Gender dysphoria is a medical diagnosis defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association’s handbook of official diagnoses, as “[T]he distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.” The World Health Organization recognizes gender dysphoria (formerly called gender identity disorder or GID) as “characterized by a persistent and intense distress about assigned sex together with a desire to be, or insistence that one is, of the other sex.”

The American Medical Association (AMA) established in a 2008 resolution that gender dysphoria (then GID) is a “serious medical condition” with symptoms including “distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death.”

The treatment for gender dysphoria involves some combination of “triadic therapy”: hormone therapy, gender-affirming surgery and/or Real Life Experience (living for a period of time in accordance with your gender identity). Each patient must be evaluated on a case-by-case basis, with expert medical judgment required for both reaching a diagnosis and determining treatment. There is no set formula for gender transition.

These treatment protocols are outlined in the Standards of Care published by the World Professional Association for Transgender Health (WPATH), which keeps the public up to date on the “professional consensus about the psychiatric, psychological, medical, and surgical management of gender dysphoria.”

The myth that transition-related care is “cosmetic” or “experimental” is discriminatory and out of touch with current medical thinking. The AMA and WPATH have specifically rejected these arguments, and courts have affirmed their conclusion. For instance, in O’Donnabhain v. Commissioner, a case brought by Gay and Lesbian Advocates and Defenders (GLAD), the Internal Revenue Service lost its claim that such treatments were cosmetic and experimental when a transgender woman deducted her gender-affirming surgery procedures as a medical expense.

Some employers worry that covering transition-related health care will raise the cost of insurance premiums, but data show that is not the case. While the cost is prohibitive for many individuals, it’s negligible when an insurance plan takes it on because gender dysphoria is negligible when an insurance plan is able to allocate the costs.

For example, San Francisco, which became the first U.S. city to provide insurance coverage for gender-dysphoria-related care in 2001, quickly learned that the change would not cost municipal employees anything at all. After four years, during which time the city paid out only 11 gender-dysphoria-related claims, the surcharge that employees had been paying to cover the policy change was reduced to zero. There simply was no need to take in the extra money, because the cost of covering these claims was so insignificant.

Not treating gender dysphoria, on the other hand, can be quite a strain on the health care system. According to the AMA, “Delaying treatment for [gender dysphoria] can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illness, depression, and substance abuse problems.”

When the Affordable Care Act was enacted, the law’s antidiscrimination provisions created an important new tool to combat anti-LGBT and especially anti-transgender discrimination in health care. In a letter dated July 12, 2012, the Office of Civil Rights (OCR) in the federal Department of Health and Human Services (HHS) responded to a letter signed by Lambda Legal and the New Beginning Initiative confirming that the HHS prohibition against sex discrimination “extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or femininity…[and] also prohibits sexual harassment and discrimination regardless of actual or perceived sexual orientation or gender identity of the individuals involved.”

This means that transgender and gender-nonconforming individuals cannot be discriminated against in any way by programs or activities administered by HHS or any entity established under the ACA. Complaints can be filed with the OCR, which will investigate such complaints as sex discrimination.

This has prompted a number of states (CA, CO, CT, IL, MD, NY, OR, VT and WA) and the District of Columbia to issue “insurance bulletins” reminding private insurers that it is against state law and the Affordable Care Act (ACA) to allow discrimination against transgender policy holders.