for transgender Americans.  With support and coordination from the U.S. Digital Service, federal agencies are removing barriers to access government services by improving the customer experience of transgender, non-binary, and gender non-conforming Americans:

• Accessing retirement savings. The Social Security Administration is announcing that it is removing the requirement that transgender people show proof of identity such as doctor’s notes in order to update their gender information in their social security record by the fall of 2022. This will significantly improve transgender individuals’ experience in accessing their retirement benefits, obtaining health care, and applying for jobs.
• Filing an employment discrimination complaint . The U.S. Equal Employment Opportunity Commission (EEOC) is announcing that it will promote greater equity and inclusion for members of the transgender community by giving individuals the option to select an “X” gender marker during the voluntary self-identification questions that are part of the intake process for filing a charge of discrimination.
• Applying for federal student aid. The Department of Education plans to propose next month that the 2023-24 FAFSA (Free Application for Federal Student Aid) will include an opportunity for applicants to indicate their gender identity as well as their race/ethnicity when applying for federal financial aid. The questions, which will be posted for public comment, will be in a survey that accompanies the application. This privacy-protected information would help to inform the Department about possible barriers students, including transgender and nonbinary students, face in the financial aid process.
• Visiting the White House.  The White House Office of Management and Administration is announcing that it is beginning the process of implementing updates that will improve the White House campus entry process for transgender, gender non-conforming, and non-binary visitors by adding an “X” gender marker option to the White House Worker and Visitor Entry System (WAVES) system. This change will ensure that transgender, non-binary, and gender nonconforming people can visit the People’s House in a manner that respects and affirms their gender identity.

Advancing inclusion and visibility in federal data. In too many critical federal surveys and data systems, transgender, non-binary, and gender non-conforming people are not fully reflected. To improve visibility for transgender Americans, agencies are announcing new actions to expand the collection and use of sexual orientation and gender identity (SOGI) data.

• The White House announced that the President’s proposed Fiscal Year 23 budget includes $10 million in funding for additional critical research on how to best add questions about sexual orientation and gender identity to the Census Bureau’s American Community Survey, one of our nation’s largest and most important surveys of American households. This data collection will help the federal government better serve the LGBTQI+ community by providing valuable information on their jobs, educational attainment, home ownership, and more.
• The Department of Health and Human Services has released the findings of the federal government’s first-ever user research testing conducted with transgender Americans on how they want to see themselves reflected on Federal IDs. This groundbreaking user research by the Collaborating Center for Question Design and Evaluation Research (CCQDER) at the National Center for Health Statistics (NCHS) directly informed the State Department’s adopted definition of the “X” gender marker.
• The Department of Health and Human Services  has released a comprehensive new consensus study on Measuring Sex, Gender Identity, and Sexual Orientation. This work, commissioned by the National Institutes of Health and carried out by the National Academies of Sciences, Engineering, and Medicine, will inform additional data collections and future research in how to best serve LGBTQI+ Americans.

These announcements build on the Biden-Harris Administration’s historic work to advance equality for transgender Americans since taking office, including: Combatting legislative attacks on transgender kids at the state level.

• Condemning anti-transgender bills. The President has consistently made clear that legislative attacks against transgender youth are un-American, and are bullying disguised as legislation. In his March, 2022 State of the Union Address, the President said, “The onslaught of state laws targeting transgender Americans and their families is wrong. As I said last year, especially to our younger transgender Americans, I will always have your back as your President, so you can be yourself and reach your God-given potential.” The White House has also hosted listening sessions with transgender youth and advocates in states across the country that are impacted by anti-transgender legislative attacks.
• Reaffirming that transgender children have the right to access gender-affirming health care. In March, following state actions that aim to target parents and doctors who provide gender-affirming care to transgender children with child abuse investigations, the Department of Health and Human Services took multiple actions to support transgender children in receiving the care they need and promised to use every tool available to protect LGTBQI+ children and support their families.
• Department of Justice statements of interest and amicus briefs. The Department of Justice’s Civil Rights Division has filed Statements of Interest and amicus briefs in several matters to protect the constitutional rights of transgender individuals, including in Brandt v. Rutledge , a lawsuit challenging legislation restricting access to gender-affirming care for transgender youth; B.P.J. v. West Virginia State Board of Education , a lawsuit challenging legislation restricting participation of transgender students in school sports; Corbitt v. Taylor , a lawsuit challenging legislation restricting the ability to change gender markers on state driver’s licenses; and Adams v. School Board of St. John’s County , which involves the right of a transgender boy to use the boys’ restroom at his school.

Advancing civil rights protections for transgender Americans

• Fighting for passage of the Equality Act.  President Biden  continues to call  on the Senate to pass the Equality Act, legislation which will provide long overdue federal civil rights protections to transgender and LGBTQI+ Americans and their families. As the White House has  said , passing the Equality Act is key to addressing the epidemic levels of violence and discrimination that transgender people face. The Administration’s first Statement of Administration Policy was in support of the Equality Act, and the White House has convened national leaders to discuss the importance of the legislation.
• Signing one of the most comprehensive Executive Orders on LGBTQI+ rights in history.  Within hours of taking office, President Biden signed an  Executive Order  which established that it is the official policy of the Biden-Harris Administration to prevent and combat discrimination against LGBTQI+ individuals, and to fully enforce civil rights laws to prevent discrimination on the basis of gender identity or sexual orientation. This Executive Order is one of the most consequential policies for LGBTQI+ Americans ever signed by a U.S. President. As a result of that Order, the Departments of Health and Human Services , Housing and Urban Development , Education , Consumer Financial Protection Bureau , and Justice have announced that they are expanding non-discrimination protections for transgender people in health care, housing, education, credit and lending services, and community safety programs.

Supporting transgender service members and veterans

• Reversing the discriminatory ban on transgender servicemembers.  In his first week in office, President Biden  signed  an Executive Order reversing the ban on openly transgender servicemembers serving in the Armed Forces, enabling all qualified Americans to serve their country in uniform. President Biden believes that an inclusive military strengthens our national security As a result of his Executive Order, the Department of Defense issued new  policies  which prohibit discrimination against transgender servicemembers, provide a path for transgender servicemembers to access gender-affirming medical care, and require that all transgender servicemembers are treated with dignity and respect.
• Supporting transgender veterans. To ensure that transgender veterans are treated with dignity and respect, the Department of Veterans Affairs (VA) launched an  agency-wide review  of its policies and practices to ensure that transgender veterans and employees do not face discrimination on the basis of gender identity or expression. In June, VA also announced that it is beginning the regulatory process to remove restrictions that prevent transgender veterans from accessing the gender-affirming care they need and deserve.

Responding to the crisis of anti-transgender violence and advancing safety

• Establishing a White House-led interagency working group on anti-transgender violence. To address the crisis of anti-transgender stigma and violence, during Pride Month in 2021 the White House established the first Interagency Working Group on Safety, Opportunity, and Inclusion for Transgender and Gender Diverse Individuals. The Working Group is co-led by the White House Domestic Policy Council and Gender Policy Council. To inform the priorities of the Working Group, throughout the fall of 2021 the White House convened 15 historic listening sessions with transgender and gender diverse people, advocates, and civil rights leaders from across the country and around the world, including a White House roundtable with transgender women of color .
• Releasing a White House report uplifting the voices of transgender people on gender-based violence and discrimination. On Transgender Day of Remembrance, the White House released a  report  sharing the perspectives from White House listening sessions, uplifting the voices and advocacy of transgender people throughout the country, and highlighting over 45 key, early actions the Biden-Harris Administration is taking to address the root causes of anti-transgender violence, discrimination, and denial of economic opportunity.
• Department of Justice civil rights enforcement actions. On September 14, 2021, the Department of Justice announced that it was launching a statewide civil investigation into Georgia’s prisons, which includes a focus on sexual abuse of transgender prisoners by other prisoners and staff. The Department of Justice’s Civil Rights Division and U.S. Attorney’s Office for the District of Puerto Rico also obtained a federal indictment charging three men with hate crimes for assaulting a transgender woman because of her gender identity.
• Ensuring non-discrimination protections in community safety programs. The Department of Justice issued a Memorandum from the Assistant Attorney General for Civil Rights regarding the application of Bostock v. Clayton County to the nondiscrimination provisions of the Safe Streets Act, the Juvenile Justice and Delinquency Prevention Act, the Victims of Crime Act, and the Violence Against Women Act to strengthen non-discrimination protections for transgender and LGBTQI+ individuals in key community safety programs.
• Strengthening protections for transgender individuals who are incarcerated. In January 2022 the Bureau of Prisons revised its manual on serving transgender offenders , improving access to gender-affirming care and access to facility placements that align with an inmate’s gender identity.
• Honoring those lost to violence.  The White House and the Second Gentleman of the United States hosted a first of its kind vigil in the Diplomatic Room of the White House to honor the lives of transgender and gender diverse people killed in 2021, and the countless transgender and gender diverse people who face brutal violence, harassment, and discrimination in the United States and around the world. The President also released a statement honoring the transgender people who lost their lives to violence.
• Advancing safety and justice for transgender and Two-Spirit Indigenous people. LGBTQI+ Native Americans and people who identify as transgender or “Two-Spirit” are often the targets of violent crimes. On November 15, 2021, President Biden signed an Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. The Executive Order directs federal agencies to work hand in hand with Tribal Nations and Tribal partners to build safe and healthy Tribal communities to address the crisis of Missing and Murdered Indigenous People, including LGBTQI+ and “Two-Spirit” Native Americans.

Advancing health equity and expanding access to gender-affirming health care to support transgender patients

• Protecting transgender patients from health care discrimination. The Department of Health and Human Services (HHS) announced that it would interpret and enforce section 1557 of the Affordable Care Act’s prohibition on discrimination on the basis of sex in certain health programs to prohibit discrimination on the basis of gender identity and sexual orientation.
• Advancing gender-affirming care as an essential health benefit.  In 2021, the Centers for Medicare and Medicaid Services (CMS) approved the first ever application from a state to add additional gender-affirming care benefits to a state’s essential health benefit benchmark plan.
• Advancing health equity research on gender-affirming care.  The National Institutes of Health (NIH) announced that it will increase funding for research on gender-affirming procedures to further develop the evidence base for improved standards of care. Research priorities include a more thorough investigation and characterization of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.
• Ending the HIV crisis among transgender and gender diverse communities.  In December, 2021, in recognition of World AIDS Day, the White House Office of National AIDS Policy released a revised National HIV/AIDS Strategy which now identifies transgender and gender diverse communities as a priority population in the federal government’s strategy to end the HIV epidemic.
• Advancing access to gender-affirming care through Ryan White HIV/AIDS Program. The Health Resources and Services Administration announced that it has released a letter encouraging Ryan White HIV/AIDS Program service providers to provide access to gender affirming care and treatment services to transgender and gender diverse individuals with HIV. The letter reaffirms the importance of providing culturally-affirming health care and social services as a key component to improving the lives of transgender people with HIV.
• Ensuring transgender patients can access birth control. In 2021 HHS issued a final rule to strengthen the Title X family planning program, fulfilling the Biden-Harris Administration’s commitment to restore access to equitable, affordable, client-centered, quality family planning services. The rule requires family planning projects to provide inclusive care to LGBTQI+ persons. Additionally, the rule prohibits discrimination against any client based on sex, sexual orientation, gender identity, sex characteristics, or marital status.

Supporting transgender students and their families

• Ensuring educational environments are free from sex discrimination and protecting LGBTQI+ students from sexual harassment.  President Biden signed an  Executive Order  recommitting the Federal Government to guarantee educational environments free from sex discrimination, including discrimination on the basis of sexual orientation or gender identity. The Executive Order charged the Department of Education with reviewing the significant rates at which students who identify as LGBTQ+ are subject to sexual harassment, including sexual violence. The Department of Education has announced that it intends to propose amendments to its Title IX regulations this year.
• Protecting the rights of transgender and gender diverse students. The Department of Education has affirmed that federal civil rights laws protect all students, including transgender and other LGBTQI+ students, from discrimination. The Department published a notice in the Federal Register announcing that it interprets Title IX’s statutory prohibition on sex discrimination as encompassing discrimination based on sexual orientation and gender identity.
• Department of Justice memorandum on Title IX. The Department of Justice issued a memorandum regarding the application of Bostock to Title IX.
• Speaking directly to transgender students. The Department of Justice, Department of Education, and Department of Health and Human Services issued a joint back to school message for transgender youth.
• Outreach and education to transgender and gender diverse students and their families. The Department of Education has published fact sheets and other resources showing the federal government’s support for transgender students, highlighting the ways schools can support students, reminding schools of their duty to investigate and address harassment based on sexual orientation or gender identity, and informing students how they can assert their rights and file complaints.
• Advancing research to address the harms of so-called conversion therapy.  The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it will update its 2015 publication  Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth  to reflect the latest research and state of the field. 

Promoting fair housing and ending homelessness for transgender Americans

• Advancing fair housing protections on the basis of gender identity. In February 2021 the Department of Housing and Urban Development (HUD) announced that it would administer and enforce the Fair Housing Act to prohibit discrimination on the basis of gender identity and sexual orientation.
• Ensuring safety and access to services for transgender people experiencing homelessness. In April, HUD withdrew the previous administration’s proposed “Shelter Rule,” which would have allowed for federally funded discrimination against transgender people who seek shelter housing. By withdrawing the previous administration’s proposed rule, the agency has restored protections for transgender people to access shelter in line with their gender identity. HUD has also released new tools for recipients to ensure compliance with these requirements in shelters and other facility settings.

Advancing economic opportunity and protections for transgender workers

• Ensuring nondiscrimination protections for transgender and gender diverse workers. In November 2021, the Department of Labor’s Office of Federal Contract Compliance Programs proposed to rescind the agency’s 2020 rule “Implementing Legal Requirements Regarding the Equal Opportunity Clause’s Religious Exemption,” an important step toward protecting workers from discrimination while safeguarding principles of religious freedom.
• Ensuring equal access to the workforce development system. The Department of Labor is enforcing discrimination prohibitions in workforce development programs funded by the Workforce Innovation and Opportunity Act, protecting workers from discrimination based on their gender identity or transgender status.

Advancing gender equity and transgender equality at home and around the world

• Advancing transgender equality in U.S. foreign policy and foreign assistance. In line with the Presidential Memorandum on Advancing the Human Rights of LGBTQI+ Persons Around the World , the United States is making significant investments to uphold dignity, equality and respect for transgender persons globally.  For example, USAID supports the Global Barometer for Transgender Rights and the LGBT Global Acceptance Index which track progress and setbacks to protecting transgender lives around the world.  The Department of Health and Human Services through the United States President’s Emergency Plan for AIDS Relief supports inclusive health care services for transgender individuals, enabling health clinics to provide care to the transgender community. And through the Department of State’s Global Equality Fund , local transgender rights organizations receive support to document human rights violations and provide critical legal assistance to community members.  
• Establishing the White House Gender Policy Council to Advance Gender Equity and Equality.  President Biden signed an  Executive Order  establishing the White House Gender Policy Council to advance gender equity and equality across the whole of the government, including by addressing barriers faced by LGBTQ+ people, in particular transgender women and girls, across our country.  

Supporting transgender leaders and public servants

• Making the Federal government a model employer for transgender public servants. President Biden signed an  Executive Order  which takes historic new steps to ensure the Federal government is a model employer for all employees – including transgender, gender non-conforming, and non-binary employees. The Executive Order charges agencies with building inclusive cultures for transgender employees by: expanding the availability of gender-neutral facilities in Federal buildings; ensuring that employee services support transgender employees who wish to legally, medically or socially transition; advancing the use of non-binary gender markers and pronouns in Federal employment processes; and expanding access to gender-affirming care and inclusive health benefits.
• Appointing historic transgender leaders. The Biden-Harris Administration includes barrier-breaking LGBTQI+ leaders, including Assistant Secretary for Health Dr. Rachel Levine, who is the first openly transgender person ever confirmed by the U.S. Senate. In October, she was also named a four-star admiral in the U.S. Public Health Service Commissioned Corps, becoming the first openly transgender person to hold that rank in any of the country’s uniformed services. Over 14 percent of Biden-Harris Administration appointees identify as LGBTQI+.

Advancing visibility for transgender Americans

• Issuing the First White House Proclamation for Transgender Day of Visibility.  On March 31, 2021 President Biden became the first U.S. President to issue a  proclamation  commemorating Transgender Day of Visibility.  
• Hosting a White House Virtual Convening on Transgender Equality.  In June, White House Press Secretary Jen Psaki hosted a first-of-its-kind  national conversation  on equality for transgender, gender non-conforming, and non-binary Americans.
• Releasing a toolkit on equality and inclusion for transgender Americans.  The White House released a new  toolkit  with best practices for advancing inclusion, opportunity, and safety for transgender Americans.
• Establishing a National Pulse Memorial. On June 25, 2021, President Biden signed H.R. 49 into law to designate the National Pulse Memorial. As the President acknowledged in his statement on the fifth anniversary of the Pulse nightclub shooting, we must acknowledge gun violence’s particular impact on LGBTQ+ communities across our nation, and we must drive out hate and inequities that contribute to the epidemic of violence and murder against transgender women – especially transgender women of color. As the President has said, Pulse Nightclub is hallowed ground.

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TLDEF's Trans Health Project

Gender affirmation surgery.

Policy: Gender Affirmation Surgery Policy Number: HUM-0518-020 Last Update: 2023-09-28

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Updated on Nov 27, 2023

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Gender Affirming Surgery

• Clinical Policy Bulletins
• Medical Clinical Policy Bulletins

Number: 0615

Table Of Contents

The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States.  Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.”

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  

Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).

The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022). 

It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively.  On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given.  A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters.  After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters.  These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school. 

Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints.  Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment.  Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high.  For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs.  Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations.  For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty.  Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known.  All patients considering treatment need counseling and medical monitoring.

Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health.  These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.  Through 2009, a total 192 MTF and 50 FTM transgender persons were seen.  These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability.  Mental health and psychiatric problems were inversely correlated with age at presentation.  The prevalence of gender affirming surgery was low (31 % for MTF).  The number of persons seeking treatment has increased substantially in recent years.  Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.  The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency.  The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers.  They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.

Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism.  Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved. 

Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast.  Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed.  A full-thickness skin graft is taken from the right groin to reconstruct the areola.  The right groin donor site is closed primarily in layers.”  

The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple.  Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, are included in code 19318. 

Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women

Jiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation.  These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice.  Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone.  These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery.  A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty.  Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty.  The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty.  The remaining patients had risk factors leading the surgeon to recommend vulvoplasty.  Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty.  The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only. 

Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered.  Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery

Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells.  These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts.  Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining.  The depths, sizes, secretions, and sensations of the vaginas were evaluated.  The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding.  The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years.  Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery.  The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B.  There was no stenosis in neither group.  The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B.  These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A.  All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5%  in group B expressed satisfaction.  The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina.  The size of neo-vagina, secretion, sensation, and orgasm was good and proper.  More than 93.7 % of patients had satisfaction with sexual intercourse.  They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation.  The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration.  No cases of stenosis or stricture were recorded.  Level of Evidence = IV.  These preliminary findings need to be validated by well-designed studies.

Pitch-Raising Surgery in Transfeminine Persons

Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals.  These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery.  They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total.  Objectively, a substantial rise in post-operative fundamental frequency was identified.  Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality.  The majority of patients appeared satisfied with the outcome.  However, none of the studies used a control group and randomization process.  The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design. 

Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice.  These researchers conducted a comprehensive review of the voice literature.  Publications were identified by searching 6 electronic databases and bibliographies of relevant articles.  A total of 22 publications met inclusion criteria.  Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people.  The quality of the evidence was appraised.  The extent and quality of studies investigating trans-masculine people's voice function was found to be limited.  There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.  The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Facial Feminization Surgery

Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth.  The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity.  Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation.  Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures.  These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling.  A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures.  Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs.  Most facial feminization surgery procedures could be safely completed in 6 months, barring complications.  All patients showed excellent cosmetic results and were satisfied with their procedures.  Both frontal and profile views achieved a loss of masculine features.  The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome.  The level of evidence of this study was IV.

Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features.  The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face.  Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed.  These researchers appraised the current facial feminization surgery literature.  They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization.  Data on techniques, outcomes, complications, and patient satisfaction were collected.  A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports.  Articles covered a variety of facial feminization procedures.  A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications.  Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.  The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients.  These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.  

In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck.  State policies on transgender care for Medicaid insurance providers were collected for all 50 states.  Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined.  The largest medical insurance companies in the U.S. were identified using the National Association of Insurance Commissioners Market Share report.  Policies of the top 49 primary commercial medical insurance companies were examined.  Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % of commercial medical insurance providers had a published policy on GAS coverage.  Genital reconstruction was described as a medically necessary aspect of transgender care in 100 % of the commercial policies reviewed; 93 % discussed coverage of FGAS, but 51 % considered these procedures cosmetic.  Thyroid chondroplasty (20 %) was the most commonly covered FGAS procedure.  Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13 % of the medical policies reviewed.  The authors concluded that while certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers.  Level of Evidence = V.

Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women.  While there are slightly more transgender women than transgender men in the population (33 % transgender women, 29 % transgender men, 35 % non-binary, 3 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization.  Still, the primary area of focus for facial feminization is generally the upper 1/3.  Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty".  While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration.  Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties.  Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus.  This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus.  Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill.  Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge.  An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors.

Forehead Feminization Cranioplasty

Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years.  However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs).  In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL.  They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO.  The search terms included variations of forehead setback/FFC.  Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched.  Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted.  Main outcomes and measures included complications and complication rate observed following FFC.  Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM.  A total of 10 articles describing FFC were included, entailing 673 patients.  The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies.  The authors concluded that complications following FFC were rare and infrequently required reoperation.  Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed.  Level of Evidence = III.

Hand Feminization and Masculinization

Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria.  Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands.  These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care.  They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population.  From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search.  There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation.  The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation.  The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand.  These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs.  Level of Evidence = III.

Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery

Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery.  Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery.  These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement.  A search was performed in OVID Medline, Embase, Willey Online Library and PubMed.  Specialty-related journals, grey literature and reference lists of relevant articles were manually searched.  From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence.  Healing times were poorly reported or often not mentioned.  A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction.  Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications.  Average follow-up ranged from 6 weeks to 14.8 months.  The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data.  These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications.  Patients seeking this surgery overseas should be informed of the potential difficulties they may face.

Urethral Complications and Outcomes in Transgender Men

Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty.  Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized.  These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction.  They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals.  Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model.  A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap,  and 6 studies (221 patients) on "second flap".  Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques.  For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %.  The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap.  Overall, most patients were able to void while standing and were satisfied with the outcomes.

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
• A strong desire for the primary and/or secondary sex characteristics of the other gender
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.

Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Characteristics of a Qualified Health Professionals (From SOC-8)

Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):

• Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
• Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
• Are able to assess capacity to consent for treatment.
• Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
• Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
• Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required.

Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8):

• Training and documented supervision in gender-affirming procedures;
• Maintenance of an active practice in gender-affirming surgical procedures;
• Knowledge about gender diverse identities and expressions;
• Continuing education in the field of gender-affirmation surgery;
• Tracking of surgical outcomes.

Characteristics of health care professionals working with gender diverse adolescents:

• Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
• Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
• Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
• Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
• Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

The above policy is based on the following references:

• Almazan AN, Boskey ER, Labow B, Ganor O. Insurance policy trends for breast surgery in cisgender women, cisgender men, and transgender men. Plast Reconstr Surg. 2019;144(2):334e-336e. 
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
• Azul D, Nygren U, Södersten M, Neuschaefer-Rube C. Transmasculine people's voice function: A review of the currently available evidence. J Voice. 2017;31(2):261.e9-261.e23.
• Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: A systematic review. Ann Transl Med. 2021;9(7):607.
• Bowman C, Goldberg J. Care of the Patient Undergoing Sex Reassignment Surgery. Vancouver, BC: Vancouver Coastal Health, Transcend Transgender Support & Education Society, and the Canadian Rainbow Health Coalition; January 2006. 
• Buncamper ME, Honselaar JS, Bouman MB, et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12(7):1626-1634.
• Byne W, Bradley SJ, Coleman E, et al.; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796.
• Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45(3):369-380. 
• Colebunders B, Brondeel S, D'Arpa S, et al. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5(1):103-109.
• Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.  Int J Transgend. 2022; 23 sup1:S1-S259.
• Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011.
• Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232.
• Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1). 
• Djordjevic ML, Bizic MR, Duisin D, et al. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J Sex Med. 2016;13(6):1000-1007.
• Eggerstedt M, Hong YS, Wakefield CJ, et al. Setbacks in forehead feminization cranioplasty: A systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749.
• Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: Single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745.
• Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.
• Gorbea E, Gidumal S, Kozato A, et al. Insurance coverage of facial gender affirmation surgery: A review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. 2021;165(6):791-797.
• Guan X, Bardawil E, Liu J, Kho R. Transvaginal natural orifice transluminal endoscopic surgery as a rescue for total vaginal hysterectomy. J Minim Invasive Gynecol. 2018;25(7):1135-1136.
• Hembree et al. Endocrine Treatment of Transsexual Persons:  An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154.
• Hohman MH, Teixeira J. Transgender surgery of the head and neck. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; February 27, 2022.
• Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12(6):1499-1512.
• Hu C-H, Chang C-J, Wang S-W, Chang K-V. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24.
• Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med. 2018;15(6):902-906.
• Jolly D, Wu CA, Boskey ER, et al. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294.
• Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2016;106 (1):74-79.
• Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145.
• Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315.
• Lee J, Nolan IT, Swanson M, et al. A review of hand feminization and masculinization techniques in gender affirming therapy. Aesthetic Plast Surg. 2021;45(2):589-601.
• Lee YL, Hsu TF, Jiang LY, et al. Transvaginal natural orifice transluminal endoscopic surgery for female-to-male transgender men. J Minim Invasive Gynecol. 2019;26(1):135-142.
• Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: Extensive personal experience. Endocr Pract. 2013;19(4):644-650.
• Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833.
• Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42(3):435-452.
• Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open. 2019;21:63-74. 
• Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: Systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770. 
• Nakatsuka M. [Adolescents with gender identity disorder: Reconsideration of the age limits for endocrine treatment and surgery]. Seishin Shinkeigaku Zasshi. 2012;114(6):647-653.
• Ngaage LM, Knighton BJ, McGlone KL, et al. Health insurance coverage of gender-affirming top surgery in the United States. Plast Reconstr Surg. 2019;144(4):824-833. 
• Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 1: Breast/chest, face, and voice). Ann Surg. 2022;275(1):e52-e66.
• Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 2: Genital reconstruction). Ann Surg. 2022;275(1):e67-e74.
• Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431-436.
• Patel H, Arruarana V, Yao L, et al. Effects of hormones and hormone therapy on breast tissue in transgender patients: A concise review. Endocrine. 2020;68(1):6-15.
• Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: Patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448..
• Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4).
• Salgado CJ, Fein LA. Breast augmentation in transgender women and the lack of adherence amongst plastic surgeons to professional standards of care. J Plast Reconstr Aesthet Surg. 2015;68(10):1471-1472.
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• Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery. Aesthetic Plast Surg. 2018;42(2):491-497.
• Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261.
• Spack NP. Management of transgenderism. JAMA. 2013;309(5):478-484.
• Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009;62(3):294-306; discussion 306-308.
• Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg. 2022;92(3):373-378.
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• UK National Health Service (NHS), Oxfordshire Primary Care Trust, South Central Priorities Committee. Treatments for gender dysphoria. Policy Statement 18c. Ref TV63. Oxford, UK: NHS; updated September 2009.
• Van Damme S, Cosyns M, Deman S, et al. The effectiveness of pitch-raising surgery in male-to-female transsexuals: A systematic review. J Voice. 2017;31(2):244.e1-244.e5.
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Policy History

Effective: 05/14/2002

Next Review: 07/11/2024

Review History

Definitions

Additional Information

Clinical Policy Bulletin Notes

State Information

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What does it mean for someone to have the protected characteristic of “gender reassignment” under the Equality Act 2010? The government, public bodies, many employers and even employment tribunals are often confused about this.

Having the protected characteristic of gender reassignment does not mean that someone’s sex has changed or give them the right to make other people pretend that it has. 

These FAQs cover the definition of the characteristic and who it covers – and what this means for employers and service providers. 

Download these gender reassignment FAQs as a PDF.

What is the protected characteristic of “gender reassignment”?

What does it mean to have this characteristic , who can have this characteristic , does having the protected characteristic of gender reassignment mean that a person must be treated as the opposite sex , does the equality act outlaw “misgendering”, is it harassment to “out” a person as transgender , can employers have policies which require people to refer to transgender people in particular situations in a particular way , what should employers and service providers do to avoid the risk of harassment claims , should schools have rules about “misgendering”.

The Equality Act 2010 at Section 7 defines the protected characteristic of “gender reassignment” as relating to a person who is: 

“proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.”

The law refers to this as being “transsexual”. But the term more commonly used today is “transgender” or “trans”. This broadly relates to anyone at any stage of a personal process. For example:

• A man tells his employer that he is considering “transitioning” and is seeing a therapist with the potential result of being referred for medical treatment.
• A man identifies as a “transwoman” without having any surgery or treatment.
• A woman identified as a “transman” for several years and took testosterone, but has now stopped and “detransitioned”.

The Equality Act protects people from direct and indirect discrimination, harassment or victimisation in situations that are covered by the Equality Act, such as in the workplace or when receiving goods or services.

Direct discrimination

Direct discrimination is when you are treated worse than another person or other people because:

• you have a protected characteristic
• someone thinks you have that protected characteristic (known as discrimination by perception)
• you are connected to someone with that protected characteristic (known as discrimination by association).

For example: an employee tells their employer that they intend to transition. Their employer alters their role against their wishes to avoid them having contact with clients.

The comparator is a person who is materially similar in other aspects but does not have the protected characteristic (“is not trans”). 

Indirect discrimination

Indirect discrimination happens when a policy applies in the same way for everybody but disadvantages a group of people who share a protected characteristic, and you are disadvantaged as part of this group. This is unlawful unless the person or organisation applying the policy can show that there is a good reason for the policy. This is known as objective justification .

For example: an airport has a general policy of searching passengers according to their sex. Everyone travelling needs to follow the same security procedures and processes, but it makes transgender travellers feel uncomfortable. This could be indirect discrimination, so the airport reviews its policy and changes it so that any passenger may ask to be searched by a staff member of either sex and have a private search, out of view of other passengers. 

Harassment is unwanted behaviour connected with a protected characteristic that has the purpose or effect of violating a person’s dignity or creating a degrading, humiliating, hostile, intimidating or offensive environment.

For example: a transgender person is having a drink in a pub with friends and is referred to by the bar staff as “it” and mocked for their appearance.

Victimisation

Victimisation is when you are treated badly because you have made a complaint of gender-reassignment discrimination under the Equality Act or are supporting someone who has made a complaint of gender-reassignment discrimination. For example:

For example: a person proposing to undergo gender reassignment is being harassed by a colleague at work. He makes a complaint about the way his colleague is treating him and is sacked.

The Equality Act also provides that if a person is absent from work because of gender-reassignment treatment, their employer cannot treat them worse than they would be treated if absent for illness or injury. 

Does a person have to be under medical supervision?

No. This was explicitly removed from the definition in 2010. Gender reassignment can be a personal process. 

Must they have a gender-recognition certificate or be in the process of applying for one?

No. The protected characteristic is defined without reference to the Gender Recognition Act.

Do they have to have made a firm decision to transition? 

No. Protection against discrimination and harassment attaches to a person who is proposing to undergo, is undergoing or has undergone a process (or part of a process).

During the passage of the Equality Act, the Solicitor General stated in Parliament: 

“Gender reassignment, as defined, is a personal process, so there is no question of having to do something medical, let alone surgical, to fit the definition. “Someone who was driven by a characteristic would be in the process of gender reassignment, however intermittently it manifested itself.  “At what point [proposing to undergo] amounts to ‘considering undergoing’ a gender reassignment is pretty unclear. However, proposing’ suggests a more definite decision point, at which the person’s protected characteristic would immediately come into being. There are lots of ways in which that can be manifested – for instance, by making their intention known. Even if they do not take a single further step, they will be protected straight away. Alternatively, a person might start to dress, or behave, like someone who is changing their gender or is living in an identity of the opposite sex. That too, would mean they were protected. If an employer is notified of that proposal, they will have a clear obligation not to discriminate against them.” 

In the case of Taylor v Jaguar Land Rover , a male employee told his employer that he was “gender fluid” and thought of himself as “part of a spectrum, transitioning from the male to the female gender identity”. He said to his line manager: “I have no plans for surgical transition.” He started wearing women’s clothing to work, asked to be referred to by a woman’s name and raised a question about which toilets he should use. The Employment Tribunal concluded that he was covered by the protected characteristic. 

Can children have the protected characteristic? 

Yes. In the case of AA, AK & Ors v NHS England , NHS England argued that children who are waiting for assessment by the Tavistock Gender Identity Development Service (GIDS) do not have the protected characteristic as they have not yet reached the stage of proposing to transition. The Court of Appeal rejected this argument. It noted that the definition of “gender reassignment” does not require medical intervention and can include actions such as changing “one’s name and/or how one dresses or does one’s hair”.

The court concluded:

“There is no reason of principle why a child could not satisfy the definition in s.7 provided they have taken a settled decision to adopt some aspect of the identity of the other gender.”

It noted that the decision did not have to be permanent. 

Is “Gillick competence” relevant to the protected characteristic?

No. “Gillick competence” refers to the set of criteria that are used for establishing whether a child has the capacity to provide consent for medical treatment, based on whether they have sufficient understanding and intelligence to fully understand it.

Having the protected characteristic of gender reassignment (that is, being able to bring a claim for gender-reassignment discrimination) does not depend on having any diagnosis or medical treatment. Therefore Gillick competence is not relevant to the Equality Act criteria. 

No. There is nothing in the Equality Act which means that people with the protected characteristic of “gender reassignment” need to be treated in a particular way, or differently from people without the characteristic. 

Article 9 and 10 of the European Convention of Human Rights protect the fundamental human rights of freedom of speech and freedom of belief. 

In the case of Forstater v CGDE [2021] it was established that the belief that men are male and women are female, and that this cannot change and is important, is protected under Article 9 and in relation to belief discrimination in the Equality Act. 

This means that employers and service providers must not harass or discriminate against people because they recognise that “transwomen” are men and “transmen” are women. Employers and service providers cannot require people to believe that someone has changed sex, or impose a blanket constraint on expressing their belief. 

No. “Misgendering” is not defined or outlawed by the Equality Act. 

In general, people who object to “misgendering” mean any reference to a person who identifies as transgender by words that relate to their sex. This can include using the words woman, female, madam, lady, daughter, wife, mother, she, her and so on about someone who identifies as a “transman”, or man, male, sir, gentleman, son, husband, father, he, him and so on about someone who identifies as a “transwoman”. 

Any form of words may be harassment, but this depends on the circumstances and the purpose and effect of the behaviour. Harassment is unwanted conduct related to a relevant protected characteristic that has the purpose or effect of violating a person’s dignity, or creating an intimidating, hostile, degrading, humiliating or offensive environment for a person.   An employment tribunal would also consider:

• that person’s perception
• the other circumstances of the case
• whether it is reasonable for the conduct to have that effect.

Tribunals have emphasised that when judging harassment context is everything, and warned against a culture of hypersensitivity to the perception of alleged victims.

Employment tribunal judgments

As Lord Justice Nicholas Underhill found in Dhellwal v Richmond Pharmacology [2009], a case decided under the Race Relations Act:

“What the tribunal is required to consider is whether, if the claimant has experienced those feelings or perceptions, it was reasonable for her to do so. Thus if, for example, the tribunal believes that the claimant was unreasonably prone to take offence, then, even if she did genuinely feel her dignity to have been violated, there will have been no harassment within the meaning of the section.”

In the Forstater case, the employment appeal tribunal said that it was not proportionate to “impose a requirement on the Claimant to refer to a trans woman as a woman to avoid harassment”. It said that:

“ Whilst the Claimant’s belief, and her expression of them by refusing to refer to a trans person by their preferred pronoun, or by refusing to accept that a person is of the acquired gender stated on a GRC, could amount to unlawful harassment in some circumstances, it would not always have that effect. In our judgment, it is not open to the Tribunal to impose in effect a blanket restriction on a person not to express those views irrespective of those circumstances.”

In the case of de Souza v Primark Stores [2017] , a transgender claimant who went by the name of Alexandra, but whose legal name was Alexander, was found to have been harassed by colleagues who made a point of using the male form of name when they knew he did not want them to, but not by being issued with a “new starter” badge that showed his legal name. 

In the case of Taylor v Jaguar Land Rover [2020] , a male claimant who wore women’s clothing  to work was judged to have been exposed to harassment by colleagues saying “What the hell is that?”, “So what’s going on? Are you going to have your bits chopped off?”, “Is this for Halloween?” and referring to the claimant as “it”. 

Not necessarily. 

A person can be “outed” as transgender in two different ways: 

• Their sex is commonly known and recorded, but their transsexualism is not (for example a man who cross-dresses at the weekend and is considering transitioning is “outed” at work by someone who has seen them at a social event).
• They are disappointed in the expectation of being treated as one sex when they are actually the other (for example a person who identifies as a “trans woman” is referred to as male by a woman in a changing room).

In Grant v HM Land Registry [2011] , which concerned the unwanted disclosure that an employee was gay, Lord Justice Elias found that this did not amount to harassment: 

“Furthermore, even if in fact the disclosure was unwanted, and the claimant was upset by it, the effect cannot amount to a violation of dignity, nor can it properly be described as creating an intimidating, hostile, degrading, humiliating or offensive environment. Tribunals must not cheapen the significance of these words. They are an important control to prevent trivial acts causing minor upsets being caught by the concept of harassment.”

The perception (or hope) of transgender people that they “pass” as the opposite sex is often not realistic. Their sex is not in fact hidden, but is politely ignored by some people in some situations. It is not reasonable for them to be offended by other people recognising their sex, particularly if they are seeking access to a single-sex service. Acknowledging someone’s sex, particularly where there is a good reason, is unlikely to be harassment. 

In the first-instance case of Chapman v Essex Police , a transgender police officer felt embarrassed and upset when a police control-room operator double-checked his identity over the radio because his male voice did not match the female name that the operator could see. The tribunal did not uphold a complaint of harassment, finding that the claimant was “too sensitive in the circumstances”.

Yes, but those policies must be proportionate. Employers cannot have blanket policies against “misgendering”, but can have specific policies concerning how staff should refer to transgender people in particular situations. Organisations should recognise that these policies constrain the expression of belief, and therefore they should seek to achieve their specific aims in the least intrusive way possible.

When determining whether an objection to a belief being expressed is justified, a court will undertake a balancing exercise. This test is set out in the case of Bank Mellat v HM Treasury :

• Is the objective the organisation seeks to achieve sufficiently important to justify the limitation of the right in question?
• Is the limitation rationally connected to that objective?
• Is a less intrusive limitation possible that does not undermine the achievement of the objective in question?
• Does the importance of the objective outweigh the severity of the limitation on the rights of the person concerned?

For example: 

• A company provides a specialist dress service to transsexual and transvestites. The men who use the service expect to be called “she” and “her” and referred to as Madam. It is justified for the employer to train and require staff to use this language when serving customers. 
• Staff at a full-service restaurant greet customers as “Sir” and “Madam” as they arrive. The restaurant’s policy is that staff should use the terms which appear most appropriate based on gendered appearance, and to defer to customer preference if one is expressed. This is justified by the aim of creating the service and ambience that the restaurant owners seek to provide. 
• A public body assesses claimants for medical benefits, including individuals with mental-health conditions. It directs its staff to refer to claimants using the terms which the claimants prefer, including using opposite-sex pronouns when requested, in order to make them feel comfortable. However, it recognises that in recording medical information, assessors must be able to be accurate about claimants’ sex. This is justified by the aim of providing a service that is accessible and effective for vulnerable clients. 

The case of David Mackereth v AMP and DWP concerned a doctor who lost his job undertaking claimant health assessments for the Department for Work and Pensions because he refused to comply with its policy on using claimants’ preferred pronouns. The employer’s policy was found not to have amounted to unlawful harassment or discrimination against Dr Mackereth, in the particular circumstances of his job. However, the Employment Appeal Tribunal stated that “misgendering” would not necessarily be harassment: 

“Such behaviour may well provide grounds for a complaint of discrimination or harassment but, as the EAT in Forstater made clear, that will be a fact-specific question to be determined in light of all the circumstances of the particular case.”

Relevant considerations

In Higgs v Farmor’s School [2023] Mrs Justice Eady sets out the considerations that are likely to be relevant considering whether constraining the expression of a belief (“manifestation”)  in order to avoid harassment or discrimination is justified in the context of employment. These include:

• the content of the manifestation
• the tone used
• the extent of the manifestation
• the worker’s understanding of the likely audience
• the extent and nature of the intrusion on the rights of others, and any consequential impact on the employer’s ability to run its business
• whether the worker has made clear that the views expressed are personal, or whether they might be seen as representing the views of the employer, and whether that might present a reputational risk
• whether there is a potential power imbalance given the nature of the worker’s position or role and that of those whose rights are intruded upon;
• the nature of the employer’s business, in particular where there is a potential impact on vulnerable service users or clients
• whether the limitation imposed is the least intrusive measure open to the employer.

Employers cannot force employees to believe that people can change sex, or prevent them expressing that lack of belief except in limited circumstances. So what should employers do to protect transgender people from harassment, and themselves from liability? 

They should have ordinary policies against bullying and harassment, including jokes, name-calling, humiliation, exclusion and singling people out for different treatment.

They should seek to avoid putting people in situations they will reasonably experience as hostile or humiliating.

Ambiguous rules put people in situations where it is reasonable to feel offended. For example, an employer provides “female” toilets, showers and changing rooms, but allows some male staff in because they identify as transgender. This creates a hostile environment: 

• female staff are surprised, shocked, humiliated and upset to find themselves sharing with a colleague of the opposite sex
• male staff members who want people to treat them as women may be challenged or face comments that are intended to intimidate, humiliate or degrade them.

This was the situation faced by the Sheffield Hospital Trust , which had a policy that transgender staff could use opposite-sex facilities. It had to deal with the fall-out when women complained about seeing a half-naked male in their changing room and the male staff member sued for harassment after being questioned about this.

Rather than putting these two groups of people together in a environment where both will reasonably feel harassed, employers should have clear rules about facilities that are single-sex, and also, where possible, provide a unisex alternative for anyone who needs it, including people who feel that they have “transitioned away from their sex” and therefore do not wish to use single-sex facilities shared with members of their own sex. The EHRC last year provided guidance on single-sex services which encouraged clear rules and policies.

It should be made clear to people who have the protected characteristic of “gender reassignment” that having this characteristic does not mean it is reasonable for them to expect others to believe or pretend to believe they have changed sex, or for them to be allowed to break (or expect to be an exception to) rules that aim to protect the dignity and privacy of others. 

If a person breaks a clear rule against entering a space provided for the opposite sex, it is not reasonable for them to feel offended when this is pointed out. 

No. It would not be lawful for schools to have a policy that forbids, punishes or denigrates pupils who use clear words about the sex of other people (such as pronouns, but also boy/girl, male/female and so on), nor to require pupils to refer to some classmates as if they were the opposite sex.

• To do so constrains the freedom of speech of pupils in a way that is unjustified and discriminates against them on the basis of belief. 
• It is inconsistent with schools’ safeguarding duty of care , and with their record-keeping responsibilities, for staff to misrepresent the sex of pupils in their records or in introducing them to their peers. 
• In order to explain and enforce sex-based rules designed to keep children safe (such as who is allowed in which showers, toilets, dormitories or sports teams), schools must be able to use clear and unequivocal language. 
• It is not reasonable to expect that a child at school, or transferring between schools, can avoid being “outed” as the sex that they are . 

We do not think that any policy which tells teachers or pupils to lie about the sex of pupils, constrains them from using clear sex-based language or treats them detrimentally if they do would pass the proportionality test. It is an unreasonable constraint on speech that is neither required nor justified in order to avoid discrimination on the basis of gender reassignment. 

Schools form part of a system that is regulated at a national level. In England that system is the responsibility of the Secretary of State for Education. It is the responsibility of the Secretary of State to make this legal situation clear across the English school system by issuing the long-awaited DfE guidance. 

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Billing and Coding: Gender Reassignment Services for Gender Dysphoria

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Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia. Gender Reassignment Therapy GD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery. Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered. NON-SURGICAL TREATMENT Initiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional. The criteria for cross sex hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Member must be at least 18 years of age;
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria. Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks. READINESS FOR THE TREATMENT OF GENDER DYSPHORIA Readiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. TRANS-SPECIFIC CANCER SCREENINGS Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals. There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender. Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
• Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met. Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

• The individual is at least 18 years of age.
• A gender reassignment treatment plan is created specific to an individual beneficiary
• The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD:

 A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
• A strong desire for the primary and/or secondary sex characteristics of the other gender.
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

 B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

• That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
• That the patient has had persistent and chronic gender dysphoria.
• That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.
• The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
• Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).
• The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

 SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):

• Orchiectomy - removal of testicles
• Penectomy - removal of penis
• Vaginoplasty - creation of vagina
• Clitoroplasty - creation of clitoris
• Labiaplasty - creation of labia
• Mammaplasty - breast augmentation
• Prostatectomy -removal of prostate
• Urethroplasty - creation of urethra

When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):

• Breast reconstruction (e.g., mastectomy) - removal of breast
• Hysterectomy - removal of uterus
• Salpingo-oophorectomy - removal of fallopian tubes and ovaries
• Vaginectomy - removal of vagina
• Vulvectomy - removal of vulva
• Metoidioplasty - creation of micro-penis, using clitoris
• Phalloplasty - creation of penis, with or without urethra
• Urethroplasty - creation of urethra within the penis
• Scrotoplasty - creation of scrotum
• Testicular prostheses - implantation of artificial testes

Services or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.

The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiary’s medical condition after considering the individual’s specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.   The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:

• The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
• The urethral opening is moved to a position similar to that of a female.
• A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.
• Labia are created out of skin from the scrotum and adjacent tissue.
• A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting CPT ® code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:

• Portions of the clitoris are used, as well as the adjacent skin.
• Prostheses are often placed in the penis to create a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum.
• The vagina is closed or removed.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

Transwoman procedures (male to female) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

Transman procedures (female to male) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

All unlisted procedure codes will suspend for medical review. The following CPT ® codes are considered cosmetic. When billed with any Covered ICD-10 Codes listed below, the service will not be covered (list may not be all-inclusive):

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

The following diagnosis codes are considered covered when applicable criteria have been met:

ICD-10-CM Codes that DO NOT Support Medical Necessity

All other diagnosis codes will be denied as non-covered.

ICD-10-PCS Codes

Additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Other Coding Information

Coding table information, revision history information, associated documents.

• Gender Reassignment
• Gender Dysphoria

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Page Help for Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)

Introduction.

This page displays your requested Article. The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

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South Carolina Bans Gender Transition Care for Minors

By Adeel Hassan

South Carolina’s Republican governor, Henry McMaster, signed a bill on Tuesday that bars health professionals from performing gender-transition surgeries, prescribing puberty blocking drugs and overseeing hormone treatments for patients under 18. The state now joins about two dozen others that have passed laws restricting or banning what doctors call gender-affirming care for minors.

The law, which goes into effect immediately, also requires principals, teachers and other school staff members to tell parents when their children want to use a name other than their legal one, or pronouns that do not match their sex assigned at birth.

South Carolina lawmakers tried to pass similar legislation in 2021 and 2022 but failed to get them through the State House of Representatives. In 2022, the clock ran out on a broader bill banning transition care for minors, but lawmakers put a clause in the state budget that banned a pediatric clinic at a public hospital from using state funds on transition care for people under 16. The clinic soon went further, ending hormonal treatments to anyone under 18.

This year, House Republicans made gender-transition treatment a priority. “When God created us, he created us male and female, that’s it,” said David Hiott, the House majority leader and a co-sponsor of the bill, at the start of the legislative session in January. “All these other folks that want to change that from birth, change that through their life, we need to stand up against that.”

The measure, known as House Bill 4624, was passed by the legislature earlier this month. The new legislation not only expands the ban on care for minors to all providers statewide, but also bars adults under 26 from using Medicaid to cover the costs for such care.

In a social media post on Tuesday, Mr. McMaster said the bill “protects our state’s children from irreversible gender transition procedures” and added that he would meet with its supporters at a ceremonial signing next week.

At a House committee hearing in January, Dr. Elizabeth Mack, president of the South Carolina chapter of the American Academy of Pediatrics, criticized the measure, saying there was “no mainstream organization that doesn’t support gender-affirming care.”

“Gender-affirming care is evidence-based, suicide-prevention care,” she said at the time. She added that gender-transition surgery was currently not being performed in South Carolina, and that transition care was being done only after much deliberation between doctors, parents and children.

Why It Matters

Before Tuesday, South Carolina was one of just two states in the South without a ban on gender-transition care for minors; Virginia is now the only one.

Lawsuits have been filed in many states that have the bans, and courts have issued mixed rulings. In three states, the laws have been blocked.

The U.S. Supreme Court could agree to hear the case against Tennessee’s ban on transition care for minors, which may affect the legal challenges in other states with similar bans.

According to a recent survey , transgender and nonbinary Americans face stark rates of unemployment and harassment. The survey, which included more than 92,000 participants, also found that a vast majority of them were satisfied with their decision to transition.

“There’s clear data and medical opinion on one side,” Jace Woodrum, the executive director of the South Carolina chapter of the American Civil Liberties Union, said. “And then on the other side, an uncited science.”

What’s Next

Mr. Woodrum, who is the first transgender director of an A.C.L.U. state chapter, said that his organization was weighing a lawsuit over the South Carolina ban. Other groups that support transgender rights have said that they would immediately try to help families with grants and other financial support to travel to other states for care.

Adeel Hassan is a reporter and editor on the National Desk. He is a founding member of Race/Related , and much of his work focuses on identity and discrimination. He started the Morning Briefing for NYT Now and was its inaugural writer. He also served as an editor on the International Desk.  More about Adeel Hassan

E&C Republicans Press HHS Secretary Becerra for Scientific Literature Used to Justify Irreversible Gender Transition Procedures for Children

Washington, D.C. — House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA), Subcommittee on Health Chair Brett Guthrie (R-KY), and Subcommittee on Oversight and Investigations Chair Morgan Griffith (R-VA) wrote to Department of Health and Human Services (HHS) Secretary Xavier Becerra asking for a briefing and information on what evidenced-based scientific and pediatric medical literature the department relies upon to promote gender transition procedures for children.

KEY LETTER EXCERPT : 

“Officials at HHS contend that sex reassignment procedures on minors are unanimously accepted medical practice, despite a growing body of research from European medical experts and authorities warning otherwise. According to a recent HHS production in response to a request under the Freedom of Information Act (FOIA), it seems HHS’s position rests entirely on a two-page publicly available brochure advocating for such drastic, life-altering procedures on children. The Committee seeks information to better understand the body of medical information HHS has consulted to establish its policy promoting sex reassignment for children.” 

“All of HHS’s medical treatment recommendations, especially medical treatment recommendations for children, should be based on rigorous and well-established research that has definitively illustrated the long-term benefits of performing such procedures. Therefore, it is puzzling that HHS actively advocates for off-label use of puberty blockers without justification—such as substantial evidence gathered through a randomized controlled trial. In doing so, HHS is effectively advocating for unregulated medical experimentation on children.” 

BACKGROUND : 

• Under the Biden administration, HHS has advocated for sex reassignment procedures, including the use of serum puberty blockers.   
• These are chemical hormonal suppressants that have a history of predominantly being used to treat U.S. children experiencing precocious puberty (i.e., the early onset of puberty affecting about 1% of U.S. children); they also have been used on sex-offenders and are known to stunt normal childhood development for children unaffected by precocious puberty.   
• Contrary to HHS’s proclamation that “there is no argument among medical professionals,” a substantial number of medical experts from around the world have publicly denounced sex transition procedures on minors as irresponsible, including a July 2023, letter signed by clinicians and researchers published in the Wall Street Journal. 
• On March 12, 2024, the National Health Service (NHS) of England announced it will no longer widely allow puberty blockers to be administered to children.   
• A United Kingdom court noted the obvious about administering puberty blocking chemicals onto children: “[i]t is highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences of the administration of puberty blockers.” 
• Several European countries have restricted “sex change surgeries, hormones, and puberty blockers for children.”  
• In Finland, Dr. Riittakerttu Kaltiala, a pediatrician specializing in gender medicine reportedly noted , “using a child’s preferred name and pronouns—is ‘not a neutral act’ but rather one that can solidify what is otherwise likely to be a passing phase into a more permanent state of mind, or ‘identity,’ and put the minor on a path to drugs and surgeries.” 

CLICK HERE to read the full letter.

Transgender golfer compared to 'castrated male dog' by anonymous rival after US Open chance

T ransgender golfer Hailey Davidson has been hit with a shocking insult, likened to a 'castrated male dog' by an unnamed competitor, despite clinching an alternate spot for the US Women's Open.

The 30-year-old Scottish golfer proved her resilience at the 36-hole qualifier at Bradenton Country Club, where she tied for third and just missed out on direct entry. Nevertheless, Davidson triumphed in the playoff hole against Jasmine Suwannapura and Louise Olsson Campbell, securing the top alternate position.

Her victory edges her closer to participating in the prestigious tournament at Lancaster Country Club in Pennsylvania, which runs from May 30 to June 2, with only one withdrawal needed for her to join the lineup.

READ MORE: Transgender golfer wins women's event, eyes place on LPGA Tour and responds to hate READ MORE: Transgender golfer subjected to testosterone testing and player poll after tournament win

Davidson took to Instagram to share her joy, exclaiming: "So you're telling me there's a chance! " She also posted a snapshot of the alternate player regulations from the USGA, affirming "I DO in fact have legal documentation from the USGA that allowed me to play in the first place so zero rules were broken as always."

However, Davidson's rightful place in the competition didn't shield her from criticism, as another golfer who spoke anonymously to OutKick questioned the integrity of transgender athletes competing in women's sports.

"It is not fair," the rival contended, before delivering the harsh analogy: "There's not any other way to explain it other than if you neuter a male dog, it's still a male dog. We never call them a female dog."

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She also put forward the idea of specialized tournaments for transgender players who have gone through gender-affirming surgery expressing her views, "I believe if transgender golf is getting more attention, aka popular, then let's do a trans open for them."

Recalling an incident during the qualifiers, the golfer described how Davidson made a 40-foot shot off the green and celebrated with what was called a 'male tone', remembering, "Everyone was in shock and not a single person clapped."

The inclusive gender policy embraced by LPGA, Epson Tour, Ladies European Tour, LET Access Series, and LPGA Professionals competitions, since abandoning the 'female at birth' requirement in 2010, has allowed trans women to take part in women's events.

However, these participants must identify as female, present evidence of gender reassignment surgery, undergo at least one year of hormone therapy, and maintain testosterone levels within a defined threshold.

Striking a contrast with other sports, World Athletics has prohibited transgender women from participating in the female category at global contests. Confirming earlier this year, the organization's president, Lord Coe, announced that from March 31 onwards, no transgender athlete who had experienced male puberty would be permitted to compete in female world ranking competitions.