By Madeleine Valer, Civil Beat
Published: Dec. 1, 2025
After coming out as transgender to her therapist and her wife in 2023, one of Geena Thielen’s first priorities was to get rid of her facial hair.
The affordable housing developer began hair removal treatments, some of which were covered by her health insurance plan through the Hawaii Medical Service Association.
But in February 2024, HMSA started to deny her laser treatments, stating in letters to Thielen that the procedure doesn’t fall under the company’s “Medical Policy for Gender Identity Services.” Thielen’s hair removal was not medically necessary, the insurer said, even though Thielen’s dermatologist and therapist both deemed the procedures vital for treating her gender dysphoria.
“Seeing facial hair is a painful reminder of all the things wrong with me and with this body,” Thielen wrote in an appeal to HMSA’s advocacy department in January. “HMSA is deliberately withholding needed medical treatments, and that is immoral.”
The company’s denial also appears to violate a state law passed in 2022 that prevents health insurers from denying coverage for gender-affirming care procedures by classifying them as cosmetic rather than medically necessary. Act 39, known as the Gender Affirming Treatment Act, lists procedures ranging from laser hair removal to genital surgeries as medically necessary treatments for gender dysphoria.
But advocates for the LGBTQ community say they’ve heard from dozens of community members over the last three years who have continued to receive denials from their insurance providers for gender-affirming procedures.
Emily Hills, a senior staff attorney at the ACLU of Hawaiʻi, called those denials a “persistent problem” that is keeping transgender Hawaiʻi residents from accessing care essential to their mental health and well-being. Major medical associations, including the American Academy of Pediatrics and the American Medical Association, say gender-affirming care is medically necessary for trans patients.
Insurers not covering the care was already a problem before President Donald Trump took office. But since his inauguration, the trans community has been facing a litany of attacks from a president who has declared the government recognizes only two genders and referred to gender-affirming care for children as “genital mutilation.”
The U.S. Department of Justice has issued subpoenas to clinics and doctors treating trans youth, federal health insurers have stopped covering hormone therapy and gender-affirming surgeries for young people altogether, and patients and providers fear being targeted for seeking and giving care.
While advocates say ensuring health insurance companies like HMSA are complying with state law is important, protecting Hawaiʻi residents’ access to care in the Trump era is the top priority. The state Democratic Party’s Stonewall Caucus is working with legislators to draft a shield bill to protect doctors and patients in Hawaiʻi from being criminally prosecuted or sued by one of the 27 states where this gender-affirming care is banned.
“We’re coming together and asking our lawmakers to do the right thing,” said Stonewall Caucus Chair Abby Simmons, “to protect health care for all.”
Gender-Affirming Care In Hawaiʻi
Hawaiʻi has one of the highest per-capita populations of transgender people in the nation and māhū, which means “dual spirit” or “third gender,” is deeply rooted in Native Hawaiian culture. According to the Williams Institute at UCLA, 3.6% of Hawaiʻi youth and 0.7% of adults identify as transgender.
But it wasn’t until 2011 that the state officially outlawed discrimination of trans people in the workplace.
Even after the state’s anti-discrimination law passed, gender-affirming health care was still not widely covered by health insurers. Many transgender patients were also being denied basic medical care and being discriminated against in medical settings simply for being trans, community members and advocacy groups told the Legislature.
To remedy this, lawmakers in 2016 passed a bill prohibiting insurers from discriminating against a person based on gender identity. At least nine other states, including California, already had similar laws. The U.S. Department of Health and Human Services also had banned anti-trans discrimination within the Affordable Care Act.
But insurers in Hawaiʻi continued to deny coverage of gender-affirming care, classifying many of the treatments as cosmetic, which prompted lawmakers to come up with the Gender Affirming Treatment Act to prevent insurers from applying blanket exclusions to gender-affirming treatments.
HMSA opposed the bill, writing in testimony that it created conflicts with the state’s medical necessity statute. It also said the measure would cause premiums to go up and cost the insurance company an additional $1.5 million annually.
Then-Gov. David Ige signed it into law in June 2022 — two years later HMSA denied Thielen’s request for coverage for laser hair removal treatments.
In its denial, the insurer attached an assessment from a third-party company, the Medical Review Institute of America, stating “there are no comparative studies that confirm that laser hair removal is superior to intensive behavioral health treatments such as psychotherapy and medication therapy and use of estrogen therapy or other hair-removal options such as shaving.”
Facial hair removal by electrolysis or laser for gender affirmation is recommended by the World Professional Association for Transgender Health, a nonprofit that publishes international standards of care for trans patients. Other states with gender-affirming care laws similar to Hawaiʻi’s include the procedure as a covered treatment for gender dysphoria on their state-run health plans, such as MassHealth in Massachusetts and Medi-Cal in California. And patients who desired gender-affirming hair removal and received it had lower rates of psychological distress compared to a control group, according to a 2021 study in JAMA Dermatology.
Kenric Murayama, executive vice president of HMSA, said in an emailed statement the company couldn’t comment on specific medical claims.
“HMSA continues to afford coverage of benefits in accordance with members’ plan documents,” the statement says. “Determinations of medical necessity for procedures are made on an individual basis.”
Scott Saiki, former state speaker of the House who is now the state’s insurance commissioner, did not respond to requests for an interview.
California, which passed its Insurance Gender Nondiscrimination Act in 2013 has cracked down on insurance companies for denying coverage for gender-affirming treatments. Last year, the state fined Anthem Blue Cross $850,000 for denying coverage for 22 procedures, including hair removal, voice therapy and breast augmentation.
Thielen has continued to pay out of pocket for her hair removal treatments and estimates she’s spent about $3,000 so far. She also spent $15,000 on a vocal feminization surgery last month, which HMSA also declined to cover.
Though she said she feels lucky to have the resources to continue paying for her care, she wants to speak up for those who don’t.
“At the end of the day,” she said, “my journey is not going to be stopped by HMSA. Somebody else’s will be.”
Health Insurers Limiting Coverage
Advocates fear the anti-trans actions by the Trump administration will embolden health insurance companies to deny more gender-affirming procedures. Several health insurance companies have already changed their policies.
Kaiser Permanente, the state’s second-largest health insurance provider and widely considered by members of the trans community to be the best policy for gender-affirming care coverage in the state, said it paused gender-affirming surgeries for patients under 19 in August. Although gender-affirming surgeries can include breast reduction or augmentation and vaginal or penile construction surgeries, these types of procedures are rarely performed on youth.
In a statement, Kaiser Permanente spokeswoman Tammy Brownfield said the company had to consider “significant risks being created for health systems, clinicians, and patients under the age of 19 seeking this care” in making its decision.
Federal health insurance policies have stopped covering gender-affirming care altogether at Trump’s direction.
HMSA will stop covering gender-affirming hormone therapies and surgical procedures next year for members of any age under its federal plan, which covers federal employees in Hawaiʻi.
Murayama said the policy change was “in alignment with guidance and requirements established by the federal government,” and added that the company continues to comply with all laws governing its federal plans.
TRICARE, the insurance provider for military service members which has 150,000 beneficiaries in the state, in January eliminated coverage of all gender-affirming care for people under 19, including hormone replacement therapy and puberty blockers. It also stopped covering gender-affirming surgeries for adults.
Catherine Nelson, an army officer stationed at Schofield Barracks on Oʻahu and founder of the nonprofit Trans Military Hub, said she started having trouble getting her estrogen pills filled after the policy change went into effect and is being referred to private clinics for future refills.
Nelson had also been on the waiting list for a gender-affirming bottom surgery for years, but will no longer be able to get it covered by TRICARE.
Nelson, like thousands of other transgender troops across the country, is being forced out of the military prematurely because of a Department of Defense policy issued in February banning trans people from serving in the armed forces. After serving eight years in the army, three of them in Hawaiʻi, Nelson is not eligible for early retirement and will instead be given an “administrative separation with honorable discharge” at the end of the year.
“It stings,” she said. “Here I am having transitioned and done my job, consistently getting rated in the top 10%. Most of my soldiers didn’t even know I was trans until this started coming up, and I had to be like, ‘Hey guys, I’m not going to be around anymore, here’s why.’”
She estimates around 2,000 trans service members will have to leave the military across the country, around 50 of them in Hawaiʻi. More may choose not to reenlist, she said, if they have young transgender dependents who can no longer get care covered through TRICARE.
Climate Of Fear
Because of these policy changes, Haylin Dennison, executive director of Spill the Tea Cafe, a Honolulu nonprofit that offers mental health therapy and support groups to primarily LGBTQ youth, has stopped listing gender dysphoria as a diagnosis on some of her patients’ medical records. She’s afraid a health insurance company might deny them coverage outright.
It’s not the only change she’s had to make this year.
She’s stopped letting kids involved with the organization be featured on the news for events like their annual LGBTQ prom because of an increase in hateful online comments and death threats.
The kids she serves have had different reactions to what’s going on in the country, Dennison said. Some want to be in the streets protesting while others have said they want to hold off on transitioning altogether.
That’s why it’s especially important that Hawaiʻi pass a shield law this year, she said.
“Without explicit shield protections for gender-affirming care,” she said, “providers are scared, families are still going to be scared, our kids are still going to have this crippling anxiety.”
Simmons, chair of the state’s Stonewall Caucus, which focuses on LGBTQ policy, is working with lawmakers on drafting a bill. The caucus wants to see certain things included, like protections against patient information being shared with out-of-state law enforcement and having gender-affirming care medications excluded from prescription drug monitoring programs.
Advocates have also called on Gov. Josh Green to issue an executive order protecting gender-affirming care.
Hawaiʻi passed a similar shield law for abortion care after the fall of Roe v. Wade. Eighteen states and Washington, D.C., have shield laws for gender-affirming care in place.
The goal is to protect Hawaiʻi residents from out-of-state investigations, like the one launched by the Texas Attorney General into the Seattle Children’s Hospital for providing gender-affirming care to Texas kids, Simmons said.
“That creates this chilling effect for access to gender-affirming care itself,” she said. “Less and less providers want to provide this sort of health care because it comes with such a risk.”
With so many government institutions becoming hostile to trans people, it’s increasingly important for those still serving the community to signal that they’re a safe space, said Lily Hoang, office manager at Evolve Health, a transgender health clinic in Honolulu.
On top of the reception desk sits a Blåhaj — a small stuffed shark from IKEA that has become an online symbol for the trans community — and a stuffed Pokemon with the colors of the trans flag. Hoang points them out to patients who seem nervous.
“We want to make sure the whole space feels comforting,” she said.
Nicole Ryan, founder and medical director of Evolve, said many of her patients feel scared right now, which is why it’s essential for lawmakers to ensure access to gender-affirming care continues in Hawaiʻi.
“It saves lives,” she said. “Statistically, suicide rates go down when we see transgender patients getting the care that they need and being able to transition into who they truly are.”
For Thielen, all of the challenges she’s encountered on her transition journey have been worth facing and underscore the importance of this care and the value of protecting it.
“There’s no greater joy,” she said, “than being able to live authentically as yourself.”