Exclusion of Medically Necessary Gender-Affirming Surgery for America's Armed Services Veterans.

Gender dysphoria, the term used in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM) to describe distress at the incongruence between one's gender and anatomy, affects approximately 0.6 percent of the population. It is estimated that there are 134,000 Armed Forces veterans in the United States with gender dysphoria. Although gender-affirming surgery is widely accepted as a medically necessary intervention for appropriately selected patients with gender dysphoria, the Veterans Health Administration (VHA) Health Benefits package and VHA Directive 2013-033 specifically prohibit gender-affirming surgery within Veterans Affairs (VA) facilities or using VA funding. This policy, which has been legally challenged after being reaffirmed in January 2017, denies medically necessary care to veterans, causing harm to individual patients and reinforcing discrimination and prejudicial treatment of a minority population. We argue that the policy is indefensible as it violates the basic ethical principles of beneficence, nonmaleficence, and justice.