gender reassignment regulations

States That Have Restricted Gender-Affirming Care for Trans Youth

As the issue of trans rights has become more political, states are increasingly banning gender-affirming care for trans minors.

States Restricting Gender-Affirming Care

Sue Ogrocki | AP

Trans-rights activists protest outside the House chamber at the Oklahoma state Capitol on Feb. 6, 2023, in Oklahoma City.

A large majority of transgender adults in the United States – 78% – say living with a gender different from the one assigned to them at birth has made them more satisfied with their lives, according to a survey from The Washington Post and Kaiser Family Foundation .

Among respondents, more than three-quarters had changed their type of clothing, hairstyle or grooming habits to align with their preferred gender, while 31% had used hormone treatments and 16% had undergone gender-affirming surgery or a related surgical treatment to alter their appearance.

But such options are becoming available on a more limited basis, as politicians in multiple states have attempted to restrict trans Americans’ ability to seek gender-affirming medical treatments.

What Is Gender-Affirming Care? 

The Human Rights Campaign, a LGBTQ+ advocacy group, defines gender-affirming care as “age-appropriate care that is medically necessary for the well-being of many transgender and non-binary people who experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth.” The organization notes both the American Medical Association and the American Academy of Pediatrics support “age-appropriate, gender-affirming care for transgender and non-binary people.”

Conservatives often oppose the concept of gender-affirming care – which may or may not include surgery or other interventions – for various reasons, including religious beliefs and concerns about child abuse. “You don’t disfigure 10-, 12-, 13-year-old kids based on gender dysphoria,” Florida Gov. Ron DeSantis, a Republican, said at an August news conference.

Some have expressed concern about a lack of data on the possible long-term consequences of gender-affirming medical treatment for minors. A 2022 Reuters investigation , for example, found “no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning.” Others, according to the article, have raised alarms about children who are not appropriately evaluated before receiving gender-affirming medical care.

These States Have Banned Gender-Affirming Care for Minors

Mississippi

North Carolina

North Dakota

South Dakota

West Virginia

Below are the states that have moved to restrict some form of gender-affirming care for minors in 2023 and so far in 2024, based largely on legislation tracking from the Equality Federation, an advocacy accelerator that works with a network of state-based LGBTQ+ organizations.

Some states, such as Arizona and Alabama , passed bans prior to 2023 and are not included on the list.

Dozens of bills are still being considered by lawmakers in other states, according to the federation. And officials elsewhere, including in Florida and Missouri, have bypassed state legislatures altogether.

Signed into law by new Republican Gov. Sarah Huckabee Sanders in March, Arkansas’ law will make health care providers liable for civil action for up to 15 years after a minor turns 18 if they performed a gender transition procedure on that minor – essentially making it easier to file malpractice lawsuits in these situations. On that note, experts say the law acts as a de facto ban on gender-affirming care for children because it makes it nearly impossible for providers to get malpractice insurance, according to the AP . In 2021, state lawmakers passed the nation’s first ban on gender-affirming care for minors. The move was temporarily blocked shortly after, but on June 20, 2023, a federal judge issued a permanent injunction against it, ruling the ban unconstitutional. It marked the first time such a state ban was overturned, but the more recent law signed by Sanders was still set to go into effect.

The state Department of Health’s Board of Medicine announced a new rule in March that prohibits several types of treatment and procedures – such as sex reassignment surgeries and puberty blockers – for treating gender dysphoria in minors. Then, on May 17, DeSantis signed into law a similar gender-affirming care ban from the state legislature , which, in addition to prohibiting procedures from being performed on minors, also grants Florida courts “temporary emergency jurisdiction” over a child if they have been subjected to or “threatened” with sex-reassignment prescriptions or procedures. The law also requires transgender adults to get written consent before undergoing such procedures by using a form adopted by the Board of Medicine and Board of Osteopathic Medicine, according to Reuters. But on June 6, a district court judge in Florida issued a preliminary injunction that temporarily blocked enforcement of some parts of the law on behalf of several young plaintiffs. Months later, the same judge ruled that the parts of the law that apply to transgender adults can still be enforced while it is challenged in court.

Senate Bill 140 was signed into law by Georgia Republican Gov. Brian Kemp in late March. The legislation , pushed forward by the Republican majority in the state’s General Assembly, prohibits “certain surgical procedures for the treatment of gender dysphoria in minors from being performed in hospitals and other licensed healthcare facilities.” There are exceptions, including treatments that are deemed “medically necessary” and situations covering continued treatment for minors undergoing “irreversible hormone replacement therapies” prior to July 1, 2023. A federal judge on Sept. 5 allowed Georgia to resume enforcing the portion of the law banning doctors from starting hormone therapy for transgender minors, weeks after blocking it with a preliminary injunction. The prohibition on surgical procedures was not covered by the legal challenges.

The state’s GOP Gov. Brad Little approved a bill that criminalizes providing gender-affirming care for youth. Signed on April 4, 2023, and set to go into effect in January 2024, the law was intended to make it a felony to provide hormones, puberty blockers or other gender-affirming medical care to minors. But in December 2023, a federal judge issued a temporary injunction blocking the law’s enforcement. Then the U.S. Supreme Court in April 2024 ruled that the state could enforce the ban against everyone except the plaintiffs who challenged it. Even before that ruling, Little in March signed a new law which will prevent transgender people in Idaho from using publicly funded programs to help cover the cost of gender-affirming care. The ban included in the legislation, which is scheduled to go into effect on July 1, 2024, extends to state employees on work health insurance and adults using Medicaid.

Republican Gov. Eric Holcomb signed into law on April 5 a bill banning all gender-affirming care for minors, after previously saying there was “some vagueness to it,” according to the AP. The governor said in a statement that “permanent gender-changing surgeries with lifelong impacts and medically prescribed preparation for such a transition should occur as an adult, not as a minor.” The parts of the law banning puberty blockers and hormone treatments for minors were blocked by a federal judge on June 16, 2023, following a request for a preliminary injunction by the American Civil Liberties Union of Indiana. But a federal appeals court ruling on Feb. 27, 2024, allowed those restrictions to go into effect.

Iowa’s ban , signed into law on March 22, prohibits health care professionals from “knowingly” performing certain medical practices on minors if they are “for the purpose of attempting to alter the appearance of, or affirm the minor’s perception of, the minor's gender or sex, if that appearance or perception is inconsistent with the minor's sex.” Practices covered by the law include hormone therapies and surgical procedures. As with other states’ laws, there are some exceptions, including a “medically verifiable disorder of sex development.”

The state on March 29 joined others in banning gender-affirming medical care for minors when the Republican-led Kentucky General Assembly voted to override Democratic Gov. Andy Beshear’s veto, becoming the first state led by a Democrat to approve such a ban in 2023. The law notes that any health provider who violates the prohibition can have their license or certificate revoked. A federal judge on June 28 temporarily blocked the portion of the law that would have banned transgender youth from accessing puberty blockers and hormone therapy, but that same judge lifted the injunction on July 14 – allowing the restrictions to go into effect. A federal appeals court panel on July 31 allowed the state to continue enforcing the law – and so did another in September.

With a successful override attempt of former Democratic Gov. John Bel Edwards’ veto by the state’s Republican supermajority legislature, Louisiana approved a ban on gender-affirming care for minors on July 18. The law , which went into effect on Jan. 1, 2024, covers procedures such as hormone therapies, puberty blockers and gender-reassignment surgeries. The ban’s ultimate approval came after a Republican lawmaker cast a tie-breaking vote to kill the legislation in May. But it was eventually resurrected and passed before Edwards’ veto. New Gov. Jeff Landry, a Republican, has supported the ban, saying in a post in X in May 2023, “Pediatric sex changes should have no place in our society.”

Mississippi’s law – among the first to be enacted in 2023 – bans any person from knowingly providing or engaging in conduct that aids and abets the performance of gender transition procedures on a minor in the state. The ban also prohibits the use of public funds or tax deductions for such procedures. Republican Gov. Tate Reeves said when he signed the bill into law that “radical activists” are telling children they are “just a surgery away from happiness,” according to the AP .

GOP Gov. Mike Parson on June 7 signed a bill that will restrict gender-affirming health care for minors and some adults in Missouri starting in late August. The law prevents the state’s Medicaid division from covering such treatment for people of any age, and prohibits providers from prescribing puberty-blockers or cross-sex hormones to minors until Aug. 28, 2027, unless they were being treated prior to the bill’s effective date. Missouri initially banned gender-affirming care in April through an emergency regulation from state Attorney General Andrew Bailey that limited treatments for both minors and adults, the latter of which was believed to be a first in the country . But Bailey terminated the rule – which had already been on pause due to a lawsuit – on May 16, citing the state legislature’s imminent ban. A circuit judge on Aug. 25 allowed the law to take effect.

Signed into law on April 28 by Republican Gov. Greg Gianforte, Montana’s ban on gender-affirming care for minors covers both surgical procedures and medications such as puberty blockers and testosterone. As with other state laws, the prohibition has exceptions including for someone “diagnosed with a disorder of sexual development.” Any physician who performs a banned procedure can be also sued in the 25 years following it if the after-effects result in any injury, “including physical, psychological, emotional or physiological harms.” Democratic state Rep. Zooey Zephyr, a transgender woman, was exiled from the Montana House floor after she said her fellow Republican lawmakers would have “blood on their hands” if they passed the bill. The law was set to take effect on Oct. 1, but a state judge issued a preliminary injunction on Sept. 27 that blocked its enforcement, according to the AP.

Republican Gov. Jim Pillen signed into law on May 22, 2023, a bill that limits gender-affirming medical care for minors, which covers people under the age of 19 in Nebraska. The law , which also bans abortions at 12 weeks of pregnancy, includes a ban on surgical procedures and limitations on “prescribed drugs related to gender alteration.” The regulations for hormone therapies – recommended by the state’s chief medical officer, a political appointee – were later approved by Pillen on March 12, 2024, and include a seven-day waiting period to start puberty-blocking medications or hormone treatments and a requirement for transgender patients under 19 to meet several therapy benchmarks. The gender-affirming care portion of the new law went into effect on Oct. 1, 2023.

Looking Back at 2023

The state’s Republican-dominated legislature on Aug. 16 voted to successfully override a veto from Democratic Gov. Roy Cooper and approve a ban on gender-affirming care for minors in North Carolina. The bill’s language covers both transition surgeries and puberty-blocking drugs or cross-sex hormones. The law goes into effect immediately, but as with other state bans that have been approved, there are some exceptions to the prohibition.

Republican Gov. Doug Burgum on April 19 signed a veto-proof bill into law that criminalizes providing gender-affirming medical care to minors. The law , which went into effect immediately as an “emergency measure,” makes performing sex reassignment surgery on a minor a felony, and makes providing gender-affirming medication such as puberty blockers to minors a misdemeanor. Burgum recommended in a statement that “thoughtful debate around these complex medical policies should demonstrate compassion and understanding for all North Dakota youth and their families,” according to the AP.

Republican Gov. Mike DeWine on Jan. 5, 2024, signed an executive order that prohibits young Ohioans from getting gender-affirming surgeries done before they turn 18. The order, which took effect immediately, came just a week after DeWine vetoed a bill from the state legislature that would have instituted a broader restriction on gender-affirming care for minors, including hormone therapies. But on Jan. 24, the state Senate successfully voted to override the governor’s veto, meaning the more wide-reaching ban – which also prohibits transgender girls and women from girls’ and women’s sports teams at both the K-12 and collegiate level – was expected to take effect in 90 days. That was until a judge on April 16 blocked the law by issuing a temporary restraining order.

GOP Gov. Kevin Stitt on May 1 signed into law a ban on gender-affirming care for minors in Oklahoma, saying he was “thrilled” to do so and “protect our kids.” The bill allows for any physician who knowingly provides gender transition procedures to be charged with a felony, but the prosecution must occur before the minor patient turns 45. The law went into effect immediately, but on May 18 the state agreed to not enforce it while opponents sought a temporary court order blocking it. A federal judge in October later declined to stop the law from taking effect.

Signed into law on Feb. 13, House Bill 1080 prohibits South Dakotan health care professionals from administering various types of gender-affirming procedures on minors. If a provider violates the law, the legislation requires a professional or occupational licensing board to revoke any license or certificate held by the provider. GOP Gov. Kristi Noem strongly supported the bill before signing it, according to the AP .

Tennessee’s legislation , which was signed by Gov. Bill Lee in March but was set to go into effect on July 1, bans health care providers from performing or offering to perform a medical procedure on a minor if its purpose is to enable that minor “to identify with, or live as, a purported identity inconsistent with the immutable characteristics of the reproductive system that define the minor as male or female.” It also prohibits such procedures if the purpose is to treat “purported discomfort or distress from a discordance between the minor's sex and asserted identity.” There are exceptions, and the law establishes penalties for providers who violate it. Just days before its July 1 effective date, a federal judge on June 28 temporarily blocked the portion of the law that would have banned transgender youth from accessing puberty blockers and hormone therapy. U.S. District Judge Eli Richardson, however, did not block the law’s ban on surgical procedures. A federal appeals court on July 8 temporarily reversed Richardson’s ruling, meaning the law can take effect at least until the court conducts a full review.

GOP Gov. Greg Abbott on June 2 signed a bill banning gender-affirming care for minors in Texas. The law contains exceptions similar to other states’ efforts at restricting transition care. The Texas Supreme Court on Aug. 31 allowed the law to go into effect on Sept. 1, overruling a state district judge who had issued a temporary injunction against the ban a week prior. The law’s passage was not Texas’ first attempt at limiting gender-affirming care: Abbott in 2022 ordered the investigation of families who were receiving such care, but the order was halted by a judge in the state.

Republican Gov. Spencer Cox signed into law on Jan. 28 the first gender-affirming care ban of the year. The Utah legislature’s Senate Bill 16 restricts health providers from performing “sex characteristic surgical procedures on a minor for the purpose of effectuating a sex change” or hormonal transgender treatment on minors who weren’t diagnosed with gender dysphoria before July 1, 2023. Cox said his approval of the law was an effort at least in part to pause “these permanent and life-altering treatments for new patients until more and better research can help determine the long-term consequences,” the AP reported .

A new law signed by GOP Gov. Jim Justice on March 29 prohibits minors from being prescribed hormone therapy and puberty blockers, or from receiving gender-affirming surgery. The law , which will take effect in January 2024, contains an exception geared toward youth for whom “treatment with pubertal modulating and hormonal therapy is medically necessary to treat the minor’s psychiatric symptoms and limit self-harm, or the possibility of self-harm.” In these cases, the minor must receive consent from their parents or guardians along with two medical providers.

Republican Gov. Mark Gordon on March 22 signed into law a measure that prohibits gender-affirming medical care for transgender minors. The ban , which is set to go into effect on July 1, 2024, covers treatment such as surgeries and puberty-blockers. While he did sign the bill, Gordon added that the legislation means the government is “straying into the personal affairs of families,” according to the AP.

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Tags: Arkansas , Florida , Georgia , Iowa , Mississippi , South Dakota , Tennessee , Utah , transgender people

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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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Employing Transgender Workers

Editor's Note: On October 1, 2022, the U.S. District Court for the Northern District of Texas concluded that the U.S. Equal Employment Opportunity Commission (EEOC) misapplied the U.S. Supreme Court's ruling in Bostock v. Clayton County, Ga. in its June 2021 technical assistance document on LGBTQ+ workplace discrimination protections. The EEOC's guidance expanded the legal definition of sex discrimination to include sexual orientation and gender identity in employment situations. It stated that workers have the right to use a bathroom that corresponds to their gender identity and the right to be free of harassment, including intentional and repeated use of the wrong pronouns. The EEOC is likely to appeal this ruling and may continue to pursue other litigation regarding the interpretation of Bostock as it relates to employer policies and practices.  See  Federal Judge Strikes Down EEOC's LGBTQ Guidance .

This article focuses on workplace issues related to the employment of transgender individuals in an organization. Among the issues are those that may surface when an employee makes the transition from living as one sex to living as the other.

Overview Background The Legal Framework Organization Policies Workplace Issues Additional Resources Endnotes

The term "transgender" is commonly used to refer to individuals whose gender identity and/or expression is different from their sex assigned at birth or with standard societal expectations of the male and female gender roles. Transgender people may be straight, lesbian, gay, bisexual, or asexual, just as nontransgender people can be. 1

Transgender individuals often suffer discrimination in various aspects of their lives, including employment. This discussion sets forth reasons that employers should be knowledgeable and accommodating toward transgender workers and should tolerate no workplace discrimination against them. The article explains HR's role in helping an organization prepare for and meet its responsibilities in this area.

"Transgender is an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth," according to the APA. "Gender identity refers to a person's internal sense of being male, female, or something else; gender expression refers to the way a person communicates gender identity to others through behavior, clothing, hairstyles, voice, or body characteristics." 2

One of the transgender identities is that of transsexual—a person whose gender identity is different from the individual's assigned sex. "Often, transsexual people alter or wish to alter their bodies through hormones, surgery, and other means to make their bodies as congruent as possible with their gender identities," the APA explains. "This process of transition through medical intervention is often referred to as sex or gender reassignment, but more recently is also referred to as gender affirmation." 3

It is important to note that while the APA website references transsexual people, they also state that, "the term "transsexual" is largely outdated, but some people identify with it; this term should be used only for an individual who specifically claims it."

Statistics on the numbers of transgender individuals are scarce. What is better documented is that many—perhaps most—transgender men and women are targets of discrimination and sometimes violence and hate crimes. Discrimination may be overt, such as denial of access to a workplace restroom, or it may be subtle, such as disapproving glances or privacy-invading questions from co-workers.

In some instances, a transgender person will make the change to the other gender while employed. The means of making such a transition may or may not include medical or surgical procedures, but it will result in the person living as a member of the other sex. In such circumstances, the employer should help the person with workplace concerns during and after the transition and should help the rest of the workforce deal with the transition.

The Legal Framework

Title vii of the civil rights act.

Title VII protects individuals against employment discrimination on the basis of race and color, national origin, sex, and religion; it applies to employers with 15 or more employees. Among the types of employers required to comply with Title VII are private-sector organizations (including employment agencies and labor organizations) as well as state and local governments and the federal government.

Although official rulings on complaints of discrimination against transgender employees have varied over the years, the U.S. Supreme Court ruled on June 15, 2020 that sexual orientation and gender identity or expression are included in the definition of "sex", therefore, employers may not discriminate against transgender individuals in employment. See  What You Should Know: The EEOC and Protections for LGBT Workers .

In addition to the federal interpretations of what constitutes sex discrimination under Title VII, legal protections are emerging for transgender employees at the state and local levels.

State and local anti-discrimination laws

Numerous states and localities across the United States have enacted laws that expressly prohibit employment discrimination based on gender identity and expression. Employees working in those states , regardless of where the employer is headquartered, are protected by those laws.

Patient Protection and Affordable Care Act (Affordable Care Act or ACA)

Section 1557 is the nondiscrimination provision of the ACA which prohibits sex discrimination in health insurance. The law was designed to reform the U.S. health care system by expanding the availability of health insurance, regulating coverage and restructuring health care delivery, including how it is paid for. In July 2012, the U.S. Department of Health and Human Services (HHS) stipulated that the law's prohibition against sex discrimination applies to transgender people.

On May 13, 2016, the HHS Office for Civil Rights issued the final rule implementing Section 1557.

However, on December 31, 2016, the U.S. District Court for the Northern District of Texas issued an opinion in Franciscan Alliance, Inc. et al v. Burwell , enjoining the Section 1557 regulation's prohibitions against discrimination on the basis of gender identity and termination of pregnancy on a nationwide basis. Then on June 12, 2020, the HHS released final rules eliminating anti-discrimination protections based on gender identity in health care and health insurance.

Whether or not Title VII's protections for LGBTQ+ individuals will affect the most recent HHS ruling remains to be seen. The ACA's protections were based on Title IX definitions of sex, not Title VII, but they are related, and more litigation is expected.

Americans with Disabilities Act of 1990

The Americans with Disabilities Act of 1990 (ADA), including changes made by the ADA Amendments Act of 2008 , specifically excludes from its definition of disability "transvestism, transsexualism, pedophilia, exhibitionism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders." 4 Nonetheless, some transgender individuals may suffer from depression or other medical conditions that could be covered under the law. Employers should consult with legal counsel before making any negative employment-related decisions related to a medical disability of a transgender worker.

State disability discrimination laws

Although the ADA excludes gender identity disorders from its definitions of disability, state disability discrimination laws may be broader and may not contain such exclusions. Employers should check with their attorneys regarding their states' laws on gender identity issues.

Family and Medical Leave Act of 1993

Some treatments and procedures for transgender employees may not qualify for employment leave under terms of the Family and Medical Leave Act (FMLA), but others may. Some that may qualify could include treatment related to gender dysphoria, overnight hospital stays related to sex-reassignment surgeries and continued counseling with a mental health professional. As with all requests for FMLA leave, the employer should follow normal notification procedures and review each medical certification to determine FMLA applicability.

State family and medical leave laws

Some states' medical leave laws may be broader than the federal FMLA. For example, the FMLA does not include domestic partners in its definition of "spouse," but some state medical leave laws do. Employers should know the terms of their states' laws on family and medical leave.  

Global anti-discrimination protections

Several countries have protections in place to prevent various types of human rights discrimination aimed at transgender individuals. For example, in the United Kingdom (UK) the 1999 Sex Discrimination (Gender Reassignment) Regulations are applicable to all stages of employment. Both the UK and Spain allow transgender individuals to change their name and gender on official documents without undergoing surgical changes. In the European Union, a 1996 decision in the European Court of Justice provided workplace discrimination protections for workers undergoing gender reassignment.

South Africa and many states and territories in Australia also prohibit discrimination against transgender people.

In 2006 a group of international human rights experts met in Yogyakarta, Indonesia to outline international rules relating to sexual orientation and gender identity, known as the Yogyakarta Principles . In 2017 additional rules were added to form the Yogyakarta Principles plus 10.

See  Employers in India Expand Inclusion to Cover LGBTQ Employees .

Organization Policies

In light of the various legal protections and legislative initiatives pertaining to transgender employees, employers should update their policies and practices to make sure gender identity and gender expression are explicitly included. Following are some of the workplace policies that employers should examine:

• Anti-discrimination policy. As a commitment to equality, compliance under Title VII  and where state law requires, ensure sexual orientation, gender identity, gender expression and similar terms are on the list of protected classes. See  Equal Employment Opportunity Policy: Detailed . 
• Dress code policy. Avoid gender stereotypes, such as men must wear dress trousers and women must wear skirts. Do not apply dress codes to off-duty conduct. Consider adding a provision that workers may dress in accordance with their full-time gender expression. See  When Do Dress Codes That Perpetuate Gender Stereotypes Cross the Line?
• Benefits policies and offerings. Follow applicable state laws and monitor the federal law for changes to the ACA. Title VII will not allow the conditions of employment to be discriminatory based on sex, which will apply to benefit offerings. Some states will prohibit discrimination on the basis of gender identity as well and benefits must be designed to meet those requirements. See  3 Checklists for Avoiding LGBTQ Discrimination in Your Benefits Programs .
• Diversity and inclusion initiatives. Make certain that transgender workers are included in the organization's affinity groups, local outreach efforts, internal programming and related training. See  How to Create Inclusive Workplaces for Transgender and Nonbinary Employees .
• Recruitment and selection processes. Review processes for possible disparate impact or treatment of transgender workers. Improve processes by educating recruitment teams, contacting outreach organizations and conducting anti-discrimination analysis as needed. See  Hiring Bias and Workplace Bias .

Training employees to recognize and eliminate discrimination in the workplace is important for every employer and updating the organization's presentations to cover transgender workers is essential to provide equal opportunity to all employees. Such training should be included in both new-hire and annual training offerings. In addition, the employer's updated anti-discrimination training should be offered to all employees so that they understand the organization's expectations when a transgender employee is joining their ranks or when a current employee is in gender transition. Various support groups may be able to provide sample training presentations or speakers to help employers ensure the training is appropriate. See SHRM's sample training presentations for templates that can be used to prepare and educate a workforce on employer nondiscrimination and diversity and inclusion expectations in general.  

Workplace Issues

Some transgender individuals make the transition to full-time expression as another gender while on an employer's payroll. The transition may or may not include surgery, but it will likely require management's help with the person's adjustment in the workplace—and to help with co-workers' concerns throughout the process.

Make preparations

Although the number of people making a gender transition while remaining in their jobs appears to be increasing, few managers receive training to prepare for the moment when an employee informs them of plans to make such a transition. Knowledge of principles and techniques relevant to more familiar discrimination areas can be applied to issues that arise when an employee transitions. For a transition to be considered successful, it must work for the person in transition, for the people the individual works with and for the organization. If the organization follows basic guidelines, this process can go smoothly.

A complete discussion on managing a gender transition in the workplace is outside the scope of this article, but some general principles are offered. Management typically meets with the employee in transition, discusses changes that need to be made, and lets the timing of those changes be guided by the employee. Matters that may come up for consideration during the process include the following:

• The person's name on organization documents.
• Coverage under employer health benefits.
• Communications to co-workers.
• Security clearances.
• Restroom and dressing room use.
• Dress code rules.
• Medical leave eligibility determinations.
• Employee conduct expectations and training.
• Client and customer communications.

Approach each transition individually

No two transitions are exactly alike. Some people, because of medical circumstances, are precluded from taking hormones or having surgery. Some postpone or decide against major surgical procedures because the costs are prohibitive for them and are not covered by their health insurance. Some in transition may choose cosmetic surgery, electrolysis, voice training or other procedures.

The specific steps of transition and their timing vary among individuals, and individuals vary in how public they want their transition to be. Some prefer that very few people know about the transition, and they want to blend in quietly as members of their new gender. Others are committed to educating people about transgender issues, are eager to answer questions and continue to talk openly about being transgender long after transition.

Work situations vary, too. The many circumstances that may have a bearing on how the transition should be handled include the nature of the enterprise and the degree to which it is public or private, the organizational culture, the composition of the workforce, the type of work being done, the physical layout of the workplace, and the amount of interaction the transgender employee has with peers, superiors, subordinates, vendors and clients. Because of such variables, there is no single formula for managing transitions in the workplace; rather, the process must be tailored to meet the needs of each specific situation.

Be knowledgeable about the legal definitions of gender

There is no single means of defining a person's legal gender, and there is no point in time when a transgender person changes from one gender to the other. The laws and rules on gender vary according to jurisdiction. For example, many states permit a transgender person to obtain a new driver's license with relative ease; this can help accommodate the medical requirement that a transgender person in surgical transition must live as a member of the person's new gender for at least a year prior to undergoing genital reconstructive surgery. In other states, changing the sex designation on any form of state-issued identification may be very difficult or even impossible. No uniformity on this issue exists among the states, between state and federal policies, or even among federal agencies.

Another influence on how transgender people are viewed is the context in which legal gender is being considered. Having a driver's license that shows the person's new sex is generally sufficient to enable a transgender person to be treated legally as a member of that gender. Some agencies, however, will not acknowledge a transgender person's new sex until the person presents evidence that the individual has taken an irreversible step to alter the body in the direction of the target sex. Such an irreversible step could be taking hormones over a period of time or having chest or genital reconstructive surgery. For some purposes, only genital surgery meets the requirement for having changed sex, but the exact nature of the genital surgery may be unspecified.

Given the variables in the law, tying recognition of gender in the workplace to legal recognition of the person's sex is problematic. Even more dubious is any attempt to base the person's acknowledged gender on medical or surgical treatment milestones. The most sensible approach for the employer is to consider the person to be a member of the sex in which the person presents. This approach is in accord with the growing legal trend toward recognizing that a transgender person should be treated as a legal member of the gender in which the individual lives life.

Some transgender and gender-nonconforming individuals prefer to use pronouns other than he/him/his or she/her/hers, such as they/them/theirs or ze/hir. See  Using Employees' Preferred Gender Pronouns .

Know how to deal with co-workers' attitudes

Many co-workers want to be supportive of transgender workers. Some employees, however, may be offended by the idea of a transgender person. Gender transition may run counter to their religious beliefs or moral standards. To reduce the likelihood of negative reactions to gender transition, the organization can establish a culture of appreciation of differences, provide adequate training and treat all employees fairly.

Diversity in a workplace means employees are able to work with all people; it does not require that employees believe in or accept transgenderism. Employees are entitled to their beliefs, but they should also be required to treat the transgender person—and every other employee—with respect.

Inclusion is about a diverse workforce becoming more productive, innovative and creative. It is about effectively harnessing the full range of available perspectives and experiences to create business advantage. To create a more inclusive environment, some organizations define appropriate workplace behaviors that are consistent with the employer's stated beliefs and values about inclusion and productivity. This process is about changing employees' workplace behaviors to be in accordance with the company's values, not changing an employee's personal beliefs and values. See  Creating a Trans-Inclusive Workplace .

Like all workers, transgender employers will be happier and more productive in a positive, supportive working environment. Just as an older worker employed in a workplace with mostly younger employees or a male employee working with mostly women might feel out of his element and comfort zone—and maybe even a bit ostracized—a transgender person regularly encounters such environments. Therefore, an employer that can foster and provide a positive, inclusive working environment, based on respect and professionalism, will likely enjoy workers who are happy to be there, engaged in their work and in the organization's success, and respectful of others.

Communicate well

Information about the organization's policies and guidelines for managing a gender transition should be widely accessible for employees, supervisors and managers, and HR professionals. The HRC's Workplace Gender Transition Guidelines 5 recommends that information appear in various venues, including these:

• The organization's intranet, particularly the HR resources pages and any pages for LGBTQ+ employee groups.
• The company's online and print code of conduct documents, covering employment nondiscrimination, equal employment opportunity policy, dress code, restroom policy and other topics.
• The search engine used to navigate company sites and pages. Users should be able to find information by searching terms such as transition guidelines, gender identity, gender expression, transgender, transsexual, cross-dress, gender reassignment, sex reassignment, sex change or transgendered. (The terms sex change and transgendered are not preferred terminology, but are intended to capture potential searches).
• Employee assistance program resources.
• HR hotline resources.

See  Template for Gender Transition Guidelines .

When announcing an employee's plan to transition, senior management can send a strong message of support for the transitioning employee and set the tone for what is expected of staff.

Additional Resources

Checklist: LGBTQ+ Anti-Bias and Title VII Compliance

Memo to Employees Announcing the Gender Transition of a Co-worker

How should an employer handle a transgender employee's request for a name change?

How should a company handle issues related to the use of workplace restrooms by transgender employees?

How to Accommodate 'Gender-Nonbinary' Individuals—Neither Men nor Women

The Benefits of Offering Gender Neutral Bathrooms in the Workplace

Infographic: Flip the Script: Transgender in the Workplace—Words

Infographic: Flip the Script: Transgender in the Workplace – Actions

1 American Psychological Association. (n.d.). Answers to your questions about transgender people, gender identify and gender expression. Retrieved from http://www.apa.org/topics/lgbt/transgender.aspx

4 Title 42, Chapter 126, Sec. 12211. Definitions. Retrieved from https://www.ada.gov/pubs/adastatute08.htm#12211 5 Human Rights Campaign. (n.d.). Workplace gender transition guidelines. Retrieved from http://www.hrc.org/resources/entry/workplace-gender-transition-guidelines

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The State of Transgender Health Care: Policy, Law, and Medical Frameworks

I review the current status of transgender people’s access to health care in the United States and analyze federal policies regarding health care services for transgender people and the limitations thereof. I suggest a preliminary outline to enhance health care services and recommend the formulation of explicit federal policies regarding the provision of health care services to transgender people in accordance with recently issued medical care guidelines, allocation of research funding, education of health care workers, and implementation of existing nondiscrimination policies. Current policies denying medical coverage for sex reassignment surgery contradict standards of medical care and must be amended.

The term transgender is an adjective that has been widely adopted to describe people whose gender identity, gender expression, or behavior does not conform to what is socioculturally accepted as, and typically associated with, the legal and medical sex to which they were assigned at birth. 1 Gender nonconformity, or a desire to express gender in ways that differ from gender-cultural norms linked to sex assigned at birth, was until very recently considered a mental pathology by the psychiatric community. 2 Although recognition and classification of gender nonconformity appeared in Western medicine in the 1920s, gender identity disorder (GID) first appeared as a distinct diagnosis in the American Psychiatric Association’s (APA’s) third edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM ) in 1980 2 and remained a category until the newest edition of the DSM (the DSM-5 ). 3 Over the past few decades, after professional as well as public debates, the APA has moved toward differentiating gender nonconformity from mental illness. On December 1, 2012, the board of the APA approved changing the diagnosis of GID to that of gender dysphoria in the DSM-5, 3 a significant move toward depathologizing gender variance. Psychiatrists increasingly agree that being transgender is not an illness to be cured or overcome (nor, for that matter, a state that can be altered). However, those who suffer because of the misalignment of their physical characteristics with their gender identity may benefit from treatment. 4

Current estimates have suggested that 0.3% of US adults, or close to 1 million people, identify as transgender. 5 (Other estimates have varied widely from a high prevalence of 1:500 or more 6 to 1:11 900–1:45 000 for male-to-female individuals and 1:30 400–1:200 000 for female-to-male individuals. 7–10 ) Demographic studies to date have been limited 7 because national surveys have not included questions recognizing gender identity. Furthermore, important methodological debates remain unresolved, including those about conflation of terms (e.g., differentiation among gender, gender identity, and sex ) and appropriate ways to accurately describe the transgender population (e.g., according to self-identification, gender expression, gender identity, or wish for medical treatment). 8 One way of estimating the proportion of transgender people in the population is through data on medical care, specifically medical assistance in the process of adapting gender presentation to align with identity, a process known as transitioning. However, this approach does not identify transgender people who have not opted for or who have faced insurmountable obstacles in accessing such care. Even using the conservative estimate of 0.3%, the number of people living in the United States who identify as transgender is nearly 1 million. Health care for this population has historically been, and continues to be, overlooked by governmental, health care, and academic establishments.

Transgender people have a unique set of mental and physical health needs. These needs are compounded by prejudices against transgender people within both the medical system and society at large. These prejudices create barriers to accessing timely, culturally competent, medically appropriate, and respectful care. 9,11,12 These societal and medical barriers are associated with increased risk of violence, suicide, and sexually transmitted infections. 11 Additionally, transgender people may have health needs related to gender transition, including hormonal therapy and surgery, that can create an undesired and unavoidable dependency on the medical system for basic identity expression. This combination of high medical needs and barriers to accessing appropriate care may give rise to a self-perpetuating cycle of risk exposure, stigmatization, prejudice, and eventually poor health outcomes.

Transition-related medical care, otherwise referred to as gender-confirming therapy , is designed to assist an individual with the adjustment of primary and secondary sexual characteristics to align with gender identity. 9,13 Such therapy may include hormonal therapy, surgical therapy, or both depending on individual needs and wishes, as well as ability to access such services. Procedures for gender confirmation may include breast or chest surgery, hysterectomy, genital reconstruction, facial hair removal, and plastic reconstruction, as appropriate to the particular person. 14

Denial of, or severely limited access to, medical care for transgender people, whether explicitly by refusal of coverage or implicitly by prejudice and lack of knowledge among health care workers, may have detrimental effects on both short- and longer term health and well-being of transgender people. Moreover, the failure to comprehensively address the medical needs of transgender people stands in contradiction to the medical profession’s prized values of equity and respect. 15 As such, I argue that a new approach is urgently needed: one that not only recognizes the unique health care needs of this group of people, but does so in an ethical, principled, and timely manner.

TRENDS IN DATA COLLECTION

Over the past few decades, a growing body of research has been published regarding lesbian, gay, bisexual, and transgender (LGBT) health. 16,17 However, most of the literature and published data have involved sexual minorities (i.e., lesbians, gays, and bisexuals) or the LGBT community as a whole, leaving unaddressed specific needs, issues, and barriers faced by transgender and gender-nonconforming people. Although a growing body of literature has addressed the overall health and health indicators of transgender people, 12,18,19 the evidence-based work on gender-confirming treatment (medical and surgical transition care) is still limited. For example, few high-quality systematic studies have been conducted 20 ; of those conducted, many are observational in nature. 4,11,21 (Because of the relative availability of funding for HIV/AIDS-related research and high HIV prevalence among transgender people, 11 much of the research to date regarding transgender health policy has focused on HIV/AIDS; see also Brennan et al. 21 ) Further compounding the lack of rigorous research and data, the limited body of published work includes examples of research that may be construed as objectifying and may lead to misunderstanding or prejudice by readers (including authors’ use of assigned rather than chosen gender pronouns 22 ), which brings with it the risk of perpetuating or deepening misconceptions and unconscious prejudices among health care professionals.

In the past few years, several key public health bodies have recognized the lack of robust data on health indicators and on what constitutes medically appropriate care and the negative effect it has had on the quality of care provided to sexual and gender minorities; attempts to address these knowledge gaps have resulted in recent reports on LGBT health, for example, by the Institute of Medicine 17 and Healthy People 2020. 23

In a recently published response to the Institute of Medicine report on LGBT health, the National Institute of Health’s LGBT Research Coordinating Committee found that most LGBT health research

is focused in the areas of Behavioral and Social Sciences, HIV (human immunodeficiency virus)/AIDS, Mental Health, and Substance Abuse. Relatively little research has been done in several key health areas for LGBT populations including the impact of smoking on health, depression, suicide, cancer, aging, obesity, and alcoholism. 24 (p8)

In this same report, the LGBT Research Coordinating Committee called for increased research on transgender-specific health needs, including those associated with transitioning and the safety and efficacy of surgical sex reassignment procedures, as well as mental health and routine clinical care.

On June 29, 2011, US Department of Health and Human Services Secretary Kathleen Sibelius announced that the department would begin collecting data in its population health surveys that would facilitate identification of health issues and reduction of health disparities among LGBT populations. 25 These data will be collected by integrating questions regarding sexual orientation and gender identity into the National Health Interview Survey and, as an initial step toward the creation of a governmental standard for LGBT health data collection, under Section 4302 (nondiscrimination) of the Patient Protection and Affordable Care Act (ACA). 26 Starting in January 2013, the National Health Interview Survey has included a sexual-orientation specific question. HHS is currently testing survey questions on gender identity with the express purpose of capturing data about transgender people. 27

MEDICAL NEEDS

Transgender people, particularly low-income transgender people and transgender people of color, have reported even higher rates of discrimination in accessing competent and comprehensive care than other sexual minorities. 28 In 2008, the National Center for Transgender Equality and the National Gay and Lesbian Task Force partnered to conduct the first large-scale, national survey of transgender people, funded by the Network for LGBT Health Equity (formerly the Network for LGBT Tobacco Control). The study’s overarching objective was to map out the needs of and the issues faced by transgender people. 11 The 70-question survey was developed by an interdisciplinary team of social and health science researchers, grassroots and national transgender rights advocates, expert lawyers, statisticians, and LGBT movement leaders. The survey was completed online or in paper form and returned by more than 7500 respondents recruited through community organizations and community e-mail distribution lists, with direct outreach through organizations serving hard-to-reach populations, such as rural, homeless, and low-income transgender and gender-nonconforming people. The responses of 6456 people were included in the analysis, with a geographical distribution representative of the US population.

The landmark survey confirmed and expanded existing knowledge regarding areas of increased risk and specific difficulties that transgender people face in navigating the health care system. 11 It found that 19% of respondents reported having been denied health care by a provider because of their gender identity, and 28% reported verbal harassment in a medical setting. More than a quarter (28%) of respondents postponed care because of discrimination and disrespect, and a third (33%) postponed preventive care. Nineteen percent of respondents reported that they lacked insurance coverage (compared with 15% of the general population at that time 29 ), and a lower proportion of insured people received employment-based insurance than in the general population, which is likely attributable to high rates of job loss resulting from bias (as reported in the survey). 11

Looking at specific vulnerabilities, the survey reported that transgender people have a particularly high likelihood of being HIV-positive and using drugs, alcohol, or smoking as a mechanism to cope with discrimination compared with the general population. The lifetime suicide attempt rate was 41% of the respondent population (compared with 1.6% in the general population). 11 Each of these vulnerabilities was enhanced among racial minorities and among those participating in sex work, drug use and sales, or both. The survey reported that 75% of transgender women (i.e., female-identified or male-to-female transgender people) and more than 90% of transgender men (i.e., male-identified or female-to-male transgender people) either had or wanted to have surgical treatment, and 85% of transgender people either had or hoped to have hormonal treatment. 11

A modest but growing body of research has examined the efficiency of medical treatment. Gender-confirming surgery, often referred to as sex reassignment surgery (SRS), 1 has been shown to be beneficial in alleviating gender dysphoria (the distress associated with the difference between an individual’s expressed or experienced gender and socially assigned gender). 4,30,31 A 1992 study reported that hormone therapy improves quality of life as assessed by the Short Form-36 (SF-36) Health Survey, a 36-question validated survey assessing measures of health and well-being. 32 Increasingly, the overall consensus among those providing medical care to transgender people is that

sex reassignment generally, and SRS specifically, is associated with a high degree of patient satisfaction, a low prevalence of regrets, significant relief of gender dysphoria, and aggregate psychosocial outcomes that are usually no worse and are often substantially better than before sex reassignment. 33 (pp423–424)

Medical professional associations are increasingly publicly supporting inclusion of health care for transgender people and opposing the commonly held but slowly changing notion that such care is frivolous, cosmetic, experimental, or unnecessary. Since the early 1980s, the World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association) has been publishing standards of care (SOC). 9 Both SRS and hormonal therapy are endorsed by the SOC as necessary care for gender dysphoria, being both effective and often life saving. 9 Other professional societies, including the American College of Obstetricians and Gynecologists, 34 the Endocrine Society, 35 the American Medical Association, 36,37 and the American Psychological Association, 38 have endorsed these recommendations. They have each published statements encouraging care for transgender patients and urging public and private health insurance coverage for treatment of gender dysphoria.

In terms of costs, the American Medical Association has estimated provision of health care to transgender people to be nearly cost saving (incremental cost-effectiveness estimate = $500). 37 In 2001, San Francisco, California, became the first US city and county to remove transgender access exclusions from its employee health plan; in 2006, employee surcharges to cover these benefits were dropped because costs of reimbursement proved to be significantly lower than previously estimated. 39

Beyond insurance coverage, access to care is limited by the dearth of physicians who focus on, or are comfortable with, providing care for transgender people. A stark example is the paucity of surgeons performing genital reconstructive surgery: As of 2012, only 6 identified surgeons in the United States performed genital reconstructive surgery (Eric Plemons, PhD, written communication, January 3, 2013), thus limiting options for people seeking this surgery.

Other issues that transgender people often encounter in their interaction with the health care system include lack of respect and acceptance of chosen gender by health care staff, privacy and safety, 1 cultural appropriateness and understanding, and adequate knowledge of some of their specific medical needs. 11,12,40 (For example, while breach of confidentiality is always a serious matter, it can have particularly far-reaching consequences for the safety of transgender people when it leads to involuntary “outing,” or exposure of transgender identity.) Given the widespread lack of knowledge about transgender populations, and the absence of transgender health issues from most medical school curricula, 41 much remains to be done to shape a medical workforce that is well informed regarding the needs of this population and capable of providing appropriate care. Therefore, educating health practitioners about these issues is crucial. Of utmost importance is education of primary care providers, along with specialists in fields of particular relevance (including endocrinology, urology, obstetrics and gynecology, and plastic and reconstructive surgery, as well as emergency medicine). However, because physicians from all specialties treat transgender people, the basics of transgender health care should be addressed in medical, physician assistant, and nursing schools on a national scale.

US REGULATORY AND POLICY LANDSCAPE

Among issues of access to care that must be addressed nationally, that of insurance coverage and affordability of care has primary importance.

Federal Agencies and Regulations

As the US population ages, an increasing proportion of the population, including the transgender population, will become dependent on Medicare for access to care. Although Medicare covers both routine care (through parts B and 1) and hormonal treatment (part D), SRS is not covered. The specific language used by the Center for Medicare and Medicaid Services in explaining this lack of coverage is telling:

Transsexual surgery, also known as sex reassignment surgery or intersex surgery, is the culmination of a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. Transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex. For the male-to-female, transsexual surgery entails castration, penectomy and vulva-vaginal construction. Surgery for the female-to-male transsexual consists of bilateral mammectomy, hysterectomy and salpingo-oophorectomy, which may be followed by phalloplasty and the insertion of testicular prostheses. Transsexual surgery for sex reassignment of transsexuals is controversial. Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental. Moreover, there is a high rate of serious complications for these surgical procedures. For these reasons, transsexual surgery is not covered by Medicare. 42 (sect140.3)

Several issues arise from this language. First, SRS is neither controversial nor experimental; rather, it is a well-recognized therapy advocated for by leading medical associations. This claim cannot serve as a basis for denying coverage for necessary treatment. The terminology and definitions in this statement are inaccurate, outdated, and inconsistent with current APA guidelines. The statement conflates intersexuality with being transgender and fails to acknowledge the wide range of possible gender expressions. Neither does it address the high rate of serious sequelae of failing to treat transgender people who have a need for gender-confirming surgery. Risk of complication is not sufficient grounds for rejecting treatment. As with any other procedure, one must evaluate the potential risk of complication in the context of the condition being treated and the risks of failure to treat.

In June 2011, in an effort to standardize care for transgender veterans, the Veterans Health Administration in the US Department of Veterans Affairs (VA) published directives regarding provision of care to transgender (and intersex) veterans (Patrick Paschall, JD, policy counsel, National Gay and Lesbian Task Force, oral communication, January 8, 2013). The directives state that

medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery. 43 (p2)

This policy clarifies the obligation of VA medical providers to extend comprehensive care to transgender veterans. The directives, however, deny coverage of SRS on the basis of a VA regulation excluding gender alterations from the medical benefits package, 44 despite the recognition of such alterations as part of care. Furthermore, these directives also contradict VA policy to provide “care and treatment to Veterans that is compatible with generally accepted standards of medical practice.” 34,35,37,43 (p2) However, an increasing commitment to LGBT inclusion in the VA, particularly through the recently founded Office for Diversity and Inclusion, has led to significant progress in health care delivery for transgender people. In June 2011, the Veterans Health Administration added protections based on gender identity to Equal Employment Opportunity Commission protections for employees, 45 and it is currently providing training for health care providers in services for transgender veterans. 46

High rates of unemployment in the transgender population are also a major barrier to maintaining health and appropriate health care. 2 Accordingly, employment of transgender people in the health care workforce is recommended because it offers an important avenue to address some of the challenges and barriers this population faces in the health care system. Although the burden of educating medical professionals should not rest on transgender people, increasing participation of transgender people in the health care workforce can facilitate and catalyze education and increase the understanding of issues faced by transgender people. This, in turn, has the potential to create safer and welcoming spaces for transgender people who seek medical care. Regarding employment more generally, in April 2012 the Equal Employment Opportunity Commission ruled that the Civil Rights Act’s prohibition against sex employment discrimination (title VII) applies to transgender people. See Macy v Holder. 47

In July 2012, in response to a letter from LGBT organizations, the US Department of Health and Human Services issued a statement clarifying that the ban on sex discrimination in section 1557 (nondiscrimination) of the ACA includes discrimination on the basis of gender identity. 48 This federal policy statement, the 1st of its kind, has wide implications, including for Medicare and Medicaid. This statement, along with the Equal Employment Opportunity Commission ruling, should not only increase access of transgender people to appropriate health care but also help alleviate concerns about discrimination and promote active participation in the health care system.

Some additional protections for transgender people are expected with implementation of the ACA. Standards for qualified health providers (QHPs) participating in the exchange programs ban discrimination in any of their activities, including on the basis of sexual orientation or gender identity:

Non-discrimination. A QHP issuer must not, with respect to its QHP, discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. 49 (p916)

Additionally, coverage denial based on being transgender as a preexisting condition will be banned under the ACA starting in 2014. To what extent and how promptly these protections will be implemented, and whether they will lead to higher rates of coverage for mental health services, cross-sex hormone therapy, or gender affirmation surgery, remains to be seen. These advances do not, however, provide an explicit and directed protection of transgender people within the health care system, nor do they address coverage of specific treatments that transgender people may need.

The Ending LGBT Health Disparities Act, a federal bill introduced in 2009, proposed the addition of a sexual orientation and gender identity nondiscrimination clause to all Medicaid, Medicare, and Children’s Health Insurance programs, with gender identity meaning

the gender-related identity, appearance, or mannerisms, or other gender-related characteristics of an individual, with or without regard to the individual's designated sex at birth. 50

The bill included federal grants to improve access and health promotion to gender and sexual minorities, in part through dedicated LGBT health centers, research related to gender and sexual minorities’ health disparities, and a requirement that sexual orientation and gender identity be included in federally funded health surveys. It also aimed to amend the Public Health Services Act by setting national standards for cultural competency of health care service to include sexual and gender minority cultural competency. Also important, the bill included a prohibition against discrimination on the basis of sexual orientation or gender identity under the health benefits program for federal employees and in the provision of health care and other benefits for members of the armed forces and veterans. This bill, though it did not directly relate to treatment coverage, would not only have increased access to care for all those directly affected by it, but may also have helped create a positive and inclusive climate for transgender people as full members of the population whose health is of concern. The bill was not passed, however, and so developments in enabling access to care for transgender people remain dependent on incremental advances within the current legal frameworks.

Court Decisions and Treatment Coverage

Given prisoners’ restriction of liberties, it is perhaps not surprising that some of the most serious limitations on transgender people’s access to health care have been in the US prison system. In most states, either incarcerated transgender people are housed according to their external genitals or no specific policy exists regarding their treatment and housing. 51,52 More surprising, perhaps, is that these abuses coexist alongside some of the most important advancements in protection of these rights. In several instances, federal courts have upheld the rights of transgender prisoners to receive both hormonal and surgical treatment. These decisions were based on the WPATH standards of care and on expert opinions that transition care (both hormonal and surgical) is medically necessary. The courts reasoned that the denial of transition care amounts to cruel and unusual punishment, a violation of the Eighth Amendment.

A landmark case is Fields v Smith. 53 In 2005, Wisconsin passed the Inmate Sex-Change Prevention Act, prohibiting funding of transition therapy (both hormonal and surgical) for transgender prisoners. 54 Several transgender women whose care was abruptly cut off filed against this law, claiming unconstitutionality on the basis of both the Eighth Amendment (cruel and unusual punishment) and the Equal Protection Clause. A federal district court found that the law constituted deliberate indifference to the plaintiffs’ medical needs in violation of the Eighth Amendment and violated the plaintiffs’ right to equal protection. The Seventh Circuit court affirmed the district court’s order.

In Adams v Federal Bureau of Prisons 55 in 2010, a federal district court judge denied a motion to dismiss the complaint of Vanessa Adams, who was denied hormonal treatment. Though Adams was by that time receiving care, the Federal Bureau of Prisons had not changed its policy of refusing hormone therapy for transgender people. The case resulted in a reversal of policy that denied inmates initiation of treatment of GID. In Kosilek v Spencer 52 in 2012, the District of Massachusetts Court ruled in favor of Michelle Kosilek, requiring the Massachusetts Department of Corrections to provide SRS for Kosilek. The court based its ruling on doctors’ expert opinions stating that in severe cases SRS is medically necessary; in this case, Justice Wolf, citing the WPATH Standards of Care, upheld previous rulings that GID is a severe medical condition requiring treatment. Justice Wolf also underscored that treatment cannot be denied on the basis of cost, because prisoners routinely receive care that is perceived as expensive. As Levi 56 pointed out, more than asserting the right or need for treatment of GID or limits to treatment within the prison system, the Kosilek ruling relates to what she called transgender exceptionalism, or the fear of controversy as a guiding principle for decisions made by government officials. In O’Donnabhain v Commissioner in 2010, the US Tax Court ruled in a manner similar to the rulings regarding prisoners’ right to transition care. 57 The court found that SRS and hormonal therapy are tax deductible under the Internal Revenue Code because they constitute necessary medical treatment.

Given these affirmations by the judicial system of the medical necessity for transition care, I argue that the federal Medicaid program should require participating states to cover gender-confirming treatment. 58 Although according to the statute governing the Medicaid programs (Title XIX of the Social Security Act, 42 USC § 1396), states “may place appropriate limits on a service based on such criteria as medical necessity,” 59 (p273) they may also not arbitrarily deny benefits solely on the basis of “diagnosis, type of illness, or condition.” 59 (p273) In fact, as early as 1980, the US Court of Appeals (Eighth Circuit) found that denial of coverage for SRS is an

arbitrary denial of benefits based solely on the diagnosis, type of illness, or condition where physician and hospital care are mandatory services and such surgery is “the only successful treatment known to medical science.” 60

A previously used measure for the reasonableness of the legislature’s standards has been general acceptability by the professional medical community as an “effective and proven treatment.” 61 Thus, although coverage of treatment must ultimately depend on particular need, as prescribed by the treating physician, it seems clear that as a category of treatment, gender-confirming care should be covered by individual states’ Medicaid programs, as by other publicly funded programs.

Many states currently have laws that explicitly deny Medicaid coverage of gender-confirming therapies, either specifically (e.g., Iowa, 62 Massachusetts 63 ) or because it is included in the category of cosmetic and experimental surgery (e.g., Missouri 64 and Illinois 65 ). 58 Legal challenges to the legislation have been successful in those states that did not have a statute or regulation explicitly excluding transition treatment from being covered; existing treatment exclusions have consistently been upheld. 58 After such challenges, Iowa and Minnesota added provisions excluding SRS from Medicaid coverage; currently, only California covers SRS under Medi-Cal. 58 However, True 58 suggested that the O’Donnabhain ruling may affect Medicaid coverage of SRS because upheld exclusions were based on the premise of lack of medical necessity for SRS. As medical opinion confirms that SRS is necessary, effective, nonexperimental, and without a comparable substitute; this opinion becomes even more widely echoed in the medical literature and court decisions; and the WPATH standards of care gain recognition as the professionally accepted guidelines for treatment of gender dysphoria, the provisions and statutes excluding coverage of gender-confirming surgery are likely to become increasingly harder to defend. I would contend that the argument for such provisions to be found invalid by the courts under the Federal Medicaid Act will be increasingly strong because they appear to be based on invalid rationales, put unreasonable restrictions on medically necessary treatment, and discriminate on the basis of diagnosis, which is in violation of the Federal Medicaid Act. Successful challenges to the legality of Medicaid coverage denial may also affect denial under Medicare and in the VA.

DIAGNOSES AND THEIR EFFECT ON CARE

In the United States, the medical establishment follows the APA definition as set out in the DSM for diagnosis and care of transgender people. In the fourth edition, text revision, of the DSM ( DSM-IV-TR ), diagnostic criteria for GID included strong and persistent cross-gender identification, persistent discomfort with the current sex, or sense of inappropriateness in the gender role of that sex. 66 More importantly, the discomfort must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the DSM-5, GID has been replaced with the term gender dysphoria. 3 The new classification emphasizes gender incongruence rather than cross-gender identification in an effort to reflect the individual’s felt sense of incongruence with natal gender, as opposed to pathologizing gender-atypical behavior. (Despite the APA’s stated intention, the new criteria seem to retain diagnosis based on gender nonconformity and fail to differentiate between distress caused by societal prejudice and that caused by a mental disorder.) Additionally, gender dysphoria is now separated from the chapters on sexual dysfunctions and paraphilias. In contrast to the dichotomized DSM - IV-TR GID diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.

At the outset, I must state that the inclusion of gender identity and transgender-related matters in the DSM reflects an inherent problem. Although diagnostic coding is necessary to facilitate access to medical and surgical transition care, the pathologizing and stigmatizing suggested by its designation as a mental disorder is not. Such designation gives rise to an inherent contradiction in terms: what is presented as a mental condition has recognized medical and surgical treatment:

Gender Dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical. 3 (p14)

These treatments are aimed not at affecting or changing mental state but rather at addressing the physical components that lead to the dysphoria. Such logic makes GID or gender dysphoria a unique case of surgically treatable mental illness, which is an oxymoron.

When the category of gender dysphoria was proposed, several LGBT and transgender organizations, including Lambda Legal, urged the APA to prioritize coverage of transitional treatment of transgender people as a medical necessity for a recognized condition over demedicalizing and depathologizing transgender people. 67 The current changes reflect an effort to strike a balance between stigmatization and the need to maintain access to care. 68

Future deliberations as to how to enable coverage of transgender-related care without designating a mental condition might consider an approach similar to that taken toward pregnancy and preventive care. Pregnancy is a condition that is recognized clinically and coded under the World Health Organization’s International Classification of Diseases. 69 It is treated, billed, and covered accordingly (with various policy options related to coverage of what is medically deemed necessary) without being pathologized. Similarly, preventive care is offered and routinely covered and is often considered necessary, independent of any diagnosis. So, too, I would suggest, can need for SRS be covered for transgender people without necessitating a DSM diagnosis.

RECOMMENDATIONS

Given the widespread acknowledgment of the health care needs of transgender people, action must be taken to ensure timely access to appropriate care. Such action includes, first and foremost, a requirement that all governmentally funded programs, including the VA, Medicaid and Medicare, Children’s Health Insurance Program, and Indian Health Services, include coverage of transition care and a requirement to ensure safe, appropriate, and sensitive care in federally funded health centers.

Private insurance may ultimately follow adoption of full coverage by federally funded programs, but until it does, federal guidelines protecting transgender people from discrimination by private insurance companies is warranted, including a ban on the practice of denying medical care coverage by linking the care to transition (which is not covered under most policies). To what extent the inclusion of gender identity in the ACA nondiscrimination clause will lessen this type of denial remains to be seen. Continued monitoring is necessary. More importantly, because a relatively high proportion of transgender people are uninsured, the expansion of Medicaid after implementation of the ACA significantly increases transgender people’s access to medical care (beyond transition care and SRS).

As work to enhance access to medical care progresses, the need for appropriate care will also increase. Models of care for marginalized minority populations with particular health needs can be based on existing general health care systems or implemented through specialized clinics and health care centers. Spurred by the AIDS epidemic and its toll on the gay community, dedicated LGBT health centers have been active in the United States since the 1980s. Although only a handful of centers are, at present, dedicated explicitly and exclusively to transgender patients, LGBT community health centers have provided care and often been active participants in and drivers of knowledge accumulation and dissemination regarding transgender health and treatment. These centers include the Fenway Center in Boston, Massachusetts; the Callen Lorde Community Health Clinic in New York City; and the Lyon-Martin Health Services in San Francisco. Achieving widespread access to acceptable, competent, appropriate, and affordable care, while promoting centers of clinical and research excellence in transgender health care, will require a combination of creating and strengthening dedicated centers as well as addressing transgender people’s health needs within the general health system.

Bias against transgender people takes an enormous toll on their health through direct harm, lack of appropriate care, and a hostile environment and through transgender people’s avoidance of the medical system as a result of discrimination and lack of respect. The medical establishment has a duty, and an ability, to protect transgender patients from such harms. Transgender-sensitive care must be incorporated into medical, nursing, and paramedical curricula, as has been done with other cultural competencies. Clear guidelines for all federally funded health centers, in line with the WPATH standards of care, need to be drafted and adopted by leading medical societies, including guidelines related to appropriate language, adoption of gender-neutral bathrooms, health records respectful of names and gender pronouns, and other safe environment measures.

Federal grants should be offered for programs teaching postgraduate-level care of transgender patients, including SRS. The ACA has taken a first positive step in that direction by providing funding for LGBT cultural competency trainings, which have already been implemented in big-city health departments, with training underway for staff of the National Health Service Corps.

Such measures are not only essential for the creation of an equitable health system, but will also likely result in improved health outcomes for the transgender population as barriers to access are removed and knowledge is enhanced. Incorporation of questions regarding gender identity into health surveys will also enable monitoring of progress and effects of these measures.

National surveys and health-related data sets must start to gather information about populations of transgender people by including questions pertaining to gender identity and sexual orientation. Several approaches are possible (including self-identification and identification of gender expression), and although none are perfect and all raise potential issues related to disclosure and the tension between identity and behavior, inclusion of such questions is a necessary step toward building a foundation of knowledge regarding the health and needs of transgender people. Though the National Transgender Discrimination Survey is an immense step forward in gathering data on health needs as transgender people perceive them, a need remains for data collection on outcomes, both through incorporating gender-identity identifiers into existing national surveys and through directed research. Last, it is essential that those who are caring for transgender patients collect and publish their data, in order to improve care for transgender people. It goes without saying that all such research must be conducted with sensitivity and respect toward participants.

Acknowledgments

I thank Diana Bowman, LLB, PhD, for her encouragement, guidance, and help. I also thank Alicia Cohen, MD, for her incisive and insightful comments. Last, I am grateful to Rachel Neis for her support, careful readings, and thoughtful discussions and comments.

Human Participant Protection

Human participant protection was not required because this study involved no participants.

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gender reassignment

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A physiological and ultimately surgical procedure, under medical supervision, for the purpose of changing a person's sexual characteristics. The process is undertaken by transsexual persons. A transsexual is a person who firmly believes that he or she belongs to the sex opposite to the sex (or gender) to which he or she was assigned by the anatomical structure of his or her body at birth, a condition known as gender dysphoria. It is important to distinguish a transsexual person from a transvestite, who merely wishes to dress in clothes of the opposite sex. Previously, under English law transsexual persons who had undergone gender reassignment were not recognized in their acquired gender, and although able to obtain some official documents in their new name and gender, they could not obtain a new birth certificate or marry in their acquired gender. Under the Gender Recognition Act 2004, a transsexual person may apply to the Gender Recognition Panel for the issue of a full Gender Recognition Certificate. Before issuing the certificate the Panel must be satisfied that the applicant has, or has had, gender dysphoria, has lived in his or her acquired gender for the past two years, and intends to continue to live in that gender until death. The certificate entitles the applicant to be legally recognized in his or her acquired gender, to a new birth certificate, and to marry in that gender. Transsexual persons who have not acquired a Gender Recognition Certificate will not be entitled to have their birth certificates amended and will still only be able to marry in the sex registered at birth. Important cases in this area include Corbett v Corbett [1971] P 83 (HL), Goodwin v UK (App no 28957/95) (2002) 35 EHRR 18, and Bellinger v Bellinger [2003] UKHL 21, [2003] 2 AC 467.

Initially discrimination in the workplace with respect to a person's sexual orientation or transsexualism was outside the ambit of the Sex Discrimination Act 1975 (see sex discrimination). The definition of sex within that Act referred to discrimination on grounds of biological gender and hence covered discrimination only between men and women. As a result of a series of cases before both the European Court of Justice and the European Court of Human Rights, the UK Sex Discrimination Act now includes transsexualism within its definition. As gender reassignment is an ongoing process, regulations have been issued clarifying the protections to be given at the workplace to a transsexual undergoing this process. The Sex Discrimination (Gender Reassignment) Regulations 1999 bring UK law into line with the decision of the European Court of Justice in Case C-13/94 P v S and Cornwall CC [1996] IRLR 347, in which discrimination on grounds of gender reassignment was ruled to be contrary to European Community law.

The Regulations provide protection against discrimination by employers at all stages of the reassignment process, starting when an individual indicates an intention to begin reassignment. The Regulations also cover recruitment procedures, vocational training, and discrimination with respect to pay (see equal pay). The Sex Discrimination Act as amended by the Regulations outlaws direct discrimination and provides for employees who are absent from work to undergo treatment to be treated no less favourably than they would be if the absence was due to sickness or personal injury. The protection is extended to postoperative treatment on a transsexual's return to work. Transsexuals are also protected from harassment. There is a defence to a complaint of less favourable treatment if being a man, or a woman, is a genuine occupational requirement for the employment in question. In addition, there are further supplementary exceptions, some of which apply only temporarily while the process of reassignment is continuing. One exception is where the job is likely to involve the holder of the job being called on to perform intimate body searches pursuant to statutory powers (e.g. a police officer). In that case, however, the employer must take into account whether there are already enough employees who are capable of carrying out those duties whom it would be reasonable to employ on those duties. In no case will less favourable treatment be justified under the exceptions where the individual concerned has acquired a Gender Recognition Certificate under the Gender Recognition Act 2004. This allows for legal recognition of the acquired sex, and the person must be treated as being of that sex for all purposes (Goodwin v UK (App no 28957/95) (2002) 35 EHHR 447; Case C-117/01 KB v National Health Service Pensions Agency [2004] IRLR 240 (ECJ).

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Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

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A review into how children with gender dysphoria are treated in england has been released. here's what it means for australia.

Former AFL star Danielle Laidley tells her story — 'nothing more, nothing less'

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Bans on Transition Care for Young People Spread Across U.S.

In the past three months, 10 Republican-led states have passed laws banning gender-affirming care for minors.

• Share full article

By Francesca Paris

Ten states in the past three months have passed laws prohibiting what is known as gender-affirming care for young people, in a rapid effort by Republican lawmakers across the country.

The laws ban or significantly limit the use of puberty blockers, cross-sex hormones and transition surgery for people under 18. Last week, Indiana and Idaho became the most recent states to pass bans.

States With Bans on Gender-Affirming Care for People Under 18

Before this year, just three state legislatures had enacted full or partial bans. In addition to the 10 signed into law, bans have passed at least one chamber of seven more state legislatures on the path toward enactment this year.

Florida’s state medical boards also issued a rule last year prohibiting doctors from offering gender-affirming care to new patients under 18. Though not a law, the decree has the same effect of ending care.

Two more state legislatures, in Oklahoma and South Carolina , have successfully pushed major hospitals to stop providing gender-affirming care for minors by linking the care to the use of public funds.

And Missouri’s attorney general on Thursday announced a temporary order severely restricting gender-affirming care for both adults and minors by mandating strict requirements including evidence of three years of gender dysphoria documented by physicians. It is set to take effect on April 27.

Including prior bans, this means gender-affirming medical care has been restricted by law or other means in 13 states, with another two under judicial review.

These state-level actions are part of a broader wave of anti-trans legislation that has been proposed and passed across the United States. And hospitals have faced significant harassment for providing gender-affirming care in the last few years.

Republican state legislators have called gender-affirming care experimental and harmful, and say that children are not mature enough to make permanent decisions.

Major medical organizations in the U.S. support this care, however. And opponents of the bans say they infringe on the rights of young people, parents and doctors, and pose significant mental health risks to a vulnerable population.

The A.C.L.U. of Indiana filed a lawsuit on April 5 after the governor signed a ban on gender-affirming care into law; families have sued in Florida; and advocates in other states have signaled their intent to sue. Court injunctions have temporarily stopped bans that were passed in previous years in Alabama and Arkansas .

In some states, teenagers already on medication for gender dysphoria will be permitted to continue treatment indefinitely or taper off until a set cutoff date. In states that have passed bans without exceptions, minors taking puberty blockers or cross-sex hormones will have to travel to another state or stop treatment entirely.

All 10 bills passed so far this year permit hormonal therapy and genital surgery for reasons other than gender transition, such as surgery for children with ambiguous sex characteristics or puberty blockers for those experiencing early puberty.

States That Have Banned Some or All Gender-Affirming Care

States with a total ban, states with a partial ban, states with a ban blocked by a court.

There is continuing research in the United States and Europe about the risks and benefits of gender-affirming care for young people. But the American Academy of Pediatrics and the American Medical Association have urged states not to interfere with or limit care, pointing to evidence that suggests allowing adolescents to access this care can reduce depression and the risk of suicide. Minors also need parental consent in states where they can get hormone therapy.

Some doctors who have voiced concerns about how and when adolescents should receive gender-affirming care joined an open letter last month opposing the bans.

“There is consensus in the field, and amongst these signatories, that gender-affirming medical care is important and beneficial for many transgender youth,” the letter said.

The bills have moved through G.O.P.-dominated legislatures and been signed into law by Republican governors in nine states so far this legislative session. In Kentucky, Republicans overrode the Democratic governor’s veto .

“In signing this bill, I recognize our society plays a role in protecting minors from surgeries or treatments that can irreversibly damage their healthy bodies,” Gov. Brad Little wrote on signing Idaho’s ban last week.

Several of the bans include significant exceptions: Arizona’s ban, passed last year, prohibits only surgery, which is rare among transgender teenagers. Georgia’s law bans cross-sex hormones and operations but not puberty blockers. And West Virginia’s ban allows the care to continue if two providers agree that the treatment is necessary to “limit self-harm, or the possibility of self-harm.”

That amendment was proposed by the Republican State Senate majority leader, Tom Takubo, who in a floor speech last month referred to significant mental health benefits that gender-affirming medical care has for some teenagers with gender dysphoria.

Who is affected

There are about 53,000 transgender adolescents in the states where some or all gender-affirming care has been banned, out of some 300,000 nationwide, according to estimates from the Williams Institute — or around 1.4 percent of all adolescents.

Many of the major gender clinics across the Midwest and the South typically treat only one hundred or two hundred adolescents, and not all of them are getting hormone therapy. Estimates from Reuters suggest that a few thousand young transgender people nationwide initiate puberty blockers or cross-sex hormones annually.

Providers expect the bans and closures will put pressure on states where gender-affirming care remains legal. The gender health program at Children’s Minnesota has a wait list of around a year, according to its director, Angela Kade Goepferd. She fears the list will grow as patients from nearby states seek care.

“As it stands now, there’s a huge hole for access to care for transgender adolescents through the center part of the country and across the South,” she said. “Kids already driving hours for care within their own state are going to have to cross state lines.”

For families who can’t afford that much travel, “their kids just won’t have access to care,” she said.

When Alabama’s ban was first passed last spring, the University of Alabama at Birmingham prepared to send its patients to neighboring states. Then a court paused the part of the law that banned gender-affirming medication.

“Now some of the neighbors that we called last May are calling us, because their states are passing laws,” said Hussein Abdul-Latif, a pediatric endocrinologist with the university hospital system.

Future bans

Lawmakers in more than a dozen states are considering bans or restrictions on gender-affirming care. Many of those states, however, have at least one chamber held by Democrats or have a Democratic governor, severely limiting the bills’ prospects.

States That May Ban Gender-Affirming Care for Minors This Legislative Session

Kansas Republicans passed a ban on gender-affirming care, but the Democratic governor, Laura Kelly, is expected to veto it, and the bill’s support so far is short of a veto-proof majority. Wyoming Republicans’ attempts at passing similar legislation died in the Legislature this year.

Bans seem more realistic in several other G.O.P.-controlled states, especially Texas and Oklahoma , where legislation has passed at least one chamber of the Legislature. Last year , Texas declared that providing gender-affirming care was child abuse, though a court has partly blocked the state from investigating families. Adolescents in the state are still able to get some care, but it’s not clear how many providers have ceased to offer services.

In Nebraska, Democrats brought the legislative session to a standstill by filibustering the state’s proposed ban, but the legislation has made headway in recent days.

And bills banning care in Montana and North Dakota have been sent to those states’ Republican governors.

In South Carolina, the measure has clear support: More than half the State Senate co-sponsored one of the bans introduced. And in North Carolina, which has a Democratic governor, Roy Cooper, Republicans introduced a ban last week — on the same day that they gained a veto-proof majority.

A chart with an earlier version of this article misstated when the ban on gender-affirming care starts in Kentucky. It starts on June 29, not Jan. 1, 2024.

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Billing and Coding: Gender Reassignment Services for Gender Dysphoria

Document note, note history, contractor information, article information, general information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

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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Sweden votes on controversial gender reassignment law

Sweden was the first country to introduce legal gender reassignment in 1972, but a proposal to lower the minimum age from 18 to 16 to be voted on by parliament Wednesday has sparked controversy.

Issued on: 17/04/2024 - 04:31

The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

Beyond lowering the age, the proposals also aim to make it simpler for a person to change their legal gender. 

"The process today is very long, it can take up to seven years to change your legal gender in Sweden ," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Under the proposal, two new laws would replace the current legislation: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

If parliament adopts the bill as expected on Wednesday, people will be able to change their legal gender starting at the age of 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes would however only be allowed from the age of 23, unchanged from today. 

Gender dysphoria surging 

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it. 

Some critics have expressed concerns about biological males in women's locker rooms and prisons, and fear the legal change will encourage confused youths to embark down the path toward surgical transitions.

Others have insisted that more study is needed given the lack of explanation for the sharp rise in gender dysphoria.

Deep divisions 

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT. 

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

RFSL's Ponkala disagreed, saying the simplified process was important for transgender people, a "vulnerable" group.

"They face a lot of risks... We see that the political climate has hardened," he said. 

Kristersson, the prime minister, has defended the proposal as "balanced and responsible".

But he has also admitted he wanted to keep the age at 18 but gave in to strong forces in his party.

His own government has been split on the issue, with the Moderates and the Liberals largely in favour and the Christian Democrats and Sweden Democrats against. 

He has had to seek support from the left-wing opposition to get the proposal through parliament.

If adopted, the new law would come into force on July 1, 2025.

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The sex discrimination (gender reassignment) regulations 1999, you are here:.

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1. Citation, commencement and extent

2. Discrimination on the grounds of gender reassignment

3. Discrimination in relation to pay, etc.

4. Exceptions for genuine occupational qualifications

5. Ministers of religion, etc.

6. Discrimination in vocational training—provision of goods, facilities or services

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New federal rule bars transgender school bathroom bans, but it likely isn’t the final word

FILE - A protester outside the Kansas Statehouse holds a sign after a rally for transgender rights on the Transgender Day of Visibility, March 31, 2023, in Topeka, Kan. A new rule from President Joe Biden’s administration assuring transgender students be allowed to use the school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states that seek to make sure they can’t. (AP Photo/John Hanna, File)

FILE - Oklahoma Gov. Kevin Stitt, center, signs a bill that prevents transgender girls and women from competing on female sports teams, March 30, 2022, in Oklahoma City. A new rule from President Joe Biden’s administration assuring transgender students be allowed to use the school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states that seek to make sure they can’t. (AP Photo/Sean Murphy, File)

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A new rule from President Joe Biden’s administration blocking blanket policies to keep transgender students from using school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states.

The clash over bathroom policy and other elements of a federal regulation finalized last week could set the stage for another wave of legal battles over how transgender kids should be treated in the U.S.

In recent years, transgender people have gained visibility and acceptance in the U.S. — and some conservative officials have pushed back.

Most GOP-controlled states now have laws reining in their rights. Measures include laws to keep transgender girls out of girls school sports, limiting which school bathrooms transgender people can use, requiring school staff to notify parents if their student identifies in school as transgender, and barring school staff from being required to use the pronouns a transgender student uses.

Most of those policies have been challenged in court.

Here’s a look at the new regulation, the states’ laws and what could happen next.

WHAT’S THE HEART OF THE REGULATION?

The 1,577-page regulation finalized last week seeks to clarify Title IX, the 1972 sex discrimination law originally passed to address women’s rights and applies to schools and colleges that receive federal money.

The regulations, which are to take effect in August, spell out that Title IX bars discrimination based on sexual orientation and gender identity, too.

Many Republicans say this wasn’t the intent of the law.

The new rules also provide more protections to students who make accusations of sexual misconduct.

RULE CONTRADICTS BATHROOM LAWS

At least 11 states have adopted laws barring transgender girls and women from using girls’ and women’s bathrooms at public schools.

The new regulation opposes those sweeping policies.

It states that sex separation at schools isn’t always unlawful. However, the separation becomes a violation of Title IX’s nondiscrimination rule when it causes more than a very minor harm on a protected individual, “such as when it denies a transgender student access to a sex-separate facility or activity consistent with that student’s gender identity.”

The laws are in effect in Alabama, Arkansas, Florida, Iowa, Kansas, Kentucky, North Dakota, Oklahoma and Tennessee. A judge’s order putting enforcement on hold is in place in Idaho. A prohibition in Utah is scheduled to take effect July 1.

RULE ALLOWS PARENTAL NOTIFICATION REQUIREMENTS

At least seven states have laws or other policies calling for schools to notify parents if their children are transgender.

The regulation seems to authorize those requirements, stating that “nothing in these final regulations prevents a recipient from disclosing information about a minor child to their parent who has the legal right to receive disclosures on behalf of their child.”

The requirements are already law in Alabama, Arizona, Arkansas, Idaho, Indiana and North Carolina. The Arizona law requires schools to provide information to parents but does not specifically include details about students’ gender expression or sexuality. Virginia asked schools to provide guidance to the state’s school districts to adopt similar policies, though they’re not written into state law.

ARE PRONOUN RESTRICTIONS LEGAL? IT DEPENDS

At least four states — Florida, Kentucky, Montana and North Dakota — have laws intended to protect from discipline teachers and/or students who won’t use the pronouns transgender or nonbinary students use.

The regulations wrestle with this, finding that “harassing a student — including acts of verbal, nonverbal, or physical aggression, intimidation, or hostility based on the student’s nonconformity with stereotypical notions of masculinity and femininity or gender identity — can constitute discrimination on the basis of sex under Title IX in certain circumstances.”

But they also spell out that “a stray remark” does not constitute harassment and seek to protect the right of free speech.

THE BIG DEBATE: SPORTS PARTICIPATION

The new rules don’t specifically mention whether states can ban transgender girls from girls sports competitions. The Biden administration has put on hold a policy that would forbid schools from having outright bans.

State laws that contain such bans have been adopted in at least two dozen states in the name of preserving girls sports. But judges have paused enforcement of some of them, including in a ruling last week that applies only to one teenage athlete in West Virginia.

While the new rules are not specific to sports participation, advocates on both sides believe they could apply.

“They may be saying that this doesn’t address it, but through the broad language they’re using, the ultimate result is you have to allow a boy on a girls team,” said Matt Sharp, a lawyer with Alliance Defending Freedom, falsely identifying transgender girls as boys. Alliance Defending Freedom is a conservative group that has represented female athletes challenging sports participation by transgender women and girls.

“This document gives a good sense that says you can’t have a rule that says, ‘If you’re transgender, you can’t participate,’” said Harper Seldin, an American Civil Liberties Union lawyer.

WHAT HAPPENS NOW?

Lawsuits, probably.

After the rules were unveiled last week, Tennessee Attorney General Jonathan Skrmetti posted on X that “TN is prepared to defend Title IX & protect against unlawful regulations that redefine what sex really means.”

“We absolutely plan to challenge this betrayal of women in court,” Florida Attorney General Ashley Moody said in a statement Monday.

Oklahoma Attorney General Gentner Drummond submitted comments critical of the rule before it was finalized.

Over the last two decades, attorneys general have frequently sued the opposing party’s president over rules and executive orders.

Sharp of Alliance Defending Freedom said his group is still dissecting the federal rules but does represent groups that could be affected, including female athletes and religious schools and could sue over aspects of the rules. He expects states to do the same thing.

“I don’t think a lot of states want to wait until the federal government enforces this,” he said.

The ACLU’s Seldin said his organization will watch carefully how the rules play out.

“What do theses laws and regulations mean in terms of transgender youth and transgender students who find themselves attacked in every aspect of their lives?” he asked.

___ Associated Press reporter Brendan Farrington in Tallahassee, Florida; Jonathan Mattise in Nashville, Tennessee; and Sean Murphy in Oklahoma City contributed to this article.

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Economic strain, social relations, gender, and binge drinking in Moscow

2008, Social Science & Medicine

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To estimate the prevalence of hazardous drinking and its socio-economic distribution among Russian men. Participants were an age-stratified, population-based random sample of men aged 25-54 years living in Izhevsk, a city in the Urals, Russia. Interviewers administered questionnaires to cohabiting proxy respondents about behavioural indicators of hazardous drinking derived from frequency of hangover, frequency of drinking beverage spirits, episodes in the last year of extended periods of drunkenness during which the participant withdraws from normal life (zapoi), consumption of alcoholic substances not intended to be drunk (surrogates) and socio-economic position. Logistic regression was used to examine associations between socio-economic position and indicators of hazardous drinking in the past year. Of 1750 men, 79% drank spirits and 8% drank surrogates at least sometimes in the past year; 25% drank spirits and 4% drank surrogates at least weekly and 10% had had an episode of zapo...

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During the study period, Russia’s public health crisis, which was characterised in the 1990s and until 2005 by dramatic fluctuations of all-cause mortality and of mortality from alcohol-related causes, has continued. Research carried out during the past two decades suggested that this public health crisis was driven by excessive and hazardous alcohol consumption, by high rates of smoking, by deterioration of the health system and of other broader social-economic determinants in the country, with alcohol playing a substantial proximal role among them. However, after 2005 mortality trends began to decline, and this decline has continued up to 2013. The amendments to alcohol legislation introduced since 2001, and especially those in 2006 and later in 2011, have likely played a positive role in diminishing the production and consumption of illegal and unrecorded spirits, which has subsequently led to an improvement in alcohol-driven health indicators. However, life expectancy in Russia still remains 10–15 years lower than in Western countries and corresponds closely to the previous 1960-levels in the Soviet Union, suggesting that the quality and implementation of recent alcohol control measures has not led to significant improvements in the health status of Russian citizens, which would be expected to correspond to the level of other modern industrialised countries.

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Why a homework club could work for your child

What is a homework club?

Homework clubs offer a place for your child to work in a supportive environment out of school hours.

Why choose a homework club?

Some children are so self-motivated that they’re able to work diligently on homework and ignore the distractions of normal family life, but not everyone finds it so easy.

Boost Your Child's English & Maths!

• Weekly programme for each school year
• Worksheets sent direct to your inbox
• Keeps your child's learning on track

Doing homework requires a quiet space to work at home and support from you. If your job or other children make it tricky to provide those things you might want to consider the option of a homework club.

Who runs homework clubs?

Schools and many public libraries offer them, usually after school finishes for the day. Check what’s available with your school and local authority. The biggest advantage of a school-based homework club is that it’s on the same premises, so children don’t have to travel to the club.  Familiarity with teachers is also a plus point, and your child is in an environment where they are already relaxed.

If your child would prefer a change of location at the end of the school day a library homework club might be the answer. They usually run from 4pm to 6.30pm and sometimes for a few hours on a Saturday morning. “We find that children start getting more homework from the age of nine onwards so our clubs are of most benefit for eight to 14-year-olds,” says Lucy Love, manager for children and young people at libraries run by Enfield Council. “Under-eights can come to the club but a parent or carer must be with them.”

What benefits do clubs offer?

“The great thing about library homework clubs are the homework centre assistants – while they don’t do the child’s work, they have the knowledge and experience to guide them to the relevant books or online resources such as encyclopaedias,” explains Lucy. “We encourage children to use online data, as it’s usually the most up-to-date, and can offer equipment such as protractors and SATs papers. Homework clubs are also a great way of helping the child’s transition to secondary school.”

What to do after homework club

• When you get home, ask your child to explain what their homework is – this will show you they have understood it properly themselves.  
• Help your child to settle down and concentrate by making sure there are no distractions around them when they go over their homework with you.  
• Encourage your child to check their work to reinforce the learning they have done.

Give your child a headstart

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What Is Homework Club?

Homework club is an after school club for students to complete homework/school work. Students report to a specific classroom and are supervised by a teacher. The teacher will offer assistance and check on students to make sure they are completing school work. The length of homework club will vary by school but usually lasts for about an hour after the school day ends. 

Who Is Homework Club For?

Homework club if for students that struggle to complete school work and homework. 

Students that attend homework club benefit from a quiet place to complete work after school. 

Homework club is usually available to all students but often students with a 504 or an IEP will get first consideration.

In my school we have limited spaces in homework club so it’s up to us, the teachers, to choose students that will benefit from it the most.

If you need a description of what homework is then I answered that in this article .

How Often Is Homework Club?

How often a school has homework club really depends on the school and the district. 

First of all not all schools have the means to offer homework club to students.

Because the teacher that supervises the students in homework club needs to be compensated and some schools don’t have the money to pay them. 

For schools that do have the money to pay a teacher to supervise homework club they may offer homework club every day or only a few days a week. 

The middle school I work at offers our students homework club two days a week. 

Is Homework Club Effective?

Whether or not homework club is effective depends on two things: the teacher supervising and the students. 

If the supervisor engages with the students and sets expectations for work completion then the club can have an impact.  

However, if the supervising teacher is not engaged then the students will not get as much work done. 

In my experiences I have seen homework as beneficial to students but have also had students that attend it and it doesn’t seem to impact their grade or learning at all.

Often the students that are in homework club are students that struggle with work completion and organization.

This is why the teacher that supervises them really needs to have them set daily or weekly goals to ensure that work completion is taking place.

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I (Allen) am currently teaching at a public school in a western suburb of Chicago. My teaching career started in 2004. Some of my interests outside of teaching is being with my family, biking, playing video games, travelling, and making the Teacher Adviser website.

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After-School Homework Club

Homework Club is a place for your student to complete homework, receive peer tutoring, and socialize with friends in a structured, supervised environment. The program begins immediately after school and is available until 5:00 pm each school day, including early release days.

Openings are filled on a first-come, first-served basis. 

Please click the link below for your campus to register for the 2nd semester program that begins when school returns from winter break on January 4, 2024:

REGISTER AT Christos GILBERT

REGISTER AT Christos Phoenix

Registration for Christos Scottsdale Homework Club 24-25 will be available by July 2024.

For questions regarding billing and/or the registration process, please contact the Billing Specialist, Wendy Hood at [email protected] or 602-396-7574

For questions regarding the program, please contact Kim Pfeifer-Adams at [email protected]

Frequently Asked Questions:

Q. Is tutoring provided during After-School Homework Club?

No. Homework Club is not a tutoring program. We provide supervised homework time that includes teacher-led Spalding dictation for the applicable grades.

Q. Is a snack provided for After-School Homework Club?

No. Scholars are given time to eat a snack. However, we are not able to provide the snack. We encourage you to pack a snack specifically for the after-school program daily.

Upcoming Events

Enrollment is open: 24-25.

Seats are filled on a first-come, first-served basis. Submit your application to Great Hearts Christos before space fills up.

Gilbert Open House

Prospective parents, join us on April 9th at Great Hearts Christos Gilbert to learn more about our academy and if it's right for your family.

Phoenix Open House

Learn about Christos Phoenix at our upcoming Open House. Meet with administration, teachers, tour the school, and learn more about financial aid options.

Homework Club

 and tkphilosophy.

At CPC Homework Club, we walk the line between the discipline of work and the creative innovation of young children. We offer care for TK – 5 th grade in a small group environment where friendships can grow and last throughout their school career. There is help and resources available for homework and space to follow their own desires whether it is art, sports, or science investigation.

We cook our own snack on Fridays, and we offer care during Albany Unified School breaks.

Homework Club Daily Schedule

The creative play center.

1151 Portland Avenue Albany, CA 94706

[email protected]

(510) 524-9399

Preschool: 9am - 1pm Extended: 8am - 6pm

Contact CPC

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Admission process & tours.

Our program runs from mid-August to June with weekly summer camps.  

We begin offering tours in January for the following Fall. When you schedule a tour, you will receive an application. We will notify you in February if there is room for your child in the Fall. There is an application fee of $75 due with your application and $100 deposit toward your first month’s tuition is due upon acceptance.

Tours are 9:30 am for the preschool and 2:15 for the Homework Club by appointment.

We will stop offering tours once we are full and place you on a waitlist. We clear our waitlist every year. Contact us in January, if you are still interested in the following fall.

Homework Club Monthly Fees 2024 – 2025

Payable one month ahead. (August 1 st payment due for September care.)

Kindergarten Early Bird Pick Up

1 st – 3 rd / early bird pick up, 4 th – 5 th / late bird pick up (additional cost for early release days).

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Homework Clubs

Need Help with your Homework?

• Volunteers are available to help Kindergarten – 8th-grade students with their homework after school.
• Social studies
• Assistance in languages other than English may be provided based on volunteers’ availability.
• Got questions? Read our Frequently Asked Questions .

HOMEWORK CLUB EVENTS

Interested in Volunteering?

We are looking for volunteers (age 15+) to help local students reach academic success online and foster their ability to succeed in school. Every school year, volunteers are needed late-September to late-May. Volunteer are trained prior to coming onboard. Homework Club will not meet during school breaks and library holiday closures. Volunteers need to commit to a minimum of 2 consecutive hours per week, for the duration of the program.

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Our tutorials provide high quality, step-by-step instructions for all grades with every lesson of every subject. Our on-campus classes offer an after school program serving students in elementary through high schools, ages 5-16. Homework Club provides a quiet, structured, safe environment for students to complete their homework with the help of highly qualified instructors and mentors. …

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6051 Bellaire Ave

North Hollywood, CA 91606

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My girls and I are very pleased and happy with Homework Club. This program provides an excellent virtual sessions utilizing audio/video chat and on campus tutoring. Most importantly they're able to support my girls with all school subjects. The tutors are amazing and the director is wonderful, she always takes her time to validate all assignments are completed on time and accurately. Amazing pricing for tutoring and flexible hours. I absolutely recommend Homework Club!

Very happy how hw club helped my son succeed. Highly recommend sending your kids there. When they come home all of the hw is done so the stress of doing hw is no longer an issue.

I have been taking my kids to Homework Club and now my sister is taking both of her kids there. I have nothing but wonderful things to say about this company, about their service. Their personal approach to every kids needs is something to talk about. No kid is the same and they go out of their way to make sure that they all go home with their work complete correctly, accurately and they understand it all.

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Cost of Living Estimator in Moscow, Russia

Currency: EUR USD --- AED AFN ALL AMD ANG AOA AUD AWG AZN BAM BBD BDT BGN BHD BIF BMD BND BOB BRL BSD BTN BWP BYN BZD CAD CDF CHF CLF CLP CNH CNY COP CRC CUC CVE CZK DJF DKK DOP DZD EGP ERN EUR FJD FKP GBP GEL GGP GHS GIP GMD GNF GTQ GYD HKD HNL HRK HTG HUF IDR ILS IMP INR IQD IRR ISK JEP JMD JOD JPY KES KGS KHR KMF KPW KRW KWD KYD KZT LAK LKR LRD LSL LYD MAD MDL MGA MKD MNT MOP MRU MUR MVR MWK MXN MYR MZN NAD NGN NIO NOK NPR NZD OMR PAB PEN PGK PHP PKR PLN PYG QAR RON RSD RUB RWF SAR SBD SCR SDG SEK SGD SHP SLL SOS SRD STD STN SVC SYP SZL THB TJS TMT TND TOP TRY TTD TWD TZS UAH UGX USD UYU UZS VES VND VUV WST XAF XAG XCD XDR XOF XPF YER ZAR ZMW ZWL Sticky Currency

Members of your household:

Eating lunch or dinner in restaurants: 0.0% 2.0% 5.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% of the time

When eating in restaurants, you are choosing inexpensive restaurants: 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% of the time

Drinking Coffee outside of your home: A lot High Moderate Low No

Going out (cinema, nightlife, etc.): none very low (twice per month per household member) low (three times per month per household member) average (once per week per household member) high (twice per week per household member) very high (3-4 times per week per household member)

Smoking (household overall): packs of cigarettes per day

Alcoholic beverages (consume): A lot Moderate Low No

At home, we are eating: Western Asian food

Driving car: A lot Moderate Low No

Taking Taxi: Daily one round trip Two round trips per Week One round trip per Week One round trip per Month No

Paying for public transport tickets: Monthly, All Members Monthly, 2 Family Members Monthly, 1 Family Members On-Demand, around 5 round trips weekly per family member On-Demand, around 4 round trips weekly per family member On-Demand, around 3 round trips weekly per family member On-Demand, around 2 round trips weekly per family member On-Demand, around 1 round trip weekly per family member None

Sport Memberships: All Household Members 1 Household Member 2 Household Members No

Vacation and Travel: Three per year (one week each), relatively expensive Two per year (one week each), relatively expensive Once per year (one week each), relatively expensive Twice per year (one week each), relatively inexpensive Once per year (one week each), relatively inexpensive None

Buying Clothing and Shoes : A Lot Moderate Low

Rent: none Apartment (1 bedroom) in City Centre Apartment (1 bedroom) Outside of Centre Apartment (3 bedrooms) in City Centre Apartment (3 bedrooms) Outside of Centre Sharing a Room in 3 Bedroom apartment City Centre Sharing a Room in 3 Bedroom apartment Outside of Centre Mortgage for 1 bedroom apartment (approximate) Mortgage for 3 bedroom apartment (approximate)

Number of your children going to kindergarten:

Number of your children going to the private school:

* Our estimator doesn't include insurance, health-related expenses, parking fees, or domestic help. It doesn't take into calculations income tax.

Copyright © 2009-2024 Numbeo. Your use of this service is subject to our Terms of Use and Privacy Policy

Cost of living and prices in Moscow, prices of food, rent, shopping, etc. 🇷🇺 Updated Jul 2023

Moscow, Russia is a bustling city located in Eastern Europe, with a population of over 12 million people. It is situated at an elevation of 144 meters above sea level, with coordinates of 55.75583 latitude and 37.61730 longitude. The time zone for Moscow is Europe/Moscow, GMT: 3.0.

When it comes to cost of living, Moscow can be quite expensive, especially for those on a tight budget. However, it is important to consider the benefits of living in such a vibrant city. Moscow offers a rich culture, history, and nightlife, as well as job opportunities and a high standard of living. It is important to do your research and budget accordingly in order to make the most of your experience in Moscow.

Another important factor to consider when it comes to cost of living in Moscow is transportation. Moscow has an extensive public transportation system, including buses, trams, and a metro system. It is important to plan ahead and budget for transportation costs in order to navigate the city efficiently and cost-effectively.

Cost of Living Estimate in Moscow

Total cost of living in Moscow for two person with average consumption for one month will be 864.89 USD , no rent price included. Click here to calculate cost-of-living estimate in Moscow

You can calculate cost of living in Moscow by changing quantity using input near each good or service. Resulting total will appear in a floating box in the bottom of your screen.

Restaurants prices

If you're looking for an upscale dining experience in Moscow, you won't be disappointed. The city boasts a variety of high-end restaurants serving sophisticated cuisine from around the world. From French and Italian to Japanese and Chinese, you'll find a wide range of options to fit every taste. Many of these restaurants offer stunning views of the city skyline or historic landmarks like the Kremlin. For those looking to indulge in some traditional Russian fare, there are plenty of options as well. With hearty soups, rich stews, and savory meat pies, Russian cuisine is sure to satisfy those seeking comfort food.

If you're on a budget or just looking for a quick snack, don't worry – Moscow has plenty of affordable eating options as well. Street food is a popular choice in the city, with vendors selling piping hot blinis (thin pancakes) with various fillings, fresh kebabs, and savory pastries on almost every corner. Cafeterias and canteens located in shopping centers and office buildings offer inexpensive meals with a variety of options. And of course, there are plenty of fast food chains around the city, from familiar names like McDonald's to local chains serving up burgers and fries with a Russian twist. No matter what your budget or taste, Moscow has something to offer.

Markets prices

Moscow, Russia is known for its high level of luxury and opulent living. As such, market prices in Moscow tend to reflect this trend, with many goods and services priced higher than in other parts of the country. The city also boasts a large number of upscale boutiques and luxury department stores, selling designer clothing and accessories for those who are willing to pay a premium.

However, there are also a wide range of market prices in Moscow to cater to different budgets and tastes. From traditional markets and bazaars selling local produce and souvenirs, to mid-range shopping centers and malls with a mix of local and imported goods, there is something for everyone in Moscow. Despite the higher cost of living, the city's diverse shopping scene ensures that consumers can find a range of prices and options to suit their needs.

Transportation prices

When visiting Moscow, Russia, there are various modes of transportation to choose from. One of the most common options is the metro, which is one of the fastest and most efficient systems in the world. The metro has over 200 stations, making it easy to navigate and access different parts of the city. It runs from 5:30 am to 1:00 am, and the trains come frequently, meaning you won't have to wait long for your ride. Additionally, the metro stations themselves are worth a visit, as many of them are beautifully designed and decorated with mosaics, sculptures, and other works of art.

If you prefer to see Moscow from a different perspective, you can also take a boat tour on the Moscow River. This is a great way to explore the city's famous landmarks, including the Kremlin, St. Basil's Cathedral, and the Moskva-City skyscrapers. The boat tours run from April to October and vary in length and price. Some tours even offer dining options, allowing you to enjoy a meal while cruising along the river. Overall, a boat tour is a relaxing way to take in the sights and sounds of Moscow while learning about its history and culture.

Utilities Per Month prices

Travelers visiting Moscow, Russia should be aware that utilities costs can be quite high, especially during the winter months. This is due in part to the extreme cold temperatures that require constant heating. As a result, many apartment buildings and hotels in Moscow have centralized heating systems which can be very expensive to run. In addition, the cost of electricity and water can also be high during certain times of the year. Visitors should plan accordingly and budget for higher than expected utilities costs during their stay in Moscow.

One way to save money on utilities during a trip to Moscow is to be mindful of energy usage when staying in an apartment or hotel room. This might include turning off lights and electronics when not in use, regulating the thermostat to conserve energy, and limiting water usage. Another option is to stay in a budget-friendly accommodation that offers lower utilities costs, such as a hostel or sharing an apartment with other travelers. Overall, travelers to Moscow should be aware of the potential cost of utilities and plan accordingly to ensure a smooth and budget-friendly stay.

Sports And Leisure prices

Moscow offers a diverse range of sports and leisure activities for visitors to enjoy. Football fans can catch a game at the famous Luzhniki Stadium, which hosted the World Cup final in 2018. Ice skating is also a popular activity in the city, with numerous rinks available during the winter months. For those seeking a more relaxed experience, the city has several parks and gardens, including Gorky Park, which features outdoor yoga and fitness classes. Additionally, the city has a number of museums and galleries, such as the Tretyakov Gallery, which showcases some of Russia's most famous art.

Moscow is also a great destination for those interested in traditional Russian sports. Visitors can witness the intensity of Russian martial arts at a Sambo tournament or attend a game of bandy, a form of ice hockey played with a ball instead of a puck. For a truly unique experience, tourists can even try their hand at curling, a sport with a dedicated following in Russia. And after a long day of exploring the city, guests can relax in one of Moscow's many spas, which offer everything from hot stone massages to aromatherapy treatments. Overall, travelers to Moscow are sure to find something to suit their interests and tastes in the city's vibrant sports and leisure scene.

Salaries And Financing prices

If you're planning a trip to Moscow, it's helpful to know that salaries and financing in Russia's capital city can vary greatly depending on your profession and industry. For example, the average salary for a software developer in Moscow is significantly higher than the average salary for a cashier or sales assistant. Additionally, financing options may be limited for those without proper documentation or proof of employment. It's important to research and plan accordingly, especially if you're planning a longer stay in Moscow.

One thing to keep in mind is the cost of living in Moscow. While some industries may offer higher salaries, the cost of rent, transportation, and other expenses can be quite high in this bustling city. It's a good idea to budget carefully and explore options for affordable housing and transportation. If you're looking to save money, there are many free or low-cost activities to enjoy in Moscow, such as visiting public parks and gardens or exploring the city's museums during free admission days. With careful planning and budgeting, you can make the most of your experience in Moscow without breaking the bank.

Childcare prices

Childcare prices in Moscow, Russia can be quite high, particularly for schools and kindergartens. Families may need to budget carefully in order to afford high-quality childcare options for their children. However, many families do find that the investment in childcare is well worth it, as it can provide children with strong educational and social foundations that will benefit them for years to come.

When it comes to schools and kindergartens in Moscow, there are a wide variety of options available to families. Some schools and kindergartens are public and therefore more affordable, but others are private and can be quite expensive. Families should carefully research the options available to them and consider factors such as the quality of education, the location of the school or kindergarten, and the overall cost. It's also important to note that some schools and kindergartens may have long waiting lists, so families should plan ahead and apply as early as possible to secure a spot for their child.

Clothing And Shoes prices

Moscow is a bustling city with plenty of places to shop for clothing and shoes. From high-end luxury stores to trendy street markets, there's something for everyone. The prices vary greatly, so it's important to do some research before you head out to shop. If you're looking for designer labels and the latest fashion trends, head to one of the many luxury malls or department stores located throughout the city. Here, you'll find premium clothing and footwear at equally premium prices.

For those on a budget, there are cheaper options available too. Markets like Gorbushka and Danilovsky Market offer a more affordable shopping experience, with plenty of stalls selling clothing and shoes at lower prices. If you're willing to haggle, you can often get an even better deal. There are also a number of second-hand stores and vintage shops located throughout the city, where you can find unique and unusual fashion at reasonable prices. No matter what your budget, there's no shortage of places to find great clothing and shoes in Moscow!

Rent Per Month prices

Short-term rentals are a great option for travelers who want to experience the local culture and stay in a more authentic setting than a hotel. Moscow has a variety of options for short-term rentals, from private apartments to shared rooms. Prices can vary depending on location, amenities, and the time of year, but overall it can be a more affordable option than staying in a hotel.

For those who prefer a bit more luxury, there are also short-stay serviced apartments available in Moscow. These apartments typically come with housekeeping services, a concierge, and amenities like a fitness center or pool. Prices for these types of accommodations can be on the higher side, but can be a convenient and comfortable option for those who are willing to pay a bit more for their stay.

Buy Apartment prices

Moscow is known for its luxury properties and high-end real estate market, making it a prime destination for those looking to invest in a prestigious property. The city offers a variety of options to choose from, including modern apartments, historic mansions, and cozy cottages. With a plethora of real estate agents available to help navigate the market, buyers have access to a wide range of prices.

Over the past few years, the Moscow real estate market has grown steadily, offering different options for buyers to choose. The rising popularity of Moscow among foreign investors has led to an increase in demand, driving up prices in prime neighborhoods. However, buyers can still find affordable properties in emerging areas of the city. With a fluctuating market, it is important to work with a knowledgeable agent who can provide insight into pricing trends and local market conditions to get the best deal possible.

Cost of living in the cities nearby

• Lyubertsy, Russia
• Khimki, Russia
• Mytishchi, Russia
• Balashikha, Russia
• Odintsovo, Russia
• Korolyov, Russia
• Shchyolkovo, Russia
• Fryazino, Russia
• Zhukovskiy, Russia
• Podolsk, Russia