Vermont opens door for gender-affirming surgery for transgender youth

Vermont health insurance regulators are planning to tweak Medicaid rules so transgender youth no longer have to wait until age 21 to seek gender-affirming surgery.

The changes are aimed at removing barriers for people seeking a suite of surgeries in order to alleviate gender dysphoria, a conflict between a person's gender identity and physical gender, said Nissa James, policy director for the Department of Vermont Health Access.

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Gender-affirming surgeries covered by Medicaid include 16 types of genital surgery, as well as breast augmentation or mastectomy, a surgery that removes the whole breast.  

The new rule, proposed at the end of May, eliminates an age minimum and allows youths under 18 to get surgeries with informed consent from a parent or guardian.

Nearly a quarter of all Vermonters, and 50 percent of Vermonters under the age of 18, rely on Medicaid for health insurance, according to the Department of Health.

A medical necessity 

The changes would be "enormously positive" for transgender people in Vermont, especially individuals in their late teens, said Dr. Rachel Inker, who runs the Transgender Health Clinic at the Community Health Centers of Burlington. 

"Having young people have to wait until they were 21 just didn't really make any sense," Inker said. 

As a provider, Inker sees surgery as medically necessary for the people who want it, she said. 

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The choice to have surgery is a personal one that should be explored in every age group, Inker said, although people who are young enough can be given puberty-blocking treatments to inhibit development of secondary sex characteristics like breasts or facial hair. 

Older teens may have already developed those characteristics, Inker said, and face going to college or getting a job while their gender identity and gender presentation are mismatched. 

She cited young transgender men wishing to get top surgery to remove breast tissue as an example of the kind of procedures commonly requested by teenagers between 16 and 18.

Life-saving 

These surgeries are life-saving, said Dana Kaplan, executive director of Outright Vermont, an organization that supports LGBTQ youth. 

Gender identity develops as young as three, he said.

"Here is an opportunity to say you can live the life that is authentically yours," he said. "Why would we get in the way of that?"

A "staggering" percentage of transgender and non-binary youth have reported considering suicide, Kaplan said. Having access to medical care that affirms their identity can save young people years of the distress caused by living in a body conflicting with their gender identity.

"When a kid gets to the point where they say 'I really, really need this to be comfortable in my body' — again, why would we get in the way of that?" he said.  

The change would only apply to Medicaid, but Kaplan said Medicaid could set a precedent for other providers. 

Informed consent

The new rules would drop the minimum hormone therapy requirement for genital surgeries from two years to one year. Hormone therapy would no longer be a requirement for breast-removal surgery. 

The rules also reduce some of the requirements to get surgery covered, like the need to have letters of support from two psychiatrists. The new rules ask for a mental health provider and a medical provider to evaluate the procedures as medically necessary.

Patients of every age must submit paperwork documenting that they give informed consent. For people under the age of 18, their parents or guardians must give informed consent. 

Next steps

The Medicaid Policy Unit is accepting public comment about the proposed changes through July 17. Comments can be emailed to AHS.MedicaidPolicy@Vermont.gov.

Regulators will file a final version of the rule after the public comment period. The Legislative Committee on Administrative Rules will then review the proposal, hold a hearing and vote on whether to put it into effect.

Contact Jess Aloe at 802-660-1874 or jaloe@freepressmedia.com. Follow her on Twitter @jess_aloe