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Over the past two decades, insurance coverage for gender affirming healthcare has rapidly expanded. Gender affirming care includes surgical, hormonal, or other care that enables patients to physically present as the gender they identify with. For example, genital modification, facial feminization surgery, chest reconstruction, hormone replacement therapy, voice modification, and more. However, insurance generally only covers care that is “medically necessary” (allowing the individual to be perceived as a certain gender), rather than “cosmetic” (enhancing attractiveness). So how do insurers decide what care is medically necessary?

To study this process, Tara Gonsalves examined national health insurance plans published between 2002 and 2022. The plans detail which gender-affirming care procedures are considered medically necessary vs. cosmetic, along with the insurer’s reasoning for that decision. Individuals who undergo a procedure defined as cosmetic—and subsequently denied coverage—can submit an appeal to a review board to argue that the procedure was medically necessary. Gonsalves also examined 225 of these appeals that were filed between 2009 and 2019.

Starting in 2009, no appeals were approved. But, 6 years later more appeals were approved than denied—signaling a substantial shift in what counted as “medically necessary.” Gonsalves found that, in order to distinguish between medically necessary and cosmetic procedures, insurers started defining which parts of the body are gendered and what features are masculine or feminine.insurers started defining which parts of the body are gendered and what features are masculine or feminine.

However, Gonsalves also found that the decision-making processes for appeals relied heavily on stereotypes of an ideal male or female body. For example, in a case involving facial feminization procedures, a reviewer described “softer” noses, prominent cheekbones, and narrower chins as feminine features. Reviewers tended to judge individuals against the ideal of a white, thin body, ignoring differences across age, weight, race, and other variations. 

Expanding insurance coverage has made care more affordable and accessible for transgender individuals. The increasing visibility of transgender and nonbinary individuals can challenge the male/female gender binary. At this same time, this study highlights how using gendered stereotypes as the justification for gender affirming care is also reaffirming societal gender norms.