At 10 years of age, Chris (his name has been changed for privacy) became convinced that something was deeply amiss. He was a boy, but his body looked like a girl. What he saw in the mirror and what he felt inside were profoundly at odds. Growing up in rural Texas in the 1980s, he knew it didn’t matter how he felt; in society’s eyes, he looked like, and therefore could only be, one thing: a girl.
Bullying, violence, and even sexual assault ensued as Chris navigated puberty, high school, suicidality, and a deepening isolation. Whisperings of a faraway haven in California, where boys could be boys no matter what they looked like, gave him hope. In college, he discovered the LGBTIQA+ community and initially came out as lesbian before realizing his identity as a trans male. Inspired by trans male rapper Katastrophe, who transitioned in San Francisco, Chris decided to follow suit.
San Francisco, a city in California considered the land of opportunity, had its drawbacks. A prohibitive cost of living left Chris undomiciled and lining up in front of shelters every night. Trans life in a shelter was much like his childhood: plagued with violence, sexual assault, and transphobia.
Despite the challenging circumstances, however, there were several beacons of hope. California’s universal healthcare insurance system provided access to testosterone therapy, finally enabling Chris to initiate his transition. For the first time, his dysphoria began to ease. But it was only the beginning.
Several years later, Chris’s insurance approved and covered his gender affirmation surgeries, including mastectomy, hysterectomy, phalloplasty, and finally facial masculinization surgery with Rahul Seth, MD, at the University of California, San Francisco Facial Plastic and Reconstructive Surgery. With newfound confidence, Chris turned his sights toward giving back. He lobbied the city to help start Jazzie’s Place, San Francisco’s first LGBTIQA+-specific shelter. He also successfully led an effort to obtain insurance coverage for phalloplasty and was the San Francisco Medicaid program’s first patient to have the procedure covered.
Advances in Access to Care
Access to gender affirmation care and surgery in California has evolved over the past two decades and has set precedents for the rest of the nation. Prior to 2013, transition-related surgeries were not covered by insurance in the state, but since then, a multitude of state-based legislative actions have dramatically improved access (see Table 1). A selected few are discussed here.
The California Insurance Gender Non-Discrimination Act (IGNA) was the first major milestone. It was first introduced in 2005 as assembly bill (AB) 1586, banning health insurance plans from excluding coverage based on sexual orientation and gender identity. However, explicit banning of transgender insurance exclusions waited until 2013 with Letter 12-K from the Department of Managed Health Care, part of the state of California’s California Health and Human Services Agency. Letter 12-K led to a profound increase in utilization of surgical transition procedures (JAMA. 2023;329:819–826). The law prohibited California insurances from denying coverage for medically necessary transition-related care, including hormone therapy and gender-affirming surgery (GAS).
Another notable legislative victory came with AB 2119 (Foster care: gender affirming health care and mental health care) in 2018, despite much opposition. Transgender and gender nonconforming youth are known to be overrepresented in California’s foster care system, likely due to increased family rejection and societal intolerance (Fam Court Rev. 2009;47:552–569). AB 2119 advocated for California Medicaid, known as Medi-Cal, coverage of gender-affirming health and behavioral health care for foster youth. The legislation set the precedent in ensuring that transgender foster youth, as a right, receives healthcare that’s consistent with national standards. It recognized that gender-affirming care, including counseling, hormone therapy, and surgeries, could be medically necessary for transgender youth and required the state’s Department of Social Services to assist in facilitating access to these treatments.
Access to gender affirmation care and surgery in California has evolved over the past two decades and has set precedents for the rest of the nation.
Despite the progress on insurance coverage, the low supply of qualified and, in some cases, willing physicians to care for the transgender patient has become apparent. Culturally competent training of physicians in transgender care is lacking, and patients often travel long distances to find capable providers in their network.
SB 923, the Transgender, Gender Diverse and/or Intersex (TGI) Inclusive Care Act, was recently passed in 2023. The law requires provision of continuing medical education with an evidence-based, culturally competent curriculum to help physicians provide inclusive care for TGI individuals. Additionally, it mandates that health insurance companies provide TGI cultural competency training for their staffs.
Barriers to Access
Despite legislation for improved insurance coverage for GAS and competency training in California, several obstacles remain.
A small provider network. Identifying experienced and qualified surgeons trained in GAS, especially for the less commonly practiced masculinization procedures, can be difficult. Although exposure during training is increasing, the number of skilled surgeons performing these surgeries is limited, leading to longer wait times and potential geographic barriers for patients (Int J Transgend Health. 2022;23:458–471).
Insurance limitations. While California has made progress in mandating coverage for transgender care as discussed above, some insurance plans still impose restrictions or denial of coverage for certain GAS procedures. This can include stringent requirements such as extensive documentation or arbitrary prerequisites for coverage, causing delays and added burden.
Affordability. Despite insurance coverage, significant out-of-pocket costs can still be associated with GAS. Deductibles, co-pays, and noncovered expenses can accumulate, making these procedures nearly unaffordable for some individuals, and prohibitive for many patients of lower socioeconomic status (Int J Transgend Health. 2022;23:458–471). This financial burden can hinder access to surgeries and limit options for individuals seeking comprehensive gender affirmation care.
Addressing ongoing challenges requires continued advocacy and policy initiatives to ensure equitable access to gender-affirming surgery.
Intersectional barriers. Transgender patients who belong to marginalized communities, such as people of color, immigrants, elderly patients, or individuals with disabilities, may face additional challenges due to multiple forms of discrimination. This can include issues related to language barriers, ageism, lack of cultural competency among providers, and systemic biases that disproportionately impact marginalized communities (Plast Reconstr Surg Glob Open. 2020;8:e3008). Some insurance policies still impose age restrictions or criteria for GAS, making it challenging for transgender youth and adolescents to access the care they need.
Addressing these ongoing challenges requires continued advocacy and policy initiatives to ensure equitable access to GAS. Expanding the provider network, addressing insurance barriers, increasing financial assistance programs, and improving cultural competency within healthcare systems are crucial to enhance access to these procedures for all California transgender patients.
Our facial plastics center sees more than 50 patients per year for GAS. Our ability to help these patients is heavily dependent on the supportive legislative climate in our state. We’re fortunate to have providers who are well-trained in feminizationand masculinization surgery, a well-funded transgender center of excellence, university and departmental support for GAS initiatives, and the ability to provide early exposure to GAS for our trainees. While sociopolitical climates differ, California’s transgender health policies provide a template for legislative strategy in caring for this population.
And as for Chris? Today, he’s a transgender community leader and fierce advocate for mental health. He is incredibly grateful for what Dr. Seth and others have given him. Looking in the mirror, he can finally see what he’s always felt on the inside, and that gives him unmeasurable hope.
Dr. Mohan, Dr. Seth, and Dr. Knott are all from the division of facial plastic and reconstructive surgery in the department of otolaryngology at the University of California, San Francisco. Dr. Seth also practices at Golden State Plastic Surgery in Walnut Creek, Calif.
Table 1. Selected legislative advances in California for transgender patient access to care.
| YEAR | LAW | SUMMARY |
|---|---|---|
| 2004 | California Insurance Equality Act (AB 2208) | Mandated coverage for registered domestic partners that’s equal to spousal coverage. |
| 2005/2013 | Insurance Gender Non-Discrimination Act | Mandated coverage for registered domestic partners that’s equal to spousal coverage. |
| 2008 | Transgender and Nonbinary Health and Equity Act (SB 1729) | Required education for nursing home professionals in order to reduce discrimination against LGBTIQA+ seniors. |
| 2018 | Gender Health in Foster Care (AB 2119) | Mandated that child welfare agencies must ensure access to clinicians who provide gender-affirming treatment for transgender youth. |
| 2023 | Transgender, gender diverse and/or intersex (TGI) Inclusive Care Act (SB 923) | Required TGI-specific cultural competency training for healthcare professionals and insurance staffs. |