Medicare Repeals Ban on Sex-reassignment Surgery, but Inequalities Persist

July 15, 2015 in inQueery

On May 30th, 2014 the Department of Health and Social Services (HHS) Appeals Board (DAB) repealed Medicare’s federal coverage ban on sex reassignment surgery. This ban was introduced in 1981, when medical experts deemed sex reassignment surgery too experimental. Today major medical groups including The American Medical Association, American Psychiatric Association, and the American Psychological Association consider sex reassignment surgery as a viable option for treating gender dysphoria and improving the health and lives of trans people. Improvements in surgical procedures have been accompanied by greater understanding of trans identities and experiences. For example, in the American Psychiatric Association’s handbook, The Diagnostic and Statistical Manual of Mental Disorders, “gender identity disorder” was recently changed to “gender dysphoria” to emphasize that gender-nonconformity itself is not a disorder. The medicalization of trans identity is complex, and before there is a fuller understanding of trans experiences, these limiting definitions produce sub-par results and fail to meet the needs of most trans people. Still, Medicare coverage of sex reassignment surgery will surely benefit some trans seniors.

Denee Mallon, seventy-four-year-old transwoman and war veteran, filed a lawsuit against HSS after Medicare refused to cover the sex-reassignment surgery her doctors recommended. Though her struggle to receive her surgery had started much earlier, two years after filing her case Mallon was the first person to receive sex reassignment surgery covered by Medicare. In an interview with NBC News, Mallon explained that when she was able to afford her surgery in the late 1970s and early 1980s she was unable to get approval from her doctors. When Mallon acquired a doctor’s approval for her surgery in the late 1980s, she could no longer afford it. More than thirty years since starting her transition in 1978, Mallon received the first sex reassignment surgery covered by Medicare. As to the significance of this surgery will have in her life, Mallon stated: “Now I’m finally being me, and I have been for quite a while. And with the surgery I’ll even be more of who I am.”

Though overturning Medicare’s federal coverage ban on sex reassignment surgeries is a step forward, in forty-five states sex reassignment surgeries have yet to be covered under Medicaid, which provides health care coverage for low-income patients. Even with insurance coverage, trans people may face additional barriers to receiving sex reassignment surgeries. According to the ruling, “The decision does not bar CMS (The Centers for Medicare and Medicaid Services) or its contractors from denying individual claims for payment for transsexual surgery for other reasons permitted by law. Nor does the decision address treatments for transsexualism other than transsexual surgery.” (NCD 140.3) This means that hormone therapy is not covered for trans individuals under Medicare. The lack of a single medical program for sex reassignment surgeries in the U.S. explains the shortage of surgeons trained to perform sex reassignment surgeries. Low Medicare reimbursement rates for sex-reassignment surgery discourages surgeons who cannot ask patients for additional payments. Class barriers to adequate trans health care continue to be left unaddressed by Medicare.

At a time when trans people are increasingly visible in mainstream media, a narrow focus on sex reassignment surgery obscures broader struggles for trans health care. Trans narratives in the media often portray sex reassignment surgery is the ultimate goal of all trans people, or the ‘cure’ for gender dysphoria. This sets up hierarchies of trans identities where post-op trans people are considered “more valid” than trans people who have not chosen or been able to medically transition. Because of the long-standing social, legal, and economic barriers, many trans people who have wanted to undergo sex reassignment surgery or medically transition with hormone therapy have been unable to do so. Insurance coverage of sex reassignment surgeries and hormone treatment does not begin to address the systematic violence trans people face in education, healthcare, prisons, immigration detention centers, and broader society.

Hannah Rogge is a guest contributor at Inqueery.