How do I access top surgery, facial feminization surgery (FFS), or other forms of gender affirming care?

“I want to access gender affirming care, but I don’t know how.” This is a common issue that many of us in the trans + nonbinary community face early on in the process of deciding to pursue a medical transition. Let’s break this down into parts so you can get closer to the care you need. 

First, we need to understand that “gender affirming care” is an umbrella term without a singular meaning. It encapsulates hormone replacement therapy (HRT - estrogen, testosterone, etc.), top surgery (full mastectomy or radical breast reduction), facial feminization surgery (FFS), breast augmentation, bottom surgery (phalloplasty, metoidioplasty, vaginoplasty), and more. So it’s important to spend time getting clear on what gender affirming care looks like for you! One of the most important questions to reflect on is “what is bringing me gender dysphoria right now, and what sorts of changes do I want to see to alleviate this dysphoria?”

Once we’re clear on what sorts of treatment you want as part of your gender affirming care plan, let’s shift our focus to how we get access to this care through insurance. There are a few critical factors here including your age, your state of residence, and your insurance. 

First, especially given the present administration, it is often difficult to access gender affirming care as a minor. Many clinics that provide this care have had to close due to federal government funding cuts; the best way to find a provider as a minor might be to call your insurance plan and ask about providers in network who treat minors, or ask other minors and their families in your community where they have successfully obtained care. Additionally, if you are under the age of 26 and still on your parent’s insurance plan, keep in mind that some information about insurance claims will be visible to the policy holder, including the date, the service / procedure, and the cost. If you are not out yet to your parents, this may be something to keep in mind or inquire about with your insurance company directly. 

Second, requirements for coverage of gender affirming care by insurance plans vary state to state here in the U.S., with some states offering more protections than others. In California, where I practice, there are substantial protections for gender affirming care. Nearly all healthcare plans in the state are required to have coverage for gender affirming care, and they cannot discriminate based on gender identity. If you’re in another state, you can look up your state’s requirements for coverage of gender affirming care. Generally your state will have an insurance commissioner, and their website will likely have more information about what insurance plans within the state are required to cover. 

Third, even if you live in California or another state where your insurance plan very likely has to offer coverage for gender affirming care, what this coverage looks like can still vary quite a bit. If you have a high deductible plan with a $5,000 deductible plus a $2,000 out of pocket maximum and want top surgery, for example, you will have to pay that $5,000 deductible before insurance kicks in, and then you still may need to meet your $2,000 out of pocket maximum. The surgery is still “covered” and insurance will foot the rest of the bill, but the cost is still very high (up to $7000 in this case) to you as the patient. So take a look at your insurance plan and identify your deductible and out of pocket maximum. 

It is also important to understand whether your insurance plan is a HMO or a PPO, as this often determines how you will start the process of finding a healthcare provider for gender affirming care. You can see if you have an HMO or a PPO by looking at your insurance card; it is often printed there. HMOs are structured around a primary care physician, and require referrals to any specialist provider. So if you have an HMO, you will need to talk to your primary care provider and ask for a referral to one or more of the following: an endocrinologist (HRT), a plastic surgeon (top surgery / breast augmentation / FFS) or a plastic reconstructive surgeon + urologist (bottom surgeries). You will have to explain to your provider more about the reason for the referral, and likely this will mean a discussion with them more in depth about your gender dysphoria. If you have a PPO, on the other hand, you typically do not need a referral to specialist providers and can seek one on your own. You can call the office of an endocrinologist, plastic surgeon, or urologist directly and inquire if they accept your insurance and if they offer the kind of treatment you’re looking for. 

For most gender affirming surgeries, like top surgery, FFS, or bottom surgery, a letter of support from a therapist is often required to get the procedure covered by insurance. Some surgeon’s offices will not even have a consultation with a potential patient without a letter. If you are only seeking HRT, in my experience, letters of support from a therapist are typically not required for insurance coverage. So obtaining this letter is often the next step for folks seeking surgery specifically as part of their gender affirming care plan. I offer these letters free of cost for folks in California, which involves a one-time, hour long meeting. If you are outside of California and looking for a letter writer, check out Do Something Identities or GALAP for resources.

If you need a letter of support and reside in the state of California, please reach out to me via email at gabby@therapybeyondthebinary.com for a free letter.