Gender affirmation surgery

Gender affirmation surgery can be essential to your mental health and wellbeing if you don't identify with the sex you were born with or you have gender dysphoria. Unfortunately, surgery can be really expensive in Australia, with options in short supply. However, by taking full advantage of what's covered by Medicare and private health insurance, you can still significantly lower the costs.

How much does gender affirmation surgery cost in Australia?

Gender affirmation surgery isn't cheap in Australia. Excluding contributions from Medicare or private health insurance, it can cost approximately $30,000 depending on what treatments you need. This includes surgery fees, specialist visits, hospital accommodation, anesthesiologist fees, counselling and hormone therapy.

You may sometimes see gender affirmation surgery referred to as gender affirmation surgery. Older terminology also includes sex reassignment surgery (SRS) or gender reassignment surgery (GRS).

Is gender affirmation surgery covered by Medicare?

Yes, but only partly. Medicare can cover some of the individual treatments associated with gender affirmation surgery including surgeries, medications, tests and consultations. Approved treatments are listed on the Medicare Benefits Schedule (MBS), but you will still need your doctor's referral to get covered. Here are some examples of the treatments that Medicare can pay towards:

Medicare can also cover your GP visits, blood tests, psychological counselling and a few prescriptions – again, with the right referrals from your doctor.

Unfortunately though, you'll still face significant out-of-pocket expenses. This is because specialist care for trans people and those with gender dysphoria is in extremely short supply in Australia. Most surgeries are performed privately and private doctors are free to charge more than what a public facility would (this is called the gap). Because there is such a short supply, fees are likely to be high. Medicare will pay 75-85% of the MBS fee but you could still be faced with thousands of dollars left to pay.

What Medicare won't cover

There are a few treatments that Medicare won't pay for at all. Along with the expenses mentioned above, you will also need to come up with the full amount for the following, unless you have private health insurance:

• Your accommodation and theatre fees (since you'll be in a private clinic)
• Cosmetic surgery that is considered not medically necessary (such as breast implants and cosmetic facial reconstruction)
• Some medications for hormone replacement therapy (HRT)

Will private health insurance cover gender affirmation surgery?

Luckily, private health insurance can cover you in some of the areas that Medicare falls short. Here's where it can help:

• It will pick up the tab on that 15-25% that Medicare didn't pay on treatments you received in a private clinic.
• It will cover your accommodation and theatre fees for any treatments that are on the MBS.
• It can pay for some of the hormone prescriptions that Medicare won't cover.
• It can help out with additional psychology sessions if you feel you need them.

Keep in mind, there will typically be a waiting period before you can claim for most treatments. These can be anywhere from 2-12 months depending on the treatment.

What level of private health cover will you need?

Here are some tips to help make sure you get the right cover:

• Double-check the MBS item numbers with your insurer. Every insurer is different, so your best bet is to double-check that your insurer doesn't exclude or restrict any treatments you plan on having. The most accurate way of doing this is to get your MBS item numbers from your doctor so you can relay this to the insurer and get an estimate of costs, or a heads up on any restrictions.
• Get a hospital policy that covers you in a private clinic. This is the minimum that you need, covering you for treatment in a private hospital, but depending on the surgery you need, you might need more comprehensive cover.
• Get a top extras policy. Some extras policies will cover prescriptions that Medicare won't, but you'll need a top-level extras policy if you want your HRT prescriptions covered.
• Cover for the "gap". This is the difference between what Medicare and private health insurance covers, and what the surgeon charges. Some insurance providers have agreements with specific surgeons so that you can reduce these out-of-pocket expenses.

Is top surgery covered by Medicare or private health insurance?

Top surgery refers to breast implants if you're transitioning from male-to-female, and breast reduction/removal if you're transitioning from female-to-male.

It may be possible to get a Medicare benefit for your surgeon, anaesthetist and assistant fees, but only if you can prove that your surgery is "medically necessary"; that is, essential to your health and not simply a cosmetic issue. Unfortunately in Australia, proving this can be tricky, depsite the World Professional Association for Transgender Health (WPATH) stating that top surgery is "not merely another set of elective procedures". Having said that, it's still worth speaking to your doctor to see if you can get covered.

In addition, some private health insurers may also cover your stay in a private hospital and a portion of your surgeon, assistant and anaesthetist fees. You'll need to ask your surgeon for the MBS item number so you can get Medicare and your private insurer to contribute towards the costs.

Top surgery cost in Australia

Top surgery can cost you approximately $4,000 to $18,000, according to Trans Hub. For female-to-male (FTM) top surgery, Pure Aesthetics says you can expect out-of-pocket expenses to start at around $10,200. This includes the surgeon's fee, anaesthetist costs and hospital fees if you have private health insurance coverage.

The Australian Professional Association for Trans Health (AusPATH) has a list of surgeons who can perform top surgery in Australia here.

What is hormone therapy?

Hormone therapy is when you take medication to help you look and feel more like the gender you really are. It's usually the first step of your journey towards transitioning and will make you look more like the other sex. For example, individuals born as female will take androgens which will make them look more masculine. Those born male will take oestrogen and anti-androgens which will make them look more feminine.

What is an endocrinologist and how can you find one?

There's nothing stopping your GP from issuing you the drugs you need, but they will probably refer you to an endocrinologist instead. This is a doctor who specialises in hormones.

You can trigger major mood and behaviour reactions if you disrupt the balance of hormones in your body, so it's very important to go through hormone therapy with the help of an endocrinologist who can help you make lifestyle and medication adjustments as you get used to the changes.

Your GP should have the names and numbers of a few endocrinologists and they can make the right referrals. There are also a number of websites online that can help you find a doctor in your state that provides gender affirming hormonal care, such as the NSW Trans Hub.

At this point, it's probably worth asking your GP to refer you to a psychologist because some endocrinologists won't prescribe you the medication unless they are absolutely sure that you are mentally ready for it. Don't wait until your first appointment with the endo to find out they want you to see a psychologist. See the psychologist first and show up to your first endo appointment with the right paperwork.

Is hormone therapy covered by Medicare and private health insurance?

Medicare will cover your visit to the endocrinologist plus any blood work they do. As for the medication itself, it's a mixed bag. Medicare pays for some hormones through the Pharmaceutical Benefits Scheme (PBS), but they won't pay for others.

Since you might need a few medications, there's a good chance you won't be covered for some of them. Luckily private health insurance can help you here too, by offering a refund on certain medications that aren't covered by the PBS.

Important note: Medicare can deny you cover for certain medications if you're registered as the gender that you do not identify with (for example, men are not normally supposed to take estrogen). So if you are transitioning from male to female, you'll need to update your gender details with Medicare and other government departments before you can get estrogen. There's more on how to do this later in this guide.

Is psychological treatment covered?

Seeing a psychologist can be a great way to get support as you go through this challenging journey. Your doctor may even require it before starting some of your treatments.

The good news is that both Medicare and private health insurance can help cover your sessions. Anyone with a Medicare card can get up to 10 sessions per year covered. All you have to do is see a GP and ask them to put you on a mental health treatment plan. Depending on your psychologist, the rebates available on the plan may cover all or part of their fee. So, you may not be out of pocket any amount, or there could be a gap payment owing.

A private health insurance extras policy can also be used on top of Medicare to cover the gap payments, or to use towards additional sessions. You can also use it on its own to get a contribution towards your psychology appointments if you don't have a mental health care plan; in this case, you don't have to see a GP or get a mental health treatment plan. You can just book directly with the psychologist.

Services you can use to find help

There are quite a few national organisations that offer support, services and counselling to transgender people all around Australia. Here are a few you can reach out to:

• Headspace
• A Gender Agenda
• Gender Centre
• Trans Health Australia

There are also several state- and territory-based support and service organisations, so keep an eye out for one in your area.

Updating your documents

As of July 2013, anyone in Australia has the right to update their gender with any government agency. You can do so by submitting one of the following:

• A statement from a registered medical practitioner or a registered psychologist
• A valid Australian government travel document, such as a passport
• A state or territory birth certificate (you can have your gender and/or name changed by filling out the appropriate forms from your local Births, Deaths and Marriages Registry)
• A document from your local Birth, Deaths and Marriages Registry recognising your change of name and/or gender