Francesca Maria Lorenzini

Stevie Singleton, 33, went through two attempts and more than three months of waiting to get his hysterectomy approved for insurance in Pocatello, Id. The first time Singleton sent the request, insurers did not provide any insight into the reasons for the rejection, so his doctor recommended making another attempt. This time, the request was accepted after only a week and a half.
“The funny thing is [that] it was sent through the exact same way both times, as needed for gender dysphoria” Singleton said.

Denials and delays in medical care and insurance approval are common among the transgender population in the U.S. This is due to multiple interlacing causes that span from bureaucratic issues to poverty. As a result of the Affordable Care Act, transgender people are protected from discrimination in the healthcare system. And health plans cannot refuse or limit coverage for transition-related care if it is medically necessary, according to the National Center for Transgender Equality. But the definition of “medically necessary” can depend on who is doing the defining.

Gender-affirming care, as defined by the World Health Organization, encompasses a range of behavioral, psychological and medical interventions to treat gender dysphoria, a condition that results in discomfort or distress when a person’s biological sex and gender identity differ. Trans individuals without access to these treatments are at higher risk of depression, anxiety and suicide, according to the American Medical Association.

The World Professional Association for Transgender Health describes gender-affirming care as medically necessary. But several private insurance companies deem some procedures cosmetic and federal programs such as Medicare and Medicaid do not have a national policy about covering these treatments. Since federal law doesn’t define gender-affirming care as medically necessary, its coverage varies from state to state.
Idaho state Medicaid, for example, has no explicit policy regarding coverage of transgender-related health care and a 2022 lawsuit filed against the state shows that there are transgender people who have been denied Medicaid coverage for these treatments.
“It’s really subjective, probably based on who comes across the request,” said Singleton referring to his personal struggles in having his hysterectomy approved for insurance.

Jeff Main is the executive director of Point of Pride, a non-profit organization that provides direct financial assistance to trans people who need them. He said that it is common for these individuals to have to go through one or two appeals before they are able to get coverage for gender-affirming care. And the most common reason for rejection is that the procedure is not deemed medically necessary.

In 2021, the Center for American Progress found that 46% of transgender respondents were denied coverage for gender-affirming care in the previous year. And recently approved bans on gender-affirming care for minors are expanding to include adults. Since the beginning of 2023, bills that restrict access to gender-affirming care for minors have dramatically increased in Republican-led states.
“Within a few months, a ban was passed or in the process of being passed in virtually every southern state,” said Carolyn Jones, program manager of the Southern Trans Youth Emergency Project, a regional campaign that provides support to individuals who are impacted by anti-trans bans in the South.

But recent laws ban the use of federal or state funds for gender-affirming care for transgender adults too. Kansas, Oklahoma and Texas have bills moving through their legislatures to ban care for people under 21. In South Carolina for people under 26. Such restrictions on gender-affirming care can also affect non-trans individuals.
“For a lot of trans topics, the broader cisgender population thinks, ‘that’s not my issue,” Main said. “But in actuality, attacks on the trans community regularly impact cis people.”

Hormone therapy is needed, for instance, by those who are affected by gynecomastia – the overdevelopment of the breast tissue in men or boys. About 65% of adult men are affected by it, but the National Institute of Health says it is asymptomatic in most cases. Currently, Medicaid policy explicitly excludes transgender-related health care for all ages in nine states, while thirteen states cover it on a case-by-case basis if medically necessary.
“It really is two different countries in many ways,” Alex Keuroghlian, associate professor of psychiatry at Harvard Medical School and director of the Division of Education and Training at The Fenway Institute, said referring to gender-affirming care coverage and treatment in the country. “And it’s unfortunate because this is medically necessary evidence-based care and should be part of primary medical care.”

And there are policies that only cover some elements of gender-affirming care. “Undergoing gender affirming care means a multitude of things,” said Lindsay Mahowald, research data analyst at the UCLA Williams Institute who uses gender neutral pronouns.

Insurance might cover hormone replacement and surgery, but not many other gender affirming medical interventions. When trans man Samson Winsor, 29, got top surgery in 2018, Federal Blue Cross Blue Shield insurance covered only a portion of the surgery under his father’s plan. The total cost of the procedure was $10,000 and insurance covered 80% of it. Winsor raised about $4,000 through crowdfunding to pay for out-of-pocket costs and stay at home for a few weeks so he could heal. His father didn’t support his transition and made persistent efforts to have him removed from coverage.
“Some people are easily removed from their policies,” he said. “Whether their parents don’t accept them or if an abusive spouse changes the plans on them.”

Mental health treatments are also part of the transitioning process, but many insurance plans don’t cover that aspect.
“We know for a fact that a lot of transgender people struggle with their mental health in a way that can be profoundly impactful and certainly life-threatening,” Mahowald said.

According to the 2015 U.S. Transgender Survey by the National Center for Transgender Equality, 40% of transgender individuals have attempted suicide in their lifetime, nearly nine times higher than the rate of suicide in the U.S. general population (4.6%). Apart from anti-trans bans across the country, medical care is more likely to be denied or delayed for transgender people due to bureaucratic issues in insurance approvals.

Oliver Hall, trans health director at Kentucky Health Justice Network, a non-profit organization for reproductive rights, says one of the reasons is their legal name and gender might not be updated on their documentation.
“They [health insurers] say ‘why would a man need a hysterectomy?’,” Winsor said. “You’re rejected also because of that.”

The 2015 U.S. Transgender Survey reports that 68% of trans people do not have access to an ID that accurately reflects their name or gender identity. According to the survey, cost was one of the main barriers respondents faced in changing their documents. But the Center for American Progress also showed in a 2021 survey that 34% of transgender respondents reported that a health insurance company refused to change their records to reflect their current name or gender.

Lack of documentary evidence is another barrier in accessing health insurance. There are states that set a lot of requirements to get gender-affirming care for insurance such as referrals or letters of support from doctors and therapists.
“I know plenty of people that it’s completely out of their reach because of the requirements,” Singleton said. “You’re already going through so much dealing with the changes and having to meet all of these extra requirements just makes it feel so impossible sometimes.”

Federal programs are crucial for transgender populations as they experience disproportionately high rates of poverty due to unemployment. Many lack the financial resources to meet fundamental human needs such as proper housing, clean water and medical attention.
“I would say [unemployment] probably is the biggest factor at play,” Mahowald said.

And even when these treatments are covered by insurance, related expenses might be harder to afford. Singleton had to appeal to crowdfunding when he got top surgery. With few surgeons capable of doing this kind of operation in Idaho, his doctor recommended traveling to the University of Utah Hospital. It is about a three-hour drive from Singleton’s home.

Nikolai Poloney is a trans man – this is not his legal name – who lives in Maryland, a state where gender-affirming care is federally covered. He wants to have top surgery at some point, but he needs a solid aftercare plan as he’ll have to stay at home for three weeks.
“I would probably need to hire a health care professional to help me with that,” he said. “Insurance might help a little bit, but it would still probably be pretty expensive.”

*This story was part of my master’s project at Columbia Graduate School of Journalism and received the James A. Weschler Award for National Reporting.