Posted on August 10, 2022 by Austin Lang
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Posted on August 10, 2022 by Austin Lang
Gender-Affirming Medicare refers to a group of medical procedures, both medicinal and surgical, designed to treat gender dysphoria: the feelings of discomfort and distress when one’s assigned gender does not align with their gender identity.
Gender dysphoria and the concept of gender being an identity are nothing new. Depictions of transgender individuals can be found in art from the Mediterranian dating back 9000 years. Hippocrates, one of the most outstanding figures in the history of medicine, observed what are now believed to be transgender or non-gender conforming individuals in his work On Airs, Waters, and Places.
The role of transgender and third-gender individuals in the culture and religion of indigenous tribes is well documented. What is new is the advent of medical techniques to help treat gender dysphoria and the willingness of society to challenge the transphobic beliefs that forced many transgender, genderqueer, and nonbinary individuals to suffer in silence.
Gender dysphoria is considered a medical condition: therefore, gender-affirming healthcare is covered under Original Medicare, though the exact scope of what will be performed, or if medical intervention is even necessary, depends on the individual.
This article aims to be as informative as possible for people unfamiliar with the concept of gender affirmation, those doing initial research for themselves or a loved one, or those looking to take the next step in their journey of affirmation.
As a result, this guide is divided into several sections.
It is possible to seek gender affirmation at any age, and people who receive hormone therapy or gender-affirming surgery in their youth require care throughout their lifetimes. This is no different from having prescription medication or requiring checkups following major surgery. People do not stop being gender non-conforming once they become eligible for Medicare, and it is never too late to seek gender-affirming care. In addition, Medicare is not exclusively for seniors. People of any age can qualify for Medicare under certain circumstances, and our goal is to help everyone navigate the intricacies of Medicare: not just seniors. As such, this article will make no assumptions about the age of the person seeking gender-affirming services.
Gender, as a concept, is deceptively complicated. Many people assume gender is an innate biological feature of a person, but that isn’t true. Biological sex refers to the characteristics, like genitalia, typically used to identify someone as male or female. Gender refers explicitly to the societal and cultural assumptions applied to an individual based upon their biological sex.
Sex is biological, though the exact mechanics of determining an individual’s can be quite complex. There have been medical cases where individuals born with outwardly male genitalia were later found to have ovaries in place of testes, for example.
Additionally, there are relatively common cases with cisgender women possessing Y chromosomes, typically only found in men. An individual can be born possessing both male and female characteristics: a condition known as being intersex. Instead, we assign genders based on the initial presentation of sexual characteristics.
For many people, however, this assignment is incorrect. It simply does not align with their conception of who they are. They may feel like they were born into the wrong body or are being forced to pretend to be someone they’re not. These people are considered transgender, trans- being Latin for “on the other side of.”
It’s important to note that gender is distinct from sexuality: a trans woman may be attracted to men, women, all genders, or no one at all. There is no expectation of changing your sexuality to match your expressed gender, and gender affirmation does not affect one’s sexuality. If you were attracted to people of a specific gender before transitioning, that attraction would remain even after you transition.
Many transgender individuals experience a condition known as gender dysphoria (GD), which refers to the distress that occurs due to a mismatch between their assigned gender and gender identity. Not all transgender and gender non-conforming individuals experience GD, but the symptoms can be debilitating for those who do.
Symptoms of gender dysphoria include:
Gender dysphoria can lead to depression, stress, and anxiety. People with GD are at heightened risk for eating disorders, substance abuse, and suicide. Attempting to treat GD by suppressing the feelings of dysphoria and forcing an individual to conform to a specific gender invariably results in worsened symptoms. The scientifically supported treatment for GD is gender affirmation, designed to help an individual explore the source of their dysphoria and, if necessary, provide medical interventions to alleviate their gender incongruence.
It is a common misconception that gender affirmation means immediately beginning hormones and surgery. While medical interventions like these are a part of gender affirmation, they are never the first step. Indeed, many people never undergo surgery or hormone therapy at all. Instead, there are three broad types of gender affirmation.
Social Affirmation refers to the process of expressing one’s authentic gender identity, such as by starting to use one’s chosen name and pronouns, altering one’s appearance in non-permanent ways (such as changing one’s hairstyle or dressing in different clothes), and participating in life as one’s authentic self. Social affirmation is mainly psychological and is the first step in the gender affirmation process. Because social affirmation isn’t medical, Medicare won’t cover most of it, though it can help cover any psychological counseling you receive as part of the gender affirmation process. Local LGBTQA+ resource centers may be able to provide you with resources to help with the social affirmation process.
Legal Affirmation refers to affirming one’s gender within the legal and legislative systems. This includes legally changing one’s name, updating one’s gender identification on legal documentation and IDs, and affirming one’s rights in various legal and bureaucratic systems. Be aware that Medicare does not take your gender into consideration when providing services: it will provide its usual level of coverage for the services determined necessary by your doctor. LGBTQA+ resource centers can help you here as well.
Medical Affirmation only occurs once it is clear that medical intervention is needed to address the gender incongruence. It includes medicinal and surgical interventions designed to help align one’s gender characteristics with gender identity. Many people never seek out medical affirmation, and those who choose medical affirmation don’t necessarily seek out surgery.
There are two broad types of medical affirmation: hormone therapy and surgery.
A person’s sexual characteristics are primarily determined by the presence of hormones in the body: testosterone for male characteristics and estrogen for female characteristics. Hormone therapy induces a process similar to puberty, developing masculine or feminine characteristics.
Someone undergoing feminizing hormone therapy will experience a decrease in muscle mass and body hair, redistribution of body fat, and the development of breast tissue. Someone undergoing masculinizing hormone therapy may experience a deepening of the voice, an increase in muscle mass and body hair, and possible development of male pattern baldness.
Hormone therapy also affects primary sexual characteristics and may affect your libido and fertility. Speak with your doctor before beginning treatment if you plan on having children.
There is no upper age limit on hormone therapy. However, your doctor may recommend against it if you are suffering from a health condition that could be exacerbated by hormone alteration, such as breast or prostate cancer. You will likely need to continue taking hormones for your entire life and will require regular checkups to screen for conditions related to elevated hormone levels.
Medicare does cover gender-affirming hormone therapy if deemed medically necessary. Doctor’s visits, health screenings, and counseling are covered under Medicare Part B, while the hormones are covered under Medicare Part D.
Many surgical procedures can treat gender dysphoria, which usually involves surgically altering the body’s sexual characteristics. Surgery is typically applied in conjunction with hormone therapy, particularly in metoidioplasty, which relies on masculinizing hormone therapy to work.
However, hormone therapy is not a prerequisite for most other forms of top or bottom surgery. Unlike hormone therapy, which doctors can prescribe with parental permission, you must be 18 or older to undergo gender affirmation surgery.
There are two broad types of gender-affirming surgery. Please be aware that we will discuss these surgeries in respectful, clinical detail. Feel free to skip this section if you are uncomfortable with this topic.
Top Surgery refers to the alteration of breast tissue. For Female-to-Male (FTM) or Female-to-Nonbinary (FTN) individuals, this usually involves the reduction or removal of breast tissue and is often considered a vital part of the gender affirmation process. Individuals who cannot or do not undergo top surgery often rely on garments known as binders to conceal their breasts, potentially leading to health complications if misused.
For Male-to-Female (MTF) and Male-to-Nonbinary (MTN) individuals, top surgery is not always required, as feminizing hormone therapy can result in the development of breasts regardless of age. However, some elect to receive breast augmentation to increase breast size.
Bottom Surgery refers to the surgical alteration of the genitalia (genitoplasty) to match one’s gender identity. For FTM and FTN individuals, options include phalloplasty and metoidioplasty.
Phalloplasty refers to the creation of a phallus using tissue from elsewhere in the body and is often used in non-gender affirming contexts when reconstructing the male genitalia due to trauma, disease, or congenital condition. It requires multiple surgeries to complete and can result in a more natural-looking but ultimately non-functional phallus. Individuals who undergo phalloplasty will lack erogenous sensation and will require the use of erectile rods to achieve an erection.
Metoidioplasty is done in individuals undergoing masculinizing hormone therapy. Rather than constructing a phallus from non-erogenous tissue, it instead focuses on converting the clitoris, which naturally enlarges during hormone therapy, into a phallus. As a result, the erogenous sensation is maintained, and individuals can achieve erection unassisted. Metoidioplasty is often combined with urethral lengthening, allowing the new phallus to be used for urination.
Of the two procedures, Metoidioplasty is more affordable, less invasive, and has fewer side effects. Both procedures are often performed in conjunction with scrotoplasty, in which a scrotum is formed from the labia majora. Some individuals elect to receive testicular implants as part of this treatment.
MTF and MTN individuals may undergo vaginoplasty, most commonly through a technique known as penile inversion. This is when existing genital or colon tissue is used to construct a vaginal vault. The testes are removed, and the prostate is left in place to preserve erogenous sensation. Those seeking gender-affirming care may choose to follow their vaginoplasty with labiaplasty for cosmetic reasons. Like a phalloplasty, you may require additional assistance to maintain an active sex life, such as using a dilation device.
In addition to top and bottom surgery, there are other procedures an individual can undergo to aid in gender affirmation.
Facial gender surgery involves modifying one’s appearance to match gender identity. It is performed in multiple procedures and involves modifying the jaw, nose, and forehead shape. MTF and MTN individuals may also undergo tracheal shaving to reduce the prominence of their Adam’s apple. Facial gender surgery is often performed in conjunction with cosmetic procedures like adding filler or removing facial hair through laser or electrolysis. As facial gender surgery is considered a cosmetic procedure, it is not usually covered under Medicare.
Voice feminization surgery is most commonly performed in MTF and MTN individuals and involves surgically altering the pitch of one’s voice. It is possible to surgically masculinize one’s voice as well. However, as this is a common side effect of hormone therapy, it is less common. Voice surgery is less common than other gender-affirming surgeries, as it is only recommended when voice therapy fails to produce the desired result. It is also considered cosmetic and therefore not covered by Medicare.
Medicare will cover top and bottom surgery on a case-by-case basis if deemed medically necessary. Breast reduction, metoidioplasty, and vaginoplasty are more likely to be covered than breast enhancement, phalloplasty, and labiaplasty, though this can vary depending on your situation. This type of care will be covered under Medicare Part A for inpatient procedures and Medicare Part B for outpatient procedures.
As always, purely cosmetic procedures are not typically covered.
Unfortunately, no national mandate requires Medicare to provide gender-affirming care, meaning they will only provide it if deemed medically necessary to treat gender dysphoria.
Fortunately, it is possible to appeal a rejection, just as you can appeal similar decisions. The process varies depending on whether you are under Original Medicare or Medicare Advantage. Depending on the circumstances, you may wish to contact a lawyer to help with your appeal. Many lawyers offer pro bono services to people seeking gender-affirming care, so contact your local LGBTQA+ resource center for more information.
Unfortunately, transphobia is still rampant in all aspects of society, including parts of the health care system. You may face discrimination while seeking gender-affirming care, including but not limited to:
You have the right to be treated with respect and to receive all necessary medical treatment. If you are harassed, denied coverage, or otherwise mistreated, you should report the incident to CMS as soon as possible. Contacting a lawyer may also be beneficial if the infraction is severe enough to warrant legal action.
If you are looking for a Medicare Advantage, Medigap, or Medicare Part D plan to help in your gender affirmation journey, we can help. Call our licensed insurance agents at (800) 950-0608 to begin your search today.