The government of the state of Vermont is currently accepting public comments on a proposal to remove all age limits on sex reassignment surgery (SRS) for Medicaid recipients. The full, four-page proposed rule is available on the Vermont Human Services website.

Vermont’s Department of Financial Regulation issued a press release on June 24, signaling the state’s intention to move ahead with the rule change. Governor Phil Scott “recently proposed updates to Vermont’s Health Care Administrative Rules to allow transgender youth under age 21 to undergo gender-affirming surgery through Medicaid.”

Medicaid is a federal program that provides health insurance to low-income individuals. Although minimum benefits for all states are determined by the Centers for Medicare and Medicaid Services (CMS), each state administers its own Medicaid program and decides for itself which other procedures will be covered and which will not be. (Note: Some states have adopted a different name for their Medicaid program; e.g., California’s Medi-Cal and Oregon’s Oregon Health Plan.)

The public comment period for the Vermont Medicaid policy change is open until July 17. You do not have to be a Vermont resident to submit a comment regarding this change. If this proposal sounds to you like the wrong thing for a state government to do, please take a few moments to comment. See instructions at the bottom of this article.

Why should you care about this issue? We’ll have more to say about that later in this post, but for now, here’s what Rachel Inker, who works at the Transgender Health Clinic at Community of Health Centers of Burlington, had to say when interviewed by the Burlington Free Press:

“The choice to have surgery is a personal one that should be explored in every age group.” 

Is Vermont an outlier with the proposed change to its Medicaid SRS policy? Let’s take a look.

Only two states have explicitly removed minimum age limits for SRS

In our research for this article, we were unable to find an online resource that compiles information about Medicaid rules for under-18 surgeries in all 50 states. The information we provide below is based on our painstaking search of the Medicaid websites in all 50 states, as well as the websites for HRC, ACLU, and TranscendLegal, all organizations that lobby for medical transition coverage in the United States. Some of the information we found is based on a review of recent news articles on the topic.  Note: It is possible we have missed something; if we have, please provide your corrections in the comments section of this post, and please provide links for the missing or incorrect information.

In quite a few cases, the information about Medicaid coverage of SRS is buried in obscure documents that are not available via a standard search for terms like “gender dysphoria.” For example, the Oregon Health Plan (OHP) indicated it would cover medical transition beginning in 2015, but many previously active links now land on unrelated pages (e.g., https://www.oregon.gov/OHA/HPA/CSI-HERC/FactSheets/Gender-dysphoria.pdf) or are broken. A search of the list of covered services on OHP comes up empty for the keywords “gender dysphoria” and “transgender,” but a deeper investigation uncovers the full policy. It’s worth asking: Why is clear policy information about gender transition so difficult to find?

As of this writing, this is what we have found regarding SRS coverage for Medicaid recipients under the age of 18:

• Only 2 states have removed minimum age limits for SRS, New York and New Hampshire. But in contrast to the proposed Vermont rule change, the policy statements for these states seem to express reservations. For example, the New York statement contains this caveat: “Although the minimum age for Medicaid coverage of gender reassignment surgery is generally 18 years of age, the revised regulations allow for coverage for individuals under 18 in specific cases if medical necessity is demonstrated and prior approval is received.”
• In 19 states, SRS is not included in the standard Medicaid benefits for any age—that is, they do not explicitly list SRS among covered procedures. That generally means they would consider it on a case-by-case basis. It’s worth noting that this is also the policy of Medicare (the federal insurance program for adults over 65 and disabled persons), which as of 2016 declined to cover medical transition as a standard benefit because of the poor quality of research supporting it.
• Only 10 states expressly exclude SRS for any age. (See July 26, 2018, article in the Journal Sentinel.)
• The remaining 21 states (including Washington, D.C.) expressly cover SRS (see slide 10 of this document on fenwayhealth.org); Colorado, Hawaii, Nevada, and Massachusetts specify that Medicaid SRS coverage is only for adults over 18. Several others–including California and Oregon (see page 205)–indicate that  they follow the WPATH Standards of Care 7 guidelines (which specify SRS for adults only, see page 27), while others (such as Connecticut and Washington ) appear to make no explicit stipulation as to whether they cover under-18 SRS. The Connecticut policy document hedges: “Genital surgery is typically not carried out in adolescents until the adolescent has the capacity to make fully informed decisions and consent to treatment.”

So even some very liberal states (like Massachusetts) only cover gender reassignment surgeries for people over 18. (Note: In some states where Medicaid will not cover genital surgeries for those under 18, it will cover mastectomies on a case-by-case basis. This is in alignment with the WPATH Standards of Care 7.)

A caveat: When it comes to medical transition coverage by Medicaid (for any age), the landscape is rapidly changing. State Medicaid offices are under increasing pressure by trans activist organizations to provide these services. For example, last year a federal judge in Wisconsin ordered the state Medicaid office to cover surgeries for two patients (FTM and MTF). A caveat is also in order when discussing the WPATH Standards of Care since certain activist clinicians are in favor of abolishing minimum-age guidelines in the upcoming SOC 8.

Why Vermont, and why now?

Vermont is a rural state with a small population. Yet, even with its small population, the NGO Outright Vermont “serves over 2,100 LGBTQ youth and their families, and nearly 5,000 educators and service providers in every county in Vermont.”

The numbers of children and young people seeking gender services in Vermont have grown rapidly in recent years. And one reason for this rapid growth may have to do with the activities of this small but very influential charity. Charity Navigator.com, which provides information about a large number of charities, lists  Outright Vermont – inexplicably – as a disaster relief organization. It was founded in 1989 for the laudable purpose of supporting lesbian, gay, and bisexual youth. However, if you look at its activities in recent years, it seems to be largely concentrated on transgender issues.

One of the ways the charity uses its funds (some of which are provided from government sources)  is to run summer camps and provide gender-identity programs to Vermont public schools. Outright Vermont has more than 60 volunteers who go into schools across the state. Because the charity fails to consider the possibility that social contagion may account for a significant portion of the increase in transgender-identifying kids, it fails to see how much it may be perpetuating the very distress it seeks to alleviate. Through its work in schools, the charity could be serving as a vector of social contagion. (To read about how efforts to raise public awareness about anorexia created a contagion among adolescent girls in Hong Kong in the mid-1990s, see the first chapter of Crazy Like Us by Ethan Watters.)

4thWaveNow has been following with great interest the ongoing news coverage about Mermaids in the UK and the large influence that charity has exerted on policy and clinical decisions at Tavistock and Portman, the NHS youth gender clinic in the UK. Charities like Outright Vermont and the larger and better-funded California organization Gender Spectrum appear to be exerting a similar influence in the United States.

What does Outright have to do with the proposed change in the Vermont Medicaid rule? According to a June 14 article in the Vermont Digger,

“Both Outright Vermont and the Community Health Centers of Burlington — the organizations that Kaplan and Inker are a part of, respectively — participated in drafting and providing feedback on the rule. According to Inker, the process began last fall, and several additional groups took part.”

Is the charity simply unaware of the increasing number of desisters and detransitioners? Surprisingly, no. The website links to a document developed by the University of Vermont that states “many children who are trans will end up identifying with their sex assigned at birth post puberty.” The document even acknowledges that “there is no way to predict which children will persist or desist as adults.”

At the same time, the Outright Vermont website states that no age is too young for transition. How can this be? If many children desist after puberty, how can the charity justify puberty blockers, followed by cross-sex hormones? Such a protocol prevents the child from ever experiencing natural puberty, so they never have the opportunity to desist. Even social transition, often claimed to be a benign course of action, may reduce the likelihood that a child will eventually become comfortable in their natural body. (See Could social transition increase persistence rates in “trans” kids?)

Why this policy change is a bad idea

There are at least two important reasons this policy change is a bad idea. First, we know that many young people desist from a trans identity. Anyone who follows detransitioner accounts on Twitter and other social media will have noticed a rapidly increasing number of people, particularly women, who are speaking out about the negative effects transition has had on their lives. With the numbers of detransitioners increasing rapidly, how then does it make sense to pass a policy to make it even easier for young people to make irreversible changes earlier than they already can?

Another reason this policy change doesn’t make sense is the compelling evidence for social contagion. The study published last year by Dr. Lisa Littman suggests that social contagion may be a significant factor in the increase of trans-identifying young people. Many people, particularly activists, have criticized her study for only talking to parents, but she acknowledges the limitations of her study and indicates this is only preliminary research. Much more is warranted. But in the meantime, many detransitioners have begun speaking out about their own experiences, which corroborate Dr. Littman’s findings.

Although Littman’s is the first study to focus exclusively on the possibility of social contagion, other studies have suggested the role it may play. For example, this 2015 qualitative study surveyed 17 gender clinics around the world; some clinicians pointed out the influence of the Internet on the rise in youth clamoring for medical intervention:

“They [adolescents] are living in their rooms, on the Internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist

A better use of resources

Outright Vermont has done important work for gay, lesbian, and bi youth since its establishment in 1989. We also support its efforts to prevent bullying. No child, regardless of how they present themselves or who they’re attracted to, should be bullied. But the charity fails to see that some aspects of gender identity undermine support for GLB youth—in fact, all youth. Because of the serious, irreversible, and lifelong health effects from hormones and surgery, medical transition should be the last resort for young people experiencing discomfort with their bodies.

So instead of pushing for a policy to lower the age limit and making it easier for kids to make decisions they may come to regret, wouldn’t it make more sense for this charity to spend its resources on looking at ways, other than transition, to help girls and boys become more comfortable in their bodies without the need to become medical patients for the rest of their lives?

Insult to injury

Perhaps the most distressing part about the Vermont proposed rule is this statement near the end of it:

“Vermont Medicaid does not cover reversal or modification of the surgeries approved under this rule.”

If incongruence between your biological sex and your perceived gender is sufficiently distressful to put you at risk of suicide, then it would work the same way in the other direction, wouldn’t it? If, after you transitioned, you then regret the effects on your body and decide you would like to return to living as your biological sex, how is it any less life-saving to provide you with those services?

If the change in policy is really driven by the desire to eliminate the distress of incongruence between biological sex and gender identity, then surely Medicaid should cover gender reassignment reversal surgeries just as willingly, right?

Vermont Medicaid won’t be alone in covering surgeries to affirm trans identities, while refusing to cover surgeries for those who detransition or otherwise come to regret the outcomes of medical interventions. Oregon also refuses to cover revisions unrelated to surgical complications.

Opens the door to prepubescent surgery

The article in the Burlington Free Press begins with the sentence, “Vermont health insurance regulators are planning to tweak Medicaid rules so transgender youth no longer have to wait until age 21 to seek gender-affirming surgery.” The word “youth” suggests adolescents. But in reality the rule opens the possibility of surgery at any age, including prepubescent children.

We can hear the objections now: “No one is proposing to give SRS to prepubescent children.” But is this strictly true? Further down in the same article, we find this very interesting quote from Dr. Rachel Inker, who runs the Transgender Health Clinic at the Community Health Centers of Burlington:

“The choice to have surgery is a personal one that should be explored in every age group.” 

Every age group?

The Swedish Pediatric Society recently published a statement [English translation] saying that “giving children the right to independently make life-changing decisions [about hormonal interventions for gender dysphoria…] lacks scientific evidence and is contrary to medical practice.”

In addition, more and more people—even among those who promote gender affirmation—acknowledge the possible ill health effects of puberty blockers like Lupron. Johanna Olson-Kennedy, director of The Center for Transyouth Health and Development at Children’s Hospital Los Angeles, the largest pediatric gender clinic in the world, has been worried for the past eight years that youth who spend too long on blockers, as per the Endocrine Society guidelines that suggest blocking in Tanner 2 and cross-sex hormones at 16, will suffer significant bone density loss. In her “Puberty Suppression: What, When, and How” presentation at the 2017 Seattle Gender Odyssey Conference, she stated:

“You need to have sex steroids for bone protection and probably a lot of other things that we are not nearly as clued in as we need to be. … For the young people in my practice, I hesitate to have people on just blockers in that age range for more than two years.”

She’s also concerned about “emotional lability [which] is really common with blockers.” In addition, she rightfully points out that,

“if you practice a model where you don’t start hormones until 16, you’re putting a 14-year-old trans boy in menopause, which you just have to understand is potentially going to be a trainwreck.” (clip of excerpted section and  audio of full presentation)

In fact, some of the clinicians who are the most aggressive in promoting early transition urge skipping blockers altogether and going straight to cross-sex hormones. Since cross-sex hormones administered before the end of puberty permanently sterilize them anyway and (in the case of natal males) prevent the development of sufficient penile tissue to create a neovagina, what’s to stop them from proceeding straight to surgery? In addition, some parents are resorting to tucking and taping their natal sons’ penises, while others are purchasing plastic penises for their natal female daughters. Earlier surgeries would eliminate the need for these interventions, so it’s not a stretch to imagine that removing minimum age limits entirely could open up the door to prepubescent surgeries.

In fact, a similar rationale is already driving down the age for “top surgery,” the euphemism for double mastectomies. To prevent the pain and harm that binders cause girls, clinicians are removing their breasts at earlier and earlier ages—sometimes as early as 12 or 13 years of age.

As one provider from Vermont says in the Burlington Free Press article, “Having young people have to wait until they were 21 just didn’t really make any sense.”

So let’s not be under any illusions here. This rule change opens the door to the government paying not only for double mastectomies for 12-year-old girls but also the removal of the penises and testicles of prepubescent boys. Can under-18 phalloplasties be far behind?

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How to submit a comment on the Vermont rule

1. Go to https://secure.vermont.gov/SOS/rules/index.php. The rule, titled “Gender Affirmation Surgery for the Treatment of Gender Dysphoria,” is second on the list.
2. Click the small green button labeled “View” in the right column.
3. Scroll down to the section labeled Contact Information and click the green button labeled “Send a Comment.”
4. Complete the form.

You may also submit comments by emailing them to this account: AHS.MedicaidPolicy@Vermont.gov.

According to an email we received from the Vermont Agency of Human Services, “after the close of the public comment period on 7/17/19, comments will be reviewed and considered. When ready, the final proposed rule will be filed with the Secretary of State and the Legislative Committee on Administrative Rules (LCAR). The meeting schedule for LCAR can be found on the LCAR website. It is unknown at this time which meeting this final proposed rule would be scheduled for, but when it is filed and scheduled it will be posted on the LCAR agenda online. The rule does not take effect immediately after the LCAR hearing–an adopted rule must be filed. The timelines and procedures for filing an adopted rule are outlined at 3 V.S.A. §843.”