gender reassignment surgery hawaii

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Hawaii just expanded gender-affirming care for trans residents

The new law clarifies that treatments insurers had deemed ‘cosmetic’ should be covered as long as a medical provider deems them medically necessary.

In 2016, Hawaii took a seemingly small but significant step forward for its transgender and nonbinary residents: The state passed a law barring insurance companies from discriminating against residents based on their gender identity. But in the years since the anti-discrimination law, trans residents, advocates and lawmakers found that it hadn’t done enough — people were still being denied coverage for gender-affirming care.

On Thursday, Hawaii Gov. David Ige (D) signed a bill into law that clarifies certain treatments insurers had deemed “cosmetic” — such as laser hair removal, voice therapy and facial feminization surgery — should be covered as long as a medical provider deems them medically necessary. The legislation, H.B. 2405, would also require insurers to give patients clear information about which gender transition services are covered.

“The bill is key to protecting people from discrimination in accessing gender-affirming treatment,” Ige said at a signing ceremony, Honolulu Civil Beat reported. The governor also signed two other bills expanding LGBTQ protections in state: one that bars people from being excluded from juries because of their gender identity and expression, and another establishing a commission that will examine the status of Hawaii’s LGBTQ residents.

The health-care bill, which was crafted with input from health-care providers, trans advocates and insurers, passed with overwhelming support in both chambers of Hawaii’s legislature. The law went into effect immediately on Thursday.

The coverage issue highlights how difficult it is for transgender people to access medically necessary and potentially lifesaving gender-affirming health care, even in areas that embrace and support them, said Hawaii state Rep. Aaron Ling Johanson (D), a champion of the bill and chair of the state’s Consumer Protection and Commerce Committee.

Johanson said the policy change had been a “passion project” for him.

“One of the things that we came to find was that … ‘cosmetic’ treatments are a very critical part of accomplishing gender-affirming care for the patient,” Johanson said. But “clashes” persisted between trans Hawaii residents and insurance companies, he said, because some insurers decided the care was not medically necessary, even if a patient’s medical provider had recommended it. (Hawaii Medical Service Association, the state’s largest insurer, declined to comment.)

“It’s just heartbreaking when you hear from a lot of these folks who have higher rates of depression or thoughts of suicide because they’re just stuck in a system that doesn’t help them,” Johanson added.

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Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, said that when it comes to gender-affirming surgeries, insurers tend to cover “top” and “bottom” surgeries (chest and genital surgeries), but not procedures such as facial or vocal surgeries. That’s a big oversight, Liang said, considering how important these characteristics are in everyday life.

“When you engage with somebody, the first thing that they appreciate, really, is your face and facial expressions,” Liang said, adding that many of her patients have also shared stories of being misgendered over the phone. Some worry their voice is “a telltale giveaway” of their transition. (Non-invasive procedures, such as laser hair removal and voice therapy, are also more likely to be denied by insurers.)

Generally, Liang said, gender-affirming care, which includes psychosocial and educational resources as well as medical interventions, helps transgender people live more freely, whether that’s relieving their gender dysphoria or reducing the likelihood they’ll be singled out or discriminated against.

“It really is a medical necessity,” Liang said. “These patients are living with an incongruence that permeates all aspects of their lives.”

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In passing its new gender-affirming care bill, Hawaii has joined a handful of states, including Washington and Colorado , that have tried to expand access to transition care.

Trans people and their advocates have long noted the structural barriers to receiving care. Fighting to get treatments covered can be a costly, overwhelming and time-consuming process, experts said. And even when patients can get their treatments approved and covered, there are not many providers capable of performing these procedures, and it is not unusual for patients to travel out of state or to be put on lengthy waiting lists to receive it.

This is true even in “progressive” places like Hawaii, where some residents have traveled to California — a five-hour flight — to get the transition care they need, advocates say.

Jenn Jenkins, a policy advocate who worked on Hawaii’s health-care bill, said that in their eyes, the law simply clarifies what was intended in the state’s 2016 nondiscrimination policy.

“This is already the law. It was just not as plainly written as we’ve done it [now],” Jenkins said. Still, this clarification could greatly expand gender-transition access for Hawaii residents, particularly trans women who had been particularly susceptible to having their claims denied, Jenkins added.

Advocates and lawmakers in Hawaii agree the bill is a significant step forward at a time when other states are looking to limit access to transition care among trans youth and adults. Conservative lawmakers who have introduced bills curbing access to gender-affirming care for minors say the policies are meant to protect children.

For Johanson, the lawmaker, Hawaii’s emphasis on community care — the “aloha spirit” — helped facilitate the bill’s passage. Jenkins, meanwhile, noted that Hawaiians have been “much more open to the idea of a spectrum of gender” because those beliefs are deeply rooted in Hawaiian culture.

Native Hawaiians have long recognized a third gender identity , “mahu.” Historically, trans and nonbinary Hawaiians have taken roles as teachers and leaders in their communities, explained Maddalynn “Maddie” Sesepasara, a trans advocate who manages the Kua’ana Project , a transgender support organization.

This cultural reverence was made apparent in 2019, Sesepasara said, when indigenous elders protesting a billion-dollar telescope at the summit of Mauna Kea mountain called on Hawaii’s mahu community to join them.

“We know we have a place. We know we are respected,” Sesepasara added.

That doesn’t mean trans people in Hawaii have not faced the same systemic barriers, discrimination and violence trans people face elsewhere, advocates say. After Christian missionaries came to the islands, “mahu” became a derogatory term, Sesepasara said, though this has slowly changed over the last several decades.

Medical transitions are a personal choice — one that not all trans and nonbinary people are able to make or willing to seek. But for people in Hawaii who need medical treatments to affirm their gender identity, these procedures could mean the difference between being targeted and being able to “blend in” and be comfortable in society, Sesepasara said.

And a time when the cost of living has soared on the islands, some residents have become increasingly desperate to complete their transitions.

“These are not cosmetic surgeries,” Sesepasara said. “These are surgeries that are going to save transgender folks in Hawaii.”

Jenkins hopes Hawaii’s new law could be a “little bulb of light” for trans communities in other parts of the country, where vitriol and attacks against trans people and other LGBTQ individuals have spiked .

“It’s our contribution to the possibility that we can change things for the better,” they said.

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Hawaii transgender resources

Below are resources in Hawai’i for our community, part of this site’s American resources by state. See also major US-based trans websites  and national advocacy groups .

Transgender surgery options in Hawaii

Health Hawaii ( health.hawaii.gov )

• Gender Minorities Resource Hub
• https://health.hawaii.gov/harmreduction/sexual-gender-minority/gender/ 
• G-ECHO Gender Affirming Providers Directory (PDF)
• https://health.hawaii.gov/harmreduction/files/2023/09/G-ECHO-Gender-Affirming-Directory-September-2023.pdf
• https://health.hawaii.gov/harmreduction/files/2023/06/G-ECHO-Gender-Affirming-Directory-1.pdf [original]

Hawai’i Health & Harm Reduction Center – HHHRC ( hhhrc.org )

• Kua’ana Project

Manakai o Malamai ( manakaiomalama.com )

• Integrative health center offers gender affirming care

World Professional Association of Transgender Health ( wpath.org )

• Member search:  Hawaii

Planned Parenthood  ( plannedparenthood.org )

• Honolulu Health Center
• Kahului Health Center

Chrysalis Counseling and Consulting ( chrysalisconsulting.us )

• Laura Moidel Acevedo LMHC

State of Hawaii ( portal.ehawaii.gov )

• Name Change Portal ( namechange.ehawaii.gov )

National Center for Transgender Equality ( transequality.org )

• ID Documents Center | Hawaii

Human Rights Campaign  ( hrc.org )

Lambda Legal ( lambdalegal.org )

Williams Institute  ( williamsinstitute.law.ucla.edu )

ACLU Hawai’i ( acluhi.org )

University of Hawai’i at Manoa ( manoa.hawaii.edu )

• LGBTQ+ Center

University of Hawai’i at Hilo ( hilo.hawaii.edu )

LGBT Center Waikiki ( facebook.com/LGBTCenterWaikiki )

National Queer Asian Pacific Islander Alliance – NQAPIA ( nqapia.org )

Democratic Party of Hawai’i LGBT Caucus ( lgbtcaucushawaii.com )

Pride at Work Hawai’i ( facebook.com/PrideAtWorkHI )

The Lavender Clinic (lavenderclinic.org) [ archive ]

KUA'ANA PROJECT

​Kua'ana is the Hawaiian term for older sibling. In the 'ohana (family) structure,  kua'ana take responsibility of caring for the kaina (younger sibling) and guide them as they pursue their goals.  Through the Kua’ana Project, peers of the transgender community kōkua (assist) other transpersons using their own personal experiences. Whether it be to search for jobs, legally change their names, or access stable housing, our Kua’ana Project staff are able to support and encourage kaina with compassion and understanding. 

To learn more about our services , please call (808) 521-2437 or email [email protected].

‘IKE AKU, ‘IKE MAI. KŌKUA AKU, KŌKUA MAI. PĒLĀ KA NOHONA ‘OHANA.

Watch, observe. help others and accept help. that is the family way., meet maddie, our kua‘ana project manager.

Maddalynn “Maddie Ashton” Sesepasara has been a part of the HHHRC family since 2001 when, as part of Life Foundation, she participated in Hawaii’s ‘Aha UTOPIA for five years. Maddie, a transgender woman of Samoan and Chinese descent, joined Life Foundation in 2003 as an HIV Health Educator and Outreach Worker. She rejoined the ranks of Life Foundation in 2012 after a time at Kulia Na Mamo, assuming her former position with a new gusto for the community. Maddie has helped to coordinate several HIV awareness campaigns since her initial involvement with UTOPIA Hawaii, and has emerged as a prominent voice in the community. Throughout the years, Maddie has dedicated her work to HIV awareness and reducing the stigma of HIV in her community.

KUA‘ANA PROJECT STAFF

Shalani Placencia

Kua‘ana Project Peer Navigator

KUA‘ANA SERVICES

• About the Hawai‘i Health & Harm Reduction Center A one-hour presentation for community groups and partner organizations that covers the misison of HHHRC and the services we offer. This presentation is free and can be tailored to your organizational needs and interests.
• Harm Reduction 101 Harm Reduction is a philosophy and set of strategies for working with those engaged in potentially harmful behaviors. This interactive session will explore the tenants of Harm Reduction, provide insight and practice into the theories of Harm Reduction and provide resources to services working in the spirit of Harm Reduction. Training length: 8 hours
• HIV, Hepatitis C, & STD 101" This full day training provides participants with an overview of HIV, viral hepatitis, and other common sexually transmitted diseases. Participants learn to identify the signs, symptoms, transmission methods, and risk factors for these diseases. Participants then learn how to integrate harm reduction methods, motivational interviewing, and sexual health counseling into substance use treatment and counseling. Participants also learn about the medical and social service resources available to people living with HIV, viral hepatitis, or those at risk for an STD. This class is highly interactive and provides participants of all learning styles an opportunity to engage with the material. Training length: 8 hours
• LGB Cultural Competency HHHRC offers LGB Cultural Competency training designed to increase knowledge and skills to effectively interact with LGB people, as well as support and provide affirming care. This training also integrates the unique viewpoints of local and Hawaiian Cultures. As the largest LGB&T organization in the pacific, our agency can offer the most comprehensive and competent training when it comes to sensitive topics regarding sexuality.
• Mental Health First Aid Mental Health First Aid is a 1-day course that teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders. The training gives you the skills you need to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis. Mental Health First Aid is for anyone, but especially people in roles where they interact with the public, or where mental health challenges are more frequent.
• Motivational Interviewing Motivational interviewing, a treatment approach developed by William Miller, has been well established as an effective way to promote behavior change in individuals. Following a brief review of the fundamental MI principles and micro-skills, this experiential Introduction to MI skill development training will focus on helping clients/patients to engage in change talk, and then make commitments to make behavioral changes based on goals that they have identified. Ample time will be devoted to real play and group practice sessions to enable training workshop participants to gain the skills necessary to elicit change talk from clients/patients with low levels of readiness for change, thereby increasing levels of motivation and moving them toward action to address their substance use issues. Training length: 8 hours
• Opioids & Overdose: Prevention & Response Overdose is the leading cause of accidental death in Hawaii and around the U.S. This interactive session will explore the impact of opioids on the body and identify the risks for accidental opioid overdose. Participants will be certified to administer Naloxone, the opioid antagonist. 4 hours ADAD approved CEUs. Training length: 1 - 4 hours
• Transgender Cultural Humility This training focuses on the importance of respect and dignity when interacting with people of trans experience. Utilizing the unique viewpoints of our Hawaiian and local cultures, we aim to increase humility and capacity for understanding when it comes to one of our most vulnerable populations. This training is perfect for service providers, frontline customer service workers, management, or anyone wishing to better understand people of trans experience and provide appropriate, affirming services or care.

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HHHRC is proud to be a founding member of the coalition to change the outdated discriminatory Section 23 added to Hawaiʻi's Constitution a generation ago. Remove the Hawaiʻi legislature’s authority to limit marriage to opposite-sex couples. Let's make sure Hawaiʻi remains an inclusive and welcoming place for all loving couples. 

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There’s so much to consider when looking for a surgeon to perform your gender-affirming surgery: experience with the procedure, geographic location and the types of insurance they accept are all primary concerns. Before getting bogged down with too many details, start your journey by searching for surgeons that offer the procedures that you’re interested in. All set? Let’s go!

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Dr. Eric Bensimon has dedicated his career to helping trans women seeking FFS. With over 15 years experience, Dr. Eric Bensimon is one of the world’s most experienced surgeons practicing Facial Feminization Surgery.

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Dr. Jacobs is an award-winning and board-certified plastic surgeon in San Francisco who joined The Gender Confirmation Center in July, 2022. Dr. Jacobs has more than 30 years of plastic surgery experience and provides outstanding surgical care for transmasculine, transfeminine and non-binary patients.

Dr. Michael Safir

Dr. Safir is a board-certified urologist in Los Angeles who specializes exclusively in gender-affirming bottom surgery procedures. With subspecialty certification in Female Pelvic Medicine and Reconstructive Surgery, Dr. Safir is one of a handful of urologists in the world with individual fellowship training and experience in both male and female genital reconstruction. He gained extensive experience over five years performing genital surgeries at one of the highest volume gender surgery centers in the world and is now affiliated with Align Surgical Associates out of Los Angeles. Dr. Safir’s vast experience in urology has made him a popular choice among transgender people from across the U.S. seeking bottom surgery.

Dr. Heidi Wittenberg

Dr. Wittenberg is an experienced urogynecologist and reconstructive pelvic surgeon in San Francisco who works exclusively with trans patients, offering female-to-male and male-to-female bottom surgery. Dr. Wittenberg is the director of MoZaic Care, which specializes in gender affirming genital and pelvic surgeries, and a Founder Surgeon and Co-Director for the first SRC accredited Center of Excellence in Gender Confirmation Surgery, at Greenbrae Surgery Center.

Dr. Ashley DeLeon

Dr. DeLeon is a board-certified surgeon who specializes exclusively in Gender Surgery. Dr. DeLeon is fellowship trained in gender-affirming procedures and has vast experience with pelvic and breast surgery. Dr. DeLeon focuses specifically on Vaginoplasty, Orchiectomy, FTM Top Surgery and Phalloplasty procedures. She also teaches at Texas A&M Health Science Center College of Medicine and the University of Texas at Austin Dell Medical School.

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Dr. Dulin is a board-certified surgeon with many years of experience performing Top Surgery, Metoidioplasty, Breast Augmentation, FFS and Orchiectomy.

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Hawaii’s Transgender Community Pushes For Better Health Insurance Coverage

When the Hawaii Legislature’s session kicked off in January, members of the state’s transgender community and their advocates were hopeful they could get proposals passed making it easier to get medical procedures related to gender transition covered by health insurance.

But as the legislative session winds down, it’s looking increasingly unlikely that those measures will pass.

The House has just one more day — Thursday — to hold a hearing for a concurrent resolution that would express the Legislature’s support for “gender transition treatments and services as medically necessary for the purposes of health insurance coverage,” according to the original draft of the proposal.

A bill with a similar message died earlier in the session. Instead, the Hawaii Senate passed a resolution on its own asking the auditor to look into the issue.

The state insurance commissioner testified that an audit would be necessary before insurance mandates could be expanded, but advocates for Hawaii’s transgender community argued that an audit doesn’t go far enough.

Hawaii passed a law in 2016 to “prohibit the denial, exclusion, or limitation of health care services or treatment to a person on the basis of a person’s actual gender identity or perceived gender identity.”

That means Hawaii insurance companies can’t discriminate against someone for being transgender, and in practice, insurance companies cover medications such as hormones and certain gender reassignment surgeries such as orchiectomies.

Jen Jenkins, community co-chair to the Sexual and Gender Minority Workgroup, said they want the Legislature to clarify the law to make clear that all transition services are medically necessary for the purposes of insurance coverage.

A previous version of this story incorrectly said Jenkins worked at the ACLU.

“Trans people in Hawaii aren’t getting the health care that they’re guaranteed to by law,” Jenkins said.

Jenkins is backing the original version of Senate Concurrent Resolution 161 after House Bill 285 died earlier this session. Rep. Mark Nakashima told Civil Beat he declined to hear the measure after the Hawaii Medical Service Association told him that it wasn’t necessary.

“My understanding from the insurance companies is that they don’t deny any procedure on the basis of gender identity. The one exception to that is what they consider cosmetic surgery like breast implants, which may be necessary for someone who is transitioning to a woman, but at the moment they consider that cosmetic,” he said. “If it was considered cosmetic, I didn’t question it.”

That’s disappointing to Camara Miyamoto, director of the LGBTQ center at the University of Hawaii at Manoa, who called the bill “absolutely critical.”

“It’s a matter of life and death,” he said.

An $8,000 Loan

That’s how Breanna Zoey Connors feels. On Tuesday, the 37-year-old trans woman underwent breast augmentation surgery in Honolulu. Connors doesn’t expect that her insurance, HMSA, will cover the procedure. Instead, she took out an $8,000 loan from her 401(k) to pay out-of-pocket.

She said insurance covers some procedures related to her transition, such as a vaginoplasty, but she expects to pay $20,000 to $40,000 out-of-pocket for facial surgery and isn’t yet sure where the money will come from. But going into debt is worth it, she says, because of the mental anguish of being constantly misgendered.

“It’s just so traumatic,” she said, “not being able to have the world see you as you are.”

She’s been plagued by depression and anxiety that’s been exacerbated by the financial stress of the procedures. In February, she felt suicidal at the thought of the high costs.

“I’m very thankful I’m still here today,” she said.

Stefanie Park, assistant vice president of medical management at HMSA, told Civil Beat that the company approves gender transition services such as psychotherapy and gender confirmation surgery “as long as they’re considered medically necessary” per its policy.

“Other surgical procedures which can be considered cosmetic in nature must be reviewed on a case-by-case basis for medical necessity,” she said. “Cosmetic services that do not restore or materially improve a physical function are ineligible for coverage for all of our members regardless of gender or gender identity.”

A spokeswoman for Kaiser referred Civil Beat to the company’s policy , which includes “behavioral health assessments and counseling, hormone therapy, and gender affirming surgeries.”

“Kaiser supports culturally competent care to all of its patients, and supports parity in coverage without discriminating on any protected basis,” the company wrote in its public testimony on House Bill 285.

Both companies supported the idea of an impact assessment audit prior to approving a mandate, according to their public testimony.

Broader Issue

Compared with other states, Hawaii is considered a relatively LGBTQ-friendly state in terms of state laws, in part because of the 2016 law to ensure insurance companies don’t discriminate against transgender people, introduced by Sen. Chris Lee.

“The intent was to make sure that people’s gender identity and everything associated with it is covered because it’s a core part of who people are and how they’re perceived in society,” Lee told Civil Beat. He said he expects that in some cases, breast augmentation would be covered.

Rodrigo Heng-Lehtinen, deputy executive director at the National Center for Transgender Equality, said it’s common for transgender people to have to fight to get procedures covered even with the existence of non-discrimination laws.

He noted the insurance company Aetna recently announced it would cover breast augmentation for transgender people and believes the industry is headed in that direction.

“I think some insurance companies are going to get there kicking and screaming,” he said. “It is eventually going to happen because it is considered essential care.”

Laura Edwards-Leeper is a psychologist and professor at Pacific University who has worked with transgender youth and adults for many years. She said from her perspective, insurance coverage for medical interventions for transgender people is critical for their mental and physical health.

“For trans females who have gone through male puberty and have all of the masculinizing effects of testosterone, it can be very, very hard for them to ‘blend in’ as a woman if that’s their goal,” she said. “A lot of them have very permanent effects from male puberty. It puts them literally in danger because they are then targeted by people who engage in hate crimes.”

She said insurance coverage is hugely important not only so that transgender people who need the procedures can feel better but also so they aren’t getting targeted for appearing transgender.

“It’s very different than cosmetic surgery for cisgender people who just want bigger boobs,” she said. “We’re talking about helping them live comfortably in society so they can be perceived correctly and live a happy life like everybody wants to. The surgeries are very expensive and so very few people can afford that out of pocket.”

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Beyoncé’s ‘Cowboy Carter’

Hawaii eases process to switch gender on birth certificates

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HONOLULU (AP) — Gov. David Ige signed a bill Monday that will allow transgender men and women in Hawaii to more easily change the gender on their birth certificate.

The new law eliminates the requirement that someone must undergo gender reassignment surgery before officially making the switch.

“I know that this has been a tough issue,” Ige said. “As all of you know, the birth certificate is one of those foundation documents.”

Many in the transgender community can’t afford or don’t want to undergo costly surgeries. But having a birth certificate that reflects their gender expression is critical for school transcripts, job applications, health insurance and many other aspects of life, advocates said.

“With this new law, it’s life-changing,” said Tia Thompson, 30, of Honolulu, who was denied a birth certificate that reflects her female gender identity. “Words cannot express what’s going on.”

Thompson delayed applying for college because she wanted to apply as a woman, and she needs her birth certificate to indicate she’s female, she said. Her goal is to play volleyball on a women’s team.

“This is going to have a great impact on the university,” said Camaron Miyamoto, coordinator at the Lesbian Gay Bisexual Transgender Student Services Office at the University of Hawaii at Manoa. He has said one student who transitioned from male to female was denied financial aid because she had not signed up for Selective Service, which is a requirement for men when they turn 18.

“There’s a lot of students that ask, ‘Why do they need to know?’” Miyamoto said.

But a birth certificate is a historical record, and allowing people to change it could affect couples contemplating a marriage or officiants performing the ceremony, opponents said. More than a dozen lawmakers voted against the bill, and some feared the state could end up issuing false documents that could help criminals skirt the law.

At least six other states have made similar changes to their birth certificate laws. Hawaii’s law went into effect immediately.

“This is going to open doors to a lot of transgender rights,” Thompson said. “We still have a long way to go, it’s not over. This is one step.”