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Navigating payment and policy barriers to gender-affirming care for transmasculine individuals: A qualitative study and policy assessment

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  • D'Angelo, Alexa B.
  • Dearolf, Michelle
  • Restar, Arjee
  • Tsui, Emma K.
  • Zewde, Naomi
  • Grov, Christian

Abstract

Over the past decade, access to and insurance coverage for gender-affirming medical and surgical treatment for transgender (trans) individuals in the U.S. has improved. Despite this, trans individuals continue to experience insurance-related barriers to gender-affirming care (GAC)—and in particular, transmasculine individuals may face gender-specific barriers resulting from regulations on masculinizing hormones. In this study, we interviewed transmasculine individuals from across the U.S. about their gender-affirming care experiences with a focus on insurance, payment and policy-related barriers to care. Interviews were conducted via video-conferencing software, analyzed using a codebook approach to thematic analysis, and contextualized within a broader analysis of the policy landscape dictating coverage for gender-affirming care. Participants reported insurance denials for gender-affirming care, as well as challenges with prior-authorization requirements, letter requirements, restrictive formulary lists and other challenges that complicated and/or barred access to care. Many discussed adaptive strategies to these challenges, which included utilizing community resources and knowledge, as well as receiving material support from family, friends, and partners, and developing technical and interpersonal savvy skills in response to insurance challenges. Participants expressed a range of emotional responses with regard to payment and related challenges, from annoyance and frustration to hopelessness. Our findings illuminate the persisting challenges that transmasculine individuals face when attempting to access and pay for gender-affirming care, despite improvements in insurance coverage and legal protections in recent years resulting from the Bostock ruling by the Supreme Court and the expansion of the ACA’s Section 1557.

Suggested Citation

  • D'Angelo, Alexa B. & Dearolf, Michelle & Restar, Arjee & Tsui, Emma K. & Zewde, Naomi & Grov, Christian, 2025. "Navigating payment and policy barriers to gender-affirming care for transmasculine individuals: A qualitative study and policy assessment," Social Science & Medicine, Elsevier, vol. 366(C).
    • Handle: RePEc:eee:socmed:v:366:y:2025:i:c:s0277953624011201
    DOI: 10.1016/j.socscimed.2024.117666
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    References listed on IDEAS

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    1. Rena M. Conti & Brigham Frandsen & Michael L. Powell & James B. Rebitzer, 2021. "Common Agent or Double Agent? Pharmacy Benefit Managers in the Prescription Drug Market," NBER Working Papers 28866, National Bureau of Economic Research, Inc.
    2. David Byrne, 2022. "A worked example of Braun and Clarke’s approach to reflexive thematic analysis," Quality & Quantity: International Journal of Methodology, Springer, vol. 56(3), pages 1391-1412, June.
    3. Jordan, Sid P., 2024. "Compelling care: A grounded theory of transmasculine self-defense and collective protection at the clinic," Social Science & Medicine, Elsevier, vol. 345(C).
    4. Kia, Hannah & Kenney, K.A. & Abramovich, Alex & Ferlatte, Olivier & MacKinnon, Kinnon Ross & Knight, Rod, 2023. "“Nowhere else to be found”: Drawing on peer support experiences among transgender and gender-diverse people to substantiate community-driven gender-affirming care," Social Science & Medicine, Elsevier, vol. 339(C).
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