Sign here? Financial agreements may leave doctors in the driver's seat

When he arranged to undergo top surgery, Cass Smith-Collins of Las Vegas selected a surgeon touted as an early developer of the procedure who does not contract with insurance. "I had one shot to get the chest that I should have been born with, and I wasn't going to chance it to someone who was not an expert at his craft," he says. (Bridget Bennett for KFF Health News/Bridget Bennett for KFF Health News)

Cass Smith-Collins jumped through hoops to get the surgery that would match his chest to his gender.

Living in Las Vegas and then 50, he finally felt safe enough to come out as a transgender man. He had his wife's support and a doctor's letter showing he had a long history of gender dysphoria, the psychological distress felt when one's sex assigned at birth and gender identity don't match.