how much does gender reassignment surgery cost usa

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How to afford transgender surgery expenses.

Updated: Nov 11, 2022, 2:00pm

Transgender surgeries—also called gender affirmation or gender confirmation surgeries—are medical procedures you can undergo to affirm your gender identity.

The cost of these kinds of surgeries are often steep, and health insurance coverage for them can vary by policy. “Even if a procedure is covered by insurance, there are still deductibles and out-of-pocket maximums,” said Wynne Nowland, CEO of Bradley & Parker, who transitioned at 56. Surgeries that are solely cosmetic might not be covered by insurance at all.

The good news is that several financing options are available to help you pay for procedures. Some organizations even offer grants and scholarships that can help you afford surgery costs.

How Much Does Transgender Surgery Cost?

The cost of transgender surgery can vary by provider and the type of surgery you choose to get. For a female-to-male transition, masculinization chest surgery (also known as top surgery) might cost $3,000 to $10,000 while chest surgery for a male-to-female transition could cost $5,000 to $10,000, according to Longwood Plastic Surgery.

Bottom surgeries, such as vaginoplasty or phalloplasty, can cost $25,600 and $24,900, respectively, according to estimates from The Philadelphia Center for Transgender Surgery. Additional procedures can increase the transition expenses from there. Aside from the actual surgery cost, other hidden expenses can arise as well.

For example, you could need help at home while in recovery if you don’t have a good support system, according to Nowland. There may also be travel and hotel expenses, which are typically not covered by insurance. Nowland says the best way to prepare for surgery is to reach out to insurance to discuss coverage and plan on saving the funds you’ll need to proceed.

If you’re considering borrowing money to pay for surgery and recovery costs, here are four options to consider.

Related: Does Being Transgender Affect Life Insurance?

4 Ways to Finance Transgender Surgery Costs

Personal loans, credit cards, medical credit cards and home equity loans are products you could use to pay for transgender surgery costs over time. Here’s what you need to know about each:

Personal loans are typically unsecured installment loans that provide a lump sum you can use for almost any legal personal expense, including medical bills. Lenders may offer loans of $1,000 to $100,000. However, your credit and income can affect how much you can borrow and your interest rate.

The average annual percentage rate (APR) for a five-year personal loan is 15.93% as of Sept. 19, 2022, but rates can go up to 36% APR. The good news is that many lenders let you prequalify for personal loans online without a hard credit check , allowing you to shop around for rates and compare costs before borrowing.

Credit Cards

Credit cards give you access to a credit line you can use to cover medical bills. You’ll then pay off the balance over time. While certain credit cards have annual fees, many don’t. Some credit cards even offer an introductory 0% APR for a number of months when you open a new account.

Standard interest applies after the interest-free period, but charging and paying off procedures during the interest-free period could be an affordable way to finance bills. That said, credit cards are usually best for expenses you can repay relatively quickly since interest rates can be higher than personal loans, so maintaining a high balance over several years can get costly.

Medical Credit Cards

Medical credit cards are designed specifically for medical bills and could be a financing option recommended by your doctor’s office.

CareCredit is a popular medical credit card that offers no-interest financing plans of six, 12, 18 or 24 months on transactions over $200. There’s a catch, though: If you don’t pay off the balance during the financing period, interest is charged retroactively from the time of your purchase.

For purchases of at least $1,000, CareCredit offers extended financing terms of 24, 36, 48 or 60 months. The APR for payment plans is fixed and ranges from 14.90% to 17.90%, depending on how much you borrow and the loan term you choose.

Home Equity Loans or Lines of Credit

If you own a house, home equity loans and home equity lines of credit (HELOCs) are ways to borrow from the equity you’ve built up. Here’s how both of these options work:

• Home equity loans: A home equity loan is an installment loan that lets you borrow money in a lump sum, which you could use to cover transgender surgery costs. Homeowners are typically able to borrow up to 85% of home equity, and loan terms can range from five to 30 years.
• HELOCs: These are lines of credit you can draw from and pay down with a variable interest rate. A HELOC could be a better alternative to a home equity loan if you have ongoing costs as it will give you the flexibility to borrow only what you need and pay it back as you go.

The advantage of home equity products for medical expenses is that interest rates may be lower than unsecured personal loans since the collateral (your home) backing minimizes risk for the lender.

However, since your home secures the transaction, you could lose your house if you can’t keep up with loan payments. If the value of your home decreases, there’s also a chance you could go underwater on the house if you end up owing more on your mortgage and loan than the home is worth.

Can You Get Transgender Surgery Grants?

Several organizations offer grants to help cover transition costs, including gender-affirming surgery, which is money you don’t have to pay back. Requirements for grant funding can vary, but in some cases, you need to show that you’ve saved up some money on your own for the surgery to be awarded money. Here are a few examples of organizations offering grants:

• Jim Collins Foundation : The Jim Collins Foundation offers two grants. General Fund grants can cover all gender-affirming surgery costs while Krysallis Anne Hembrough Legacy Fund grants can cover 50% of surgery costs for recipients who match the grant funds awarded.
• Point of Pride : Point of Pride offers an annual scholarship-like program that provides financial assistance for gender-affirming surgery.
• The Loft LGBTQ+ Community Center : TransMission grant funds through the Loft LGBTQ+ Community Center aren’t enough to cover the full cost of surgery. However, grants may be used to help pay for therapy, hormones and other transition expenses.

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Tips to Pay For Transgender Surgery Expenses

As you come up with a plan and explore ways to pay for surgeries, here are a few tips to consider:

• Double-check your insurance policy. Read policy terms carefully and reach out to your insurer to ask about what surgeries are covered. “Like all covered insurance procedures, expect to deal with some red tape, but your patience in doing so will be worth it,” said Nowland.
• Use a health savings account (HSA) or flexible spending account (FSA). HSAs and FSAs are both tax-advantaged accounts designed to help you stash money for medical expenses, which could include gender-affirming surgeries. You can make pre-tax contributions to both accounts from your salary if you set them up with your employer. If you set up an HSA on your own, you can deduct contributions from your tax return.
• Consider crowdfunding. Crowdfunding is when you set up a campaign to raise funds. If you prefer to keep medical procedures private, creating a campaign and asking for donations may not be the right route to take. But if you feel comfortable sharing your story, setting up a GoFundMe or Fundly fundraising page could be a way to cover the cost of your surgeries. Bonfire is another site you can use to fundraise by selling customized t-shirts.
• Get support from family and peers. If you have friends or family able to gift or loan you money, it can be more affordable than taking out a loan from a bank, online lender or credit union.

How to Save Up for Gender Affirming Surgery

Using a combination of funding sources is a strategy that could help you rely less heavily on loans.

Different surgeons charge different fees, so compare prices to project costs. From there, you can determine how much you’ll need to save and by when. If you don’t use an FSA or HSA to save, consider stashing your savings for surgery in a high-yield savings account so your savings earn more interest than it would in a traditional savings account.

Certain savings tools can make setting aside money easier. For example, banks often have recurring transfer features you can set up to automatically move money from a checking account to your savings on a schedule. Plus, savings apps like Digit exist, which can connect to your bank account, use an algorithm to review your cash flow and put spare money away for you automatically. Your savings can grow over time, so you can pay for treatment and surgery as you go.

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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Health Reporting in the States

Bill of the month: a plan for affordable gender-confirmation surgery goes awry.

Emmarie Huetteman

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

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.

Wren Vetens thought she'd done everything possible to prepare for her 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.

Deducing the procedure would run from $19,000 to $25,000, based on prices posted online, they purchased insurance from Consolidated Health Plans. It would pay a maximum of $25,000 for the operation.

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.

Tell Us Your Billing Story

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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.

After mother and daughter complained about the last-minute surprise, a hospital representative offered a solution: If they paid out of pocket and in full before Vetens' surgery — forgoing their use of insurance — the hospital would accept just $20,080, assuring them the hospital would charge nothing to Vetens' insurer. But if they did not decide and pay up right away, the surgery would be canceled.

"I certainly felt that I had no choice," Vetens said.

After Moreland gave the hospital her credit card number for payment, they thought the financial roller coaster was over and Vetens could focus on recovery.

Then the bill came.

Patient: Wren Vetens, then 23, a Ph.D. student at the University of Wisconsin-Madison

Total bill: $91,850.20

Insurance payment: $25,427.91

Vetens owed: $13,191.95 (after $20,080 that was counted as a deposit)

Service provider: University of Wisconsin Hospital in Madison

Medical treatment: Vetens underwent a procedure known as penile inversion vaginoplasty to address her diagnosis of gender dysphoria, a condition resulting from one's sex identified at birth being in conflict with one's gender identity.

The procedure, in which the patient's penile and scrotal tissue is used to create a vagina, generally takes about two to four hours and requires a short inpatient stay, according to Dr. Madeline Deutsch, the medical director for transgender care at the University of California, San Francisco.

Candidates for the procedure must live for at least one year in their identified gender role and undergo at least one year of hormone therapy, Deutsch said. Preparation also includes permanent hair removal.

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.

Officials at University of Wisconsin Hospital said they offered Vetens the option to pay $20,080 for these reasons: to secure extra experience and exposure for the hospital's programs for transgender patients, and to shield Vetens from an even bigger bill. "We were trying to protect the patient," said Dr. Katherine Gast, Vetens' surgeon.

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

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.

As both parties hedged their bets in trying to determine what a penile inversion vaginoplasty was worth, Vetens was stuck in the middle with the prospect of hugely varying payments.

Lisa Brunette, a hospital spokeswoman, said that, despite having provided Vetens an estimate of $100,000, the hospital really did not know how much it would charge for the procedure because it did not know how much it would be reimbursed by the insurance company. Vetens was the second person to have the procedure at the hospital.

The spokeswoman for the hospital said its contract with Vetens' insurer "relies on a complex formula."

And in an apparent chicken-and-egg quandary, Drew DiGiorgio, president and chief executive of Consolidated Health Plans, said the insurer did not know how much it would reimburse because it did not know how much the hospital would charge.

When Moreland called the hospital to pay the $20,080 price — an option she acknowledged many simply could not afford — she asked for an itemized bill.

The next day, she received a brief letter outlining some of the general services included for the price, such as "physician's fee" and "post surgery labs." Then it simply said: "Penile Inversion Vaginoplasty — $20,080.00."

"How in the world did you come up with a number if you have no idea what it covers?" she asked.

Had Vetens chosen a hospital that did not contract with her insurer, the family could have been reimbursed 60 percent, or about $12,000 of the money paid, since her insurance pays a portion of out-of-network care.

But since Consolidated Health Plans has a contract with the University of Wisconsin Hospital, it said it would not reimburse anything at all. Contracts between insurers and providers discourage such sideline cash transactions, since hospitals can make more money when patients use insurance, as evidenced by Vetens' bill.

Vetens and Moreland appealed to Consolidated Health Plans, feeling that they had been "the victims of a bait-and-switch scam."

The surprises didn't end there. Though multiple hospital representatives reassured Vetens that they wouldn't charge her insurance after her cash payment, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000.

A hospital bill followed, identifying their $20,080 as "pre-payment," treating it like a partial deposit. Vetens owed more than $13,000, it said.

Studies have shown that more than half of hospital bills contain errors , a problem made worse by the fact that medical bills — with codes and jargon — can be nearly impossible for even savvy patients to understand.

"That was not supposed to happen. That was an error," said Abby Abongwa, a hospital billing official. "That was absolutely an error on our part."

Resolution: After the bill for $91,850 arrived, an alarmed Vetens showed it to her surgeon. The hospital quickly apologized and repaid her insurance company.

Within a few weeks of receiving the appeal — which noted that Vetens and Moreland had contacted a national media outlet — Consolidated Health Plans reimbursed Vetens nearly $18,000, offering her no explanation for why the company had ultimately decided to reverse its earlier judgement that it would not pay anything toward her care.

With their reimbursement, Vetens and Moreland paid about $2,100 for the surgery, all told.

The Takeaway: Be mindful that online pricing estimates frequently represent cash prices, which are often far lower than the price hospitals will bill your insurance.

Ask about a cash price — you may get a better deal. But if you forgo insurance, you're on your own. Your insurer is under no obligation to pay you back for any part of the bill or help you troubleshoot billing, and any payment you make likely will not count toward your deductible.

Enlist your doctor's help. Gast, Vetens' surgeon, proved a powerful advocate for her patient when disputes arose about billing and pricing. Billing representatives might not always be responsive to patients, but it's in the hospital executives' interest to keep staff surgeons happy.

Some of these issues can be settled only through legislation. Right now, there is no legal requirement for hospitals to provide itemized bills to patients. Hospital bills are fraught with errors, and there is little accountability for providers who bill erroneously.

In the meantime, don't be afraid to ask questions and fight back.

Bram Sable-Smith, who contributed to the audio story, is part of NPR's reporting partnership with Side Effects Public Media, member station KBIA and Kaiser Health News.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

You can follow Emmarie Huetteman on Twitter: @emmarieDC .

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Does Insurance Cover Gender-Affirming Care?

Determining what your plan covers.

• Gender-Affirming Surgery Costs
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Other Ways to Pay for Gender-Affirming Care and Surgery

Tips for financing gender-affirming care and surgery, the bottom line.

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In many cases, health insurance in the U.S. covers gender-affirming care. However, whether or not your insurance plan will cover a specific gender-affirming treatment can depend on your state, your employer, and your plan's benefits.

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, however, and the process can be murky and require preauthorization.
• Gender-affirming care can cost tens of thousands of dollars without insurance coverage.

Major insurance companies today generally recognize transgender-related care as being medically necessary . However, at least 24 states have passed new laws or enacted new policies limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage for certain procedures by their insurers.

1.6 million

The estimated number of Americans age 13 or older who identify as transgender, according to a 2022 study.

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association, which reaffirmed its advocacy for such care in 2023. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the one they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care can include hormones, surgery, or counseling. The care aligns a person's gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act (ACA) banned health insurance discrimination based on sexual orientation and gender identity. Before the law's passage, medically necessary gender-affirming surgeries and hormones often weren't covered by insurers.

A 2024 rule from the Department of Health and Human Services stated that covered entities (a term that includes both insurance plans and providers such as doctors) could not "deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition or other gender-affirming care if such denial, limitation, or restriction results in discrimination on the basis of sex."

However, insurance is also regulated at the state level and rules can vary based on whether it is an ACA, public, or employer plan, so they don't apply evenly to all insurers.

Investopedia / Candra Huff

Policyholders and plan members can generally find out what's available to them in their member booklet. This should have been given to you when you got the policy or, if it's an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer's clinical evidence criteria to qualify for claim coverage. For example, to begin hormone therapy, the requirements might include a diagnosis of gender dysphoria from a licensed mental health professional.

Some plans may list exclusions for certain procedures. Even if an exclusion exists in the documentation, it can still be worthwhile to apply for pre-authorization or pre-approval for the procedure to obtain an official decision. For one thing, as the Transgender Legal Defense & Education Fund, notes, "the plan booklet may simply be out of date."

Even if you're turned down, that is not necessarily the final word. If a preauthorization request or a claim is denied, an attorney, healthcare advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service's medical necessity and appropriateness.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving half the states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer buys its coverage from an insurance company or is funding the plan itself. If the employer's plan is self-funded, it is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer can decide what health care is or is not covered.

In the Human Rights Campaign's 2023-2024 Corporate Equality Index, a record 94% of the companies it evaluated offered at least one transgender-inclusive plan option.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov Marketplace. Most insurers have eliminated transgender-specific exclusions, which ACA regulations explicitly ban.

Still, policies vary by state and in what they cover. As the Healthcare.gov website notes, "Many health plans are still using exclusions such as 'services related to sex change' or 'sex reassignment surgery' to deny coverage to transgender people for certain health care services."

It suggests that before enrolling in a plan, consumers should carefully review its terms: "Plans might use different language to describe these kinds of exclusions. Look for language like 'All procedures related to being transgender are not covered.' Other terms to look for include 'gender change,' 'transsexualism,' 'gender identity disorder,' and 'gender identity dysphoria.'"

Fortunately, according to Out2Enroll, an organization connecting the LGBT+ community with healthcare coverage, when it recently reviewed silver Marketplace options in 32 states it found that "the vast majority of insurers did not use transgender-specific exclusions" and that "40% of plans had language indicating that all or some medically necessary gender-affirming care would be covered by the plan." (ACA coverage is broken down into bronze, silver, gold, and platinum plans, with silver being a moderately priced level.)

Out2Enroll also has state-specific Transgender Health Insurance Guides on its website for help in choosing a plan.

Medicare and Medicaid Coverage

About 6% of transgender adults receive their health coverage from Medicare, the federal insurance program primarily for Americans over age 65. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Private Medicare Advantage plans should abide by the same rules as traditional Medicare, but patients on such plans should try to get preauthorization before accessing transition-related services, the National Center for Transgender Equality advises.

Some 21% of transgender adults receive Medicaid, the joint federal and state health insurance plan for low-income Americans. On a state-by-state basis, Medicaid coverage is uneven. Medicaid programs explicitly cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in 10 states bar coverage of transgender-related care for people of all ages, and programs in three states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access some types of gender-affirming care. TRICARE, the health benefits provider for military members, says it "covers hormone therapy and psychological counseling for gender dysphoria. TRICARE generally doesn't cover surgery for the treatment of gender dysphoria. However, active duty service members may request a waiver for medically necessary, gender affirming surgery."

The Veterans Health Administration offers gender-affirming healthcare, including hormones and prosthetics, mental health care, and other healthcare. Coverage for gender-affirming surgery has traditionally been denied but is currently undergoing a review.

How Much Does Gender-Affirming Surgery Cost?

The cost of gender-affirming care might range from $25,000 to $75,000, according to an estimate from the Human Rights Campaign.

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam's apple removal, and forehead reduction.

Bottom surgery may include:

• Phalloplasty : Creation of penis 
• Metoidioplasty : Phallus created from existing genital region tissue. 
• Hysterectomy : Uterus and cervix removal  
• Nullification surgery : Creating a gender-neutral look in the groin
• Oophorectomy : Removal of one or both ovaries
• Vaginoplasty and vulvoplasty : Creation of vagina and vulva 
• Orchiectomy : Testicle removal 

Research published in 2022 by JAMA Surgery found that while gender-affirming surgery can be costly, insurance (for patients who have it) will often cover most of the cost. Looking at phalloplasty and vaginoplasty procedures specifically, it reported:

However, not all transgender people desire surgery. According to 2019 research statistics, only 28% of transgender women get any type of surgery, and only 4% to 13% receive genital surgery. Surgery is more common among transgender men, with 42% to 54% getting some type of surgery; up to 50% get genital surgery.

How Much Does Gender-Affirming Medication Cost?

Gender-affirming medication is far more common than surgery. As many as 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to the Journal of Law, Medicine & Ethics .

The costs of gender-affirming medications can vary widely. While they are often at least partially covered by insurance, they also come with out-of-pocket costs, which may continue through the patient's lifetime.

For example, a study in the Journal of General Internal Medicine reported that, "in 2019, median prices for feminizing and masculinizing hormone therapy ranged from $6.76 to $91.15 and $31.82 to $398.99, respectively." At the same time, patients' "median out-of-pocket costs ranged from $5.00 to $10.71 and $10.00 to $12.86 for feminizing and masculinizing hormone therapy, respectively." Those prices refer to a 30-day supply.

Other costs can be involved as well. For example, patients who are taking hormones may need periodic blood tests to monitor their health.

A 2020 study in Annals of Family Medicine found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those who are uninsured) were more likely to take nonprescription hormones from unlicensed sources, which may not be monitored for quality and potentially carry serious health risks.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are some options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards cab be another avenue for covering the costs of gender-affirming care or surgery, although they tend to have very high interest rates if you run a balance.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations, such as the Jim Collins Foundation, offer grants for people seeking gender-affirming care or surgery.

Health Accounts 

If you have a flexible spending account (FSA) or health savings account (HSA) , consider allocating some account money for gendering-affirming care or surgery if you are anticipating it.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Loan or Line of Credit (HELOC) 

You could take out a home equity loan or line of credit to cover the costs of gender-affirming care or surgery. With these types of loans, you can typically borrow up to a certain percentage of your home's equity. Interest rates are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can't repay the loan, your could lose your home. 

Friends and Family Loans 

If you've got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. To avoid misunderstandings, it's usually best to have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues, or even strangers.

When you're financing gender-affirming care or surgery, you may be able to save some money if you follow these tips.

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. Doing this homework could save you a lot of money.

Check the Interest Rate Before You Borrow 

Be sure to investigate how much you'll pay to borrow money if you decide to go the credit card or loan route. 

Try Negotiating or Set up a Payment Plan

You can sometimes negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn't willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that will cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-Affirming Care Cost in the U.S.?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. A common range is anywhere from $25,000 to $75,000, according to the Human Rights Campaign. Health insurance may cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one 2019 study, about 31% of the plans it looked at online claimed to cover puberty blockers. That makes it all the more important for patients and their families to shop around for insurance.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress, some people still encounter problems obtaining health insurance to cover such care or paying the out-of-pocket costs involved. People who expect to need gender-affirming care will want to read their insurance plan's coverage details carefully and ask questions if they're unsure about what's covered.

Human Rights Campaign. " Map: Attacks on Gender-Affirming Care by State ."

KFF. " Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions ."

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

UCSF Transgender Care. " Initiating Hormone Therapy ."

American Medical Association. " Transgender Coverage Issue Brief ."

U.S. Department of Health and Human Services. " Section 1557 of the Patient Protection and Affordable Care Act ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan ."

Federal Register. " Vol. 89, No. 88 / Monday, May 6, 2024 / Rules and Regulations ," Page 37701.

Movement Advance Protect. " Healthcare Laws and Policies ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan: Differences Between Self-Funded and Insured Plans. "

Human Rights Campaign. " Corporate Equality Index 2023-2024 ."

HealthCare.gov. " Transgender Health Care ."  

Out2Enroll. " Plan Information for 2024 ."

Healthcare.gov. " How to Pick a Health Insurance Plan ."

KFF. " Trans People in the U.S.: Identities, Demographics, Wellbeing. "

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

TRICARE. " Gender Dysphoria Services ."

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Annals of Family Medicine, November 2020. " Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ," See Abstract: Results.

Translational Andrology and Urology. " Demographic and Temporal Trends in Transgender Identities and Gender Confirming Surgery ."

JAMA Surgery. " Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the U.S. "

The Journal of Law, Medicine, and Ethics. " Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population ."

Journal of General Internal Medicine. " Gender Affirming Hormone Therapy Spending and Use in the USA, 2013-2019 ."

Transgender Health. April 11, 2019. " Health Care Insurance of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information ," See Table 1.

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You Won't Believe How Much It Costs to Be Transgender in America

I decided to come out to my family and friends as transgender at 15. At the time I didn't really know what impact that decision would have on my life, but I knew I'd been in the wrong body for as long as I could remember. I didn't quite have the words to articulate my feelings until I found a YouTube of someone transitioning. I realized there was a medical term for the feelings, and that I too could transition to the gender I identified with — I was born a boy, but now I could become a girl.

Luckily, everyone I told was extremely understanding and supportive. My parents took the time to educate themselves on the issue and did everything in their power to make my transition as easy as possible. I was incredibly fortunate to have this foundation of support, as one of the greatest setbacks that transgender teens face is being shunned by families. Many in fact, end up homeless or attempting suicide .

Another frequent setback is the cost of transition. It's a very expensive process, and unfortunately, unlike in other Western countries, healthcare doesn't automatically cover most (or any) of these costs . (Some insurances and employers do, however, and the Human Rights Campaign website has an excellent resource that can walk you through the process.) This makes the prospect of transitioning seem unachievable to a lot of people struggling with gender identity. So how much does it all cost exactly? It depends of course on the desired transition, but here are some of the most popular treatments and procedures, and what they've cost me so far. It should also be noted, however, that no one has to undergo any of the below in order to identify as transgender. This is simply my journey.

Hormone Therapy: $1,500/Year

Deciding to transition into the opposite gender is not a decision that should be taken lightly. I underwent two years of therapy despite knowing in my heart that I was making the right choice. This process was one of the most rewarding stages of my transition. It felt liberating to have a healthcare professional validate my decision and help me understand my feelings on a deeper level. Unfortunately, professional therapy costs thousands of dollars a year, and most trans youth simply can’t afford it. Once my therapist and I decided that transitioning was the right decision for me, I began hormone replacement therapy, also known by its nickname: HRT. It's one of the most powerful tools a person transitioning can have at their disposal. I was initially put on anti-androgens to halt my body’s production of testosterone. This stopped my male puberty right in its tracks, and prevented the development of things like facial hair, excessive muscle, and a deeper voice. Three months later I was placed on estrogen, which was super exciting for me. Soon thereafter my body began to change—my skin became softer, my fat began redistributing itself to my breasts and hips, and my voice started changing. You can’t even begin to imagine how rewarding this process can be for a transgender teenager. Sadly, this incredibly crucial transformation also comes at a price. I had to visit my MD once a month to have my hormone levels checked, and to renew the prescription for my medication. It also costs a whopping $1,500 every year (at least). Once some people complete their gender reassignment surgery, they stop taking this medication, but I'm still on it. I started when I was 16 and am now 25, so that's about $13,500 so far, and I plan to be on HRT for the rest of my life.

Gender Reassignment Surgery: $30,000-Plus

Nearly two years after beginning my therapy and hormone replacement therapy, I was ready for my gender reassignment surgery at 18. In order to have this surgery, most doctors will require proof of at least two years of therapy, as this is not a reversible procedure. They also need to be certain that you're fully aware of the decision that you're making and all of its consequences. For me, it was one of the happiest moments in my life. There are really no words to describe the excitement and anticipation I felt leading up to surgery. I will say, however, that I cannot stress enough enough how important it is to do your research before choosing a GRS surgeon. Only a handful of doctors in the world are truly experts in this field, and choosing the wrong one can lead to catastrophic results. This step in the transition is very expensive, and the average cost is upwards of $30,000. In addition to the actual procedure, you also have to pay for travel costs and hotel accommodations if a good physician does not live in your neighborhood. But in my opinion, this is a small price to pay for a lifetime of completion. I feel incredibly blessed that I had the opportunity at such a young age, and the opportunity to live my life in a way that feels true to me, in part, because of this surgery.

Facial Feminization Surgery: $25,000-$60,000

A year after having gender reassignment surgery, I went back under the knife for facial feminization surgery — a set of reconstructive procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. In my personal experience, this is the most life changing surgery of them all. As a young transgender woman, nothing was more important to me than being able to "blend" into society seamlessly. It's not only crucial for vanity reasons (what girl wants to look like a boy?), but also for safety reasons. Being trans often subjects you to discrimination, bullying, and physical aggression .

It's so important to members of the trans community that our outward appearance and inner self are in complete harmony. Speaking from personal experience, although not often, I did occasionally come across some level of bullying prior to having FFS. It's simply a lot easier to be singled out and targeted when the aggressor can identify you as being trans. But again, there's a price to pay for the procedure. Board certified surgeons that are qualified to do these procedures will charge anywhere from $25,000 to $60,000 depending on the amount of work you get. Mine cost about $30,000 , as I only opted for the procedures that I thought would benefit me the most at the time, which were forehead and jawline contouring.

Breast Augmentation: $5,000-$10,000

Having a breast augmentation as a transgender woman is an entirely personal choice. I know many who have chosen not to, and instead let their hormones do all the work when it comes to breast development. I chose to have surgery because I wanted a fuller bosom, and my hormones didn't help completely on that front. This surgery will cost between $5,000 and $10,000, and it all depends on the surgeon you choose, where that person is located, and what type of implant you want. Breast augmentation was by far the most painful of all the surgeries. In fact, after all the other procedures, I usually only felt some level of discomfort. When I woke up from this one, it was like an elephant was sitting on my chest.

Looking back at those two years of my life, from about 16 to 19, in which most of my transition took place, I often tell friends that I didn’t feel any less "female" prior to having the surgeries. And I think this is very important. Transitioning simply brought all the puzzle pieces together. I never had a waking moment where I thought in order to feel or be female, I needed to undergo multiple surgeries. My brain, heart, and soul felt 100% female prior to transition. Oftentimes, after surgery, my relatives would ask if I felt any different. My answer was always the same: no. I've always been the same old Elle.

I chose to undergo these surgeries to better my life experience, not to "become" female because I already was. Nowadays, I really only think about the process of transition when I am filming a Youtube video related to it. My journey into the person I am today would not have been possible if that 15-year-old me hadn't stumbled upon someone else going through the same thing. I hope I can help others in the same way.

For more information on transgender individuals and some of the issues and hardships they frequently face, check out the LGBT organization, the Human Rights Campaign .

Related: Trans Teen Wins Right to Use Bathroom of His Choice

Check out Teen Vogue ’s December/January issue cover star, Fernanda Ly.

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Americans considering gender-affirming surgery can find themselves at the start of an exciting new chapter but the costs to be steep. For many, managing the expenses related to transitioning requires planning and may call for more than one financing solution.

Wolsey Bradley and his wife, Lucky, had to be creative in financing their procedures. The couple used credit cards, medical credit cards, cash and insurance to pay for nearly $50,000 in medical expenses related to their transitions.

"We’ve probably paid for our surgeries in every way you can think of," Wolsey says.

Borrowing money or financing a procedure can also be an option when savings or insurance doesn’t cover all the costs.

How much does gender-affirming surgery cost?

The price tag for individual gender-affirming surgical procedures can range from $8,000 to $64,000, according to 2022 research in the Journal for Law, Medicine and Ethics. The cost generally covers the surgeon’s fee, facility costs, anesthesia fees, medical tests, medication and post-surgery needs, depending on the type of procedure.

For people who need a series of procedures, the combined expenses can reach six figures.

Ways to finance gender-affirming surgery costs

The best-case scenario is for health insurance to cover the costs of gender-affirming surgery, also known as gender-confirmation surgery. If that’s not an option, other ways include personal loans and credit cards. Consider these options to pay for gender-affirming surgery and care:

Online personal loan.

Credit union personal loan.

Credit card.

CareCredit.

Home equity line of credit.

Family loan.

Online personal loan

Online lenders offer unsecured personal loans that can be used for almost any purpose, including medical costs. Loan amounts range from $1,000 to $100,000, and interest rates and monthly payments are fixed over the life of the loan.

Online lenders typically let you pre-qualify and apply for a personal loan online, and some loans have next-day funding. However, online loans can be one of the most expensive ways to cover gender-affirming surgery costs. Compare the annual percentage rates (APRs) of multiple lenders to receive the best rates and monthly payments that fit your budget.

Use our personal loan calculator to see estimated rates and monthly payments.

Whom it’s best for: Borrowers who qualify for a low rate and prefer an online experience.

» MORE: Compare medical loans

Credit union personal loan

Credit unions also offer personal loans, often with lower rates and more flexible terms than those of online lenders. Like online lenders, credit unions set loan terms based on your credit score and history, but some may consider factors outside your credit score, making it easier to qualify for funding. The loan amounts offered may not cover the total cost of surgery, and you must qualify for credit union membership.

Whom it’s best for: Credit union members and those with thin or imperfect credit histories.

Credit card

Credit cards are one way to cover a small procedure or a portion of a costlier surgery, but interest rates can be high.

If you have good or excellent credit (a score of 690 or above), you could be eligible for a credit card with an introductory 0% APR . There is no interest during the card's promotional period, which can usually last 15 to 21 months. You have to pay off the balance within the promotional period to avoid paying interest.

When using a credit card, ensure that your medical costs don't reach the credit limit, which can negatively affect your credit score.

Whom it’s best for: Cardholders with a comfortable amount of credit available and who are looking to pay for minor procedures.

Wolsey says he used CareCredit to help cover $5,000 of his nearly $15,000 chest reconstruction surgery cost. CareCredit is a credit card used specifically for financing health care expenses . If your doctor accepts it, you can apply at their office or online.

CareCredit offers attractive zero-interest promotional financing for a designated term, but unlike most 0% APR credit cards, it defers interest . That means if you don’t pay your balance within the promo period, you must pay all your interest retroactively from the date of purchase. CareCredit’s standard APR is 29.99%, which may be higher than the rates of other credit card issuers.

Whom it’s best for: Individuals who need help covering a small procedure or a portion of a larger procedure and can pay off the debt within the promotional period.

Home equity line of credit

If you own a house, a home equity line of credit allows you to borrow against it, sometimes up to 85% of its appraised value minus any amount you still owe on the mortgage. You can borrow and repay the funds as often as needed during the term, and highly qualified borrowers may get lower APRs.

However, you could lose your home if you can’t repay the HELOC. Interest rates are usually variable, so monthly payments could fluctuate, and some HELOCs have closing costs, an appraisal fee or other fees.

Whom it’s best for: Homeowners with equity in their homes who are unsure of the total cost or number of procedures they’ll have and want flexible credit to draw from.

Family loan

A no-interest or low-interest loan from a relative may be an affordable and lowest-risk option. However, it’s worth weighing the potential impact of this arrangement on your relationship with the family member. Formalizing the process with a promissory note — a document that details factors like interest and repayment terms — and consulting a tax preparer can help make the feeling of borrowing from family easier.

Whom it’s best for: Those looking for a low-cost way to pay for the procedures and who feel comfortable borrowing from family members.

» MORE: Family loans: How to borrow from and lend to family

Other ways to cover gender-affirming care costs

Surgery grants.

Some foundations and organizations offer grants — funds that don’t need to be repaid — for gender-affirming surgery. The Jim Collins Foundation , Point of Pride and Genderbands are examples of organizations that offer funding. Check their websites for eligibility requirements and application deadlines.

Flexible spending accounts

Your employer-provided insurance may allow you to contribute to a flexible spending account, up to $3,050 annually. The money in an FSA isn't taxed and can be used to pay out-of-pocket health expenses like co-pays or prescriptions.

Payment plan

Some health care providers allow you to set up payment plans that break up large medical bills into more affordable monthly payments. The total monthly payment depends on the procedure’s cost and terms you negotiate with your health care provider, and there may be billing charges or fees associated with the plan.

» MORE: How to pay off medical bills: 6 options

Additional tips: Compare and plan

After managing thousands of dollars in medical expenses — and spreadsheets to track them — Wolsey and Lucky have found additional ways to save on costly surgeries.

Don’t always choose the cheapest option

It may be tempting to shop based on price alone, but it benefits you to find a reputable surgeon with experience in the procedures you need. Working with someone unsuitable could mean you’ll have to pay someone else to fix mistakes — something that Lucky has witnessed in her community.

“I had a couple of friends who went with a cheaper surgeon just because it was less money, and they ended up spending a lot more because other surgeons had to fix it," she says.

Compare options

Having multiple options allows you to make the best decision for yourself and your budget.

"You can go into any surgeon’s office and get them to give you a quote. It’s like buying a car," Wolsey says. Through this approach, Wolsey and Lucky found a surgeon who performed the procedures they needed at a more affordable price.

“The surgeon who did my first bottom surgery and Lucky’s final round of facial feminization surgery does time on the table. She does not charge for each individual procedure she does.”

Budget and plan

Before you take out a loan or apply for a credit card, add the monthly payments into your budget to determine whether you can afford them.

“I think financially you really have to check what you have. You have to be really aware of how well you are budgeting and paying off debt,” Wolsey says.

On a similar note...

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Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population

Kellan baker.

1: WHITMAN-WALKER INSTITUTE, WASHINGTON, DC, USA

2: JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH, BALTIMORE, MD, USA

Arjee Restar

3: CENTER FOR APPLIED TRANSGENDER STUDIES, CHICAGO, IL, USA

4: UNIVERSITY OF WASHINGTON, SEATTLE, WA, USA.

Associated Data

For supplementary material accompanying this paper visit https://doi.org/10.1017/jme.2022.87.

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services.

Introduction

Transgender people have a gender identity that is different from the sex they were assigned at birth, and many seek multiple ways to access and attain gender affirmation across their lifetime. 1 Gender affirmation refers to the multifaceted ways in which one may attain recognition of their gender socially (by publicly expressing their gender), psychologically (by rejecting internalized transphobia), legally (by correcting their gender marker and name on identification documents and records), and medically (by pursuing medical interventions like hormones or surgery). 2 Gender affirmation is a non-linear, non-prescriptive pathway that is tailored to individual goals and affirmation needs, and it has been linked to multiple positive health outcomes such as better quality of life; 3 lower rates of mental health conditions such as depression, anxiety, and psychological distress; 4 decrease in or elimination of distress associated with gender dysphoria; and mitigation of stigma. 5

In the context of medical interventions, the Standards of Care for Transgender and Gender Diverse People maintained by the World Professional Association for Transgender Health (WPATH) have established categories of health services and procedures that are recognized as gender-affirming medical care. These services include psychological support, hormone therapy, and reconstructive surgeries. 6 Hormone therapy typically involves estrogens and anti-androgens for transgender women and other transfeminine people and testosterone for transgender men and other transmasculine people. Surgeries that may be part of gender affirmation for transgender people include genital surgeries, such as phalloplasty or vaginoplasty; gonadectomy; chest surgeries, including mastectomy or mammoplasty; and facial surgeries, particularly for transgender women.

There are multiple structural and economic barriers that transgender people face when seeking gender-affirming medical services and procedures. Compared to the general US population, transgender people are more likely to be uninsured (14% vs. 11%), unemployed (15% vs. 5%), and living in poverty (29% vs. 12%). 7 Even for people with insurance, reports of insurance denials are common, 8 and many people report that deductibles and other out-of-pocket costs like copays and coinsurance for hormones and surgeries are a major economic barrier to pursuing gender-affirmation care. 9 One study using Centers for Medicare and Medicaid Services prescription drug plan formulary files found that out-of-pocket costs for gender-affirming hormone therapy can be substantial, ranging between $84 to $2,716 in 2010 and from $72 to $3,792 in 2018. 10 Moreover, insurers often require proof of referral letters for hormone initiation as well as surgical procedures from mental health professionals, which can also serve as a limiting factor given the inadequate workforce capacity of gender-affirming therapists, counselors, social workers, primary care providers, and surgeons, particularly in geographical areas that are prone to insurance network inadequacy issues and policy restrictions in the US. 11

The objective of the present study was to investigate temporal trends in coding, utilization, and costs of gender-affirming hormone therapy and surgeries using a proprietary commercial insurance claims database that captures all encounters for enrolled beneficiaries.

As a step to providing coverage of gender-affirming care, one imperfect approach has been to characterize a need for gender-affirming care using diagnoses such as gender dysphoria, which replaced gender identity disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 12 This change, like the revision to the International Classification of Diseases , 11th Revision (ICD-11) to create a new diagnosis of gender incongruence (codes: HA60, HA61, HA6Z), clarifies that the target of gender-affirming medical interventions is not the person’s gender identity itself but rather the clinically significant distress that can accompany a lack of alignment between gender identity and sex assigned at birth. 13

Over the last decade, interest among insurance carriers, regulators, and medical coders about trends in gender-affirming care has grown as nondiscrimination laws and private employer practices have evolved toward ensuring coverage for and broadening the availability of these services. 14 Because no national health survey consistently asks questions about gender identity, efforts to track trends and measure the effects of coverage changes have focused on alternative sources of data, such as insurance claims. 15 The objective of the present study was to investigate temporal trends in coding, utilization, and costs of gender-affirming hormone therapy and surgeries using a proprietary commercial insurance claims database that captures all encounters for enrolled beneficiaries. We anticipated that transgender people in this database would be identified in all geographic regions and that claims for hormone therapy and gender-affirming surgeries would come from diverse clinical specialties and would increase over time, particularly in the period after 2010, when the Affordable Care Act (ACA) made private health insurance broadly more accessible and both public and private payers began to remove coverage exclusions of gender-affirming care. 16 We also expected that the age at which transgender people were first identified in the database would drop over time in parallel with general U.S. population trends, which have shown increasing numbers of people identifying as transgender at younger ages. 17 Finally, we anticipated that the system-wide costs of gender-affirming care would increase over time as insurance coverage of these services became more common, but that the impact of covering gender-affirming care on payers’ budgets would be small.

We accessed the OptumLabs Data Warehouse (OLDW), which contains insurance claims data for more than 200 million people covered by commercial and Medicare Advantage plans. The OLDW Unified View provides nationwide de-identified physician, facility, and pharmacy claims, as well as person-level enrollment and demographic information. Claims include ICD-9 and ICD-10 diagnostic codes (up to five codes for physician claims and up to nine codes plus any admitting diagnosis, if present, for facility claims), Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, health plan and patient paid amounts, type of facility, provider type, and an internal provider identification number. OLDW is a closed system that captures complete records of health service utilization during periods of enrollment. Claims data are refreshed monthly and are accessible for research after a six-month lag. The demographic information in the Unified View is year of birth, recorded sex, census region, and race/ethnicity. Race/ethnicity is imputed through a proprietary process by a third party and provided to OLDW for use in analyses. Most fields are 100 percent populated, with the exception of imputed race/ethnicity, which is approximately 70 percent complete. Individuals receive a unique identifier and can be followed over time whenever they are enrolled in coverage.

Study Population

Using an approach developed by researchers at the Veterans Administration (VA) and elsewhere, 18 we identified transgender people by searching OLDW for transgender-specific diagnostic codes in all physician and facility claims of people with simultaneous commercial medical and pharmacy coverage. Medicare Advantage enrollees were not included. Before the U.S. conversion to ICD-10 in mid-2015, we searched for the following ICD-9 codes in any diagnosis position: transsexualism (302.5x), gender identity disorder in children (302.6), and gender identity disorder in adolescents and adults (302.85). In 2015 and later, we added the following ICD-10 codes in any position: transsexualism (F64.0); gender identity disorder in adolescence or adulthood (F64.1); gender identity disorder in childhood (F64.2); other gender identity disorders (F64.8); gender identity disorder, unspecified (F64.9); and personal history of sex reassignment (Z87.890). 19 To improve specificity, we required two instances of at least one code separated by 30 days in the claims history. 20 The first appearance of any transgender-specific diagnosis code in a person’s claims history was designated as their index date of diagnosis, which was used to assess trends in the age at which people received their first transgender-specific code in the OLDW database. Research indicates that a child’s sense of gender identity typically develops around the age of three, so we excluded children who were younger than three on their index date. 21

To assess trends in prescribing patterns, we extracted the transgender-specific diagnostic codes assigned on each person’s index date, along with the demographic variables of year of birth, race/ethnicity, region, and recorded sex. We categorized age in 2021 as 4-17, 18-29, 30-39, 40-49, 50-59, 60-69, and 70+; race/ethnicity as white, Black, Asian, Hispanic, or unknown; and location by census region (Northeast, South, Midwest, West). Recorded sex was either male or female; OLDW contains very few instances of sex being recorded as “unknown,” so we dropped those rare cases. It was impossible to know whether this variable referred to gender identity or to sex assigned at birth, so while it was included as a covariate, it should not be interpreted as a true estimate of the proportions of transmasculine and transfeminine people in the database. To assess patterns in use of transgender-specific diagnostic codes by specialty, we also extracted the internal OLDW identification number and specialty of clinicians who assigned these codes in any encounter, regardless of whether it was the index diagnosis.

Outcome Measures

Following published guidelines for hormone therapy in transgender people, 22 we characterized gender-affirming testosterone therapy as at least one pharmacy claim for any formulation of testosterone without any claim for an estrogen formulation; for transgender women and other transfeminine people, gender-affirming hormone therapy was at least one claim for an estrogen formulation with at least one claim for an anti-androgen such as spironolactone or bicalutamide. Dutasteride and finasteride, which may be used by transfeminine people for purposes of gender affirmation but also by transmasculine people to prevent hair loss associated with testosterone use, were not included. 23 We classified people with claims for both testosterone and estrogen formulations as transmasculine because of the potential use of estrogen formulations for birth control among people assigned female at birth, regardless of gender identity. We did not use recorded sex data to classify hormone therapy because it was impossible to determine whether the sex variable in the database referred to current gender identity or to assigned sex at birth. Gonadotropin-releasing hormone (GnRH) analogs, which may be prescribed to transgender adolescents of any gender to delay the onset of puberty as a precursor to eventual hormone replacement therapy with testosterone or estrogens, were included as a separate category. For each gender-affirming hormone therapy claim, we extracted the generic and brand names, dosage, out-of-pocket and health plan paid amounts, and the prescribing provider’s specialty and internal OLDW identification number (Appendix A, Table A.1).

To identify gender-affirming surgeries, we first extracted all physician and facility claims that included a transgender-specific ICD-9 or ICD-10 diagnostic code in any position. We then used published coverage protocols 24 to identify claims with ICD-9 or ICD-10 procedure codes or CPT codes that can be used to bill for the following categories of gender-affirming surgical procedures: phalloplasty or metoidioplasty, hysterectomy, and mastectomy for transgender men and other transmasculine people and vaginoplasty, orchiectomy, mammoplasty, and facial feminization for transgender women and other transfeminine people (Appendix A, Table A.2). Codes that could not be readily associated with a specific gender were grouped as “unspecified top surgery” (i.e., mastectomy or mammoplasty) or “unspecified genital surgery” (i.e., phalloplasty/metoidioplasty or vaginoplasty). We confirmed the composition of this code list with a surgeon who performs high volumes of these procedures (Loren Schecter, personal communication, August 20, 2019).

Descriptive Analyses

We calculated the incidence by year of transgender people newly identified in OLDW using their index date. The denominator for both annual incidence and the total number of transgender people with coverage by year was the count of all people with commercial coverage in OLDW in that year. We explored trends in coding by calculating the mean age at index diagnosis for people with index dates between 1993 to 2000, 2001 to 2010, and 2011 to 2020, as well as by assessing the relative proportions of transgender-specific diagnostic codes assigned by each clinical specialty. We used χ 2 tests to compare index codes by demographics.

The assessment of gender-affirming health services utilization consisted of annual counts of individual hormone therapy prescriptions in each category (testosterone, estrogens plus anti-androgens, and GnRH analogs), annual counts of the number of people receiving any gender-affirming hormone therapy prescription, counts of episodes of individual surgical procedures in each category of surgeries by year, and annual counts of transgender people who underwent any gender-affirming surgical procedure. Procedures that occurred within 14 days of each other were counted as a single episode. We calculated the percentage of people who received hormone therapy or a surgical procedure among all individuals identified as transgender in the database who were enrolled in coverage for any part of each year. We used multivariable logistic regression models to identify demographic characteristics associated with receipt of hormone therapy or gender-affirming surgery. Statistical significance was set at α = 0.05, and analyses were conducted in R (version 4.0.2).

Annual costs for each category of hormone therapy were calculated from a payer perspective by summing the health plan paid costs; we also calculated average annual health plan paid costs per person for each category. Average and annual costs for each type of surgery were similarly calculated from a payer perspective, and all costs incurred during the 14-day window after each procedure were included. We calculated the annual budget impact of the overall cost of gender-affirming care, including all types of hormone therapy and surgical procedures, using the total OLDW population with commercial coverage in each year as the denominator. All costs were estimated in 2019 dollars.

We identified 16,619 people who had physician or facility claims and met our inclusion criteria between 1993 and 2019. Of this group, 15,790 also had pharmacy claims. The annual incidence of index codes, meaning the appearance of an individual’s first transgender-specific code in the database, rose from 4 per million enrollees in 1993 to 149 per million in 2019, with more than 80 percent of that growth occurring between 2011 and 2019. Between 1993 and 2000 and between 2001 and 2010, an average of 18 and 166 people, respectively, received a transgender-specific code for the first time each year; between 2011 and 2019, an average of 1,646 people were newly identified as transgender in OLDW each year. The number of people in OLDW with transgender codes in each year similarly increased slowly through the first two decades before beginning an exponential rise around 2011 ( Figure 2.1 ). In 1993, the number of transgender people with coverage in OLDW was 71 per million enrollees; this number rose slowly to 178 per million in 2010 before climbing rapidly to 411 per million by 2019. The mean age at index diagnosis declined from 33.9 years in 1993 to 26.3 years in 2019 ( Figure 2.2 ). The transgender population was young, with the largest proportion (46%) in the age group between 18 and 29 as of 2019. The majority were identified in the database as female (53%) and white (67%), and most (35%) lived in the South, where OLDW has large representation ( Table 2.1 ).

Annual New Identifications and Total Count of Transgender People in the OptumLabs Data Warehouse, 1993-2019

Age Distribution of Newly Identified Transgender People by Index Year, 1993-2019

Demographics of Transgender People Identified in the OptumLabs Data Warehouse, 1993-2019

The most common index code during the ICD-9 period was the non-specific code 302.85 (Gender Identity Disorder in Adolescents or Adults). Codes with sexual orientation subclassification (e.g., 302.53; Transsexualism, Heterosexual Sexual History) became less common throughout the ICD-9 period; these codes were phased out in the conversion to ICD-10 in mid-2015 (Appendix A, Figure A.1 ). Immediately following the conversion, there was a temporary spike in the use of F64.1 (Dual-Role Transvestism). There was no increase over time in the use of codes specific to children (e.g., F64.2, Gender Identity Disorder in Childhood). While transgender-specific diagnostic codes typically appeared in claims for services that could be part of gender affirmation, including mental health counseling as well as hormone therapy and surgeries, the use of these codes was not confined to gender-affirming care: these codes were also identified in claims for encounters such as arthroscopic knee surgeries and influenza vaccines. The provider specialties that used these codes most often were social work, family practice, and psychology (Appendix A, Figure A.2 ).

Seventy-two percent of transgender people had at least one encounter for gender-affirming hormone therapy. The clinical specialties most likely to write prescriptions for hormone therapy were family practice (28%) and endocrinology (18%) (Appendix A, Table A.3 ). Many individual providers were represented, and no single provider wrote more than 1.6 percent of all the prescriptions in the claims database. Hormone therapy by gender was roughly even between transmasculine and transfeminine regimens: 46 and 54 percent of people on hormone therapy were classified as transmasculine or transfeminine, respectively. Only 0.4 percent of those on hormone therapy were observed to have received GnRH treatment, and 78 percent of those who had been on GnRH treatment subsequently received prescriptions for estrogens or testosterone. While the number of people on GnRH treatment remained consistently low, the number of people receiving hormone therapy with estrogen or testosterone increased rapidly beginning around 2011 ( Figures 2.3 and 2.4 ). In 2011, 17 percent of transgender people identified in this database were receiving gender-affirming hormone therapy, and by 2019 this proportion had increased almost 4-fold, to 65 percent. The average payer costs of gender-affirming hormones were consistently low for both testosterone and estrogen therapy, at $121 and $153 per year; GnRH therapy cost an average of $2,410 per person per year ( Table 2.2 ). As a proportion of total costs, out-of-pocket spending per year was 38 percent for estrogens, 25 percent for testosterone, and 8 percent for GnRH.

Number of People with Claims for Gender-Affirming Hormone Therapy by Year and Medication Type, 1993-2019

Annual Health Plan Paid Cost by Gender-Affirming Hormone Therapy Type, 1993-2019

Frequency and Costs of Claims for Gender-Affirming Hormone Therapy, 1993-2019

GnRH = gonadotropin-releasing hormone

* Average weighted by proportion of people with prescriptions for each type of therapy; denominator is the total number of transgender people identified in OLDW (N = 16,619)

Temporal trends in the frequency of gender-affirming surgeries paralleled those of hormone therapy. Throughout the first two decades of claims, gender-affirming surgeries were performed infrequently, if at all, but the annual number of procedures performed began to increase around 2011: in 2011, 21 people (0.5% of all transgender people with coverage that year) underwent a gender-affirming surgery, and by 2019, that number had risen to 794 (8%) ( Figures 2.5 and 2.6 ). Overall, 14 percent of the transgender people identified for this analysis had ever undergone a gender-affirming surgery while enrolled in OLDW, of which mastectomy was the most common procedure. The per-episode payer costs of gender-affirming surgeries ranged from $6,927 for orchiectomy to $45,080 for vaginoplasty and $63,432 for phalloplasty ( Table 2.3 ). As vaginoplasty and phalloplasty were frequently multi-episode procedures, the total average cost of these procedures per person was $53,645 and $133,911, respectively. There were substantially lower odds of having undergone surgery among people living in the South (adjusted odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.63, 0.88), although there were no differences by imputed race (Appendix A, Table A.4 ). No single provider was responsible for more than 6.6 percent of surgeries.

Number of Gender-Affirming Surgical Procedures by Year, 2010-2019

Annual Health Plan Paid Cost by Gender-Affirming Procedure Type, 2010-2019

Frequency and Costs of Claims for Gender-Affirming Surgeries, 1993-2019

Over the time period covered by this study, the annual frequency of gender-affirming hormone therapy and surgeries increased both in absolute terms and as a proportion of the number of transgender people identified in the database, and costs changed accordingly. In 2019, each covered transgender person incurred an average of $1,776 in costs for gender-affirming hormone therapy and surgeries combined. Considered on a per-member basis across the entire commercially insured population in OLDW, the budget impact of gender-affirming care in 2019 was $0.73 per year, or $0.06 per member per month (PMPM).

To our knowledge, this is the first study to evaluate temporal trends in coding, utilization, and costs for both gender-affirming hormone therapy and surgeries. We found that the number of people receiving transgender-specific diagnostic codes and accessing gender-affirming care in this privately insured population has increased rapidly over the decade between 2011 and 2019. Even as coverage of gender-affirming care has expanded, its budget impact remains small: the PMPM estimate of providing gender-affirming care in 2019 was $0.06 when distributed across all people with commercial coverage in OLDW. This is in line with estimates from a cost-effectiveness study that estimated the costs of coverage for gender-affirming care at $0.016 when spread across the entire U.S. population. 25

These trends in utilization of gender-affirming health services align with broader societal trends in the visibility of transgender people. The time frame of this increase coincides with policy reforms over the last decade lifting several barriers that previously limited both the use of transgender-specific codes and the provision of gender-affirming care. In 2010, the ACA introduced new guaranteed-issue protections in private insurance that were interpreted by the U.S. Department of Health and Human Services (HHS) to prohibit the designation of a transgender identity as a pre-existing condition for which insurance coverage could be restricted or denied. 34 Between 2010 and 2014, HHS promulgated several regulations that codified nondiscrimination protections on the basis of gender identity in insurance marketing, benefit design, and coverage determinations. 26 Around the same time, individual states began to adopt or strengthen similar protections by interpreting existing law to prohibit unfair discrimination against transgender people in both state-regulated health insurance markets and state Medicaid programs. 27 These reforms included the 2014 rescission of Medicare’s ban on coverage for gender-affirming surgeries and a 2016 HHS regulation that prohibited blanket exclusions of gender-affirming care in both public and private coverage. 28 Though the Trump administration revised that regulation in 2020 and future activity by the Biden administration remains unknown, state and federal courts have consistently found that discrimination against transgender people on the basis of gender identity is a form of sex discrimination. 29 As of early 2021, 24 states and territories prohibited blanket transgender coverage exclusions in state-regulated private coverage, up from one in the pre-2010 period. 30 The biggest increase in the number of people being identified as transgender in OLDW in the decade between 2010 and 2020 occurred in the South, where no states apart from Virginia, Maryland, and Delaware have state-specific protections. This pattern is consistent with the hypothesis that the 2016 national regulation played a substantial role in removing barriers to private coverage for transgender people, though more research is needed to explore this possibility.

The findings of this study indicate that the impact of gender-affirming care on payer budgets has remained nominal even as national trends in coverage policies have made this care more accessible to transgender people. Future directions for research include assessing the health outcomes associated with access to gender-affirming care, improving methods for identifying transgender people in insurance claims databases, and investigating opportunities to link different data sources to provide a more complete picture of the health needs and experiences of transgender people.

As restrictions on coverage for gender-affirming care have receded, other studies using data sources such as the National Inpatient Sample have identified increases in the number of gender-affirming surgeries performed in the U.S. 31 The present study expands this evidence base by analyzing the frequency of individual procedures and assessing trends in hormone therapy use as well; a better understanding of the availability and uptake of both gender-affirming surgeries and hormone therapy is important for insurance carriers seeking to ensure the adequacy of their coverage and provider networks for these services and for hospitals and other health service organizations identifying trends in patient care needs. These data may also help federal and state insurance regulators establish baseline estimates of service availability and utilization, which can be used to monitor market conduct and identify potential concerns related to inadequacy of benefit designs or inappropriate use of utilization management tools. For instance, this study found that utilization of GnRH treatment remained low, even as the number of people identified in the 4-17 age group increased. This pattern is consistent with reports that barriers in insurance coverage of GnRH treatment for transgender adolescents remain high. 32 Some regulators are beginning to explore the degree to which restrictions on coverage of GnRH treatment for this population may violate nondiscrimination requirements on the basis of gender identity and age. 33

Limitations

This study has several limitations, many of which relate to the difficulty of using diagnoses in insurance claims as proxies for gender identity, which is a complex aspect of personal identity that has social, legal, and medical components. Because this insurance claims database does not currently include any self-reported data on gender identity, it was not possible to determine how many people in the database would self-identify as transgender but are not captured by the algorithm based on transgender-specific diagnostic codes. The proportion of the population in this database that was identified as transgender was 411 per million in 2019 (0.04%), which is comparable to other estimates from clinical records but much less than estimates from more representative population surveys that use self-report, which range between 0.1 percent and 2.0 percent. 34 It was also impossible to definitively identify claims for gender-affirming care, as the assessment of coding practices indicated that these codes may be applied to services provided to transgender people that do not have any relation to gender affirmation. We thus may have incorrectly categorized unrelated services as gender-affirming care; this was a particular concern with services that may be more commonly needed for other indications, such as hysterectomy and estrogen therapy.

At the same time, we may have missed services and procedures that were provided for purposes of gender affirmation but were not submitted with transgender-specific diagnostic codes. The number of claims with procedure codes that might indicate a gender-affirming service but that were not coded with relevant diagnostic codes was very small among the group of people identified as transgender, but it was not possible to know how many such procedures for purposes of gender affirmation were performed for people who were not included in the transgender group. The routine capture of self-reported gender identity data in clinical records, including both medical records and claims, would aid in assessments of transgender population size and health services costs and use. Similarly, more consistent coding standards guiding the application of both diagnostic codes related to a need for gender-affirming care and procedure codes describing the provision of this care would improve estimates of the frequency and costs of these procedures.

The number of people with transgender-specific diagnostic codes in this commercial insurance claims database has increased sharply over the last decade, in tandem with law and policy changes that seek to remove barriers to coverage for this population. In 2019, almost 10,000 people were identified as transgender in this database, representing 0.04 percent of people with commercial coverage in OLDW. In the same year, 65 percent of people identified as transgender were receiving gender-affirming hormone therapy, and 8 percent had some gender-affirming surgical procedure. The annual cost of providing gender-affirming care for this population was $1,776 per person, or $0.06 per member per month. The findings of this study indicate that the impact of gender-affirming care on payer budgets has remained nominal even as national trends in coverage policies have made this care more accessible to transgender people. Future directions for research include assessing the health outcomes associated with access to gender-affirming care, improving methods for identifying transgender people in insurance claims databases, and investigating opportunities to link different data sources to provide a more complete picture of the health needs and experiences of transgender people.

The authors have no conflicts to disclose.

Acknowledgments

Our gratitude goes out to Jodi B. Segal, M.D., M.P.H. of the Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, and Helene Hedian, M.D. of the Johns Hopkins School of Medicine. We would also like to thank Optum Labs and the Robert Wood Johnson Foundation Health Policy Research Scholar Program.

Biographies

Kellan Baker, Ph.D., M.P.H., M.A., is affiliated with the Whitman-Walker Institute, Washington, DC, USA and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Arjee Restar, Ph.D., M.P.H., is affiliated with the Center for Applied Transgender Studies, Chicago, IL, USA and the Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.

Appendix A: Supplementary Material

Hormone Therapy Prescriptions by Provider Specialty

Associations Between Demographic Characteristics and Gender-Affirming Medical Services

OR = odds ratio, CI = confidence interval, Ref = reference category

Index Codes by Year, 1993-2019

Use of Transgender-Specific Codes by Provider Specialty

Supplementary material

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Guide to paying for gender reassignment surgery

Not every trans person opts for surgery, but here's what you need to know if you're considering it

Published: June 3, 2021

Author: Elly Belle

Editor: Adriana Ocañas

Reviewer: Antonio Ruiz-Camacho

How we Choose

With queer and trans people constantly under attack from waves of legislation and discrimination directly targeting them, taking a direct stand against the hate is one of the most impactful actions. Pride month isn’t the only time we should be learning how we can do our part to support people…

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With queer and trans people constantly under attack from waves of legislation and discrimination directly targeting them, taking a direct stand against the hate is one of the most impactful actions.

Pride month isn’t the only time we should be learning how we can do our part to support people in the LGBTQIA+ community, including the estimated 1.4 million U.S. adults who identify as transgender,  but it is an opportune moment to take stock and understand their experiences.

See related: Guide to LGBT finances: You can live a richer life

A few important things to understand about sex, gender and trans people

Sex and gender are not the same thing – and gender is often more personal and culturally constructed. While sex is someone’s biological and physiological characteristics, a person’s gender is the behaviors, roles, expectations and activities they relate to in society.

Not everyone identifies with the sex they were assigned at birth, and thanks to more exposure in pop culture and the amplifying of trans people’s voices, people are increasingly starting to explore their gender identity.

Another important thing to know and consider is transgender people exist everywhere and come from all kinds of backgrounds. They come from all walks of life and of all ethnicities and races. And what it means and looks like to be trans will be different for each person, which is why it’s so critical not to make blanket assumptions about transness.

In many places, it’s still dangerous to be openly trans, and not all trans people are even remotely safe to present as who they truly are inside. Wearing the clothing, makeup or other external accessories that make them feel most affirmed and like themselves is not always possible.

For this and many other reasons, it’s important to remember that you can’t tell someone’s gender just by looking at them.

Gender reassignment procedures

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.

Types of surgeries and their costs

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.

Bottom surgery refers to vaginoplasty, phalloplasty or metoidioplasty, all various procedures that change a person’s genitals to match their gender. Trans women might also opt for facial feminization surgery, so their facial features match how they want to see themselves.

Hormone replacement therapy (HRT) is also a popular mode of transitioning and involves using testosterone or estrogen to reach one’s desired gender presentation.

These methods are not just for binary trans people, or trans men and women, either. Non-binary people and genderqueer people might medically or hormonally transition as well.

The cost breakdown includes:

How to budget for the costs of transitioning

Transitioning isn’t limited to medical costs and procedures. Other things to budget for include post-surgery care or even buying new clothes that match your gender presentation and make you feel affirmed in your identity. It might also include makeup and accessories that help you feel like yourself. And of course, for trans women and transfemmes, much of this will include the pink tax .

Everyday costs

“So far, it’s all been relatively manageable. But I will say that trying to cultivate a wardrobe with gender-affirming looks and clothing has been the most expensive,” says Evelyn, a trans woman who began transitioning within the last half-year. “The biggest thing as a trans woman that has surprised me is shoes. Mainly women’s shoes usually only go up to about 11-12. I have a size 14-15, so most of the time, I would have to order from special stores, or places that custom-make shoes for drag queens.”

Buying new clothing and accessories is not the only option, though. You can do clothing swaps with other trans people, go thrifting or ask friends if they have old clothes they want to get rid of that match your new gender presentation.

Clothing and makeup, despite how expensive they can be, have brought the most joy to Evelyn. “My personality is very extra and outgoing and colorful, and my male-passing clothing always were dull and very narrow fitting. Now, I am buying all these flowy cardigans and scarves and really living my Stevie Nicks meets City girl dreams,” she says.

“I feel so powerful and so happy when I walk around, and the wind picks up my long cardigan and I move with a grace I didn’t think I would ever be able to have.” Despite how much costs can weigh you down, the people who spoke with us explain that transition feels freeing.

Sasha, a Latinx non-binary trans woman who began HRT in January 2020, says that her job in tech and excellent health insurance is what’s made it possible for her to afford transitioning. The most expensive part of her transition, she says, has been hair removal.

“I have spent thousands of dollars on both laser and electrolysis. I looked at my credit card history and to date, I’ve spent $5,003.25 on electrolysis (with probably another $1,500 or so before I’m totally clear of facial hair). As for laser for body hair, I have paid around $3,000 for it so far.”

In total, Sasha has spent about $8,000 just on hair removal, and she says she still has $2,000 or more to go. “This has been far and away the most expensive part of transition because insurance won’t cover it. They will only cover electrolysis for preparation for bottom surgery,” Sasha says.

There are some important things she wishes she’d been told earlier, like the costs and benefits of laser versus electrolysis. While electrolysis is more expensive and takes a longer time, it permanently removes hair. Laser is faster and cheaper but not permanent.

“I decided to go with laser early on in my transition because it was cheaper and seemed to be a good option at the time. For facial hair removal, I would’ve liked to have started out with electrolysis because although it is a slower process, the results are for life. So, I wasted some time and some money on laser for my face early on that I wish I hadn’t,” she says.

Although surgeries and other medical necessities have certainly helped Sasha transition, some of the most affirming purchases she has made in the last few years are accessories that help her feel gender euphoric.

“I bought these leather high-heeled boots that I absolutely love. Playing with makeup is something I always wanted to do and since allowing myself the pleasure, I’ve had so much fun trying different eyeshadows and lipsticks,” she says.

Alex, who has been out as a nonbinary trans woman since 2017, says she’s been most surprised by how quickly transition expenses add up. “They are wildly inaccessible to those without disposable income and require maintenance,” she says of things like budgeting for nail and hair appointments and medspa procedures (like laser hair removal, Botox and fillers).

Legal costs

When transitioning, some people choose to legally change their names and some don’t. The costs can vary depending on where you live. For Sasha, it cost $350 to get a court-ordered name change and publish her name change in a local paper, which is a legally required part of the process.

“I wouldn’t have had to pay that if I had had a legal counsel that guided me through the process of waiving those fees, which is totally possible, but I didn’t know how to navigate it,” she says. Once her name change is official, she’ll also have to pay for copies of the court order.

See related: Major issuers slow to adopt Mastercard True Name card

Social costs

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.

Some of the social costs of transitioning that Alex says she’s experienced include “ongoing stress and hypervigilance when in public, and exhaustion from being hyper-focused on how I’m being perceived by others.”

However, there are also positive, affirming social experiences that come with transition ­– and that joy is just as important to acknowledge and to be able to look forward to.

The pieces of clothing that Alex has invested in that have made her feel like her truest self include crop tops and big pants, neutral blushes and lipstick and skin tints. And the most affirming experience she’s had related to her transition has been relearning what sex and pleasure feels like in her changing body, she explains.

Options on how to pay

Crowdfunding, loans and credit cards are some of the main ways that trans women who spoke with us said they’ve been able to pay for medical bills.

Like Sasha explained, even if you have insurance or a well-paying job, some costs are just too great, and insurance doesn’t cover everything.

Other options to pay for the numerous costs listed above include:

• Personal loan from a credit union: Although credit unions provide virtually all of the same services and products as banks, their goal is to enable members to borrow at the lowest possible cost.
• Credit cards: A 0% APR credit card may be your best option as many offer introductory APR periods of usually 12 months or longer.
• Home equity line of credit: A  HELOC  is a variable-rate home equity product that works like a credit card – you have access to a credit line that you can draw from and pay back as needed.
• CareCredit: Instead of an open-ended date to pay off your debt (like with a regular credit card), a CareCredit credit card has fixed monthly payments over a set term ranging from six months to 60 months.
• Online personal loan : A personal loan is best for people who may need more time to pay down their balances. You’ll get a low fixed rate that can last for several years.
• Family loan: If a family member is willing to help, make sure to formalize the deal by writing up a contract that includes terms, dates and conditions.
• Crowdfunding: GoFundMe and Indiegogo are great examples of crowdfunding platforms.
• Surgery grants: Point of Pride, Genderbands and The Jim Collins Foundation are all great places to start when looking at this option.

See related: When should you use medical credit cards?

Allyship to trans people

“It is still a very dangerous thing to be trans in the world. I am extremely privileged and due to my job and the resources I have, I can shield myself from many of the hardships a lot of other trans people face. Most trans folks don’t have that luxury,” Sasha says.

The best way to support trans people is to give to them directly, she explains. Donating to transition funds is crucial. “If you see a way that directly supports a trans person’s housing, surgeries, HRT, food, etc., whether that be through a GoFundMe, Venmo, or whatever, if you have the resources, give! Especially to Black and Indigenous trans folks,” she says.

“For cis allies, I challenge you to really listen to trans people. I find that when I speak to cis allies, they do a lot of talking and not a lot of listening. Listen to what trans people tell you about what their experience is like living in this world. It will help you understand how to be a better ally.”

Speaking out against transphobia, sharing your own pronouns and respecting others’ pronouns is yet another important way to support trans people. Doing all these things even when you don’t think there are any trans people to hear it or see it is especially necessary. Because not everyone is able to be or wants to be openly trans, you never know what these actions might mean to someone.

Cis people as well as trans people can embrace their unique gender identities in many ways by “cultivating self-reflective practices that make space for you to think about your gender instead of taking it for granted,” says Alex.

“Everyone, cis or not, has their own relationships to gender. Not all cis people adhere to gender roles in the same way. We are all unique and it’s misleading to think that only trans people divert from gender expectations.”

Even if you’re cisgender, embracing your own unique gender identity and exploring your gender presentation can be eye-opening. Understanding your own gender could help you care more about understanding and respecting other people’s, and stands to give you deeper self-knowledge.

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Laura Dorwart

Laura Dorwart is a writer living in Oberlin, Ohio, with her family. She has bylines at VICE, The New York Times, The Guardian and many others. She has a Ph.D. from UCSD, an MFA in nonfiction writing from Antioch University Los Angeles and experience in UX writing and copywriting for brands such as KeyBank. Follow her work at www.lauradorwart.com.

Patrick McHugh

Chief Creative Officer and Cofounder at Euphoria.LGBT

Patrick McHugh is the Chief Creative Officer and Cofounder of Euphoria.LGBT, a health-tech company building technology for the transgender community to alleviate the great pains associated with gender transition. A communications, research and design specialist, McHugh leads the research and content-writing efforts for Solace and Bliss.

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Updated: December 5, 2023

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• Options and Average Costs

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Advertising & Editorial Disclosure

Between 1.4 million and 1.65 million adults in the U.S. identify as transgender, according to the Williams Institute at UCLA's School of Law. For many transgender and gender non-conforming individuals, medical transition is a significant and empowering part of their journey. Transition may include hormonal treatment and/or surgery known as gender confirmation surgery or gender affirmation surgery.

Many transgender individuals go through the process of transition — which includes legal, psychological, social and medical experiences — to resolve gender incongruence between their internal sense of self and external anatomy. Gender identity refers to an individual's experienced gender and sense of self.

Not all transgender people want to undergo gender confirmation surgery. But for those who do, the process can help to alleviate gender dysphoria . Gender confirmation surgery also doesn’t change or “reassign” one’s gender or sex. Instead, it allows transgender and gender non-conforming people to change their bodies to reflect their gender identity more accurately.

While hormonal treatment and/or surgery is a deeply important step for many trans and gender non-conforming people, it can also be expensive. Learn more about the average costs of medical transition care options and find resources and ways to help fund procedures.

Medical Transition Care Options and Average Costs

Medical transition care options are diverse in terms of procedures, costs and outcomes. Each transgender person, along with their medical provider, should choose the options that make the most sense in terms of budget and desired results.

The main two medical transition care options are hormonal transition and gender confirmation surgery. Here’s a breakdown of the average costs of each kind of gender-confirming healthcare treatment.

Hormonal Transition

Average Cost: $20–350/month

The majority of transgender individuals who seek out medical transition choose to undergo hormonal transition, also known as hormone therapy. Because of its relative affordability and accessibility, hormone therapy can be a particularly effective option for those experiencing gender dysphoria or looking for an alternative to surgery. Hormone therapy can help trans men and women, as well as nonbinary and gender non-conforming individuals, achieve significant physical changes.

Patients who undergo masculinizing hormone therapy often take testosterone. Testosterone therapy can affect a patient’s fat distribution, facial characteristics, vocal cords, hair growth patterns, libido, menstrual cycles and more. Testosterone typically comes in the form of injections (approximately $80 per month), patches ($300 per month), and gels ($300–350 per month) .

Patients who go through feminizing hormone therapy often take estrogen or testosterone blockers such as spironolactone and/or progesterone. Like testosterone therapy, this can affect a patient’s voice, facial appearance, libido, fertility, emotions and fat distribution. It can also promote breast development. On average, oral estrogen costs about $20 per month, while estrogen injections can cost up to $200 per month and spironolactone up to $20 per month.

Gender Confirmation Surgeries

Average Cost: $5,000–$50,000

Gender confirmation surgery for transgender patients refers to reconstructive surgeries to bring patients' bodies into conformity with their experienced gender. Surgeries might include reconstruction of the chest and/or face. Depending on the type of surgery, patients may have a recovery period from about two weeks to several months after their initial hospitalization.

Like all surgeries, these procedures come with potential risks. But patients who seek out board-certified surgeons and follow all pre- and post-op guidelines are usually satisfied with their results.

Here are some of the most common gender confirmation surgeries that transgender and gender non-conforming patients seek out.

Types of Surgeries for Trans Men

For trans patients, gender confirmation surgery might include removing breast tissue and reconstructing the chest, facial masculinization surgery (FMS) to make their facial features appear more masculine, removing and reconstructing the external genitalia, and removing internal reproductive organs.

Here are the most common forms of gender confirmation surgery for trans men and nonbinary patients.

Average Cost: $10,000–$50,000

Here is what FMS surgery may include:

• Thyroid cartilage enhancement: An “Adam’s apple” is made using a small incision in the chin area and an implant in the throat region.
• Cheek augmentation: Small incisions inside the mouth allow the surgeon to place implants in the cheek to create a more angular appearance.
• Forehead lengthening or augmentation: Forehead lengthening and augmentation procedures involve lengthening the area between the eyes and scalp, and sometimes placing an implant, to create a more masculine, angular forehead.
• Jaw and chin augmentation: Jaw and chin reshaping and implants can help to widen the face and contour the jawline for more masculine facial proportions.
• Nose reshaping: Rhinoplasty can help to widen the nose and masculinize the facial proportions.

Surgery procedures could include:

• Facial masculinization surgery (FMS): FMS may include thyroid cartilage enhancement, cheek augmentation, forehead lengthening or augmentation, jaw and chin augmentation and nose reshaping.
• Periareolar procedure: The areolas and nipples are resized and repositioned during this surgery. Two circular incisions around the areolas allow the surgeon to remove the “ring” of chest tissue.
• Keyhole procedure: The keyhole procedure involves just one semi-circular incision below each of the nipples. Keyhole top surgery also allows most patients to keep the sensation in their nipple area.
• Double incision: In double incision top surgery, the surgeon makes two incisions at the top and bottom of the pectoral muscles. The nipples and areolas are removed and replaced with nipple grafts.
• Inverted-T top surgery: Inverted-T top surgery involves horizontal and vertical incisions and the removal of chest tissue but not nipples. Sensation is retained for most patients.
• Metoidioplasty: Metoidioplasty involves releasing the clitoris from the ligament attached to it and repositioning it to create a penis. With this procedure, patients can also choose to undergo urethral lengthening and remove vaginal tissue.
• Phalloplasty: Surgeons use skin grafts from other parts of the body (usually the thigh or forearm) to create a penis. A vaginectomy, or the closing of the opening in the front of the pelvis, as well as scrotoplasty, which creates a scrotum, can be included in some phalloplasty procedures. This is the most expensive of bottom surgery options for trans men, with price tags up to $150,000 in some cases.
• Hysterectomy: A hysterectomy includes the removal of the uterus and ovaries.

Types of Surgeries for Trans Women

Around half of trans patients choose to undergo breast augmentation, facial feminization surgery (FFS) (which involves a variety of procedures that make facial features appear more feminine) and the removal or reconstruction of genitalia.

Average Cost: $20,000–$50,000

Facial feminization surgery (FFS) may include:

• Genioplasty: Genioplasty uses surgical incisions inside the mouth to contour the chin for a softer, rounder shape.
• Cheek augmentation: Implants, fat transfers or fillers can soften the face to create a more feminine look.
• Brow lift: A brow lift raises the eyebrows for a shorter forehead, softer look, and enlarged appearance of the eyes.
• Tracheal shave: The neck bump created by thyroid cartilage is reduced in a tracheal shave.
• Lip lift or augmentation: Lip augmentation can be achieved with implants and fillers. A lip lift emphasizes the upper lip.

Here are some of the most common gender confirmation surgeries for trans women:

• Facial feminization surgery (FFS): This surgery may include genioplasty, cheek augmentation, brow lifts, tracheal shave and lip lift or augmentation.
• Breast augmentation/augmentation mammoplasty: Breast augmentation is one of the most common gender confirmation surgeries for trans women and nonbinary patients. It might involve saline or silicone implants or even fat transfers from other parts of the body.
• Vaginoplasty: In vaginoplasty, a surgeon uses skin grafts from another part of the body (usually the scrotum or abdomen) to create a vaginal canal. The surgeon also uses existing genital tissue to create a clitoris. This allows most patients to have penetrative intercourse.
• Orchiectomy: An orchiectomy is often a transfeminine patient ’s first gender affirmation surgery. It involves the removal of the testicles.
• Vulvoplasty: A vulvoplasty involves the external part of the vagina rather than the vaginal canal. Skin from the patient’s genitalia is used to create a vaginal opening, the inner and outer labia, a clitoris and an opening that allows the patient to urinate.

Additional Alternatives

Some trans women undergo voice feminizing therapy to adapt their voice to their gender identity. In voice feminizing therapy, vocal cords are surgically altered to raise the patient’s vocal pitch.

Some trans patients might also choose to undergo gender confirmation surgery in the form of body contouring procedures. These might include liposuction or abdominoplasty as well as implants in the calves, buttocks or other areas.

In the U.S., it is illegal for most public and private health insurance providers to discriminate against transgender patients or deny them transition-related care. However, trans patients may still face financial and logistical barriers. Here’s what you should know about health insurance coverage and gender confirmation surgery.

Type of Barriers

Transgender patients still sometimes face health disparities and barriers to medical care, including transition-related medical care. These are some of the obstacles that trans and gender non-conforming people might face when trying to access healthcare and insurance coverage.

• Differences in state-by-state health insurance coverage: Each U.S. state has different policies regarding health insurance and trans-related care. Some U.S. states legally require health insurance providers to cover transition-related care while others do not.
• Difficulty accessing up-to-date and accurate insurance information: The language in health insurance plan summaries can be out-of-date or vague. This can lead to discriminatory denials of care.
• Discrimination and stigma: Discrimination against the LGBTQ community remains widespread, and transgender people may face health disparities and stigma in the context of medical care as a result, as well as other financial challenges . A 2015 study by the National Center for Transgender Equality revealed that about one-third of transgender patients said they were denied medical care or harassed by a medical provider.
• Lack of training and cultural competency among health providers: Some healthcare providers haven’t had adequate training in healthcare for transgender patients, which can lead them to make questionable decisions.

Additional Insurance Considerations

Transgender patients might also have questions about Medicaid coverage and Medicare coverage for gender confirmation surgery and other transition-related care. Both Medicare and Medicaid are prohibited from denying coverage of trans-related care if it is medically necessary.

The Veterans Health Administration (VHA) provides some coverage for transition-related medical care to transgender veterans . However, there is still an exclusion when it comes to coverage of gender confirmation surgery.

If you have insurance through your employer, you might be able to save up for your out-of-pocket surgery costs with a non-taxed Flexible Spending Account (FSA).

Ways to Navigate Health Insurance for Gender-Confirming Surgeries

It can be challenging to navigate health insurance coverage for gender confirmation surgery, but it’s not impossible. It’s important to know your rights as a patient when interacting with providers and finding the best health insurance plan for your needs. Here are some tips to keep in mind.

Stay informed

Remember that your health insurance plan should cover your transition-related care. Make sure that you read your insurance provider’s member handbook. Ask for the medical policy and any specific documents about eligibility for trans-related medical care to determine if you qualify.

Find a plan with no exclusions

Look for a health insurance plan that doesn’t have exclusions for either all transition-related care or specific kinds of treatments. You can often find this information in the medical policy.

Ask your current or potential employer about coverage

If you’re in the negotiation phase of a job interview, don’t be afraid to ask your potential employer about transition-related health coverage. If your current company or school doesn’t cover transition-related care, you might want to advocate for coverage.

Understand informed consent vs. WPATH standards

Before choosing a plan and care provider, find out about your potential provider’s ethical approach. An informed consent model of care allows you to make your own transition-related decisions after being informed of the risks by a physician. The WPATH standards of care might require additional steps, such as letters of support from therapists and other providers.

Look into pre-authorization

You'll need to see your primary care physician before requesting pre-authorization for surgery. It is also known as prior authorization. You might need to gather documents such as letters from medical providers before applying. Depending on the plan you selected, your primary care physician can provide you with a referral. Keep in mind that the referral or pre-authorization may not guarantee the surgery or other procedures will be authorized. National Center for Transgender Equality addresses common health coverage questions related to pre-authorization that may be helpful. It may be a good idea to speak with your health coverage provider directly.

Appeal denials

If you are denied coverage for a transition-related procedure, do not be afraid to appeal your insurance provider’s decision. Some exclusions might be prohibited or deemed discriminatory.

Outside of partial or full health insurance coverage, there are several other options for financing gender confirmation surgery, such as loans, lines of credit, grants and scholarships and fundraising.

There are several different personal loans you can use to fund your transition-related care.

• Bank or credit union loans: To qualify for a loan from a bank or credit union, you’ll need a good credit score and history.
• Family loans: If a family member can extend you a personal loan, consider creating a promissory note so that you have a repayment schedule in writing.
• Online loans: If your credit history is less than ideal, an online personal loan could be a good option.

Grants and Scholarships

Several organizations offer grants and scholarships to cover some or all of the costs associated with gender-confirming surgeries. These can help you avoid or offset any potential medical debt .

• The Jim Collins Foundation : The Jim Collins Foundation is dedicated to funding gender-confirming surgeries for trans people who need them. Grants are awarded on an annual basis.
• Genderbands Transition Grants : Genderbands offers transition grants to offset the expense of gender confirmation surgery for trans and nonbinary recipients.
• Rizi Xavier Timane Trans Surgery Grant : Rizi Xavier Timane, DSW, established a grant program to aid in the costs of gender-confirming surgeries for trans and nonbinary individuals.
• TransMission : The Loft LGBTQ+ Community Center’s TransMission is a small scholarship fund that helps trans and nonbinary recipients with medical, surgical and legal expenses.
• Stealth Bros & Co. Surgery Support Fund : The Stealth Bros & Co. Support Fund offers financial aid to trans men and transmasculine people for surgery, hormone therapy and related expenses.
• Black Transmen, Inc. Surgery Scholarship : Black trans men in the U.S. who have already been approved for surgery by a surgeon can apply for up to $1,000 in financial assistance.
• Point of Pride : Point of Pride offers scholarship-like funding for gender-confirming surgeries on an annual basis with a competitive application process each November.

Fundraising

Many people may raise funds for their gender confirmation surgery. For example, some throw parties with suggested donation amounts so friends, family and other supporters come together. Others raise money for their procedures by selling original art and letting would-be buyers know that they’re supporting a good cause.

Line of Credit

A home equity line of credit (HELOC) is one option if you own your home. With a HELOC, you can borrow against your home’s appraised value and repay it over time.

Certain surgeons partner with medical financing companies to help gender confirmation surgery patients make payments over time. You may want to check your credit score with a free report . Other surgeons allow patients to make smaller payments in installments.

Advocacy Organizations Making a Change

Many LGBTQ advocacy organizations are making a difference in the lives of transgender and gender non-conforming people every day. Here are just a few of the LGBTQ charities , nonprofits and other organizations making positive changes.

• The Sylvia Rivera Law Project : In addition to impact litigation advocacy, the Sylvia Rivera Law Project offers legal services and resources to aid people in their journey toward gender self-determination.
• Transgender Legal Defense & Education Fund : The Transgender Legal Defense & Education Fund is a nonprofit that fights for trans rights and against discrimination. The organization’s Trans Health Project helps transgender people access trans-confirming health insurance.
• Transgender Law Center : The Transgender Law Center is a trans-led advocacy organization that offers educational materials and other resources around healthcare, immigration, incarceration and employment.
• National Center for Transgender Equality : The National Center for Transgender Equality offers educational materials, self-help guides and other resources for the trans community.
• SPARTA : SPARTA is a nonprofit organization dedicated to transgender, nonbinary and gender non-conforming people serving in the U.S. military.

Expert Insight on Financing Gender Confirming Surgery

• What steps should trans, nonbinary and gender non-conforming employees take when navigating health insurance coverage for gender confirmation surgery?
• What are some other factors that employees should consider in terms of transition-related care and employer-provided health insurance?
• What are the most important forms of support a trans or nonbinary person can get from their employer?
• What are some of the most common financial barriers faced by trans, nonbinary and gender non-conforming patients when seeking transition-related care, including gender affirmation surgery?
• What are the steps a transitioning individual might take to financially prepare for gender affirmation surgery?

Additional Resources for Trans-Related Healthcare and Support

If you are a transgender or gender non-conforming patient seeking funding or support for your gender confirmation surgery, various resources can help. Here are some of the best resources available for trans people, loved ones and allies who want to know more about gender confirmation surgery.

• National Center for Transgender Equality's Know Your Rights : The National Center for Transgender Equality regularly updates its guide to existing and expanding legal protections for trans people in the U.S.
• HealthCare.gov's Transgender Health Care : The website helps explain what to know about applying for Marketplace health insurance coverage as a trans or gender non-conforming patient.
• HRC's Corporate Equality Index : Human Rights Campaign (HRC) publishes an annual guide to workplace policies and benefits for LGBTQ employees, including a list of companies that offer trans-inclusive benefits.
• Transgender Law Center's Transgender Health Benefits Guide : The Transgender Law Center offers a guide to healthcare advocacy for trans and gender non-conforming patients, including advice on what to do if you face discriminatory denials of care.
• Out2Enroll : Out2Enroll helps members of the LGBTQ community find and enroll in health insurance plans.
• Trans-Health.com's Trans Health Clinics : The clinics in this list specialize in transition-related and trans-confirming care and mental health support.

Social Support

• Transbucket : Initially started in 2009, Transbucket is an online resource and peer-to-peer support group exclusively dedicated to trans participants, primarily discussing gender confirming surgeries and medical transition.
• Gender Spectrum : Gender Spectrum hosts online support groups for trans, nonbinary and gender non-conforming youth, as well as parents and educators.
• Sam & Devorah Foundation for Trans Youth : The Sam & Devorah Foundation for Trans Youth connects members of the trans community with mentors who can offer emotional support and advice as well as empowerment and "building the confidence and skills critical for self-agency and leadership."

Mental Health Support

• The Trevor Project : The Trevor Project provides a number of resources, including suicide prevention and crisis intervention services, to LGBTQ people under 25.
• Trans Lifeline : The Trans Lifeline is a hotline offering peer-to-peer support services for trans callers, as well as their family, friends and allies.
• The Tribe, LGBTribe : The LGBTribe offers mental health support and wellness tools to LGBTQ participants.

About Laura Dorwart

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• Introduction
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Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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How much does male to female (MTF) surgery cost in 2024?

Explore the interactive cost guide below for detailed pricing information on a range of MTF surgeries and compare costs in different countries.

• Transgender Surgery

Did you know? 

In 2024 , there is a high demand for gender-affirming surgeries. Recent data shows a 25% increase in interest in MTF surgery, highlighting the changing landscape of accessible and affordable care.

Sex reassignment surgery is a procedure enabling individuals to transition to their self-identified gender, typically involving hormone therapy. Male-to-female (MTF) reassignment surgery includes 'top' and 'bottom' surgeries, as well as facial feminization. In some places, like India, it's on the rise due to affordable costs, with an average MTF surgery cost of $2438 to $6095 .

Looking to gather information about the costs associated with personalized treatments from a t op plastic surgeon ? Don't hesitate.

You might be wondering why hormone therapy is necessary in male-to-female surgery. Read on to discover all the details.

In hormone therapy, female hormones like estrogen and progesterone are injected into male bodies to foster a more feminine appearance. Anti-androgens are incorporated due to higher male androgen production. Male-to-female transgender hormone therapy costs approximately $30 per month, with therapist visits averaging around $100 .

Let's read ahead to what male-to-female gender reassignment surgery costs.  

What does MTF top surgery cost?

Breast augmentation and implant surgery are the initial steps in the male-to-female gender reassignment process. Through this transformative procedure, one can effortlessly obtain the desired breast size. This method encompasses both the insertion and placement of implants, ensuring a comprehensive augmentation. The cost for this procedure may fluctuate depending on the chosen hospital and surgeon.

The MTF Breast augmentation surgery cost is given below:  

What is the male-to-female (MtF) bottom surgery cost?

The cost of male-to-female (MtF) bottom surgery, a vital step in the journey of gender affirmation, can vary depending on several factors. These factors may include the specific type of surgery chosen, the geographic location of the surgical facility, and individual healthcare providers' fees. 

Here, we provide an overview of the estimated costs for common MtF bottom surgeries:

What is included in facial feminization surgery, and what is its cost?

Facial Feminization Surgery (FFS) is a transformative cosmetic procedure that aims to soften and reshape male facial characteristics into more feminine features. This comprehensive surgery involves a series of procedures, including lip and cheekbone augmentation, hairline adjustment to reduce forehead size, and sculpting of the jaw and chin. The goal is to harmonize and enhance facial traits for a more feminine appearance.

The total Male to male-to-female feminization surgery cost may go up from $9,000 to $12,000. 

Do you know Robotic surgery is an effective alternative to traditional penile inversion and Vaginoplasty in transgender cases. It utilizes small tools on a robotic arm, marking a revolutionary advancement in surgery.

Take charge of your health and your life.  Contact us today!

If you're curious about the expenses of male-to-female sex reassignment surgery across various countries, let's explore further. Keep reading to find out more.

Factors affecting the cost of male-to-female surgery

The number of surgical procedures performed for gender reassignment is on the rise. With the surge in cases, the male-to-female surgery cost is also becoming more affordable and nominal in Asian countries compared to other nations. However, a few factors still affect the total cost of surgery.

• Lack of insurance coverage from major companies
• Pre and post-operative charges
• Pre-operative counselling charges (if required)
• Hormonal Therapy charges
• Hospital charges
• Doctor’s fee for all the different treatments
• Higher costs or prices for cosmetic surgery procedures such as facial feminization surgery.

Your well-being is our priority -   call us to book your appointment today

Insurance and Financing for MTF Surgeries 

Insurance and Financing for MTF Surgeries Gender-affirming surgeries, such as those involved in male-to-female (MTF) transitions, often come with associated costs. Understanding your insurance coverage and financing options can greatly aid in managing these expenses.

• Insurance Coverage: Review your policy for coverage of gender-affirming surgeries.
• Medicaid and Medicare: Some states offer coverage through these programs.
• Out-of-Pocket Costs: Plan for co-payments, deductibles, and uncovered services.
• Financing Options: Explore personal loans, medical financing, and crowdfunding.
• Consultation with Experts: Seek guidance from experienced healthcare providers.

1.) How long does a male-to-female transition take? Some transitions may take less than a month, and some can even take years. It mostly depends on the mental and physical health of the person and what kind of treatment you are involved in.

2.) How long does it take to grow breasts on estrogen?

The estimated time to grow breasts through estrogen is 2 to 6 months. It also depends on factors like fatty tissue levels, body genetics, etc.

3.) How long does it take to recover from male-to-female surgery?

It takes an average of 2 to 8 weeks to recover from male-to-female transition surgery. However, penectomy and vaginoplasty are major surgeries that need more care and usually take longer to recover.

4.) Can I undergo MTF transition without surgery?

Yes, many individuals choose to undergo MTF hormone therapy and other non-surgical procedures to achieve their desired gender expression without surgery. It's essential to discuss your options with a healthcare provider.

5.) What is the typical duration of hormone therapy for MTF transition?

The duration of hormone therapy varies from person to person. Typically, individuals undergo hormone therapy for an extended period, often lifelong, to maintain their desired physical and emotional changes. Your healthcare provider can provide more personalized guidance.

Health Tips, Health Care and Fitness Tips, Health News | TheHealthSite.com

National Center for Biotechnology Information (nih.gov)

https://my.clevelandclinic.org/health/treatments/21526-gender-affirmation-confirmation-or-sex-reassignment-surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994261/

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Question and Answers

48 yaşında bir erkeğim trans birey olarak kadın olmak istiyorum hormon tedavisi istiyorum. hangi ilaçlardan başlamalıyım.

For someone who is 48 years old and seeking to transition from male to female, it's important to consult with an endocrinologist before starting any hormone therapy. They will guide you on the appropriate medications and dosages based on your specific needs. 

Answered on 2nd Aug '24

Dr. Vinod Vij

if I have top surgery without T can I develop pecs if I hit the gym a lot?

If you don't take testosterone or undergo top surgery, you can still build your pecs by lifting weights. Pecs, short for pectoral muscles, can grow with exercises like chest presses and push-ups, which target these muscles. Pace yourself, use the correct form, and be consistent with your workouts. Your pecs can still develop even without testosterone.

Answered on 29th July '24

I'm male and would like to know how to grow breasts without HRT?

Hormones and surgery are the only ways of growing breasts safely. The appearance of women's breasts in some regions is partly dependent on hormones during puberty and pregnancy. Trying to get a larger breast by force can cause some serious medical issues. If you are worried about your body, it's important to talk to a plastic surgeon for safe and honest guidance.

Answered on 22nd Aug '24

I am a 32 years old male who has got into cross dressing some 8 years back, now my urge of being like this has grown, last two years I have been I’m eating dian35 prescribed by a doctor in Malaysia, but now I believe I shall be needing more strong dose since the transformation is already 2 years and can see few changes

It seems like you may be going through some changes about turning into the opposite sex. Understand that these changes are complicated and might need some medical interventions. You might require different amounts of hormones to help you through the process. Talk about what is bothering you and your symptoms with a doctor who can help you figure out the best way forward.

Answered on 18th July '24

Namaste , I am a transgender and I am feeling desperate about my facial hair and tried many ways to reduce facial hair but my hairs are growing continuously. I want to know solution

For transgender individuals, hormone therapy can often help reduce facial hair growth. It's important to consult with an endocrinologist , who specializes in hormone-related conditions, for personalized advice and treatment options. They can guide you on the best course of action tailored to your needs.

Answered on 10th July '24

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I Can't Afford to Transition: The Unseen Costs of Being Transgender

Living authentically comes with a hefty price tag.

Trans(form) is a month-long series on MarieClaire.com that explores the challenges, surprises, and victories of transitioning today. See the full collection  here .

Ari Klamka, 28, is a lot like his peers—when he found himself in need of money for a special project, he created  a GoFundMe page . But he wasn't looking to make a movie, or support a charity, or run a marathon. He was looking for the right to become himself.

Klamka is transgender, and he's facing an unfortunately common problem in the modern landscape of transgender issues: The cost of fully transitioning is prohibitively expensive.

"I've legally changed my name and gone through countless physical and social changes over the past two years," Klamka  writes on his GoFundMe page . "Though the next step I will be taking is the biggest and most important to me." It's not just a chest reconstructive surgery he has to pay for, but the doctors' visits, pain medications, continued hormones, and lost wages from taking time off to recover. His job as a veterinary assistant offers insurance, but it won't cover his needs.

Some phalloplasties can cost upwards of $100,000.

"I was born in the wrong body" is a common phrase used by transgender individuals to explain their desire for transition. And while not all those who identify as transgender want to physically alter their bodies or appearance, many see those changes as essential to becoming who they are and who they want to be. In too many cases, it can even be  life and death .

When Caitlyn Jenner revealed her true self to the world, she did so after undergoing  facial feminization surgery  and breast augmentation. Transitioning isn't just an enormous mental and emotional step—it's an expensive one, too.

Hormones might set you back $100 a month. Surgery? Anywhere from $5,000 to $50,000—and even higher. Some phalloplasties can cost upwards of $100,000, according to the  Transgender Law Center .

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The financial barriers are abundant, but they are born of two central issues: insurance and discrimination. "For transgender individuals to have access to insurance coverage continues to be a real problem," says Anand Kalra, the Transgender Law Center's health programs manager. Kalra explains that the transgender community—due in large part to being discriminated against—face higher rates of poverty. Translation? They're less likely to be insured. "Just having access to regular medical care can be an extreme challenge," he says.

Dr. Douglas Senderoff, a  New York-based plastic surgeon  who often works with transgender patients, agrees. "Most of the patients I consult with for transgender surgery are in difficult financial situations due to discrimination," he says. "It's often difficult for them to find quality, high-paying jobs."

Navigating the pitfalls of insurance language and coverage is frustrating for anyone. When you're trans, it's that much harder.

Even for those who are insured, there are still endless hoops to jump through. Not only is it difficult to find physicians who are trained and respectful of trans issues—Kalra recounts stories of people making same-day appointments with trans-friendly doctors, then carpooling for hours to get there—but navigating the pitfalls of insurance language and coverage is frustrating for  anyone . When you're trans, it's that much harder.

Some insurance agencies are making moves to update their policies. In fact, Aetna—one of the biggest health carriers in the U.S.—became the first major health-benefits company to cover gender-reassignment surgery for its holders in 2009. While others are following suit, there's still a divide between what's needed and what patients can get.

"Many providers have exclusions, deep in the plan documents, where they won't pay for things not only related to your transition, but  because  of your transition," Kalra says. "I've seen circumstances where a person broke their leg and had a cast put on, only to be told by the insurance agency that they're not going to pay for that because the person was on hormones. The insurance company was claiming that hormones had weakened the person's bones, even though clinical research has shown that's not true."

While many insurers are willing to work with individuals, there are far too many horror stories for them to be considered isolated incidents. "It can be exhausting and intimidating, and so confusing," Kalra says.

Worse, it can be life-threatening. In the face of desperation, it can seem to some like the only option is an unlicensed back-alley practitioner—resulting in  botched surgeries and potentially fatal injections .

Thankfully, there's recourse. Ten states plus D.C. have issued non-discrimination stipulations specifically related to health insurance. You can go through an appeals process in many states if your insurance says it won't cover specific items. "Sometimes, even when your insurance should say yes to something, they say no, because that's what they're used to when it comes to transgender needs," says Kalra. "For years, there weren't many rules. Now, they can still say no—but you can do something about it."

Dr. Harrison Lee, the surgeon who  performed Caitlyn Jenner's facial feminization procedures , does see the insurance landscape changing. "It's important to understand that for insurance to pay for any transgender surgery, the surgery needs to be considered 'medically necessary,'" he explains. Thanks to Jenner and other television shows depicting transgender characters, "Americans are becoming more aware of the plight of the transgender community. Health-insurance companies realize the need to cover transgender surgery as a medically necessary procedure as opposed to a cosmetic one. I  have  noticed that insurance companies are more cooperative when seeking approval for coverage."

For now, the solutions are those standard-bearers of American healthcare: patience and perseverance. And there's creativity.

Nina Iraheta, 23, is a trans woman working as a receptionist at an optical company. She emigrated to the U.S. from Brazil at the age of 13. "I already knew by that age that I was in the wrong body," she says. She experimented in high school with eyeliner and growing out her hair. "The littlest changes were making a difference, emotionally," she says. "I was happier."

She learned about hormone treatments in college, and after graduation, she found herself with the typical 20-something conundrum: no savings, crazy rent, and major student loans. Those needs, along with the cost of hormones and a desire for breast implants, led her to join  SeekingArrangement.com .

The site helps introduce "sugar babies" to "sugar daddies"—it's a place, according to its tagline, "where beautiful, successful people fuel mutually beneficial relationships." The average sugar baby receives $3,000 a month from a relationship, and out of the 3.8 million sugar babies on the network, there are over 15,000 transgender individuals. Iraheta makes sure her suitors know that she is transgender, and she now has one sugar daddy she sees on a weekly basis.

"It's been good," she says of her three-month experience. "You have to have a connection with the person; it doesn't work if you don't. I put all the money he gives me towards surgery."

Iraheta wants to go through "the whole process," and is currently undergoing laser hair removal treatments while continuing her hormone therapy. She's hoping to start her full transition by the age of 24.

Both Klamka with his GoFundMe page and Iraheta with her sugar daddy describe their situations as "frustrating," but they're committed to making it work.

"Sometimes I ask myself, 'Is this worth it? Is it worth going through all this? Do I  need  these surgeries?'" Iraheta says. "But then I realize that yes, I do. I would be happier. I already am happier."

This story is a part of  Marie Claire 's features series on what it means to transition today. Check back throughout the summer to read more, or find collected articles  here .

Samantha Leal is the Deputy Editor at Well+Good, where she spends most of her day thinking of new ideas across platforms, bringing on new writers, overseeing the day-to-day of the website, and working with the awesome team to produce the best stories and packages. Before W+G, she was the Senior Web Editor for Marie Claire and the Deputy Editor for Latina.com, with bylines all over the internet. Graduating from the Medill School of Journalism at Northwestern University with a minor in African history, she’s written everything from travel guides to political op-eds to wine explainers (currently enrolled in the WSET program) to celebrity profiles. Find her online pretty much everywhere @samanthajoleal.

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Study: Paying for Transgender Health Care Cost-Effective

Most health insurance plans do not cover care associated with transitioning to the opposite sex.

A new analysis led by the Johns Hopkins Bloomberg School of Public Health suggests that while most U.S. health insurance plans deny benefits to transgender men and women for medical care necessary to transition to the opposite sex, paying for sex reassignment surgery and hormones is actually cost-effective.

The researchers, reporting online in the Journal of General Internal Medicine , say that the cost of surgery and hormones is not significantly higher than the cost of treatment for depression, substance abuse and HIV/AIDS, all of which are highly prevalent in those who are transgender but are not in a position to medically transition to the opposite sex. In 2014, the Center for Medicare and Medicaid Services began paying for sex reassignment surgery and other transitional care, after a 33-year-ban on covering those costs was lifted.

“Providing health care benefits to transgender people makes economic sense,” says study leader William V. Padula, PhD, MS, MSc, an assistant professor of health policy and management at the Bloomberg School. “Many insurance companies have said that it’s not worth it to pay for these services for transgender people. Our study shows they don’t have an economic leg to stand on when they decide to deny coverage. This is a small population of people and we can do them a great service without a huge financial impact on society.”

Estimates vary widely but it is believed that between 3,000 and 9,000 Americans undergo sex reassignment surgery each year. Transition medical care can include hormone replacement therapy, mastectomy, plastic surgery, psychotherapy and more.

For their study, Padula and colleagues analyzed data from the 2011 National Transgender Discrimination Survey, which includes information on access to medical care and health outcomes, as well as the Healthcare Bluebook, which outlines the cost of medical services. They also looked at previously published research on the topic.

When determining cost-effectiveness of medical services in the U.S., policymakers consider something cost-effective if the price is below $100,000 per year of quality of life. In the first five years, the researchers found, providing health care for transgender people cost between $34,000 and $43,000 per year of quality of life; after 10 years, the cost dropped to between $7,000 and $10,000 per year of quality of life.

Padula likens the case of paying for transgender care to caring for people with rare diseases. For example, cystic fibrosis affects just 30,000 people in the United States but can be treated as a chronic condition with the availability of new medications at a cost of $300,000 per year. While this is neither cost-effective nor individually affordable, Padula says, society has decided to pay for the treatment out of compassion. The same can be done for transgender people, he says.

Health insurance policies also pay for treatments that can be considered elective, such as breast reduction and spinal fusion as well as medication for erectile dysfunction. Some employers and health insurance companies do offer at least one plan that covers transition care, but that is not the norm, Padula says.

“Most U.S. health insurance policies still contain transgender exclusions, even though treatment of gender identity disorder is neither cosmetic nor experimental,” he says.

The new analysis calculated that the cost to cover transgender people would be fewer than two pennies per month for every person with health insurance coverage in the United States.

“We would be paying a very small incremental amount to improve the quality of life for a population that is extremely disenfranchised from health care and other services we consider a right,” Padula says. “For this small investment for a small number of people, we could improve their lives significantly and make them more productive members of society.”

He says that providing sex-reassignment surgery and other services to transgender people could help mitigate the expenses of treating depression, which often occurs in people who cannot transition, often because they do not have the financial means, as well as drug abuse and HIV/AIDS.

“ Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis ” was written by William V. Padula, Shiona Heru and Jonathan D. Campbell. Heru worked with the Commonwealth of Massachusetts Group Insurance Commission and Campbell is with the University of Colorado.

Funding for this study includes an F32 National Research Service Award from the Agency for Healthcare Research and Quality, a University of Chicago Medicine Small Grant in Diversity Research and a merit fellowship from Western New England University School of Law in affiliation with the Gender and Sexuality Center.

Media contacts for the Johns Hopkins Bloomberg School of Public Health: Stephanie Desmon at 410-955-7619 or  [email protected]   and Susan Murrow at 410-955-7624 and  [email protected] .