State mandates payment for children’s breast removal

As a child, Erin Brewer would have had her healthy breasts amputated if presented with the opportunity to fulfill her strong desire to be a boy. Instead, she said, a school psychologist helped her come to terms with her gender. Now, she is grateful to have nursed her three children.

Today’s gender-dysphoric girls in California might not be so fortunate. A Dec. 30 letter from the office of California Insurance Commissioner Ricardo Lara said state health insurers may no longer deny coverage for girls of any age to undergo a double mastectomy. The letter, addressed to San Diego transgender activist and mother Kathie Moehlig, redefines the surgery as “reconstructive” rather than cosmetic, labeling breasts “abnormal structures of the body caused by congenital defects.” Moehlig’s daughter, who now identifies as a male, had a double mastectomy at age 14.

Two girls ages 13 and 14 had the same surgery as part of a 2018 federally funded study at Children’s Hospital Los Angeles. Of the 68 female participants, all 25 or younger, 33 were under the age of 18. Researcher Johanna Olson-Kennedy concluded that 67 out of 68 found relief from “chest dysphoria” following the surgery.

The average age of the post-surgical patients was 19, hardly an age at which to draw long-term conclusions.

“This is so heartbreaking to me,” said Brewer, co-founder of Partners for Ethical Care, an advocacy group challenging the affirming medical approach for children with gender dysphoria. “Girls at 6 or 7 years old have no concept of having a baby, wanting to nurse that baby, or having sexual intimacy … they are now told they don’t have body dysmorphia, they have a congenital defect.”

The pro-LGBT World Professional Association for Transgender Health (WPATH) recommends mastectomies for individuals at least 18 years old but said the surgery “could be carried out earlier” on a case-by-case basis. In its standards of care, WPATH states current evidence is insufficient to predict the long-term outcomes of completing a gender role transition during early childhood.

The California Department of Insurance instructed companies to consider a patient’s specific clinical situation, not her age, to determine medical necessity for double mastectomies.

California law restricts therapists, clinicians, and medical professionals from steering gender-dysphoric youth toward accepting their bodies. “There is no way to develop a good clinical plan when therapists and medical professionals are hamstrung on what they can recommend as far as treatment plans go,” Brewer said.

Meanwhile, the letter also opened the door for insurers to cover transgender treatments and surgeries if coverage is already available for those services under different circumstances, “including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training.”

“I don’t think people understand the implications of this,” Brewer said. “What happens in California can easily bleed over into other states.”