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specified (and if the veteran meets other criteria), the veteran can opt to receive care in the community at the VA’s expense. The initial legislation appropriated $15 billion to fund care in the community and also to expand the VA’s workforce to improve access [52-54]. The initial money has all been spent, and with each additional reallocation there is increasing pressure to control VACAA-related expenditures [53, 54]. Although the results of the NSO survey were not released, it is very likely that the VHA is no different than the private sector. In the experience of the first author (WK), the number of surgeons and centers that have expertise in performing gender-affirming surgery in the US is small relative to demand. Accordingly, there is access-to-care delay for all transgender surgical candidates. The current requirement is that, for care within the VHA, the time from referral to completion of surgery should not exceed one year [55]. Of note, there is no specification regarding wait times once a veteran is referred to the private sector via Choice. Since there is a large backlog of transgender veterans who might access surgical services at the same time, the VHA would likely not meet VACAA access criteria within the VA system, creating the potential for a large expenditure for surgical care in the community via the Choice mechanism. No alternatives, such as altering VACAA access criteria to be in line with the current reality for gender-affirming surgery in the community, appear to have been considered. How much would community care cost? There are no data specific to the veteran population, but using the employee utilization rate for gender-affirming care at large civilian employers and the cost per University of California claimant receiving genderaffirming care, Belkin [56] estimated that providing comprehensive gender care to active military personnel would cost $438 per year per transgender service member and just $2.64 per year per member of the military. By extrapolation, gender care for the estimated 8,800 active transgender service members [57] would surely represent a small part of $187 billion that comprises the overall VHA annual budget [54]. In addition, Belkin’s cost estimates would also likely be overestimates as the VHA has been shown to provide more cost-efficient care than the private sector [58]. As far as we can determine, gender-affirming surgery is the only medically necessary intervention specifically denied to America’s Armed Services veterans through the VHA. The withholding of medically necessary surgery has obvious negative health consequences for our veteran population. In addition, this singling out of one minority population for denial of services reinforces and encourages the social and religious discrimination that transgender people already experience. Budgetary concerns and the ambient political climate cannot justify a policy that results in patient harm and that encourages discrimination [59]. We conclude that the prohibition on gender-affirming surgery in the VHA clearly violates the ethical principles of beneficence, nonmaleficence, and justice. AMA Journal of Ethics, April 2018 407 Summary and Recommendation Gender dysphoria is a common condition, and the consensus of the scientific medical community is that gender-affirming surgery is medically necessary for appropriate candidates. Both Tricare and the VHA policy documents expressly prohibit this surgery in military and VHA facilities and deny reimbursement for gender-related surgical services in the community. Unrealistic access-to-care requirements have created a weak and indefensible justification for continuation of the VHA’s ban on gender-affirming surgery. We strongly advocate the immediate revision of VA Directive 2013-003 and of the Health Benefits package to allow the provision of all medically necessary surgical services for America’s veterans, and we advocate for a similar revision of policy by Tricare for active duty, reserve, and retired military personnel. References 1. Swaab DF, ed. The Human Hypothalamus: Basic and Clinical Aspects. Pa Introduction Gender transition or affirmation is the process of changing the gender characteristics a person was born with to the gender characteristics a person identifies with. Gender transition/affirmation surgery is one of the last steps in this process. This surgery changes sexual characteristics - the genitals and breasts, and in some cases other body areas such as the face or trunk (often referred to as feminization and masculinization surgery) - so they align with the preferred gender. Because these surgeries cannot be easily reversed, they are usually done at the end of a long-term process involving the accurate diagnosis of gender dysphoria, counseling about treatment options, and helping the person get ready for hormone treatment when desired and for surgery. This policy describes the procedures that are covered as part of gender transition/affirmation surgery and the criteria that are required for coverage. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like
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