Dr. Draion Burch has 52 patients who are transgender – word has gotten around about his work as an OB-GYN at Magee-Womens Hospital at the University of Pittsburgh Medical Center, bringing in people from around the country. Since he first began working in Pittsburgh, his practice has doubled, and with the implementation of President Barack Obama’s health care law, the uptake has grown even faster

The law, commonly called Obamacare, increased transgender Americans’ access to care they weren’t able to receive before – including routine tests, hormone therapy, mental health and substance abuse services.

It’s a far-cry from where things were.

Being transgender, recognized as “gender dysphoria” by the psychiatric community, was once labeled as a pre-existing condition by insurance companies, who would raise premiums on patients or deny them coverage. They also would broadly link various medical conditions to being transgender, refusing reimbursement.

Burch says he’s heard horror stories from patients about past experiences they have had with doctors. One patient was told to leave a doctor’s office.

“We don’t know how to help people like you,” he says, recalling the patient’s account.

But while the health care law has improved access for transgender people, it still is not officially interpreted under national civil rights statutes to cover much of the care advocates hope it eventually will. Most notably, the government has yet to write new provisions that could classify as discrimination a provider’s refusal to pay for gender transition, which sometimes involves hormone therapy or surgery that in some states currently must be approved by a doctor before being covered.

“Many people still believe that the health care that transgender people need in relation to gender transition is somehow not real health care, that it’s cosmetic, that it’s not really necessary,” says Harper Jean Tobin, policy director at the National Center for Transgender Equality. “That is the kind of thinking, historically, that is behind these exclusions.”

Statutes preventing discrimination against the transgender community are seen as critical even to ensuring basic care. Because of difficulties with societal acceptance and employment, transgender people face much higher rates of HIV infection, smoking, drug and alcohol use and suicide attempts than the general population, according to the National Center for Transgender Equality and the National LGBTQ Task Force.

At the same time, they also are hesitant to use medical services because of misunderstanding and discrimination on the part of providers, a poll by the two groups shows. Of those surveyed, half said they had to teach their doctors and health care providers basic information about themselves and the medications they were taking, one-fifth were refused services, and 28 percent said they went without medical care on at least one occasion because they were afraid of discrimination at a hospital or clinic.

Currently, discrimination is prohibited in a health care setting that receives government funding. Under Obamacare, patients who are transgender have the same option as everyone else of buying tax-subsidized private insurance plans in government-run marketplaces without being turned down. The law also expanded the definition of income limits for Medicaid, the government’s program for poor and disabled Americans. The change provides more low- or even no-cost health coverage options for poor people who live in the District of Columbia or one of the 28 states that have expanded this definition – a key development for the transgender community, whose members often face high rates of poverty and unemployment.



Still, gaps remain. Tobin says exclusions to medical care associated with transition – including hormone replacement therapy or sex reassignment surgery – haven’t changed in most states, making her wonder whether the plans offered truly provide better benefits compared to where they were before the health law.

Rules against exclusions related to paying for transition through private plans or Medicaid exist in nine states and the District of Columbia, and trans people have seen benefits through those rules, Tobin says, but that, “in most of the country the potential of the law to remove these barriers has so far been unfulfilled.”

Part of the reason for that is because the Department of Health and Human Services’ Office of Civil Rights is still crafting final rules for specifics about what constitutes discrimination in a health care setting. The agency is responsible for enforcing these laws by first reviewing complaints from patients who say they have faced discrimination on the basis of sex, race, sexual orientation or other factors. The rules haven’t yet been interpreted on a national level to mean that denying someone transition-related surgery is discrimination, though patients can submit complaints to the office for review.

The Office of Civil Rights declined to comment on the issue, saying that it anticipated rules would be delivered “in the next few months.”

Robin Maril, senior legislative counsel at the Human Rights Campaign, the largest LGBT civil rights advocacy group and political lobbying organization in the country, says her organization continues to urge the agency to publish the regulations.

“Although we have informal guidance that [the Office of Civil Rights] is accepting claims of discrimination on the basis of gender identity and sex stereotyping ... formal regulations are necessary to make these protections permanent," she said in an email.

Pennsylvania, where Burch practices, isn’t one of the states that has created exclusion rules. He spends about two hours on the phone each week negotiating costs with health insurance companies on behalf of his patients, particularly for gender-reassignment surgery. “I write a lot of letters and I’ve been through a lot of appeals processes,” says Burch, who is also an American Osteopathic Association spokesman on transgender health.



Before having patients undergo surgery and potentially being surprised by a massive medical bill, he checks on prices and works to make it affordable for them. Sometimes approval for a procedure such as a hysterectomy, an operation in which the uterus is removed, can take a year. If paid for out of pocket, the surgery can cost more than $10,000. This does not include procedures involving plastic surgeons, who typically do not accept insurance.

Clare Krusing, spokeswoman for America’s Health Insurance Plans, which represents the industry, says the organization doesn’t have data on the number of requests for transgender services under the health care law.



“Health plans rely on the clinical guidance, recommendations and medical evidence on safety and effectiveness from the specialty medical groups when coming up with their coverage policies on specific treatments,” she wrote in an email. “Coverage may vary and may be dependent on employers’ inclusion of this benefit as part of coverage, but plans will cover medically necessary transgender services and treatments for patients.”

Leading medical groups, including the American Medical Association, support the position that gender transition is medically necessary. “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with [gender dysphoria],” the organization wrote in a resolution.

Even if trans patients are covered for these procedures, it can be difficult for them to find doctors who know how to work with them, or even want to. On the behavioral health side, there aren’t enough providers for most Americans, and insurers have broad definitions of what services should and should not be included.

Other than undergoing medical procedures, trans people may change their names and gender listings on driver’s licenses and Social Security cards. All of these, however, also have medical and employment implications, whether making it more difficult to apply for a job and pay for health services or making it difficult to match their health records at various facilities, for instance.

Something as simple as using the pronouns trans people prefer and the name they identify with – even when it’s different from what is on their ID card or medical records – can be crucial to patient care. Patients who come to Burch – who himself goes by “Dr. Drai,” pronounced like the moniker of a famous hip-hop mogul – often complain that former doctors they went to didn’t adhere to this basic principle.

Though it is important for patients to find doctors who understand their needs, Burch says it’s up to doctors to educate themselves. He knows medical schools didn’t always teach students how to work with patients who are transgender as they might now – because he didn’t have that training in school.