Patients say insurance covered their sex changes but not detransition care

Editor’s note: This story contains descriptions of medical attempts to alter sex characteristics. It may not be suitable for all readers.

When Abel Garcia received breast implants in 2018, he didn’t think about how hard it would be to get them removed.

Garcia, a male who at the time wanted to look like a female, said it was relatively easy to get the initial sex-change treatments. In 2016, he started taking cross-sex hormones. Two years later, he was in the operating room getting breast implants. His insurance provider covered both interventions.

A few months after that, Garcia changed his mind about the implants—and about his desire to become a woman.

But this time, Garcia’s insurance would not cover the surgery to remove the implants. That’s because his insurance provider doesn’t include reversal services as part of its “gender-affirming care” health coverage.

“My request to detransition by getting the implants removed was considered medically not necessary,” he said.

Garcia has joined a growing number of former transgender patients who, despite undergoing earlier medical procedures to alter their external sex traits, later want to change them back to their original appearance. Whether a detransitioner can get insurance coverage for his treatment depends on his provider and, sometimes, what state he lives in.

In March, Texas legislators proposed a bill that would require insurance companies to cover detransition treatments. Last June, Arizona Gov. Katie Hobbs vetoed a bill that would have required insurers to cover detransition procedures. Also last year, a similar bill died in Florida, and Tennessee legislators did not advance a bill that would have required medical providers who perform transgender procedures to also provide detransition treatment.

Insurance companies also take differing approaches to this treatment. WORLD reviewed the clinical policy guidelines for five major healthcare providers—United Healthcare, Cigna Healthcare, Kaiser Permanente, Centene Corporation, and Medicaid. Both United Healthcare’s and Cigna’s policies say the companies might cover reversals if the patient meets some of the same criteria for treating gender dysphoria, like being over 18 and having the capacity to consent. Centene considers detransition services “on a case-by-case basis.” Kaiser Permanente requires a patient to obtain two letters from members of the World Professional Association for Transgender Health and supportive documentation from a doctor, surgeon, and a therapist.

Medicaid coverage varies from state to state. Last month, Dr. Mehmet Oz, head of the Centers for Medicare & Medicaid Services, advised state Medicaid programs to stop covering gender-affirming services.

But some detransitioners worry Oz’s directive could also jeopardize their medical care if insurance companies interpret the guidance to include procedures that undo transgender interventions. In 2020, 30-year-old Camille Kiefel, who identified as non-binary at the time, received a double mastectomy—covered by Medicaid—to remove her healthy breasts. Now, she hopes Medicaid will pay for the reversal as a step toward “getting the support under the system that harmed us.”

She said that finding someone in the medical field who can understand what she’s asking for has not been easy. Her doctor’s office seemed confused when she called to ask about detransition.

“I reached out and they said, ‘Well, we don’t think we can cover it for you, because you’re cisgender,’” Kiefel said. “Then I followed up and they said, ‘Well, actually, we think we might be able to cover it, but it’s going to be under [the medical coverage policy for] “gender-affirming care.”’”

Garcia realized doctors weren’t prepared for him either. His insurance provider took a year and a half to approve his reversal. The surgeon who removed the implants billed the procedure to insurance as “gynecomastia”—excessive breast tissue in males. Garcia believes this was deceptive and hid the fact that this was a transgender-related procedure.

“Until the medical professionals start to actually count detransitioning and give proper medical codes for us so we can get proper billing, any and all medical related care to us is going to be different than most people,” Garcia said.

But Garcia’s surgeon may not have had another option. When doctors’ offices bill insurance, they are required to assign a medical code to every diagnosis and procedure. However, there are no medical billing or procedure codes designed for detransition or reversals of transgender treatments.

Medical billing codes are developed and maintained by the American Medical Association, which stated in 2023 that sex change procedures are “evidence-based” and “can be life saving.”

WORLD asked the association why there aren’t separate diagnosis and procedure codes for patients who want to detransition. A representative responded that detransition-specific codes weren’t necessary because patients already access treatments for different reasons. “Medical procedures and surgeries apply across patients with different diagnoses,” he said. “The AMA does not group codes by the type of diagnosis.”

In other words, a female patient getting breast implants after a breast cancer diagnosis would get the same procedure code as a male patient getting implants for a sex change or a female detransitioner getting implants after regretting her double mastectomy.

Still, some doctors argue that billing codes are necessary to help medical institutions establish a standard procedure for detransition, said Dr. Jared Ross, an emergency medicine physician in South Carolina and a senior fellow with the research group Do No Harm.

“We don’t routinely take boys and castrate them and inject them full of estrogen, and when they decide this is wrong for them, how do we manage that?” Ross said. “How do we manage a boy who doesn’t have his own testicles anymore? We just don’t have the answers for this.”

Ross said he asked several patients who formerly identified as transgender what their doctors told them when they expressed regret. “When they went to their doctors who took them down this path, they were either convinced, ‘Oh, doubt is a normal part of the process,’ or they were simply dismissed,” he said.

Some say the number of people who regret their gender transition surgery is very low. According to the 2022 U.S. Trans Survey, less than 2% were dissatisfied with their decision to undergo surgery, compared to 88% who were “a lot more satisfied.”

On Thursday, the Department of Health and Human Services released a report about pediatric gender dysphoria treatments. “The detransition rate is unknown,” it read, citing studies where regret rates ranged anywhere from less than 5% to 25%.

While Garcia said he had his doubts before he got breast implants, he didn’t fully realize his regret until months after the surgery: “I had to ask myself, ‘What am I doing?” he said. “No matter what I was going to do, whether I continued transitioning, whether I took all the hormones in the world, had every surgery to look as much as a woman, I realized that I would not be a woman. I would just be a man either cosplaying as a woman or doing a caricature of what I believed a woman was.”