Israeli Health Ministry Clears HMO Funding for Genital Reassignment Surgery Abroad

In order get HMO support for patients requesting surgery, health officials had to deem the surgery treatment for a 'birth defect.'


Genital reassignment surgery has not been performed in Israel since September 2012, when plastic surgeon Dr. Haim Kaplan stopped doing the operations. Dozens of men and women with authorization to undergo the surgery have asked their health maintenance organizations (HMO) to fund the operation for them overseas, only to be rejected on the grounds that they don’t meet the criteria. The Health Ministry’s appeals committees have generally upheld the decision of the HMOs in these cases.

The ministry recently resolved to end this practice, and this week officials sent a clear message to the HMOs and its own appeals committees that gender reassignment does meet the criteria for funding surgery abroad.

While the solution may not be the most elegant from the theoretical perspective - defining GRS as the surgical correction of a “birth defect,” on the practical level it could be a godsend.

In a letter sent on Monday to the heads of the appeals committees, Health Administration director Dr. Arnon Afek made it clear the sex-change surgery is included in the “basket” of state-subsidized drugs and health services provided to all Israelis.

“A health service can be provided abroad if it belongs to one of five areas, including birth defects. A committee that evaluated the issue on the instruction of the director of the Health Administration concluded that sex-change surgery should be seen as falling into the category of ‘birth defect,’ a position that was accepted by the director,” Afek wrote in the letter.

He went on to say that whenever an HMO receives a request to fund a health service overseas it must determine whether the requested service, or an alternative, can be provided within Israel, and also whether the patient’s life would be at risk if the service is not provided. Afek specified that

if these two conditions are not met, the HMO must ask whether there is an “exceptional circumstance” that would nevertheless justify the decision to pay for the treatment.

“Female-to-male sex change operations are not performed in Israel due to a lack of medical proficiency in performing the surgery. At this stage there is no plan to perform them,” Ofek acknowledged in the letter.

He adds that although the operation is not considered to be lifesaving, in light of its inclusion in the “health basket” and the fact that it is “critical to the patient’s life and quality of life, and goes to the core of their gender identity, and is not being performed in Israel now or in the foreseeable future, and in the absence of a nonsurgical alternative, this is an obvious case of “exceptional circumstances” that justifies, and even requires, the funding of the service despite its not being necessary in order to avoid loss of life.

Even though both female-to-male and male-to-female operations are included in the basket of subsidized services, the recent directive applies only to female-to-male operations performed abroad. That, due to the Health Ministry’s stopgap solution of bringing a surgeon from abroad for several

days to perform a number of male-to-female operations.

In November, Dr. Marci Bowers, the world-famous U.S. transgender surgeon (known to television

viewers from the documentary series “Sex Change Hospital”), did just that. She is scheduled to return in May for a second round of operations.

For Israel’s transgender community, Afek’s directive was long in coming.

“We welcome the measure, it’s clearly a great achievement and we hope it will help many people who meet all the criteria but are up against a brick wall,” says Nora Greenberg, a consultant on gender-identity issues who is an activist in the local transgender community. “The message sent by the

Health Ministry to the kupot holim is: ‘Stop harassing people who are waiting for surgery, from the legal perspective you can approve the funding,’” she says.

According to Greenberg, there are around 16 women in Israel who are awaiting female-to-male genital reassignment surgery - the operation that is the subject of the directive. But she notes that the letter won’t solve all the problems. “There are seven or eight women who were born male who

need sex-change surgery, in addition to a number of women who need revision surgery, due to complications, and that must be done abroad because it requires techniques that aren’t in use here.”