The Trans Healthcare Gap

In exactly a week, I’m having surgery. More specifically, I’m having what is known as “top surgery,” which is female-to-male chest reconstruction surgetumblr_inline_mxmeg4kxqA1snsabvry. The procedure is fairly common for FTM trans folk, and the surgeon I am seeing has done about 300 of them in the last few years.

The procedure is performed by plastic surgeons, whose main practice is usually breast implants, Botox, face lifts, etc.  To be honest, it was a little strange being in the waiting room of the facility, which felt more like the reception area of a Massage Envy location than a surgery center.  Warm brown tones, low lighting, candles and scented oil diffusers, overstuffed chairs, etc.  The staff wear all black and little name tags.  There was probably a fountain filled with river rocks somewhere.

Everyone was lovely.  The surgeon is a very nice man who I guess is in his late 40s– but then again, he is  a plastic surgeon.  He was in good shape and seemed lively, not like the very nervous/stressed/bro-y three surgeons I had met with previously.  No, this doctor made me feel comfortable immediately.

The first thing he said was “I’m really excited about this.” I asked him why and he told me that FTM chest surgeries are his favorite procedures to do. I asked him why that was.  I’m not sure what I thought he was going to say, but in my head, I was thinking “at $5k + a pop, I bet they’re your favorite!”  Instead, the doctor said:

“Every one of my patients comes here because there is something about themselves they’re unhappy with.  But what I do for trans guys is different.  There’s something about helping someone realize who they truly are. They are the happiest of all my patients, which makes me happy.”

Okay, McDreamy, you can stay.

We talked over how things would go, he took some photos, drew all over me with red marker, and then left me with the nurses for the rest of the visit.  The nurses were super respectful and kind, and I could tell that they were used to having folks like me around.  I’m really excited.

As excited as I am, I also have a great deal of frustration going into this procedure. It has been a long, complicated road to get here.  That, friends, is the real focus of this post.

It used to be, not that long ago, that a trans person would have to see a psychiatrist/psychologist for a year before being able to start hormones.  Then, surgeons usually required a year of hormones and living out as your true gender before they would do anything, and even then you had to have two letters of recommendation from healthcare professionals to certify that you *really are trans* and you’re not crazy.

Thank goodness, this model of “care” has gone by the wayside.  As policies toward trans healthcare have changed, the process has become shorter, if not simpler. Under my insurance, which covers hormones and surgery (more on that in a minute), the only requirement is that I have a letter from one mental health professional certifying that I have gender identity disorder. No hormone requirement, no “out” requirement necessary.

Okay, insurance.  Health insurance is a bureaucratic mess at best and a nightmare at most for just about everyone.  Just imagine how hard it is when you have some medical condition that is 1. uncommon, and 2. socially unpopular.  Until 2014, insurance companies could outright refuse to cover any trans-related care, calling it a “pre-existing” condition.

In 2014, after the dust settled for the most part around the Affordable Care Act, some states began interpreting the ACA’s prohibition on gender-based discrimination and mandate to cover pre-existing conditions and issuing their own guidance requiring insurers in the state to cover transgender-related care. Thankfully, California is one of those states.  New York recently joined the fray.

So theoretically, my care should be covered by all insurance that operates in California.  Except, my work uses a “privately funded” insurance plan, which means it gets to control what is and is not covered, not the state. And wouldn’t you know– trans care is not covered.  I raised a stink about this and HR is “working on it.” Truthfully, they’ve never had a trans employee (that they know of) and so they never had to consider transition-related care. Hopefully my struggles with this will help make it easier for the next trans person at my firm.

So I had to drop my work healthcare and enroll in Covered California, the CA branch of Obamacare. EVERY SINGLE PLAN COVERED TRANS CARE! I picked my PPO, double-checked all the paperwork to make sure surgery is covered, and immediately sought out a surgeon who could do it.

Wouldn’t you know, there are NO SURGEONS who do top surgery who also take insurance. None (except for Kaiser, which has their own plastic surgeons). I even called the insurance company to see if they could somehow figure out if any of their customers had ever actually had the procedure done, and if so, where they went.  No such luck.  And just imagine my trying to describe my situation and top surgery to the poor customer service lady that answered the phone…

A friend of mine who is in medical school at the moment told me that plastic surgery (“plastics,” she calls it) is the most competitive residency out of med school. It’s no secret that plastic surgeons make tons of dough, so I guess that is a big part of the reason why.  Because they perform services that are largely “elective,” plastic surgeons exist almost entirely outside of the insurance world, because insurance simply doesn’t cover cosmetic procedures. There are also only a few surgeons that do top surgery for trans guys, so they pretty much have control over the market.

So, even though I have insurance that covers this procedure, I cannot get it covered because there are no doctors that actually take insurance. It is a gap in the policy and practice of trans healthcare that begs to be closed. However, as the market stands, surgeons have little incentive to get in-network with insurance carriers because there are plenty of trans guys that scrimp and save to be able to fork over the $5-15k it costs to have the surgery done.

I am fortunate to have a job and a support network that can make paying for this on my own possible. But the reality is that most trans people can’t afford surgical procedures or hormone therapy without insurance coverage.I can only hope that some doctors and surgeons see this gap between policy and practice, and take the steps to get affiliated with insurance networks, even if it ends up being just out of the goodness of their own hearts. The trans community could really use the help.

3 thoughts on “The Trans Healthcare Gap”

  1. plastics rarely accepts insurance; procedures are so darn lucrative. i really hope that therapies and surgeries, like those you undergo, become more feasible for ALL. way too many gaps. i wish you all the best in your recovery and beyond!


  2. Such interesting insight into a problem in healthcare that I had never thought about. I’m sorry you’ve had to deal with so many hurdles. Thinking of you—hope your surgery goes smoothly.


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