Leaked report into German health insurance imposes tough new rules for trans people and erases non-binary people completely

Germany: Health insurers toughen rules for gender affirmation surgeries

A leaked report suggests Germany’s health insurers will soon require trans people to demonstrate the “everyday experiences” of their gender for a year in order to receive reimbursement for gender affirmation surgeries.

New guidelines by the MDS, the association that makes decisions on which medical treatments are eligible for reimbursement, were leaked in a report Friday (27 November).

The 50-page document says reimbursements for surgeries should be given “only if psychiatric and psychotherapeutic means” do not alleviate gender dysphoria.

It adds that “surgical interventions on – from a health insurance perspective – a healthy body” should only be offered in the case of  a “particularly profound form of transsexualism”.

The document contains just one paragraph referring to non-binary people, who are defined as not being trans, meaning they would not be eligible for reimbursement from health insurers.

A copy of the report, a collaboration between the MDS and GKV-Spitzenverband, the National Association of Statutory Health Insurance Funds, was leaked on a German trans forum.

One user predicted the guidelines would increase paperwork for medical practitioners and “will result in more rejections”.

“This new directive will not improve anything for us in practice, but will only make things worse,” they added.

Many worry that the guidelines will be used as de facto treatment guidelines for gender affirmation surgeries

Under its social and medical requirements for treatment, the report states that trans people must have at least 12 psychiatric or psychotherapeutic sessions each lasting 50 minutes.

It makes it mandatory for trans people to have “everyday experience in the desired gender role continuously” for at least 12 months. It argues this pre-requisite is to “minimise the risk of regrets and re-transitions”.

Many have voiced their concerns on Twitter about how this will be tested or proven in insurance claims.

One tweeted: “[It’s] not much of a change because German non-binary people already have to lie about their gender here to get any kind of medical transition, but I can’t believe they decided to double down on that instead of… making healthcare inclusive to all who need it.”

The report claims to take a “holistic view” of transgender health and gender affirmation surgeries.

It will require “comprehensive diagnostics” which includes “recording of psychosexual development” and “specialist psychiatric or psychosomatic examination”. The new guidelines also require a physical examination “with a urological or gynaecological survey as well as endocrinological findings”.

It says that any pre-existing mental illnesses must be “excluded or be adequately treated and stabilised” before gender dysphoria can be diagnosed.

The leaked document is an update of a report released in 2009. It states that it aims to include more recent scientific findings on gender dysphoria and gender affirmation.

Until 2011, trans people in Germany had to undergo enforced sterilisation or be “permanently infertile” in order to obtain legal recognition of their gender. Similar laws are still in place in Finland among other nations.

The report uses the term “transsexualism” in accordance with the ICD-10, which classifies diseases and health problems in Germany. It has since been removed from the section on “mental disorders”, but this diagnostic classification is still used in some legal cases.

An update to the report is planned for when the ICD-11 comes into law.

Previously, Germany approved plans to legally recognise a third gender in official documents. It followed the court ruling in favour of an intersex person to offer a third option on birth forms, rather than just ‘male’ or ‘female’. However, this requires a medical certificate stating a “variant of gender development” is present. Thus, it does little to recognise non-binary people.

PinkNews has contacted GKV-Spitzenverband for comment.