The hidden barriers to detransitioning

NICK EICHER, HOST: Coming up next on The World and Everything in It…the cost of detransitioning.

In the U.S., many insurance companies now cover cross-sex hormones and surgeries to alter sex characteristics. But when someone wants to reverse those procedures? Coverage gets murky.

Some companies don’t cover detransition. Others bury the process in red tape. And that has the attention of lawmakers.

MARY REICHARD, HOST: Last week, Texas approved a bill requiring insurance companies to cover medical care for side effects and procedures related to detransition.

If Republican Governor Greg Abbott signs it, Texas would be the first state to make that law stick.

WORLD’s Juliana Chan Erikson has that story.

JULIANA CHAN ERIKSON: For Abel Garcia, getting insurance to pay for his breast implants was the easy part. Once doctors diagnosed him with gender dysphoria at age 18, they wrote prescriptions for estrogen supplements and breast implant surgery.

ABEL GARCIA: They got me as soon as they could to transition to get the implants. Did the recovery, everything went well, no issues, no complications.

But three months after the plastic surgery, Garcia came to a startling realization.

GARCIA: It all came crashing down like an avalanche one day, and I had to ask myself, What am I doing?

Garcia decided he wanted to get the implants removed… but he discovered that gender transition in the United States is a one-way street. Therapist after therapist continued to affirm his chosen gender identity, rather than his birth identity. And the insurance companies that said cross-sex hormones and surgeries were medically necessary told a different story about reversal treatments.

GARCIA: They replied back to me, saying that my request to detransition by getting the implants removed was considered medically not necessary.

WORLD reached out to Inland Empire Health Plan, Garcia’s insurance company, to ask about that policy. The provider said that due to privacy rules, they could not confirm Garcia’s membership, or the treatments he received.

Major health insurance providers generally cover gender-affirming procedures. But when it comes to reversals, they vary. Some will only grant them on a case by case basis.

Dr. Jared Ross is an emergency medicine physician in South Carolina and a senior fellow with the research group Do No Harm.

ROSS: You would never imagine having an anorexic girl go to a doctor and say, I'm fat. I need ozempic. I need gastric bypass, I need liposuction. The doctor would never say “Yes, of course, you're fat.”

He says insurance companies used to only cover breast implants for women who’ve lost their breasts to cancer or a traumatic injury.

ROSS: For someone to just say, oh, I want breast implants. Oh, no, I want them removed. Insurance doesn't really get involved in either side of that.

But cases like Garcia’s reveal an emerging trend. Most major insurance companies now cover breast implants in men diagnosed with gender dysphoria. And Ross says that’s a problem.

ROSS: We are cutting into the body to address a mental health issue…It's completely inappropriate and completely unethical.

Ross says doctors, patients and insurance companies have to grapple with the fact that most of these patients’ bodies will never truly return to normal when they change their minds.

ROSS: The human body is not a Lego set. We can't simply remove parts and put them back.

Adding to the confusion, doctors and insurance providers don’t have a billing code specifically for detransition procedures. For every doctor-patient interaction, there is a multi-digit code identifying it for insurance billing. There is a code for everything a doctor could ever encounter, from being struck by a duck to walking into a lamppost. But there isn’t a code for someone who wants to reverse a gender change procedure.

The American Medical Association develops and maintains these medical procedure codes. When WORLD asked the association why there aren’t codes for these patients, a representative said many patients get the same procedure but for different reasons. So there doesn’t need to be a distinction.

When Garcia appealed and got approval for surgeries to remove the implants and reconstruct his chest, the surgeon didn’t label that a reversal.

GARCIA: He mentioned it was gynecomastia.

That’s a condition when men have enlarged breasts. But that billing code hides the truth of what Garcia was experiencing, and some want to change that.

KIEFEL: We're not actually studying the people who've been harmed by this

Camille Kiefel is head of Detrans Help, a support group for detransitioners. She says if there was a medical billing code for detransition, Garcia and others would have an easier time getting approved for reversal procedures. It would also make it easier to figure out how many patients are asking for them.

KIEFEL: Part of it's going to be documentation, and then the other thing is just easily getting access to what we need.

Kiefel herself had a double mastectomy when she was 30, back when she considered herself non-binary. Now, she wants to go back to looking like a woman. She acknowledges that breast implants aren’t medically necessary, but says they’re important in other ways.

KIEFEL: It’s important for their self-esteem, for being able to go on and live their life, like start a family if they want to, be in relationships.

Abel Garcia has spent several years trying to fix what was broken. Along the way, he proposed to his girlfriend and is planning a wedding for next year.

GARCIA: I'm just working on trying to live my life, and do the best that I can to live as a man. And say I deserve some happiness after the insanity I’ve been going through the last couple of years.

Dr. Ross says the U.S. has a long way to go, not just to undo the damage, but also to prevent it from happening. He says Texas is heading in the right direction, by requiring insurance to cover reversal procedures and prohibiting minors from receiving them in the first place.

ROSS: There are minors there that were harmed, and there may be minors who were harmed out of state who go to Texas for for help, because they see Texas as as a beacon of light, as a state that has definitely led the path in trying to protect children from this.

Reporting for WORLD, I’m Juliana Chan Erikson.

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