Do I need to refer a patient with diagnosed gender dysphoria to another provider because my employer's (or insurer's) policy is against transgender care, despite the medical necessity of their ongoing hormone therapy?

Do Not Refer This Patient Away—Continue Their Medically Necessary Care

You should continue providing care to this patient with gender dysphoria and not refer them elsewhere based solely on employer or insurer policy restrictions, as denying medically necessary transgender care increases suicide risk, drives patients to obtain hormones through dangerous illegal channels, and violates professional medical standards established by major medical organizations. 1

The Medical Necessity Framework

The decision to provide hormone therapy for diagnosed gender dysphoria is not elective—it is medically necessary treatment determined by you and your patient's healthcare team. 1

• Multiple major medical organizations explicitly recognize gender transition-related medical services as medically necessary, including the American Medical Association, American Psychological Association, American Psychiatric Association, American Congress of Obstetricians and Gynecologists, and American Academy of Family Physicians. 1, 2
• When transgender persons receive appropriate medical care, they experience improved mental health, a 20% reduction in depression after 1 year, reduction in suicide rates, and lower overall healthcare costs. 1, 2, 3
• The World Professional Association for Transgender Health has established standards emphasizing treatments that achieve "lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment." 1, 2

The Mortality Risk of Denying Care

Transgender persons face a 41% lifetime suicide attempt rate, with the highest rates among those who experience job loss, harassment, poverty, and barriers to care. 1

• Transgender youth who receive inadequate treatment are at increased risk for self-mutilation and using illicit venues to obtain treatments. 1
• More than 50% of transgender persons have obtained injected hormones through illegal means or outside traditional medical settings when denied appropriate care. 1
• Denying this patient a referral or continuation of care directly increases their risk of obtaining hormones unsupervised, which carries serious health consequences including unmonitored cardiovascular risk, thromboembolism, and polycythemia. 4, 5, 6

Professional Standards Supersede Employer Policies

The American College of Physicians explicitly recommends that medical facilities adopt nondiscrimination policies that include gender identity and that public and private health benefit plans provide all covered services to transgender persons as they would all other beneficiaries. 1

• Primary care physicians are recognized as integral members of the transgender healthcare team, positioned to prescribe and monitor gender-affirming hormone therapy as part of routine practice. 3
• The American College of Physicians explicitly supports primary care physicians in providing comprehensive transgender care, including hormone replacement therapy. 3
• Your professional obligation to provide medically necessary care supersedes administrative policies that create blanket exclusions on transgender healthcare. 1

Practical Steps Forward

Continue Care While Addressing Barriers

Document in the medical record that this is medically necessary treatment for diagnosed gender dysphoria, using the established diagnostic criteria from DSM-5. 1, 2

• Frame the hormone therapy as treatment for a diagnosed medical condition (gender dysphoria), not as elective care. 1, 2
• Cite the evidence that denying this care increases suicide risk and drives patients to dangerous alternatives. 1
• Reference the professional standards from major medical organizations that consider this medically necessary. 1, 2, 3

Challenge the Policy Directly

Work with your institution's medical leadership, legal department, and ethics committee to challenge policies that prevent provision of medically necessary care. 1

• The cost of including transgender healthcare in employee health benefit plans is minimal—two-thirds of employers providing transition-related coverage reported zero actual costs. 1
• Many professional medical organizations have established that blanket exclusions on transgender care are discriminatory and harmful. 1
• Federal precedent exists: HHS lifted the Medicare ban on gender reassignment surgery in 2014, and the Federal Employees Health Benefits Program no longer prohibits coverage. 1

If Forced to Refer

If you are absolutely compelled to refer despite these arguments, ensure continuity of care by:

• Providing a warm handoff to a provider experienced in transgender care, not simply giving the patient a list of names. 2, 3
• Ensuring the patient has sufficient medication supply during the transition period to prevent dangerous interruption of hormone therapy. 3, 6
• Documenting that you are referring under duress due to institutional policy, not due to medical appropriateness. 1
• Providing the patient with written documentation of their current hormone regimen, target levels, monitoring schedule, and any relevant laboratory values. 3, 6

Critical Pitfalls to Avoid

Do not frame this as a "lifestyle choice" or "elective procedure"—this undermines the medical necessity argument and increases the patient's risk. 1, 2

Do not delay care while navigating administrative barriers—interruption of established hormone therapy can worsen dysphoria and increase suicide risk. 2, 3, 4

Do not assume the patient can easily find alternative care—19% of transgender persons lack any health insurance, and they face unemployment rates double the general population. 1, 7

Do not abandon the patient—even if forced to refer, maintain contact and advocacy until care is successfully transferred. 2, 3