Medicare funding for gender surgery denied despite ‘unmet need’

A federal government agency has asked for more information about the long-term impacts of gender-affirming surgery for transgender adults before agreeing to fund it under Medicare, despite acknowledging an unmet need for the service.

Australia’s leading surgical groups are lobbying the government to fund private patients undergoing a raft of 30 gender-affirmation surgeries, to provide more equitable access to patients across the country.

The surgeries include operations to remove breasts, reconstruct patients’ chests, genitals, faces and voices which, if the application is approved, would have their medical costs 75 per cent covered by the Medicare Benefits Scheme.

Following an initial consideration of clinical evidence the Medical Services Advisory Committee (MSAC) last month agreed there was an “unmet clinical need for gender-affirming surgeries for people with gender incongruence”.

However, the committee found the evidence supporting the Australian Society of Plastic Surgeons-led application was not yet strong enough to approve funding. It called for more information on the longer-term outcomes of surgery and the rates of people who experience distress and regret after undergoing gender affirmation processes.

“MSAC considered that the systematic review … did not undertake a sufficiently robust literature review and was limited in its assessment of all relevant clinical evidence,” the committee found.

“MSAC considered that the identified evidence appeared to support superior clinical outcomes in the short term, but was of the view further assessment of the comparative safety and clinical effectiveness of gender-affirming surgeries is required.”

This should happen before the proposal went to the “economic and financial analysis” stage, the committee said.

The committee makes recommendations to the federal health minister about items to be taxpayer funded on the Medicare Benefits Schedule.

It wanted to see more evidence about a number of aspects of gender-affirming care, including the “natural history” of gender incongruence and dysphoria, more information about the distress experienced by some people before and after surgery, about regret and detransition rates, and the preferences for non-binary individuals in the absence of surgery.

Multidisciplinary teams should be involved in the diagnosis of gender incongruence, as well as any decision to undergo surgery.

“More work needs to be done,” the committee said.

The committee has asked the Department of Health to gather this extra information.

The MSAC advice comes after the federal government asked the National Health and Medical Research Council to review the Australian Standards and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents to develop new national guidelines.

A spokesperson for the health department said that while the MSAC was “cognisant” of the review into child and adolescent treatments, the surgery funding application for adults was being considered separately.

The Medicare application was backed by groups including the Royal Australian College of Surgeons and the Australian Medical Association.

The Australian Society of Plastic Surgeons immediate past president, Associate Professor Nicola Dean, who oversaw the application, welcomed the committee’s recognition that more needed to be done for those with gender incongruence.

“It’s important because gender incongruence is a real phenomenon, and it is a condition which is not common. It’s probably around 1 per cent of the population, and only a subgroup of that population who will want surgical intervention,” Dean said.

“It’s a condition which has been associated with all sorts of disadvantages in terms of mental health and suicidality, and the evidence shows that if people are offered surgery it can improve their health-related quality of life, and they can then often become much more healthy and productive as members of society.”

The plastic surgeons’ society said 51 studies and more than 156,000 individuals spoke to the safety, effectiveness, and life-changing impact of gender-affirming surgery.

The application’s consultation received 2706 responses, with the majority being from people with health conditions that could benefit from the surgery, and 92.5 per cent of responses in favour of public funding.

Dean said a further examination of the long-term impacts of gender affirmation surgery would focus on all aspects of its outcomes.

“There’s regret for specifics of a surgical procedure, and that is different than regretting embarking on a surgical process,” she said.

“The regret rate for choosing to undergo surgical procedures at all is very low. The regret rate is often to do with people wishing they’d chosen ‘surgery A’ versus ‘surgery B’, or they wish they’d chosen it at a slightly different time in their life. So trying to understand the nuance around that is really useful.”

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