Cultural shifts sometimes happen in ways you can’t help but notice, like the sudden growth of transgender themes on television. But there are also a bunch of quiet maneuvers you don’t see, producing change through obscure bureaucratic procedures.
To begin your introduction to one of those little-noticed avenues of change, take a moment to read the Independent Medical Review (IMR) obtained by California health care regulators in 2025 on behalf of a biological male (in the record, a “transgender female”) who wanted his health insurance company to buy him a prosthetic “vagina”.
The transgender patient had a history of depression, “with possible psychotic features,” and was taking anti-psychotic medication when his insurer denied coverage for a surgically created artificial vagina. (Surgical neo-vaginas are created by penile inversion, or less frequently by cutting out a piece of the patient’s bowels and sewing it into a surgical hole between his legs.)
Appealing that decision, the potentially psychotic patient asked the California Department of Managed Health Care (DMHC), which regulates health insurance plans, to conduct a review in which an independent medical expert would decide if his surgery was medically necessary.
A finding on an IMR is binding. Insurers must cover procedures an “independent expert” finds “medically necessary.” As the state’s IMR request form says: “Health plans must follow the IMR decision and promptly provide the service.”
In this case, a psychiatrist reviewed the patient’s surgical request, with no review by a surgeon. The psychiatrist overturned the insurer’s refusal to pay. A male on anti-psychotic medications got a surgically implanted fake vagina, in a procedure covered by insurance, because a psychiatrist found the surgery to be medically necessary.
Hellbound and Down 