U.S. Insurers Often Don't Cover Permanent Hair Removal for Transgender and Gender Minority Patients

By Linda Carroll

March 27, 2020

(Reuters Health) - Transgender and gender minority patients in the U.S. often don't have insurance coverage for permanent hair removal, which could be a barrier for gender-affirming care, a new study concludes.

In an analysis of 174 private and public insurance policies, researchers found that just 8 (4.6%) covered permanent hair removal without explicit restrictions, according to results published in JAMA Dermatology.

"Hair removal can be a vital component of the gender affirmation process for many transgender and gender minority individuals, as hormone therapy - for example, estrogen in transgender females - often does not adequately remove facial and body hair," coauthors Nicholas Thoreson and Dr. Erica Dommasch said in an email. "Less than 5% of the policies covered hair removal outside surgery."

Among 123 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 postoperatively for gender-affirming surgery, while 7 (14.9%) permitted coverage for hair removal without explicit restrictions.

Among the 51 public 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.

"Clinicians should know that requesting coverage for hair removal may sometimes be successful, even when the policy guidelines don't explicitly mention coverage," said Thoreson, a researcher at Boston University Medical School and Dr. Dommasch, an assistant professor of dermatology at Beth Israel Deaconess Medical Center and Harvard Medical School. "Beyond that, clinicians should continue to act as advocates for their patients and work with key stakeholders including gender minority people, policy makers, and insurance companies to develop formal guidelines for coverage of permanent hair removal for patients undergoing gender affirmation."

To take a closer look at whether insurers were covering hair removal for transgender and gender minority patients, the researchers combed through the private health insurance policies available on the Patient Protection and Affordable Care Act (ACA) marketplace and policies under Medicaid, the state-run insurance program for low-income individuals.

They found that ACA marketplace policies in states without laws providing transgender care protections were less likely to cover hair removal without restrictions compared to policies in states with protections in place: coverage was provided in just two out of 85 policies (2.4%) in states without transgender care protections versus five out of 38 policies (13.2%) in states with protections.

Medicaid policies were less likely to cover preoperative and nonsurgical hair removal than private policies listed on the ACA marketplace.

The findings were "striking," said Dr. Gina Sequeira, an adolescent medicine fellow at the UPMC Children's Hospital in Pittsburgh. "I was surprised at how few insurers had any real coverage for hair removal. Papers such as this one are a call to action for us as providers. We have to do a better job of supporting our patients."

"Based on my clinical experience, hair removal has a pretty critical role for transgender women," said Dr. Sequeira, who was not involved in the new research. "Facial and body hair often are among the causes of the dysphoria many of my patients feel. I have one patient, a 21-year-old transgender woman, who is so distressed by her facial hair that she doesn't leave the house for several months at a time."

Often patients have to save for years to be able to pay for hair removal because their insurers don't cover it, Dr. Sequeira said.

"This research also highlights the importance of providing puberty blockers earlier - before terminal hair growth has occurred - because once terminal hair growth has occurred it's really hard to stop it," Dr. Sequeira said.

SOURCE: https://bit.ly/2UgbOl0 JAMA Dermatology, online March 25, 2020.

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