Should Medicare fund sex change surgery?

March 30, 2013 in Health Insurance, Medical Care

I had a WOAH moment yesterday when I opened this email from a doctor who passes along developments in the exploding world of transgender health:

Medicare announced that beginning March 28, 2013 and for a 30 day period, it is inviting comments from the public regarding reconsideration of its current policy to deny coverage of sexual reassignment surgery.

Anyone wanting to recommend a change of this policy and to advocate for medicare covering sexual reassignment surgery, the website to go to is

http://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=269

Don’t bother trying to open the link. Less than 24 hours after the Centers

graphic courtesy of Wikimedia

for Medicare and Medicaid Services posted this announcement, they took it down. A spokesperson told The Hill the agency decided not to take public comments while a challenge to the agency’s policy is “working its way through the proper administrative challenges.”

Medicare and Medicare, and almost all commercial insurance plans, don’t fund surgery for men or women who feel like they were born into the wrong body.

So since Medicare can’t or won’t ask, we will:

Should Medicare and Medicaid fund sex change or gender reassignment surgery?

22 responses to Should Medicare fund sex change surgery?

  1. Put simply, no. At the risk of sounding as if I support rationing, I honestly believe that age should be a factor when considering this particular treatment.

    • Should the diagnosis of post-op reassignment surgery on a mental health aftercare claim also not be covered, if the patient pays out of pocket?

    • If nothing else, asking this question opens up a lot of the issues vis a vis Medicare reform. For example, I know it is your first reaction to equate Medicare with old age. But between 10%-20% of people on Medicare are not over 65. They are under 65 but with a certified disability that lets them collect as much Social Security as if they were 65. In many places — but not Massachusetts — getting on Medicare is a good deal for them. (Everyone I’ve run into in this situation in Massachusetts would have been better off staying on Commonwealth Care but were forced over to Medicare anyways.)

    • yes….. tell me about it

  2. C. Sommers – just wondering – are there other treatments that don’t make sense, in your opinion, for those 65 and older?

    • Hi Martha —

      Please explain the rest of the story. Why did CMS pull back on receiving comments so soon after asking for them? I assume it’s because they are questioning whether any part of CMS — Medicaid, CHIPs, Obamacare or Medicare — should pay. If one of them pays for it then all should.

      As for your question, that is why this is such a good starting point to consider relative to all Medicare reform (and maybe re all healthcare reform, as opposed to healthcare insurance reform).

      Will we do heart transplants for 64 year olds on Obamacare but not 65 year olds on Medicare? Wasn’t there a 67-year-old woman (already a grandmother) in Italy a few years back that had a baby? How about saying no to prostrate-cancer surgery after you’re 80; I’m told you won’t die of it then anyways (98% probability you won’t–what the hell, roll the dice). And so forth. And so forth. These all sound like good arguments for getting government out of the healthcare business altogether.

      • Dennis – I don’t have the back story on why the request for comments was withdrawn. The official statement talks about waiting for the resolution of the administrative challenge.

        I take it you don’t see any role for government to assess what’s effective treatment and when. What do you think about giving an outside agency authority to make such assessments?

  3. Quality of life should always be the primary objective. Quality of life encompasses the physical health and mental health of the patient. Both pieces would be affected when a patient on Medicare (over 65 or disabled). First should always be the mental health assessment and qualifications for this procedure. Noting that the group of individuals who mentally qualify for this procedure are at a higher risk for suicide and so the coverage should extend to longer mental health benefits for before and after the surgery. As a side note to those who say no, should the diagnosis of post-op reassignment surgery on a mental health aftercare claim also not be covered, if the patient pays out of pocket? Then the person’s physical health should be considered as with any major surgery.

    With regard to Medicaid, quite frankly if this procedure is not covered then the burden is on the provider alone. The patient would not (*typically) see a bill if they have Medicaid, regardless of whether any government money went toward the procedure.

    • Mental health care isn’t covered by Medicare. There are other preventative care measures which also aren’t covered, which should come first.

  4. Of course it should be covered. What civilized country would allow people to suffer so immensely when there are valid medical procedures available to correct birth incongruities of gender and sex? The answer is that no civilized country would deny medical treatment to those in need. The United States is incredibly behind on this stuff in terms of getting over its infantile fixation with variances in sexual orientation and problems of gender and sex development. The bigotry of this country is sometimes overwhelming and extremely hard to tolerate.

  5. Yes, of course it should.

    The only reason it isn’t is because of an ideologically-based report(1) by a professor of ethics in 1980 who wanted transsexuals mandated out of existence.(2) (3) The mechanism for getting rid of them was to be by denying all but the most wealthy access to necessary health care.

    That’s why a procedure with a track record of 90%+ success over the previous 20 years was labelled “experimental”. Now it’s been 50 years, tens of thousands of such procedures performed successfully with a 98% improvement rate, and it’s still labelled “experimental”…. “unproven”… despite the evidence. (4)

    (1) Paper Prepared for the National Center for Health Care Technology on the Social and Ethical Aspects of Transsexual Surgery
    Janice G. Raymond Assistant Professor of Medical Ethics and Women’s Studies
    Hampshire College/University of Massachusetts Amherst, Massachusetts June, 1980

    (2) “I contend that the problem with transsexualism would best be served by morally mandating it out of existence”
    The Transsexual Empire : The making of the She-Male :
    Janice G. Raymond

    (3) “All transsexuals rape women’s bodies by reducing the real female form to an artifact, and appropriating this body for themselves. ”
    Ibid

    (4) AMA Resolution 122 Removing Financial Barriers to Care for Transgender Patients

  6. I’m from New Zealand, so ignore me if you want but I am also a sex change transsexual female. My SRS/GRS was 3rd Feb, 2006.
    1. It is not a mental health issue directly. (see below)
    2. It is not elective or cosmetic surgery but necessary, life changing surgery.

    The only way this issue becomes a mental health issue is not because the problem, ‘Transsexualism’ is a mental helth issue, it isnt. But because of the stigma from society caused by it. It effects the mental health and well being of many who are transsexual. The highest suicide rates abound, anxiety, depression and a range of mental health issues are caused, not by being transsexual but caused by a society that doesnt understand, accept and discriminates.
    There is another ‘cure’ and that is to fix a sick society. But that is incredibly slow and difficult and in the mean time, many Transsexals continue to be sadly effected individually.

    Providing SRS/GRS is the quickest and most cost effective way currently available to reduce suicide rates, on going medication and associated health care costs. To get people back into being productive tax paying members of society.

    The costs involved with providing SRS/GRS will soon be returned and more by the reduction in ongoing medical cost if a patient is denied SRS/GRS. They will have a much better chance to get back into the taxpayer bracket and off benefits. Their individual mental well being will be considerably enhanced and they can become a valued member of society.
    Racheal.

  7. i am a full time 37 year old transgender woman from truro nova scotia canada & i think that the goverment should pay for use to have our full surgery to become the persion & the gender that we want to be full time like FFS,BREAST,SRS & etc too.they should pay for all of our meds too.

    • Sorry but we differ.
      I dont agree they should pay for all.
      Why breat augmentation? Heaps of natal woman have a or b cup and breasts will grow with hormone treatment. If you want to argue from BA than you would need to argue all natal woman are entitled to BA.
      Same with FFS, there are heaps of natal woman out there with stuffed up ugly faces like mine, why should TS be entitled to fix it but not natal woman?

      SRS is totally different and sepaerate. You are fixing a defect basically that natal woman dont have. SRS is corrective surgery.

      Again, ‘all the meds’? hormones and blockers yes but only the same meds others have paid for beyond that.

      • For Breast Augmentation and Facial Feminisation Surgery – it’s not always needed. That’s something that should be assessed on a case by case basis.

        However, there’s a good case for arguing that, at least in some cases, it’s preventative medicine. It can prevent conditions such as fractured skulls, contusions and even mortality, caused by someone looking obviously transsexual.

        Few if any non-trans women have ended up in ERs due to looking too male. Depending on the age at transition, this can be a real danger for Trans women. Transition young – and there’s no problem. Transition in late middle age, and there are many women severely affected by menopause who look similar. But in between, appearance can pose significant physical as well as psychological problems.

        • “However, there’s a good case for arguing that, at least in some cases, it’s preventative medicine. It can prevent conditions such as fractured skulls, contusions and even mortality, caused by someone looking obviously transsexual.”

          Common now that is going to the sublime and ridicualous. If you dont put reality in your asking and ask the ridiculous, you will be laughed at and get nothing. If you present child like demands then you will be treated as a child.

          Your comment doesnt support your arguement but does support arguements for more Police, more Human Rights agencies, more education of the ill informed bigots. More education on safety within the TG community. Those are all preventative and offer bigger benefits to a broader sector of society.

          Why should Transsexuals get BA and FFS and natal ladies not?

          • It should be obvious.

            If a Trans person doesn’t get puberty-delaying hormone blockers before puberty then mere SRS and HRT will not undo all the effects of the incorrect puberty. So BA and FFS is then indicated to rectify that.

            But that’s if and only if the person was unable to access hormone-blockers prior to puberty requiring an early diagnosis and access to the medication and use of that medication. And if all 3 of those were not the case then the other treatments are appropriate.

            Of course BR (breast reconstruction) post-cancer and similar facial reconstructions are also appropriate for Cisgender women are they not?

            Simple. Simple and fair.

            See how that is all fair and square?

  8. Ah yes, this was predictable. Years ago, I was in contact with many professionals in Europe and elsewhere. All agreed that the reason for funding was found in DSM. Without that, any surgery was simply a matter of choice. This is now reflected in the spread of the transgender umbrella where surgery is not as high a priority as it once was. If the procedure is not justified for medical reasons, why should it be covered? On what basis? Indeed such was the reason why Ray Blanchard added to the coverage in Canada with his concepts – it justified surgery for the older types. In the US, where there is no state medicare, one might argue that the “stigma” was negative and there was no reason to retain the DSM listing. In most European and Commonwealth countries, those with state medicare, the justification for covering surgery was the DSM designation. Take that away and you loose any reason for funding the surgery. It becomes like cosmetic surgery, a comparison I loath but must consider. Those who hold it does not warrant coverage are not bigots, but rather are simply applying the standard test of medicare – is the procedure medically necessary. Yes, it should be covered; no, it should not be. “Preventative”? Oh my. That is more than a slippery slop. The test, again, is medically necessary. Once you leave that classification, funding is gone – or shall be with budget cuts and more. Andrea James once said that if it was delisted from DSM, coverage would be continued. That was part of her paen to her cohorts. Well? On what basis? She never gave a clear answer and I doubt she can now.
    I expect to see defunding in most countries if both medical classifications take GID out of the DSM. I can see no justification for funding if it is not medically necessary.

    • Great comment Willow and so agree.
      Alas Transsexuals, for who SRS/GRS is a necessary surgery have been engulfed by the vastly outweighing non TS, Transgender who dont place such an importance upon surgery.
      They have been more offended that anything that might relate to them, which mostly it didnt, wasnt included in a mental health diagnosie and wanted it gone from the DSM. They never considered it provided a treatment pathway for others, namely Transsexuals.

      I totally agree Transsexualism is not a mental illness and shouldnt be in the DSM but before calls to remove it blanketly were made, a new treatment pathway needed to be created.

      Alas slowly the non TS, TG are getting rid of it from the DSM, as they are getting rid of Transsexuals by not acknowledging them or respecting them. Assimulating them into the borg.

      Without the pathways, we have no medical condition and with no medical condition, we need no treatment unless its cosmetic and we want to do it ourselves.

      Thanks TG

      • The largest American transgender study found that even self-identified crossdressers have medical needs with almost 50% intending some degree of medical transition.

        You may need to stop judging the majority of Trans people by anti-Trans stereotypes because the studies show the truth is oh so very different from the myths that pervade the perception of them.

  9. Aimes said on May 2, 2013

    Yes they should cover this surgery. Those against it should try forcing themselves ti live as the opposite gender for a few years and they’ll start to get a small glimpse of how much the fight to go back to the gender they are, really is. Most that aren’t transcended or don’t know someone that is have a hard time understanding and that’s why they don’t agree.

Leave a reply

You must be logged in to post a comment.