SP29. Disparities in Coverage of Gender-Affirming Bottom Surgery and Fertility Services

PURPOSE: The majority of transgender and gender diverse (TGD) individuals presenting for gender-affirming bottom surgery are of reproductive age. Expert organizations recommend that patients undergo fertility counseling prior to sterilizing surgery, and numerous studies demonstrate TGD individuals desire parenthood. While tremendous gains have been made in coverage for bottom surgery, it is unknown whether there has been similar progress in access to fertility care. METHODS: A cross-sectional analysis of health insurance policy for bottom surgery and fertility services was conducted on the top ten insurers based on national market share in October 2024. Coverage was categorized as prior authorization, case-by-case, state-specific, or no coverage by two reviewers based on website review of plan policy and evidence of coverage documentation. Phone calls were made if coverage information was not found online or if there were reviewer disagreements. RESULTS: The top ten insurers comprising 57% of the national market share were included. Every insurer had prior authorization criteria for bottom surgery coverage from gonadectomy to reconstruction for TGD individuals assigned male and female at birth. For fertility preservation, specifically sperm, oocyte, and embryo cryopreservation, four insurers had no coverage, one had prior authorization criteria inclusive of TGD individuals if the negotiated plan included fertility services, and one had case-by-case coverage. The remaining four insurers provided coverage that varied by state, following state policies on iatrogenic fertility. In the vast majority of states, however, these insurers offered no coverage. Only one insurer covered any further assisted reproduction procedures. CONCLUSION: Despite offering coverage for gender-affirming bottom surgery, most insurers do not cover fertility services, leaving TGD individuals without the option of fertility preservation when undergoing medically necessary, sterilizing procedures. State mandates for fertility preservation coverage expand the availability of these services, and under an argument of equivalent care and nondiscrimination, the definition of iatrogenic infertility in these policies should include TGD individuals. As reproductive health policy evolves, an allied, inclusive approach can help increase access to fertility care for marginalized patient populations.