Wren Vetens was promised a significant discount on the cost of her gender-confirmation surgery if she paid in cash upfront, without using her health insurance. Yet afterward, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000. Lauren Justice for KHN hide caption
cost of sex change surgery
She chose a doctoral program in physics at the University of Wisconsin-Madison, a school that not only embraced transgender students like her, but also granted insurance coverage for her gender-confirmation surgery when she enrolled in 2016. When uncertainty over the fate of an Obama-era anti-discrimination rule allowed the state to discontinue such coverage, Vetens and her mother, Kimberly Moreland, an OB-GYN, shopped for another plan.
With that information in hand, Vetens planned ahead: She got her insurer's preapproval and scheduled surgery during winter break of her second year, allowing time for recovery before returning to her studies.
So, she was shocked when a hospital representative called her a couple of months before the long-awaited surgery estimating the bill would be $100,000. That meant she would be on the hook for as much as $75,000 after her insurer's $25,000 payout.
With preparations for the surgery well underway, Vetens was feeling overwhelmed with stress. "There were days when I just couldn't get out of bed for a whole day," she said, describing two weeks of panic attacks.
What gives: Though gender dysphoria is relatively uncommon, many of the billing and insurance issues Vetens encountered are typical for patients planning major surgery. Much of her stress and frustration arose from the vast difference between online price estimates ($19,000-$25,000), the hospital's billed price to the insurer ($91,850) and what it was willing to accept as an upfront cash payment ($20,080).
Hospitals set list prices high because insurers with whom they have contracts typically negotiate them down. In exchange for charging an insurer's members a lower price, doctors and hospitals gain access to those customers, who have incentives to use these in-network providers. Hospitals may offer package deals for procedures to patients, if they pay cash upfront, in part because the hospital avoids the hassle of negotiation.
Dr. Kimberly Moreland (left) helped her daughter shop for an insurance plan that would cover Vetens' gender-confirmation surgery. Yet mother and daughter still found themselves caught between the hospital and the insurer. Courtesy of Richard Malatesta/Kimberly Moreland hide caption
In the past six years, Claire, an IT infrastructure engineer living in New York, has spent thousands of dollars on medical care that most Americans never have to think about. There was hormone therapy, hair removal, and what's known as "bottom surgery." And that was just the start of it.
It didn't take long for Claire to realize that being transgender comes at a cost. By the time she came out in 2013, she was already struggling with what's commonly called gender dysphoria, a form of emotional distress that results from identifying as a different gender than the one designated at birth.
But for Claire and many other transgender people, the costs aren't just emotional: Many are also financial. The cost of medical treatments can add up to more than $100,000, and they're often not covered by health insurance. Plus, transgender people face discrimination in the workplace, which translates to unemployment rates that are as much as three times as high than they are for the general public.
Now, most medical professionals offer trans patients hormones and surgeries to change their bodies to match their gender identities. Surgeons can construct a penis (phalloplasty) or vagina (vaginoplasty), augment or remove the breasts, and feminize or masculinize the face with plastic surgery.
The procedures are long, complicated, and often painful. Vaginoplasty, for example, is a six-hour surgery with a recovery time of up to a year and a half, while phalloplasty has a similar recovery time and can take as long as 12 hours in the operating room.
While cost estimates vary widely, the Philadelphia Center for Transgender Surgery estimates that "bottom surgery" costs about $25,600 for male-to-female patients and about $24,900 for female-to-male. The center provides estimates for other common trans-related surgeries, such as breast augmentation ($9,000), bilateral mastectomy (up to $10,900), facial feminization (up to $70,100), and facial masculinization (up to $53,700).
Public healthcare providers are also increasingly covering transgender care. Medicare, the US government health program for the elderly and people with disabilities, began covering gender-affirming surgeries about five years ago. Earlier this year, Illinois joined 17 other states and the District of Columbia when it announced that its Medicaid program for people with low incomes would cover gender-affirming surgery.
"Access to competent inclusive healthcare for transgender people has increased," Naomi Goldberg, a policy director at the LGBT think tank Movement Advancement Project, or MAP, said. She credited several recent changes in the US, including "increased understanding about what it means to be transgender," in addition to "improved medical care and standards, and improved education for healthcare providers."
But gaps in coverage remain. In Arizona, for example, the American Civil Liberties Union is suing the University of Arizona for listing explicit exclusions for "gender-reassignment surgery" in their healthcare plans. According to MAP, several states, including Wyoming and Alaska, have language in their laws that bans coverage of certain treatments for transgender patients in state Medicaid programs, such as what Alaska calls "transsexual surgical procedures."
To pay for procedures that insurers consider cosmetic, transgender people often seek help from friends or turn to crowdfunding platforms like Indigogo and GoFundMe. A quick search for "transgender surgery" on GoFundMe, for example, yields more than 3,000 results. The site offers a guide on how to fund "gender-confirmation surgery."
"I was lucky to have a lot of people in my life that were able to contribute to that, but I still had a lot of extra costs," he said. Those don't stop at medical procedures. There are a lot of other expenses most people never have to think about, such as chest binders and prosthetic genitals for transgender men.
Those who want to transition physically or externally have many different options, from getting gender reassignment procedures and buying a new wardrobe and accessories that match their gender, to choosing against surgery.
Trans people can also transition without surgery or medical procedures by changing their clothing, pronouns, name and gender presentation. Either way, money can often be a barrier for trans folks, and getting accurate information about the costs of transitioning can be a hurdle in and of itself.
For those who do wish to get surgery to alleviate gender dysphoria and have a body that matches their gender (and are at least 18 years of age, in most cases), the costs vary significantly depending on details like insurance coverage and location.
The types of surgeries that trans people seek are more informally known as top surgery, which is a reconstructive surgery that alters the appearance of the chest, either taking breasts away for a more masculine/flat chest or adding breasts for those who want to appear more feminine. Top surgeries are performed by a plastic surgeon with training in transgender and gender-affirming medical procedures.
The costs of transitioning are also not simply financial. Trans people who choose to live openly often face discrimination, rejection and even violence. Black trans women and trans women of color face these dangers the most. The risk of being fired from a job, bullied or harassed at work or having to move to an entirely new community because of transphobia is also high.
Aetna considers reversal of gender affirming surgery (performing surgical procedures to return anatomy to that of the sex assigned at birth) medically necessary for persons who regret their gender-related surgical intervention, where applicable requirements for gender affirming surgery listed above are met.
Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).
The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022).
It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession. 2ff7e9595c
Comments