Countries Supporting Gender Affirmation Related Procedures

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Amrita Sarkar Advisor: Transgender Wellbeing and Advocacy
India HIV/AIDS Alliance, New Delhi February 2021

Background .................................................................................................................... 3 Example from countries supporting gender affirmation care related procedures for transgender community through their policies, CSOs and insurance coverage ..... 5 Conclusion...................................................................................................................... 8 Acknowledgement.......................................................................................................... 9


Transgender people are based in all parts of the world. Apart from going through name and gender change process, a significant percentage of the same population want to access gender affirmation care-related procedures.
Harry Benjamin (1966) put a great effort for raising awareness on the specific health care needs of this particular set of population. Because of him, the idea that transgender people should not be subjected to conversion therapies became scientifically accepted, that helped resulting in consolidation of the current treatment guidelines.1
In 1980, the DSM-III (Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition) was introduced which was the first manual to describe gender identity disorder as a psychosexual condition. Later, a definition consolidated in the DSM-III-R (1987), DSM-IV (1994) and DSM-IV-TR (2000). According to DSM V, some people who are transgender will experience “gender dysphoria,” which refers to psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. In the same document, it was also mentioned that people who are transgender may pursue multiple domains of gender affirmation, including social affirmation (ex., changing one’s name and pronouns), legal affirmation (ex., changing gender markers on one’s government-issued documents), medical affirmation (ex., pubertal suppression or gender-affirming hormones), and/or surgical affirmation (ex., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.).
In 1975, with the publication of the ICD-9, the diagnosis of transsexualism was first described. Later, in the 10th version of the International Classification of Diseases (ICD 10), The World Health Organisation (WHO) already has removed. 2
Comparison between ICD-10 and DSM-53:

Manual Concept of gender Parent category
Diagnosis name
Associated clinical presentations:

ICD-10 Gender binary Gender identity disorders
Evidence of significant distress or impairment in

DSM-5 Gender fluidity Gender dysphoria Gender dysphoria in adolescents and adults The condition is associated with clinically significant distress or

1 2 World Health Organization (WHO). Manual of the international statistical classification of diseases, injuries and causes of death. 9th ed. Geneva: WHO; 1977. 3

Manual significant distress or impairment in important areas of functioning Overlapping diagnoses with disorders of sex development (DSD) Time required to establish the diagnosis
Criterion A



social or other important

impairment in social, school, or

areas of functioning (Criterion other important areas of


functioning (Criterion B)

If an individual with a DSD also

satisfies the diagnostic


requirements for gender

incongruence, both diagnoses

should be assigned

Of at least 6 months duration

Of at least two years duration and is shown by at least two of

Criterion A

1. A marked incongruence

between one’s

experienced/expressed gender

and primary and/or secondary

sex characteristics

Desire to live and be accepted 2. A strong desire to be rid of

as a member of the opposite one’s primary and/or secondary

sex, usually accompanied by sex characteristics

the wish to make one’s body 3. A strong desire for the

as congruent as possible with primary and/or secondary sex

one’s preferred sex through characteristics of the other

surgery and hormonal



4. A strong desire to be of the

other gender

5. A strong desire to be treated

as the other gender

6. A strong conviction that one

has the typical feelings and

reactions of the other gender

In ICD-11, gender incongruence is defined as a marked and persistent incongruence between a person's experienced gender and assigned sex. This is to note, the World Health Organization (WHO) officially adopts the International Classification of Diseases – 11th Revision (ICD-11).4
The World Association for Transgender Health (WPATH) provides Standards of Care (SOC) thatrecommends the standards to be used by all health professionals across the globe when working with transgender individuals5. Still, there are country-specific requirements and there are regional guidelines available accordingly (ex. ‘Blueprint for
4 5

the provision of comprehensive care for trans people and trans communities in Asia and the Pacific’)6. Similarly in India, Association for Transgender Health in India (ATHI) has developed standard of care in Indian context7.
The above mentioned information helps us to understand, being a transgender person not at all is any kind of physical or mental illness but a state or condition that might require to access gender affirmation care-related procedures by a certain percentage of the same population. And there are examples from various countries, stating their support the transgender community in terms of gender affirmation care-related procedures by introducing new acts/policies towards and coverage of insurance as per their needs.
Example from countries supporting gender affirmation care-related procedures for transgender community through their policies, CSOs and insurance coverage:
1. As reported, 20 countries have passed some form of legislation recognizing transgender rights, according to the Global Commission on HIV and the Law8.
1.1 In 2012, Argentina's Senate unanimously approved the Gender Identity Law making sex-change surgery a legal right. The procedure is included in both public and private health care plans.
1.2 After two years, the Danish Parliament followed Argentina's lead and allowed legal gender recognition for transgender people (for 18+ years), solely based on their self-determination -- without any medical intervention. This is to state that, Denmark is the only European country that does not require any psychiatric diagnoses or any certificate by a medical professional, according to Transgender Europe.
1.3 In 2015, Malta's government adopted the Gender Identity, Gender Expression, and Sex Characteristics Act. introduced a simplified procedure which respects the privacy of the person requesting that one's official documents be changed to reflect the person's gender" and acknowledges that "gender identity is considered to be an inherent part of a person which may or may not need surgical or hormonal treatment or therapy" and "sex characteristics of a person vary in nature and all persons must be empowered to make their decisions affecting their own bodily integrity and physical autonomy."
1.4 In 1987, Iran's religious leader, Ayatollah Khomeini, issued a fatwa (a legal decision handed down by a religious leader) allowing the sexual reassignment
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surgery. Though "the law utterly fails" to recognize transgender people who do not undergo medical intervention, according to international human rights organization Outright Action International. While the government does allow for and subsidize, gender reassignment surgery, critics of the government's policy say it can be a double-edged sword for transgender people.
2. In the USA, under Section 1557 of the Affordable Care Act, May 13, 2016, discrimination based on gender identity has been banned. The rule applies to discrimination in health settings that receive federal financial assistance, every health program administered by the Department of Health and Human Services, and every health program administered by Title I of the Affordable Care Act. The rule states - it is unlawful for an insurance carrier to “have or implement a categorical coverage exclusion or limitation for all health services related to gender transition”. 9 Study shows, (reviewing after 1,350 silver marketplace plan options in 36 states) - the vast majority of insurers did not use transgender-specific exclusions and 2) nearly half (46%) of plans had language indicating that all or some medically necessary transition-related care would be covered by the plan.10
2.1 Medicare and Medicaid are the two US government programs that provide medical and other health-related services to specific individuals. Medicaid is a social welfare or social protection program, and Medicare is a social insurance program. Medicare coverage is nationwide (USA), but there are variations in their policies and guidelines, which are state-specific. Medicare changed its rules to include surgeries for medical reasons, which includes gender reassignment.11
2.2 California State Insurance letter mandating that California Insurance providers cannot discriminate against gender identity regardless of federal law. Very recently a transwoman has created a Google map, covering the places of USA provides trans-affirming care services12. They have to provide trans-affirming insurance coverage for California.13
Also, there are organisations spread across all over the USA to work for the transgender community and their core health needs, including gender affirmation care. Such as:
2.3 The Transgender Law Centre encourages everyone seeking transition-related care to ask the primary care provider to submit a preauthorization request to the insurance company for the required procedures. Once the provider’s office has submitted paperwork to the insurance company, either for a preauthorization or
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for as a bill after the procedure, the insurer will send an Explanation of Benefits (EOB) to the applicant and the provider, either along with payment to the provider or with a notice saying payment has been denied. If payment has been denied, they refer to this as an “insurance denial”.14
2.4 Fenway Health, Boston manages gender-affirming treatment for transgender and gender diverse adults through primary care teams under an informed consent model of care.15
2.5 Callen-Lorde’s team of LGBTQ friendly insurance navigators help to determine the applicant eligibility for free or low-cost health insurance under Medicaid and the Affordable Care Act.16
2.6 Transgender Health and Wellness Center California, which also has a great page explaining California Insurance for Transgender health care.17
2.7 UCSF one of the leading medical institutions in the US provides a lot of gender affirming care related services.18 UCSF’s Center of Excellence for Transgender Health (Trans CoE) was founded in 2009 with their mission to increase access to comprehensive, effective, and affirming health care services for transgender and gender diverse communities.19
3. In Germany, the Federal Social Court ruled in 1987 that gender reassignment measures in the case of transsexuality are subject to payment” (BSG 3 RK 15/86). The costs for gender-modifying or gender-adjusting treatments are only covered by the health insurances once the medical necessity of the respective treatment has been determined in each individual case.20
4. Australian military, covers the cost of transition-related care - over a 30-month period, Australian troops out of a fulltime force of 58,000 underwent gender transition — an average of 1 service member out of 11,154 per year. Also, Medicare and private both contribute toward the cost of gender reassignment surgery in Australia. It includes surgery fees, specialist visits, blood work, hospital accommodation, anesthesiologist fees, psychological counselling and hormone replacement therapy.21
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5. In Canada, transition-related medical services are approved by various provincial institutions and medical practitioners. Public/'state' insurance in most provinces in Canada covers gender affirmation care surgeries and the public health care coverage is managed by individual provinces rather than the federal government22.
6. National Health Service (NHS) UK, covers the provision of non-surgical Gender Identity Services for adults that are prescribed as specialized services. 23 They pay for phalloplasty and have a surgeon in London who performs the operation.
7. Sweden Government provides gender-affirming health care for transgender and gender-nonconforming people. They have multidisciplinary care teams to offer personalized, patient-centred care that addresses each individual’s unique health care needs.24 Also, the national health insurance covers all costs for medical care and pharmacological treatment, except facial surgery.25
Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies (now also known as gender affirmation procedure), for transgender individuals. Further details about global access to transgender health care can be found online at the Wikipedia26.
According to the information provided above, it is clearly understood that many countries across the globe help their transgender citizens in terms of access to health care and most importantly support and services required for gender affirmation related procedures. Similarly, regarding insurance companies, there are such companies spread across the globe who does provide insurance support for gender affirmation related procedures. Some of them may have their own criteria though. In terms of supporting the transgender community, India took a very bold step introducing NALSA judgement in 2014 (though it did not show much impact at the ground level) and now the Transgender Persons (Protection of Rights) Act which has various section covering the health-related concerns of transgender community members. It has been mentioned that there would be facilities to be provided for the transgender community members in terms of access to gender affirmation related care through strengthening and sensitizing the health care sector and also there would be the provision of insurance policies for them. Now, to
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ensure the successful implementation of such provisions, the Government of India needs to take the following steps –
1) There would be transgender-inclusive health care services both in public and private settings at free or at a very nominal rate since most of them belong to poor socioeconomic strata and
2) To pass a directive to the insurance companies, helping the transgender community members to access the health insurance policies as per their specific needs. And there need to be insurance policies available for their gender affirmation related procedures at a very nominal rate. Also, a monitoring mechanism would be very helpful for its effective implementation.
Regarding the examples taken from various countries supporting gender affirmation care, I am thankful to some of my friends and colleagues who are based in different parts of the globe and have provided me important links to be incorporated in this document. I would like to thank the following people:
1. Tiffany Woods, Transgender Sexual Health, Community Engagement Specialist, Office of AIDS, California Department of Public Health, USA
2. Paul Causey, Chief Moderator, MSM Asia Google Group 3. Dr Ruth Pearce, Trans Learning Partnership 4. Noah Adams, Toronto, Ontario 5. Christine Milrod, Ph.D., LMFT, WPATH-CM, Southern California Transgender
Counseling 6. Elke Günzler, Berlin 7. Aliza Grossberg, St. Louis, Missouri, USA 8. Amee Wurzburg, Carrboro, North Carolina, USA 9. Dwight Cook, Co-founder at Working With Pride, Mumbai, India 10. Julia Mariella Wiræus, Works at Freelance and SVT, Sweden 11. Nada Chaiyajit, Senior Advisor to the Governing Board on Laws, Human Rights and
Equality at Rainbow Sky Association of Thailand 12. Alexandra R DeRuiz, Program Coordinator of Jauría Trans at Border Agencia de
Activismo, Mexico City, Member of IRGT (International Reference Group of Transwomen and HIV

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Countries Supporting Gender Affirmation Related Procedures