EXECUTIVE SUMMARY *
"Transgender" individuals are those "who transiently or permanently identify with a gender different from their natal gender" (that is, from their biological sex at birth). Some (not all) who identify as transgender seek surgery, known as "gender reassignment surgery," to make their bodies resemble that of their preferred gender. While surveys show most who identify as transgender would like to have surgery, many are unable to obtain it due to the high cost, and the fact that many health insurers do not provide coverage for such procedures on the grounds that they are "cosmetic" and/or "elective." Transgender activists are pushing to overcome such barriers by having these procedures declared "medically necessary."
Federal Government Policy
The largest federal health care program is Medicare, which provides health care to senior citizens. In 1989, the U.S. Department of Health and Human Services (HHS) issued a "National Coverage Decision" (NCD) explicitly denying coverage for "sex reassignment surgery," deeming it "experimental" and warning of "a high rate of serious complications." In 2014, an HHS Departmental Appeals Board overturned the 1989 NCD, ruling that "transsexual surgery is safe" and "effective," thus allowing it to be covered on a case-by-case basis.
In 2016, however, the Centers for Medicare & Medicaid Services under HHS (CMS) declined to issue a new NCD that would mandate coverage for such surgery under Medicare, declaring that "there is not enough high quality evidence to determine whether gender reassignment surgery improves health outcomes." CMS examined 33 studies, but found that all had "potential methodological flaws," and that "[o]verall, the quality and strength of evidence were low." Patients in the best studies "did not demonstrate clinically significant changes" after surgery. One of the strongest studies, out of Sweden, showed a suicide rate among post-surgical transgender patients that was nineteen times that of the general population.
The 2014 appellate decision was made by three lawyers, with input only from pro-transgender experts and briefs. The 2016 decision memo was based on an original review of the research by a six-member team that included three medical doctors and a Ph.D.
The burden of proof must rest on those who claim that gender reassignment surgery is "medically necessary." The 2016 CMS Decision Memo strongly suggests that the evidence is lacking to make this assertion.
* The Executive Summary does not contain citations as these are embedded in the text of this paper.