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Transgender women who hold Aetna cards now have easier access to an operation that will help them live their more authentic lives.

The major insurance carrier, which covers an estimated 39 million people, announced last week that it has expanded its coverage of gender-affirming procedures to include breast augmentation.

Four transgender women who were denied breast augmentation surgery as part of their gender-affirming treatment brought the issue to the company’s attention through the Transgender Legal Defense & Education Fund.

That advocacy led Aetna to update its clinical policy to cover breast augmentation for trans women as medically essential when certain clinical requirements are met, such as a letter of referral from a qualified mental health professional and persistent, well-documented gender dysphoria.

Aetna’s move is a step toward a more progressive medical system, experts say, but there is still a lack of standardized care.

“Many companies still consider [gender-affirming surgeries] to be elective procedures and require patients to go through appealing denials and that kind of thing,” said Dale Melchert, staff attorney at the Transgender Law Center. “That is not best practice.”

Insurance plans vary greatly in how they’ll cover top surgery for transgender patients.

A 2019 survey published in Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons, found that 96 percent of the 57 evaluated insurers covered bilateral mastectomy, which is usually performed for transgender men. However, only 68 percent of those insurers covered breast augmentation for patients who are transgender women.

The cost of the procedure can also differ based on where a person lives, meaning a person seeking gender-affirming top surgery would have to shell out thousands of dollars if insurance won’t help alleviate some of the cost burden. Not being able to access this surgery can often worsen gender dysphoria.

Because of Aetna’s size and market share, the inclusion of breast augmentation under its umbrella of procedures is an important step forward for health coverage for transgender people, said Paula Neira, a lawyer and secretary of GLMA, an LGBTQ health advocacy group.

“I want to laud them for doing what they should’ve done a while ago,” she said. “It’s a progressive step forward and I don’t want to negate that. However, many other insurers have already recognized this. They’re not blazing the path.”

Only 18 states and the District of Columbia specifically include coverage for gender-affirming care under their Medicaid programs, despite regulations issued in 2016 that bar Medicaid programs from excluding coverage for all types of gender-affirming care. More than 152,000 transgender people rely on Medicaid, according to a 2019 report from the University of California at Los Angeles. Twelve states exclude Medicaid coverage for gender-affirming care and 20 states have not expressly addressed such coverage, according to the report.

“Different states either outright refuse to cover it or their policies are silent about it,” Neira said. “It’s still a challenge to navigate insurance coverage to be able to access gender affirming surgery.”

“Misogyny pervades even trans health care,” Melchert said.

Aetna’s announcement can help communicate that this is medically necessary treatment for transgender and gender-diverse people, said Alex Keuroghlian, director of the National LGBTQIA+ Health Education Center and an associate professor of psychiatry.

Gender-affirming procedures are often a critical aspect for being able to function and thrive in one’s identity — something cis-born people can take for granted, he said.

People with gender dysphoria experience higher rates of suicide ideation compared with the rest of the population. Forty percent have attempted suicide in their lifetime, according to the 2015 U.S. Transgender Survey.

Keuroghlian said that his soon-to-publish research shows that gender-affirming surgeries helped mitigate suicide ideation, distress and even cigarette smoking.

“People really have great reductions in gender dysphoria,” he said. “I hope that other insurers will follow suit and continue to expand access.”

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