Gender Affirmation Surgery in California

by Suresh Mohan, MD, Rahul Seth, MD, and P. Daniel Knott, MD •

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).