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surgery within Veterans Affairs (VA) facilities or using VA funding. This policy, which has been legally challenged after being reaffirmed in January 2017, denies medically necessary care to veterans, causing harm to individual patients and reinforcing discrimination and prejudicial treatment of a minority population. We argue that the policy is indefensible as it violates the basic ethical principles of beneficence, nonmaleficence, and justice. Introduction Considerable data in the peer-reviewed scientific literature supports the hypothesis that a person’s gender identity, i.e., where one places oneself along the male-female gender spectrum, is determined largely by biological rather than social factors and that a person’s gender can be incongruent with chromosomal and anatomic sex [1-4]. In fact, this incongruence between anatomic sex and gender identity, currently termed gender dysphoria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 302.85) [5] and transsexualism in the International Statistical Classification of Diseases and Related Health Problems (ICD-10 F64.0) [6], has been recognized and documented in human populations worldwide since antiquity [7-9]. It is now estimated that 0.6 percent of the US population—roughly 1.4 million people—self-identify as transgender [10]. Access to gender-affirming treatment, however, is denied to some segments of the US population. AMA Journal of Ethics, April 2018 403 For the over two million active-duty, reserve, and retired Armed Services members in the United States [11], TRICARE® provides comprehensive health insurance coverage; for the approximately 22 million Armed Services veterans [12], comprehensive health care is available through the Veterans Health Administration (VHA). TRICARE [13], the VHA Health Benefits package [14], and VHA Directive 2013-003 [15] have specific policies on transgender health care that provide for coverage of mental health services and hormone therapy but specifically prohibit gender-affirming surgery. This article focuses on the medical necessity of gender-affirming surgery for appropriately selected candidates and on the evolution and ethics of the VHA policy; TRICARE’s policy has similar ethical implications. The Benefits of Gender-Affirming Treatment For trans male patients, gender-affirming surgical procedures can include mastectomy, hysterectomy and oophorectomy, and genital reconstruction (i.e., phalloplasty, metoidioplasty). For trans female patients, gender-affirming surgery can include orchiectomy, facial feminization, thyroid chondroplasty, breast augmentation, and vaginoplasty. There is strong and rapidly accumulating evidence that patients with gender dysphoria benefit from mental health, hormonal, and reconstructive surgical interventions during the social transition from their assigned to their intrinsic gender. Although there are no large multicenter studies in this area, multiple retrospective and a smaller number of single-center prospective studies on facial feminization [16-19], chest reconstruction [20], and genital sex reassignment [21] clearly demonstrate that gender-affirming surgery substantially improves the mental and physical health of transgender patients. This convincing body of evidence has led many major professional organizations, including the American Medical Association [22], the World Professional Association for Transgender Health [23], the National Association of Social Workers [24], the American Public Health Association [25], the American Society of Plastic Surgeons, the American Psychiatric Association, the American Psychological Association, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Endocrine Society to endorse the medical necessity of genderaffirming care, including gender-affirming surgery, for people with gender dysphoria [26]. Based on the preponderance of evidence and professional expert opinion, the insurance industry has, over the past 5-10 years, shifted from viewing gender-affirming surgery as “cosmetic” or “elective” to recognizing that surgery is part of the medically necessary treatment for gender dysphoria [27]. Most major health insurers, including Blue Cross Blue Shield in many states, the Kaiser Permanente system, Medicare, Medicaid (in fourteen states), and many employer plans— including those of Goldman Sachs Group and General Motors—consider gender-affirming surgery a medically necessary and covered health benefit [28-31]. This change in insurance coverage occurred prior to the passage of the Affordable Care Act (ACA), Section 1557 of which expressly prohibits the 404 www.amajournalofethics.org denial of health care or coverage based on sex, gender identity, and sex stereotyping in federal agencies or in entities that receive federal funding for health coverage [32, 33]. It is also worth noting that gender-affirming care, including surgery, is a covered health benefit in most developed countries [34]. Barriers to Gender-Affirming Surgery Although we accept the overwhelming evidence that gender dysphoria is common and that surgical gender affirmation is an effective treatment for appropriately selected patients, we acknowledge that there are strong cultural, religious, and even isolated academic opinions to the contrary [35, 36]. For example, Mayer

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