On Monday, the American Medical Association released a statement recommending that states not require sex-reassignment surgery in order for a person to change the gender designation on their birth certificate.

The new policy was adopted at the AMA’s annual meeting of its House of Delegates, which last year welcomed the Gay and Lesbian Medical Association (GLMA) as the first LGBT organization represented among its membership.

“For many transgender people, a needless operation should not be a government requirement to amend a sex designation on a birth certificate,” AMA President Ardis Dee Hoven announced. “State laws must acknowledge that the correct course of treatment for any given individual is a decision that rests with the patient and the treating physicians.”

Adjusting identification documents during or after a gender transition can be tricky. Each state has a different set of rules and requirements, and these documents often fall into several jurisdictions.

For example, states typically issue birth certificates, while a passport is a federal document. But New York City has a separate vital records division, so those who are born there have birth certificates issued by the city.

Ohio, Idaho, and Tennessee refuse to amend birth certificates after a gender transition. According to anecdotal reports cited by Lambda Legal, an LGBT advocacy organization, officials in Texas often refuse to adjust gender designations even though a judge can technically order them to do so.

Changing one’s gender on identification documents isn’t a cosmetic whim, but a matter of safety. A 2011 report on transgender discrimination released by the National Gay and Lesbian Task Force found that 40 percent of people who presented an ID that did not match their gender expression were harassed, with some reporting assault as well. The report also found that only one-fifth of people who had transitioned were able to update all of their personal identification records.

San Francisco’s Transgender Law Center helps people navigate the complex process of adjusting their gender designation.

“A lot of transgender people end up becoming experts on law and procedure because we have to,” Anand Kalra, the center’s health programs administrator, told VICE News.

Kalra said that dropping the surgery requirement is a step in the right direction because sex-reassignment surgery is inaccessible for many transgender people.

“One thing that gets missed a lot is the overall extreme degree of economic marginalization that transgender people experience,” he said, noting that unemployment rates among transgender people are very high. “We did a study showing that trans people in California were twice as likely to have a bachelors degree but also twice as likely to live below the poverty line.”

The AMA’s shift in position is a positive development — not because gender transition surgery is “needless,” as its press release described it, but because it’s simply out of reach for many transgender people.

There are also, of course, people who prefer to transition without surgery. The AMA’s point is that an individual’s gender identification is best left to that person and their doctor, not the state.

“What we’re really talking about here is ensuring transgender people have access to and receive care as determined by their healthcare providers based on the appropriate medical standards of care, not based on arbitrary decisions or exclusions,” Hector Vargas, GLMA’s executive director, told VICE News.

Treatment for people diagnosed with gender dysphoria includes hormone therapy, mental health counseling, and sex-reassignment surgery. A 2008 AMA resolution described these elements of care for transgender people as a “medical necessity.”

Transgender advocates speaking with VICE News emphasized that the consideration of whether or not to undergo sex-reassignment surgery is complicated for individuals.

“At the core of this issue is the question of self-determination and the ability to be affirmed as who we are,” said Elana Redfield, a staff attorney at New York’s Sylvia Rivera Law Project (SRLP).

Redfield told VICE News that part of the reason only 33 percent of transgender people have sex-reassignment surgery is because many simply can’t afford the cost, which is around $30,000 in the US.

“Surgeries are prohibitively expensive for individuals, and most insurance doesn’t cover them,” she said. “We believe everyone should be able to affirm their identity and have all the tools they need to do so.”

Reina Gossett, SRLP’s membership director, added that insurance should cover the surgery for transgender people who want it, but the procedure shouldn’t be required in order for a person’s ID to reflect their gender expression. “One shouldn’t hinge on the other,” she said.

“There’s this overall inability to get and sustain formal employment,” Kalra told VICE News, pointing out that discrimination against transgender people is a major barrier to their securing jobs and housing. “Many transgender women in particular end up doing survival sex work because that’s all they can get. These are not options that come with health insurance.”

Advocates applauded when the Obama administration recently lifted a band on Medicare coverage for sex-reassignment surgeries. But Medicare only covers those age 65 or older. That’s a long time to wait for a procedure that the AMA described as a necessary element of healthcare for many transgender people.

Even though some private insurance companies have started covering the procedure, it’s clear that many in the transgender community will remain unable to access surgery until it’s covered by Medicaid, the state-managed federal healthcare program for low-income Americans.

SRLP asserts that state healthcare costs would actually drop if Medicaid covered sex-reassignment surgeries because this would help eliminate the serious mental health and substance abuse problems that result from the lack of access.

The cost of surgery remains a major obstacle for many transgender people. But meanwhile, those people still need appropriate identification.

A major victory came just last week when New York State dropped the surgery requirement for changing the gender designation on documents. It was the fourth state to do so, after Oregon, Washington, and Vermont. The District of Columbia also dropped its surgery requirement last August, a development heralded by some as the beginning of a “snowball effect.”

That’s exactly what advocates are hoping for.

“The state shouldn’t be telling people what kind of medical care they have to get,” Kalra said.

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