Cost Of Sex Change Surgery

Wren Vetens was promised a significant discount on the cost of her gender-confirmation surgery if she paid in cash upfront, without using her health insurance. Yet afterward, Vetens received an explanation of benefits saying the hospital had billed her insurer nearly $92,000. Lauren Justice for KHN hide caption

She chose a doctoral program in physics at the University of Wisconsin-Madison, a school that not only embraced transgender students like her, but also granted insurance coverage for her gender-confirmation surgery when she enrolled in 2016. When uncertainty over the fate of an Obama-era anti-discrimination rule allowed the state to discontinue such coverage, Vetens and her mother, Kimberly Moreland, an OB-GYN, shopped for another plan.

With that information in hand, Vetens planned ahead: She got her insurer's preapproval and scheduled surgery during winter break of her second year, allowing time for recovery before returning to her studies.

So, she was shocked when a hospital representative called her a couple of months before the long-awaited surgery estimating the bill would be $100,000. That meant she would be on the hook for as much as $75,000 after her insurer's $25,000 payout.

With preparations for the surgery well underway, Vetens was feeling overwhelmed with stress. "There were days when I just couldn't get out of bed for a whole day," she said, describing two weeks of panic attacks.

What gives: Though gender dysphoria is relatively uncommon, many of the billing and insurance issues Vetens encountered are typical for patients planning major surgery. Much of her stress and frustration arose from the vast difference between online price estimates ($19,000-$25,000), the hospital's billed price to the insurer ($91,850) and what it was willing to accept as an upfront cash payment ($20,080).

Hospitals set list prices high because insurers with whom they have contracts typically negotiate them down. In exchange for charging an insurer's members a lower price, doctors and hospitals gain access to those customers, who have incentives to use these in-network providers. Hospitals may offer package deals for procedures to patients, if they pay cash upfront, in part because the hospital avoids the hassle of negotiation.

Dr. Kimberly Moreland (left) helped her daughter shop for an insurance plan that would cover Vetens' gender-confirmation surgery. Yet mother and daughter still found themselves caught between the hospital and the insurer. Courtesy of Richard Malatesta/Kimberly Moreland hide caption

In the past six years, Claire, an IT infrastructure engineer living in New York, has spent thousands of dollars on medical care that most Americans never have to think about. There was hormone therapy, hair removal, and what's known as "bottom surgery." And that was just the start of it.

It didn't take long for Claire to realize that being transgender comes at a cost. By the time she came out in 2013, she was already struggling with what's commonly called gender dysphoria, a form of emotional distress that results from identifying as a different gender than the one designated at birth.

But for Claire and many other transgender people, the costs aren't just emotional: Many are also financial. The cost of medical treatments can add up to more than $100,000, and they're often not covered by health insurance. Plus, transgender people face discrimination in the workplace, which translates to unemployment rates that are as much as three times as high than they are for the general public.

Now, most medical professionals offer trans patients hormones and surgeries to change their bodies to match their gender identities. Surgeons can construct a penis (phalloplasty) or vagina (vaginoplasty), augment or remove the breasts, and feminize or masculinize the face with plastic surgery.</