Gender transition is in transition

Transgender health management has seen important advances in the recent past. Some notable remaining issues revolve around the standard of care and insurance coverage.

A transgender person is someone whose gender identity, i.e. how they experience themselves as a male, female or else, does not agree with their biological (genetic, physiological) status, which determines the sex assigned at birth. An accurate number of transgender people is difficult to ascertain. Estimates suggest that 0.6% of the US adult population identify as transgender.

Gender incongruence used to be classified as a mental disorder by the WHO but is now considered a sexual health condition due to its inherent healthcare needs (see video). One typical symptom is gender dysphoria. This is the clinically relevant distress associated with the misalignment of sex and gender identity. It can have various effects including substance abuse, depression and even suicide.

Surveys suggest that sexual health workers and endocrine physicians not specialised in transgender care may be neither entirely comfortable nor sufficiently trained to provide comprehensive care. Physicians who seek specific further education will find it easier to learn about hormone therapy than other aspects of transgender care including gender-affirming surgery (GAS; also still called gender reassignment surgery), which aligns the transgender person’s physique with their gender identity. This is alarming because gender-affirming intervention is an effective treatment of gender dysphoria.

The insurance debate

Another aspect calling for further development is US insurance coverage of gender transition-related procedures. Whilst it used to be categorically excluded, US regulations began to change markedly from 2012 with further manifestations in subsequent years. Nevertheless, there are still disputes over legal interpretations of sex and gender identity. In contrast, the UK National Health Service (NHS) has provided transgender care for years. A key moment towards progress in the UK was a 1999 Court of Appeal ruling followed by more wide-ranging legislation including the Equality Act 2006.

The three main arguments that tend to be launched against covering GAS by public health insurance are summarised and refuted in the table below.

Argument against GAS coverage	Counterargument
GAS is merely a cosmetic intervention, which should not be publicly funded.	Even though GAS may involve cosmetic procedures, this is not its sole purpose. GAS is therapeutically indicated to treat gender dysphoria with the aim to improve mental and physical well-being. —
It is not a cost-effective intervention.	Due to the potentially wide-ranging positive effects on the individual and resulting reduced healthcare costs, there is evidence for cost-effectiveness. Considering that GAS can prevent suicide, it is a life-saving treatment for some and, in that sense, on a par with other essential healthcare services. —
If GAS gets funded, related types of surgery, e.g. rhinoplasty (nose correction), will have to be covered, too. Where will this end?!	This is only true if the impact of the surgery was of equal value, e.g. prevents suicide. Whilst this may be so in individual cases, and therefore should be covered for those patients, covering justified GAS does not cause a blanket approval for all related surgeries. As long as the same stringent eligibility standards apply to GAS and other interventions, there is no good reason to exclude any patients in need.

On a brutally calculating level, probably the main reason for the existence of public health insurance is that a country needs its inhabitants to be productive. They must work, pay tax and have no need for social security support. Losing fit individuals to any medical condition that severely impedes their productivity incurs a social cost that can far exceed the healthcare spending needed to ameliorate their condition. Thus, treatment exclusion criteria must be carefully assessed in the context of their wider implications.

How much is it?

In the financial year of 2016/17, the NHS spent £3,525,460 on GAS, mostly male-to-female procedures. Whilst not cheap, GAS falls in line with some other life-saving publicly funded interventions (see table below).

Procedure	Average NHS Cost (FY 2016/17)
male-to female GAS	£10,369
female-to-male GAS	£31,780
lung transplant operation	£40,076
case of complex tuberculosis	£21,598
1 day in intensive care bed	£1,932

In the discussion of transgender people, you may not necessarily picture troops. But in fact, you are twice as likely to find a transgender person in the US military than amongst US civilians. If the US military funded transition-related care, it has been estimated to cost $5.6 million per year or 22 cents per military member per month out of the $47.8 billion annual health care budget.

Considering that GAS can prevent suicide, it is a life-saving treatment for some and, in that sense, on a par with other essential healthcare services.

One voice

To bring some of the mainly academic deliberations above to life, listen to US-based musician and transgender man Sam Bettens (see vlog). As he announces that he has received a GAS date, he also explains some of the practical and psychological aspects of gender dysphoria as well as the privilege of healthcare access.

References

• BAKER, K.E., 2017. The Future of Transgender Coverage. N Engl J Med, 376(19), pp. 1801-1804.
• BELKIN, A., 2015. Caring for Our Transgender Troops — The Negligible Cost of Transition-Related Care. N Engl J Med, 373(12), pp. 1089-1092.
• DAVIDGE-PITTS, C., NIPPOLDT, T.B., DANOFF, A., RADZIEJEWSKI, L. and NATT, N., 2017. Transgender Health in Endocrinology: Current Status of Endocrinology Fellowship Programs and Practicing Clinicians. The Journal of Clinical Endocrinology & Metabolism, 102(4), pp. 1286-1290.
• DEPARTMENT OF HEALTH, 2008. Trans: A practical guide for the NHS. http://www.ncuh.nhs.uk/about-us/equality-and-diversity/documents/transgender-nhs-guide.pdf edn. London, UK: Department of Health.
• GO, J.J., 2018. Should Gender Reassignment Surgery be Publicly Funded? Journal of Bioethical Inquiry, 15(4), pp. 527-534.
• LEFKOWITZ, A.R.F. and MANNELL, J., 2017. Sexual health service providers’ perceptions of transgender youth in England. Health & Social Care in the Community, 25(3), pp. 1237-1246.
• PADULA, W.V., HERU, S. and CAMPBELL, J.D., 2016. Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis. Journal of General Internal Medicine, 31(4), pp. 394-401.
• WHO, 2019-last update, ICD-11: Classifying disease to map the way we live and die [Homepage of World Health Organization], [Online]. Available: https://www.who.int/health-topics/international-classification-of-diseases [07/30, 2019].
• WINTER, S., DIAMOND, M., GREEN, J., KARASIC, D., REED, T., WHITTLE, S. and WYLIE, K., 2016. Transgender people: health at the margins of society. The Lancet, 388(10042), pp. 390-400.