Transsexual healing: Medicaid funding of sex reassignment surgery

Abstract

Federal requirements for state Medicaid programs are surveyed, and case law regarding Medicaid funding of sex reassignment surgery is reviewed. States have attempted to exclude sex reassignment surgery (SRS) from Medicaid coverage on various bases, concluding, for example, that the procedure constituted "cosmetic surgery." Judicial scrutiny of such exclusions has usually resulted in the state action being found violative of the federal Medicaid statute and accompanying regulations. In those cases upholding the state exclusion, the primary judicial obstacle to funding has been a determination that SRS is "not medically necessary" or is "experimental." The author explores the recent scientific literature concerning long-term outcomes following SRS and concludes that the procedure, for purposes of Medicaid funding, is neither "unnecessary" nor "experimental," and that the categorical exclusion of SRS from Medicaid coverage is therefore inappropriate. The author recommends case-specific determinations of eligibility for Medicaid funding, utilizing the standards of care promulgated by The Harry Benjamin International Gender Dysphoria Association.

Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of theStandards of Care

“…Thus, it is difficult to determine the effectiveness of hormones alone in the relief of gender dysphoria. A comprehensive review of over 2,000 patients in 79 studies by Pfäfflin andJunge between 1961 and1991 reported favorable effects of sex-reversal therapies including hormones and surgery based mainly on observational findings (Pfäfflin & Junge, 1998). Most patients seeking sex-reversal therapy report improved psychosocial outcomes ranging between 87% (MtF) and 97% (FtM) (Green & Fleming, 1990).…”

“…In addition, the current SOC does not provide discussion of the medical 146 Jamie Feldman and Joshua Safer 147 necessity or data on the effectiveness of crossgender hormone therapy. The absence of this critical information conveys a sense of crossgender hormone therapy as either experimental or cosmetic in nature, discouraging providers, health care systems, and insurers from approaching it as part of standard medicine (Gordon, 1991;Thaler, 2007).…”

“…We cannot assume that physicians are educated in transgender care prior to consulting the SOC; medical school training in sexual health overall is limited in both the United States and Europe, and often less than 10 hours total (Parish & Clayton, 2007;Pryor, 2006;Wagner, 2005). Because the SOC are often viewed as the definitive professional document on transgender care (Gordon, 1991;Lombardi, 2001), it is imperative that the SOC present comprehensive, evidence-based guidance regarding transgender hormone therapy to ensure access to quality care. This guidance should include an evidence-based review of the literature regarding the medical necessity, effectiveness and risks of hormone therapy, the prescribing physician's responsibilities, and a clinical framework for initiating and monitoring adult hormone therapy.…”

Patient Satisfaction with Transgender Health Services

“…First, transgender patients are among the most socially stigmatized of sexual minorities, facing discrimination in health care coverage and insensitivity from ill-informed health providers (Bockting et al, 1998;Clements, Wilkinson, Kitano, & Marx, 1999;Gordon, 1991;Kammerer, Mason, Connors, & Durkee, 1999;Lombardi, 2001;Lombardi & van Servellen, 2000). Transgender-specific health care rarely is a covered benefit.…”

Gender Dysphoria: Overview

“…Similar situations have been found in other studies, 27---29 reflecting the problems that these patients have in order to obtain hormone treatments in public hospitals in and out of Spain, consequently increasing the risk of complications. 30 Despite the fact that there are no similar studies in Mexico, we should take the data into account given the risks that self-medication involves.…”