D.C. Mayor Vincent C. Gray on Thursday announced that the city will recognize gender dysphoria as a medical condition, forcing insurance companies to cover treatments such as gender-reassignment surgery for transgender people.
The coverage extends to all D.C. residents with group or individual health insurance — including the roughly one-third of city residents receiving Medicaid benefits — whose doctors diagnose the condition and for whom treatment is deemed medically necessary.
“This action places the District at the forefront of advancing the rights of transgender individuals,” Mr. Gray said at his ceremonial office at City Hall. The District joins California, Colorado, Connecticut, Oregon and Vermont in requiring the coverage, which the federal government will not be made to offer to its employees.
Transgender activists applauded the move, saying it guarantees coverage for treatments such as gender reassignment surgery that can cost tens of thousands of dollars and which have been denied by insurance companies that deemed the procedures cosmetic.
“This isn’t about who’s paying for things. This is about whether or not it’s medical care and who gets to decide that,” said Mara Keisling, executive director of the National Center for Transgender Equality. “Nobody in America wants their health care decisions made by the insurance companies.”
The National Center for Transgender Equality estimates that 2,000 transgender people live in the District, though it’s unclear know how many might seek treatment under the coverage.
A survey last year of more than 600 transgender people from the D.C. area indicated that 46 percent living in the area earn less than $10,000 a year — making the specific inclusion of Medicaid in Thursday’s announcement an important factor, said Nico Quintana, a senior organizer with the DC Trans Coalition.
City officials pointed out that the move was a clarification to a bulletin issued in March notifying health insurers to remove language that discriminated on the basis of gender identity and expression so that transgender individuals could obtain medical benefits.
After receiving numerous inquiries about the scope of last year’s announcement, the District’s Department of Insurance, Securities and Banking sought greater detail.
“I don’t think we got any formal complaints. What we did get was a lot of questions,” said Philip Barlow, the department’s insurance commissioner. “I suspect that people were waiting for clarity before they moved ahead.”
As a result, the city’s position on the matter is “the clearest and most direct of any of the jurisdictions out there,” Mr. Barlow said.
The American Psychiatric Association last year replaced the term “gender identity disorder” with “gender dysphoria” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
In a statement explaining the change to its official listing of diagnoses, the association said the purpose was to make clear that “gender nonconformity is not in itself a mental disorder.” The critical element of the diagnosis, the statement said, is “clinically significant distress” and that the association sought a diagnosis that would not stigmatize all transgender people but would ensure access to medical care and insurance coverage to those who suffered from the condition.
The District, in recognizing gender dysphoria, mandated that insurance providers determining the medical necessity of treatment refer to the World Professional Association for Transgender Health Standards of Care, the standard of medical care for transgender people.
City officials have noted that insurance companies operating in the District had explicit policies that excluded transgendered people from some of the same services offered to others — including mastectomies for breast cancer, hormone replacement therapy and high blood pressure medications.
“These residents should not have to pay exorbitant out-of-pocket expenses for medically necessary treatment when those without gender dysphoria do not,” said Mr. Gray, who is running for re-election this year among a crowded field of contenders.
Amy Loudermilk, of the District’s office of gay, bisexual and transgender affairs, said that without anti-discrimination policies it can be difficult to enforce a proper standard of care for transgender patients.
In the case of a woman who was transitioning to become a man, once a health insurance company begins to recognize the patient as male, the patient no longer would be afforded coverage for procedures such as mammograms or gynecological exams, Ms. Loudermilk said.
It’s also unclear whether inclusion of treatments for gender dysphoria could add to the cost of health care coverage in the District.
“Sometimes a mandate in and of itself could drive up the cost if it was a high-cost service and a lot of people were requesting it,” said Susan Pisano, spokeswoman for America’s Health Insurance Plans, a national trade association representing the health insurance industry.
A study of the use of gender transition shows that coverage is low among companies that offer such benefits and typically adds no cost to a health care plan.
A report released in September by the Williams Institute at the University of California, Los Angeles, found that among employers with 1,000 to 10,000 employees, only one out of 10,000 employees takes advantage of transition-related benefits when available.
The institute, which specializes in research on sexual orientation, surveyed 34 employers and, of the 26 who provided information about coverage costs, found that 22 of the employers reported no increase in the cost of premiums for adding transition-related benefits to coverage. Four of the companies reported increased insurance costs based on expected use of the coverage.
Some local employers already have adopted health care plans that cover treatments for gender identity disorder, Ms. Keisling said.
While not speaking specifically to gender-reassignment surgery or other treatments for gender identity disorder, Ms. Pisano said that the support of health insurance companies for covering a treatment depends on the scientific evidence behind it.
“I think it’s going to depend, generally, on the weight of the evidence that supports that particular treatment,” she said. “Is it something that the research says is safe or is an effective treatment?”