Gender dysphoria, the distress a person experiences as a result of the conflict between one’s gender presentation and anatomy — affects roughly 1.4 million people in the United States.1 A person’s gender identity is likely determined largely by biology rather than by social factors, according to several peer-reviewed scientific studies.2

Gender-affirming surgery is an effective treatment that is widely accepted as medically necessary for individuals experiencing gender dysphoria. It is estimated that approximately 134,000 armed forces veterans in the United States have gender dysphoria.3 However, the Veterans Health Administration (VHA) Health Benefits package and VHA Directive 2013-003 specifically deny coverage for gender-affirming surgery. Although VHA Directive 13414 issued “major changes” to the previous directive, the policy still reinforces discrimination against transgender people and causes harm to veterans who could benefit from receiving gender-affirming surgery.

“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,” wrote William M. Kuzon, Jr, MD, PhD, and colleagues, in an article published in the AMA Journal of Ethics.2 “Although there are no large multicenter studies in this area, multiple retrospective and a smaller number of single-center prospective studies on facial feminization,5-8 chest reconstruction,9 and genital sex reassignment10 clearly demonstrate that gender-affirming surgery substantially improves the mental and physical health of transgender patients.”

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The VHA Health Benefits package should cover all medically necessary surgical services — including gender-affirming surgery. Yet, according to Dr Kuzon and colleagues, this procedure is the only medically necessary intervention specifically denied to US armed services veterans.

These physicians are advocating for an immediate revision that protects and helps active duty, reserve, and retired US military personnel who have gender dysphoria.

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“This singling out of one minority population for denial of services reinforces and encourages the social and religious discrimination that transgender people already experience,” Dr Kuzon and colleagues wrote. “Budgetary concerns and the ambient political climate cannot justify a policy that results in patient harm and that encourages discrimination.11 We conclude that the prohibition on gender-affirming surgery in the VHA clearly violates the ethical principles of beneficence, nonmaleficence, and justice.”


  1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles, CA: The Williams Institute. June 2016. Accessed June 20, 2018.
  2. Kuzon WM Jr., Sluiter E, Gast KM. Exclusion of medically necessary gender-affirming surgery for America’s armed services veterans. AMA J Ethics. 2018;20(4):403-413.
  3. Kauth MR, Blosnich JR, Marra J, Keig Z, Shipherd JC. Transgender health care in the US military and Veterans Health Administration facilities. Curr Sex Health Rep. 2017;9(3):121-127.
  4. Department of Veterans Affairs. VHA Directive 1341. Providing Health Care for Transgender and Intersex Veterans. May 23, 2018. Accessed June 20, 2018.
  5. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448.
  6. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19(7):1019-1024.
  7. Satterwhite T, Morrison SD, Ludwig DC, et al. Abstract: prospective quality of life outcomes after facial feminization surgery. Plast Reconstr Surg Glob Open. 2017;5(suppl 9):204-205.
  8. Capitán L, Simon D, Kaye K, Tenório T. Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg. 2014;134(4):609-619.
  9. Van de Grift TC, Kreukels BP, Elfering L, et al. Body image in transmen: multidimensional measurement and the effects of mastectomy. J Sex Med. 2016;13(11):1778-1786.
  10. Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8(12):3379-3388.
  11. Bushatz A. VA Scraps Rule to Allow Sex-Change Surgeries Over Funding. November 14, 2016. Accessed June 20, 2018.