Policy Statement: The Medical Necessity of Gender Affirmation

The National LGBTI Health Alliance has approved a new policy on the medical necessity of gender affirmation.

Medical gender affirmation is necessary and beneficial for intersex, trans and gender diverse people who seek such intervention on their own behalf. There are many intersex people in Australia who have been subjected to medical intervention without their own fully informed consent.

For trans and gender diverse people who seek medical gender affirmation, extensive research has documented that hormones, surgery and related affirmation procedures are medically necessary and beneficial.

The Commonwealth Sex Discrimination Act (Sexual Orientation, Gender Identity and Intersex Status) 2013 prohibits both direct and indirect discrimination against people on the basis of gender identity and intersex status. The prohibition against indirect discrimination applies to cases in which a general policy or requirement that does not specifically target intersex, trans or gender diverse people disproportionately affects these populations.

Key aspects:

All people’s gender identities and intersex status should be respected, without regard to medical intervention.

Some intersex, trans and gender diverse people do not seek medical gender affirmation due to financial or personal reasons. The Sex Discrimination Act (Sexual Orientation, Gender Identity and Intersex Status) 2013 (SDA) provides federal anti-discrimination protection for intersex people and for trans and gender diverse people without any requirement for medical intervention. We support this legislative recognition that all people’s gender identities and intersex status should be respected.

No one should have to undergo gender or sex affirming medical intervention without their own fully informed consent.

As noted in a recent Senate Inquiry, intersex people from infancy through adulthood have been subjected to unwanted medical interventions in Australia to impose a gender identity or sex. We support implementation of the recommendations in the Senate Report that would ensure all people are protected from involuntary or coerced “normalising” medical interventions.

Medical gender affirmation is necessary and beneficial for intersex, trans and gender diverse people who seek such intervention.

For those trans and gender diverse people who seek medical gender affirmation, extensive research has documented that hormones, surgery and related affirmation procedures are medically necessary and beneficial.

Intersex people who have experienced coerced or involuntary medically unnecessary “normalising” interventions and sterilisation as infants, adolescents or adults may need medical procedures to repair these unwanted interventions to the extent possible. Sterilisation of intersex people creates a lifelong need for hormone treatment; such treatment may or may not be consistent with a person’s legally recognised gender. Surgical interventions during childhood may require later revision for a variety of reasons, including scarring, complications, or growth during puberty. It is necessary to ensure that such interventions are not required for people to be legally recognised in accordance with their self-identified sex or gender category.

Hormone replacement is a medical requirement both for people who have undergone sterilisation and for people who are affirming their gender. Despite recent changes to the Medicare Benefits Schedule (MBS) to remove gender-specific language from some item codes, coverage for hormones under the Pharmaceutical Benefits Scheme (PBS) is generally restricted by gender. For example, intersex women with CAIS have reported being unable to acquire testosterone on the PBS. There is no appropriate PBS item code for intersex women and trans women who receive Androcur. As a result, these women have been listed inaccurately in their medical records under item code 1404, “to reduce drive in sexual deviations in males”—a code used to describe male sex offenders. It is unclear whether or not testosterone and estrogen are available to people with an ‘X’ gender marker.

These interventions should receive equitable insurance coverage.

Based on extensive research evidence, the World Professional Association for Transgender Health (WPATH), the American Medical Association (AMA) and other international professional bodies have adopted official policy statements that medical coverage for gender affirmation is medically necessary for those trans people who seek these interventions.

Failure to cover medical gender affirmation has a disproportionate effect on trans and gender diverse people. This lack of coverage also has a disproportionate effect on those intersex people who seek to affirm their identities or to repair the damage from previous interventions. In the light of recent SDA changes, such lack of coverage for medical gender affirmation needs to be seriously considered, including provisions for indirect discrimination.

Policy recommendation

The Alliance recommends that Medicare and private health insurance firms provide equitable coverage of gender affirmation interventions for which intersex, trans and gender diverse people have given fully informed consent on their own behalf.