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.

Legally Me: The Struggle of Officially Redefining Yourself

FullSizeRender (3)About two weeks ago, the State of California, through a LA Superior Court judge, granted my legal name and gender change. I was very emotional when I finally got my hands on the certified copy of the court order. This was what I had been waiting for.

I filed my petition for a name and gender change back in February. I would have done it sooner, but the filing fee in LA Superior Court is $435, and I was still catching up on bills and debts following my graduation from law school and the following 5 months without income.

So I filed in February. All the websites I had read on the subject of filing a name and gender change made it clear that the petition would take about 6 weeks to process and grant. The state would have to clear my paperwork, and then run a criminal background check to make sure I wasn’t changing my name and gender to run away from any parole duties or anything like that. So I filed my papers and paid my fee.

The nice clerk at the name change calendar took my paperwork and stepped away from her desk to look at a series of calendar pages that were posted on the wall. I got an uneasy feeling when she skipped over March, April, May, and June, and walked all the way over to the end of the year. She made a mark on a page, and then walked back.

“December 12th” she said. My mouth fell open. I’m not even sure if I made a sound, but all I could think inside was “NOOOOOOOOOOOOOOOO!”

I must have had some obvious reaction because she looked at me and said “Sorry, the judge that hears these petitions can only do one day a week. After you wait the required time for the criminal check, December is the next available time on her calendar.” I asked her if it was possible to try another court, maybe one not so busy. She told me that CA law requires you file such a petition in your home court. I was suddenly actually sad I didn’t live in Orange County anymore– I happened to be, she told me, at the busiest court in the State of California.

I was crushed. I also filled with dread, thinking about how hard the next 10 months would be still walking around with a female ID and everything else. I already was growing a beard and had my voice drop an octave–I couldn’t imagine how difficult it would be to explain that my ID was me after a further 10 months of testosterone!

I went back to my office and told my supervising partner what happened. “That’s absurd. You cannot go another 10 months with the wrong documents. You need this changed now, before you spend too much more time building a professional reputation under the wrong identity.” He suggested we file a motion to accelerate my hearing date in the court ex parte (meaning, you go in on your own without being scheduled by the court).

“You write the motion and draft a declaration for you and one for me. I’ll be your attorney. We will go fight this.” he said.

I did everything he asked, and compiled all my documentation of my transition– my coming out letter to my office, my diagnosis, my therapist letter, my doctor’s affidavit, and proof that I passed a criminal background check before joining the Bar. We went in the following Thursday and the judge agreed to accelerate my date to May.

I was ecstatic. Still, it was 3 months away, but 3 was much better than 10. And the whole time I kept thinking to myself: this is so screwed up.

What would I have done if I wasn’t a lawyer? I mean, I understand legal crap, and I could barely fill out all the paperwork for the petition. I can’t imagine how a non-lawyer would manage. And a non-lawyer wouldn’t even know that you can go in ex parte and ask the court to do something.

The law for name and gender changes in CA definitely does not reflect the needs of the community that process is designed to serve. People who are changing their name and gender are transitioning, usually. Not all trans people take hormones or have surgery. But many do. It’s only been 4 months since I filed my petition and I already look much different– fuller beard, bigger build, deeper voice. After 10 months I would have been some giant, beardy dude with an ID that said “Anna.”

I had already begun to receive push back from people about my ID not being me– bouncers, cashiers at the grocery store, the TSA… but people not wanting to serve me was one thing. I couldn’t imagine the safety hazard that comes from having an ID and a physical presentation that do not match. Especially for people like trans women, who are already often subject to high levels of harassment, violence, and even murder.

The legal process of transitioning does not in any way line up with the physical process of transitioning in other ways, too.

For example, up until a year ago, trans people changing their names and genders had to publish a notice in a public news paper for 6 weeks announcing to the whole world what they were changing their name/gender to and from. I had a friend who transitioned 20 years ago, and published his notice in a Korean-language only news paper, out of fear that his employer would learn his plans to transition. It finally dawned on the legislature that maybe making trans people put their business out in public was a safety hazard, and so thankfully that requirement did not apply to me. Still– are you kidding me?

Another example is the requirement that a doctor testify that you have “transitioned” at the time of your petition. I actually had my petition delayed two weeks because my doctor originally wrote that I was “transitioning,” rather than saying I had “transitioned.” This made total sense to me– after all, how can I have already transitioned if I haven’t changed my name and gender marker? The judge took issue with the “-ing” instead of “-ed” and actually made me get a new declaration from my doctor.

This requirement is completely ignorant of many facts about being trans, like
even if one has the financial resources to physically transition, this can take years. I mean, I will be going through major surgeries and such for the next few years at least. And I will be on testosterone for the rest of my life. Surely the legislature cannot assume that one will go through allllllll of that before having an ID that conforms to their gender expression? It also places a huge emphasis on the medical aspects of transition, where many trans people don’t go through medical procedures at all. Or the fact that a name and gender change is part of the transition,thus it cannot already be done before the petition is granted.

Luckily, my doctor didn’t have a problem re-writing mine, but he could have easily refused to do so because what the court wanted was technically not accurate.

So finally, after much hassle, I got my paper. I was filled with joy. Filled with relief. Filled with frustration at how hard it was to get there. And honestly, a bit filled with dread about the next 6 months of bureaucracy and updating my identity everywhere else.

I am sure this is not the end of my struggle to legally become myself. I decided to volunteer with some legal aid students to run a hotline where other people struggling with the process can contact attorneys for help, so I can put what I have learned to work helping others.