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 now 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 of the top American 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 their 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; no one knows how many. 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. Stanford began covering sex-change surgery in 2010.

Princeton says on its website that it has been named a "top 10 trans friendly university" and that "recently, we launched an online guide" for transgender students. The university’s student policy covers hormone therapy but not surgery, but it is, along with Yale, one of several in that category that say they are considering adding surgical coverage.

"The university is actively exploring the possibility of offering benefits for gender reassignment surgery," for both students and employees, said Martin A. Mbugua, a Princeton spokesman.

In this field, colleges and universities may be lagging behind the corporate world; the Human Rights Campaign, the nation’s largest gay rights group, says that about one-quarter of Fortune 500 companies have health plans that cover sex changes, and a larger number cover hormone therapy.

"It is often more a knowledge and will gap, than a mechanics and cost issue," said Deena Fidas, deputy director of the Human Rights Campaign’s workplace project. "You have to start with Transgender 101, if you will, and demystify."

Sex reassignment surgery encompasses a variety of procedures that alter the anatomy to create physical traits of the opposite gender, sometimes but not always including genital reassignment. Surgery is typically preceded by psychological counseling, and often by hormone treatments. The treatment can cost tens of thousands of dollars, but college administrators say the additional cost of covering the services is negligible because so few people seek medical treatment for gender reassignment, and fewer still have surgery.

Campus activists say that the colleges that are covering sex-change treatments now are those that, five to 10 years ago, were among the first to take smaller steps like allowing a student who was born biologically male but identifies as female to have a female roommate and use a women’s restroom. For colleges that have not yet confronted such questions, "gender reassignment is a high bar," said Shane Windmeyer, executive director of Campus Pride, a national group that supports students who do not fall into the usual categories of sexual identity or orientation.

"Trans issues are new to many campus communities," he said. "You ask a lot of administrators about it, even at places that are familiar with lesbian and gay and bisexual issues, and they look at you kind of blankly."

In 2007, Campus Pride added sex reassignment coverage to its annual "inclusiveness index" that rates several hundred colleges and universities.

The colleges providing sex-change coverage tend to have large contingents of socially liberal, privileged students, who take for granted that they can and should voice their views. Administrators at several campuses said it was students who brought the issue to their attention.

Calling it a lobbying campaign "would be an overstatement," said Margaret Klawunn, vice president for campus life and student services at Brown. "But students had been asking about it, so we’d been looking at it for a couple of years, whether our health plan was in line with our nondiscrimination policy."