Coding, Coverage, and Care: The Infrastructure of Transgender Health Inequities

Journal of Quality in Health Care & Economics
ISSN: 2642-6250
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Coding, Coverage, and Care: The Infrastructure of Transgender Health Inequities J Qual Healthcare Eco
Coding, Coverage, and Care: The Infrastructure of Transgender
Health Inequities
Mewani A¹, Datuowei E¹* and Chapa G²
¹Lehman College, City University of New York, USA
²York College, City University of New York, USA
*Corresponding author: Erela Datuowei, Lehman College, City University of New York, USA,
Email: erela@earlyscholars.org
Mini Review
Volume 8 Issue 4
Received Date: June 05, 2025
Published Date: July 09, 2025
DOI: 10.23880/jqhe-16000439
Abstract
Transgender healthcare in the U.S. is a product of evolving medical standards, transient legal protections, and systemic
disparities. Shortcomings in medical documentation and coding systems concurrent with political shifts and geographic
divides further complicate access, leaving many without essential services. Meaningful change requires more than policy
tweaks; it demands systemic reform, from provider training to equitable insurance coverage. Without recognition of these
issues and sustained investment in inclusive healthcare policies, disparities will persist, underscoring the urgent need for
systemic change to ensure equitable care for all.
Keywords: Transgender Healthcare; Gender-Affirming Care; Healthcare Access; American Psychiatric Association; DSM-5,
ICD-10
Abbrevations
APA: American Psychiatric Association; ACA: Affordable
Care Act.
Introduction
Transgender healthcare in the United States exists at
the crossroads of shifting medical standards, evolving legal
protections, and persistent systemic discrimination. For
decades, transgender individuals have faced formidable
challengesinaccessingappropriate,affirming,andaffordable
healthcare services.
These challenges span from outdated diagnostic coding
systems to the political volatility surrounding healthcare
rights.
OverviewoftheStateofTransgenderHealthcare
The American Psychiatric Association (APA) first
classified transgender individuals as mentally ill in 1980
[1] It took over three decades for the APA to change their
classification from a disorder to a dysphoria [2]. This
diagnostic framework initially required labels such as
“gender identity disorder” for individuals to access care,
placing control over transgender people’s autonomy in the
hands of often untrained providers [3]. Despite the DSM-5’s
2013 shift toward depathologization, systemic inequities
continue to shape the healthcare experiences of transgender
individuals [2].
The legal and political landscape surrounding
transgender healthcare has fluctuated significantly
across presidential administrations. Under the Trump

2
Datuowei E, et al. Coding, Coverage, and Care: The Infrastructure of Transgender
Health Inequities. J Qual Healthcare Eco 2025, 8(4): 000439.
Copyright© Datuowei E, et al.
administration, over 75 anti-trans laws were enacted or
reinforced. This severely limited access to gender-affirming
care. It also reversed protections previously ensured under
the Affordable Care Act (ACA).
Changes under the Trump administration included
the elimination of gender identity protections, restrictions
on Medicaid and Medicare coverage, and bans on
gender-affirming care for minors [4,5]. Such policies
disproportionately affected transgender individuals in
conservative states. This widened existing healthcare
disparities [6].
The Biden administration, in contrast, reinstated many
protections and reduced the number of active anti-trans laws
to 18.7 Federal efforts were made to restore ACA protections,
improve documentation for gender identity, and expand
coverage for gender-affirming services. However, progress
remains uneven, particularly in states that continue to
resist federal guidelines or where implementation of these
protections remains weak.
Medical Documentation and Coding Challenges
One of the most pressing structural challenges in
transgender healthcare is the inadequacy of medical
documentation and coding systems. The absence of specific
ICD-10 codes for transgender pregnancies, gender-affirming
surgeries (e.g., penile transplants), and reproductive
procedures presents a significant barrier to effective
care. These coding gaps prevent accurate documentation,
impede insurance reimbursement, and limit the ability
of healthcare institutions to assess care quality through
audit mechanisms [8,9]. This systemic erasure hinders
research, data collection, and policy development aimed at
addressing disparities [10]. The persistence of the outdated
“transsexualism” classification further illustrates how the
medical establishment has failed to evolve in step with
contemporary understandings of gender identity [11].
Carceral and Rural Healthcare Exclusions
Healthcareaccesswithincorrectionalfacilitiesremainsone
of the most marginalized and neglected areas of transgender
medical care. Incarcerated transgender individuals, as legal
wards of the state, are entitled to constitutionally protected
healthcare under the Eighth Amendment. Yet, they often
encounter systemic neglect, with limited or denied access
to hormone therapy, gender-affirming surgeries, and even
basic medical services. The landmark case Gamble IV [12]
established that deliberate indifference to the serious medical
needs of incarcerated individuals constitutes cruel and
unusual punishment, underscoring the state’s obligation to
provide adequate care [12].
While a few jurisdictions have recognized the medical
necessity of gender-affirming care, many others deny such
treatments, citing budgetary and security concerns [13].
These denials are not only ethically problematic but also
exacerbate psychological distress and reinforce health
disparities. Incarcerated transgender individuals are also
often placed in facilities that do not align with their gender
identity, increasing their exposure to violence and trauma
[14,15]. These intersecting vulnerabilities contribute to
disproportionately poor health outcomes in this population,
further highlighting the need for explicit federal protections
within carceral healthcare systems.
Geographic disparities further exacerbate inequities in
transgender healthcare. Rural areas lack not only gender-
affirming medical providers but also general practitioners
trained in transgender health issues [16].
This scarcity forces many transgender individuals to
travel significant distances or entirely forgo care, especially
for specialized services such as hormone therapy or
reproductive assistance [16]. Mistrust of the medical system
is amplified in these contexts, where healthcare professionals
may be undertrained, discriminatory, or entirely unfamiliar
with the unique healthcare needs of transgender patients
[17].
Although telehealth offers a promising avenue to close
some gaps, access to broadband, state-level regulatory
barriers, and lack of provider availability still limit its full
potential.
Reproductive and Telehealth Barriers
Reproductive healthcare access is another critically
underexamined aspect of transgender medical care.
Transgender men and non-binary individuals capable of
becoming pregnant often face unique and compounding
barriers when seeking reproductive services, including
abortion. Medical systems, historically designed for
cisgender patients, frequently misgender these individuals
or fail to provide adequate support [18,19].
The lack of inclusive diagnostic codes for transgender
pregnancies makes it difficult to collect data or allocate
resources for appropriate care [20]. Despite federal
abortion protections, state-level policies vary widely in
their inclusivity and access. Some states such as California,
New York, Illinois, Oregon, and Rhode Island have
explicitly extended reproductive rights to transgender
individuals, including legal protections for providers and
gender-affirming coverage under public health plans [19].
Conversely, in states with strict abortion laws, transgender
individuals often face additional challenges due to gender-

3
exclusive language in statutes, provider discrimination, and
the scarcity of inclusive reproductive services [20–22].
The overturning of Roe v. Wade intensified these
challenges. In states where abortion access is now heavily
restricted, transgender individuals have been pushed
further to the margins. Reports indicate an increase in self-
managed abortions among this population, often using
medications sourced online or through informal networks.
These practices introduces significant medical risks,
especially without supervision [20,22]. The intersection of
reproductive injustice and transphobia creates compounded
vulnerabilities.
Despite progress in select regions, there remains a
national deficiency in institutional preparedness to address
transgender health needs. Advocacy groups and researchers
consistently call for the integration of transgender-
specific diagnostic codes, equitable insurance coverage,
and mandatory education for healthcare professionals
on gender-affirming care [23]. Empirical research
demonstrates that when providers receive adequate training
in transgender health, both health outcomes and patient
satisfaction improve.9 Moreover, systemic improvements in
medical education and health policy planning must include
transgender perspectives to avoid perpetuating exclusion
[17]. Longitudinal studies on gender-affirming treatment
outcomes and structural barriers are also critical for guiding
effective and inclusive healthcare policies [24].
Looking ahead, it is essential that efforts to improve
transgender healthcare are not limited to symbolic
gestures or superficial policy changes. Meaningful reform
must include structural upgrades to electronic health
records, uniform federal protections for gender-affirming
procedures, and the expansion of inclusive reproductive
services. The lack of medical coding alone has ripple effects
that hinder everything from insurance coverage to patient
safety audits and public health planning [16,25]. Moreover,
policy implementation must ensure that coverage for
gender-affirming treatments under Medicaid and Medicare
is consistent across all states. Failure to address these
infrastructural and legal shortcomings leaves healthcare
inequities not only unresolved but entrenched.
Actionable Recommendations
To achieve equity in transgender health, reforms must
address legal, administrative, clinical, and educational
infrastructure simultaneously. Federal policymakers
should scale up sanctuary laws modeled on progressive
states like New York, California and Vermont [26,27]. while
updating national diagnostic coding systems to account
for transgender-specific procedures and reproductive
experiences [28]. Addressing rural and incarcerated
populations also demands federally mandated access
to gender-affirming care in prisons and the creation or
regional hubs, such as UMass’s TRANScend Clinic, to serve
as outreach centers for the underserved [29]. Insurance
reforms should enforce ACA Section 1557 nondiscrimination
provisions and require insurers to cover medically necessary
services aligned with WPATH standards, as demonstrated by
Maryland’s Trans Health Equity Act [30].
Medical education should incorporate mandatory
transgender health modules following UCLA’s example of
integrating gender-affirming care into physician training
[31]. Health systems should offer comprehensive, embedded
care and culturally competent staff. Finally, robust data
infrastructure is long overdue; public health agencies must
fund longitudinal studies on gender-affirming interventions
and require the collection and reporting of transgender-
specific health metrics using updated coding [32].
Concusion
Inconclusion,transgenderhealthcareintheUnitedStates
remains a landscape marked by disparity, despite recent
legislative progress. From the erasure embedded in medical
coding systems to the systemic neglect of incarcerated and
rural transgender individuals, the challenges are deeply
structural. Policy shifts at the federal level have yielded
some improvements, but many barriers persist at the state
level and within medical institutions themselves. Without a
coordinated effort to reform documentation systems, expand
access to gender-affirming services, and ensure inclusive
reproductive care, healthcare inequities for transgender
individuals will continue to widen. Future progress depends
not merely on political will but on sustained structural
investment in a healthcare system that affirms and protects
all gender identities.
Take Home Message: The paper offers an overview
of the current infrastructure of transgender health, the
gaps in care related to coding and documentation, and the
recommendations for improvement.
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