eTable. Number of ACA Private Insurance Policies per State
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Thoreson N, Marks DH, Peebles JK, King DS, Dommasch E. Health Insurance Coverage of Permanent Hair Removal in Transgender and Gender-Minority Patients. JAMA Dermatol. Published online March 25, 2020. doi:10.1001/jamadermatol.2020.0480
To what extent do health insurance policies cover permanent hair removal for transgender and other gender-minority patients?
In a cross-sectional study performed in September 2019, 166 of 174 Medicaid and Affordable Care Act marketplace policies (95.4%) broadly excluded or did not mention gender-affirming care, excluded or did not mention coverage of hair removal, or only permitted coverage in the setting of genital surgery. Medicaid policies and private policies in states without legal protections for transgender coverage were less likely to cover permanent hair removal.
This study’s findings suggest that most insurance plans do not cover permanent hair removal for transgender and gender-minority patients.
Hair removal can be an essential component of the gender affirmation process for gender-minority (GM) patients whose outward appearance does not align with their gender identity.
To examine the health insurance policies in the Affordable Care Act (ACA) marketplace and Medicaid policies for coverage of permanent hair removal for transgender and GM patients and to correlate the policies in each state with statewide protections of coverage for gender-affirming care.
Design and Setting
Private health insurance policies available on the ACA marketplace and statewide Medicaid policies were examined in a cross-sectional study from September 1 to October 31, 2019, and January 17 to 30, 2020. Policies were assessed for coverage of permanent hair removal. Language concerning hair removal was found in each policy’s medical or clinical coverage guidelines and separated into general categories.
Main Outcomes and Measures
Logistic regression analyses were performed to compare Medicaid policies and ACA policies in states with and without transgender protections.
A total of 174 policies were analyzed, including 123 private insurance policies and 51 statewide Medicaid policies. Of these policies, 8 (4.6%) permitted the coverage of permanent hair removal without explicit restrictions. The remaining 166 policies (95.4%) broadly excluded or did not mention gender-affirming care; prohibited coverage of hair removal or did not mention it; or only permitted coverage of hair removal preoperatively for genital surgery. The ACA marketplace policies in states without transgender care protections were less likely to cover hair removal without restrictions than ACA policies in states with protections (2 of 85 policies [2.4%] in states without transgender care protections vs 5 of 38 policies [13.2%] in states with transgender care protections), and Medicaid policies were less likely to cover preoperative or nonsurgical hair removal compared with ACA policies (6 of 51 Medicaid policies [11.8%] vs 47 of 123 ACA policies [38.2%]).
Conclusions and Relevance
Despite adoption of statewide restrictions on GM health care exclusions by several states, most Medicaid and ACA policies examined in this study did not cover permanent hair removal for transgender patients. Many GM patients seeking hair removal may be required to pay out-of-pocket costs, which could be a barrier for gender-affirming care.
Hair removal can be an important component of gender affirmation for many transgender and other gender-minority (GM) individuals, defined as people whose gender identity differs from their sex assigned at birth.1 Gender-minority people, most often transwomen, may undergo hair removal of facial, axillary, and other body regions to align their gender identity and expression.2 Surveys of GM individuals2,3 have revealed that 85% of transwomen desire removal of excess facial or body hair and that laser hair removal is the most common facial procedure performed for transwomen. More important, feminizing hormone therapy is insufficient for removing facial hair; thus, alternative methods of hair removal are often necessary components of affirmation for transgender individuals.2 The World Professional Association for Transgender Health standards of care designate electrolysis and laser as valid modalities for hair removal in the treatment of gender dysphoria and in those individuals who are affirming their gender expression.4 In addition, gender-affirming procedures such as phalloplasty or vaginoplasty may require hair removal, typically electrolysis, on surgical graft sites, most commonly the forearm or thigh for phalloplasty, or the penile shaft, base of penis, scrotum, and perineum preoperatively for vaginoplasty.5 This procedure is necessary to reduce postprocedural complications secondary to disruption of the surgical graft by unwanted hair growth.6,7
The most common methods of hair removal include laser hair removal (LHR) and electrolysis. Electrolysis uses chemical or heat energy to destroy the hair follicular unit.8 Subtypes of electrolysis include galvanic, which uses a caustic chemical to destroy the hair follicle; thermolysis, which involves thermal destruction through the use of an electric current; or a combination of both.9 Laser hair removal works through selective thermolysis, which targets thermal damage to melanin in the hair follicle, causing collateral damage to the hair shaft.10 Laser hair removal can treat multiple hair follicles simultaneously and thus can treat larger areas in less time compared with electrolysis. However, LHR is ineffective in treating light or vellus hairs.11 Electrolysis is currently the only US Food and Drug Administration–approved method of permanent hair removal, whereas LHR is only approved for permanent hair reduction.9 In this study, hair removal refers to the treatment of unwanted hair regardless of modality and refers to permanent hair reduction and removal in the clinical setting unless indicated otherwise.
For GM patients undergoing feminization procedures, cost is the most frequently cited barrier to care, and health insurance coverage is therefore essential for these patients.2 Section 1557 of the Affordable Care Act (ACA) prohibits sex discrimination in health care programs that receive federal funding, and existing regulations from the Department of Health and Human Services have interpreted this to include gender identity protections for transgender and gender-nonconforming individuals.12-14 Gender identity discrimination can include the denial of services for gender-affirming care that would otherwise be covered for cisgender patients, the refusal to cover treatment typically associated with one gender because the patient identifies with another gender, and broad exclusions of all gender-affirming care.14 However, in June 2019, the US Department of Health and Human Services proposed regulatory changes to revoke the interpretation prohibiting health care discrimination based on gender identity.13 Although these federal regulations have yet to be finalized, there remains substantial state-by-state variability in regulations regarding gender-affirming care based on interpretation of federal laws and regulations from the ACA and the Medicaid Act.15,16 As of 2019, 20 states and the District of Columbia have explicit legal protections for transgender care in private health insurance coverage (California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington), whereas the remaining 30 states have no such legal protections.16 (The Maine legislature passed an emergency measure bill, signed into law in March 2019, that contained language preventing categorical exclusions or limitations of coverage related to gender transition in private health insurance policies.17) Medicaid coverage guidelines for gender-affirming care differentially determine how federal regulations are interpreted on a state-by-state basis. In this cross-sectional study, we examined US health insurance coverage for GM patients undergoing permanent hair removal as preoperative preparation for gender-affirming surgery or for modification of physical appearance.
Because this study did not include human participants, no institutional review board approval was required based on criteria of the Health and Human Services Common Rule.18 In this cross-sectional study, we examined private health plans from the ACA marketplace found on the Out2Enroll website from September 1 to 30, 2019. That website provides transgender and GM health insurance coverage information from certificate of coverage documents for silver plans on the ACA marketplace. These plans are the marketplace standard and the most common type of plan selected, requiring moderate monthly premiums and costs.19,20 We further analyzed each private health care plan listed in Out2Enroll on their respective websites to identify individual medical policies concerning gender-affirming care or certificate of coverage documents, depending on what was available. Such policies serve as a set of guidelines for determining medical services that may be eligible for coverage as well as additional detail concerning coverage of specific procedures and treatments. Certificate of coverage documents were taken from individual silver plans from the Out2Enroll website or the individual health insurance websites and were included if medical policy documents for gender-affirming care were unavailable. In September 2019, state-by-state statutes of Medicaid coverage for transition-related care in all 50 states and the District of Columbia and a list of state-specific restrictions on transgender health care exclusions were found on the Movement Advancement Project website16; the project is an independent think tank that collects data on transgender care exclusions in legislation for Medicaid and private insurance policies. Each plan was examined for coverage of hair removal for GM patients. We excluded any plans that lacked coverage information online. An initial search of all online documents was conducted from September 1 to October 31, 2019, with a second search performed January 17 to 30, 2020, to identify any recently updated documents or changes in policy.
We created categories for all Medicaid and ACA hair removal coverage guidelines based on information provided in the included insurance policies. As each policy was reviewed, new categories were created and existing categories were expanded or redefined to accommodate new information in each policy. All Medicaid and ACA coverage policies were coded into the following 6 categories concerning coverage: (1) exclusion of coverage for gender-affirming care, consisting of policies with language broadly excluding coverage for treatments or procedures related to gender-affirming care, including surgery; (2) policy documents silent on coverage of gender-affirming care; (3) hair removal by any means excluded from coverage; (4) hair removal coverage not mentioned; (5) hair removal only covered preoperatively for gender-affirming surgery (ie, phalloplasty or vaginoplasty); and (6) hair removal coverage provided without explicit restrictions, including nonsurgical hair removal. The number of policies in each category was counted for all states and compared in states with and without explicit legal protections for insurance coverage of transgender care. Two separate binomial logistic regression analyses were run in SPSS, version 25 (IBM Corporation) to compare hair removal coverage among the different policies. One analysis was used to compare ACA policies in states with and without explicit legal transgender protections, and the second analysis compared Medicaid policies with all ACA policies. All results with 2-sided P < .05 were considered statistically significant.
A total of 174 ACA and Medicaid plans were examined for hair removal coverage. One hundred thirty ACA plans were available on the Out2Enroll site, and 7 of these plans were excluded from analysis owing to lack of available coverage information online. The remaining 123 plans came from 38 states (eTable in the Supplement and Figure). Ninety-two (74.8%) of these private insurance policies came from medical policies concerning gender-affirming care on the individual health insurance websites, and 31 (25.2%) came from certificate of coverage documents of silver plans on the ACA marketplace. All 51 Medicaid policies from 50 states and the District of Columbia were included in the analysis.
Twenty-one ACA and 6 Medicaid policies were recategorized at the second analysis performed in January 2020 to reflect recently updated policy documents or documents found that were more specific to individual policies, including 3 policies which had previously excluded gender-affirming care. Several Medicaid policies were recategorized owing to recent changes in transgender care coverage. Wisconsin’s Medicaid program, which previously excluded gender-affirming care, was modified after the state declined to appeal a decision from a federal judge permanently enjoining transgender care exclusions in November 2019.21,22 In addition, GM access to care for Medicaid recipients in Iowa remains uncertain owing to an appropriations bill allowing Medicaid to exclude gender-affirming care despite a recent court ruling banning transgender care exclusions.16
Among the 123 ACA private health plan policies, 6 (4.9%) broadly excluded gender-affirming care, 9 (7.3%) were silent on gender-affirming care, 52 (42.3%) excluded hair removal coverage, and 9 (7.3%) did not mention it. Among the 47 policies that covered hair removal, 40 (85.1%) only permitted coverage preoperatively for gender-affirming surgery, whereas 7 (14.9%) permitted coverage for hair removal without explicit restrictions. Among the 51 Medicaid policies, 10 (19.6%) broadly excluded gender-affirming care, 19 (37.3%) were silent on gender-affirming care, 3 (5.9%) prohibited hair removal coverage, 13 (25.5%) did not mention hair removal coverage, 5 (9.8%) included coverage in the context of genital surgery, and 1 (2.0%) covered hair removal outside the context of genital surgery.
Among the 123 ACA private health plan policies, 38 (30.9%) came from states with explicit legal protections for private insurance coverage of transgender care, including 5 of the 7 ACA policies with unrestricted hair removal coverage. Eighty-five of 123 ACA policies (69.1%) came from states without such protections, including 5 of the 6 ACA policies with broad exclusions of gender-affirming care. Private insurance and Medicaid policies sorted by coverage category and statewide legal protections are listed in the Table. For the statistical analysis, private health plans that covered hair removal outside of genital surgery had more than 6 times the odds of being offered in states with explicit legal protections for transgender insurance coverage, with 5 of 38 policies (13.2%) in states with protections offering coverage vs 2 of 85 (2.4%) in states without protections (odds ratio [OR], 6.3; 95% CI, 1.2-34.0; P = .03). When private plans were compared with Medicaid state policies, private plans had significantly higher odds of hair removal coverage (preoperative and unrestricted hair removal coverage combined), with 47 of 123 private insurance policies (38.2%) offering some form of hair removal coverage vs 6 of 51 Medicaid policies (11.8%) (OR, 4.6; 95% CI, 1.8-11.7; P = .001).
Most of the insurance policies examined excluded hair removal coverage entirely or only covered hair removal for preoperative preparation. Only a minority of plans allowed for coverage of hair removal outside of genital surgery, and none of these plans specifically mentioned coverage for different body sites. No plan made a distinction between electrolysis and LHR in terms of coverage differences. The ACA marketplace policies were more likely to cover preoperative and nonsurgical hair removal than Medicaid policies, whereas ACA policies in states with legal protections for transgender care coverage were more likely to cover nonsurgical hair removal. Although many plans contained language restricting hair removal coverage or did not mention hair removal at all, they also contained clauses permitting coverage of cosmetic procedures deemed “medically necessary” that could be used for hair removal coverage, particularly in the case of preoperative electrolysis. As such, the restrictions mentioned herein may not apply to actual clinical scenarios. Letters of medical necessity may suffice in some circumstances to grant coverage for preoperative or nonsurgical hair removal.
Only private insurance policies available on the ACA marketplace and Medicaid coverage guidelines were used in this study, and the private insurance plans were limited to 38 states. The medical policies used to define health insurance categories were guidelines used to define coverage but did not necessarily pertain to individual plans offered, whereas the certificate of coverage documents were only specific to their individual plans and did not go into the same level of detail. In addition, it was impossible to analyze any policies that were silent on transgender and GM coverage for hair removal coverage. Owing to the limited number of policies examined in this study and the lack of private insurance policies examined outside of the ACA marketplace, this study could not provide a complete account of hair removal coverage in the US, thereby preventing broader conclusions about the effect of state laws on hair removal insurance coverage.
States with laws protecting coverage of gender-affirming care are more likely to also have private insurance plan coverage for GM hair removal. In addition, significantly fewer statewide Medicaid policies had coverage of hair removal for GM individuals compared with ACA private insurance policies. This finding has broad implications for GM people owing to the importance of hair removal for gender affirmation, because out-of-pocket costs are likely a significant barrier to care in this population.2 Modification of physical appearance and expression, including facial and body hair removal, is often a necessary component of affirmation for many transgender and GM individuals. More important, hair removal plays a major role for many of these individuals beyond preoperative care.8 The American Academy of Dermatology position statement on sexual and GM health in dermatology upholds that gender-affirming treatments and procedures that aid in the mental or physical well-being of GM individuals (which would include hair reduction) are medically necessary and should be covered by private and public insurance policies.23 Excluding hair removal coverage might prevent many GM people from accessing a crucial component of the gender affirmation process. Health insurance policies both private and public should recognize this and cover hair removal for GM patients without restricting coverage to preoperative care. Formal guidelines developed through collaboration among GM people, physicians, policy makers, insurance companies, and other stakeholders for coverage of permanent hair removal in the GM population are needed to ensure consistent and affordable access to care, regardless of insurance type.
Accepted for Publication: February 5, 2020.
Corresponding Author: Nick Thoreson, BS, Boston University School of Medicine, 72 E Concord St, Boston, MA 02118 (email@example.com).
Published Online: March 25, 2020. doi:10.1001/jamadermatol.2020.0480
Author Contributions: Dr Dommasch had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Thoreson, Marks, Peebles, Dommasch.
Acquisition, analysis, or interpretation of data: Thoreson, King, Dommasch.
Drafting of the manuscript: Thoreson, Peebles, Dommasch.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Thoreson, King.
Obtained funding: Dommasch.
Administrative, technical, or material support: Marks.
Supervision: Peebles, Dommasch.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by Stern Grant Dermatology Research Funding.
Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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