Over the last decade, as activists started pushing colleges to accommodate transgender students, they first raised only basic issues, like recognizing a name change or deciding who could use which bathrooms.
But the front lines have shifted fast, particularly at the nation's elite colleges, and a growing number are offering students health insurance plans with coverage for gender reassignment surgery.
No college or university offered such treatment just six years ago, but when Brown University said last week that its student health plan would be extended to cover sex-change surgery beginning in August, advocates for transgender students said Brown would become the 36th college to do so.
Twenty-five additional colleges do not cover surgery, but their student plans do cover related hormone therapy, and 20 universities have plans that cover some or all sex-change treatments for their employees, according to the Transgender Law and Policy Institute.
Those lists include many top universities Harvard, Stanford, Cornell, Penn, Emory, Northwestern, the University of California system, Yale, Princeton, MIT, Washington University and others.
Colleges are not required to provide health coverage for students, many of whom are still covered by their parents' plans, but they generally do.
The idea still seems radical to plenty of people; last year, when Sandra Fluke, a law student, became famous for speaking in favor of an insurance mandate for contraceptive coverage, conservatives painted her as part of a fringe element because she also supported sex-change coverage.
But since 2008, the American Medical Association has advocated the same thing for treatment of gender identity disorder. Other medical groups, like the American Psychiatric Association, have taken the same position. Several major insurers have taken the stance that the treatment, including surgery, can be considered medically necessary. The Internal Revenue Service considers the expenses tax-deductible.
The issue directly affects only a tiny number of students. But universities recognize that their insurance plan sends a signal to the much larger number of students for whom the rights of transgender people have taken a place alongside gay rights as a cause that matters.
"Students notice whether the issues that they care about, that make them feel like it's a more comfortable and welcoming place, are being discussed and addressed," said Ira Friedman, a doctor who is associate vice provost for student affairs at Stanford and director of the student health center there.