The World Professional Association for Transgender Health (WPATH) asserted that cross-sex hormones and surgeries were "medically necessary" so that insurance companies would pay for those procedures, allowing concerns about the treatments' affordability to dictate claims about their effectiveness, newly unsealed court documents show.
WPATH's standards of care, which guide clinical practice in the United States, were updated in 2022 to include language about the medical necessity of hormones and surgeries because, as one WPATH official wrote in an email, the group was frustrated with America's "obtuse and unhealthy system of healthcare 'coverage.'"
Most private insurance plans and state Medicaid policies exclude procedures deemed elective or cosmetic. That is why, in 2016, WPATH issued a statement describing gender treatments as "medically necessary" and urging U.S. insurers to cover them.
"We needed a tool for our attorneys to use in defending access to care," a WPATH official recalled in a January 2022 email, one of the many communications unsealed last month during the course of litigation. "The original Medical Necessity Statement was specific to the US because this was where we were experiencing the problem."
But that statement lacked the authority of WPATH's formal standards of care, which set guidelines for doctors and are frequently cited in court battles, including those over insurance coverage for transgender treatments.
So, the official continued, it was "important" to include language from the 2016 statement in "the actual [standards of care]."
"I have long wanted this (and many of our other policy statements) to become part of the [standards of care] because that gives them greater force," the official wrote to colleagues, whose names are redacted in the court documents.
Everyone was on the same page. When the eighth version of the standards of care, known as SOC-8, came out in September 2022, the standards included for the first time a recommendation that health systems provide "medically necessary gender-affirming health care."
That language wouldn't just expand insurance coverage, WPATH members declared, but would also give doctors more leeway to prescribe gender treatments on demand.
It creates a "very broad category" that "any 'goodwilling' clinician can use for this purpose," one official commented on a draft of SOC-8.
The documents show how one of the core claims of American gender medicine—that these treatments are "medically necessary" and can't be withheld without causing harm—was shaped by legal and financial pressures unconnected to medical evidence. They came to light through litigation challenging an Alabama law that bans puberty blockers and cross-sex hormones for minors, one of the first red-state efforts to restrict the treatments.
Alabama subpoenaed troves of materials related to the development of SOC-8, which the plaintiffs had cited at least 15 times, during the discovery process. What emerged was a portrait of a political organization masquerading as a medical one, claiming the mantle of science in order to promote policies demanded by activists.
The documents showed, for example, that the Biden administration's assistant secretary for health, Rachel Levine, pressured WPATH to remove age minimums for gender treatments, including surgeries, from its standards of care. They also showed that WPATH muzzled a team of researchers at Johns Hopkins University who found "little to no evidence" for those treatments, telling the researchers that they "cannot publish their findings independently."
"It is paramount," top WPATH officials said in one email, "that any publication based on the WPATH SOC8 data is thoroughly scrutinized and reviewed to ensure that publication does not negatively affect the provision of transgender healthcare in the broadest sense."
The revelations have called into question a host of policies based on SOC-8, which the document's lead author, Eli Coleman, said was developed with the "most rigorous protocol in the world."
Hospitals, government agencies, insurance providers, and federal courts routinely defer to WPATH's standards of care on the grounds that the standards are "evidence-based." States that have rejected those standards, including Alabama, have faced a flood of litigation seeking to overturn their bans on pediatric gender medicine, which have been framed as assaults on science and expertise.
"When it comes to gender-affirming care," Coleman wrote in an op-ed last year, "it's time we trust the experts."
The back-and-forth over insurance coverage for those treatments, which has not been previously reported, raises additional questions about the credibility of the experts recommending the treatments for minors. It comes as plaintiffs are leaning heavily on WPATH, and its use of the term "medically necessary," to force state benefit plans to cover gender treatments.
A year after that language was inserted into SOC-8, the state of Georgia agreed to include sex-change operations in its public benefit plan as part of a settlement agreement with the Transgender Legal Defense & Education Fund. The agreement explicitly cited the "Standards of Care of the World Professional Association for Transgender Health," adding that "transgender healthcare coverage generally includes medically necessary transgender surgery."
That logic formed the basis for a landmark appellate court ruling in April that all state health plans must underwrite gender care. The 8-6 opinion, from the Fourth U.S. Circuit Court of Appeals, drew heavily on the WPATH standards, describing them as "authoritative" and "generally accepted" by the medical community.
Many private insurers, including Blue Cross, United Healthcare, and Cigna, likewise base coverage decisions on WPATH's standards of care. The standards have even influenced the prescribing practices of Planned Parenthood—the second-largest provider of cross-sex hormones in the country—which will give the drugs to 18-year-olds, including those with special needs, after just a 30-minute consultation.
Asked about the role that insurance coverage had played in the development of SOC-8, WPATH said that it was merely following the lead of other medical fields.
"Health professionals across areas of care have been forced to use the most expansive definitions just to ensure coverage for their patients; gender-affirming care is no different," the group told the Washington Free Beacon. "Science should always come first, regardless of cost to insurance companies."
WPATH, the organization added, "has only ever been solely concerned with evidence-based health care."
The update to the standards of care came as many European health authorities had started to question whether gender treatments were, in fact, medically necessary for everyone who was requesting them. The number of young people diagnosed with gender dysphoria had exploded since 2008, rising by as much as 4,000 percent in the United Kingdom, driving up wait times at gender clinics and raising concerns about the role of social contagion.
Such statistics formed the backdrop for Finland's 2020 decision to place new guardrails on puberty blockers and cross-sex hormones for minors. England and Sweden have since made similar moves, in part because the median patient seeking the drugs—a biological girl with preexisting mental health problems—no longer matches the study population on which older research into puberty blockers was based.
The result has been a growing clinical divide between Europe and the United States. WPATH's deliberations about insurance shed new light on the sources of that divide, suggesting it is a function, in part, of structural differences between American and European health care systems.
"In Europe, because public health insurance systems have a duty to allocate funds responsibly, there's more of an incentive to make sure the treatments they cover are in fact evidence-based," said Leor Sapir, a fellow at the Manhattan Institute who studies gender medicine. "In the United States, insurance companies can always recover their costs by raising premiums."
Since those premium hikes are modest and not easily traceable to gender medicine, Sapir added, there are fewer financial incentives to look closely at the treatments' efficacy.
"Taxpayers don't sense it in their wallets," Sapir said.
That contrast illustrates an irony in the fight over gender medicine: It is partly thanks to the American health care system, ostensibly WPATH's bête noire, that the group has exerted so much influence in the United States.
Terms and concepts introduced with insurance in mind have now saturated public debate. CNN alone asserted that cross-sex hormones are "medically necessary" in at least 35 separate articles since 2022. The phrase has buttressed the argument, made by top officials in the Biden administration's Department of Health and Human Services, that transgender medicine is, in the words of Levine, "suicide prevention care" for minors as well as adults.
"Even though 'medical necessity' is technical language geared toward having an effect on insurance, the term has seeped out of the legal world and into the broader world," Sapir said. "It's now persuaded Americans that if they don't receive this kind of care on demand, with minimal to no gatekeeping, they are at imminent risk of death by suicide."
America's system of health care coverage, Sapir added, has shaped ideas about gender medicine as much as it has been shaped by them.
It also shaped what appears to have been a six-month back-and-forth over what language would maximize the odds of insurance coverage. Officials in charge of revising SOC-8 replaced "wishing" with "in need of" to make clear that the treatments were "necessary," for example, with one official writing, in April 2022, that "wishing makes the needed care seem optional."
"Would it be possible or advisable or prudent to replace 'wishing' with 'in need of' here?" the official asked.
The change was implemented in the final draft of SOC-8, the first update to the standards of care in 10 years.
WPATH also swapped "treatments" for "health care" throughout the document, because, as one official put it, the term "treatment" might "imply pathology."
"I wonder if, under normal circumstances, we would speak of treatment for pregnancy," the official wrote.
The same official suggested, with less success, that SOC-8 include a call for universal health insurance—the very system that has helped constrain the growth of gender medicine in Europe.
"I woould [sic] suggest the following" language, the official wrote: "We recommend that health care systems should provide medically necessary gender affirming psychological, medical and surgical HEALTHCARE for trans and gender diverse children, adolescents and adults, AND SUCH HEALTHCARE SHOULD IDEALLY BE PROVIDED WITHIN UNIVERSAL HEALTHCARE COVERAGE."
That language did not make the final cut.